Kumar: The Use Of Complementary Therapies In Western Sydney

Ashwin Kumar (2003) 'The Use Of Complementary Therapies In Western Sydney'
Sociological Research Online, vol. 8, no. 1, <http://www.socresonline.org.uk/8/1/kumar.html>

To cite articles published in Sociological Research Online, please reference the above information and include paragraph numbers if necessary

Received: 5/12/2002 Accepted: 28/2/2003 Published: 28/2/2003

Abstract

This paper, based on a survey of 523 people in the western region of Sydney (Australia), explores the responses of a cross-sectional sample in terms of what respondents considered to be complementary therapeutics, who is using them, and how often. The paper also explores in a limited way some of the reasons for using complementary therapeutics and, in particular, why some people had elected not to use complementary therapeutics. Although past studies have been limited by the absence of a sound theoretical base for the understanding of complementary therapeutics and their use, the findings lend support to a pluralist vis-‡-vis post-modernist explanation.

Keywords:

Alternative; Complementary; Healthism; Medicine; Pluralism; Survey

Introduction

1.1

Despite the hegemony of biomedicine, the use of complementary therapeutics^[1] remains a popular choice in Australia, as well as in other post-industrial societies. Due to sufficient community interest, the Australian government commissioned a report on the use of complementary therapeutics in 1977 which found that members of the community had grave doubts about the use of biomedicine, and that "alternative" services were playing an increasingly important role for patients (Webb Report, 1977). This report also recommended that, due to the wide use of complementary therapeutics, there existed a strong need to regulate practitioners of complementary therapeutics, and also to incorporate their services into the State health system. Furthermore, a study commissioned by the Victorian Social Development Committee in 1985 revealed that 400,000 Victorian adults had consultations with natural therapists in the previous year (VPSDC, 1986). This committee concluded that there was sufficient evidence to suggest that complementary therapeutics played an important role in the lives of many Victorians. Likewise, a 1993 South Australian survey of 3,004 randomly selected adults found that 48.5% had used at least one non- medically prescribed form of complementary therapeutic (MacLennan et al., 1996). This survey also found that users of complementary therapeutics reported spending an average of $10 monthly, which if representative of Australia's general population, calculates to an annual expenditure of $621 million per year.

1.2

Similarly, results from opinion polls and large-scale surveys of practitioners in Britain suggest that the use of complementary therapeutics remains a popular choice (RSGB, 1984; Fulder, 1988; Thomas et al. 1991; Doyle, 1993; Buckle, 1994; Owen, 1995). Moreover, surveys on the use of complementary therapeutics in the Netherlands show considerable rates of usage (Ooijendijk et al., 1981; Menges, 1994). Similar results have been reported in the United States (Seaward, 1994; Wardwell, 1994; Baer, 1995; Gallagher, 1995). Accordingly, these overseas results, together with research from Australia, indicate that the use of complementary therapeutics remains a popular choice. This is supported by this current study in which I explored, among other things, who used or did not use complementary therapeutics, how often, and what was considered to be a complementary therapeutic.

1.3

The popularity of complementary therapeutics has aroused considerable interest among researchers, and in particular, has raised the question as to why individuals do use complementary therapeutics despite constant vilification of these practices. In earlier research, the use of complementary therapeutics was treated as an interesting but marginal institution, supported by a fringe minority (Wallis & Morley, 1976; Sharma, 1992; 1994; 1996). Usually these earlier studies were situated sociologically in terms of unlegitimated knowledge, deviant sects and cults, and discourse was heavily polarized around notions of (ir)rationality (Sharma, 1994; 1996; Furnham, 1993). Moreover, these studies overlooked the possibility of research subjects choosing unorthodox forms of treatment. Most recent researchers, however, have recognized that complementary therapies are accepted by a sizeable proportion of the population as legitimate options to conventional biomedicine, and that the values and beliefs which lead people to adopt them form a significant part of contemporary culture that simply cannot be polarized around notions of (ir)rationality.

1.4

Research from the 1980s-90s has largely involved quantitative research methods which attempted to identify a range of demographic, personal, and attitudinal variables which have been associated with the use of complementary therapies. These factors have included: demographic characteristics (Cleary, 1982; Eisenberg et al., 1993; Lloyd et al., 1993); prognosis for a specific disease such as AIDS and cancer (Greenblatt et al., 1991; McGinnis, 1991; Lerner & Kennedy, 1992); dissatisfaction with the effectiveness of conventional biomedicine (Moore et al., 1985; Donnelly et al., 1985; Furnham & Smith, 1988); perceptions of practitioner/client relationships (Hewer, 1983); health and illness beliefs, including personal control over health outcomes (Furnham & Smith, 1988); psychological morbidity (Cleary, 1982; Furnham & Smith, 1988); and social or religious beliefs (King & Deforge, 1988; Stern et al., 1992).

1.5

From this growing body of research there appear to be three dominant sets of explanations as to why individuals use complementary therapeutics:

The medical outcome hypothesis: It is suggested that individuals are disillusioned with biomedicine as it has failed to deliver the promise of good health and to eradicate pain and suffering that result from disease, and moreover, in recent times we are witnessing an increase in the number of iatrogenic illnesses (Inglis and West, 1983; Anyinam, 1990).
The medical encounter hypothesis: Proponents of this argument state that people turn to complementary therapeutics due to dissatisfaction with the doctor-patient relationship, in which the "human touch" has been lost, and patients are forced into a passive role. Conventional biomedicine, so this argument goes, is largely seen as Fordist medicine (Easthope, 1993).
The postmodern hypothesis: Proponents of this argument state that in contemporary times a new value system has emerged which offers differing ideas and understandings regarding nature, science, technology, health, authority, individual responsibility and consumerism. Complementary therapeutics are viewed as serving the interests of "the" postmodern individual. Furthermore, the growing popularity of complementary therapeutics is seen as representing a crack in the hegemony of modernist understandings of the Self-based on biomedical science and a Cartesian separation of body and mind. The plurality of self-help and self healing "communities" which has emerged consists of heterogeneous and partially overlapping knowledges, languages and practices, often based upon eclectic borrowings of pre-modern traditions and hybridised appropriations of non-western knowledges and customs (Bakx, 1991; Easthope, 1993; Coward, 1989; Siahpush, 1998). This post-modernist view critiques much past research into complementary and biomedical practices, which has employed largely quantitative research methods and has investigated chiefly the medical outcome and medical encounter hypotheses, with limited social understandings as to why people use complementary therapeutics.

1.6

Although the criticisms raised by the post-modern hypothesis are to some extent valid, there still remain some very fundamental questions that require exploration and to which quantitative methods may contribute. Furthermore, there are major theoretical problems with a post-modern hypothesis as an explanation in the use of complementary therapeutics. I do not propose here to critique all of the hypotheses, or all of the problems that a post- modern hypothesis may present, nor to offer a full theoretical account of the use of complementary therapeutics. Rather, the current findings highlight some problems with a post-modern explanation, and suggest a more fruitful theoretical base may be that of pluralism.

1.7

In Australia, the use of complementary therapeutics continues to grow at an exponential rate, and is predicted to parallel estimates in other countries such as the USA and Europe (Siahpush, 1998; Easthope, 1996; Willis, 1989a; 1989b; Lloyd, 1993; Kermode, Myers & Ramsay, 1998). The increasing popularity of complementary therapeutics in Australia is further illustrated by the growing number of complementary therapeutic health care clinics, conferences, and curricula implemented in medical schools (Easthope, 1996; Siahpush, 1998; Willis, 1989a). Additionally, new research centers, such as the Centre for Traditional Chinese Medicine at the University of Western Sydney (Macarthur), and the Centre for Complementary and Alternative Medicine at Southern Cross University, represent the first large-scale endeavours to research complementary therapeutic use in Australia. The use of complementary therapeutics is indeed popular and increasing. Therefore, some understanding of this trend in the Australian context would be of considerable value in building a larger picture and of value to health professionals.

1.8

Both quantitative and qualitative studies to date have largely taken for granted that people in fact do use complementary therapies, and despite a growing number of surveys our knowledge of the extent of such use is limited. Our knowledge is also driven by a common sense notion of what complementary therapeutics are, with many studies simply asking informants to respond to generic questions on the use of "alternative" or "complementary" "medicine", and a commonly held assumption-wantonly presented in the popular and academic press-that the use of complementary therapeutics has in fact increased. Therefore, one of the aims of the present study was to address both the theoretical and methodological limitations of earlier studies by discerning what exactly respondents consider to be "alternative", who is using complementary therapeutics, and why some people elect to use or not use them. A number of other core questions pertaining to the demographic features of users, and membership in private health funds were formulated to explore the various relationships among variables.

1.9

These aims were achieved in part by means of an exploratory survey administered to over 500 respondents largely in the western Sydney metropolitan area.^[2] The administered questionnaire was divided into four sections: (1). Demographic data; (2). The use of complementary therapeutics and/or practitioners; (3). Access to complementary practitioners; (4). The non-use of complementary therapeutics.

1.10

Serendipitously, the very construction of and reflection upon the survey and its topic area was found to reflect a populist and often ill-informed awareness of complementary therapies and show a degree of antagonism not toward orthodox biomedicine per se but toward the keepers of the biomedical discourse who stigmatized both complementary practitioners and their clients. Despite this, as the data show, there was substantial use of complementary therapeutics by respondents, but not at the expense of biomedicine. While this result may initially suggest support for the post-modernist hypothesis, this and other evidence in fact can support a pluralist theory of health seeking.

Methods

2.1

The main aims of this exploratory study were to determine what respondents considered as complementary therapeutics, who was using them and why, how often, and why some people had elected not to use complementary therapeutics. With these aims in mind a survey was constructed.^[3]

2.2

The survey was divided into four sections: demographics, questions pertaining to the use of complementary substances and/or practitioners, questions pertaining to the access of complementary practitioners, and questions targeted at those who had not used such therapies. Section 1 of the survey required all of the participants to include their demographic details. Most of the questions in Sections 2-4 took the form of forced-choice questions, typically asking for yes or no responses. Section 2 firstly asked participants if they had ever used complementary substances and/or a complementary practitioner. (Those participants who answered no to either of these were required to go to Section 3). In Section 2 participants who had used complementary therapeutics were asked questions such as: when they had last used complementary therapeutics and how often they used it, what type of complementary therapeutics they had used, their reasons for using complementary therapeutics, whether they would use complementary therapeutics more if Medicare or a private health fund covered it, and how their views had changed since using complementary therapeutics. The final question in Section 2 presented the participants with a list of therapies and substances and asked if they considered any of these as "alternative".

2.3

All of the participants were required to complete Section 3 of the survey. This section asked questions relating to access to a complementary practitioner, whether complementary therapeutics should be used in conjunction with mainstream biomedicine, and whether participants would use complementary therapeutics if they had a terminal illness.

2.4

Finally, Section 4 of the survey required participants who had never used complementary therapeutics to give reasons for why this was the case.

Sampling & Recruitment

2.5

This research study was initially designed to utilize random sampling techniques. However, due to severe difficulties associated with finding participants who had used some form of complementary therapies, and the lack of any existing participant data sets and/or recruitment profiles for the western Sydney region, I was forced to utilize non-random sampling for participant recruitment. My undergraduate students at the University of Western Sydney, Nepean, administered the Survey. In an attempt to limit bias, these students were instructed to give out five questionnaires, of which only two could be given to either family or friends. The remainder were administered to neighbours, local shopkeepers, other acquaintances, and strangers. To ensure confidentiality participants were asked to place their surveys in an envelope which was opened by the authors.

The participants

2.6

The sample comprised 306 (58.5%) male participants, and 217 (41.5%) female (total 523), ranging from ages 15-65, from Sydney, Australia. As shown in Table 1, the sample was slightly skewed towards the younger groups.^[4] Overall, 74% of the sample was Australian born, 54% of the participants were single, 32% were married, 6% divorced, 4% de facto, and 4% did not respond. Twenty-nine percent of the sample was currently studying, while 6.5% were currently unemployed, and 6.1% were housepeople. Table 2 shows the income distribution of the sample. Table 3 shows the types of occupations in which the employed participants were engaged, and compares these with the 1997-1998 statistics published by the Australian Bureau of Statistics. As Table 3 indicates, the sample was slightly skewed towards the more professional and managerial occupations. Finally, 251 (48.36%) of 519 respondents were currently a member of a private health fund, while 268 (51.64%) were not. That nearly half of the respondents had health insurance is perhaps at first surprising, given the predominantly young age groups of respondents, their low income and assumed good health. However, it would be reasonable to assume that many of the young respondents were covered by their parents' insurance. Looked at another way, however, a majority of respondents (51.2%) said they did not hold private health insurance, and this is consistent with the decline of private insurance throughout Australia in the late 1990s.

Results

3.1

This study was intended to be exploratory research, examining issues such as: what are considered to be complementary therapeutics, who uses them and why, how often people use them, and why do people elect not to use complementary therapeutics.

What constitutes complementary therapeutics?

3.2

Respondents were given a list of potential complementary therapeutics; aromatherapy, naturopathy, acupuncture, massage, acupressure, and meditation were considered by more of the participants to be "alternative" (Table 4).^[5] It should be noted that therapies such as homeopathy, colour therapy, osteopathy, and Alexander technique scored high on don't know for ratings on whether or not a therapy was alternative. This is possibly because the therapies were unknown to the participants, rather than participants being unsure of their status. A chi-square analysis was carried out to compare those who considered each therapy to be alternative against those who did not consider it to be alternative. This analysis revealed that, overall, most people considered each of the therapies to be alternative, with one exception: physiotherapy.

3.3

Respondents were asked about what type of complementary substances or practitioners they had used; the most popular substances listed were "herbal", including such substances as: bach flowers, herbal tablets, herbal teas, tonics and marijuana. Other popular therapies are listed in Table 5.^[6]

Who is using complementary therapeutics:

3.4

Overall, 326 (62%) of the participants stated that they had either used complementary substances and/or had consulted a complementary practitioner; 60% of the sample had used a complementary substance, while 41% had consulted a complementary practitioner. Of these participants, 35.4% had used only one therapeutic, 28.9% had used two, 19% had used three, 9.2% had used four, and 7.6% had used five or more therapeutics.

3.5

Because of the skew in the data towards the younger group, the age groups were recoded into two groups: younger (aged 15-34), and older (35-65). A logistic regression was carried out to examine age, gender, and age by gender effects. As shown in Table 6, the younger group was found to use complementary substances more than the older group^[7], and women were found to use complementary substances more than men^[8]. The younger group also reported more than the older group that they had consulted a complementary practitioner^[9].

3.6

A chi-square analysis found that those people who belonged to a health fund were more inclined to visit a complementary practitioner^[10]; however, there were no significant differences found for those belonging to a health fund and using a complementary substance (Table 7). Moreover, participants who were using or had used complementary therapeutics were asked whether they would use it more if Medicare or a private heath fund covered it; a chi-square analysis revealed that an overwhelming number of such participants (74%) would use it, compared to those who would not^[11] (26%).

3.7

Another interesting result was that use of complementary substances^[12] and/or a complementary practitioner^[13] did not significantly differ according to income.

Circumstances in which alternative therapies are used:

3.8

Participants who had already used a complementary therapeutic were asked why they had used it; the McNemar Test revealed that a minor illness was significantly the most common reason^[14], followed by prevention^[15], and then a major illness (Table 8). The total sample was asked whether they would use complementary therapeutics if they had a terminal illness; most people said that they would. Of those who answered the question, 395 (80%) stated that they would use complementary substances compared to 96 (20%) who said that they would not^[16], while 368 (78%) stated that they would consult a complementary practitioner if they had a terminal illness, compared to 105 (22%) who said they would not^[17].

3.9

The total sample also was asked whether complementary therapeutics should be used "on their own", "in conjunction with mainstream medicine", or "not at all". A chi-square analysis revealed that more respondents felt that they should be used in conjunction with mainstream medicine^[18] (see Table 9).

3.10

While more females than males had used complementary therapeutics and would more so recommend their use, they were also greater users of such therapies in conjunction with biomedicine^[19], and more strongly recommended this joint approach to health and illness^[20]. To confound these data, more females than males used alternative therapies because they found biomedicine inadequate ^[21] (see Table 14).

How often people use complementary therapeutics:

3.11

Of those who had used complementary therapeutics, it was interesting to find that 57% had used it within the last 12 months, while 25% had used it within the last 5 years, and 41% in the last 10 years.

3.12

As shown in Table 10, the logistic regression found that women compared to men had used complementary therapeutics more in the last year^[22]. It was also found, not surprisingly, that the older group had used complementary therapeutics more compared to the younger group in the last 10 years^[23]. The smaller number of respondents indicating use in the last 5 or 10 years is probably reflective of the fewer respondents in the older age categories, and therefore this question cannot be taken to indicate an increase in the use of complementary therapeutics. However, respondents on average knew 7 other people who had also used complementary therapies^[24] and this may be suggestive of not only a networking effect, but also an increasing awareness and use of complementary therapies.

3.13

Table 11 shows the regularity of use of complementary substances and/or a complementary practitioner; it was found that more people use them on an irregular basis than on a daily, weekly, or monthly basis^[25].

Attitudinal response to the use of complementary therapies:

3.14

Overall, there was an overwhelming positive response to complementary therapies (Table 12), with 31.4% of 523 respondents affirming a positive outcome and 22.8% a partly positive outcome (total 54.2%-or 92.8% of 305 respondents). More females than males affirmed a positive outcome ^[26] vis-à-vis only 4.2% who affirmed they did not benefit from the experience/s.

3.15

A similar question asked if the use of such therapeutics had changed their views (Table 13). Of the 317 respondents who answered this question and who had used such forms of therapy, 67.8% said the experience had changed their view favourably, 6.3% unfavourably, while 25.9% said not at all; (this latter category may also contain a few people who already held a "favourable" attitude). It was found that more females than males significantly changed their view favourably, while only slightly more males said their view had not changed at all^[27].

3.16

Supporting this trend, question #24 asked if respondents would recommend non-allopathic therapeutics to others: 90.37% of 322 respondents who had used complementary therapies said yes, with more females than males saying so^[28].

How respondents came to know about and/or use complementary therapeutics:

3.17

A series of questions asked respondents to indicate how they came to use complementary therapeutics in terms of who recommended them or what factors influenced them; multiple answers were permitted, providing 337 responses. Friends (35%) were only slightly ahead of Family (32%) in terms of recommendation, although Chi tests show that both the youngest age group (15-24) and females were recommended more by their family^[29]. This is consistent with findings reported by Cant and Sharma (1999, p. 35-36), and in Australia by Lloyd et al., (1993).

3.18

22.8% said their GP had recommended the use of complementary therapeutics. However, it must be noted that the kind of therapeutic recommended is unknown and may include physiotherapy, chiropractic, acupuncture, vitamins and massage, all of which are to varying degrees accepted or referred to by many allopathic practitioners.

3.19

Other factors which influenced the use of complementary therapeutics, apart from being personally recommended, were also elicited, and included: found mainstream biomedicine inadequate (43.1%); through advertising (9.1%); from the media (24.8%); and other (22.9%). At first this may appear to suggest that people are somewhat dissatisfied with biomedicine, and that those who experience a complementary therapy gain a favourable attitude. But a somewhat different picture arises if all sources of information and recommendation about complementary therapeutics are combined and analyzed. Since multiple answers were permitted for this range of questions, respondents who had used complementary therapeutics provided 446 responses, as Table 14 shows.

3.20

These data are consistent with other data found in the survey:

respondents use non-allopathic therapeutics recommended primarily by friends, family and by a lesser but not insignificant number of GPs
the inadequacy of biomedicine is not a major factor in the use of non- allopathic therapeutics
respondents had used or do recommend the use of non-allopathic therapeutics with biomedicine
complementary therapeutics were a secondary option (43.8%) or used about half the time (39%) (total: 82.8%), vis-à-vis a primary option (13%) or used exclusively (4.2%) (total: 17.2%) (N=313)
more females than males indicated that they would use complementary therapeutics about half the time^[30].

Why people elect not to use complementary therapeutics:

3.21

As shown in Table 15, for those who elected not to use complementary therapeutics, the main reasons given were lack of interest (11.3%) and skepticism (9%). Of further interest was that 58% of 197 respondents who had never used complementary therapeutics said that they were more likely to use them than not (42%) if the therapies were covered by health insurance. Both the younger age group and females were predominant in saying they would use alternative therapies if covered by medical insurance^[31]. This compares with those (319) who had used non-allopathic therapeutics: 73.7% said they would use such therapeutics more if they were covered by Medicare; 26.3% said they would not.

Degree of research by respondents into complementary therapeutics:

3.22

Of those who stated they had actually used a complementary therapeutic, only 118 (37.1%) respondents stated that they had researched it before use, compared to 200 (62.9.3%) who had not.^[32] This differs significantly from two previous studies: 78% of respondents reported by Lloyd (1993) had accurate and detailed knowledge of their therapists' qualifications; and Sharma (1992) found that her respondents had informed themselves about the therapy and possible cures for their problem. While these differences may be accounted for in terms of samples and methods, they also serve to highlight both the complexity of the subject area and the need for consistent and comparable research.

Discussion

4.1

Previous Australian research has suggested that users of complementary therapeutics come from a wide cross-section of the population, and the results of the present study confirm this (Tables 1-3). While there was some skewing of the sample toward professional occupational status (Table 3), there was nevertheless a significant spread of respondents from other socio-economic positions and ages. Because the survey was administered by young University students, it is not surprising that the sample was also slightly skewed toward the younger age groups and toward unmarried respondents, but this also serves to confirm that younger people are willing to use-and perhaps increasingly use-complementary therapeutics, when one would expect them to be healthy. This of course begs the questions of why (younger) people use complementary therapeutics and what forms.

4.2

When we take into account the types of complementary therapeutics used, the data are less specific, for complementary therapeutic users may include in their repertoire of therapies vitamins, physiotherapy, chiropractic and massage, which are generally accepted as orthodox. There seems to be some hint of this "complementary orthodoxy" in that most respondents used complementary therapies for prevention and/or minor ailments (Table 8), and that many respondents were unaware of "less mainstream" therapies such as Alexander technique and colour therapy (Tables 4 & 5).

4.3

The analysis also revealed that women used complementary therapeutic substances more than men, which may indicate that females are more concerned about their own health and perhaps that of others-as, some would argue, has been traditionally the case.

4.4

While nearly half the respondents held health insurance (Table 7), they chose at some time to use complementary therapeutics, despite many of these not being covered by health insurance-although again, the survey data do not reveal which therapies were used.^[33] However, the data make it clear that an overwhelming number of participants would use complementary therapeutics if covered by health insurance, suggesting that complementary therapeutics are now largely socially accepted but hindered in practice by institutional economics. This is further supported by the favourable outcome reported (Table 12) by respondents in their use of complementary therapeutics, and their favourable shift in attitude (Table 13), as well as their overwhelming willingness to use complementary therapeutics if they suffered from a terminal illness.

4.5

But this is not to suggest a rejection of biomedical therapeutics, as 74% of respondents reported that complementary therapeutics should be used in conjunction with biomedicine (Table 9). Further, at this time, for these respondents, complementary therapeutics was considered useful for minor illnesses or as a preventative (Table 8), and for many on an irregular/occasional basis (Table 11).

4.6

Nevertheless, the pervasiveness of a favourable attitude toward complementary therapeutics and their use is indicated by the diverse sources of information and recommendation for complementary therapeutic use (Table 14), and that respondents reported having known on average 7 other people who had used complementary therapeutics. Overall, then, the data indicate an extensive experience with-and willingness to use-complementary therapeutics by a majority of diverse respondents. Despite this, both a lack of theoretical explanation of and an orthodox resistance to complementary therapeutics is evident in the literature. It is to these issues that I turn briefly in the following section.

Theoretical Issues

Modern medical science can be proud of its astounding accomplishments... Nevertheless...unproved, unorthodox, and fraudulent practices have continued to flourish, ranging from the medically trivial (but economically important) remedies for baldness and obesity to the "alternative" practices promoted for serious disease. Their impact on traditional [orthodox] practice has been underestimated. These practices...represent an unalterable opposition to the basic premise of modern medicine, its cornerstone of objective scientific investigation... (Holohan, 1987, Journal of the American Medical Association editorial].

5.1

The main themes of such editorials and criticisms by orthodox practitioners-epitomized by the above quote- are the lack of scientific evaluation of complementary therapeutics, the lack of ethical standards and safeguards for clients, and the danger of clients being denied orthodox treatment for serious disease. On the other hand, the major criticisms that can be made of such hegemonic views is that all forms of non-orthodox therapeutics are lumped together and tarred with the same brush (Vincent and Furnham, 1997, p. 77), and that such views attempt to ignore the fact that more and more people are utilizing complementary therapies-as this study affirms-despite sometimes contrary advice.

5.2

While the achievements of orthodox medicine are indeed impressive, many commentators have pointed out the adverse consequences of an increasingly technological and impersonal approach to medicine and health, and they have suggested that these factors might underlie the assumed growth in the popularity of more "alternative", less technologically based, less invasive and more supportive therapies. Criticisms of orthodox medicine commonly aired have been that: it is too technical; client autonomy is lost; that there is a dependency on drugs or surgery; it is physician-centred; diagnostic and intellectual skills are valued above communication skills; and settings for health care are often located for the benefit of doctors rather than clients.

5.3

Such a litany of popular criticism more recently has found articulation in a post-modern hypothesis (Coward, 1989; Bakx, 1991; Easthope, 1993; Siahpush, 1998). This hypothesis rests, in part, on a contemporary view of the world in which nature is seen as gentle, caring, kind, benevolent and safe, where people value consuming natural products and avoid preservatives and other artificial ingredients, and people consider science and technology as potentially harmful. There is some empirical evidence in support of the relationship between the use of complementary therapeutics and subscription to such values (see Siahpush, 1998; Sharma, 1992; Furnham and Forey, 1994); and some indication of a shift towards "holistic" or multifaceted health (Anyinam, 1990; Furnham and Smith, 1988). And one may, with some stretch of the imagination, construe, as the post-modern hypothesis contends, a popular rejection of scientific and professional authority and a demand for participation in health care (Riessman, 1994; Easthope, 1993; Taylor, 1984). There is also, it is argued, a belief in individual responsibility (Cassileth, 1989), evident in media and popular emphasis on diet, exercise, self-help strategies and life-style changes (Siahpush, 1998; Furnham and Forey, 1994). And finally, consumerism, it is argued, is another post-modernist trend which has been responsible for the growing interest in complementary therapeutics that offer people a range of therapies from which to choose, in which consumer advocacy and patients' rights have become popular catch-cries (Siahpush, 1998; Carroll, 1994).

5.4

I argue that much of the empirical evidence-including my own-does not support such a post-modernist hypothesis; one can readily interpret the evidence in a coherent and integrated way without resorting to populist notions of post-modernity which read like end-of-the-millennium escape clauses for meaning and thought. I find, in fact, that the data do not show a rejection of authority or expertise, and that the predominantly young sample in other respects does not reject science and technology. Indeed the interpretation of empirical evidence in this field within a post-modernist framework creates certain contradictions, but which may be readily resolved by adopting a framework of pluralism.

5.5

In short, it is questionable that there is a worldwide-and therapeutic specific-rejection of authority. Data about complementary therapeutics show that users still (and perhaps increasingly) use biomedicine, and that most do not even research complementary therapeutics, thereby placing their health in the hands of another "expert".^[34]

5.6

While it is likely that individuals, communities and institutions are searching for alternative configurations of praxis (Giddens, 1990; 1991) within the context of complementary therapeutics by attempting to negotiate control with the experts, that appropriated control is then often transferred to another expert: to that of the complementary therapist. While this may allow for greater participation on the part of the client, and reinforce notions of control of the Self, it nevertheless reinforces the notion of control. The fact that clients of complementary practitioners do little research into their ailment, the therapies or the practitioners-as the data show-and similarly, those holding private health insurance were not particularly knowledgeable about health care nor exhibited active involvement in decision making (Calnan et al., 1993), suggests a transference of expertise. So one may wonder how much different this selection of expertise is from that of selecting a GP or dentist?

5.7

Rather, the increased use of both complementary and biomedical therapeutics constitutes an increase in medicalization and social control. The rise of complementary therapeutics could be perceived in fact as signifying a different way of practicing power. While the underlying theories of complementary therapeutics and biomedicine about causation and treatment may differ, treatment orientations are in fact in many ways similar and seek similar results, consistent with Parsons' sick role: the reintegration of the individual into and the establishment of appropriate relationships. Complementary therapeutics reinforce a normative order with their stress on individual responsibility, self-discipline and the creation of disciplined bodies and minds. Thus, rather than being liberating, complementary therapeutics have the capacity to effect a self-responsible, self-policing and politically conformist subject. What becomes evident is a shift into another realm of "medicine".

5.8

Perhaps, then, the only thing that may be postmodern about complementary therapies is that the client now has the ability to choose the expert, to transfer legitimacy from one expert to another who operates in a more personalized and less synthetic therapeutic framework, but a medicalized therapeutic framework nevertheless.

5.9

Although one could acknowledge complementary therapeutics as a dimension of the reflexive nature of high modernity (Giddens, 1991), with their stress on self monitoring and the confessional nature of certain kinds of holistic consultation, this is not necessarily a destabilization of or incompatibility with biomedicine and science as forms of knowledge. While one could argue that there is some post-modernist rejection of universalism in favour of individualism, this in itself does not constitute a fragmentation of the authority of a medical narrative. Rather, it constitutes an open acknowledgement of the limitations and shortcomings of the biomedical narrative and the shift to complementary therapeutics as constituting a new configuration of a health meta-narrative in which both biomedicine and complementary therapeutics play a part.

5.10

This was clearly evident from the respondents who claimed that complementary therapies should be used in conjunction with biomedicine, that they tend to be used for non-critical conditions, and from the sources of legitimation for using such therapies. For the client, the health narrative has expanded, not been divided.

5.11

Given the greater awareness of and access to diverse information, there arises the holding of multiple understandings of what facilitates health and what causes disease; this may encourage the use of a mix of services and a more critical stance toward medical expertise, constituting a shift from "patient" to "consumer". While it is generally agreed that the general public has become increasingly sceptical about certain aspects of biomedicine (Gabe et al., 1994), this has constituted only a fracturing of societal trust and not a complete loss of support by the lay public (Bakx, 1991). Rather, there has been an increase in the knowledgeability of the lay public who are more informed and more reflexive, especially as knowledge has become more pluralized (Giddens, 1990; 1991).

5.12

Consumerism, for example, is one of the key tenets of a postmodernist argument. But consumerism does not mean stepping outside of a medical or therapeutic paradigm; it means the maximization of choice within a reconfigured paradigm, the ready provision of information, reduced waiting time, attention by appointment, the encouragement of consumers to complain, and the taking of consumers' views into account by a social policy of conducting surveys to ascertain satisfaction levels.

5.13

And finally, post-modernism seems to imply a middle-class and/or intellectual reflexivity; if this were true, and was consistent with the demographic profile of users of complementary therapeutics, then there may be fewer theoretical problems. However, the key social, intellectual and economic tenets of post-modernism relegate the working class to incapacity, while this data and that of others (Siahpush, 1998; Budd & Sharma, 1994) show that users of complementary therapeutics cross all classes and age groups.

5.14

All this is hardly a case for a post-modernist trend or ideology among users of complementary therapeutics-as this study attests.

5.15

The data suggest that, while there is a trend to use non-allopathic therapeutics, and perhaps use them more, particularly amongst younger age groups and by women, such use is often in conjunction with biomedicine and/or as a secondary option. Overall, this is suggestive of two things: firstly, that there is not a sweeping dissatisfaction with biomedicine, nor, conversely, an unequaled swing toward using non-allopathic therapeutics-on their own, at least. Secondly, the use of two philosophically different medical models-different according to the views of its authorized practitioners- suggests a current (although not entirely new) trend in health seeking and maintenance. But humans have always used whatever is at hand to enhance or maintain their health, and they will readily flit from one remedy to another, from one philosophical model to another, without cognitive anguish, for the bottom line is that most of us wish not to be sick.

5.16

What then is unique about the contemporary utilization of both allopathic and non-allopathic therapeutics? Is it a feature of modern society that people will try anything: a factor of desperation? Or is it, in keeping with postmodernist trends of the ideal body, a factor of willingness and availability in the seeking of perfect health?

5.17

These questions are only partly answerable from the current study, and the wide range of complementary therapeutics the respondents used. What may also shed some light on how people think of complementary therapeutics, and suggest avenues for further research, are the types of therapeutics which respondents considered "non-allopathic", as Tables 3 and 4 showed. Notable from these tables was that naturopathy; acupuncture, acupressure and massage were largely considered "alternative", when in fact the biomedical model is increasingly acknowledging their therapeutic value-in limited circumstances.

5.18

These data, and the fact that only 37.1% of 318 respondents claimed to have undertaken some research into complementary therapeutics before using them, may suggest a number of things. Firstly, that many respondents randomly and rather trustingly use complementary therapeutics, largely based on the recommendation of others in their social group; or, secondly, the types of complementary therapeutics such as vitamins, physiotherapy, massage and chiropractic require little understanding, and this may be due in part to many complementary therapeutics being non-invasive; those treatments which require the ingestion of substances or minor invasive techniques such as acupuncture may be explained satisfactorily at the time of consultation.^[35]

5.19

Clearly, however, there has been an expansion of the complementary therapeutic sector, which has produced a wider availability of services from which a person can choose: a plurality of services. But we also need to look at the plurality of reasons as to why people actually use those services which have increasingly become available. It is in this sense that there is both a plurality of motivation in the use of complementary therapeutics and in their provision, such that we cannot claim it to be posited in a discrete set of values to which postmodernity ironically and paradoxically claims as its own.

5.20

Why people choose complementary therapies is, therefore, more complex than first appears. First, it depends on the particular branch of complementary therapy under consideration, as well as the illness for which treatment is sought. Second, the decision may be made out of curiosity or due to depression or desperation; it may be spontaneous, or long considered and researched; it may be recommended by family, friends or even a GP, or spurred by the media; some clients are positively attracted to complementary therapies, others sceptical, while some gain a positive experience and propagate its usefulness, and others experience no improvement. Whatever the reasons for seeking a complementary therapy-and they are numerous-we cannot simply assume that clients are turning away from orthodox medicine; rather, clients tend to seek complementary treatment as a supplement-or parallel-to, not a substitute for, "orthodox" health care (Vincent & Furnham, 1997; Rasmussen and Morgall, 1990; Thomas et al., 1991). In fact, it is rare for clients to abandon orthodox medicine altogether. Thus there is little foundation to the fear that complementary therapies and therapists threaten orthodox medicine and its practitioners, partly because of the limited range of problems treated by the former and the scale on which care is provided. We find in fact that the use of complementary therapies is for illnesses to which orthodox medicine cannot respond, or for which it has not been effective over time, or for alternatives to invasive therapies, and for minor but often chronic illnesses.

5.21

The turn to complementary therapies, then, is perhaps not surprising in an era when people are perceived, treated and empowered as clients, while medicine continues to deal with people as patients- with all the classical connotations that that term implies. These factors constitute the emergence of a medical pluralism, allowing for an expansion of therapeutic modalities (Bakx, 1991).

5.22

In many respects this Sydney survey lends evidence to the argument that people are using complementary therapies and gaining a positive experience, but so too are they not outrightly rejecting orthodox treatments. Overall, their responses indicate a desire to use both therapeutic models selectively, on their own terms, and to have that choice legitimated through medical insurance-as evidenced by the large majority of the sample who would use complementary therapies or use them more if they were covered by health funds.

5.23

In designing and piloting this study, and as indicated in the responses, it became clear people had had both positive and negative experiences of both therapeutic models, but they essentially wanted, when sick, to get better. They also wanted answers, not merely for their illness episode, but for what therapies would or might work.

Conclusion

6.1

It has not been only a client- centred approach which has spurred a growing official interest in complementary therapeutics, nor has it been altruism which has led to calls for proper funding and investigation of the various therapies. Rather, and perhaps ironically, it has been an orthodox medical discourse. This is exemplified in a 1992 statement by the US Senate Appropriations sub-committee for the National Institute of Health (NIH):

The Committee is not satisfied that the conventional medical community...has fully explored the potential that exists in unconventional (sic) medical practices. Many routine and effective medical procedures now considered commonplace were once considered unconventional and counter indicated...

6.2

While the Committee commended and established an office to carry out such investigations, like other such offices and investigations, the discourse of verification and legitimation is that of orthodox medicine. Such an approach centres, mistakenly, on the question of scientific verification, not on the need to offer clients both care and cure, which would require health care workers and clients to rethink their roles and strategies.

6.3

While orthodox practitioners may be opposed to complementary therapies and practitioners, and the latter opposed to integration and a hegemonic discourse, the client in the meantime is left to fumble through his/her suffering, adopting therapies on hearsay. If the evidence is not crystal clear that complementary therapies are efficacious then they should be investigated within a discourse of co-operation, for what is painfully obvious is that a rising class of empowered clients are demanding whatever therapies may work, and a right to an informed choice.

6.4

Finally, as Holohan's (1987) editorial above suggests, remedies and practices may be medically trivial but they are economically important. While orthodox practitioners may feel their power, expertise, status and legitimacy threatened by complementary therapeutics, we should not neglect the economic dimension of health. In a spirit of co-operation into the investigation of complementary therapies, there could arise a worthwhile adoption of certain therapies and procedures that may serve to enhance not only all practitioners but also the ailing, overburdened health systems throughout the Western world.

6.5

This study lends some credence to these views. It affirms the substantial use of complementary therapies within the Australian context, highlighting a consumer-led trend in which the client is forging a new configuration of utilization among a plurality of health services, and to which established practices must rapidly adapt-for a number of social, therapeutic and economic reasons.

Tables

Table 1: Frequency and percentages of age groups (N = 523).

Age Groups	Frequency	%
15-24	232	44.4
25-34	102	19.5
35-44	73	14.0
45-54	75	14.3
55-65	41	7.8
Total	523	100

Table 2: Percentages of income groups (N = 523).

Income pa	%
<$15,000	42
$15,000 to $30,000	21
$30,000 to $45,000	20
45,000 to $60,000	8
$60,000+	4
No response	5

Table 3: Percentages for participants' occupations compared with ABS (1997-1998) statistics.

Occupation	Sample (%)	ABS (%)
Managers	16.2	7.5
Professionals	24.1	17.5
Paraprofessionals	12.2	10.4
Trades People	10.9	13.6
Clerical/sales persons	30.7	31.8
Labourers	2.3	10.1
Plant Operators/drivers	3.6	9.1

Table 4: Frequencies for therapies considered alternative.

	Frequencies
Therapies	Yes	No	Don't know	N	?????????
Aromatherapy	255	27	29	311	184.3***
Naturopathy	254	21	38	313	197.4***
Acupuncture	251	33	27	311	167.3***
Massage	244	55	17	316	119.5***
Acupressure	243	23	43	309	182.0***
Meditation	240	49	23	312	126.2***
Homeopathy	201	30	83	314	126.6***
Vitamin Pills	176	104	33	313	18.5***
Chiropractic	171	107	33	311	14.7***
Colour Therapy	157	43	106	306	65.0***
Physiotherapy	144	145	25	314	not sig
Osteopathy	133	65	107	305	23.4***
Alexander Technique	102	21	179	302	53.3***

* p < .05, ** p < .01, *** p < .001

Table 5: Frequencies of the types of complementary substances used and practitioners visited.

Complementary therapeutic	Frequencies*	%
Herbs/herbalist	114	17.8
Massage	78	12.2
Chiropractor	77	12.0
Physiotherapy	62	9.7
Aromatherapy	61	9.5
Naturopathy	61	9.5
Vitamins	59	9.2
Acupuncture	59	9.2
Meditation	34	5.3
Homeopathy	26	4.1
Iridology	10	1.6
Totals	641	100

*Multiple responses were permitted.

Table 6: Frequencies and percentages of men and women who have used a complementary substance and/or have seen a complementary practitioner (N = 523).

	Total	Younger Women (15-34 yrs)	Younger Men (15-34 yrs)	Older Women (35-65 yrs)	Older Men (35-65 yrs)	Results
Used a Complementary substance	315 (60%)	119 (23%)	41 (8%)	84 (16%)	71 (14%)	age* sex***
Used a complementary practitioner	215 (41%)	72 (14%)	46 (9%)	64 (12%)	33 (6%)	age***

* p < .05, ** p < .01, *** p < .001

Table 7: Frequencies and percentages of people in and not in a private health fund who have used complementary substances and/or have consulted a complementary practitioner (N = 523).

	Health fund	No health fund	x²
Used complementary therapeutic	159 (30%)	156 (30%)	not significant
Used complementary practitioner	114 (22%)	101 (19%)	3.7*

* p < .05, ** p < .01, *** p < .001

Table 8: Frequencies of the reasons why participants would use complementary therapeutics (N = 326).

Reasons used	Frequencies (%)
Major illness	38 (7%)
Minor illness	212 (41%)
Prevention	121 (23%)

Table 9: Frequencies whether complementary therapeutics should be used on their own, in conjunction with mainstream medicine, or not at all (N = 523).

Use of complementary therapeutics	Frequencies (%)
On their own	81 (15.5%)
In conjunction with mainstream biomedicine	387 (74%)
Not at all	30 (5.7%)
Missing	25 (4.8%)

Table 10: Frequencies of those who used complementary therapeutics over time (N = 523).

Used in the last:	Total	Younger Women (15-34 yrs)	Younger Men (15-34 yrs)	Older Women (35-65 yrs)	Older Men (35-65 yrs)	Results
12 months	186 (36%)	78 (15%)	39 (7%)	48 (9%)	21 (4%)	sex**
5 years	81 (15%)	27 (5%)	22 (4%)	19 (4%)	13 (3%)	not sig.
10 years	41 (8%)	7 (1%)	8 (2%)	17 (3%)	9 (2%)	age***

* p < .05, ** p < .01, *** p < .001

Table 11: Frequencies of regularity of use of complementary therapeutics (N = 523).

How often used	Total
Daily	64 (12%)
Weekly	53 (10%)
Monthly	46 (9%)
irregular/occasional	156 (30%)

p < .05, ** p < .01, *** p < .001

Table 12: Frequencies of Positive/Negative Outcomes (N = 523).

Outcomes of Alternative Therapy Use	Frequencies	%*
Positive	164 (31.4%)	53.8
Negative	22 (4.2%)	7.2
Partly Positive	119 (22.8%)	39.0
Missing/not used	218 (41.7%)

*Excludes "missing/not used" N = 305.

Table 13: Frequencies of Attitude Change.

Has Your View of Alternative Therapies Changed	Frequencies	%*
Favourably	215 (41.4%)	67.8
Unfavourably	20 (3.8%)	6.3
Not at all	82 (15.7%)	25.9
Missing/not used	206 (39.4%)

*Excludes "missing/not used" N = 317.

Table 14: Factors which influenced the 1st use of complementary therapeutics.

Recommended by:	No. of Respondents
Friends	118 (26.5%)
Family	108 (24.2%)
GP	77 (17.3%)
Other	34 (7.6%)
Other Factors:
Biomedicine inadequate	47 (10.5%)
Media	27 (6.0%)
Advertising	10 (2.2%)
Other	25 (5.6%)
Total	446

Table 15: Reason why people elect not to use complementary therapeutics (N = 523).

Reasons	Total
Too expensive	14 (2.7%)
Not interested	59 (11%)
Bad reports	4 (1%)
Sceptical	47 (9%)

* p < .05, ** p < .01, *** p < .001

Notes

¹ I have used the term "complementary" rather than "alternative" to refer to a range of therapies and their practitioners which derive from a knowledge base distinct from that of biomedicine and which generally do not hold the special legitimation or status that the State has conferred upon biomedicine, although in Australia at least there are a number of exceptions to this such as acupuncture performed by a GP and chiropractic. While "complementary" would be better suited if it were reciprocated by a recognition on the part of orthodox medicine of its own complementary role, it does nevertheless convey a greater sense of equality or reciprocity than does "alternative", and does not necessarily imply subordination. Perhaps serious consideration should be given to the term "médicines parallèles" (Cant and Sharma, 1999, pp. 5-9; Inglis and West, 1983). Acknowledgement is also given to the fact that complementary modes of healing found in Western countries are diverse and that they should no longer be treated as a single category, and hence comments throughout this paper may refer to all such therapies or only some. In fact, my research set out in part to consider what therapies were considered by respondents to be "alternative/complementary" and thereby which ones could, according to the sampling, be excluded from such a generic category. This of course still leaves designated "alternative" therapies lumped together; but indeed this probably reflects the popular perception of "alternative" therapies as belonging to some generic conceptual category.

² The inner and outer western areas of Sydney are generally considered lower-middle class/upper-working class areas. However, due to data collection complexities, there occurred a skewing of the sample toward the middle/lower-middle socio-economic groups of the region, as Table 3 suggests.

³ For a copy of the questionnaire please follow this link

⁴ All percentages are rounded to one decimal place, and all percentage totals rounded to 100%, unless otherwise indicated.

⁵ Unfortunately, due to a questionnaire design fault, respondents who had not used any complementary therapeutics were not able to indicate which therapies they considered "alternative".

⁶ Although the questionnaire asked respondents to indicate what the complementary therapeutics had been used for, the response was so low that the data are not valid. This low response rate may be a function of why participants used complementary therapies: primarily for minor illnesses and for prevention of illness (see Table 8).

⁷ (x² (1, N = 523) = 4.5; p < .05)

⁸ (x² (1, N = 523) = 11.5; p < .001)

⁹ (x² (1, N = 523) = 12.61; p < .001)

¹⁰ (x² (1, N = 523) = 3.7; p < .05)

¹¹ x² (1, N = 523) = 71.5; p < .001)

¹² (x² (4, N = 497) = 2.0, p < .57)

¹³ (x² = (4, N = 497) = 6.75, p < .15)

¹⁴(x²?(1, N = 326) = 33.06; p < .000)

¹⁵ (x²?(1, N = 326) = 47.54; p < .000)

¹⁶(x² (N = 491) = 182.1; p < .001)

¹⁷ (x²?(N = 473) = 146.2; p < .001)

¹⁸(x² (2, N = 498) = 449.2; p < .000)

¹⁹ (x² = 0.003; p<.01)

²⁰ (x² = 0.001; p<001)

²¹ (x² = 0.004; p<.05)

²²(x²?(1, N = 523) = 10.0; p < .01)

²³(x² (1, N = 523) = 13.0; p < .001)

²⁴(std. dev. = 23.712; median = 3.0)

²⁵ (x² (1, N = 523) = 193.8; p < .000)

²⁶ (x² = 0.002; p<.01)

²⁷ (x² = 0.001; p<.001)

²⁸ (x² = 0.000; p<.001)

²⁹ (x²?= 0.006; p<.01; x²?= 0.01; p <.001)

³⁰ (x²?= 0.001; p<.001)

³¹ (x²?= 0.003; p<.01; x²?= 0.002; p<.01)

³² (x²?(N = 318) = 21.1; p < .000).

³³ When the survey was administered, many health insurance companies were providing coverage-at a higher premium and usually on referral of a GP-for such therapies as chiropractic, physiotherapy, acupuncture, naturopathy and massage. This recent date of acceptance of some complementary therapeutics by health funds in Australia may also account for the younger vis-à-vis the older groups having consulted a complementary practitioner.

³⁴ For example, we generally do not find among University students a widespread disbelief about what one always has been told and taken for granted; what we in fact find, sadly, is the antithesis: an uncritical credentialism.

³⁵ This of course raises the issue of complementary practitioners being more empathetic and informative vis-à-vis biomedical personnel.

Acknowledgements

: Much of insight of this paper has derived from conversations with Professor Lesley Wilkes and Dr. Antoinette Cotton, as part of my doctoral research program at the School of Nursing, University of Western Sydney, Australia. I am indebted to my undergraduate students for their help in administering the study questionnaire. Thanks to the three anonymous reviewers for their critical readings and constructive comments on earlier versions of the paper.

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