A Randomized Three-Arm Double-Blind Placebo-Controlled Study of Homeopathic Treatment of Children and Youth with Attention-Deficit/Hyperactivity Disorder.

Objectives: Approximately 30% of children diagnosed with attention-deficit/hyperactivity disorder (ADHD), the most prevalent mental health disorder in children worldwide, do not respond to conventional pharmaceutical treatments. Previous studies of homeopathic treatment for ADHD have been inconclusive. The objectives of this study were to determine if there (a) is an overall effect of homeopathic treatment (homeopathic medicines plus consultation) in the treatment of ADHD; (b) are any specific effects the homeopathic consultation alone in the treatment of ADHD; and (c) are any specific effects of homeopathic medicines in the treatment of ADHD. Design: The design was a randomized double-blind placebo-controlled clinical trial. Setting/Location: Toronto, Canada. Subjects: Children aged 6-16 years diagnosed with ADHD. Interventions: Participants were randomized to one of three arms: Arm 1 (Remedy and Consultation); Arm 2 (Placebo and Consultation); or Arm 3 (Usual Care). Outcome Measures: Primary Outcome was the change of CGI-P T score between baseline and 28 weeks. Results: There was an improvement in ADHD symptoms as measured by the Conner 3 Global Index-Parent T-score in the two groups (Arms 1 and 2) that received consultations with a homeopathic practitioner when compared with the usual care control group (Arm 3). Parents of the children in the study who received homeopathic consultations (Arms 1 and 2) also reported greater coping efficacy compared with those receiving usual care (Arm 3). There was no difference in adverse events among the three study arms. Conclusions: In this study, homeopathic consultations provided over 8 months with the use of homeopathic remedy was associated with a decrease in ADHD symptoms in children aging 6-16 years when compared with usual treatment alone. Children treated with homeopathic consultations and placebo experienced a similar decrease in ADHD symptoms; however, this finding did not reach statistical significance when correcting for multiple comparisons. Homeopathic remedies in and of themselves were not associated with any change in ADHD symptoms. Clinical Trial Registration: This trial was registered on ClinicalTrials.gov; NCT02086864.

Toward a 'green allopathy'? Naturopathic paradigm and practice in Ontario, Canada.

Epistemic tensions have long been evident within naturopathy, a heterodox healthcare occupation licensed across much of North America. Naturopaths less inclined toward bioscientific explanatory and evidentiary norms have long used the trope of the 'green allopath' to critique the practices of their more biomedically- (i.e., 'allopathically') inclined colleagues. Using the 'green allopathy' narrative as a conceptual starting point, this work uses a qualitatively-driven, mixed methods design involving interviews (n = 17) and a census-style survey (n = 366) to characterize the paradigmatic and practice patterns of licensed naturopaths in Ontario, Canada between 2017 and 2019. At odds with many interviewees' accounts, survey results suggest that the occupation's overall epistemic character, aligned with the concept of holism, has not changed much over the last two decades. Nevertheless, findings suggest notable changes in Ontario naturopaths' clinical practice patterns over the same period, including: more frequent use of botanical medicines, nutritional supplements and acupuncture; less frequent use of physical medicine (e.g., massage, hydrotherapy); and, an overall reduction in homeopathic usage. Controlling for other factors, older naturopaths are more likely to rely often on non-biomedical diagnostic modes (p = 0.042), suggesting an emerging shift, in practice, toward a 'green allopathy'. Naturopaths' widespread ongoing engagement with therapeutic modalities whose epistemic premises diverge strongly from conventional biomedicine (e.g., homeopathy, East Asian medicine), appears mediated by the increasing body of related bioscientific evidence, and by gender and age (p-values <0.05). Gender and age also significantly predict naturopaths' alignment with more pharmaceutically-oriented care (p values < 0.05). Though naturopathy's 'green allopathization' appears underway, the demographic predominance of women within the profession may temper this trend in the years ahead.

Safety, Effectiveness, and Professional Judgment: A Survey of Training-Related Perspectives Among Physiotherapists Who Practise Acupuncture in Ontario.

Purpose: Physiotherapists practise various forms of acupuncture worldwide, but no international consensus exists as to the appropriate duration of related training programs. In this cross-sectional study, we aimed to characterize the training-related backgrounds and views of acupuncture-practising physiotherapists. Method: A total of 426 physiotherapists who practised acupuncture in Ontario completed an online survey that included training-related items and an open-ended question (39 provided training-related responses). Statistical analyses included multivariate and multinomial logistical regression models. Thematic analysis was used to interpret respondents' textual responses to the open-ended question. Results: Respondents, who practised predominantly Western medical acupuncture, dry needling, or both, had completed acupuncture-related training programs ranging from < 25 to ≥ 300 hours. Those who had completed programs lasting > 100 hours were significantly more likely to self-report excellent clinical results and an enhanced ability both to recruit and retain patients and to earn a higher income. They were also more likely to endorse longer trainings as necessary for safe and effective patient care. Respondents to the open-ended question expressed a range of views, including the need for more stringent training requirements. Conclusions: PT regulatory requirements for longer (>100 hour) acupuncture trainings may better support clinical effectiveness and safety, patient satisfaction, and professional outcomes.

Objectif : les physiothérapeutes exercent diverses formes d'acupuncture dans le monde, mais il n'y a pas de consensus international sur la durée appropriée des programmes de formation qui s'y rattachent. Dans cette étude transversale, les chercheurs visent à caractériser les expériences de formation et les points de vue des physiothérapeutes qui exercent l'acupuncture. Méthodologie : au total, 426 physiothérapeutes qui exercent l'acupuncture en Ontario ont rempli un sondage en ligne qui incluait des points liés à la formation et une question ouverte (39 ont fourni des réponses liées à la formation). Les analyses statistiques incluaient les modèles de régression logistique multivariées et multinomiales. Les chercheurs ont utilisé l'analyse thématique pour interpréter les réponses textuelles des répondants à la question ouverte. Résultats : les répondants, qui exercent majoritairement l'acupuncture médicale occidentale, les aiguilles sèches ou ces deux techniques, avaient suivi un programme de formation en acupuncture variant entre moins de 25 heures et au moins 300 heures. Ceux qui avaient suivi un programme de plus de 100 heures étaient beaucoup plus susceptibles d'autodéclarer d'excellents résultats cliniques, une meilleure capacité de recruter et de conserver leurs patients ainsi que de gagner un revenu plus élevé. Ils sont également plus susceptibles de prôner une formation plus longue qu'elle est nécessaire pour donner des soins sécuritaires et efficaces aux patients. Les répondants à la question ouverte ont exprimé une variété de points de vue, y compris la nécessité d'exigences de formation plus rigoureuses. Conclusions : les exigences en matière de réglementation de la physiothérapie selon lesquelles une formation plus longue (plus de 100 heures) est exigée, peuvent mieux soutenir l'efficacité et l'innocuité cliniques, la satisfaction des patients et les résultats professionnels.

A mixed-methods survey of physiotherapists who practice acupuncture and dry needling in Ontario, Canada: practice characteristics, motivations, and professional outcomes.

BACKGROUND: Physiotherapists (PTs) across the globe are increasingly incorporating filiform needling techniques (e.g., acupuncture, dry needling) into their clinical toolkits; and, the evidence base for these complementary therapies is becoming progressively more robust. However, to date, little is known about needling PTs themselves. METHODS: Using a cross-sectional survey design, PTs authorized to perform needling therapies in Ontario, Canada were recruited for anonymous participation (n = 2061) in an online survey. The survey asked providers about their demographics and practice characteristics, rationale for and views about therapeutic needling, and their related clinical and professional outcomes. The response rate was 20.7% (n = 426), and 22.3% (n = 95) of respondents provided textual responses to an open-ended qualitative question. RESULTS: While study respondents' demographic features appear similar to their broader professional population, Ontario's needling PTs are less likely to work in public sector settings. Most completed training in medical acupuncture rather than dry needling, and typically used needling in over one-third of patient visits. Almost all endorsed needling as an effective musculoskeletal treatment, the primary factor informing their adoption of the practice. While many viewed traditional Chinese medical theories as a useful explanatory framework, most relied on biomedical epistemology to drive their needling work. A majority of respondents reported that the inclusion of needling within their clinical toolkits had improved their likelihood of achieving excellent clinical results, helped support patient recruitment and retention, and heightened their professional satisfaction. While a few reported earning a higher income as a result, most reported that their clinical use of needling in addition to other PT modalities reduced their physical fatigue after a day's work. CONCLUSIONS: This study represents a first scholarly investigation into the motivations, training backgrounds and practice patterns of PTs who use acupuncture or dry needling. Additional research from other jurisdictions is needed to evaluate the transferability of study findings.

A cross-sectional workforce survey of three traditional and complementary medicine professions in Ontario, Canada.

BACKGROUND: Workforce studies about traditional and complementary medicine (T&CM) occupations in industrialized countries are scant; and, these occupations' position within the broader occupational workforce remains unclear. This study aims to address these gaps using a comparative approach. METHODS: Naturopaths, traditional Chinese medicine (TCM) / acupuncture practitioners, and homeopaths in Ontario, Canada were surveyed regarding their demographics, practice characteristics and self-reported income. Results were compared with parallel data from within and outside of Ontario. RESULTS: Study response rate: 23.3% (n = 1205). While predominantly female (57.9%), Ontario's TCM/acupuncture profession was less feminized than the naturopathic (77.1%) and homeopathic (78.3%) groups. Naturopaths were significantly younger than, and reported fewer years of clinical experience than, the other two groups. About half of TCM/acupuncture practitioners, and almost one-third of homeopaths had trained outside of Canada, predominantly in East and South Asia, respectively. More TCM/acupuncture practitioners (58.9%) and homeopaths (57.6%) had multilingual clinical practices than naturopaths (19.1%). Homeopaths worked fewer hours and saw fewer patients per week than the other occupations. Self-reported mean incomes varied across groups, with naturopaths earning more on average ($63,834, SD $57,101) than did TCM/acupuncture practitioners ($45,624, SD $44,081) or homeopaths ($29,230, SD $41,645). Holding other variables constant, internationally-trained practitioners reported earning one-third less than their Canadian-trained counterparts. DISCUSSION & CONCLUSIONS: Study findings echo occupationally-specific data from other industrialized jurisdictions; and, affirm that different T&CM occupations have distinctive demographic and practice characteristics. The demographic makeup of Ontario's TCM/acupuncture and homeopathy occupations suggests a role for these groups in delivering culturally-responsive care within Asian ethnic communities. T&CM practitioner incomes, in particular for internationally-trained practitioners, fell below the provincial population income median, and in many cases below the poverty line. T&CM occupations' relative socio-political marginality may be impacting clinicians' ability to earn a viable living.

A Comparative Study for License Application Regulations on Proprietary Chinese Medicines in Hong Kong and Canada.

Ethnopharmacological Relevance: Chinese Medicine plays a symbolic role among traditional medicines. As Chinese Medicine products are widely used around the globe, regulations for Chinese Medicine products are often used as models for the efficient regulation of natural products that are safe, and high-quality. Aim of the Study: We aimed to compare the regulatory registration requirements for Proprietary Chinese Medicines in Hong Kong and Canada. Materials and Methods: We compared registration requirements for Proprietary Chinese Medicine in Hong Kong and Canada based on publicly available information provided by the respective Regulators. A marketed product, Zhizhu Kuanzhong Capsule (SFDA approval number Z20020003; NPN approval number 80104354), was used as a case study to demonstrate the similarities and differences of the requirements in both Hong Kong and Canada. Results: There were similarities and differences between the two regulatory systems in terms of the quality, safety and efficacy requirements. Despite the superficial appearance of similar categories and groups/classes, Hong Kong requires significantly more primary test data compared to Canada's reliance on attestation to manufacturing according the standards outlined in approved reference pharmacopeias/texts. Conclusion: Improved understand of the similarity and differences will enable applicants to plan appropriate strategies for gaining product approval. Exploring ways to harmonize the regulatory process has the potential to benefit manufacturers, regulators, and patients by increasing efficiency and decreasing costs.

A Survey of Acupuncture-Providing Registered Massage Therapists in Ontario, Canada: Motivation, Training, and Practice Characteristics.

BACKGROUND: An increasing number of licensed massage therapists in several countries are providing acupuncture to their clients, but little is known about this practice. PURPOSE: To characterize the motivations, training backgrounds, practice patterns, and clinical experiences of licensed massage therapists who perform acupuncture. RESEARCH DESIGN: The study used a cross-sectional, online survey design involving acupuncture-providing registered massage therapists (RMTs) in the province of Ontario, Canada, where acupuncture is explicitly permitted within the massage therapy profession's scope. Analysis involved descriptive statistics and thematic content analysis of qualitative findings. RESULTS: The survey response rate was 33.7% (n=212), representing 25.5% of all Ontario RMTs rostered to practice acupuncture. Participant demographics mirrored the RMT profession as a whole, except that providers were, on average, several years older than other RMTs. Most respondents (72.7%) had completed over 200 hours of training in acupuncture; most training included clean needle technique (96.8%), clinical supervision (93.5%), traditional Chinese medicine content (83.4%), and a final examination (96.8%). Respondents typically used acupuncture in about one-third of their sessions (mean 32.3%, SD 5.0) with an average of 10.5 weekly clients (SD 14.3). Acupuncture-providing RMTs had been initially motivated by acupuncture's potential effectiveness for musculoskel-etal conditions (97.2%), a wish to attract more clients (61.3%), and physical fatigue from delivering manual therapies (48.3%). Most reported being more likely to achieve excellent clinical results (84.9%), experience greater professional satisfaction (79.9%), and attract or retain clients (64.8%) since using acupuncture. A minority also reported earning a higher income (34.6%) and experiencing more adverse events in practice (21.5%). Qualitative responses added explanatory nuance to numeric results. CONCLUSIONS: This study of the use of acupuncture by Ontario's licensed massage therapists represents a first scholarly account of an emerging global trend that holds promise in enhancing clinical care, professional stability, and provider longevity. Additional research is needed to investigate the practice's use in other jurisdictions, and to establish international standards for safe and effective practice.

Religion, Spirits, Human Agents and Healing: A Conceptual Understanding from a Sociocultural Study of Tehuledere Community, Northeastern Ethiopia.

This paper explores the relationship among religion, spirits and healing in the Tehuledere community in the northeastern part of Ethiopia and focuses on how this knowledge can inform primary healthcare reform. The study employed qualitative ethnographic methods. Participatory observation, over a total of 5 months during the span of 1 year, was supplemented by focus group discussions (96 participants in 10 groups) and in-depth interviews (n = 20) conducted with key informants. Data were analyzed thematically using narrative strategies. The present study revealed that members of the study community perceive health, illness and healing as being given by God. Many of the Tehuledere people attribute illness to the wrath of supernatural forces. Healing is thought to be mitigated by divine assistance obtained through supplication and rituals and through the healing interventions of nature spirit actors. We found that the health, illnesses and healing were inextricably linked to religious and spiritual beliefs. Our findings suggest that religious and spiritual elements should be considered when drafting and implementing primary healthcare strategies for the study communities and similar environments and populations around the globe.

Evaluating the international standards gap for the use of acupuncture needles by physiotherapists and chiropractors: A policy analysis.

BACKGROUND: Acupuncture needles have become an increasingly-popular treatment tool used by multiple health professions. However, the World Health Organization (WHO)'s 1999 training guidelines for acupuncture address only medical doctors and licensed acupuncturists, leaving a gap as to appropriate training standards for other professions. AIMS AND METHODS: With reference to an extensive document analysis, and interviews with seventeen acupuncture educators from across several professions in Ontario, Canada, this work uses a critical qualitative policy analytic approach to: a) present a comprehensive account of statutory training requirements for acupuncture-needling physiotherapists and chiropractors in the United States, Canada, and Australia; and b) evaluate competing stakeholder discourses pertaining to recent related controversies. RESULTS: A wide range of educational requirements are evident across the jurisdictions under study (most below the 200-hour WHO guideline for physicians); and there is considerable disagreement among stakeholders as to what constitutes sufficient training in various forms of acupuncture, including 'dry needling'. Organizations defending brief post-graduate training for needling physiotherapists and chiropractors are generally associated with these two professions, and contend that their 'dry needling' practices differ substantially from traditional acupuncture. Characterizing such brief training as insufficient, opportunistic and unsafe, and 'dry needling' as a subset of acupuncture practice, are the voices of all acupuncture educators interviewed, as well as professional organizations representing physicians, licensed acupuncturists, and some physiotherapists and chiropractors. DISCUSSION AND CONCLUSION: Critiquing claims on both sides of the debate, this work calls for the development of independent, international safety-geared training guidelines that explicitly address the recent, evidence-informed trend towards biomedicalized acupuncture needling. Findings also suggest a need for additional research regarding the current shift towards overlapping-rather than exclusive-health professional practice scopes in industrialized countries.

A Systematic Narrative Review of the Evidence for Labeling of Natural Health Products and Dietary Supplements.

Background: It is not clear what information is needed on labels of natural health products and dietary supplements to support informed consumer choice and use of these products. Aim: The purpose of this review was to explore if/how label information impacts consumer decision-making about food, over-the-counter drugs, and natural health products/dietary supplements and to make recommendations about how this evidence may be applied to natural health products/dietary supplements. Method: A narrative analysis of a systematic review was performed. Medline and Embase databases were systematically searched to identify relevant studies from 1985 to February 2018 for all available English-language articles. This was supplemented with hand searches of the reference lists of review articles. Results: One hundred and fifty-one studies met the inclusion criteria, and after excluding review articles, 127 were included in the analysis. The findings from the studies were categorized into three main themes: (1) impact of labeling on consumer behavior (the majority of studies found that changes in label format or information had little to no effect on consumer behavior such as purchasing); (2) consumer comprehension of label information (significant proportions of consumers were unable to accurately interpret information found on natural health product/dietary supplement, over-the-counter medication, or food labels); and (3) label formatting/design, including standardization of information in fact tables (standardization, front-of-pack, and contrasting color panels were preferred and best attracted consumer attention). Conclusions: Many consumers did not regularly read product labels, nor understand the information they read on those labels. There was evidence that consistency of information was preferred by many consumers. Font size clearly impacted consumers' ability to read and understand the information on labels and this needed to be balanced with the amount of information required on labels. There was evidence that symbols that are simple and used sparingly are helpful in providing direction to consumers. Finally, regardless of what information was on the label, changing labels alone was unlikely to have a significant impact on consumer behavior.

Pharmacy Competencies for Interprofessional Integrative Health Care Education.

Objective. To address the gap in evidence-based knowledge among pharmacy students and practicing pharmacists regarding complementary and integrative health approaches due to insufficient education and a lack of standardized training. Methods. The National Center for Integrative Primary Healthcare (NCIPH) developed 22 pharmacy competencies linked to a set of 10 interprofessional "metacompetencies" in integrative health care. Results. The NCIPH pharmacy competencies are well-aligned with the current educational standards and Center for the Advancement of Pharmacy Education (CAPE) outcomes for pharmacy programs. Therefore, the NCIPH competencies may provide a foundation for the incorporation of interprofessional integrative health care education into pharmacy curricula. Conclusion. The NCIPH pharmacy competencies in integrative health care, linked to the interprofessional "metacompetencies," are aligned with educational standards and outcomes, and may serve as a basis for pharmacy curriculum.

Statutory Regulation of Traditional Medicine Practitioners and Practices: The Need for Distinct Policy Making Guidelines.

The World Health Organization (WHO) has called for the increased statutory regulation of traditional and complementary medicine practitioners and practices, currently implemented in about half of nations surveyed. According to recent WHO data, however, the absence of policy guidelines in this area represents a significant barrier to implementation of such professional regulations. This commentary reviews several key challenges that distinguish the statutory regulation of traditional medicine practitioners and practices from biomedical professional regulation, providing a foundation for the development of policy making parameters in this area. Foremost in this regard are the ongoing impacts of the European colonial encounter, which reinforce biomedicine's disproportionate political dominance across the globe despite traditional medicine's ongoing widespread use (particularly in the global South). In this light, the authors discuss the conceptual and historical underpinnings of contemporary professional regulatory structures, the tensions between institutional and informal traditional medicine training pathways, and the policy challenges presented by the prospect of standardizing internally diverse indigenous healing approaches. Epistemic and evidentiary tensions, as well as the policy complexities surrounding the intersection of cultural and clinical considerations, present additional challenges to regulators. Conceptualizing professional regulation as an intellectual property claim under the law, the authors further consider what it means to protect traditional knowledge and prevent misappropriation in this context. Overall, the authors propose that innovative professional regulatory approaches are needed in this area to address safety, quality of care, and accessibility as key public interest concerns, while prioritizing the redress of historical inequities, protection of diverse indigenous knowledges, and delivery of care to underserved populations.

Tool to assess causality of direct and indirect adverse events associated with therapeutic interventions.

OBJECTIVE: To develop and test a tool to assess the causality of direct and indirect adverse events associated with therapeutic interventions. The intervention was one or more drugs and/or natural health products, a device, or practice (professional delivering the intervention). METHODS: Through the assessment of causality of adverse events, we can learn about factors contributing to the harm and consider what modification may prevent its reoccurrence. Existing scales (WHO-UMC, Naranjo and Horn) were adapted to develop a tool (algorithm and table) to evaluate cases of serious harmful events reported through a national surveillance study. We also incorporated a novel approach that assesses indirect harm (caused by the delay in diagnosis/treatment) and the health provider delivering the intervention (practice). The tool was tested, revised and then implemented to assess all reported cases of serious events resulting from use of complementary therapies. The use of complementary therapies was the trigger to report the event. Each case was evaluated by two assessors, out of a panel of five, representing different health care professionals. RESULTS: The tool was used in assessment of eight serious adverse events. Each event was independently evaluated by two assessors. The algorithm facilitated assessment of a serious direct or indirect harm. Assessors agreed in the final score on seven of eight cases (weighted kappa coefficient of 0.75). CONCLUSION: A tool to support the assessment of causality of adverse events was developed and tested. We propose a novel method to assess direct and indirect harms related to product(s), device(s), practice or a combination of the previous. Further research will probably help evaluate this approach across different settings and interventions.

2016 INCAM Research Symposium: Expanding Person-Centred Care through Integrative Health Research.

The following are abstracts of research presentations given at the 9th INCAM Research Symposium. The theme for this year's conference was "Expanding Person-Centred Care through Integrative Health Research", which was held on November 18 and 19, 2016 at the Toronto Marriott Bloor Yorkville Hotel in Ontario, Canada. The abstracts are grouped under the categories of oral or poster presentation based on their presentation at the Symposium. For more information, please visit: http://www.iscmr.org/content/canadian-chapter---public.

State risk discourse and the regulatory preservation of traditional medicine knowledge: The case of acupuncture in Ontario, Canada.

Several United Nations bodies have advised countries to actively preserve Traditional Medicine (TM) knowledge and prevent its misappropriation in regulatory structures. To help advance decision-making around this complex regulatory issue, we examine the relationship between risk discourse, epistemology and policy. This study presents a critical, postcolonial analysis of divergent risk discourses elaborated in two contrasting Ontario (Canada) government reports preceding that jurisdiction's regulation of acupuncture, the world's most widely practised TM therapy. The earlier (1996) report, produced when Ontario's regulatory lobby was largely comprised of Chinese medicine practitioners, presents a risk discourse inclusive of biomedical and TM knowledge claims, emphasizing the principle of regulatory 'equity' as well as historical and sociocultural considerations. Reflecting the interests of an increasingly biomedical practitioner lobby, the later (2001) report uses implicit discursive means to exclusively privilege Western scientific perspectives on risk. This report's policy recommendations, we argue, suggest misappropriation of TM knowledge. We advise regulators to consider equitable adaptations to existing policy structures, and to explicitly include TM evidentiary perspectives in their pre-regulatory assessments.

Exploring approaches to patient safety: the case of spinal manipulation therapy.

BACKGROUND: The purpose of this study was to gain insight into the current safety culture around the use of spinal manipulation therapy (SMT) by regulated health professionals in Canada and to explore perceptions of readiness for implementing formal mechanisms for tracking associated adverse events. METHODS: Fifty-six semi-structured telephone interviews were conducted with professional leaders and frontline practitioners in chiropractic, physiotherapy, naturopathy and medicine, all professions regulated to perform SMT in the provinces of Alberta and Ontario Canada. Interviews were digitally audio-recorded for verbatim transcription. Transcripts were entered into HyperResearch software for qualitative data analysis and were coded for both anticipated and emergent themes using the constant comparative method. A thematic, descriptive analysis was produced. RESULTS: The safety culture around SMT is characterized by substantial disagreement about its actual rather than putative risks. Competing intra- and inter-professional narratives further cloud the safety picture. Participants felt that safety talk is sometimes conflated with competition for business in the context of fee-for-service healthcare delivery by several professions with overlapping scopes of practice. Both professional leaders and frontline practitioners perceived multiple barriers to the implementation of an incident reporting system for SMT. CONCLUSIONS: The established 'measure and manage' approach to patient safety is difficult to apply to care which is geographically dispersed and delivered by practitioners in multiple professions with overlapping scopes of practice, primarily in a fee-for-service model. Collaboration across professions on models that allow practitioners to share information anonymously and help practitioners learn from the reported incidents is needed.

Making sense of "alternative", "complementary", "unconventional" and "integrative" medicine: exploring the terms and meanings through a textual analysis.

BACKGROUND: Medical pluralism has flourished throughout the Western world in spite of efforts to legitimize Western biomedical healthcare as "conventional medicine" and thereby relegate all non-physician-related forms of healthcare to an "other" category. These "other" practitioners have been referred to as "unconventional", "alternative" and "complementary", among other terms throughout the past half century. METHODS: This study investigates the discourses surrounding the changes in the terms, and their meanings, used to describe unconventional medicine in North America. Terms identified by the literature as synonymous to unconventional medicine were searched using the Scopus database. A textual analysis following the method described by Kripendorff 2013 was subsequently performed on the five most highly-cited unconventional medicine-related peer-reviewed literature published between 1970 and 2013. RESULTS: Five commonly-used, unconventional medicine-related terms were identified. Authors using "complementary and alternative", "complementary", "alternative", or "unconventional" tended to define them by what they are not (e.g., therapies not taught/used in conventional medicine, therapy demands not met by conventional medicine, and therapies that lack research on safety, efficacy and effectiveness). Authors defined "integrated/integrative" medicine by what it is (e.g., a new model of healthcare, the combining of both conventional and unconventional therapies, accounting for the whole person, and preventative maintenance of health). Authors who defined terms by "what is not" stressed that the purpose of conducting research in this area was solely to create knowledge. Comparatively, authors who defined terms by "what is" sought to advocate for the evidence-based combination of unconventional and conventional medicines. Both author groups used scientific rhetoric to define unconventional medical practices. CONCLUSIONS: This emergence of two groups of authors who used two different sets of terms to refer to the concept of "unconventional medicine" may explain why some journals, practitioner associations and research/practice centres may choose to use both "what is not" and "what is" terms in their discourse to attract interest from both groups. Since each of the two groups of terms (and authors who use them) has different meanings and goals, the evolution of this discourse will continue to be an interesting phenomenon to explore in the future.

Development and Preliminary Face and Content Validation of the "Which Health Approaches and Treatments Are You Using?" (WHAT) Questionnaires Assessing Complementary and Alternative Medicine Use in Pediatric Rheumatology.

OBJECTIVE: Complementary and alternative medicine (CAM) is commonly used by children with juvenile idiopathic arthritis (JIA), yet no validated questionnaires assess that use. The objective of this study was to develop child self- and parent proxy-report questionnaires assessing CAM use and to determine the face and content validity of the "Which Health Approaches and Treatments are you using?" (WHAT) questionnaires in pediatric rheumatology. METHODS: A sequential phased mixed methods approach was used to develop the questionnaires. A Delphi Survey of 126 experts followed by an interdisciplinary consensus conference of 14 stakeholders in CAM, general pediatrics and pediatric rheumatology was held to develop consensus on the content of the questionnaires using a nominal group technique. To determine face and content validity of the questionnaires, two groups, including (a) a purposive sample of 22 children with JIA 8 to 18 years and their parents from the Children's Hospital of Eastern Ontario and the Hospital for Sick Children, and (b) 21 Canadian pediatric rheumatology experts, participated in interviews. Participants were independently asked about the goal, understandability and comprehensiveness of the WHAT questionnaires, as well as the relevance of items. RESULTS: Consensus was reached on 17 items of the WHAT questionnaires. The domains found to be relevant were child's CAM use, factors associated with CAM use, perceived impact of CAM use, and communication about CAM. A total of 15 items in the parent proxy-report questionnaire and 13 items in the child report questionnaire showed adequate content validity. CONCLUSIONS: Consensus was reached by experts on the content of a pediatric CAM questionnaire. Face and content validity testing and modifications made to the WHAT questionnaires have helped ensure adequate preliminary validity for use in pediatric rheumatology. This constitutes the basis for further testing of these questionnaires in pediatric rheumatology and for adaptation to other chronic diseases.

Supportive but "worried": perceptions of naturopaths, homeopaths and Chinese medicine practitioners through a regulatory transition in Ontario, Canada.

BACKGROUND: In line with recent World Health Organization recommendations, many jurisdictions are taking steps to regulate practitioners of traditional, complementary and alternative medicine (TCAM). Previous studies have examined TCAM practitioners' generally-supportive views about professional regulation; however, little research has been conducted on TCAM practitioners' experiences and perspectives amidst an active regulatory process. In 2006 and 2007, the province of Ontario, Canada announced it would grant self-regulatory status to three TCAM practitioner groups--homeopaths, naturopaths and Chinese medicine practitioners/acupuncturists. METHODS: In 2011 and 2012, part-way through each group's regulatory process, we surveyed all practitioners from these three groups (n=1047) that could be identified from public registries and professional associations. The data presented here are derived from the sub-sample of homeopaths (n=234), naturopaths (n=273) and Chinese medicine practitioners/acupuncturists (n=181) who provided answers to an open-ended question about their opinions of the regulatory process at the end of the survey. An inductive, thematic analysis of qualitative survey responses was conducted. RESULTS: Survey responses affirmed a pro-regulatory stance across all groups, but revealed considerable 'worry' amongst practitioners as to how the regulations might be implemented. Four primary 'worry-related' themes emerged: a) regulation's potential administrative and financial burden on practitioners; b) scope-related concerns; c) implementation of fair registration standards; and d) whether regulation might erode the groups' distinctive worldviews. Some occupationally-specific concerns appeared related to each group's particular stage of professionalization. Other 'worries' may be related to the relative marginality of TCAM practitioner groups within biomedically-dominant national health care systems, and the possibility that inter-professional hierarchies may be emerging between particular TCAM groups. Specific concerns around overlapping practice scopes between TCAM and other professions raised questions about the implementation of non-monopolistic regulatory models such as Ontario's. CONCLUSIONS: Overall, this study will help inform regulators and TCAM practitioner groups to navigate the unique challenge of regulating health care providers long excluded from national health care systems, who frequently work from within paradigms distinct from mainstream biomedicine.