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COMPLEMENTARY THERAPIES

Decision-making related to complementary and alternative medicine

use by people with Type 2 diabetes: a qualitative study

Hsiao-Yun Annie Chang, Marianne Wallis, Evelin Tiralongo and Hui Lan Wang

Aims and objectives. To explore how complementary and alternative medicine (CAM) users make decisions about CAM use.

Specifically, an exploration of the processes used by people with Type 2 diabetes, related to the assessment of information

sources, factors influencing decision-making and the role of other key individuals, was undertaken.

Background. Patients with chronic illnesses increasingly seek to use CAM to improve their well-being. Currently, however,

the decision-making processes related to CAM use among people with Type 2 diabetes are poorly understood.

Methods. An exploratory study using a naturalistic design, with in-depth semi-structured interviews, was undertaken.

Purposive sampling was used to recruit participants with Type 2 diabetes who used CAM alongside conventional medicine.

The data were analysed in a three-step coding process. Ethical approval was gained from a human research ethics

committee.

Results. Evidence about CAM use from interview data was consistent with a multi-dimensional decision-making processes

used by participants. Four major categories emerged: recognising the need for using CAM; assessing the potential CAM

before use; matching CAM use to personal philosophy; and ongoing evaluation of CAM.

Conclusion. As diabetes affects the entirety of a person’s being self-management, incorporating CAMs has become a way of

controlling the condition and improving well-being. It is important for health professionals to consider clients’ CAM use

and to incorporate this information, where appropriate, into management plans.

Relevance to clinical practice. Health care professionals should be aware of patients who use CAM while under conven-

tional medical care and should discuss CAM use at various points in the client journey to facilitate better communication.

Key words: complementary and alternative medicine, decision-making, nursing, qualitative study, Type 2 diabetes

Accepted for publication: 24 June 2012

Introduction

Diabetes mellitus is a group of metabolic disorders character-

ised by hyperglycaemia (American Diabetes Association

2010). It affects more than 220 million people worldwide,

and 90% of those people have Type 2 diabetes (World Health

Organization 2009). Diabetes is associated with numerous

health problems, such as, neuropathy, retinopathy and angi-

opathy and is a leading cause of many diseases, such as infec-

tions, heart disease, stroke and renal disease. Consequently,

people with diabetes have double the risk of dying than their

peers without diabetes (World Health Organization 2009).

Authors: Hsiao-Yun Annie Chang, PhD, RN, BN, MN, Assistant

Professor, School of Nursing, Fooyin University, Kaohsiung,

Taiwan; Marianne Wallis, BSc, PhD, RN, Professor of Clinical

Nursing Research, Research Centre for Clinical and Community

Practice Innovation & Gold Coast Health Service District, Griffith

University, Gold Coast, Qld; Evelin Tiralongo, BPharmSc, PhD,

Senior Lecturer, School of Pharmacy, Griffith University, Gold

Coast, Qld, Australia; Hui Lan Wang, RN, BN, MN, Lecturer,

Jen-Teh Junior College of Medicine, Nursing and Management,

Miaoli County, Taiwan

Correspondence: Hsiao-Yun Annie Chang, Assistant Professor,

School of Nursing, Fooyin University, 151, Chinhsueh Rd., Ta-liao,

Kaohsiung, Taiwan. Telephone: +886 986502206.

E-mail: [email protected]

To prevent or delay the development of the complica-

tions associated with diabetes and to lead healthy, produc-

tive lives, people with diabetes increasingly seek treatment

through complementary and alternative medicine (CAM).

The prevalence of CAM use among people with diabetes

ranges from 17–72�8% worldwide, and the most popular therapies are nutritional supplements, herbal medicines,

nutritional advice, spiritual healing and relaxation tech-

niques (Chang et al. 2007). As most of the surveys of

CAM use are conducted with participants accessed

through conventional hospitals, it can be assumed that

many people with diabetes are using CAM and conven-

tional medicine concurrently (Chang et al. 2007). How-

ever, people with diabetes under the care of conventional

medicine practitioners seldom discuss their use of CAM

with healthcare professionals and this could lead to dan-

gerous interactions and negative outcomes for patients

(Chang et al. 2011).

The decision-making process related to CAM use has

been most frequently described for patients with cancer

(Shumay et al. 2001, Thorne et al. 2002, Balneaves et al.

2007, Evans et al. 2007, Lu et al. 2010, Watt et al. 2011).

However, these studies have focused on many different

aspects of the issue and it is difficult to gain a clear picture

of the processes involved. What these studies do indicate is

that factors affecting the decision-making, for patients with

cancer, include: culture and family relationships (Watt et al.

2011); dissatisfaction with conventional treatments and/or

health professionals (Shumay et al. 2001); problematic rela-

tionships with conventional health professionals (Shumay

et al. 2001, Thorne et al. 2002); and a desire to be proac-

tive in self-management (Thorne et al. 2002, Balneaves

et al. 2007). In terms of the processes undertaken by cancer

sufferers who decide to use CAM, a number of studies have

identified that patients may go through a number of steps

or stages and that a key area of difficulty in the decision-

making process relates to assessment of complex and con-

tradictory sources of information (Thorne et al. 2002,

Evans et al. 2007). In addition, it appears that cancer suf-

ferers may be active or passive in the decision-making pro-

cess (Evans et al. 2007) and will often evaluate the

effectiveness of CAM use once they have commenced

(Thorne et al. 2002).

While this literature is useful, the decision-making,

related to CAM use, of patients with cancer may not be

transferable to other patient populations, such as people

with Type 2 diabetes. As yet, the dynamic nature of the

decision-making process related to CAM use among people

with Type 2 diabetes has not been described in the litera-

ture. Additionally, decision-making related to CAM use

may be different in other social and cultural contexts. For

example, within the Chinese culture, there is a strong belief

in Chinese cultural norms and an acceptance of certain tra-

ditional remedies and these will influence the ways in which

CAMs are selected and used (Chang & Li 2004). To enable

effective health funding planning, it is important to under-

stand decision-making related to the use of CAM and fac-

tors that affect that decision-making.

Methods

Aim

The aim of this study is to explore how people with

Type 2 diabetes who were CAM users made decisions

about their use of CAM. Specifically, an exploration of

the processes used by people with Type 2 diabetes, related

to the assessment of information sources, factors influenc-

ing decision-making and the role of other key individuals,

was undertaken.

Research design

The qualitative research approach undertaken in this study

was a form of naturalistic inquiry. The aim of this

approach is to understand how people make meaning out

of a situation or a phenomenon within a real-world setting.

This approach is mediated through the researcher as an

instrument: the strategy is inductive, and the outcome is

descriptive (Merriam 2002). This study involved semi-struc-

tured interviews with participants who were interested in

contributing their experiences of CAM use and their

decision-making related to its use.

Study participants

Patients attending the diabetes clinics at three hospitals,

from different regions within Taiwan, between August

2006 and February 2007 were invited to participate in the

study. The target participants were purposively selected if

they were able to discuss their experiences, had a range of

experiences related to CAM use and came from diverse

backgrounds; those with information-rich, unusual or

extreme experiences were also included. The choice of 16

participants was consistent with the guiding principle of

‘data saturation’ that is, ‘sampling to the point at which no

new information is obtained and redundancy is achieved’

(Polit-O’Hara & Beck 2004, p. 308).

H-YA Chang et al.

Data collection instrument

A semi-structured, conversational-style interview was con-

ducted to cover a specific set of topics related to the study.

The interview guide was developed to answer the research

question ‘What is the decision-making process related to

CAM use, reported by people with type 2 diabetes using

CAM?’ To structure interviews, three main sections were

included: an introduction focusing the interviewee on the

topic of the interview; a main section consisting of questions,

follow-ups and probes; and an ending which thanked partic-

ipants and allowed for final comments. The main section of

the interview focused on the research concepts, including

personal experience of CAM use, the meaning of CAM use

and the CAM use decision-making process. The main ques-

tions in the interview guide aimed at the various partici-

pants’ levels of understanding. Double-barrelled, ambiguous

and directive questions were avoided. Probes were used to

facilitate further explicit descriptions of the decision-making

process or to clarify areas of confusion. The interview ques-

tions developed as the interviews progressed because further

ideas arose from the analysis of first few interviews.

Data collection process

At the time of the initial contact, the information sheet and

the informed consent form were explained to potential par-

ticipants. Consent to participate in the study was obtained

before proceeding with the interview. An interview guide

was used to ensure that all relevant topics were discussed

with the interviewees. To balance flexibility and consistency

in the research, the sequencing of questions was not the

same for each participant, as it depended on the process of

the interview and the responses from the participants. Inter-

view data were collected in three ways: (1) audio-recording

of the interview; (2) note taking during the interview;

and (3) note taking after the interview. Permission was

obtained prior to recording the interview. The field notes

reminded the researcher of key ideas or concepts identified

by the participant. Participants were encouraged to answer

in their own words with as much detail as they wished.

The interviews were conducted in the language of Mandarin

or Fujan and lasted generally for approximately half hour

to an hour each with a maximum of two hours.

Data analysis

Initial interview and field notes were fully transcribed.

Three coding steps were used to analyse the qualitative

data: (1) open coding, (2) axial coding and (3) selective

coding. Data analysis was performed manually and

recorded using Microsoft Word. Initially, the researcher

read and re-read through the text, coding line by line, to

gain familiarity and identify accounts within the data. Later

conceptually linked elements of text were grouped together

for further analysis. The researcher established analytical

memos or notes containing ideas and thoughts about the

data as well as the reasons for grouping them in a particu-

lar way. The categories appeared incomplete at first but

were reviewed and refined with further data collection and

analysis. Data analysis ended when no new information

emerged about a category and removing new data from the

present data did not affect the analysis.

To strengthen the reliability of the interpretation and

findings, the raw data were analysed in Chinese initially.

Once the data were collected, the researcher and a Taiwan-

ese expert who is competent in qualitative research proce-

dures analysed the raw data individually. After completing

the initial coding, the researcher and the Taiwanese expert

discussed it together to detect bias or inappropriate subjec-

tivity and eventually agreed through consensus on the emic

codes that would be moved forward in the process of cate-

gory generation. Codes were compared for study partici-

pants and meaningful relationships among the codes

identified to generate etic subcategories and categories.

After discussion, the categories and subcategories that could

best describe the experience of the participants were

decided in a collective view. These categories and subcate-

gories were translated into English by the interpreter. The

two experts from Australia cross-checked the data analysis

and removed any interpretations that could not be substan-

tiated by verbatim quotes.

Rigour

Lincoln and Guba’s (1985) four trustworthiness criteria

were employed: credibility; confirmability; dependability;

and transferability. Confirmability and dependability were

ensured in this study by verbatim recording, auditing of

transcripts and notes taking during the study process.

During data collection and analysis, ideas about labelling

the phenomena were explored with the experts and congru-

ence of the research results between experts was developed.

Credibility was ensured after completion of raw data analy-

sis: the researcher paraphrased two participants’ statements

and asked them during the next clinic visit for confirmation.

The feedback from participants ensured most findings pre-

sented their point of view and only minor misunderstanding

of participants’ words was clarified because dialect was used

during the interview. For dependability, the qualitative

Complementary therapies CAM decision-making in people living with T2DM

findings were compared not just with the literature but also

with the quantitative results of this study in the discussion

chapter. The transferability of the results will be determined

by the readers of this article. If the recommendations at the

end of the document logically extend from the data analysis,

they will have the potential to transfer to other settings.

Ethical considerations

Permission for this study was granted from the University

Human Research Ethics Committee. Written permission to

interview the patients was also obtained from hospital sites

in Taiwan. Individual consent to participate in the study

was obtained before proceeding with the interview. Identi-

fying information was deleted from the transcripts of the

files. Data are presented in such a way as to ensure partici-

pants are not identifiable.

Results

The 16 participants were six men and ten women, ranging

in age from 38–71, with an average age of 53 years. Nine

were Fujian Taiwanese, four Chinese Taiwanese and three

Hakka Taiwanese. Fourteen participants were married and

only two were widowed. Their highest education levels ran-

ged from primary school to master’s degree. Most of them

practised either Buddhism or Daoism and only one did not

practise any religion. The length of time they had been

diagnosed with diabetes ranged from one to 25 years with

an average of 10 years. All participants were taking either

or both oral anti-diabetes agents and insulin as treatment

for their diabetes.

Through constant comparative analysis, four major cate-

gories emerged from the qualitative interview data: ‘recogn-

ising the need for using CAM’; ‘assessing potential CAM

before use’; ‘matching CAM use to personal philosophy’;

and ‘ongoing evaluation of CAM’ (see Fig. 1). The follow-

ing section explains each category which consisted of a

number of subcategories.

Recognising the need for CAM use

Increasing symptom distress, over a lengthy period of time,

and deteriorating physical function and ability raised sev-

eral issues regarding physical, mental and spiritual health

for participants. In living with these problems, participants

began to recognise the need to take action to manage their

condition, disease, bodily functions and life. Either before

or simultaneous with the decision to explore CAM use,

many participants reported being aware of a number

of needs: the need to be in control, the need to improve

well-being and the need for spiritual comfort. Controlling

diabetes and related health problems such as distress,

chronic illness and multi-dimensional health issues, through

the use of CAM, enabled participants to retain their origi-

nal roles in daily life. A participant stated:

Assessing potential CAM before use:

- Listening to the opinions of others

- Assessing products

Recognising the need for CAM use:

- The need to be in control - The need for well-being

- The need for spiritual comfort

Matching CAM use to personal philosophy:

- Belief or scepticism - Proactive involvement in

health management - Critical assessment of

information

On-going evaluation of CAM:

- Monitoring blood glucose levels

- Evaluation linked to expectation

- Alertness to the therapeutic process

- Motivational supports - Product attributes

The decision- making

process of CAM use

Figure 1 Categories and subcategories of

the decision-making processes of comple-

mentary and alternative medicine (CAM)

use by CAM users with Type 2 diabetes.

H-YA Chang et al.

I realised what had been damaged in my body when I was dis-

charged… I was pretty shocked with the result of my liver function

test …plus diabetes…These two diseases are in the top ten leading

causes of death. …Then… (sigh)…I was really sad…very sad

(weeping). So, after I was discharged from hospital for a month, I

started to think about other therapies which may help me to have

more control of my body. (Tom)

When participants were diagnosed with diabetes, the reality

began to sink in for them that diabetes was a lifelong con-

dition and a potential threat to life. They still had the desire

for a normal, healthy life. Thus, the need to maintain and

improve their physical, psychological and social well-being

became their motivation to use CAM. Many participants

stated that they used CAM to ‘maintain physical health’,

‘maintain my body in good health’ and ‘live with peace of

mind’. One participant particularly mentioned that a

machine, which she had bought as part of a CAM, was

expensive ‘but I bought this machine, just as I bought my

health back (Vine)’.

Another factor in recognising the need for CAM use is

spiritual comfort. The most common religions in Taiwan

derive from Chinese folk religion (Buddhism and Daoism),

which believe that a human being is a microcosm of the

universe. People believe that their experience of illness is

closely linked to the spiritual. Therefore, Chinese exorcism

is a very popular religious activity for treating illness in

Taiwan using different techniques, for example, use of talis-

mans, various invocations of higher powers, chemicals, poi-

sons and other techniques to drive demons from the body.

One female participant particularly mentioned ‘when you

get sick, you need not just a person (doctor) but also God’,

she continued:

Otherwise, how would you be cured? If I feel the need, I go there

to see him (‘Ji-tong’乩童, spiritual medium). I don’t have a certain

routine, sometimes once per week or sometimes over 2 weeks. I

went when I felt sick and did not feel better after seeing the doctor.

Then, whatever Chinese Gods were suitable I would pray (‘Bai-bai’

拜拜) to them. (Ellen)

Assessing the potential of a CAM before use

Once participants recognised the need for CAM, they

required multiple sources of data prior to making any deci-

sion to go ahead with the procedure. Many participants

described a consistent, sequential process of information-

gathering as an antecedent to the concrete decision to pro-

ceed. The interviews revealed that participants investigated

and assessed the potential for CAM to select a suitable

therapy. They were influenced by many factors that fell into

two main subcategories: listening to the opinion of others

and assessing products.

People live surrounded by family and relatives, friends,

other acquaintances and the media; all of which had the

potential to influence people’s choice of CAM. The influ-

ence of the opinion of others on CAM decision-making was

described by many participants during the interviews. Three

emerging patterns became evident from the data under this

major subcategory: the decision was influenced by family,

positive outcomes reported by others, and promotion by

authoritative sources.

In the Chinese tradition, the family shapes the beliefs and

attitudes of all family members. As one participant stated:

My daughter bought some nutritional supplements such as megavi-

tamin, glucosamine and vitamin C to us. She thinks it would be

better if I complement my treatment with these. (Gavin)

CAM therapies were frequently given as a gift from the

younger generation such as a son, daughter or child-in-law.

As Ellen stated that ‘my daughter bought this course of

treatment for me’. This kind of action by members of the

younger generation in Chinese families is crucial and com-

mon. These activities demonstrated how dutiful the child is

in Chinese tradition because it represents the filial piety of

Confucianism. However, positive outcomes from friends

and other acquaintances also prompted CAM use.

Many participants had heard stories from relatives,

friends or close associates who offered opinions and per-

sonal testimonials of how they were cured using specific

CAM therapies. People were interested in and believed this

information – the so-called ‘word-of-mouth promotion’.

They valued this information highly and considered this

form of communication highly credible. Participants during

the interviews often mentioned ‘my friend ate this’, ‘my col-

league taught me’ ‘my husband’s friend has used it’.

CAM information could also be derived from profession-

als or be promoted by some authoritative sources, such as

TV shows, organisational websites, books and journals.

Professionals in this context could be either conventional

healthcare practitioners or CAM practitioners. The advice

given by conventional healthcare professionals was not

popular with participants; only one participant reported it.

Many participants mentioned that ‘Fragrant-toon tea (香椿,

Toona sinensis Roem)’ is frequently promoted on TV.

Owen stated, ‘the Internet and TV all talked about it’.

Although participants tended to rely on the media as their

information source, they preferred promotional sales from

the national TV broadcasting network rather than local TV

stations. In addition, the Internet was rarely the first

port-of-call for CAM information.

Complementary therapies CAM decision-making in people living with T2DM

Assessing products is a crucial influential factor in the

decision-making process related to CAM use. As one partic-

ipant claimed, ‘when I don’t trust the product, I won’t buy

it (Fiona)’. When assessing products, participants took into

account product promotional material, information on

product reliability and the price. Many participants

reported that the reason they started using CAM related to

promotion of the product because salespeople often used

information about the product as a sales tool. The benefits

of a product may have been exaggerated and hard sales tac-

tics sometimes lead to participants making unplanned pur-

chases of CAM therapy in a short period of time. However,

many participants stated that they preferred to select the

product after learning more about it and whether it was

trustworthy. They often reported that they only used cer-

tain ‘brands’, ‘shops’ or ‘products with GMP (produced

according to Good Manufacturing Practice Standard)’. Par-

ticipants liked to select CAM according to the products’

reliability because they felt this established whether or not

the product performed consistently over time.

Apart from perceived product reliability, price affordabil-

ity was one of the criteria used in the decision-making pro-

cess for CAM use. The cost of CAM use was not discussed

frequently in the interviews, but participants often nomi-

nated an acceptable price range of different products. This

may indicate that when people faced the initial decision to

consider and identify CAM options, they took into account

their needs, personal testimonials, endorsements by authori-

tative sources and the product’s apparent reliability rather

than price. As previously mentioned, the choice of CAM

could be affected by listening to the opinion of others and

the results of assessing products. However, among partici-

pants, the perceived need for a specific CAM was a funda-

mental reason for its use. Therefore, even though they often

accepted recommendations from trusted members of their

social network, many still made their own decisions related

CAM use.

Matching CAM use to personal philosophy

The participants in this study varied widely in terms of

demographics, personality (beliefs, values and attitudes),

resources, motivation and opinions regarding CAM use.

The findings of the study indicated that the decision to use

CAM was closely related to personal philosophy. Three sub-

categories emerged from the data: belief or scepticism, pro-

active involvement in their self-management and critical

assessment of information. A significant proportion of the

participants who used CAM did so because it was congruent

with their individual values, worldview, spiritual/religion/

personal philosophy or belief regarding the nature and

meaning of health and illness. By contrast, some participants

also aired their scepticism as to the efficacy of CAM thera-

pies for diabetes control. One commented that the use of

CAM is like an individual’s belief in religion: ‘This part (the

use of CAM) is just like a religion. In fact, a believer always

believes, a non-believer never believes (Tom).’

While their decisions could be influenced by the opinions

of others, the participants also showed a capacity to assess

the information available to them critically. One participant

particularly highlighted that he made his decisions for him-

self. He stated that ‘the disease is in my body, so the choice

should depend on me. What people say… well, I believe

myself, and I only believe myself (David).’ Many partici-

pants endorsed this sentiment: ‘dare not take anything with-

out caution (不敢亂吃, don’t eat random stuff or eat

indiscriminately)’. As Gavin put it: ‘I’m also afraid to buy

things without consideration or to try things without being

careful, those are not so good (Gavin)’. When participants

obtained all the CAM information from their various envi-

ronments, they matched it with their personal philosophy

and then made a decision whether to use CAM or not.

However, participants undertook an ongoing critical assess-

ment before making decisions to use CAM but also under-

took this assessment through the course of CAM use.

Ongoing evaluation of CAM

After beginning CAM use, participants evaluated the pros

and cons and then decided whether to continue to use it or

to cease. This was a highly individualised process. As the

participants’ overall goals of CAM use were to control ill-

ness, to improve well-being, and to comfort the spirit, the

effectiveness of CAM in doing one of these three things was

an important criterion in many people’s account of CAM

during the interviews, but not the only one. Some partici-

pants also encountered several barriers, which affected their

CAM use. Several convergent subcategories emerged from

the data, including monitoring blood glucose levels, evalua-

tion linked to expectation, alertness to the therapeutic

process, motivator support and product attributes.

Because one reason for CAM use among participants was

the need to be in control, blood glucose monitoring pro-

vided insight into the effectiveness of diabetes management

and allowed the people with diabetes to understand how

well they were exercising control over the disease. Partici-

pants found that ‘Fragrant-toon tea’ (香椿, Toona sinensis

Roem) was effective in the control of blood sugar. They

experienced their blood sugar being ‘down’ or ‘controlling

around the range’, and a participant reported that ‘I forgot

H-YA Chang et al.

to take it. I found my blood sugar was kind of high, more

than 200 [mg/dl] (Leaf).’ Apart from blood sugar level, a

number of participants described measures in which they

evaluated the outcome of their decision of CAM use. How-

ever, performance could be either expected or unexpected

depending on participants’ perceptions of the effects of

CAM use. Many participants had previously mentioned the

need for well-being and the need for spiritual comfort; they

subsequently decided to continue the use of specific thera-

pies based on perceived positive outcomes of CAM use.

The positive evaluations mostly depended on partici-

pants’ subjective perceptions rather than on objective mea-

surement of outcome. Some participants who did qi-gong

characterised this exercise as helping them to improve gen-

eral health, for example: ‘I can feel the “Qi” (氣, invisible

force) through my head down to here (the stomach). After

exercise, I feel good, and my energy is much better (Bill).’

Indeed, how the CAM therapy made participants feel was

far more important than whether the therapy was evidence-

based or had observable outcomes. The congruence of the

therapy with a personal value system was significant; for

example, Yelly believed that illness is the result of a bad

deed committed during a previous life; thus, frequently

practising the religious activity ‘Da-fo-qi’ (打佛七, Chinese

Yoga for worshiping God) would compensate for her

misdeed.

During the use of CAM, participants were also alert to

every aspect that could affect them. A participant described:

Individuals have this kind of contradiction; all of them have that

kind of watchfulness (or wariness). So you have to try it (CAM)

and always observe your body and watch the response after taking

it. (Gavin)

Participants described that even though they observed few

changes in their health status after commencing CAM, they

felt that there was no harm being done; thus, they were will-

ing to keep using it. However, there were participants who

stated that the reason they ceased CAM use was not to do

with effectiveness, rather they lost their enthusiasm for the

specific therapy. Additionally, three participants stressed

that the reason they did not use specific therapies was

because they disliked the flavour of these CAM remedies.

Participants appeared to be willing to experiment with

different CAM therapies once options were identified. This

experimentation was carried out before making a final deci-

sion and was used to justify and test whether a therapy was

right for them individually. Participants’ weighed up the

pros and cons of CAM use and used these in their decision-

making.

Discussion

Analysis of the process undertaken by patients revealed a

dynamic of four major stages in CAM use decision-making

including i) recognising the need for CAM use, ii) assessing

potential CAM before use, iii) matching CAM use with per-

sonal philosophy and iv) ongoing evaluation of CAM. Evi-

dence about CAM use from interview data was consistent

with multi-dimensional decision-making processes used by

other populations (Thorne et al. 2002, Balneaves et al.

2007, Evans et al. 2007). From the time, participants were

diagnosed with Type 2 diabetes, and they were faced with

dozens of decisions regarding the control of their disease

each day. In most first world countries, the most common

model of health service delivery is a dichotomous one in

which conventional medicine and CAM rarely intersect

(Kemper et al. 2007). However, the results of this study

clearly indicate that for Taiwanese people with diabetes the

dichotomy between conventional medicine and CAM is

irrelevant; they will use whatever they believe will help them.

CAM use is a self-management strategy utilised by people

with Type 2 diabetes, and they incorporate this use into a

healthy lifestyle, a finding that is consistent with a previous

study (Thorne et al. 2002). For example, some participants

mentioned the efficacy of herbal tea and nutritional supple-

ments for keeping their diabetes under control, particularly

Toona sinensis Roem tea in maintaining stable blood glu-

cose levels. Many participants used dietary modification,

biofield exercises and even spiritual healing strategies as a

complementary way to self-manage their illness; as well as

adjusting their lifestyle to promote their well-being. Stress

was reported by a few participants as causing elevated blood

glucose levels, and people integrated strategies to control

their stress and blood glucose levels by including prayer,

yoga and meditation into their general lifestyle. These

actions resulted in a good balance of physiological and psy-

chological health and a better outcome for diabetes control.

The most important sources of information and motiva-

tion to use CAM were recommendations by families,

friends and relatives, an observation consistent with both

previous quantitative and qualitative studies (Lee et al.

2004, Moolasarn et al. 2005, Kumar et al. 2006). Indeed,

participants in the interviews reported that listening to the

opinion of others weighed heavily in the decision-making

process. In addition, information was spread widely

through word-of-mouth, which served as a mediating inter-

personal process affecting people’s health-seeking behav-

iours. Lind et al. (2006) and MacLennan et al. (2002)

found that a large amount of expenditure on CAM use was

out of individuals’ pockets; however, the monetary cost of

Complementary therapies CAM decision-making in people living with T2DM

CAM use did little to influence CAM use decision-making

among people with Type 2 diabetes living in Taiwan. One

explanation may be that traditional Chinese medicine is

covered by Taiwan’s National Health Insurance. The other

reason may be related to the fact that CAM therapy is

often given as a gift to represent dutiful affection from

juniors. The overall lack of importance that many partici-

pants placed on price as a factor in their CAM decision-

making was a significant finding of the interviews. This

may indicate that when people are faced with the initial

decision to consider and identify CAM options, they take

into account their needs, personal testimonials, endorse-

ments by authoritative sources and the product’s apparent

reliability rather than price.

Despite the finding that social networks affect peoples’

choice of CAM, the majority of participants emphasised

making their own decisions about CAM use. It is indi-

cated that if people are faced with a wide range of

options they try to match their behaviour/choice with their

personal philosophy, which is similar to previous studies

(Thorne et al. 2002, Bishop et al. 2010). Many partici-

pants who used CAM closely connected the therapies to

their personal background or cultural practices, particu-

larly in the realm of supernatural healing therapies or

TCM. In fact, personal philosophy is influenced by where,

what and how people learn, which is grounded in culture,

in which traditions, attitudes, beliefs and values are

acquired, shared and held by a group of people. A per-

sonal philosophy affects every aspect of a person’s life,

including their attitude towards illness, health status and

health-related behaviours (Leininger & McFarland 2002).

This finding is in keeping with more recent research that

suggests that CAM use is a choice based on personal phi-

losophy as it encompasses a wide range of therapies and

offers participants the opportunity to manage their condi-

tion in different ways at various points in the course of

disease (Kuan et al. 2011).

The perceived effectiveness of CAM in meeting partici-

pants’ expectations is crucial in the process of evaluating

CAM. In the qualitative interviews, the feeling of being more

in control of illness and health and the self-perception of sat-

isfaction towards CAM are key determinants of the effec-

tiveness of CAM use rather than scientific evidence, a

finding which is supported by the studies of Evans et al.

(2007) and Balneaves et al. (2007). It is reasonable to specu-

late that a psychological process of selecting and evaluating

CAM therapies takes place in the decision-making process

among most users. However, it is of concern that a placebo

effect might occur in the process of evaluating CAM among

people with Type 2 diabetes because of their expectations or

beliefs about the benefits of CAM (Adams 2007). In addi-

tion, effectiveness is not the only factor that influences the

decision whether to continue or to cease CAM use. Many

participants also highlighted the loss of motivational sup-

ports to reinforce their engagement with CAM use. Another

interesting finding is that although participants did not use

CAM primarily to reduce their blood glucose levels, the

majority of CAM users still monitored the change of their

blood sugar levels as an indicator whether the therapies were

suitable or effective for them. In short, even people who do

not use CAM primarily for diabetes eventually expect to

have better diabetes control as well as other benefits.

A number of participants reported that they observed

adverse effects and discontinued CAM. This may reflect the

problems of unsupervised CAM use, the dangers of CAM-

drug interactions, the side-effects of CAM and poor quality

CAM products. However, discontinuing therapy did not

mean other CAM therapies were avoided. In particular,

substantial intention to use other CAM therapies was

reported by interviewees after they had ceased one CAM

therapy. Thus, when a new product was introduced that

became a prime motivator, people wished to try it in the

hope of a better outcome. This result is also supported by

recent research in other clinical client groups and CAM

users in Taiwan (Kuan et al. 2011).

Strengths and limitations of the study

To our knowledge, this is the first qualitative research study

to elaborate on the decision-making process surrounding

CAM use, in people with diabetes, in an Asian context.

This qualitative research provides insight into the active

decision-making process of people choosing CAM during

the course of diabetes and also provides preliminary

insights into the illness experience and life management of

Taiwanese people living with Type 2 diabetes, particularly

as it relates to CAM use. The trustworthiness of the find-

ings was maintained using several strategies; as described in

the section on rigour. This study has several limitations

related to the recruitment of participants. The participants

were attending hospital-based diabetes clinics, and they

were a group that self-selected to participate in the inter-

views. Thus, the methods used to recruit participants might

have excluded specific patient groups and would have

included a large proportion of highly motivated clinic cli-

ents. However, this qualitative research study was designed

to develop a thorough understanding of the decision-mak-

ing processes used by CAM users who were concurrently

using CAM while being treated through the mainstream

medical system. Consequently, these findings may not be

H-YA Chang et al.

generalised to all people with diabetes, but may be transfer-

able to people in similar circumstances.

Implications for clinical practice

Since people with Type 2 diabetes who attend a diabetic

clinic do not use CAM in place of conventional medicine

but rather to complement it, healthcare professionals will

need to acknowledge CAM use, learn to discuss CAM use

with their patients, and be able to do so in an open-

minded, respectful manner. Additionally, taking a history

of CAM use to assess potential benefit or harm related to

CAM use is needed. This information may be beneficial for

further investigation and also minimises risks to a patient

from potential CAM-drug interactions. Diabetic nurses are

a vital resource because they spend more time listening to

patients than other professionals in the multidisciplinary

diabetes team. Thus, they are appropriate to be a communi-

cator between CAM and conventional diabetic care. How-

ever, Chu and Wallis (2007) pointed out that without the

organisational policies, resources and professional educa-

tion related to CAM, healthcare professionals are limited in

their abilities to include CAM into their practice. Therefore,

there is an urgent need to establish an ethical framework

for CAM practice, regulation and policy as well as up to

date continuing education on CAM for healthcare profes-

sionals as a supportive system to integrate CAM and con-

ventional medicine into the care of our patients.

The recommendations of significant others (word of

mouth) profoundly influence the decision-making process of

CAM use among people with Type 2 diabetes. This indicates

a lack of guidance and reliable CAM information. Therefore,

patients need to be further educated about CAM, and this

education should also include patients’ key care person such

as family. Another important recommendation is an urgent

need to use rigorous research designs to establish the efficacy

of several CAM that are currently being used by people

with Type 2 diabetes including popular Chinese herbal teas,

specific nutritional supplements, dietary modifications,

manipulative-based therapies and supernatural healing thera-

pies. Because all of these therapies have their own potential

benefits and potential adverse effects, they should be evalu-

ated for quality, safety and efficacy before use.

Conclusions

This study confirms that people with diabetes often use

CAM in combination with some form of conventional med-

icine. However, what motivates one individual to use CAM

is not necessarily what leads the next individual to do so.

Additionally, participants were more concerned about their

personal perceptions of the outcomes they experienced

related to CAM use than to the opinions of health profes-

sionals that derived from the scientific knowledge system. It

can be seen from the findings that word-of-mouth was a

common primary source of CAM information. People may

be using multiple types of therapist and therapy at any one

time or moving in a sequential manner from one type of

therapy to another in the search for a solution to their

health problems. From the participants’ points of view, it is

uncommon for people with diabetes to visit several kinds of

CAM practitioner for diabetes and its complications, but

rather it is common to seek treatment in a generic manner

for staying healthy in mind, body and spirit. Even though

participants did not always use CAM for the management

diabetes, they were all concerned about the effects, of any

CAM they used, on their blood glucose levels. Healthcare

professionals must be aware of patients who use CAM,

while under conventional medical care and should initially

and continually consult these patients about CAM use

to facilitate better communication and decision-making

because understanding CAM therapies and their integration

into patient care is needed to ensure patient safety and opti-

mise health care.

Ethical approval

The Ethics Committee of the Griffith University approved

the detailed research protocol for this study (protocol

number NRS/06/06/HREC).

Acknowledgements

The authors are deeply grateful to participants, nurses and

directors of three hospitals for their helps with this study.

We would also like to thank the editor and reviewers for

their valuable comments and suggestions.

Contributions

Study design: H-YAC, MW, ET; data analysis: H-YAC,

HLW, MW and manuscript preparation: H-YAC, MW, ET.

Conflict of interest

None declared.

Complementary therapies CAM decision-making in people living with T2DM

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