Commentary

The integration of bio-medicine and culturally based alternative medicine: implications for health care providers and patients
Brenda Lovell1

Abstract: Complementary and alternative medicine (CAM) are therapies used along with or in place of bio-medicine. Many forms of CAM originate in culture, referred to as culturally based alternative medicines. Usage of CAM is high with large numbers of patients using CAM for mental health, pain and musculoskeletal problems. Their desire for holistic care may be the impetus for this interest, as alternative care practitioners spend more time analyzing illness symptoms. These factors along with the global migration of immigrants accustomed to traditional medicine but now immersed in biomedical health care systems, has created potential for misunderstanding. Drug interactions for some forms of CAM taken with bio-medicine can occur. Insufficient scientific studies about CAM has reduced acceptance and educational opportunities to learn about CAM are limited. Ideas for policy and research are forming. (Global Health Promotion, 2009; 16 (4): pp. 6568). Key words: complementary and alternative medicine, health education, patient communication, patient safety

Introduction
The usage of complimentary and alternative medicine (CAM) in Canada and around the world is on the rise. In the USA during 1997, more than 42 percent of the adult population used CAM to deal with symptoms and health problems (1, 2). In Canada during 1997, 4050 percent of the population was using CAM (3). The grouping together of complementary and alternative with the acronym CAM supports expediency, although further analysis of the applications and properties and how they differ warrants clarification and discussion.

Defining CAM
Complementary therapies/medicine would be used along with bio-medicine; chiropractic and acupuncture are examples. Alternative medicine would consist of medical practices that are not in conformity with standards of the medical community, not taught at medical school, and generally not available at North American hospitals (4). These would be used in place of bio-medicine with Naturopathy and Homeopathy as examples. Additionally, many forms of alternative medicine form their basis in culture, which then impact health beliefs and practices. Culturally based alternative medicines are forms of

1. Correspondence to: Brenda Lovell, University of Manitoba, 490 Drake Centre, Winnipeg, Manitoba, Canada R3T 5V4. Tel: (204) 7893368; Fax: (204) 7893905. (lovellb@cc.umanitoba.ca)
Global Health Promotion 1757-9759; Vol 16(4): 6568; 348132 Copyright The Author(s) 2009, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975909348132 http://ghp.sagepub.com

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traditional medicine, indigenous healing beliefs and practices of a particular culture or society pre-dating contact with Europeans, inseparable from concerns with spiritual issues (5). Included is traditional Chinese herbal medicine, Indian Ayurveda, Native American, Latin American, African and other folk medicine practices. Naturopathy and Homeopathy have their origins in western culture, but draw upon culturally based ancient remedies (6, 7). All of these practices would be alternatives to bio-medicine and not have achieved integration within the bio-medical health systems that dominate contemporary societies. It is important to note that what constitutes alternative may vary in different contexts, especially in countries which integrate alternative and bio-medicine simultaneously within their health care systems.

meaning behind symptoms, furthers the notion of partnership between patient and practitioner (2, 9). Second, immigrants from developing countries who may have relied on traditional healers for their basic health needs (15), are settling in developed countries which are predominantly bio-medicine.

Research and policy

The increased diversity in patients has the potential to lead to misunderstanding and misapplication. In response, the British and American Medical Associations have called upon health care providers to learn about CAM, and to discuss these practices with their patients (11). Scientific evidence of the curative qualities of many complimentary and alternative therapies is limited (16), and consequently the lack of published scientific studies has greatly reduced acceptance by many in the biomedical community (15, 17). The World Health Organization in its efforts to promote dialogue has released a global strategy on traditional, complementary, and alternative medicine, outlining steps to improve the safety, efficacy, and the availability of these practices (15). However, the gap is potentially widening between allopathic and traditional practitioners in both developed and developing countries (15). Traditional healers do not believe that monitoring or regulation of their practices is warranted; they assert that the efficacy of their products has stood the test of time (15). Health care providers during the medical encounter are exposed to the complex relationship between a patients health beliefs and associated behaviors. These beliefs in turn directly influence use of health services, compliance, and affect health outcomes (18). In particular research has found that patients using folk remedies may present for care to a practitioner of bio-medicine (18). Second, harmful interactions between herbal medicines and allopathic drugs have been documented, in particular for CAM delivery systems that are indigested, smoked, inhaled or injected (8, 15). Finally, the inability to achieve a shared understanding and acceptance of each others beliefs inhibits the therapeutic relationship (18). From this analogy we see that the relationship is complex and can compromise patient safety, unless steps are taken to consciously manage this interaction. To further complicate this issue, research by Eisenberg found that 6372 percent of patients did not disclose at

Users of CAM
Research studies have found that use of CAM among specific population groups is vast. Women, the higher educated, and individuals suffering from pain, anxiety, and musculoskeletal problems were the main users (2). Fatigue, headaches, insomnia, and depression are also common reasons cited for seeking treatment from alternative practitioners (8). A study of breast cancer survivors in Ontario found that 66.7 percent of women were using some form of CAM (9). The usage of CAM has been found to widespread among pediatric populations as well (10). Patients were also found to be integrating their usage of CAM with treatments prescribed from psychiatrists (8). In addition, 80 percent of the worlds population use herbal medicine (1). Two distinct forms of patients have emerged from this analogy. First, patients in health systems dominated by bio-medicine are exploring CAM due in part to increased patient autonomy, a proliferation of information available via the Internet, and the desire for health care options not offered by biomedicine (11, 12). The desire to achieve a more holistic form of care may be a motivating factor as to why patients use CAM (2). Studies have indicated that these practitioners use a holistic patientcentered model, drawing upon the unique factors and mental state inherent in each individual (2, 6). Practitioners spend more time with the patient, which may allow for a more open exchange of concerns that the patient has (1, 13, 14). The focus on prevention, emotional support and discovery of the
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least one type of CAM treatment to their physicians (19). Common reasons for patient nondisclosure were: they thought it wasnt important for their health care provider to know (61%); their health care provider didnt ask (60%); and they thought it was none of their health providers business (31%). Patients want to discuss their complementary medicine with a physician, and feel guidance from a physician is helpful when making decisions about CAM (17). However, patients feel disclosing usage of traditional therapies might result in lower quality of care or hinder the caregiver/patient therapeutic relationship (15, 19). Health care providers can encourage patient disclosure by attempting to gain familiarity with the most common forms of CAM to be able to assess patients for interactions, and to know where to find information about other treatments (8), irrespective of whether or not they endorse these therapies. Asking patients in a nonjudgmental way about their use of CAM can also support patient disclosure (8).

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Conclusion
Governments and organizations around the world are working to formulate strategies and ideas for policy and research. Physicians and other health care providers may lack the educational opportunities to learn about CAM or health beliefs that are bounded in culture. Grand Rounds, continuing professional development workshops, and other forms of discussion group, would be ideal venues to bridge this gap. Similarly, public health education should become a priority to ensure that patients use CAM responsibly, and to promote the importance of good provider/patient communication surrounding this issue. References
1. Frohock F. Moving lines and variable criteria: Differences/connections between allopathic and alternative medicine. In: Sheehan H, Brenton B, editors. Global perspectives on complementary and alternative medicine. Ann Am Acad Pol Soc Sci. 2002; 583(1): 217. 2. Goldstein M. The emerging socioeconomic and political support for alternative medicine in the United States. In: Sheehan H, Brenton B, editors. Global perspectives on complementary and alternative medicine. Ann Am Acad Pol Soc Sci. 2002; 583(1): 458. 3. de Bruyn T. Taking stock: policy issues associated with complementary and alternative health care. In: Shearer R, Simpson J, editors. Perspectives on complementary 11.

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and alternative health care: A collection of papers prepared for Health Canada. Ottawa: Health Canada; 2001: 21, 34. Verhoef MJ, Sutherland LR. General Practitioners Assessment of and Interest in Alternative Medicine in Canada. Soc Sci Med. 1995; 41(4): 51115. Johnston SL. Native American traditional and alternative medicine. In: Sheehan H, Brenton B, editors. Global perspectives on complementary and alternative medicine. Ann Am Acad Pol Soc Sci. 2002; 583(1): 1978. Baer H. Toward an integrative medicine: Merging alternative therapies with biomedicine. Walnut Creek, CA; Altamira Press; 2004. National Center for Complementary and Alternative Medicine. Questions and answers about homeopathy [Internet]. Available at: http://nccam.nih.gov/health/ homeopathy (accessed September 2008). Yager J, Siegfreid SL, DiMatteo TL. Use of alternative remedies by psychiatric patients: illustrative vignettes and a discussion of the issues. Am J Psychiatry. 1999; 156(9): 143237. Boon H, Stewart M, Kennard MA, Gray R, Sawka C, Brown JB, et al. Use of complementary/alternative medicine by breast cancer survivors in Ontario: Prevalence and perceptions. J. Clin.Oncol. [Online]. 2000; 18(13): 251521. (accessed April 2007). Jean DJ, Cyr C. Use of complementary and alternative medicine in a general pediatric clinic. Pediatrics. 2007; 120(1): 13841. Jonas W. Policy, the public, and priorities in alternative medicine research. In: Sheehan H, Brenton B, editors. Global perspectives on complementary and alternative medicine. Ann Am Acad Pol Soc Sci. 2002; 583(1): 32. Tataryn D, Verhoef M. Combining conventional, complementary, and alternative health care: A vision of integration. In: Shearer R, Simpson J, editors. Perspectives on complementary and alternative health care: A collection of papers prepared for Health Canada. Ottawa: Health Canada; 2001. p. 87. Boon H. Patient-practitioner communication in conventional and complementary medicine contexts. In: Dube L, Ferland G, Moskowitz DS, editors. Emotional and interpersonal dimensions of health services: Enriching the art of care with the science of care. Montreal & Kingston: McGill-Queens University Press; 2003. pp. 10614. Hughes K. Health as individual responsibility: Possibilities and personal struggle. In: Tovey P, Easthope G, Adams J, editors. The mainstreaming of complementary and alternative medicine: Studies in social context. New York: Routledge; 2004. p. 36. Fink S. International efforts spotlight traditional, complementary, and alternative medicine. Am J Public Health. 2002; 92: 17349. Advisory Group on Complementary and Alternative Health Care: Health Systems Division, Health Canada. The need for guidelines: ethical issues in the use of complementary and alternative health care in Canada today. In: Shearer R, Simpson J, editors. Perspectives on complementary and alternative health
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care: A collection of papers prepared for Health Canada. Ottawa: Health Canada; 2001. p. 42. 17. Coulter I. Integration and paradigm clash: The practical difficulties of integrative medicine. In: Tovey P, Easthope G, Adams J, editors. The mainstreaming of complementary and alternative medicine: Studies in social context. New York: Routledge; 2004. p. 108.

18. Pachter LM. Culture and clinical care: folk illness beliefs and behaviors and their implications for health care delivery. JAMA. 1994; 271(9): 6904. 19. Eisenberg DM, Kessler RD, Van Rompay M, Kaptchuk TJ, Wilkey SA, Appel S, et al. Perceptions about complementary therapies relative to conventional therapies among adults who use both: Results from a national survey. Ann Intern Med. 2001; 135: 34451.

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Rsums

sest tout particulirement proccupe de la manire dont les systmes de surveillance actuels pouvaient sappliquer au domaine de la promotion de la sant, pour en particulier dvelopper les bases de donnes probantes pour la pratique de la promotion de la sant. Suite ces discussions, lAlliance mondiale pour la Surveillance des Facteurs de Risque (WARFS), qui est un Groupe de Travail l'chelle mondiale de lUIPES, a t forme afin de travailler fournir des connaissances et de lexpertise en matire de surveillance comme un outil pour faire progresser la promotion de la sant. Pour les membres de lUIPES qui seraient intresss participer aux travaux de ce groupe, cet article fournit un aperu de lorientation stratgique de la WARFS et des sous-groupes de travail nouvellement forms. (Global Health Promotion, 2009; 16(4): pp.58-60)

Un programme de nutrition favorable la sant avec des louveteaux

A. Sotgiu, A. Mereu, G. Spiga, V. Coroneo et P. Contu
Ce commentaire dcrit le dveloppement du programme de Nutrition Sant men par lUniversit de Cagliari auprs de 19 groupes de scouts italiens. Au total, 353 enfants gs de 6 10 ans ont particip ce programme. Les objectifs taient de dvelopper par le jeu les connaissances des enfants sur le rgime alimentaire mditerranen. Ce projet a t dvelopp entre les mois de janvier et juin 2006. Les activits ont t menes par les chefs des louveteaux dans le but damliorer les connaissances de ces jeunes scouts en matire de nutrition. Chaque semaine, ils ont essay un jeu diffrent, ce qui a montr quils sintressaient de plus en plus cette initiative et avaient envie de participer. Cette exprience a prouv quil est possible dimpliquer les enfants dans un contexte extrascolaire pour mener un programme de promotion de la sant. (Global Health Promotion, 2009; 16(4): pp.61-64)

Lintgration de la biomdecine et des mdecines alternatives bases sur la culture : implications pour les prestataires de soins et les patients
B. Lovell
Les mdecines complmentaires et alternatives (MCA) sont des thrapies utilises en complment ou la place de la biomdecine. De nombreuses formes de MCA tirent leur origine de la culture et sont qualifies de mdecines alternatives bases sur la culture. Les MCA sont largement utilises par un grand nombre de patients y recourant pour des problmes de sant mentale, des problmes musculosquelettiques, ou en cas de douleur. Leur dsir de prise en charge holistique pourrait bien tre lorigine de cet engouement, dans la mesure o les prestataires de soins alternatifs passent plus de temps analyser les symptmes dune maladie. Ces facteurs, associs larrive dimmigrants habitus une mdecine traditionnelle et dsormais immergs dans des systmes de soins de sant biomdicaux, ont gnr un terreau favorable une certaine incomprhension. Des interactions mdicamenteuses peuvent survenir pour certaines formes de MCA utilises paralllement des traitements biomdicaux. Linsuffisance dtudes scientifiques portant sur les MCA a diminu leur acceptation et les opportunits dapprendre sur les MCA dans un cursus denseignement sont limites. Des ides de politiques et de travaux de recherche sont cependant en train dmerger. (Global Health Promotion, 2009; 16(4): pp.65-68)

Crer le document Promouvoir la sant lcole : des preuves laction

L. St Leger et I. M. Young
Depuis presque un sicle, les coles ont t impliques dans la promotion de la sant et lducation pour la sant partout dans le monde. Mais les initiatives qui sinscrivent en milieu scolaire ont-elles un impact sur lducation des jeunes et sur leur sant ? Cet article dcrit le processus dlaboration du document Promouvoir
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sus subgrupos de trabajo recin creados para aquellos miembros de la UIPES que estn interesados en participar. (Global Health Promotion, 2009; 16(4): pp. 58-60)

Programa de nutricin sana para nios de la Seccin Menor de los scouts

A. Sotgiu, A. Mereu, G. Spiga, V. Coroneo y P. Contu
Este comentario describe el desarrollo del programa Nutricin Sana realizado por la Universidad de Cagliari con 19 grupos de scouts italianos. Participaron en l un total de 353 nios de edades comprendidas entre los 6 y 10 aos. El objetivo era desarrollar el conocimiento de los nios sobre la dieta mediterrnea a travs de juegos. El proyecto se realiz entre enero y junio de 2006. Las actividades se llevaron a cabo por los dirigentes de la Seccin Menor o rama de Lobatos con el objetivo de mejorar los conocimientos sobre nutricin de dicha rama. Cada semana organizaron un juego diferente que mostr un aumento del grado de inters y de participacin de esta rama. La experiencia demostr que es posible hacer participar a los nios en un contexto ajeno a la escuela para llevar a cabo un programa de promocin de la salud. (Global Health Promotion, 2009; 16(4): pp. 61-64)

La integracin de la biomedicina y de la medicina alternativa de base cultural: implicaciones para los profesionales de la atencin de salud y los pacientes
B. Lovell
La medicina complementaria y la alternativa (MCA) son terapias utilizadas junto con la biomedicina o en lugar de ella. Muchas formas de MCA tienen su origen en la que se aplican, y se las denomina medicinas alternativas de base cultural. Existe un elevado grado de utilizacin de MCA para la salud mental y los problemas de dolor y msculo esquelticos. El deseo de recibir una atencin integral del elevado nmero de pacientes que recurre a ellas podra ser el motivo de este inters, puesto que los profesionales de la medicina alternativa dedican ms tiempo a analizar los sntomas de la enfermedad. Estos factores, as como las migraciones de personas acostumbradas a la medicina tradicional que ahora viven inmersas en sistemas de salud biomdicos son caldo de cultivo para la confusin. Algunos remedios de la MCA pueden interferir con los frmacos de la biomedicina. La escasez de estudios existentes sobre la MCA ha reducido su aceptacin y son limitadas las oportunidades educativas de aprender sobre ella. Estn surgiendo ideas para formular polticas y llevar a cabo investigacin al respecto. (Global Health Promotion, 2009; 16(4): pp. 65-68)

Elaboracin del documento Promover la salud en la escuela: de la evidencia a la accin

L. St Leger y I. M. Young
Hace casi un siglo que escuelas de todo el mundo participan en la promocin de la salud y en la educacin para la salud. Las iniciativas de este tipo realizadas en la escuela, cambian los resultados educativos y de salud de los jvenes? Este trabajo describe el proceso de elaboracin del texto Promover la salud en la escuela: de la evidencia a la accin. El documento se realiz principalmente para el sector educativo. Desarrolla las razones por las cuales las escuelas deberan emprender iniciativas relacionadas con la salud. Subraya adems los principales descubrimientos de la literatura de este sector sobre qu es posible lograr en el mbito de la salud escolar y las circunstancias en las cuales se consiguen los avances. La atencin se centra tanto en la evidencia procedente del sector de la enseanza, a saber, escuelas eficaces, enfoques de aprendizaje y de enseanza, y del sector sanitario, es decir, una escuela entera o Escuela Promotora de Salud (EPS), como en la

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