According to the World Health Organization (2013), traditional medicine involves knowledge, skills and practices based on theories, beliefs and experiences in a variety of cultures. Whether it is supported by evidence or not, traditional medicine is used to maintain health and prevent disease, as well as to diagnose, improve or treat physical and mental health conditions. Similarly, complementary medicine encompasses a broad set of practices that are not part of a country's mainstream healthcare. The concepts of traditional and complementary medicine (TCM) overlap and cover products and practice used to address to health issues (WHO, 2013).
The WHO (2013) supports TCM, since it is a source of treatment (sometimes the only one) for many people around the world. Therefore, the WHO (2013) advocates its safe, rational and informed use and promotes scientific research to provide evidence and ensure responsible use.
Health professionals often do not know whether their patients use TCM, even though it can potentially interfere with treatment prescribed by a conventional health provider. Therefore, understanding TCM and its importance in patients' lives is fundamental to safe treatment and to avoid unwanted interactions (Grant et al, 2012). The use of TCM has greatly increased in the western society over the past two decades (Wu et al, 2019) so it is essential that health professionals are aware of its use in their daily work.
TCM is used by both healthy people and those with diseases. It has been suggested that greater knowledge and sensible use of these treatments would increase both their success rate and their use (Pressman and Buff, 2001). Several studies have aimed to determine which social, economic or cultural groups use these therapies the most. However, the literature presents different results. A review by Wootton and Sparber (2001) showed that the profile of TCM users varied widely. They noted that some studies found TCM was used most by people in the lowest socioeconomic groups, while others found that the heaviest TCM users were those with the highest socioeconomic profile. Moreover, factors such as age, sex, educational level, health system and cultural group have been investigated in relation to TCM use but no major conclusions have been drawn in terms regarding this.
In the field of long-term conditions, specifically chronic kidney disease (CKD), the literature shows how TCM can provide therapeutic options for patients to gain relief of symptoms. Therefore, the quality of life of patients undergoing intensive renal replacement therapies could be improved by using this kind of treatment (Arjuna Rao et al, 2016). People with long-term conditions that cause fatigue, discouragement, despair, anxiety, depression and pain are likely to seek or be more amenable to using supplements that may improve their quality of life or optimise their conventional treatment (Pérez Lapuente et al, 2013; Sánchez Quiles et al, 2014).
In the general population, the use of TCM in patients with long-term conditions has increased and interest is growing in interventions that may relieve certain symptoms. Better education provided by healthcare providers about the risks and benefits of TCM could encourage patients to understand the importance of informing practitioners about their use and prevent potential interactions between conventional treatment and TCM. Furthermore, staff training could offer new treatment perspectives, cover novel scientific knowledge and increase intervention possibilities (Burrowes and Van Houten, 2005).
The aim of this study was to identify the role played by health professionals in advising patients on the use of TCM or in providing this type of treatment. More specifically, the authors aimed to analyse knowledge of TCM among health professionals in a nephrology unit and examine the advice they gave on TCM to patients.
Methods
Study design and setting
A cross-sectional descriptive study was conducted between February and May 2017 in a nephrology department of a university hospital in Barcelona, Spain.
Participants
This study included 62 health professionals (nurses, nursing assistants and physicians) from a nephrology department. The inclusion criteria were that participants must have worked in the nephrology speciality for more than a year and give formal consent to take part in the study. Exclusion criteria included being involved in professional TCM practice outside the workplace, being part of the research group and having been involved in preparing the survey.
Practitioners were contacted personally during their work shift by the staff responsible for the study. Once the inclusion and exclusion criteria had been applied and signed informed consent obtained, a questionnaire was given to each participant for completion at a time of his or her choosing.
Instruments
An ad-hoc survey, based on a literature review, was created. The main objective of the survey was to acquire knowledge of TCM among health professionals in a nephrology unit and identify the advice given to patients on it so key areas for improvement could be identified. To achieve the highest standards of quality and validity for this questionnaire, the six quality dimensions proposed in the literature consulted were followed: relevance; accuracy; timeliness and punctuality; accessibility and clarity; comparability; and coherence (Di Lonardo et al, 2017).
The first part of the questionnaire gathered sociodemographic data (age, sex, profession and years of experience). The second part, prepared to provide answers to the research questions, comprised 15 closed-ended questions.
Statistical analysis
For the analysis of the results, we used the Student's t-test to compare the means between parametric variables, the Mann–Whitney U test for nonparametric variables and the χ2 test to compare proportions. The level of statistical significance was set at P<0.05. The analysis was performed with the statistical software package SPSS 23 (IBM).
Ethical considerations
This study was conducted in accordance with the principles guiding healthcare and research in the field of social health. Data confidentiality was guaranteed in accordance with the European General Data Protection Regulation 2016/679 and the law on data protection and guarantee of digital rights of Spain. Before data collection, all participants gave written informed consent. This project was approved by the research ethics committee of the hospital where the study was performed (number 2018/7797/I).
Findings
The study included 62 practitioners. Their sociodemographic characteristics are shown in Table 1 and the results of the ad hoc questionnaire in Table 2.
| Characteristic | |
|---|---|
| Age (mean ± SD) | 37.61 ± 11.05 years |
| Sex: % (n) | Women: 87.1% (54) |
| Professional category: % (n) | Nurses: 54.83% (34) |
| Years of experience: % (n) | 1–5 years: 27.42% (17) |
| Question | Answer | Result: % (n) | |
|---|---|---|---|
| 1 | How many alternative therapies do you know of? | I do not know of any | 6.45% (4) |
| I know 1 or 2 | 19.35% (12) | ||
| I know more than 3 | 74.20% (46) | ||
| Median known [interquartile range (IQR)] | 4.5 [2; 6.25] | ||
| 2 | Have you received training in alternative therapies? | Yes | 32.26% (20) |
| No | 67.74% (42) | ||
| 3 | What kind of training have you received? |
University education | 11.29% (7) |
| Training in the workplace | 1.62% (1) | ||
| Specialised course | 16.13% (10) | ||
| All of them | 3.23% (2) | ||
| 4 | How many alternative therapies do you use? | I do not use any | 58.06% (36) |
| I use 1 or 2 | 27.42% (17) | ||
| I use more than 3 | 14.52% (9) | ||
| Median used [IQR] | 1.5 [1; 3] | ||
| 5 | Do you think that alternative therapies should be included in clinical practice? | Yes | 62.90% (39) |
| No | 9.68% (6) | ||
| I don't know | 27.42% (17) | ||
| 6 | Do you recommend patients to use alternative therapies? | Yes | 22.58% (14) |
| No | 32.26% (20) | ||
| Sometimes | 45.16% (28) | ||
| 7 | When you recommend them, do you recommend them based on your personal experience? |
Yes | 37.10% (23) |
| No | 30.65% (19) | ||
| 8 | How do you recommend them? | As a therapy | 9.68% (6) |
| Answers from 67.74% (42) who recommend them | As a complementary treatment | 58.06% (36) | |
| 9 | Do you think that their effect is attributable to the placebo effect? | Yes | 8.06% (5) |
| No | 48.39% (30) | ||
| I don't know | 43.55% (27) | ||
| 10 | Have any patients asked you for information about alternative therapies? | Yes | 27.42% (17) |
| No | 72.58% (45) | ||
| 11 | Do you think the information you provided was satisfactory? |
Yes | 11.29% (7) |
| No | 4.84% (3) | ||
| I don't know | 11.29% (7) | ||
| 12 | Do you consider it important to include specific training on alternative therapies in university teaching programmes? | Yes | 77.42% (48) |
| No | 8.06% (5) | ||
| I don't know | 14.52% (9) | ||
| 13 | Do you need to know if your patients use alternative therapies in case it interferes with conventional treatment? | Yes | 50% (31) |
| No | 29.03% (18) | ||
| I don't know | 20.97% (13) | ||
| 14 | Would you advocate the safe, rational and informed use of this type of treatment and promote scientific research into it? | Agree | 90.32% (56) |
| Indifferent | 8.06% (5) | ||
| Disagree | 1.61% (1) | ||
| 15 | Would you conduct research in this field? | Yes | 82.26% (51) |
| No | 17.74% (11) |
There were no statistically significant differences between age and the training received (P=0.918), between age and personal TCM use (P=0.247), or between age and the advice practitioners gave their patients (P=0.822).
Equally, there were no statistically significant differences between the training received in TCM and being a nurse or a nursing assistant (P=0.137), between training received and being a nurse or a physician (P=0.745), or between training received and being a nursing assistant or a physician (P=0.440).
Of the 26 practitioners who used TCM in their personal lives, 13 had received training in it and 13 had not. No statistically significant differences were found between personal TCM use and having received training, or personal use and not having been trained (P=1).
Among the 20 staff members who had received training in TCM, 17 recommended its use to patients and three did not. This difference was statistically significant (P=0.002). Among those who had not received training in TCM (n=42), 25 recommended these treatments to their patients and 17 did not. This difference was not statistically significant (P=0.217).
Of the 42 participants who recommended TCM use, 22 used it in their daily lives and 20 did not (P=0.758). Of these, 18 believed that these kinds of alternative treatment could interact with conventional treatments, 15 did not believe there was any type of interaction and nine were unsure (P=0.223).
Discussion
Although the 62 practitioners surveyed were aware of a large number of alternative therapies—74.20% claimed to know more than three alternative therapies, with median of 4.5 [interquartile range (IQR) 2; 6.25] (Table 2; question 1)— this knowledge was not related to training (only 32.26% had received formal training (Table 2; question 2) or personal use in their daily lives (41.94% used some form of TCM and the median number of alternative therapies used was 1.5 [IQR 1; 3]) (Table 2 question 4). In contrast, 67.74% of participants stated they had recommended the use of these therapies to patients at some time (Table 2; question 6).
These questions have previously been explored in the literature. Shorofi and Arbon (2017) found that, while nurses had received insufficient training in TCM, they were willing to attend courses so they could integrate them into patient care. Similarly, Bahall and Legall (2017) found that knowledge of TCM was low among practitioners. Most used TCM personally, but were reluctant to recommend it to patients. The results of the present study suggest the same conclusions, providing consistency in terms of external validity. As mentioned above, professionals who had received training in TCM (32.26% of the sample) tended to recommend them more frequently; the result was statistically significant.
On the other hand, a large number of practitioners had not received training (67.74%) but still recommended the use of TCM to their patients. This contradiction can be understood by the fact that most of the those surveyed recommended this type of therapy based on their personal experience and as complementary treatments to mitigate symptoms and help manage the disease. Nevertheless, a large proportion of participants doubted the effectiveness of these treatments (43.55%) and a small percentage believed that the effect of TCM could be attributed to the placebo effect (8.06%) (Table 2; question 9). These results demonstrate the need for training in these treatments, as they suggest that many professionals attach little importance to TCM and believe it to be harmless.
As Kinchen and Loerzel (2018) concluded, nursing students are open to using and recommending TCM, but identified a lack of knowledge and time as barriers to doing so. Therefore, it is important to include training on TCM in universities. This recommendation is supported in this study by the finding that only 8.06% of the professionals interviewed were against the inclusion of formal training in TCM in universities. Moreover, 77.42% of participants acknowledged it was important to include TCM in undergraduate health programmes and 14.52% did not have a clear opinion on the topic (Table 2; question 12).
Poor knowledge of TCM is a widespread problem worldwide (Zyoud et al, 2016). The data in this study are supported by earlier literature. Zyoud et al (2016) reported a sample of 267 patients receiving haemodialysis, of whom 64.4% had used some type of alternative therapy in the previous month.
Likewise, Arjuna Rao et al (2016) described a cohort of 200 patients, of whom 26% usually used TCM. These findings show that, to a greater or lesser extent, patients are using TCM. Scant knowledge about this use and questions about its safety were the main problems identified.
Half of the professionals surveyed in the present study believed that TCM did not interact with the conventional treatment prescribed. These responses suggest that these practitioners believe there is no need to know if patients use TCM because it does not interact with conventional treatments (Table 2; question 13), a belief that is contradicted by the literature.
According to the WHO (2013), adverse drug reactions to alternative medicines had more than doubled in the previous 3 years. Many of these products are sold as dietary supplements and are regulated as food, not as medicines, so can be sold without government evaluation or approval. As tests are not required, many herbal supplements are manufactured with wide variations in their composition. Once again, it is essential for nephrology professionals to evaluate patients' use of these products to understand their risks and benefits and to be able to provide safe advice (Kirk and Dunker, 2014).
Limitations
The main limitation of this study is that the results are drawn from a single centre. The results would have been considerably enriched by the inclusion of more practitioners from other centres as well as from conducting in-depth interviews to enrich the findings.
In addition, it would be interesting to explore patients' knowledge and training on TCM to see if the results are similar to those about practitioners presented in this paper.
Implications for practice
The findings of this study confirm and alert practitioners to the possibility that patients with kidney disease use TCM, which may interact with conventional treatments. The data suggest practitioners receive little training in TCM, a high proportion of health professionals recommend the use of TCM to patients, and many practitioners are unaware of how important these treatments are both to patients and because they can interact with conventional treatment.
These data should be reviewed with practitioners and formal training in TCM requested. Training in TCM is important, as is identifying its use among patients and their knowledge of its effects.
Conclusions
Practitioners are interested in TCM, in being trained on this topic and in its inclusion in clinical practice.
Although more than half of the professionals in this study recommend TCM to patients as a complementary treatment, based on their personal experience, it would be appropriate to establish a common strategy so staff would provide the same information and to guarantee advice is safe, professional and of a high quality.
This study suggests that TCM use can be interpreted as a risk behaviour prompted by professional advice. This indicates the need to introduce formal training programmes so the use of TCM in the management of symptoms in people with CKD is truly beneficial and safe. It is also important to increase patients' knowledge of TCM to ensure these therapies do not interfere with conventional treatment.