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The perceived efficacy of complementary and orthodox medicine: preliminary findings and the development of a questionnaire
RESEARCH
The perceived efficacy of complementary and orthodox medicine: preliminary findings and the development of a questionnaire C. Vincent and A. Furnham University College London, London, UK
SUMMARY. This study examined the perceived efficacy of five different types of alternative medicine (acupuncture, herbalism, homoeopathy, hypnosis and osteopathy) and orthodox medicine in treating 25 common complaints ranging from cancer to the common cold. Subjects completed a questionnaire measuring their state of health; experience of complementary medicine; sources of information about complementary medicine; and perceived efficacy of orthodox and complementary treatments in the treatment of each condition. Personal accounts of treatment appeared to be particularly important sources of information on complementary medicine, and also highly valued in assessing its efficacy. Orthodox medicine was clearly seen, by the great majority of subjects, as being more effective in the treatment of most complaints, especially in the treatment of major, life-threatening conditions. Complementary medicine was seen as more effective in the treatment of minor and chronic conditions, though generally not superior to orthodox medicine. For some specific conditions complementary medicine was seen as the most effective treatment: osteopathy and acupuncture were both perceived as valuable in the treatment of back pain, and herbalism was perceived as a valid treatment for fatigue and stress; hypnosis was seen as useful in the treatment of a variety of psychological problems, and seen as superior to orthodox techniques. The fact that people are able to specify which complementary therapies are likely to be effective in which conditions should make researchers cautious about treatment ‘complementary medicine’ as an umbrella term.
INTRODUCTION In the last 25 years interest in complementary medicine has increased steadily, and has been especially rapid over the last decade. This growth of interest has also led to an increase in research into the efficacy of complementary medicine and peoples’ changing attitudes towards it.l-‘t The reasons for this increased interest and use of complementary medicine are not well understood. Some people
may have become dissatisfied with orthodox medicine, rejecting its reliance on high technology, wary of the dangers of invasive techniques and the toxicity of many drugs; others may retain a belief in the value and effectiveness of orthodox medicine, at least in certain areas, and yet find some aspects of complementary medicine attractive. The popularity of the complementary therapies appears to be more than just a discontent with the existing medical profession.5 An increasing number also
Charles Vincent MPhil, PhD, Adrian Furnham MA, MSc, DPhil, DSc, Department of Psychology, London WClE
6BT. UK.
128
University
College London, Gower Street,
The perceived efficacy of complementary and orthodox medicine
see complementary
medicine
as an avant-garde
for new ideas about health and the body and there are signs that some of the principles of complementary medicine are being accepted within orthodox medicine. Questionnaire studies have examined the attitudes of orthodox medical students and practitioner@ and found high rates of interest and knowledge, and referral of patients to complementary practitioners. Discussions of complementary medicine in the medical literature frequently centre around questions of efficacy. There are now a number of reviews which assess the evidence for individual therapies, and review trials which compare complementary therapies with placebo or with orthodox treatments.lo-12 While the methodology of many of the studies is far from satisfactory,13 there is reasonably strong evidence for the efficacy of some complementary therapies for some conditions. Such studies are important but their results may have little bearing on how effective ordinary people perceive complementary therapies to be. Impressions of the effectiveness of a therapy may be based on quite different criteria, such as word of mouth recommendation. Almost nothing is known about how effective people perceive complementary therapies to be, and yet it is probably an influential factor in determining whether they will use or recommend such a therapy. The present study aims to examine the perceived efficacy of complementary and orthodox medicine in the treatment of a number of illnesses and problems, of different degrees of severity. In accordance with previous studies59 it is predicted that orthodox medicine will be perceived as the most efficacious for major, life threatening, chronic and degenerative illnesses whilst complementary medicine will be perceived as more efficacious for minor and psychological illnesses. The study set out to determine how people assess the efficacy of complementary medicine, and to discover where people obtain the information they need to assess efficacy. Individuals may seek advice and consult family, friends and neighbours, in addition to those practising either orthodox or complementary medicine. 2 The study also investigated how highly members of the public rate these sources.
METHOD
Subjects
There were 135 subjects, 53 men and 82 women (1: 1S), from the general public. Ages ranged from 19 years to 77 years old with a mean age of 33 years. As regard marital status 74 (54.8%) were single, 45 (33.5%) were married, 2 (1.5%) were widowed, 5 (3.7%) were divorced and 8 (5.9%) were cohabiting. In all, 44 (36%) were
129
professionals, 36 (25.7%) were white collar workers, 14 (10.3%) were blue collar workers, 37 (26.4%) were students, including mature students, and the other 2 (1%) were unemployed. The majority (82%) had no current illness, 16% admitted to having minor complaints and 2% believed they were quite seriously ill. However, 34 (25%) had been seriously ill at some time in the past. 17 subjects (12%) had had some experience of one or more forms of complementary medicine: 6 had visited a hypnotist (4.4%) 7 an acupuncturist (5.2%) 7 a herbalist (5.2%). 13 a homoeopath (9.6%), 4 (3%) an osteopath and 5 (3.7%) another type of complementary practitioner. 6 of those who had been to a complementary practitioner considered that the treatment had been effective, but 11 considered that the treatment was not effective. However, over half of the sample (53.3%) claimed to know a person close to them who had effective treatment from a complementary practitioner.
Questionnaire The questionnaire was divided into 3 sections: in the first section subjects were asked demographic questions and questions concerning their experience of complementary medicine; the second section concerned the sources of information used (or which would be used) in assessing the efficacy of a complementary therapy; the third section contained a list of 25 illnesses: subjects were asked to indicate how effective they considered various complementary therapies (hypnosis, acupuncture, herbalism, homoeopathy and osteopathy) and orthodox medicine to be in curing each of these illnesses, by giving a score between 1 (not at all effective) and 5 (very effective). Short definitions of each complementary treatment were given in case some subjects were not familiar with them.
Procedure Questionnaires were distributed by 6 undergraduate research students to subjects at various restaurants, mainline railway stations, a children’s clinic, and in hospital waiting rooms in Central London, as part of an exercise on random sampling. Subjects were assured that confidentiality would be maintained and that all information would be seen only by university research staff. 240 questionnaires were distributed and 135 fully completed were returned (a response rate of 56%) to experimenters immediately after completion of questionnaires or by post within the following week. The actual response rate was 69% but many questionnaire were not fully completed and hence discarded. This was not a large or structured sample, but there is no reason to think that it is unrepresentative.
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Complementary Therapies in Medicine: Research
RESULTS Sources of information Table I summarises the findings on the sources and types of information that people use in assessing the value of a complementary therapy. The respondents reported that their most important source of information was talking to friends/relatives. Following this, they would turn to media sources, i.e. newspaper/magazine articles, television/radio programmes. The opinion of friends who had received the treatment was not only the most common but also the most valued source of information; the opinion of friends suffering the same problem and a doctor’s opinion were equally respected. The most highly rated kind of information was personal accounts of treatment. Overall this suggests that people seeking information about cornpIementary medicine are most likely to turn to their friends or relatives, particularly those who have received treatment and are able to recount their personal experiences. In addition, while scientific books and articles were not necessarily readily turned to for information, the subjects felt that the information they contain is highly valid. Perceived efficacy of orthodox and complementary medicine Ratings for the efficacy of each treatment for each of the 25 complaints are shown in Table 2. Inspection of Table 2 suggests that orthodox medicine
Table 1 Sources of information about complementary
was perceived as being very much more effective than complementary medicine for the great majority of complaints by this group of people. Assessments are generally cautious, with only one rating being greater than 4 on a 5-point scale. Orthodox medicine receives a mean rating of 4.47 in the treatment of appendicitis. There is certainly no widespread belief in the efficacy of complementary medicine, although it must be remembered that few of the respondents had any experience of complementary medicine. Taking a mid-point rating of 3.00 as a benchmark for an assessment of a moderately effective treatment we can see that: orthodox treatment receives 15 ratings of 3.0 or over, hypnosis 4, acupuncture and osteopathy one each for back pain, and herbalism and homoeopathy none. Overall ratings for the efficacy of each treatment suggest that hypnosis, homoeopathy, acupuncture and herbalism are seen as very much equivalent, though their pattern of high and lower scores do differ. Osteopathy is given a lower rating, but this assessment should be treated with cauticn. Homoeopathy, acupuncture and herbalism aim to treat a far wider range of complaints than osteopathy, which is primarily, but not exclusively, focused on musculo-skeletal problems. Osteopathy is therefore likely to receive a low overall score. For 9 of the complaints at least 1 form of complementary medicine were perceived as significantly more effective than orthodox medicine. The mean scores and F-ratios for the relevant treatments and comparisons are shown in Table 3. In each case the F-ratio refers to the comparison of the individual complementary therapy
medicine
Question
Source
How much do you use each of the following sources of information to find out about complementary medicine?
Friends Magazines TV/radio Scientific/books Layman books Advertisments
If you were trying to decide whether a treatment might be able to help you, whose opinion would be most important to you?
Friends who received treatment Friends with the same problem Friends with no experience Religious advisor Complementary practitioner Doctor
What kind of information would be most important to you in helping you make up your mind about a complementary therapy?
Scale: 5 = a great deal; 1 not at all.
Personal accounts Magazine articles TV/radio Scientific books Layman books Advertisments
Mean
SD
3.34 2.87 2.70 2.28 1.93 1.90
1.24 1.12 1.13 1.22 0.99 0.96
4.14
1.00
3.77
1.10
1.62 1.37
0.85 0.89
3.15 3.77
1.40 1.10
4.13 3.05 2.90 3.03 2.31 1.73
1.00 1.02 1.04 1.2.5 1.04 1.00
The perceived efficacy of complementary Table 2 Perceived efficacy of complementary
and
orthodox medicine
131
-
and orthodox medicine
Hypnosis
Acupuncture
Herbalism
Homoeopathy
Osteopathy
Orthodox Medicine
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Allergies Appendicitis Arthritis Asthma Back pain Blood pressure Bronchitis Cancer Common cold Depression Diabetes Drinking problem Fatigue Hay fever Heart attack Insomnia Menstrual problems Migraine Nerves Obesity Pneumonia Skin problems Stopping smoking Stress Sudden weight loss
1.75 1.16 1.39 1.72 1.83 1.74 1.21 1.45 1.21 3.03 1.18 1.51 2.57 1.61 1.23 3.27 1.48 2.19 2.90 2.67 1.13 1.57 3.54 3.32 2.01
1.07 0.51 0.78 1.06 1.12 1.09 0.51 0.86 0.65 1.27 0.59 0.62 1.35 1.04 0.60 1.36 0.84 1.23 1.34 1.53 0.40 0.93 1.34 1.37 1.34
2.12 1.36 2.62 1.88 3.27 2.00 1.43 1.51 1.35 1.80 1.40 1.87 2.30 1.92 1.43 2.24 1.89 2.67 2.39 1.99 1.38 1.82 2.51 2.68 1.64
1.15 0.70 1.30 1.09 1.30 1.19 0.77 0.87 0.75 0.98 0.75 1.11 1.22 1.15 0.88 1.24 1.17 1.32 1.24 1.17 0.77 1.05 1.44 1.31 1.09
2.91 1.42 2.34 2.42 1.82 2.27 2.12 1.78 2.54 1.87 1.84 1.62 2.66 2.52 1.45 2.55 2.61 2.47 2.30 1.80 1.69 2.69 1.96 2.29 1.72
1.18 0.84 1.14 1.12 0.96 1.18 1.11 1.05 1.31 1.07 1.04 1.02 1.29 1.20 0.82 1.19 1.23 1.08 1.17 0.93 1.01 1.17 1.14 1.16 0.93
2.94 1.37 2.40 2.50 1.87 2.06 2.03 1.92 2.21 1.77 1.71 1.56 1.95 2.46 1.53 2.08 2.20 2.24 2.09 1.71 1.64 2.51 1.75 1.89 1.63
1.38 0.78 1.34 1.35 1.09 1.17 1.13 1.18 1.33 1.10 0.98 0.94 1.14 1.28 0.92 1.15 1.26 1.26 1.29 1.06 1.oo 1.29 1.03 1.16 1.00
1.46 1.21 2.50 1.37 3.60 1.48 1.29 1.24 1.28 1.34 1.20 1.23 1.96 1.30 1.29 1.50 1.49 1.66 1.62 1.34 1.23 1.33 1.35 1.93 1.30
0.93 0.70 1.32 0.76 1.34 0.95 0.70 0.68 0.75 0.79 0.56 0.69 1.16 0.69 0.73 0.85 0.93 1.04 0.93 0.83 0.70 0.73 0.75 1.18 0.69
3.57 4.47 3.25 3.68 3.09 3.73 3.96 3.51 2.68 2.56 4.06 2.42 2.26 3.31 3.85 2.75 3.42 3.13 2.64 2.61 3.97 3.31 2.07 2.26 2.98
1.38 1.09 1.22 1.15 1.09 1.09 1.10 1.29 1.48 1.32 1.06 1.31 1.28 1.19 1.26 1.30 1.18 1.25 1.25 1.32 1.21 1.21 1.16 1.23 1.34
Overall mean
2.03
.605
1.97
,710
2.10
,661
1.99
,785
1.53
.54
3.18
.71
Minimum rating = 1 not at all effective. Maximum rating = 5: very effective.
with orthodox medicine (repeated measures ANOVA with contrasts). Osteopathy and acupuncture are both seen as useful in the treatment of back pain, and herbalism is seen as a valid treatment for fatigue and stress, or at least orthodox treatment is seen as particularly ineffective for these complaints. There is considerable belief in the efficacy of hypnosis in the treatment of a variety of psychological
Table 3 Conditions
for which complementary
problems.
Perceived efficacy by illness type A preliminary factor analysis of the 25 disorders rated in this study revealed that, as far as ratings of efficacy were concerned, they could be effectively classified into
medicine is perceived as more effective than orthodox medicine
Complaint
Complementary treatment
Back pain
Osteopathy Acupuncture Hypnosis Hypnosis
3.61 3.28 3.04 3.13
3.10 3.10 2.57 2.42
4.98 0.08 5.87 * 8.52 *
Herbalism Hypnosis Hypnosis Hypnosis Hypnosis Acupuncture Hypnosis Acupuncture Herbalism
2.66 3.27 2.90 2.67 3.55 2.52 3.33 2.68 2.29
2.26 2.76 2.65 2.61 2.07 2.07 2.26 2.26 2.26
3.13 5.09 ’ 0.78 0.03 65.91 **’ 6.83 * 20.1 ** 2.79 0.02
Mean score complementary
Mean score orthodox
F-ratio
-
Depression Drinking problems Fatigue Insomnia Nerves Obesity Stopping smoking Stress
‘p < 0.05; l *p < 0.01; “‘p < 0.001
l
l
l
l
-
I32
Complementary Therapies in Medicine: Research
4 groups: (i) Major medical conditions - appendicitis, bronchitis, cancer, diabetes, heart attack and pneumonia; (ii) Minor conditions - common cold, hay fever, insomnia, menstrual problems and migraine; (iii) Chronic conditions - allergies, arthritis, asthma, back pain, blood pressure and skin problems, and (iv) Psychological problems - depression, drinking problems, fatigue, nerves, obesity, stopping smoking, stress and weight loss. Ratings on these various complaints were arithmetically computed to form 4 scores per subject. Table 4 shows the mean efficacy for each therapy, in each of these 4 groups of conditions. Table 4 Perceived efficacy by illness type Type Major Minor Chronic Psych
Hypn.
Acup.
Herb.
Homoeo.
Osteo.
Orth.
1.23 1.95 1.66 2.92
1.41 2.02 2.26 2.15
1.70 2.52 2.37 2.02
1.67 2.23 2.38 1.80
1.24 1.41 1.92 1.50
3.98 3.05 3.45 2.48
Table 4 suggests that people were, on the whole, emphatic that orthodox medicine is much more effective in any major illness. Complementary medicine was seen as more effective for minor problems and chronic conditions, though orthodox medicine was still rated as superior. For psychological problems complementary medicine and orthodox medicine was very much equivalent. This suggests that most people are not ‘for or against’ complementary medicine, but see it as useful in certain quite specific types of problem - especially those where orthodox medicine is seen as less effective. People are, to some extent, aware that particular complementary therapies should be targeted at particular conditions. Factors associated with a belief in the efficacy of orthodox or complementary medicine A difference score was computed to examine the relative strength in beliefs about orthodox and complementary medicine. This score (the overall mean efficacy of complementary medicine minus the overall mean for orthodox medicine) was correlated with each of the demographic variables and with the ratings of the sources of information. A positive correlation indicates a positive
association between the factor in question and a relatively stronger belief in complementary medicine, None of the demographic variables predicted a belief in the efficacy of complementary medicine, though there was a tendency for older people to have a stronger belief in orthodox medicine. A stronger belief in complementary medicine was associated with, not surprisingly, having visited a complementary practitioner, (though the experience could of course have decreased a person’s belief). A stronger belief in complementary medicine was associated with valuing personal accounts (r = 0.21, p> 0.02) and with reading magazine articles (r = 0.21, p> 0.02) and books for the layperson (r = 0.25, p> 0.01). A stronger belief in complementary medicine was also associated with higher ratings for the importance of other people’s opinions, both lay and professional: with friends who had had the treatment (r - 0.20, p> 0.02), friends with the same problem (r = 0.24, p> O.OOS),a complementary practitioner (r = 0.24, p > 0.01) and, in contrast, most strongly with lower ratings for the opinion of a doctor (r = -0.34, p> 0.001). This suggests overall that people who value recommendation of a therapy are also those who rate complementary medicine more highly and that they are prepared to read about a therapy when assessing its value. A belief in complementary medicine is inversely related to attaching importance to a doctor’s opinion. This does not necessarily mean that people rating complementary medicine highly do not value their doctor’s views in other areas, but they may be prepared to partly disregard them when considering complementary medicine. However, complementary therapy is indeed complementary to orthodox medicine and many ill people take the two together, unknown to their physician. Similarities and differences between therapies Table 5 shows the correlation between average efficacy scores for each complementary therapy and orthodox medicine. The most striking fact is the series of small inverse (though non-significant) correlations between ratings of complementary medicine and ratings of orthodox medicine which suggest that there may be some truth in the idea that some people who believe in complementary medicine are those who are dissatisfied or distrustful or orthodox medicine.
Table 5 Correlations between ratings of efficacy Hypn. Hypnosis Acupuncture Herbalism Homoeopathy Osteopathy Orthodox
0.62”’ 0.62”’ 0.39” 0.33” -0.14
Acup.
0.66”’ 0.45”’ 0.31”’ -0.08
Herbal
0.46”’ 0.38”’ -0.18
Homoeo.
Osteo.
0.21’ -0.15
-0.17
Orthodox
The perceived efficacy of complementary
Ratings for herbalism, hypnosis and acupuncture are highly correlated, which may mean that people fall back on a general view of the efficacy of complementary medicine when they do not have any specific information to guide them. Homoeopathy is clearly seen as distinct from these 3, either because it is genuinely perceived as distinct or because it is simply less well known. A similar pattern emerged when the correlation matrix was repeated for each of the 4 illness types described above.
To what extent have people turned against orthodox medicine? We identified a group of people whose average efficacy
scores for complementary medicine were greater than their average scores for orthodox medicine. Table 6 shows firstly that, even in this small group of 10 people who believed complementary medicine to be more effective than orthodox medicine, ratings for the efficacy of complementary medicine are not outstandingly high. Equally ratings for the efficacy of orthodox medicine are quite low. There is no indication of ‘blind faith’ in complementary medicine as a panacea for all ills.
DISCUSSION Orthodox medicine was clearly seen, by the great majority of subjects, as being more effective in the treatment of most complaints, especially in the treatment of major, life-threatening, conditions. This was in agreement with previous work in this field.s.9 Complementary medicine, on the other hand, was seen as more effective in the treatment of quite specific minor conditions, though not superior to orthodox medicine. Acupuncture, homoeopathy and herbalism were seen as valuable in the treatment of chronic conditions. Osteopathy and acupuncture were both perceived as useful in the treatment of back pain, and herbalism as a valid treatment for fatigue and stress; equally, orthodox treatment was seen as particularly ineffective for these complaints. Hypnosis was seen as useful in the treatment of a variety of psychological problems, and seen as superior to orthodox techniques. Personal accounts of treatment appear to be particu-
Major Minor Chronic Psych Overall
133
larly important sources of information on complementary medicine, and are also highly valued in assessing its efficacy. Magazine articles and lay books were also seen as very useful, though it is not clear precisely for what purpose. While it seems that personal recommendation is an important source of these perceptions, and that it may outweigh a medical opinion, it is not clear why people believe these therapies are effective. It might be that they are seen as genuinely effective, or as simply providing a much needed support in chronic illness, or it might be that complementary practitioners are perceived as more willing to take minor complaints seriously or offer emotional support to those with chronic illness. Perceived efficacy is probably a crucial factor in a person’s decision to seek complementary treatment and maintain a treatment regime but it is only one approach to trying to understand the appeal of complementary medicine. Janz & Becker14 argued that people have a ‘health model’ made up of a number of different dimensions, which determines when and whether they seek professional health care. These dimensions include perceived readiness or propensity to act, perceived susceptibility and perceived seriousness of illness. The present study is limited in its scope since it does not consider these other factors that may underlie a decision to seek complementary treatment. For instance, we did not examine people’s health beliefs or other attitudes towards complementary medicine, or dissatisfaction with orthodox medicine. There are, however, some important results from this preliminary study with reference to further work. The first is that people distinguish between the different types (particularly the more established ones) of complementary medicine. Secondly, different complementary therapies are perceived to be effective for different conditions: hypnotherapy for more psychological conditions; acupuncture and osteopathy for back pain, etc. This suggests that patients are likely to be judicious ‘shoppers’ of complementary medicine, going to a particular therapeutic tradition or, indeed, orthodox medicine, depending on their perceived diagnosis. Researchers should be wary of using complementary medicine as a convenient umbrella term, without being aware of the different ways in which they are perceived. Thirdly, this study suggests that many people are sceptical of the benefits of orthodox medicine. Compared to complementary medicine ortho-
Table 6 Perceived efficacy by illness type for people with strong belief in complementary Type
and orthodox medicine
medicine
Hypn.
Acup.
Herb.
Homoeo.
Osteo.
Orth.
1.63 2.80 2.40 3.48 2.64
2.00 2.70 3.05 2.93 2.69
2.40 3.42 3.15 3.04 3.00
2.35 3.32 3.18 2.93 2.93
1.62 1.80 2.32 1.92 1.92
3.36 2.14 2.20 1.68 2.30
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Complementary
Therapies
in Medicine:
Research
dox medicine is perceived as relatively efficacious, but the absolute scores indicate ordinary people do not rate it very highly.
Reilly D. ‘Young doctors’ 1983; 287: 337-339.
References I. Fulder S, Monro R. Complementary
2.
3. 4.
5.
medicjne in the United Kjngdom: patients, practitioners and consultants, Lancet 1985; ii(8454): 542-545. Furnham A, Smith C. Choosing alternative medicine: a comparison of the beliefs of patients visiting a GP and a homoeopath. Sot Sci Med 1988; 26: 685-687. Sharma U. Complementary medicine today: practitioners and patients. London: Routledge, 1992. British Medical Association. Complementary medicine: new approaches to good practice. Oxford: Oxford University Press, 1993. Furnham A, Forey J. The attitudes, behaviours and beliefs of patients of conventional vs complementary (alternative) medicine. J Clin Psycho1 (in press).
IO. Il.
12. 13.
14.
views
on alternative
medicine.
BMJ
Wharton R Lewith G. Complementary medicine and the general practitioner. BMJ 1986; 992: 1498-1500. Anderson E, Anderson P. General practitioners and alternative medicine. J Roy Coll Gen Pratt 1988; 37: 52-55. Fumham A, Bhagrath R. A comparison of health beliefs and behaviours of clients of orthodox and complementary medicine. Br J Clin Psycho1 1993; 32: 237-246. Richardson P H, Vincent C A. Acupuncture for the treatment of chronic pain: a review of evaluative research. Pain 1986; 24: 15-40. ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criterion based meta-analysis. J Clin Epidemiol 1990; II: l19l1199. Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991; 302: 316323. Vincent C A. Acupuncture as a treatment for chronic pain. In Lewith G T. Aldridge D A, eds. Clinical research methodology. London: Hodder and Stoughton, 1993. ~~289-308. Janz N, Becker M. The health belief model: a decade later. Health Educ Quart 1984; I I: l-47.
The perceived efficacy of complementary and orthodox medicine: preliminary findings and the development of a questionnaire C. Vincent and A. Furnham University College London, London, UK
SUMMARY. This study examined the perceived efficacy of five different types of alternative medicine (acupuncture, herbalism, homoeopathy, hypnosis and osteopathy) and orthodox medicine in treating 25 common complaints ranging from cancer to the common cold. Subjects completed a questionnaire measuring their state of health; experience of complementary medicine; sources of information about complementary medicine; and perceived efficacy of orthodox and complementary treatments in the treatment of each condition. Personal accounts of treatment appeared to be particularly important sources of information on complementary medicine, and also highly valued in assessing its efficacy. Orthodox medicine was clearly seen, by the great majority of subjects, as being more effective in the treatment of most complaints, especially in the treatment of major, life-threatening conditions. Complementary medicine was seen as more effective in the treatment of minor and chronic conditions, though generally not superior to orthodox medicine. For some specific conditions complementary medicine was seen as the most effective treatment: osteopathy and acupuncture were both perceived as valuable in the treatment of back pain, and herbalism was perceived as a valid treatment for fatigue and stress; hypnosis was seen as useful in the treatment of a variety of psychological problems, and seen as superior to orthodox techniques. The fact that people are able to specify which complementary therapies are likely to be effective in which conditions should make researchers cautious about treatment ‘complementary medicine’ as an umbrella term.
INTRODUCTION In the last 25 years interest in complementary medicine has increased steadily, and has been especially rapid over the last decade. This growth of interest has also led to an increase in research into the efficacy of complementary medicine and peoples’ changing attitudes towards it.l-‘t The reasons for this increased interest and use of complementary medicine are not well understood. Some people
may have become dissatisfied with orthodox medicine, rejecting its reliance on high technology, wary of the dangers of invasive techniques and the toxicity of many drugs; others may retain a belief in the value and effectiveness of orthodox medicine, at least in certain areas, and yet find some aspects of complementary medicine attractive. The popularity of the complementary therapies appears to be more than just a discontent with the existing medical profession.5 An increasing number also
Charles Vincent MPhil, PhD, Adrian Furnham MA, MSc, DPhil, DSc, Department of Psychology, London WClE
6BT. UK.
128
University
College London, Gower Street,
The perceived efficacy of complementary and orthodox medicine
see complementary
medicine
as an avant-garde
for new ideas about health and the body and there are signs that some of the principles of complementary medicine are being accepted within orthodox medicine. Questionnaire studies have examined the attitudes of orthodox medical students and practitioner@ and found high rates of interest and knowledge, and referral of patients to complementary practitioners. Discussions of complementary medicine in the medical literature frequently centre around questions of efficacy. There are now a number of reviews which assess the evidence for individual therapies, and review trials which compare complementary therapies with placebo or with orthodox treatments.lo-12 While the methodology of many of the studies is far from satisfactory,13 there is reasonably strong evidence for the efficacy of some complementary therapies for some conditions. Such studies are important but their results may have little bearing on how effective ordinary people perceive complementary therapies to be. Impressions of the effectiveness of a therapy may be based on quite different criteria, such as word of mouth recommendation. Almost nothing is known about how effective people perceive complementary therapies to be, and yet it is probably an influential factor in determining whether they will use or recommend such a therapy. The present study aims to examine the perceived efficacy of complementary and orthodox medicine in the treatment of a number of illnesses and problems, of different degrees of severity. In accordance with previous studies59 it is predicted that orthodox medicine will be perceived as the most efficacious for major, life threatening, chronic and degenerative illnesses whilst complementary medicine will be perceived as more efficacious for minor and psychological illnesses. The study set out to determine how people assess the efficacy of complementary medicine, and to discover where people obtain the information they need to assess efficacy. Individuals may seek advice and consult family, friends and neighbours, in addition to those practising either orthodox or complementary medicine. 2 The study also investigated how highly members of the public rate these sources.
METHOD
Subjects
There were 135 subjects, 53 men and 82 women (1: 1S), from the general public. Ages ranged from 19 years to 77 years old with a mean age of 33 years. As regard marital status 74 (54.8%) were single, 45 (33.5%) were married, 2 (1.5%) were widowed, 5 (3.7%) were divorced and 8 (5.9%) were cohabiting. In all, 44 (36%) were
129
professionals, 36 (25.7%) were white collar workers, 14 (10.3%) were blue collar workers, 37 (26.4%) were students, including mature students, and the other 2 (1%) were unemployed. The majority (82%) had no current illness, 16% admitted to having minor complaints and 2% believed they were quite seriously ill. However, 34 (25%) had been seriously ill at some time in the past. 17 subjects (12%) had had some experience of one or more forms of complementary medicine: 6 had visited a hypnotist (4.4%) 7 an acupuncturist (5.2%) 7 a herbalist (5.2%). 13 a homoeopath (9.6%), 4 (3%) an osteopath and 5 (3.7%) another type of complementary practitioner. 6 of those who had been to a complementary practitioner considered that the treatment had been effective, but 11 considered that the treatment was not effective. However, over half of the sample (53.3%) claimed to know a person close to them who had effective treatment from a complementary practitioner.
Questionnaire The questionnaire was divided into 3 sections: in the first section subjects were asked demographic questions and questions concerning their experience of complementary medicine; the second section concerned the sources of information used (or which would be used) in assessing the efficacy of a complementary therapy; the third section contained a list of 25 illnesses: subjects were asked to indicate how effective they considered various complementary therapies (hypnosis, acupuncture, herbalism, homoeopathy and osteopathy) and orthodox medicine to be in curing each of these illnesses, by giving a score between 1 (not at all effective) and 5 (very effective). Short definitions of each complementary treatment were given in case some subjects were not familiar with them.
Procedure Questionnaires were distributed by 6 undergraduate research students to subjects at various restaurants, mainline railway stations, a children’s clinic, and in hospital waiting rooms in Central London, as part of an exercise on random sampling. Subjects were assured that confidentiality would be maintained and that all information would be seen only by university research staff. 240 questionnaires were distributed and 135 fully completed were returned (a response rate of 56%) to experimenters immediately after completion of questionnaires or by post within the following week. The actual response rate was 69% but many questionnaire were not fully completed and hence discarded. This was not a large or structured sample, but there is no reason to think that it is unrepresentative.
I30
Complementary Therapies in Medicine: Research
RESULTS Sources of information Table I summarises the findings on the sources and types of information that people use in assessing the value of a complementary therapy. The respondents reported that their most important source of information was talking to friends/relatives. Following this, they would turn to media sources, i.e. newspaper/magazine articles, television/radio programmes. The opinion of friends who had received the treatment was not only the most common but also the most valued source of information; the opinion of friends suffering the same problem and a doctor’s opinion were equally respected. The most highly rated kind of information was personal accounts of treatment. Overall this suggests that people seeking information about cornpIementary medicine are most likely to turn to their friends or relatives, particularly those who have received treatment and are able to recount their personal experiences. In addition, while scientific books and articles were not necessarily readily turned to for information, the subjects felt that the information they contain is highly valid. Perceived efficacy of orthodox and complementary medicine Ratings for the efficacy of each treatment for each of the 25 complaints are shown in Table 2. Inspection of Table 2 suggests that orthodox medicine
Table 1 Sources of information about complementary
was perceived as being very much more effective than complementary medicine for the great majority of complaints by this group of people. Assessments are generally cautious, with only one rating being greater than 4 on a 5-point scale. Orthodox medicine receives a mean rating of 4.47 in the treatment of appendicitis. There is certainly no widespread belief in the efficacy of complementary medicine, although it must be remembered that few of the respondents had any experience of complementary medicine. Taking a mid-point rating of 3.00 as a benchmark for an assessment of a moderately effective treatment we can see that: orthodox treatment receives 15 ratings of 3.0 or over, hypnosis 4, acupuncture and osteopathy one each for back pain, and herbalism and homoeopathy none. Overall ratings for the efficacy of each treatment suggest that hypnosis, homoeopathy, acupuncture and herbalism are seen as very much equivalent, though their pattern of high and lower scores do differ. Osteopathy is given a lower rating, but this assessment should be treated with cauticn. Homoeopathy, acupuncture and herbalism aim to treat a far wider range of complaints than osteopathy, which is primarily, but not exclusively, focused on musculo-skeletal problems. Osteopathy is therefore likely to receive a low overall score. For 9 of the complaints at least 1 form of complementary medicine were perceived as significantly more effective than orthodox medicine. The mean scores and F-ratios for the relevant treatments and comparisons are shown in Table 3. In each case the F-ratio refers to the comparison of the individual complementary therapy
medicine
Question
Source
How much do you use each of the following sources of information to find out about complementary medicine?
Friends Magazines TV/radio Scientific/books Layman books Advertisments
If you were trying to decide whether a treatment might be able to help you, whose opinion would be most important to you?
Friends who received treatment Friends with the same problem Friends with no experience Religious advisor Complementary practitioner Doctor
What kind of information would be most important to you in helping you make up your mind about a complementary therapy?
Scale: 5 = a great deal; 1 not at all.
Personal accounts Magazine articles TV/radio Scientific books Layman books Advertisments
Mean
SD
3.34 2.87 2.70 2.28 1.93 1.90
1.24 1.12 1.13 1.22 0.99 0.96
4.14
1.00
3.77
1.10
1.62 1.37
0.85 0.89
3.15 3.77
1.40 1.10
4.13 3.05 2.90 3.03 2.31 1.73
1.00 1.02 1.04 1.2.5 1.04 1.00
The perceived efficacy of complementary Table 2 Perceived efficacy of complementary
and
orthodox medicine
131
-
and orthodox medicine
Hypnosis
Acupuncture
Herbalism
Homoeopathy
Osteopathy
Orthodox Medicine
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Allergies Appendicitis Arthritis Asthma Back pain Blood pressure Bronchitis Cancer Common cold Depression Diabetes Drinking problem Fatigue Hay fever Heart attack Insomnia Menstrual problems Migraine Nerves Obesity Pneumonia Skin problems Stopping smoking Stress Sudden weight loss
1.75 1.16 1.39 1.72 1.83 1.74 1.21 1.45 1.21 3.03 1.18 1.51 2.57 1.61 1.23 3.27 1.48 2.19 2.90 2.67 1.13 1.57 3.54 3.32 2.01
1.07 0.51 0.78 1.06 1.12 1.09 0.51 0.86 0.65 1.27 0.59 0.62 1.35 1.04 0.60 1.36 0.84 1.23 1.34 1.53 0.40 0.93 1.34 1.37 1.34
2.12 1.36 2.62 1.88 3.27 2.00 1.43 1.51 1.35 1.80 1.40 1.87 2.30 1.92 1.43 2.24 1.89 2.67 2.39 1.99 1.38 1.82 2.51 2.68 1.64
1.15 0.70 1.30 1.09 1.30 1.19 0.77 0.87 0.75 0.98 0.75 1.11 1.22 1.15 0.88 1.24 1.17 1.32 1.24 1.17 0.77 1.05 1.44 1.31 1.09
2.91 1.42 2.34 2.42 1.82 2.27 2.12 1.78 2.54 1.87 1.84 1.62 2.66 2.52 1.45 2.55 2.61 2.47 2.30 1.80 1.69 2.69 1.96 2.29 1.72
1.18 0.84 1.14 1.12 0.96 1.18 1.11 1.05 1.31 1.07 1.04 1.02 1.29 1.20 0.82 1.19 1.23 1.08 1.17 0.93 1.01 1.17 1.14 1.16 0.93
2.94 1.37 2.40 2.50 1.87 2.06 2.03 1.92 2.21 1.77 1.71 1.56 1.95 2.46 1.53 2.08 2.20 2.24 2.09 1.71 1.64 2.51 1.75 1.89 1.63
1.38 0.78 1.34 1.35 1.09 1.17 1.13 1.18 1.33 1.10 0.98 0.94 1.14 1.28 0.92 1.15 1.26 1.26 1.29 1.06 1.oo 1.29 1.03 1.16 1.00
1.46 1.21 2.50 1.37 3.60 1.48 1.29 1.24 1.28 1.34 1.20 1.23 1.96 1.30 1.29 1.50 1.49 1.66 1.62 1.34 1.23 1.33 1.35 1.93 1.30
0.93 0.70 1.32 0.76 1.34 0.95 0.70 0.68 0.75 0.79 0.56 0.69 1.16 0.69 0.73 0.85 0.93 1.04 0.93 0.83 0.70 0.73 0.75 1.18 0.69
3.57 4.47 3.25 3.68 3.09 3.73 3.96 3.51 2.68 2.56 4.06 2.42 2.26 3.31 3.85 2.75 3.42 3.13 2.64 2.61 3.97 3.31 2.07 2.26 2.98
1.38 1.09 1.22 1.15 1.09 1.09 1.10 1.29 1.48 1.32 1.06 1.31 1.28 1.19 1.26 1.30 1.18 1.25 1.25 1.32 1.21 1.21 1.16 1.23 1.34
Overall mean
2.03
.605
1.97
,710
2.10
,661
1.99
,785
1.53
.54
3.18
.71
Minimum rating = 1 not at all effective. Maximum rating = 5: very effective.
with orthodox medicine (repeated measures ANOVA with contrasts). Osteopathy and acupuncture are both seen as useful in the treatment of back pain, and herbalism is seen as a valid treatment for fatigue and stress, or at least orthodox treatment is seen as particularly ineffective for these complaints. There is considerable belief in the efficacy of hypnosis in the treatment of a variety of psychological
Table 3 Conditions
for which complementary
problems.
Perceived efficacy by illness type A preliminary factor analysis of the 25 disorders rated in this study revealed that, as far as ratings of efficacy were concerned, they could be effectively classified into
medicine is perceived as more effective than orthodox medicine
Complaint
Complementary treatment
Back pain
Osteopathy Acupuncture Hypnosis Hypnosis
3.61 3.28 3.04 3.13
3.10 3.10 2.57 2.42
4.98 0.08 5.87 * 8.52 *
Herbalism Hypnosis Hypnosis Hypnosis Hypnosis Acupuncture Hypnosis Acupuncture Herbalism
2.66 3.27 2.90 2.67 3.55 2.52 3.33 2.68 2.29
2.26 2.76 2.65 2.61 2.07 2.07 2.26 2.26 2.26
3.13 5.09 ’ 0.78 0.03 65.91 **’ 6.83 * 20.1 ** 2.79 0.02
Mean score complementary
Mean score orthodox
F-ratio
-
Depression Drinking problems Fatigue Insomnia Nerves Obesity Stopping smoking Stress
‘p < 0.05; l *p < 0.01; “‘p < 0.001
l
l
l
l
-
I32
Complementary Therapies in Medicine: Research
4 groups: (i) Major medical conditions - appendicitis, bronchitis, cancer, diabetes, heart attack and pneumonia; (ii) Minor conditions - common cold, hay fever, insomnia, menstrual problems and migraine; (iii) Chronic conditions - allergies, arthritis, asthma, back pain, blood pressure and skin problems, and (iv) Psychological problems - depression, drinking problems, fatigue, nerves, obesity, stopping smoking, stress and weight loss. Ratings on these various complaints were arithmetically computed to form 4 scores per subject. Table 4 shows the mean efficacy for each therapy, in each of these 4 groups of conditions. Table 4 Perceived efficacy by illness type Type Major Minor Chronic Psych
Hypn.
Acup.
Herb.
Homoeo.
Osteo.
Orth.
1.23 1.95 1.66 2.92
1.41 2.02 2.26 2.15
1.70 2.52 2.37 2.02
1.67 2.23 2.38 1.80
1.24 1.41 1.92 1.50
3.98 3.05 3.45 2.48
Table 4 suggests that people were, on the whole, emphatic that orthodox medicine is much more effective in any major illness. Complementary medicine was seen as more effective for minor problems and chronic conditions, though orthodox medicine was still rated as superior. For psychological problems complementary medicine and orthodox medicine was very much equivalent. This suggests that most people are not ‘for or against’ complementary medicine, but see it as useful in certain quite specific types of problem - especially those where orthodox medicine is seen as less effective. People are, to some extent, aware that particular complementary therapies should be targeted at particular conditions. Factors associated with a belief in the efficacy of orthodox or complementary medicine A difference score was computed to examine the relative strength in beliefs about orthodox and complementary medicine. This score (the overall mean efficacy of complementary medicine minus the overall mean for orthodox medicine) was correlated with each of the demographic variables and with the ratings of the sources of information. A positive correlation indicates a positive
association between the factor in question and a relatively stronger belief in complementary medicine, None of the demographic variables predicted a belief in the efficacy of complementary medicine, though there was a tendency for older people to have a stronger belief in orthodox medicine. A stronger belief in complementary medicine was associated with, not surprisingly, having visited a complementary practitioner, (though the experience could of course have decreased a person’s belief). A stronger belief in complementary medicine was associated with valuing personal accounts (r = 0.21, p> 0.02) and with reading magazine articles (r = 0.21, p> 0.02) and books for the layperson (r = 0.25, p> 0.01). A stronger belief in complementary medicine was also associated with higher ratings for the importance of other people’s opinions, both lay and professional: with friends who had had the treatment (r - 0.20, p> 0.02), friends with the same problem (r = 0.24, p> O.OOS),a complementary practitioner (r = 0.24, p > 0.01) and, in contrast, most strongly with lower ratings for the opinion of a doctor (r = -0.34, p> 0.001). This suggests overall that people who value recommendation of a therapy are also those who rate complementary medicine more highly and that they are prepared to read about a therapy when assessing its value. A belief in complementary medicine is inversely related to attaching importance to a doctor’s opinion. This does not necessarily mean that people rating complementary medicine highly do not value their doctor’s views in other areas, but they may be prepared to partly disregard them when considering complementary medicine. However, complementary therapy is indeed complementary to orthodox medicine and many ill people take the two together, unknown to their physician. Similarities and differences between therapies Table 5 shows the correlation between average efficacy scores for each complementary therapy and orthodox medicine. The most striking fact is the series of small inverse (though non-significant) correlations between ratings of complementary medicine and ratings of orthodox medicine which suggest that there may be some truth in the idea that some people who believe in complementary medicine are those who are dissatisfied or distrustful or orthodox medicine.
Table 5 Correlations between ratings of efficacy Hypn. Hypnosis Acupuncture Herbalism Homoeopathy Osteopathy Orthodox
0.62”’ 0.62”’ 0.39” 0.33” -0.14
Acup.
0.66”’ 0.45”’ 0.31”’ -0.08
Herbal
0.46”’ 0.38”’ -0.18
Homoeo.
Osteo.
0.21’ -0.15
-0.17
Orthodox
The perceived efficacy of complementary
Ratings for herbalism, hypnosis and acupuncture are highly correlated, which may mean that people fall back on a general view of the efficacy of complementary medicine when they do not have any specific information to guide them. Homoeopathy is clearly seen as distinct from these 3, either because it is genuinely perceived as distinct or because it is simply less well known. A similar pattern emerged when the correlation matrix was repeated for each of the 4 illness types described above.
To what extent have people turned against orthodox medicine? We identified a group of people whose average efficacy
scores for complementary medicine were greater than their average scores for orthodox medicine. Table 6 shows firstly that, even in this small group of 10 people who believed complementary medicine to be more effective than orthodox medicine, ratings for the efficacy of complementary medicine are not outstandingly high. Equally ratings for the efficacy of orthodox medicine are quite low. There is no indication of ‘blind faith’ in complementary medicine as a panacea for all ills.
DISCUSSION Orthodox medicine was clearly seen, by the great majority of subjects, as being more effective in the treatment of most complaints, especially in the treatment of major, life-threatening, conditions. This was in agreement with previous work in this field.s.9 Complementary medicine, on the other hand, was seen as more effective in the treatment of quite specific minor conditions, though not superior to orthodox medicine. Acupuncture, homoeopathy and herbalism were seen as valuable in the treatment of chronic conditions. Osteopathy and acupuncture were both perceived as useful in the treatment of back pain, and herbalism as a valid treatment for fatigue and stress; equally, orthodox treatment was seen as particularly ineffective for these complaints. Hypnosis was seen as useful in the treatment of a variety of psychological problems, and seen as superior to orthodox techniques. Personal accounts of treatment appear to be particu-
Major Minor Chronic Psych Overall
133
larly important sources of information on complementary medicine, and are also highly valued in assessing its efficacy. Magazine articles and lay books were also seen as very useful, though it is not clear precisely for what purpose. While it seems that personal recommendation is an important source of these perceptions, and that it may outweigh a medical opinion, it is not clear why people believe these therapies are effective. It might be that they are seen as genuinely effective, or as simply providing a much needed support in chronic illness, or it might be that complementary practitioners are perceived as more willing to take minor complaints seriously or offer emotional support to those with chronic illness. Perceived efficacy is probably a crucial factor in a person’s decision to seek complementary treatment and maintain a treatment regime but it is only one approach to trying to understand the appeal of complementary medicine. Janz & Becker14 argued that people have a ‘health model’ made up of a number of different dimensions, which determines when and whether they seek professional health care. These dimensions include perceived readiness or propensity to act, perceived susceptibility and perceived seriousness of illness. The present study is limited in its scope since it does not consider these other factors that may underlie a decision to seek complementary treatment. For instance, we did not examine people’s health beliefs or other attitudes towards complementary medicine, or dissatisfaction with orthodox medicine. There are, however, some important results from this preliminary study with reference to further work. The first is that people distinguish between the different types (particularly the more established ones) of complementary medicine. Secondly, different complementary therapies are perceived to be effective for different conditions: hypnotherapy for more psychological conditions; acupuncture and osteopathy for back pain, etc. This suggests that patients are likely to be judicious ‘shoppers’ of complementary medicine, going to a particular therapeutic tradition or, indeed, orthodox medicine, depending on their perceived diagnosis. Researchers should be wary of using complementary medicine as a convenient umbrella term, without being aware of the different ways in which they are perceived. Thirdly, this study suggests that many people are sceptical of the benefits of orthodox medicine. Compared to complementary medicine ortho-
Table 6 Perceived efficacy by illness type for people with strong belief in complementary Type
and orthodox medicine
medicine
Hypn.
Acup.
Herb.
Homoeo.
Osteo.
Orth.
1.63 2.80 2.40 3.48 2.64
2.00 2.70 3.05 2.93 2.69
2.40 3.42 3.15 3.04 3.00
2.35 3.32 3.18 2.93 2.93
1.62 1.80 2.32 1.92 1.92
3.36 2.14 2.20 1.68 2.30
I34
Complementary
Therapies
in Medicine:
Research
dox medicine is perceived as relatively efficacious, but the absolute scores indicate ordinary people do not rate it very highly.
Reilly D. ‘Young doctors’ 1983; 287: 337-339.
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