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Health products, preparations, practitioners and practices collectively referred to as “traditional, complementary and alternative medicine” (TCAM) are used extensively worldwide.[[1,2]] TCAM approaches are used by at least 80% of member states across all World Health Organization (WHO) regions and, in some regions, traditional (Indigenous) medicine is the only source of primary healthcare.[[2]] A systematic review of studies exploring TCAM use among general populations across 15 developed or developing countries reported a 12-month prevalence of use of one or more TCAM approaches ranging from 9.8% to 76%; similarly, 12-month prevalence of visits to one or more TCAM practitioners ranged from 1.8% to 48.7%.[[3]] The prevalence and patterns of TCAM use vary across countries due to differences in TCAM availability, affordability, regulations, cultural and historical significance, and conventional healthcare system advancement.[[1,2]]

The WHO defines traditional medicine (TM) and complementary/alternative medicine (CAM) separately and acknowledges that, in many countries, the terms are used interchangeably. The WHO definition of TM states: “Traditional medicine has a long history. It is the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.”[[2]] In some contexts, TM is described as a subset of CAM (health knowledge, beliefs, preparations and practices that usually sit outside the dominant health system), and vice versa. The term integrative medicine (IM, or integrative health) is also now used in the context of TCAM and refers to the coordinated use of both conventional and TCAM approaches in a patient-focused manner to achieve the best possible health and wellbeing outcomes for individual patients.[[4]] Definitions and terminology for TM, CAM and IM are not universally relevant, or accepted, and continue to evolve; similarly, products and practices included under the different terms vary across different studies exploring prevalence of use.

In New Zealand, TM preparations and practices include those used in rongoā Māori, the traditional medical system of Māori, as well as those used in traditional Pasifika medicine, of which there are several systems. In addition, numerous other TCAM approaches are available: CAMs/natural health products (NHPs) are sold in pharmacies, supermarkets, health food stores and through online outlets, and TCAM practices/therapies can be accessed through TCAM practitioners, such as herbalists, homoeopaths, naturopaths, traditional Chinese medicine and traditional Ayurvedic medicine practitioners.[[5]]

This work is a comprehensive review of research exploring the use of TCAM in New Zealand, including prevalence of use, access, expenditure, reasons for use and user and health practitioner perspectives. This paper, the first in a series of three, reviews research relating to the prevalence of use of TCAM, use of TCAM with conventional medicines and expenditure on TCAM products/preparations and practices.

Methods

This scoping review adopted a systematic process to identify relevant studies and summarise results.

The operational definition used for TCAM in this review was: “all health systems, modalities, and practices not typically considered part of conventional Western medicine that are used for health maintenance, disease prevention, and treatment.”[[6]] This included:

  • TCAM products/preparations
    — Complementary medicines: includes, but is not limited to, products or preparations described as natural health products, complementary/alternative medicines/remedies, dietary supplements, nutraceuticals and/or traditional medicines (products or preparations used in traditional medicine systems, such as rongoā Māori, or traditional Chinese medicine)
  • TCAM practices
    — Complementary therapies/practices: including but not limited to mind–body therapies (e.g., hypnotherapy, yoga), manipulative/body-based methods (e.g., osteopathy, chiropractic) and energy therapies (e.g., reiki, therapeutic touch)
    — Traditional medicine practices: such as traditional Chinese medicine, Ayurvedic medicine, rongoā Māori as well as other treatments, such as acupuncture, cupping

Chiropractic and osteopathy are regulated in New Zealand, but these health practitioners are included in this review as they are not necessarily considered part of mainstream medicine in this country.

This review included studies/reports on the prevalence and/or examination of any aspects of TCAM use across any subpopulation in New Zealand and health practitioners’ perspectives on consumers’ TCAM use. This review excluded studies/reports on: the benefits/harms of TCAM or specific TCAM products/therapies; the effectiveness of TCAM; the use of vitamins/minerals for prevention/treatment of medically diagnosed deficiencies/disorders (e.g., folic acid for prevention of neural tube defects); the use of TCAM for recreational purposes; letters to editors, commentaries and editorials.

The following electronic databases were searched from their inception to 7 June 2019 using systematic literature search strategies: MEDLINE; EMBASE; AMED; IPA (International Pharmceutical Abstracts); CINAHL; PsycINFO; Scopus. Grey literature was searched through Google Scholar’s and New Zealand government and relevant organisations’ websites using keywords. Reference lists of included studies were hand-searched to capture any additional relevant publications.

Search terms comprised combinations of subject headings and keywords related to three key concepts: (1) complementary and alternative medicine, (2) prevalence/utilisation and (3) New Zealand. The search strategy for MEDLINE is available on request from the authors. Search results were exported to a reference manager software (EndNote), duplicates were removed and studification (grouping publications from the same study) was done. The study selection comprised title and abstract screening then full-text screening. One reviewer (ELL) assessed study eligibility; a second reviewer (JB) was consulted when necessary. Data were extracted from the included studies by one researcher (ELL) and checked by a second researcher (JB). A data-extraction form was developed by the authors to extract general information about each study (e.g., author, publication year, participant characteristics, study design, methods) and specific information relevant to the review questions (e.g., TCAM terminologies and definitions used, aspects of TCAM use explored, key outcomes).

The extracted data were analysed, and tables depicting the study characteristics, including data collection tools and methods, participant characteristics (age, location, ethnicity, health status), settings and outcomes are presented. Studies included in this review were conducted at different time points; therefore, expenditure on TCAM expressed in New Zealand dollars was adjusted to 2020 using the Reserve Bank of New Zealand’s calculator.[[7]] Current values (year 2020) accounting for inflation are in parenthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist was used to guide reporting of this study.[[8]]

Results

Identification of studies

In total, 72 records (studies/reports) met the inclusion criteria. The screening and selection process is summarised using a PRISMA flow diagram (Figure 1).[[9]]

Characteristics of included studies

Studies were conducted from two perspectives: (1) health practitioners (TCAM[[10–15]] and conventional medical practitioners[[14,16–23]]); (2) population (including non-users and consumers of TCAM).[[18–20,24–81]] A table summarising the characteristics of the 72 included studies is available from the authors on request.

Figure 1: PRISMA flow diagram of literature search and study selection process.

Definitions and descriptions of TCAM terms

Twenty studies[[10-–13,15,25,39,40,49,50,54,58,70,71,73,75–77,79,80]] investigated a specific TCAM practice (e.g., chiropractic, osteopathy) or product/substance (e.g., melatonin, fish oil) only. The remaining studies examined non-specific TCAM use. Multiple studies[[21,35,44, 45,47,48,51,55–57,61–64,68]] used an operational definition for TCAM. The TCAM term used in some studies was described; it was unclear if the description was used as an operational defintion.[[14–17,19,27–29,41,43,78]] The terms most commonly used were “complementary and alternative medicine” (to describe all TCAM approaches including products and practices) and “dietary supplements” (to describe products). However, the definitions adopted for each term differed across studies and ranged from broad concepts inclusive of various products/practices (e.g., spiritual healing, massage) to tighter concepts with additional criteria limiting the products/practices included (Table 1). Less frequently used terms were “non-prescription health supplements,” “alternative therapist” and “unconventional practitioner.”

Table 1: CAM definitions/descriptions used across studies.

Types of TCAM explored in included studies

The types of TCAM included in studies exploring consumer use can be broadly categorised into “practices” and “products.” As individual types of products were usually not defined, and as questionnaires were not appended in most publications, it is unclear whether products such as herbal remedies reported by consumers were accessed through practitioners or self-prescribed. For studies that explored the use of products and did not indicate access through practitioners, these are categorised under products.

Studies/reports from the consumers’ perspective were conducted using quantitative, qualitative or mixed-methods approaches. Quantitative studies mainly examined a variety of TCAM practices,[[25,43,47,59–62,64]] products[[18,24,29,36,38,41,42,44–46,48,51,52,55–58,72]] or products and practices.[[19,20,26–28,31,33,35,37,53,78]] Several studies investigated participants’ use and experiences with a single TCAM practice, such as osteopathy,[[40]] traditional Pacific healers[[49]] and chiropractic.[[77,80]] Qualitative studies mostly explored consumers’ experiences with a specific TCAM practice, such as acupuncture,[[39,71]] massage therapy,[[75,76]] rongoā medicine,[[50]] traditional Chinese medicine[[54]] and traditional Tongan healing.[[30]]

The classification of TCAM products and practices varied across studies, which made direct comparison difficult. For instance, herbal products were analysed and reported in multiple ways: collectively as a product category,[[55]] and/or as individual herbs/active ingredients.[[44]] Categories were also sometimes incorrectly defined: for instance, one study regarded garlic, a botanical product, as an individual ingredient, “garlic,” and did not code it under the category “botanical product.”[[56]] In addition, TCAM practices, such as acupuncture, were analysed separately from traditional Chinese medicine,[[47]] when in reality some acupuncture practices originated from and may be considered a component of traditional Chinese medicine. Some studies grouped TCAM products and practices based on their intended use/function: for example, “antioxidants,”[[33]] “joint treatment” and “treatment to increase immunity.”[[44]] Some TCAM products or practices included in the studies were not distinct: for instance, “cleanser,”[[44]] “detoxification,”[[33, 35]] “lifestyle,”[[53]] “heat treatment.”[[78]]

The scope and range of TCAM products and practices differed between studies and were diverse. A table of the more than 70 terminologies used to describe or identify specific TCAM practices or products is available  from the authors on request. Most studies included products such as vitamins, minerals, herbal remedies and essential fatty acids and practices such as chiropractic, osteopathy, homeopathy and naturopathy. Some TCAM practices included less frequently were reflexology,[[26,31,35,53]] kinesiology, crystal healing, bloodletting and rebirthing.[[43]]

Prevalence of use

Thirty-eight studies reported data on the prevalence of use of one or more TCAM practices or products/preparations among consumers. Most studies reported prevalence in terms of lifetime use,[[18,20,27,28,35,42,44,52,78]] previous 12-months use[[41,43,45,47,48,55,56,61,62,64]] or both.[[19,25,53]]

Nationally representative general population studies

Nine studies/reports relating to three nationally representative studies reported prevalence of use. Data were derived from three government health surveys: the New Zealand Health Survey (NZHS),[[47,61,62]] New Zealand (Adult or Children) Nutrition Survey (separate surveys for adults and children),[[45,48,55–57]] and New Zealand Mental Health Survey (NZMHS) (Supplementarty Table 1).[[64]] The first two surveys examined TCAM use for any health reason, whereas the NZMHS explored TCAM consultations specifically for mental health problems. The New Zealand (Adult or Children) Nutrition Survey included the use of products (dietary supplements) only, and the other surveys (NZHS and NZMHS) included TCAM practices only. All studies presented prevalence in terms of previous 12-months use, except the New Zealand Children Nutrition Survey 2002, where the prevalence of use over the previous 24 hours was reported. The New Zealand Adult Nutrition Survey 1997 reported both previous 12-months use and previous 24-hours use.

As these surveys were heterogenous in the methods and definitions used, an overall prevalence range is not reported. Two surveys were repeated across two time periods, which enabled an analysis of usage trends. Based on the New Zealand Adult Nutrition Surveys in 1997 and 2008/9, the prevalence of dietary supplement use over the previous 12 months reduced slightly from 59% to 47.6% respectively. From the NZHS in 2002/3 and 2006/7, the prevalence of CAM practitioner consultations over the previous 12 months were 23.4% and 18.2% respectively, although the later survey excluded chiropractors and osteopaths and reported use of these practitioners separately (Table 2). The 2002/3 NZHS reported that Māori and Pacific healers were consulted by 0.9% and 0.2% of respondents, respectively, corresponding to 6.0% of Māori respondents and 4.6% of Pasifika respondents.[[62]] Self-treatment with rongoā Māori or Pacific medicine(s) were not explored.

Table 2: Prevalence of TCAM use derived from nationally representative general population data. View Table 2.

Other studies: non-nationally representative, or nationally representative sub-populations

The remaining 29 studies reported on the prevalence of TCAM use among consumers in specific ethnic populations, with certain medical conditions or in particular healthcare settings and locations across New Zealand (Supplementary Table 1).

Six studies explored TCAM use among children: two explored the use of TCAM products and practices,[[26,28]] two included TCAM practices only,[[59, 60]] one included TCAM products only[[52]] and one explored a single TCAM practice (traditional Pacific healers).[[49]] In a study involving children with dyspraxia, 100% reported the use of at least one “food supplement” (not further defined).[[26]] Of the remaining studies, prevalence of lifetime TCAM use ranged from 29% among children hospitalised due to acute illness[[28]] to 70% among children attending general practitioner or paediatric diabetes outpatient clinics in Christchurch.[[52]]

Among studies that explored TCAM use in adults, eleven included TCAM products and practices,[[19,20,27,31,33,35,37,44,46,53,78]] ten included TCAM products only[[18,24,29,36,38,41,42,51,58,72]] and two included TCAM practices only.[[25, 43]] There is substantial variation in the reported prevalence of use of TCAM products/practices across studies. For instance, the prevalence of lifetime TCAM products and practices use ranged from 56.1% among adults presenting to emergency care in North Shore Hospital, Auckland,[[53]] to 91% among inpatients in Gisborne Hospital.[[35]]

For TCAM subcategories, vitamins and minerals were most commonly reported, although the prevalence of use varied considerably as the definitions, study populations and prevalence periods differed across studies. Prevalence of use of herbal products[[29]]/therapies[[35]]/supplements[[37]]/extracts[[41]]/mixtures[[53]]/medicines[[78]]/remedies[[19]] (not defined in respective studies) also differed across studies. Lifetime use of 47% was reported among inpatients in a hospital,[[35]] and previous 12-months use of 15.1% and 4.4% were recorded among patients with Crohn’s disease[[41]] and adults presenting to a hospital emergency care centre,[[53]] respectively.

Several studies reported consumers’ use of traditional Māori[[20,44]] or Pacific medicine[[28,49]] or both.[[35]] In a study of attendees to a hospital emergency department, more than half (51.7%) of those who used traditional Māori treatment (7.3% of CAM users) grew or collected the plants and made the treatment themselves.[[44]] Use of traditional medicine is not exclusive to specific ethnic groups. Among inpatients at Gisborne hospital, 13% of non-Māori respondents reported having used rongoā Māori.[[35]]

TCAM use with conventional medicine

Many patients consider TCAM a safe choice and would take conventional medicines concurrently. Four studies explored the concurrent use of TCAM with conventional medicine.[[44,52,65,79]] Two quantitative studies reported the extent of TCAM use with conventional medicines among consumers.[[44,52]] In a survey involving hospital emergency department attendees, around one-quarter of CAM users were taking conventional medicines concurrently, and one user experienced serotonin syndrome associated with concurrent use of paroxetine and St. John’s wort.[[44]] Among children attending general practitioner or paediatric outpatient clinics in Christchurch, approximately one-fifth (18%) had used both TCAM and conventional medicines concurrently and did not disclose their CAM use to their physicians.[[52]]

Interviews with Māori regarding Māori health and wellbeing revealed that the use of rongoā is perceived to be compatible with use of Western medicines.[[79]] An exploratory study of patients with gout found that various therapies, such as Epsom salts, glucosamine, cod liver oil, chondroitin and kawakawa, are used complementary to prescribed conventional medications.[[65]]

Cost of TCAM

Table 3 summarises the findings from four studies that reported consumers’ monthly spending on TCAM products and/or practices.[[29,33,42,78]]

Two studies explored the costs from health practitioners’ perspectives. Massage therapists reported a median of 16–20 hours of client care per week and most frequently charge NZD 60/hour (NZD 72/hour).[[15]] Chiropractors in New Zealand indicated that the average number of adjustments visits per week they performed was 142, and that on average one-third of their practices were related to Accident Compensation Corporation (ACC) insurance claims.[[13]]

Table 3: Cost of TCAM reported in studies.

ACC = Accident Compensation Corporation.*Year of publication used to calculate cost adjustment.

Discussion

This scoping review mapped publicly available evidence from studies/reports exploring the prevalence of use of TCAM in New Zealand.

Substantial evidence exploring TCAM use exists, but information from robust nationally representative studies is limited, as these studies have not comprehensively assessed the prevalence of use of both TCAM practices and TCAM products used in self-care. The New Zealand Adult Nutrition Survey 2008/9[[55]] and the NZHS 2006/7[[61]] explored the use of dietary supplements only (47.6%) and TCAM practitioners only (18.2%), respectively. This suggests that, although the 12-month prevalence of use of any TCAM in New Zealand is unknown, it was at least 47.6% in 2008/9.

Research indicates that a broad range of TCAM practices and products is used by people of all ages and ethnicities and with various health conditions. New Zealanders access these products and practices through multiple avenues, including conventional medical practitioners, and pay substantial sums of money out-of-pocket. Collectively, this indicates that there is a sizable demand for and use of TCAM among New Zealanders.

Several gaps were identified in the data: there are no current, nationally representative and comprehensive data on the prevalence of use of TCAM products and practices among patients/consumers in New Zealand, including the types of TCAM products/practices used, how they are accessed, and patterns of use of TCAM alongside conventional medicine. There are also substantial gaps in data on direct and indirect personal and government expenditure on TCAM products/practices, including government-funded treatments such as those covered by ACC and Work and Income New Zealand (WINZ).

Data indicate that the prevalence of visits to TCAM practitioners over the previous 12 months in New Zealand is comparable to that reported in national surveys from the USA (16.2%),[[82]] UK (12.1%)[[83]] and Canada (12.4%).[[84]] The overall use of TCAM (products and practices) in New Zealand (at least 47.6% in 2008/09) is similar to that in developed countries, such as the USA (~30%)[[85]] and Australia (63.1%).[[86]] Despite evidence of a high prevalence of use of TCAM products in New Zealand, there are yet no specific regulations governing the quality, efficacy and safety of these products. Many herbal and homeopathic products are exempt from the requirements of the Medicines Act 1981.[[87]] TCAM products do not have a specific regulatory framework in New Zealand; most are captured by the Dietary Supplements Regulations 1985, but these regulations do not require assessment of quality, efficacy and safety of TCAM products prior to marketing.[[88]] Thus, there are no assurances about product content and, therefore, pharmacological activity. Instances of adulteration, including with added conventional pharmaceutical ingredients, have occurred in TCAM products distributed in New Zealand.[[89,90]] Some TCAM products distributed in New Zealand are produced to Good Manufacturing Practice (GMP) standards; however, there is no straightforward way for health professionals and consumers to identify these products (unless a product holds an overseas authorisation, for example, is a listed/registered medicine on the Australian Register of Therapeutic Goods[[91]]). In New Zealand, the Natural Health and Supplementary Products Bill was introduced in 2011 with the intention of regulating NHPs, including requiring manufacturers to produce their products according to GMP standards and to provide bibliographic and/or traditional-use evidence to support claims of health benefits.[[92]] However, the Bill lapsed in 2017 without being implemented.[[93]]

Many types of conventional practitioners in New Zealand are required to comply with standards of practice[[94,95]] and a codes of ethics[[96]] around recommending/using TCAM products/practices in their practice. Some clinical practice guidelines review evidence of, and include recommendations on, TCAM use for treatment of disease (e.g., use of acupuncture for smoking cessation[[97]]). Of practitioners typically considered to be TCAM practitioners in New Zealand, only chiropractors and osteopaths are regulated under the Health Practitioners Competence Assurance (HPCA) Act 2003.[[98]] Applications for traditional Chinese medicine practitioners and Western medical herbalists to be regulated under the Act were made in 2010 and 2015, respectively; discussions are ongoing.[[99]] New Zealand has a unique traditional medicine system (rongoā Māori)[[100]] founded on Indigenous medical practices handed down through generations of practitioners. Rongoā Māori is a traditional healing system developed and formulated in Māori culture, and which includes physical, emotional, family and spiritual aspects of health; it may involve use of rongoā rākau (preparations of native plants) and other substances of natural origin, as well as mirimiri (massage) and karakia (prayer), as part of an holistic healing approach.[[100]] Māori traditional healers are the holders of traditional knowledge of the harvesting, preparation and use of these medicinal products. This knowledge is often unique to the practitioner and differs between iwi depending on their geographical area and the teaching of their ancestors; in this regard, they are the holders of the “intellectual property” of these preparations. New Zealand is constitutionally a bi-cultural country and a multi-ethnic society;[[101]] in addition to rongoā Māori, traditional Pasifika medicine, and imported traditional medicine systems from other cultures, such as traditional Chinese medicine and Ayurvedic medicine, are also present. Currently, access to some TCAM (e.g., acupuncture, rongoā services) is government funded.[[100,102]] Government-funded rongoā Māori providers are required to adhere to the rongoā standards, Tikanga ā-Rongoā.[[103]] Intentions to regulate TCAM products, practices and/or practitioners in New Zealand would need to account for, and carefully consider, the impact on and protection of mātauranga Māori[[97]], the broad range of existing products/practices/practitioners and the impact on funding, as well as the practice of TCAM, as part of the wider New Zealand healthcare system.

Despite consumers’ beliefs in TCAM as a natural and, therefore, safe healthcare option, adverse events can occur with the use of TCAM, including when its used together with conventional medicine. TCAM is frequently self-selected by consumers and is obtained outside the conventional healthcare system. Therefore, consumption/use is often unknown to conventional medical practitioners, unless its use is disclosed by the consumers themselves. Consumers choose to use TCAM for numerous reasons, and the conditions of use, including disclosure to health practitioners, will be explored and discussed in a later paper in the series.

Globally, a uniform definition for TCAM does not exist, despite efforts towards reaching a consensus.[[104,105]] Hence it is not surprising that studies in New Zealand use a wide range of TCAM terms and definitions. Although the New Zealand Ministerial Advisory Committee on Complementary and Alternative Health in 2004 agreed to adapt the definition from the United States National Center for Complementary and Alternative Medicine (now the National Center for Complementary and Integrative Health),[[5]] few New Zealand studies did so. Depending on how TCAM is defined and operationalised, prevalence estimates can vary considerably. In a systematic review, prevalence of use rates were inflated when studies included “prayer” as a TCAM approach in their operational definition.[[3]] Numerous New Zealand studies did not report (using) an operational definition, which implies that participants’ responses were based on their own understanding or interpretation of TCAM (or other terms used in the respective studies); such an approach is not standardised and is susceptible to underreporting or overreporting. Most studies also utilised different data collection tools, methods and prevalence measurements (e.g., lifetime, previous 12 months, 2 weeks, 2 months, during illness), adding to the challenges in aggregating data and comparing them locally and internationally.

Reliable nationally representative data on prevalence, patterns of use, expenditure and modes of access to TCAM products and practices (including where therapies are provided by conventional health practitioners or funded by the Ministry of Health, ACC or WINZ) are needed in New Zealand. A robust, comprehensive study on prevalence of TCAM use in New Zealand would need to include a standardised TCAM definition, scope and measurement of prevalence of use. It should collect respondents’ National Health Index (NHI) numbers (a unique identifier for every person who uses health and disability support services in New Zealand) to allow for data integration and linkage across studies/databases. Data collected from the survey would serve as a useful resource at a population level for monitoring trends in TCAM use, alone and in conjunction with conventional medicine(s). Data on prevalence indicate not only the breadth of TCAM use in New Zealand, but also, to some extent, patients’ unmet healthcare needs within the current publicly funded healthcare system. Therefore, any change in TCAM regulations would need to consider the impact on the allocation of public healthcare resources and funding. A substantial prevalence of use could also prompt the initiation of an in-depth review on the safety and efficacy of TCAM. Hence a comprehensive understanding of the extent, scope and patterns of TCAM use in New Zealand, together with evidence-based information on safety and efficacy, could contribute to informing government healthcare policy and decision-making.

This scoping review provides an overview and understanding of data on use of and access to TCAM in New Zealand and has identified gaps in knowledge for future studies. The work has several strengths and limitations. First, no formal evaluation of the quality of evidence was undertaken for the included studies. Also, information was gathered from a range of study designs and methods, restricting comparability across studies. A comprehensive search strategy was developed and used, but given the lack of standardisation in TCAM terminologies, some studies may have been missed. Another limitation is the use of a single reviewer for screening and data extraction, which may have introduced bias.

Conclusion

Numerous, typically small, localised studies exploring TCAM use in New Zealand are available; however, there is a lack of comprehensive, nationally representative data on prevalence and patterns of use of TCAM, including use in relation to conventional medicine(s). Existing data have been collected using various methods, limiting the comparability and further analysis. There is evidence of substantial use of TCAM among patients/consumers of different ages and ethnicities and with diverse health conditions. Given the high prevalence of use and ongoing lack of regulation, reliable, current, nationally representative data on prevalence of use of all TCAM products/preparations and practices/therapies is warranted for New Zealand.

Supplementary material

  • Supplementary Table 1: Prevalence of TCAM use from other (non-nationally representative, or nationally representative sub-populations) studies. View Supplementary Table 1.

Summary

Abstract

Aim

Traditional, complementary and alternative medicine (TCAM) is a popular healthcare choice worldwide. The extent of data available on TCAM, including prevalence and patterns of use in New Zealand, is unknown. This scoping review aims to map the existing research describing the use of TCAM (including prevalence, access, expenditure and concurrent use with conventional medicines) in New Zealand.

Method

Research databases (MEDLINE, EMBASE, AMED, IPA (International Pharmaceutical Abstracts), CINAHL, PsycINFO and Scopus) and grey literature (Google Scholar and New Zealand government and relevant organisations’ websites) were searched for studies published before 7 June 2019. Studies reporting on the prevalence and/or exploring aspects of TCAM use were included in this review.

Results

In total, 72 studies were reviewed. Available data suggest that TCAM use is widespread among New Zealanders, and some consumers pay large sums of money out-of-pocket. A wide range of TCAM practices and products is used by people of all ages and ethnicities and with various health conditions. There is some evidence of consumers using TCAM concurrently with conventional medicines. Studies were generally small, localised and conducted in sub-populations (e.g., specific age groups, health conditions). Different TCAM definitions, data collection tools, methods and prevalence measurement were used across studies, thereby limiting the comparability of data locally and internationally.

Conclusion

A considerable number of studies/reports on TCAM use are available. Still, there is a lack of comprehensive, nationally representative data on prevalence and patterns of use of TCAM, including its use in relation to conventional medicine(s) in New Zealand.

Author Information

E Lyn Lee: Doctoral candidate, School of Pharmacy, University of Auckland, Auckland, New Zealand. Jeff Harrison: Associate Professor in Clinical Pharmacy; School of Pharmacy, University of Auckland, Auckland, New Zealand. Joanne Barnes: Associate Professor in Herbal Medicines; Deputy Head of School, School of Pharmacy, University of Auckland, Auckland, New Zealand.

Acknowledgements

Correspondence

Joanne Barnes: Associate Professor in Herbal Medicines; Deputy Head of School, School of Pharmacy, University of Auckland, 85 Park Rd, Grafton, Auckland 1023

Correspondence Email

j.barnes@auckland.ac.nz

Competing Interests

JB has received fees, honoraria and travel expenses from the Pharmaceutical Society of New Zealand (PSNZ) for preparation and delivery of continuing education material on complementary medicines (CMs) for pharmacists (2013, 2015); provided consultancy to the Pharmacy Council of New Zealand on Code of Ethics statements on CMs (unpaid) and competence standards (paid); was a member of the New Zealand Ministry of Health Natural Health Products (NHPs) Regulations Subcommittee on the Permitted Substances List (2016–2017) for which she received fees and travel expenses. JB has a personal viewpoint that generally supports regulation for CMs.

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Health products, preparations, practitioners and practices collectively referred to as “traditional, complementary and alternative medicine” (TCAM) are used extensively worldwide.[[1,2]] TCAM approaches are used by at least 80% of member states across all World Health Organization (WHO) regions and, in some regions, traditional (Indigenous) medicine is the only source of primary healthcare.[[2]] A systematic review of studies exploring TCAM use among general populations across 15 developed or developing countries reported a 12-month prevalence of use of one or more TCAM approaches ranging from 9.8% to 76%; similarly, 12-month prevalence of visits to one or more TCAM practitioners ranged from 1.8% to 48.7%.[[3]] The prevalence and patterns of TCAM use vary across countries due to differences in TCAM availability, affordability, regulations, cultural and historical significance, and conventional healthcare system advancement.[[1,2]]

The WHO defines traditional medicine (TM) and complementary/alternative medicine (CAM) separately and acknowledges that, in many countries, the terms are used interchangeably. The WHO definition of TM states: “Traditional medicine has a long history. It is the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.”[[2]] In some contexts, TM is described as a subset of CAM (health knowledge, beliefs, preparations and practices that usually sit outside the dominant health system), and vice versa. The term integrative medicine (IM, or integrative health) is also now used in the context of TCAM and refers to the coordinated use of both conventional and TCAM approaches in a patient-focused manner to achieve the best possible health and wellbeing outcomes for individual patients.[[4]] Definitions and terminology for TM, CAM and IM are not universally relevant, or accepted, and continue to evolve; similarly, products and practices included under the different terms vary across different studies exploring prevalence of use.

In New Zealand, TM preparations and practices include those used in rongoā Māori, the traditional medical system of Māori, as well as those used in traditional Pasifika medicine, of which there are several systems. In addition, numerous other TCAM approaches are available: CAMs/natural health products (NHPs) are sold in pharmacies, supermarkets, health food stores and through online outlets, and TCAM practices/therapies can be accessed through TCAM practitioners, such as herbalists, homoeopaths, naturopaths, traditional Chinese medicine and traditional Ayurvedic medicine practitioners.[[5]]

This work is a comprehensive review of research exploring the use of TCAM in New Zealand, including prevalence of use, access, expenditure, reasons for use and user and health practitioner perspectives. This paper, the first in a series of three, reviews research relating to the prevalence of use of TCAM, use of TCAM with conventional medicines and expenditure on TCAM products/preparations and practices.

Methods

This scoping review adopted a systematic process to identify relevant studies and summarise results.

The operational definition used for TCAM in this review was: “all health systems, modalities, and practices not typically considered part of conventional Western medicine that are used for health maintenance, disease prevention, and treatment.”[[6]] This included:

  • TCAM products/preparations
    — Complementary medicines: includes, but is not limited to, products or preparations described as natural health products, complementary/alternative medicines/remedies, dietary supplements, nutraceuticals and/or traditional medicines (products or preparations used in traditional medicine systems, such as rongoā Māori, or traditional Chinese medicine)
  • TCAM practices
    — Complementary therapies/practices: including but not limited to mind–body therapies (e.g., hypnotherapy, yoga), manipulative/body-based methods (e.g., osteopathy, chiropractic) and energy therapies (e.g., reiki, therapeutic touch)
    — Traditional medicine practices: such as traditional Chinese medicine, Ayurvedic medicine, rongoā Māori as well as other treatments, such as acupuncture, cupping

Chiropractic and osteopathy are regulated in New Zealand, but these health practitioners are included in this review as they are not necessarily considered part of mainstream medicine in this country.

This review included studies/reports on the prevalence and/or examination of any aspects of TCAM use across any subpopulation in New Zealand and health practitioners’ perspectives on consumers’ TCAM use. This review excluded studies/reports on: the benefits/harms of TCAM or specific TCAM products/therapies; the effectiveness of TCAM; the use of vitamins/minerals for prevention/treatment of medically diagnosed deficiencies/disorders (e.g., folic acid for prevention of neural tube defects); the use of TCAM for recreational purposes; letters to editors, commentaries and editorials.

The following electronic databases were searched from their inception to 7 June 2019 using systematic literature search strategies: MEDLINE; EMBASE; AMED; IPA (International Pharmceutical Abstracts); CINAHL; PsycINFO; Scopus. Grey literature was searched through Google Scholar’s and New Zealand government and relevant organisations’ websites using keywords. Reference lists of included studies were hand-searched to capture any additional relevant publications.

Search terms comprised combinations of subject headings and keywords related to three key concepts: (1) complementary and alternative medicine, (2) prevalence/utilisation and (3) New Zealand. The search strategy for MEDLINE is available on request from the authors. Search results were exported to a reference manager software (EndNote), duplicates were removed and studification (grouping publications from the same study) was done. The study selection comprised title and abstract screening then full-text screening. One reviewer (ELL) assessed study eligibility; a second reviewer (JB) was consulted when necessary. Data were extracted from the included studies by one researcher (ELL) and checked by a second researcher (JB). A data-extraction form was developed by the authors to extract general information about each study (e.g., author, publication year, participant characteristics, study design, methods) and specific information relevant to the review questions (e.g., TCAM terminologies and definitions used, aspects of TCAM use explored, key outcomes).

The extracted data were analysed, and tables depicting the study characteristics, including data collection tools and methods, participant characteristics (age, location, ethnicity, health status), settings and outcomes are presented. Studies included in this review were conducted at different time points; therefore, expenditure on TCAM expressed in New Zealand dollars was adjusted to 2020 using the Reserve Bank of New Zealand’s calculator.[[7]] Current values (year 2020) accounting for inflation are in parenthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist was used to guide reporting of this study.[[8]]

Results

Identification of studies

In total, 72 records (studies/reports) met the inclusion criteria. The screening and selection process is summarised using a PRISMA flow diagram (Figure 1).[[9]]

Characteristics of included studies

Studies were conducted from two perspectives: (1) health practitioners (TCAM[[10–15]] and conventional medical practitioners[[14,16–23]]); (2) population (including non-users and consumers of TCAM).[[18–20,24–81]] A table summarising the characteristics of the 72 included studies is available from the authors on request.

Figure 1: PRISMA flow diagram of literature search and study selection process.

Definitions and descriptions of TCAM terms

Twenty studies[[10-–13,15,25,39,40,49,50,54,58,70,71,73,75–77,79,80]] investigated a specific TCAM practice (e.g., chiropractic, osteopathy) or product/substance (e.g., melatonin, fish oil) only. The remaining studies examined non-specific TCAM use. Multiple studies[[21,35,44, 45,47,48,51,55–57,61–64,68]] used an operational definition for TCAM. The TCAM term used in some studies was described; it was unclear if the description was used as an operational defintion.[[14–17,19,27–29,41,43,78]] The terms most commonly used were “complementary and alternative medicine” (to describe all TCAM approaches including products and practices) and “dietary supplements” (to describe products). However, the definitions adopted for each term differed across studies and ranged from broad concepts inclusive of various products/practices (e.g., spiritual healing, massage) to tighter concepts with additional criteria limiting the products/practices included (Table 1). Less frequently used terms were “non-prescription health supplements,” “alternative therapist” and “unconventional practitioner.”

Table 1: CAM definitions/descriptions used across studies.

Types of TCAM explored in included studies

The types of TCAM included in studies exploring consumer use can be broadly categorised into “practices” and “products.” As individual types of products were usually not defined, and as questionnaires were not appended in most publications, it is unclear whether products such as herbal remedies reported by consumers were accessed through practitioners or self-prescribed. For studies that explored the use of products and did not indicate access through practitioners, these are categorised under products.

Studies/reports from the consumers’ perspective were conducted using quantitative, qualitative or mixed-methods approaches. Quantitative studies mainly examined a variety of TCAM practices,[[25,43,47,59–62,64]] products[[18,24,29,36,38,41,42,44–46,48,51,52,55–58,72]] or products and practices.[[19,20,26–28,31,33,35,37,53,78]] Several studies investigated participants’ use and experiences with a single TCAM practice, such as osteopathy,[[40]] traditional Pacific healers[[49]] and chiropractic.[[77,80]] Qualitative studies mostly explored consumers’ experiences with a specific TCAM practice, such as acupuncture,[[39,71]] massage therapy,[[75,76]] rongoā medicine,[[50]] traditional Chinese medicine[[54]] and traditional Tongan healing.[[30]]

The classification of TCAM products and practices varied across studies, which made direct comparison difficult. For instance, herbal products were analysed and reported in multiple ways: collectively as a product category,[[55]] and/or as individual herbs/active ingredients.[[44]] Categories were also sometimes incorrectly defined: for instance, one study regarded garlic, a botanical product, as an individual ingredient, “garlic,” and did not code it under the category “botanical product.”[[56]] In addition, TCAM practices, such as acupuncture, were analysed separately from traditional Chinese medicine,[[47]] when in reality some acupuncture practices originated from and may be considered a component of traditional Chinese medicine. Some studies grouped TCAM products and practices based on their intended use/function: for example, “antioxidants,”[[33]] “joint treatment” and “treatment to increase immunity.”[[44]] Some TCAM products or practices included in the studies were not distinct: for instance, “cleanser,”[[44]] “detoxification,”[[33, 35]] “lifestyle,”[[53]] “heat treatment.”[[78]]

The scope and range of TCAM products and practices differed between studies and were diverse. A table of the more than 70 terminologies used to describe or identify specific TCAM practices or products is available  from the authors on request. Most studies included products such as vitamins, minerals, herbal remedies and essential fatty acids and practices such as chiropractic, osteopathy, homeopathy and naturopathy. Some TCAM practices included less frequently were reflexology,[[26,31,35,53]] kinesiology, crystal healing, bloodletting and rebirthing.[[43]]

Prevalence of use

Thirty-eight studies reported data on the prevalence of use of one or more TCAM practices or products/preparations among consumers. Most studies reported prevalence in terms of lifetime use,[[18,20,27,28,35,42,44,52,78]] previous 12-months use[[41,43,45,47,48,55,56,61,62,64]] or both.[[19,25,53]]

Nationally representative general population studies

Nine studies/reports relating to three nationally representative studies reported prevalence of use. Data were derived from three government health surveys: the New Zealand Health Survey (NZHS),[[47,61,62]] New Zealand (Adult or Children) Nutrition Survey (separate surveys for adults and children),[[45,48,55–57]] and New Zealand Mental Health Survey (NZMHS) (Supplementarty Table 1).[[64]] The first two surveys examined TCAM use for any health reason, whereas the NZMHS explored TCAM consultations specifically for mental health problems. The New Zealand (Adult or Children) Nutrition Survey included the use of products (dietary supplements) only, and the other surveys (NZHS and NZMHS) included TCAM practices only. All studies presented prevalence in terms of previous 12-months use, except the New Zealand Children Nutrition Survey 2002, where the prevalence of use over the previous 24 hours was reported. The New Zealand Adult Nutrition Survey 1997 reported both previous 12-months use and previous 24-hours use.

As these surveys were heterogenous in the methods and definitions used, an overall prevalence range is not reported. Two surveys were repeated across two time periods, which enabled an analysis of usage trends. Based on the New Zealand Adult Nutrition Surveys in 1997 and 2008/9, the prevalence of dietary supplement use over the previous 12 months reduced slightly from 59% to 47.6% respectively. From the NZHS in 2002/3 and 2006/7, the prevalence of CAM practitioner consultations over the previous 12 months were 23.4% and 18.2% respectively, although the later survey excluded chiropractors and osteopaths and reported use of these practitioners separately (Table 2). The 2002/3 NZHS reported that Māori and Pacific healers were consulted by 0.9% and 0.2% of respondents, respectively, corresponding to 6.0% of Māori respondents and 4.6% of Pasifika respondents.[[62]] Self-treatment with rongoā Māori or Pacific medicine(s) were not explored.

Table 2: Prevalence of TCAM use derived from nationally representative general population data. View Table 2.

Other studies: non-nationally representative, or nationally representative sub-populations

The remaining 29 studies reported on the prevalence of TCAM use among consumers in specific ethnic populations, with certain medical conditions or in particular healthcare settings and locations across New Zealand (Supplementary Table 1).

Six studies explored TCAM use among children: two explored the use of TCAM products and practices,[[26,28]] two included TCAM practices only,[[59, 60]] one included TCAM products only[[52]] and one explored a single TCAM practice (traditional Pacific healers).[[49]] In a study involving children with dyspraxia, 100% reported the use of at least one “food supplement” (not further defined).[[26]] Of the remaining studies, prevalence of lifetime TCAM use ranged from 29% among children hospitalised due to acute illness[[28]] to 70% among children attending general practitioner or paediatric diabetes outpatient clinics in Christchurch.[[52]]

Among studies that explored TCAM use in adults, eleven included TCAM products and practices,[[19,20,27,31,33,35,37,44,46,53,78]] ten included TCAM products only[[18,24,29,36,38,41,42,51,58,72]] and two included TCAM practices only.[[25, 43]] There is substantial variation in the reported prevalence of use of TCAM products/practices across studies. For instance, the prevalence of lifetime TCAM products and practices use ranged from 56.1% among adults presenting to emergency care in North Shore Hospital, Auckland,[[53]] to 91% among inpatients in Gisborne Hospital.[[35]]

For TCAM subcategories, vitamins and minerals were most commonly reported, although the prevalence of use varied considerably as the definitions, study populations and prevalence periods differed across studies. Prevalence of use of herbal products[[29]]/therapies[[35]]/supplements[[37]]/extracts[[41]]/mixtures[[53]]/medicines[[78]]/remedies[[19]] (not defined in respective studies) also differed across studies. Lifetime use of 47% was reported among inpatients in a hospital,[[35]] and previous 12-months use of 15.1% and 4.4% were recorded among patients with Crohn’s disease[[41]] and adults presenting to a hospital emergency care centre,[[53]] respectively.

Several studies reported consumers’ use of traditional Māori[[20,44]] or Pacific medicine[[28,49]] or both.[[35]] In a study of attendees to a hospital emergency department, more than half (51.7%) of those who used traditional Māori treatment (7.3% of CAM users) grew or collected the plants and made the treatment themselves.[[44]] Use of traditional medicine is not exclusive to specific ethnic groups. Among inpatients at Gisborne hospital, 13% of non-Māori respondents reported having used rongoā Māori.[[35]]

TCAM use with conventional medicine

Many patients consider TCAM a safe choice and would take conventional medicines concurrently. Four studies explored the concurrent use of TCAM with conventional medicine.[[44,52,65,79]] Two quantitative studies reported the extent of TCAM use with conventional medicines among consumers.[[44,52]] In a survey involving hospital emergency department attendees, around one-quarter of CAM users were taking conventional medicines concurrently, and one user experienced serotonin syndrome associated with concurrent use of paroxetine and St. John’s wort.[[44]] Among children attending general practitioner or paediatric outpatient clinics in Christchurch, approximately one-fifth (18%) had used both TCAM and conventional medicines concurrently and did not disclose their CAM use to their physicians.[[52]]

Interviews with Māori regarding Māori health and wellbeing revealed that the use of rongoā is perceived to be compatible with use of Western medicines.[[79]] An exploratory study of patients with gout found that various therapies, such as Epsom salts, glucosamine, cod liver oil, chondroitin and kawakawa, are used complementary to prescribed conventional medications.[[65]]

Cost of TCAM

Table 3 summarises the findings from four studies that reported consumers’ monthly spending on TCAM products and/or practices.[[29,33,42,78]]

Two studies explored the costs from health practitioners’ perspectives. Massage therapists reported a median of 16–20 hours of client care per week and most frequently charge NZD 60/hour (NZD 72/hour).[[15]] Chiropractors in New Zealand indicated that the average number of adjustments visits per week they performed was 142, and that on average one-third of their practices were related to Accident Compensation Corporation (ACC) insurance claims.[[13]]

Table 3: Cost of TCAM reported in studies.

ACC = Accident Compensation Corporation.*Year of publication used to calculate cost adjustment.

Discussion

This scoping review mapped publicly available evidence from studies/reports exploring the prevalence of use of TCAM in New Zealand.

Substantial evidence exploring TCAM use exists, but information from robust nationally representative studies is limited, as these studies have not comprehensively assessed the prevalence of use of both TCAM practices and TCAM products used in self-care. The New Zealand Adult Nutrition Survey 2008/9[[55]] and the NZHS 2006/7[[61]] explored the use of dietary supplements only (47.6%) and TCAM practitioners only (18.2%), respectively. This suggests that, although the 12-month prevalence of use of any TCAM in New Zealand is unknown, it was at least 47.6% in 2008/9.

Research indicates that a broad range of TCAM practices and products is used by people of all ages and ethnicities and with various health conditions. New Zealanders access these products and practices through multiple avenues, including conventional medical practitioners, and pay substantial sums of money out-of-pocket. Collectively, this indicates that there is a sizable demand for and use of TCAM among New Zealanders.

Several gaps were identified in the data: there are no current, nationally representative and comprehensive data on the prevalence of use of TCAM products and practices among patients/consumers in New Zealand, including the types of TCAM products/practices used, how they are accessed, and patterns of use of TCAM alongside conventional medicine. There are also substantial gaps in data on direct and indirect personal and government expenditure on TCAM products/practices, including government-funded treatments such as those covered by ACC and Work and Income New Zealand (WINZ).

Data indicate that the prevalence of visits to TCAM practitioners over the previous 12 months in New Zealand is comparable to that reported in national surveys from the USA (16.2%),[[82]] UK (12.1%)[[83]] and Canada (12.4%).[[84]] The overall use of TCAM (products and practices) in New Zealand (at least 47.6% in 2008/09) is similar to that in developed countries, such as the USA (~30%)[[85]] and Australia (63.1%).[[86]] Despite evidence of a high prevalence of use of TCAM products in New Zealand, there are yet no specific regulations governing the quality, efficacy and safety of these products. Many herbal and homeopathic products are exempt from the requirements of the Medicines Act 1981.[[87]] TCAM products do not have a specific regulatory framework in New Zealand; most are captured by the Dietary Supplements Regulations 1985, but these regulations do not require assessment of quality, efficacy and safety of TCAM products prior to marketing.[[88]] Thus, there are no assurances about product content and, therefore, pharmacological activity. Instances of adulteration, including with added conventional pharmaceutical ingredients, have occurred in TCAM products distributed in New Zealand.[[89,90]] Some TCAM products distributed in New Zealand are produced to Good Manufacturing Practice (GMP) standards; however, there is no straightforward way for health professionals and consumers to identify these products (unless a product holds an overseas authorisation, for example, is a listed/registered medicine on the Australian Register of Therapeutic Goods[[91]]). In New Zealand, the Natural Health and Supplementary Products Bill was introduced in 2011 with the intention of regulating NHPs, including requiring manufacturers to produce their products according to GMP standards and to provide bibliographic and/or traditional-use evidence to support claims of health benefits.[[92]] However, the Bill lapsed in 2017 without being implemented.[[93]]

Many types of conventional practitioners in New Zealand are required to comply with standards of practice[[94,95]] and a codes of ethics[[96]] around recommending/using TCAM products/practices in their practice. Some clinical practice guidelines review evidence of, and include recommendations on, TCAM use for treatment of disease (e.g., use of acupuncture for smoking cessation[[97]]). Of practitioners typically considered to be TCAM practitioners in New Zealand, only chiropractors and osteopaths are regulated under the Health Practitioners Competence Assurance (HPCA) Act 2003.[[98]] Applications for traditional Chinese medicine practitioners and Western medical herbalists to be regulated under the Act were made in 2010 and 2015, respectively; discussions are ongoing.[[99]] New Zealand has a unique traditional medicine system (rongoā Māori)[[100]] founded on Indigenous medical practices handed down through generations of practitioners. Rongoā Māori is a traditional healing system developed and formulated in Māori culture, and which includes physical, emotional, family and spiritual aspects of health; it may involve use of rongoā rākau (preparations of native plants) and other substances of natural origin, as well as mirimiri (massage) and karakia (prayer), as part of an holistic healing approach.[[100]] Māori traditional healers are the holders of traditional knowledge of the harvesting, preparation and use of these medicinal products. This knowledge is often unique to the practitioner and differs between iwi depending on their geographical area and the teaching of their ancestors; in this regard, they are the holders of the “intellectual property” of these preparations. New Zealand is constitutionally a bi-cultural country and a multi-ethnic society;[[101]] in addition to rongoā Māori, traditional Pasifika medicine, and imported traditional medicine systems from other cultures, such as traditional Chinese medicine and Ayurvedic medicine, are also present. Currently, access to some TCAM (e.g., acupuncture, rongoā services) is government funded.[[100,102]] Government-funded rongoā Māori providers are required to adhere to the rongoā standards, Tikanga ā-Rongoā.[[103]] Intentions to regulate TCAM products, practices and/or practitioners in New Zealand would need to account for, and carefully consider, the impact on and protection of mātauranga Māori[[97]], the broad range of existing products/practices/practitioners and the impact on funding, as well as the practice of TCAM, as part of the wider New Zealand healthcare system.

Despite consumers’ beliefs in TCAM as a natural and, therefore, safe healthcare option, adverse events can occur with the use of TCAM, including when its used together with conventional medicine. TCAM is frequently self-selected by consumers and is obtained outside the conventional healthcare system. Therefore, consumption/use is often unknown to conventional medical practitioners, unless its use is disclosed by the consumers themselves. Consumers choose to use TCAM for numerous reasons, and the conditions of use, including disclosure to health practitioners, will be explored and discussed in a later paper in the series.

Globally, a uniform definition for TCAM does not exist, despite efforts towards reaching a consensus.[[104,105]] Hence it is not surprising that studies in New Zealand use a wide range of TCAM terms and definitions. Although the New Zealand Ministerial Advisory Committee on Complementary and Alternative Health in 2004 agreed to adapt the definition from the United States National Center for Complementary and Alternative Medicine (now the National Center for Complementary and Integrative Health),[[5]] few New Zealand studies did so. Depending on how TCAM is defined and operationalised, prevalence estimates can vary considerably. In a systematic review, prevalence of use rates were inflated when studies included “prayer” as a TCAM approach in their operational definition.[[3]] Numerous New Zealand studies did not report (using) an operational definition, which implies that participants’ responses were based on their own understanding or interpretation of TCAM (or other terms used in the respective studies); such an approach is not standardised and is susceptible to underreporting or overreporting. Most studies also utilised different data collection tools, methods and prevalence measurements (e.g., lifetime, previous 12 months, 2 weeks, 2 months, during illness), adding to the challenges in aggregating data and comparing them locally and internationally.

Reliable nationally representative data on prevalence, patterns of use, expenditure and modes of access to TCAM products and practices (including where therapies are provided by conventional health practitioners or funded by the Ministry of Health, ACC or WINZ) are needed in New Zealand. A robust, comprehensive study on prevalence of TCAM use in New Zealand would need to include a standardised TCAM definition, scope and measurement of prevalence of use. It should collect respondents’ National Health Index (NHI) numbers (a unique identifier for every person who uses health and disability support services in New Zealand) to allow for data integration and linkage across studies/databases. Data collected from the survey would serve as a useful resource at a population level for monitoring trends in TCAM use, alone and in conjunction with conventional medicine(s). Data on prevalence indicate not only the breadth of TCAM use in New Zealand, but also, to some extent, patients’ unmet healthcare needs within the current publicly funded healthcare system. Therefore, any change in TCAM regulations would need to consider the impact on the allocation of public healthcare resources and funding. A substantial prevalence of use could also prompt the initiation of an in-depth review on the safety and efficacy of TCAM. Hence a comprehensive understanding of the extent, scope and patterns of TCAM use in New Zealand, together with evidence-based information on safety and efficacy, could contribute to informing government healthcare policy and decision-making.

This scoping review provides an overview and understanding of data on use of and access to TCAM in New Zealand and has identified gaps in knowledge for future studies. The work has several strengths and limitations. First, no formal evaluation of the quality of evidence was undertaken for the included studies. Also, information was gathered from a range of study designs and methods, restricting comparability across studies. A comprehensive search strategy was developed and used, but given the lack of standardisation in TCAM terminologies, some studies may have been missed. Another limitation is the use of a single reviewer for screening and data extraction, which may have introduced bias.

Conclusion

Numerous, typically small, localised studies exploring TCAM use in New Zealand are available; however, there is a lack of comprehensive, nationally representative data on prevalence and patterns of use of TCAM, including use in relation to conventional medicine(s). Existing data have been collected using various methods, limiting the comparability and further analysis. There is evidence of substantial use of TCAM among patients/consumers of different ages and ethnicities and with diverse health conditions. Given the high prevalence of use and ongoing lack of regulation, reliable, current, nationally representative data on prevalence of use of all TCAM products/preparations and practices/therapies is warranted for New Zealand.

Supplementary material

  • Supplementary Table 1: Prevalence of TCAM use from other (non-nationally representative, or nationally representative sub-populations) studies. View Supplementary Table 1.

Summary

Abstract

Aim

Traditional, complementary and alternative medicine (TCAM) is a popular healthcare choice worldwide. The extent of data available on TCAM, including prevalence and patterns of use in New Zealand, is unknown. This scoping review aims to map the existing research describing the use of TCAM (including prevalence, access, expenditure and concurrent use with conventional medicines) in New Zealand.

Method

Research databases (MEDLINE, EMBASE, AMED, IPA (International Pharmaceutical Abstracts), CINAHL, PsycINFO and Scopus) and grey literature (Google Scholar and New Zealand government and relevant organisations’ websites) were searched for studies published before 7 June 2019. Studies reporting on the prevalence and/or exploring aspects of TCAM use were included in this review.

Results

In total, 72 studies were reviewed. Available data suggest that TCAM use is widespread among New Zealanders, and some consumers pay large sums of money out-of-pocket. A wide range of TCAM practices and products is used by people of all ages and ethnicities and with various health conditions. There is some evidence of consumers using TCAM concurrently with conventional medicines. Studies were generally small, localised and conducted in sub-populations (e.g., specific age groups, health conditions). Different TCAM definitions, data collection tools, methods and prevalence measurement were used across studies, thereby limiting the comparability of data locally and internationally.

Conclusion

A considerable number of studies/reports on TCAM use are available. Still, there is a lack of comprehensive, nationally representative data on prevalence and patterns of use of TCAM, including its use in relation to conventional medicine(s) in New Zealand.

Author Information

E Lyn Lee: Doctoral candidate, School of Pharmacy, University of Auckland, Auckland, New Zealand. Jeff Harrison: Associate Professor in Clinical Pharmacy; School of Pharmacy, University of Auckland, Auckland, New Zealand. Joanne Barnes: Associate Professor in Herbal Medicines; Deputy Head of School, School of Pharmacy, University of Auckland, Auckland, New Zealand.

Acknowledgements

Correspondence

Joanne Barnes: Associate Professor in Herbal Medicines; Deputy Head of School, School of Pharmacy, University of Auckland, 85 Park Rd, Grafton, Auckland 1023

Correspondence Email

j.barnes@auckland.ac.nz

Competing Interests

JB has received fees, honoraria and travel expenses from the Pharmaceutical Society of New Zealand (PSNZ) for preparation and delivery of continuing education material on complementary medicines (CMs) for pharmacists (2013, 2015); provided consultancy to the Pharmacy Council of New Zealand on Code of Ethics statements on CMs (unpaid) and competence standards (paid); was a member of the New Zealand Ministry of Health Natural Health Products (NHPs) Regulations Subcommittee on the Permitted Substances List (2016–2017) for which she received fees and travel expenses. JB has a personal viewpoint that generally supports regulation for CMs.

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92) New Zealand Government [Internet]. Natural Health and Supplementary Products bill [cited 2020 Nov 10]. Available from: http://www.legislation.govt.nz/bill/government/2011/0324/latest/whole.html.

93) Zoio N. Natural health products bill quietly killed off [cited 2021 May 5]. Available from: https://www.pharmacytoday.co.nz/article/print-archive/natural-health-products-bill-quietly-killed.

94) Medical Council of New Zealand [Internet]. Doctors and CAM (complementary and alternative medicine) Wellington: Medical Council of New Zealand; 2017 [cited 2020 Nov 10]. Available from: https://www.mcnz.org.nz/assets/standards/7eb60db2d2/Doctors-and-CAM-Complementary-and-alternative-medicine.pdf.

95) Pharmacy Council of New Zealand [Internet]. Pharmacy council complementary and alternative medicines - statement and protocol for pharmacists 2020 [cited 2020 Nov 10]. Available from: https://www.pharmacycouncil.org.nz/wp-content/uploads/Complementary-and-Alternative-Medicines-CAM-Statement.pdf.

96) Pharmacy Council of New Zealand. Code of Ethics - Safe effective pharmacy practice Wellington: Pharmacy Council of New Zealand; 2018 [cited 2020 Nov 10].

97) Ministry of Research Science and Technology [Internet]. Vision Mātauranga: Unlocking the innovation potential of Māori knowledge, resources and people 2007 [cited 2021 Apr 16]. Available from: https://www.mbie.govt.nz/assets/9916d28d7b/vision-matauranga-booklet.pdf.

98) Ministry of Health [Internet]. Health Practitioners Competence Assurance Act: responsible authorities under the Act 2020 [cited 2020 Nov 10]. Available from: https://www.health.govt.nz/our-work/regulation-health-and-disability-system/health-practitioners-competence-assurance-act/responsible-authorities-under-act.

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100) Ministry of Health [Internet]. Rongoā Māori: traditional Māori healing [cited 2020 Nov 10]. Available from: https://www.health.govt.nz/our-work/populations/maori-health/rongoa-maori-traditional-maori-healing.

101) Stats NZ [Internet]. New Zealand’s population reflects growing diversity: New Zealand Government; 2019 [cited 2020 Nov 10]. Available from: https://www.stats.govt.nz/news/new-zealands-population-reflects-growing-diversity.

102) Accident Compensation Corporation [Internet]. Treatment we can help pay for [cited 2020 Nov 10]. Available from: https://www.acc.co.nz/im-injured/what-we-cover/treatment-we-pay-for/.

103) Ministry of Health [Internet]. Tikanga ā-Rongoā Wellington: Ministry of Health; 2014 [cited 2021 Apr 16]. Available from: https://www.health.govt.nz/system/files/documents/publications/tikanga-a-rongoa-english-apr14-v2.pdf.

104) Gaboury I, April KT, Verhoef M. A qualitative study on the term CAM: is there a need to reinvent the wheel? BMC Altern Med. 2012;12:131.

105) Holmberg C, Brinkhaus B, Witt C. Experts' opinions on terminology for complementary and integrative medicine - a qualitative study with leading experts. BMC Altern Med. 2012;12:218.

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Health products, preparations, practitioners and practices collectively referred to as “traditional, complementary and alternative medicine” (TCAM) are used extensively worldwide.[[1,2]] TCAM approaches are used by at least 80% of member states across all World Health Organization (WHO) regions and, in some regions, traditional (Indigenous) medicine is the only source of primary healthcare.[[2]] A systematic review of studies exploring TCAM use among general populations across 15 developed or developing countries reported a 12-month prevalence of use of one or more TCAM approaches ranging from 9.8% to 76%; similarly, 12-month prevalence of visits to one or more TCAM practitioners ranged from 1.8% to 48.7%.[[3]] The prevalence and patterns of TCAM use vary across countries due to differences in TCAM availability, affordability, regulations, cultural and historical significance, and conventional healthcare system advancement.[[1,2]]

The WHO defines traditional medicine (TM) and complementary/alternative medicine (CAM) separately and acknowledges that, in many countries, the terms are used interchangeably. The WHO definition of TM states: “Traditional medicine has a long history. It is the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.”[[2]] In some contexts, TM is described as a subset of CAM (health knowledge, beliefs, preparations and practices that usually sit outside the dominant health system), and vice versa. The term integrative medicine (IM, or integrative health) is also now used in the context of TCAM and refers to the coordinated use of both conventional and TCAM approaches in a patient-focused manner to achieve the best possible health and wellbeing outcomes for individual patients.[[4]] Definitions and terminology for TM, CAM and IM are not universally relevant, or accepted, and continue to evolve; similarly, products and practices included under the different terms vary across different studies exploring prevalence of use.

In New Zealand, TM preparations and practices include those used in rongoā Māori, the traditional medical system of Māori, as well as those used in traditional Pasifika medicine, of which there are several systems. In addition, numerous other TCAM approaches are available: CAMs/natural health products (NHPs) are sold in pharmacies, supermarkets, health food stores and through online outlets, and TCAM practices/therapies can be accessed through TCAM practitioners, such as herbalists, homoeopaths, naturopaths, traditional Chinese medicine and traditional Ayurvedic medicine practitioners.[[5]]

This work is a comprehensive review of research exploring the use of TCAM in New Zealand, including prevalence of use, access, expenditure, reasons for use and user and health practitioner perspectives. This paper, the first in a series of three, reviews research relating to the prevalence of use of TCAM, use of TCAM with conventional medicines and expenditure on TCAM products/preparations and practices.

Methods

This scoping review adopted a systematic process to identify relevant studies and summarise results.

The operational definition used for TCAM in this review was: “all health systems, modalities, and practices not typically considered part of conventional Western medicine that are used for health maintenance, disease prevention, and treatment.”[[6]] This included:

  • TCAM products/preparations
    — Complementary medicines: includes, but is not limited to, products or preparations described as natural health products, complementary/alternative medicines/remedies, dietary supplements, nutraceuticals and/or traditional medicines (products or preparations used in traditional medicine systems, such as rongoā Māori, or traditional Chinese medicine)
  • TCAM practices
    — Complementary therapies/practices: including but not limited to mind–body therapies (e.g., hypnotherapy, yoga), manipulative/body-based methods (e.g., osteopathy, chiropractic) and energy therapies (e.g., reiki, therapeutic touch)
    — Traditional medicine practices: such as traditional Chinese medicine, Ayurvedic medicine, rongoā Māori as well as other treatments, such as acupuncture, cupping

Chiropractic and osteopathy are regulated in New Zealand, but these health practitioners are included in this review as they are not necessarily considered part of mainstream medicine in this country.

This review included studies/reports on the prevalence and/or examination of any aspects of TCAM use across any subpopulation in New Zealand and health practitioners’ perspectives on consumers’ TCAM use. This review excluded studies/reports on: the benefits/harms of TCAM or specific TCAM products/therapies; the effectiveness of TCAM; the use of vitamins/minerals for prevention/treatment of medically diagnosed deficiencies/disorders (e.g., folic acid for prevention of neural tube defects); the use of TCAM for recreational purposes; letters to editors, commentaries and editorials.

The following electronic databases were searched from their inception to 7 June 2019 using systematic literature search strategies: MEDLINE; EMBASE; AMED; IPA (International Pharmceutical Abstracts); CINAHL; PsycINFO; Scopus. Grey literature was searched through Google Scholar’s and New Zealand government and relevant organisations’ websites using keywords. Reference lists of included studies were hand-searched to capture any additional relevant publications.

Search terms comprised combinations of subject headings and keywords related to three key concepts: (1) complementary and alternative medicine, (2) prevalence/utilisation and (3) New Zealand. The search strategy for MEDLINE is available on request from the authors. Search results were exported to a reference manager software (EndNote), duplicates were removed and studification (grouping publications from the same study) was done. The study selection comprised title and abstract screening then full-text screening. One reviewer (ELL) assessed study eligibility; a second reviewer (JB) was consulted when necessary. Data were extracted from the included studies by one researcher (ELL) and checked by a second researcher (JB). A data-extraction form was developed by the authors to extract general information about each study (e.g., author, publication year, participant characteristics, study design, methods) and specific information relevant to the review questions (e.g., TCAM terminologies and definitions used, aspects of TCAM use explored, key outcomes).

The extracted data were analysed, and tables depicting the study characteristics, including data collection tools and methods, participant characteristics (age, location, ethnicity, health status), settings and outcomes are presented. Studies included in this review were conducted at different time points; therefore, expenditure on TCAM expressed in New Zealand dollars was adjusted to 2020 using the Reserve Bank of New Zealand’s calculator.[[7]] Current values (year 2020) accounting for inflation are in parenthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist was used to guide reporting of this study.[[8]]

Results

Identification of studies

In total, 72 records (studies/reports) met the inclusion criteria. The screening and selection process is summarised using a PRISMA flow diagram (Figure 1).[[9]]

Characteristics of included studies

Studies were conducted from two perspectives: (1) health practitioners (TCAM[[10–15]] and conventional medical practitioners[[14,16–23]]); (2) population (including non-users and consumers of TCAM).[[18–20,24–81]] A table summarising the characteristics of the 72 included studies is available from the authors on request.

Figure 1: PRISMA flow diagram of literature search and study selection process.

Definitions and descriptions of TCAM terms

Twenty studies[[10-–13,15,25,39,40,49,50,54,58,70,71,73,75–77,79,80]] investigated a specific TCAM practice (e.g., chiropractic, osteopathy) or product/substance (e.g., melatonin, fish oil) only. The remaining studies examined non-specific TCAM use. Multiple studies[[21,35,44, 45,47,48,51,55–57,61–64,68]] used an operational definition for TCAM. The TCAM term used in some studies was described; it was unclear if the description was used as an operational defintion.[[14–17,19,27–29,41,43,78]] The terms most commonly used were “complementary and alternative medicine” (to describe all TCAM approaches including products and practices) and “dietary supplements” (to describe products). However, the definitions adopted for each term differed across studies and ranged from broad concepts inclusive of various products/practices (e.g., spiritual healing, massage) to tighter concepts with additional criteria limiting the products/practices included (Table 1). Less frequently used terms were “non-prescription health supplements,” “alternative therapist” and “unconventional practitioner.”

Table 1: CAM definitions/descriptions used across studies.

Types of TCAM explored in included studies

The types of TCAM included in studies exploring consumer use can be broadly categorised into “practices” and “products.” As individual types of products were usually not defined, and as questionnaires were not appended in most publications, it is unclear whether products such as herbal remedies reported by consumers were accessed through practitioners or self-prescribed. For studies that explored the use of products and did not indicate access through practitioners, these are categorised under products.

Studies/reports from the consumers’ perspective were conducted using quantitative, qualitative or mixed-methods approaches. Quantitative studies mainly examined a variety of TCAM practices,[[25,43,47,59–62,64]] products[[18,24,29,36,38,41,42,44–46,48,51,52,55–58,72]] or products and practices.[[19,20,26–28,31,33,35,37,53,78]] Several studies investigated participants’ use and experiences with a single TCAM practice, such as osteopathy,[[40]] traditional Pacific healers[[49]] and chiropractic.[[77,80]] Qualitative studies mostly explored consumers’ experiences with a specific TCAM practice, such as acupuncture,[[39,71]] massage therapy,[[75,76]] rongoā medicine,[[50]] traditional Chinese medicine[[54]] and traditional Tongan healing.[[30]]

The classification of TCAM products and practices varied across studies, which made direct comparison difficult. For instance, herbal products were analysed and reported in multiple ways: collectively as a product category,[[55]] and/or as individual herbs/active ingredients.[[44]] Categories were also sometimes incorrectly defined: for instance, one study regarded garlic, a botanical product, as an individual ingredient, “garlic,” and did not code it under the category “botanical product.”[[56]] In addition, TCAM practices, such as acupuncture, were analysed separately from traditional Chinese medicine,[[47]] when in reality some acupuncture practices originated from and may be considered a component of traditional Chinese medicine. Some studies grouped TCAM products and practices based on their intended use/function: for example, “antioxidants,”[[33]] “joint treatment” and “treatment to increase immunity.”[[44]] Some TCAM products or practices included in the studies were not distinct: for instance, “cleanser,”[[44]] “detoxification,”[[33, 35]] “lifestyle,”[[53]] “heat treatment.”[[78]]

The scope and range of TCAM products and practices differed between studies and were diverse. A table of the more than 70 terminologies used to describe or identify specific TCAM practices or products is available  from the authors on request. Most studies included products such as vitamins, minerals, herbal remedies and essential fatty acids and practices such as chiropractic, osteopathy, homeopathy and naturopathy. Some TCAM practices included less frequently were reflexology,[[26,31,35,53]] kinesiology, crystal healing, bloodletting and rebirthing.[[43]]

Prevalence of use

Thirty-eight studies reported data on the prevalence of use of one or more TCAM practices or products/preparations among consumers. Most studies reported prevalence in terms of lifetime use,[[18,20,27,28,35,42,44,52,78]] previous 12-months use[[41,43,45,47,48,55,56,61,62,64]] or both.[[19,25,53]]

Nationally representative general population studies

Nine studies/reports relating to three nationally representative studies reported prevalence of use. Data were derived from three government health surveys: the New Zealand Health Survey (NZHS),[[47,61,62]] New Zealand (Adult or Children) Nutrition Survey (separate surveys for adults and children),[[45,48,55–57]] and New Zealand Mental Health Survey (NZMHS) (Supplementarty Table 1).[[64]] The first two surveys examined TCAM use for any health reason, whereas the NZMHS explored TCAM consultations specifically for mental health problems. The New Zealand (Adult or Children) Nutrition Survey included the use of products (dietary supplements) only, and the other surveys (NZHS and NZMHS) included TCAM practices only. All studies presented prevalence in terms of previous 12-months use, except the New Zealand Children Nutrition Survey 2002, where the prevalence of use over the previous 24 hours was reported. The New Zealand Adult Nutrition Survey 1997 reported both previous 12-months use and previous 24-hours use.

As these surveys were heterogenous in the methods and definitions used, an overall prevalence range is not reported. Two surveys were repeated across two time periods, which enabled an analysis of usage trends. Based on the New Zealand Adult Nutrition Surveys in 1997 and 2008/9, the prevalence of dietary supplement use over the previous 12 months reduced slightly from 59% to 47.6% respectively. From the NZHS in 2002/3 and 2006/7, the prevalence of CAM practitioner consultations over the previous 12 months were 23.4% and 18.2% respectively, although the later survey excluded chiropractors and osteopaths and reported use of these practitioners separately (Table 2). The 2002/3 NZHS reported that Māori and Pacific healers were consulted by 0.9% and 0.2% of respondents, respectively, corresponding to 6.0% of Māori respondents and 4.6% of Pasifika respondents.[[62]] Self-treatment with rongoā Māori or Pacific medicine(s) were not explored.

Table 2: Prevalence of TCAM use derived from nationally representative general population data. View Table 2.

Other studies: non-nationally representative, or nationally representative sub-populations

The remaining 29 studies reported on the prevalence of TCAM use among consumers in specific ethnic populations, with certain medical conditions or in particular healthcare settings and locations across New Zealand (Supplementary Table 1).

Six studies explored TCAM use among children: two explored the use of TCAM products and practices,[[26,28]] two included TCAM practices only,[[59, 60]] one included TCAM products only[[52]] and one explored a single TCAM practice (traditional Pacific healers).[[49]] In a study involving children with dyspraxia, 100% reported the use of at least one “food supplement” (not further defined).[[26]] Of the remaining studies, prevalence of lifetime TCAM use ranged from 29% among children hospitalised due to acute illness[[28]] to 70% among children attending general practitioner or paediatric diabetes outpatient clinics in Christchurch.[[52]]

Among studies that explored TCAM use in adults, eleven included TCAM products and practices,[[19,20,27,31,33,35,37,44,46,53,78]] ten included TCAM products only[[18,24,29,36,38,41,42,51,58,72]] and two included TCAM practices only.[[25, 43]] There is substantial variation in the reported prevalence of use of TCAM products/practices across studies. For instance, the prevalence of lifetime TCAM products and practices use ranged from 56.1% among adults presenting to emergency care in North Shore Hospital, Auckland,[[53]] to 91% among inpatients in Gisborne Hospital.[[35]]

For TCAM subcategories, vitamins and minerals were most commonly reported, although the prevalence of use varied considerably as the definitions, study populations and prevalence periods differed across studies. Prevalence of use of herbal products[[29]]/therapies[[35]]/supplements[[37]]/extracts[[41]]/mixtures[[53]]/medicines[[78]]/remedies[[19]] (not defined in respective studies) also differed across studies. Lifetime use of 47% was reported among inpatients in a hospital,[[35]] and previous 12-months use of 15.1% and 4.4% were recorded among patients with Crohn’s disease[[41]] and adults presenting to a hospital emergency care centre,[[53]] respectively.

Several studies reported consumers’ use of traditional Māori[[20,44]] or Pacific medicine[[28,49]] or both.[[35]] In a study of attendees to a hospital emergency department, more than half (51.7%) of those who used traditional Māori treatment (7.3% of CAM users) grew or collected the plants and made the treatment themselves.[[44]] Use of traditional medicine is not exclusive to specific ethnic groups. Among inpatients at Gisborne hospital, 13% of non-Māori respondents reported having used rongoā Māori.[[35]]

TCAM use with conventional medicine

Many patients consider TCAM a safe choice and would take conventional medicines concurrently. Four studies explored the concurrent use of TCAM with conventional medicine.[[44,52,65,79]] Two quantitative studies reported the extent of TCAM use with conventional medicines among consumers.[[44,52]] In a survey involving hospital emergency department attendees, around one-quarter of CAM users were taking conventional medicines concurrently, and one user experienced serotonin syndrome associated with concurrent use of paroxetine and St. John’s wort.[[44]] Among children attending general practitioner or paediatric outpatient clinics in Christchurch, approximately one-fifth (18%) had used both TCAM and conventional medicines concurrently and did not disclose their CAM use to their physicians.[[52]]

Interviews with Māori regarding Māori health and wellbeing revealed that the use of rongoā is perceived to be compatible with use of Western medicines.[[79]] An exploratory study of patients with gout found that various therapies, such as Epsom salts, glucosamine, cod liver oil, chondroitin and kawakawa, are used complementary to prescribed conventional medications.[[65]]

Cost of TCAM

Table 3 summarises the findings from four studies that reported consumers’ monthly spending on TCAM products and/or practices.[[29,33,42,78]]

Two studies explored the costs from health practitioners’ perspectives. Massage therapists reported a median of 16–20 hours of client care per week and most frequently charge NZD 60/hour (NZD 72/hour).[[15]] Chiropractors in New Zealand indicated that the average number of adjustments visits per week they performed was 142, and that on average one-third of their practices were related to Accident Compensation Corporation (ACC) insurance claims.[[13]]

Table 3: Cost of TCAM reported in studies.

ACC = Accident Compensation Corporation.*Year of publication used to calculate cost adjustment.

Discussion

This scoping review mapped publicly available evidence from studies/reports exploring the prevalence of use of TCAM in New Zealand.

Substantial evidence exploring TCAM use exists, but information from robust nationally representative studies is limited, as these studies have not comprehensively assessed the prevalence of use of both TCAM practices and TCAM products used in self-care. The New Zealand Adult Nutrition Survey 2008/9[[55]] and the NZHS 2006/7[[61]] explored the use of dietary supplements only (47.6%) and TCAM practitioners only (18.2%), respectively. This suggests that, although the 12-month prevalence of use of any TCAM in New Zealand is unknown, it was at least 47.6% in 2008/9.

Research indicates that a broad range of TCAM practices and products is used by people of all ages and ethnicities and with various health conditions. New Zealanders access these products and practices through multiple avenues, including conventional medical practitioners, and pay substantial sums of money out-of-pocket. Collectively, this indicates that there is a sizable demand for and use of TCAM among New Zealanders.

Several gaps were identified in the data: there are no current, nationally representative and comprehensive data on the prevalence of use of TCAM products and practices among patients/consumers in New Zealand, including the types of TCAM products/practices used, how they are accessed, and patterns of use of TCAM alongside conventional medicine. There are also substantial gaps in data on direct and indirect personal and government expenditure on TCAM products/practices, including government-funded treatments such as those covered by ACC and Work and Income New Zealand (WINZ).

Data indicate that the prevalence of visits to TCAM practitioners over the previous 12 months in New Zealand is comparable to that reported in national surveys from the USA (16.2%),[[82]] UK (12.1%)[[83]] and Canada (12.4%).[[84]] The overall use of TCAM (products and practices) in New Zealand (at least 47.6% in 2008/09) is similar to that in developed countries, such as the USA (~30%)[[85]] and Australia (63.1%).[[86]] Despite evidence of a high prevalence of use of TCAM products in New Zealand, there are yet no specific regulations governing the quality, efficacy and safety of these products. Many herbal and homeopathic products are exempt from the requirements of the Medicines Act 1981.[[87]] TCAM products do not have a specific regulatory framework in New Zealand; most are captured by the Dietary Supplements Regulations 1985, but these regulations do not require assessment of quality, efficacy and safety of TCAM products prior to marketing.[[88]] Thus, there are no assurances about product content and, therefore, pharmacological activity. Instances of adulteration, including with added conventional pharmaceutical ingredients, have occurred in TCAM products distributed in New Zealand.[[89,90]] Some TCAM products distributed in New Zealand are produced to Good Manufacturing Practice (GMP) standards; however, there is no straightforward way for health professionals and consumers to identify these products (unless a product holds an overseas authorisation, for example, is a listed/registered medicine on the Australian Register of Therapeutic Goods[[91]]). In New Zealand, the Natural Health and Supplementary Products Bill was introduced in 2011 with the intention of regulating NHPs, including requiring manufacturers to produce their products according to GMP standards and to provide bibliographic and/or traditional-use evidence to support claims of health benefits.[[92]] However, the Bill lapsed in 2017 without being implemented.[[93]]

Many types of conventional practitioners in New Zealand are required to comply with standards of practice[[94,95]] and a codes of ethics[[96]] around recommending/using TCAM products/practices in their practice. Some clinical practice guidelines review evidence of, and include recommendations on, TCAM use for treatment of disease (e.g., use of acupuncture for smoking cessation[[97]]). Of practitioners typically considered to be TCAM practitioners in New Zealand, only chiropractors and osteopaths are regulated under the Health Practitioners Competence Assurance (HPCA) Act 2003.[[98]] Applications for traditional Chinese medicine practitioners and Western medical herbalists to be regulated under the Act were made in 2010 and 2015, respectively; discussions are ongoing.[[99]] New Zealand has a unique traditional medicine system (rongoā Māori)[[100]] founded on Indigenous medical practices handed down through generations of practitioners. Rongoā Māori is a traditional healing system developed and formulated in Māori culture, and which includes physical, emotional, family and spiritual aspects of health; it may involve use of rongoā rākau (preparations of native plants) and other substances of natural origin, as well as mirimiri (massage) and karakia (prayer), as part of an holistic healing approach.[[100]] Māori traditional healers are the holders of traditional knowledge of the harvesting, preparation and use of these medicinal products. This knowledge is often unique to the practitioner and differs between iwi depending on their geographical area and the teaching of their ancestors; in this regard, they are the holders of the “intellectual property” of these preparations. New Zealand is constitutionally a bi-cultural country and a multi-ethnic society;[[101]] in addition to rongoā Māori, traditional Pasifika medicine, and imported traditional medicine systems from other cultures, such as traditional Chinese medicine and Ayurvedic medicine, are also present. Currently, access to some TCAM (e.g., acupuncture, rongoā services) is government funded.[[100,102]] Government-funded rongoā Māori providers are required to adhere to the rongoā standards, Tikanga ā-Rongoā.[[103]] Intentions to regulate TCAM products, practices and/or practitioners in New Zealand would need to account for, and carefully consider, the impact on and protection of mātauranga Māori[[97]], the broad range of existing products/practices/practitioners and the impact on funding, as well as the practice of TCAM, as part of the wider New Zealand healthcare system.

Despite consumers’ beliefs in TCAM as a natural and, therefore, safe healthcare option, adverse events can occur with the use of TCAM, including when its used together with conventional medicine. TCAM is frequently self-selected by consumers and is obtained outside the conventional healthcare system. Therefore, consumption/use is often unknown to conventional medical practitioners, unless its use is disclosed by the consumers themselves. Consumers choose to use TCAM for numerous reasons, and the conditions of use, including disclosure to health practitioners, will be explored and discussed in a later paper in the series.

Globally, a uniform definition for TCAM does not exist, despite efforts towards reaching a consensus.[[104,105]] Hence it is not surprising that studies in New Zealand use a wide range of TCAM terms and definitions. Although the New Zealand Ministerial Advisory Committee on Complementary and Alternative Health in 2004 agreed to adapt the definition from the United States National Center for Complementary and Alternative Medicine (now the National Center for Complementary and Integrative Health),[[5]] few New Zealand studies did so. Depending on how TCAM is defined and operationalised, prevalence estimates can vary considerably. In a systematic review, prevalence of use rates were inflated when studies included “prayer” as a TCAM approach in their operational definition.[[3]] Numerous New Zealand studies did not report (using) an operational definition, which implies that participants’ responses were based on their own understanding or interpretation of TCAM (or other terms used in the respective studies); such an approach is not standardised and is susceptible to underreporting or overreporting. Most studies also utilised different data collection tools, methods and prevalence measurements (e.g., lifetime, previous 12 months, 2 weeks, 2 months, during illness), adding to the challenges in aggregating data and comparing them locally and internationally.

Reliable nationally representative data on prevalence, patterns of use, expenditure and modes of access to TCAM products and practices (including where therapies are provided by conventional health practitioners or funded by the Ministry of Health, ACC or WINZ) are needed in New Zealand. A robust, comprehensive study on prevalence of TCAM use in New Zealand would need to include a standardised TCAM definition, scope and measurement of prevalence of use. It should collect respondents’ National Health Index (NHI) numbers (a unique identifier for every person who uses health and disability support services in New Zealand) to allow for data integration and linkage across studies/databases. Data collected from the survey would serve as a useful resource at a population level for monitoring trends in TCAM use, alone and in conjunction with conventional medicine(s). Data on prevalence indicate not only the breadth of TCAM use in New Zealand, but also, to some extent, patients’ unmet healthcare needs within the current publicly funded healthcare system. Therefore, any change in TCAM regulations would need to consider the impact on the allocation of public healthcare resources and funding. A substantial prevalence of use could also prompt the initiation of an in-depth review on the safety and efficacy of TCAM. Hence a comprehensive understanding of the extent, scope and patterns of TCAM use in New Zealand, together with evidence-based information on safety and efficacy, could contribute to informing government healthcare policy and decision-making.

This scoping review provides an overview and understanding of data on use of and access to TCAM in New Zealand and has identified gaps in knowledge for future studies. The work has several strengths and limitations. First, no formal evaluation of the quality of evidence was undertaken for the included studies. Also, information was gathered from a range of study designs and methods, restricting comparability across studies. A comprehensive search strategy was developed and used, but given the lack of standardisation in TCAM terminologies, some studies may have been missed. Another limitation is the use of a single reviewer for screening and data extraction, which may have introduced bias.

Conclusion

Numerous, typically small, localised studies exploring TCAM use in New Zealand are available; however, there is a lack of comprehensive, nationally representative data on prevalence and patterns of use of TCAM, including use in relation to conventional medicine(s). Existing data have been collected using various methods, limiting the comparability and further analysis. There is evidence of substantial use of TCAM among patients/consumers of different ages and ethnicities and with diverse health conditions. Given the high prevalence of use and ongoing lack of regulation, reliable, current, nationally representative data on prevalence of use of all TCAM products/preparations and practices/therapies is warranted for New Zealand.

Supplementary material

  • Supplementary Table 1: Prevalence of TCAM use from other (non-nationally representative, or nationally representative sub-populations) studies. View Supplementary Table 1.

Summary

Abstract

Aim

Traditional, complementary and alternative medicine (TCAM) is a popular healthcare choice worldwide. The extent of data available on TCAM, including prevalence and patterns of use in New Zealand, is unknown. This scoping review aims to map the existing research describing the use of TCAM (including prevalence, access, expenditure and concurrent use with conventional medicines) in New Zealand.

Method

Research databases (MEDLINE, EMBASE, AMED, IPA (International Pharmaceutical Abstracts), CINAHL, PsycINFO and Scopus) and grey literature (Google Scholar and New Zealand government and relevant organisations’ websites) were searched for studies published before 7 June 2019. Studies reporting on the prevalence and/or exploring aspects of TCAM use were included in this review.

Results

In total, 72 studies were reviewed. Available data suggest that TCAM use is widespread among New Zealanders, and some consumers pay large sums of money out-of-pocket. A wide range of TCAM practices and products is used by people of all ages and ethnicities and with various health conditions. There is some evidence of consumers using TCAM concurrently with conventional medicines. Studies were generally small, localised and conducted in sub-populations (e.g., specific age groups, health conditions). Different TCAM definitions, data collection tools, methods and prevalence measurement were used across studies, thereby limiting the comparability of data locally and internationally.

Conclusion

A considerable number of studies/reports on TCAM use are available. Still, there is a lack of comprehensive, nationally representative data on prevalence and patterns of use of TCAM, including its use in relation to conventional medicine(s) in New Zealand.

Author Information

E Lyn Lee: Doctoral candidate, School of Pharmacy, University of Auckland, Auckland, New Zealand. Jeff Harrison: Associate Professor in Clinical Pharmacy; School of Pharmacy, University of Auckland, Auckland, New Zealand. Joanne Barnes: Associate Professor in Herbal Medicines; Deputy Head of School, School of Pharmacy, University of Auckland, Auckland, New Zealand.

Acknowledgements

Correspondence

Joanne Barnes: Associate Professor in Herbal Medicines; Deputy Head of School, School of Pharmacy, University of Auckland, 85 Park Rd, Grafton, Auckland 1023

Correspondence Email

j.barnes@auckland.ac.nz

Competing Interests

JB has received fees, honoraria and travel expenses from the Pharmaceutical Society of New Zealand (PSNZ) for preparation and delivery of continuing education material on complementary medicines (CMs) for pharmacists (2013, 2015); provided consultancy to the Pharmacy Council of New Zealand on Code of Ethics statements on CMs (unpaid) and competence standards (paid); was a member of the New Zealand Ministry of Health Natural Health Products (NHPs) Regulations Subcommittee on the Permitted Substances List (2016–2017) for which she received fees and travel expenses. JB has a personal viewpoint that generally supports regulation for CMs.

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