Traditional and complementary medicine for promoting healthy ageing in WHO Western Pacific Region: Policy implications from utilization patterns and current evidence.

BACKGROUND: With increasing burden of chronic non-communicable diseases (NCD), ageing becomes a global public health concern, and the World Health Organization Western Pacific Region has no exception. To address the NCD challenge, priority should be given to promote healthy ageing across the life-course. As traditional and complementary medicine (T&CM) is popular within the Region, it is of policy interest to explore possibilities of applying T&CM for promoting healthy ageing. METHODS: We first summarized sources of clinical evidence supporting the use of T&CM. We then searched publications through MEDLINE from its inception to April 2020 to identify studies focusing on the perception of T&CM among older people. Finally, taking current evidence base and patient choice into account, we generated policy recommendations for of integrating T&CM into health systems. RESULT: Experiences from countries with different income levels suggested that promoting evidence-based T&CM as self-care modalities would be the most efficient way of maximizing impact among the older population, especially via a train the trainer approach. Meanwhile, popularity of natural products in the Region mandates policy makers to implement appropriate regulation and quality assurance, and to establish pharmacovigilance to detect potential harm. The role of pharmacists in advising patients on self-medication using natural products needs to be strengthened. CONCLUSION: Policy-makers will benefit from continued global dialogue and sharing of experience in T&CM policy development and implementation. Harmonizing regulatory frameworks for natural products at regional and global levels, including mutual recognition of regulatory approval, to improve standards and protect patients could be a priority.

Use of Traditional and Complementary Medicine as Self-Care Strategies in Community Health Centers: Cross-Sectional Study in Urban Pearl River Delta Region of China.

In China, Community Health Centers (CHCs) are major providers of primary care services, but their potential in empowering patients' self-management capacity has not been assessed. This study aims to describe self-care practice patterns amongst CHC attendees in urban China.In this cross-sectional quantitative study, 3360 CHC patients from 6 cities within the Pearl Delta Region were sampled using multistage cluster sampling.Thirty-seven per cent had used with over-the-counter Chinese herbal medicines (OTC CHMs) in the past year and majority of respondents found OTC CHMs effective. OTC CHMs were more popular amongst those who needed to pay out of pocket for CHC services. Less than 10% used vitamins and minerals, and those with a lower socioeconomic background have a higher propensity to consume. Although doubts on their usefulness are expressed, their use by the vulnerable population may reflect barriers to access to conventional health care, cultural affinity, or a defense against negative consequences of illnesses. About 25% performed physical exercise, but the prevalence is lower amongst women and older people. Taiji seems to be an alternative for these populations with promising effectiveness, but overall only 6% of CHC attendees participated.These results suggest that CHCs should start initiatives in fostering appropriate use of OTC CHM, vitamins, and minerals. Engaging community pharmacists in guiding safe and effective use of OTC CHM amongst the uninsured is essential given their low accessibility to CHC services. Prescription of Taiji instead of physical exercises to women and older people could be more culturally appropriate, and the possibility of including this as part of the CHC services worth further exploration.

Electroacupuncture and splinting versus splinting alone to treat carpal tunnel syndrome: a randomized controlled trial.

BACKGROUND: The effectiveness of acupuncture for managing carpal tunnel syndrome is uncertain, particularly in patients already receiving conventional treatments (e.g., splinting). We aimed to assess the effects of electroacupuncture combined with splinting. METHODS: We conducted a randomized parallel-group assessor-blinded 2-arm trial on patients with clinically diagnosed primary carpal tunnel syndrome. The treatment group was offered 13 sessions of electroacupuncture over 17 weeks. The treatment and control groups both received continuous nocturnal wrist splinting. RESULTS: Of 181 participants randomly assigned to electroacupuncture combined with splinting (n = 90) or splinting alone (n = 91), 174 (96.1%) completed all follow-up. The electroacupuncture group showed greater improvements at 17 weeks in symptoms (primary outcome of Symptom Severity Scale score mean difference [MD] -0.20, 95% confidence interval [CI] -0.36 to -0.03), disability (Disability of Arm, Shoulder and Hand Questionnaire score MD -6.72, 95% CI -10.9 to -2.57), function (Functional Status Scale score MD -0.22, 95% CI -0.38 to -0.05), dexterity (time to complete blinded pick-up test MD -6.13 seconds, 95% CI -10.6 to -1.63) and maximal tip pinch strength (MD 1.17 lb, 95% CI 0.48 to 1.86). Differences between groups were small and clinically unimportant for reduction in pain (numerical rating scale -0.70, 95% CI -1.34 to -0.06), and not significant for sensation (first finger monofilament test -0.08 mm, 95% CI -0.22 to 0.06). INTERPRETATION: For patients with primary carpal tunnel syndrome, chronic mild to moderate symptoms and no indication for surgery, electroacupuncture produces small changes in symptoms, disability, function, dexterity and pinch strength when added to nocturnal splinting. TRIAL REGISTRATION: Chinese Clinical Trial Register no. ChiCTR-TRC-11001655 (www.chictr.org.cn/showprojen.aspx?proj=7890); subsequently deposited in the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR-TRC-11001655).

Mindfulness-based cognitive therapy v. group psychoeducation for people with generalised anxiety disorder: randomised controlled trial.

BACKGROUND: Research suggests that an 8-week mindfulness-based cognitive therapy (MBCT) course may be effective for generalised anxiety disorder (GAD). AIMS: To compare changes in anxiety levels among participants with GAD randomly assigned to MBCT, cognitive-behavioural therapy-based psychoeducation and usual care. METHOD: In total, 182 participants with GAD were recruited (trial registration number: CUHK_CCT00267) and assigned to the three groups and followed for 5 months after baseline assessment with the two intervention groups followed for an additional 6 months. Primary outcomes were anxiety and worry levels. RESULTS: Linear mixed models demonstrated significant group × time interaction (F(4,148) = 5.10, P = 0.001) effects for decreased anxiety for both the intervention groups relative to usual care. Significant group × time interaction effects were observed for worry and depressive symptoms and mental health-related quality of life for the psychoeducation group only. CONCLUSIONS: These results suggest that both of the interventions appear to be superior to usual care for the reduction of anxiety symptoms.

Patients' experience of Chinese Medicine Primary Care Services: Implications on Improving Coordination and Continuity of Care.

Chinese medicine (CM) is major form of traditional and complementary medicine used by Chinese populations. Evaluation on patients' experience on CM service is essential for improving service quality. This cross sectional study aims (i) to assess how CM clinics with different administrative model differ in terms of quality from patients' perspective; and (ii) to investigate how quality varies with patients' demographic and health characteristics. Five hundred and sixteen patients were sampled from charity and semi-public CM clinics in Hong Kong, and were invited to assess their experience using the Primary Care Assessment Tool (PCAT). Results indicated that overall mean PCAT scoring is satisfactory, achieving 70.7% (91.26/129) of total score. Ratings were lower in areas of "coordination of patient information", "continuity of care", and "range of service provided". Impact of administrative models, including involvement of tax-funded healthcare system and outreach delivery, were minimal after adjusting for patient characteristics. Demographic and health characteristics of patients did not contribute to substantial variations in scoring. To improve patient experience, policy makers should consider strengthening care coordination, continuity and comprehensiveness in CM primary care services. Sharing of electronic records and establishing referral system are potential solutions for linking CM and conventional healthcare services.

The incidence of cancer deaths among hypertensive patients in a large Chinese population: a cohort study.

Current evidence is mixed regarding the association between antihypertensive prescriptions and cancer mortality. We evaluated this association in a large Chinese hypertensive population. We followed for five years all patients who were prescribed their first-ever antihypertensive agents between 2001 and 2005 in a public healthcare sector of Hong Kong. The association between antihypertensive drug class and cancer mortality was evaluated by Cox proportional hazard models with propensity score matching. Age, gender, socioeconomic status, service settings, district of residence, proportion of days covered reflecting medication adherence, and the number of comorbidities were adjusted. From 217,910 eligible patients, 9500 (4.4%) died from cancer within five years after their first-ever antihypertensive prescription. Most cancer deaths occurred in the digestive (38.9%) and respiratory system (30.4%); the breast (6.2%); and the lympho-hematopoietic tissues (5.3%). The proportion of patients who died from cancer was the highest in the calcium channel blocker (CCB) group (6.5%), followed by thiazide diuretics (4.4%), angiotensin converting enzyme inhibitors (4.2%) and ß-blockers (2.6%). When compared with ß-blockers, patients prescribed CCBs (Adjusted Hazard Ratio [AHR]=1.406, 95% C.I. 1.334-1.482, p<0.001) were more likely to die from cancer. Thiazide users were also more likely to suffer from cancer deaths (AHR=1.364, 95% C.I. 1.255-1.483, p<0.001), but became insignificant in stratified analysis. The association between cancer mortality and use of CCB, and perhaps thaizide, may alert physicians to the need for more meticulous and comprehensive care of these patients in clinical practice. We recommend prospective studies to evaluate cause-and-effect relationships of these associations.

Views on traditional Chinese medicine amongst Chinese population: a systematic review of qualitative and quantitative studies.

BACKGROUND: Health-care professionals worldwide have started to appreciate patients' perspectives on the use of complementary and alternative medicine (CAM) particularly given its popularity. However, cultural perspectives may vary and it may not be possible to apply research findings on the use of CAM from the west to the east. OBJECTIVE: This systematic review aims to synthesize usage patterns of traditional Chinese medicine (TCM) amongst Chinese populations in different parts of the world and explore potential geographical variations. SEARCH STRATEGY: Six international and four Chinese databases were searched, and manual searches of relevant monographs and government publications were carried out. INCLUSION CRITERIA: Quantitative, qualitative or mixed-method research that aimed to investigate Chinese patients' perception of, and perspectives on, TCM was included. DATA EXTRACTION AND SYNTHESIS: For each study included, texts under the headings of 'results' or 'findings' were extracted and subjected to analysis. A thematic synthesis approach was adopted for synthesizing qualitative and quantitative studies. MAIN RESULTS: Amongst the 28 studies included, twenty were quantitative surveys, six were qualitative studies and two were mixed-method studies. The overall methodological quality was mediocre. Data synthesis suggested that patients from all regions share a common cultural affinity to TCM and consider it to be an effective complement to western medicine (WM) for treating chronic or serious diseases. However, heterogeneous views on (i) disclosing TCM use to WM doctors and (ii) the potential harm of herbs emerged across different study locations. DISCUSSION AND CONCLUSIONS: Future research should explore how variation in health systems may influence patients' perception of CAM in different countries.

Integrating traditional chinese medicine services in community health centers: insights into utilization patterns in the pearl river region of china.

In China's healthcare reform, community health centers (CHCs) are designed to take a pivotal role in providing primary care. Whilst about 20% of all outpatient care in China is delivered by the traditional Chinese medicine (TCM) sector, hospitals, instead of CHCs, are major providers. Using current patterns of patient utilization this study aims to inform CHCs on how they may strengthen access to TCM services. Three thousand three hundred and sixty CHC patients from six cities within the urban Pearl Delta Region were enumerated using multistage cluster sampling. Fifty-two percent had visited herbalists within three months with a mean visit frequency of 1.50 times. Herbal treatments, which are cheaper than western medicines, were more popular amongst those who needed to pay out of pocket including the uninsured. Herbal medicines appeared to be an alternative for those who are underinsured. Acupuncturists and massage therapists were visited by smaller proportions, 6.58% and 5.98%, respectively, with a mean three-month visit of 0.27 and 0.26 times. Access was restricted by lack of social insurance coverage. Whilst increasing provision of TCM in CHCs might respond to patient demand, increasing insurance coverage for TCM needs to be evaluated using current evidence on safety and effectiveness.

Organizational determinants of interprofessional collaboration in integrative health care: systematic review of qualitative studies.

CONTEXT: Inteprofessional collaboration (IPC) between biomedically trained doctors (BMD) and traditional, complementary and alternative medicine practitioners (TCAMP) is an essential element in the development of successful integrative healthcare (IHC) services. This systematic review aims to identify organizational strategies that would facilitate this process. METHODS: We searched 4 international databases for qualitative studies on the theme of BMD-TCAMP IPC, supplemented with a purposive search of 31 health services and TCAM journals. Methodological quality of included studies was assessed using published checklist. Results of each included study were synthesized using a framework approach, with reference to the Structuration Model of Collaboration. FINDINGS: Thirty-seven studies of acceptable quality were included. The main driver for developing integrative healthcare was the demand for holistic care from patients. Integration can best be led by those trained in both paradigms. Bridge-building activities, positive promotion of partnership and co-location of practices are also beneficial for creating bonding between team members. In order to empower the participation of TCAMP, the perceived power differentials need to be reduced. Also, resources should be committed to supporting team building, collaborative initiatives and greater patient access. Leadership and funding from central authorities are needed to promote the use of condition-specific referral protocols and shared electronic health records. More mature IHC programs usually formalize their evaluation process around outcomes that are recognized both by BMD and TCAMP. CONCLUSIONS: The major themes emerging from our review suggest that successful collaborative relationships between BMD and TCAMP are similar to those between other health professionals, and interventions which improve the effectiveness of joint working in other healthcare teams with may well be transferable to promote better partnership between the paradigms. However, striking a balance between the different practices and preserving the epistemological stance of TCAM will remain the greatest challenge in successful integration.

Emotionless holism: factor and Rasch analysis of the Chinese Integrative Medicine Attitude Questionnaire.

OBJECTIVE: To examine the Eastern-Western difference in the interpretation of Integrative Medicine Attitude Questionnaire (IMAQ) by assessing the psychometric properties of a revised Chinese medicine (CM)-specific version of IMAQ (CM-IMAQ). METHODS: Factor and Rasch analysis were performed with data collected from a mail survey of 165 Hong Kong Western medical doctors (WMD) randomly sampled from the official registry. The structural validity, unidimensionality, item fit, and differential item functioning (DIF) of the Hong Kong CM-IMAQ were evaluated. RESULTS: Confirmatory factor analysis (CFA) demonstrated that the original IMAQ factor structure was not concordant with our data on Chinese WMD, and subsequent explanatory factor analysis (EFA) validated a new three-factor model for CM-IMAQ: (1) attitude towards "tonification", (2) attitude towards the effectiveness of CM, and (3) attitude towards CM knowledge. The original IMAQ factor on holism and doctor-patient relationship disappeared. Rasch analysis confirmed the unidimensionality of "tonification" and the effectiveness domains, but further refinement of the knowledge domain is needed. CONCLUSIONS: Cultural adaptation of the IMAQ has demonstrated differences between Eastern and Western doctors trained in allopathic medicine in their interpretations of holism in healthcare. For Chinese WMD, the emphasis of holistic care is placed on "tonifying" the body rather than on nurturing the mind and spirit. Confucian and Taoist conceptualizations of mental health as well as the persistent stigma towards mental illness within modern Chinese culture may explain why Chinese WMD do not regard mental health promotion as part of routine healthcare.

Developing policy for integrating biomedicine and traditional chinese medical practice using focus groups and the delphi technique.

In Hong Kong, statutory regulation for traditional Chinese medicine (TCM) practitioners has been implemented in the past decade. Increasing use of TCM on top of biomedicine (BM) services by the population has been followed; but corresponding policy development to integrate their practices has not yet been discussed. Using focus group methodology, we explore policy ideas for integration by collating views from frontline BM (n = 50) and TCM clinicians (n = 50). Qualitative data were analyzed under the guidance of structuration model of collaboration, a theoretical model for understanding interprofessional collaboration. From focus group findings we generated 28 possible approaches, and subsequently their acceptability was assessed by a two round Delphi survey amongst BM and TCM policy stakeholders (n = 12). Consensus was reached only on 13 statements. Stakeholders agreed that clinicians from both paradigms should share common goals of providing patient-centered care, promoting the development of protocols for shared care and information exchange, as well as strengthening interprofessional connectivity and leadership for integration. On the other hand, attitudes amongst policy stakeholders were split on the possibility of fostering trust and mutual learning, as well as on enhancing innovation and governmental support. Future policy initiatives should focus on these controversial areas.

Complementary and alternative medicine education for medical profession: systematic review.

Purpose. To help integrate traditional, complementary and alternative medicine (TCAM) into health systems, efforts are being made to educate biomedical doctors (BMD) and medical students on TCAM. We systematically evaluated the effect of TCAM education on BMD and medical students' attitude, knowledge, and behavior towards TCAM utilization and integration with biomedical medicine. Methods. Evaluative studies were identified from four databases. Methodological quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI). Study outcomes were classified using Kirkpatrick's hierarchy. Results. 3122 studies were identified and 12 studies of mediocre quality met inclusion criteria. Qualitative synthesis showed usage of diverse approaches including didactic, experiential learning, varying length, teacher background and intensity of exposure. More positive attitudes and improved knowledge after intervention were noted especially when teachers were BM trained. However, few studies assessed behavior change objectively. Finally, longer-term objective outcomes such as impact on patient care were not assessed. Conclusions. Lack of use of objective and reliable instruments preclude firm conclusion on the effect of TCAM education on study participants. However, positive changes, although mostly subjectively reported, were noted in most studies. Future evaluation should use validated or objective outcome assessments, and the value of using dual trained instructors.

Referral to and attitude towards traditional Chinese medicine amongst western medical doctors in postcolonial Hong Kong.

Recognizing the international trend for patients to choose both allopathic western medicine (WM) and traditional, complementary and alternative medicine (TCAM), the World Health Organization has called for stronger collaboration between WM doctors (WMD) and TCAM practitioners. This resonates with the situation in Hong Kong where the dominant modality of patient care is primarily based on WM practice while traditional Chinese medicine (TCM) is often used as a complement. The roots of this utilization pattern lie in colonial history when TCM was marginalised during the British administration. However since 1997 when China regained sovereignty, policies to regulate and professionalize TCM practices have been formally introduced. Despite both its popularity and this policy shift, progress on implementing collaboration between WM and TCM clinicians has been slow. This study, the first since 1997, explores current attitudes and referral behaviours of WMD towards use of TCM. We hypothesised that WMD would have positive attitudes towards TCM, due to regulation and cultural affinity, but that few actual TCM referrals would be made given the lack of a formal collaboration policy between elements within the healthcare system. Our results support these hypotheses, and this pattern possibly rooted from structural inhibitions originating from the historical dominance of WM and failure of services to respond to espoused policy. These have shaped Hong Kong's TCAM policy process to be closer with situations in the West, and have clearly differentiated it from integration experiences in other East Asian health systems where recent colonial history is absent. In addition, our results revealed that self use and formal education of TCM, rather than use of evidence in decision making, played a stronger role in determining referral. This implies that effective TCAM policies within WM dominated health systems like Hong Kong would require structural and educational solutions that foster both increased understanding and safe referrals.

Using Chinese version of MYMOP in Chinese medicine evaluation: validity, responsiveness and minimally important change.

BACKGROUND: Measure Yourself Medical Outcome Profile (MYMOP) is a patient generated outcome instrument applicable in the evaluation of both allopathic and complementary medicine treatment. This study aims to adapt MYMOP into Chinese, and to assess its validity, responsiveness and minimally important change values in a sample of patients using Chinese medicine (CM) services. METHODS: A Chinese version of MYMOP (CMYMOP) is developed by forward-backward-forward translation strategy, expert panel assessment and pilot testing amongst patients. 272 patients aged 18 or above with subjective symptoms in the past 2 weeks were recruited at a CM clinic, and were invited to complete a set of questionnaire containing CMYMOP and SF-36. Follow ups were performed at 2nd and 4th week after consultation, using the same set of questionnaire plus a global rating of change question. Criterion validity of CMYMOP was assessed by its correlation with SF-36 at baseline, and responsiveness was evaluated by calculating the Cohen effect size (ES) of change at two follow ups. Minimally important difference (MID) values were estimated via anchor based method, while minimally detectable difference (MDC) figures were calculated by distribution based method. RESULTS: Criterion validity of CMYMOP was demonstrated by negative correlation between CMYMOP Profile scores and all SF-36 domain and summary scores at baseline. For responsiveness between baseline and 4th week follow up, ES of CMYMOP Symptom 1, Activity and Profile reached the moderate change threshold (ES>0.5), while Symptom 2 and Wellbeing reached the weak change threshold (ES>0.2). None of the SF-36 scores reached the moderate change threshold, implying CMYMOP's stronger responsiveness in CM setting. At 2nd week follow up, MID values for Symptom 1, Symptom 2, Wellbeing and Profile items were 0.894, 0.580, 0.263 and 0.516 respectively. For Activity item, MDC figure of 0.808 was adopted to estimate MID. CONCLUSIONS: The findings support the validity and responsiveness of CMYMOP for capturing patient centred clinical changes within 2 weeks in a CM clinical setting. Further researches are warranted (1) to estimate Activity item MID, (2) to assess the test-retest reliability of CMYMOP, and (3) to perform further MID evaluation using multiple, item specific anchor questions.

A qualitative study of the views of patients with long-term conditions on family doctors in Hong Kong.

BACKGROUND: Primary care based management of long-term conditions (LTCs) is high on the international healthcare agenda, including the Asia-Pacific region. Hong Kong has a 'mixed economy' healthcare system with both public and private sectors with a range of types of primary care doctors. Recent Hong Kong Government policy aims to enhance the management of LTCs in primary care possibly based on a 'family doctor' model. Patients' views on this are not well documented and the aim of the present study was to explore the views of patients with LTCs on family doctors in Hong Kong. METHODS: The views of patients (with a variety of LTCs) on family doctors in Hong Kong were explored. Two groups of participants were interviewed; a) those who considered themselves as having a family doctor, b) those who considered themselves as not having a family doctor (either with a regular primary care doctor but not a family doctor or with no regular primary care doctor). In-depth individual semi-structured interviews were carried out with 28 participants (10 with a family doctor, 10 with a regular doctor, and 8 with no regular doctor) and analysed using the constant comparative method. RESULTS: Participants who did not have a family doctor were familiar with the concept but regarded it as a 'luxury item' for the rich within the private healthcare system. Those with a regular family doctor (all private) regarded having one as important to their and their family's health. Participants in both groups felt that as well as the more usual family medicine specialist or general practitioner, traditional Chinese medicine practitioners also had the potential to be family doctors. However most participants attended the public healthcare system for management of their LTCs whether they had a family doctor or not. Cost, perceived need, quality, trust, and choice were all barriers to the use of family doctors for the management of their LTCs. CONCLUSIONS: Important barriers to the adoption of a 'family doctor' model of management of LTCs exist in Hong Kong. Effective policy implementation seems unlikely unless these complex barriers are addressed.

Postgraduate education for Chinese medicine practitioners: a Hong Kong perspective.

BACKGROUND: Despite Hong Kong government's official commitment to the development of traditional Chinese medicine (TCM) over the last ten years, there appears to have been limited progress in public sector initiated career development and postgraduate training (PGT) for public university trained TCM practitioners. Instead, the private TCM sector is expected to play a major role in nurturing the next generation of TCM practitioners. In the present study we evaluated TCM graduates' perspectives on their career prospects and their views regarding PGT. METHOD: Three focus group discussions with 19 local TCM graduates who had worked full time in a clinical setting for fewer than 5 years. RESULTS: Graduates were generally uncertain about how to develop their career pathways in Hong Kong with few postgraduate development opportunities; because of this some were planning to leave the profession altogether. Despite their expressed needs, they were dissatisfied with the current quality of local PGT and suggested various ways for improvement including supervised practice-based learning, competency-based training, and accreditation of training with trainee involvement in design and evaluation. In addition they identified educational needs beyond TCM, in particular a better understanding of western medicine and team working so that primary care provision might be more integrated in the future. CONCLUSION: TCM graduates in Hong Kong feel let down by the lack of public PGT opportunities which is hindering career development. To develop a new generation of TCM practitioners with the capacity to provide quality and comprehensive care, a stronger role for the government, including sufficient public funding, in promoting TCM graduates' careers and training development is suggested. Recent British and Australian experiences in prevocational western medicine training reform may serve as a source of references when relevant program for TCM graduates is planned in the future.