Complementary health therapies: Moving towards an integrated health model

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1 Collegian (2013) 20, Available online at jo ur nal homep age: Complementary health therapies: Moving towards an integrated health model Julieanne Hilbers, PhD(Ed), Reg Psych, BSc(Hons), Grad Dip(Ed) a,, Craig Lewis, MBBS, MMed, FRACP b,1 a Diversity Health, Prince of Wales Hospital, High St, Randwick, NSW 2031, Australia b Department of Medical Oncology, Prince of Wales Hospital, Prince of Wales Clinical School, University of New South Wales, Randwick, NSW 2031, Australia Received 6 July 2010; received in revised form 4 March 2012; accepted 6 March 2012 KEYWORDS Complementary; Alternative; Integrated; Holistic Summary Background: There is increasing use of complementary and alternative medicines (CAMs), particularly amongst patients with cancer. This paper aims to better understand the types of CAM people are using and explore the reasons for using these approaches. This paper will also identify what patients want from health professionals in relation to CAM and the actions and attitudes of health professionals towards CAM. Finally, this paper will discuss the potential implications for health services. Method: Two surveys were conducted, a self-administered survey was completed by oncology patients; and a second online survey completed by staff. Results: Patients used CAM as an adjunct to services they receive from conventional health services, not as an alternative. The positive and empowering role that complementary health practices play in people s lives was a common theme as was the need for CAM to be used with care. Survey responses by health care staff revealed mixed views of CAM. Most staff had positive views about CAM as a treatment adjunct and said they responded to patients accordingly. Only a minority expressed scepticism and were less inclined to support CAM use by their patients. Nevertheless, few staff instigated discussions around CAM. Conclusion: This paper presents key considerations for health services wanting to better respond to CAM and adopt an integrated approach to health care Australian College of Nursing Ltd. Published by Elsevier Ltd. Background Corresponding author. Tel.: addresses: julieanne.hilbers@sesiahs.health.nsw.gov.au (J. Hilbers), craig.lewis@sesiahs.health.nsw.gov.au (C. Lewis). 1 Tel.: This research explores complementary and alternative medicine (CAM) from a person-centred perspective. This approach allows a holistic, patient-centred view of health and recognises self-determination and the impact of sociocultural practices on the patient journey /$ see front matter Australian College of Nursing Ltd. Published by Elsevier Ltd. doi: /j.colegn

2 52 J. Hilbers, C. Lewis What is complementary and alternative medicine? A core challenge with CAM is gaining agreement on its scope and definition. A definition offered by Eskinazi (1998) and adopted by the New South Wales Department of Health refers to CAM as a heterogeneous collection of therapeutic substances and techniques based on theory and explanatory mechanisms that are not consistent with the western clinical model of medicine. The United States of America (USA) National Centre for Complementary and Alternative Medicine (2000) divides CAM into five major categories: Alternative medical systems: traditional Chinese medicine and Ayurveda (Eastern systems), homeopathy and naturopathy (Western systems); Mind-body interventions: patient support groups, meditation, prayer, mental healing, and therapies using creative outlets; Biologically based therapies: herbs, foods, vitamins, minerals and dietary supplements; Manipulative and body based methods: therapeutic massage, chiropractic, osteopathy; and Energy therapies: therapeutic touch, Reiki, Qi gong, electromagnetic and acupuncture. Directions and core themes in CAM usage Increasing the use of CAM A systematic review undertaken by Ernst (2000) showed that it is difficult to accurately define the true prevalence of CAM use within the general population. However, he notes international studies conducted in industrialised countries, revealed that the most likely users of CAM are female, affluent, middle aged and white. Australian research indicates that CAM use is increasing (Australian Bureau of Statistics, 2008). A study by Girgis, Adams, and Sibbritt (2005) found that 22% of cancer patients use CAM. Considerable CAM use has also been found in patients presenting to Australian emergency departments (Taylor, Walsham, Taylor, & Wong, 2004). Reasons why people use CAM People use CAM for numerous reasons (Astin, 1998; Bensoussan & Lewith, 2004; Coulter & Willis, 2004; NSW Cancer Council, 2009; Robotin & Penman, 2006; Sanderson, Koczwara, & Currow, 2006; Siahpush, 1999). For many, it is consistent with traditional beliefs and practices from their cultural and/or religious background, and CAM practices such as massage, acupuncture and the use of herbs in Chinese Traditional Medicine stem from long-standing customs in health and healing (Bolton, Sekneh, & Leung, 2002). Secondly, CAM may be congruent with values, beliefs and spiritual/philosophical orientations towards natural lifestyles, as a manifested assertion of treating the whole person by encompassing the mind, body and spirit, not just focusing on the physical (Astin, 1998; Siahpush, 1999; Testerman, Morton, Mason, & Ronan, 2004). Research into the spiritual and/or religious needs of patients and families (Hilbers, Haynes, & Kivikko, 2010) found that the majority of hospital patients, their families and carers have some religious affiliation or spiritual connection, which becomes more important when a person is ill. Complementary and alternative medicine such as herbal supplements, diet and stress management techniques are widely used for everyday health maintenance and illness prevention complementary and alternative medicine potentially allows people to be more active participants in their health care and treatment than mainstream health models (Snyderman & Weil, 2002) and is often viewed as useful when orthodox treatment has been ineffective or has caused unpleasant side effects (George, Ioannides-Demos, Santamaria, Kong, & Stewart, 2004). Disclosing CAM Despite the widespread use of CAM, patients are unlikely to discuss CAM use with their doctors (Ernst, 2000; George et al., 2004). The fear of judgement by health staff appears to be a contributing factor in inhibiting open communication (George et al., 2004). This contrasts with the person-centred care that most patients say they want, where they are listened to respectfully, have their views taken seriously, and are given the opportunity to talk about what is important to them, to ask questions and express concerns (Australian Resource Centre for Healthcare Innovations, 2006). This reluctance to disclose CAM use has serious implications for medicine management (Chrystal, Allan, Fergeson, & Isaacs, 2003). Holistic view of health There is a shift in contemporary health care practice within the USA, Canada, United Kingdom (UK) and Australia towards a more holistic view of health where medicine and/or therapies combine complementary and conventional approaches that support physical, social, psychological, emotional and spiritual wellbeing (Senate Community Affairs References Committee (SCARC), 2005). Many CAM practices focusing on nutrition and/or exercise are now standard within health promotion and rehabilitation programmes, whilst counselling is central in social support and psychological specialties. Other practices such as chiropractic, homeopathy, naturopathy and acupuncture are now being recognised by private health funds (Cohen, 2004; McCabe, 2005). Health professionals attitudes and skills Hirschkorn and Bourgeault (2005) conducted a systematic review of the English language literature on health care providers attitudes towards CAM. A broad survey of the literature suggested that physicians in Western industrialised and primarily English-speaking nations demonstrate both tolerance for, and moderate interest in, CAM. There is growing interest in and use of CAM by medical professionals, especially general practitioners (Hall & Giles-Corti, 2000; Hassed, 2005; Pirotta, Cohen, Kotsirilos, & Farish, 2000); and in health services which integrate complementary therapies, particularly in association with cancer services (SCARC, 2005). The incorporation of CAM into medical courses has grown but to date most medical professionals still have limited training or understanding of CAM (Ernst, 2003). At a

3 Complementary health therapies: Moving towards an integrated health model 53 Table 1 Types of CAM for which there is clinical-trials based evidence for their use in the management of side-effects of cancer treatment. Psychotherapy, counselling, relaxation, support groups: help reduce stress Meditation: improves sleep and reduces stress Yoga: improves sleep and reduces stress Massage: helps reduce pain and fatigue, and improves sleep Tai chi: relieves pain, improves flexibility and strength, and reduces stress Reflexology: reduces anxiety Spiritual practices: help reduce stress Acupuncture: reduces nausea, vomiting and fatigue from chemotherapy and radiotherapy Aromatherapy: improves sleep Art and music therapy: provide distraction from pain and aid relaxation Eating more vegetables, fruits and legumes, together with regular physical activity has many benefits. These healthy habits may help slow the development of many cancers and may also help reduce the risk of cancer recurring or secondary cancers Exercise may also boost your energy levels, decrease fatigue, relieve stress, and lower anxiety and depression. Modified from NSW Cancer Council, minimum, basic knowledge about the most commonly used practices is required for health professionals to engage in effective communication with patients (George et al., 2004). Evidence base to support use Until recently CAM has existed as an independent, parallel health care system, mainly ignored by conventional and medical practitioners on the grounds that it there is no compelling evidence to accept or reject its use, and because the available research has substantial methodological flaws or systematic biases (Coulter & Willis, 2004; Kerridge & McPhee, 2004). The NSW Cancer Council (2006) advise that some CAM can be harmful, particularly when combined with other treatments and used without clinical consultation. However, they also described a variety of complementary therapies for which there is evidence from clinical studies to support their use in management of treatment-related side-effects (Table 1). Potential for local research The literature review highlighted the lack of exploration of this topic within the Australian hospital setting, with the majority of previous research focusing on primary care practitioners. With this in mind the aim of the researchers was to explore the experiences, perceptions and opinions of hospital patients in relation to the themes outlined above, in particular what CAM people are using; why are they using CAM; what patients want from health staff with relevance to CAM; how staff respond to this; and what are the implications for health services. Method This study involved an initial literature review that explored general views and experiences of CAM. An exploratory qualitative research approach was adopted that comprised of an ethics approved, cross-sectional survey of patients with cancer who were either currently receiving active treatment or in follow-up post-treatment. The research was conducted within two public hospitals, including a public academic teaching hospital and a women s health specialist hospital, co-located on the same campus in metropolitan Sydney, Australia. Key themes identified in the literature and from consultations with oncology staff were used to inform the development of the questions framed on the National Centre for Complementary and Alternative Medicine definition of CAM outlined previously. Given local research highlighted the importance of spirituality within the health care context (Hilbers et al., 2010) this was made a stand alone item. The survey instrument comprised of 15 core items, most of which were phrased as closed-choice statements (responses were limited to Yes, No, or Undecided boxes) or as multiple ordinal questions as shown in Table 2 (CAM patient questionnaire). Questionnaires were predominantly handed out by staff who asked patients if they would be willing to participate. Patients who were very ill or tired, distressed, cognitively impaired or unable to read English were excluded from the study. Questionnaires were also left in oncology department waiting areas for patients to self-administer. A second self-administered online survey using Survey Monkey, drawing on the first survey schedule was made available to staff. It was promoted through e-newsletters and general broadcasts to staff employed at the forementioned public academic teaching hospital and a second public hospital within the same health service area. Results Given the self-selected nature of the survey and lack of validation data, only descriptive results are reported. A total of 100 questionnaires were completed for both surveys so percentages correspond to actual numbers. The qualitative data was coded for emergent themes by the first co-author and then reviewed by a research officer. The quotes provided are drawn from the free text and seek to provide more detail on the views and opinions of patients and health professionals.

4 54 J. Hilbers, C. Lewis Table 2 Example questions from the patient survey. 1. It is helpful for medical staff to know about a patient s use of complementary health treatments and practices Yes No Undecided 6. Please tick and then list which of the following you currently use or have tried in the past? Alternative medical systems: such as traditional Chinese medicine and Ayurveda (Eastern systems), homeopathy and naturopathy (Western systems) Mind-body interventions: such as patient support groups, prayer, meditation, mental healing such as psychotherapy, counseling, relaxation, Petrea King Quest for Life program, Gawler Foundation program, and therapies using creative outlets (eg. art, music and dance therapy) Biologically based therapies: such as herbs, foods, vitamins, minerals and dietary supplements (eg. shark cartilage, antioxidants, aromatherapy) Manipulative and body based methods: such as therapeutic massage, chiropractic, osteopathy, yoga and pilates Energy therapies: such as therapeutic touch, Reiki, Qi gong, Tai Chi, reflexology, Bowen therapy, energetic healing, electromagnetic therapies (including microwave therapy) and acupuncture Spiritual practices: spiritual healing, prayer, rituals Other: anything else you do to heal, stay healthy and well 10. How comfortable are you discussing complementary health beliefs and practices with your doctor? Very comfortable Moderately comfortable Not comfortable Not relevant to me..

5 Complementary health therapies: Moving towards an integrated health model 55 Table 3 Patient characteristics. Sex: Female 78 Male 22 Age: or over 9 Highest level of education attained: Postgraduate 11 Tertiary (University/TAFE or equivalent) 48 Secondary school (year 10 or 12) 35 Other 3 CALD background: Countries represented 18 Born in Australia 63 Non-English speaking country of birth 19 Spoke a language other than English at home 9 Currently receiving treatment: Chemotherapy 53 Radiotherapy 21 Patients responses Patient characteristics are presented in Table 3. Eighty seven percent of the patient participants agreed that CAM can have a positive effect on people s health. Seventy per cent were of the opinion that CAM practices become more important when a person is unwell, whilst 69% supported the statement that CAM may affect a person s response to treatment. Three quarters (73%) believed CAM can relieve side-effects, with Chinese herbs, meditation, walking, peppermint and massage listed as practices that do so. When asked what CAM they currently used or had used in the past, 10 participants indicated they had not tried any CAM practices. On average people indicated they had used at least three types of CAM with half indicating that they used biological (54%) and/or manipulative (52%) based practices. The most common CAM practices were: Alternative medical systems: the most common being acupuncture, Chinese medicine (herbal and TCM), homeopathy and naturopathy. Mind-body interventions: meditation was the main practice listed. Others included prayer, programmes offered by the Quest for Life centre, support groups, counselling and psychotherapy, hypnosis and music. Biologically based therapies: vitamins, minerals and dietary supplements being the most frequently listed along with herbs, antioxidants and diet control (e.g. a balanced diet). Manipulative and body based methods: massage, followed by yoga and chiropractic. Energy therapies: acupuncture, Reiki, QiGong and Bowen therapy. Spiritual practices: prayer was the major practice although spiritual healing (hands on) was also mentioned. Other activities mentioned included exercise (e.g. walking, swimming, gym, aqua), eating well and staying positive (e.g. positive thinking, laughing, enjoying life). Since being diagnosed patients stated they had taken up exercise (especially walking) (19%), increased communication, socialising with family and friends (10%), positive thinking (8%), prayer (7%), meditation (8%) and yoga (6%). The majority of patients (86%) felt it was helpful for medical staff to know about a patient s use of complementary health treatments and practices, but several expressed concerns about discussing CAM: They need to know, but some doctors don t believe and want you to stop everything when it isn t really necessary to stop all only some and Open dialogue is important. Negative responses from medical staff to comments or questions leads to patient not talking about use of CAM and increases risk of side effects. Eighty five percent of patients said they would use complementary health modalities if such treatments were offered at their hospital. The major practices patients expressed an interest in were massage, meditation, yoga and vitamins, but there was a broad interest across the range of modalities (Table 4). Comments about the provision of CAM services focused predominately on the positive impact such services would have on health outcomes: Hopefully it s not all about drugs. But staying healthy and positive, I consider a holistic approach to be vital. The general wellbeing of the patient is paramount even if you cannot change the outcome of the disease. I also think it helps you to live longer with a better quality of life. Some respondents viewed the provision of CAM services as conditional: I would have to feel confident the practitioners were very experienced and of the highest calibre, Providing the complementary practitioner worked alongside the medical specialist. The majority of patients said they were comfortable discussing complementary health beliefs and practices with their primary care physician, hospital nurse or hospital specialist (see Fig. 1). Of interest was the finding that patients were generally more comfortable discussing their complementary health beliefs and practices with their primary care physician compared with the treating hospital medical and nursing team. Only a third (37%) had actually discussed their practice with their hospital specialist. In cases where it had been discussed, the patient was most likely to have initiated the discussion (81%). Several patients who had raised the topic of CAM with their doctor commented on the poor response they received. When asked how they obtained information about CAM, 35% stated it was from family and friends, whilst a quarter (24%) used publications such as books and health magazines, and 16% used the Internet. Only 15% received their CAM information from medically trained staff. When patients were invited to make a general comment or say what they wanted from hospital services, several themes emerged. These were: Positive role of complementary health practices: I am certain I would not be alive now if it were not for my regular medical treatment, but I strongly believe that

6 56 J. Hilbers, C. Lewis GP Hospital Doctor Hospital Nurses No response Not relevant to me Not comfortable Moderately comfortable Very comfortable No response Not relevant to me Not comfortable Moderately comfortable Very comfortable No response Not relevant to me Not comfortable Moderately comfortable Very comfortable Number of respondents Figure 1 How comfortable are you discussing complementary health beliefs and practices with GP, Hospital Doctor, Hospital Nurse? complementary foods/herbs/practices can boost one s ability to fight this insidious thing called Cancer., I believe complementary therapies empower people dealing with cancer, and they feel they are contributing to getting well, and not being a victim of the disease or the system. Collaboration: Accept that both mainstream and complementary medicine would work very well together., All our health and well being would be better served by collaboration between practitioners of all kinds of health practice. Communicate: Be proactive in discussing options., Initiate discussions at the onset of treatment., Suggest, advise on various alternative/complementary options available to patients for their consideration. Providing literature would help. Use complementary medicine carefully: Be cautious but open minded and only introduce things of proven benefit., Embrace it, but keep the main focus on traditional medicine. Staff responses A total of 124 people viewed the online survey with 100 completing the minimum number of questions considered sufficient to generate meaningful data (18 of the 30 questions). A wide range of health professions were represented including doctors (12%), nursing (29%), allied health (27%), pharmacists (3%), administration (12%), management (5%), research (5%) and other (3%). The results showed that the majority of staff (92%) agreed that complementary health practices can have a positive effect on people s health. Over half felt that CAM becomes more important when a person is unwell. The majority of staff (82%) agreed that complementary health practices may affect a person s response to conventional treatment. Nearly all staff (97%) felt it is helpful for medical staff to know about a patient s use of complementary health treatments and practices. A comparison of patient versus staff responses to key statements in the survey is shown in Table 5. On average, staff had personally tried practices from four of the six CAM categories listed. The most preferred interventions were manipulative and body based methods (87%), such as therapeutic massage, yoga, pilates, chiropractic and osteopathy; biological based therapies (82%) such as vitamins, dietary supplements, herbs, food and minerals; and mind body interventions (63%) including meditation, counselling, relaxation and creative pursuits. Half the respondents indicated that they used alternative medical systems such as Chinese medicine, naturopathy, homeopathy or ayurvedic (54%). A similar number (53%) had experienced energy therapies: acupuncture, reflexology, qi gong, reiki and bowen therapy. Spiritual practices were important for a smaller group (27%) with prayer, healing and rituals being mentioned. When asked if there was anything else they did to stay healthy the dominant themes were exercise, eating well and having a positive attitude. Only two survey participants indicated they had not tried any CAM practices. When asked if they had ever used complementary health treatments instead of treatment provided by mainstream services, more than a quarter of staff (27%) stated they had. These preferred interventions were biological (vitamins, minerals, teas), manipulative and body based (massage, feldenkris), alternative health systems (naturopathy), energy based (acupuncture, qi gong, tai chi) and mind body based practices. When asked if they found these treatments helpful, 33 responses were positive and one was negative. Staff said that they accessed information about CAM from family and friends (58%), publications (57%), complementary health practitioners (55%), the Internet (48%) and medical staff (30%). A third of staff respondents (32%) had attended a course on complementary health. Sixteen members of staff had formal qualifications or experience in a complementary therapy including acupuncture, counselling, reiki, massage

7 Complementary health therapies: Moving towards an integrated health model 57 Table 4 CAM modalities patients would use if offered. CAM modalities Number of interested respondents Alternative medical systems Naturopathy 10 Homeopathy 7 Chinese 6 Other modalities or comments 3 (e.g. ayuveda) Mind body interventions Meditation 10 Petrea King/Gawler Foundation 7 Relaxation 6 Support group 6 Counselling 4 Arts (music, art, dance) 3 Biologically based therapies Vitamins, minerals, supplements 14 Dietary and food 8 Herbs 6 Antioxidants 4 Other (chiropractic, osteopathy) 3 Manipulative and body based methods Massage 22 Yoga 14 Pilates 6 Other (relaxation) Energy therapies Tai Chi 5 Reiki 3 Qi Gong 3 All 2 Other (bowen, acupuncture, 4 reflexology) Spiritual practices Prayer 5 Spiritual healing 3 Other (all, rituals) 2 Other Exercise programmes including 5 gardening Other (hypnosis, crosswords) 2 Social interaction 2 and aromatherapy. When staff were asked if they would be prepared to offer complementary health treatments to patients if the opportunity arose, half (50%) answered yes. Nearly all respondents (96%) were comfortable discussing CAM with other staff. Of the 88% of respondents who said it was relevant to their work, 86% reported they felt comfortable discussing CAM with patients, albeit dissuasively in some cases. Despite the importance placed by staff on knowing about patients CAM practices, when asked to think back to their last patient, only 29% of those for whom it was relevant had had a discussion with them about complementary therapies. Table 5 Patients versus staff agreement with the following statements. Patients CAM practices can have a positive effect on people s health CAM can become more important when a person is unwell CAM may affect a person s response to conventional treatment CAM can relieve side effects It is helpful for medical staff to know about a patient s use of complementary health treatments and practices Staff When staff were invited to make a general comment or say what they wanted from hospital services, several themes emerged. These were: Awareness of CAM use by patients: Be more aware of the number of patients who use CAM and not be dismissive of it, Have a greater awareness and always include it as part of the admission/treatment assessment. Accept that people use a range of practices to meet their health needs: Acknowledge that many people believe in and use complementary health practices and allow patients to discuss these., Accept the notion that people have a responsibility to manage their own health in a way that they feel is appropriate. I would like to see an integration of other health care systems aside from western medicine. Be open to the potential that certain CAM practices can complement mainstream medical treatment: Have a policy to be open to discussion about complementary medicine, so that patients feel comfortable discussing them, and staff can ensure anything that the patients use is safe, does not interact with their conventional treatment, and that information is available to patients perhaps as leaflets to inform of therapy interactions etc. Only consider CAM that is evidence-based: Ensure that every scarce health dollar is spent on providing only scientifically proven best practice health care (including appropriate proven preventative health interventions) and supporting all patients spiritual, cultural and social needs., Look at the real evidence, RCTs etc., listen to both sides, not just the practitioners pushing their own agendas, and make an informed decision., Consider making some therapies available to patients, but there needs to be much discussion on what therapies are appropriate in the hospital setting. Provide education and support for staff: Educate doctors and nurses about complementary medicines and introduce as routine question, particularly preop. Facilitate open communication: Ensure that patients consider this option and they feel comfortable discussing it with their medical practitioner.

8 58 J. Hilbers, C. Lewis A small number of staff clearly stated that there was no evidence to support CAM: Absolutely, so we can protect the patient from the potential harm these therapies can do and provide them with evidence-based information so they can make an informed choice. The issue of competing demands on the budget was also raised: At a time when the provision of existing care is being constrained by budgetary restrictions it would be an inappropriate use of resources to be providing complementary health practices. Discussion This research was not concerned with exploring the validity or otherwise of particular CAM approaches. Rather it sought to obtain a general understanding of people s perceptions and experiences, recognising the self-determination of individuals to manage their health and health care. Potential limitations of our research include: The lack of agreed understanding of the scope of CAM generally may lead some to disagree with the definition of CAM chosen in this survey. The inclusion of patients accessing a women s based oncology service meant that a significant proportion of patients surveyed were white middle class women. However this group had been previously identified as being more likely to engage in CAM practices (Ernst, 2000). There was a difference in the origin of the staff sample compared with the patient population. The staff sample was generated from two general hospital services within the same area health service but staff from the women s health specialist hospital were not surveyed. Also, whilst the staff sample included non-clinical staff this group were excluded from the analysis of specific clinical questions. Although the study population included a diverse range of ethnic backgrounds representative of patients attending the treating centres, the exclusion of patients who were unable to read English prevented a more complete understanding of potential implications of CAM use within patients from a culturally and linguistically diverse background. Complementary and alternative medicine is an issue that can be divisive. The nature of its definition means it encompasses a broad field of practice. There is little research examining the views and opinions of CAM within the Australian context. This research sought to contribute to this field. It was exploratory and utilised an open question format so as to not inherently elicit positive or negative views of CAM. It sought to explore the role CAM currently plays within patients treatment regimens and self-directed health practices, health care staff s own practices and how staff respond to CAM use by patients. Health service providers need to adopt patient-centred approaches that respond to patient diversity. Encouraging open dialogue between health practitioners and patients/families/carers about CAM is essential for effective health care collaboration and maximising patient safety (Chrystal et al., 2003). Understanding the (potential) role of CAM is also necessary to effectively plan future service delivery. The movement towards an integrated approach to health care is inevitable and is occurring most rapidly in the USA, UK and Canada, particularly within oncology services (Deng & Cassileth, 2005; Journal of the Society for Integrative Oncology 2010). In Australia, CAM-specific services for patients receiving treatment for cancer are offered in several metropolitan hospitals in Sydney, and there are several not-for profit organisations involved with the provision of CAM services and information. The NSW Cancer Council and the Cancer Institute NSW are also actively conducting research and education about CAM. Most of the services connected to these public and private health services tend to focus on non-invasive, nonbiological modalities, particularly those that address the psychosocial needs of patients such as counselling and support groups. Body techniques such as massage, therapeutic touch and meditation are also offered. Several services incorporate energy based modalities drawing on traditional approaches including tai chi, and qi gung. The common guiding philosophy of most health care services is to do no harm with an active commitment to improve patients qualityof-life. Generally, hospital-based CAM services are provided from dedicated centres using accredited practitioners, often supported by volunteers. Services generally allow for selfreferral as well as referrals from medical staff. The extent of CAM use, and the importance attached to it by respondents in this survey, in conjunction with the literature and overall world wide trends suggests the need for a health service culture where questions about complementary and alternative health practices are routinely asked and can be discussed without judgment. At a minimum, patients complementary health practices need to be included when taking a detailed medical history and as part of the ongoing dialogue between practitioners and patients about health management and treatment decisions. The findings indicate that some staff are interested in the adoption of a more integrated health approach. Certainly there is a strong foundation of current CAM-related practices including nutrition advice, psycho-social counselling, meditation, spiritual support, and the use of creative arts. Additionally, a number of staff reported that they had CAMrelated skills which were not being utilised in the workplace. The interest shown by participants in having access to CAM information and services as part of their hospital experience suggests that public based health services need to explore their role in relation to CAM and/or the adoption of more integrated health care models. The following issues are potential starting points for discussion as health services negotiate this. 1. Adoption of population health models that recognise health is a culturally defined construct encompassing physical, mental, social, spiritual and environmental dimensions of wellbeing (Brown, Grootjans, Ritchie, Townsend, & Verrinder, 2005, World Health Organisation, 1946). In doing so, adopting more person/family/community-centred approaches which are responsive to diversity and enable people to play an active role in their health care decisions and actions.

9 Complementary health therapies: Moving towards an integrated health model 59 Table 6 Responding to CAM-related patient needs at the clinical level. 1. Be open to understanding the benefits and limitations of CAM. 2. Take a person-centred approach that involves patients as active partners in decision-making about their care. This includes: Asking about CAM as part of patients medical history Paying close attention to patients spiritual and emotional needs Establishing why patients use CAM (what are their goals for CAM and conventional treatments?) Answering patients questions Making referrals to CAM practitioners where appropriate. 3. Be informed about available complementary medicines and practices that: Are safe and effective Have consistently been shown to be ineffective and/or harmful (or where there is a lack of research) Are consistently asked about by patients (George et al., 2004; Kerridge & McPhee, 2004) 2. In line with the trends in the USA, Canada and Europe, a more integrated model of health care provision that utilises a broader range of approaches to optimising health should be taken (Australasian Integrative Medicine Association, 2010; Snyderman & Weil, 2002). This requires moving away from use of the terms alternative and complementary medicine which are potentially divisive. The adoption of more inclusive terminology such as integrated services enables more holistic and tailored health approaches to be considered across the spectrum of prevention to treatment and rehabilitation. 3. An increased commitment to research is needed to build an evidence base for efficacy and effectiveness for CAM. Research and evaluation needs to be incorporated into any integrated health programme development in order to inform continued quality enhancement of that and other services. This requires a (re)conceptualisation of evidence (Glasby & Beresford, 2006). For example, identifying useful qualitative research frameworks in addition to randomised controlled trials, with both processes incorporating quality of life measures. Frameworks that offer a person-centred understanding of health care should incorporate factors such as self-determination, psychosocial perspectives, and spiritual/cultural contexts. Such studies could monitor how CAM supports people to come to terms with a diagnosis, relief from pain and other symptoms of cancer treatment, its contribution to wellbeing before and after surgery and other interventions, and during palliative care. 4. An increased focus on education is needed. This education must come at both the patient and health system levels. Some staff stated how evidence supports CAM whilst others stated the reverse. This discrepancy reinforces requests from staff for education, such as indications and settings where particular CAM practice(s) may be beneficial. It would be advantageous to have available a broad range of written and consultation information about CAM. 5. Explore a harm minimisation approach to integrating services. In the first instance this would involve services only adopting established modalities already recognised within conventional health care services that are accepted as doing no harm. For example, exercise programmes, nutritional advice, counselling and support groups which are targeted at specific points in the patient journey (e.g. diagnosis, living with cancer, grief and bereavement), information services, beauty therapy, prayer and spiritual/religious support, ritual and celebration, well-established body manipulation practices (e.g. chiropractic, osteopathy), meditation and relaxation techniques, massage, and creative therapies (e.g. music, art and movement). In addition there should be an examination of less established modalities where there is some research that indicates potential benefits to health and/or quality-oflife including hands-on energetic and energy practices (e.g. acupuncture, reiki, tai chi, gi gung), aromatherapy and education on biological products (e.g. herbal, ayuvedic, minerals and dietary supplements). 6. Consideration needs to be made in the planning of health service environments that utilise healthenhancing design principles and incorporate facilities and spaces for a range of integrated health services to be provided. 7. A model whereby health professionals are able to start to respond to CAM-related patient needs to be provided at the clinical level. Such a model is shown in Table 6 (modified from George et al., 2004; Kerridge & McPhee, 2004). Conclusion The responses from these two surveys reinforced results of previous studies which show that people use CAM as an adjunct to services they receive from conventional health services, not as an alternative. The positive and empowering role that complementary health practices play in people s lives was reiterated, as was the need for CAM to be used with care. The extent of CAM use, and the importance attached to it by most users, suggests there is a need for a healthcare culture where CAM is routinely discussed and considered without judgement. If health care services are going to be active players in continuing to meet the health care needs of current and future populations they will also need to adopt a more inclusive, positive approach to CAM and work towards more integrated approaches. This involves building

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