Table 1 describes the sociodemographic characteristics of participants from group 1 (Lebanese adults), group 2 (CAM providers), and group 3 (HCPs). The mean age of participants was 37.8, 47.8 and 36 years for groups 1, 2, and 3, respectively. Approximately, 71% of group 1, 46% of group 2, and 57% of group 3 were males. The majority of participants from group 1 (64.3%) and all subjects from groups 2 and 3 were employed.
General overview of interviews
The results of the thematic analysis of the interviews are presented within three main themes and their corresponding sub-themes: the understanding of CAM, the Push and the Pull factors. For each domain, a selection of participants’ quotes is included in this section. A more extensive list of the quotes for each domain are presented in Additional file 4.
Understanding of CAM
Despite a few differences using the triangulation approach, the three study groups had similar perspectives on what CAM stands for and its various types.
The majority of participants from the three study groups understood CAM as an umbrella concept that encompasses all products and practices that are used to manage different health conditions other than CM. This was conveyed through statements like “different than conventional medicine”, “not part of conventional medicine”, and “other than standardized medical care”. Study participants also described CAM as everything that is “cultural”, “traditional”, and “ancient”.
Participants from all stakeholder groups had a generally good knowledge of the different types of CAM and all combined listed a total of 32 distinct practices belonging to the CAM categories. A number of listed practices were however not part of the conventional CAM categories such as exercise, drawing, psychological therapy, hypnosis, and a number of folkloric and cultural practices (e.g. use of natural soaps and salts), reflecting a certain degree of ambiguity in the conceptualization of CAM among participants. Herbal medicine was the most frequently listed type of CAM (58.5% of participants), followed by Chinese medicine (36.5%), and cupping therapy (Hujama) (26.8%). Around 22% of participants mentioned faith, religion, or a form of prayer as a type of CAM that people commonly resort to in Lebanon.
Participants from all groups clearly differentiated CAM from CM and made numerous comparisons between them. For Lebanese adults, the main difference between CAM and CM was that CAM is “natural”, “non-chemical”, and “non-pharmacological”, while CM is mostly referred to as chemical and invasive, having used terms like “taking medications”, “injections”, “chemical pills”, “pharmacological”, “visiting the doctor”, and “surgical and physical medicine” to refer to it.
A few adults described CAM as holistic health practices that engage the mind to promote health and physical wellbeing and focus on the interactions between the brain, body, and soul. In this group, a few participants distinguished between CAM and CM with regards to scientific legitimacy wherein CM was associated with scientific evidence and CAM was not. One Lebanese adult defined CAM as “everything that is not pharmacological, has not been tested, and lacks supportive assessment”.
The statements of the CAM providers generally echoed those of Lebanese adults as they viewed their therapies as natural and more “holistic”, “multi-disciplinary”, “individualized”, and “empowering” alternatives to CM. For CAM providers, the holistic nature of CAM was its primary distinguishing factor from CM, and the reason why they thought CAM was more effective than CM.
Examples of statements made by CAM providers include:
G2_2: “I believe that CAM is the way to heal everything because I believe that the mind is really powerful, and it controls every part of us.”
G2_3: “CAM works on detoxifying the body, mind, and spirit and works on reestablishing these connections. To reach wellness you need a balance of the three”.
CAM providers disagreed, both among themselves and with Lebanese adults, on what the scope of practice for CAM is and should be. While some acknowledged that CM treatments are necessary and indispensable when it comes to treating “complex” conditions such as cancer, and that CAM’s effectiveness is limited to rather less complex ailments, others believed that the practice of CAM should be better recognized given that CAM is the historical foundational basis of modern CM and “the first medicine on earth”. As asserted by one CAM provider:
G2-9: “Alternative medicine is not an accurate term; it [CAM] should be referred to as the main medicine. One hundred years ago, this type of medicine was available in all houses and its development resulted in today’s medicine that is being taught in universities”.
As for Lebanese HCPs, the definition of CAM revolved primarily around the therapies that “were not taught in medical school” and that they “prescribed to patients other than pills and medications”. In general, HCPs expressed positive views towards CAM, describing it as a “diverse field of medicine” that is “progressively growing”. Some HCPs acknowledged that CAM might be a “satisfying alternative” to CM for patients as it may provide them with “psychological relief”, especially when traditional medicine “cannot intervene” or causes side effects. Only one HCP thought CAM was a field that is new and unknown in Lebanon and the Middle Eastern region in general.
Push and Pull Factors
Participants from the three study groups expressed a range of views on the factors that drive CAM use in Lebanon, including the two a priori themes1) Push factors which drive Lebanese patients away from the use of CM; and 2) Pull factors which make CAM therapies more attractive treatment options. Within each of these themes, subthemes emerged from the data collection. We compared the perspectives of Lebanese adults with that of CAM providers and Lebanese HCPs with regards to these different subthemes.
Limitations of CM are gains for CAM
Participants from all three study groups agreed among each other that failure of CM to treat conditions or alleviate symptoms is the primary factor that pushes patients away from CM and towards the use of CAM. Lebanese adults shared different experiences where they felt desperate after being told that they had incurable conditions, had developed resistance to biomedical treatments, or had experienced more suffering from conventional treatments, but had then found relief in CAM. The below quotes showcase different instances where CAM was used as a last resort out of desperation and loss of hope in CM:
G1_1: “I had a car accident that caused me neck pain which was extended to my arms. I visited many class (A) doctors in Lebanon who prescribed medications, cortisone, and physiotherapy, but nothing was beneficial. That is why I went for an osteopath. The first session was very painful, but after 3 days, the pain was reduced by 50% and after 15 days the feeling of numbness in my hands was completely gone.”
G1_4: “I went to a doctor who did a lot of hearing tests and told me that my case has no cure and that I must live with it. Then my husband told my case to another doctor who prescribed this herbal medication. After taking it, I found it to be very beneficial.”
CAM providers added that CM treatments are generally limited in the scope of care they provide, and that what patients often seek in CAM in terms of psychological support and individualized care is often not offered in conventional care. A few CAM providers said:
G2_1: “CAM is a holistic alternative that focuses on spiritual, psychological, biological, and other factors that are not addressed in the classical conventional medicine”.
G2_2: “I also think in many cases the use of CAM is related to the limitations in medicine as medicine alone is not enough”.
Participants from all study groups noted that patients often seek CAM therapies as a last resort after having tried conventional therapies. While only two Lebanese adults said they had dropped CM when it failed to bring them satisfaction, the majority combined CM with one or more CAM modality for the management of a given condition though to different extents. One HCP said:
HCPs acknowledged that CAM could offer a viable treatment option to desperate patients when CM fails and shared their positive experiences on CAM and how it helped patients feel better. One HCP said:
G3_1: “I have seen cases such as vitiligo whereby years of traditional treatments didn’t cure the patient, then he used herbal medicine and got cured. Patient infertility is another example. The patient used CAM (herbal medicine) and then she got pregnant.”
Distrust in the CM system
Lebanese adults spoke of another major factor that pushes them away from CM and towards the use of CAM, which is their mistrust in Lebanese physicians’ knowledge and intentions when prescribing medication. Lebanese adults shared a common perception that HCPs are primarily driven by financial gain, and are influenced by pressure from pharmaceutical companies to prescribe their products. Lebanese adults and a few CAM providers believed that HCPs in Lebanon view the CAM industry as a threat to their business, which makes the intentions behind their advice on CAM questionable. One CAM provider said:
G2_6: “Traditional medicine practitioners might think that CAM providers are taking away their patients, so they start thinking in a selfish way, believing that CAM might decrease the number of patients, so they don’t encourage its use”.
The below quote reflects Lebanese adults’ negative perceptions towards physicians’ knowledge and intentions.
A combination of other factors related to specific aspects of the patient-physician interaction were also found to account for Lebanese adults’ dissatisfaction with CM. These included physician’s inadequate explanation of the reasons to advise against CAM, little time spent to discuss alternative treatment options with the patient, and physicians’ general lack of understanding of patients’ need for CAM, as shown in the excerpts below.
G1_6: “He [the physician] will not understand. He will tell me there are medications why would you take this herb”.
G2_1: “Classical conventional medicine does not give enough time to the patient. Therefore, patients refer to CAM. The ideal timing and care that the patient usually seeks are found in alternative medicine.”
HCPs attributed their negative attitude towards CAM to their lack of knowledge on its use and to their concerns over its safety, which are primarily related to the lack of experience and exposure to CAM in medical schools and the paucity of scientific studies on CAM. The below excerpts summarize HCPs point of view on this issue:
G3_1: “Health care providers aren’t knowledgeable about CAM. This is a weakness for me because we don’t study CAM in university because there aren’t enough studies on it. But it is being used very commonly. When we encounter someone using CAM we don’t know how to react, we don’t have the knowledge and we have to make a personal effort and search for information on it”.
G3_4: “If a patient comes to me and tells me that they are taking a certain type of herbal medication, I will tell them that we don’t support it because we don’t have enough information on it. As a healthcare provider, I think that I don’t have much information about it because we have a kind of blockage towards it. We always stop their use and advise for drugs that are tested and that can be used safely without any side effects, unlike CAM whose side effects are not clearly known”.
In addition to the mentioned Push factors, a number of CAM providers also believed that patients who start using CAM simply seek to “avoid the chemicals” and “the side effects that are secondary to conventional treatments” and use what they perceive as natural and safer alternatives.
The three groups of the study population all addressed a number of “Pull” factors that make CAM an attractive treatment option, though their perspectives were, in some instances, divergent. These factors include the perceived effectiveness and safety of CAM, CAM therapies’ lower cost compared to CM treatments, as well as the significant role of social network in shaping their CAM knowledge and behaviors.
Perceived effectiveness and safety
A few Lebanese adults believed that CAM therapies work on the biological aspect of the disease while others described its effects to be “both biological and psychological”. CAM providers believed CAM therapies to be effective in “boosting immunity”, “reducing oxidation”, “increasing oxygen availability”, and “cleansing the body”, which in turn would protect from diseases in early and preventative stages.
A few other CAM providers added that the holistic and non-chemical nature of CAM therapies evokes a certain degree of psychological relief and a sense of empowerment in patients, which adds another layer to its effectiveness.
When discussing the types and stages of diseases where CAM is effective the most, different opinions were shared. One Lebanese adult believed in CAM’s ability to “decrease the progression of chronic diseases”, while another stated that “CAM is effective on acute diseases and conditions such as scars and inflammation” only. On the other hand, only three HCPs believed in the effectiveness of CAM at all, except in cases where traditional medicine fails to treat such as in cases of infertility, vitiligo, and rheumatism.
While most Lebanese adults and CAM providers perceived CAM therapies to be natural and thus safe, participants from the HCPs group raised concerns over CAM therapies’ safety and elaborated on the reasons behind their reluctance to advise patients on CAM. HCPs emphasized the lack of scientific evidence behind the use of most CAM therapies, their unknown side effects and levels of toxicity, as well as the lack of regulation of the CAM industry in Lebanon. One HCP said:
G3_1: “Afterall, even though they [CAM] are herbs, they also contain chemicals and the reaction to them depends on the dosage. So as long as we don’t know the dosage or the type of CAM they [patients] are taking, patients are at great risk of developing side effects. Not to mention that some herbs are even poisonous”.
Participants from all three study groups agreed that CAM’s lower cost compared to CM makes it a much more attractive option for patients who seek cheaper and cost-effective treatments to manage their ailments, especially when considering some CAM therapies such as prayer or laughter. Below are a few quotes to reflect the role of cost as an enabler of CAM use.
G1_9: “CAM also saves money. It is not necessary to take medications every time I have a sore throat. Each medication might cost around 20$, so I resort to herbal remedies first”.
G2_5: “Laughter yoga is not costly, since all you need is to laugh and allow this laughter to happen”.
G3_7: Patients prefer the easiest and the cheapest way, which is CAM, and then they seek medical advice if their case got complicated.
Social support and culture
According to most participants from all three study groups, a main motivator for the use of CAM in Lebanon is positive social influence. Individuals surrounding patients such as “friends and family members play an essential role in influencing their use of CAM”, and because “people are affected by their surroundings, if individuals around them are using CAM and benefiting from it then they will automatically be encouraged to use it themselves”. Additional file 4 summarizes the quotes that reflect the central role of social support in driving CAM use among the Lebanese people from the perspective of all three stakeholders.
A few Lebanese adults elaborated that they specifically rely on information from their network of people of older age and those living in rural areas, whom they thought had more experience and exposure to the Lebanese cultural practices. One Lebanese adult said:
G1_9: “I take advice from people of older generations such as my grandparents since during their time, traditional medicine was not that popular. I take advice especially from those who live in rural areas since they have a lot of experience with such herbs, and they know more than I do”.
Moreover, Lebanese adults’ choice of therapy was found to be largely influenced by the common and time-honored practices that were passed on to them across generations through cultural heritage. A few HCPs believed that the Lebanese culture predisposes people to prefer all that is natural and non-medical.
Only a few participants from each group mentioned religious support as an important driver to the use of CAM in Lebanon, where “some patients have religious ideologies and believe in CAM which motivates its use”.
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