Culture and CAM

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

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

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    Increase awareness of research opportunities in
    CAM in ethnically diverse populations

    Identify strategies to develop rigorous research
    using CAM interventions that promote health and
    decrease disparities.

    Discuss the development of a research program in
    CAM and ethnically diverse populations.
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        What is Complementary and
        Alternative Medicine (CAM)?

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                 Definition of CAM
“A broad domain of health resources that encompass
health systems, modalities, and practices and their
accompanying theories and beliefs, other than those
intrinsic to the dominant health system of a particular
society or culture in a given historical period.”
5 Domains identified by NCCAM
 •   Alternative Medical Systems
 •   Biological Based Products
 •   Mind Body Interventions
 •   Manipulative and Body Based Practices
 •   Energy Medicine
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                Cultural Diversity:
            Influences on Health Care
Different values and beliefs with every different
Cultural Competency
• Have to have a knowledge base about the varying
  modalities with the skills and abilities to provide
  culturally competent care including respect,
  compassion, and dignity
“Varying Modalities” = “Complementary and
Alternative Medicine”
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             Education                   Place

                                 OF DIVERSITY                          Marital
                                  IN HEALTH
                      Ethnicity                            Gender

                            Religious                     Experience
 MasterMarch 17, 2007
       Teachers Taskforce    Beliefs    NCCEMNA                             6
     December 2005
         Is there a science to CAM?

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

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                 Medical Anthropology
    How is illness explained by cultures?
     • Emic: universal culture
     • Etic: inside the culture
    Naturalistic Explanation: illness is related to
    whatever is known in that culture
    Ethnocentric: your own is always the best
    How are cross-cultural remedial therapies used?
    How does the culture experience health vs. illness
    vs. wellness?
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    A sub-field of Medical Anthropology examining
    traditional medicine
     • Chinese Medicine
     • Ayurvedic Medicine
    Focuses on “medicine” whose knowledge and practices
    have been orally transmitted over the centuries.
    Uses an anthropological approach (not medical approach).
     • the perception and context of use of traditional medicines, and not
       their bio-evaluation.
    Journal of Ethnobiology and Ethnomedicine:

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    What happens when a cultural practice (or
    CAM) is “acculturated”…..taken out of the
    country of origin and moved to another
     • Is Chinese medicine the same here as in China?
    NCCAM research priorities: partnership
    with countries who are considered CAM to
    get to the roots of the practice.
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            Where do we see “cultural”
               influences in CAM
    Folklore Medicine
    Alternative Health Systems

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                       Folk Medicine
The Evil Eye
(mal de ojo)                                        Tonic

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

                                                   Snake Oil
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    Example of Folklore Medicine
    Superstitions                Shaminism
    Animism                      Belief in Religions
    Witchcraft                   Faith Healing
    Ancestor Worship             Herbs

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

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

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

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          Folk Medicine: ANCESTOR
    belief in the divine
    power and divine
    guidance of dead
    seen in many cultures:
    Asian, African
    American (Kwanza),
    Native Indian among a

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                            Folk Medicine:
  spirit possession
  has its roots in Africa
  now practiced in Cuba,
  Haiti and in the US
  (New Orleans)
  music and dance are
  ways of expression of
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Folk Medicine: SHAMANISM
 practitioners apply magic and speak to the
 spirits of nature
 can perform both physical and spiritual or
 faith healings
 discover their powers through ecstasy and
 Anthropology of “Consciousness”
 • Out of body experiences
 • Near Death Experience

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            Folk Medicine: BELIEF IN
    Faith healing or miracle healing
    Beliefs in the existence of spirits (good
    spirits and bad spirits or demons)
    Belief in the existence of ghosts, and in
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Folk Medicine: FAITH HEALING
    the use of religious folk objects or items,
    and prayers to cure illnesses
     • exorcism
     • ritual healings performed by voodoo priests and
       priestesses, and by Shamans
     • use of charms for protection or as lucky charms

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 Folk Medicine: HERBS OR HOME
    Fresh steaks and poltice - for treating infected wounds.
    Molasses - for treating sour throat and a baby’s teething
    Fresh cucumber and wet bag of tea - for treating a bad eye.
    Garlic - for reducing high cholesterol and high blood
    The juice from nim leaves - for curing malaria.
    Chinese acupuncture - for treating blood clotting and
    margarine headache.
    There are also alternative remedies for dieting, cancer
    treatment, diabetes, heart disease, skin care, weight loss
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                 Herbal Medicine
    Almost two-thirds of the earth’s 6.1 billion people
    rely on the healing power of herbal medicine.
    For them nothing else is affordable or available.

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               Cultural Influences in
            Alternative Health Systems
    Not related to folklore
    Based on cultural history, ethics, values,
    and beliefs of a specific culture
    Some have evidenced based research

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            Alternative Health Systems
    Ayurveda (Indian)         Middle Eastern
    Chinese                   Tibetan
    Native American           Central and South
    Indian                    American Cultures
    Aboriginal                Homeopathy
    African                   Naturopathy

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

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    Can we keep “traditional” vs. “non-
     traditional” separated and provide
  culturally competent and sensitive care?
Health care providers who discredit CAM use can
no longer deny the benefits
 • need to respond to the challenges evolving from issues
   related to the use of CAM
 • It is here to stay……

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       CAM and Health Disparities
    Does the use of CAM decrease health disparities?

    Does the use of CAM result in health disparities?

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

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

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       NCCAM Research Priorities
    Mechanisms of Action
    Phase I and II Clinical Trials
    Exploratory Studies
    Areas of Special Interest
     • Anxiety and Depression, CVD, ethnomedicine, immune
       modulation/enhancement, IBS, insomnia, liver diseases,
       obesity/metabolic syndrome, respiratory diseases
       (prevention and treatment)
    NCAAM highly interested in minority and gender
    health and health disparities
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                 Hierarchy of Research
    Evidenced Based Medicine based on RCTs (Borgerson,
     • Meta Analysis
     • Systematic Reviews
    RCTs (experimental designs) are considered the best
    scientific evidence (rigorous) because of
     • Randomization
     • Placebo
     • Control

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         NIH Clinical Trials (RCTs)
Comparisons to
Standard Therapies                 Phase III

Preliminary evidence               Phase II
of safety and efficacy

Dose finding, Side                 Phase I
effects, Clinical
67% of funding

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                 Clinical Trials and CAM –
                   backwards approach?
This is
                       Large portion of people using a product and
                                     consider it safe
67% of               Has it been compared to other standard therapies?
                        What has been done to determine if it is safe
In CAM,                             and has efficacy?
Phase I, II,
and III
Trials are                           How does it work?
missing                                 What is the
                                    mechanism of action?

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        How do we test the Placebo
 Can all CAM therapies fit in this RCT
 hierarchical model?
  • Can all CAM use a “placebo” to test the
    effectiveness of the treatment?
        • Hypnosis, Tai Chi, massage
  • If you can’t test the placebo effect, does that
    mean it is not evidenced based?

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   How can we show evidenced based research
  in CAM if we can’t do RCTs (with placebo)?

Walach et al., 2006
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       How do you develop a program of
             Research in CAM?
BS in nursing
• Certifications, CEUs
Masters: expert in a clinical field
Doctorate: research in your clinical area of expertise
• PhD is terminal degree for research preparation
Post-Doc: adding knowledge to that area of research
K Award: adding another dimension of knowledge
related to research

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 Developing a Program of Research:
           10 years……
    Small funding
     • Local grants: $500.00
    Larger Funding
     • National Professional Organizations: $5000.00
    Public Funding
     • Samueli Institute: $150,000
    NIH Funding
     • Different type of funding mechanisms (see handouts)
     • K or R mechanisms
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     What makes you competitive?
Showing you can complete research projects starting with pilot
studies that build on each other
Showing a progression of growth in your research
•   Hierarchy of research designs
•   Larger budgets
•   Larger studies
•   Multi-site studies
Showing that you disseminate the data
• Presentations: national and international
• Publications: nursing and non-nursing journals
Working with teams – no one does it alone anymore!
• Intramural Mentors
• Extramural Mentors

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                 Take Home Message
    Be patient with yourself.
    It takes time and persistence.
    Don’t give up – if you want to be a researcher.
    Find people who support you.
    There is enough wealth and goodness for everyone.
    Celebrate our Diversity!

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