Introduction
A study was conducted by Parker J Magin , F.R.A.C.G.P and his team about the use and perception of CAM in the treatment of Acne, Psoriasis and Atopic Eczema. The paper titled ‘Complementary Alternate Medicine Therapies in the Treatment of Acne, Psoriasis and Atopic Eczema: Results of a Qualitative Study of Patient’s Experience and Perceptions’ and published in the Journal of Alternative and Complimentary Medicine, Volume 12, November 5, 2006, pp 451 to 457, © Mary Ann Liebert Inc. The use of Complementary and Alternative Medicine therapies has seen a rising trend throughout the world. “A general increase in the use of CAM to almost 6 million people in the UK each year.” (About Researching Complimentary and Alternative Therapies).
In this context, a critical analysis of the above paper is being done here along with a brief overview of its contents.
A brief overview of the paper
The purpose of the research was to study the use and perceptions of CAM therapies on the treatment of acne, psoriasis and Atopic eczema. The study was a qualitative one done through interviews with patients all of whom have used CAM therapies along with conventional therapies. A total of 62 patients were personally interviewed for the study (29 patients with acne, 26 with psoriasis and 7 with Atopic eczema). Of this 25 were males and the rest females and the age group lay between thirteen and seventy three years. Interviews were taped with the consent of the interviewees and the results codified. It is to be noted here that the study does not focus on any particular type or field of CAM, but treats it as a whole. In other words all types of CAM are considered to be having the same effect irrespective of any differences in medicines or therapies that may exist. The patients were from an unnamed non-capital city in Australia. The layout of the paper is as follows. After the abstract, and introduction is given followed by the methodology used. The results are then given for acne alone and the other two conditions grouped together. The reason for such a structure is that according to the paper acne is a non serious and temporary affliction whereas the other two were generally considered to be serious, chronic and with no cure available at present. This is followed by a discussion on the findings. At the end are the conclusions, acknowledgements and references. The study also acknowledges a previous qualitative study done on the same topic and certain comparisons are done occasionally.
The paper starts by giving studied figures of the use of CAM specifically for skin ailments (including the three ailments mentioned hers) in USA, Britain and Israel. Cultural attributes, unsatisfactory results with conventional treatment, a feeling that natural products are safer and lack of perceived safety of chemicals used in conventional treatments are some of the reasons why patients choose CAM exclusively or in conjunction with conventional treatments. With regard to CAM therapies in Acne, the study found that patients were more optimistic about results than in the other instance. An interesting finding here was that there was no specific treatment for acne and the patients were given treatments that were good for the skin in general. Some of the specific therapies were mentioned used witch hazel and tea tree oil. Patients agree that CAM maybe less effective than certain conventional treatments like oral isotretinoin and antibiotics, but were generally satisfied by using CAM. The paper suggests that it was due to the less serious nature of the disease that prompted patients to go in for CAM and also because they were perceived to be safer. In the case of CAM treatment for psoriasis and Atopic eczema, the outlook was different. None of the patients agreed that CAM alternatives were better or even effective for their conditions. The use of CAM was resorted to because the ineffectiveness of conventional therapies and also because there were no other alternatives available. It was more of a trial and error method with patients willing to try anything that might give them relief. CAM was preferred because here too it was considered to be natural and hence safer. Unlike in the treatment of acne, CAM in the case of psoriasis and eczema had specific treatments for the disease. A detailed list of oral, topical and behavioural therapies is given even though no classification as which treatment was adopted for a particular disease was not made available. Some patients were not aware of exactly what they were taking. It is also interesting to note that even though every patient with either psoriasis or eczema were sceptical about the effectiveness of CAM in reliving their condition, they believed that CAM is effective in the treatment of other diseases. One common thread that runs though all the afflictions is that many patients more so in the case of acne had lessened psychological impact with the use of CAM. The paper notes that all practitioners should take note of the fact during treatment. The paper acknowledges support of a National Health and Medical Research Council Postgraduate Scholarship and a New South Wales Primary Care Research Bursary.
Analysis
As mentioned before the type of research conducted here is qualitative in nature. Analysis of qualitative data will never be accurate as those data from a quantitative study. “In contrast, qualitative studies are usually not based upon standardized instruments and often utilize smaller, nonrandom samples. Hence, assessing the accuracy of qualitative findings is less straightforward.” (Qualitative research assessment tool, P. 1).
But in the present instance it is the use and perception of the patients about CAM that is under study. While the use can be quantitatively analysed perceptions cannot be done. Only qualitative analysis can be done. Hence at least for the second part, the methodology used is correct. The authors have clearly defined the research problem. But the problem could have been defined to be a little more specific. There are many types of complimentary alternative therapies. Certain CAM therapies are effective for certain types of diseases while others maybe effective for a different type. It would have been more effective if the authors had concentrated on a specific CAM therapy instead of including all the therapies collectively.
The literature used in the analysis is taken solely from transcripts of interviews with the patients selected for the study. Excerpts from the replies of patients were given as illustrations to substantiate the findings. The whole methodology has been done in this manner. Whatever references that have been made in discussion and introduction seems to be in support of the findings of the results from the interview. No views that could contradict the finding were given at any point of time. Even though not mentioned in the list of topical therapies used by the patients given in the paper, coal-tar is effective in slowing down rapid growth of cells and also helps in relieving inflammation, itching and scaling. “Coal tar is available in topical, shampoo and bath solution forms. Tar can help slow the rapid proliferation of skin cells and help reduce inflammation, itching and scaling. It can also be used in combination with phototherapy.” (Psoriasis Treatment). The authors could have used other resources especially since the sample size used was very small.
The authors have done a lot of referencing as a part of their research work. This paper was published in November 2006. A look at the dates of the 30 works referenced reveal that no paper from the year 2006 was taken up for study. Only two papers from the year 2005 were used. Two papers were from 2004, four from 2003 were used. Papers dated prior to 2000 numbered twelve. More current works at least after the year 2000 could have been used. All references are appropriate, but only seem to support the findings of the paper since no contradictory research papers or other studies were quoted.
The methodology used is qualitative in nature and is appropriate for the study done here. More importance is given to perceptions of patients regarding CAM and for this purpose a qualitative study is ideal. “understanding the experiences of individuals and communities in relation to health, illness and disease;” (Qualitative research). But a drawback that could be pointed out is that the number of respondents selected seems to be too small. They were also not balanced in the sense that while about 26 were interviewed for acne and psoriasis, only 7 patients with Atopic eczema were selected. No mention as to why only such a small number or why there was difference in the numbers among the three affliction came about. There could be a possibility that data from those afflicted with eczema could therefore be unreliable. Even otherwise the number of patients interviewed is too small for a representative result. “Nevertheless, in qualitative work, we do try to discover something. We may be seeking to uncover: the reasons why consumers may or may not be satisfied with a product;” (DePaulo, 2000).
The researchers were very clear about the way they conducted the research. The way the patients were selected was mentioned in detail in the paper. Citing the paper “. Data collection consisted of semi structured interviews with patients with acne psoriasis or Atopic eczema. Recruitment was by invitation to participate mailed to subjects from an earlier quantitative phase. ……. All participants provided written consent prior to the interview and were informed that they could stop the interview any time…….” The questions were not pre-planned and were based on a theme list developed by the research team. Details as to how the data was evaluated were also given in detail. There is enough information for the study to be independently repeated. It can be seen from this that data collection procedures were clearly described.
The authors have made references to ethical concerns. The paper makes it clear that all participants were selected through invitation and interviewees came forward voluntarily. All participants were free to stop the interview at any time they wanted. They were also free not to answer any questions if they so wish. “Extra care must be taken to avoid violating the confidentiality of those who make research possible.” (Ethics).
None of the interviewers were selected by practitioners themselves. Otherwise issues of coercion or use of influence on patients by the practitioners could have been raised. Moreover the study was given approval by the Human Research Ethics Committee, University of New Castle, Callaghan, New South Wales, Australia. The authors have a clean slate as far as ethical issues are concerned.
Internal Validity may not be very relevant here since this is a qualitative data analysis. The terms that are more relevant here are creditability and trustworthiness and through them defensibility. “When qualitative researchers speak of research validity, they are usually referring to qualitative research that is plausible, credible, trustworthy, and, therefore, defensible.” (Johnson, 1997). There is no cause to doubt either in this case except for the fact that the sampling size is small.
Data analysis was done in a scientific manner as can be seen from the following excerpt from the paper. “Thematic data analysis was cumulative and concurrent throughout the data collection period with coding and analysis following the inductive tradition, with a code book developed as part of the constant comparison coding technique. Each transcript was separately coded by two members of the research team. Differences in research perspective were fed back into the analysis, and agreement was reflected in the interpretation of data. Data collection continued until thematic saturation had been achieved.” “Thematic analysis focuses on identifiable themes and patterns of living and/or behaviour.” (Aranson, 1994).
Even though the paper is aimed at a professional reader, the language could have been less ambiguous in some places. The ideal example that can be given is at the end of the discussion section. To quote “Thus, from our analysis, the differences in uses and impact of CAM between the two groups is based on perceptions of the essential nature of the skin disease rather than on perceived attributes of CAM.”
On the whole, barring some shortcomings the paper is a commendable effort by the authors. An unbiased and sincere effort can be detected here. The one factor to be noted is that very little research has done in this area and more research would be informative and welcome.
References
About researching complimentary and alternative therapies: Increasing research. (2002). Cancer Research UK. 2008. Web.
Qualitative research assessment tool. 2008. Web.
Psoriasis Treatment –Topicals: Over-the-counter topicals. (2008). National Psoriasis Foundation. Web.
Qualitative research. (2008). Australian Government – National Health and Medical Research Council. Web.
DePaulo, Peter. (2000). Sample size for qualitative research: Size does matter, even for a qualitative sample. Quirks, Marketing Research Review. 2008. Web.
Ethics. (1998). Multimethod Taskforce. 2008. Web.
Johnson, R. Burke. (1997). Examining the validity structure of qualitative research. BNET. The go to place for management. 2008. Web.
Aranson, Jodi. (1994). A Pragmatic view of thematic analysis: Performing a thematic analysis. The Qualitative Report, 2(1). Spring. 2008. Web.