Healthcare providers' views on the acceptability of financial incentives for breastfeeding: a qualitative study.

BACKGROUND: Despite a gradual increase in breastfeeding rates, overall in the UK there are wide variations, with a trend towards breastfeeding rates at 6-8 weeks remaining below 40% in less affluent areas. While financial incentives have been used with varying success to encourage positive health related behaviour change, there is little research on their use in encouraging breastfeeding. In this paper, we report on healthcare providers' views around whether using financial incentives in areas with low breastfeeding rates would be acceptable in principle. This research was part of a larger project looking at the development and feasibility testing of a financial incentive scheme for breastfeeding in preparation for a cluster randomised controlled trial. METHODS: Fifty-three healthcare providers were interviewed about their views on financial incentives for breastfeeding. Participants were purposively sampled to include a wide range of experience and roles associated with supporting mothers with infant feeding. Semi-structured individual and group interviews were conducted. Data were analysed thematically drawing on the principles of Framework Analysis. RESULTS: The key theme emerging from healthcare providers' views on the acceptability of financial incentives for breastfeeding was their possible impact on 'facilitating or impeding relationships'. Within this theme several additional aspects were discussed: the mother's relationship with her healthcare provider and services, with her baby and her family, and with the wider community. In addition, a key priority for healthcare providers was that an incentive scheme should not impact negatively on their professional integrity and responsibility towards women. CONCLUSION: Healthcare providers believe that financial incentives could have both positive and negative impacts on a mother's relationship with her family, baby and healthcare provider. When designing a financial incentive scheme we must take care to minimise the potential negative impacts that have been highlighted, while at the same time recognising the potential positive impacts for women in areas where breastfeeding rates are low.

Prevalence of visits to massage therapists by the general population: a systematic review.

OBJECTIVE: To systematically review 12-month prevalence of visits to massage therapists by representative samples of the general population across countries. METHODS: Surveys reporting estimates of overall CAM use were included. Studies were identified via database searches. Study quality was assessed using a six-item tool. RESULTS: Twenty-two surveys across six countries were included. Estimates for 12-month prevalence of visits to massage therapists by adults ranged from 0.4% to 20% and the median was 5.5%. Estimates for children were 0.3%-3.8% (median 0.7%), while estimates for older adults were 1.5%-16.2% (median 5.2%). 16 surveys (73%) met at least four of six quality criteria. CONCLUSIONS: This review summarises 12-month prevalence of visits to massage therapists in six countries (USA, UK, Canada, Australia, Singapore and South Korea). A small but significant percentage of these general populations visit massage therapists each year.

Prevalence of visits to five types of complementary and alternative medicine practitioners by the general population: a systematic review.

OBJECTIVE: To systematically review surveys of 12-month prevalence of visits to complementary and alternative medicine (CAM) practitioners for five therapies: acupuncture, homeopathy, osteopathy, chiropractic, and medical herbalism. METHODS: Studies were identified via database searches to 2011. Study quality was assessed using a six-item tool. RESULTS: Forty-one surveys across 12 countries were included. Twenty-five (61%) met four of six quality criteria. Prevalence of visits by adults were (median, range): acupuncturists 1.4% (0.2-7.5%, N = 27 surveys), homeopaths 1.5% (0.2-2.9%, N = 20 surveys), osteopaths 1.9% (0.2-4.4%, N = 9 surveys), chiropractors 7.5% (0.3-16.7, N = 33 surveys), medical herbalists 0.9% (0.3-4.7%, N = 14 surveys). Estimates were slightly lower for children and higher for older adults. There was little change over the past 15-20 years. CONCLUSIONS: This review summarises 12-month prevalence of visits to CAM practitioners in Europe, North America, Australia, East Asia, Saudi Arabia and Israel. A small but significant percentage of these general populations visit CAM practitioners each year.

Getting inside acupuncture trials--exploring intervention theory and rationale.

BACKGROUND: Acupuncture can be described as a complex intervention. In reports of clinical trials the mechanism of acupuncture (that is, the process by which change is effected) is often left unstated or not known. This is problematic in assisting understanding of how acupuncture might work and in drawing together evidence on the potential benefits of acupuncture. Our aim was to aid the identification of the assumed mechanisms underlying the acupuncture interventions in clinical trials by developing an analytical framework to differentiate two contrasting approaches to acupuncture (traditional acupuncture and Western medical acupuncture). METHODS: Based on the principles of realist review, an analytical framework to differentiate these two contrasting approaches was developed. In order to see how useful the framework was in uncovering the theoretical rationale, it was applied to a set of trials of acupuncture for fatigue and vasomotor symptoms, identified from a wider literature review of acupuncture and early stage breast cancer. RESULTS: When examined for the degree to which a study demonstrated adherence to a theoretical model, two of the fourteen selected studies could be considered TA, five MA, with the remaining seven not fitting into any recognisable model. When examined by symptom, five of the nine vasomotor studies, all from one group of researchers, are arguably in the MA category, and two a TA model; in contrast, none of the five fatigue studies could be classed as either MA or TA and all studies had a weak rationale for the chosen treatment for fatigue. CONCLUSION: Our application of the framework to the selected studies suggests that it is a useful tool to help uncover the therapeutic rationale of acupuncture interventions in clinical trials, for distinguishing between TA and MA approaches and for exploring issues of model validity. English language acupuncture trials frequently fail to report enough detail relating to the intervention. We advocate using this framework to aid reporting, along with further testing and refinement of the framework.

'Homeopathy': untangling the debate.

There are active public campaigns both for and against homeopathy, and its continuing availability in the NHS is debated in the medical, scientific and popular press. However, there is a lack of clarity in key terms used in the debate, and in how the evidence base of homeopathy is described and interpreted. The term 'homeopathy' is used with several different meanings including: the therapeutic system, homeopathic medicine, treatment by a homeopath, and the principles of 'homeopathy'. Conclusions drawn from one of these aspects are often inappropriately applied to another aspect. In interpreting the homeopathy evidence it is important to understand that the existing clinical experimental (randomised controlled trial) evidence base provides evidence as to the efficacy of homeopathic medicines, but not the effectiveness of treatment by a homeopath. The observational evidence base provides evidence as to the effectiveness of treatment by a homeopath. We make four recommendations to promote clarity in the reporting, design and interpretation of homeopathy research.

A randomised, controlled, triple-blind trial of the efficacy of homeopathic treatment for chronic fatigue syndrome.

OBJECTIVE: There is no management regime for chronic fatigue syndrome (CFS) that has been found to be universally beneficial and no treatment can be considered a "cure". Patients with CFS may use complementary and alternative medicine (CAM). Our aim was to evaluate homeopathic treatment in reducing subjective symptoms of CFS. METHOD: Using a triple-blind design (patient and homeopath blind to group assignment and data analyst blind to group until after initial analyses to reduce the possibility of bias due to data analyst), we randomly assigned patients to homeopathic medicine or identical placebo. One hundred and three patients meeting the Oxford criteria for CFS were recruited from two specialist hospital out patient departments. Patients had monthly consultations with a professional homeopath for 6 months. Main outcome measures were scores on the subscales of the Multidimensional Fatigue Inventory (MFI) and proportions of each group attaining clinically significant improvements on each subscale. Secondary outcome measures were the Fatigue Impact Scale (FIS) and the Functional Limitations Profile (FLP). Ninety-two patients completed treatment in the trial (47 homeopathic treatment, 45 placebo). Eighty-six patients returned fully or partially completed posttreatment outcome measures (41 homeopathic treatment group who completed treatment, 2 homeopathic treatment group who did not complete treatment, 38 placebo group who completed treatment, and 5 placebo group who did not complete treatment). RESULTS: Seventeen of 103 patients withdrew from treatment or were lost to follow-up. Patients in the homeopathic medicine group showed significantly more improvement on the MFI general fatigue subscale (one of the primary outcome measures) and the FLP physical subscale but not on other subscales. Although group differences were not statistically significant on four out of the five MFI subscales (the primary outcome measures), more people in the homeopathic medicine group showed clinically significant improvement. More people in the homeopathic medicine group showed clinical improvement on all primary outcomes (relative risk=2.75, P=.09). CONCLUSIONS: There is weak but equivocal evidence that the effects of homeopathic medicine are superior to placebo. Results also suggest that there may be nonspecific benefits from the homeopathic consultation. Further studies are needed to determine whether these differences hold in larger samples.

Empathy, enablement, and outcome: an exploratory study on acupuncture patients' perceptions.

OBJECTIVES: To conduct an exploratory, retrospective study of acupuncture patients' perceptions of practitioner empathy, patient enablement, and health outcome, and to investigate the associations between them. METHODS: In a retrospective, observational study, questionnaires were distributed to 192 patients randomly selected from a population of 6348 who, several months previously, had participated in a survey of acupuncture safety, and had agreed to be contacted again. The main measures included patients' perceptions of their practitioners' empathy using the Consultation and Relational Empathy Measure, the Patient Enablement Instrument, and the Glasgow Homeopathic Hospital Outcome Scale (measuring change in main complaint and well-being). RESULTS: A total of 143 (74%) patients responded (27% men and 73% women) with an average age of 51 years. Comparisons between the population, the sample selected, and the responding sample showed reasonable equivalence. The majority of patients (71%) were in the middle of an ongoing course of treatment at the time of completing the questionnaires for this study. 36% of patients were attending for reasons of "general well-being," 34% for musculoskeletal problems, 11% for emotional or psychological problems, and 19% for other reasons. Empathy and enablement scores were not influenced by age or reason for attendance, but men showed significantly lower scores than women (p < 0.05). Patient enablement was significantly positively correlated with perception of their practitioners' empathy (Spearman's rho = 0.256, p < 0.01). Enablement in turn was strongly positively correlated with the outcome of both the main complaint (rho = 0.457, p < 0.0001) and improved well-being (rho = 0.521, p < 0.0001). CONCLUSION: Patients' perceptions of consultations with their acupuncturists suggest that their experience of empathy is significantly associated with patient enablement, which in turn is highly correlated with improved self-reported health outcomes.

Complementary and alternative medicine use by patients with cancer in Wales: a cross sectional survey.

OBJECTIVES: To determine the prevalence and cost of complementary and alternative medicine (CAM) use, and examine perceived satisfaction and reasons for using CAM. DESIGN AND SETTING: Cross sectional survey of 1697 patients with breast, prostate, lung or neurological cancer registered with a single NHS authority in Wales. PARTICIPANTS: One thousand and seventy-seven (64%) of patients, aged 18 years or over with cancer diagnosis of at least 3 months, returned analysable questionnaires. Thirty patients were interviewed by telephone. MAIN OUTCOME MEASURES: Number and proportion that had used CAM in the past 12 months, the types of CAM used, expenditure, satisfaction, demographic characteristics, and reasons for using CAM. RESULTS: Five hundred and thirty-four, 49.6% (95% CI 46.6-52.6) of participants, reported using at least one type of CAM during the past 12 months: 221, 16.4% (95% CI 14.3-18.8), had consulted a CAM practitioner (average cost per person, 28 lbs. per month); 166, 15.4% (95% CI 13.4-17.7), indicated using CAM techniques (average cost per person, 16 lbs. per month); 456, 42.3% (95% CI 39.4-45.3), reported using over-the-counter diets, remedies or supplements (average cost per person, 10 lbs. per month). Dissatisfaction with CAM use was low, and most users indicated that they represented value for money. CAM users were more likely to be female, younger, better qualified, and to have used CAM before their current illness than non-users. Patients used CAM primarily for symptom relief and relaxation. CONCLUSIONS: Nearly half the cancer patients in this study had used CAM. A co-ordinated approach to quality assurance, information and advice, and the assessment of risk/benefit and cost effectiveness of CAM use is needed.