INTRODUCTION1-10:
Complementary
and alternative medicine (CAM) has been defined as a group of diverse medical
and health care systems, practices and products that are not generally
considered as part of conventional medicine. [1] The National Center
for Complementary and Alternative Medicine (NCCAM) defines CAM as “medical and
health systems, applications and products currently not considered as part of
conventional medicine”. [2] CAM is widely used in the prevention and treatment of an
extensive range of ailments from ancient days. The use of CAM by
common people and healthcare professionals are increasing significantly all
over the world in recent years. [3-6]
It is
reported that a good number of US citizens used some form of CAM. [7] Malaysians
are choosing CAM modalities for treatment of health problems as well as for
health maintenance. [8] There is also a quite high prevalence of use
of CAM in Malaysia. [8] Another study reported that 64% outpatients
with chronic disease in Malaysian Public Hospitals were using some form of CAM.
Among them, 78% of these patients reported that their conditions had improved
with CAM. Therefore, it can be concluded that Malaysian common people had faith
and preference for CAM.[9]
Ayurveda, which in Sanskrit means the science of life
started in the 10th century BC and took shape between the 5th
century BC and 5th century AD. [10-11] This form of CAM
is widely practiced in South Asia. Traditional Chinese Medicine, on the other
hand, was practiced all over the world that started in the 8th
century BC. The most common form
of this treatment is acupuncture. [11-12]
Homeopathy was established by Hahnemann (1755-1843) but was mentioned first during
462-377 BC which is practiced throughout Europe, Asia and North America. [13] Thus, CAM modalities are not newly developed and
practiced but were part of the life of our ancestors. [12, 14] CAM
was practised to ensure the health
well-being of a normal person and also as a holistic approach to treating a
disease. [10-11]
There are the various types of CAM
modalities which can be grouped into three, namely natural products, mind-body
medicine, and manipulative and body-based practice. [2] The natural
product category includes a wide range of herbal products, vitamins, minerals
and other natural (botanical) products like probiotics.[15-16] The
natural product practices focus on the brain, mind, body and behaviors and are
grouped as mind-body medicine. Mind-body medicine classically emphasizes on
meditation approach that are believed to encourage and uphold health. Those CAM
modalities are relaxation, hypnosis, visual imagery, meditation, yoga,
biofeedback, tai chi, qi gong, cognitive-behavioural therapies, group support,
autogenic training, and spirituality.[17] Manipulative and
body-based practices include Chiropractic and Osteopathic manipulation, Massage
therapy, Tui Na, Reflexology, Rolfing, Bowen technique, Trager bodywork,
Alexander technique, Feldenkrais method, and a host of others.[18]
This method emphasizes on structure and systems of the body. Another type of
CAM modalities is movement therapies, traditional healers and manipulation of
energy. Movement therapies include Pilates, while energy manipulation practices
are Reiki, magnet and light therapy. [2, 19-20]
There are several key factors to why
the community chooses CAM modalities despite knowing that there is little and
equivocal evidence on CAM therapies. [21-22] Firstly, people seem to
use CAM modalities as it is cost-effective. [12] Next reason to prefer
CAM and traditional medicine that people believe these medications are painless
and no adverse drug reactions. [12, 23] Many CAM modalities offer
painless treatments like Ayurveda, but many chronic diseases are not curable
with conventional medicine and quite often threaten life. [24] Therefore, people have
not many alternatives but to choose CAM modalities in treating chronic illness. [25-28] The other
reason for the inclination to CAM over conventional medicine is the frustration
with the traditional orthodox treatment. [29] In addition to all,
people want the emphasis to be on their wellness and not their illness and many
believe in the message of a holistic model of health. [30-31] CAM
has not only gained interest among the common people but also among health
professionals. [31] Many surveys and research on knowledge and
attitude of medical students towards CAM therapies have produced positive
results towards CAM. [32-36] These attitudes of medical students
towards CAM have been influenced by their own spiritual and religious beliefs.
[37-39]
The integration of CAM instructions
into the medical curriculum is significantly growing not only in the United
States of America but all over the world. [33, 40] In America, some
type of CAM-related curriculum is offered primarily in elective courses in
approximately 73% to 86% of pharmacy schools in the nation. [41-43] The
Malaysian National Policy on Traditional and Complementary Medicine (TCM) was
formed in the year 2001 [44-45] which was aimed at delivering
appropriate education and training of TCM to practitioners and establishes
strong research and development in TCM activities. The government has
formalized a system of education for TCM practitioners which includes MDTM,
Bachelor of Acupuncture and Naturopathy which are now offered nationwide in
government as well as private institutions of higher learning. Besides that,
the government educates western trained doctors and pharmacist by offering
special courses and annual seminar and conferences on TCM. [45]
The blooming interest in CAM modalities
among the lay people have influenced the increase in research done in this area
of study. Since healthcare professionals are accessed for information of
different CAM modalities it is of utmost important for them to have knowledge
of these practices to be able to advise their patients. It is reported that
medical, pharmacy and nursing students’ knowledge and positive attitudes
towards CAM are very high. [33, 39, 40] Many of responding students
prefer some sort of CAM modalities to be incorporated into their medical
curriculum as they think they should have enough knowledge of these therapies
to be able to advise their patients. As the 10th Malaysian Plan
(2011-2015) aimed to integrate CAM therapies in health care centers it is
important for current medical students to develop good knowledge of these
therapies. [45] Thus, it is crucial to determine the knowledge of
and attitude towards Complementary and Alternative Medicine of the medical
students of Universiti
Kuala Lumpur-Royal College of Medicine Perak (UniKL-RCMP), Malaysia parallel to satisfy the
future expectations of the integrated healthcare system.
MATERIALS AND METHODS:
This was a cross-sectional, descriptive study. The target population of this study was all the medical
students of phase 1A (185 students), phase 1B (108 students) and phase 2 (105
students), a total of 398 students of UniKL-RCMP. By using Epi Info software calculated the
sample size was 186 with 95% confidence interval. All the medical students of 3 different phases of UniKL-RCMP who are willing to participate in this study were included. Students who
were absent and unwilling were excluded from the study. The convenient sampling
method was used in this research with at least a minimum number of 186
respondents. A set of questionnaires were developed to collect data from the
respondents. The questionnaire consisted of 6 socio-demography questions asking
for their age, gender, year of study, race, religion, and hometown. Next
section consists of 10 true statements to evaluate the respondents’ knowledge
of CAM therapies. Questions were 1. Complementary and alternative medicine
focus on the healing power of nature and the mobilization of the body's own
resource to heal it (Q1); 2. Ayurvedic medicine was originated from India (Q2);
3. Acupuncture can be used to reduce withdrawal symptoms from drugs (Q3);
4. Acupuncture can be used to relieve
pain (Q4); 5. Massage help regulates blood circulation (Q5); 6. Garlic can be
used to lower lipid levels (Q6); 7. Ginseng is safe to be used in people with
high blood pressure (Q7); 8. Gingko Biloba is commonly used in people with
Alzheimer's disease (Q8); 9. Chiropractic is the science of the spinal
manipulation and commonly used to treat lower back pain (Q9); 10. Homeopathy is
legal to be practical in Malaysia (Q10). Final section consisted of 10 positive
statements towards CAM to evaluate attitude on a Likert-scale. Data was
collected from July to September 2011 and analysed by using SPSS V16.0. This study was approved from the
Research and Ethics Committee (MREC) and the National Medical Research Registry
(NMRR) was obtained. Students’
identity and the responses and information provided by them were kept strictly
confidential.
RESULTS:
A
total of 398 sets of questionnaires were distributed to the target population.
Only 267 completed questionnaires were returned back. So the response rate was
67%. Among 267, male respondents were 74 (28%) and the female were 193 (72).
Their ethnicity was Malay (87%), Chinese (4%), Indian (6%), and others (3%). Similarly, the distribution according to
religion was Islam (87%), Hindu (5%), Buddha (2%), Christian (3%), and others
(3%). Study participants were formed
Phase 1A (49%), Phase 1B (21%) and Phase 2 (30%). The study respondents’ demographic profile is
shown in Table 1. The mean age of the
study respondents was 20.19±1.445 years.
Regarding the assessment of participant’s
knowledge on CAM modalities, on an average 57% respondents correctly answered.
The answers of the respondents were compared by Chi-Square test between Phase
1A, 1B and 2, and statistically significant (p=0.05 or <0.05) differences
were observed at six occasions, but no differences observed on Q3 (p=0.101), Q6
(p=0.170), Q8 (p=0.191), and Q (p=0.917) (Table 2). There were no significant
(p>0.05) observations noticed when compared between genders with any
questions regarding knowledge (Table 3). Again knowledge level, when compared
between ethnic origins of the participants only Q5 (p=0.025) and Q6 (p=0.008)
possess statistically significant findings (Table 4). The knowledge level of
the participants when compared between religious origin, no statistically
significant (p>0.05) differences were observed except Q5 (p=0.018) (Table
5). The study population showed good (67%), moderate (32%) and poor (1%)
attitude respectively towards CAM modalities (Figure 1). But there were no statistically significant
(p=0.202) observation seen when compared among the different phases of students
(Table 6).
Table
1: The Demographic Characteristics of the Study Respondents.
|
Characteristics
|
Frequency
|
Percentage (%)
|
|
Gender
|
Male
|
74
|
28
|
|
Female
|
193
|
72
|
|
Race
|
Malay
|
231
|
87
|
|
Chinese
|
10
|
4
|
|
Indian
|
17
|
6
|
|
Others
|
9
|
3
|
|
Reli-gion
|
Islam
|
233
|
87
|
|
Hindu
|
12
|
5
|
|
Buddhist
|
6
|
2
|
|
Christian
|
8
|
3
|
|
Others
|
8
|
3
|
|
Home
town
|
Perlis/Kedah/ Penang/ Perak
|
83
|
31
|
|
Melaka/N. Sembilan/Johor
|
48
|
18
|
|
Kelantan/Terengganu
|
40
|
15
|
|
Selangor/Pahang/KL
|
84
|
32
|
|
Sabah/Sarawak
|
12
|
4
|
|
Medi-cal year
|
Phase 1
|
132
|
49
|
|
Phase 1B
|
55
|
21
|
|
Phase 2
|
80
|
30
|
Figure
1: The frequency of people with good, moderate and poor attitude towards CAM
modalities in our study population (%)
Table 7: Shows the Frequency
of Respondents with Good, Moderate and Poor Attitude towards CAM Modalities and
Its Association with Gender on Crosstab (Chi-Square) Analysis.
|
Category
|
Gender (%)
|
P value
|
|
Male
|
Female
|
|
Good
|
42(16)
|
136(51)
|
0.202
|
|
Moderate
|
30(11)
|
55(20)
|
|
Poor
|
2(1)
|
2(1)
|
Similarly, there were no statistically
(p=0.202) significant association found when compared between gender (Table 7).
Similarly, there were no statistically significant differences observed between
race (p=0.240) and religion (p=0.325) in attitude.
DISCUSSION:
The aim of this study was to determine the knowledge
and attitude of UniKL-RCMP medical students towards CAM modalities and to make
a comparison among the 3 different phases of students. The response rate in our
study was 67% that exceeded the minimum sample size requirement of 186. The
proportion of phase 1A, 1B and 2 medical students who responded to this survey
was 72%, 51% and 76% respectively with an associated confidence interval of
95%. The response of phase 1A and phase 2 medical students was high as they
were recruited in the lecture halls before and after their lectures. Whereas
the response of phase 1B students was low because they were recruited during
their free time since they did not have lectures during our study period. The
current study response rate was higher than other similar studies conducted in Malaysia
[14, 46-47] but lower than one African [48] and Asian
study. [49]
Out of 267 respondents, 28% were male and 72% were
female. High numbers of female
students were also reported in other CAM studies of Malaysia. [46, 47] The
mean age of the students was 20±1.445 years. Age of the present study also
corresponds with other studies of Malaysia and Turkey. [33, 46] The
study population of UniKL-RCMP was dominated by Malay which was more than
three-quarter of the population (87%). Similar findings also observed with
previous one study [46] but differ from another one. [47]
Knowledge of CAM modalities that received top scores
were Q5 (76%), Q4 (73%) and Q10 (71%).
Regarding the attitude on CAM modalities, 67% of the respondents had
possessed good attitude towards CAM modalities (Figure 1). It is reported from,
the USA that medical students have adequate knowledge about CAM modalities,
especially massage, herbal medicine, and meditation. [50] Similarly, in an Australian study of
medical students showed a high knowledge level about acupuncture, meditation,
and massage. [50] German medical students perceived that their
knowledge level was better in acupuncture and homeopathy. [51] The
difference could be attributed to the location and culture where the study was
conducted.
In case of attitude towards CAM modalities, 67% of the
study population had a good attitude towards CAM modalities which were little
higher compared to the Turkish study (65%) [33] but was lower than
the Singapore study (85%) [39]
and USA study (80%). [34, 52-53] Although, CAM modalities are
available in Malaysia but medical students are rarely exposed to such
treatments.
Out of the 3 phases, phase 2 medical students seemed
to be most knowledgeable about the origin of Ayurveda medicine from India, the
use of acupuncture for pain relieving, massaging for the regulation of blood
circulation and the practice of homeopathy in Malaysia. Phase 1B medical
students scored remarkably well on the same knowledge as phase 2 as perhaps
they were in the medical school for more than one year. Surprisingly, Phase 1
medical students were more knowledgeable on the safe use of ginseng in high
blood pressure patients and to explain this issue was very difficult. Turkish
medical students were more knowledgeable about spirituality than present study
respondents. [40] The difference again could be due to the location
and cultural background of the study population and the teaching program of the
medical schools.
It is reported that female participants were more
inclined towards CAM modalities. [54] It was also reported that
female medical students knew more about tai chi, Ayurvedic medicine and reiki
than the male students but regarding other modalities such as hypnosis and
meditation male students scored more. [40] On the other hand,
results of the current study showed that female students knew more about
massage and homeopathy while male students knew more about herbal medicine and
chiropractic. However, these results were statistically insignificant.
In terms of race, the highest correct responses on
knowledge of CAM was given by the Chinese students. On the use of garlic to
lower blood lipid levels, Chinese students scored highest (90%). But only 2
questions, the knowledge on massage for regulating blood circulation and use of
garlic to lower blood lipid levels were statistically significant. This could
be attributed to the Chinese’s habit in practicing CAM modalities. In terms of
religion, knowledge on massage for regulating blood circulation was rated
higher (78%) among the Muslims followed by Hindus (75%) and others (75%),
Buddhist at the 67% and Christian at 25%. All 3 phases were generally positive
in their attitude towards CAM modalities. The result was consistent with the
studies conducted among Turkish medical students, [40] Irish medical
students [55] and Czech pharmacy students. [56] This was
perhaps due to the long history of CAM modalities and its practice among
Malaysians and the reported benefit of them against many chronic diseases. Current
study found that female respondents had a higher positive attitude (51%)
compared to male respondents (16%). Chinese students showed the highest
positive attitude (70%) followed by Malays (69%), Indians (59%) and the lowest
was recorded among the other race group (33%). However the association between
all demographic characteristics of the study population and attitude towards
CAM modalities were statistically insignificant in every domain.
Use of CAM worldwide has been increased in few fold,
especially chronic diseases because dissatisfaction and adverse drug reactions
with conventional medicine. [54, 57] A similar study also reported
that low level of knowledge regarding CAM modalities among healthcare providers
is a growing concern. [54] As there is no proper answer for many
chronic diseases, there are enormous growth of CAM both in developed and
developing countries. But the efficacy and adverse drug reactions of CAM have
not been fully established, [58] rather there were multiple reports
of adverse drug reactions. [59], [60] Current study found a high
percentage of UniKL-RCMP medical students showed a good attitude towards CAM
modalities (67%). This prevalence could be implied for further consideration
towards including basic CAM modalities as part of the medical curriculum.
CONCLUSION:
In
conclusion, the overall knowledge of medical students of UniKL-RCMP on CAM was
fairly good like all other studies conducted around the globe. The attitude
towards CAM was fairly positive compared to other recent studies. Female
students seemed to have higher knowledge and positive attitude towards CAM. The
measures that can be taken to improve knowledge of medical students towards CAM
are to integrate CAM related subjects in the medical curriculum. However, the
government should play an important role in educating the public as well as the
healthcare professionals on the merits and demerits of CAM, and certainly their
attitude could also be improved if they were given basic information on CAM.
Lack of scientific proofs might be the cause of lack of positive attitude
towards CAM. Thus, it is important to evaluate the knowledge and attitude among
medical and allied health sciences students towards CAM as these studies can
help determine the need for integrating CAM not only in the medical curriculum
but also in the healthcare delivery system of Malaysia.
ACKNOWLEDGEMENT:
We express our heartiest gratitude to those students
participated in this study. We are also
much grateful to the Dean, University of Kuala Lumpur.
LIMITATION OF
THE STUDY:
This
was a cross sectional with its inherent constraint. Therefore, need more in
depth research.
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