- Email: [email protected]
Complementary medicine use in multi-ethnic paediatric outpatients
ARTICLE IN PRESS Complementary Therapies in Clinical Practice (2008) 14, 17–24
www.elsevierhealth.com/journals/ctnm
Complementary medicine use in multi-ethnic paediatric outpatients Nicola Robinsona,, Mitch Blairb, Ava Lorenca, Nadine Gullya, Pauline Foxa, Kathryn Mitchella a
Centre for Complementary Healthcare and Integrated Medicine (CCHIM), Faculty of Health & Human Sciences, Thames Valley University, Paragon House, Boston Manor Road, Brentford, Middlesex TW8 9GA, UK b Imperial College, London, UK
KEYWORDS Complementary medicine; Medicine; Herbal; Homeopathy; Children; Ethnic groups
Abstract Objective: To determine the prevalence and determinants of complementary medicine (CM) use in a multi-ethnic paediatric outpatient population. Methodology: A parent-completed questionnaire survey of paediatric outpatients attending general and sub-specialist outpatient clinics at a North West London hospital during September to December 2005. Results: Parents’ use of CM for their children in this multi-ethnic population was higher than expected at 37%. Use was correlated with parental CM use and education but independent of ethnic group. Parental CM use and child’s health status were significant predictors of child CM use. The main reason for using CM was word of mouth (45%) and the main source of information was friends and family (51%). The most popular treatments used for children were homeopathy and herbal medicine (used by 30% and 28% of CM users, respectively). 88% of CM was bought over the counter and 53% of CM use was not reported to their doctor. Parents also used traditional complementary remedies for their children. Conclusions: These results suggest that CM use in children is higher than previously estimated in the UK. This indicates the need for greater professional awareness of CM as part of clinical care. There is a need to acknowledge the beliefs that inform parents’ decision-making process. & 2007 Elsevier Ltd. All rights reserved.
Introduction Corresponding author. Tel.: +44 (0) 20 8209 4172.
E-mail address: [email protected] (N. Robinson).
Complementary medicine (CM) use in the UK, Europe and the USA is prevalent.1 Although national surveys are not widely available, child
1744-3881/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2007.07.003
ARTICLE IN PRESS 18 CM use prevalence estimates vary by country, at 17.9% in the UK,2 1.8% in the USA,3 11% in Canada,4 and 51% in Australia.5 Prevalence in hospital patients and outpatients is between 11% and 53%,4,6–8 with greater use reported in children with chronic disease, from 40% to 89%.9–17 It is however difficult to compare prevalence rates due to differing study designs, particularly sampling methods. The main concerns around CM use in children are safety, efficacy and potential interaction of complementary medicines with each other and with pharmaceutical medicines. Limited data has shown adverse effects and harmful interactions of some CM used by children, including herbal medicine and homoeopathy.18–20 CM use is rarely recorded by general practitioners (GPs), due to parent reluctance to report and GPs failing to ask during consultation.21,22 As parents increasingly choose CM as a treatment option, we need to more fully understand the determinants of such use in order to inform both parents and health professionals. The aim of this study was to investigate prevalence and determinants of the use of CM for children with chronic diseases in a multi-ethnic population.
N. Robinson et al. perceived effectiveness, and details of two examples of CM use, including cost, attendance, where CM was obtained, efficacy and communication with doctors. With their appointment letter, parents were sent an invitation to participate with an information sheet, including a standard list and description of CM treatments from the House of Lords report.24 All parents were approached in the waiting area by researchers AL and NG, who explained the study before parents gave written consent to participate. The questionnaire was completed by the parent while they waited for their child’s appointment. If parents were unable to read English or required an interpreter at the consultation they were excluded. Harrow National Health Service local research ethics committee (NHS LREC) ethical approval was received in July 2005. Analysis used frequency tables, cross tabulations and chi-squared, t tests or Mann Whitney tests as appropriate. Multiple logistic regression was used to determine the factors associated with CM use and non-use. SPSS version 13 was used for statistical analysis.
Results Methods This cross-sectional study surveyed all parents with a child attending a specialist paediatric outpatient appointment at Northwick Park hospital between September and December 2005. In addition to general paediatric outpatients, clinics included gastroenterology, haematology, neuro-development, neurodisability, renal, oncology, physiotherapy, attention deficit and hyperactivity disorder (ADHD), behavioural, cardiology, child development, dietician, enuresis and endocrinology clinics. The high number of ethnic minority patients reflects the local population. The study sample size was powered to detect a statistical difference of 1.75 times greater usage in ethnic minority groups with the intention of identifying this difference using a two tailed test with a 90% significance at the 5% level (the Brent and Harrow ethnic minority children population is approximately 40–55% according to 2001 census).23 The target sample size was 200. The parent-completed questionnaire was adapted from a standardised questionnaire.8 The questionnaire included demographic and clinical data, information on previous use of CM, including types of CM, motivations for use and
A total of 339 parents were approached, of whom 243 agreed to participate (a response rate of 72%). Forty-two questionnaires were unusable as were incomplete (9) or not returned (33). Thirty percent of non-participation was due to lack of time. Twelve questionnaires were excluded prior to statistical analysis to eliminate groups with less than five respondents (those with children over 16, non-biological parent, or answering ‘don’t know’ to parental CM use). Data collected on non-respondents demonstrated that the non-respondents were not significantly different in date of appointment, follow up or new, clinic type, age or postcode. Religion was significantly different for respondents/non-respondents (p ¼ 0.008), with greater response from ‘none’ religion and less from Muslim. Table 1 gives demographic details. The sample was comparable to Brent and Harrow 2001 census data in terms of ethnic distribution, though there were fewer 5–9 year olds, higher parental qualifications and 3 times more children with chronic disease. Use of CM for their child was reported by 69 (37%) parents (lifetime use). Of these, 25 (36%) users had used CM more than 10 times and 41 (60%) believed it worked. Homeopathy and herbal medicine were
Demographic characteristics of study sample showing CM users and census data for Brent and Harrow
Variable
Total respondents n ¼ 189 Frequency
Age 0–4 5–9 10–15
%
Children are CM users n ¼ 69
Children are CM non-users n ¼ 120
Brent and Harrowa
Frequency
Frequency
%
%
%
p value 1. chi squared 2. t test 3. Mann Whitney test 0.7371
72 55 62
38.1 29.1 32.8
24 22 23
34.8 31.9 33.3
48 33 39
40.0 27.5 32.5
38.1 37.4 34.6 0.0262
36 69 63 13 5 3
19.0 35.0 37.1 33.9 2.7 1.6
12 19 28 6 4
17.4 27.5 40.6 8.7 5.8
24 50 35 7 1
20.5 42.7 29.9 6.0 0.9
71.1 21.0 7.9
Ethnicity (child’s) White Mixed Asian Black Chinese/other Data missing
88 19 60 16 0 6
48.1 10.4 32.8 8.7 0.0 3.2
28 11 23 6 0
41.2 16.2 33.8 8.8 0.0
60 8 37 10 0
52.2 7.0 32.2 8.7 0.0
52.0 3.4 28.8 13.0 3.1
0.2031
0.9541 English as first language Yes No Data missing
64.4 35.6 4.8
44 24
64.7 35.3
72 40
64.3 35.7
51.3%b 48.7b 0. 9261
20 0 4 2 77 38 21 16 11
11.2 0 2.2 1.1 43.3 21.3 11.8 9.0 5.8
10 0 1 1 28 14 7 6
14.9 0 1.5 1.5 41.8 20.9 10.4 9.0
10 0 3 1 49 24 14 10
9.0 0 2.7 0.9 44.1 21.6 126 9.0
9.5 0.8 4.4 0.8 47.5 18.4 9.7 1.6 7.3
19
Religion (parent’s) None Buddhist Jewish Sikh Christian Hindu Muslim Other Data missing
116 64 9
ARTICLE IN PRESS
Health status Excellent Very good Good Fair Poor Data missing
Complementary medicine use in multi-ethnic paediatric outpatients
Table 1
20
Table 1 (continued ) Variable
Total respondents n ¼ 189 Frequency
Parent education No qualifications GCSE A level First degree Postgraduate Data missing
%
Children are CM users n ¼ 69
Children are CM non-users n ¼ 120
Brent and Harrowa
Frequency
Frequency
%
%
%
p value 1. chi squared 2. t test 3. Mann Whitney test 0.0101
12 66 36 35 31 9
6.7 36.7 20.0 19.4 17.2 4.8
2 15 17 17 15
3.0 22.7 25.8 25.8 22.7
10 51 19 18 16
8.8 44.7 16.7 15.8 14.0
22.7 12.8 18.5 10.6 29.9 0.0101
21 76 86
11.5 41.5 47.0
6
3.2
3 25 41
4.3 36.2 59.4
18 51 45
15.8 44.7 39.5
n/a n/a n/a
Data missing Income £0–£9,999 £10,000–£14,999 £15,000–£19,999 £20,000–£29,999 £30,000–£39,999 over £40,000 Data missing
14 18 14 26 29 49 39
9.3 12.0 9.3 17.3 19.3 32.7 20.6
4 4 7 6 14 23
6.9 6.9 12.1 10.3 24.1 39.7
10 14 7 20 15 26
10.9 15.2 7.6 21.7 16.3 28.3
n/a n/a n/a n/a n/a n/a
Parental CM use Yes No
90 89
50.3 49.7
56 12
82.4 17.6
34 77
30.6 69.4
n/a n/a
Chronic disease Chronic disease No chronic disease Data missing b
0.0503
0.0001
0.3761 85 98 6
46.4 53.6 3.2
34 33
50.7 49.3
51 65
44.0 56.0
15.2 84.8
From 2001 census data [www.statistics.gov.uk]. For Harrow, data unavailable for Brent. From ‘Pupil Level Annual School Census’ (PLASC), January 2006. [Personal Communication with Dudley Bateup, Harrow].
N. Robinson et al.
a
ARTICLE IN PRESS
Age when left education Under 16 16–18 Over 18
ARTICLE IN PRESS Complementary medicine use in multi-ethnic paediatric outpatients most popular (see Table 2). Parents also reported a range of traditional remedies, including ‘‘homemade remedies’’ to treat a urine infection; ghee for a blocked nose; Indian spices for stomach ache; ashton and parsons herbal powder; milk, salt, head compress; fish oil; cumin seeds; usi berry tincture and onion and honey mix; lavender oil and olive oil massage. Of those using CM, 88% were obtained over the counter (OTC) these were bought from a variety of sources; 52% from a shop and 36% from a chemist (n ¼ 49). The cost of CM was low; 25 parents who gave information spent nothing on the CM, with only one parent spending more than £40, average cost £9.66 per use. Fifty-one (66%) parents had used conventional medicine first. Forty-seven parents (54%) did not report CM use to the child’s doctor, and 100 (57%) parents thought doctors should know more about CM.
Table 2
Types of CM used N ¼ 69 parents Responses
Homeopathy Herbal medicine Osteopathy Aromatherapy Other Reflexology Chiropractic Acupuncture Shiatsu Total
Frequency
Percent
32 30 15 11 9 4 3 2 1 107
29.9 28.0 14.0 10.3 8.4 3.7 2.8 1.9 0.9 100
21
CM was used for a wide range of conditions, particularly for infections and for diseases affecting the skin, gastrointestinal or urogenital systems and psychological problems. See Fig. 1 for details. The proportion of children attending each clinic was very similar between users and non-users. Presence of chronic disease was not associated with CM use (p ¼ 0.54). Non-parametric tests demonstrated that income, parental CM use, parental education (both qualifications and school leaving age) and poor child health rating were significantly correlated with child CM use, see Table 1. Multiple logistic regression analysis, carried out on 142 cases (those with no missing data), showed that CM use can be predicted by parental CM use and child’s health status (see Table 3). Parental CM use was more highly associated, increasing the odds of child CM use by 9.7 times. The odds of CM use increased by 1.5 as health status decreased (from excellent to poor). Word of mouth was a common reason for using CM, given by 45 (45%) parents, followed by fear of side effects of conventional medicine 14 (14%) and dissatisfaction with conventional medicine 9 (9%). The main source of information for parents on therapy choice was friends or family, 42 (51%), followed by own decision, 22 (27%) and referral, 14 (17%).
Discussion Overall use of CM in our paediatric outpatient population in North West London is higher than previous UK child surveys.2,4,8 The high use may be due to the socio-demographic profile or increasing Gastro-intestinal 12.5%
Skin 18.2%
Emotional/ Psychological 11.4%
Infections 19.3%
Respiratory 6.8%
Nutrition / blood 1.1% Cardio vascular 1.1% General health 4.5%
Obstetric/ Gynaecological/ Urinary Tract Disorder 9.1%
Central Nervous System 4.5%
Musculoskeletal/ joint problems 5.7% Ear/ nose/ pharynx 5.7%
Fig. 1 Conditions CM was used for.
ARTICLE IN PRESS 22
N. Robinson et al. Table 3 Variable
Multiple regression analysis results 95% CI for exp(b) b (SE)
Lower Exp(b) Upper
Parental use 2.27 (0.43) 4.2 Health status 0.42(0.21) 1.02 R2 ¼ 0.25 (Cox & Snell), w2 ¼ 41.44, po0.001. po0.001. po0.05.
0.34
9.69 1.52
22.32 2.26
(Nagelkerke).Model
popularity of CM over time, or the relatively poor health of the population (clinic versus population sample). Prevalence is lower than that found in Wales and Australia,6 which may be due to the differing ascertainment methods, clinical setting (tertiary care), or variations between the countries of study, such as CM availability or press coverage. Our sample had a higher proportion of ethnic minorities than previously reported UK samples but we failed to demonstrate any ethnic differences in CM use. This may be due to the assumption made that ethnic groups have homogenous beliefs, especially in this population where many families have mixed ethnic origin or have lived in the area for a long time.26 Parental education, income and parental use were the most strongly associated determinants of CM use. Due to small numbers independent analysis of ethnicity, controlling for income/religion was not performed. In adults CM is mostly used for musculoskeletal27 and back problems28,29 as well as pain, anxiety and urinary tract problems.28 This is in contrast with the use of CM for children which focused on infections, skin and gastrointestinal problems, reflecting the prevalence of these specific diseases in the childhood population. Potential safety issues of CM use for children, particularly herbal preparations, one of the most commonly used CM in this study are of concern.30 Many of our other findings have been confirmed by previous literature; Firstly a higher level of education and higher personal use of CM amongst parents using CM for their children may indicate they are more informed about CM.4,6 Education may however be linked to higher income to cover the cost of CM, the relationship with income is supported by previous findings.2,4–6,31 Secondly, the sources of information on CM in this population (word of mouth and friends/family) and the high use of OTC products are similar to previous findings2,5,31 and indicate that parents are seeking CM information outside of the healthcare consulta-
tion.31 They are also not generally reporting this to their primary health care provider, as shown in previous studies.2,5,6,21,22,31–33 Parental CM use as a predictor of child CM use has also been reported previously.3,4,31–33 Presence of a chronic illness did not affect CM use, which is probably due to the bias of this population towards chronic disease though CM was increasingly likely to be used if parents perceive their child’s health as poor. This variable is however subject to parents’ perception of child’s health, likely to be affected by other factors. The use of CM for children of poor health correlates with the high prevalence of CM use in this population of children requiring specialist secondary care, and agrees with findings that CM is popular among children with a specific disease.9–17,33 This needs to be verified by comparison with a general population survey. This study adds to the body of literature suggesting patients are approaching health care with higher levels of knowledge and expectation. This may be in part accounted for by the recent post-modern growth of ‘individualism’, which emphasises taking control and increasing empowerment.6,25 Although the use of the Internet was not specifically investigated here, research shows that it has made it much easier for patients to take control of their lives and healthcare25 and is commonly used by adolescents for health information.34 The role of the health professional must change to accommodate these trends to one of information ‘‘provider’’ to information ‘‘expert’’.35 Further research is needed on what advice is given, if any, to parents on OTC purchases, for example by pharmacists and health food store staff. The enquiry and recording of CM use by healthcare practitioners is also essential to monitor this use. This will require educational support both in terms of building doctors’ knowledge of CM and encouraging non-threatening ways in which information can be exchanged with mutual benefit.
Limitations Non-random (convenience) sampling may have created bias. Every effort was made to approach every parent, but those who went immediately into appointments may have been missed. A high response rate (72%) reduced the risk of nonrespondent bias. Non-respondents significantly differed to respondents in terms of the child’s consultant and parent reported religion. Most of the difference in the former was accounted for by variations in time available to complete, based on differing consultation patterns in the clinics
ARTICLE IN PRESS Complementary medicine use in multi-ethnic paediatric outpatients themselves, which is unlikely to bias findings on the use of CM. Variation in religion may be due to cultural differences or language difficulties, which may have biased the results by masking a relationship between religion and CM use and indicates the need for specific research on ethnic/religious groups, such as focus groups, to facilitate response and translation. Response did not vary according to postcode, suggesting that deprivation did not affect the responses. The sample was powered to detect an ethnic difference; a larger sample may be required to identify the influence of some factors. Results may differ in a primary care setting as referral to outpatient clinics may depend on parents requesting specialist conventional healthcare. Therefore this sample may have excluded children using CM who do not use conventional medicine or attend paediatric clinics. In addition, the study population can be expected to have a lower health status than the general population. Parents may also have been reluctant to disclose CM use in a hospital setting, based on the low report of CM use to paediatricians.21,22,36 The questionnaire had previously been used8 so further validation tests were not performed. The questionnaire was limited by being self-completed, as language and literacy problems may have created bias, although bias was reduced by the researcher being present to aid understanding.
Conclusion This study has revealed a high use of CM amongst paediatric outpatients which may have safety implications. Parents appear to be taking a selfinformed self-management approach to the use of CM for their children. It is necessary to acknowledge the range of beliefs that inform parents’ decision-making on treatment for their children. Further research investigating the prevalence in the wider community and to investigate traditional, culturally related CM practices, preferably with same language methods of enquiry and larger samples has now commenced. In addition, sources of information on CM for parents and their doctors would be a useful addition to healthcare practice to ensure the safe and effective use of CM for children.
Competing interests None to declare.
23
Funding No external funding was received.
Acknowledgements We would like to thank the staff, parents and children of the Paediatric outpatients department of Northwick Park Hospital for their time and cooperation.
References 1. Harris P, Rees R. The prevalence of complementary and alternative medicine use among the general population: a systematic review of the literature. Complementary Ther Med 2000;8:88–96. 2. Simpson N, Roman K. Complementary medicine use in children: extent and reasons. A population based study. Br J Gen Pract 2001;51(472):914–6. 3. Davis MP, Darden PM. Use of complementary and alternative medicine by children in the United States. Arch Pediatr Adolescent Med 2003;157(4):393–6. 4. Spigelblatt L, Laine-Ammara G, Pless IB, Guyver A. The use of alternative medicine by children. Pediatrics 1994;94(6): 811–4. 5. Lim A, Cranswick N, Skull S, South M. Survey of complementary and alternative medicine use at a tertiary children’s hospital. J Paediatr Child Health 2005;41(8): 424–7. 6. Cincotta DR, Crawford NW, Lim A, Cranswick NE, Skull S, South M, et al. Comparison of complementary and alternative medicine use: reasons and motivations between two tertiary children’s hospitals. Arch Dis Child 2006;91:153–8. 7. Madsen H, Andersen S, Nielsen RG, Dolmer BS, Host A, Damkier A. Use of complementary/alternative medicine among paediatric patients. Eur J Pediatr 2003;162(5): 334–41. 8. Simpson N, Pearce A, Finlay F, Lenton S. The use of complementary medicine in paediatric outpatient clinics. Ambulatory Child Health 1998;3(351):356. 9. Andrews L, Lokuge S, Sawyer M, Lillywhite L, Kennedy D, Martin J. The use of alternative therapies by children with asthma: a brief report. J Paediatr Child Health 1998;34(2): 131–4. 10. Braganza S, Ozuah PO, Sharif I. The use of complementary therapies in inner-city asthmatic children. J Asthma 2003;40(7):823–7. 11. Day AS, Whitten KE, Bohane TD. Use of complementary and alternative medicines by children and adolescents with inflammatory bowel disease. J Paediatr Child Health 2004; 40(12):681. 12. Fernandez CV, Stutzer CA, MacWilliam L, Fryer C. Alternative and complementary therapy use in pediatric oncology patients in British Columbia: prevalence and reasons for use and nonuse. J Clin Oncol 1998;16(4):1279–86. 13. Hagen L, Schneider R, Stephens R, Modrusan D, Feldman BM. Use of complementary and alternative medicine by pediatric rheumatology patients. Arthritis Care Res 2003;49(1):3–6. 14. Martel D, Bussieres J-F, Theoret Y, Lebel D, Kish S, Moghrabi A, et al. Use of alternative and complementary therapies in
ARTICLE IN PRESS 24
15.
16.
17.
18.
19.
20.
21.
22.
23. 24. 25.
26.
N. Robinson et al. children with cancer. Pediatr Blood Cancer 2005;44(7): 660–8. Reznik M, Ozuah PO, Franco K, Cohen R, Motlow F. Use of complementary therapy by adolescents with asthma. Arch Pediatr Adolescent Med 2002;156(10):1042–4. Southwood TR, Malleson PN, Roberts-Thomson PJ, Mahy M. Unconventional remedies used for patients with juvenile arthritis. Paediatrics 1990;85(2):150–4. Stern RC, Canda ER, Doershuk CF. Use of nonmedical treatment by cystic fibrosis patients. J Adolescent Health 1992;13:612–5. Chan TY. The prevalence use and harmful potential of some Chinese herbal medicines in babies and children. Vet Hum Toxicol 1994;36(3):238–40. Crowe S, Lyons B. Herbal medicine use by children presenting for ambulatory anesthesia and surgery. Paediatr Anaesth 2004;14(11):916–9. Gagnon E, Recklitis C. Parents’ decision-making preferences in pediatric oncology: the relationship to health care involvement and complementary therapy use. PsychoOncology 2003;12(5):442–52. Everett LL, Birmingham PK, Williams GD, Brenn BR, Shapiro JH. Herbal and homeopathic medication use in pediatric surgical patients. Paediatr Anaesth 2005;15(6):455–60. Cockayne N, Duguid M, Shenfield GM. Health professionals rarely record history of complementary and alternative medicines. Br J Clin Pharmacol 2004;59(2):254–8. Census 2001. /www.statistics.gov.uk.2006S. House of Lords Select Committee on Science and Technology Sixth Report on CM. 2000. Coulter ID, Willis EM. The rise and rise of complementary and alternative medicine: a sociological perspective. eMJA 2004;/https://mja.com.au/public/issues/180_11_070604/ cou10061_fm.htmlS. Pieroni A, Sheikh QZ, Ali W, Torry B. Traditional medicines used by Pakistani migrants from Mirpur living in Bradford,
27.
28. 29.
30.
31.
32.
33.
34.
35.
36.
Northern England. Complementary Ther Med 2007; in press, corrected proof. Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complementary Ther Med 2001;9(1): 2–11. Astin JA. Why patients use alternative medicine: results of a national study. J Am Med Assoc 1998(19):1548–53. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. J Am Med Assoc 1998;280(18):1569–75. Ernst E. Serious adverse effects of unconventional therapies for children and adolescents: a systematic review of recent evidence. Eur J Paediatr 2002;162:72–80. Yussman S, Ryan S, Auinger P, Weitzman M. Visits to complementary and alternative medicine providers by children and adolescents in the United States. Ambulatory Pediatr 2004;4(5):429–35. McCann LJ, Newell SJ. Survey of paediatric complementary and alternative medicine (CAM) use in health and chronic illness. Arch Dis Child 2006;91:173–4. Sibinga EMS, Ottolini MC, Duggan AK, Wilson MH. Parentpediatrician communication about complementary and alternative medicine use for children. Clin Pediatr 2004; 43(4):367–73. Gray NJ, Klein JD, Noyce PR, Sesselberg TS, Cantrill JA. Health information-seeking behaviour in adolescence: the place of the internet. Soc Sci Med 2005;60(7):1467–78. Ahmad F, Hudak PL, Bercovitz K, Hollenberg E, Levinson W. Are physicians ready for patients with internet-based health information? J Med Internet Res 2006;8(3):e22. Ottolini MC, Hamburger EK, Loprieato JO, Coleman RH, Sachs HC, Madden R, et al. Complementary and alternative medicine use among children in the Washington, DC area. Ambulatory Pediatr 2001;1(2):122–5.
www.elsevierhealth.com/journals/ctnm
Complementary medicine use in multi-ethnic paediatric outpatients Nicola Robinsona,, Mitch Blairb, Ava Lorenca, Nadine Gullya, Pauline Foxa, Kathryn Mitchella a
Centre for Complementary Healthcare and Integrated Medicine (CCHIM), Faculty of Health & Human Sciences, Thames Valley University, Paragon House, Boston Manor Road, Brentford, Middlesex TW8 9GA, UK b Imperial College, London, UK
KEYWORDS Complementary medicine; Medicine; Herbal; Homeopathy; Children; Ethnic groups
Abstract Objective: To determine the prevalence and determinants of complementary medicine (CM) use in a multi-ethnic paediatric outpatient population. Methodology: A parent-completed questionnaire survey of paediatric outpatients attending general and sub-specialist outpatient clinics at a North West London hospital during September to December 2005. Results: Parents’ use of CM for their children in this multi-ethnic population was higher than expected at 37%. Use was correlated with parental CM use and education but independent of ethnic group. Parental CM use and child’s health status were significant predictors of child CM use. The main reason for using CM was word of mouth (45%) and the main source of information was friends and family (51%). The most popular treatments used for children were homeopathy and herbal medicine (used by 30% and 28% of CM users, respectively). 88% of CM was bought over the counter and 53% of CM use was not reported to their doctor. Parents also used traditional complementary remedies for their children. Conclusions: These results suggest that CM use in children is higher than previously estimated in the UK. This indicates the need for greater professional awareness of CM as part of clinical care. There is a need to acknowledge the beliefs that inform parents’ decision-making process. & 2007 Elsevier Ltd. All rights reserved.
Introduction Corresponding author. Tel.: +44 (0) 20 8209 4172.
E-mail address: [email protected] (N. Robinson).
Complementary medicine (CM) use in the UK, Europe and the USA is prevalent.1 Although national surveys are not widely available, child
1744-3881/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2007.07.003
ARTICLE IN PRESS 18 CM use prevalence estimates vary by country, at 17.9% in the UK,2 1.8% in the USA,3 11% in Canada,4 and 51% in Australia.5 Prevalence in hospital patients and outpatients is between 11% and 53%,4,6–8 with greater use reported in children with chronic disease, from 40% to 89%.9–17 It is however difficult to compare prevalence rates due to differing study designs, particularly sampling methods. The main concerns around CM use in children are safety, efficacy and potential interaction of complementary medicines with each other and with pharmaceutical medicines. Limited data has shown adverse effects and harmful interactions of some CM used by children, including herbal medicine and homoeopathy.18–20 CM use is rarely recorded by general practitioners (GPs), due to parent reluctance to report and GPs failing to ask during consultation.21,22 As parents increasingly choose CM as a treatment option, we need to more fully understand the determinants of such use in order to inform both parents and health professionals. The aim of this study was to investigate prevalence and determinants of the use of CM for children with chronic diseases in a multi-ethnic population.
N. Robinson et al. perceived effectiveness, and details of two examples of CM use, including cost, attendance, where CM was obtained, efficacy and communication with doctors. With their appointment letter, parents were sent an invitation to participate with an information sheet, including a standard list and description of CM treatments from the House of Lords report.24 All parents were approached in the waiting area by researchers AL and NG, who explained the study before parents gave written consent to participate. The questionnaire was completed by the parent while they waited for their child’s appointment. If parents were unable to read English or required an interpreter at the consultation they were excluded. Harrow National Health Service local research ethics committee (NHS LREC) ethical approval was received in July 2005. Analysis used frequency tables, cross tabulations and chi-squared, t tests or Mann Whitney tests as appropriate. Multiple logistic regression was used to determine the factors associated with CM use and non-use. SPSS version 13 was used for statistical analysis.
Results Methods This cross-sectional study surveyed all parents with a child attending a specialist paediatric outpatient appointment at Northwick Park hospital between September and December 2005. In addition to general paediatric outpatients, clinics included gastroenterology, haematology, neuro-development, neurodisability, renal, oncology, physiotherapy, attention deficit and hyperactivity disorder (ADHD), behavioural, cardiology, child development, dietician, enuresis and endocrinology clinics. The high number of ethnic minority patients reflects the local population. The study sample size was powered to detect a statistical difference of 1.75 times greater usage in ethnic minority groups with the intention of identifying this difference using a two tailed test with a 90% significance at the 5% level (the Brent and Harrow ethnic minority children population is approximately 40–55% according to 2001 census).23 The target sample size was 200. The parent-completed questionnaire was adapted from a standardised questionnaire.8 The questionnaire included demographic and clinical data, information on previous use of CM, including types of CM, motivations for use and
A total of 339 parents were approached, of whom 243 agreed to participate (a response rate of 72%). Forty-two questionnaires were unusable as were incomplete (9) or not returned (33). Thirty percent of non-participation was due to lack of time. Twelve questionnaires were excluded prior to statistical analysis to eliminate groups with less than five respondents (those with children over 16, non-biological parent, or answering ‘don’t know’ to parental CM use). Data collected on non-respondents demonstrated that the non-respondents were not significantly different in date of appointment, follow up or new, clinic type, age or postcode. Religion was significantly different for respondents/non-respondents (p ¼ 0.008), with greater response from ‘none’ religion and less from Muslim. Table 1 gives demographic details. The sample was comparable to Brent and Harrow 2001 census data in terms of ethnic distribution, though there were fewer 5–9 year olds, higher parental qualifications and 3 times more children with chronic disease. Use of CM for their child was reported by 69 (37%) parents (lifetime use). Of these, 25 (36%) users had used CM more than 10 times and 41 (60%) believed it worked. Homeopathy and herbal medicine were
Demographic characteristics of study sample showing CM users and census data for Brent and Harrow
Variable
Total respondents n ¼ 189 Frequency
Age 0–4 5–9 10–15
%
Children are CM users n ¼ 69
Children are CM non-users n ¼ 120
Brent and Harrowa
Frequency
Frequency
%
%
%
p value 1. chi squared 2. t test 3. Mann Whitney test 0.7371
72 55 62
38.1 29.1 32.8
24 22 23
34.8 31.9 33.3
48 33 39
40.0 27.5 32.5
38.1 37.4 34.6 0.0262
36 69 63 13 5 3
19.0 35.0 37.1 33.9 2.7 1.6
12 19 28 6 4
17.4 27.5 40.6 8.7 5.8
24 50 35 7 1
20.5 42.7 29.9 6.0 0.9
71.1 21.0 7.9
Ethnicity (child’s) White Mixed Asian Black Chinese/other Data missing
88 19 60 16 0 6
48.1 10.4 32.8 8.7 0.0 3.2
28 11 23 6 0
41.2 16.2 33.8 8.8 0.0
60 8 37 10 0
52.2 7.0 32.2 8.7 0.0
52.0 3.4 28.8 13.0 3.1
0.2031
0.9541 English as first language Yes No Data missing
64.4 35.6 4.8
44 24
64.7 35.3
72 40
64.3 35.7
51.3%b 48.7b 0. 9261
20 0 4 2 77 38 21 16 11
11.2 0 2.2 1.1 43.3 21.3 11.8 9.0 5.8
10 0 1 1 28 14 7 6
14.9 0 1.5 1.5 41.8 20.9 10.4 9.0
10 0 3 1 49 24 14 10
9.0 0 2.7 0.9 44.1 21.6 126 9.0
9.5 0.8 4.4 0.8 47.5 18.4 9.7 1.6 7.3
19
Religion (parent’s) None Buddhist Jewish Sikh Christian Hindu Muslim Other Data missing
116 64 9
ARTICLE IN PRESS
Health status Excellent Very good Good Fair Poor Data missing
Complementary medicine use in multi-ethnic paediatric outpatients
Table 1
20
Table 1 (continued ) Variable
Total respondents n ¼ 189 Frequency
Parent education No qualifications GCSE A level First degree Postgraduate Data missing
%
Children are CM users n ¼ 69
Children are CM non-users n ¼ 120
Brent and Harrowa
Frequency
Frequency
%
%
%
p value 1. chi squared 2. t test 3. Mann Whitney test 0.0101
12 66 36 35 31 9
6.7 36.7 20.0 19.4 17.2 4.8
2 15 17 17 15
3.0 22.7 25.8 25.8 22.7
10 51 19 18 16
8.8 44.7 16.7 15.8 14.0
22.7 12.8 18.5 10.6 29.9 0.0101
21 76 86
11.5 41.5 47.0
6
3.2
3 25 41
4.3 36.2 59.4
18 51 45
15.8 44.7 39.5
n/a n/a n/a
Data missing Income £0–£9,999 £10,000–£14,999 £15,000–£19,999 £20,000–£29,999 £30,000–£39,999 over £40,000 Data missing
14 18 14 26 29 49 39
9.3 12.0 9.3 17.3 19.3 32.7 20.6
4 4 7 6 14 23
6.9 6.9 12.1 10.3 24.1 39.7
10 14 7 20 15 26
10.9 15.2 7.6 21.7 16.3 28.3
n/a n/a n/a n/a n/a n/a
Parental CM use Yes No
90 89
50.3 49.7
56 12
82.4 17.6
34 77
30.6 69.4
n/a n/a
Chronic disease Chronic disease No chronic disease Data missing b
0.0503
0.0001
0.3761 85 98 6
46.4 53.6 3.2
34 33
50.7 49.3
51 65
44.0 56.0
15.2 84.8
From 2001 census data [www.statistics.gov.uk]. For Harrow, data unavailable for Brent. From ‘Pupil Level Annual School Census’ (PLASC), January 2006. [Personal Communication with Dudley Bateup, Harrow].
N. Robinson et al.
a
ARTICLE IN PRESS
Age when left education Under 16 16–18 Over 18
ARTICLE IN PRESS Complementary medicine use in multi-ethnic paediatric outpatients most popular (see Table 2). Parents also reported a range of traditional remedies, including ‘‘homemade remedies’’ to treat a urine infection; ghee for a blocked nose; Indian spices for stomach ache; ashton and parsons herbal powder; milk, salt, head compress; fish oil; cumin seeds; usi berry tincture and onion and honey mix; lavender oil and olive oil massage. Of those using CM, 88% were obtained over the counter (OTC) these were bought from a variety of sources; 52% from a shop and 36% from a chemist (n ¼ 49). The cost of CM was low; 25 parents who gave information spent nothing on the CM, with only one parent spending more than £40, average cost £9.66 per use. Fifty-one (66%) parents had used conventional medicine first. Forty-seven parents (54%) did not report CM use to the child’s doctor, and 100 (57%) parents thought doctors should know more about CM.
Table 2
Types of CM used N ¼ 69 parents Responses
Homeopathy Herbal medicine Osteopathy Aromatherapy Other Reflexology Chiropractic Acupuncture Shiatsu Total
Frequency
Percent
32 30 15 11 9 4 3 2 1 107
29.9 28.0 14.0 10.3 8.4 3.7 2.8 1.9 0.9 100
21
CM was used for a wide range of conditions, particularly for infections and for diseases affecting the skin, gastrointestinal or urogenital systems and psychological problems. See Fig. 1 for details. The proportion of children attending each clinic was very similar between users and non-users. Presence of chronic disease was not associated with CM use (p ¼ 0.54). Non-parametric tests demonstrated that income, parental CM use, parental education (both qualifications and school leaving age) and poor child health rating were significantly correlated with child CM use, see Table 1. Multiple logistic regression analysis, carried out on 142 cases (those with no missing data), showed that CM use can be predicted by parental CM use and child’s health status (see Table 3). Parental CM use was more highly associated, increasing the odds of child CM use by 9.7 times. The odds of CM use increased by 1.5 as health status decreased (from excellent to poor). Word of mouth was a common reason for using CM, given by 45 (45%) parents, followed by fear of side effects of conventional medicine 14 (14%) and dissatisfaction with conventional medicine 9 (9%). The main source of information for parents on therapy choice was friends or family, 42 (51%), followed by own decision, 22 (27%) and referral, 14 (17%).
Discussion Overall use of CM in our paediatric outpatient population in North West London is higher than previous UK child surveys.2,4,8 The high use may be due to the socio-demographic profile or increasing Gastro-intestinal 12.5%
Skin 18.2%
Emotional/ Psychological 11.4%
Infections 19.3%
Respiratory 6.8%
Nutrition / blood 1.1% Cardio vascular 1.1% General health 4.5%
Obstetric/ Gynaecological/ Urinary Tract Disorder 9.1%
Central Nervous System 4.5%
Musculoskeletal/ joint problems 5.7% Ear/ nose/ pharynx 5.7%
Fig. 1 Conditions CM was used for.
ARTICLE IN PRESS 22
N. Robinson et al. Table 3 Variable
Multiple regression analysis results 95% CI for exp(b) b (SE)
Lower Exp(b) Upper
Parental use 2.27 (0.43) 4.2 Health status 0.42(0.21) 1.02 R2 ¼ 0.25 (Cox & Snell), w2 ¼ 41.44, po0.001. po0.001. po0.05.
0.34
9.69 1.52
22.32 2.26
(Nagelkerke).Model
popularity of CM over time, or the relatively poor health of the population (clinic versus population sample). Prevalence is lower than that found in Wales and Australia,6 which may be due to the differing ascertainment methods, clinical setting (tertiary care), or variations between the countries of study, such as CM availability or press coverage. Our sample had a higher proportion of ethnic minorities than previously reported UK samples but we failed to demonstrate any ethnic differences in CM use. This may be due to the assumption made that ethnic groups have homogenous beliefs, especially in this population where many families have mixed ethnic origin or have lived in the area for a long time.26 Parental education, income and parental use were the most strongly associated determinants of CM use. Due to small numbers independent analysis of ethnicity, controlling for income/religion was not performed. In adults CM is mostly used for musculoskeletal27 and back problems28,29 as well as pain, anxiety and urinary tract problems.28 This is in contrast with the use of CM for children which focused on infections, skin and gastrointestinal problems, reflecting the prevalence of these specific diseases in the childhood population. Potential safety issues of CM use for children, particularly herbal preparations, one of the most commonly used CM in this study are of concern.30 Many of our other findings have been confirmed by previous literature; Firstly a higher level of education and higher personal use of CM amongst parents using CM for their children may indicate they are more informed about CM.4,6 Education may however be linked to higher income to cover the cost of CM, the relationship with income is supported by previous findings.2,4–6,31 Secondly, the sources of information on CM in this population (word of mouth and friends/family) and the high use of OTC products are similar to previous findings2,5,31 and indicate that parents are seeking CM information outside of the healthcare consulta-
tion.31 They are also not generally reporting this to their primary health care provider, as shown in previous studies.2,5,6,21,22,31–33 Parental CM use as a predictor of child CM use has also been reported previously.3,4,31–33 Presence of a chronic illness did not affect CM use, which is probably due to the bias of this population towards chronic disease though CM was increasingly likely to be used if parents perceive their child’s health as poor. This variable is however subject to parents’ perception of child’s health, likely to be affected by other factors. The use of CM for children of poor health correlates with the high prevalence of CM use in this population of children requiring specialist secondary care, and agrees with findings that CM is popular among children with a specific disease.9–17,33 This needs to be verified by comparison with a general population survey. This study adds to the body of literature suggesting patients are approaching health care with higher levels of knowledge and expectation. This may be in part accounted for by the recent post-modern growth of ‘individualism’, which emphasises taking control and increasing empowerment.6,25 Although the use of the Internet was not specifically investigated here, research shows that it has made it much easier for patients to take control of their lives and healthcare25 and is commonly used by adolescents for health information.34 The role of the health professional must change to accommodate these trends to one of information ‘‘provider’’ to information ‘‘expert’’.35 Further research is needed on what advice is given, if any, to parents on OTC purchases, for example by pharmacists and health food store staff. The enquiry and recording of CM use by healthcare practitioners is also essential to monitor this use. This will require educational support both in terms of building doctors’ knowledge of CM and encouraging non-threatening ways in which information can be exchanged with mutual benefit.
Limitations Non-random (convenience) sampling may have created bias. Every effort was made to approach every parent, but those who went immediately into appointments may have been missed. A high response rate (72%) reduced the risk of nonrespondent bias. Non-respondents significantly differed to respondents in terms of the child’s consultant and parent reported religion. Most of the difference in the former was accounted for by variations in time available to complete, based on differing consultation patterns in the clinics
ARTICLE IN PRESS Complementary medicine use in multi-ethnic paediatric outpatients themselves, which is unlikely to bias findings on the use of CM. Variation in religion may be due to cultural differences or language difficulties, which may have biased the results by masking a relationship between religion and CM use and indicates the need for specific research on ethnic/religious groups, such as focus groups, to facilitate response and translation. Response did not vary according to postcode, suggesting that deprivation did not affect the responses. The sample was powered to detect an ethnic difference; a larger sample may be required to identify the influence of some factors. Results may differ in a primary care setting as referral to outpatient clinics may depend on parents requesting specialist conventional healthcare. Therefore this sample may have excluded children using CM who do not use conventional medicine or attend paediatric clinics. In addition, the study population can be expected to have a lower health status than the general population. Parents may also have been reluctant to disclose CM use in a hospital setting, based on the low report of CM use to paediatricians.21,22,36 The questionnaire had previously been used8 so further validation tests were not performed. The questionnaire was limited by being self-completed, as language and literacy problems may have created bias, although bias was reduced by the researcher being present to aid understanding.
Conclusion This study has revealed a high use of CM amongst paediatric outpatients which may have safety implications. Parents appear to be taking a selfinformed self-management approach to the use of CM for their children. It is necessary to acknowledge the range of beliefs that inform parents’ decision-making on treatment for their children. Further research investigating the prevalence in the wider community and to investigate traditional, culturally related CM practices, preferably with same language methods of enquiry and larger samples has now commenced. In addition, sources of information on CM for parents and their doctors would be a useful addition to healthcare practice to ensure the safe and effective use of CM for children.
Competing interests None to declare.
23
Funding No external funding was received.
Acknowledgements We would like to thank the staff, parents and children of the Paediatric outpatients department of Northwick Park Hospital for their time and cooperation.
References 1. Harris P, Rees R. The prevalence of complementary and alternative medicine use among the general population: a systematic review of the literature. Complementary Ther Med 2000;8:88–96. 2. Simpson N, Roman K. Complementary medicine use in children: extent and reasons. A population based study. Br J Gen Pract 2001;51(472):914–6. 3. Davis MP, Darden PM. Use of complementary and alternative medicine by children in the United States. Arch Pediatr Adolescent Med 2003;157(4):393–6. 4. Spigelblatt L, Laine-Ammara G, Pless IB, Guyver A. The use of alternative medicine by children. Pediatrics 1994;94(6): 811–4. 5. Lim A, Cranswick N, Skull S, South M. Survey of complementary and alternative medicine use at a tertiary children’s hospital. J Paediatr Child Health 2005;41(8): 424–7. 6. Cincotta DR, Crawford NW, Lim A, Cranswick NE, Skull S, South M, et al. Comparison of complementary and alternative medicine use: reasons and motivations between two tertiary children’s hospitals. Arch Dis Child 2006;91:153–8. 7. Madsen H, Andersen S, Nielsen RG, Dolmer BS, Host A, Damkier A. Use of complementary/alternative medicine among paediatric patients. Eur J Pediatr 2003;162(5): 334–41. 8. Simpson N, Pearce A, Finlay F, Lenton S. The use of complementary medicine in paediatric outpatient clinics. Ambulatory Child Health 1998;3(351):356. 9. Andrews L, Lokuge S, Sawyer M, Lillywhite L, Kennedy D, Martin J. The use of alternative therapies by children with asthma: a brief report. J Paediatr Child Health 1998;34(2): 131–4. 10. Braganza S, Ozuah PO, Sharif I. The use of complementary therapies in inner-city asthmatic children. J Asthma 2003;40(7):823–7. 11. Day AS, Whitten KE, Bohane TD. Use of complementary and alternative medicines by children and adolescents with inflammatory bowel disease. J Paediatr Child Health 2004; 40(12):681. 12. Fernandez CV, Stutzer CA, MacWilliam L, Fryer C. Alternative and complementary therapy use in pediatric oncology patients in British Columbia: prevalence and reasons for use and nonuse. J Clin Oncol 1998;16(4):1279–86. 13. Hagen L, Schneider R, Stephens R, Modrusan D, Feldman BM. Use of complementary and alternative medicine by pediatric rheumatology patients. Arthritis Care Res 2003;49(1):3–6. 14. Martel D, Bussieres J-F, Theoret Y, Lebel D, Kish S, Moghrabi A, et al. Use of alternative and complementary therapies in
ARTICLE IN PRESS 24
15.
16.
17.
18.
19.
20.
21.
22.
23. 24. 25.
26.
N. Robinson et al. children with cancer. Pediatr Blood Cancer 2005;44(7): 660–8. Reznik M, Ozuah PO, Franco K, Cohen R, Motlow F. Use of complementary therapy by adolescents with asthma. Arch Pediatr Adolescent Med 2002;156(10):1042–4. Southwood TR, Malleson PN, Roberts-Thomson PJ, Mahy M. Unconventional remedies used for patients with juvenile arthritis. Paediatrics 1990;85(2):150–4. Stern RC, Canda ER, Doershuk CF. Use of nonmedical treatment by cystic fibrosis patients. J Adolescent Health 1992;13:612–5. Chan TY. The prevalence use and harmful potential of some Chinese herbal medicines in babies and children. Vet Hum Toxicol 1994;36(3):238–40. Crowe S, Lyons B. Herbal medicine use by children presenting for ambulatory anesthesia and surgery. Paediatr Anaesth 2004;14(11):916–9. Gagnon E, Recklitis C. Parents’ decision-making preferences in pediatric oncology: the relationship to health care involvement and complementary therapy use. PsychoOncology 2003;12(5):442–52. Everett LL, Birmingham PK, Williams GD, Brenn BR, Shapiro JH. Herbal and homeopathic medication use in pediatric surgical patients. Paediatr Anaesth 2005;15(6):455–60. Cockayne N, Duguid M, Shenfield GM. Health professionals rarely record history of complementary and alternative medicines. Br J Clin Pharmacol 2004;59(2):254–8. Census 2001. /www.statistics.gov.uk.2006S. House of Lords Select Committee on Science and Technology Sixth Report on CM. 2000. Coulter ID, Willis EM. The rise and rise of complementary and alternative medicine: a sociological perspective. eMJA 2004;/https://mja.com.au/public/issues/180_11_070604/ cou10061_fm.htmlS. Pieroni A, Sheikh QZ, Ali W, Torry B. Traditional medicines used by Pakistani migrants from Mirpur living in Bradford,
27.
28. 29.
30.
31.
32.
33.
34.
35.
36.
Northern England. Complementary Ther Med 2007; in press, corrected proof. Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complementary Ther Med 2001;9(1): 2–11. Astin JA. Why patients use alternative medicine: results of a national study. J Am Med Assoc 1998(19):1548–53. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. J Am Med Assoc 1998;280(18):1569–75. Ernst E. Serious adverse effects of unconventional therapies for children and adolescents: a systematic review of recent evidence. Eur J Paediatr 2002;162:72–80. Yussman S, Ryan S, Auinger P, Weitzman M. Visits to complementary and alternative medicine providers by children and adolescents in the United States. Ambulatory Pediatr 2004;4(5):429–35. McCann LJ, Newell SJ. Survey of paediatric complementary and alternative medicine (CAM) use in health and chronic illness. Arch Dis Child 2006;91:173–4. Sibinga EMS, Ottolini MC, Duggan AK, Wilson MH. Parentpediatrician communication about complementary and alternative medicine use for children. Clin Pediatr 2004; 43(4):367–73. Gray NJ, Klein JD, Noyce PR, Sesselberg TS, Cantrill JA. Health information-seeking behaviour in adolescence: the place of the internet. Soc Sci Med 2005;60(7):1467–78. Ahmad F, Hudak PL, Bercovitz K, Hollenberg E, Levinson W. Are physicians ready for patients with internet-based health information? J Med Internet Res 2006;8(3):e22. Ottolini MC, Hamburger EK, Loprieato JO, Coleman RH, Sachs HC, Madden R, et al. Complementary and alternative medicine use among children in the Washington, DC area. Ambulatory Pediatr 2001;1(2):122–5.