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The homeopathic choice for children: a qualitative research on the decision making process of the families
Homeopathy (2015) 104, 176e181 Ó 2015 The Faculty of Homeopathy. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.homp.2015.05.001, available online at http://www.sciencedirect.com
ORIGINAL PAPER
The homeopathic choice for children: a qualitative research on the decision making process of the families Elio Rossi1,*, Marco Picchi1, Mariella Di Stefano1, Anna Maria Marongiu2 and Patrizia Scarsini2 1 2
Homeopathic Clinic, Local Health Unit n. 2, Tuscan Regional Homeopathic Reference Centre, Italy U.O. Psychology, Local Health Unit n. 2, Italy Aim: To explore the experiences of parents who chose homeopathic treatment for their children, with particular regard to the decision-making process within the family and the availability of conventional and homeopathic healthcare services. Methods: Semi-structured interview with parents immediately after or before the homeopathic visit at the Homeopathic Clinic of Campo di Marte Hospital of Lucca (Italy) from1st March, 2012 to 18 July 2012. Answers were analyzed by frequency of response and grouped into main areas: 1. Choice of homeopathy. 2. Intra-family dynamics. 3. Behaviour in emergency situations. 4. The relationship with the homeopathic doctor. 5. The role of friends and acquaintances. 6. The ‘cut off’ of use of homeopathy. Results: Parents who choose homeopathic treatments for their children are strongly influenced by context. The choice of homeopathy is usually made by mothers and is rarely hindered by fathers, grandparents or friends, whose approval is important and encourages parents to use homeopathy for their children, both for prevention and treatment. Easy access to the homeopathic doctor was frequently requested, especially for acute situations. Conclusion: This research confirms the importance of context in decision making processes. Other characteristics of families which use homeopathy, such as level of education, personal coping strategies and family context should be investigated. Homeopathy (2015) 104, 176e181.
Keywords: Patient choice; Children; Homeopathy; Decision making process; Conflicts between parents
Introduction According to the last survey on health conducted by the Italian National Institute of Statistics (ISTAT) in 2005, in Italy 9.6% of children aged <14 years use CM (Complementary Medicines), of which 7.9% use homeopathy.1 Many of the parents of children and teenagers who receive CM use CM for themselves (31% both, 64.4% one, usually the mother). A survey performed by the Health Regional
*Correspondence: Elio Rossi, Ambulatorio di omeopatia, Padiglione B, Ospedale Provinciale Campo di Marte, 55100 Lucca, Italy. E-mail: [email protected] Received 10 February 2014; revised 5 May 2015; accepted 5 May 2015
Agency (ARS) in Tuscany Region2 in 2009 reported that 25.2% of pediatric patients under the age of 14 used CM. The most common was homeopathy used by 23.4% (acupuncture 0.5%; herbal medicine 1.3%). Our research suggests that people who choose homeopathy have a relatively high level of education, prefer to participate in the management of their own health and have a lot of information at their disposal, both on conventional and unconventional medicine.3 These parents perceive consultation with a homeopath as being more appropriate than consultation with a conventional physician.4 However, with the exception of these data, very little information is available about the reasons that motivate families to choose homeopathic therapy, and about the social and family context that can promote or hinder their choice,
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thus expanding or reducing the area of use of homeopathy for the families. During our 16 years of homeopathic practice in a public clinic, parents have often told us about their difficulties in using homeopathic remedies. The reasons range from conflict with grandparents (who frequently take care of grandchildren full time and are often not sufficiently informed about CM) to the problem of getting in touch with the homeopathic doctor during an emergency or acute situations. As a consequence, parents have to manage the therapies alone and decide whether to use homeopathic or allopathic drugs, for example when the fever persists or a sore throat is too severe. In the present work we investigated the most frequent problems of the families who choose the homeopathic approach for their children.
Aim To explore the experiences of parents who chose homeopathic treatment for their children, with particular regard to the decision-making process within the family and the availability of conventional and homeopathic healthcare services.
Methods Semi-structured interviews, about half an hour long, were conducted, with 20 open questions administered by a psychologist immediately after or before the homeopathic consultation; the parents of the children were asked to participate in a research concerning their opinions and experiences as CM users. Answers were recorded on audio tape and transcribed to an MS Word file. Field notes were taken on block notes, and each note was marked with the number of the case. The questions concerned demographic data, parents’ decision to choose homeopathy, relatives and friends’ reaction to the choice, children’s pathologies, satisfaction with the results, ease of access to the homeopathic doctor, behaviour in case of serious diseases. Starting from the twenty answers provided for each question, we identified some main themes allowing us to study the most common experiences, cases, situations or opinions [Figure 1].
Sample The sample was parents of 20 pediatric patients treated with homeopathy for at least six months at the Homeopathic Clinic of ‘Campo di Marte’ Hospital (Lucca, Tuscany) from 1st March to 18th July 2012. The sample was selected so as to cover a wide range of ages and diseases (Table 1). The inclusion criteria were: families of patients aged <14years, followed at the hospital for at least six months. The children sampled were 9 females (mean age: 9 years) and 11 males (mean age: 8 years).
Data analysis The data analysis was conducted by a psychologist with specific training in both qualitative and quantitative data analysis. Qualitative analysis aimed to understand the reasons that led parents to choose homeopathy for their children and the most appropriate context for the homeopathic approach to diseases. As in the case of acupuncture,5 we hypothesized a ‘path model’ in which parents, like anyone involved in decision-making strategies for other people, make choices not only according to the outcomes but also to the changes that take place in a particular context. We collected responses concerning the history of the family and its internal dynamics, including grandparents’ influence. We continued with the responses related to the relationship with the homeopathic doctor in connection to the use of homeopathy, and considered the importance of the broader context of friends and acquaintances. The interviewees’ records were analyzed in their manifest as well as latent content, taking into account the most commonly used words (‘grandparents’, ‘health’, ‘prevention’, ‘friends’, ‘illness’, ‘mother’s willingness’, ‘doctors’.....), trying not to lose the non-verbal expressions of uncertainty, doubt, and desire of the parents. We were interested in exploring how people behaved in their social reality and the interviewer (a psychologist) did not interfere with any expressions of feeling or opinion. We had also provided for the interpretation of any outlying cases, but no such intervention was necessary.
Informed consent and ethicalapproval All patients were asked to sign a privacy disclaimer and an informed consent form for the use of their data and their answers for future research. There are no rules or laws in Italy that recommend to obtain ethical approval when no drugs are administered. However, authorization was asked to the person responsible for the clinical structure in which the Homeopathic Clinic is located.
Results The use of open questions allows researchers to collect information that could otherwise be lost when using closed questions. However, the information collected was heterogeneous and difficult to analyze and synthesize. In order to facilitate the interpretation of the results, we grouped parents’ answers into five main components (each composed of three or more items). We added a sixth, general component, which helped synthesize the relationship between the environmental context in which parents choose to comply to the homeopathic approach and the various situations in which the homeopathic remedies are used.
Components 1 Choice of homeopathy “My children have never taken antibiotics!” (SB.’s mother) Item 1: “Who are your family members?” Homeopathy
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Figure 1 Flow chart of decision-making strategies used by parents for the homeopathic treatments for their children.
Item 2: “How long have you known and have you been using homeopathy?” Item 3: “Can you describe the reasons that made you use homeopathic treatments?” Item 4: “Who uses homeopathic remedies in your family?” Item 9: “What kind of problems related to your children’s health do you most frequently face?” Families are mainly composed of parents with two children. Only one family has three or more children. Half of the parents know and have been using homeopathy for more than 15 years.
Homeopathy
The main reason for using homeopathy is for prevention, e.g. to prevent colds in winter, also for allergies. Homeopathy is often used by the whole family. The most frequently mentioned problems were colds, cough, sore throat, catarrhal otitis, asthma, anxiety-linked disorders, celiac disease, conjunctivitis (Table 1). 2 Intra-family dynamics “The mother proposed and the father agreed” (AT’s parents) Item 5: “Did you find any resistance in your family to your choice of homeopathic medicine?” Item 6: “If any, how did you solve these disagreements?”
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179 Table 1 Most frequently faced diseases in the sample Item 9 e What kind of problems related to your children’s health do you most frequently face? Asthma Allergy Sore throat Headache Colds Upper respiratory tract Lower respiratory tract Intestinal diseases Anxiety Sleeping disorders Conjunctivitis Flu syndrome Ear infection Prevention respiratory recurrent diseases
3 3 5 1 12 2 2 1 1 1 1 3 2 12
Item 7: “Which parent proposed homeopathy to treat the children?” Item 8: “As a parental couple have you ever disagreed on the therapy to be used in case of illness of your children?” Item 16: “What are the attitudes of the families of origin towards the parents’ choice of treating children with homeopathy?” Item 17: “How did you manage grandparents’ requests to change therapy for your children?” Couples usually agreed to use homeopathy for their children (sometimes only two fathers did not agree completely), but the mothers were usually unwavering; the mothers were also those who proposed homeopathic remedies. In almost half of the cases there was no disagreement on the use of homeopathy even for acute diseases. In case of high fever, fathers chose to integrate the homeopathic therapy with traditional drugs (generally paracetamol and sometimes antibiotics). In 30% of the sample, both parents preferred allopathic treatment for chronic diseases. The difficulty was sometimes admitted, but mothers prevailed over fathers on the choice of continuing the homeopathic remedy: “Fever is our body’s natural response to fight an external pathogenic agent”. Homeopathy occasionally seems to be an ideological choice, and in these cases mostly due to the mother’s opinion. When homeopathy was ineffective, fathers were more willing than their wives to turn to allopathic medicine. There were mothers who said: ‘...I dragged him to this choice ..’ ‘..allopathic medicines should be used only as a last resort.’. In some cases the homeopathic choice appears to be more radical, more ideological, and the attitude of greater intransigence during the homeopathic treatment generally depends on the mother. In acute disease that continue after homeopathic treatment without resolution the husband generally would generally prefer allopathic treatment, while the mother would continue with homeopathy: “I’m the one who is generally pushing towards these types of therapies; (.) the allopathic medicines are the last to be taken and by necessity”. 35% of the sample reported that grandparents were not adequately informed on complementary medicine, but
did not oppose such treatment administered for their grandchildren. Grandparents often agreed and actively collaborated in treating children with homeopathic remedies; they were rarely skeptical, and in any case did not influence the parents’ decisions. “The children are mine, and if the grandparents want to see their grandchildren, they must follow my instructions” was the answer of a mother during an interview. 3 Behaviour in emergency situations “In the end and by necessity we use traditional drugs” (GR.’s parents) Item 10: “Have you ever experienced emergency situations for your children’s health, which caused conflicts in the choice of homeopathic versus allopathic treatment? How was the emergency situation solved?” Item 11: “What would you need in order to be able to make a more serene decision?” Item 15: “Have you ever faced any emergency situations in which the medical personnel did not respect your choice to use homeopathic treatments?” 50% of our sample reported that their children had not experienced any serious acute conditions; other children had used allopathic treatment because of the severity of the disease. Others, who had received adequate support from the homeopathic physician, continued to use homeopathy. The majority of parents reported sufficient knowledge to face non-serious diseases; 30% said that a more support from the homeopathic doctor (along with more help from the pharmacists and therapeutic indications on the labelling of homeopathic medicines) could support them in acute conditions. All parents who had used allopathic drugs said they had done so because of the severity of the disease. 4 Relationship with the homeopathic doctor “I thought it was useful and pleasant to find homeopathy in the public health service” (SG.’smother) Item 12: “In relation to health problems of your family and in particular of your children, what do you think about your relationship with your homeopathic doctor?” Item 13: “Have you ever experienced any difficulties in accessing or communicating with your homeopathic doctor?” Item 14: “How did you solve difficulties that may have arisen in the consultation of the homeopathic doctor?” Many parents were satisfied with their homeopathic doctor, but they say that the waiting list was too long and that access to the public service was difficult (60%). The general comment was that: “.if there were more homeopathic doctors in the public health system, there would be more people interested in.”. The homeopathic doctor should be more widely represented in the Public Health System in order to attract an increasing number of people. More homeopathic doctors within the Healthcare System “would increase the possibility of use by households, especially those in need”. Families rarely change their GP, but try to solve the difficulties by turning to private consultation or using their own homeopathic knowledge. Parents Homeopathy
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especially appreciate that homeopathic doctors prescribe allopathic drugs only when absolutely necessary. 5 The role of friends and acquaintances in the choice of homeopathy “What will they use?!” (AP.’s grandparents) Item 18: “Have you observed any disposition towards homeopathic treatments among your friends and acquaintances?” Item 19: “What do you think could be key methods to support the choice of homeopathy?” Item 20: “Which homeopathic treatment would you suggest to a friend, and for what kind of illness?” Family friends of our sample generally believe that the choice of non-conventional treatment is growing steadily. However, some of them expressed criticism or skepticism over homeopathic medicine; others thought that only a limited number of people would turn to homeopathy to treat their children. The best key methods to support the choice of homeopathy in their view was: passing information by word of mouth among friends, increasing the number of homeopathic doctors in the public health service, more information from the media and the web or from pharmacists (50% in total). Indeed, some families find it “useful to consult internet blogs to get information and to share opinions, the informal network of friends can also be useful to support the dissemination and use of homeopathic medicine”. Parents in our sample would suggest to their friends to use homeopathic treatments mainly for prevention, and for allergy, asthma, anxiety, gastrointestinal diseases and dermatitis. 6 ‘Cut off’ in the use of homeopathy (An hypothesis of decision making strategy toward the use of CM based on environmental conditions) In our sample data we observed that when parents’ friends and grandparents are in favour of homeopathy, they generally use it for their children to prevent diseases rather than just to cure. In acute conditions, parents decide to use allopathic drugs if “they find it difficult to contact the homeopathic doctor” (57%), and they always (100%) say that: “an easier access to the homeopathic doctor would make it easier to choose”.
Discussion Our sample was very limited, yet the parents we interviewed often answered in a similar way. We observed that homeopathic remedies are used for a wide range of diseases, but mainly for those of the upper respiratory tract. The decision to use homeopathy is made mostly by the mothers but with the fathers’ agreement, and homeopathy is often used by other relatives as well. Homeopathy often seems to be a cultural choice, in agreement with Kemper et al. (2008) “.largely because they found these health care alternatives to be more congruent with their own values”.6 Homeopathy
Prevention is the main objective and is connected with the first child’s birth. Some parents previously used homeopathy for their health care. One of the most common causes in our homeopathic clinical practice7 is of a family with a little child in his/her first year of nursery who immediately starts to suffer from upper respiratory tract diseases (coryza, pharingo-tonsillitis, otitis, etc.), and to take antibiotics, corticosteroids, etc. Once recovered, the child returns to the nursery/school and, after a short time has the same problems (fever, respiratory symptoms). The pediatrician prescribes the same treatment, and so on, week after week. The request for homeopathic treatment often starts from this (negative) experience. Analyzing intrafamily dynamics we observe that grandparents rarely agree with the parents’ homeopathic choice, as they are accustomed to allopathic drugs, but their opinion is rarely explicitly expressed. It seems they do not dare to oppose the parents’ ideas and the consequent decisions. If any conflict appears within the family, this can take place in acute conditions that are experienced only by a small number of families. In such cases, they are willing to use allopathic medicine, and their choice does not depend on the physician, but on the possible severity of the disease. The parents’ choice to use homeopathic remedies when there are no severe diseases seems to be different from that described by Rise and Seinsbekk4 “None of the parents used solely homeopathic treatment, and they emphasized that they still would see a physician and use conventional medical treatment when necessary”. In this article parents seem to choose the therapeutic approach for their children case by case. However, better access to the homeopathic doctor would probably make it possible to use complementary medicine even in presence of more severe diseases. Very often homeopathic doctors are not accessible to the patient; it is quite difficult to phone them or to have a home visit when needed; they are not available at weekends, and non-homeopathic acute medical service is provided. This problem calls into question the relationship with the homeopathic doctor: parents said that the choice of a specific homeopathic doctor depends on his/her accessibility (even by phone) and flexibility (he sometimes has to consider allopathic remedies as well). This is in agreement with Kliems and Witt8 “Patients identified the availability of time, both in itself and as a prerequisite for other physician characteristics, as the single most important factor”. Owing to the long waiting lists in public homeopathic clinics, people sometimes prefer to book the visit in advance, so as to be able to see the doctor at regular intervals. Taking into account all the answers we received, there seem to be some ‘cut off’ points to make parents’ ‘homeopathic choice’ suitable for several contexts or situations. Firstly, many of the parents decided to use it for their children when they already used it for themselves or it is particularly congruent with their own beliefs. When grandparents and friends appreciated (or used) the homeopathic approach, parents expanded its use to preventive
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181 Use of homeopathic medicine for children related to family and enviromental condiƟons
Emergency situaƟons treatment
Treatment and prevenƟon Only treatment
ered to be very important and encourages parents to use homeopathy for their children, both for prevention and treatment. In severe diseases, easy access to the homeopathic doctor might, in some cases, allow parents to continue to use homeopathic remedies. In our sample, parents seem to desire personal management of their own and their children’s health, and to avoid a passive attitude towards the healthcare system. In the future it would be interesting to study other characteristics of people who use homeopathy, e.g. level of education, inclusion/exclusion from the social context, personal coping-strategies, with particular attention to internal/external collocation of both locus of control, and decision-making strategies.
Conflict of interest Agreement between mother and father
Favorable aƫtude of grandparents and friends
Wide availability oŌhe homeopathic doctor
Figure 2 Use of homepathic medicine for children related to family and environmental conditions.
No conflict of interest. All the costs for this study were supported by the Public Healthcare System of the Tuscany Region.
Acknowledgments purposes. This seems to be similar to what happens with acupuncture.5 Friends and acquaintances are important to arouse interest in homeopathy or to support the choice of homeopathic treatment, and many parents in our sample recommended it to their friends because of its effectiveness to cure the diseases they had to face. “Family, friends and health care professionals played a role in these processes, providing support, advice, and increasing people’s general familiarity with acupuncture”.5 Another ‘cut off’ point seems to be linked to the availability of the homeopathic doctor: parents said that when they are able to reach the specialist easily, they could manage acute conditions consistently with their homeopathic choice. We have summarized these concepts in Figure 2. Finally, the choice of homeopathy seems to be the result of interaction among personal beliefs, environmental reinforcements and clinical effectiveness, which require a continuous participatory process of the patients (or of young patients’ parents). Parents wish to be active in the healing process (as shown by the great attention to the issue of prevention), but they are also extremely sensitive when the context is not favourable to their choice: homeopathic doctors are not considered as ‘health suppliers’, but as “wellness resources”.
Conclusions Parents who choose homeopathic treatment for their children are strongly influenced by the context. The choice is usually made by mothers and is rarely hindered by fathers, grandparents or friends, whose approval is consid-
We thank Laura Cignoni for the English translation.
References 1 Istat. Le medicine non convenzionali in Italia (Non conventional medicine in Italy), Year of 2005, http://www.istat.it/salastampa/ comunicati/non_calendario/20070821_00/testointegrale.pdf; 2007 (accessed in August 2014). 2 Da Fre M, Voller F. Regional survey on complementary medicine, bio-natural and wellness practices (2010). Unit of Epidemiology, Regional Health Agency of Tuscany. Collana dei Documenti ARS 56, http://www.ars.toscana.it/files/pubblicazioni/Volumi/2011/56_ medicine_complementari.pdf; 2011 (accessed in September 2014). 3 Du Y, Knopf H. Paediatric homoeopathy in Germany: results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Pharmacoepidemiol Drug Saf 2009 May; 18(5): 370e379 http://dx.doi.org/10.1002/pds.1720. 4 Rise MB, Steinsbekk A. How do parents of child patients compare consultations with homeopaths and physicians? A qualitative study. Patient Educ Couns 2009 Jan; 74(1): 91e96 http: //dx.doi.org/10.1016/j.pec.2008.07.039. 5 Bishop FL, Lewith GT. Patients’ preconceptions of acupuncture: a qualitative study exploring the decisions patients make when seeking acupuncture. BMC Complementary Altern Med: 102. Available at: http://www.biomedcentral.com/1472-6882/13/102, 2013;13 (Accessed in June 2014). 6 Kemper KJ, Vohra S, Walls R. The use of complementary and alternative medicine in pediatrics. Pediatrics 2008; 122: 1374. 7 Rossi E, Bartoli P, Panozzo M, Bianchi A, Da Fre M. Outcome of homeopathic treatment in paediatric patients: an observational study from 1998 to 2008. EUJIM 2010; 2: 115e122. 8 Kliems H, Witt CM. The good doctor: a qualitative study of German homeopathic physicians. J Altern Complement Med 2011; 17(3): 265e270.7 http://dx.doi.org/10.1089/acm.2010.0158. Epub 2011 Mar.
Homeopathy
ORIGINAL PAPER
The homeopathic choice for children: a qualitative research on the decision making process of the families Elio Rossi1,*, Marco Picchi1, Mariella Di Stefano1, Anna Maria Marongiu2 and Patrizia Scarsini2 1 2
Homeopathic Clinic, Local Health Unit n. 2, Tuscan Regional Homeopathic Reference Centre, Italy U.O. Psychology, Local Health Unit n. 2, Italy Aim: To explore the experiences of parents who chose homeopathic treatment for their children, with particular regard to the decision-making process within the family and the availability of conventional and homeopathic healthcare services. Methods: Semi-structured interview with parents immediately after or before the homeopathic visit at the Homeopathic Clinic of Campo di Marte Hospital of Lucca (Italy) from1st March, 2012 to 18 July 2012. Answers were analyzed by frequency of response and grouped into main areas: 1. Choice of homeopathy. 2. Intra-family dynamics. 3. Behaviour in emergency situations. 4. The relationship with the homeopathic doctor. 5. The role of friends and acquaintances. 6. The ‘cut off’ of use of homeopathy. Results: Parents who choose homeopathic treatments for their children are strongly influenced by context. The choice of homeopathy is usually made by mothers and is rarely hindered by fathers, grandparents or friends, whose approval is important and encourages parents to use homeopathy for their children, both for prevention and treatment. Easy access to the homeopathic doctor was frequently requested, especially for acute situations. Conclusion: This research confirms the importance of context in decision making processes. Other characteristics of families which use homeopathy, such as level of education, personal coping strategies and family context should be investigated. Homeopathy (2015) 104, 176e181.
Keywords: Patient choice; Children; Homeopathy; Decision making process; Conflicts between parents
Introduction According to the last survey on health conducted by the Italian National Institute of Statistics (ISTAT) in 2005, in Italy 9.6% of children aged <14 years use CM (Complementary Medicines), of which 7.9% use homeopathy.1 Many of the parents of children and teenagers who receive CM use CM for themselves (31% both, 64.4% one, usually the mother). A survey performed by the Health Regional
*Correspondence: Elio Rossi, Ambulatorio di omeopatia, Padiglione B, Ospedale Provinciale Campo di Marte, 55100 Lucca, Italy. E-mail: [email protected] Received 10 February 2014; revised 5 May 2015; accepted 5 May 2015
Agency (ARS) in Tuscany Region2 in 2009 reported that 25.2% of pediatric patients under the age of 14 used CM. The most common was homeopathy used by 23.4% (acupuncture 0.5%; herbal medicine 1.3%). Our research suggests that people who choose homeopathy have a relatively high level of education, prefer to participate in the management of their own health and have a lot of information at their disposal, both on conventional and unconventional medicine.3 These parents perceive consultation with a homeopath as being more appropriate than consultation with a conventional physician.4 However, with the exception of these data, very little information is available about the reasons that motivate families to choose homeopathic therapy, and about the social and family context that can promote or hinder their choice,
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thus expanding or reducing the area of use of homeopathy for the families. During our 16 years of homeopathic practice in a public clinic, parents have often told us about their difficulties in using homeopathic remedies. The reasons range from conflict with grandparents (who frequently take care of grandchildren full time and are often not sufficiently informed about CM) to the problem of getting in touch with the homeopathic doctor during an emergency or acute situations. As a consequence, parents have to manage the therapies alone and decide whether to use homeopathic or allopathic drugs, for example when the fever persists or a sore throat is too severe. In the present work we investigated the most frequent problems of the families who choose the homeopathic approach for their children.
Aim To explore the experiences of parents who chose homeopathic treatment for their children, with particular regard to the decision-making process within the family and the availability of conventional and homeopathic healthcare services.
Methods Semi-structured interviews, about half an hour long, were conducted, with 20 open questions administered by a psychologist immediately after or before the homeopathic consultation; the parents of the children were asked to participate in a research concerning their opinions and experiences as CM users. Answers were recorded on audio tape and transcribed to an MS Word file. Field notes were taken on block notes, and each note was marked with the number of the case. The questions concerned demographic data, parents’ decision to choose homeopathy, relatives and friends’ reaction to the choice, children’s pathologies, satisfaction with the results, ease of access to the homeopathic doctor, behaviour in case of serious diseases. Starting from the twenty answers provided for each question, we identified some main themes allowing us to study the most common experiences, cases, situations or opinions [Figure 1].
Sample The sample was parents of 20 pediatric patients treated with homeopathy for at least six months at the Homeopathic Clinic of ‘Campo di Marte’ Hospital (Lucca, Tuscany) from 1st March to 18th July 2012. The sample was selected so as to cover a wide range of ages and diseases (Table 1). The inclusion criteria were: families of patients aged <14years, followed at the hospital for at least six months. The children sampled were 9 females (mean age: 9 years) and 11 males (mean age: 8 years).
Data analysis The data analysis was conducted by a psychologist with specific training in both qualitative and quantitative data analysis. Qualitative analysis aimed to understand the reasons that led parents to choose homeopathy for their children and the most appropriate context for the homeopathic approach to diseases. As in the case of acupuncture,5 we hypothesized a ‘path model’ in which parents, like anyone involved in decision-making strategies for other people, make choices not only according to the outcomes but also to the changes that take place in a particular context. We collected responses concerning the history of the family and its internal dynamics, including grandparents’ influence. We continued with the responses related to the relationship with the homeopathic doctor in connection to the use of homeopathy, and considered the importance of the broader context of friends and acquaintances. The interviewees’ records were analyzed in their manifest as well as latent content, taking into account the most commonly used words (‘grandparents’, ‘health’, ‘prevention’, ‘friends’, ‘illness’, ‘mother’s willingness’, ‘doctors’.....), trying not to lose the non-verbal expressions of uncertainty, doubt, and desire of the parents. We were interested in exploring how people behaved in their social reality and the interviewer (a psychologist) did not interfere with any expressions of feeling or opinion. We had also provided for the interpretation of any outlying cases, but no such intervention was necessary.
Informed consent and ethicalapproval All patients were asked to sign a privacy disclaimer and an informed consent form for the use of their data and their answers for future research. There are no rules or laws in Italy that recommend to obtain ethical approval when no drugs are administered. However, authorization was asked to the person responsible for the clinical structure in which the Homeopathic Clinic is located.
Results The use of open questions allows researchers to collect information that could otherwise be lost when using closed questions. However, the information collected was heterogeneous and difficult to analyze and synthesize. In order to facilitate the interpretation of the results, we grouped parents’ answers into five main components (each composed of three or more items). We added a sixth, general component, which helped synthesize the relationship between the environmental context in which parents choose to comply to the homeopathic approach and the various situations in which the homeopathic remedies are used.
Components 1 Choice of homeopathy “My children have never taken antibiotics!” (SB.’s mother) Item 1: “Who are your family members?” Homeopathy
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Figure 1 Flow chart of decision-making strategies used by parents for the homeopathic treatments for their children.
Item 2: “How long have you known and have you been using homeopathy?” Item 3: “Can you describe the reasons that made you use homeopathic treatments?” Item 4: “Who uses homeopathic remedies in your family?” Item 9: “What kind of problems related to your children’s health do you most frequently face?” Families are mainly composed of parents with two children. Only one family has three or more children. Half of the parents know and have been using homeopathy for more than 15 years.
Homeopathy
The main reason for using homeopathy is for prevention, e.g. to prevent colds in winter, also for allergies. Homeopathy is often used by the whole family. The most frequently mentioned problems were colds, cough, sore throat, catarrhal otitis, asthma, anxiety-linked disorders, celiac disease, conjunctivitis (Table 1). 2 Intra-family dynamics “The mother proposed and the father agreed” (AT’s parents) Item 5: “Did you find any resistance in your family to your choice of homeopathic medicine?” Item 6: “If any, how did you solve these disagreements?”
Family decision making and homeopathy E Rossi et al
179 Table 1 Most frequently faced diseases in the sample Item 9 e What kind of problems related to your children’s health do you most frequently face? Asthma Allergy Sore throat Headache Colds Upper respiratory tract Lower respiratory tract Intestinal diseases Anxiety Sleeping disorders Conjunctivitis Flu syndrome Ear infection Prevention respiratory recurrent diseases
3 3 5 1 12 2 2 1 1 1 1 3 2 12
Item 7: “Which parent proposed homeopathy to treat the children?” Item 8: “As a parental couple have you ever disagreed on the therapy to be used in case of illness of your children?” Item 16: “What are the attitudes of the families of origin towards the parents’ choice of treating children with homeopathy?” Item 17: “How did you manage grandparents’ requests to change therapy for your children?” Couples usually agreed to use homeopathy for their children (sometimes only two fathers did not agree completely), but the mothers were usually unwavering; the mothers were also those who proposed homeopathic remedies. In almost half of the cases there was no disagreement on the use of homeopathy even for acute diseases. In case of high fever, fathers chose to integrate the homeopathic therapy with traditional drugs (generally paracetamol and sometimes antibiotics). In 30% of the sample, both parents preferred allopathic treatment for chronic diseases. The difficulty was sometimes admitted, but mothers prevailed over fathers on the choice of continuing the homeopathic remedy: “Fever is our body’s natural response to fight an external pathogenic agent”. Homeopathy occasionally seems to be an ideological choice, and in these cases mostly due to the mother’s opinion. When homeopathy was ineffective, fathers were more willing than their wives to turn to allopathic medicine. There were mothers who said: ‘...I dragged him to this choice ..’ ‘..allopathic medicines should be used only as a last resort.’. In some cases the homeopathic choice appears to be more radical, more ideological, and the attitude of greater intransigence during the homeopathic treatment generally depends on the mother. In acute disease that continue after homeopathic treatment without resolution the husband generally would generally prefer allopathic treatment, while the mother would continue with homeopathy: “I’m the one who is generally pushing towards these types of therapies; (.) the allopathic medicines are the last to be taken and by necessity”. 35% of the sample reported that grandparents were not adequately informed on complementary medicine, but
did not oppose such treatment administered for their grandchildren. Grandparents often agreed and actively collaborated in treating children with homeopathic remedies; they were rarely skeptical, and in any case did not influence the parents’ decisions. “The children are mine, and if the grandparents want to see their grandchildren, they must follow my instructions” was the answer of a mother during an interview. 3 Behaviour in emergency situations “In the end and by necessity we use traditional drugs” (GR.’s parents) Item 10: “Have you ever experienced emergency situations for your children’s health, which caused conflicts in the choice of homeopathic versus allopathic treatment? How was the emergency situation solved?” Item 11: “What would you need in order to be able to make a more serene decision?” Item 15: “Have you ever faced any emergency situations in which the medical personnel did not respect your choice to use homeopathic treatments?” 50% of our sample reported that their children had not experienced any serious acute conditions; other children had used allopathic treatment because of the severity of the disease. Others, who had received adequate support from the homeopathic physician, continued to use homeopathy. The majority of parents reported sufficient knowledge to face non-serious diseases; 30% said that a more support from the homeopathic doctor (along with more help from the pharmacists and therapeutic indications on the labelling of homeopathic medicines) could support them in acute conditions. All parents who had used allopathic drugs said they had done so because of the severity of the disease. 4 Relationship with the homeopathic doctor “I thought it was useful and pleasant to find homeopathy in the public health service” (SG.’smother) Item 12: “In relation to health problems of your family and in particular of your children, what do you think about your relationship with your homeopathic doctor?” Item 13: “Have you ever experienced any difficulties in accessing or communicating with your homeopathic doctor?” Item 14: “How did you solve difficulties that may have arisen in the consultation of the homeopathic doctor?” Many parents were satisfied with their homeopathic doctor, but they say that the waiting list was too long and that access to the public service was difficult (60%). The general comment was that: “.if there were more homeopathic doctors in the public health system, there would be more people interested in.”. The homeopathic doctor should be more widely represented in the Public Health System in order to attract an increasing number of people. More homeopathic doctors within the Healthcare System “would increase the possibility of use by households, especially those in need”. Families rarely change their GP, but try to solve the difficulties by turning to private consultation or using their own homeopathic knowledge. Parents Homeopathy
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especially appreciate that homeopathic doctors prescribe allopathic drugs only when absolutely necessary. 5 The role of friends and acquaintances in the choice of homeopathy “What will they use?!” (AP.’s grandparents) Item 18: “Have you observed any disposition towards homeopathic treatments among your friends and acquaintances?” Item 19: “What do you think could be key methods to support the choice of homeopathy?” Item 20: “Which homeopathic treatment would you suggest to a friend, and for what kind of illness?” Family friends of our sample generally believe that the choice of non-conventional treatment is growing steadily. However, some of them expressed criticism or skepticism over homeopathic medicine; others thought that only a limited number of people would turn to homeopathy to treat their children. The best key methods to support the choice of homeopathy in their view was: passing information by word of mouth among friends, increasing the number of homeopathic doctors in the public health service, more information from the media and the web or from pharmacists (50% in total). Indeed, some families find it “useful to consult internet blogs to get information and to share opinions, the informal network of friends can also be useful to support the dissemination and use of homeopathic medicine”. Parents in our sample would suggest to their friends to use homeopathic treatments mainly for prevention, and for allergy, asthma, anxiety, gastrointestinal diseases and dermatitis. 6 ‘Cut off’ in the use of homeopathy (An hypothesis of decision making strategy toward the use of CM based on environmental conditions) In our sample data we observed that when parents’ friends and grandparents are in favour of homeopathy, they generally use it for their children to prevent diseases rather than just to cure. In acute conditions, parents decide to use allopathic drugs if “they find it difficult to contact the homeopathic doctor” (57%), and they always (100%) say that: “an easier access to the homeopathic doctor would make it easier to choose”.
Discussion Our sample was very limited, yet the parents we interviewed often answered in a similar way. We observed that homeopathic remedies are used for a wide range of diseases, but mainly for those of the upper respiratory tract. The decision to use homeopathy is made mostly by the mothers but with the fathers’ agreement, and homeopathy is often used by other relatives as well. Homeopathy often seems to be a cultural choice, in agreement with Kemper et al. (2008) “.largely because they found these health care alternatives to be more congruent with their own values”.6 Homeopathy
Prevention is the main objective and is connected with the first child’s birth. Some parents previously used homeopathy for their health care. One of the most common causes in our homeopathic clinical practice7 is of a family with a little child in his/her first year of nursery who immediately starts to suffer from upper respiratory tract diseases (coryza, pharingo-tonsillitis, otitis, etc.), and to take antibiotics, corticosteroids, etc. Once recovered, the child returns to the nursery/school and, after a short time has the same problems (fever, respiratory symptoms). The pediatrician prescribes the same treatment, and so on, week after week. The request for homeopathic treatment often starts from this (negative) experience. Analyzing intrafamily dynamics we observe that grandparents rarely agree with the parents’ homeopathic choice, as they are accustomed to allopathic drugs, but their opinion is rarely explicitly expressed. It seems they do not dare to oppose the parents’ ideas and the consequent decisions. If any conflict appears within the family, this can take place in acute conditions that are experienced only by a small number of families. In such cases, they are willing to use allopathic medicine, and their choice does not depend on the physician, but on the possible severity of the disease. The parents’ choice to use homeopathic remedies when there are no severe diseases seems to be different from that described by Rise and Seinsbekk4 “None of the parents used solely homeopathic treatment, and they emphasized that they still would see a physician and use conventional medical treatment when necessary”. In this article parents seem to choose the therapeutic approach for their children case by case. However, better access to the homeopathic doctor would probably make it possible to use complementary medicine even in presence of more severe diseases. Very often homeopathic doctors are not accessible to the patient; it is quite difficult to phone them or to have a home visit when needed; they are not available at weekends, and non-homeopathic acute medical service is provided. This problem calls into question the relationship with the homeopathic doctor: parents said that the choice of a specific homeopathic doctor depends on his/her accessibility (even by phone) and flexibility (he sometimes has to consider allopathic remedies as well). This is in agreement with Kliems and Witt8 “Patients identified the availability of time, both in itself and as a prerequisite for other physician characteristics, as the single most important factor”. Owing to the long waiting lists in public homeopathic clinics, people sometimes prefer to book the visit in advance, so as to be able to see the doctor at regular intervals. Taking into account all the answers we received, there seem to be some ‘cut off’ points to make parents’ ‘homeopathic choice’ suitable for several contexts or situations. Firstly, many of the parents decided to use it for their children when they already used it for themselves or it is particularly congruent with their own beliefs. When grandparents and friends appreciated (or used) the homeopathic approach, parents expanded its use to preventive
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181 Use of homeopathic medicine for children related to family and enviromental condiƟons
Emergency situaƟons treatment
Treatment and prevenƟon Only treatment
ered to be very important and encourages parents to use homeopathy for their children, both for prevention and treatment. In severe diseases, easy access to the homeopathic doctor might, in some cases, allow parents to continue to use homeopathic remedies. In our sample, parents seem to desire personal management of their own and their children’s health, and to avoid a passive attitude towards the healthcare system. In the future it would be interesting to study other characteristics of people who use homeopathy, e.g. level of education, inclusion/exclusion from the social context, personal coping-strategies, with particular attention to internal/external collocation of both locus of control, and decision-making strategies.
Conflict of interest Agreement between mother and father
Favorable aƫtude of grandparents and friends
Wide availability oŌhe homeopathic doctor
Figure 2 Use of homepathic medicine for children related to family and environmental conditions.
No conflict of interest. All the costs for this study were supported by the Public Healthcare System of the Tuscany Region.
Acknowledgments purposes. This seems to be similar to what happens with acupuncture.5 Friends and acquaintances are important to arouse interest in homeopathy or to support the choice of homeopathic treatment, and many parents in our sample recommended it to their friends because of its effectiveness to cure the diseases they had to face. “Family, friends and health care professionals played a role in these processes, providing support, advice, and increasing people’s general familiarity with acupuncture”.5 Another ‘cut off’ point seems to be linked to the availability of the homeopathic doctor: parents said that when they are able to reach the specialist easily, they could manage acute conditions consistently with their homeopathic choice. We have summarized these concepts in Figure 2. Finally, the choice of homeopathy seems to be the result of interaction among personal beliefs, environmental reinforcements and clinical effectiveness, which require a continuous participatory process of the patients (or of young patients’ parents). Parents wish to be active in the healing process (as shown by the great attention to the issue of prevention), but they are also extremely sensitive when the context is not favourable to their choice: homeopathic doctors are not considered as ‘health suppliers’, but as “wellness resources”.
Conclusions Parents who choose homeopathic treatment for their children are strongly influenced by the context. The choice is usually made by mothers and is rarely hindered by fathers, grandparents or friends, whose approval is consid-
We thank Laura Cignoni for the English translation.
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