Family Practice Advance Access originally published online on November 5, 2004
Family Practice 2004 21(6):654-660; doi:10.1093/fampra/cmh613
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Family Practice Vol. 21, No. 6 © Oxford University Press 2004, all rights reserved.
Complementary and alternative medicine use in patients with chronic diseases in primary care is associated with perceived quality of care and cultural beliefs
a Department of Community, Occupational and Family Medicine and b Department of Psychological Medicine, The National University of Singapore
Correspondence to A/P Ng Tze Pin, Department of Psychological Medicine, The National University of Singapore, Faculty of Medicine, 16 Medical Drive, Singapore 119074; Email: cofngtp{at}nus.edu.sg
Received 30 May 2004; Accepted 17 June 2004.
Lee GBW, Charn TC, Chew ZH and Ng TP. Complementary and alternative medicine use in patients with chronic diseases in primary care is associated with perceived quality of care and cultural beliefs. Family Practice 2004; 21: 656–662.
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Abstract |
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Objectives. The purpose of our study was to determine the prevalence of complementary and alternative medicine (CAM) use and its clinical and psycho-social correlates, including perceived satisfaction with care and cultural health beliefs.
Methods. A cross-sectional study was carried out in public sector primary care clinics in Singapore using a random sample of 488 adult patients with chronic diseases. The measures were CAM use, satisfaction with care and traditional health beliefs.
Results. The 1 year prevalence of CAM use was 22.7%. In univariate analyses, factors associated with CAM use included: middle age, arthritis, musculoskeletal disorders and stroke, multiple conditions, poor perceived health, family use of CAM, recommendation by close social contacts, strong adherence to traditional health beliefs and perceived satisfaction with care. Patients who were dissatisfied/very dissatisfied with the cost of treatment [odds ratio (OR) = 1.79, 95% confidence interval (CI) 1.15–2.82] and waiting time (OR = 1.96, 95% CI 1.20–3.19) were more likely to use CAM. Patients who were very satisfied with the benefit from treatment were much less likely to use CAM (OR = 0.49, 95% CI 0.29–0.83). Satisfaction with doctor–patient interaction was not associated with CAM use. Being ‘very satisfied’ on overall care satisfaction was significantly associated with much less CAM use (OR = 0.30, 95% CI 0.14–0.68). Multivariate analyses confirmed that CAM use was significantly and independently predicted by the ‘chronic disease triad’ (arthritis/musculoskeletal disorders/stroke) (OR = 4.08, 95% CI 2.45–6.83), overall satisfaction with care (OR = 0.32, 95% CI 0.14–0.74) and strong adherence to traditional health beliefs (OR = 1.88, 95% CI 1.07–3.31).
Conclusion. CAM use in Asian patients is prevalent and associated with the ‘chronic disease triad’ (of arthritis, musculoskeletal disorders and stroke), satisfaction with care and cultural beliefs. In particular, CAM use is not associated with the quality of doctor–patient interaction.
Keywords. Care satisfaction, chronic diseases, complementary alternative medicine, prevalence, primary care.
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Introduction |
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Complementary and alternative medicine (CAM) has become increasingly popular over the past decade.1–3 In 1 year, almost half of Australians had used at least one complementary remedy,1 and spent almost twice as much on complementary medicines ($621 million per year) than their contributions to pharmaceuticals. The most popular complementary remedies include chiropractic and homeopathy in the USA and The Netherlands, respectively,1–4 and acupuncture in Australia.4,5 Research indicates that most physicians are not informed that their patients use CAM.1,2
The use of CAM has always been very common among Chinese and other Asian patients in countries such as Taiwan, Singapore and Hong Kong.6–8 It has been shown that although most Chinese patients usually seek help first from doctors trained in Western medicine for most illnesses, a large proportion (42%) consulted traditional Chinese herbalists for further consultation for the same illness.8
The reasons why patients choose to use CAM have been much discussed, but not fully understood.9,10 The known determinants of CAM use include socio-demographic and patient characteristics. Many studies indicate that CAM users tend to be women, of white ethnicity, middle-aged or have more education. Also, they were more likely to be in perceived poor health,1,2,11–14 and suffer from one or more chronic conditions,11–14 especially mental, musculoskeletal and metabolic disorders. In Singapore, it is well known that acupuncture and traditional medicines are most commonly sought for treatment of arthritis, other musculoskeletal disorders and stroke.
There are other complex psycho-social and cultural factors. It is commonly held that patients choose to use CAM because they are dissatisfied with conventional treatments that are perceived to be ineffective or have unpleasant side effects, or to be impersonal or too costly.14–18 It has, however, been pointed out that disenchantment with conventional medicine is not necessarily the reason why patients turn to CAM.9 This appears to be supported by a recent US study that reported "users of alternative health care are no more dissatisfied with or distrustful of conventional care than nonusers are".19 Patients may also find CAM attractive because it is consonant with their personal values, religious and health philosophies.19–24 It has been suggested that CAM offers them a consultation model that is more appropriate and egalitarian for their illness.20–22 Others propose that people who use CAM are more likely to hold postmodern ‘new age’ values.23,24 On the other hand, it has been argued that simply ‘fundamental pragmatism’ leads patients to try out alternatives that might offer help.10
Among the predominantly Chinese patients in Singapore (Chinese 77%, Malay 14%, Indian 8%), the unique philosophies and theories underlying Traditional Chinese Medicine (TCM), Malay Jamu and Indian Ayurvedic medicine are embedded in their cultural mindset. For example, traditional concepts and beliefs about health, illness and remedies, such as ‘Yin’ and ‘Yang’, ‘harmony of different humors’ and ‘balance of energies’ strongly influence the health behaviour of Chinese patients. The degree to which people adhere to traditional health beliefs also varies. While some patients strongly hold on to traditional health beliefs, other may abandon them in favour of ‘scientific rationalism’; most patients probably hold onto a syncretism of multiple health belief systems. Few studies have investigated the role of adherence to cultural health beliefs as a factor in CAM use.
Empirical evidence in support of the relationships with care satisfaction and cultural beliefs are scanty and mostly based on anecdotal accounts, qualitative or descriptive data. Studies that investigated a single specific aspect of primary care quality such as doctor–patient relationship or overall care satisfaction and ignored various specific domains may give incomplete or misleading understanding of the relationship between CAM use and care satisfaction. The association of cultural health beliefs and patients' use of CAM has also been seldom reported.
In this study, we examine the prevalence of CAM use in Singaporean patients with chronic diseases in ambulatory primary care, and examine its association with demographic, clinical, psycho-social and health care correlates of CAM use, including perceived satisfaction with care and cultural health beliefs.
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Methods |
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Patients
The eligible subjects in this study were selected at two medical centres (Singapore Health Services Polyclinics) providing public sector primary out-patient care in Singapore over a 1 week period in January 2003. Eligible patients were Singaporean citizens or permanent residents, adults above 21 years of age, who have been treated in the past year for one or more of 12 chronic conditions: asthma, chronic obstructive pulmonary disease (COPD), diabetes mellitus, hypertension, dyslipidaemia, coronary artery disease, cardiac failure, cardiac arrhythmias, stroke, arthritis, gout and other musculoskeletal conditions, such as chronic backache. Patients with cognitive impairment were excluded.
Given an required sample size of 500 for an estimated prevalence of 25% with precision of ±2%, and an average number of 1500 patients seen in a typical week, a one in three sample of patients in each centre was chosen for study. Every third eligible patient was selected, using a systematic sampling procedure, for interview by trained medical students, after informed consent. Of a total of 1670 eligible patients, 539 were sampled, among whom 488 (91%) participated and completed the interview. There were no statistically significant differences in demographic and clinical characteristics in participating and non-participating patients. The study was approved by the Ethics Committee of Singapore Health Services Polyclinics of the Ministry of Health.
Questionnaire
The interviewer-administered questionnaire was used to determine CAM use; a glossary of terms was used to identify and classify the type of CAM. A patient was considered to be a CAM user only if he/she used it in the past 12 months specifically for any one or more of the chronic diseases that he/she had. In particular, diet therapy was defined as ‘any specific food, extracts, supplements taken for the purpose of treating the disease of interest’, excluding those prescribed by Western doctors or taken for preventive measures, such as vitamin supplements. The questionnaire was translated into Chinese, Malay and Tamil, and piloted at both centres on 30 patients, following which a number of questions were rephrased for ease of understanding and to eliminate ambiguities, and a few questions were removed or added. Data on non-responders and prevalence were used to estimate the required final sample size. The length of the interview averaged 20 min.
Clinical information included the number and duration of chronic diseases, number of hospitalization(s) in the past year for problems related to their condition, and the presence of polypharmacy (defined as >4 medicines taken for a minimum period of 3 months in the past year).
A single-item question on self-reported health status ("In general, would you say that your health is ‘very poor’, ‘poor’, ‘fair’, ‘good’ or ‘excellent’"?) was used to assess the health impact of chronic diseases and illness severity. The question has been shown in many studies to have high predictive validity and was an item included in the well-known SF-36 Health Survey scale.25
Mental well-being was assessed using the Centre for Epidemiological Research Survey questionnaire with eight items for depressive symptoms (CES-D8).26
The patient's satisfaction with care was evaluated by a questionnaire scale with a total of 12 items that comprised six items on a dimension of ‘clinic service and care’ (care overall, general environment, waiting time, information and advice, cost of treatment, and perceived benefits from treatment; 1 = very satisfied, 2 = satisfied, 3 = dissatisfied, 4 = very dissatisfied) and another six items on a dimension of ‘doctor satisfaction’ related to the quality of doctor–patient interaction (amount of time with doctor, openness to questions, personalized view of patient, competency, ease and confidence with doctor, faith and trust in doctor; 1 = strongly agree, 2 = agree, 3 = disagree, 4 = strongly disagree). Factor analysis supports the validity of the scale (see Appendix); Cronbach's alpha coefficients for inter-item reliability for the ‘doctor satisfaction’ and the ‘clinic service and care satisfaction’ scales were 0.79 and 0.80, respectively. The summary scores for the two subscales were derived from the mean scores of the component items.
Three questions were asked on specific self-care behaviours related to attempts made by the patient to learn more about his/her own medical condition; the patient's ability to take prescribed therapy; and their ability to keep follow-up appointments (1 = not all all, 2 = seldom, less than a quarter of the time, 3 = sometimes, about half the time, 4 = most of the time, more than three quarters of the time).
The patient's social network and support was evaluated by two questions on the patient's living arrangements (1 = living alone, 2 = living with family, relative or friends), and the presence of a caregiver who was able to look after the patient's health needs.
The influence of cultural beliefs was assessed by a question that asked about how strongly the patient believed in traditional theories regarding health, illness and remedies, such as Chinese concepts of ‘Yin’ and ‘Yang’, ‘harmony of different humors’, ‘balance of energies’ and central concepts of Malay ‘Bomoh’ and Indian Ayuverdic medicine. The terms of reference and descriptions of these health concepts appropriate to the ethnic group were first explained to the patient before they were asked for their response.
Family influence on the patient's usage of CAM was assessed with three questions on whether the family, close relative or friends also used or recommended using CAM.
Statistical analysis
Categorical data analyses were performed with point estimates of odds ratios (ORs) of association and 95% confidence intervals (CIs) in univariate analyses, and adjusting for confounding variables in multiple logistic regression analyses. Independent candidate variables in regression models included gender, age, ethnicity, monthly household income, type of housing (a surrogate for socio-economic status), study centre, medical conditions, number of co-morbid medical conditions, years since diagnosis, depression (CES-D8 
7), self-reported health status, number of prescription medicines, hospitalization in past year, use of other primary care provider, satisfaction with ‘clinic service and care’ and ‘doctor–patient interaction’, psycho-social and cultural variables [living arrangement (living alone versus living with someone), presence of caregiver, specific self-care behaviour, family use of CAM, family and friends' recommendation of CAM and a strong belief in traditional health theories].
Both full saturated models with all predictor variables included and stepwise forward selection models were used to evaluate model-building strategies. Significant variables identified from univariate analyses were included in the final regression model using forward selection procedures for entry at P = 0.05 and removal at P = 0.10. As both models gave similar results, only the stepwise selection model is presented. All statistics analyses were carried out using Statistics Package for the Social Sciences (SPSS).
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Results |
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Patient description
Among the 488 patients, 49% were over 60 years of age and 57% were female. The great majority (90.4%) were Chinese. More than half the patients (65%) had only a primary or no education, and 54% had a total monthly household income of <S$1500. The most common clinical conditions were hypertension (83.4%), dyslipidaemia (41.6%) and diabetes mellitus (37.5%);
44% had two or more chronic conditions.
Prevalence
The 1 year prevalence of CAM use was 22.7%. This varied greatly among individual chronic diseases (Table 1), being most prevalent in arthritis, other musculoskeletal disorders and stroke (42–73%), and lowest for dyslipidaemia (4.4%) and coronary arterial disease (none). The most common CAMs used were TCM (37.8%), traditional dietary therapy (29.7%) and acupuncture (27.5%). Only a small proportion of the patients (16.3%) had informed their polyclinic doctors of CAM use.
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Correlates of CAM use
In univariate analyses, a number of variables were significantly and positively associated with CAM use (Table 2). Middle age (46–60 years) was strongly associated with CAM use (OR = 2.91, 95% CI 1.36–6.25). Several specific chronic disorders each were significantly associated with CAM use: arthritis (OR = 3.46, 95% CI 1.76–6.79); other musculoskeletal disorders (OR = 5.46, 95% CI 1.90–15.7); and stroke (OR = 2.28, 95% CI 1.07–4.86). As these three chronic diseases conform to the most common indications known locally for seeking CAM, they were grouped together as a ‘chronic disease triad’ variable (OR = 4.10, 95% CI 2.48–6.76); number of concomitant chronic diseases (OR = 1.76, 95% CI 1.02–3.02 for one concomitant disease, and OR = 2.26, 95% CI 1.32–3.88 for two or more diseases, respectively), and self-reported poor health status (fair or poor versus very good to excellent OR = 2.90, 95% CI 1.43–5.86). Satisfaction with the quality of service and care provided by the clinics was significantly associated with CAM use; compared with patients who were very satisfied, those who reported being very dissatisfied were significantly more likely to use CAM (OR = 2.90, 95% CI 1.18–7.14). In particular, patients who were dissatisfied and very dissatisfied with the cost of treatment (OR = 1.79, 95% CI 1.15–2.82) and waiting time (OR = 1.96, 95% CI 1.20–3.19) were significantly more likely to use CAM (results not shown in Table 2). The use of CAM by family members (OR = 2.40, 95% CI 1.53–3.77), recommendation of CAM use by relatives and friends (OR = 3.46, 95%CI 2.22–5.41) and a strong belief in traditional theories (OR = 1.92, 95% CI 1.12–3.30) were all significantly associated with CAM use.
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It is worth noting that satisfaction with doctor–patient interaction was not significantly associated with CAM use (P = 0.29). Other demographic variables, frequencies of hospitalizations, polypharmacy, depression and use of psychotropic drugs, specific self-care behaviour and social support all failed to show significant associations with CAM use in univariate analyses.
In multiple logistic regression analyses, CAM use was significantly and independently predicted by the ‘chronic disease triad’ (arthritis/musculoskeletal disorders/stroke) (OR = 4.21, 95% CI 2.52–7.01), dissatisfaction with the quality of service and care provided by the clinics (OR = 2.90, 95% CI 1.18–7.14), and strong adherence to traditional health beliefs (OR = 1.87, 95% CI 1.06–3.27). The final model explained 12% of the variance (Table 3).
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Discussion |
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Our 1 year prevalence estimate of 22% of CAM use was higher compared with two studies in primary care settings in Israel27 and Japan28 (7.9 and 19%, respectively). Among Chinese patients in Canada who consult a family physician,29 a higher proportion of patients (28%) reported currently using Chinese herbal medicines, and another 18% reported using CAM in the past year. However, reported prevalence estimates of CAM use are expected to vary widely depending on the populations studied, the range and heterogeneity of CAM therapies, and the time periods for reporting prevalence (current, 1 year or lifetime). Our estimates of CAM use should also be extrapolated cautiously to all primary care patients in Singapore because public sector primary out-patient care clinics serve only 20% of the population, and patients served by private GPs have a greater proportion of those with arthritis and musculoskeletal disorders and the level of patient satisfaction appeared to be better.29
Our finding that a very large majority of patients (84%) did not inform their family physicians of their CAM use is consistent with the findings of many studies. In Australia1 and Italy,14 the proportions are 57.2 and 59.3%, respectively. We found that patients with specific chronic diseases, namely arthritis, musculoskeletal diseases and stroke, were more likely to use CAM. As a group, these chronic diseases form a well known ‘triad’ of indications for acupuncture and other CAM use. This association has also been reported in previous studies.11–14
The higher usage of CAM in middle-aged patients observed in this study is in agreement with that reported in Western populations.1–9 Unlike most of these studies, however, we did not observe a positive association of better education with CAM use. However, in Japan,26 a lower educational level was also found to be associated with more frequent CAM use. It is likely that in Asian populations, education and cultural influence are intertwined such that less educated patients were more culture-bound to the use of CAM; in Western populations, better educated patients behave like ‘cultural creatives’19 in exploring alternative medicines.
A prevailing hypothesis to explain the increasing use of alternative medicine is that "People seek out these alternatives because they are dissatisfied in some way with conventional treatment".15–18 This is supported by our observation that patients who were dissatisfied with the cost of treatment and waiting time were more likely to use CAM. Conversely, patients who were very satisfied with the benefits they derived from their treatment were much less likely to use CAM. This last observation is in strong support of the pragmatic view of CAM use.
A recent study has found that "users of alternative health care are no more dissatisfied with or distrustful of conventional care than nonusers are".19 Our results do not agree with this. It should be noted that in the US study, perceived satisfaction with care was circumscribed within the context of a recent visit to a medical doctor and limited to five questions that focused on the doctor–patient interaction (overall satisfaction, communication, trust and confidence). We have also examined this aspect of satisfaction with the quality of the doctor–patient interaction, and indeed found no relationship with CAM use. This is interesting because the perception that patients use CAM because they regard conventional modern medicine as being ‘impersonal’ appears not to be valid. Our results are in agreement with a number of other studies which support a relationship between patient satisfaction with conventional care and CAM use16–19 and identify specific aspects of the quality of care to be associated with CAM use.
Another hypothesis of CAM use is that alternative medicines are seen as being more compatible with the patients' values, spiritual/religious philosophy, or beliefs regarding the nature and meaning of health and illness.19–24 Our results support this hypothesis. Hardly any patients in our study hold postmodern or ‘new age’ views, but patients who held strong beliefs about traditional theories of health, illness and remedies were more likely to use CAM. Also, patients with family members who use CAM and who recommend CAM to others were also more likely to use CAM. Together, these findings suggest that culturally transmitted values and beliefs have a strong influence on CAM use.
Conclusion
CAM use in Asian patients is prevalent and was largely not disclosed to their primary care physicians. It is strongly determined by the ‘chronic disease triad’ (arthritis, musculoskeletal disorder and stroke), perceived satisfaction with care and cultural health beliefs. In particular, CAM use is not associated with the quality of doctor–patient interaction.
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Declaration |
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Funding: No funding was received from any pharmaceutical companies.
Ethical approval: The study was approved by the Singapore Health Services Ethical Committee.
Conflicts of interest: None.
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Appendix |
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Acknowledgments |
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We would like to thank Drs Tan Chee Beng, Tan Ngiap Chuan, Tay Ee Guan, Wong Song Ung and June Tan, and the staff of Singhealth Polyclinics for their kind and generous support and assistance of the study.
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References |
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