Characteristics of global naturopathic education, regulation, and practice frameworks: results from an international survey.

BACKGROUND: This descriptive study provides the first examination of global naturopathic education, regulation and practice frameworks that have potential to constrain or assist professional formation and integration in global health systems. Despite increasing public use, a significant workforce, and World Health Organization calls for national policy development to support integration of services, existent frameworks as potential barriers to integration have not been examined. METHODS: This cross-sectional survey utilized purposive sampling of 65 naturopathic organisations (educational institutions, professional associations, and regulatory bodies) from 29 countries. Organizational representatives completed an on-line survey, conducted between Nov 2016 - Aug 2019. Frequencies and cross-tabulation statistics were analyzed using SPSSv.25. Qualitative responses were hand-coded and thematically analysed where appropriate. RESULTS: Sixty-five of 228 naturopathic organizations completed the survey (29% response rate) from 29 of 46 countries (63% country response rate). Most education programs (68%) were delivered via a national framework. Higher education qualifications (60%) predominated. Organizations influential in education were professional associations (75.4%), particularly where naturopathy was unregulated, and accreditation bodies (41.5%) and regulatory boards (33.8%) where regulated. Full access to controlled acts, and to health insurance rebates were more commonly reported where regulated. Attitude of decision-makers, opinions of other health professions and existing legislation were perceived to most impact regulation, which was globally heterogeneous. CONCLUSION: Education and regulation of the naturopathic profession has significant heterogeneity, even in the face of global calls for consistent regulation that recognizes naturopathy as a medical system. Standards are highest and consistency more apparent in countries with regulatory frameworks.

Disclosure of complementary medicine use to medical providers: a systematic review and meta-analysis.

Concomitant complementary medicine (CM) and conventional medicine use is frequent and carries potential risks. Yet, CM users frequently neglect to disclose CM use to medical providers. Our systematic review examines rates of and reasons for CM use disclosure to medical providers. Observational studies published 2003-2016 were searched (AMED, CINAHL, MEDLINE, PsycINFO). Eighty-six papers reporting disclosure rates and/or reasons for disclosure/non-disclosure of CM use to medical providers were reviewed. Fourteen were selected for meta-analysis of disclosure rates of biologically-based CM. Overall disclosure rates varied (7-80%). Meta-analysis revealed a 33% disclosure rate (95%CI: 24% to 43%) for biologically-based CM. Reasons for non-disclosure included lack of inquiry from medical providers, fear of provider disapproval, perception of disclosure as unimportant, belief providers lacked CM knowledge, lacking time, and belief CM was safe. Reasons for disclosure included inquiry from medical providers, belief providers would support CM use, belief disclosure was important for safety, and belief providers would give advice about CM. Disclosure appears to be influenced by the nature of patient-provider communication. However, inconsistent definitions of CM and lack of a standard measure for disclosure created substantial heterogeneity between studies. Disclosure of CM use to medical providers must be encouraged for safe, effective patient care.

Associations between complementary medicine utilisation and the use of contraceptive methods: Results of a national cross-sectional survey.

BACKGROUND AND PURPOSE: This study examines the relationship between the use of complementary medicine (CM) interventions or consultations with CM practitioners and women's choice of contraceptive method. MATERIALS AND METHODS: A secondary analysis of a cross-sectional survey of Australian Women aged 34-39 years from the Australian Longitudinal Study on Women's Health (ALSWH) was conducted. Associations between use of CM and contraception were analysed using Chi-squared tests and multivariate logistic regression. RESULTS: Based on the responses from the included women (n = 7299), women who consulted a naturopath/herbalist were less likely to use implant contraceptives (OR 0.56; 95% confidence interval (CI) 0.33; 0.95). Those consulting a chiropractor (OR 1.54; 95%CI 1.05; 2.25) or an osteopath (OR 2.16; 95% CI 1.32; 3.54) were more likely to use natural contraception. CONCLUSION: There may be a link between women's choice of contraceptive method and their use of CM, in particular, with CM practitioner consultations.

Collaborating with medicine? Perceptions of Australian naturopaths on integrating within the conventional medical system.

Complementary and alternative medicine (CAM) is an increasingly prevalent part of contemporary health care. Whilst there have been some attempts to understand the dynamics of CAM integration in the health care system from the perspective of conventional care providers and patients, little research has examined the view of CAM practitioners. This study aims to identify the experiences of integration within a conventional healthcare system as perceived by naturopaths. Qualitative semi-structured interviews were conducted using a purposeful sample of 20 practising naturopaths in South East Queensland, Australia to discuss their experiences and perceptions of integrating with conventional medical providers. Analysis of the interviews revealed five broad challenges for the integration of CAM according to naturopaths: competing paradigms between CAM and conventional medicine; co-option of CAM by conventional medical practitioners; the preservation of separate CAM and conventional medical worlds by patients and providers due to lack of formalised relations; negative feedback and biases created through selective or limited experience or information with CAM; and indifferent, reactive and one-sided interaction between CAM and conventional medical providers. Naturopaths support the integration of health services and attempt to provide safe and appropriate care to their patients through collaborative approaches to practice. The challenges identified by naturopaths associated with integration of CAM with conventional providers may impact the quality of care of patients who choose to integrate CAM and conventional approaches to health. Given the significant role of naturopaths in contemporary health-care systems, these challenges require further research and policy attention.

A brief intervention for weight control based on habit-formation theory delivered through primary care: results from a randomised controlled trial.

BACKGROUND: Primary care is the 'first port of call' for weight control advice, creating a need for simple, effective interventions that can be delivered without specialist skills. Ten Top Tips (10TT) is a leaflet based on habit-formation theory that could fill this gap. The aim of the current study was to test the hypothesis that 10TT can achieve significantly greater weight loss over 3 months than 'usual care'. METHODS: A two-arm, individually randomised, controlled trial in primary care. Adults with obesity were identified from 14 primary care providers across England. Patients were randomised to either 10TT or 'usual care' and followed up at 3, 6, 12, 18 and 24 months. The primary outcome was weight loss at 3 months, assessed by a health professional blinded to group allocation. Difference between arms was assessed using a mixed-effect linear model taking into account the health professionals delivering 10TT, and adjusted for baseline weight. Secondary outcomes included body mass index, waist circumference, the number achieving a 5% weight reduction, clinical markers for potential comorbidities, weight loss over 24 months and basic costs. RESULTS: Five-hundred and thirty-seven participants were randomised to 10TT (n=267) or to 'usual care' (n=270). Data were available for 389 (72%) participants at 3 months and for 312 (58%) at 24 months. Participants receiving 10TT lost significantly more weight over 3 months than those receiving usual care (mean difference =-0.87kg; 95% confidence interval: -1.47 to -0.27; P=0.004). At 24 months, the 10TT group had maintained their weight loss, but the 'usual care' group had lost a similar amount. The basic cost of 10TT was low, that is, around £23 ($32) per participant. CONCLUSIONS: The 10TT leaflet delivered through primary care is effective in the short-term and a low-cost option over the longer term. It is the first habit-based intervention to be used in a health service setting and offers a low-intensity alternative to 'usual care'.

"What about diet?" A qualitative study of cancer survivors' views on diet and cancer and their sources of information.

Given the abundance of misreporting about diet and cancer in the media and online, cancer survivors are at risk of misinformation. The aim of this study was to explore cancer survivors' beliefs about diet quality and cancer, the impact on their behaviour and sources of information. Semi-structured interviews were conducted with adult cancer survivors in the United Kingdom who had been diagnosed with any cancer in adulthood and were not currently receiving treatment (n = 19). Interviews were analysed using Thematic Analysis. Emergent themes highlighted that participants were aware of diet affecting risk for the development of cancer, but were less clear about its role in recurrence. Nonetheless, their cancer diagnosis appeared to be a prompt for dietary change; predominantly to promote general health. Changes were generally consistent with healthy eating recommendations, although dietary supplements and other non-evidence-based actions were mentioned. Participants reported that they had not generally received professional advice about diet and were keen to know more, but were often unsure about information from other sources. The views of our participants suggest cancer survivors would welcome guidance from health professionals. Advice that provides clear recommendations, and which emphasises the benefits of healthy eating for overall well-being, may be particularly well-received.

Energy and nutrient intakes of young children in the UK: findings from the Gemini twin cohort.

Data on the diets of young children in the UK are limited, despite growing evidence of the importance of early diet for long-term health. We used the largest contemporary dietary data set to describe the intake of 21-month-old children in the UK. Parents of 2336 children aged 21 months from the UK Gemini twin cohort completed 3-d diet diaries in 2008/2009. Family background information was obtained from questionnaires completed 8 months after birth. Mean total daily intakes of energy, macronutrients (g and %E) and micronutrients from food and beverages, including and excluding supplements, were derived. Comparisons with UK dietary reference values (DRV) were made using t tests and general linear regression models, respectively. Daily energy intake (kJ), protein (g) and most micronutrients exceeded DRV, except for vitamin D and Fe, where 96 or 84 % and 70 or 6 % of children did not achieve the reference nutrient intake or lower reference nutrient intake (LRNI), respectively, even with supplementation. These findings reflect similar observations in the smaller sample of children aged 18-36 months in the National Diet and Nutrition Survey. At a population level, young children in the UK are exceeding recommended daily intakes of energy and protein, potentially increasing their risk of obesity. The majority of children are not meeting the LRNI for vitamin D, largely reflecting inadequate use of the supplements recommended at this age. Parents may need more guidance on how to achieve healthy energy and nutrient intakes for young children.

Are the CAM professions engaging in high-level health and medical research? Trends in publicly funded complementary medicine research grants in Australia.

INTRODUCTION: Developing research capacity is an essential part of professional development in the health professions, as well as essential to improving health care delivery. CAM is one area in which the importance of research capacity has been previously highlighted. METHODS: To determine whether academic and research CAM practitioners were actively engaged in high-level CAM research in Australia successful National Health and Medical Research Council grants data for projects starting between 2000 to present (2013) were collated and analyzed. RESULTS: CAM practitioners are not involved in most NHMRC-funded research, with non-clinical academics leading nearly half of all NHMRC-funded CAM grants. Conventional medical practitioners led the majority of CAM grants headed by clinicians. Only Chinese medicine and naturopathy practitioners appear to be building capacity, with NHMRC-funded CAM grants led by these practitioner groups increasing. University CAM faculties are for the most part not engaging in high level research, with most NHMRC-funded CAM projects being led by groups outside these faculties. Even the majority NHMRC-funded research led by CAM clinicians is administered outside university CAM faculties. CONCLUSIONS: The CAM professions have a low level of engagement with high-level health and medical research in Australia. Current levels of engagement appear to be dependent more on individual clinician involvement rather than professional strategy. Failure to engage with high-level health and medical research may pose challenges for the CAM professions, unless research engagement is improved. This requires an active and concerted effort from within CAM ranks to build research capacity in the CAM professions.

Homeopathy in rural Australian primary health care: a survey of general practitioner referral and practice in rural and regional New South Wales, Australia.

INTRODUCTION: Homeopathy has attracted considerable recent attention from the Australian conventional medical community. However, despite such increased attention there has been little exploration of the interface between homeopathy and Australian conventional medical practice. This article addresses this research gap by exploring homeopathic practice and referral by rural and regional Australian general practitioners (GPs). MATERIALS AND METHODS: A 27-item questionnaire was sent to all 1486 GPs currently practising in rural and regional New South Wales, Australia (response rate 40.7%). RESULTS: Few GPs in this study utilised homeopathy in their personal practice, with only 0.5% of GPs prescribing homeopathy in the past 12 months, and 8.5% referring patients for homeopathic treatment at least a few times over the past 12 months. Nearly two-thirds of GPs (63.9%) reported that they would not refer for homeopathy under any circumstances. Being in a remote location, receiving patient requests for homeopathy, observing positive responses from homeopathy previously, using complementary and alternative medicine (CAM) practitioners as information sources, higher levels of knowledge of homeopathy, and being interested in increasing CAM knowledge were all independently predictive of increased referral to homeopathy amongst GPs in this study. GPs in this study were less likely to refer to homeopathy if they used peer-reviewed literature as the major source of their information on CAM. CONCLUSIONS: Homeopathy is not integrated significantly in rural general practice either via GP utilisation or referral. There is significant opposition to homeopathy referral amongst rural and regional GPs, though some level of interaction with homeopathic providers exists.

Communication about colorectal cancer screening in Britain: public preferences for an expert recommendation.

BACKGROUND: Informed decision-making approaches to cancer screening emphasise the importance of decisions being determined by individuals' own values and preferences. However, advice from a trusted source may also contribute to autonomous decision-making. This study examined preferences regarding a recommendation from the NHS and information provision in the context of colorectal cancer (CRC) screening. METHODS: In face-to-face interviews, a population-based sample of adults across Britain (n=1964; age 50-80 years) indicated their preference between: (1) a strong recommendation to participate in CRC screening, (2) a recommendation alongside advice to make an individual decision, and (3) no recommendation but advice to make an individual decision. Other measures included trust in the NHS and preferences for information on benefits and risks. RESULTS: Most respondents (84%) preferred a recommendation (47% strong recommendation, 37% recommendation plus individual decision-making advice), but the majority also wanted full information on risks (77%) and benefits (78%). Men were more in favour of a recommendation than women (86% vs 81%). Trust in the NHS was high overall, but the minority who expressed low trust were less likely to want a recommendation. CONCLUSION: Most British adults want full information on risks and benefits of screening but they also want a recommendation from an authoritative source. An 'expert' view may be an important part of autonomous health decision-making.

Socioeconomic variation in uptake of colonoscopy following a positive faecal occult blood test result: a retrospective analysis of the NHS Bowel Cancer Screening Programme.

BACKGROUND: Bowel cancer is a serious health burden and its early diagnosis improves survival. The Bowel Cancer Screening Programme (BCSP) in England screens with the Faecal Occult Blood test (FOBt), followed by colonoscopy for individuals with a positive test result. Socioeconomic inequalities have been demonstrated for FOBt uptake, but it is not known whether they persist at the next stage of the screening pathway. The aim of this study was to assess the association between colonoscopy uptake and area socioeconomic deprivation, controlling for individual age and sex, and area ethnic diversity, population density, poor self-assessed health, and region. METHODS: Logistic regression analysis of colonoscopy uptake using BCSP data for England between 2006 and 2009 for 24 180 adults aged between 60 and 69 years. RESULTS: Overall colonoscopy uptake was 88.4%. Statistically significant variation in uptake is found between quintiles of area deprivation (ranging from 86.4 to 89.5%), as well as age and sex groups (87.9-89.1%), quintiles of poor self-assessed health (87.5-89.5%), non-white ethnicity (84.6-90.6%) and population density (87.9-89.3%), and geographical regions (86.4-90%). CONCLUSION: Colonoscopy uptake is high. The variation in uptake by socioeconomic deprivation is small, as is variation by subgroups of age and sex, poor self-assessed health, ethnic diversity, population density, and region.

Family-based behavioural treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial.

BACKGROUND: The best outcomes for treating childhood obesity have come from comprehensive family-based programmes. However there are questions over their generalizability. OBJECTIVE: To examine the acceptability and effectiveness of 'family-based behavioural treatment' (FBBT) for childhood obesity in an ethnically and socially diverse sample of families in a UK National Health Service (NHS) setting. METHODS: In this parallel group, randomized controlled trial, 72 obese children were randomized to FBBT or a waiting-list control. Primary outcomes were body mass index (BMI) and BMI s.d. scores (SDSs). Secondary outcomes were weight, weight SDSs, height, height SDSs, waist, waist SDSs, FM index, FFM index, blood pressure (BP) and psychosocial measures. The outcomes were assessed at baseline and after treatment, with analyses of 6-month data performed on an intent-to-treat (ITT) basis. Follow-up anthropometric data were collected at 12 months for the treatment group. RESULTS: ITT analyses included all children with baseline data (n=60). There were significant BMI SDS changes (P<0.01) for the treatment and control groups of -0.11 (0.16) and -0.10 (1.6). The treatment group showed a significant reduction in systolic BP (-0.24 (0.7), P<0.05) and improvements in quality of life and eating attitudes (P<0.05), with no significant changes for the control group. However the between-group treatment effects for BMI, body composition, BP and psychosocial outcomes were not significant. There was no overall change in BMI or BMI SDSs from 0-12 months for the treatment group. No adverse effects were reported. CONCLUSIONS: Both treatment and control groups experienced significant reductions in the level of overweight, but with no significant difference between them. There were no significant group differences for any of the secondary outcomes. This trial was registered at http://www.controlled-trials.com/ under ISRCTN 51382628.

Systematic review and economic modelling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence.

OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence (SUI) through systematic review and economic modelling. DATA SOURCES: The Cochrane Incontinence Group Specialised Register, electronic databases and the websites of relevant professional organisations and manufacturers, and the following databases: CINAHL, EMBASE, BIOSIS, Science Citation Index and Social Science Citation Index, Current Controlled Trials, ClinicalTrials.gov and the UKCRN Portfolio Database. STUDY SELECTION: The study comprised three distinct elements. (1) A survey of 188 women with SUI to identify outcomes of importance to them (activities of daily living; sex, hygiene and lifestyle issues; emotional health; and the availability of services). (2) A systematic review and meta-analysis of non-surgical treatments for SUI to find out which are most effective by comparing results of trials (direct pairwise comparisons) and by modelling results (mixed-treatment comparisons - MTCs). A total of 88 randomised controlled trials (RCTs) and quasi-RCTs reporting data from 9721 women were identified, considering five generic interventions [pelvic floor muscle training (PFMT), electrical stimulation (ES), vaginal cones (VCs), bladder training (BT) and serotonin-noradrenaline reuptake inhibitor (SNRI) medications], in many variations and combinations. Data were available for 37 interventions and 68 treatment comparisons by direct pairwise assessment. Mixed-treatment comparison models compared 14 interventions, using data from 55 trials (6608 women). (3) Economic modelling, using a Markov model, to find out which combinations of treatments (treatment pathways) are most cost-effective for SUI. DATA EXTRACTION: Titles and abstracts identified were assessed by one reviewer and full-text copies of all potentially relevant reports independently assessed by two reviewers. Any disagreements were resolved by consensus or arbitration by a third person. RESULTS: Direct pairwise comparison and MTC analysis showed that the treatments were more effective than no treatment. Delivering PFMT in a more intense fashion, either through extra sessions or with biofeedback (BF), appeared to be the most effective treatment [PFMT extra sessions vs no treatment (NT) odds ratio (OR) 10.7, 95% credible interval (CrI) 5.03 to 26.2; PFMT + BF vs NT OR 12.3, 95% CrI 5.35 to 32.7]. Only when success was measured in terms of improvement was there evidence that basic PFMT was better than no treatment (PFMT basic vs NT OR 4.47, 95% CrI 2.03 to 11.9). Analysis of cost-effectiveness showed that for cure rates, the strategy using lifestyle changes and PFMT with extra sessions followed by tension-free vaginal tape (TVT) (lifestyle advice-PFMT extra sessions-TVT) had a probability of greater than 70% of being considered cost-effective for all threshold values for willingness to pay for a QALY up to 50,000 pounds. For improvement rates, lifestyle advice-PFMT extra sessions-TVT had a probability of greater than 50% of being considered cost-effective when society's willingness to pay for an additional QALY was more than 10,000 pounds. The results were most sensitive to changes in the long-term performance of PFMT and also in the relative effectiveness of basic PFMT and PFMT with extra sessions. LIMITATIONS: Although a large number of studies were identified, few data were available for most comparisons and long-term data were sparse. Challenges for evidence synthesis were the lack of consensus on the most appropriate method for assessing incontinence and intervention protocols that were complex and varied considerably across studies. CONCLUSIONS: More intensive forms of PFMT appear worthwhile, but further research is required to define an optimal form of more intensive therapy that is feasible and efficient for the NHS to provide, along with further definitive evidence from large, well-designed studies.

Patient experiences of colonoscopy, barium enema and CT colonography: a qualitative study.

Previous studies of patient experience with bowel screening tests, in particular CT colonography (CTC), have superimposed global rating scales and not explored individual experience in detail. To redress this, we performed qualitative interviews in order to characterize patient expectations and experiences in depth. Following ethical permission, 16 patients undergoing CTC, 18 undergoing colonoscopy and 15 undergoing barium enema agreed to a semi-structured interview by a health psychologist. Interviews were recorded, responses transcribed and themes extracted with the aim of assimilating individual experiences to facilitate subsequent development and interpretation of quantitative surveys of overall satisfaction with each diagnostic test. Transcript analysis identified three principal themes: physical sensations, social interactions and information provision. Physical sensations differed for each test but were surprisingly well tolerated overall. Social interactions with staff were perceived as very important in colouring the whole experience, particularly in controlling the feelings of embarrassment, which was critical for all procedures. Information provision was also an important determinant of experience. Verbal feedback was most common during colonoscopy and invariably reassuring. However, patients undergoing CTC received little visual or verbal feedback and were often confused regarding the test outcome. Barium enema had no specific advantage over other tests. Qualitative interviews provided important perspectives on patient experience. Our data demonstrated that models describing the quality of medical encounters are applicable to single diagnostic episodes. Staff interactions and information provision were particularly important. We found advantages specific to both CTC and colonoscopy but none for barium enema. CTC could benefit greatly from improved information provision following examination.

Single blind, randomised trial of efficacy and acceptability of oral picolax versus self administered phosphate enema in bowel preparation for flexible sigmoidoscopy screening.

OBJECTIVE: To compare the acceptability and efficacy of two methods of self administered bowel preparation for flexible sigmoidoscopy screening: a single phosphate enema and a single sachet of Picolax. DESIGN: Single blind, randomised trial. SETTING: Endoscopy units of two general hospitals. PARTICIPANTS: 1442 men and women aged 55-64 years who had agreed to be screened by flexible sigmoidoscopy. MAIN OUTCOME MESURESs: Attendance rates, compliance with allocated preparations, adverse effects, quality of bowel preparation, procedure time, and yield of neoplasia. RESULTS: Compliance with the enema was higher than with the Picolax (608 (84%) v 566 (79%); difference 6%, 95% confidence interval 2% to 10%). Almost half of those who refused Picolax used an enema at home. Wind, incontinence, and sleep disturbance were more frequent in the Picolax group than the enema group; bottom soreness was more frequent in the enema group. Around 30% (187) found the diet restriction required by Picolax difficult; 78% (471) found the enema easy to administer. The quality of preparation was better with the enema; the proportion of procedures complete to the descending colon was greater and the mean duration of the procedure was shorter. There was no significant difference in polyp detection rates. CONCLUSION: A single phosphate enema self administered around one hour before leaving home is a more acceptable and effective method of preparing the distal bowel for flexible sigmoidoscopy than Picolax.

Mood and drinking: a naturalistic diary study of alcohol, coffee and tea.

Understanding the pattern of associations between mood and consumption of alcohol, coffee and tea may provide information about the factors governing beverage drinking. The associations between mood and the consumption of alcohol, coffee and tea during everyday life were assessed. A naturalistic study was carried out with 18 male and 31 female volunteers from two working groups (psychiatric nursing and school teaching). Participants completed daily records of drink consumption, together with ratings of anxious and positive moods for 8 weeks. Potential moderators of associations were self-reported drinking to cope, high perceived job demands and social support at work. Day-by-day associations were analysed using Spearman correlations. There were substantial individual-differences in associations between mood and daily alcohol, coffee and tea consumption. Overall, alcohol intake was associated with high positive and low anxious mood. This effect was not present among participants with high drinking to cope ratings. Coffee and tea drinking were not consistently related to mood across the entire sample. However, job demands influenced the association between coffee consumption and anxious mood in men, and those who experienced high job demands drank more coffee on days on which they felt anxious. In contrast, women but not men who enjoyed high social support at work felt more relaxed on days on which they drank more tea. These results indicate that people vary widely in the extent to which mood is related to the drinking of alcohol, coffee and tea. The strength of associations is influenced by gender, motivational factors, and by stress and coping resources.