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• Published: 01 August 1997

Researching alternative medicine

• Wayne B. Jonas 1  

Nature Medicine volume  3 ,  pages 824–827 ( 1997 ) Cite this article

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In 1992 the US Congress created the Office of Alternative Medicine (OAM), placing it within the NIH, one of the foremost bio-medical research establishments world-wide. The OAM is currently funded to the tune of $40 million per year. Although alternative and unconventional medicine attracts considerable attention (and finances) from the public in Western societies, many within the established medical and research communities are outwardly cynical and dismissive of alternative medical practices. We have asked Wayne B. Jonas. Director of the OAM, to discuss what the OAM hopes to achieve and how it is going about it.

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Alternative Medicine and Healthcare Delivery: A Narrative Review

• First Online: 07 January 2023

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• Ibrahim Adekunle Oreagba 3 &
• Kazeem Adeola Oshikoya 4  

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The global trend toward increased acceptability and use of complementary and alternative medicines (CAMs), across all age groups, is well documented in the literature. Consequently, further systematic evaluation and meta-analysis are necessary to evaluate the quality, efficacy, safety, and regulation of these range of therapies by combining all the available evidence in the literature. Furthermore, the role of CAM in healthcare delivery and its utilization in a digital age cannot be overemphasized. Evidence-based results would guide both patients willing to use CAMs and their providers in making an informed decision. This narrative review addressed the above points. There is subtle evidence supporting the quality, efficacy, and safety of CAM therapies and products; however, much of the evidence is inconsistent due to the varied CAM types and regulatory policies from country to country. More research is required in this field to further harness the gains of CAM therapies and products globally. CAM users and providers should exercise caution with the available therapies and products. Care should also be taken when consulting CAM therapies online.

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Potential factors that influence usage of complementary and alternative medicine worldwide: a systematic review

• Mayuree Tangkiatkumjai   ORCID: orcid.org/0000-0002-9442-970X 1 ,
• Helen Boardman 2 &
• Dawn-Marie Walker 3  

BMC Complementary Medicine and Therapies volume  20 , Article number:  363 ( 2020 ) Cite this article

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To determine similarities and differences in the reasons for using or not using complementary and alternative medicine (CAM) amongst general and condition-specific populations, and amongst populations in each region of the globe.

A literature search was performed on Pubmed, ScienceDirect and EMBASE. Keywords: ‘herbal medicine’ OR ‘herbal and dietary supplement’ OR ‘complementary and alternative medicine’ AND ‘reason’ OR ‘attitude’. Quantitative or qualitative original articles in English, published between 2003 and 2018 were reviewed. Conference proceedings, pilot studies, protocols, letters, and reviews were excluded. Papers were appraised using valid tools and a ‘risk of bias’ assessment was also performed. Thematic analysis was conducted. Reasons were coded in each paper, then codes were grouped into categories. If several categories reported similar reasons, these were combined into a theme. Themes were then analysed using χ 2 tests to identify the main factors related to reasons for CAM usage.

231 publications were included. Reasons for CAM use amongst general and condition-specific populations were similar. The top three reasons for CAM use were: (1) having an expectation of benefits of CAM (84% of publications), (2) dissatisfaction with conventional medicine (37%) and (3) the perceived safety of CAM (37%). Internal health locus of control as an influencing factor was more likely to be reported in Western populations, whereas the social networks was a common factor amongst Asian populations ( p < 0.05). Affordability, easy access to CAM and tradition were significant factors amongst African populations ( p < 0.05). Negative attitudes towards CAM and satisfaction with conventional medicine (CM) were the main reasons for non-use ( p < 0.05).

Conclusions

Dissatisfaction with CM and positive attitudes toward CAM, motivate people to use CAM. In contrast, satisfaction with CM and negative attitudes towards CAM are the main reasons for non-use.

Peer Review reports

Use of complementary and alternative medicine (CAM) has become widespread in the last two decades. The prevalence of CAM use in general populations worldwide ranges from 9.8% to 76% [ 1 ]. Twelve systematic reviews report reasons for CAM use mainly in cancer populations compared to other condition-specific populations [ 2 , 3 , 4 , 5 ].

Five of the systematic reviews aimed to determine reasons for CAM use in either general or condition-specific populations [ 2 , 5 , 6 , 7 , 8 ]. The reviews reported that the main reasons for CAM use were: (a) expected benefits and perceived safety of CAM, (b) control and participation in their therapy, and (c) alignment of socioculture, beliefs and needs. The other six reviews also reported reasons for CAM use, but this issue was not their main aim [ 3 , 4 , 9 , 10 , 11 , 12 ]. Their findings showed various reasons for CAM use, such as: (1) the benefits and safety of CAM, (2) availability and accessibility of CAM, (3) influence from friends, family, and the mass media, and (4) dissatisfaction with conventional medicine (CM). One systematic review from sub-Saharan Africa also reported barriers to CAM use that included: (a) the absence of conclusive scientific evidence for CAM, (b) a lack of belief in safety and efficacy of CAM, and (c) unhygienic practice in product preparation [ 9 ].

A narrative review (Jones et al., 2019) aimed to determine factors influencing CAM use in Australia and reported that cancer and other condition-specific populations shared some reasons for CAM use: (a) self-perceived ill health, (b) sense of well-being and (c) integrative treatment [ 13 ].

However these reviews do not directly compare similarities and differences in the reasons for CAM use between populations. There are also limited systematic reviews reporting reasons for not using CAM. The present review aimed to provide comprehensive understanding of factors influencing different populations to use/not use CAM.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 statement was employed in the present systematic review [ 14 ]. Research questions of this review were 1) What were the similarities and differences in reasons for using/not using CAM amongst general and condition specific populations? and 2) What were the similarities and differences in reasons for using/not using CAM amongst populations in each region?

Search strategy

The databases – PubMed: National Library of Medicine, ScienceDirect and EMBASE were searched. It is recommended that two or more databases are searched. EMBASE alone has the highest percentage recall of papers and, as a result, gains in searching resources beyond EMBASE are modest [ 15 , 16 , 17 ]. Keywords used were ‘herbal medicine’ OR, ‘herbal and dietary supplement’ OR, ‘complementary and alternative medicine’, AND ‘reason’ OR ‘attitude’. Free-text terms combined with Boolean operators and filters were used for searching relevant studies [ 18 ]. For example, ‘complementary and alternative medicine’ AND ‘reason’; ‘complementary and alternative medicine’ AND ‘attitude’. All permutations of these key words were performed. Herbal medicine and dietary supplements were used as keywords due to these products being extensively used worldwide, compared to other types of CAM [ 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. Pubmed and EMBASE were chose because they are the main sources suggested by the Cochrane centre and provide relevant studies in this field [ 26 ]. Meanwhile, the ScienceDirect database has published information relating to the social sciences A date range of January 2003 to December 2018 was set as the World Health Organization’s (WHO) 2002 definition of CAM was used to underpin this research: “CAM are used to refer to a broad set of health care practices that are not part of a country’s own tradition, or not integrated into its dominant health care system” [ 27 ]. This current review began in 2019 and has reviewed relevant sources published ovevr a 15 year period from 2003 to 2018.

Selection criteria

Original articles published in English from 2003 to 2018 were reviewed. Quantitative, and qualitative studies, and mixed-methods research were included as each type of publication provided a different informational perspective and complemented each other. No limits were set regarding country of origin or type of population. This process was conducted by two independent reviewers.

Exclusion criteria

Conference proceedings, pilot studies, study protocols, letters, literature reviews or systematic reviews were excluded. The studies which did not report on factors or reasons for using, or not using, CAM were excluded. Furthermore, papers which studied some specific groups were also excluded, i.e. students, medical professionals, pregnant women, people aged less than 15 years, care givers, or specific sexual identities or ethnic groups. This exclusion was due to the premise that each group has a specific characteristic which may underpin their reasons for CAM usage, which may deviate from other populations. As the present review focused on the reasons and attitudes influencing people to use/not use CAM, efficacy trials of CAM were also excluded.

Data extraction and risk of bias assessment

The process of extracting data from publications was conducted by two independent reviewers. Any disagreements were resolved by discussion with a third reviewer. The included quantitative studies were appraised using a standard tool adapted from Gan’s study, which contained 10 items and assessed a study’s internal and external validity [ 22 ]. Meanwhile, the qualitative studies were assessed by a standard tool from Jakes’ study, which evaluated agreement between research questions, methods, representation, interpretation of results, influence of researchers, evidence of ethical approve and a flow from the analysis to conclusion [ 12 ]. These tools have been used for evaluating studies in the CAM field and seem to be appropriate to assessing the methodologies of the observational and qualitative studies included in this present systematic review.

Data synthesis and statistical analysis

Data in the present systematic review was analysed by both qualitative and quantitative methods conducted by two independent reviewers [ 28 ]. An inductive thematic approach was performed to identify themes of reasons for use and non-use of CAM [ 28 ]. All use or non-use reasons in each publication were coded by hand, and then grouped into a category according to the reason(s). If several categories reported similar reasons, such categories were combined into one theme. The themes, therefore, emerged from this process. This process was forward and backward analysed until the themes were consistent. Then, similarities and differences of the themes between general and condition-specific populations, and between Western and Asia populations were analysed by χ 2 -tests. Tests were two-tailed and a p -value < 0.05 was considered statistically significant.

Searching via the three databases provided 10,887 publications. After excluding irrelevant publications based on their title and abstract, 2,007 publications remained, from which 861 duplicates were removed. 799 publications met the exclusion criteria and were therefore not included. From the 347 full-text articles reviewed, 116 publications were excluded due to an absence of reporting factors or reasons for CAM use, resulting in 231 publications from 51 countries being included in the analysis (Fig. 1 ).

Flowchart of study identification process

Thirty-seven out of the 231 included publications were qualitative studies (16%) mainly from the United Kingdom (UK) [ 29 , 30 , 31 , 32 , 33 , 34 ], the United States (US) [ 35 , 36 , 37 , 38 ], Australia [ 39 , 40 , 41 ] or Canada [ 42 , 43 , 44 ]; a survey or cross-sectional study were the most commonly employed quantitative methods in the included publications (80.5%). Only eight mixed method papers (3.5%) reported the reasons for CAM use [ 32 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ]. Eleven papers (4.8%) were conducted in elderly populations [ 35 , 39 , 42 , 43 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ], and six (2.6%) in women only populations [ 29 , 38 , 39 , 59 , 60 , 61 ].

The highest number of all included publications originated in Asia (25.5%), followed by Europe (20.9%), North America (20.0%) and the Middle East (14.7%). A small number of publications from Australia were also included in the present systematic review (7.8%).

To gather information the majority of the quantitative papers utilised questionnaires which provided a list of factors or reasons for using CAM based on previous studies. The majority of the included qualitative studies utilised interviews or focus groups with open-ended questions and employed thematic or inductive analyses. Sixty-four percent of the included publications defined CAM based on the National Center for Complementary and Alternative Medicine (NCCAM), the World Health Organization (WHO, 7%), and the others, e.g. the Food and Drug Administration, the Dietary Supplement and Health Education Act (DSHEA), Ernst’s definition, Eisenberg’s definition, etc.

Figure 2 shows an increase in the number of publications related to reasons for CAM use amongst condition-specific populations since 2013, compared with publications involving general populations. The total number of publications dealing with CAM use amongst general and condition-specific populations in this review was 48 (21%) and 179 (77%), respectively. The number of the papers in condition-specific populations is higher than in general populations (Fig. 2 ), i.e. cancer (29.0% of publications), diabetes (5.6% of publications), cardiovascular disease and hypertension (5.2% of publications), human immunodeficiency virus (HIV) (3.5% of publications), inflammatory bowel disease (3% of publications), pain (3% of publications), chronic kidney disease (2.6% of publications), and depression (0.9% of publications). The majority of studies in the present review reported various types of CAM use (69%), followed by herbal medicine (18%) and traditional medicine, including traditional Chinese medicine (1%).

Trend in numbers of the publications of reasons for CAM use

The risk of bias assessment resulted in one quantitative publication being excluded due to poor internal and external validity. The included studies addressing general populations had a low bias risk (mode of a total score = 10, range 7-10), and for condition-specific populations there was a moderate risk of bias (mode of a total score = 7, range 5 – 10). The weaknesses of studies involving condition-specific populations was mainly due to a lack of reporting of their randomisation procedure (73% of the publications), how representative the sample was (64%), and non-response bias (48%). Details of the risk of bias assessment provided in a supplementary material no. 1 .

Lack of reporting the researcher’s background (69% of the publications) and the influence of reseachers on the research (60%) were the main weaknesses of the included qualitative studies in both general and condition-specific populations.

Themes of reasons for use and non-use of CAM

Both quantitative and qualitative studies reported similar reasons for CAM use. Thirty-three (14.3%) publications provided reasons for use as well as non-use of CAM. The present systematic review found three main factors related to reasons for CAM use: positive attitudes toward CAM, negative attitudes toward CM, and other factors, i.e. influence of their social network, their doctor’s recommendation, having an internal health locus of control and tradition (Fig. 3 ). Reasons for non-use of CAM were having negative attitudes toward CAM and positive attitudes toward CM.

Factors related to reasons for CAM use and non-use

Reasons for CAM use amongst general and condition-specific populations

There was no difference in reasons for CAM use between general and condition-specific populations. The top three reported reasons for CAM use in all populations were perceived benefits (84% of publications), and safety of CAM (37%), and dissatisfaction with CM (37%). The most reported expected benefits of CAM were treatment of illnesses, alleviation of symptoms, reducing side effects of CM, maintenance of well-being, or prevention of disease. People also reported that using CAM was a last resort [ 29 , 44 , 52 , 62 , 63 , 64 ]. Improving physical and emotional well-being, and quality of life were further reasons for using CAM in patients with cancer [ 50 , 63 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 ]. The cancer patients also reported using CAM to reduce side effects of CM [ 33 , 45 , 65 , 66 , 69 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 ]. Western populations in both the general and condition-specific populations were more likely to report combining CAM and CM helped them [ 33 , 54 , 74 , 81 , 82 , 83 , 84 ]. Likewise, condition-specific populations in some Asian and Middle East countries perceived that CAM complemented CM [ 63 , 85 , 86 , 87 , 88 , 89 ]. Even though CAM is more likely to be a mainstream therapy in Asian countries, the Asian condition-specific populations tend not use CAM as a substitute for CM. However, CM is substituted with CAM amongst general populations in Japan [ 90 ].

Regarding dissatisfaction with CM, being ineffective and/or causing side effects were the most frequently reported reasons in both general and condition-specific populations for their lack of satisfaction [ 29 , 36 , 40 , 54 , 81 , 87 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 ]. Some patients wanted to use CAM in order to either avoid side effects resulting from CM or to decrease the number of conventional medicines taken [ 49 , 92 , 103 , 108 , 109 , 110 , 111 , 112 ]. A lack of trust in CM as the reason for using CAM was reported in three publications from Asia, two from the Middle East and one from Europe [ 61 , 94 , 113 , 114 , 115 , 116 ]. Additionally, condition-specific populations decided to use CAM to avoid invasive care or aggressive treatment [ 80 , 111 ]; or they were disappointed with or had negative experience of conventional care and/or the staff providing it [ 41 , 80 , 86 , 97 , 103 , 105 , 117 , 118 , 119 ]. CAM users in both Asian and Western populations preferred to visit CAM practitioners because they provided fuller explanations and more time when compared with conventional health professionals [ 34 , 66 , 86 ]. Condition-specific populations in Asia and Africa often found it difficult to access CM; a circumstance which drove them to use CAM [ 97 , 120 ].

Only 8.7% of publications found that condition-specific populations viewed CAM as natural, and thus safe [ 21 , 29 , 49 , 65 , 67 , 76 , 92 , 100 , 106 , 107 , 112 , 114 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 ]. Six studies from Europe, Asia and Africa also reported ‘being curious’ as the reason for using CAM [ 92 , 97 , 130 , 131 , 132 , 133 ].

Other factors were influenced by CAM users’ social networks (27% of publications), having an internal health locus of control defined as preferring to control or decide choices of health treatments themselves (28%), affordability of CAM (24%), willingness to try or use CAM (including hope) (21%), conventional health professionals’ recommendation (18%), easy access to CAM (14%), belief in a holistic approach (12%), and tradition/belief (12%). Internal health locus of control and a holistic approach were more likely to reported by Western populations, as such reasons may be developed from or informed by a Western perspective [ 30 , 31 , 34 , 37 , 42 , 45 , 46 , 48 , 50 , 55 , 56 , 67 , 68 , 71 , 73 , 80 , 91 , 93 , 95 , 106 , 107 , 125 , 126 , 127 , 128 , 130 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 ].

Similarities and differences in reasons for CAM use amongst patients with cancer and other chronic illnesses

The literature shows that patients with various illnesses share the main reasons for CAM use, such as perceived benefits of CAM use or dissatisfaction with CM rather than having different reasons in specific diseases [ 36 , 40 , 41 , 48 , 57 , 62 , 84 , 86 , 87 , 92 , 96 , 99 , 104 , 108 , 125 , 160 , 161 , 162 , 163 , 164 , 165 , 166 , 167 ]. However, being influenced by social media, having an internal health locus of control, or willingness to try CAM were reported more frequently by cancer patients than other members of condition-specific populations (Fig. 4 ). Meanwhile dissatisfaction with CM, affordability of CAM and easy access to CAM were more frequently reported by patients with other chronic illnesses ( p < 0.05). Patients with cancer, whilst accepting the efficacy and safety of CM, may use CAM in order to complement the efficacy of chemotherapy and/or reduce its unpleasant side effects (36% of publications in cancer populations) [ 33 , 34 , 45 , 63 , 64 , 65 , 66 , 67 , 69 , 71 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 88 , 122 , 123 , 124 , 139 , 152 ].

Comparing the reasons for CAM use amongst cancer patients and patients with other chronic illnesses. * Statistical significant at p < 0.05

Reasons for CAM use in each region

There was no global difference in the reported reasons for using CAM, namely the benefits of CAM, dissatisfaction with CM, and safety of CAM, see Fig. 5 . However, the number of publications in Europe (35% of publication), North America (48%) and South America (75%) that reported dissatisfaction with CM as the reason for using CAM was higher than in other populations. The benefits (89% of publications) and safety of CAM (50%) were reported as of the main reasons for CAM use in Australian populations.

Comparison of the reasons for CAM use worldwide. * Statistical significant at p < 0.05

An internal health locus control, affordability and easy access of CAM, as well as tradition/belief were significantly different in each region ( p < 0.05). Internal health locus control influenced people in Australia (50% of publications), South America (50%), and Europe (48%). Additionally, tradition significantly influenced CAM use in South America (38% of publications), Africa (28%) and Asia (17%), compared with other regions. A high proportion of publications in Asian (37%) and Australian populations (33%) reported that social networks influenced them to use CAM, compared with other regions. African populations had the highest proportion of reported affordability of CAM (67%) and easy access (56%) as reasons for CAM use, whilst no report of these reasons was found in European populations. European populations (23% of publications) are more likely to report conventional health professionals’ recommendations for CAM use as their reason, compared with other regions.

Regarding reasons for CAM use amongst Western and Asian populations, Asian populations more frequently reported using CAM due to being influenced by members of their social network, low costs of CAM, easier access to CAM and tradition than Western populations ( p < 0.05), Fig. 6 . Meanwhile, having an internal health locus of control is the main reason for CAM use in Western populations ( p < 0.05).

Comparison of the reasons for CAM use between Asian and Western populations. * Statistical significant at p < 0.05

Reasons for non-use amongst Western and Asian populations

The studies of reasons for non-use are limited compared to the reasons for using CAM, so comparison of the reasons for non-use in each region cannot be made. No publications from the Middle East or South America were included in the present systematic review. Two publications from Africa and Australia were included. The majority of studies in the included publications were conducted in Asia, Europe or North America. Therefore, we compared Asian and Western populations.

Thirty papers in condition-specific populations [ 45 , 47 , 65 , 75 , 79 , 80 , 95 , 107 , 115 , 120 , 123 , 124 , 130 , 150 , 152 , 157 , 162 , 168 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 ], six in general populations [ 180 , 181 , 182 , 183 , 184 , 185 ], one publication involving elderly people [ 53 ] and one publication involving females [ 61 ] reported the reasons for not using CAM. Asian populations more frequently reported doubt about the efficacy of CAM or lower effectiveness of CAM compared to CM, concerns about side effects of CAM, and inconvenience or unavailability of CAM than did members of Western populations ( p < 0.05), Fig. 7 [ 47 , 75 , 79 , 120 , 170 , 172 , 174 , 175 , 176 , 177 , 179 , 180 , 181 ]. Some publications in Asian populations also reported concern about CAM reducing the efficacy of CM as a reason for non-use [ 169 , 170 ].

Reasons for non-use between Asian and Western populations. * Statistical significant at p < 0.05

Meanwhile, Western populations mainly reported satisfaction with CM (45% of publications, p < 0.05) or had never considered using CAM (60%, p < 0.05) [ 45 , 65 , 95 , 123 , 124 , 130 , 150 , 152 , 157 , 162 , 171 , 182 , 184 , 186 ]. Other reasons for the non-use of CAM were lack of reliable information about the efficacy of CAM, the high cost of CAM, and it not being recommended by conventional health professionals or the ‘patient’s’ family.

The included studies in the present systematic review can be seen to represent CAM use worldwide as they were mainly from Asia, Europe, North America, Middle East, and Australia. Recently, researchers in Asia have become interested in this field as several CAMs are embedded in their culture and society. Publications from this region has been rising since 2008; however, readers should be aware that the present systematic review included a small number of eligible publications from Australia and South America. Although a high number of publications originated in Australia, they tended to study specific populations, e.g. middle-aged women, and other topics, rather than reasons for CAM use. Researchers may less likely to investigate reasons for CAM use in South America, compared to other regions. Therefore, the findings in the present systematic review may be less likely to be generalisable in Australian and South American populations.

The present systematic review included a high number of publications amongst cancer, diabetic, cardiovascular disease, and HIV populations. It would therefore seem that illnesses, such as these which cannot be satisfactorily treated by CM, or when CM has significant unpleasant side-effects, drive some patients to seek CAM. Cancer populations have been studied regarding reasons for CAM use more than other condition-specific populations. There are six systematic reviews of the reasons for CAM use in patients with cancer [ 2 , 3 , 5 , 8 , 187 , 188 ].

As expected, three main factors related to reasons for CAM use in the present systematic review were positive attitudes toward CAM, negative attitudes toward CM and other factors, i.e. the influence of their social network, their doctor’s recommendation, having an internal health locus of control and tradition. The top three reported reasons for CAM use were perceived benefits and safety of CAM, and dissatisfaction with CM. These findings are consistent with previous systematic reviews [ 3 , 9 , 10 , 11 , 12 ]. These reasons are similar in both general and condition-specific populations, and in populations from different global regions, as cited frequently above. Although the present systematic review included a limited number of publications from Australia, benefits and safety of CAM were reported as the main reasons for CAM use in Australian populations. These findings agree with a previous systematic review in Australia [ 6 ].

Despite limited scientific evidence for the benefits of CAM [ 189 ], the ‘expected benefits’ of CAM was the most frequently reported reason for CAM use. This finding is not surprising as people tend to seek CAM as a way of meeting their needs or filling a gap left by conventional medicine. The included publications amongst the cancer population are more likely to report CAM use for reducing the negative and often unpleasant side effects of CM. This finding is consistent with systematic reviews of CAM users with prostate or advanced cancer [ 3 , 4 ]. Additionally, the cancer population seems to accept the efficacy and side effects of CM, and therefore uses CAM to complement CM.

Previously, people believed that CAM is natural and safe [ 190 ]. This idea may have led many patients with chronic illnesses on using CAM instead of CM. However, the present systematic review indicates that a small number of the included publications amongst condition-specific populations reported that CAM is safe as a reason for CAM use. Therefore, CAM as natural therapy is not the main reason for CAM use; a point which may be linked to the high number of reported adverse events from using CAM [ 191 , 192 , 193 ]. Patients therefore should use CAM with caution or under supervision from conventional or CAM practitioners.

Regarding other factors related to CAM use in each region, nearly half of the included publications reported that internal health locus control influenced people in Australia, South America, and Europe. However, this reason may have been reported less by Asian, Middle Eastern and African people, as they may not explain their reasons in such terms. Tradition also significantly influenced CAM use in South America, Africa and Asia, compared with other global regions. This orientation may be because CAM, for example, herbal medicine, is embedded in such regions and therefore aligns with their populations’ socio-culture values. Social networks influenced Asian and Australian populations to use CAM, compared with other regions, as they may have a close-knot family or community structure.

Affordability of CAM, together with easy access, are likely to be the main reasons for CAM use amongst African populations. The high cost of, and poor accessibility to, CM appears to influence people to use CAM in Africa [ 57 , 58 , 97 , 164 , 183 , 194 , 195 , 196 , 197 , 198 , 199 , 200 , 201 ]. Meanwhile, no report of these reasons was found in European populations. CAM may not be cheap and easy to access in Europe, compared with CM as users have to personally pay for CAM and it can be difficult to access [ 19 ]. Moreover, European populations are more likely to report conventional health professionals’ recommendations for CAM use as their reason for choosing that option, compared with other global regions. This option may be because health care is readily available in most European countries; so when they have a health problem, they visit their general practitioner.

There are limited publications reporting reasons for non-use of CAM in each region. Further studies relating to this issue are required, particularly in populations from Africa, the Middle East and South America. The present systematic review found that Asian populations are more likely to question the efficacy and safety of CAM, and to be concerned about potentially harmful interactions between herbal medicines and CM. These findings imply that Asian populations seem to understand the limitations of CAM, the efficacy and safety of CAM, and are aware of herb-drug interactions.

The findings confirm that Western populations do not use CAM if they are satisfied with the efficacy and safety of CM. This outcome may be because they can easily access CM, and CAM is less likely to be considered as an option for chronic illnesses in Western countries. However, if they were to become disappointed with the CM/staff, they may decide to use CAM. This possibility is consistent with the systematic review of patients with cancer, which reported that the patients who were satisfied with CM did not use CAM [ 3 ]. Lack of reliable information about the efficacy of CAM, as a barrier to CAM use reported in the present systematic review, is consistent with the findings from a previous systematic review [ 9 ].

Limitations of this review

Although this review only selected a small number of key words, and only three search engines in order to search the literature the findings returned 43% duplicate publications. Further reviews should search using a wide range of CAM types as keywords, e.g. yoga, acupuncture, relaxation, etc., in order to confirm the findings from the present review. There was a small number of publications addressing the reasons for CAM use in South America (n = 8); thus the findings from that continent should be interpreted with caution. This review included only publications in English; as a result the findings did not represent publications in other languages. Regarding the results from the search strategy used in this review, only 5% of the papers were excluded due to being non-English. This outcome is unlikely to have any significant impact on the findings of the present review, as most of the studies were conducted in Europe, from where a high number of publications in English were identified for inclusion in this review.

Results of publications in condition-specific populations representing a national population should also be interpreted with caution due to only 36% of these studies being designed to represent the patient population. The present systematic review found poor external validity of the included studies amongst condition-specific populations, therefore future studies should be aware of this issue.

Impact of the findings for conventional health professionals

Expected benefits of CAM are the main reason for CAM use despite a lack of clinical trials. To promote the rational use of CAM, health care providers should be ready to provide such information to their patients and conventional medicine guidelines should report reliable information about CAM, and be easily available to, health care providers. The findings in the present review have confirmed that being disappointed with CM or associated professional providers, particularly in Western populations, is more likely to influence condition-specific populations to use CAM. To prevent patients from using CAM inappropriately, health care providers should spend more time clearly explaining treatment options, the likely treatment outcomes and potential negative effects of CAM, including herb-drug interactions.

Having an internal health locus of control seems to be a main reason for CAM use in Western populations. This finding implies that patients prefer deciding a therapy by and for themselves. To decrease inappropriate use of CAM, conventional health care providers should offer sufficient health information to their patients, as well as holding a discussion with a patient, before deciding upon a health therapy.

A person’s social network is more likely to influence their decision making regarding CAM in Asian populations. Therefore, health care providers should educate not only patients about how to properly use CAM, but also their friends and family members.

It is clear that the main reasons for CAM use in all populations are a positive attitude toward CAM, that is the perceived benefit and safety of CAM, and a negative attitude toward CM, a dissatisfaction with CM. Having an internal health locus of control is a more frequently reported reason for CAM use in Western populations, whilst being influenced by social networks is a common reason for its adoption amongst Asian populations. Affordability, easy access to CAM and tradition are the most common reasons amongst African populations. Negative attitudes towards CAM and satisfaction with CM are more likely to be the reason for non-use. Conventional health professionals should acknowledge that people may turn to CAM in order to serve their needs. Therefore, health care providers should regularly ask their patients about their use of CAM before that providers prescribes any conventional medicines, in order to prevent undesirable adverse effects or CAM-drug interactions. Further studies are required to investigate reasons for CAM use in South America and reasons for non-use in all global regions, in order to provide more conclusive evidence in this field.

Availability of data and materials

The included publications in this systematic review were assessed their risk of bias in order to evaluate the quality of publications. This information provided in its supplementary information file. The other datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Complementary and Alternative Medicine

Conventional Medicine

Human Immunodeficiency Virus

The Preferred Reporting Items for Systematic Revews and Meta-Analyses

The United Kingdom

The United States

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Tangkiatkumjai, M., Boardman, H. & Walker, DM. Potential factors that influence usage of complementary and alternative medicine worldwide: a systematic review. BMC Complement Med Ther 20 , 363 (2020). https://doi.org/10.1186/s12906-020-03157-2

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• v.322(7279); 2001 Jan 20

Research into complementary and alternative medicine: problems and potential

Richard l nahin.

a Division of Extramural Research, Training and Review, National Center for Complementary and Alternative Medicine, National Institutes of Health, 9000 Rockville Pike, Bethesda MD 20892-2182, USA, b National Center for Complementary and Alternative Medicine

Stephen E Straus

The growing use of unsubstantiated complementary and alternative medicine therapies by people in the United States 1 along with its increasing coverage by third party payers 2 encouraged Congress to create the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health. The centre's mission is “to explore complementary and alternative healing practices in the context of rigorous science; to educate and training CAM researchers; and to disseminate authoritative information to the public and professionals.” 3 To complete this mission, NCCAM supports publicly relevant and scientifically rigorous research to identify those complementary and alternative medicine practices that are safe and effective.

The centre's resources, although generous ($68.3m (£46m) for fiscal year 2000), are not sufficient to study all complementary and alternative medicine practices. NCCAM therefore developed criteria to help prioritise the many possible research opportunities (box). As part of the evaluation process, NCCAM seeks advice from its national advisory council, complementary and alternative medicine and conventional clinicians, members of the scientific research community, the public, sister federal agencies, and other stakeholders.

Summary points

• Many early clinical trials investigating complementary and alternative medicine have had serious flaws
• Clinical investigations of complementary and alternative medicine are made difficult by factors such as use of complex, individualised treatments and lack of standardisation of herbal medicines
• Other problems include difficulties in accruing, randomising, and retaining patients and in identifying appropriate placebo interventions
• Despite these complexities, rigorously designed clinical trials are possible, including pragmatic studies of complete complementary and alternative medicine systems
• Strong commitment is required from the research community to provide information about complementary and alternative medicines to the public and health professionals

Allocation of resources

Staff at the centre are often asked why limited resources are being spent on research that is perceived as replicating previously published work, especially when other western countries have already integrated some of these practices into standard care. Unfortunately, many of the studies have been small, their results variable or inconsistent, and their research designs inadequate. Systematic reviews have found that many clinical trials testing complementary or alternative medicine have major flaws, such as insufficient statistical power, poor controls, inconsistency of treatment or product, and lack of comparisons with other treatments, with placebo, or with both. These reviews typically conclude that larger, well designed studies are necessary before making authoritative recommendations. Specific examples of such reviews include the use of Hypericum perforatum (St John's wort) to treat depression 4 ; Ginkgo biloba to delay cognitive decline in patients with Alzheimer's disease 5 ; Serenoa repens (saw palmetto) to relieve symptoms associated with benign prostatic hyperplasia 6 ; and glucosamine and chondroitin sulphate to treat osteoarthritis. 7 NCCAM is currently supporting randomised controlled trials for these four dietary supplements that have been designed with the scientific rigour demanded by experienced scientists and the American public.

One reason for investing so much in research into dietary supplements is that their use is growing rapidly in the United States. Although consultations with complementary and alternative medicine practitioners (acupuncturists, chiropractors, naturopathic physicians, etc) remained stable on a percentage basis from 1993 8 to 1998, 1 use of dietary supplements greatly increased. Billions of dollars are spent on dietary supplements in the United States every year. The Dietary Supplement Health and Education Act, which was passed in 1994, made it easier to obtain these natural products. The act also loosened the federal control over dietary supplements, with the result that most commercially available products are not well characterised or standardised. Another issue is that the optimal dose, schedule, and route of administration of most dietary supplements have not been determined systematically; nor are the frequency and extent of drug reactions and interactions known. NCCAM therefore believes that most dietary supplements are not yet ready for large, expensive trials despite their wide use by patients. At a minimum, preclinical studies, pharmacokinetics testing, and developmental phase I and II trials are necessary before these products can be launched into definitive clinical trials. NCCAM is vigorously encouraging research in these areas through a series of focused initiatives. 9

Criteria for prioritising research opportunities

• Quantity and quality of available preliminary data to help determine the most appropriate type of research (basic versus clinical research; phase I or II clinical trial versus phase III trial)
• Extent of use by the US public (greatest weight given to interventions in wide use)
• Public health importance of disease being treated (greatest weight to diseases associated with highest mortality or morbidity or for which conventional medicine has not proved optimal)
• Feasibility of conducting the research
• Cost of research

Problems with research design

Although many people in the United States self medicate with dietary supplements, many others seek care from practitioners of traditional systems of medicine, including Ayurveda (from India), Kampo (from Japan), traditional Chinese medicine, Native American medicine, and more recently developed systems such as naturopathy and chiropractic. 1 , 10 – 12 Despite the diverse cultures, geographical locations, and beliefs from which these systems developed, they share several common characteristics such as the use of complex interventions often including botanical medications; individualised diagnosis and treatment of patients; an emphasis on maximising the body's inherent healing ability; and treatment of the “whole” patient by addressing their physical, mental, and spiritual attributes rather than focusing on a specific pathogenic process as emphasised in western biomedicine.

Despite this emphasis on multimodality treatment regimens, most research investigating traditional systems of medicine have examined only one, or perhaps two, interventions taken from a whole treatment system. For instance, there are hundreds of small studies examining the efficacy of acupuncture needling alone for treating asthma, pain, hypertension, or nausea. Yet in real practice, acupuncture needling would be just one of an arsenal of interventions used by a licensed acupuncturist including botanical potions, cupping, dietary changes, exercise therapy (such as Tai Chi or Qi Gong), moxibustion, and Chinese massage. Similarly interventions such as yoga, a single botanical medication, or meditation are just single components of complex systems of medicine. So investigators are faced with either designing a trial of a single intervention that does not accurately reflect true clinical practice or undertaking a multifaceted intervention trial that is complicated to design and implement.

Research design is further confounded by the wide variation in how many forms of complementary and alternative medicine are practised. For instance, there are multiple approaches of chiropractic medicine and acupuncture practised in the United States. Within these approaches the treatment may vary for individual patients presenting with the same conventional diagnosis because practitioners often focus on the symptoms of the disease rather than a primary pathology. Furthermore, the number and length of treatments and the specific treatment used may vary both between individuals and for an individual during the course of treatment. For example, when designing a randomised controlled trial for acupuncture, the investigator is faced with choices concerning the selection of points, the depth of needle insertion, and the frequency and scheduling of treatment. Unless these choices are made in an evidence based fashion, the trial will be compromised.

Difficulties in accruing, randomising, and retaining patients are other potential areas of concern. Some issues common to all clinical trials, such as the use of broad exclusion criteria and inadequate outreach to underserved populations, can limit patient participation and reduce generalisability. We also know that patients with a strong preference for a particular treatment will refuse randomisation. 13 – 15 Moreover, should patients accept randomisation, the easy access of dietary supplements and other complementary interventions in the open market greatly increases the likelihood of “cheating” by the control group. This problem has also been found in trials of dietary and behavioural interventions used in conventional medicine. 16

Finding appropriate placebos or shams for treatments such as acupuncture, chiropractic, massage therapy, or complex herbal mixtures is challenging. Complementary and alternative treatments typically involve extended and intensive interactions between the patient and the practitioner, which greatly increase the possibility of a placebo effect. 17 , 18 Double blinding of the interventions may not be possible because the experienced practitioner will know which treatment is sham and which the intervention. The practitioner, in turn, may consciously or unconsciously convey this information to the patient. The variability of practice also affects the choice of a placebo. 19 For instance, superficial insertion of acupuncture needles at valid acupuncture points has been used as a control in many acupuncture trials. 20 , 21 Yet, the Japanese school of acupuncture advocates that such superficial needling is effective, and some research supports this view. 22

Approaches to good design

Given the complex nature of diagnosis and treatment in traditional systems of medicine, how should we design clinical trials? Approaches vary from that of the typical pharmaceutical drug trial, in which strict, standardised diagnostic criteria are used with a defined and standardised treatment, to the other extreme, in which investigations of a whole system are undertaken in its proper context so that both the diagnosis and treatment may be highly individualised.

In studies of a system of traditional medicine to treat a specific disease the investigators consider the system as a whole, instead of a single core modality. These full spectrum studies can be done without identifying the underlying mechanism of action for each intervention, provided there is a clear, clinically relevant end point. For example, NCCAM is currently supporting a phase II randomised trial comparing three approaches to treating women with temporomandibular disorder: naturopathic medicine, traditional Chinese medicine, and usual conventional care. Patients randomised to receive either naturopathic or Chinese medicine are diagnosed and treated in the traditional manner. The end points for the study include validated measures of temporomandibular disease as well as reassessment of the naturopathic or Chinese medicine diagnosis, with all variables being analysed on an intention to treat basis.

A second approach is to study a specific modality adapted from a traditional system of medicine for treating a specific disease. NCCAM currently supports several such trials, including a double blind randomised controlled trial of acupuncture using traditional Chinese medicine needling points specific for depression. The treatment is compared with acupuncture at points that are used to treat other conditions and a waiting list control. The acupuncture treatments are individualised and based on the Chinese medicine diagnosis. Blinding is maintained by having different practitioners diagnose, treat, and evaluate the patients. Monthly assessment by the diagnosing acupuncturist allows for modifications of the treatment plan as needed. The outcome measures include both standard measures of depression (such as the Hamilton rating scale for depression) and reassessment of the Chinese medicine diagnosis, with all analysis done on an intention to treat basis.

A third approach is a trial of a single intervention, such as a herbal medicine to treat a conventionally diagnosed disease. This is the most common approach currently used to investigate complementary and alternative medicine, and ongoing trials are studying hypericum for depression; acupuncture for symptomatic relief of osteoarthritis; G biloba for preventing dementia; shark cartilage as an adjunctive therapy for non-small cell lung cancer; and glucosamine and chondroitin for osteoarthritis.

All of the above examples are randomised controlled trials. They show that despite increases in complexity and possibly cost, it is possible to design high quality trials investigating complementary and alternative medicine. However, the trials require much more preparation than trials of conventional medicine and individual trial components (blinding, placebo, consistency of intervention even if individualised, etc) often need extensive piloting before the trial.

Although randomised controlled trials are the accepted standard of clinical research, NCCAM values other types of high quality research, including careful observational studies. For many complementary and alternative therapies, there is no reliable information concerning the types of practices used for particular diseases or conditions; the numbers and types of patients who use them; how the practices are delivered (including dose used); how well patients respond to treatment; and relevant side effects. These issues can be investigated in observational studies. In addition, observational studies afford pragmatic ways of answering some types of questions, such as the evaluation of rare adverse events, as well as being a viable research option when randomisation of patients might be considered unethical or unacceptable.

The conduct of high quality research on complementary and alternative medicine requires a commitment by the research community, as well as sustained financial support from governments and industry. This commitment is essential if the public and healthcare providers are to have sufficient information on safety and efficacy to make informed decisions concerning use of complementary and alternative medicine. We envision that compelling data will facilitate meaningful interactions between conventional and complementary practitioners and ultimately lead to the development of interdisciplinary partnerships that incorporate validated complementary practices into patient care.

National Institutes of Health data show steep growth in expenditure on dietary supplements

  Competing interests: None declared.

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Study demonstrates the advantages of S/U grades for D.V.M. students

While S/U grading has been used at other institutions, it has not been widely applied at CVM, and the research team took advantage of the opportunity to explore the effects of an alternative system. Photo: Chris Montgomery/Unsplash

Researchers from the Cornell University College of Veterinary Medicine (CVM) found that a satisfactory/unsatisfactory (S/U) grading system used during the early months of COVID-19 increased veterinary students’ well-being and time for self-care without sacrificing academic performance. According to their paper, published in the Journal of Veterinary Medical Education , D.V.M. students performed similarly on letter-graded and S/U coursework, offering the opportunity to consider alternative grading systems that support both students’ health and learning.

Research has shown that workplace burnout is prevalent among veterinarians, highlighting the importance of promoting well-being during training and beyond. “In our profession we have a responsibility to investigate ways to improve the lives of our D.V.M. students as they transition into their professional careers,” said study co-author and assistant clinical professor in the Department of Population Medicine and Diagnostic Sciences Ashleigh Newman ‘06.

Pandemic grading alternative offers research opportunity

After stay-at-home orders were issued in New York, Cornell temporarily offered an S/U grading system for the spring 2020 semester before returning to standard-letter grading in the fall. First author Kelly Lyboldt, D.V.M. ‘05, an associate professor of practice in the Department of Biomedical Sciences, said that professors were concerned about the impacts the rapid conversion to online courses might have on students’ stress levels and learning. The college ultimately decided to institute S/U grading for DVM students.

While pass/fail grading isn’t common in academia, human medicine programs have experimented with S/U grading since the 1960s to allay students’ anxiety. Studies showed that S/U grading positively affected students’ well-being without altering academic outcomes. Opponents have argued that alternatives to letter grades could undermine the rigor of medical training. Still, human medical students have received S/U grades on United States Medical Licensing Examinations since 2022, shifting the emphasis from numerical scores to clinical excellence and interpersonal skills.

While S/U grading has been used at other institutions, it has not been widely applied at CVM,, and thus the team took advantage of the opportunity to explore the effects of an alternative system. A cohort of veterinary students took a core course that spanned the spring and fall 2020 semesters, and faculty were able to compare the results of S/U and letter-graded classes. According to Lyboldt, the research team hypothesized that the S/U system would alleviate students’ stress over their GPAs without sacrificing motivation or academic success.

The team used academic performance data from the 2020 Foundation Course III — a two-part course on animal organ systems covering physiology, pharmacology, clinical pathology, and anatomic pathology — along with a questionnaire about students’ educational experiences and well-being during the course. While students received S/U grades for the spring 2020 course, administrative support kept track of their numerical and letter grades for both semesters, since a “Satisfactory” grade requires a final score above C –. Out of 118 students in the cohort, 68% responded to the questionnaire.

Gaining time for self-care while maintaining motivation to learn

In terms of academic performance, the grading system made little difference in students’ final numerical grades: 83.7% and 84.3% for the spring and fall 2020 semesters, respectively. Data also supported the team’s prediction that, without the pressure of achieving a particular letter grade, 95% of students reported redirecting some of their energy to achieving a healthier balance between academics and caring for their physical and mental wellbeing.

A majority of students saw S/U grading and the open-book exams that accompanied it positively.

One critique around S/U grading in educational literature involves motivation: will students still work hard if they’re not striving for a high GPA? Fortunately, students said their motivation to study was unchanged by the grading system. Around half of those who agreed that S/U grading contributed to their well-being on the survey reported improved learning and enjoyment of the material.

“A lot of us noticed our conversations with students in the spring S/U semester were drastically different than those in the fall,” said Lyboldt. “They seemed more curious about the material, and asked about content instead of points on a quiz.”

Not everyone enjoyed the temporary grading system. Almost 50% of questionnaire responders would have preferred a final letter grade in the spring 2020 class. The authors suspect that’s because grades are important for internships, and their spring 2020 grades would have enhanced their overall GPAs.

The future of S/U grading at CVM

While CVM isn’t throwing in the towel on letter grades, the college did move to S/U grading for fourth-year D.V.M. students performing clinical rotations. Foundation Course III is now hybrid, with weekly S/U quizzes and built-in reflection opportunities for graded assignments, along with a letter-graded final exam and letter for the final grade.

Eleni Casseri, M.P.H. ’19, D.V.M. ’24, took a hybrid version of Foundation Course III. “The pass/fail grading on the quizzes took a lot of pressure off me,” she said. “It wasn’t about whether I got 80% or 85%; it was about learning material because I’m going to be a doctor someday. I felt like I wasn’t just trying to pass another class.”

The research team also believes that S/U grading allows students the space for low-stakes failures and learning resilience. “Our veterinary students are very intelligent and motivated individuals,” said Kathryn D. Bach ‘04, M.S. ‘09, Ph.D. ‘19, paper co-author and lecturer in the Department of Population Medicine and Diagnostic Sciences. “We want them to focus on growing after their mistakes instead of stressing about impacts to their GPAs.”

Antonia Jameson Jordan, D.V.M. ‘99, Ph.D. ’08, is a senior lecturer in the Department of Biomedical Sciences and paper co-author who sees S/U grades within a larger context. “Our students have been pushing for years for the college to support their wellness,” she explained. “It’s great to find systems that support students’ learning, health, and ability to be great veterinarians.”

As CVM continues to examine and refine its curriculum, these findings will help in establishing approaches that optimize long-term learning and healthy habits for sustaining a lifetime of career satisfaction in veterinary medicine.

Written by Jennifer DeMoss

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