Factors inuencing the lack of communication on complementary and alternative medicine by clinicians in higher healthcare: A cross-sectional survey in China

Purpose Complementary and alternative medicine (CAM) is well documented and widely applied in healthcare, however, there is a paucity of knowledge on the attitudes of high healthcare clinicians regarding CAM, as well aspects related to the communications by clinicians on the use of CAM. Such communication can be important in assuring agreement about therapeutic plans and the use of CAM as complimentary higher healthcare. The study investigated the communication about CAM between patients and clinicians, as well as factors that inuence the communication of clinicians about CAM. Methods The study made use of the CAM Health Belief Questionnaire (CHBQ), a 10-item Likert-scale questionnaire that assesses the attitudes and beliefs of healthcare professionals towards CAM. The cross-sectional survey was distributed to 360 doctors in traditional Chinese Mmedicine (TCM) and western medicine (WM) from the departments of Internal Medicine (physicians) and Surgery (surgeons). The survey was distributed in 5 different hospitals in China over the period from May to August 2019.


Introduction
The concurrent use of complementary and alternative medicines (CAM) along with conventional medicine is growing globally, and patients look to more natural ways of healthcare [1]. According to the World Health Organization (WHO), traditional medicine is the knowledge, skills and theories based on beliefs and experiences of indigenous communities to maintain holistic health dealing with mental and physical wellbeing. In recent years, CAM has become a billion-dollar industry as a result of interest in alternative therapies, especially among patients with chronic illnesses that are not well treated with conventional western medicine. Complementary practices involve the healthcare interventions used alongside traditional medicine and other related therapies that could not be readily found in mainstream healthcare and are considered indispensable in some cultures [1]. Globally, CAM has been commonly employed in countries such as Italy, Germany, Canada, France, and USA, and the proportion of users of CAM treatments ranges from 40 % to 90% [2].
Clinicians may sometimes face with challenges in engaging patients on the use of CAM, particularly in regions where CAM has been used for centuries, typically in developing countries and some developed countries. The attitudes of health care providers about and experiences with CAM vary widely based on geographical location and patient characteristics, and these may in uence how clinicians discuss CAM with patients. Recent studies indicate some positive and negative effects of CAM on the treatment of chronic illnesses and other diseases that are di cult to cure. For example, there is a risk of side effects or interaction, such as interactions between phytotherapy and anti-cancer drugs [3,4]. Some studies mention physicians concern CAM therapies lack of scienti c evidence of effectiveness and did not understand the use of CAM [5,6]. Due to a lack of understanding of CAM and lack of scienti c background, clinicians may nd it challenging to recommend CAM treatment [7,8], potentially affecting the doctor-patient relationship where patients look for CAM use in their treatment. These could ultimately have a signi cant impact on the patient's nal treatment plan and compliance.
Studies about different perspectives of the CAM use between oncology professionals and their patients have been conducted in USA, Norway, Japan and Brazil [9][10][11][12]. Almost all of the studies have shown that clinicians from different countries have negative opinions on CAM use due to a lack of scienti c evidence on its e cacy and interaction of drugs with anti-cancer therapies. Consequently, solving the communication gap regarding the use of CAM was getting more and more attention. In China, only a few surveys on doctors' attitudes and communication towards CAM have been performed [13]. However, the participants were only limited to the oncology department and western medicine physicians. Here, we consider two special situations faced by Chinese patients: First, the Traditional Chinese medicine (TCM) doctor is legally protected in China, as China is one of the nations where TCM is a legal practice. Compared with patients from other countries, Chinese patients seem to have a greater chance of receiving CAM treatments, since this is part of cultural practice as well as a compulsory part of education in medical healthcare. Second, internet access is widely available in China due to the development of ecommerce and smartphones in China in recent years, thus, CAM interest has also been rapidly growing via internet marketing among Chinese patients. To further explore these issues, we surveyed Chinese doctors to explore their attitudes towards CAM, and opinions about the use of CAM by patients. The goal of this study was to: (1) understand the doctor's attitude towards CAM, (2) quantify the proportion of doctors discussing CAM with patients, and (3) explore reasons that doctors are reluctant to discuss CAM therapies with patients. Understanding these issues could ensure that there is safe and effective integration of CAM with multiple modes of the treatment in a higher health setting.

Study population
The sample population was clinicians from Wuxi and Nanjing, China. A total of 360 doctors with specialties in traditional Chinese medicine (TCM) and western medicine (WM) from the departments of Internal Medicine (medical oncology, respiratory, gastroenterology, gynecology, endocrinology) and Surgery (orthopedics, gastrointestinal surgery, neurological surgery, urology, obstetrics, surgeons). All participants took part in the study voluntarily, and ethical clearance was approved by the Ethics Committee of Wuxi Xishan District Hospital of Traditional Chinese Medicine. The inclusion and exclusion criteria of doctors are shown in gure 1.

Questionnaire
The questionnaire survey tool for this study was following the CAM Health Belief Questionnaire (CHBQ) Survey, aimed at assessing the attitudes and beliefs of healthcare professionals towards complementary and alternative medicine (CAM). The CHBQ was validated and developed for physicians and has been widely used in studies assessing physicians' attitudes about CAM [14][15][16][17]. It is a self-administered questionnaire, and for this study, it was paper-based. A pilot study was conducted with a subset of the target population (20 clinicians) to assess the comprehension and readability of the questions. Relevant adjustments were made to some questions based on the outcome of the pilot study. The aspects evaluating the CAM communication and in uencing factors were based on the previous research [5,[18][19][20]. Some options in the questionnaire allowed the participants to select multiple responses to a single question.

Data analysis
All data obtained were analyzed by SPSS Windows Software version 20.0 after being incorporated into a Microsoft Excel spreadsheet. Means and standard deviations were used to describe continuous variables such as Likert scale questions. Chi-square tests and Man Whitney U test were used to measure the differences between the participants' responses. Statistical signi cance was accepted at P values of less than 0.05.

Demographic information
A total of 360 questionnaires were distributed among the doctors who participated in this study, and 329 questionnaires were returned with complete information, with a response rate of 91.4%. The demographic pro le of the participants in this study is shown in Table 1. A large proportion of the participants was female 228 (69.3%), and the majority aged between 30 and 50 years old (44%) with a mean age of 38.40±1.85 years. Most of the 329 respondents (63.8%, n =210) worked in the internal medicine department and 119 (36.2%) in the surgery department; mostly practiced in WM (89.4%), and only a minority in TCM (10.6%).

Perceptions and attitudes about CAM
Clinicians generally showed a positive attitude towards CAM ( Figure 2). The majority (76%) of the clinicians did not nd CAM to be a threat to public health, and more than half (51.1%) agreed that physical and mental health is maintained by underlying energy or vital force. When asked whether substances not tested by scienti cally approved methods should be banned, there was a 50/50 split in those who agreed and disagree (35.5% agreed, 35.8% disagreed). We found that WM doctors tended to believe more strongly that the use of CAM therapies which have not been scienti cally tested should be discouraged than TCM doctors (Chi-square = 7.47 n=329 p<.05). Over 60% of the participants disagreed that CAM is a placebo, while males generally tend to agree that the patient's expectations, health beliefs and values should be incorporated into the patient care process than females (Chi-square = 19.5 n=329 p<.05)

CHBQ score outcomes
The CAM Health Belief Questionnaire (CHBQ) was 46.53±10.8, above the average score of 35, indicating a positive attitude towards CAM by participating doctors in this study. The attitude towards CAM was in uenced by several factors including category, gender, department, academic quali cation, selfapplication, and familiarity. Clinicians with practicing in TCMs had a positive attitude towards CAM than WM clinicians (U test p<.001). The positive attitude was associated with higher academic quali cation (U test p=0.002), and mostly for males and physicians. The majority of the participants (77.5%) reported using at least one form of CAM in past years, but only 33.1% had communicated with patients about CAM in the past one week. Those who have used CAM treatments had a more positive attitude than those who never did (U test p=0.002), and similarly, those who communicated about CAM with patients had a more positive attitude than those who did not (U test p<.001). The age of the respondents and the number of year in practice had no effect on the attitude of the participants towards CAM. ( Table 2)  Participants generally are discomfort towards sharing or communicating about CAM with their patients.
When asked "How many times did you initiate the conversations about CAM in the past a week?" many indicated less than 3 times (80.3%) or between 3-6 times (21.9%). In addition, many of the doctors indicated that they felt neutral (28.1%) or somewhat uncomfortable (38%) discussing CAM with patients. When asked "What is your reaction towards patients' question about the availability of CAM?", most (38.8%) reported they could encourage patients to use CAM, and they typically communicate with patients about CAM modalities, mainly TCM therapy (77.2%), followed by acupuncture (60.2%), massage (52%), and nutrition (45%). Further, when asked "what is the level or main source of knowledge on CAM?", most doctors had at least taken a course (67.5%), while 22.3% of the doctors were familiar with CAM but had not taken any coursework or formal training, although 10.6% clinicians had a CAM degree or certi cation. Table 4   Table 4 Distribution of answers provided by clinicians: The Response of clinicians associated with CAM asking.

Factors in uencing doctors' willingness to discuss CAM with their patients
Overall, the lack of training in CAM in higher health doctors in uenced their ability or comfort to discuss CAM with patients ( Figure 3). 38.5% of the participants indicated that the lack of communication with patients about the use of CAM was because of the lack of training. Others associated it with the lack of adequate scienti c evidence to show support for the effectiveness of the CAM therapies, and were worried and fearful about its impact on the effectiveness of conventional drugs. The nancial burden on patients or time constraints were not considered as a barrier for the lack of communication around CAM therapies.

Discussion
In recent year, the use of CAM has taken center stage with a wealth of evidence showing its sudden resurgence. It is not surprising that since over 80% of the population in developing countries still relies on CAM, half number of people in the developed counties use CAM [16]. Typically, the general view of CAM is that it is a supportive and holistic type of therapy that enhances overall health. That said, there are variations in its use across countries. Furthermore, its use in higher health and perceptions of its use in higher health have been a key area of interest, as patients may want to combine the use of CAM with more conventional treatments. In this study, we aimed to understand the perceptions of clinicians in higher health on CAM and the factors in uencing their communication of CAM use with their patients in higher health settings. We found that a large proportion of the clinicians in this study had a positive attitude towards CAM and felt that it is important in patient care; however, they did not communicate about CAM with their patients. They found it uncomfortable to do so and provided several reasons for the lack of communication which included lack of adequate training, poor scienti c evidence to prove the e cacy of CAM treatments and worried whether it would interact negatively with conventional medicines.
Moreover, it appears that those who had previous experience of CAM use were more comfortable to communicate, and those who had a higher degree (more skills and knowledge) appeared to easily communicate about the use of CAM with their patients. Surprisingly, males showed a stronger positive outlook in the attitude towards CAM. Further, there were differences between physicians and surgeons, where physicians were more likely to recommend or communicate about CAM with their patients. Because of the role they play, physicians may be more likely to communicate CAM therapies as part of holistic care.
In China, TCM is the dominant form of CAM. National Health Commission emphasizes the combination of traditional Chinese and western medicine. Therefore, it not surprising that over three-fourths (76%) of doctors disagreed that CAM was a threat to public health. Furthermore, more than half (52.3%) doctors think that CAM is bene cial, which was also not surprising since CHBQ score of Chinese clinicians was higher than in other countries. The clinicians who had certi cation in TCM had a positive attitude towards CAM more than WM clinicians. These were found to be similar in other countries including Kuwait [21], and Malaysia [22]. Further, physicians and surgeons differed in their attitude towards CAM, with physicians having a positive attitude towards CAM. When looking at the participant pro le, the majority of surgeons held a WM certi cate or license while physicians held a TCM certi cate or license. This is important since those who held a TCM license were most likely to communicate with patients about CAM, and often had experience in the use of CAM. CAM may not be relevant to surgical treatment, because the surgical treatment is still dominated by western medicine [23].
We found that Chinese doctors have a positive attitude towards CAM and feel that complementary therapies could bene t from the integration of CAM. However, we show in this study that there is a general tendency to discourage the communication about CAM use, especially among the doctors who practice WM. A similar result was found in a survey conducted among oncologists in Shanghai who discourage communication about CAM [13]. In these instances, WM practitioners required scienti c background to support the effectiveness of CAM before they could trust it. This was found in another study where the lack of scienti c evidence on e cacy discouraged the clinician from communication about CAM use with patients [5]. In China, CAM courses are compulsory, however, in our sample population, the WM practitioners had little training and did not take enough courses in CAM [24]. As a result, they are not familiar with CAM therapies and could not be in a position to advice patients on the use of CAM. Further, the increase in the number of negative reports on the failures of CAM is adding to the fear and reluctance in sharing or communicating about CAM use with patients [25][26][27][28].
Interestingly, the age of the patient and the potential nancial burden were not found to be important when communicating about CAM with patients; instead, clinicians have no such worries due to a high coverage of insurance on CAM [29]. Clinicians who suggested CAM or communicated about it with patients typically recommended the following modalities, TCM, acupuncture, massage and nutrition, since these have been the popular treatments in Chinese culture since ancient times. This was found to be the same in other studies, where massage and herbal medicine were the most recommended CAM [30].
Our study indicates that there is a positive attitude towards CAM and that there is a potential to incorporate it into complementary medicine in higher health. However, there are challenges regarding the negative perceptions on the scienti c evidence for support for CAM use, as well as the lack of training evidence among the majority of clinicians practicing in WM. Therefore, it is essential to improve the training for clinicians to ensure patients' safety and improve patient care [31][32][33][34]. In particular, improvements in CAM training may help relieve doctors' discomfort related to answering questions about CAM. Although the Chinese health management department emphasizes the policy of integrating Chinese and western medicine, surgeons may feel less comfortable than physicians about initiating discussions about CAM. This nding opens the possibility of training and self-application-speci c interventions. Therefore, more research should focus on understanding how to increase the rates of CAM discussion and on designing interventions to improve patients' satisfaction with communication [35].

Limitations
Our research has several limitations: It is a cross-sectional study design, and the factors affecting doctors' response cannot be studied over time. This survey was based on self-reported data, so recall bias might have affected the results. Many participants were not familiar with CAM, which might have affected some of the results. Moreover, the results of this survey only represent the opinions of participants in Wuxi and Nanjing, which cannot be generalized to other cities of China.

Conclusion
Although clinicians have a good attitude towards CAM, they are reluctant to talk about CAM usage with patients for a variety of reasons including safety and scienti c evidence for e cacy and lack of training in CAM. We suggest that clinicians actively initiate a discussion with their patients about CAM use, while at the same time, attaining professional training on CAM which should be provided to all clinicians to effective and safe use of CAM for their patients.

Con icts of Interest
The authors declare that there are no con icts of interest.
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