Posts Tagged ‘ Health care ’

Why Do People Use Alternative Medicine?


ResearchBlogging.orgI often read that the reason people are turning to complementary/alternative/integrative(take your pick) medicine is because they are dissatisfied with the care received from mainstream/conventional/”western”* medicine. This may be true for a small segment of the population, those with a chronic illness or with terminal cancer spring to mind. But is this generally true of altmed users? Those who pick up a bottle of homeopathic remedy from the pharmacy or occasionally visit a naturopath?

I don’t think it’s quite as simple as that. A study “Why Patients Use Alternative Medicine” published in 1998 in the JAMA looked at this question using a survey sent to randomly selected participants. 1500 participants were sent the survey and 1035 completed it. Not too bad for a survey response rate.

The survey was geared to look at the use of altmed based on three paradigms:

“1. Dissatisfaction: Patients are dissatisfied with conventional treatment because it has been ineffective,5-6 has produced adverse effects, or is seen as impersonal, too technologically oriented, and/or too costly.

2. Need for personal control: Patients seek alternative therapies because they see them as less authoritarian16 and more empowering and as offering them more personal autonomy and control over their health care decisions.

3. Philosophical congruence: Alternative therapies are attractive because they are seen as more compatible with patients’ values, worldview, spiritual/religious philosophy, or beliefs regarding the nature and meaning of health and illness.”

According to the survey results satisfaction, or lack thereof,  with conventional medicine did not correlate well with altmed use. 54% of respondents reported being “highly satisfied” with conventional medicine providers, of these 39% use alternative therapies. Of those who were highly dissatisfied (40%) only 9% were users of altmed.

It seemed as if those who were fans of medicine overall were more likely to participate in both camps. A sort of “the more the merrier” approach to health care.

What was predictive of alternative medicine use was personal philosophy. Those who considered there to be a strong mind/body/spirit connection as well as those who had had a “transformational experience” were more likely to use alt med than those who did not.

Education and health status also correlated with altmed use. Those with higher educations were more likely to use it, as were those who described themselves as having a lower health status.

The situation was slightly different for those who shunned conventional medicine altogether in order to embrace altmed. These folks tended to be distrustful of and dissatisfied with conventional practitioners, as well they desired a high degree of control over their health and believed in the importance and value of “inner experiences”.

This proportion of the population was quite small however – only 4.4% of the survey respondents fell into this group. Even so somehow the reasons for this group’s embrace of altmed has been generalised to the wider population.

The observation that users of altmed tend to be greater consumers of health services overall is also supported by the paper “Association Between Use of Unconventional Therapies and Conventional Medical Services“. This survey had a base of 16,068 individuals from which to pull data representing a 77% response rate from the 24,676 pool that was originally sampled.

According to this survey only 6.5% of the population use both altmed and conventional medicine** (and 1.8% using only altmed), with this group making more visits to their physician than those who used conventional medicine only. One possible reason for this is the so-called “worried well”, a portion of the population that focuses on their health to a degree higher than would be expected given their health status. Support for this is given within the paper:

“Compared with those with only conventional visits, those who used both types of care had significantly more outpatient physician visits (7.9 vs 5.4; P<.001), and used more of all types of preventive services except mammography. These groups did not differ significantly in inpatient care, prescription drug use, or number of emergency department visits.”

This on it’s own does not show a “worried well” connection but in the comments section of the paper it was noted:

“…there was no difference in any of the 4 self-reported health measures between respondents who had physician visits only, and those who had those visits in conjunction with unconventional therapy. Poor health status appeared to drive use of health services in general, that is, those using no services reported better health than those using either conventional medical services or unconventional therapies. However, poor health was not associated with increased use of unconventional therapies over and above conventional medical care.” [emphasis added]

So it would seem, at least in this sample, that dissatisfaction with conventional care cannot be the driving force for the majority of altmed users. More plausible is that altmed users seek to make the most of every perceived avenue for health.

Another survey published in 2001 also supported the general conclusion that dissatisfaction with conventional medicine does not lead to altmed use for most consumers. “Perceptions about Complementary Therapies Relative to Conventional Therapies among Adults Who Use Both: Results from a National Survey” surveyed 831 respondents who used both regular and alternative medicine.

Of these 70% would visit a conventional medicine practitioner as their first port of call. Only 15% went to a altmed provider first. There was also no significant difference in the level of confidence in altmed providers and regular medical professionals.

To quote the conclusion:

“National survey data do not support the view that use of CAM therapy in the United States primarily reflects dissatisfaction with conventional care.”

From a paper presented at the Proceedings of the 1997 Conference of
the Australian Association for Social Research and published in the Journal of Sociology; “Postmodern values, dissatisfaction with conventional medicine and popularity of alternative therapies“[PDF File download]:

“Those individuals who value natural remedies, are against chemical drugs, do not favour technological progress, and welcome variety in choice of therapy are more likely to have a positive attitude towards alternative medicine.”

These attitudes were enveloped under the “postmodern” rubric and were found to be a better predictor of altmed use than satisfaction levels with regard the conventional medicine.

To elaborate on that point, a further finding was that dissatisfaction with interactions with physicians rather than health outcomes was associated altmed use. This is a subtle point and worth dwelling on as it seems to be a valid criticism of the way in which conventional medicine is practised. It was not that altmed users were unhappy with the actual results of the care received via conventional medicines but the way in which they feel they are treated by doctors.

It seems that those turning to altmed may feel that conventional doctors do not give enough respect, time, don’t listen and are too authoritative. I don’t want to put too much emphasis on this perspective as it isn’t entirely consistent with the picture built up so far and the sample size of this survey was relatively small compared with the ones above (only 209 respondents), but it is worth considering.

In conclusion, while it might be true that some dissatisfaction does lead to an increase in the use of alternative medicine it seems unlikely to me that this is the main reason. I’m not sure why it has become the go-to reason trotted out by participants on both sides of the debate, ease I suppose. I could of course be wrong, perhaps there is a mountain of research out there that I’ve missed pointing in the complete opposite direction. I’m willing to grant that possibility, in the absence of such though I’ll have to go with personal philosophy being the largest contributing reason people use altmed.

——————————————————————–

*I hate with a passion the label “Western Medicine”, what? – people from other cultures can’t use science? Nonsense.

** I suspect that the wildly differing definitions of what constitutes “Alternative” medicine are to be blamed for the fluctuating figures around the proportion of users.
————————————————————————-

Astin, J. (1998). Why Patients Use Alternative Medicine: Results of a National Study JAMA: The Journal of the American Medical Association, 279 (19), 1548-1553 DOI: 10.1001/jama.279.19.1548

Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S, & Davis RB (2001). Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Annals of internal medicine, 135 (5), 344-51 PMID: 11529698

Druss, B. (1999). Association Between Use of Unconventional Therapies and Conventional Medical Services JAMA: The Journal of the American Medical Association, 282 (7), 651-656 DOI: 10.1001/jama.282.7.651

Siahpush, M. (1998). Postmodern values, dissatisfaction with conventional medicine and popularity of alternative therapies Journal of Sociology, 34 (1), 58-70 DOI: 10.1177/144078339803400106

Aditional reading:

Joy, J.M. (2004). Complementary and Alternative Medicine (CAM): Do Barriers to and Dissatisfaction with Traditional Care Affect CAM Utilization Patterns, Masters Thesis, Texas Tech University Health Sciences Center

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The Freedom of Ignorance: Health Freedom, What is it and Do We Want it?


When policy around how herbal remedies, alternative medicines, supplements and all sorts of other practices outside the mainstream of medical practice is discussed the concept of “Health Freedom” inevitably comes up. It’s not always couched in that term but the idea is that people should be free to choose whatever method of healthcare that they wish.

Sounds good right? Who wants to impinge in someone’s freedom to make their own decisions? Isn’t that what living in a free country is all about? Personal autonomy, the right to take action unfettered by how someone else thinks I should run my life. That’s how I want to live, why should I want to take that away from others?

Well, I don’t. But the notion of freedom has always come with a caveat (several actually), that is – it is inherently restricted by ignorance. Is someone who is uninformed about the actual state of affairs truly free?

That’s what those who speak out about alternative medicine are actually trying to achieve. We aren’t attempting to “defend our turf” or “squelch the competition” we are attempting to inform the public about the true underpinnings of these therapies and point out they they are either unsupported by science or have in fact been disproved.

As has been noted before, a majority of New Zealanders are unaware that Homeopathic medicines do not contain any active ingredient and yet many people think they are scientifically proven.

Education was also the intent of the co-ordinated Sciblogs rebuttal to the poorly conceived and executed series on alternative therapies printed by the Herald earlier this year. (see here, here, here and here)

Policies that are aimed at restricting access to herbal or alternative medicine usually are doing so from the aspect of quality control. Does the remedy or practice have good evidence of efficacy, is it safe? These are the questions that we should be asking about every medical practice, not just those in the “alternative” (or complementary, or integrative, pick your marketing phrase of choice) camp.

Unfortunately is is not in the interests of those pushing alternative modalities to undergo strict evidence based testing so the issue is re-packaged from a quality control issue to a “freedom” issue.

Similar tactics are seen in arenas outside the medical realm. In biology the evolution vs creationism/intelligent design “debate” is framed as “Academic Freedom” as is the debate around climate change. This is not a coincidence. Whether or not these decisions are made consciously or not there has been convergence on the “Freedom” aspect of these cases for a reason, people respond to it. We are jealous of our freedom, and rightly so, freedom forms the basis of our society.

But as I alluded above, freedom is not an absolute and unalloyed good under all circumstances. It comes up against restrictions in all sorts of ways, some epistemological (as in the case of whether a choice is really free if the person is not aware of all the factors affecting that choice) and some are practical (as in should we allow freedom to include the freedom to sell harmful products?).

Conclusion

The natural/alternative remedies debate is not, at it’s heart, about freedom at all. Rather it is about education and quality control. We should subject all medical practices to the same rigorous examination regarding safety and efficacy. Long term “after market” monitoring should also factor into this equation to catch those practices that looked good in the necessarily limited testing that they are subjected to prior to being rolled out to the general public but may still have safety problems.

In this way we should be able to serve the public’s health interests and avoid false choices about freedom.

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New Zealand Pharmacy Ethics in Relation to Homeopathy in the Wake of Homeopathy Report


Earlier this year I wrote a post (along with fellow Sciblogger Grant) concerning the sale of homeopathic remedies in pharmacies. Monday night saw the release of England’s Science and Technology Committee’s “Evidence Check 2″ report on Homeopathy (also ably covered by Grant). One of the issues covered by the report is that of pharmacy responsibilities regarding sale of these remedies. Essentially the report recommended that sales continue but with adequate disclaimers stating that there is no scientific evidence that homeopathic products work beyond the placebo effect.

I see this as a compromise between commercial freedom to sell safe, though not necessarily effective, products and patient informed consent. It’s reasonable even if I disagree that it is ideal. Regardless, I thought it was a good excuse to look once again at our own pharmacies and see how the selling of scientifically unsupported remedies aligns with their professional responsibilities.

Enquiring into this area I was directed to the Pharmacy Council Code of Ethics for pharmacists. The Pharmacy Council seems to fill the function of professional association and regulatory body for pharmacists their functions including:

prescribe the qualifications required for scopes of practice within the profession, and, for that purpose, to accredit and monitor educational institutions and degrees, courses of studies, or programmes

and

consider the cases of health practitioners who may be unable to perform the functions required for the practice of the profession

Perusing the Code of Ethics (which may be found Here) I found a number of sections that I feel should preclude pharmacists from selling homeopathic remedies in good conscience. In order to try and represent the spirit of the code as accurately as possible I have included here both the relevant over-arching Principles that pharmacists should strive for as well as the Specific Obligations that I feel make my point (any emphases are mine).

The first principle is one of patient autonomy:

Principle 1: Autonomy
The pharmacist shall promote patient
self-determination, respecting the
patient’s right to understandable
information, privacy, and confidentiality

1.4 Professional services
Where the patient is seeking or receiving, from the
pharmacist or from other personnel for whom he or
she has responsibility, any professional service or
intervention, the pharmacist must ensure that the
patient is provided with credible, understandable
information about reasonably expected results,
outcomes or effects of the service or intervention, any
risks of receiving the service or intervention, and any
insufficiency of evidence about the efficacy of the
service or intervention
, to allow the patient to make
an informed choice.

This to my reading implies that should pharmacists sell homeopathic remedies they are obligated to inform the patient of the lack of scientific underpinnings for the use of the remedy. One of the objections I have run into regarding the sale of these remedies in pharmacies is that they are commercial enterprises and are within their rights to sell products regardless of their medicinal value. This is partially true but these remedies are specifically sold to treat symptoms, not as entertainment, confection or cosmetic. The Code has several entries covering this aspect the first of which is:

1.5 Independent information
The pharmacist must ensure that their advice is
independent of personal commercial considerations.

Does this not imply that the sale of unscientific medicines should not be undertaken simply because it make financial sense? We will return to this point later.

The next Principle covers patient needs:

Principle 2: Beneficence
The pharmacist shall optimise medicines
related health outcomes for the patient
according to their concerns, needs,
cultural values and beliefs

2.2 Quality use of medicines
The pharmacist must provide scientifically-based,
unbiased medicines information
to healthcare
providers, patients and the community in order to
optimise medicines related health outcomes
.

My reading of this point leads me to understand that any information provided regarding pharmacy products must have scientific backing and moreover must not be biased by the pharmacist’s own views. Any such information regarding homeopathy must therefore be negative.

But, what if the pharmacist is not asked for this information? After all, I do not usually go in asking for a lecture if I already think I know what I need. I think the next obligation covers this instance:

2.8 Involvement in sale of medicines and other
therapies

The pharmacist must be involved and intervene in the
sale of any medicine, complementary therapy, herbal
remedy or other healthcare product whenever this is
necessary to ensure a reasonable standard of
pharmaceutical care
.

Scientifically speaking homeopathy should not be considered to encompass a “reasonable standard of pharmaceutical care”.

The next Principle of relevance concerns fairness:

Principle 4: Justice
The pharmacist shall practise fairly and
justly and promote family, whanau and
community health

4.4 Commercial interests not to override good
practice

The pharmacist must ensure that commercial interests
are not permitted either to override the independent
exercise of their own professional judgement on
behalf of a patient or to compromise the standard of
care provided by them or to affect their cooperation
with other healthcare providers.

Once again the issue of financial gain over patient care is addressed with commercial interests coming off second best when the standard of care is concerned.

The next Principle is one I feel is of especial importance when the reputation of pharmacists in the wider community is considered and their self representation in the media is a factor (remember, they’re the health professional you see most often). This is trustworthiness, pharmacists are seen as, and promote themselves as, first and foremost medical professionals not business interests. The sale of homeopathic medicines is antithetical to this position and undermines their credibility in this regard, in direct contraction to the Code of Ethics as follows:

Principle 7: Trustworthiness
The pharmacist shall act in a manner
that promotes public trust in the
knowledge and ability of pharmacists
and enhances the reputation of the
profession

7.7 Non-medical goods and services
The pharmacist must not purchase or sell from a
pharmacy any product or service which may be
detrimental to the good standing of the profession or bring the profession into disrepute.

If the sale of scientifically worthless remedies such as homeopthy does not do this I don’t know what would, perhaps offering Therapeutic Touch?

Finally the Principle of dignity undermines the pharmacist’s sale of unsupported medicines:

Principle 8: Dignity
The pharmacist shall provide
information about professional services,
medicines and healthcare products in a
dignified manner without making
exaggerated or unsubstantiated claims

8.4 Medicines not ordinary articles of
commerce

A pharmacist must only participate in promotional
methods that do not encourage the public to equate
medicines with ordinary articles of commerce
.

If the previous examples of why remedies should not be sold with the sole purpose of earning money for the pharmacist this should put that argument to rest. The sale of medicines (which many people consider homeopathy to be) should not be equated with ordinary articles of commerce. This puts the lie to arguing that these remedies are simply another commodity to be bought and sold like chewing gum regardless of therapeutic value.

8.8 Evidence of efficacy
The pharmacist must only promote to a potential
purchaser that any medicine, complementary therapy,
herbal remedy or other healthcare product associated
with the maintenance of health is efficacious when
there is credible evidence of efficacy.

This last obligation explicitly refers to promotion of a therapy to a patient by the pharmacist which I don’t think any reputable pharmacist would do for homeopathy but arguably the presence of the product in the store constitutes an implicit promotion of it to potential customers. This point goes back to the principle of trustworthiness, the public trusts the pharmacist to stock efficacious products. To include unscientific therapies among their wares undermines and betrays this trust. Perhaps I am naive to think so but I think the Pharmacy Council’s own Code of Ethics backs me up when I say that we should hold pharmacists to a higher standard than your average shop owner.

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