Do physicians & allied health workers have same believe in complementary and alternative medicine (CAM)?

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1 Do physicians & allied health workers have same believe in complementary and alternative medicine (CAM)? Turan Set, Abdul Sattar Khan, Umit Avsar, Memet Isik Ataturk University Medical Faculty Department of Family Medicine, Erzurum, Turkey Abstract Aim: The purpose of this study was to assess whether family physicians and allied health workers are aware with and have positive attitudes about complementary and alternative medicine (CAM). Methods: It is a cross-sectional study conducted during April to June 2011 at family medicine health care clinics in Erzurum, Turkey. There were 231 family physicians in 72 family medicine health care clinics working together with an allied health professional (nurse, midwife or health technician). Out of 462 participants invited, 333 (72.0%) accepted to join. The structured and pre-tested questionnaire was self-completed by all participants. Results: The main finding was that two groups differed significantly (p=0.001) as regard to their level of knowledge. The other variables like gender, age or working experience did not show any significant affect to knowledge level. The comparison in between the groups shows that out of six questions related to attitudes, only two questions have significant (p=0.001) difference otherwise there was no significant difference among agreements. Whereas physicians have suggested CAM to their patients more (p=0.004) as compared to allied health professionals during last one year. Conclusions: Both groups have limited knowledge but positive attitude and shows significant difference. However both groups are ready to learn more about CAM and want to improve their knowledge. Key words: Complementary and alternative medicine, health workers, family physician Introduction Complementary and alternative medicine (CAM) refers to a group of medical and health systems, practices, disciplines and products that are not considered as a part of conventional medicine [1,2]. According to estimates, more than 80% of the developing world and half of the developed world utilize CAM [3,4]. There are several reasons for using CAM including dissatisfaction with conventional medicine via failed treatments and high costs as well as high expenses incurred from conventional medicinal treatments [5]. Eventually, people turn to CAM because they believe mind/ body therapies are important for health maintenance or simply because they find it an interesting concept worth experimentation [6,7]. Turkey is different from other developed countries in that there are no official regulations for many CAM modalities. There are several reasons for this including having no complementary practitioners as the curricula in medical and allied sciences colleges do not have enough CAM-related content. Therefore, in Turkey there is limited information about the general approaches among family physicians and allied health workers regarding CAM [8]. Since it is important that health workers should be aware of CAM in order to practice it appropriately, this study is an attempt to assess the knowledge, attitude and behavior of family physicians and allied health workers regarding CAM. Materials and methods Study Design and Setting We conducted a cross-sectional knowledge, attitude and behavior survey. The study was conducted during April to June 2011 at family medicine health care clinics in Erzurum, Turkey. There were 231 family physicians in 72 family medicine centers serving to a population of around people on a list based manner. Each family physician was working together with an allied health professional (nurse, midwife or health technician). Journal of Society for development in new net environment in B&H 1661

2 Study Sample and Data Collection All family physicians and allied health workers in the city were invited to participate in the study. The invitation letter and questionnaire were sent through the health directorate and again collected back through the same route utilizing the official postal system. Out of 462 participants invited, 333 (72.0%) accepted to join. The structured and pre-tested questionnaire was self-completed by all participants. Questionnaire a. Preparation The researchers have developed a questionnaire. It was based on the prior experience of authors, input from colleagues, peers as well as from previous published papers. The draft so prepared was then pre-tested on 10 respondents and modified according to the pre-tests results. The results of the pre-testing were not included in the final analysis of the data. b. Segments The questionnaire was divided into four sections. Section 1: General Information The first section comprised socio-demographic information such age, gender, and educational level. Section 2: Knowledge This section assesses the knowledge of the respondents regarding CAM. It contains total 7 questions. The first three questions are comprised of pictures of different plants (linden, thyme, and daisy) while other questions have some answers to be ticked by respondents. Section 3: Attitude This part of the questionnaire comprised of questions related to attitude of health workers towards CAM. This segment contains 6 questions based on a five point Likert scale [9] from strongly agree to strongly disagree. Section 4: Behavior This section comprised of 5 questions related to the behavior of health workers such as Have you ever suggested any CAM to your patients in last one year? Statistical Analysis The data was analyzed using Windows SPSS version As part of descriptive statistics, n (%) and mean ± standard deviations were given where appropriate. Associations were assessed using Chisquare and independent samples t tests. Socio-demographic variables with a significant p value were subjected to a multiple logistic regression analysis to determine which factors were independent predictors of knowledge, attitude and behavior. A p<0.05 was considered significant. All odds ratios were recorded with a 95% confidence interval. Ethical Considerations All efforts were made in this study to fulfill the ethical considerations in accordance with the Declaration of Helsinki. The confidentiality of each participant was strictly ensured throughout the project. The Local Ethics Committee at the Faculty of Medicine, Ataturk University, has approved the study. Results Results for 333 participants were analyzed. Mean age was 32.3 ± 6.2 years. 193 participants (58.3%) were females while 138 participants (41.7%) were males. A total of 158 family physicians (47.7%) and 173 allied health professionals (52.3%) have participated in the study. Participants mean working experience was 8.7±5.1 years. The majority (n=53; 36.6%) had knowledge about herbal treatment followed by 47 participants (32.4%) who were aware about acupuncture. The most recognized herb was daisy (n=83; 24.9%). Two hundred twenty nine participants (89.8%) knew the method for applying acupuncture (Table 1). When compared the knowledge level with different demographic features (Table 2), significant difference (p=0.001) was found only in between physicians and other health workers. The other variables like gender, age or working experience did not show any significant difference. We combined the responses of the participants as A is equal to strongly agree and agree and B is equal to strongly disagree and disagree. Table 3 depicts that there is a significant difference (p=0.043) in physicians and health workers, opinion. The majority (n=98; 80%) strongly agreed to take part 1662 Journal of Society for development in new net environment in B&H

3 in any course related to CAM. Very less number (n=36; 32.7%) of physicians expressed that CAM is a thread for public health; allied health workers also had similar opinions. However majority physicians (n=90; 76.3%) strongly agreed plus agreed that unproven treatments should be prohibited; Table 1. Overall knowledge about CAM HealthMED - Volume 6 / Number 5 / 2012 allied health workers had similar opinions in this regard too. Regarding the question about usage of CAM and benefits of CAM on placebo effects, the two groups had different opinions (p=0.001). Table 4 shows that almost one third (n=96; %28.8) of participants had advised diet therapy Items for checking of knowledge Unknown Known Picture of linden Picture of thyme Picture of daisy Laxative effect of Senna Knows at least one CAM Knows Method for Acupuncture (MCQ) Knows Ginko is an Herbal extract (MCQ) CAM: Complementary and alternative medicine, MCQ: Multiple choose question. Table 2. Comparison of Knowledge scores with demographic features Knowledge score n Mean SD Physicians Groups of Participants AHW Males Gender Females year Working experience 11 year year Age groups 41 year SD: Standard Deviation, AHW: Allied health workers. Journal of Society for development in new net environment in B&H 1663 P Table 3. Comparison of attitudes of Physicians & Allied health workers Groups Physicians AHW Total P Interested to take part in an course of CAM A B CAM is a thread for public health A B Unproven treatments should be prohibited A B CAM should be used together with modern A medicine B CAM can be used sometimes instead of A modern medicine B Benefits of CAM depends on placebo effects A B A: Strongly agree + agree, B: Strongly disagree + Disagree, AHW: Allied health workers, CAM: Complementary and alternative medicine.

4 followed by 19.6% (n=65) herbal treatment and massage advised by 15% (n=50) during last one year. However about the utilization, around 20% (n=53) had utilized mainly diet, herbal treatment and praying (n=53, 21.9%; n=53, 21.9%; n=50, 20.7%, respectively) followed by massage (n=42; 17.4%) and acupuncture (n=9; 3.7%). Table 4. Comparison between advised and utilized of CAM by health workers Types of CAM CAM suggested CAM utilized Diet therapy Herbal treatment Massage Praying Acupuncture Meditation Hypnosis Yoga Bio-energy Leach therapy Cupping Others Total CAM: Complementary and alternative medicine. There was no significant difference (p > 0.05) between males and females regarding the use of CAM as a suggestion. Whereas physicians have suggested CAM to their patients more (p=0.004) as compared to allied health professionals during last one year (Table 5). Discussion This study demonstrated that primary care health workers and allied health workers have significant differences in their knowledge regarding CAM and indeed both groups show insufficient knowledge however they utilize and suggest complementary and alternative methods frequently. Although the trend shows an upsurge of the number of physicians in the last 40 years [10] however still the requirements of the patients are not fulfilled with full satisfaction, one reason why peoples are still searching for alternative methods. There are always some alternative methods [11] present since the medicine has evolved but it s practices are always in question. Although some neighbor countries use CAM widely [12], however the situation in Turkey is different and the Table 5. CAM-related behavior of health workers by gender and profession Gender Female Male Have you ever suggested any CAM to your Yes 70 36, ,9 patients in last one year? No , ,1 Have you ever tried any CAM on you in Yes 69 35, ,0 last year? No , ,0 Always Do you ask your patients about their use of Sometimes CAM? Never Groups Physicians AHW Have you ever suggested any CAM to Yes 76 48, ,4 your patients in last one year No 82 51, ,6 Have you ever tried any CAM on you in Yes 52 32, ,9 last year? No , ,1 Always Do you ask your patients about their use of Sometimes CAM? Never CAM: Complementary and alternative medicine, AHW: Allied health workers. P Journal of Society for development in new net environment in B&H

5 use of CAM is still a debatable topic. This study showed the knowledge, attitudes and behavior of family physicians and allied health workers that play a pivotal role in delivery of health care. The overall trend is almost same as it is mentioned in different published studies in Turkey [8]. Despite of the claim [3] of the policy makers that during last 10 years the traditional medicine awareness is increased among modern physicians or health workers, this study shows that only one third of the sample was aware about the herbal treatment followed by almost 30% who knows about acupuncture. Which is different from the results of another Turkish study [8] that shows a higher level of knowledge i.e., 61% were aware about CAM fully. In fact, other studies [13,14] rather reinforced our results and show low level of knowledge. In addition to these studies, another study [15] shows the low level of knowledge for acupuncture with 40% unable to answer even one question (of eight) correctly however it differs from our results that shows almost 90% were aware about the method of acupuncture. The literature also depicts that this method is practiced more [16] among the general practitioners (GPs). Our data shows that there is a significant difference in the level of knowledge in between physicians and other allied health workers. In deed the physicians were more able to give the answers of MCQs present in the questionnaire. Yet there is no study present in Turkey to compare these results so it is difficult to generalize the results or get any inference. Nonetheless some international studies [17,18] also showed that doctors are more aware than students and it is also second by another study on nursing students [19] shows a limited knowledge regarding CAM. In spite of low level of awareness, the participants had a positive approach towards CAM as almost 60% are interested to attend a course related to CAM, which is comparable to the results of other Turkish study [8]. Therefore it is understood that in Turkey the health workers are likely to apply and practice CAM if they are fully trained. Further, a study [17] in Germany shows that doctors and students both recommended that CAM should be a part of medical curriculum. Though it doesn t mean that are ready to practice even unproven treatment as our study shows that more than 50% participants of the study are in a favor to practice evidence based medicine (EBM). A survey of medical students in USA also favors the EBM practice of CAM [20]. Additionally they prefer to give CAM with modern medicine. Sometimes there is a difference in believing and practicing. In our study the health workers are not only advising CAM frequently but also using for themselves. A study in New Zealand showed that the most common CAM therapy practiced by GPs was acupuncture, and chiropractic manipulation was the most common GP-referred therapy for patients [16]. However usage rate of CAM by patients was not a part of our study so we cannot conclude that after receiving advice from health workers which therapies were commonly used during last one year. In order to appropriately counsel the patients, health workers should have information on CAM and need to practice it for them, if it is indicated. Our study showed that almost all participants have used CAM during last year. Diet (22%), herbal treatment (22%) and prayer (21%) are among the most commonly used CAM by health workers. Certainly it is matching with their advise to patients however not comparable to a study done in Turkey in 2007, which shows only 29% of GPs were using some type of CAM for themselves [8]. As one study in USA highlighted, prayer specifically for one s own health (43.0%) was on the top [1] similarly this study shows that praying is one of three most commonly advising and using CAM among the participants. Actually, herbal therapy has an important position as a complementary part of pharmacotherapy in modern medicine [21]. Conclusion Both health workers have limited knowledge with significant difference however ready to enhance their knowledge that shows their positive attitude towards CAM. They are not only advising it to patients but having believed so also utilize for themselves. Therefore it is recommended to provide training opportunities for health workers to learn more about CAM or perhaps including in curriculum will enhance the standardization of the training and provide chances to learn and practice it more and more for effective use for patients. Journal of Society for development in new net environment in B&H 1665

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