Family Practice 2002 (Feb); 19 (1): 57–64 ~ FULL TEXT
Kendall Kroesen [a], Carol M Baldwin [a,b,c,g], Audrey J Brooks [a,c] and Iris R Bella, [b,c,d,e,f]
Kendall Kroesen, PhD,
Research Service Line (0-151),
Southern Arizona VA Health Care System,
3601 South Sixth Avenue,
Tucson, AZ 85723, USA
a Research Service Line, Southern Arizona VA Health Care System,
b Department of Medicine,
c Department of Psychology,
d Department of Psychiatry,
e Department of Family and Community Medicine,
f Program in Integrative Medicine and
g Arizona Respiratory Center, University of Arizona, Tucson Arizona, USA
Background Use of complementary and alternative medicine (CAM) is growing quickly in the USA, prompting hypotheses about why people turn to CAM. One reason for increasing use of CAM modalities may be dissatisfaction with the conventional care system. However, recent studies suggest that dissatisfaction is not a major factor.
Objectives This paper provides another perspective on the possible relationship between dissatisfaction with conventional care and the use of CAM.
Methods Qualitative data collection, in the form of 12 focus groups with 100 CAM users, was used to inquire about issues surrounding the use of CAM. Focus group participants were military veterans enrolled in the Southern Arizona VA Health Care System, and their significant others. Qualitative analysis identified key themes emerging from the focus groups.
Results Although participants were satisfied in general terms with their conventional care, there were particular aspects of the conventional care system that they criticized. Dissatisfaction with aspects of conventional care, particularly its reliance on prescription medications, was an important component in their motivation to use CAM. Results also suggest that the conventional medical system's lack of holism (inadequate information regarding diet, nutrition and exercise, and ignorance of social and spiritual dimensions) is also an important motivation for turning to CAM in this particular population.
Conclusions Independent research and a sense of responsibility on the part of focus group participants for their own health seemed to be taking them outside the domain of the conventional health care system.
Keywords Alternative medicine, complementary medicine, herbal drugs, holistic health
From the Full-Text Article:
The overarching issues voiced by the focus group participants in this study included drug side effects, prescription monitoring, concerns with the pharmaceutical industry and interest in ‘more natural' alternatives. Participants linked their CAM use to scepticism regarding these conventional care-related issues. They also reported wanting greater emphasis on preventive measures, such as nutrition and exercise. Finally, some participants said that medical care should be more holistic.
We found that dissatisfaction with certain specific aspects of conventional care was motivating CAM use, while at the same time veterans expressed overall satisfaction with conventional care. This contradicts some investigators, who found that dissatisfaction with conventional care did not play a role in CAM utilization. For example, Astin's four-item ‘satisfaction' measure failed to predict CAM use.  Astin's satisfaction questions, however, addressed generalities rather than the specific issues in which respondents might find the conventional care system lacking. Our focus group participants probably would have had high satisfaction scores on such a measure. Satisfaction measures too often treat satisfaction as a unidimensional construct, and do not discriminate between patients' particular likes and dislikes.  Qualitative approaches, such as the focus group data reported here, can help to provide the finer discrimination lacking in global patient satisfaction measures.
Barrett et al.  also asserted that dissatisfaction with conventional medicine does not predict CAM use. They wrote, "In contrast, most patients who use CAM continue to utilize and appreciate conventional medicine, although they often do not tell their physician about their unconventional choices". Our results suggest that continued use and appreciation of conventional care does not preclude the possibility that frustration with a few specific aspects of conventional care is influencing use of CAM.
Other studies agree that, for the most part, CAM-using patients are not replacing conventional medicine with CAM. [6, 8, 10, 28] There are several reasons why patients stay with conventional medicine, even when it does not meet all their needs. Our respondents, as well as those of Barrett et al.,  indicated that CAM affordability was a major concern. In both studies, respondents paid for most CAM expenses out-of-pocket. However, most conventional health care was covered by insurance. Individuals who have health care coverage were not likely to give up a service with such low out-of-pocket costs. In addition to having low out-of-pocket cost, conventional care is a highly socially legitimized service. Conventional medical care in the USA is generally considered to be among the best care in the world. Even apart from the issue of access, it would be hard for patients to walk away from what society, in general, considers an important, indeed, ‘conventional', service. It is not surprising that our focus group participants had not given up on conventional care despite its inability to meet some needs.
Consistent with our findings, Chez and Jonas  have suggested that conventional medicine, with its emphasis on the mechanistic, reductionist, organ-specific approach to care, is lacking in the areas of comprehensive care and the management of chronic disease. Focus group participants' ‘natural is better' attitude is part of a pervasive US folk model about the relationship between the natural world (generally benign) and artificial things (potentially more dangerous). 
Like our respondents, those in the study by Barrett et al.  often did not tell conventional providers about their CAM use. Rather than considering this a shortcoming on the part of patients, it might be seen as part of conventional medicine's failure to meet these patients' needs. Many participants hoped that conventional providers would become more knowledgeable about CAM, acknowledge its potential usefulness and counsel them about CAM. Under current conditions, some patients may be avoiding conflicts with their valued conventional providers by simply not discussing CAM.
Also consistent with our findings, Barrett et al.  found a desire among patients for ‘holism' and ‘empowerment'. For Barrett et al., the theme of holism included the ideas of a patient–practitioner alliance, mind–body integration, staying healthy and limitations to conventional care. This is similar to what our focus group participants said about preventive and holistic care. Barrett et al. also encountered the theme of empowerment, which implied responsibility and self-direction. Our focus group participants were also taking responsibility for their health care. These overlapping findings suggest that veteran CAM users are similar to civilian CAM users in their desire for conventional medicine to address these specific issues.
There are inherent limitations to this study. Since they were self-selected, focus group participants may have been among the more dedicated or vocal CAM users and may not have been representative of the average CAM user enrolled in the SAVAHCS. There were no comparison focus groups of non-users. However, we intentionally invited only CAM users in order to (i) expand our understanding of the reasons for, and patterns of CAM use, and (ii) use the themes emerging from focus groups as background for a larger random sample survey of SAVAHCS patients. Furthermore, focus groups with CAM non-users would not have addressed the question of the role of dissatisfaction with conventional medicine in motivating CAM use. While our participants generally reflected the demographics of the SAVAHCS population, they were probably older, more infirm and less financially secure than the non-veteran public. In addition, they may have had more chronic conditions, which are the least amenable to conventional care (and which were predictive of CAM use in Astin's  study). Due to their health status, our participants also may have experienced a higher rate of dispensed prescriptions, and a higher rate of side effects. Comparisons between veteran and non-veteran CAM use must be made with caution.
Despite its limitations, this study is one of the first to address CAM use among military veterans. The nationwide veteran population over 75 years of age is expected to rise 43% between 1997 and 2005.  This population is relatively less healthy than the non-veteran population, and has a higher rate of co-morbidity.  Substantial CAM use in this population would have serious implications for health care. For example, although many participants worried about potential negative interactions between prescription medications, few participants mentioned possible negative interactions between botanical remedies and prescribed medications (e.g. Gingko biloba interacting with anticoagulant and antiplatelet agents ). Potential lack of awareness of these interactions suggests that primary care providers should query patients regarding botanical remedies, as well as prescription and other over-the-counter medications they may be taking, and caution patients accordingly.
Our findings indicate that veterans in this study are taking a more active role in their health care by researching and monitoring their conventional care more closely, adopting CAM into their routine and using preventive measures as a part of their health care. Focus group participants had begun to move their care beyond the bounds of a conventional medical system that was not meeting all of their needs. They clearly linked these unmet needs with their use of CAM. Their dissatisfaction was with a few specific, well-defined aspects of the conventional health care system. Participants seemed to be dissatisfied with both the outcome of conventional care (e.g. failure to improve chronic conditions, control pain or reduce intolerable drug side effects) and with the process of conventional medicine (e.g. lack of prevent-ive care or superficial encounters with providers). Since participants also expressed praise for the conventional medical system, it may be that some participants are simply recognizing its inherent limitations rather than expressing dissatisfaction per se.
Qualitative studies such as this can alert physicians to patients' widespread use of complementary and alternative remedies, and some of their motivations for doing so. The willingness of patients to take on this degree of personal responsibility toward monitoring their care and creating a healthier lifestyle should be incorporated into physician treatment planning.
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