Acupuncture

The use of Complementary and Alternative Medicine (CAM) in pediatric medicine has increased
significantly over the last decades. One of the most CAM methods used is acupuncture. Saks
(2019) defines acupuncture as traditional Chinese medicinal practice that involves insertion of
needles on given sites of the body to render therapeutic effects. The insertion of needles at
specific acupoints is hypothesized to improve energy flow in the body resulting in improved
health and well-being. The underlying mechanism of action of acupuncture has not been fully
explored, yet some current literature show that the technique can alleviate variety of conditions
and ailments better than their allopathic equivalents.

However, the technique has remained controversial. Its use among pediatric population
specifically utilization among children is significantly lower than other CAM interventions. Saks
(2019) denotes that the use of acupuncture among children is perceived to be apprehensive due
to limited research on the technique utilization. Lin et al. (2021) adds that the apprehension can
be attributed to perception that children fear needles. Lin et al. (2021) contends that treatment
expectations may play a central role in acceptability of acupuncture use among children. Wang et
al. (2019) established that caregivers of children tend to prefer medication and relaxation training
therapies over acupuncture. The underlying cause of CAM choices informing the attitude and
concerns has to been fully investigated. According to Chokshi et al. (2017), substantial body of
evidence have shown that acupuncture use among children is common among families who have
previous experience of use indicating being familiar with the practice is a critical determinant
influencing the attitude and choice of its use in pediatric settings.

Acupuncture therapy is considered non-conventional with limited data being available

concerning its acceptance and the attitudes informing its choice for use among pediatric patients.
Studies show that caregivers tend to show hesitance in discussing CAM-related interventions
such as acupuncture and the experience of their children with conventional medical practitioners.
Lin et al. (2015) ascertains that medical providers managing pediatric patients with critical or
chronic illness or often more willing to discuss CAM interventions with caregivers. Conversely
most caregivers collect information from other source which may be non-medical. In the context
of pediatric physician lack of expertise, time constraint and skepticism may result in discomfort
when discussing CAM interventions for young patients. Currently, limited literature exists on the
modalities by which providers determine and consider the use acupuncture for pediatric patients.

The purpose of this thesis will be to investigate the attitude of the parents and children towards
acupuncture techniques. Several factors are examined that could shape the attitude of caregivers
and children towards acupuncture which may determine the preference or apprehension on
utilizing the technique. The study will employ systematic review design to examine whether the
attitudes are influenced by:
 The description of the acupuncture techniques by medical providers
 Previous experience of caregivers with acupuncture techniques
Method
Search Methods
After painstaking review of scope, and medical subject headings for suitable search terms, 2
electronic data base were chosen. The two electronic data bases chosen were; Embase and
PubMed which are two primary health databases. The data bases will be searched with date
limits of the last 12 years. The inclusion criteria for consideration in the review had to satisfy the
following criteria; they had to be clinical qualitative studies, be published in English and present
analysis on caregivers and children experience with acupuncture. Further, the reference list of the
chosen papers will be hand searched for their proper identification and ensuring they are peer-
reviewed literature which would have been missed during the search.

Several exclusion criteria were used. Systematic reviews and meta-analysis were excluded.
Additionally, studies involving children from Asia will be excluded. Studies show that most
children from Korea and China have undergone an acupuncture treatment (Saks, 2019).
Therefore, the perception and attitude of the caregivers and children will not relevant for the
study.

The key words that will be used in the search at PubMed and Embase will include; “beliefs”,
“attitudes”, “Acupuncture Therapy”, “Alternative medicine”, “behavior” and “acceptance”. The
key words will be applied as Tiab and Mesh terms together with other relevant synonyms. The
scope of this study will focus on the clarification of the attitudes of children and parents towards
acupuncture treatment.
Search Outcomes
The search will include search for online literature in seeking appropriate articles that will be
used in the systematic review. Studies will be selected by appraisal using a dual-stage process.
Firstly, the abstracts and titles when available will be identified from the PubMed and Embase
database using the search strategy and exclusion done as highlighted. The entire search strategy
is highlighted in table 1.
Exclusion Criteria Number of Studies
Total number of records 120
Exclusion of duplicates 63
Screening 53
Eligibility 12
Systematic reviews and meta-analysis 3
Location or setting of the study 2

Selection and Screening of Studies

The screening was started with abstracts and title that were retrieve during the search. 120
studies were identified and excluded as appropriate. Full text articles were retrieved from the
remaining 63 studies, 53 which were excluded because they never satisfied the inclusion
 threshold as indicated in figure 1. The remaining 19 studies originated from studies conducted in
the Eurozone countries, Australia, South America and United States between 2012 and 2022.
The studies had data collected from children and caregivers who had undergone treatment under
different acupuncture paradigms. PRISMA flow chart in figure 1 is used to represent the
selection process that was used.

Articles Identified Extra records identified

Iden through database through other sources
tific
atio (n=119) (n=1)
n

Articles after duplicate exclusion (n=63)

Scre
enin
g
Articles excluded
Screened records (n=39)
(n=53)
Eligi
bilit
y
Full text records
Full text records evaluated for excluded with
eligibility reason

Incl (n=14) N= 4
ude
d

Articles included in
qualitative synthesis
(n=10)

Data Synthesis and Abstraction

The selected study in the review used various data collection methods. Most of the studies used
semi-structured and unstructured interviews. All the studies selected highlighted the fundamental
direction for questioning. Such a thematic analysis will be scrutinized for four primary areas that
includes; experience of illness, reasons for choosing acupuncture therapy, impacts linked to the
treatment and experience after using acupuncture.
 Extraction of all the direct quotes from the participants in the studies will be done. Moreover, the
retrieved excerpts will be analyzed, then assigned sub codes, categories and annotations using
constant comparison method. Statistical Package for Social Sciences (SPSS) software will be
used for managing data and analysis.
Results
Four over-arching themes have been identified and used for categorizing the selected articles as
summarized in table 2 below.
Author (year) Study Population
Trifa et al. 12 question survey given to 164
2018 participants consisting of caregivers
with children who are undergoing
general anesthesia interventions. Their
knowledge on acupuncture and pre-
operative were questioned. The
majority of the 164 caregivers were
between 20- 40 years with 82% being
mothers of the patient.
Stampini et al. A sample of 147 parents with children
2019 were questioned about CAM, being
questioned about effectiveness
perception, parental socio-economic
and children health.
Revuelta- 169 families sampled to determine the
Iniesta et al. prevalence of CAM use and spiritual
2014 practices in pediatric oncology in
Scotland.
Zuzak et al. Data collected from 20 European
2013 countries. The countries represented
69% of the total population.
Method Main Results
Mixed 70% of the caregivers were familiar with
method the acupuncture techniques while 38%
were aware of hypnotherapy, followed my
music therapy at 60%. CAM acceptance
was 51%. However, the acceptance of
music therapy was highest at 50%,
followed by hypnotherapy at 17% and
acupuncture at 13%.
Qualitative Among the 147 participants with children
study who had been involved in the survey
38.1% had used CAM in the previous year
while 48.3% had been treated with CAM at
least once in a lifetime. Children who had
been treated using CAM were averagely
younger than their non-treated counterpart.
85.6% of the caregivers were willing to
explore CAM while 78.9% would consider
the intervention if allopathic methods
failed.
Qualitative Among the 169 families sampled only 74%
study returned the completed questionnaires.
57% had used spiritual intervention while
using conventional methods of treatment.
Moreover, 53% had used CAM with most
of them using the technique to reduce
stress.
Narrative From the 20 countries sampled in the study
Non- the CAM use by the general population
systematic was available for 90% for the countries
study under examination. Surveys concerning
CAM use among children indicated that
55% of the countries had widespread use of
the technique. Extrapolation of the data on
usage found 52% range when adjusted to
capture the entire European population.
Besides, CAM experts specializing in

Anheyer et al. 16 participants including 9 medical
2018 doctors and 7 nurses from rural
children hospital in Ruhr region
Germany. 68.8% of the participants
were female.
Smith et al. Participants consisted of 21 parents
2020 composed of 1 man and 20 women.
The average of the participants was 43
years with 43% having at least
bachelors.
Stub et al. 22 families from Norway sampled with
2021 24 adults being couple participants.
Two individuals with cancer were
included in the sample.
pediatrics reported in increase in use in the
technique.
Qualitative Most of the participants had minimal
study knowledge on evidence or possibilities of
the therapies under investigation. However,
most believed that CAM could be an
appropriate enhancement on various
interventions. Physician emphasized on the
need for developing evidence base and
standardization while the nurses focused
more on theoretical knowledge and
practical. A consensus was built among the
participants that integration of CAM and
conventional medicine was appropriate for
enhancing outcomes among patients.
Qualitative Three primary themes were identified
study during the analysis; experience of the
caregivers in researching CAM
interventions. Another theme identified
was navigation of CAM information and
techniques that was categorized to be
having the following sub-themes:
evaluating CAM interventions on children
and what counts as effective, assessment of
information on what can be presumed to be
evidence. Lastly, the final theme was the
capacity to create trustworthy and a central
theme. Analysis of the identified theme
indicated that parents made CAM decision
influenced by costs, time and pragmatism.
Qualitative Most of the respondents had previous
study experience with CAM. A significant
number had personal experience with
CAM prior to their children were
diagnosed with cancer. Notably, the
medical providers did not raise issues
about CAM as pointed out by the
participants. However, those caregivers
that raised questions about CAM got
positive response. All the participants
reported not to have received adequate
information concerning CAM at healthcare
facilities which they could appreciate.
Instead, most reported to have received
layman recommendations which they
rejected since it was below par in the

Mano and A sample of 240 parent participants
Davis, 2009 reading vignettes varying in
description.
Rocha et al. 199 children diagnosed and treated for
2017 cancer at health institutions located in
Montevideo Uruguay and Buenos
Aires, Argentina.
Aveni et al. Sample of 4925 healthcare
2016 professionals consisting of 111
midwives, 2372 nurses, 1969 medical
doctors and 145 physical therapists
employed in Lausanne University
Hospital Switzerland.
context of their philosophy and health
values.
Qualitative Factorial analysis of the vignette questions
study indicated that two factors determined the
utilization of acupuncture techniques:
information seeing (x=0.70) and
acupuncture acceptability (x=0.88).
Acceptability of acupuncture interventions
was increased significantly by previous
experience while reducing interest in
information seeking. Caregivers with
previous experience were highly likely to
report desire to explore acupuncture
intervention for their children. Besides,
biomedical exposure of parents with
experience improved their interest in
pursuing for more information.
Additionally, biomedical explanation was
substantive predictor of parental likely
agreement with vignette (d=0.36).
However, common acupuncture concerns
included its potential ineffectiveness,
limited research and fear of needles.
Cross The study found that the use of Traditional
sectional Complementary/Alternative Medicine
qualitative (TCAM) among pediatric patients with
study cancer has been well documented in
Argentina and Uruguay. Both countries
recorded 47% and 76% respectively
concerning variations in the use of
modalities of TCAM used in the supportive
care in health sector. However, it was
noted that both countries harness TCAM as
a primary supportive care. Some of the
predominant predictors of TCAM included
wealth index, and mother’s education.
Cross 1247 respondents participated in the study
sectional
accounting for 25.3% response rate. 96.1%
survey
of the respondents agreed strongly that
CAM could be beneficial in pain
management. Notably, more midwives
(100%) and nurses (96.7%) agreed that
CAM was useful compared to physicians

Ormsby et al. Participants involved included two
2018 separate groups of groups consisting of
16 mid-wives. Interviews were
conducted with nine doctors, 4 general
practitioners, 2 maternity service
managers and 3 obstetricians.
(93.8%).
Qualitative Most of the participants had a positive
study
perception about acupuncture and were
open to its inclusion conventional medical
care since the considered it to safe and
efficacious.

Description of Studies
Treatment Outcomes
166 pediatric patients were involved in the study after undergoing general anesthesia during the
study period with their caregivers being invited to be participants. However, 2 caregivers
rejected the invite reducing the number of the participants in the study to be 164. A significant
number (68%) of the participant’s age ranged from 20 to 40 years with most of them being
caregivers of children in pre-operative care (82%). Fathers accounted for 13% while other
caregivers were 5% of the total participants. Majority of the caregivers (70%) were familiar with
acupuncture techniques while 60% of the participants were conversant with music therapy and
hypnotherapy (38%). The acceptance CAM modalities in the perioperative setting was
significantly high for music therapy (50%), 17% for hypnotherapy and 13% for acupuncture. The
overall acceptance of CAM as alternative intervention was 51% for caregivers with cases in
perioperative settings. Minimal differences existed on patient characteristics. It was noted that
being familiar with acupuncture and music therapy was highly correlated to the chances of CAM
acceptance at an odd ratio of 3.36.
Specific Health Beliefs
190 participants were sampled from Uruguay (n=100) and Argentina (n=90) in the study. The
number of male participants was slightly higher in both countries with Argentina having 57%
and Uruguay 58% male representation. A significant difference existed between TCAM use and
family wealth index (p=.016) and mother’s level of education (p=.45) among Argentinian
respondents. Similarly, significant differences were observed for mother’s level of education
(p=.051) and age (p=.45) among Uruguayan participants.

Concerning prevalence, the TCAM therapies constructs were substantially higher in Argentina
with high test-retest reliability. The study found high prevalence of use among Uruguayan (76%)
in comparison to 47% of the Argentinian participants. The most frequently used therapies
among Argentinians were touch healing (8%), energy healing (14%), diet change (21%) and
nutritional oral supplements (9%). Conversely, diet change, plant based medication and manual
healing were the most commonly used therapies among Uruguayans. Besides, a significant
number of Uruguayans used several forms of TCAM than their Argentinian counterparts
(p<0.001). High proportion of TCAM therapies were considered highly effective in both
countries Uruguay (75%) and Argentina (68%).
One of the primary determinant for TCAM use was mother’s education serving as the central
determinant to the use of the therapy. Children whose mothers had at least college education
were highly to use TCAM than those of from less learned parenthood. However, fathers
education was a significant predictor for TCAM use in Argentina (p<. 038). The demographic
variables were linked with number of TCAM therapies used in Uruguay. The number of TCAM
therapies increased with level of the mother education (p<.001). More TCAM therapies was
associated with affiliation to Catholicism (p<.001). Besides, wealth quantile was statistically
significant predictor for Argentinians (p<.010) while the contrary was true for Uruguayan
participants (p<.415). Participants from wealthy background were 8.5 time likely to use TCAM
than those from low income backgrounds. It was found that previous use in a family was critical
determinant for TCAM use among Uruguayan participants.
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