Student nurses, midwives and health visitors' attitudes, knowledge, and experience of complementary and alternative medicine in Hungary

1 Student nurses, midwives and health visitors' attitudes, knowledge, and experience of complementary and alternative medicine in Hungary Andrea Sárvárya*, Lívia Hajduné Demcsákb, Sándorné Radób, Péter Takácsc, Attila Sárváryb aDepartment of Psychology, Faculty of Health, University of Debrecen, Hungary postal address: Faculty of Health, University of Debrecen, 4400 Nyíregyháza, Sóstói u. 2-4., Hungary bDepartment of Nursing Science, Faculty of Health, University of Debrecen, Hungary postal address: Faculty of Health, University of Debrecen, 4400 Nyíregyháza, Sóstói u. 2-4., Hungary cDepartment of Health Informatics, Faculty of Health, University of Debrecen, Hungary postal address: Faculty of Health, University of Debrecen, 4400 Nyíregyháza, Sóstói u. 2-4., Hungary E-mail addresses: sarvary.a[email protected]ideb.hu (A. Sárváry), hajdune.demcsak.liv[email protected]eb.hu (L.H. Demcsák), [email protected] (S. Radó), [email protected] (P. Takács), sarvary.at[email protected]deb.hu (A. Sárváry) *Corresponding author: Andrea Sárváry e-mail address: sarvary.and[email protected]deb.hu, postal address: Faculty of Health, University of Debrecen, 4400 Nyíregyháza, Sóstói u. 2-4., Hungary phone number: +36 42 404411/147 2 Abstract Introduction: Complementary and alternative medicine (CAM) has become an important part of healthcare. This study aimed to compare three groups of health care students' attitudes towards, knowledge of, personal use of, and opinions about the integration of CAM into higher education and health care in Hungary. Comparisons were made between those participating and those who did not participate in a Complementary Medicine (CM) course as an optional course during student training. Methods: A survey of the 314 full time students (nurses, midwives and health visitors) were asked to take part in an online survey using a self-complete questionnaire. Data were analyzed using descriptive statistics. Results: Students' attitudes towards CAM were positive. The most commonly known alternative methods were massage, relaxation, acupuncture, herbal medicine and meditation. The most commonly personally used and perceived as being effective CAM modalities were herbal medicine, massage and relaxation. Most students believed that the integration of CAM into higher education and into health care is necessary. There were no differences in attitudes towards CAM between students who participated and those who did not participate in the CM course. Participants considered the course to be useful and reported higher knowledge about three CAM modalities and preferred formal education as information sources. Conclusion: Health care students are open to learning CAM. Increasing the number of health care students in the CM courses would result in ensuring that future health care professionals obtain reliable knowledge about CAM practices which may in turn make their work more effective. Key words: complementary and alternative medicine; attitude; knowledge; nursing, health visitor and midwifery students; Complementary Medicine course 3 1.Introduction The use of complementary and alternative medicine (CAM) for various health problems continues to increase worldwide [1-5]. Its popularity is similar or even higher among patients with chronic illnesses compared to the average population [1,6,7]. Since 2000s the number of evidence based CAM modalities has dramatically increased although evidence gaps still exist [8,9]. However, health care providers may not be aware of the evidence base and may be hard pressed to provide reliable advice to patients and inform them about the available therapeutic options and their use [10]. Moreover, the therapeutic approach of health professions, like nursing, midwifery and health visitors have been acknowledged as having a more holistic approach to care and welcomed more ‘complementary’ approaches to health [11,12]. International research has investigated the knowledge about CAM and attitudes towards CAM among medical, pharmacy, nursing and midwifery students and different health professionals [10,12-19]. Most of the studies have shown positive attitudes towards CAM among health care students, but differences were found between genders, among years and specialties of the students [14-17]. Previous studies have also explored nurses’ attitudes towards CAM, their knowledge about it and its professional use. Nurses’ attitudes about CAM have been generally positive but their knowledge proved to be poor about the use of CAM modalities therefore they felt they could not give credible information and advice concerning CAM modalities [10,1821]. Since health care providers play an important role in the education of the patients, a high demand has emerged for educational institutions of health care workers to teach this discipline. The medical and health care educational organizations and institutions recognized the increasing demand of CAM and its integration into the curriculum. Different organizations developed recommendations and core curriculum for higher institutions in the USA. For example, the Society of Teachers of Family Medicine Group on Alternative Medicine developed a curriculum guideline [22] and the Education Working Group of the Consortium of Academic Health Centers for Integrative Medicine published a list of core competencies of integrative medicine for medical universities developed by 23 academic health centers [23]. The American Association Colleges of Nursing in the core curriculum outlined in 1998 also included the main elements of CAM desired to integrate it to the curriculum. [24]. As early as 1999, the support the integration of CAM into the education the National Institute of Health and the National Center for Complementary and Alternative Medicine (now National Center for Complementary and Integrative Medicine - NCCIM) funded 14 higher institutions to perform such programs [25]. It is important to note that since 2015 the NCCIM has been using the term Complementary Health Approach instead of Complementary and Alternative Medicine. Previous studies revealed that there was no difference concerning the need for the integration of CAM into the curriculum among students [15,16]. In a study from Turkey comparing nursing and medical students’ knowledge and attitude towards CAM showed significant difference between the two groups both in integration of CAM into clinical practice (57.8% vs. 32.6%) and into curriculum (61.3% vs. 37.9%) with the higher rate of nurses [13]. However, these results were not strengthened by another study carried out at seven faculties of medicine covered all region of Turkey [14]. According to the results of this study, medical students with high rate believed that CAM should be included in the curriculum, knowledge of CAM would be useful in their professions, and doctors should be familiar with CAM methods [14]. These results were also supported by a study from Kuwait [15]. 4 During the era of socialism in Hungary only some types of CAM were tolerated (e.g. herbal medicine). Different types of CAM appeared at the end of the 1980s and since the change of the regime a rapid increase has occurred in this field. The market relating to CAM was uncontrolled for a long time and the regulation of CAM entered into force only in 1997 [26]. The decree (11/1997 (V. 28) NM rend.) lists the types of non-conventional therapies and determines which ones can be performed by medical doctor only (e.g. manual therapies, Traditional Chinese Medicine, neural therapies) or by other graduations (e.g. acupressure, reflexology). Although the education of the Traditional Chinese Medicine started in 1987 at a medical university, the introduction of optional courses of some types of CAM did not begin until the end of the 1990s in other medical universities [26]. In Hungary, the education of health visitors (started in 1975) and midwives (started in 2004) is at BSc level in higher education. Nursing students’ education is at three different levels: at vocational school, in higher education at BSc (started in 1989) and at MSc level (started in 2010). Health visitors are preventive professionals, who care for children until 18 years. They work in districts with close connections with pediatric family doctors/general practitioners or in schools. Using CAM therapies health care providers have a good opportunity to press patients to take part in their care and healing process actively [10,12]. Thus the knowledge of CAM has become very important to nursing practice [12] and to the practice of other health professions. At the University of Debrecen, Faculty of Health the education of CAM for nurses and health visitors and later on for midwives also started in 1995 titled Complementary Medicine course. There is only limited data concerning the use of CAM in Hungary. Two national representative surveys showed a significant increase in visiting CAM practitioners from 6.6% to 23.9% from 1991 to 1999 [27,28]. However, based on the data from the national representative health surveys in 2000, only a small number of the Hungarian population consulted CAM practitioners in the previous 12 months (males: 3%, females: 4%) and this slightly increased to 2003 (males: 3.6%, females: 6.1%) [29,30]. It is important to note that these rates did not include those CAM therapies, which were used as home remedies or self-treatment. There was also no distinction between those visiting physicians who were also CAM therapists and those visiting only CAM practitioners. Therefore, these rates may underestimate the real use of CAM and are not comparable with the aforementioned national data or with the international data. In the literature there have been only a few studies comparing attitudes towards CAM and its knowledge in different groups of health care students [13,16,31], and no surveys were found from Hungary. Nurses, midwives and health visitors spend the most time with patients during their health care. Therefore the primary aim of the research was to investigate and compare nursing, health visitor and midwifery students’ attitudes and knowledge towards CAM, its personal use and its perceived effectiveness. In addition, the study aimed to reveal the information sources used by these students and their opinions about the integration of CAM into high education as well as health care system in Hungary. As the third aim of the study comparisons were made between students who participated and those who did not participate in the Complementary Medicine course. 2.Methods 2.1.Study Questionnaire A cross-sectional survey was designed using a self-administered questionnaire. The eighteen CAM therapies included were: Traditional Chinese Medicine, acupuncture, homeopathy, meditation, relaxation techniques, hypnotherapy, Mind Control (relaxation technique), 5 magnets, Prananadi1, Reiki2, therapeutic touch, kinesiology, massage, acupressure, chiropractic, reflexology, herbal medicine and non-herbal supplements [20]. Some of these therapies were selected due to their popularity in Hungary. The term alternative medicine was defined in the questionnaire as follows: ‘a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine, and are not taught in medical universities, and are not used in hospitals and are not integrated into the dominant health care system and most of them can be practiced without having M.D. (medical doctor) degrees’ [32,33]. The questionnaire was pre-tested among 8 students for content, language clarity, easy for use, and time required to fill out the questionnaire. Modifications were made as necessary in order that the questionnaire could be simple to answer. 2.1.1.General attitudes towards CAM The students’ general attitudes towards CAM were measured by an item list. After selecting statements based on other questionnaires [34,35], eight experts (six women and two men) classified them as follows: items accepted by people characterized with a positive and accepting attitude toward CAM (Group A); those with negative (rejecting) attitude (Group B); and those that are neutral (neither accepting nor rejecting) (Group C). Those items were selected in the final list, which had been considered to characterize negative or positive attitude toward CAM by all experts. The final version consisted of 7 positive (see table 2: 1-7 statements) and 5 negative statements (see table 2: 8-12 statements). Responses were given on a 7 point Likerttype scales, ranging from 1 (strongly disagree) to 7 (strongly agree). 2.1.2.Knowledge of CAM Students were asked to indicate their knowledge about each CAM modality using a 4-point scale (none, very little, some, a lot). 2.1.3.Information sources Students were asked to indicate sources where their knowledge about CAM comes from by responding ‘yes’ or ‘no’. The following knowledge source categories were given: ‘scientific journals or books’ ‘TV or radio’ ‘the Internet’ ’ other people (family members, relatives, friends)’ ‘newspapers or magazines’ ’formal education’, ‘special courses’ and ‘health care related professions’. 2.1.4.Personal use and perceived effectiveness of CAM Students were asked to respond using ‘yes’ or ‘no’ with reference to 18 CAM practices and if used to assess their effectiveness on a 7-point Likert-type scale ranging from 1 (it was completely ineffective) to 7 (it was completely effective). 2.1.5.Integration of CAM into higher education and health care system Students were asked to indicate how much they agree with four items concerning integration of CAM modalities into undergraduate curriculum and health care system on a 7-point Likert-type scale ranging from 1 (strongly disagree) to 7 (strongly agree). 2.1.6.Evaluation of Complementary Medicine course Complementary Medicine course is a two semester optional course, which can be chosen by 2nd, 3rd and 4th years health care students. The course contains theory (14 hours) and practice (28 hours) in both semesters. Lectures cover the most popular and the most widely used CAM and other treatment methods in Hungary (e.g.: basic of Traditional Chinese Medicine, herbal medicine, acupuncture, massage, chiropractic, balneotherapy). During this two semester course 6 students obtain knowledge about indications and contraindications of CAM therapies, about their efficiency and about their side effects. On the practice the teacher presents the most frequently used CAM techniques, e.g. preparing methods and indications of herb teas, compress and balneotherapy, moxa treatment, manual therapy, acupuncture and chiropractic. The course is taught by a physician, acupuncture practitioner, who is responsible for the content of the program. Students were asked to indicate (‘yes’ or ‘no’) whether they had participated in the Complementary Medicine course and how much of it was useful on a 7-point Likert-type scale ranging from 1 (it was completely useless) to 7 (it was completely useful). Further, they were asked to indicate the appropriate form of education of this subject: optional, elective or compulsory course. (Optional course: during their studies students can freely choose courses from a given list of courses that are not absolutely related to their specialty. Elective course: during their studies students have to select courses from a given list of courses that are connected to their specialty.) 2.2.Study sample The study sample consisted of students in Faculty of Health at the University of Debrecen from 1st, 2nd, 3rd and 4th years. The sample was composed of the all full time nursing (124), midwifery (204) and health visitor (196) students (524, females: 506, males: 18). As the study aimed to make comparisons between students who participated (131) and those who did not participate (63) in Complementary Medicine course 2nd, 3rd and 4th year students consisted a subsample (194). First year students were excluded from the subsample, because they had no possibility to take part in this course. 2.3.Data collection The study was conducted at the University of Debrecen, Faculty of Health in Nyíregyháza between April and June 2013. The Eva-sys online version of the questionnaire was used in order to increase the efficiency of data collection. Data collection took place during seminars when computers were available for students. Students had one occasion to complete the questionnaire. Before filling in the questionnaire the students were given a brief description of what the study entailed. The participation in the study was voluntary. Written permission to proceed the research was obtained from the University of Debrecen Faculty of Health. 2.4.Statistical analysis Data were evaluated with the help of Statistical Package for Social Sciences (SPSS) software program (Version 22.0). Similarly to other studies [36,37], all Likert-scale responses with any degree of agreement were grouped together as positive responses, and all responses with any degree of disagreement were grouped together as negative responses. For instance, ‘agreed a little’ and ‘agreed moderately’ and ‘agreed strongly’ (indicating 5 or 6 or 7 on the Likert scale) were considered and grouped together as positive response. To evaluate respondents’ attitudes, a scale was developed from the 12 statements. Since, the internal consistency of this measure was found high (Cronbach’s coefficient alpha = 0.851, Guttman λ2= 0.858), this measure was found reliable. To summarize the data, descriptive statistics were used. ANOVA was used to reveal whether the difference of Likert scale averages is significant among nursing, health visitor and midwifery students. An independent sample Ttest was used to reveal whether the difference of Likert scale averages is significant between students who participated and those who did not participate in the Complementary Medicine course. Simple cross-tabulations, Chi-square tests (Pearson) and Fisher exact test were used toanalyze differences in agreeing with statements, knowledge, personal use, perceived effectiveness of CAM, information sources, and opinion about the integration of CAM among 7 the three groups of health care students, and between students who participated and those who did not participate in the Complementary Medicine course. Results were considered to be significant when the p value was less than 0.05. 3.Results Three hundred and fourteen students (females: 299, males: 15) completed the questionnaire from 1st, 2nd, 3rd and 4th years, giving a response rate of 59.9% (314/524). Our study sample was representative with the respect to proportions of gender and specialties of students. Respondents consisted of three groups: 83 (26.4%) nurses, 126 (40.1%) midwives and 105 (33.4%) health visitors. Data were collected from 1st (120, 38.2%), 2nd (74, 23.6%), 3rd (79, 25.2%) and 4th (41, 13.1%) year students (Table 1). The mean age was 21.6 years (range 1831). Table 1 Year and specialty characteristics of the study sample Specialty of students Year No (%) Total No (%) 1st 2nd 3rd 4th nursing 28 (33.7) 30 (36.1) 23 (27.7) 2 (2.4) 83 (26.4) midwifery 48 (38.1) 23 (18.3) 35 (27.8) 20 (15.9) 126 (40.1) health visitor 44 (41.9) 23 (21.9) 19 (18.1) 19 (18.1) 105 (33.4) Total No (%) 120 (38.2) 76 (24.2) 77 (24.5) 41 (13.1) 314 (100) As for the subsample, one hundred and thirty one students participated in the Complementary Medicine course from 2nd, 3rd and 4th year (131/194, 67.5%): 33 (33/57, 57.9%) nurses, 48 (48/78, 61.5%) midwives and 50 (50/59, 84.7%) health visitors. This optional course was the most popular among health visitor students (Table 2). Table 2 Nursing, Midwifery and Health Visitor Students participating in the Complementary Medicine course Year Participating in the Complementary Medicine course No. Nursing students Midwifery students Health visitor students total yes no total yes no total yes no 2nd (n=74) 30 14 16 23 6 17 21 14 7 3rd (n=79) 25 17 8 35 24 11 19 19 0 4th (n=41) 2 2 0 20 18 2 19 17 2 total (n=194) 57 33 24 78 48 30 59 50 9 3.1.General attitudes towards CAM 8 In general, all three groups of students’ attitudes were found to be positive according to the Likert scale averages: midwives’ attitudes were the most positive (Mean (M) = 5.08, standard deviation (std) = 0.96), followed by health visitors (M = 5.02, std = 0.92) and nurses (M = 4.93, std = 0.77). There were no significant differences in nursing, health visitor and midwifery students’ attitudes (p=0.511). There were no significant differences (p=0.322) in attitudes between the groups who participated in the Complementary Medicine course (M = 5.3, std= 0.9) and those who did not (M = 5.1, std = 0.8). Over 70% of the students agreed (Table 3) that CAM brings about an improvement in patients’ well-being (232, 74.4%), and considered it to be a useful supplement to regular medicine (227, 72.3%). Most students also believed that CAM does have important results (225, 71.9%) and it can provide an answer in cases where conventional medicine has no solution (223, 71.7%). Over one-third of students believed that the results of CAM are in most cases due to a ’placeboeffect’ (118, 37.7%). Furthermore, approximately one-quarter of students believed that CAM was dangerous because it raised unfounded hopes and may lead to disappointment later (87, 27.7%) and that patients almost never get better using only CAM (69, 22.0%). Less than 20% of students considered CAM to be dangerous because it increases the possibility of negative side effects (52, 16.9%) and a minority of students agreed that treatment with CAM modalities should be forbidden by law (31, 9.9%). There was a significant difference between nursing (51, 61.4%), health visitor (75, 73.5%) and midwifery students’ (97, 77.0%) opinions regarding whether CAM treatments can provide an answer in cases where conventional medicine has no solution (p = 0.045). There were no significant differences in the attitude statements between students who participated and those who did not participate in the Complementary Medicine course. Table 3 Nursing, Health Visitor and Midwifery Students’ General Attitudes towards Complementary and Alternative Medicine (CAM) Statements Agreed* No. (%) total No. (%) N = 314 nurses No. (%) N= 83 health visitors No. (%) N = 105 midwive s No. (%) N = 126 p 1. CAM brings about an improvement in patients’ well-being. 232 (74.4) 56 (68.3) 78 (75.0) 98 (77.8) 0.305 2. CAM is useful supplement to regular medicine. 227 (72.3) 57 (68.7) 81 (77.1) 89 (70.6) 0.377 3. CAM does have important results. 225 (71.9) 57 (68.7) 75 (71.4) 93 (74.4) 0.662 4. CAM treatments can provide an answer in cases where conventional medicine has no solution. 223 (71.7) 51 (61.4) 75 (73.5) 97 (77.0) 0.045 5. I believe that CAM may have positive effect on general health outcomes. 209 (67.0) 53 (64.6) 70 (67.3) 86 (68.3) 0.860 6. I believe in alternative approaches in health area. 196 (63.0) 50 (61.0) 66 (63.5) 80 (64.0) 0.902 9 7. CAM has advanced considerably in recent years in understanding of illness and diseases. 168 (53.5) 45 (54.2) 59 (56.2) 64 (50.8) 0.707 8. The results of CAM are in most cases due to a ’placebo-effect’. 118 (37.8) 31 (37.8) 46 (43.8) 41 (32.8) 0.230 9. The increase in CAM use is dangerous because it raises unfounded hopes and leads to disappointment later. 87 (27.7) 22 (26.5) 27 (25.7) 38 (30.2) 0.724 10. Patients almost never get better using only CAM. 69 (22.0) 15 (18.1) 24 (22.9) 30 (23.8) 0.597 11. The increase in CAM use is dangerous because it increases the possibility of negative side effects. 52 (16.9) 9 (11.1) 22 (21.6) 21 (16.8) 0.172 12. Treatment with CAM modalities should be forbidden by law. 31 (9.9) 4 (4.8) 13 (12.4) 14 (11.1) 0.188 *Percentages of ‘agreed a little’, ‘agreed moderately’, and ‘agreed strongly’ responses were combined 3.2.Knowledge of CAM More than 80% of the study participants reported (Table 4) that they knew something or a lot about massage (269, 86.5%). The knowledge about the other modalities (over 60%) was as follows: relaxation (242, 77.3%), acupuncture (211, 67.8%), herbal medicine (207, 66.6%), meditation (206, 66.5%) and homeopathy (204, 66.0%). Among the least known types of CAM were kinesiology (36, 11.6%), Reiki (34, 10.9%) and Prananadi (22, 7.1%). There was no significant difference between the three groups’ knowledge about CAM modalities. However, significant differences were found between students who participated and those who did not participate in the Complementary Medicine course in the knowledge about Traditional Chinese Medicine (58, 45.0%, vs. 18, 29.0%, p = 0.027), acupuncture (99, 76.2%, vs. 37, 59.7%, p = 0.011) and chiropractic (80, 61.1%, vs. 29, 46.0%, p = 0.032). Table 4 Nursing, Health Visitor and Midwifery Students’ Knowledge of CAM modalities CAM modalities Knowledge* No. (%) Total N= 314 Nurses N = 83 Health visitors N = 105 Midwives N = 126 p massage 269 (86.5) 73 (88.0) 87 (84.5) 109 (87.2) 0.753 relaxation 242 (77.3) 57 (69.5) 86 (81.9) 99 (78.6) 0.121 acupuncture 211 (67.8) 59 (71.1) 77 (74.0) 75 (60.5) 0.070 herbal medicine 207 (66.6) 55 (66.3) 69 (67.0) 83 (66.4) 0.993 meditation 206 (66.5) 56 (68.3) 75 (72.1) 75 (60.5) 0.165 homeopathy 204 (66.0) 53 (64.6) 75 (71.4) 76 (62.3) 0.334 chiropractic 181 (58.4) 45 (54.2) 65 (64.4) 71 (56.3) 0.318 Traditional Chinese Medicine 126 (40.5) 33 (40.2) 39 (37.1) 54 (43.5) 0.615 non-herbal supplements 124 (40.3) 34 (42.0) 42 (40.4) 48 (39.0) 0.915 Mind Control 124 (40.0) 37 (45.1) 43 (41.3) 44 (35.5) 0.363 acupressure 113 (36.6) 31 (38.3) 39 (38.2) 43 (34.1) 0.761 hypnotherapy 108 (35.0) 24 (30.0) 39 (37.5) 45 (36.0) 0.543 16 References [1] Akinci AC, Zengin N, Yildiz H, Sener E, Gunaydin B. 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