Family Health Strategy doctors and nurses' perceptions of complementary therapies
Sônia de Castro S ThiagoI,II; Charles Dalcanale TesserIII
I Prefeitura Municipal de Florianópolis. Florianópolis, SC, Brasil
II Programa de Pós-Graduação em Saúde Coletiva. Universidade Federal de Santa Catarina (UFSC). Florianópolis, SC, Brasil
III Departamento de Saúde Pública. Centro de Ciências de Saúde. UFSC. Florianópolis, SC, Brasil
OBJECTIVE: To analyze Estratégia de Saúde da Família (Family Health Strategy) professionals' perception of complementary and integrative therapies.
METHODS: A study with 177 doctors and nurses was conducted in 2008, based on a self-administered questionnaire. The outcome variables were "interest in complementary and integrative therapies" and "agreement with the National Policy on Complementary and Integrative Therapies. Sex, age, graduate level of education, postgraduate level of education, length of time since graduation, length of time of work, having children, providing complementary and integrative therapies in the workplace, and using homeopathy or acupuncture comprised the independent variables. Data were analyzed using Chi-square test and Fisher's exact test.
RESULTS: A total of 17 health centers provided complementary and integrative therapies; 12.4% of professionals had a specialization in homeopathy or acupuncture; 43.5% of doctors were specialists in family and community medicine/family health. Of all participants, 88.7% did not know the national directives for this area, although 81.4% agreed with their inclusion in the Sistema Único de Saúde (Unified Health System). The majority (59.9%) showed an interest in qualifications and all agreed that these therapies should be approached during the graduate course. Agreement with the inclusion of such therapies was significantly associated with the fact of being a nurse (p = 0.027) and using homeopathy for oneself (p = 0.019). Interest in complementary therapies was associated with the use of homeopathy for oneself (p = 0.02) and acupuncture by family members (p = 0.013).
CONCLUSIONS: Complementary and integrative therapies are accepted by the professionals studied. This acceptance is associated with previous contact with such therapies and, probably, with residency/specialization in family and community medicine/family health.
Descriptors: Complementary Therapies. Health Knowledge, Attitudes, Practice. Health Personnel. Family Health Program. Primary Health Care, manpower.
The growing demand for complementary medicine and therapies and their increasing acceptance by health professionals is a relatively recent fact. Eisenberg et al8 showed that a third of Americans used a certain type of complementary medicine or therayp in 1993, with an increase in research on such theme from this time on.3,15,16 In the last decades, techniques originated from different cultural and healing traditions such as acupuncture have slowly been tested and recognized by biomedicine and incorporated into medical specialties. Social, academic and institutional recognition of these therapies emphasize the consensus that biomedicine exists among other types of care, in a cultural context characterized by therapeutic or health care pluralism (according to Helman10) - although maintaining its hegemony in an increasingly medicalization.1,18,21
A continuous growth in the number of medical consultations with specialists in homeopathy and acupuncture and in the search for complementary therapies can be observed in the context of private health care in Brazil. This growth is not occurring with the same intensity in public health services, thus suggesting socially unequal access to these therapies.1
Recognizing the therapeutic pluralism of each country and reflecting this in health care is a challenge when public policies are planned. Recommendations of the World Health Organization (WHO) Alma-Ata International Conference of 1978, updated in 2002, suggest strategies for the implementation of Traditional Medicine and Complementary and Alternative Types of Medicine (TM/CAM) in public health services of member countries.a
Health care comprehensiveness, established as a directive by the 8th Brazilian Health Conference and formalized as a doctrinal principle of the Sistema Único de Saúde (SUS - Unified Health System), points to the offer of these therapies in Brazil. They can contribute to the partial de-medicalization on professional care, in addition to their being socially valued and expected. Decree 971,b passed in 2006, provides for the inclusion of homeopathy, medicinal plants/phytotherapy, acupuncture/Chinese medicine and thermal water therapy in the SUS, mainly in Primary Health Care (PHC). The objective is to promote an increase in the number of approaches to health and to make available promotion, preventive and therapeutic options to SUS users14 that are different from biomedicine. The inclusion of these therapies in the SUS represents respect for system principles,17,18 although in a controversial way.
Studies show that health professionals, especially doctors, are unaware of complementary therapies, despite their interest in learning about them and agreeing with their inclusion in public health services or courses in the health area.3,4,18,19 Similar results were obtained with medical students.20
Organized social movements were in favor of the implementation of Complementary and Integrative Therapies (CIT) in the SUS, in the city of Florianópolis, Southern Brazil. The 2003 and 2006 Conferências Municipais de Saúde (Municipal Health Conferences), complemented in 2007, included guidance on inclusion of CIT in the basic health network and the provision of homeopathic medicines and acupuncture supplies in their final resolutions.c
The demand for studies on this theme in Brazil can be observed, especially on the relationship between Primary Health Care professionals and complementary types of medicine and therapies. Studies of this nature could enable the observation of this relationship in Brazil, in addition to the construction of policies and projects of inclusion and the offer of such therapies in the cities. Doctors and nurses are key care agents in the context of the Estratégia Saúde da Família (ESF - Family Health Strategy) and important social participants in health care, with great responsibility in diagnostic actions and preventive and therapeutic guidance.
The present study aimed to analyze the ESF professionals' perception of complementary and integrative therapies.
An exploratory study was conducted with ESF doctors and nurses of the city of Florianópolis, between September and November 2008.
Data were collected from 46 Health Centers (HC) of this city. Florianópolis showed a population coverage by the ESF of approximately 77%, with 94 family health teams.
A self-administered questionnaire was used, initially developed by researchers with closed-ended questions and one open-ended question. A pilot test was conducted with ten professionals, with characteristics similar to those of study subjects. Of all 188 professionals, 177 (94.2%) responded to the questionnaire: 82 doctors and 95 nurses. A total of 12 doctors refused to participate in the study and one nurse was included in it, in addition to those expected.
The outcome variables were "professionals' interest in CIT" and "opinion about the inclusion of CIT in the SUS". Interest in CIT was considered as "yes" (shows interest) when the professional pointed out that they would like to participate in a training course or obtain a specialization/qualification in the area. In contrast, "no" (shows no interest) was considered when indicating no or little interest or that they would like to know more about this.
Sex, age, graduate level of education, postgraduate level of education, length of time since graduation, having children (only for the variable "interest in CIT"), length of time of work in the SUS, offer of a certain CIT in the HC where one works, and use of CIT (homeopathy or acupuncture) for oneself or by the family comprised the independent variables. Use of CIT was categorized into "yes", when "many times/often" and "always" were indicated, and "no", when "never", "rarely" and "sometimes" were indicated. The choice to exclusively value the use of homeopathy and acupuncture resulted from the fact that these therapies are provided by the municipal health network and that they are the most well-known, in addition to phytotherapy.
Data on the follow-up of patients or their referral to a certain CIT were used to estimate the use or recommendation of a certain CIT during the professional activity for their users. The offer of CIT in HCs was analyzed in the questionnaires, a piece of information that was subsequently confirmed by telephone.
Data were analyzed using Chi-square test and Fisher's exact test, when necessary. The database was formatted in the EpiData software and the results analyzed using the EpiData Analysisand Stata version 9.0 software programs.
The project was approved by the Municipal Department of Health in June 2008 and by the Human Research Ethics Committee of the Universidade Federal de Santa Catarina , on July 28th, 2008 (protocol 181/08).
The professionals studied were predominantly females (70.6%), married (51.4%), without children (59.9%), young (mean of 35 years), and with up to five years of length of time since graduation (40.5%). The majority of them (84.2%) had one or more specializations, 77 (43.5%) performed residency in Family and Community Medicine or specialization in Family Health, and 22 professionals (12.4%) had a specialization in homeopathy or acupuncture. Other courses in CIT areas (such as phytotherapy, florals and massage therapy) were reported by 39 professionals (22.0%).
The majority of professionals (59.9%) associated CIT with broader understanding of the health-disease process than in biomedicine, 5.1% associated them with the placebo effect, and 8.5% believed that only those CIT that had been proved by science should be used.
Among professionals, 88.7% did not know the directives of the Política Nacional de Práticas Integrativas e Complementares (PNPIC - National Policy on Complementary and Integrative Therapies), although 81.4% agreed with what it recommends (Table 1). The inclusion of CIT in the three levels of health care was accepted by 45.8% of individuals, while 51.3% believed that they could be provided in primary and/or secondary care. In addition, 59.9% were very interested in CIT, expecting to obtain training or a qualification in the area; whereas 6.8% reported having no or little interest in these therapies. All professionals agreed that CIT should be approached in courses in the area of health.
A total of 17 HCs (36.7%) provided nine different therapies, ranging from medical rationalities (homeopathy, Chinese and Ayurvedic medicine) and therapeutic practices (acupuncture, auriculotherapy, massage, massage therapy, chiropractic and phytotherapy), among which acupuncture and homeopathy were those most frequently present. Groups with activities considered complementary (yoga, biodance, relaxation, meditation, dance, tai chi chuan) were offered in seven HCs. According to 55.4% of professionals, the community had an interest in these practices (Table 1).
Nurses showed slightly greater interest, when compared to doctors and individuals working in HCs that provide a certain type of CIT, those with greater length of time since graduation, and those without children, although there was no statistically significant difference. "Use of homeopathy for oneself" (p = 0.002) and "use of acupuncture by family members" (p = 0.013) had a statistically significant association with interest in CIT. "Use of homeopathy by family members" and "use of acupuncture by oneself" had a borderline statistical significance (Table 2).
"Agreement with the inclusion of CIT in the SUS or not" was statistically associated with having a graduate level of education - nurses were more favorable to the PNPIC (p = 0.027) - and with the use of homeopathy as treatment for oneself (p = 0.019).
Some of the professionals reported not knowing or knowing little about CIT, especially about anthroposophic, ayurvedic and traditional Chinese medicine (Figure). An average level of knowledge was predominant for homeopathy and acupuncture, in contrast with higher lack of knowledge about phytotherapy and medicinal plants.
Professionals referred few patients to treatments that were not provided by the municipal health network, such as ayurvedic medicine, anthroposophic medicine, traditional Chinese medicine, and therapeutic touch. Homeopathy, massage, phytotherapy and medicinal plants had similar proportions of referrals. Referring one to acupuncture was more prevalent than the other categories, when 2/3 of cases were sometimes or always referred (Table 4).
Support for the inclusion of CIT from the doctors and nurses studied can become a more disseminated reality in Brazil, although other studies for comparison are practically inexistent. Studies support the hypothesis that there is growing interest in complementary therapies and sensitization of health professionals, especially those in primary care, at the same time that demand for such therapies increases.3,4,16,19
Explanations about the phenomenon include dissatisfaction with biomedicine (iatrogenia; expensive and invasive methods; focus on the disease, rather than the patient; and impersonality) and the qualities attributed to complementary types of medicine and therapies (comprehensiveness of care, humanism in the doctor-patient relationship, promotion of the body's healing forces, lower potential harm, more holistic approach to the health-disease-care process).15,18 The majority of professionals studied reported that CIT are based on a broader understanding of the health-disease process, which could be associated with their interest in these therapies.
The growth and institutionalization of these practices in Brazil was observed, causing corporative organizations to raise questions at the time the PNPIC was passed. In 2006, the Conselho Federal de Medicina (Brazilian Medical Council) stated the following about the PNPIC in its newspaper: "The decree that authorizes the application of 'alternative' techniques by the SUS was rejected",d based on arguments of invasion of private medical activities by non-doctors and of lack of scientific proof of CIT. However, the results of the present study showed primary care doctors' openness towards and interest in this theme in the city of Florianópolis. This suggests that there may be divergences between the macro-political positions of this category and the doctors' attitude, especially those in primary care, unless this finding is an idiosyncrasy of the city studied, perhaps resulting from the proportion of specialists in Family and Community Medicine, Family Health, Public Health or a certain CIT.
Health professionals' lack of knowledge about complementary therapies can lead to incorrect concepts, which may cause difficulties in the doctor-patient relationship and with colleagues who practice these specialties.9,18 Sales18 observed the notion that homeopathy would only serve for simple and common, although prevalent, problems, held by non-homeopathic medical professionals and managers in contact with homeopathy in public services or in the university environment. The generalization of this finding to the remaining CIT can be hypothesized to understand the reason why approximately half of the professionals, although supporting CIT and showing interest in them, restrict their support for primary and/or secondary care. Results of the present study indicate the professionals' relative ignorance of this subject, thus suggesting the need for qualification courses and promotion of these themes to implement PNPIC in the city. Promoting the introduction of the theme in the curricula of courses in the area of health would be a measure to be considered.18,20 In most cases, such courses do not provide knowledge about other types of medicine and therapies, including those about acupuncture and homeopathy, which are medical specialties. ESF professionals of Florianópolis recognize this reality and are in favor of the inclusion of CIT in courses in the area of health.
These data emphasize the current paradox, where a high level of social medicalization, belief in science and biomedicine and consistent growth in the search for other types of care coexist.11,21 Results of the present study do not provide in-depth analyses or explanations about the position of most professionals, although they suggest that there is sensitization to the social movement to revalue CIT. The patients' demand for healing practices that are not used by biomedicine and the professionals' search for specialization in these areas could represent a deep social change towards health care, including broader cultural transformations.1,2,6,12,21 Other medical rationalities, such as homeopathy and traditional Chinese medicine, and therapeutic practices centered on patient care and health promotion, which encourage their autonomy, facilitate better doctor-patient relationship and stimulate patients' self-healing mechanisms, have been valued.9,12,18 They can contribute for the family health strategy to strengthen its role in the art of healing and health care, disease prevention and health promotion.
The difference in medical professionals' and nurses' interest in CIT in the present study probably occurred due to the fact that doctors rely more on and justify their professional practice according to biomedicine and its great number of drugs, whereas nurses could expect to use non-biomedical therapies to better care for their patients. This finding is in accordance with other studies that emphasize nurses' greater openness towards CIT.5,18
Homeopathy and acupuncture are the most valued CIT present in the city's HCs, which is in accordance with other countries. However, qualified professionals do not always have the time, space or authorization to perform such therapies, so that many do not do this in the ESF. In the open-ended question of the questionnaire, these professionals reported that acupuncture needles and homeopathic drugs had not been provided and professional qualification had not been encouraged by the Municipal Department of Health. The inexistence of a municipal policy or institutional support for these practices, at the time of this study, partly explains the low level of CIT present in the ESF in the city of Florianópolis.
The use of medicinal plants is a disseminated popular practice, within reach of the majority of individuals. Professionals' lack of knowledge about these practices probably determines the absence of encouragement for their use. Qualification of Family Health teams to use and handle medicinal plants seems to be a measure that should be taken by municipal managers (and the institutions that offer professional qualification) to provide professionals with knowledge about their efficacy and safety and to involve the communities to recover the cultural aspects of their use. This would enable other therapeutic options.
It was observed that 43.5% of the doctors studied were specialists in Family and Community Medicine and that 12.4% were specialists in homeopathy and/or acupuncture. These percentages are probably higher than those in the rest of the country (although researchers of the present study do not know any studies that deal with this). This may result from the fact that the specialization in Family and Community Medicine or Public Health is more valued in the city's public examinations, something that has been occurring for many years. This could be reflected in the results, which may hardly be extended to other cities as a consequence. On the other hand, this suggests that a medical qualification with a specialization in primary health care (Family and Community Medicine) can interfere with these results, because there seems to be an elective affinity between CIT and this medical specialty. McWhiney13 indicates that Family and Community Medicine provides access to CIT, because there is an overlapping of the values shared by both: an emphasis on an individual's diagnosis, rather than the disease alone; the search to understand the biological, psychological and social dimensions and their interactions; valuing of the health belief system; and emphasis on the development of a cooperative relationship with patients.
There could have been an induced effect of "politically correct" responses, once the theme of complementary therapies has a certain evidence in the media, due to positive social valuing and the PNPIC being passed. This could result in overestimation of professionals' openness towards and sympathy for the theme. Nonetheless, the internal consistency and convergence of results with international studies indicate coherence of the findings of the present study.
The offer of multiple therapeutic and care options through complementary and integrative practices is a possibility in Brazilian cities and a reality in several of them, encouraged by the PNPIC.7,14 The results of the present study suggest that there is support from ESF doctors and nurses of the local health network of Florianópolis to implement CIT. Such support can exist on a significant level in other Brazilian cities and an important first step could be made if managers surveyed this to develop local policies in a sustainable way, as these can provide complementary therapies in the SUS.
New studies on this theme must be conducted in Brazil, and measures to implement the offer of CIT in the SUS must be taken in a democratic, participative and co-responsible way among managers, professionals and City Health Councils.
1. Andrade JT. Medicina Alternativa e Complementar: experiência, corporeidade e transformação. Salvador: Edufba / Fortaleza: EdUECE; 2006.
2. Barros NF. A construção da Medicina Integrativa: um desafio para o campo da saúde. São Paulo: Hucitec; 2008.
3. Ben-Arye E, Frenkel M, Klein A, Sharf M. Attitudes toward integration of complementary and alternative medicine in primary care: perspectives of patients, physicians and complementary practitioners. Patient Educ Couns. 2008;70(3):395-402. DOI:10.1016/j.pec.2007.11.019
4. Brescia SM. Actitud y opinión de los pediatras ante las medicinas alternativas. Arch Argent Pediatr. 2004;102(2):88-95.
5. Ceolin T, Heck RM, Pereira DB, Martins AR, Coimbra VCC, Silveira DSS. Inserción de terapias complementarias en el sistema único de salud atendiendo al cuidado integral en la asistencia. Enferm Glob. 2009;(16):1-9. DOI:10.4321/S1695-61412009000200017
6. Davis-Floyd R, St. John G. Del médico al sanador. Buenos Aires: Creavida; 2004.
7. De Simoni CL, Benevides I, Barros NF. As práticas Integrativas e Complementares no SUS: realidade e desafios após dois anos de publicação da PNPIC. Rev Bras Saude Fam. 2008;IX (Spec):72-6.
8. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States- prevalence, costs and patterns of use. New Eng J Med. 1993;328(4):246-56. DOI:10.1056/NEJM199301283280406
9. Franco JA, Pecci C. La relación médico-paciente, la medicina científica y las terapias alternativas. Medicina (B. Aires). 2002;63(2):111-8.
10. Helman C. Cultura, saúde e doença. 5.ed. Porto Alegre: Artes Médicas; 2009.
11. Le Fanu J. The rise and fall of modern medicine. London: Carroll & Graf; 2000.
12. Luz ML. Novos saberes e práticas em saúde coletiva: estudos sobre racionalidades médicas e atividades corporais. São Paulo: Hucitec; 2003.
13. McWhinney IR. Manual de medicina de família e comunidade. 3.ed. Porto Alegre: Artmed; 2010.
14. Revista Brasileira Saúde da Família. Brasília (DF): Ministério da Saúde; 2008;IX Spec.
15. Nogales-Gaete J. Medicina alternativa y complementaria. Rev Chil Neuro-Psiquiatr. 2004;42(4):243-50. DOI:10.4067/S0717-92272004000400001
16. Ock SM, Choi JY, Cha YS, Lee J, Chun MS, Huh CH, et al. The use of Complementary and Alternative Medicine in a General Population in South Korea: Results from a National Survey in 2006. J Korean Med Sci. 2009;24(1):1-6. DOI:10.3346/jkms.2009.24.1.1
17. Queiroz MS. O itinerário rumo às medicinas alternativas: uma análise em representações sociais de profissionais da saúde. Cad Saude Publica. 2000;16(2):363-75. DOI:10.1590/S0102-311X2000000200007
18. Salles S. Homeopatia, universidade e SUS: resistências e aproximações. São Paulo: Hucitec/Fapesp; 2008.
19. Sawni A, Thomas R. Pediatricians' attitudes, experience and referral patterns regarding complementary/alternative medicine: a national survey. BMC Complement Altern Med. 2007;7:18. DOI:10.1186/1472-6882-7-18.
20. Teixeira MZ. Homeopatia: desinformação e preconceito no ensino médico. Rev Bras Educ Med. 2007;31(1):15-20. DOI:10.1590/S0100-55022007000100003
21. Tesser CD, Barros NF. Medicalização social e Medicina alternativa e complementar: pluralização terapêutica do sistema único de saúde. Rev Saude Publica. 2008;42(5):914-20. DOI:10.1590/S0034-89102008000500018
Charles Dalcanale Tesser
Departamento de Saúde Pública - Centro de Ciências da Saúde
Universidade Federal de Santa Catarina
Campus Universitário - Trindade
88040-970 Florianópolis, SC, Brasil
Article based on Master's dissertation by Thiago SCS, presented to the Universidade Federal de Santa Catarina in 2009.
The authors declare that there are no conflicts of interest.
a Organización Mundial de la Salud. Estrategia de la OMS sobre medicina tradicional 2002-2005. Ginebra; 2002.
b Ministério da Saúde. Portaria nº 971, de 3 de maio de 2006. Aprova a Política Nacional de Práticas Integrativas e Complementares (PNPIC) no Sistema Único de Saúde. Diario Oficial Uniao. 04 maio 2006[Cited 2006 Nov 29];Seção1:20-5. Available from: http://portal.saude.gov.br/portal/arquivos/pdf/PNPIC.pdf
c Secretaria Municipal de Saúde. Conselho Municipal. Florianópolis; 2009[Cited 2006 Nov 12]. Available from: www.pmf.sc.gov.br/saude/conselhomunicipal
d Conselho Federal de Medicina. Portal Médico. Brasília(DF); 2009[Cited 2006 Nov 29]. Available from: http://www.portalmedico.org.br/