iuhpe – global health !

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Introduction

The usage of complimentary and alternativemedicine (CAM) in Canada and around the

world is on the rise. In the USA during 1997,more than 42 percent of the adult populationused CAM to deal with symptoms and healthproblems (1, 2). In Canada during 1997, 40–50percent of the population was using CAM (3).The grouping together of complementary andalternative with the acronym CAM supportsexpediency, although further analysis of theapplications and properties and how they differwarrants clarification and discussion.

Defining CAM

Complementary therapies/medicine would be usedalong with bio-medicine; chiropractic and acupunc-

ture are examples. Alternative medicine wouldconsist of medical practices that are not in conform-ity with standards of the medical community, nottaught at medical school, and generally not availableat North American hospitals (4). These would beused in place of bio-medicine with Naturopathy andHomeopathy as examples. Additionally, many formsof alternative medicine form their basis in culture,which then impact health beliefs and practices.Culturally based alternative medicines are forms of

1. Correspondence to: Brenda Lovell, University of Manitoba, 490 Drake Centre, Winnipeg, Manitoba, Canada R3T 5V4.Tel: (204) 789–3368; Fax: (204) 789–3905. ([email protected])

Global Health Promotion 1757-9759; Vol 16(4): 65–68; 348132 Copyright © The Author(s) 2009, Reprints and permissions:http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975909348132 http://ghp.sagepub.com

Commentary

The integration of bio-medicine and culturally basedalternative medicine: implications for health care

providers and patients

Brenda Lovell1

Abstract: Complementary and alternative medicine (CAM) are therapies used along with or in placeof bio-medicine. Many forms of CAM originate in culture, referred to as culturally based alternativemedicines. Usage of CAM is high with large numbers of patients using CAM for mental health, painand musculoskeletal problems. Their desire for holistic care may be the impetus for this interest, asalternative care practitioners spend more time analyzing illness symptoms. These factors along withthe global migration of immigrants accustomed to traditional medicine but now immersed in bio-medical health care systems, has created potential for misunderstanding. Drug interactions for some

forms of CAM taken with bio-medicine can occur. Insufficient scientific studies about CAM hasreduced acceptance and educational opportunities to learn about CAM are limited. Ideas for policyand research are forming. (Global Health Promotion, 2009; 16 (4): pp. 65–68).

Key words: complementary and alternative medicine, health education, patient communication,patient safety

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traditional medicine, indigenous healing beliefs andpractices of a particular culture or society pre-datingcontact with Europeans, inseparable from concernswith spiritual issues (5). Included is traditional

Chinese herbal medicine, Indian Ayurveda, NativeAmerican, Latin American, African and other folkmedicine practices. Naturopathy and Homeopathyhave their origins in western culture, but draw uponculturally based ancient remedies (6, 7). All of thesepractices would be alternatives to bio-medicine andnot have achieved integration within the bio-medicalhealth systems that dominate contemporary societies.It is important to note that what constitutes alterna-tive may vary in different contexts, especially in coun-tries which integrate alternative and bio-medicinesimultaneously within their health care systems.

Users of CAM

Research studies have found that use of CAMamong specific population groups is vast. Women,the higher educated, and individuals suffering frompain, anxiety, and musculoskeletal problems werethe main users (2). Fatigue, headaches, insomnia,and depression are also common reasons cited forseeking treatment from alternative practitioners (8).A study of breast cancer survivors in Ontario foundthat 66.7 percent of women were using some form

of CAM (9). The usage of CAM has been found towidespread among pediatric populations as well(10). Patients were also found to be integrating theirusage of CAM with treatments prescribed from psy-chiatrists (8). In addition, 80 percent of the world’spopulation use herbal medicine (1).

Two distinct forms of patients have emerged fromthis analogy. First, patients in health systems domi-nated by bio-medicine are exploring CAM due inpart to increased patient autonomy, a proliferationof information available via the Internet, and thedesire for health care options not offered by bio-

medicine (11, 12). The desire to achieve a moreholistic form of care may be a motivating factor asto why patients use CAM (2). Studies have indicatedthat these practitioners use a holistic patient-centered model, drawing upon the unique factorsand mental state inherent in each individual (2, 6).Practitioners spend more time with the patient,which may allow for a more open exchange of con-cerns that the patient has (1, 13, 14). The focus onprevention, emotional support and discovery of the

meaning behind symptoms, furthers the notion of partnership between patient and practitioner (2, 9).Second, immigrants from developing countries whomay have relied on traditional healers for their basic

health needs (15), are settling in developed countrieswhich are predominantly bio-medicine.

Research and policy

The increased diversity in patients has the poten-tial to lead to misunderstanding and misapplication.In response, the British and American MedicalAssociation’s have called upon health care providersto learn about CAM, and to discuss these practiceswith their patients (11). Scientific evidence of thecurative qualities of many complimentary and alter-

native therapies is limited (16), and consequentlythe lack of published scientific studies has greatlyreduced acceptance by many in the biomedical com-munity (15, 17). The World Health Organization inits efforts to promote dialogue has released a globalstrategy on traditional, complementary, and alter-native medicine, outlining steps to improve thesafety, efficacy, and the availability of these prac-tices (15). However, the gap is potentially wideningbetween allopathic and traditional practitioners inboth developed and developing countries (15).Traditional healers do not believe that monitoring

or regulation of their practices is warranted; theyassert that the efficacy of their products has stoodthe test of time (15). Health care providers duringthe medical encounter are exposed to the complexrelationship between a patient’s health beliefs andassociated behaviors. These beliefs in turn directlyinfluence use of health services, compliance, andaffect health outcomes (18). In particular researchhas found that patients using folk remedies maypresent for care to a practitioner of bio-medicine(18). Second, harmful interactions between herbalmedicines and allopathic drugs have been docu-

mented, in particular for CAM delivery systems thatare indigested, smoked, inhaled or injected (8, 15).Finally, the inability to achieve a shared understand-ing and acceptance of each other’s beliefs inhibits thetherapeutic relationship (18). From this analogy wesee that the relationship is complex and can com-promise patient safety, unless steps are taken to con-sciously manage this interaction. To furthercomplicate this issue, research by Eisenberg foundthat 63–72 percent of patients did not disclose at

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least one type of CAM treatment to their physicians(19). Common reasons for patient nondisclosurewere: they thought it wasn’t important for theirhealth care provider to know (61%); their health

care provider didn’t ask (60%); and they thought itwas none of their health provider’s business (31%).Patients want to discuss their complementary medi-cine with a physician, and feel guidance from aphysician is helpful when making decisions aboutCAM (17). However, patients feel disclosing usageof traditional therapies might result in lower qualityof care or hinder the caregiver/patient therapeuticrelationship (15, 19). Health care providers canencourage patient disclosure by attempting to gainfamiliarity with the most common forms of CAM tobe able to assess patients for interactions, and to

know where to find information about other treat-ments (8), irrespective of whether or not theyendorse these therapies. Asking patients in a non-judgmental way about their use of CAM can alsosupport patient disclosure (8).

Conclusion

Governments and organizations around theworld are working to formulate strategies andideas for policy and research. Physicians and otherhealth care providers may lack the educational

opportunities to learn about CAM or health beliefsthat are bounded in culture. Grand Rounds, con-tinuing professional development workshops, andother forms of discussion group, would be idealvenues to bridge this gap. Similarly, public healtheducation should become a priority to ensure thatpatients use CAM responsibly, and to promote theimportance of good provider/patient communica-tion surrounding this issue.

References

1. Frohock F. Moving lines and variable criteria:

Differences/connections between allopathic and alter-native medicine. In: Sheehan H, Brenton B, editors.Global perspectives on complementary and alternativemedicine. Ann Am Acad Pol Soc Sci. 2002; 583(1): 217.

2. Goldstein M. The emerging socioeconomic and polit-ical support for alternative medicine in the UnitedStates. In: Sheehan H, Brenton B, editors. Global per-spectives on complementary and alternative medicine.Ann Am Acad Pol Soc Sci. 2002; 583(1): 45–8.

3. de Bruyn T. Taking stock: policy issues associated withcomplementary and alternative health care. In: ShearerR, Simpson J, editors. Perspectives on complementary

and alternative health care: A collection of papersprepared for Health Canada. Ottawa: Health Canada;2001: 21, 34.

4. Verhoef MJ, Sutherland LR. General Practitioners’Assessment of and Interest in Alternative Medicine inCanada. Soc Sci Med. 1995; 41(4): 511–15.

5. Johnston SL. Native American traditional and alterna-tive medicine. In: Sheehan H, Brenton B, editors. Globalperspectives on complementary and alternative medi-cine. Ann Am Acad Pol Soc Sci. 2002; 583(1): 197–8.

6. Baer H. Toward an integrative medicine: Mergingalternative therapies with biomedicine. Walnut Creek,CA; Altamira Press; 2004.

7. National Center for Complementary and AlternativeMedicine. Questions and answers about homeopathy[Internet]. Available at: http://nccam.nih.gov/health/ homeopathy (accessed September 2008).

8. Yager J, Siegfreid SL, DiMatteo TL. Use of alternativeremedies by psychiatric patients: illustrative vignettesand a discussion of the issues. Am J Psychiatry. 1999;156(9): 1432–37.

9. Boon H, Stewart M, Kennard MA, Gray R, Sawka C,Brown JB, et al. Use of complementary/alternativemedicine by breast cancer survivors in Ontario:Prevalence and perceptions. J. Clin.Oncol. [Online].2000; 18(13): 2515–21. (accessed April 2007).

10. Jean DJ, Cyr C. Use of complementary and alternativemedicine in a general pediatric clinic. Pediatrics. 2007;120(1): 138–41.

11. Jonas W. Policy, the public, and priorities in alterna-tive medicine research. In: Sheehan H, Brenton B,editors. Global perspectives on complementary andalternative medicine. Ann Am Acad Pol Soc Sci. 2002;583(1): 32.

12. Tataryn D, Verhoef M. Combining conventional,complementary, and alternative health care: A visionof integration. In: Shearer R, Simpson J, editors.Perspectives on complementary and alternative healthcare: A collection of papers prepared for HealthCanada. Ottawa: Health Canada; 2001. p. 87.

13. Boon H. Patient-practitioner communication in con-ventional and complementary medicine contexts.In: Dube L, Ferland G, Moskowitz DS, editors.Emotional and interpersonal dimensions of healthservices: Enriching the art of care with the scienceof care. Montreal & Kingston: McGill-QueensUniversity Press; 2003. pp. 106–14.

14. Hughes K. Health as individual responsibility:Possibilities and personal struggle. In: Tovey P, Easthope

G, Adams J, editors. The mainstreaming of complemen-tary and alternative medicine: Studies in social context.New York: Routledge; 2004. p. 36.

15. Fink S. International efforts spotlight traditional,complementary, and alternative medicine. Am J PublicHealth. 2002; 92: 1734–9.

16. Advisory Group on Complementary and AlternativeHealth Care: Health Systems Division, HealthCanada. The need for guidelines: ethical issues in theuse of complementary and alternative health care inCanada today. In: Shearer R, Simpson J, editors.Perspectives on complementary and alternative health

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care: A collection of papers prepared for HealthCanada. Ottawa: Health Canada; 2001. p. 42.

17. Coulter I. Integration and paradigm clash: Thepractical difficulties of integrative medicine. In:Tovey P, Easthope G, Adams J, editors. The main-streaming of complementary and alternative medicine:Studies in social context. New York: Routledge;2004. p. 108.

18. Pachter LM. Culture and clinical care: folk illnessbeliefs and behaviors and their implications for healthcare delivery. JAMA. 1994; 271(9): 690–4.

19. Eisenberg DM, Kessler RD, Van Rompay M, KaptchukTJ, Wilkey SA, Appel S, et al. Perceptions about com-plementary therapies relative to conventional therapiesamong adults who use both: Results from a nationalsurvey. Ann Intern Med. 2001; 135: 344–51.

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s’est tout particulièrement préoccupée de la manière dont les systèmes de surveillance actuels pouvaients’appliquer au domaine de la promotion de la santé, pour en particulier développer les bases de donnéesprobantes pour la pratique de la promotion de la santé. Suite à ces discussions, l’Alliance mondiale pour laSurveillance des Facteurs de Risque (WARFS), qui est un Groupe de Travail à l'échelle mondiale de l’UIPES,

a été formée afin de travailler à fournir des connaissances et de l’expertise en matière de surveillance commeun outil pour faire progresser la promotion de la santé. Pour les membres de l’UIPES qui seraient intéressésà participer aux travaux de ce groupe, cet article fournit un aperçu de l’orientation stratégique de la WARFSet des sous-groupes de travail nouvellement formés. (Global Health Promotion, 2009; 16(4): pp.58-60)

Un programme de nutrition favorable à la santé avec des “louveteaux”

A. Sotgiu, A. Mereu, G. Spiga, V. Coroneo et P. Contu

Ce commentaire décrit le développement du programme de Nutrition Santé mené par l’Université deCagliari auprès de 19 groupes de scouts italiens. Au total, 353 enfants âgés de 6 à 10 ans ont participé àce programme. Les objectifs étaient de développer par le jeu les connaissances des enfants sur le régime

alimentaire méditerranéen. Ce projet a été développé entre les mois de janvier et juin 2006. Les activitésont été menées par les chefs des louveteaux dans le but d’améliorer les connaissances de ces jeunes scoutsen matière de nutrition. Chaque semaine, ils ont essayé un jeu différent, ce qui a montré qu’ilss’intéressaient de plus en plus à cette initiative et avaient envie de participer. Cette expérience a prouvéqu’il est possible d’impliquer les enfants dans un contexte extrascolaire pour mener un programme depromotion de la santé. (Global Health Promotion, 2009; 16(4): pp.61-64)

L’intégration de la biomédecine et des médecines alternatives basées sur laculture : implications pour les prestataires de soins et les patients

B. Lovell

Les médecines complémentaires et alternatives (MCA) sont des thérapies utilisées en complément ou à laplace de la biomédecine. De nombreuses formes de MCA tirent leur origine de la culture et sont qualifiéesde médecines alternatives basées sur la culture. Les MCA sont largement utilisées par un grand nombrede patients y recourant pour des problèmes de santé mentale, des problèmes musculosquelettiques, ou encas de douleur. Leur désir de prise en charge holistique pourrait bien être à l’origine de cet engouement,dans la mesure où les prestataires de soins alternatifs passent plus de temps à analyser les symptômesd’une maladie. Ces facteurs, associés à l’arrivée d’immigrants habitués à une médecine traditionnelle etdésormais immergés dans des systèmes de soins de santé biomédicaux, ont généré un terreau favorable àune certaine incompréhension. Des interactions médicamenteuses peuvent survenir pour certainesformes de MCA utilisées parallèlement à des traitements biomédicaux. L’insuffisance d’étudesscientifiques portant sur les MCA a diminué leur acceptation et les opportunités d’apprendre sur lesMCA dans un cursus d’enseignement sont limitées. Des idées de politiques et de travaux de recherche

sont cependant en train d’émerger. (Global Health Promotion, 2009; 16(4): pp.65-68)

Créer le document “Promouvoir la santé à l’école : des preuves à l’action”

L. St Leger et I. M. Young

Depuis presque un siècle, les écoles ont été impliquées dans la promotion de la santé et l’éducation pour lasanté partout dans le monde. Mais les initiatives qui s’inscrivent en milieu scolaire ont-elles un impact surl’éducation des jeunes et sur leur santé ? Cet article décrit le processus d’élaboration du document Promouvoir

Résumés

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Resúmenes


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sus subgrupos de trabajo recién creados para aquellos miembros de la UIPES que estén interesados en participar.(Global Health Promotion, 2009; 16(4): pp. 58-60)

Programa de nutrición sana para niños de la Sección Menor de los ‘scouts’A. Sotgiu, A. Mereu, G. Spiga, V. Coroneo y P. Contu

Este comentario describe el desarrollo del programa Nutrición Sana realizado por la Universidad de Cagliaricon 19 grupos de ‘scouts’ italianos. Participaron en él un total de 353 niños de edades comprendidas entrelos 6 y 10 años. El objetivo era desarrollar el conocimiento de los niños sobre la dieta mediterránea a travésde juegos. El proyecto se realizó entre enero y junio de 2006. Las actividades se llevaron a cabo por losdirigentes de la Sección Menor o rama de Lobatos con el objetivo de mejorar los conocimientos sobrenutrición de dicha rama. Cada semana organizaron un juego diferente que mostró un aumento del grado deinterés y de participación de esta rama. La experiencia demostró que es posible hacer participar a los niños en uncontexto ajeno a la escuela para llevar a cabo un programa de promoción de la salud. (Global HealthPromotion, 2009; 16(4): pp. 61-64)

La integración de la biomedicina y de la medicina alternativa de base cultural:implicaciones para los profesionales de la atención de salud y los pacientes

B. Lovell

La medicina complementaria y la alternativa (MCA) son terapias utilizadas junto con la biomedicina o enlugar de ella. Muchas formas de MCA tienen su origen en la que se aplican, y se las denomina medicinasalternativas de base cultural. Existe un elevado grado de utilización de MCA para la salud mental y losproblemas de dolor y músculo esqueléticos. El deseo de recibir una atención integral del elevado número depacientes que recurre a ellas podría ser el motivo de este interés, puesto que los profesionales de la medicinaalternativa dedican más tiempo a analizar los síntomas de la enfermedad. Estos factores, así como las

migraciones de personas acostumbradas a la medicina tradicional que ahora viven inmersas en sistemas desalud biomédicos son caldo de cultivo para la confusión. Algunos remedios de la MCA pueden interferir conlos fármacos de la biomedicina. La escasez de estudios existentes sobre la MCA ha reducido su aceptación yson limitadas las oportunidades educativas de aprender sobre ella. Están surgiendo ideas para formularpolíticas y llevar a cabo investigación al respecto. (Global Health Promotion, 2009; 16(4): pp. 65-68)

Elaboración del documento “Promover la salud en la escuela:de la evidencia a la acción”

L. St Leger y I. M. Young

Hace casi un siglo que escuelas de todo el mundo participan en la promoción de la salud y en la educaciónpara la salud. Las iniciativas de este tipo realizadas en la escuela, ¿cambian los resultados educativos y de saludde los jóvenes? Este trabajo describe el proceso de elaboración del texto ‘Promover la salud en la escuela: dela evidencia a la acción’. El documento se realizó principalmente para el sector educativo. Desarrolla lasrazones por las cuales las escuelas deberían emprender iniciativas relacionadas con la salud. Subraya ademáslos principales descubrimientos de la literatura de este sector sobre qué es posible lograr en el ámbito de lasalud escolar y las circunstancias en las cuales se consiguen los avances. La atención se centra tanto en laevidencia procedente del sector de la enseñanza, a saber, escuelas eficaces, enfoques de aprendizaje y deenseñanza, y del sector sanitario, es decir, una escuela entera o Escuela Promotora de Salud (EPS), como en la








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