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| Journal of the New Zealand Medical Association,
23-March-2007, Vol 120 No 1251
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Prevalence of complementary and alternative medicine
use in Christchurch, New Zealand: children attending general practice versus
paediatric outpatients
Kris Wilson, Claire Dowson, Dee Mangin
The estimated prevalence of CAM-use in adults varies widely
depending on study methodology and population with prevalence ranges from 9 to
65%, however there is evidence that CAM-use is
increasing.1,2
A recent study of adults attending an emergency department
in New Zealand indicated that 38% of people used CAM, a quarter in conjunction
with prescribed medication and just over a third disclosed its use to their
medical practitioner.2 In children, there is
emerging evidence from secondary/tertiary care that CAM-use may be as common as
in adults.3
In a recent two-country study involving children with
chronic health conditions, CAM-use was high; in Australia prevalence of use was
51%, and in Wales it was 41%.4,5
Historically this increase in CAM-use has not been supported
by the development of adequate legislative and regulatory safeguards in New
Zealand;6,7 however, there are now moves to
change this situation. The Interim Joint Expert Advisory Committee on
Complementary Medicines (IJEACCM) has been appointed to provide advice about CAM
and their active ingredients to the Therapeutic Products Interim Ministerial
Council.8
Increased CAM-use creates an increase in the instances of
adverse effects as well as CAM and prescribed medicine interactions in the
population.9,10 Reported incidents of serious
adverse effects include anaphylactic reaction, respiratory failure, auto immune
hepatitis, and coagulation effects.9–16
Children are a particularly vulnerable population for whom
drug pharmacokinetics (and therefore doses) cannot necessarily be extrapolated
or inferred from adult
populations.4,9,12–16 Furthermore, there
are indications that non-disclosure of CAM-use to a health professional is
common and may increase the risks of an adverse reaction, particularly if used
in combination with prescribed medicines.10,17
The rate of non-disclosure was high in a population of
children with chronic health conditions studied in Australia (63%) and in Wales
(66%).4 To date, it is not clear whether
patient non disclosure is intentional, nor whether it is more or less likely to
occur in the general practice
setting.17–19
Empirical investigations of CAM-use in children to date have
focussed on chronic conditions in the secondary/tertiary sector; prevalence of
CAM-use appear higher in these populations than the general
population.20 The prevalence of CAM-use and the
rate of non-disclosure among children attending general practice for
intercurrent illness are unknown.
In this study we describe the prevalence and range of
CAM-use in New Zealand primary and secondary care paediatric populations. We
examine factors which may predict use. We also assess rates of disclosure to
clinicians in primary and secondary care settings, and the reasons for
non-disclosure.
MethodsSetting—General
practices and a secondary care diabetes paediatric outpatient clinic in
Christchurch, New Zealand.
Source population—Parents of
children under 12 with an appointment to see the doctor/specialist were
recruited from general practitioners surgeries and a paediatric outpatient
clinic. Participants were recruited between 22 November 2004 and 22 February
2005.
Participants—A researcher
(present in surgery/clinic waiting rooms) interviewed adults accompanying
children under 12 who were attending for a booked appointment with a general
practitioner or paediatrician. Practices were selected using computer-generated
random numbers from a representative and randomly selected network of
Christchurch GPs.21
Children with chronic conditions who attended hospital
outpatients’ clinics were excluded from the general practice sample. Fifty
consecutive participants were selected from 6 general practices. In addition, 50
participants were interviewed from an outpatient paediatric diabetes clinic in a
general hospital. After giving informed consent, parents answered a structured
questionnaire lasting 10 minutes, either in the surgery/clinic or later by
telephone.
Measures—As the purpose of the
study is to inform prescribers, the types of CAM studied were confined to oral
and topical preparations (including nasal)—CAMs most likely to interact
with prescribed medicine or to produce adverse effects. The questionnaire
assessed prevalence and pattern of CAM-use in the index child.
Standardised questionnaires were used to investigate
three potential predictors of CAM-use:
Additional questions were constructed to
assess:
Analysis—Data
were analysed using SPSS (version 12) software. The prevalence and disclosure of
CAM-use in the sample were calculated using descriptive statistics and 95%
confidence intervals. Statistical analyses of possible significant differences
between GP and outpatient samples were made using Chi-squared for independence
and Chi-squared for goodness of fit. Potential predictors of CAM-use were
entered into a correlation matrix to ascertain any bivariate relationships with
CAM-use (p=2-tailed). Variables found to significantly correlate with CAM-use
were then investigated further using a binary logistic regression model.
This study was approved by the Upper South (B) Ethics
Committee, New Zealand.
ResultsResponse rate—The researcher
approached 118 people with children who fitted the initial inclusion criteria.
Nine people who were approached did not fit the criteria (as they were not
parents of the child). Of the remaining 109, 3 participants who agreed to a
phone interview could not be contacted later and 6 people who were approached
declined to participate. One-hundred people agreed to participate (response rate
92%). Data were complete for all eligible participants.
Sample characteristics—Demographic
characteristics did not differ significantly between the groups except for two
variables (Table 1). There were a greater proportion of infants and younger
children in the GP sample than the outpatient sample. The GP-sample parents were
also younger.
Prevalence of CAM-use and
disclosure—The overall prevalence of CAM-use in children was 70%
(70/100, 95%CI 60–79). There was no significant difference in the reported
use of CAM in children between the GP (72%, 36/50) and paediatric diabetes
sample (68%, 34/50; χ2 (1) = 0.058, ns).
For the total CAM-user group, 23% (16/70) disclosed use of
CAM to a medical practitioner whereas 77% did not. There was no significant
difference between the GP group (81%) and paediatric diabetes sample (74%) in
non disclosure rates (χ2(1) = 0.490, ns).
For those who did not disclose their child’s CAM-use,
only 13% stated an intentional reason for doing so (e.g. “doctors deal
in prescribed medicines, not doctors domain”, “not conventional,
they only push prescribed medicine”, “scoffing”), with
87% citing unintentional reasons (e.g. “it didn’t come
up”, “the doctor didn’t ask”). There was no
difference in disclosure rates between high (≥3 CAM treatments) and low
users of CAM (<3 CAM treatments) (χ2
(1) = 0.054, ns).
Table 1. Sample
population
*Significant to p<0.05.
There was no significant difference between high and low CAM
users in the prevalence of prescribed medicine use in the last 12 months (88%
and 89% respectively) (χ2 (1) = 0.024,
ns). Of the total sample 18/100 (18%) used both CAM and prescribed medicines,
and did not disclose their CAM-use to the physician.
Table 2. Origin of information about CAM in
users (n=70)
*Māori language-based kindergarten.
Sources of information about
CAM—Table 2 describes the most common sources of information
about CAM that were reported. The most common information source was a friend,
followed by the parents’ own reading, thus indicating that self-teaching
was the usual basis underpinning parents decisions about CAM-use. Registered
health professionals and CAM specialists were less frequently consulted.
Types of CAM and reasons for
use—Participants reported the use of 35 different types of CAM.
The most commonly used preparations were arnica (43%, 95%CI 31–55),
multivitamins (17%, 95%CI 9–28), tea tree oil (14%, 95%CI 7–25),
Echinacea 14%, 95%CI 7–25), vitamin C (10%, 95%CI 4–20),
Aloe vera (10%, 95% CI 4–20), Weleda© homeopathic teething
powder (7%, 95%CI 2–16), homeopathic ‘Rescue Remedy’ (6%,
95%CI 2–14), and vitamin E (6%, 95%CI 2–14).
Nine out of 10 parents who had used CAM for their child did
so for acute or short-term conditions (Table 3). There were no significant
differences in reasons for use between general practice and outpatient
populations (χ2 (1) = 0.261, ns).
Table 3. Purpose of CAM-use: general practice
vs diabetes outpatient populations *
*Multiple responses allowed.
Predictors of CAM use—Possible child
CAM-use predictors were entered into a correlation matrix to ascertain their
relationship with the dependent variable (CAM-use = 1 / non CAM-use = 2).
Those variables found to correlate with child CAM-use were:
These variables were then entered, in a single
step, into a binary logistic regression model (Table 4). The logistic regression
analysis indicates that parental CAM-use predicts their child’s use of CAM
(p < 0.01, level, χ2 (1) = 1.808, OR
4.7, 95%CI 1.3–16.6).
Table 4. Logistic regression model for
predictors of CAM-use
*Significant to p<0.05. GH=BMQ General Harm
Subscale
The overall model is significant at the 0.001 level
according to the model Chi-squared statistic
(χ2 (5) = 24.668), and predicts
79% of responses correctly (pseudo regression coefficients: Negelkerke
R2 = 0.310, Cox & Snell
R2 = 0.219).
DiscussionThis study found a higher prevalence of CAM-use (70%) in New
Zealand compared to other countries (51% and 41% in Australia and Wales,
respectively). In addition, disclosure rates were low (23%) in comparison with
the previous children’s hospital (37% and 34% in Australia and Wales
respectively) and adult samples.2, 4
Failure to disclose was largely unintentional (87%), thus
suggesting most parents would possibly be open to discussing their child’s
CAM-use. No significant differences were found between the GP and outpatient
sample in prevalence or CAM-use pattern.
In both populations, CAM was predominantly used for
prevention and treatment of acute symptoms. This was contrary to the hypothesis
that children with chronic conditions might have higher and a wider range of
CAM-use.20,25,26 The most popular types of CAM
used in this study were those which would most likely fall into the
IJEACCM’s class one distinction (includes most CAM)—these are deemed
to be lower risk and therefore less rigorously
regulated.8
Parents were most reliant on a self-teaching method in
obtaining information about CAM, principally asking friends for advice.
Registered health professionals and CAM specialists (surprisingly) were less
frequently consulted.
These combined factors—high use, low disclosure, and
self-teaching methods—may increase the risk of interactions and undetected
adverse reactions related to CAM use. The long-term effects of CAM-use and
pharmacokinetics of combining prescribed medicines with CAM in children are
often unknown. The patient and parents are not in a position to judge the risk
of interaction and adverse effects and neither is the medical practitioner if
there has not been disclosure of use.
Several factors proved valuable predictors of CAM-use,
providing information for clinical practice on which patients may be more likely
to be using CAM for their children. Children whose parents’ use CAM are
four times more likely to use CAM than those children whose parents do not use
CAM.
The high response rate and complete dataset are strengths of
the study, as is the location within both a primary care and secondary care
population. While the overall sample size is good, the small numbers in some
subgroups limits the ability to draw conclusions on differences between these
groups.
The CAM-use and education level was only available for the
attending parent, and it is possible that CAM-use and the education level of the
other parent may be influential in the decision to use CAM. The ethnicity
distribution in the sample (Table 1) may not be representative of all regional
populations in New Zealand, therefore caution should be taken when generalising
the results to these communities.
The high prevalence of CAM-use among children (as indicated
in these data) may reflect an increasing health consumer trend towards
incorporating complementary healthcare models in the prevention and treatment of
symptoms.17
The high levels of CAM-use and low disclosure found in
overseas populations are more pronounced in New Zealand, and therefore New
Zealand practitioners need to be particularly aware of their patients’
CAM-use.
It is clear that the high prevalence of CAM-use in the
general population of children signals the consolidation of consumption and
popularity of CAM. Indeed, there is sufficient concern about the adverse effects
of CAM to encourage health practitioners to engage in dialogue with patients
about their CAM consumption practices. While there are some data about the
efficacy and safety of particular types of
CAM,27 further research is needed.
Where there is no data, the precautionary principle would
suggest active enquiry about use will at least enable minimisation of the
potential for interaction by avoiding co-prescription, and alertness to the
potential for CAM to cause adverse effects.
Competing interests: None.
Author information: Kris Wilson, Clinical
Psychology Student, University of Canterbury, Christchurch; Claire Dowson,
Senior Research Fellow and Clinical Psychologist, Department of Public Health
and General Practice, Christchurch School of Medicine & Health Sciences,
University of Otago, Christchurch; Dee A Mangin, Senior Lecturer; Department of
Public Health and General Practice, Christchurch School of Medicine & Health
Sciences, University of Otago, Christchurch
Correspondence: Dr Claire
Dowson, Department of Public Health and General Practice, Christchurch School of
Medicine and Health Sciences, PO Box 4345, Christchurch. Fax: (03) 364 3637;
email: claire.dowson@chmeds.ac.nz
Acknowledgements: Funding was provided as a
summer studentship to KW from the Canterbury Medical Research Foundation. We
also thank the survey participants; participating general practices; and
Professor Brian Darlow and outpatient staff at Department of Paediatrics,
Christchurch Hospital.
References:
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