patterns of use of complementary health services in the south-west of western australia

INTRODUCTION

The relationship between what has been termed conven-tional scientific medicine and alternative medicine, morerecently labelled complementary medicine, has been con-troversial since the re-emergence of the holistic paradigmin the 1960s. Joske and Segal outline the traditionallycompetitive relationship between these two models:

The bulk of people, particularly in the state of illness,prefer to turn to medical practitioners. Neverthelessthere has been an erosion of this position. Why do somany people, voting with their feet, reject what medicinecan offer more effectively than any other institution orgroup, namely the precise scientific diagnosis and man-agement of disease?...it is necessary to seek understand-ing of why so many people, including highly intelligentpeople, find greater satisfaction in the operations ofalternative healers than they do in the practices of ortho-dox physicians.1

Joske and Segal suggest that alternative practitionersbetter address the psycho-social and emotional dimen-sions of human need. Alternative medicine providesunique benefits that are lacking in the normaldoctor–patient relationship, which include time, empathy,personalisation, counselling and an emphasis on health.Easthope recognised that the debate is more deeply rootedin the controversy between the allopathic and homeo-pathic models of the 19th century; the former arguing thathealing should aim to exterminate germs, the latter that itshould concentrate on building up the life forces of theindividual.2 Ullman further distinguishes between conven-tional and alternative models: the former relies on defin-ing health in terms of the absence of symptoms, the latterin terms of a continuum.3 The former views the bodymechanistically as a physiological entity, the latter holisti-cally as a physiological process surrounded by subtleenergy fields. While the conventional medical modelrelies on the rational analysis of objectives and data and areductionist interpretation of this data for diagnosis, thealternative medical model relies on subjective empiricalfindings and a holistic profile.

Grossman describes the emerging complementary useof previously defined alternative medical methods in theUK:

Aust. J. Rural Health (2000) 8, 194–200

Correspondence: Dr Patricia Sherwood, Edith Cowan Uni-versity, Bunbury Campus, Robertson Drive, Bunbury, WesternAustralia 6230, Australia. Email: [email protected]

Accepted for publication October 1999.

PATTERNS OF USE OF COMPLEMENTARYHEALTH SERVICES IN THE SOUTH-WESTOF WESTERN AUSTRALIA

Edith Cowan University, Bunbury Campus, Bunbury, Western Australia, Australia

ABSTRACT: The objective of this research was to identify patterns of complementary health service usage by ruralWestern Australians in the south-west of the State. Complementary health providers identified by health users includedhomeopaths, chiropractors, naturopaths, acupuncturists, faith healers, herbalists, reiki or energy workers, counsellors,physiotherapists, osteopaths, podiatrists and reflexologists. More than half of the health provider usage in the regionwas with complementary therapists and the remainder with medical doctors. The main reason identified for usingcomplementary therapists was their level of skills and the main reason identified for not using them was a lack ofknowledge about what their services could provide.

KEY WORDS: alternative medicine, complementary health services, rural health.

Patricia Sherwood

Original Article

COMPLEMENTARY HEALTH SERVICES: P. SHERWOOD 195

In March 1985 the council for complementary and alter-native medicine was launched...and at the same time asurvey of general practitioners found that around half ofthem either already practised or would have liked topractise acupuncture, hypnotherapy, osteopathy andother therapies.4

Ullman discusses the progressive change from alterna-tive to complementary labelling, also noting the increasingadoption by medical doctors of so-called alternative thera-pies.3 He points out that more than 39% of French doctorspractice homeopathy, as do 20% of German doctors.Clearly, the cutting edge model for the 1990s is aboutintegrating relevant healing modalities.

In 1994, the British Medical Journal published anarticle by Fischer and Ward that delineated the use ofcomplementary medicines and their relative popularity indifferent European countries.5 In their consumer survey,they found that 49% of French, 46% of German, 34% ofAmerican, 31% of Belgian, 26% of British and 25% ofSwedish people surveyed had used complementary medi-cine. Sommer cites a survey conducted in Melbourne andSydney in 1994, which revealed that 50% of the generalpublic had used alternative health providers and 25% haddone so in the preceding 12 months.6 In a survey con-ducted in South Australia in 1993, Maclennan et al. foundthat 20% of respondents had consulted alternative practi-tioners.7

The objective of this survey was to begin to exploresome patterns of use of complementary therapies in ruralcommunities in the south-west of Western Australia and tocompare these patterns with use of medical doctors.

METHOD

Of the 268 people surveyed, 30% were resident in Bun-bury, 19% were resident in Busselton, 6% in Dunsbor-ough, 20% in Margaret River and 25% in the ruralhinterland of these shires. These regions were chosen asrepresentative for the survey because the following rangeof complementary health providers were resident in theregions: homeopaths, chiropractors, naturopaths,acupuncturists, faith healers, herbalists, reiki/energyworkers, counsellors, osteopaths and reflexologists. Podia-trists and physiotherapists were categories added post sur-vey and were derived from the category ‘others’ identifiedby respondents.

The respondents were chosen randomly in street sur-veys during 1995. Of the total number of respondents (n =268), 66% (177) were female and 34% (91) were male.Surveys were conducted during weekday working hours

and on weekends, so this may partially account for thefewer number of available male respondents. In addition,there was a greater reluctance by males to participate inthe street surveys on health.

The age distribution of respondents (n = 268) was con-centrated (54%; 144) in the 21–40-year-old category.Eighteen per cent (48) of respondents were in the 15–20-year-old category, 13% (35) were in the 41–50-year-oldcategory, while 15% (42) were 50 years or older. Only 2%(5) of respondents were more than 70 years old. Clearly,the street survey sample was skewed toward youths andyoung adults, with 72% of the sample being between theages of 15 and 40.

The occupational profile of respondents (n = 268) wasas follows: 17% (45) described themselves as profession-als, 15% (41) full-time parents, 13% (35) students, 12%(33) in the trades, 9% (25) retired, 8% (21) clerical work-ers, 7% (19) in retail, 5% (12) in the service industry, 5%(12) unemployed and 9% (12) other.

Four issues were surveyed. First, respondents wereasked to provide information on their actual use of med-ical doctors and complementary health providers over thepreceding 12 months. Second, respondents were asked toname the type of health issues about which each healthprovider was approached. Third, respondents were askedtheir reasons for having selected a particular healthprovider. Fourth, respondents were asked the reasons fornot choosing certain health providers. For each of theabove questions, multiple responses were permitted.

RESULTS

Actual choice of a particular health providerand frequency of consultationWhen asked ‘which type of health provider have you con-sulted over the past 12 months when you have had healthproblems?’, of the total responses (488), approximately49% stated ‘medical doctor’. While this is by far the largestcategory of responses, it is significant that more than halfof the responses (51%) referred to the complementaryhealth providers. This is analysed further in Table 1.

When respondents were asked the total number oftimes they had used each of the above health provider’s ser-vices over the past 12 months, of the 1977 times serviceshad been used, 49% were with medical doctors and theremaining 51% with complementary providers (Table 2).

Types of health issues about whichparticular providers were consultedResponses to the question ‘for what types of health issueswould you consult the above providers?’ are tabulated in

196 AUSTRALIAN JOURNAL OF RURAL HEALTH

Table 3. The category ‘general’ was used by respondentsto imply generalised feelings of unwellness. It may alsohave included issues that clients did not wish to discusswith the interviewer or issues they could not specificallyrecall. The figures are expressed as percentages of thetotal number of times each health provider was chosen bythe respondents.

Generalised health issues formed the majority of theissues for which clients consulted the medical doctors(93%), homeopaths (67.1%), naturopaths (72%), herbal-ists (73.3%) and reiki workers (78%). Back and neckproblems made up 100% of the issues for which clientsconsulted osteopaths and physiotherapists and 98% of the

issues for which chiropractors were consulted, with theremaining 2% of issues being headaches thought to berelated to neck problems. While doctors, homeopaths,naturopaths, herbalists and reiki workers were confrontedwith generalised issues, chiropractors, physiotherapists,podiatrists, reflexologists and counsellors were consultedfor single issues of expertise. Acupuncturists were theproviders consulted about the most diverse range ofissues, including general unwellness, arthritis, back andneck problems, nutrition, allergies, asthma, stress andsmoking. Counsellors, reiki providers and faith healerswere consulted about issues relating to emotional andspiritual health. Only naturopaths, herbalists, acupunctur-ists and naturopaths were consulted about health mattersrelating to nutrition.

Reasons why a particular health providerwas chosenClients were asked to state the reasons they had chosen aparticular health provider. The results are summarised inTable 4 and expressed as a percentage of the total numberof reasons.

In terms of the overall pattern of choice acrossproviders, a few factors emerged as particularly signifi-cant. With all providers, the highest percentage ofresponses focused on category C, ‘very skilled serviceprovider’. Clearly this was the most significant factor indirecting clients’ choice. The next most frequently men-tioned factor, which included all providers except thepodiatrist, was D, ‘the client experienced best results’ as aresult of consulting that particular provider for that issue.The local availability of the service, followed by less sideeffects from remedies were the next most significant fac-tors directing clients’ choices. Over the whole profile, theleast significant factor motivating choice was the negative‘no other alternative choice provided’. Only one respon-dent in the entire survey saw the health services as offer-ing no choice or alternatives to the medical doctor. Interms of the range of positive reasons (excluding categoryK) given for choosing a particular health provider, thegreatest range of reasons given was for the acupuncturist,where every reason was mentioned excepting H(routine/I’ve always been there). Reason H was given onlyby people attending medical doctors and chiropractors.This suggests that for the respondents in this survey sam-ple, their initial health provider was probably a medicaldoctor and the move to use complementary healthproviders reflects a move away from their traditional pat-tern of the medical doctor being their sole health provider.Following the acupuncturist, the health providers selectedfor the greatest range of reasons were the homeopaths,

TABLE 1: Type of health provider chosen

Service provider No. times service chosen %

Medical doctor 238 48.80

Homeopath 24 4.90

Chiropractor 53 10.85

Naturopath 32 6.50

Acupuncturist 48 9.85

Faith healer 15 3.00

Herbalist 15 3.00

Reiki/energy 18 3.65

Counsellor 24 4.90

Physiotherapist 16 3.30

Osteopath 2 0.50

Podiatrist 2 0.50

Reflexologist 1 0.25

Total 488

TABLE 2: Actual use of health services over 12 months

Service provider No. times service used %

Medical doctor 972 49.30

Homoeopath 68 3.40

Chiropractor 295 15.00

Naturopath 114 6.00

Acupuncturist 140 7.00

Faith healer 25 1.20

Herbalist 45 2.20

Reiki/energy 52 2.60

Counsellor 174 8.80

Physiotherapist 65 3.20

Osteopath 9 0.40

Podiatrist 8 0.40

Reflexologist 10 0.50

Total 1977


faith healers and herbalists (eight reasons), followed bymedical doctors and chiropractors (7), naturopaths andcounsellors (6), Reiki (5), reflexologists (4, physiothera-pists (3), osteopaths (2) and podiatrists (1).

In terms of individual health providers, doctors wereselected for their skill level, followed by the service being

available locally and the affordability of the service.These three factors accounted for 75.2% of the clients’responses when asked why they chose a medical doctor.The cheapness of the service was not a significant factorcited for any other health provider and this is no doubtrelated to the Medicare subsidy for doctors’ visits, which

TABLE 3: Types of issues about which each health provider was consulted

Percentage

Doc. Hom. Chir. Natu. Acu. Faith Herb. Reiki Phys. Oste. Cou. Podi. Refle.

General 93.3 67 72 8.3 33.3 73.3 78

Arthritis 0.5 4.1 3 2.1

Back/neck 1.6 4.1 98 6 70.9 5.5 100 100

Nutrition 8.3 13 2.1 26.7

Sinus 4.1

Women’s 3.6 3

Allergy 0.5 2.1

Headache 0.5 8.3 2.0

Asthma 4.1 3 6.2

Stress 4.2 11.0

Smoking 4.2

Emotional/mental 40.1 100

Spiritual 26.6 5.5

Feet 100 100

Doc., medical doctor; hom., homeopath; chir., chiropractor; natu., naturopath; acu., acupuncturist; faith, faith healer; herb., herbalist;

reiki, reiki/energy worker; phys., physiotherapist; oste., osteopath; cou., counsellor; podi., podiatrist; refle., reflexologist.

TABLE 4: Reasons why a particular type of health provider was selected

Percentage

Doc. Hom. Chir. Natu. Acu. Faith Herb. Reiki Phys. Cou. Podi. Refle. Oste

A 11 1.9 3.6 0.9 4.7 6.5 2.6

B 22.7 1.9 11.5 6.9 8.4 18.8 6.5 2.6 25

C 41.5 31.4 52.5 32.9 35.7 33.3 25.8 37.3 57.9 76.6 100 25 50

D 9 17.7 24.3 21.9 24.5 4.7 25.8 33.3 21 2.6 25 50

E 2.2 35.3 1.2 31.5 22.4 9.4 25.8 21 25

F 7 7.8 4.1 3.6 9.4 3.2 5.2

G 6 1.8 4.7 3.2 4.2 21 10.4

H 6 1.2

I 1.9 2.7 1.8 14.2 3.3 4.2

J 1.9 0.9

K 0.5

n 400 51 78 73 107 21 31 24 19 38 2 4 4


reiki, reiki/energy worker; phys., physiotherapist; oste., osteopath; cou., counsellor; podi., podiatrist; refle., reflexologist. A, Cost of

service is cheaper; B, service is available locally; C, very skilled service provider; D, experienced best results; E, less side effects from

remedies; F, works when all else has failed; G, referral; H, routine; I, curiosity; J, as an alternative; K, no other alternative.


is not available for other health providers in this sample.For homeopaths, the three key factors, which accountedfor 84.4% of the reasons, were the skill of the serviceprovider, best results and less side effects from remedies.Significantly, homeopaths had the highest percentage oftheir responses to ‘less side effects from remedies’. Thetop three factors governing the choice to attend a chiro-practor were the skill of the service provider, best resultsand local availability of the service (88.3%).

The top three reasons for choosing a naturopath weresimilar to those for homeopaths, namely, the skill of theprovider, best results and less side effects (82.6%). Thesethree reasons also dominated the rationale of those choos-ing acupuncturists (82.6%), herbalists (77.4%) and reikiproviders (91.6%). It is interesting that less side effectsfrom remedies was a major reason in the choice of natur-opaths, homeopaths, acupuncturists and herbalists. Thethree major reasons for choosing a faith healer includedskill level, local availability and curiosity (66.3%). Phys-iotherapists were selected primarily for their level of skill,best results and referrals (100%). Physiotherapists, chiro-practors and counsellors had numerically more referralseach than the other complementary health providers.When asked the source of referral, respondents indicatedmedical doctors. One possible explanation is that thesecomplementary health practitioners are perceived by doc-tors as being closer to the end of the continuum thatrelates to traditional medicine. There was one major factorin the choice of a counsellor, namely level of skill (76.6)and likewise with the podiatrist (100%). Reflexologistswere chosen because of local availability, skill, bestresults and less side effects (100%) and osteopaths forskill and good results (100%).

Reasons for not choosing a particular healthproviderRespondents were asked to give reasons why they wouldnot use a particular type of health provider. Multipleresponses were accepted. The results are tabulated inTable 5. In terms of the total number of responses, it isevident from Table 5 that both doctors and physio-therapists had significantly fewer responses as to why theywould not be chosen as health providers. Doctors had thelowest number of responses with only one respondentclaiming they did not know enough about what their localdoctor did. Of the complementary providers, the singlegreatest category of response, for all providers exceptcounsellors, as to why they were not chosen, was that therespondents ‘do not know enough about what they do’.This was the case for 100% of the responses forosteopaths, podiatrists and reflexologists, 67.5% of the

responses for homeopaths, 63.9% of the responses forreiki providers, 64.2% of the responses for physio-therapists, 55.5% of the responses for naturopaths, 54%of the responses for herbalists, 39.8% of the responses forfaith healers and 33.1% of the responses for chiropractors.It is very clear from these data that complementary thera-pists would be able to raise their client numbers through apublic education program about what their particularhealth service offers for clients. This is the case with allgroups except counsellors, where the principal reasons fornot using this service are that the service provider isunskilled (41.3%) and the clients do not believe the coun-sellors can do anything for them (38.2%). Significantly, fornone of the complementary providers was cost mentionedas a significant reason not to use their services. Onepossible explanation is the expectation among users thatone must pay for complementary services because thesepractitioners, unlike doctors, are not subsidised. Forhomeopaths, naturopaths, acupuncturists, herbalists andphysiotherapists, the second major category of responseswas that the clients did not believe the health providerscould do anything for their particular problem. The skilllevel of complementary health providers was questionedonly by a minority of the responses as follows: chiro-practors, 15.8%; faith healers, 34.4%; acupuncturists,16%; herbalists, 15.3%. The numbers of responses fordoctors and physiotherapists are too small to draw anyconclusions about how these percentages relate to theirperceived lack of skills. The data for the doctors arenotable because of the absence of reasons for not choosingmedical doctors. Given the normative expectations that inillness one consults a medical doctor, it is understandablethat there are few reasons why one would not go to a med-ical doctor. As complementary therapy is a new and rela-tively unknown field, it seems people need reasons to goto complementary practitioners over and above socialnorms and custom. In addition, many of the reasons fornot choosing a complementary therapist relate to igno-rance about what the therapist has to offer.

DISCUSSION

This survey of complementary therapies in rural commu-nities in the south-west of Western Australia indicates thatthe use of complementary therapies is high. Fifty-one percent of respondents had used complementary therapies inthe 12 months preceding the survey, compared to 25% inthe Sydney and Melbourne surveys of the same year.6 Theshires surveyed in this study had some unique character-istics, which would have contributed to a high usage ofcomplementary therapies. These shires are located in the


scenic south-west coastal area of the State and are partic-ularly attractive to four types of persons. First, alternativelifestylers attracted by the natural environment; second,youth attracted by the beaches and the lifestyle; third,rural resettlers who include significant numbers of profes-sional persons leaving the city to settle in rural communi-ties for lifestyle reasons; and fourth, retirees. Thesepopulation movements have resulted in a very diversifiedpopulation base and a wide range of professional skills,including a diversity of health practitioners, which isatypical of most WA shires. These shires are also charac-terised by population growth, while the majority of ruralshires in WA are experiencing population decline. Thesefactors mean that this is a unique rural region in WA andthe demand for complementary therapists in this regioncannot be generalised to other rural regions of the State,where populations are declining and the composition ofthe population is more homogenous and conservative. Thefindings of Maclennan et al. in South Australia thatfemales were more likely to use alternative healthservices7 further explains the high use of complementarytherapies. This sample was biased by the high proportionof females (64%) in the survey sample of respondents. Inaddition, Maclennan et al. indicate that alternative medi-cine users are more likely to be young7 and this samplewas relatively youthful. However, their hypothesis thatrural respondents have little choice when selectinghealth-care services is not supported by this survey, wherenot a single respondent stated that they had no otherchoice as their reason for using a complementary thera-pist. Furthermore, it needs to be stated that the surveyedtowns in this south-west region have had significant

influxes of alternative settlers, who are known to generallyprefer alternative or complementary health providers.However, there are no census data that identify thesepersons, nor research on their health preferences. Thiscould provide an interesting area of research. Given thatcomplementary therapies actually comprise the majorityof health-care services delivered in this sample, thesefindings have significant implications for the health-careindustry. For example, insurance funds that provide pack-ages covering complementary health services could have acompetitive edge in the marketplace with some con-sumers. Also, the complementary therapy field is likely toprovide increasing opportunities for employment in futureyears. This is already evident in the large range of com-plementary medical practitioner training programs beingprovided throughout Australia.

Another finding with significant implications is thatthe principal reason given for not using particular types ofcomplementary health providers is that the client does notknow what the service provides. All complementary thera-pists could better market their services as part of theiradvertising and public education programs. This is mostlikely to further increase demand for their services.

This survey confirms findings in Europe, Britain, theUnited States and urban eastern Australia, that thedemand for complementary therapies is rising rapidly.Clients are increasingly choosing health providers whocan deliver these services. This survey indicates that cur-rently in rural south-west Western Australia, these serviceproviders are not doctors. The growing demand for com-plementary therapies suggests that the doctors who chooseto integrate complementary medicine in their service

TABLE 5: Reasons for not choosing a particular health provider

Percentage

Doc. Hom. Chir. Natu. Reiki Acu. Faith Herb. Phys. Oste. Cou. Podi. Refle.

A 10 4 5.8 4.4 1.5 2.6 1 1.2 1.2

B 2 3.5 1.1 1.3 1.3 2 0.6

C 30 8.8 15.8 12.3 19 16.1 34.4 15.3 14.2 41.3

D 30 1.2 17.8 2.2 1.1 3.9 0.3 1.6 3.7

E 20 13.6 2.5 19.8 12.9 35.4 21.8 24.5 21.4 38.2

F 10 67.5 33.1 55.5 63.9 38.4 39.8 54 64.2 100 8.6 100 100

G 2.8 2.4 2.2 1.4 2.1 1.3 1.6 6.1

n 10 249 202 227 263 229 294 248 14 90 162 80 60


reiki, reiki/energy worker; phys., physiotherapist; oste., osteopath; cou., counsellor; podi., podiatrist; refle., reflexologist. A, service too

costly; B, service unavailable locally; C, service provider is unskilled; D, experienced bad results; E, do not believe they can do

anything for me; F, do not know enough about what they do; G, no health need to use this service.


delivery will be at the growing point of demand in Aus-tralia, as they are currently in Europe. Finally, there is ahigh demand for complementary health providers and ifsuch providers were to conduct a major public educationprogram about their services, indications are that demandwould grow even stronger.

REFERENCES

1 Joske R, Segal W. Ways of Healing. Melbourne: Penguin,1982.

2 Easthope G. Healers and Alternative Medicine. Aldershot,

UK: Gower, 1986.

3 Ullman D. The mainstreaming of alternative medicine.

Healthcare Forum Journal 1993; Nov: 24–30.

4 Grossman R. The Other Medicines. London: Pan, 1986.

5 Fischer P, Ward A. Complementary medicine in Europe.

British Medical Journal 1994; 309: 107–110.

6 Sommer S. Integrative medicine: The way of the future. The

Lamp 1994; 52: 31–32.

7 Maclennan A, Wilson D, Taylor A. Prevalence and cost of

alternative medicine in Australia. Lancet 1996; 347: 569.

patterns of use of complementary health services in the south-west of western australia

Documents