Segundo análisis segundo grupo focal

2.4.1 Rationale

Taking precedence over the general population in the UK (Section 2.3.1) was the interest of use of alternative medicine among patients in the UK and at the time of attending the different healthcare settings. As previously discussed, alternative medicine may be provided or referral can be made. However this is not part of the routine practice in the main healthcare system in the UK (Section 2.1.2-2.1.5). Figure 2.3 is an illustration of the two main healthcare systems in the UK that deal with patients. This is made up of primary care that consists of general practice. The other is the secondary care which involves acute care cases such as those dealt with in a hospital. The interest in both of these patient population settings was stimulated further by this researcher’s personal background as a pharmacist with a growing interest in patient safety. Some experience in hospital pharmacy followed by a master degree in medicines management in the UK continued to motivate the research towards this particular direction especially with reference to patients in the latter population setting.

A search through the literature was carried out for published studies in which the prevalence of use of alternative medicine among patients attending the two different levels of the healthcare settings in the UK was investigated. As previously, the search was conducted through different scholarly databases (Section 2.3.1). Some of the same search terms were used. It was useful in narrowing the search to add the terms patients, hospital, primary care, secondary care or conventional setting in the UK. All primary studies identified were then reviewed and also systematic reviews were included to ensure all primary studies were covered.

The literature search was narrowed down to a total of ten published primary studies conducted among adult patients when attending the healthcare settings in the UK, six of which have been summarised (Table 2.4). Five of the studies which focused on cancer patients were found to meet the search aim of this current study (Scot et al., 2005; Burke et al., 1993; Downer et al., 1994; Molassiotis et al.,

Page | 32 2005). However, due to consideration of the volume, only one of the studies ((Lewith et al., 2001) (which would become of more important as the current study progressed) was included in the summary.

Figure 2.3 The National Health Service (NHS) structure in the UK

www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstructure.aspx (reviewed 24/10/2011)

2.4.2 Prevalence of use of alternative medicine by patients attending a conventional healthcare setting

At the time the literature review was conducted and later updated, the study that was conducted by Featherstone et al. (2003) in Scotland in the UK had revealed the highest prevalence of use of alternative medicine of 71% among patients or studies conducted among the general population (Table 2.2, Section 2.3). In agreement with their conclusion their findings indicated that alternative medicine

Primary care is the first point of contact for most people and is

delivered by a wide range of independent contractors, including GPs, dentists, pharmacists and optometrists.

Secondary care is known as acute healthcare and can be either

elective care or emergency care. Elective care means planned specialist medical care or surgery, usually following referral from a primary or community health professional such as a GP.

Page | 33 use in primary care attendees was greater than use of alternative medicine reported in the general population. While this was carried out in Scotland the findings would have some similarity to what would be expected in an English setting. However, the prevalence of alternative medicine use reported in the study was from a combination of patients attending six different primary health practices in 2000. The individual practice settings were not separately reported in this paper.

The main thrust of work by Featherstone et al. (2003), was on the prevalence of alternative medicine concerning lifetime use while Murray and Shepherd (1993) had reported alternative medicine use over the 10 years before the time of their study. In other instances of studies reporting alternative medicine use specific information was not provided about the time of the prevalence of the use of alternative medicine. For example, in the study of Chandola et al. (1999) it was reported that 47 (28%) out of 166 patients attending rheumatology and orthopaedics hospital clinic had tried out the chosen therapy.

In a systematic review by Ernst (2000b) it was reported that there was a prevalence of use of alternative medicine among dermatological patients ranging between 35% and 69%. There was varied usage in seven studies in different countries of which the highest reported use being the only study that was conducted in the UK (Clark, 1998). The prevalence of use was being reported as life-time use of 69% among dermatological patients with psoriasis.

Featherstone et al. (2003) had reported only concurrent use of alternative medicine by the patients within the previous month. For a study that had reported current use in 52 of 162 cancer patients (Lewith et al., 2001), the prevalence of alternative medicine use reported was, within the NHS context, to be 14 (25%) of 56 in-patients and 22 (88%) of 27 hospice patients, and 16 (20%) of 79 out- patients. It was assumed that the out-patients were from either within or outside the NHS and unfortunately they had not collected this information in relation to out- patient treatment. In this study, data collection was by the ward staff using a structured questionnaire relating to 14 types of alternative medicine, nutrition (vitamins and minerals) and homeopathy being the only ingested types of alternative medicine.

Page | 34 2.4.3 Demographic distribution of patients using alternative medicine

Only few of the studies provided information on the demographic age, gender and education of patients using alternative medicine. For example, the association of female gender with alternative medicine use was reported in two different studies (Murray & Shepherd, 1993; Chandola et al., 1999). Murray and Shepherd (1999) reported that in all age groups up to 64 years, women were more likely to have used non-orthodox treatments. There was a rise in usage with age, which peaked

at 45 and thereafter declined. At 70 years, there was only one (male) user. The significance with age and education was reported in the study of Featherstone et

al., (2003). In this a statistical association between the decline in use of alternative

medicine and increasing age and lower education attainment was reported.

2.4.4 Methodology of the studies

The limitations of the studies were that they tended to involve small sample sizes, specific to a particular location or region or single practice (Table 2.4). This made generalisation to a wider geographical population of patients in the different healthcare settings difficult. Even though, Featherstone et al. (2003) reported on a study of 1174 patients, it was based on consecutive patients attending the six practices in a region, Grampian Tayside in Scotland. A study by Murray and Shepherd (1993) on other hand was of 233 registered practices in inner London chosen within age census. Also, sample sizes were not comparable i.e. 50 patients in the study conducted by Clark (1998). Importantly, none of the studies were carried out at the time identified within the North East region of England.

The studies listed in Table 2.4 varied in the types and numbers of alternative medicine investigated. In the population study of Thomas et al. (2001) it was reported that if only practitioner contact of the 5010 adults studied excluded self- care using remedies bought over the counter, then, alternative medicine use declined to 10.6% from 28.3%. Harris and Rees (2000) had suggested, with respect to their systematic review, that estimates for the prevalence of use of alternative medicine as a whole (consultations and/or use of products) varied in studies. They reported that the estimates tended to be larger than those for the

Page | 35 prevalence of consultations alone. This could explain why the Featherstone et al. (2003) study also complied with recommendations by Harris and Rees (2000).

The method of data collection could have an important impact on the findings of the study in terms of response or recall of data. Amongst the studies reviewed the study of Chandola et al. (1999) was the only study that had used interview; others had used postal questionnaires. This is probably why they had reported a 99% response rate. The use of interview among patients may be a reason for the high reported prevalence of use of alternative medicine by Clarke (1998) in line with the Ernst (2000b) suggestion that studies that use interviews are more likely to have a higher prevalence of use of alternative medicine.

The variations in prevalence of use of alternative medicine in different specific patient groups in the settings also made extrapolations to all patient groups difficult. For example the prevalence of alternative medicine use reported among cancer patients was 32% (Lewith et al., 2001), 69% amongst dermatological patients (Ernst, 2000) and 28% by patients with musculoskeletal conditions (Chandola et al., 1999). In the study of Featherstone et al. (2003) the health status of the patients was not reported. Molassiotis et al. (2005) had reported that there were significant differences in alternative medicine use among the different cancer diagnostic groups of the sample. Albeit not conducted in the UK, in a study on US use of herbal medicines usage was higher among patients undergoing gynaecology procedure and patients with perception of good health, but lower in patients having diabetes conditions and patients treated by a primary physician (Adusumilli et al., 2004). In contrast in another study of individuals with diabetes, similarly in US, those individuals with diabetes were 1.6 times more likely to use alternative medicine than individuals without diabetes (Egede et al., 2002).

There was also a lack of consistency in the review in the time estimate of prevalence of alternative medicine use by patients (Section 2.4.2 and Section 2.5).