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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

March 17, 2007              NCCEMNA                  1
                   Objectives
    Increase awareness of research opportunities in
    CAM in ethnically diverse populations

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

    Discuss the development of a research program in
    CAM and ethnically diverse populations.
March 17, 2007           NCCEMNA                       2
        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
culture
Cultural Competency
• Have to have a knowledge base about the varying
  modalities with the skills and abilities to provide
  culturally competent care including respect,
  compassion, and dignity
“Varying Modalities” = “Complementary and
Alternative Medicine”
 March 17, 2007         NCCEMNA                         5
                                         Work
             Education                   Place
                                                                       Class

                                                  Sexual
                                 Age
                                                 Orientation
                                                                        Income
         Health
                                 DIMENSIONS
  Parental
   Status
                                 OF DIVERSITY                          Marital
                                                                       Status
                                  IN HEALTH
Geographic
 Location
                      Ethnicity                            Gender

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




March 17, 2007      NCCEMNA           7
                     Anthropology
    Study of Man and Society
    Cultural Relativity
    Cross-Cultural Comparisons
    4 fields of study
     • Physical anthropology (biology): genetics, traits, evolution,
       adaptation
     • Cultural anthropology: field studies of culture of a particular
       people, languages, economics, family relationships, politics
     • Linguistic anthropology: communications (verbal and non-verbal),
       structure, function and history of language
     • Archaeology: human of the past

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

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




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                       Folk Medicine
The Evil Eye
(mal de ojo)                                        Tonic

 Circulated by word of mouth
 Has superstition and assumptions
 involved
 Not very scientific
 Often associated with the occult,
 mysticism, voodoo, shaminism
                    http://www.folkmed.ucla.edu/

                                                   Snake Oil
   March 17, 2007                   NCCEMNA                    13
    Example of Folklore Medicine
    Superstitions                Shaminism
    Animism                      Belief in Religions
    Witchcraft                   Faith Healing
    Ancestor Worship             Herbs
    Voodoo




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




March 17, 2007                           NCCEMNA                                   15
         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.”
March 17, 2007             NCCEMNA                         16
      Folk Medicine: WITCHCRAFT


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

March 17, 2007         NCCEMNA                      17
          Folk Medicine: ANCESTOR
                 WORSHIP
    belief in the divine
    power and divine
    guidance of dead
    seen in many cultures:
    Asian, African
    American (Kwanza),
    Native Indian among a    http://www.asia.si.edu/exhibitions/
                             online/teen/default.htm
    few

March 17, 2007          NCCEMNA                                    18
                            Folk Medicine:
                              VOODOO
  spirit possession
  has its roots in Africa
  now practiced in Cuba,
  Haiti and in the US
  (New Orleans)
  music and dance are
  ways of expression of
  spirituality
March 17, 2007          NCCEMNA              19
Folk Medicine: SHAMANISM
 practitioners apply magic and speak to the
 spirits of nature
 can perform both physical and spiritual or
 faith healings
 discover their powers through ecstasy and
 fasting
 Anthropology of “Consciousness”
 • Out of body experiences
 • Near Death Experience

 March 17, 2007          NCCEMNA              20
            Folk Medicine: BELIEF IN
                  RELIGIONS
    Saints
    Pilgrimage
    Faith healing or miracle healing
    Beliefs in the existence of spirits (good
    spirits and bad spirits or demons)
    Belief in the existence of ghosts, and in
    apparitions
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Folk Medicine: FAITH HEALING
    the use of religious folk objects or items,
    and prayers to cure illnesses
     • exorcism
     • ritual healings performed by voodoo priests and
       priestesses, and by Shamans
     • use of charms for protection or as lucky charms



March 17, 2007          NCCEMNA                      22
 Folk Medicine: HERBS OR HOME
           REMEDIES
    Fresh steaks and poltice - for treating infected wounds.
    Molasses - for treating sour throat and a baby’s teething
    problem.
    Fresh cucumber and wet bag of tea - for treating a bad eye.
    Garlic - for reducing high cholesterol and high blood
    pressure.
    The juice from nim leaves - for curing malaria.
    Chinese acupuncture - for treating blood clotting and
    margarine headache.
    There are also alternative remedies for dieting, cancer
    treatment, diabetes, heart disease, skin care, weight loss
    etc.
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                 Herbal Medicine
    Almost two-thirds of the earth’s 6.1 billion people
    rely on the healing power of herbal medicine.
    For them nothing else is affordable or available.




March 17, 2007           NCCEMNA                      24
               Cultural Influences in
            Alternative Health Systems
                    (NCCAM)
    Not related to folklore
    Based on cultural history, ethics, values,
    and beliefs of a specific culture
    Some have evidenced based research


March 17, 2007         NCCEMNA                   25
            Alternative Health Systems
    Ayurveda (Indian)         Middle Eastern
    Chinese                   Tibetan
    Native American           Central and South
    Indian                    American Cultures
    Aboriginal                Homeopathy
    African                   Naturopathy



March 17, 2007          NCCEMNA                   26
        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


March 17, 2007                  NCCEMNA                        27
    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……




March 17, 2007           NCCEMNA                        28
       CAM and Health Disparities
    Does the use of CAM decrease health disparities?

    Does the use of CAM result in health disparities?




March 17, 2007           NCCEMNA                        29
  NCCAM and Health Disparities
    Communication between groups
    Recognize diversity
     • All minority groups are not homogeneous
    Generational Changes
    Degree of Assimilation
    Adaptation to American Culture

March 17, 2007          NCCEMNA                  30
 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

March 17, 2007        NCCEMNA                    31
       NCCAM Research Priorities
    Mechanisms of Action
    Phase I and II Clinical Trials
    Exploratory Studies
    Areas of Special Interest
     • Anxiety and Depression, CVD, ethnomedicine, immune
       modulation/enhancement, IBS, insomnia, liver diseases,
       obesity/metabolic syndrome, respiratory diseases
       (prevention and treatment)
    NCAAM highly interested in minority and gender
    health and health disparities
     • http://nccam.nih.gov/research/priorities/index.htm
March 17, 2007              NCCEMNA                         32
                 Hierarchy of Research
    Evidenced Based Medicine based on RCTs (Borgerson,
    2005)
     • Meta Analysis
     • Systematic Reviews
    RCTs (experimental designs) are considered the best
    scientific evidence (rigorous) because of
     • Randomization
     • Placebo
     • Control



March 17, 2007              NCCEMNA                       33
         NIH Clinical Trials (RCTs)
Post-marketing
                                   Phase
surveillance
                                     IV
Comparisons to
Standard Therapies                 Phase III


Preliminary evidence               Phase II
of safety and efficacy

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

   March 17, 2007        NCCEMNA               34
                 Clinical Trials and CAM –
                   backwards approach?
This is
                       Large portion of people using a product and
starting
                                     consider it safe
point:
67% of               Has it been compared to other standard therapies?
funding
                        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?




    March 17, 2007                  NCCEMNA                              35
        How do we test the Placebo
                Effect?
 Can all CAM therapies fit in this RCT
 hierarchical model?
  • Can all CAM use a “placebo” to test the
    effectiveness of the treatment?
        • Hypnosis, Tai Chi, massage
  • If you can’t test the placebo effect, does that
    mean it is not evidenced based?


March 17, 2007              NCCEMNA                   36
   How can we show evidenced based research
  in CAM if we can’t do RCTs (with placebo)?




Walach et al., 2006
 March 17, 2007       NCCEMNA              37
       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

March 17, 2007            NCCEMNA                        38
 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
March 17, 2007             NCCEMNA                           39
     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

March 17, 2007                      NCCEMNA                 40
                 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!



March 17, 2007          NCCEMNA                    41

				
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