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Beliefs about the efficacy of complementary medicine: A vignette study
Complementary Therapiesin Medicine (1996)4, 85-89
©PearsonProfessionalLtd 1996
RESEARCH
Beliefs about the efficacy of complementary medicine: a vignette study A. Furnham and A. Rawlinson University College London SUMMARY. Over 90 adult subjects read six vignettes (each about 80 words long) describing middle-aged women with one of three problems: psychological (feeling tired); chronic medical (migraine) or acute medical (sudden numbness). They were described as visiting either a complementary or orthodox medical practitioner and feeling better after specific treatment. Subjects were then required to rate each vignette on such things as the efficacy of the treatment and whether they thought the person's responses proved that the therapy worked. The results showed that overall orthodox medicine was judged as more effective than complementary medicine, and that psychological problems were easier to cure than medical problems. The fact that the subjects themselves had experienced complementary medicine had little effect on their judgment of efficacy. Results were discussed in terms of the literature in this area.
belief in the importance of a healthy mind and the possible harmful effects of medical science.5 The controversy surrounding complementary medicine (CM) rests on three factors. 6 They are, first, that many of the CM disciplines have a different model of health and disease from that commonly accepted by the medical profession; second, that few systematic trials have been carried out; third, that when trials are carried out and demonstrate a positive outcome, this does not automatically validate the theories of the specific type of practice. A considerable amount of research has recently been done on the motives for choosing different practitioners. Marteau 7found that people with an internal locus of control have negative beliefs about CM, whereas people who believe their health to be beyond their control express far more positive views. However, the actual beliefs that underlie interest in CM and the extent of willingness to consult a complementary practitioner are unknown. Awareness about the importance of a healthy mind and healthy body may also explain the increasing popularity of complementary medicine as treatments for the whole person rather than treatments for simply the physical symptoms. In time, for some patients, complementary practitioners may replace non-professional support networks altogether5 If patients are attracted by the philosophy of complementary medicine, rather than seeing it as an escape from orthodox medicine, different patients may be attracted to different types of therapies. Furnham, Vincent and Wood5 suggest such patients, drawn to a therapy for very different reasons, will
INTRODUCTION Within the last two decades, there has been increasing acceptance of complementary medicine by lay people. 1,2 Twenty years ago, complementary medicine (then widely called 'alternative medicine') was not used much by the general public, out of both ignorance and scepticism. Moreover, it was ridiculed by the medical profession, who saw it as being practised by quacks and charlatans. There has also been a marked change in people's attitudes towards health and the body, which has been described as a 'quiet revolution' .3 Much of the appeal of complementary medicine derives from the setting in which treatment takes place. Therapists appear to give their patients more time, courtesy and attention but this may be because they have rather different types of patients presenting with different conditions. Healing is not perceived to be the same as curing. Patients with chronic or terminal diseases may have symptoms relieved by a skilled, compassionate healer who does not actually arrest the disease process. 4 Patients of complementary practitioners are, however, not a homogenous group. They differ in views about general practitioner (GP) satisfaction, healthy lifestyles, environmental issues, confidence in prescribed drugs, faith in medical science,
Professor Adrian Furnham DPhil, DSc, DLitt, and Anna Rawlinson BSc, Department of Psychology,
University College London, 26 Bedford Way, London WC1 0AP, UK. Correspondence to Professor Furnham. 85
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Complementary Therapies in Medicine
. themselves be different. In their study, they found acupuncture patients to be the longest sufferers of their complaints, followed by the homoeopathic group, the osteopathic group and, finally, the GP group. This suggests that patients may look to more than one form of complementary medicine for help when orthodox treatments fail them Further, they seem more likely to turn to a less widely accepted therapy, such as acupuncture, the longer they have suffered from the complaint. Many patients had tried other therapies. The GP group had been the least adventurous and the acupuncture patients the most adventurous. With regard to health beliefs and lifestyle, acupuncture patients differed most from other groups even when their medical history had been taken into account. They expressed the least satisfaction with their GPs, had the healthiest lifestyle, were most likely to read about health in newspapers, magazines, books, etc., and were the most concerned with environmental issues, while showing the least confidence in prescribed drugs. With regard to scientific health beliefs, it was once again the acupuncture patients who expressed views that differed from other groups. They expressed least faith in medical science - significantly less than other groups - placed considerably more importance on a healthy state of mind, and were significantly the most concerned about harmful effects of medical science. They showed much less support for scientific methodology, in contrast to the GP group, which did the opposite. Finally, complementary practitioners were seen as being more sympathetic, having more time to listen, being more sensitive to emotional issues, better at explaining treatments and better at explaining why a patient was ill. Earlier, Furnham and Smith8, in a comparison of GP and homoeopathic patients, found the homoeopathic group more critical and sceptical about the efficacy of orthodox medicine. They concluded that people who chose CM did so because of disenchantment with personal experiences of orthodox practitioners, rather than because of disillusionment with orthodox medicine itself. Furnham and Forey3 compared GP patients with those from a range of CM therapies on various measures such as control over health, preventative vs restorative strategies, and perceived efficiency of treatment. It was found that the complementary group were more sceptical and critical of the efficacy of modern medicine. They stayed loyal to their chosen practitioners, had tried more CM therapies, were more ecologically aware and believed the whole person rather than physical symptoms could be treated. They also had greater knowledge of the physiology of the body. The study concluded that, contrary to the idea that patients were pushed away from traditional medicine, patients were also pulled towards alternative medicine because of beliefs about its effectiveness and philosophical basis.
From these studies, it can be seen that people do distinguish between different CM therapies, and that different therapies are often perceived as being highly specific. This suggests that patients are likely to be judicial shoppers for CM, going to a particular therapeutic tradition, or indeed to orthodox medicine, depending on their own assessment of their illness. Measurement of efficacy lies at the heart of the debate between orthodox medicine and complementary medicine. Many orthodox practitioners reject user surveys and anecdotal information, arguing that success is more to do with the placebo effect or 'magical thinking'. Serious concerns have also been voiced about the possible harm done by complementary medicine. For many, however, it seems impossible to use orthodox medicine research paradigms to evaluate complementary medicine. Furnham, 9 in a study carried out among medical students found that three-quarters of them (77%) believed that some complementary therapies were effective, while a half of them knew someone who had been treated successfully. This suggest that whatever the beliefs and practices of orthodox medical educators, students, as practitioners of the future, will be increasingly sympathetic to the approach of complementary medicine. There appears to be greater acceptance of, and less scepticism about, complementary medicine among the young. This may be explained by greater concern in lower age groups about issues of health and fitness generally, and the association of new-age and green movements, with their youthful bias. The over 65s show the greatest level of resistance to alternative medicine, perhaps because older patients have continuing treatment from the GPs, or are simply more conservative or sceptical. Women actually use CM more than men, but men claim more than women that they would use it if they knew more about it. 1° Personal accounts of treatments tend to be an important source of information about conventional medicine and are highly valued in assessing its efficacy. 11,12 While it seems that personal recommendations are important and might outweigh a medical opinion, it is not clear why people believe these therapies to be effective. It may be that they are seen as genuinely effective or simply providing a muchneeded support in chronic illness. CM practitioners may be perceived as more willing to take minor illness more seriously or offer psychological support in chronic illness. This, in turn, relates to a wider question of how people perceive illness and disease and what factors they consider important in treatment and recovery. This study examines in detail the perceived efficacy of complementary and orthodox medical therapy for treating different complaints. Three hypotheses were entertained: first, that CM patients believe more in the efficacy of their own therapy irrespective of the nature of their problem. Second, CM would be rated
Beliefs about the efficacy of complementary medicine as more efficacious on 'psychological' rather than medical problems. Third, there would be an interaction between the treatment and the patient illness, so that CM is seen as more helpful with chronic illnesses and orthodox medicine (OM) more useful for acute illness.
87
asks her about her lifestyle. He discovers that she has been under stress, smokes and feels overweight. On this basis, he prescribes a treatment using 12 acupuncture needles on her hands, arms, scalp and earlobes. The needles are connected to a box which generates mild electric currents. After the session, she feels better, with the headaches gone.
Example 2
METHOD Subjects In all, 94 subjects took part in this study, of whom 41 were male and 53 female. Their mean age was 29.11 years (standard deviation = 10.47). They were asked whether they had ever used complementary medicine and 52 claimed they had. They were asked various other details such as their marital status (58% single, 29% married, 3% other); their religion (41% Christian, 12% other, 47 none); their political beliefs and their occupation. About a third were in further education and the remainder taken from a very large number of occupations.
Questionnaire Subjects were given a questionnaire which introduced the issue; they were then presented with six vignettes followed by seven questions. Each vignette (about 80 words) concerned a British woman with one of the three problems: 'psychological' (depression, feeling weak and tired), 'chronic medical' (cancer, migraines), and 'acute illness' (major stomach pains, sudden numbness). The woman was described as either visiting an orthodox doctor (GP or specialist) or alternative practitioner (acupuncturist, homoeopath or aromatherapist). Examples are given below.
In Euston, London, a 41-year-old woman, who has suffered a sudden acute pain in the stomach and lower abdomen, arrives at hospital. Here, a doctor examines her and diagnoses appendicitis. He tells her that, unless her appendix is removed by surgery, she may develop peritonitis (abdominal inflammation) which could make her seriously ill. She agrees, and is given a general anaesthetic. The surgeon operates and removes her appendix. When she wakes up from the anaesthetic, the woman feels better, with the pain gone. Each vignette ended with the patient feeling better and the symptoms gone. The aim in writing these vignettes was to make them as 'rich' and meaningful as possible, whilst still ensuring they fulfilled the 2 x 3 classification. In order to assess whether the classification was successful, two subjects were asked to classify the six vignettes into the specified categories and both were completed successfully. Table 1 shows the criteria upon which each vignette was evaluated.
Procedure Subjects completed the questionnaire in their own time. In all, there was a 82% response rate. Where possible, the subjects were debriefed.
Results
Example 1 In Ealing, London, a 42-year-old woman, who has been suffering from bad headaches, visits an acupuncturist. During the consultations, the acupuncturist first listens to the woman describe her symptoms, and
A mixed analysis of variance (ANOVA) was computed for each of the seven questions: 2 (patients of CM or OM) x 2 (CM or OM therapy) x 3 (medical problem). The between-subject variables were based on whether subjects had experienced some form of complementary
Table 1 The criteria on which each vignette was evaluated Ineffective
Very effective
a. How effective do you think the treatment was?
1
b. Do you think she will remain feeling better?
Not very likely 1 2 3
Very likely 4 5
Not very likely
Very likely
c. Do you think this is proof that the therapy works?
1
2
2
3
3
Not very likely d. If it works, why does it work? The healer talked to her The healer touched her The treatment itself worked She would have got better with time anyway
1 1 1 1
2 2 2 2
3 3 3 3
4
4
5
5
Very likely 4 4 4 4
5 5 5 5
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Complementary Therapies in Medicine
therapy or not. Fifty-two claimed they had, and 42 claimed they had not. In the seven different analyses, this main effect was only significant once. Those who had some form of complementary therapy believed that whatever the medical problems or the therapy, it was more likely to work if the 'healer' talked to the patient (F=6.43, P<0.001). There was a significant main effect for type of therapy/treatment for every question. Thus, all subjects rated orthodox medicine more effective (F=38.66, P<0.001); they believed that the patient would more likely remain better (F--94.36, P<0.001); they all thought that the story proved orthodox medical treatment worked (F=28.69, P<0.001); that it was not primarily due to the 'healer' talking to her (F=61.57, P<0.001) or touching her (F=132.30, P<0.001) but that their treatment per se worked (F=73.20, P<0.001) and that the patient would not have got better with time anyway (spontaneous remission) (F=41.93, P<0.001). There were also seven main effects for the three medical problems presented. Both treatments (OM and CM) were seen as more effective for chronic problems (F--23.88, P<0.001); it was believed that chronic problem patients will remain feeling better (F--43.22, P<0.001); and that this is proof that (both) types of therapy work (F--50.76, P<0.001). Psychological patients were judged most likely to get better because the therapist talked to them (F=142.54, P<0.001) but the acute patients were thought to get better because the therapist touched them (F=32.48, P<0.001). Both treatments applied to the chronic patients were deemed to work well (F=31.82, P<0.001) but it was thought that, of the three complaints, the 'psychological' patients were
the most likely to get better over time (F=53.41, P<0.001). As regards the statistical interactions from the analysis, no subjects x treatment or subjects x patients were x significant. Nor was any of the three-way interactions significant. However, all seven patient type x treatment was significant and the means in Table 2 show these results. The cause of these interactions is fairly clear and lies in the fact that OM and CM treatment is seen to differentiate the chronic patients more than the 'psychological patients'. Orthodox medicine is seen as most effective for chronic, but least effective for acute, patients (F=59.94, P<0.001). Orthodox medicine was perceived to have the longest-lasting effects on chronic patients, while complementary medicine was seen as less efficient at having a long-lasting effect on chronic patients (F=98.03, P<0.001). In contrast to all other conditions, the subjects believed OM treatment of chronic patients proved that it works (F=72.83, P<0.001). The subjects believed OM therapy least likely to work because the doctor talked to the patient but most likely to work in the case of psychological problem patients (F=43.63, P<0.001). CM therapy was seen to be most successful because the therapist touches (particularly psychological) patients, but much less so for OM practitioners treating chronic patients by touch (F=22.01, P<0.001). OM treatment of chronic patient problems was seen as best evidence that the theory worked, while CM treatment of psychological problems scored least high (F=47.45, P<0.001). Finally, the highest rate of 'spontaneous remission' was seen to occur in CM treatment of psychological problem patients and least in OM treatment of chronic patients (F=31.02, P<0.001).
Table 2 Mean scores from the seven question ratings of the six vignettes Patient types Questions
Treatment
Chronic
Acute
Psychological
1. How effective was the treatment? (l=Not, 5=Very)
OM CM
4.69 3.53
3.53 3.81
4.01 3.72
2. Will she remain feeling better? (l=Not likely, 5=Very likely)
OM CM
4.60 2.72
3.14 2.89
3.04 3.26
3. Is this proof that the therapy works? (l=Not likely, 5=Very likely)
OM CM
4.43 2.71
2.72 2.98
2.73 2.83
4. Worked because healer talkedto her (l=Not likely, 5=Very likely)
OM CM
1.70 2.89
1.78 3.11
3.72 3.71
5. Worked because healer touchedher (l=Not likely, 5=Very likely)
OM CM
2.05 3.72
1.67 3.02
1.75 2.24
6. Treatment itself worked (l=Not likely, 5=Very likely)
OM CM
4.71 3.05
3.70 3.43
3.49 2.99
7. She would have got better anyway (l=Not likely, 5=Very likely)
OM CM
1.23 2.68
1.42 2.49
2.49 2.80
Beliefs about the efficacy of complementary medicine DISCUSSION The results of this vignette study of perceptions of the efficacy of CM and OM yielded some interesting and counter-intuitive findings. The first major findings revealed, perhaps surprisingly, that personal experience of CM is not a powerful factor in predicting whether patients believe in its efficacy. There could be at least three possible explanations for this finding. First, that the subjects in this study were not zealous or regular consumers of CM but interested dabblers, and that, if we had involved a more clearly defined group of believers, this difference would have shown up. Second, it could be that the amalgamation of all CM practices increased the scepticism of the subjects; they may believe strongly in the efficacy of one or two specific CM therapies i.e. homoeopathy, acupuncture) but are highly sceptical of the efficacy of lesser-used CM therapies. Third, it could be that the nature of this task - namely vignette evaluation out the more subtle and sensitive features of personal experience of CM patients. There was a fairly clear main effect for type of treatment. As regards efficacy and proof, subjects rated OM more highly than CM. This is no doubt to be expected, for even the most enthusiastic consumer of CM agrees that each particular type of therapy tends to be appropriate for a highly specific problem. People appear to agree that OM is more generally efficacious than CM, particularly in the treatment of chronic conditions. However, the results did show that, where CM was perceived to work, it did so more than OM because the therapist talked to and touched the patient. As well as type of treatment, type of problem and the interaction between treatment and problem was considered most important by subjects in their ratings of efficacy. This study involved three types of medical problem chronic illness, acute illness and 'psychological' non-specific illness. Given this classification, the subjects seem to have a very clear picture of the efficacy of which treatment for which problem. Without doubt, orthodox medicine is seen to be most efficacious for chronic medical problems. Curiously, there appears to be relatively little difference in the perceived efficacy of OM and CM for acute medical problems. Furthermore, practitioners' success is attributed mainly to talking to patients with psychological problems, but touching patients with chronic medical problems. Whilst the results of this study are interesting and explicable in terms of the previous results, 3 it should be pointed out that studies like this are clearly limited -
w a s h e d
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to a small number of vignettes. The limited choice of variables (patient variables, treatment type) and their categorization could be debated. The problems are essentially two-fold. First, to write realistic and enriched vignettes requires adding details that may be both irrelevant and even confusing, so making the vignettes not strictly comparable. Equally, having a restricted number of vignettes means that classification may be unreliable. Obviously, the more prototypic the cases the better, but if the examples are limited it is likely that classification is far from perfect. Experimental (social) psychologists often use vignettes in studies to test hypotheses about how people think about particular issues. Because the experimenter can manipulate specific variables in each vignette, it is possible to test their effect directly on the subjects' rating of them. However, more qualitatively oriented researchers argue that the values and attitudes which people express about hypothetical (vignette) situations experienced by others are not the ones which they apply to themselves when they have to make judgements or choices. Both qualitative and quantitative methods have their place in research on complementary medicine.
REFERENCES
1. Fulder SJ. Complementary medicine in the United Kingdom: patients, practitioners and consultations. Lancet 1985; 2: 542-545. 2. Fulder SJ. Handbook of complementary medicine, 2nd edn. Oxford: OUP, 1992. 3. Furnham A, Forey J. The different behaviours of patients of traditional medicine versus complementary (alternative) medicine. Clin Psychol 1994; 50: 458469. 4. Smith T. Alternative medicine. BMJ 1983; 287: 388-397. 5. Furnham A, Vincent C, Wood R. The health beliefs and behaviour of complementary medicine and a general practice group of patients. J Alt Compl Med 1995; 1. 6. Anderson E. General practitioners and alternative medicine. Oxford: Research Department of Alternative Medicine, Oxfordshire Health Authority, 1992. 7. Martean T. Attitudes to doctors and the preliminary development of new scale of psychology in health. BMJ 1983; 4: 351-356. 8. Furnham A, Smith C. Choosing alternative medicine: a comparison of the beliefs of patients visiting a GP and a homoeopath. Soc Sci Med 1988; 26: 685-687. 9. Furnham A. Attitudes to alternative medicine: a study of perceptions of those studying orthodox medicine. Compl Ther Med, 1993; 1(3): 120-126. 10. Nicholls PA, Wilson JE. Doctors and conventional medicine: a survey of GPs in the potteries. Stafford: Staffordshire Polytechnic, Dept of Sociology (Occasional paper), 1986. 11. Beibrich J. Measure for efficacy: a case for holistic research. Compl Med Res 1990; 4(1): 21-25. 12. Vincent C, Furnham A. The perceived efficacy of complementary and orthodox medicine. Compl Ther Med 1994; 2(3): 128-135.
©PearsonProfessionalLtd 1996
RESEARCH
Beliefs about the efficacy of complementary medicine: a vignette study A. Furnham and A. Rawlinson University College London SUMMARY. Over 90 adult subjects read six vignettes (each about 80 words long) describing middle-aged women with one of three problems: psychological (feeling tired); chronic medical (migraine) or acute medical (sudden numbness). They were described as visiting either a complementary or orthodox medical practitioner and feeling better after specific treatment. Subjects were then required to rate each vignette on such things as the efficacy of the treatment and whether they thought the person's responses proved that the therapy worked. The results showed that overall orthodox medicine was judged as more effective than complementary medicine, and that psychological problems were easier to cure than medical problems. The fact that the subjects themselves had experienced complementary medicine had little effect on their judgment of efficacy. Results were discussed in terms of the literature in this area.
belief in the importance of a healthy mind and the possible harmful effects of medical science.5 The controversy surrounding complementary medicine (CM) rests on three factors. 6 They are, first, that many of the CM disciplines have a different model of health and disease from that commonly accepted by the medical profession; second, that few systematic trials have been carried out; third, that when trials are carried out and demonstrate a positive outcome, this does not automatically validate the theories of the specific type of practice. A considerable amount of research has recently been done on the motives for choosing different practitioners. Marteau 7found that people with an internal locus of control have negative beliefs about CM, whereas people who believe their health to be beyond their control express far more positive views. However, the actual beliefs that underlie interest in CM and the extent of willingness to consult a complementary practitioner are unknown. Awareness about the importance of a healthy mind and healthy body may also explain the increasing popularity of complementary medicine as treatments for the whole person rather than treatments for simply the physical symptoms. In time, for some patients, complementary practitioners may replace non-professional support networks altogether5 If patients are attracted by the philosophy of complementary medicine, rather than seeing it as an escape from orthodox medicine, different patients may be attracted to different types of therapies. Furnham, Vincent and Wood5 suggest such patients, drawn to a therapy for very different reasons, will
INTRODUCTION Within the last two decades, there has been increasing acceptance of complementary medicine by lay people. 1,2 Twenty years ago, complementary medicine (then widely called 'alternative medicine') was not used much by the general public, out of both ignorance and scepticism. Moreover, it was ridiculed by the medical profession, who saw it as being practised by quacks and charlatans. There has also been a marked change in people's attitudes towards health and the body, which has been described as a 'quiet revolution' .3 Much of the appeal of complementary medicine derives from the setting in which treatment takes place. Therapists appear to give their patients more time, courtesy and attention but this may be because they have rather different types of patients presenting with different conditions. Healing is not perceived to be the same as curing. Patients with chronic or terminal diseases may have symptoms relieved by a skilled, compassionate healer who does not actually arrest the disease process. 4 Patients of complementary practitioners are, however, not a homogenous group. They differ in views about general practitioner (GP) satisfaction, healthy lifestyles, environmental issues, confidence in prescribed drugs, faith in medical science,
Professor Adrian Furnham DPhil, DSc, DLitt, and Anna Rawlinson BSc, Department of Psychology,
University College London, 26 Bedford Way, London WC1 0AP, UK. Correspondence to Professor Furnham. 85
86
Complementary Therapies in Medicine
. themselves be different. In their study, they found acupuncture patients to be the longest sufferers of their complaints, followed by the homoeopathic group, the osteopathic group and, finally, the GP group. This suggests that patients may look to more than one form of complementary medicine for help when orthodox treatments fail them Further, they seem more likely to turn to a less widely accepted therapy, such as acupuncture, the longer they have suffered from the complaint. Many patients had tried other therapies. The GP group had been the least adventurous and the acupuncture patients the most adventurous. With regard to health beliefs and lifestyle, acupuncture patients differed most from other groups even when their medical history had been taken into account. They expressed the least satisfaction with their GPs, had the healthiest lifestyle, were most likely to read about health in newspapers, magazines, books, etc., and were the most concerned with environmental issues, while showing the least confidence in prescribed drugs. With regard to scientific health beliefs, it was once again the acupuncture patients who expressed views that differed from other groups. They expressed least faith in medical science - significantly less than other groups - placed considerably more importance on a healthy state of mind, and were significantly the most concerned about harmful effects of medical science. They showed much less support for scientific methodology, in contrast to the GP group, which did the opposite. Finally, complementary practitioners were seen as being more sympathetic, having more time to listen, being more sensitive to emotional issues, better at explaining treatments and better at explaining why a patient was ill. Earlier, Furnham and Smith8, in a comparison of GP and homoeopathic patients, found the homoeopathic group more critical and sceptical about the efficacy of orthodox medicine. They concluded that people who chose CM did so because of disenchantment with personal experiences of orthodox practitioners, rather than because of disillusionment with orthodox medicine itself. Furnham and Forey3 compared GP patients with those from a range of CM therapies on various measures such as control over health, preventative vs restorative strategies, and perceived efficiency of treatment. It was found that the complementary group were more sceptical and critical of the efficacy of modern medicine. They stayed loyal to their chosen practitioners, had tried more CM therapies, were more ecologically aware and believed the whole person rather than physical symptoms could be treated. They also had greater knowledge of the physiology of the body. The study concluded that, contrary to the idea that patients were pushed away from traditional medicine, patients were also pulled towards alternative medicine because of beliefs about its effectiveness and philosophical basis.
From these studies, it can be seen that people do distinguish between different CM therapies, and that different therapies are often perceived as being highly specific. This suggests that patients are likely to be judicial shoppers for CM, going to a particular therapeutic tradition, or indeed to orthodox medicine, depending on their own assessment of their illness. Measurement of efficacy lies at the heart of the debate between orthodox medicine and complementary medicine. Many orthodox practitioners reject user surveys and anecdotal information, arguing that success is more to do with the placebo effect or 'magical thinking'. Serious concerns have also been voiced about the possible harm done by complementary medicine. For many, however, it seems impossible to use orthodox medicine research paradigms to evaluate complementary medicine. Furnham, 9 in a study carried out among medical students found that three-quarters of them (77%) believed that some complementary therapies were effective, while a half of them knew someone who had been treated successfully. This suggest that whatever the beliefs and practices of orthodox medical educators, students, as practitioners of the future, will be increasingly sympathetic to the approach of complementary medicine. There appears to be greater acceptance of, and less scepticism about, complementary medicine among the young. This may be explained by greater concern in lower age groups about issues of health and fitness generally, and the association of new-age and green movements, with their youthful bias. The over 65s show the greatest level of resistance to alternative medicine, perhaps because older patients have continuing treatment from the GPs, or are simply more conservative or sceptical. Women actually use CM more than men, but men claim more than women that they would use it if they knew more about it. 1° Personal accounts of treatments tend to be an important source of information about conventional medicine and are highly valued in assessing its efficacy. 11,12 While it seems that personal recommendations are important and might outweigh a medical opinion, it is not clear why people believe these therapies to be effective. It may be that they are seen as genuinely effective or simply providing a muchneeded support in chronic illness. CM practitioners may be perceived as more willing to take minor illness more seriously or offer psychological support in chronic illness. This, in turn, relates to a wider question of how people perceive illness and disease and what factors they consider important in treatment and recovery. This study examines in detail the perceived efficacy of complementary and orthodox medical therapy for treating different complaints. Three hypotheses were entertained: first, that CM patients believe more in the efficacy of their own therapy irrespective of the nature of their problem. Second, CM would be rated
Beliefs about the efficacy of complementary medicine as more efficacious on 'psychological' rather than medical problems. Third, there would be an interaction between the treatment and the patient illness, so that CM is seen as more helpful with chronic illnesses and orthodox medicine (OM) more useful for acute illness.
87
asks her about her lifestyle. He discovers that she has been under stress, smokes and feels overweight. On this basis, he prescribes a treatment using 12 acupuncture needles on her hands, arms, scalp and earlobes. The needles are connected to a box which generates mild electric currents. After the session, she feels better, with the headaches gone.
Example 2
METHOD Subjects In all, 94 subjects took part in this study, of whom 41 were male and 53 female. Their mean age was 29.11 years (standard deviation = 10.47). They were asked whether they had ever used complementary medicine and 52 claimed they had. They were asked various other details such as their marital status (58% single, 29% married, 3% other); their religion (41% Christian, 12% other, 47 none); their political beliefs and their occupation. About a third were in further education and the remainder taken from a very large number of occupations.
Questionnaire Subjects were given a questionnaire which introduced the issue; they were then presented with six vignettes followed by seven questions. Each vignette (about 80 words) concerned a British woman with one of the three problems: 'psychological' (depression, feeling weak and tired), 'chronic medical' (cancer, migraines), and 'acute illness' (major stomach pains, sudden numbness). The woman was described as either visiting an orthodox doctor (GP or specialist) or alternative practitioner (acupuncturist, homoeopath or aromatherapist). Examples are given below.
In Euston, London, a 41-year-old woman, who has suffered a sudden acute pain in the stomach and lower abdomen, arrives at hospital. Here, a doctor examines her and diagnoses appendicitis. He tells her that, unless her appendix is removed by surgery, she may develop peritonitis (abdominal inflammation) which could make her seriously ill. She agrees, and is given a general anaesthetic. The surgeon operates and removes her appendix. When she wakes up from the anaesthetic, the woman feels better, with the pain gone. Each vignette ended with the patient feeling better and the symptoms gone. The aim in writing these vignettes was to make them as 'rich' and meaningful as possible, whilst still ensuring they fulfilled the 2 x 3 classification. In order to assess whether the classification was successful, two subjects were asked to classify the six vignettes into the specified categories and both were completed successfully. Table 1 shows the criteria upon which each vignette was evaluated.
Procedure Subjects completed the questionnaire in their own time. In all, there was a 82% response rate. Where possible, the subjects were debriefed.
Results
Example 1 In Ealing, London, a 42-year-old woman, who has been suffering from bad headaches, visits an acupuncturist. During the consultations, the acupuncturist first listens to the woman describe her symptoms, and
A mixed analysis of variance (ANOVA) was computed for each of the seven questions: 2 (patients of CM or OM) x 2 (CM or OM therapy) x 3 (medical problem). The between-subject variables were based on whether subjects had experienced some form of complementary
Table 1 The criteria on which each vignette was evaluated Ineffective
Very effective
a. How effective do you think the treatment was?
1
b. Do you think she will remain feeling better?
Not very likely 1 2 3
Very likely 4 5
Not very likely
Very likely
c. Do you think this is proof that the therapy works?
1
2
2
3
3
Not very likely d. If it works, why does it work? The healer talked to her The healer touched her The treatment itself worked She would have got better with time anyway
1 1 1 1
2 2 2 2
3 3 3 3
4
4
5
5
Very likely 4 4 4 4
5 5 5 5
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therapy or not. Fifty-two claimed they had, and 42 claimed they had not. In the seven different analyses, this main effect was only significant once. Those who had some form of complementary therapy believed that whatever the medical problems or the therapy, it was more likely to work if the 'healer' talked to the patient (F=6.43, P<0.001). There was a significant main effect for type of therapy/treatment for every question. Thus, all subjects rated orthodox medicine more effective (F=38.66, P<0.001); they believed that the patient would more likely remain better (F--94.36, P<0.001); they all thought that the story proved orthodox medical treatment worked (F=28.69, P<0.001); that it was not primarily due to the 'healer' talking to her (F=61.57, P<0.001) or touching her (F=132.30, P<0.001) but that their treatment per se worked (F=73.20, P<0.001) and that the patient would not have got better with time anyway (spontaneous remission) (F=41.93, P<0.001). There were also seven main effects for the three medical problems presented. Both treatments (OM and CM) were seen as more effective for chronic problems (F--23.88, P<0.001); it was believed that chronic problem patients will remain feeling better (F--43.22, P<0.001); and that this is proof that (both) types of therapy work (F--50.76, P<0.001). Psychological patients were judged most likely to get better because the therapist talked to them (F=142.54, P<0.001) but the acute patients were thought to get better because the therapist touched them (F=32.48, P<0.001). Both treatments applied to the chronic patients were deemed to work well (F=31.82, P<0.001) but it was thought that, of the three complaints, the 'psychological' patients were
the most likely to get better over time (F=53.41, P<0.001). As regards the statistical interactions from the analysis, no subjects x treatment or subjects x patients were x significant. Nor was any of the three-way interactions significant. However, all seven patient type x treatment was significant and the means in Table 2 show these results. The cause of these interactions is fairly clear and lies in the fact that OM and CM treatment is seen to differentiate the chronic patients more than the 'psychological patients'. Orthodox medicine is seen as most effective for chronic, but least effective for acute, patients (F=59.94, P<0.001). Orthodox medicine was perceived to have the longest-lasting effects on chronic patients, while complementary medicine was seen as less efficient at having a long-lasting effect on chronic patients (F=98.03, P<0.001). In contrast to all other conditions, the subjects believed OM treatment of chronic patients proved that it works (F=72.83, P<0.001). The subjects believed OM therapy least likely to work because the doctor talked to the patient but most likely to work in the case of psychological problem patients (F=43.63, P<0.001). CM therapy was seen to be most successful because the therapist touches (particularly psychological) patients, but much less so for OM practitioners treating chronic patients by touch (F=22.01, P<0.001). OM treatment of chronic patient problems was seen as best evidence that the theory worked, while CM treatment of psychological problems scored least high (F=47.45, P<0.001). Finally, the highest rate of 'spontaneous remission' was seen to occur in CM treatment of psychological problem patients and least in OM treatment of chronic patients (F=31.02, P<0.001).
Table 2 Mean scores from the seven question ratings of the six vignettes Patient types Questions
Treatment
Chronic
Acute
Psychological
1. How effective was the treatment? (l=Not, 5=Very)
OM CM
4.69 3.53
3.53 3.81
4.01 3.72
2. Will she remain feeling better? (l=Not likely, 5=Very likely)
OM CM
4.60 2.72
3.14 2.89
3.04 3.26
3. Is this proof that the therapy works? (l=Not likely, 5=Very likely)
OM CM
4.43 2.71
2.72 2.98
2.73 2.83
4. Worked because healer talkedto her (l=Not likely, 5=Very likely)
OM CM
1.70 2.89
1.78 3.11
3.72 3.71
5. Worked because healer touchedher (l=Not likely, 5=Very likely)
OM CM
2.05 3.72
1.67 3.02
1.75 2.24
6. Treatment itself worked (l=Not likely, 5=Very likely)
OM CM
4.71 3.05
3.70 3.43
3.49 2.99
7. She would have got better anyway (l=Not likely, 5=Very likely)
OM CM
1.23 2.68
1.42 2.49
2.49 2.80
Beliefs about the efficacy of complementary medicine DISCUSSION The results of this vignette study of perceptions of the efficacy of CM and OM yielded some interesting and counter-intuitive findings. The first major findings revealed, perhaps surprisingly, that personal experience of CM is not a powerful factor in predicting whether patients believe in its efficacy. There could be at least three possible explanations for this finding. First, that the subjects in this study were not zealous or regular consumers of CM but interested dabblers, and that, if we had involved a more clearly defined group of believers, this difference would have shown up. Second, it could be that the amalgamation of all CM practices increased the scepticism of the subjects; they may believe strongly in the efficacy of one or two specific CM therapies i.e. homoeopathy, acupuncture) but are highly sceptical of the efficacy of lesser-used CM therapies. Third, it could be that the nature of this task - namely vignette evaluation out the more subtle and sensitive features of personal experience of CM patients. There was a fairly clear main effect for type of treatment. As regards efficacy and proof, subjects rated OM more highly than CM. This is no doubt to be expected, for even the most enthusiastic consumer of CM agrees that each particular type of therapy tends to be appropriate for a highly specific problem. People appear to agree that OM is more generally efficacious than CM, particularly in the treatment of chronic conditions. However, the results did show that, where CM was perceived to work, it did so more than OM because the therapist talked to and touched the patient. As well as type of treatment, type of problem and the interaction between treatment and problem was considered most important by subjects in their ratings of efficacy. This study involved three types of medical problem chronic illness, acute illness and 'psychological' non-specific illness. Given this classification, the subjects seem to have a very clear picture of the efficacy of which treatment for which problem. Without doubt, orthodox medicine is seen to be most efficacious for chronic medical problems. Curiously, there appears to be relatively little difference in the perceived efficacy of OM and CM for acute medical problems. Furthermore, practitioners' success is attributed mainly to talking to patients with psychological problems, but touching patients with chronic medical problems. Whilst the results of this study are interesting and explicable in terms of the previous results, 3 it should be pointed out that studies like this are clearly limited -
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to a small number of vignettes. The limited choice of variables (patient variables, treatment type) and their categorization could be debated. The problems are essentially two-fold. First, to write realistic and enriched vignettes requires adding details that may be both irrelevant and even confusing, so making the vignettes not strictly comparable. Equally, having a restricted number of vignettes means that classification may be unreliable. Obviously, the more prototypic the cases the better, but if the examples are limited it is likely that classification is far from perfect. Experimental (social) psychologists often use vignettes in studies to test hypotheses about how people think about particular issues. Because the experimenter can manipulate specific variables in each vignette, it is possible to test their effect directly on the subjects' rating of them. However, more qualitatively oriented researchers argue that the values and attitudes which people express about hypothetical (vignette) situations experienced by others are not the ones which they apply to themselves when they have to make judgements or choices. Both qualitative and quantitative methods have their place in research on complementary medicine.
REFERENCES
1. Fulder SJ. Complementary medicine in the United Kingdom: patients, practitioners and consultations. Lancet 1985; 2: 542-545. 2. Fulder SJ. Handbook of complementary medicine, 2nd edn. Oxford: OUP, 1992. 3. Furnham A, Forey J. The different behaviours of patients of traditional medicine versus complementary (alternative) medicine. Clin Psychol 1994; 50: 458469. 4. Smith T. Alternative medicine. BMJ 1983; 287: 388-397. 5. Furnham A, Vincent C, Wood R. The health beliefs and behaviour of complementary medicine and a general practice group of patients. J Alt Compl Med 1995; 1. 6. Anderson E. General practitioners and alternative medicine. Oxford: Research Department of Alternative Medicine, Oxfordshire Health Authority, 1992. 7. Martean T. Attitudes to doctors and the preliminary development of new scale of psychology in health. BMJ 1983; 4: 351-356. 8. Furnham A, Smith C. Choosing alternative medicine: a comparison of the beliefs of patients visiting a GP and a homoeopath. Soc Sci Med 1988; 26: 685-687. 9. Furnham A. Attitudes to alternative medicine: a study of perceptions of those studying orthodox medicine. Compl Ther Med, 1993; 1(3): 120-126. 10. Nicholls PA, Wilson JE. Doctors and conventional medicine: a survey of GPs in the potteries. Stafford: Staffordshire Polytechnic, Dept of Sociology (Occasional paper), 1986. 11. Beibrich J. Measure for efficacy: a case for holistic research. Compl Med Res 1990; 4(1): 21-25. 12. Vincent C, Furnham A. The perceived efficacy of complementary and orthodox medicine. Compl Ther Med 1994; 2(3): 128-135.