Felicity L. Bishop

A Systematic Review of Beliefs Involved in the Use of Complementary and Alternative Medicine

People might be attracted to and use complementary and alternative medicines (CAM) because they hold beliefs that are congruent with CAM. This article collates, examines and synthesizes the evidence surrounding this hypothesis. Most studies are cross-sectional and focus on a limited number of beliefs. Multivariate studies suggest that beliefs related to control and participation, perceptions of illness, holism and natural treatments, and general philosophies of life predict CAM use when controlling for demographic and clinical factors. Further research should examine the robustness of these relationships in different illness groups and the prospective relationships among beliefs and CAM use over time.

A systematic literature review of complementary and alternative medicine prevalence in EU

Background: Studies suggest that complementary and alternative medicine (CAM) is widely used in the European Union (EU). We systematically reviewed data, reporting research quality and the prevalence of CAM use by citizens in Europe; what it is used for, and why. Methods: We searched for general population surveys of CAM use by using Ovid MEDLINE (1948 to September 2010), Cochrane Library (1989 to September 2010), CINAHL (1989 to September 2010), EMBASE (1980 to September 2010), PsychINFO including PsychARTICLES (1989 to September 2010), Web of Science (1989 to September 2010), AMED (1985 to September 2010), and CISCOM (1989 to September 2010). Additional studies were identified through experts and grey literature. Cross-sectional, population-based or cohort studies reporting CAM use in any EU language were included. Data were extracted and reviewed by 2 authors using a pre-designed extraction protocol with quality assessment instrument. Results: 87 studies were included. Inter-rater reliability was good (kappa = 0.8). Study methodology and quality of reporting were poor. The prevalence of CAM use varied widely within and across EU countries (0.3–86%). Prevalence data demonstrated substantial heterogeneity unrelated to report quality; therefore, we were unable to pool data for meta-analysis; our report is narrative and based on descriptive statistics. Herbal medicine was most commonly reported. CAM users were mainly women. The most common reason for use was dissatisfaction with conventional care; CAM was widely used for musculoskeletal problems. Conclusion: CAM prevalence across the EU is problematic to estimate because studies are generally poor and heterogeneous. A consistent definition of CAM, a core set of CAMs with country-specific variations and a standardised reporting strategy to enhance the accuracy of data pooling would improve reporting quality.

Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture.

Summary This multifactorial mixed‐methods randomized controlled trial quantified the specific and nonspecific factors of acupuncture, and found that the practitioner, not the treatment, has the strongest effect on outcome. Abstract The nonspecific effects of acupuncture are well documented; we wished to quantify these factors in osteoarthritic (OA) pain, examining needling, the consultation, and the practitioner. In a prospective randomised, single‐blind, placebo‐controlled, multifactorial, mixed‐methods trial, 221 patients with OA awaiting joint replacement surgery were recruited. Interventions were acupuncture, Streitberger placebo acupuncture, and mock electrical stimulation, each with empathic or nonempathic consultations. Interventions involved eight 30‐minute treatments over 4 weeks. The primary outcome was pain (VAS) at 1 week posttreatment. Face‐to‐face qualitative interviews were conducted (purposive sample, 27 participants). Improvements occurred from baseline for all interventions with no significant differences between real and placebo acupuncture (mean difference −2.7 mm, 95% confidence intervals −9.0 to 3.6; P = .40) or mock stimulation (−3.9, −10.4 to 2.7; P = .25). Empathic consultations did not affect pain (3.0 mm, −2.2 to 8.2; P = .26) but practitioner 3 achieved greater analgesia than practitioner 2 (10.9, 3.9 to 18.0; P = .002). Qualitative analysis indicated that patients’ beliefs about treatment veracity and confidence in outcomes were reciprocally linked. The supportive nature of the trial attenuated differences between the different consultation styles. Improvements occurred from baseline, but acupuncture has no specific efficacy over either placebo. The individual practitioner and the patient’s belief had a significant effect on outcome. The 2 placebos were equally as effective and credible as acupuncture. Needle and nonneedle placebos are equivalent. An unknown characteristic of the treating practitioner predicts outcome, as does the patient’s belief (independently). Beliefs about treatment veracity shape how patients self‐report outcome, complicating and confounding study interpretation.

Constructing agency in treatment decisions: negotiating responsibility in cancer

People belonging to cancer patient support groups participated in focus groups concerning their experiences of orthodox and complementary medicine. Their accounts of treatment decisions for cancer were analysed through discourse analysis. Accounts of both complementary and orthodox medicine addressed an ideological dilemma concerning the positioning of individuals as active or passive. Active positions were congruent with the everyday value of autonomy and responsible individuality, but conflicted with the established expertise of the medical profession in cancer and entailed being accountable for one’s health. Passive positions reversed this situation. Complementary medicine provided an opportunity for people with cancer to negotiate active positions in a limited domain of health care. The responsibility for health associated with taking active treatment decisions was problematic in accounts of both orthodox and complementary medicine.

Placebo Use in the United Kingdom: Results from a National Survey of Primary Care Practitioners

Objectives Surveys in various countries suggest 17% to 80% of doctors prescribe ‘placebos’ in routine practice, but prevalence of placebo use in UK primary care is unknown. Methods We administered a web-based questionnaire to a representative sample of UK general practitioners. Following surveys conducted in other countries we divided placebos into ‘pure’ and ‘impure’. ‘Impure’ placebos are interventions with clear efficacy for certain conditions but are prescribed for ailments where their efficacy is unknown, such as antibiotics for suspected viral infections. ‘Pure’ placebos are interventions such as sugar pills or saline injections without direct pharmacologically active ingredients for the condition being treated. We initiated the survey in April 2012. Two reminders were sent and electronic data collection closed after 4 weeks. Results We surveyed 1715 general practitioners and 783 (46%) completed our questionnaire. Our respondents were similar to those of all registered UK doctors suggesting our results are generalizable. 12% (95% CI 10 to 15) of respondents used pure placebos while 97% (95% CI 96 to 98) used impure placebos at least once in their career. 1% of respondents used pure placebos, and 77% (95% CI 74 to 79) used impure placebos at least once per week. Most (66% for pure, 84% for impure) respondents stated placebos were ethical in some circumstances. Conclusion and implications Placebo use is common in primary care but questions remain about their benefits, harms, costs, and whether they can be delivered ethically. Further research is required to investigate ethically acceptable and cost-effective placebo interventions.

Complementary medicine use by men with prostate cancer: a systematic review of prevalence studies

Men with prostate cancer are reported as commonly using complementary and alternative medicine (CAM) but surveys have not recently been subjected to a rigorous systematic review incorporating quality assessment. Six electronic databases were searched using pre-defined terms. Detailed information was extracted systematically from each relevant article. Study reporting quality was assessed using a quality assessment tool, which demonstrated acceptable inter-rater reliability and produces a percentage score. In all, 42 studies are reviewed. All were published in English between 1999 and 2009; 60% were conducted in the United States. The reporting quality was mixed (median score=66%, range 23–94%). Significant heterogeneity precluded formal meta-analysis. In all, 39 studies covering 11 736 men reported overall prevalence of CAM use; this ranged from 8 to 90% (median=30%). In all, 10 studies reported prevalence of CAM use specifically for cancer care; this ranged from 8 to 50% (median=30%). Some evidence suggested CAM use is more common in men with higher education/incomes and more severe disease. The prevalence of CAM use among men with prostate cancer varies greatly across studies. Future studies should use standardised and validated data collection techniques to reduce bias and enhance comparability.

Why do people use different forms of complementary medicine? Multivariate associations between treatment and illness beliefs and complementary medicine use

This study investigated associations between complementary medicine use and treatment and illness beliefs. Previously validated questionnaire measures of treatment beliefs, illness beliefs, and complementary medicine use were presented and advertised online. Completed questionnaires were received from 247 participants. Logistic regression analysis showed that demographic characteristics, treatment beliefs, and illness beliefs accounted for approximately 36% of the variance in complementary medicine use. Separate analyses were conducted to predict use of different types of complementary medicine. The strength of associations between beliefs and complementary medicine use was related to the type of complementary medicine used. The results suggest that people use complementary medicine because they are attracted to it rather than because they are disillusioned with orthodox medicine, and that both treatment and illness beliefs have an important role in explaining why people use complementary medicine.

Context Effects and Behaviour Change Techniques in Randomised Trials: a Systematic Review Using the Example of Trials to Increase Adherence to Physical Activity in Musculoskeletal Pain

Objective: To describe and explore the effects of contextual and behaviour change technique (BCT) content of control and target interventions in clinical trials. Design: Review and meta-analysis of 42 trials from a Cochrane review of physical activity in chronic musculoskeletal pain. Main Outcome Measures: Two researchers coded descriptions of target and control interventions for (a) 93 BCTs and (b) whether target and control interventions shared each of five contextual features (practitioners’ characteristics, patient-practitioner relationship, intervention credibility, superficial treatment characteristics e.g. delivery modality, and environment). Quality of study reporting was assessed. Effect sizes for adherence to physical activity and class attendance were computed (Cohen’s d) and analysed separately. Results: For physical activity outcomes, after controlling for reporting quality, larger effect sizes were associated with target and control interventions using different modalities (β = −.34, p = .030), target and control interventions involving equivalent patient-practitioner relationship (β = .40, p = .002), and target interventions having more unique BCTs (i.e. more BCTs not also in the control) (β = .008, p = .030). There were no significant effect moderators for class attendance outcomes. Conclusion: Contents of control conditions can influence effect sizes and should be considered carefully in trial design and systematic reviews.

The effect of patient–practitioner communication on pain: a systematic review

Communication between patients and health care practitioners is expected to benefit health outcomes. The objective of this review was to assess the effects of experimentally varied communication on clinical patients’ pain.

Psychological Covariates of Longitudinal Changes in Back-related Disability in Patients Undergoing Acupuncture

Objectives:To identify psychological covariates of longitudinal changes in back-related disability in patients undergoing acupuncture. Materials and Methods:A longitudinal postal questionnaire study was conducted with data collection at baseline (pretreatment), 2 weeks, 3, and 6 months later. A total of 485 patients were recruited from 83 acupuncturists before commencing acupuncture for back pain. Questionnaires measured variables from 4 theories (fear-avoidance model, common-sense model, expectancy theory, social-cognitive theory), clinical and sociodemographic characteristics, and disability. Longitudinal multilevel models were constructed with disability over time as the outcome. Results:Within individuals, reductions in disability (compared with the person’s individual mean) were associated with reductions in: fear-avoidance beliefs about physical activity (&bgr;=0.11, P<0.01) and work (&bgr;=0.03, P<0.05), catastrophizing (&bgr;=0.28, P<0.05), consequences (&bgr;=0.28, P<0.01), concerns (&bgr;=0.17, P<0.05), emotions (&bgr;=0.16, P<0.05), and pain identity (&bgr;=0.43, P<0.01). Within-person reductions in disability were associated with increases in: personal control (&bgr;=−0.17, P<0.01), comprehension (&bgr;=−0.11, P<0.05) and self-efficacy for coping (&bgr;=−0.04, P<0.01). Between individuals, people who were less disabled had weaker fear-avoidance beliefs about physical activity (&bgr;=0.12, P<0.01), had more self-efficacy for coping (&bgr;=−0.07, P<0.01), perceived less severe consequences of back pain (&bgr;=0.87, P<0.01), had more positive outcome expectancies (&bgr;=−0.30, P<0.05), and appraised acupuncture appointments as less convenient (&bgr;=0.92, P<0.05). Discussion:Illness perceptions and, to a lesser extent, self-efficacy and expectancies can usefully supplement variables from the fear-avoidance model in theorizing pain-related disability. Positive changes in patients’ beliefs about back pain might underpin the large nonspecific effects of acupuncture seen in trials and could be targeted clinically.