The Use of CAM in Research in Health Disparities and Ethnically Diverse Populations

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The Use of CAM in Research in Health Disparities
and Ethnically Diverse Populations

• Norma G. Cuellar D.S.N., R.N.
• University of PA
• School of Nursing

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Objectives

• Increase awareness of research opportunities in
  CAM in ethnically diverse populations
• Identify strategies to develop rigorous research
  using CAM interventions that promote health and
  decrease disparities.
• Discuss the development of a research program in
  CAM and ethnically diverse populations.

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What is Complementary and Alternative Medicine
(CAM)?
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Definition of CAM

• A broad domain of health resources that
  encompass health systems, modalities, and
  practices and their accompanying theories and
  beliefs, other than those intrinsic to the
  dominant health system of a particular society or
  culture in a given historical period.
• 5 Domains identified by NCCAM
• Alternative Medical Systems
• Biological Based Products
• Mind Body Interventions
• Manipulative and Body Based Practices
• Energy Medicine

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Cultural DiversityInfluences on Health Care

• Different values and beliefs with every different
  culture
• Cultural Competency
• Have to have a knowledge base about the varying
  modalities with the skills and abilities to
  provide culturally competent care including
  respect, compassion, and dignity
• Varying Modalities Complementary and
  Alternative Medicine

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Master Teachers Taskforce December 2005
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Is there a science to CAM?
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Anthropology

• Study of Man and Society
• Cultural Relativity
• Cross-Cultural Comparisons
• 4 fields of study
• Physical anthropology (biology) genetics,
  traits, evolution, adaptation
• Cultural anthropology field studies of culture
  of a particular people, languages, economics,
  family relationships, politics
• Linguistic anthropology communications (verbal
  and non-verbal), structure, function and history
  of language
• Archaeology human of the past

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Medical Anthropology

• How is illness explained by cultures?
• Emic universal culture
• Etic inside the culture
• Naturalistic Explanation illness is related to
  whatever is known in that culture
• Ethnocentric your own is always the best
• How are cross-cultural remedial therapies used?
• How does the culture experience health vs.
  illness vs. wellness?

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Ethnomedicine

• A sub-field of Medical Anthropology examining
  traditional medicine
• Chinese Medicine
• Ayurvedic Medicine
• Focuses on medicine whose knowledge and
  practices have been orally transmitted over the
  centuries.
• Uses an anthropological approach (not medical
  approach).
• the perception and context of use of traditional
  medicines, and not their bio-evaluation.
• Journal of Ethnobiology and Ethnomedicine
  http//www.ethnobiomed.com/

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• What happens when a cultural practice (or CAM) is
  acculturated..taken out of the country of
  origin and moved to another country?
• Is Chinese medicine the same here as in China?
• NCCAM research priorities partnership with
  countries who are considered CAM to get to the
  roots of the practice.

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Where do we see cultural influences in CAM

• Folklore Medicine
• Alternative Health Systems

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Folk Medicine
The Evil Eye (mal de ojo)
Tonic

• Circulated by word of mouth
• Has superstition and assumptions involved
• Not very scientific
• Often associated with the occult, mysticism,
  voodoo, shaminism

http//www.folkmed.ucla.edu/
Snake Oil
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Example of Folklore Medicine

• Superstitions
• Animism
• Witchcraft
• Ancestor Worship
• Voodoo

• Shaminism
• Belief in Religions
• Faith Healing
• Herbs

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Folk Medicine SUPERSTITIONS

• traditional and informal or local explanation for
  fortune or misfortune, luck or bad luck, either
  by individuals or by folk groups.
• Interpretation of dreams
• Premonitions
• Beliefs surrounding fairies and hagging
• Using certain items or objects either for
  protection or to bring good luck
• Bad luck signs
• Folk beliefs related to weddings
• Folk beliefs about the dying, the dead, wake
  keeping, burial, and funeral.
• Superstition Database http//www.oldsuperstitions
  .com/

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Folk Medicine ANIMISM

• The separation of body and soul does not occur
• Personalized souls are found in animals and
  plants
• Belief in the supernatural power and divine role
  of inanimate or non-living things or objects such
  as lakes, rivers, mountains, hills, sacred groves
  and rocks
• Spiritual realm that is shared on this Earth
• Oldest form of a religion
• Animism is represented, among others, by the
  Mormons, Hinduism and the New Age. They proclaim
  that every human is God, and their practices will
  help each one to realize it.

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Folk Medicine WITCHCRAFT

• belief in the supernatural power of some
  individuals to cast spells, haunt or have second
  sight, and to carry out other forms of
  communication through time and space
• practitioners worship gods and goddesses
  represented by natural phenomena such the moon,
  stars, sun, and mother earth
• contemporary witchcraft is referred to as Wicca

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Folk Medicine ANCESTOR WORSHIP

• belief in the divine power and divine guidance of
  dead
• seen in many cultures Asian, African American
  (Kwanza), Native Indian among a few

http//www.asia.si.edu/exhibitions/online/teen/def
ault.htm
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Folk Medicine VOODOO

• spirit possession
• has its roots in Africa
• now practiced in Cuba, Haiti and in the US (New
  Orleans)
• music and dance are ways of expression of
  spirituality

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Folk Medicine SHAMANISM

• practitioners apply magic and speak to the
  spirits of nature
• can perform both physical and spiritual or faith
  healings
• discover their powers through ecstasy and fasting
• Anthropology of Consciousness
• Out of body experiences
• Near Death Experience

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Folk Medicine BELIEF IN RELIGIONS

• Saints
• Pilgrimage
• Faith healing or miracle healing
• Beliefs in the existence of spirits (good spirits
  and bad spirits or demons)
• Belief in the existence of ghosts, and in
  apparitions

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Folk Medicine FAITH HEALING

• the use of religious folk objects or items, and
  prayers to cure illnesses
• exorcism
• ritual healings performed by voodoo priests and
  priestesses, and by Shamans
• use of charms for protection or as lucky charms

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Folk Medicine HERBS OR HOME REMEDIES

• Fresh steaks and poltice - for treating infected
  wounds.
• Molasses - for treating sour throat and a babys
  teething problem.
• Fresh cucumber and wet bag of tea - for treating
  a bad eye.
• Garlic - for reducing high cholesterol and high
  blood pressure.
• The juice from nim leaves - for curing malaria.
• Chinese acupuncture - for treating blood clotting
  and margarine headache.
• There are also alternative remedies for dieting,
  cancer treatment, diabetes, heart disease, skin
  care, weight loss etc.

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Herbal Medicine

• Almost two-thirds of the earths 6.1 billion
  people rely on the healing power of herbal
  medicine.
• For them nothing else is affordable or available.
  

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Cultural Influences in Alternative Health
Systems (NCCAM)

• Not related to folklore
• Based on cultural history, ethics, values, and
  beliefs of a specific culture
• Some have evidenced based research

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Alternative Health Systems

• Ayurveda (Indian)
• Chinese
• Native American Indian
• Aboriginal
• African

• Middle Eastern
• Tibetan
• Central and South American Cultures
• Homeopathy
• Naturopathy

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Commonalities of the Alternative Systems

• Treatment of the whole person (mind, body,
  spirit,
• and community)
• Original forms of health practices Ayurvedic,
  Chinese, Alaska Native and American Indian
  Traditional healing, Shamanism, to name a few.
• The community and family were always part of the
  healing process.
• Herbal medications, manipulations (forms of
  massage and spinal adjustment) and dietary
  practices
• Depends on location as to type
• Spiritual practices
• May be in the form of energy healing, meditation,
  prayer, imagery, story-telling, ceremony, ritual,
  or cleansing practices that were unique to that
  culture

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Can we keep traditional vs. non-traditional
separated and provide culturally competent and
sensitive care?

• Health care providers who discredit CAM use can
  no longer deny the benefits
• need to respond to the challenges evolving from
  issues related to the use of CAM
• It is here to stay

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CAM and Health Disparities

• Does the use of CAM decrease health disparities?
• Does the use of CAM result in health disparities?

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NCCAM and Health Disparities

• Communication between groups
• Recognize diversity
• All minority groups are not homogeneous
• Generational Changes
• Degree of Assimilation
• Adaptation to American Culture

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What can we do? RESEARCH

• Identify how traditional health beliefs shape
  current health behaviors
• complement or harm Western conventional medical
  practices
• Improve the understanding of culturally diverse
  groups
• Improve competency of health care providers
  related to CAM/culture

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NCCAM Research Priorities

• Mechanisms of Action
• Phase I and II Clinical Trials
• Exploratory Studies
• Areas of Special Interest
• Anxiety and Depression, CVD, ethnomedicine,
  immune modulation/enhancement, IBS, insomnia,
  liver diseases, obesity/metabolic syndrome,
  respiratory diseases (prevention and treatment)
• NCAAM highly interested in minority and gender
  health and health disparities
• http//nccam.nih.gov/research/priorities/index.htm

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Hierarchy of Research

• Evidenced Based Medicine based on RCTs
  (Borgerson, 2005)
• Meta Analysis
• Systematic Reviews
• RCTs (experimental designs) are considered the
  best scientific evidence (rigorous) because of
• Randomization
• Placebo
• Control

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NIH Clinical Trials (RCTs)
Post-marketing surveillance
Comparisons to Standard Therapies
Preliminary evidence of safety and efficacy
Dose finding, Side effects, Clinical
pharmacology 67 of funding
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Clinical Trials and CAM backwards approach?
This is starting point 67 of funding
Large portion of people using a product and
consider it safe
Has it been compared to other standard therapies?
What has been done to determine if it is safe and
has efficacy?
In CAM, Phase I, II, and III Trials are missing
How does it work? What is the mechanism of action?
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How do we test the Placebo Effect?

• Can all CAM therapies fit in this RCT
  hierarchical model?
• Can all CAM use a placebo to test the
  effectiveness of the treatment?
• Hypnosis, Tai Chi, massage
• If you cant test the placebo effect, does that
  mean it is not evidenced based?

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How can we show evidenced based research in CAM
if we cant do RCTs (with placebo)?
Walach et al., 2006
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How do you develop a program of Research in CAM?

• BS in nursing
• Certifications, CEUs
• Masters expert in a clinical field
• Doctorate research in your clinical area of
  expertise
• PhD is terminal degree for research preparation
• Post-Doc adding knowledge to that area of
  research
• K Award adding another dimension of knowledge
  related to research

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Developing a Program of Research 10 years

• Small funding
• Local grants 500.00
• Larger Funding
• National Professional Organizations 5000.00
• Public Funding
• Samueli Institute 150,000
• NIH Funding
• Different type of funding mechanisms (see
  handouts)
• K or R mechanisms

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What makes you competitive?

• Showing you can complete research projects
  starting with pilot studies that build on each
  other
• Showing a progression of growth in your research
• Hierarchy of research designs
• Larger budgets
• Larger studies
• Multi-site studies
• Showing that you disseminate the data
• Presentations national and international
• Publications nursing and non-nursing journals
• Working with teams no one does it alone
  anymore!
• Intramural Mentors
• Extramural Mentors

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Take Home Message

• Be patient with yourself.
• It takes time and persistence.
• Dont give up if you want to be a researcher.
• Find people who support you.
• There is enough wealth and goodness for everyone.
• Celebrate our Diversity!