This research study is the first known qualitative study in Hawaiʻi developed to identify the perceptions of CAM in adults. The past studies of CAM in Hawaiʻi were quantitative and provided data on the types and frequency of CAM that was used [10,11,12, 25]. Findings of the current study may have implications for local and national policy makers, medical and CAM practitioners, and future research studies.

It is important to note that the definition and terminology of CAM is evolving. It can be seen through the history of the NCCIH, which has undergone several name changes in the past in efforts to embody an accurate definition and label. There has been ongoing debate about how to define CAM and what constitutes CAM use [26].For instance, in other countries where CAM therapies are the primary method of care, the terms complementary and alternative do not apply [27]. For the purpose of this study, the NCCIH definition was provided to the participants during the interview to minimize ambiguity.

The perceptions of CAM may influence the choice to use or not use these therapies. The results of our study demonstrated the perceptions of CAM among participants were mainly positive. All 19 self-reported CAM users had positive perceptions while the three reported non-CAM users had negative perceptions. Our participants were predominantly female (n = 17). Of note, previous studies have demonstrated that females are more likely to use CAM [28,29,30]. However, one past study in Hawaii has reported that the use of provider delivered-CAM was comparable between males and females [10]..

The perception that CAM is effective is the most common positive perception in the current study and was found to be commonly observed in previous studies. A study of 13 menopausal women in Canada reported that the participants believed their personal CAM use was effective in the treatment of their symptoms [31]. Additionally, Bahall et al. similarly reported Trinidad cardiac patients believed CAM use improved their health and increased positive clinical outcomes [32]. Another study conducted in South Korea on 649 young adults also reported that more than half of the participants perceived CAM to be effective at relieving their pain and other symptoms [33]. In this context, we could suggest from our results that users of CAM are generally satisfied with its outcomes. Like in the studies mentioned, CAM accomplished and reached their expectations of the treatment, which is why the users have positive perceptions.

The perception that CAM is “better” than conventional medicine, and therefore more desirable, has also been reported in previous studies. It is perceived that CAM has minimal side effects compared to conventional medicine. Bahall et al. similarly reported that CAM use in Trinidad cardiac patients was greatly favored due to conventional medicine’s undesirable side effects [34]. This result was repeated in a study of breast cancer survivors, which revealed some participants decided to use CAM because conventional medicine was not effective and its side effects required additional medical treatment [35]. As participants in the current study reported, a major push factor for CAM use is dissatisfaction of conventional medicine, and specifically due to the undesirable side effects that come from conventional medicine treatment plans.

The perception that CAM fosters well-being can be seen in other studies. For example, a study of type 2 diabetic patients in Taiwan revealed participants utilize CAM to improve their well-being, but also perceived CAM to be a necessity in their treatment of type 2 diabetes [36]. In contrast, a research study in Southern England described a phenomena of CAM use as a “treat” rather than a “treatment” [37]. A “treat” was a personal luxury or desire in the absence of a health need. In contrast, a “treatment” was utilized as a mean of prevention, alleviation, or cure for specific health ailments [37]. Results from these two studies mirror the perspective of the majority of our participants who claim CAM helps them feel good when used as a treatment and/or as a treat to foster well-being.

In addition, neutral perceptions of CAM corresponded to the natural and holistic characteristics. There is a common belief among CAM users in which CAM treats the person in a holistic approach by solving the root cause of disease, making it a highly favored treatment strategy. Nichol et al. reported similar ideals after having conducted a qualitative study of 15 families in Bristol, England [38]. The results demonstrated a recurring perception that CAM is natural and holistic, meaning there is little to no manipulation by man in a lab. In contrast to the present study, the participants also reported an overall “negative definition of CAM” because they thought CAM was not “medicine”. Another study in menopausal women from California showed that most of its participants considered CAM to be natural, which was desirable [39]. Another neutral perception of CAM in our study is related to CAM’s safety, in that it is not universally safe and is dependent on variable circumstances.

The negative perceptions of CAM the current study found is comparable to a qualitative study conducted with head and neck cancer patients [40]. Similarly, this study had more positive perceptions with few negative perceptions. Of the negative perceptions, the participants shared that CAM is ineffective, is a mere placebo, and is unregulated. These results are similar to those of the current study.

This study’s results have implications for policy development, practice implementation, and future research. These findings could further promote efforts to integrate CAM into mainstream health care systems through policy development and augmentation for the inclusion of CAM education provisions for all health care providers (HCP) [41]. Our data revealed that 10 participants didn’t discuss their CAM use with their doctor. Evidence suggests patients have a tendency to withhold CAM use from their healthcare providers [42]. An Australian study showed 57.2% of 1270 CAM users did not report to their doctor [43]. Meanwhile, a study of 438 physicians in Italy revealed that about half of the participants did not engage their patients in discussions about CAM [44]. A 2015 US study of 1767 adult CAM users reported 46.7% did not inform their doctor about their CAM use [45]. In the current study, most CAM users identified as being a complementary user because of their dual practice of conventional medicine and alternative medicine. Thus, communication between the HCP and their patients becomes a critical element of providing safe and effective treatment plans. An example of the integration of CAM through policy implementation would be expanding the HCPs’ scope of practice to require CAM education for each patient and to encourage HCPs to engage and initiate conversations with patients about their CAM use.

CAM use in Hawaii may be influenced by the connection between ethnicity and which CAM remedy is utilized. Results from a national study in the United States concluded CAM use differs among groups and ethnicity plays an independent role in the use of CAM modalities, the health problems for which CAM is used, and the choice of CAM practitioners [46]. Another study in California further supports the notion that patterns of CAM use and ethnic-specific CAM use vary across racial/ethnic groups [47]. This study concluded evaluation of CAM use in ethnically diverse populations should recognize ethnic-specific modalities and variation across ethnicities, which continues to emphasize the deep need for HCPs to construct cultural appropriate screening of CAM use within their patient populations.

The current study’s results also have implications for the safety and well-being of patients. Due to positive perceptions, the patient may unknowingly harm themselves when using CAM due to lack of professional guidance and inaccurate knowledge. It is the HCP’s responsibility to be fully aware of all CAM and non-CAM therapies in which their patients partake, as there is a risk of drug-drug and drug-herb interactions. To elicit this information from patients, HCPs would benefit from taking a patient-centered approach to foster a welcoming and non-judgmental environment. Engaging in the practice of patient-centered care will ensure the patient communicates about their CAM use or desire to use CAM.

In addition to integration of CAM into patient-practitioner discussion, our results reveal the importance of promulgating CAM products, such as herbs, vitamins, and minerals. The most common types of CAM products used in the current study are vitamin, mineral, and herbal supplements. Results in previous studies related to Hawaiʻi CAM [10, 12] suggest that natural products are the most common types of CAM used. The lack of regulatory policies could have an impact on CAM users’ safety and the efficacy of CAM as a whole-person treatment system. For instance, risks of taking unregulated CAM supplements include possible vitamin/mineral toxicities and heavy metal exposure. Current FDA regulation regards dietary supplements as food rather than as drugs. The result is fewer and less strict FDA rules for dietary supplements compared to drug regulations [48]. FDA policy purports that dietary supplements are not making claims to diagnose, treat, cure, or prevent disease. The perceptions of CAM users indicate beliefs contrary to FDA policy.

Future research about CAM is warranted. First, additional rigorous studies to evaluate the efficacy of specific CAM treatment interventions should be conducted. Secondly, an in-depth analysis of conventional medicine and CAM integration should be conducted to explore common beneficial and protective factors, combination potentiating factors, and detrimental risk factors. The potential of how perceptions impact health care decisions, and how positive perceptions correlate with CAM use, should be explored. These results could inform CAM providers and guide educational efforts in medical schools. Additional studies should be conducted to investigate the effect of various ethnicities on CAM use and if utilizing at home CAM treatments are more cost effective. Lastly, the triangulation of perspectives between healthcare professionals not providing CAM, healthcare professionals providing CAM, and active CAM users is needed in order to gain deeper insight into the integration of CAM into the entirety of the prevailing healthcare system.

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