Clinical review

Users and practitioners of complementary medicine

Catherine Zollman,  Andrew Vickers. 

Complementary medicine seems to be becoming more popular in Britain. Media coverage, specialist publications, and numbers of complementary therapists have all increased dramatically in the past 20 years. In this chapter we analyse this phenomenon and review available evidence about the use of complementary medicine.

	Surveys of use

Top Surveys of use Levels of use Reasons for use What conditions are treated? Complementary practitioners

Several surveys, of varying quality, have been undertaken, but interpretation is not straightforward. Some studies targeted practitioners, whereas others surveyed patients and consumers. Different definitions of complementary medicine have been usedsome include only patients consulting one of five named types of complementary practitioner, while some include up to 14 different therapies and others include complementary medicines bought over the counter. When treatments such as hypnosis are given by conventional doctors or within conventional health services, patients and surveys may not register them as "complementary." However, it is possible to make estimates from the available data, which help to chart the development of complementary practice.

View larger version (87K): [in this window] [in a new window]   Numbers of specialist publications for complementary medicine are growing

	Levels of use

Top Surveys of use Levels of use Reasons for use What conditions are treated? Complementary practitioners

How many people use complementary medicine?
The most rigorous UK survey of use of complementary medicine estimated that, in 1993, 33% of the population had used some form of complementary medicine and that over 10% had consulted a complementary practitioner in the previous year. Surveys of patients with chronic and difficult to manage diseasessuch as cancer, HIV infection, multiple sclerosis, psoriasis, and rheumatological conditionsgive levels of use up to twice as high.

How extensively is complementary medicine used?
Attempts have been made to estimate the number of complementary medicine consultations taking place in the United Kingdom. In 1993 there were about 12 million adult consultations in the six major complementary disciplines. Average consultation rates were 4.3 per patient. Estimates based on the increased number of registered complementary practitioners suggest that at least 15 million complementary medicine consultations took place in 1997, about 5% of the number of general practice consultations.

Which therapies are used?
The media often emphasise the more unusual and controversial therapies, but surveys show that most use of complementary therapy is confined to a few major disciplines. Osteopathy, chiropractic, homoeopathy, acupuncture, and herbalism are among the most popular in the United Kingdom. Spiritual healing and hypnotherapy are also often mentioned. These figures mask variations in the use of individual complementary therapies among various subsections of the population. For example, although women use more complementary medicine overall, men are more likely to consult osteopaths and chiropractors.

	Reasons for use

Top Surveys of use Levels of use Reasons for use What conditions are treated? Complementary practitioners

There are many myths and stereotypes about people who turn to complementary medicinefor example, that they have an alternative world view which rejects conventional medicine on principle or that they are lured by exaggerated advertising claims. The research evidence challenges such theories.

View larger version (79K): [in this window] [in a new window]   Stereotypes about use of complementary medicine being associated with alternative lifestyles are not supported by the research evidence

Qualitative and quantitative studies show that people who consult complementary practitioners usually have longstanding conditions for which conventional medicine has not provided a satisfactory solution, either because it is insufficiently effective or because it causes adverse effects. They have generally already consulted a conventional healthcare practitioner for the problem, and many continue to use the two systems concurrently. Some "pick and mix" between complementary and conventional care, claiming that there are certain problems for which their general practitioner has the best approach and others for which a complementary practitioner is more appropriate. Most find their complementary practitioners through personal recommendation.

Once complementary therapy is started, patients' ongoing use can be broadly classified into four categoriesearnest seekers, stable users, eclectic users, and one-off users. Decisions about using complementary medicine are often complex and reflect different and overlapping concerns. It is too early to assess whether the increasing availability of complementary medicine on the NHS is changing either the types of people who use complementary medicine or their reasons for doing so.

Who uses complementary medicine?
Survey data give us some idea of the characteristics of complementary medicine users in the United Kingdom.

View larger version (70K): [in this window] [in a new window]   Child receiving cranial osteopathy

• About 55-65% of those who consult complementary practitioners are female, a similar proportion to users of conventional healthcare
• The highest users are those aged 35-60 (users of conventional healthcare services tend to be the very old and the very young)
• Children make up a relatively small proportion of users of complementary medicine, but individual therapies differ: nearly a third of the patients of some homoeopaths are aged under 14, whereas acupuncturists, herbalists, and chiropractors see comparatively few children
• Users of complementary medicine tend to be in higher socioeconomic groups and have higher levels of education than users of conventional care
• There has been little research into ethnicity and use of complementary medicine in Britain
• More people use complementary medicine in the south of England than in Wales, Scotland, and the north of England, but evidence suggests that this reflects access to and availability of complementary practitioners rather than any fundamental regional differences in public attitudes or interest.

Are users psychologically distinct?
Some surveys have found greater psychological morbidity, and more scepticism and negative experiences with conventional medicine, among users of complementary medicine compared with users of conventional medicine. These are not necessarily inherent differences and probably reflect the fact that most people who turn to complementary medicine do so for difficult, persisting problems that have not responded to conventional treatments.

View larger version (98K): [in this window] [in a new window]   Patients are more likely to turn to complementary medicine if they have chronic, relapsing and remitting conditions such as eczema

	What conditions are treated?

Top Surveys of use Levels of use Reasons for use What conditions are treated? Complementary practitioners

Over three quarters of patients presenting to practitioners of the major complementary disciplines have a musculoskeletal problem as their main complaint. Neurological, psychological, and allergic disorders are also common. Others have problems that are not easy to categorise conventionally, such as lack of energy, and some have no specific problems but want to maintain a level of general "wellness." Case mix varies by therapy: for example, homoeopaths and herbalists tend to treat conditions such as eczema, menstrual problems, and headaches more often than musculoskeletal problems.

	Complementary practitioners

Top Surveys of use Levels of use Reasons for use What conditions are treated? Complementary practitioners

The number and profile of complementary practitioners is changing rapidly. In 1981 about 13 500 registered practitioners were working in the United Kingdom. By 1997 this figure had trebled to about 40 000, with three disciplineshealing, aromatherapy, and reflexologyaccounting for over half of all registered complementary practitioners, with roughly 14 000, 7000, and 5000 members respectively. Although membership of these disciplines is high compared with other complementary disciplines (only 1118 chiropractors and 2325 osteopaths were registered at the time), very few practise full time.

View larger version (64K): [in this window] [in a new window]   A fifth of all UK general practices provide some complementary medicine via a member of the primary healthcare team

Nearly 4000 conventional healthcare professionals also practise complementary medicine and are members of their own register (such as the British Medical Acupuncture Society for doctors and dentists). Of these, nearly half practise acupuncture (mainly doctors and physiotherapists), about a quarter practise reflexology (mainly nurses and midwives), and about one in seven practises homoeopathy (mainly doctors, chiropodists, and podiatrists). Many more conventional healthcare professionals, especially general practitioners, have attended basic training courses and provide limited forms of complementary medicine without official registration.

Complementary medicine provided by the NHS
A substantial amount of complementary medicine is provided by conventional healthcare professionals within existing NHS services, and this provision seems to be increasing. In 1987 a regional survey of general practitioners revealed that 16% practised a complementary therapy. A UK-wide survey in 1995 showed that almost 40% of all general practices offered some form of access to complementary medicine for their NHS patients, of which over 70% was paid for by the NHS. Over half of these practices provided complementary medicine via a member of the primary healthcare team, usually a general practitioner. Another local survey published in 1998 suggests that in some areas up to half of general practices provide some access to complementary medicine.

	Acknowledgments

The picture of "New Agers" is reproduced with permission of Morvan/Rex Features/SIPA Press. The pictures of cranial osteopathy, eczema, and reflexology are reproduced with permission of BMJ/Ulrike Preuss.

	Footnotes

The ABC of complementary medicine is edited and written by Catherine Zollman and Andrew Vickers. Catherine Zollman is a general practitioner in Bristol, and Andrew Vickers will shortly take up a post at Memorial Sloan-Kettering Cancer Center, New York. At the time of writing, both worked for the Research Council for Complementary Medicine, London. The series will be published as a book in spring 2000.