integrative pediatric care: parents’ attitudes toward ... · haifa, israel; fclalit mashlima,...

Integrative Pediatric Care: Parents’ Attitudes TowardCommunication of Physicians and CAM Practitioners

WHAT’S KNOWN ON THIS SUBJECT: The use of complementaryand alternative medicine (CAM) among children is prevalent indifferent countries. There have been limited data on parents’perspectives toward pediatric CAM use and its meaning in termsof parent-doctor and doctor–CAM-practitioner communication.

WHAT THIS STUDY ADDS: The study revealed that parentsreferred to conventional and CAM clinics expressed distinctiveattitudes toward CAM integration in pediatric care and perceivedphysician–CAM-practitioner communication as highly importantin promoting their children’s health and safety.

abstractOBJECTIVE: In this study, we explored parents’ perspectives toward com-plementary and alternative medicine (CAM) use by their children and itsimpact on parent-doctor and doctor–CAM-practitioner communication.

PATIENTS AND METHODS: We designed a 2-arm study of parents whoapproached either conventional primary care or CAM clinics with theirchildren to consult physicians or practitioners regarding their child’shealth.

RESULTS: A total of 599 parents responded to our questionnaire (319in 5 conventional clinics [83.9% response rate] and 280 in 21 CAMclinics [71.2% response rate]). Parents in conventional clinics re-ported less use of CAM by their children within the previous year(35.3% vs 73.7%; P� .0001) but used more traditional and homemaderemedies (46.4% vs 12.7%; P � .0001). Both parent groups largelysupported informing their child’s physician regarding CAM use andexpected the physician to initiate a CAM–related conversation and torefer their child to a CAM practitioner. The 2 groups’ respondentslargely supported communication between the child’s physician andthe CAM practitioner by the use of a referral/medical letter. Comparedwith respondents in CAM clinics, parents in conventional clinics weremore supportive of CAM integration in a pediatric primary care settingand envisioned a more dominant role of physicians regarding CAMreferral and a significant role of physicians in providing CAM.

CONCLUSIONS: Parents who are referred to conventional and CAMclinics express distinctive attitudes toward CAM integration in pediat-ric care. Parents perceive physician–CAM practitioner communicationas highly important and instrumental in promoting their children’shealth and safety. Pediatrics 2011;127:e84–e95

AUTHORS: Eran Ben-Arye, MD,a,b Zina Traube, MPH,c

Leora Schachter, MD,d Motti Haimi, MD,e Moti Levy, MD,f

Elad Schiff, MD,g,h and Efraim Lev, PhD,c,i

aComplementary and Traditional Medicine Unit, Department ofFamily Medicine, Faculty of Medicine, Technion-Israel Institute ofTechnology, Haifa, Israel; bClalit Health Services, Haifa andWestern Galilee District, Haifa, Israel; cSchool of Public Healthand iDepartment of Eretz Israel Studies, University of Haifa,Haifa, Israel; dMaccabi Complementary and Alternative MedicineService Health Maintenance Organization, Tel-Aviv, Israel;eChildren’s Health Center, Armon Tower, Clalit Health Services,Haifa, Israel; fClalit Mashlima, Complementary Clalit HealthServices, Haifa, Israel; gDepartment of Internal Medicine, Bnai-Zion Hospital, Haifa, Israel; and hDepartment of Complementary/Integrative Medicine, Law, and Ethics, International Center forHealth, Law and Ethics, Haifa University, Haifa, Israel

KEY WORDSprimary care, complementary medicine, doctor-patientcommunication, pediatric care, integrative medicine

ABBREVIATIONSCAM—complementary and alternative medicineHMO—health maintenance organization

www.pediatrics.org/cgi/doi/10.1542/peds.2010-1286

doi:10.1542/peds.2010-1286

Accepted for publication Oct 8, 2010

Address correspondence to Eran Ben-Arye, MD, Clalit HealthServices, 6 Hashahaf St, Haifa 35013, Israel. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2011 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

e84 BEN-ARYE et al by guest on October 15, 2020www.aappublications.org/newsDownloaded from

The use of complementary and alter-native medicine (CAM) among childrenis prevalent in different countries andmay have substantial impact on chil-dren’s health care. On the basis of datapresented in a 2007 National Health In-terview Survey, Birdee et al1 estimatedthat the incidence of CAM use in 2007(excluding vitamins) by childrenyounger than age 18 years was 8.7 mil-lion. The authors reported that CAMus-ers in the US were more likely thannon-CAM users to be adolescentsrather than infants or toddlers, to havea parent who uses CAM and/or a par-ent with a college education, and touse prescription medication and lesslikely to live in the southern US states.In the United Kingdom, Crawford et al2

conducted a cross-sectional survey ofCAM use by children and adolescentsattending the University Hospital ofWales and reported that 41% of the re-spondents had used at least 1 type ofCAM in the past year. High prevalenceof CAM use also is reported amongchildren with chronic diseases (eg,functional and organic gastrointesti-nal diseases3), those with unvacci-nated or partially vaccinated status,4

and those with life-threatening dis-eases (eg, cancer5). Typical CAM mo-dalities used in the pediatric popula-tion include herbs, vitamins, andhomeopathic and nutritional supple-ments, but these modalities signifi-cantly varied by the child’s age (eg,massage in infants,6 prayer or faithhealing in adolescents7), country of or-igin, and nature of disease (eg,biofeedback and guided imagery in pe-diatric pain management service).8–10

Several studies examined the effect ofpediatric CAM use on doctor-parentand doctor-child communication. Inthe United Kingdom, Fountain-Polley etal11 studied pediatric physicians’ expo-sure to CAM and reported that approx-imately half of all doctors had beenasked about CAMs in a clinical encoun-

ter. Nondisclosure of CAM use is highand may exceed 50% of parents. Cin-cotta et al12 found that 66% percent ofCAM users did not disclose CAM use totheir doctor and that none of the inpa-tient medical records documentedCAM use in the past month. Cincotta etal12 compared CAMuse characteristicsin 2 tertiary children’s hospitals in theUnited Kingdom and Australia and re-ported a higher than 60% nondisclo-sure of CAM use and very limited doc-umentation of recent CAM use ininpatient notes. Sidora-Arcoleo et al13

from Arizona interviewed parents ofchildren with asthma in primary careclinics and found that 54% of the par-ents did not disclose CAM use and thata better relationship with the healthprovider tended to result in higher dis-closure. Sibinga et al14 surveyed a con-venience sample of the caregivers whowere accompanying children to the pe-diatrician and reported that 53% ofparents expressed the desire to dis-cuss CAMwith their pediatrician; therewas an increase to 81% among thosewho used CAM for their child. TheAmerican Academy of Pediatrics con-vened and empowered the Task Forceon Complementary and AlternativeMedicine to address issues related tothe use of CAM by children and to de-velop resources to educate physicians,patients, and families.15 This task forceconcluded that the pediatrician can(with the patient’s and family’s permis-sion) include the CAM provider in over-all care-coordination activities and of-fer practical advice for doctor-patientcommunication with regard to CAM in-terest or use.

In Israel, CAM is provided in the pediat-ric context mainly by CAM services af-filiated with each of the state’s 4 healthmaintenance organizations (HMOs). Al-though the cost of treatment is par-tially covered by the HMOs, the integra-tion of CAM services within the HMOs isonly partial, and the level of interaction

between CAM and conventional practi-tioners is limited. In addition, CAM isprovided to pediatric patients in pri-vate practices and by physicians withdual conventional and CAM trainingwho offer integrative care in their clin-ics. The prevalence and characteriza-tion of these complementary and inte-grative practices is yet to be studied. Inour study, we aimed to explore par-ents’ perspectives toward the use ofCAM by their children and its meaningin terms of parent-doctor and doctor–CAM-practitioner communication. Tostudy different perspectives of parentstoward integration of CAM in conven-tional care, we approached parents in2 clinical HMO settings in Israel: con-ventional primary care clinics and CAMclinics.

PATIENTS AND METHODS

Study Sites and Participants

We designed a 2-arm study of parentswho approached 1 of the following clin-ical settings to consult practitionersregarding their child’s health:

● parents who consulted primarycare physicians (pediatricians orfamily physicians) in conventionalclinics; and

● parents who consulted CAM practi-tioners in CAM clinics.

The study was performed by using aconvenience sample of parents whovisited the clinics. Participation in thestudy was offered to parents whocame to the clinics to receive medicalservices for their child’s health during2007. Participants had to be older than18 years who are parents to childrenyounger than 18 years and medicallyinsured by Clalit Health Services orMaccabi Health Services, which arethe 2 largest HMOs in Israel, serving�78% of Israel’s population.16

Our study included 5 Clalit Health Ser-vices conventional primary care clin-ics and 21 CAM-specialized clinics (5

ARTICLES

PEDIATRICS Volume 127, Number 1, January 2011 e85 by guest on October 15, 2020www.aappublications.org/newsDownloaded from

pediatrics.aappublications.org/

Clalit Health Services clinics, 15 Mac-cabi Health Services clinics, and 1 pri-vate clinic [Meditaf]). CAM-specializedclinics are operated by the CAM ser-vices of Clalit Health Services and Mac-cabi Health Services. Funding of clini-cal care within these CAM services ispartially covered by the HMO. In theCAM-specialized clinics, initial clinicalintake is provided by medical doctorswho determine referrals to medicaldoctors or non–medical doctor CAMpractitioners who offer a variety ofCAM modalities (homeopathy, acu-puncture, manual practices, naturopa-thy, etc). Before initiation, the studywas reviewed and approved by 2 Dec-laration of Helsinki committees (localinstitutional review boards).

Study Design

A questionnaire was developed by theauthors after a comprehensive litera-ture review, the goal of which wasto assess prevalence of CAM use,reasons for its use, and parent–physician–CAM-practitioner communi-cation aspects. Thereafter, we used 3focus groups of parents to refine thequestionnaire and improve its com-prehensibility. One focus group wascomposed of parents attending a pri-mary care conventional clinic and the2 other focus groups were composedof parents attending CAM clinics. Thefocus-group participants varied bygender, age, education, health status,and CAM use. On the basis of the focusgroups’ feedback, we developed a newversion of the questionnaire, whichwas sent for reappraisal to a group of5 pediatricians, 5 family physicians,and 5 CAM practitioners. After theircomments, the questionnaire was re-fined accordingly. The authors decidedto use a broad and understandabledefinition of CAM: “Therapies oftennamed alternative, complementary,natural, or folk/traditional medicine,which are not usually offered as partof the medical treatment in the clinic.”

Added to this definition was a list ofCAM modalities (see Appendix 1).Home remedies were specifically re-ferred to as part of the traditional/folktreatments. The final version of thequestionnaire consisted of 18 ques-tions about parent and child demo-graphics and 30 questions about par-ent attitudes toward CAM in pediatriccare, which included 15 limited-choicequestions (yes, no, other, or not rele-vant), 14 multiple-choice questions,and 1 question that used a Likert-likescale. In the questionnaire introduc-tion, participants were asked to relatetheir answers to the child whom theyhad brought to the clinic for medicaltreatment.

Twelve research assistants weretrained to deliver the questionnaire ina 3-hour course that focused on com-munication issues with parents andhealth providers in the clinics. The re-search assistants had previous CAMknowledge and were instructed topresent CAM to interviewees as de-fined in the questionnaire, avoiding theinclusion of natural substances usedin a nonmedical context. Parents weregiven the option of filling out the ques-tionnaire themselves or having thequestions read to them with the re-search assistant recording the an-swers. Survey data were entered intoa computer database for additionalanalysis.

Data Analysis

Data were evaluated by using SPSS 15(SPSS Inc, Chicago, IL). Pearson’s �2

and Fisher’s exact tests were used todetect differences in the prevalenceof categorical variables and demo-graphic data between the participantsin the 2 groups (parents in conven-tional and CAM-specialized clinics).Also, a t test was performed to deter-mine any differences in the continuousvariables between the 2 groups whennormality was assumed. In cases of a

nonnormality distribution the Mann-Whitney U test was used. P values of�.05 were regarded as significant.

RESULTS

Parent-Child DemographicInformation

Of 380 eligible subjects in primary careconventional clinics, 61 declined the of-fer to participate (response rate:83.9%); thus, data for statistical analy-sis were obtained from 319 respon-dents. Of 393 eligible subjects inCAM-specialized clinics, 113 declinedparticipation (response rate 71.2%);thus, data for statistical analysis wereobtained from 280 respondents. Pa-rental respondents’ demographiccharacteristics are shown in Table 1.Children’s demographics in Table 1 re-late to the child whom the parentbrought to the clinic for medical treat-ment. Respondents in the 2 groupswere equally distributed by gender,residence (urban versus rural), andnumber of children in the family. Com-pared with parents referring to con-ventional primary care clinics, parentsin CAM clinics were older, fewer wereborn in Israeli, more were of the Jew-ish religion, and there was a greaterextent of household and self-used CAMover the previous year. Children in the2 groups were equally distributed ac-cording to gender and country of birthand had a similar prevalence ofchronic illness and history of previoushospitalizations. Children in CAM-specialized clinics were older and hadbeen referred less to emergency careaccording to their parents’ report.

Reported CAM Use

Parents in CAM clinics reported higherCAM use by their child during the pre-vious year compared with children ofparents referring to conventional pri-mary care clinics (73.7% vs 35.3%; P�.01) (Table 2). Parents in CAM clinicsalso reported higher self-CAM use dur-


ing the previous year (54.7% vs 30.7%;P � .01). Children in CAM clinics usedsignificantly more traditional Chinesemedicine (43.4% vs 10.7%; P� .0001),homeopathy (42.4% vs 20.5%; P� .01),and movement/manual-healing thera-pies (31.7% vs 16.1%; P � .01). Chil-dren in conventional clinics usedsignificantly more traditional andhomemade remedies (46.4% vs 12.7%;P� .01).

Doctor-Parent CommunicationRegarding Children’s CAM Use

Compared with parents interviewed inconventional clinics, parents in CAMclinics reported a higher rate of disclo-sure of CAM use to their physician (159of 260 [61.2%] children in CAM clinicsversus 50 of 258 [19.4%] children inconventional clinics; P� .01). Parentsin both clinical settings reported that

in most cases they were the ones toinitiate the conversation with thechild’s physician regarding CAM. Nev-ertheless, parents in CAM clinics re-ported more on their role as initiatorsof the CAM-related conversation withthe physician (90% vs 75.5%; P� .012).

When asked if physicians had re-ferred their child to CAM, parents inCAM-specialized clinics reported

TABLE 1 Demographic Characteristics of Respondents (Parents) and Children (the Parents’ Sick Child Who Came to the Clinic for Medical Examination)

Overall(N� 599)

ConventionalClinics (N� 319)

CAM Clinics(N� 280)

P

Parental characteristicsAge, mean� SD (median), y 37.64� 6.98 (37) 36.55� 7.50 (35) 38.86� 6.14 (38.5) �.01a

Gender, n (%)Father 97 (19) 61 (22) 36 (16) .07b

Mother 398 (78) 209 (74) 189 (81) —Both or other care giver, n (%) 18 (3) 11 (4) 7 (3) —Mother’s country of birth, n (%)Israeli born 435 (84.3) 245 (88.4) 190 (79.5) �.01b

Ashkenazi immigrants 16 (3.1) 7 (2.5) 9 (3.8) .45Sephardic immigrants 10 (1.9) 6 (2.2) 4 (1.7) .76Union of Soviet Socialist Republics immigrants 55 (10.7) 19 (6.9) 36 (15.1) �.01b

Mother’s religion, n (%)Jewish 459 (90) 223 (81) 236 (99) �.01b

Other religion 53 (10) 51 (19) 2 (1) —Mother’s education, n (%)Elementary school 11 (2) 11 (4) 0 (0) �.01b

High school 163 (32) 117 (43) 46 (19) �.01b

Academic 333 (66) 142 (53) 191 (81) �.01b

Household income, New Israeli Shekels, n (%)�7400 78 (22) 54 (34) 24 (13) �.01b

�7400 to�14 800 164 (47) 79 (50) 85 (44) .33b

�14 800 108 (31) 25 (16) 83 (43) �.01b

Residence, n (%)Urban 362 (89) 192 (88) 170 (89) .88b

Rural 47 (11) 26 (12) 21 (11) —Parity, n (%)1 108 (122) 59 (22) 49 (22) 1b

2 195 (40) 102 (38) 93 (42) .35b

3 126 (26) 70 (26) 56 (26) .92b

�4 60 (12) 38 (14) 22 (10) .21b

Child characteristicsAge, mean� SD (median), y 6.49� 4.91 (5.0) 6.02� 5.19 (4.5) 7.05� 4.49 (6.0) �.01c

Gender, n (%)Male 280 (54.8) 148 (53.4) 132 (56.4) .53b

Female 231 (45.2) 129 (46.6) 102 (43.6) —Country of birth, n (%)Israeli born 488 (96.4) 262 (97.4) 226 (95.4) .23b

Ashkenazi immigrants 10 (2.0) 6 (2.2) 4 (1.7) —Sephardic immigrants 0 (0.0) 0 (0.0) 0 (0.0) —Union of Soviet Socialist Republics immigrants 8 (1.6) 1 (0.4) 7 (3.0) —Chronic illness, n (%) 138 (28.5) 64 (25.0) 74 (32.5) .08b

Ever referred to emergency room, n (%) 73 (17.9) 40 (23.0) 33 (14.2) .03b

Ever hospitalized, n (%) 156 (34.5) 84 (37.5) 72 (31.6) .2b

a t test.b Fisher’s exact test.c Mann-Whitney test.

ARTICLES



higher rates of referral (54 of 236[2.9%] vs 9 of 213 [4.2%]; P � .01).Significant difference also was notedwhen only CAM users were com-pared (43 of 176 [24.4%] in CAM clin-ics versus 7 of 86 [8.1%] in conven-tional clinics; P � .01). Parents inCAM clinics reported that in mostcases they initiated physicians’ re-ferral to CAM (43 of 56 referrals[76.7%]). Although parents in con-ventional clinics reported a smallnumber of referrals, they attributedmost of them to the child’s physi-cian’s initiative (5 of 8 referrals[62.5%]).

Disclosure of Pediatric CAM Useand Its Ramifications

Parents in both groups largely sup-ported informing their child’s physi-cian of CAM use, although parents inconventional clinics supported dis-closure more than parents in CAMclinics (92.8% vs 84.7%; P � .01).Similar attitudes were reported byparents in the 2 groups regarding in-forming the child’s physician ofherbal treatment (conventional clin-ics 90.9% versus CAM clinics 82.5%;P � .01).

Parent Attitudes Regarding TheirChild’s Physician’s Views of CAM

Respondents were asked to state theirmain expectation from the child’s phy-sician concerning CAM. The main ex-pectation supported by parents in bothsettings (conventional clinics 34.7%versus CAM clinics 42.4%; P� .1) wasthat the physician should refer theirchild to a CAM practitioner when it wasappropriate and safe to do so. Otherexpectations, supported primarily byparents in conventional clinics, werethat physicians initiate by asking theparent whether he or she is interestedin CAM treatment for their child (23.3%vs 15.6%; P� .036) and that physiciansbe able to offer CAM treatments them-selves, in the clinic, after receiving ap-propriate training (9.7% vs 3%; P �.01).

Parents were asked to grade on a5-point scale to what extent theirchild’s physician’s attitude towardCAM influenced them in choosing him/her as the child’s doctor. Comparedwith parents in CAM clinics, parents inconventional clinics attributemore im-portance to the physician’s attitude to-ward CAM (median: 3 in conventional

clinics versus 2 in CAM clinics; mean�SD: 2.83� 1.47 vs 2.37� 1.32; P� .01).

Parent Attitudes RegardingDoctor–CAM-PractitionerCommunication

Respondents in the 2 groups werehighly supportive of communicationbetween the child’s physician and theCAM practitioner (95.2–97.4%). Abouthalf of the respondents in both groups(48.6–50.7%) stated that the child’sphysician should be the 1 to initiatecommunication with the CAM practitio-ners, rather than vice versa or the par-ent approaching the CAM practitioner.Referral/medical letters were viewedas the most appropriate means ofcommunication (conventional clinics37% versus CAM clinics 52%; P� .01).

Parents in both groups expressed theunderstanding that doctor–CAM-practitioner medical correspondencemay have an influence on the child’streatment (conventional clinics 89.6%versus CAM clinics 88.2%; P � .76).Parents in the 2 groups stated thatdoctor–CAM-practitioner communica-tion influences 3 domains: treatmentof the child’s disease (indicated by97% of respondents in both groups);prevention of conventional–CAM treat-ment interaction (90% in both groups);and a change in the diagnosis of thechild’s disease (87–89% of respon-dents). Parents in both groups sup-ported collaborative doctor–CAM-practitioner teamwork (parents inconventional clinics 97.2% versus CAMclinics 89.2%; P� .01).

Parent Attitudes Toward CAMIntegration in a ConventionalClinical Setting

Parents in both groups largely sup-ported (�96%) the inclusion of CAMservices in the Israeli health serviceand expressed their readiness to par-ticipate in covering payment for pedi-atric CAM services. Parents in the con-

TABLE 2 Comparison of Parents’ Perspectives in Conventional Versus CAM-Specialized ClinicsTowards CAM Use, Disclosure, Referral, and Physicians’ Attitudes Toward CAM

Conventional Clinics(N� 319)

CAM Clinics(N� 280)

P

Prevalence of pediatric CAM use during theprevious year, %

35.3 73.7 �.01

Prevalence of parental CAM use during theprevious year, %

30.7 54.7 �.01

Rate of CAM disclosure to physician, % 19.4 61.2 �.01Rate of parents supporting need todisclose CAM use to physician, %

92.8 84.7 �.01

Rate of physicians’ referral to CAM, % 4.2 22.9 �.01Rate of parents expecting their child’sphysician to generate referral to CAM, %

87.2 72.1 �.01

Extent to which the child’s physician’sattitude towards CAM influenced theparent in choosing him or her as thechild’s doctor, median (mean� SD),5-point scale

3 (2.83� 1.47) 2 (2.37� 1.32) �.01

Rate of parents expecting to receive CAMas part of their child’s care in theprimary care clinic, %

67.4 35.8 �.01


ventional clinic group mostly expectedto receive CAM as part of their child’scare in the primary care clinic (67.4%vs 35.8%; P � .01), whereas parentsinterviewed in CAM clinics largely sup-ported receiving CAM in specializedCAM centers (20.2% vs 41.0%; P� .01).Participants were asked to consider atheoretical scenario of CAM integra-tion within pediatric care in the pri-mary care clinic where their child wasreceiving treatment. Participants inboth groups expected their child’s phy-sician to generate the referral to CAM(conventional clinics 87.2% and CAMclinics 72.1%; P� .01). Parents in con-ventional clinics were less supportiveof a direct self-referral approach(12.8% vs 27.9%; P � .01). Parents inboth groups mostly expected CAMtreatment in such a theoretical sce-nario to be provided by either an phy-sician or a non–medical doctor CAMpractitioner. However, parents in con-ventional clinics, more than parents inCAM clinics, supported the option thattheir child’s physician would providethe CAM care (31.5% vs 13.3%; P� .01).

DISCUSSION

This study focuses on parental atti-tudes toward pediatric CAM treatmentand its ramifications on parent-doctoras well as doctor–CAM-practitionercommunication. Although respon-dents in conventional and CAM clinicshad different demographic character-istics, both groups reported high ex-pectations from their child’s physicianregarding various CAM-related as-pects. These expectations reflect a gra-

dient, beginning with the physician’s“passive” listening (eg, parent’s disclo-sure of CAM use) to a more active po-sition (eg, physician inquiring aboutCAM and referring or even providingCAM). Parents grading referral to CAMas their main expectation are not con-tent with “informing of” or “talkingabout” CAM but expect active involve-ment of physicians in their child’shealth concerning CAM selection. In ac-cordance with this finding, it is not sur-prising that parents in both groups re-ported that the child’s physician’sattitude toward CAM influenced themin choosing him/her as their child’sdoctor.

Our study also presents 2 distinctiveattitudes of patients in 2 clinical set-tings toward the way CAM should beintegrated in pediatric care. Table 3presents an integrative-like attitude ofparents in conventional clinical settingcompared with a more conventional-like approach of parents interviewedin CAM clinics. The integrative model ofcare, supported by parents in conven-tional clinics, is characterized by lowto medium CAM use oriented more to-ward traditional homemade remedies.In this integrative care model, parentsdisclose more of their children’s CAMuse and physicians tend less to refer toCAM, although when they do so, theyoften are the initiators of referral. Par-ents supporting this CAM integrativemodel envision its realization in pri-mary care and support a dominantrole of physicians regarding CAM re-ferral and a significant role in provid-

ing CAM. In contrast, parents inter-viewed in CAM clinics envision a morecomplementary model of care that re-flects the current situation in whichCAM and conventional care are prac-ticed in 2 distinctive settings with lim-ited interaction and dialogue betweenphysicians and CAM providers. Thus,parents in this group envision CAM in-tegration in secondary, rather thanprimary, pediatric care and expectless from the child’s physician regard-ing CAM. Referral in this integrativescenario is not entirely physician de-pendent but combines an option of di-rect self-referral to CAM. Moreover,this complementary model of caregrants a limited role to the child’s phy-sician in providing CAM.

Although dissimilarities of parents inthe 2 clinical settings exist, theyunanimously support physician–CAM-practitioner communication concern-ing their child. Moreover, they indicatethat doctor–CAM-practitioner commu-nication can influence diagnosis andtreatment as well as prevent conven-tional–CAM treatment interaction. Thissafety issue concerning the risks ofCAMmodalities, especially herbal rem-edies and nutritional supplements,and prevention of interactions withconventional drugs, is an issue of con-cern for pediatricians.17 Previous stud-ies have shown that parents whochoose CAM for their children have apreference for a “more natural” ther-apy or believe that these therapies are“natural” and thus “safe.”18,19 Thesenatural equals safe perceptions were

TABLE 3 Parents’ Perspectives of Complementary Versus Integrative Models of Care

Perspective Conventional Clinics: CAM Integrative Model CAM-Specialized Clinics: CAMComplementary Model

Desired setting of CAM provision Primary care clinics Secondary care clinicsCAM disclosure Parents expect physician’s openness to CAM use and

support CAM disclosureParents less expect their child’s physicianto ask them about CAM use

Source of CAM referral Mainly referral by physicians Referral by physicians and self-referralRole of physicians in CAM providing Significant MinorMain CAM modalities Traditional homemade remedies CAM modalities provided by practitioners

ARTICLES



challenged in various case studies andtrials reporting risks of CAM productssuch as the homeopathic preparationGali-col Infant used for infantile colic20

or the heavy metal content ofAyurvedic herbal medicine productsfrom India.21 In our study, we reportthat parents associate enhancedphysician–CAM-practitioner communi-cation with prevention of conventional–CAM treatment interaction. This atti-tude can be perceived as a middle-of-the-road, open-minded, yet somewhatskeptical approach standing betweenunderestimated (natural equals safe)and overestimated risks of CAM.

This study has several limitations. Inthe questionnaire, we used CAM cate-gories in a way that is culturally andcontextually accepted in Israel. Conse-quently, we categorized some CAMtherapies differently than the NationalCenter for Complementary and Alter-native Medicine at the National Insti-tutes of Health. In addition, localcultural and organizational character-istics of CAM usemay differ from thoseoutside of Israel. Therefore, general-ized implications for our findingsshould take these differences intoaccount.

Although the generalizability of our re-sults cannot be taken for granted, webelieve that the United States andother Western countries face similardilemmas with regard to aspects ofCAM-related parent-doctor communi-cation. The gradual transition of CAMuse from an alternative and comple-mentary context to a more integratedconcept in pediatric care is becominga pivotal theme because both healthcare providers and consumers ac-knowledge the need for effective com-munication in the triad of parents, phy-sicians, and CAM practitioners. Thisincreased awareness is echoing in theUnited States with the increasing useof CAM in the pediatric population andthe understanding of the need to take a

knowledgeable and active position inCAM decision-making.

Another potential limitation is that wedid not select a representative sampleof the various social, ethnic, and reli-gious communities in Israel but de-cided to approach patients in clinicsserving a variety of communities. Tooffset this potential bias, wemade con-siderable efforts to minimize patient-selection bias by offering participationin the study, with no language restric-tion, to every patient who entered theclinic for any medical or administra-tive reason. Thus, our results may notrepresent the total population butrather the population of patients whoactually came to the clinics. In addi-tion, this study focuses on parents ap-proaching either conventional or CAMclinics operated within HMOs, thus ex-cluding private CAM clinics. Hence, thestudy results are limited to CAM clinicsaffiliated with HMOs and public medi-cal services. Another limitation of ourstudy that could be addressed in fu-ture studies is the lack of data onemergency-department referrals andhospitalization of children in the pastyear (as opposed to data assessed inour questionnaire regarding any pastreferral to the emergency departmentor hospitalization). These data can becomplemented with information re-garding the number of immunizationsreceived and prescription and nonpre-scription medications used by the chil-dren, which are potential benchmarksfor CAM use and perspectives of par-ents and children toward alternativeversus complementary or integrativemodels of care. We also suggest, in fu-ture questionnaires, allowing morethan 1 answer to enrich the data andinsights gained from the survey.

CONCLUSIONS

Parents referring to conventional andCAM-specialized clinics, express highexpectations from the child’s physi-

cian regarding CAM, beginning fromdisclosure of use, referral to CAM,communication with CAM practitio-ners, and CAM counseling and provid-ing. Our study also shows that parentsin conventional clinics, despite usingCAM in moderation with their children,have a more integrative perspectiveregarding the physicians’ role in CAMcare compared with parents that cur-rently refer their child to CAM-specialized clinics. These parental per-ceptions illuminate the evolution ofCAM from alternative (eg, CAM nondis-closure) to complementary (CAM re-ferral) and integrative (CAM counsel-ing in conventional clinic) models ofcare.

ACKNOWLEDGMENTS

The members of the research teamfrom the International Center and Col-lege of Natural Complementary Medi-cine were Ms Yudit Halbani, Ms NivaYemini, Ms Dina Gamin, Ms Anat Levi,Ms Shulamit Doron, Mr Lior Kalfon, MsInbar Mizrahi, Ms Rachel Iuster, Ms Si-gal Salutsky, Ms OmerWainer, Ms BellaBernshtein, Mr Nadav Stoppelmann,and Ms Ronit Leibovitz.

We thank Ms Anat Klein, Director of theInternational Center and College ofNatural Complementary Medicine forher support and encouragement; MsRonit Leiba for the statistical analysis;Ms Marianne Steinmetz for editing themanuscript; and Hamichlala Leminhalfor support of the statistical workup.We also thank the following medical di-rectors and staff members in the clin-ics for their support and collaborationwith the team of researchers: DrHanan Babilsky, Dr Michael Kaffman,and Dr Sharon Kama. And, we thankMsOrit Lander for coordinating the re-search in complementary clinics andProf Shai Linn for his mentoring andconsultation.


REFERENCES

1. Birdee GS, Phillips RS, Davis RB, Gardiner P.Factors associated with pediatric use ofcomplementary and alternative medicine.Pediatrics. 2010;125(2):249–256

2. Crawford NW, Cincotta DR, Lim A, Powell CV.A cross-sectional survey of complementaryand alternative medicine use by childrenand adolescents attending the UniversityHospital of Wales. BMC Complement AlternMed. 2006;6:16

3. Vlieger AM, Blink M, Tromp E, Benninga MA.Use of complementary and alternativemed-icine by pediatric patients with functionaland organic gastrointestinal diseases: re-sults from a multicenter survey. Pediatrics.2008;122(2). Available at: www.pediatrics.org/cgi/content/full/122/2/e446

4. Wilson K, Busse JW, Gilchrist A, Vohra S,Boon H, Mills E. Characteristics of pediatricand adolescent patients attending a naturo-pathic college clinic in Canada. Pediatrics.2005;115(3). Available at: www.pediatrics.org/cgi/content/full/115/3/e338

5. Bold J, Leis A. Unconventional therapy useamong children with cancer in Saskatche-wan. J Pediatr Oncol Nurs. 2001;18(1):16–25

6. Loman DG. The use of complementary andalternative health care practices amongchildren. J Pediatr Health Care. 2003;17(2):58–63

7. Wilson KM, Klein JD. Adolescents’ use ofcomplementary and alternative medicine.Ambul Pediatr. 2002;2(2):104–10

8. Lin YC, Lee AC, Kemper KJ, Berde CB. Use of

complementary and alternativemedicine inpediatric pain management service: a sur-vey. Pain Med. 2005;6(6):452–458

9. Pitetti R, Singh S, Hornyak D, Garcia SE, HerrS. Complementary and alternativemedicineuse in children. Pediatr Emerg Care. 2001;17(3):165–169

10. Lim A, Cranswick N, Skull S, South M. Surveyof complementary and alternative medicineuse at a tertiary children’s hospital. J Pae-diatr Child Health. 2005;41(8):424–427

11. Fountain-Polley S, Kawai G, Goldstein A, Ni-nan T. Knowledge and exposure to comple-mentary and alternative medicine in paedi-atric doctors: a questionnaire survey. BMCComplement Altern Med. 2007;7:38

12. Cincotta DR, Crawford NW, Lim A, et al. Com-parison of complementary and alternativemedicine use: reasons and motivations be-tween two tertiary children’s hospitals.Arch Dis Child. 2006;91(2):153–158

13. Sidora-Arcoleo K, Yoos HL, Kitzman H, Mc-Mullen A, Anson E. Don’t ask, don’t tell: pa-rental nondisclosure of complementaryand alternative medicine and over-the-counter medication use in children’sasthma management. J Pediatr HealthCare. 2008;22(4):221–229

14. Sibinga EM, Ottolini MC, Duggan AK, WilsonMH. Parent-pediatrician communicationabout complementary and alternative med-icine use for children. Clin Pediatr (Phila).2004;43(4):367–373

15. Kemper KJ, Vohra S, Walls R; AmericanAcademy of Pediatrics, Task Force on Com-

plementary and Alternative Medicine; Provi-sional Section on Complementary, Holistic,and Integrative Medicine. The use of com-plementary and alternative medicine in pe-diatrics. Pediatrics. 2008;122(6):1374–1386

16. Yalink A. The Jerusalem Institute for IsraelResearch. Available at: http://jiis-jerusalem.blogspot.com/2009/07/2008-7.html. Ac-cessed March 28, 2010

17. Loh CH. Use of traditional Chinese medicinein Singapore children: perceptions of par-ents and paediatricians. Singapore Med J.2009;50(12):1162–1168

18. Vlieger AM, van de Putte EM, Hoeksma H. Theuse of complementary and alternative med-icine in children at a general paediatricclinic and parental reasons for use [inDutch]. Ned Tijdschr Geneeskd. 2006;150(11):625–630

19. Cuzzolin L, Zaffani S, Murgia V, et al. Patternsand perceptions of complementary/alternative medicine among paediatriciansand patients’ mothers: a review of the liter-ature. Eur J Pediatr. 2003;162(12):820–827

20. Aviner S, Berkovitch M, Dalkian H, Braun-stein R, Lomnicky Y, Schlesinger M. Use ofa homeopathic preparation for “infantilecolic” and an apparent life-threateningevent. Pediatrics. 2010;125(2). Availableat: www.pediatrics.org/cgi/content/full/125/2/e318

21. Saper RB, Kales SN, Paquin J, et al. Heavymetal content of ayurvedic herbal medicineproducts. JAMA. 2004;292(23):2868–2873

ARTICLES


www.pediatrics.org/cgi/content/full/122/2/e446







APPENDIXSample questions from the questionnaire.


APPENDIXContinued.

ARTICLES



APPENDIXContinued.


APPENDIXContinued.

ARTICLES



DOI: 10.1542/peds.2010-1286 originally published online December 27, 2010; 2011;127;e84Pediatrics

and Efraim LevEran Ben-Arye, Zina Traube, Leora Schachter, Motti Haimi, Moti Levy, Elad Schiff

Physicians and CAM PractitionersIntegrative Pediatric Care: Parents' Attitudes Toward Communication of

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/127/1/e84including high resolution figures, can be found at:

Referenceshttp://pediatrics.aappublications.org/content/127/1/e84#BIBLThis article cites 17 articles, 3 of which you can access for free at:

Subspecialty Collections

grative_medicine_subhttp://www.aappublications.org/cgi/collection/complementary_-_inteComplementary & Integrative Medicinefollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on October 15, 2020www.aappublications.org/newsDownloaded from

http://http://pediatrics.aappublications.org/content/127/1/e84

http://pediatrics.aappublications.org/content/127/1/e84#BIBL

http://www.aappublications.org/cgi/collection/complementary_-_integrative_medicine_sub

http://www.aappublications.org/cgi/collection/complementary_-_integrative_medicine_sub

http://www.aappublications.org/site/misc/Permissions.xhtml

http://www.aappublications.org/site/misc/reprints.xhtml

DOI: 10.1542/peds.2010-1286 originally published online December 27, 2010; 2011;127;e84Pediatrics

and Efraim LevEran Ben-Arye, Zina Traube, Leora Schachter, Motti Haimi, Moti Levy, Elad Schiff

Physicians and CAM PractitionersIntegrative Pediatric Care: Parents' Attitudes Toward Communication of

http://pediatrics.aappublications.org/content/127/1/e84located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2011has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on October 15, 2020www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/content/127/1/e84

integrative pediatric care: parents’ attitudes toward ... · haifa, israel; fclalit mashlima,...

Documents