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Thesis: Attitude towards Acupuncture Therapy in Children

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Affiliation

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Date
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Thesis: Attitude towards Acupuncture Therapy in Children

Background

Complementary and Alternative Medicine (CAM) in pediatric medicine has increased

significantly over the last decades. One of the most CAM methods used is acupuncture. Saks

(2019) defines acupuncture as traditional Chinese medicinal practice that involves the insertion

of needles on given sites of the body to render therapeutic effects. The insertion of needles at

specific acupoints is hypothesized to improve the body's energy flow, resulting in improved

health and well-being. The underlying mechanism of action of acupuncture has not been fully

explored, yet some current literature shows that the technique can alleviate various conditions

and ailments better than their allopathic equivalents.

However, the technique has remained controversial. Its use among the pediatric

population, specifically among children, is significantly lower than other CAM interventions.

Saks (2019) denotes that the use of acupuncture among children is apprehensive due to limited

research on technique utilization. Lin et al. (2021) add that the apprehension can be attributed to

the perception that children fear needles. Lin et al. (2021) contend that treatment expectations

may play a central role in accepting acupuncture use among children. Wang et al. (2019)

established that caregivers of children tend to prefer medication and relaxation training therapies

over acupuncture. The underlying cause of CAM choices informing the attitude and concerns

have to be fully investigated. According to Chokshi et al. (2017), a substantial body of evidence

has shown that acupuncture use among children is common among families who have previous

user experience, indicating that being familiar with the practice is a critical determinant

influencing the attitude and choice of its use in pediatric settings.

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Acupuncture therapy is considered non-conventional, with limited data available

concerning its acceptance and the attitudes informing its choice for use among pediatric patients.

Studies show that caregivers tend to show hesitance in discussing CAM-related interventions

such as acupuncture and their children's experience with conventional medical practitioners. Lin

et al. (2015) ascertain that medical providers manage pediatric patients with critical or chronic

illness or are often more willing to discuss CAM interventions with caregivers. Conversely, most

caregivers collect information from another source which may be non-medical. In pediatric

physicians, lack of expertise, time constraint, and skepticism may cause discomfort when

discussing CAM interventions for young patients. Currently, limited literature exists on the

modalities by which providers determine and consider acupuncture for pediatric patients.

The purpose of this thesis will be to investigate the attitude of the parents and children

towards acupuncture techniques. Several factors are examined that could shape the attitude of

caregivers and children towards acupuncture which may determine the preference or

apprehension on utilizing the technique. The use CAM has increased significantly in the recent

past. Empirical evidence have consistently shown that CAM interventions are more efficacious

in managing ailments and disorders such as migraines than allopathic alternatives. Studies have

shown that 46% of caregivers prefer CAM techniques over conventional medication in managing

various conditions among their children (Saks, 2019). Therefore, a need exists to examine the

primary determinants of the attitudes of not only the caregivers but also the children towards the

use of acupuncture. The study will employ a systematic review design to examine whether the

attitudes are influenced by:

1. The description of the acupuncture techniques by medical providers

2. Previous experience of caregivers with acupuncture techniques

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Method

Search Methods

Two electronic databases were chosen after a painstaking review of the scope and

medical subject headings for suitable search terms. The two electronic databases chosen were;

PubMed, a primary health databases. The databases will be searched with date limits of the last

12 years. The inclusion criteria for consideration in the review had to satisfy the following

criteria: clinical qualitative studies published in English and present analysis on caregivers and

children's experience with acupuncture. Further, the reference list of the chosen papers will be

hand searched for their proper identification and ensuring they are peer-reviewed literature which

would have been missed during the search.

Several exclusion criteria were used. Systematic reviews and meta-analyses were

excluded. Additionally, studies involving children from Asia will be excluded. Studies show that

most children from Korea and China have undergone acupuncture treatment (Saks, 2019).

Therefore, the perception and attitude of the caregivers and children will not be relevant for the

study.

The keywords that will be used in the search at PubMed will include; ""beliefs"",

""attitudes"", ""Acupuncture Therapy"", ""Alternative medicine"", ""behavior"" and

""acceptance"". The keywords will be applied as Tiab and Mesh terms and other relevant

synonyms. The scope of this study will focus on clarifying the attitudes of children and parents

towards acupuncture treatment.

Search Outcomes

The search will include a search for online literature in seeking appropriate articles used

in the systematic review. Studies will be selected by appraisal using a dual-stage process. Firstly,
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when available, the abstracts and titles will be identified from the PubMed and Embase database

using the search strategy and exclusion done as highlighted. The entire search strategy is

highlighted in table 1.

Exclusion Criteria Number of Studies

Total number of records 120

Exclusion of duplicates 63

Screening 53

Eligibility 12

Systematic reviews and meta-analysis 3

Location or setting of the study 2

Selection and Screening of Studies

The screening started with abstracts and titles retrieved during the search. One hundred

twenty studies were identified and excluded as appropriate. Full-text articles were retrieved from

the remaining 63 studies, 53 of which were excluded because they never satisfied the inclusion

threshold, as indicated in figure 1. The remaining 19 studies originated from studies conducted

in the Eurozone countries, Australia, South America, and the United States between 2012 and

2022. The studies collected data from children and caregivers who had undergone treatment

under different acupuncture paradigms. The PRISMA flow chart in figure 1 is used to represent

the selection process used.

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Articles Identified Extra records identified

Iden through the database. through other sources
tific
atio (n=119) (n=1)
n

Articles after duplicate exclusion (n=63)

Scre
enin
g
Articles excluded
(n=39)
Screened records
(n=53)
Eligi
bilit
y
Full-text records
excluded with
Full-text records evaluated for reason.
eligibility
N= 4
(n=14)
Incl
ude
d

Articles included in the

qualitative synthesis.
(n=10)

Data Synthesis and Abstraction

The selected study in the review used various data collection methods. Most of the

studies used semi-structured and unstructured interviews. All the studies selected highlighted the

fundamental direction for questioning. Such a thematic analysis will be scrutinized for four
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primary areas: experience of illness, reasons for choosing acupuncture therapy, impact linked to

the treatment, and experience after using acupuncture.

Extraction of all the direct quotes from the study participants will be done. Moreover, the

retrieved excerpts will be analyzed, then assigned sub-codes, categories and annotations using

the constant comparison method. Statistical Package for Social Sciences (SPSS) software will

manage data and analysis.

Results

Four over-arching themes have been identified and used for categorizing the selected

articles, as summarized in table 2 below.

Author (year) Study Population Method Main Results

Trifa et al. 12 question survey was given to 164 Mixed 70% of the caregivers were familiar with

2018 participants consisting of caregivers method the acupuncture techniques, while 38%

with children undergoing general knew hypnotherapy, followed by music

anesthesia interventions. Their therapy at 60%. CAM acceptance was

knowledge of acupuncture and pre- 51%. However, the acceptance of music

operative were questioned. The therapy was highest at 50%, followed by

majority of the 164 caregivers were hypnotherapy at 17% and acupuncture at

between 20- 40 years, with 82% being 13%.

mothers of the patient.

Stamping et al. A sample of 147 parents with children Qualitative Among the 147 participants with children

2019 was questioned about CAM regarding study who had been involved in the survey,

effectiveness perception, parental 38.1% had used CAM in the previous year,

socio-economic, and children's health. while 48.3% had been treated with CAM at
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least once in a lifetime. Children who had

been treated using CAM were averagely

younger than their non-treated

counterparts. 85.6% of the caregivers were

willing to explore CAM, while 78.9%

would consider the intervention if

allopathic methods failed.

Revuelta- One hundred sixty-nine families were Qualitative Among the 169 families sampled, only

Iniesta et al. sampled to determine the prevalence of study 74% returned the completed

2014 CAM use and spiritual practices in questionnaires. 57% had used spiritual

pediatric oncology in Scotland. intervention while using conventional

methods of treatment. Moreover, 53% had

used CAM, most of them using the

technique to reduce stress.

Zuzak et al. Data were collected from 20 European Narrative From the 20 countries sampled in the

2013 countries. The countries represented Non- study, the CAM use by the general

69% of the total population. systematic population was available for 90% of the

study countries under examination. Surveys

concerning CAM use among children

indicated that 55% of the countries had

widespread use of the technique.

Extrapolation of the data on usage found a

52% range when adjusted to capture the

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entire European population. Besides, CAM

experts specializing in pediatrics reported

an increase in the use of the technique.

Anheuser et al. Sixteen participants, including nine Qualitative Most participants had minimal knowledge

2018 medical doctors and seven nurses from study of the therapies under investigation,

rural children hospitals in Germany's evidence, or possibilities. However, most

Ruhr region. 68.8% of the participants believed that CAM could be an appropriate

were female. enhancement on various interventions.

Physicians emphasized the need for

developing evidence base and

standardization while the nurses focused

more on theoretical knowledge and

practice. A consensus was built among the

participants that integrating CAM and

conventional medicine was appropriate for

enhancing patient outcomes.

Smith et al. Participants consisted of 21 parents Qualitative Three primary themes were identified

2020 composed of 1 man and 20 women. study during the analysis; experience of the

The participants' average was 43 years, caregivers in researching CAM

with 43% having at least a bachelor's. interventions. Another theme identified

was the navigation of CAM information

and techniques categorized to have the

following sub-themes: evaluating CAM

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interventions on children and what counts

as effective, assessment of information on

what can be presumed to be evidence.

Lastly, the final theme was creating

trustworthiness and a central theme.

Analysis of the identified theme indicated

that parents made CAM decisions

influenced by costs, time, and pragmatism.

Stub et al. Twenty-two families from Norway Qualitative Most of the respondents had previous

2021 were sampled, with 24 adults being study experience with CAM. A significant

couple participants. Two individuals number had personal experience with

with cancer were included in the CAM before their children were diagnosed

sample. with cancer. Notably, the medical

providers did not raise issues about CAM,

as pointed out by the participants.

However, those caregivers that raised

questions about CAM got a positive

response. All the participants reported not

to have received adequate information

concerning CAM at healthcare facilities

which they could appreciate. Instead, most

reported having received layman

recommendations which they rejected

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since it was below par in the context of

their philosophy and health values.

Mano and A sample of 240 parent participants Qualitative Factorial analysis of the vignette questions

Davis, 2009 read vignettes varying in the study indicated that two factors determined the

description. utilization of acupuncture techniques:

information seeing (x=0.70) and

acupuncture acceptability (x=0.88).

Acceptability of acupuncture interventions

was increased significantly by previous

experience while reducing interest in

information seeking. Caregivers with

previous experience were highly likely to

report a desire to explore acupuncture

intervention for their children. Besides,

biomedical exposure of parents with

experience improved their interest in

pursuing more information. Additionally,

the biomedical explanation was a

substantive predictor of likely parental

agreement with vignette (d=0.36).

However, common acupuncture concerns

included its potential ineffectiveness,

limited research, and fear of needles.

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Rocha et al. One hundred ninety-nine children were Cross- The study found that traditional

2017 diagnosed and treated for cancer at sectional Complementary/Alternative Medicine

health institutions located in qualitative (TCAM) among pediatric patients with

Montevideo, Uruguay, and Buenos study cancer has been well documented in

Aires, Argentina. Argentina and Uruguay. Both countries

recorded 47% and 76% respectively

concerning variations in the use of

modalities of TCAM used in the supportive

care in the health sector. However, it was

noted that both countries harness TCAM as

primary supportive care. Some of the

predominant predictors of TCAM included

the wealth index and mothers' education.

Aveni et al. Sample of 4925 healthcare Cross- One thousand two hundred forty-seven

2016 professionals consisting of 111 sectional respondents participated in the study

midwives, 2372 nurses, 1969 medical survey accounting for a 25.3% response rate.

doctors, and 145 physical therapists 96.1% of the respondents agreed strongly

employed in Lausanne University that CAM could benefit pain management.

Hospital Switzerland. Notably, more midwives (100%) and

nurses (96.7%) agreed that CAM was

useful compared to physicians (93.8%).

Ormsby et al. Participants involved included two Qualitative Most of the participants had a positive

2018 separate groups consisting of 16 mid- study perception of acupuncture and were open
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wives. Interviews were conducted with to its inclusion in conventional medical

nine doctors, four general practitioners, care since they considered it safe and

two maternity service managers, and productive.

three obstetricians.

Description of Studies

Treatment Outcomes

One hundred sixty-six pediatric patients were involved in the study after undergoing

general anesthesia during the study period, with their caregivers being invited to be participants.

However, two caregivers rejected the invite reducing the number of participants in the study to

be 164. A significant number (68%) of the participant's ages ranged from 20 to 40 years, with

most of them being caregivers of children in pre-operative care (82%). Fathers accounted for

13%, while other caregivers were 5% of the total participants. The majority of the caregivers

(70%) were familiar with acupuncture techniques, while 60% of the participants were conversant

with music therapy and hypnotherapy (38%). The acceptance of CAM modalities in the

perioperative setting was significantly high for music therapy (50%), 17% for hypnotherapy, and

13% for acupuncture. The overall acceptance of CAM as an alternative intervention was 51% for

caregivers with cases in perioperative settings. Minimal differences existed in patient

characteristics. It was noted that being familiar with acupuncture and music therapy was highly

correlated to the chances of CAM acceptance at an odds ratio of 3.36.

Specific Health Beliefs

One hundred ninety participants were sampled from Uruguay (n=100) and Argentina

(n=90) in the study. The number of male participants was slightly higher in both countries, with
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Argentina having 57% and Uruguay having 58% male representation. A significant difference

existed among Argentinian respondents between TCAM use and family wealth index (p=.016)

and mother smothers level of education (p=.45). Similarly, significant differences were observed

for mothers' level of education (p=.051) and age (p=.45) among Uruguayan participants.

Concerning prevalence, the TCAM therapies constructs were substantially higher in

Argentina with high test-retest reliability. The study found a high prevalence of use among

Uruguayan (76%) in comparison to 47% of the Argentinian participants. The most frequently

used therapies among Argentinians were touch healing (8%), energy healing (14%), diet change

(21%), and nutritional supplements (9%). Conversely, diet change, plant-based medication, and

manual healing were the most commonly used therapies among Uruguayans. Besides, many

Uruguayans used several forms of TCAM than their Argentinian counterparts (p<0.001). A high

proportion of TCAM therapies were considered highly effective in Uruguay (75%) and

Argentina (68%).

One of the primary determinants for TCAM use was the mother's education serving as

the central determinant to the use of the therapy. Children whose mothers had at least a college

education were more likely to use TCAM than those from less learned parenthood. However,

fathers' education was a significant predictor for TCAM use in Argentina (p<. 038). The

demographic variables were linked with several TCAM therapies used in Uruguay. The number

of TCAM therapies increased with the level of the mother's education (p<.001). More TCAM

therapies were associated with affiliation to Catholicism (p<.001). Besides, wealth quantile was a

statistically significant predictor for Argentinians (p<.010), while the contrary was true for

Uruguayan participants (p<.415). Participants from wealthy backgrounds were 8.5 times more
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likely to use TCAM than those from low-income backgrounds. It was found that previous use in

a family was a critical determinant for TCAM use among Uruguayan participants.

Treatment Experience

The study examined 240 respondents exceeding the recommended factor analysis of 5 to

10 suggested for factor analysis. A parallel analysis was conducted to extract the number of

factors. Two preliminary factors were analyzed from the data collected from the vignettes and

the simulation of data sets for randomly generated values. Scree plotting was done for the

eigenvalues then a comparison was done to establish the points at which the actual data drops

below the random data. The original factors indicated that two factors could be extracted from

the data: The initial factors contributed to 39.9% of the variance and had a high correlation to

positive attitudes about acupuncture and acceptability. The result was labeled as acupuncture

acceptability. 18% of the variance constituting Factor 2 included components used to evaluate

the second opinion about acupuncture interventions. 

Moreover, exploratory factor analysis was done using a correlational matrix and principal

axis. The two-factor scores were then added by the respective items of their reversed values if

the item in the vignette had a negative loading. Meanwhile, no significant impact in the vignette

was found concerning gender. The two hypotheses of interest were tested, including the parental

experience with acupuncture multiplied by the biomedical explanation versus TCM. A

multivariate analysis of variance was then conducted, with dependent variables being

information seeking and acupuncture acceptability. The results showed that previous parental

experience with acupuncture was significant. Subsequent, univariate analysis indicated that prior

acupuncture experience had more significant acupuncture acceptability and was less likely to
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search for more information about the practice (p=<.006). Additionally, neither the two-way

interaction nor primary effects of explanation type were statistically significant (p=<. 05).

Reason for Use 

Seventy-four participants returned and completed questionnaires on the reasons for using

acupuncture. 55% of the participants (n=41) reported using CAM, while 76% of those who had

used the intervention had tried more than one therapy. However, none of the CAM considered

substituting conventional medical treatment with CAM. A statistically significant association

existed between families using CAM and high socioeconomic status (p<.001). One of the

primary reasons for using CAM was the caregivers' perception of the likely effects on their

children. 97% (n=40) of the caregivers gave more than one reason for using CAM therapies:

 Improving the quality of life during treatment 24%

 Reducing the adverse effects of therapies 15%

 Stimulating the immune system 7%

 Reducing stress 36%

54% (n=42) of the participants reported using spiritual remedies through prayers for the children

(n=39.9%), while 14% allowed their children to pray for themselves. Half of the respondents

engaged in prayer sessions reported to have experienced benefits while using CAM. 

Discussion

Stampini et al. (2019) found that the most common type of CAM used were homeopathy

and herbal regimens. Most caregivers who chose CAM were skeptical about vaccinating their

children. 85.9% of the participants were reported to be willing to seek CAM interventions in the

future. However, 78.9% of the participants reported that they would revert to conventional

medications if CAM did not yield favorable results. Further, the researchers found that general
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skepticism of caregivers towards vaccination and their socioeconomic status concerning the

pathologies being treated by CAM was consistent with the literature. 

   Revuelta-Iniesta et al. (2014) concluded that a significant number of the cohort used

CAM with an overall positive perception of its impacts among pediatric patients. 55% of the

participants utilized CAM, while 57% resorted to spiritual remedies. High socioeconomic status

was one of the primary factors identified for using CAM with minerals supplements and

massage, accounting for 22.53% and 29% of usage, respectively. The high prevalence of CAM

usage was reported to concern the need for safety and efficacy standards by physicians. Besides,

high-income individuals were more likely to use CAM than their low-income counterparts. 

Zuzak et al. (2013) concluded that CAM was highly used among the adult population and

pediatric patients. 55% of the available data on CAM use was about intervention uses in children

for various ailments. The extrapolated prevalence of CAM use among children was within the

52% range when adjusted for the population size. Moreover, a statistically significant number of

medical providers reported increased CAM therapies among pediatric patients. 

Anheyer et al. (2018) found a significant potential in CAM use among pediatric patients.

According to the study, despite the challenges of implementing CAM in pediatric healthcare

settings, many caregivers and healthcare providers had a positive attitude towards the technique.

68.9% of the caregivers reported a positive attitude towards ACM interventions for their

children. 

Limitations

The study only used ten articles due to the time constraints involved in conducting the

research. The limited research materials could potentially create a literature gap and biases in the

study. A significant number of articles on children's attitudes towards acupuncture are either
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systematic reviews, pilot studies, or meta-analyses that could be included in the thesis. Besides,

we used a significantly small samples size which lowered the evidential value. More robust

randomized controlled trials need to be conducted to establish the reliability and validity of the

study. 

Conclusion

Overall, the review has demonstrated that even though caregivers' reasons for using

acupuncture may be diverse, the underlying factors concerning attitude and perception on

pediatric patients tend to be congruent to several factors. The review has established that

caregivers' experience, treatment outcomes, and reason for use may profoundly impact their

children's attitudes and choices for seeking acupuncture interventions. However, further research

should investigate the health beliefs that determine children's attitudes to acupuncture. 
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