3.4. Self-help practices
Overall, walking and relaxation techniques were the most commonly used self-help practices (used by 61.9% and 40.4% of the respondents, respectively). The least common self-help practices were magnet therapy (3.8%) and traditional healing ceremonies (1.5%). The improvement of well-being was indicated as the most common motivation for using self-help practices. Most of the participants found that self-help practices were very or somewhat helpful (Table 5).
3.5. Use of dietary supplements
More than two-thirds of all the survey respondents (70.3%) had used at least one kind of dietary supplement in the past 12 months (including vitamins, calcium supplements, and so on). Among those respondents, 9.6% reported still using the above dietary supplements at the time of the survey. The main motivation was the improvement of well-being (>75.0%). More than 50.0% of the respondents felt that dietary supplements were somewhat helpful (data not shown).
3.6. Places to buy CHM and dietary supplements
The places that respondents most commonly chose to buy CHM and dietary supplements were pharmacies (41.0%), followed by drug stores (38.1%), and internet shopping sites (30.1%). On the contrary, purchases made by were the least common type of purchase (1.8%) (data not shown).
3.7. Complications of using CAM
Thirty-one respondents reported at least one complication from CAM treatments prescribed or recommended by health caregivers. About 50% of the complications had occurred within the last year. The treatments that most commonly caused complications were massage, CHM, and chiropractic treatments, at 25.8%, 22.6%, and 19.4%, respectively. On the contrary, acupuncture, moxibustion, and homeopathy caused fewer complications (6.5%, 3.2%, and 0%, respectively). TCM doctors, folk physiotherapists, and massage practitioners were reported to cause about 60% of the complications. The most frequent complications were musculoskeletal symptoms (64.5%), such as bone fractures, ecchymosis, and pain, followed by general symptoms (vomiting, abdominal pain, loss of appetite, diarrhea, fever), neurological symptoms (headaches, dizziness, numbness, frequent urination), and allergic symptoms (itchiness, red rash, cough), at 29.0%, 22.6%, and 16.1%, respectively (data not shown).
The Taiwanese health care system, like those of Korea and China, includes two types of medical doctors, one being WM physicians, who practice conventional medicine and one being TCM doctors, who practice traditional medicine.20–22 WM physicians can integrate WM with CAM, and some doctors with dual licenses are experts in both WM and TCM, while TCM doctors provide TCM combined with other types of CAM types.23 This study investigated the prevalence rates with which different kinds of CAM have been prescribed or recommended by WM physicians and TCM doctors in Taiwan.
The prevalence rates of respondents who had received treatment from WM physicians and TCM doctors were 82.5% and 39.7%, respectively. The most common motivation for consulting WM physicians was acute illness, while for TCM doctors, the most common motivation was to improve well-being. These results indicated that Taiwanese people seek out different kinds of treatment according to their diseases and symptoms.
Our results showed that about 37.0% and 37.7% of the participants had used CHM on the advice of WM physicians and TCM physicians, respectively. In comparison, previous studies using the I-CAM-Q in Cambodia, Thailand, and Vietnam (Table 6) indicated that the proportions of respondents using herbal medicine were 44.5%, 34.6%, and 42.9%, respectively.17 Meanwhile, studies using the Korean and Japanese versions of the I-CAM-Q reported that the prevalence rates at which Korean medicines (decoction) and Kampo medicines (prescribed and over-the-counter) were used were 36.2% and 31.1%, respectively.18,19 Contrarily, in another study, only 18.5% of Australian respondents reported using herbal medicine,24 while an internet-based survey in Sweden showed that herbal medicine usage was reported by 23% of all respondents.25 A recent internet survey of private clinic doctors in Japan showed that Kampo medicines were the most popular CAM (34.8%).26 Together, these reports indicated that herbal medicine may be still more popular in Asian countries than countries in other areas around the world.
In the previous study conducted via telephone interviews, Lin et al7 found that religious rites and exercises (qigong or yoga), CHM, and dietary supplements were the most commonly used types of CAM. The prevalence of participants using CHM was 45.1% in that study. In this survey, CHM, dietary supplements, and massage were the types of CAM most commonly prescribed or recommended by WM physicians or TCM doctors. As mentioned above, 37.0% and 37.7% of the respondents were prescribed or advised to use CHM by WM physicians and TCM doctors, respectively. The difference between this study and the Lin et al study in the rate of CHM usage may have occurred because the previous study only asked in general if the respondents had used CHM, whereas this study separated WM physicians into two categories and asked the respondents whether they had used CHM prescribed or recommended by WM physicians or TCM doctors. In Taiwan, WM physicians cannot prescribe CHM by themselves; however, they may refer patients to TCM doctors for TCM use. Another possible reason is that the present study did not include respondents who were over 69-years-old, and this might have affected the prevalence of CHM usage.
The percentages of all the respondents who received acupuncture from WM physicians or TCM doctors were 12.3% and 12.6%, respectively. Regarding moxibustion, the number of respondents who received the treatment from WM physicians (14.9%) was just slightly higher than the number who received the treatment from TCM doctors (14.1%). Similarly, WM physicians and TCM doctors also prescribed or advised 24.9% and 18.2% of the respondents, respectively, to use massage, while 12.3% and 10.7% of all the respondents received cupping from WM physicians and TCM doctors, respectively. In this study, WM physicians prescribed or advised the respondents to use moxibustion, massage, and cupping at higher rates than TCM doctors did. A previous study indicated that the senior WM physicians in Taiwan had committed to develop the integration of Chinese medicine with WM. Although the degree of such integration still has much to grow, the study showed that the WM physicians in Taiwan are already not unfamiliar with TCM or CAM therapies.27 Notably, the percentage of respondents who indicated the use of moxibustion (14.9%) received from or recommended by a physician was higher than that for acupuncture (12.3%) in this study. Although the acupuncture and moxibustion are charged together while applying for national health insurance coverage in the hospital,28 many WM physicians do not clearly distinguish acupuncture from moxibustion when giving advice to patients. However, moxibustion therapy is used not only in hospitals but also by folk therapists. At the same time, moxibustion is also among the self-care methods that people can use by themselves at home.29 Owing to its common use as a self-care method by people, some patients might mention the use of moxibustion first and then receive advice from their doctors regarding moxibustion therapy, and that might be one of the reasons that the proportion of respondents who reported using moxibustion was mildly higher than the proportion of respondents who reported using acupuncture therapy in this study.
In this study, 70.3% of respondents reported having used dietary supplements within the last year. Our results also showed that 44.8% and 19.9% of the respondents received a prescription or recommendation to use dietary supplements from WM physicians and TCM doctors, respectively. On the contrary, 19.8% of the respondents had used dietary supplements containing herbs without consulting TCM doctors in the previous year. Furthermore, the respondents were asked where they purchased CHM and dietary supplements, and 30% of them responded that they had purchased them through the internet. This finding indicates that a number of the respondents were using dietary supplements without professional advice.
Regarding self-help practices, walking and relaxation techniques were the practices most commonly used by the respondents (61.9% and 40.4%, respectively). Walking was also a common practice in other countries, such as in China,30 Japan,19 and Korea.18 A previous study proved that walking could affect both physical fitness and serum lipids in a positive way.31 Similarly, relaxation techniques were also reported as being among the commonly used self-help practices in other surveys.17,24
Based on the results of complications that the participants reported suffering due to CAM treatments, it can be concluded that TCM doctors and folk physiotherapists caused half of them; however, the total number of such cases was low (31 out of 1200). In addition, folk physiotherapists in Taiwan usually learn techniques by themselves and do not need to pass a national board examination to get a certificate, which can lead to instances of unqualified physiotherapists causing complications, although again the number of such cases in this study was small.32,33 Massage, CHM, and chiropractic treatments were reported to cause almost 70% of the complications. Massage and chiropractic treatments can cause ecchymosis, pain, and dizziness,34,35 while CHM can cause diarrhea, vomiting, and abdominal pain.36 This can help to explain why most of the complications were related to musculoskeletal, gastrointestinal, and neurological problems. In previous studies, the major adverse effect of acupuncture was infection,37 followed by subcutaneous bleeding and hematomas, and then discomfort or pain.38 However, in this study, we found that acupuncture caused fewer complications than other types of CAM. The reason for this may have been that, in university, TCM doctors are required to learn not only the basic physiological anatomy of WM, which helps to enhance their knowledge, but also safe and clear practice guidelines. Moreover, in Taiwan, only TCM doctors or WM physicians who have attended a training course on acupuncture can perform acupuncture. They are required to have a certificate from the government. Furthermore, in Taiwan, practitioners have been using nonreusable (disposable) needles during acupuncture treatment to prevent infection.
This study did have some limitations. First, it was a web-based study; therefore, we included only participants who were aged 20 to 69 years, because the elderly who are >69-years-old may not use the internet frequently. At the same time, the elderly do have a greater tendency to use CAM than younger people; therefore, this study may have underestimated the overall prevalence of CAM utilization. The second limitation was that while the respondents may have had doubts or questions when they completed the questionnaire, since our survey was not conducted via face-to-face interviews, they could not ask the researchers about the meaning of specific questions, which may have resulted in choosing inappropriate answers.
In conclusion, regarding the utilization of CAM in Taiwan, this internet-based survey revealed that CHM, dietary supplements, and massage were the types of CAM most commonly prescribed or recommended by WM physicians and TCM doctors. However, a fairly high number of the respondents had used dietary supplements without consulting with WM physicians or TCM doctors; thus, warnings are necessary to ensure that such supplements are used safely. This study further showed that the number of complications due to acupuncture in Taiwan was small, which may be related to the adequate training in biomedical knowledge received by TCM doctors, as well as safe and clear practice guidelines.
This study was supported by grants from the Japan Agency for Medical Research and Development (AMED) under Grant Numbers JP16lk0310024h0001 (2016), JP17lk0310039h0001 (2017), and “Development and Construction Plan” of the School of Medicine, National Yang-Ming University (107F-M01-07M32). M.S. Lee was supported by Korea Institute of Oriental Medicine (K18043).
We thank Prof. Wen-Hua Kuo for his contribution in connecting us with the Japanese research team. We also thank Prof. Mei-Ling Yeh, Prof. Shu-Hsin Lee, and Dr. Jen-Lin Yang for their help in revising the questionnaire.
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Keywords:© 2019 by Lippincott Williams & Wilkins, Inc.
Chinese herbal medicine; Complementary and alternative medicine; I-CAM-Q; Internet-based survey; Taiwan