Traditional Chinese Medicine: Professionalization and Integration in Hong Kong 9789629375430, 9789629373795

Citation preview

Traditional Chinese Medicine Professionalization and Integration in Hong Kong

00 TCM Chapter front matter.indd 1

13/3/2019 下午2:17

00 TCM Chapter front matter.indd 2

13/3/2019 下午2:17

Traditional Chinese Medicine Professionalization and Integration in Hong Kong

Edited by Kara Chan and Dong Dong

00 TCM Chapter front matter.indd 3

13/3/2019 下午2:17

©2019 City University of Hong Kong All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, Internet or otherwise, without the prior written permission of the City University of Hong Kong Press. ISBN: 978-962-937-379-5 Published by City University of Hong Kong Press Tat Chee Avenue Kowloon, Hong Kong Website: www.cityu.edu.hk/upress E-mail: [email protected] Printed in Hong Kong

00 TCM Chapter front matter.indd 4

13/3/2019 下午2:17

Dedicated to Stanley and Tillie Cheng – Kara Chan

In memory of Hazel Dicken-Garcia A journalism historian who visited the “Pink Hills” of Hong Kong in the 1960s – Dong Dong

00 TCM Chapter front matter.indd 5

13/3/2019 下午2:17

00 TCM Chapter front matter.indd 6

13/3/2019 下午2:17

Contents

List of Tables ix List of Figures xi Series Foreword xiii Preface xv

Part I  Legitimation and Perception 1 Development and Regulation of Traditional Chinese Medicine Practitioners in Hong Kong

3

Sian Griffiths and Vincent C. H. Chung

2 Australia and Hong Kong: Comparing Regional Influences on Chinese Medicine Education

17

Caragh Brosnan, Vincent C. H. Chung, Anthony L. Zhang, and Jon Adams

3 Public Perception of Traditional Chinese Medicine in Hong Kong

43

Kara Chan and Lennon Tsang

00 TCM Chapter front matter.indd 7

13/3/2019 下午2:17

Part II  Acupuncture as a Focus 4 How People Perceive Acupuncture: A Qualitative Study

63

Kara Chan, Judy Y. M. Siu, and Timothy Fung

5 How People Perceive Acupuncture: A Quantitative Study

87

Kara Chan, Lennon Tsang, and Timothy Fung

6 Authorization, Rationalization, and Moral Evaluation of Acupuncture by Hong Kong’s Newspapers 107 Dong Dong and Kara Chan

Part III  Hybridization and Integration 7 Medical Hybridization of Chinese Wind/Rheumatism Oils

135

Daan Kamps

8 Expert Opinions Concerning Integrated Chinese-Western Medicine

157

Kara Chan and Dong Dong

9 Conclusion and Future Perspectives

185

Kara Chan and Dong Dong

List of Resources About the Contributors Index

00 TCM Chapter front matter.indd 8

191 197 203

13/3/2019 下午2:17

List of Tables

Table 1.1

Milestones in the development of traditional Chinese medicine practitioners in Hong Kong 6–7

Table 3.1

Demographic and behavioral profiles of the respondents

48–49

Descriptive statistics of each predicting variable and the predictions made using the conceptual framework

50–51

Table 3.2

Table 3.3

Table 3.4

Table 4.1 Table 5.1 Table 5.2

00 TCM Chapter front matter.indd 9

Regression analysis for variables predicting respondents’ likelihood to consult Western medicine first when ill

52

Regression analysis for variables predicting respondents’ likelihood to consult Western medicine exclusively when ill

52

English translations of the questions asked of acupuncture users and non-users

70

Demographic and acupuncture use profiles of the respondents Perceptions of acupuncture as a medical treatment

92–93 93

13/3/2019 下午2:17

x

List of Tables

Table 5.3

Percentages of participants who perceived that the specified conditions could be treated effectively by acupuncture 94

Table 5.4

Comparison of acupuncture and Western biomedicine

95

Table 5.5

Perceived risks of acupuncture

96

Table 5.6

Factor loadings of the four-component analysis 98–99

Table 5.7

Mean scores of statements comprising the four factors based on previous acupuncture experience

100

Regression analysis for variables predicting respondents’ likelihood to consult Western biomedicine first when ill

101

Number of stories published by Ming Pao and Apple Daily concerning acupuncture in the specified time periods

111

General assessment of acupuncture-related stories published by both Ming Pao and the Apple Daily

112

Table 5.8

Table 6.1

Table 6.2

Table 6.3

Legitimizing acupuncture through authorization 115

Table 6.4

Legitimizing acupuncture through rationalization 118

Table 6.5

Legitimizing acupuncture through moral evaluation

123

Tone of reporting across various newspaper sections

124

Table 6.6

00 TCM Chapter front matter.indd 10

13/3/2019 下午2:17

List of Figures

Figure 3.1

00 TCM Chapter front matter.indd 11

Conceptual framework showing the relationships between the Chinese medicine-related predictors and the likelihood that an individual will consult Western biomedicine first or exclusively 47

13/3/2019 下午2:17

00 TCM Chapter front matter.indd 12

13/3/2019 下午2:17

Mediated Health Series Foreword

With an aging population, Hong Kong faces increasing health issues. In a city where the East meets the West, Hong Kong people are exposed to both Western biomedicine (WM) and traditional Chinese medicine (CM) as well as other forms of alternative medicine. Health information disseminated and obtained from the media plays an important role in medical decisions. Our understanding of health, sickness, and wellbeing are shaped by this mediated information, which comes in the form of news articles, leaflets, advertisements, websites, narrated stories, films, and television programs. Mediated health as an interdisciplinary field has drawn the attention of the public as well as scholars in the fields of communication, medical science, public health, sociology, anthropology, history, economics, gender studies, global and regional studies, marketing, and computer science. This series of books attempts to share current theories and practices of mediated health with health practitioners, patients, health educators, policy makers, journalists, communication practitioners, advertising and public relations professionals, and the general public. Topics in this series include: •  Media and health decision-making •  Health literacy •  Health journalism

00 TCM Chapter front matter.indd 13

13/3/2019 下午2:17

xiv

Series Foreword

•  •  •  •  • 

Mental health and social inclusion Sexual and reproductive health Doctor–patient communication Public health promotion and social marketing Intervention and prevention of communicative and non-communicative diseases • e-health •  Health economy •  Computer-mediated health communication •  Healthcare organizations •  Health policy We hope this collection of publications will help inform medical decisions and contribute to the wellbeing of individuals in Hong Kong and globally.

Kara Chan and Dong Dong Series Editors

00 TCM Chapter front matter.indd 14

13/3/2019 下午2:17

Preface

Chinese medicine (CM) was not something I was familiar with. None of my family members had consulted a CM practitioner (CMP). Then, a few years ago, I suffered from shoulder pain, which was later diagnosed as being caused by a muscle tear, likely a result of my kayaking activities. My Western biomedicine doctor (WMD) referred me to a physiotherapist. The treatment lasted for a few weeks, but instead of seeing improvement, I suffered from additional pain and eventually made the choice to discontinue treatment. Almost six months later, still in pain, I spoke with a colleague at the School of Chinese Medicine. He recommended acupuncture. Thus, in the hopes of decreasing the pain and being able to kayak again, I consulted an acupuncturist at the CM clinic on campus. He read the diagnosis and commented that the wounded area was deep inside my shoulder. He designed my treatment plan to include visits to the clinic twice a week. At that time, another colleague had just released her research findings related to acupuncture treatment of juvenile autism, leading many parents to seek out the remedy for their kids. This was apparent during my visits to the clinic, and energetic kids were often rushing around the facilities. One young boy was particularly nervous when receiving acupuncture. He kept screaming, “Help! I am going to die”. All of the children were fascinating to observe and brought an element of fun to the clinic. The treatment went well for me and I recovered within three months. This is ultimately what triggered my interest in the

00 TCM Chapter front matter.indd 15

13/3/2019 下午2:17

xvi

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

perception of acupuncture. My colleagues Dr. Timothy Fung at the School of Communication and my former colleague Dr. Siu Yuen Man, Judy at the David C. Lam Institute for East-West Studies had previously conducted a focus-group study to examine the perception of acupuncture among users and non-users. We followed it up with a survey to gather quantitative data. Later, our colleague Mr. Lennon Tsang joined the team, and we conducted another survey to measure the perception of CM among Hong Kong people. My experience of seeking out WM first and then looking for alternative health solutions is not unique. The quest for knowledge concerning CM is shared. However, much of this knowledge, particular that involving the social implications and views, is limited or difficult to find. This is largely what initiated the collation of the chapters in this book, which focuses on CM from a social scientist’s point of view. My former colleague Dr. Dong Dong at the David C. Lam Institute for East-West Studies graciously agreed to help with the book project. As we are not medical experts, it was essential to identify scholars who had published excellent works on this topic and invite them to contribute. Dr. Vincent Chung and his associates have contributed two chapters about the regulation and education of CMPs in Hong Kong. Mr. Daan Kemps, an exchange student at the David C. Lam Institute for East-West Studies, contributed a chapter on medicinal oil. A friend of mine who is a WMD suggested that I also investigate the integration of CM and WM in Hong Kong. This spurred us to interview two members of the School of Chinese Medicine at Hong Kong Baptist University for their expert opinions on policy and integration. Meanwhile, our academic backgrounds in communication and media studies inspired us to study the media coverage of CM, focusing on acupuncture. The mass media impacts the public’s awareness and perception of technologies; however, the extent of this impact (strong, limited, or minimal) is

00 TCM Chapter front matter.indd 16

13/3/2019 下午2:17

Preface

xvii

still under debate. To address this, we sampled news articles related to acupuncture from two major Hong Kong newspapers between 2001 and 2013 and conducted both content and discourse analyses to reveal the latent frames of news story-mediated legitimation. Legitimation is a key concept throughout this book, whether the chapter concerns the efforts of legitimizing CM via government policies, educational requirements, CM use (or rejection) in focusgroups and surveys, or the discursive practices of CMPs. Even the mixed history of so-called “Chinese” medical oils tells us that the sources of legitimization may vary depending on context. The terms used in this book also show a kind of legitimation. For example, throughout the book, the terms “traditional Chinese medicine” and “Chinese medicine” are used interchangeably (designated CM). However, the term “evidence-based Chinese medicine” is only used to refer to scientifically supported research. According to a colleague at the School of Chinese Medicine, this term is used mainly by researchers in research grant applications for projects scientifically investigating the effectiveness of CM and is rare in everyday language. Although it may not be used often in the public, even this shift in language highlights a form of legitimation in the research community. This book is intended to be a reference for health and para-health professionals to learn about social issues related to CM in Hong Kong. It is an anthology of articles that present the complicated process of legitimizing knowledge and power within a specific social and historical context. It is organized into three parts that help to orient the reader: Legitimation and perception, Focusing on acupuncture, and Hybridization and integration. In Part I: Legitimation and perception, we begin with a historical assessment of the legitimacy and perception of CM in Hong Kong. Chapter 1 offers insight into the history and future of CM in Hong Kong, while Chapter 2 examines CM’s historical position,

00 TCM Chapter front matter.indd 17

13/3/2019 下午2:17

xviii

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

current position, and the changes in higher education, regulatory policies, and cultural legitimacy of CM in Australia and Hong Kong. Australia is selected for comparison because the development of CM there shares a similar trajectory to that in Hong Kong — initially being marginalized and then gaining legitimacy via recognition by formal institutions. The chapter compares CM education in the two regions, assesses the constraints and opportunities for CM education, and considers implications for other regions. Chapter 3 investigates three factors that influence an individual’s choice to consult CM or WM — namely, the perceived superiority of WM over CM, efficacy, and cost. In Part II: Focusing on acupuncture, we present three chapters that focus on a specific branch of CM — acupuncture. Chapter 4 presents a qualitative analysis of how users and non-users perceive acupuncture, what make users try acupuncture in the first place, what prevents non-users from trying it, and what factors influence users’ choice of an acupuncturist. Chapter 5 discusses a quantitative study of how consumers perceive acupuncture as a medical treatment in relation to WM. Finally, using an approach that combines discourse analysis and content analysis, Chapter 6 presents our analysis of 666 news articles related to acupuncture published in Hong Kong over a 10-year period. This study reveals a complex process of generating legitimacy for health knowledge through news narratives via three major discursive constructs — authorization, rationalization, and moral evaluation. In Part III: Hybridization and integration, we highlight nuances in the integration of CM into the larger healthcare sphere. Chapter 7 describes the fascinating history of medicated oils, which in Hong Kong are generally regarded as traditional CMs but which are, in fact, a result of medical hybridization. Thus, the author highlights a critical point underlying our understanding of “Chinese” and “Western” medicine — that treatments rarely develop in isolation and integrating two seemingly different techniques may not be as

00 TCM Chapter front matter.indd 18

13/3/2019 下午2:17

Preface

xix

difficult as we think. Chapter 8, which contains interviews with two experts in the field of CM, sheds additional light onto the opportunities and challenges facing the integration of CM into the healthcare system in Hong Kong. Some of the research presented within the pages of this book has been previously published. The original publications have been cited in the acknowledgements sections where appropriate and we encourage readers to refer to them for additional insight into the methods used. We thank the respective journals for providing permission to reprint the articles in their edited and updated forms. We thank Dr. Laying Tam who did a marvelous editing job on the initial manuscripts. We are in debt to the editorial and design staff at City University of Hong Kong Press, including Carrie Yu (cover design) and Lam Yan Kiu (editorial intern), with special thanks to Dr. Abby Leigh Manthey (editor) for her reckless effort in bringing the manuscript to perfection. We also thank the David C. Lam Institute for East-West Studies for provided funding to support this book project and the exchange program partaken by Mr. Daan Kemps. Finally, I want to clarify and emphasize that there is currently no universally accepted definition of traditional CM. I concur with the World Health Organization’s remark that the “comprehensiveness of the term ‘traditional medicine’ and the wide range of practices it encompasses make it difficult to define or describe, especially in a global context”.* This is particularly important for CM and other traditional, complementary, and integrative medicines (TCIMs). Therefore, I would rather leave the definition blank and let readers supply their own.

Kara Chan 13 March 2019 * This quote from the World Health Organization can be found on their website (http://apps.who.int/medicinedocs/en/d/Jh2943e/3.html).

00 TCM Chapter front matter.indd 19

13/3/2019 下午2:17

00 TCM Chapter front matter.indd 20

13/3/2019 下午2:17

Part I Legitimation and Perception

01 TCM Chapter 1.indd 1

13/3/2019 下午2:18

01 TCM Chapter 1.indd 2

13/3/2019 下午2:18

1 Development and Regulation of Traditional Chinese Medicine Practitioners in Hong Kong Sian Griffiths and Vincent C. H. Chung

In response to the increasing popularity of traditional, complementary, and integrative medicine (TCIM) worldwide (Harris & Rees, 2000), the World Health Organization (WHO) launched the Traditional Medicine Strategy 2002−2005 (WHO, 2002) emphasizing the development of national TCIM policies among member states. In 2005, the WHO conducted a global survey on TCIM development and found that 45 of the 141 (32%) responding member states had national TCIM policies, while 51 (56%) were contemplating such development (WHO, 2005). One major element of these policies is the regulation of practitioners, and this issue is high on the policy agenda of many developed countries, including the United Kingdom (Stone, 2005), Australia (Carlton & Bensoussan, 2002), Canada (Moss, Boon, Ballantyne, & Kachan, 2007), and the United States (Eisenberg et al., 2002). In the West, the profile of TCIM rose as part of its renaissance in the late 1990s, spurred by dissatisfaction with conventional Western biomedicine (WM) as well as a growing exploration of global ideas.

01 TCM Chapter 1.indd 3

13/3/2019 下午2:18

4

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

TCIM popularity has since persisted in many countries. For instance, the 2012 survey reported in the WHO Traditional Medicine Strategy: 2014−2023 (WHO, 2013) estimated that 103 of the 129 (80%) member states recognized the value of therapeutic acupuncture, which is a key TCIM intervention. The increasing acceptance of acupuncture is reflected by its growing demand in countries such as the United States and Australia in the past decade (Su & Li, 2011; Australian Bureau of Statistics, 2008). However, in other parts of the world, both history and culture have shaped a different course and perspective on TCIM. In Hong Kong, for example, the initial policy interventions regulating TCIM practices can be dated back to the mid-19th century and were followed by a number of notable milestones with regards to regulation and professionalization (Table 1.1).

Traditional Chinese medicine in Hong Kong: A history of government regulation Hong Kong was a British colony for over 100 years, and the introduction of WM to Hong Kong and southern China by missionaries in the late 19th century likely overlapped with this period (Xie, 1998). However, although WM was considered the formal healthcare system, traditional Chinese medicine (CM) remained the medical care of choice for most of the population because of its accessibility, affordability, and cultural appropriateness. Despite CM’s wide usage, the British colonial government adopted a laissezfaire policy towards it. It was treated as an indigenous custom and was, therefore, monitored by the Secretary for Home Affairs instead of the Secretary for Health. Notably, this unrestrictive, and somewhat dismissive, attitude of the government towards CM continued for most of the 20th century. One of the few instances of government intervention occurred when sanctions were brought against the CM practice in 1894 after health officials deemed CM

01 TCM Chapter 1.indd 4

13/3/2019 下午2:18

Development and Regulation of Traditional Chinese Medicine Practitioners

5

to be “incompetent” in managing the plague epidemic (Xie, 1998). The perceived need for development further declined during the Japanese occupation in World War II, as the popularity of CM decreased when many Chinese medicine practitioners (CMPs) and clients returned to Mainland China. In the post-war period, CM practice continued only in small private settings (Xie, 1998), again with limited government intervention. The situation in colonial Hong Kong contrasts starkly with that in Mainland China, which implemented policies promoting the coexistence and integration of CM and WM in the 1950s (Taylor, 2005). Today, the WHO recognizes Mainland China as the first healthcare system in the world to fully integrate TCIM and WM at all levels of care (WHO, 2002). Mainland China’s latest healthcare reform proposal, for example, specifically highlights CM’s potential role in tackling the burgeoning problem of chronic non-communicable diseases within its ageing population (National Development and Reform Commission of China, 2008). Thus, it is not surprising that under the influence of Beijing’s long-established national CM policies, Hong Kong’s reunification with Mainland China on 1 July 1997 signified the end of stagnation in CM development in the region (Chiu, Ko, & Lee, 2005). The impetus for legislative change had also become apparent in the last decade of colonial rule, highlighted by Basic Law Article 138 (outlined in 1990 and enacted in 1997), and following the handover, the first Chief Executive of the Hong Kong Special Administrative Region (HKSAR) also announced the government’s initiatives for further CM development. A consultative document on the issue was published in the following month, and CM’s role in the Hong Kong healthcare system was officially recognized for the first time after 100 years of marginalization. The Chief Executive’s policy addresses of 2001 and 2005 as well as the 2007 election manifesto of the second Chief Executive re-emphasized similar top-down commitments (Chief Executive Officer, 2001; 2005;

01 TCM Chapter 1.indd 5

13/3/2019 下午2:18

6

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Table 1.1 Milestones in the development of traditional Chinese medicine practitioners (CMPs) in Hong Kong Date

Summary of events

Jan 1989

While drafting of the constitutional laws of postcolonial Hong Kong (Basic Law), was initiated in January 1989, the legal foundation of CM development was not laid until April 1990. Article 138 of the Basic Law states: “The government of the Hong Kong Special Administrative Region shall, on its own, formulate policies to develop Western and traditional Chinese medicine and to improve medical and health services. Community organizations and individuals may provide various medical and health services in accordance with the law.”

Aug 1989

The Working Party on Chinese Medicine was launched to conduct the first public review on CM.

1995

Under the requirements set by the Secretary for Health and Welfare, the Preparatory Committee on Chinese Medicine was formed to draft post-handover regulatory plans concerning CM.

Sept 1995

A total of 6,890 CMPs took part in the “Enrollment of Chinese Medicine Practitioners in Hong Kong” organized by the Preparatory Committee on Chinese Medicine. The information collected was used to develop future criteria for registration.

1998

The Hong Kong Baptist University founded the first full-time five-year undergraduate CM degree program, followed by similar programs launched by the Chinese University of Hong Kong in 1999 and the University of Hong Kong in 2000.

July 1999

The Chinese Medicine Ordinance was passed by the HKSAR Legislative Council.

Sept 1999

The Chinese Medicine Council of Hong Kong (CMCHK), a statutory body responsible for implementing regulatory measures, was set up under the Chinese Medicine Ordinance. The Chinese Medicine Practitioners Board and the Chinese Medicines Board were also established under this Council.

01 TCM Chapter 1.indd 6

13/3/2019 下午2:18

Development and Regulation of Traditional Chinese Medicine Practitioners

7

Table 1.1 (continued) Date

Summary of events

Dec 2001

A list of 7,707 “listed” CMPs was published in the Gazette. During the transitional period, both registered and listed CMPs were allowed to practice legally. Among them, only registered practitioners were allowed to prescribe Schedule 1 Chinese herbal medicines according to the Chinese Medicine Ordinance. Notably, the status of listed practitioners is transitional, as each is eventually expected to become a registered via assessment or examination.

June 2002

The first list of 2,384 registered CMPs was published in the Gazette.

2003

The first licensing examination for CMPs was held. Upon passing the licensing examination, listed CMPs or fresh CM graduates could attain registration status.

2005

The first batch of locally trained CM students graduated. The Continuing Chinese Medicine Education (CME) program was launched. CMPs must earn 60 CME points in three years to renew their licenses.

2008

Amendments to labor laws enabled registered CMPs to certify sick leave arising from work injuries.

Feb 2013

The Chinese Medicine Development Committee (CMDC) was established. It was charged with identifying directions, goals, and strategies related to CM services, research, and industry as well as the professional development of practitioners. Two sub-committees were set up under the CMDC: the Chinese Medicine Practice Sub-committee and the Chinese Medicines Industry Sub-committee.

Sept 2014

Phase I of the Integrated Chinese-Western Medicine Pilot Programme was launched for inpatients in three disease areas in three hospitals under the Hospital Authority.

Dec 2015

Phase II of the Integrated Pilot Programme was launched (included four more hospitals).

April 2018

Phase III of the Integrated Pilot Programme was launched (included a new disease area).

01 TCM Chapter 1.indd 7

13/3/2019 下午2:18

8

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

2007). Furthermore, the 2017 policy address of the Chief Executive contained additional government initiatives related to CM (Chief Executive Officer, 2017). These include the establishment of a unit under the Food and Health Bureau to oversee CM development and regulation as well as a government-run Chinese herbal medicine testing institute (Health, Welfare and Food Bureau and the Hospital Authority, 2005). Ultimately, these initiatives will be implemented as a way to develop Hong Kong into an international hub for scientific research on CM testing and quality control.

Promoting CM development via practitioner regulation Over the last decade, the primary focus of CM development has been on the regulation and professionalization of CMPs. There have been three notable achievements during this time: (1) the introduction of licensing requirements for CMPs via the formation of an official regulatory body (Chinese Medicine Ordinance, 1999); (2) the formalization of CM education by establishing degree programs at Hong Kong Baptist University, the University of Hong Kong, and the Chinese University of Hong Kong; and (3) the launch of the Continuing Chinese Medicine Education (CME) program as a license revalidation requirement (Chinese Medicine Council of Hong Kong [CMCHK], n.d.). The regulatory program established for Hong Kong’s CMPs was designed to clarify the qualifications of existing CMPs, protect the public from unsafe practices, and promote professional and ethical conduct among CMPs (Saks, 2002). In addition to these achievements, formal regulation of CM services resulted in increased utilization by the public (Chung, Wong, Woo, Lo, & Griffiths, 2007; Leung et al., 2005). Following this surge in use and acceptance, the Employees’ Compensation Ordinance was amended to entitle registered CMPs to issue legally recognized medical (sick leave) certificates (Labour Department, HKSAR,

01 TCM Chapter 1.indd 8

13/3/2019 下午2:18

Development and Regulation of Traditional Chinese Medicine Practitioners

9

2006), a gesture that increased patient choice and further promoted system integration. In 2008, further amendments were also made to include recognition of treatments, examinations, and certifications given by registered CMPs for workplace injury and medical expense reimbursement (Labour Department, HKSAR, n.d.). Taken together, these regulations, and the CMP empowerment resulting from them, have transformed practitioners into a new group of independent primary care providers that practice alongside their WM colleagues. Unfortunately, these measures have failed to address the broader impact of professionalization, especially in the relationship between CMPs and WM-trained professionals and the delivery of integrated patient care.

Integrating CM and WM Although CM and WM are now practiced in parallel in Hong Kong, two separate statutory bodies regulate CMPs and WM doctors (WMDs), and there is currently no communication platform established between the two professions. Discrimination towards CM by WMDs is long established (Holliday, 2003), and the effects of regulation on the attitudes of WMDs towards CMPs remains unknown. To further compound this, CM services are still mainly provided in private outpatient settings, and referral from the CM sector to the WM-focused public healthcare system is not accepted unless it is associated with designated programs. This professional and systematic compartmentalization of CM and WM is not in line with the public’s utilization pattern, in which “double-consultations” with both a CMP and a WMD is common practice (Chung et al., 2007). Policy initiatives to bring WM and CM together under a common primary care infrastructure are required to ensure the continuity, coordination, and comprehensiveness of primary care services, regardless of medical paradigm. Notably, some progress

01 TCM Chapter 1.indd 9

13/3/2019 下午2:18

10

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

has been made to achieve this, and CM clinics have been established within the public healthcare system to promote integration using a scientifically supported “evidence-based” CM approach. For example, the Hospital Authority has established a total of 18 Chinese Medicine Centres for Training and Research (CMCTRs), one in each of the 18 districts of Hong Kong. These CMCTRs operate on a tripartite collaboration model that involves the Hospital Authority, nongovernmental organizations (NGOs), and local universities, with the NGOs being responsible for the day-to-day operations at each facility (Hospital Authority, 2018). Experience from Hong Kong suggests that the parallel regulatory systems of CM and WM do not promote service coordination or integration (Dixon, Peckham, & Ho, 2007) nor do they contribute to patient-centered care or patient choice. To promote the role of CM in the Hong Kong health system, and to promote collaboration between CM and WM clinicians, more top-down policy changes have been initiated by the government in recent years. For example, the Chinese Medicine Development Committee (CMDC), chaired by the Secretary for Food and Health, was established in February 2013 to provide recommendations concerning the future direction and long-term strategy of CM development in Hong Kong. As set out in the 2016 Chief Executive Policy Address, the Hong Kong Government will also establish a CM hospital in Tseung Kwan O (Chief Executive Officer, 2016). To gather experience on how the future hospital may operate, the Hospital Authority has launched the Integrated ChineseWestern Medicine Pilot Programme (Hospital Authority, 2017). This program provides integrated Chinese-Western medicine treatment for patients receiving cancer palliative care, stroke rehabilitation, and lower back pain treatment. Moreover, according to the 2017 Chief Executive Policy Address, the new CM hospital will be operated by a non-profit organization supervised by the government and the Hospital Authority. However, the financing for this hospital has yet

01 TCM Chapter 1.indd 10

13/3/2019 下午2:18

Development and Regulation of Traditional Chinese Medicine Practitioners

11

to be determined (Chief Executive Officer, 2017). At publication, no new information concerning the establishment of this hospital is available. The government also recently proposed increased spending in the CM sector in the 2018 budget (Financial Secretary, 2018), and an HK$500 million fund will be established to support CM specialization, applied research, and knowledge exchange.

An alternative approach to regulation The history and regulation of CM in Hong Kong and Mainland China has likely impacted both its utilization and integration. Indeed, the effects are most apparent when compared to those of CM regulation and integration in the West. In the United Kingdom, for instance, a systematic review of methodologically sound survey results published from 2000 to 2011 estimated that the average 1-year prevalence of TCIM use in the population was 26.3% and the average lifetime prevalence was 44.0% (Posadzki, Watson, Alotaibi, & Ernst, 2013). Notably, compared to the Hong Kong model, the United Kingdom Department of Health has taken an alternative direction by recommending that the statutory regulation of TCIM practitioners “should take place through existing regulatory bodies”, such that the workforce development of TCIM practitioners will be concordant with the “increased emphasis on inter-professional team working” (Department of Health, 2008). These directions are in line with the initiatives mentioned in the white paper Trust, Assurance and Safety — the Regulation of Health Professionals in the 21st Century (Secretary of State for Health, 2007), which argue that “regulators with a number of professions are more aware of the interface between different professions’ practice” (p. 85). This arrangement is also thought to promote “multidisciplinary working to support integrated services to meet service users’ needs” (p. 85). If these assumptions are valid in the case of WM and TCIM, this

01 TCM Chapter 1.indd 11

13/3/2019 下午2:18

12

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

approach to regulation may provide a stronger basis for integration in the United Kingdom. However, as the influence of regulation on integration is not fully known (Dixon, 2008), strategies that go beyond regulation are required to foster integration, in both the United Kingdom and Hong Kong.

Conclusion Colocalization and organizational coordination between WMDs and TCIM practitioners may represent partial solutions in ensuring quality and continuity of patient care. Long-term planning to address the structural and financial questions involved in promoting teamwork between WMD and TCIM practitioners is also essential to ensure the sustainable development of high-quality, safe, and integrated patient care. Therefore, while practitioner development and regulation has seemingly enhanced the use and perception of TCIM by clients, the professionalization and acceptance of practitioners by their WM counterparts is lagging. The means to address these issues will likely stem from a combination of continued government regulation and legitimation, increased practitioner education, and enhanced public perception.

01 TCM Chapter 1.indd 12

13/3/2019 下午2:18

Development and Regulation of Traditional Chinese Medicine Practitioners

13

Acknowledgements This chapter is an edited version of the paper with the same title by the authors (Griffiths, S., & Chung, V. (2009). Development and regulation of traditional Chinese medicine practitioners in Hong Kong. Perspectives in Public Health, 129(2), 64–67. https://doi.org/10.1177/1757913908101611) (copyright 2009). The text has been edited and reproduced with permission from SAGE Publications, Ltd.

References Basic Law Article 138. (1997). The Basic Law of the Hong Kong Special Administrative Region of the People’s Republic of China. Retrieved from www.basiclaw.gov.hk/en/basiclawtext/images/basiclaw_full_text_en.pdft Carlton, A. L., & Bensoussan, A. (2002). Regulation of complementary medicine practitioners in Australia: Chinese medicine as a case example. Complementary Therapies in Medicine, 10(1), 20–26. https://doi.org/10.1054/ctim.2002.0521 Chief Executive Officer. (2001). The Chief Executive’s 2001 Policy Address. Retrieved from www.policyaddress.gov.hk/pa01/eindex.html Chief Executive Officer. (2005). The Chief Executive’s 2005 Policy Address. Retrieved from www.policyaddress.gov.hk/2005/eng/index.htm Chief Executive Officer. (2007). The Chief Executive’s 2007–08 Policy Address. Retrieved from www.policyaddress.gov.hk/07-08/eng/policy.html Chief Executive Officer. (2016). The Chief Executive’s 2016 Policy Address. Retrieved from www.policyaddress.gov.hk/2016/eng/agenda.html Chief Executive Officer. (2017). The Chief Executive’s 2017 Policy Address. Retrieved from www.policyaddress.gov.hk/2017/eng/policy.html Chinese Medicine Council of Hong Kong [CMCHK]. (n.d.). Continuing education in Chinese medicine (CME) for Registered Chinese Medicine Practitioners (CMPs). Retrieved from www.cmchk.org.hk/cmp/eng/#main_rcmp04.htm Chinese Medicine Ordinance. (1999). Retrieved from www.cmchk.org.hk/eng/ main_ord_cap549.htm Chiu, S. W., Ko, L. S., & Lee, R. P. (2005). Decolonization and the movement for institutionalization of Chinese medicine in Hong Kong: A political process perspective. Social Science & Medicine, 61(5), 1045–1058. https://doi. org/10.1016/j.socscimed.2004.12.026

01 TCM Chapter 1.indd 13

13/3/2019 下午2:18

14

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong Chung, V., Griffiths, S., Wong, E., Woo, J., Lo, S. V., & Yeoh, E. K. (2007). Age, chronic disease status and the choice for Western and Chinese medicine in a Chinese population. Paper presented at the 39th Asia Pacific Academic Consortium for Public Health Conference, Tokyo. Chung, V., Wong, E., Woo J., Lo, S. V., & Griffiths, S. (2007). Use of traditional Chinese medicine in the Hong Kong Special Administrative Region of China. The Journal of Alternative and Complementary Medicine, 13(3), 361–367. https:// doi.org/10.1089/acm.2006.6152 Australian Bureau of Statistics. (2008) Complementary therapies. In Australian Social Trends (15th ed.). Sydney: Australian Bureau of Statistics. Retrieved from www.abs.gov.au/AUSSTATS/[email protected]/Lookup/4102.0Chapter5202008 Department of Health. (2008). Report to Ministers from the Department of Health steering group on the statutory regulation of practitioners of acupuncture, herbal medicine, traditional Chinese medicine and other traditional medicine systems practiced in the UK. Retrieved from http://webarchive.nationalarchives. gov.uk/20130123194632/http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_086359 Dixon, A., Peckham, S., & Ho, A. P. Y. (2007). Informing UK policy development on the regulation of CAM practitioners: Lessons from Hong Kong? Social Policy & Administration, 41(7), 711–728. https://doi.org/10.1111/j.1467-9515.2007.00581.x Dixon, J. (2008). Regulating complementary medical practitioners: An international review. London: King’s Fund. Retrieved from www.kingsfund.org.uk/ publications/regulating-complementary-medical-practitioners Eisenberg, D. M., Cohen, M. H., Hrbek, A., Grayzel, J., Van Rompay, M. I., Cooper, R. A. (2002). Credentialing complementary and alternative medical providers. Annals of Internal Medicine, 137(12), 965–973. Financial Secretary. (2018). The 2018–19 Budget — Budget Speech (Healthcare). Retrieved from www.budget.gov.hk/2018/eng/budget26.html Harris, P., & Rees, R. (2000). The prevalence of complementary and alternative medicine use among the general population: A systematic review of the literature. Complementary Therapies in Medicine, 8(2), 88–96. https://doi. org/10.1054/ctim.2000.0353 Health, Welfare and Food Bureau and the Hospital Authority. (2005). Way forward in the development of Chinese medicine service in the public sector in Hong Kong. Legislative Council Panel on Health Service paper no. CB(2) 1748/04-05(05). Retrieved from www.legco.gov.hk/yr04-05/english/panels/ hs/papers/hs0613cb2-1748-5e.pdf

01 TCM Chapter 1.indd 14

13/3/2019 下午2:18

Development and Regulation of Traditional Chinese Medicine Practitioners

15

Holliday, I. (2003). Traditional medicines in modern societies: An exploration of integrationist options through East Asian experience. Journal of Medicine and Philosophy, 28(3), 373–389. https://doi.org/10.1076/jmep.28.3.373.14587 Hospital Authority. (2017). Progress update on the development of Integrated Chinese-Western Medicine Pilot Programme. Retrieved from www.fyk.org. hk/haho/ho/cad_bnc/HAB-P268.pdf Hospital Authority. (2018). Hospital Authority Tripartite Chinese Medicine Centres for Teaching and Research website. Retrieved from www.ha.org. hk/chinesemedicine/intro.asp?lan=en Labour Department, HKSAR. (2006). Summary of the new amendments made to the Employees’ Compensation Ordinance. Retrieved from www.labour. gov.hk/eng/public/ecd/SummaryNewAmendmentsECO.pdf Labour Department, HKSAR. (n.d.). Certification for Employee Benefits (Chinese Medicine) (Miscellaneous Amendments) Ordinance 2006: Commonly asked questions. Retrieved from www.labour.gov.hk/eng/public/wcp/ ChineseMedicineFAQ.pdf Leung, G. M., Wong, O. L. I., Chan, W. S., Choi, S., Lo, S. V., & the Health Care Financing Study Group. (2005). The ecology of healthcare in Hong Kong. Social Science & Medicine, 61(3), 577–590. https://doi.org/10.1016/j. socscimed.2004.12.029 Moss, K., Boon, H., Ballantyne, P., & Kachan, N. (2007). The professionalization of Western herbalists: Response to new product regulations in Canada. Complementary Therapies in Medicine, 15(4), 264–270. https://doi.org/10.1016/j. ctim.2007.01.007 National Development and Reform Commission of China. (2008). 關於《關於深 化醫藥衞生體制改革的意見（徵求意見稿）》[Deepening reform in medical, pharmaceutical and health systems (a consultation paper)]. Retrieved from www.gov.cn/gzdt/2008-10/14/content_1120143.htm Posadzki, P., Watson, L. K., Alotaibi, A., & Ernst, E. (2013). Prevalence of use of complementary and alternative medicine (CAM) by patients/consumers in the UK: Systematic review of surveys. Clinical Medicine (London), 13(2), 126–131. https://doi.org/10.7861/clinmedicine.13-2-126 Saks, M. (2002). Professionalization, regulation and alternative medicine. In J. Allsop & M. Saks (Eds.), Regulating the health professions (pp. 148–161). London: Sage. Secretary of State for Health. (2007). Trust, assurance and safety — The regulation of health professionals in the 21st century. London: The Stationery Office. Retrieved from www.official-documents.gov.uk/document/cm70/7013/7013.pdf

01 TCM Chapter 1.indd 15

13/3/2019 下午2:18

16

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong Stone, J. (2005). Regulation of CAM practitioners: Reflecting on the last 10 years. Complementary Therapies in Clinical Practice, 11(1), 5–10. https://doi. org/10.1016/j.ctcp.2004.12.001 Su, D., & Li, L. (2011). Trends in the use of complementary and alternative medicine in the United States: 2002–2007. Journal of Health Care for the Poor and Underserved, 22(1), 296–310. https://doi.org/10.1353/hpu.2011.0002 Taylor, K. (2005). Chinese medicine in early Communist China, 1945–63: A medicine of revolution. London: Routledge. World Health Organization [WHO]. (2002). WHO traditional medicine strategy 2002–2005. Geneva: World Health Organization. Retrieved from www. wpro.who.int/health_technology/book_who_traditional_medicine_ strategy_2002_2005.pdf World Health Organization [WHO]. (2005). National policy on traditional medicine and regulation of herbal medicines — Report of a WHO global survey. Geneva: World Health Organization. Retrieved from http://apps. who.int/medicinedocs/en/d/Js7916e/ World Health Organization [WHO]. (2013). WHO traditional medicine strategy 2014–2023. Geneva: World Health Organization. Retrieved from http://apps. who.int/iris/bitstream/10665/92455/1/9789241506090_eng.pdf Xie, Y. G. (1998). 香港中醫藥史話 [History of Chinese medicine in Hong Kong]. Hong Kong: Joint Publishing.

01 TCM Chapter 1.indd 16

13/3/2019 下午2:18

2 Australia and Hong Kong:

Comparing Regional Influences on Chinese Medicine Education Caragh Brosnan, Vincent C. H. Chung, Anthony L. Zhang, and Jon Adams

As Chinese medicine (CM) has spread throughout the world, it has been absorbed, interpreted, and transformed within different national contexts (Flesch, 2013; Martyr, 2002; Pritzker, 2014; Scheid, 2002). A key channel through which such processes occur is in the training and education of CM practitioners (CMPs). It is often via education that particular philosophies and practices become predominant as the next generation of practitioners adopt them. Critically analyzing CM education in different regional settings, such as Australia and Hong Kong, can, therefore, provide useful insights into how CM is evolving internationally in addition to identifying the causes underlying these changes. CM practice in both Australia and Hong Kong is statutorily regulated. The Chinese Medicine Board of Australia (CMBA) and the Chinese Medicine Council of Hong Kong (CMCHK) are the governing bodies responsible for implementing regulations on

02 TCM Chapter 2.indd 17

13/3/2019 下午2:19

18

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

CM practices in the two regions, respectively. Obtaining a practice license from either regulatory body requires professional education in an accredited program. Unlike many other English-speaking jurisdictions, both regions offer these types of programs at public universities. The design of these 4–6-year programs invariably references the CM curriculum in Mainland China, with 60–70% of the content focusing on CM and 30–40% focusing on Western biomedicine (WM). In Hong Kong, the CM component is taught in Chinese, while the WM component is often taught in English. In both Hong Kong and Australia, registered CMPs must participate in their respective Continuing Chinese Medicine Education (CME) programs and additional professional development courses for revalidation. The majority of graduates from these programs in both regions subsequently practice in the private sector, providing outpatient services in either solo or group practices. Despite these similarities, the Hong Kong and Australian programs operate in different cultural and health system contexts. In Hong Kong, the development of CM services has become a constitutional mandate after reunification with Mainland China. While the tax-funded healthcare system currently provides limited outpatient CM services, pilot programs for CM inpatient services within public hospitals are in progress. While CM education has gained top-down legitimacy from the government (see Chapter 1), acceptance of CM graduates by Western medical doctors (WMDs) remains limited, and there has been little interprofessional collaboration between the two sectors. In Australia, the only form of CM available through the public health system is acupuncture, which is carried out by a conventional WMD. Access to CM in Australia, therefore, involves out-of-pocket expenses, although these costs may be subsidized by private healthcare funds. This is important as nearly 60% of the adult population has private health coverage in Australia (Australian Bureau of Statistics, 2013). Given these

02 TCM Chapter 2.indd 18

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

19

similarities and differences, Australia and Hong Kong constitute excellent case studies for examining how broader historical and policy contexts shape the discussion and subsequent development of CM education in WM-dominant healthcare systems.

Historical position of CM in higher education While the history of CM in Australia is vastly different from that in Hong Kong, events in each location have nevertheless impacted CM’s current position within their respective higher education systems. Australia Though still considered a complementary or alternative approach compared to mainstream WM, CM, including acupuncture and herbal treatments, has been well established in Australia since the gold rush era of the 1850s (Martyr, 2002; Xue & Story, 2004). Increased Asian migration to Australia in the late 20th century was accompanied by a significant increase in CM use (Xue & Story, 2004). Formal CM education has historically been skewed towards acupuncture, and the first acupuncture programs offering diplomas were established in the 1970s at various private colleges (Xue, Wu, Zhou, Yang, & Story, 2006). Notably, acupuncture training had previously been offered only in association with chiropractic or naturopathic colleges (Parliament of Victoria, 1975). In the early 1990s, bachelor degree programs were established or transferred from private colleges into four publicly funded universities, with the first degree program covering both acupuncture and herbal medicines opening at the Royal Melbourne Institute of Technology (RMIT) in 1996 (Xue, Wu, Zhou, Yang, & Story, 2006). This move into the university system occurred well before the statutory regulation of CM practice in Australia and was seen as a step towards offering greater access to research and teaching resources (Garvey, 2011).

02 TCM Chapter 2.indd 19

13/3/2019 下午2:19

20

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Hong Kong As a traditional remedy, CM has been used for centuries and was officially included in the healthcare system in Mainland China in the 1950s (Griffiths, Chung, & Tang, 2010). With the government’s consistent support, CM remains a crucial part of Mainland China’s health services today (Chung et al., 2013). However, CM in Hong Kong has followed a very different path from that of Mainland China because of its status as a British colony from 1841 to 1997. In the early colonial days, the local Chinese community utilized CM as their main form of healthcare. Tung Wah Hospital, opened in the late 19th century, was the first CM hospital in Hong Kong and provided a significant proportion of basic healthcare services to the local Chinese population during that period (Sinn, 1989). While CM initially held a reputable local status in the colony, following World War II, a tax-funded healthcare system was established that focused exclusively on WM, thus forcing CM into the private sector. The colonial government regarded CM as a “Chinese cultural custom” instead of a formal healthcare modality (Topley, 1975). Instead of the Secretary for Health, CM came under the administrative purview of the Secretary for Home Affairs (Lee, 1980). The marginal status of CM was also reflected in healthcare legislation at the time. The colonial Medical Registration Ordinance specified that only WMDs were subject to regulation, while the practice of CM was considered to be out of its scope (Lee, 1981). As CM and its use were unregulated, tertiary education was not a prerequisite for CMPs in Hong Kong. Apprenticeships with family members or CM masters were the usual path to a career in CM, often supplemented with lecture-based training provided by CM associations of mixed quality (Xie, 1998). In the early 1990s, the School of Professional and Continuing Education, University of Hong Kong offered the first formal CM classes. However, despite this initial appearance in the tertiary education sector, CM remained

02 TCM Chapter 2.indd 20

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

21

marginalized. Only conventional clinicians were allowed to use the title “doctor,” and this rule continues today even after regulation and increased educational integration. Moreover, sharing clinics between WMDs and CMPs was prohibited, and the latter had no rights in issuing death, sick leave, or health status assessment certificates. CMPs were also forbidden to use any WM instruments, including syringes and stethoscopes (Koo, 1998). These regulations further excluded CM from the WM-based formal medical system. The position of CM in Hong Kong was significantly changed following reunification with Mainland China on 1 July 1997, as the constitutional law of the then newly established Hong Kong Special Administrative Region (HKSAR) mandated the development of CM in the territory (Griffiths & Chung, 2009). Under this policy initiative, Hong Kong Baptist University launched a full-time, 5-year bachelor degree in CM — the first of its kind — in 1998. Like Australia, the establishment of a School of Chinese Medicine within a public university was considered a milestone for research and learning in postcolonial Hong Kong (Chung, Law, Wong, Mercer, & Griffiths, 2009).

Current position of CM in higher education In addition to the differences in historical context, differences also exist between the current position of CM in Australian higher education and that in Hong Kong higher education. However, there are also notable similarities concerning research and funding. Australia Despite having been represented within Australian universities for over two decades, the position of CM in the current education system is limited. Garvey (2011) previously described CM as just “one tiny fish in a very large tertiary education … pond” (p. 7). Indeed, only 3 of the 40 Australian universities (RMIT; the University of Technology,

02 TCM Chapter 2.indd 21

13/3/2019 下午2:19

22

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Sydney; and the University of Western Sydney) currently teach CM courses. These universities offer qualifications in both acupuncture and herbal medicine as well as a range of 4- or 5-year bachelor’s and 3-year (part-time) master’s programs. Entry requirements into these courses include an Australian Tertiary Admission Rank (ATAR) of 70–80 (out of 100), which is higher than the average ATAR of around 70 required for other programs (University Admissions Centre, 2016). These requirements imply that entrance into CM university programs is more competitive than that into some allied health degrees but less so than that into conventional medical programs. In addition to these universities, three private colleges (Endeavour College of Natural Health, Southern School of Natural Therapies, and Sydney Institute of Traditional Chinese Medicine) also offer 4-year bachelor’s degree programs in CM. Although national enrollment figures are not published regularly, a 2010 study reported a total of 144 final year students across the seven institutions offering CM degrees at that time (Moore, Canaway, & O’Brien, 2010). The Australian CM profession itself is also relatively small, but growing, with nearly 5,000 CMPs registered in 2018 (CMBA, 2018a). This is compared to over 116,000 conventional medical doctors currently registered in Australia (Medical Board of Australia, 2018), representing a practitioner-to-population ratio of 1:217 for conventional medicine versus 1:5150 for CM. Even as a minor player, CM is still subject to shifts affecting the Australian higher education sector as a whole, including cuts in public funding and increased reliance on student fees and external research grants. Policy changes are currently under discussion that would allow universities to charge uncapped fees for courses and private education providers to seek public funding. CM is unusual among complementary medicine and other educational disciplines in Australia in that CM degrees are already offered both by universities and by private colleges. The proposed deregulation of university

02 TCM Chapter 2.indd 22

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

23

funding would result in increased competition for students from private colleges, which may undercut the fees at public universities, potentially impacting CM’s position in the university sector. Indeed, unless preventive measures are taken, CM may follow a similar trajectory as the previously offered naturopathy programs and courses, which gradually disappeared from Australian universities after new funding schemes for private education were introduced in 2006 (Wardle, Steel, & Adams, 2012). At the international level, the opening of higher education markets and a new emphasis on competitive ranking systems have affected CM alongside all other university disciplines (Münch, 2014). Global competition centers on research funding and output, and university programs are increasingly evaluated against these metrics, with natural and medical science disciplines typically coming out on top (Collyer, 2013). In Australian universities, complementary medicine disciplines have struggled to keep pace in this competitive environment. Of these disciplines, CM has had the greatest success, and many competitive public research grants have been awarded to Australian-based CM research facilities in the past decade (Wardle & Adams, 2013). However, the success of CM research is not wholly recognized in the national research assessment exercise “Excellence in Research for Australia” (ERA). In fact, within the ERA, there is only a single research category for “complementary and alternative medicine,” and many of the CM studies conducted are counted within the “clinical sciences” or “pharmacology and pharmaceutical sciences” categories, thereby masking the actual research strength of CM in Australia. This merging of CM with other disciplines may also reflect a trend towards the biomedicalization of CM. Indeed, funding is typically awarded for research that fits within a biomedical paradigm, focusing on molecular biology or employing randomized controlled trials (Garvey, 2011). Such funding success may represent a double-edged sword for CM, with some commentators raising

02 TCM Chapter 2.indd 23

13/3/2019 下午2:19

24

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

concerns over the fate of CM’s traditional concepts which are not easily included in such research frameworks. Funds from the Chinese Government and Chinese pharmaceutical companies have also provided essential resources for CM research in Australia, and many universities and private colleges are affiliated with Chinese institutions (Bensoussan & Myers, 1996). However, the relationship between CM research and education in Australia is not straightforward. Recently, there has been substantial funding for complementary medicine research directed towards universities or university centers that do not necessarily teach the principles underlying the research. The Zhendong Australia-China Centre for Molecular Traditional Chinese Medicine at the University of Adelaide and the Australian Research Centre in Complementary and Integrative Medicine (ARCCIM) at the University of Technology, Sydney are two examples of established universitybased complementary medicine research programs that do not offer associated degree programs or classes. While these centers promote collaboration between research and clinical practice, increased privatization of higher education in Australia may result in a deeper split between complementary medicine research and teaching. Hong Kong In Hong Kong, it has been over 20 years since the first batch of fulltime students enrolled in an undergraduate CM program offered by a public university. While there are three Schools of Chinese Medicine in the territory (at the Chinese University of Hong Kong, Hong Kong Baptist University, and the University of Hong Kong), the scale of CM undergraduate education remains small, with only about 100 new students enrolled each year (Tam, 2013). Entry requirements from high school are similar to those for nursing degrees and lower than those for WM (Chinese University of Hong Kong, 2018; University of Hong Kong, 2018; Hong Kong Baptist

02 TCM Chapter 2.indd 24

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

25

University, 2018). The curriculum established at each institution was designed according to the accreditation requirements of the CMCHK and covers Chinese herbal medicine, acupuncture, and bonesetting (CMCHK, 2018b). The degree programs were recently extended to 6 years. However, the size of the CM workforce does not reflect this relatively small enrollment size as many CMPs have obtained registration via grandfathering processes. In February 2018, there were 7,421 registered CMPs according to the CMCHK (CMCHK, 2018a). This translates to a CMP-to-population ratio of 1:1053, significantly higher than that in Australia. The conventional doctor-to-population ratio is 1:541 (Department of Health, 2017). As CM only constitutes about 20% of all outpatient care provided in Hong Kong (Chung, Lau, Yeoh, & Griffiths, 2009), there is a slight oversupply of CMPs. This oversupply is exaggerated by an increasing number of candidates sitting for their CMCHK licensing examination. On top of local CM students, graduates from 31 recognized CM universities in Mainland China are also eligible to sit the examination and become registered CMPs in Hong Kong if they pass all requirements. Every year, more than 1000 Hong Kong high school graduates are admitted to Mainland CM universities, and the number is increasing. It is likely that they will return to Hong Kong and sit for the licensing examination in their home region (Huang, 2014). Thus, Mainland CM universities are now in direct competition with the local CM programs for enrollment. The Hong Kong program is at a slight disadvantage as it is 1 year longer than the 5-year course provided throughout Mainland China, and the fees are at least 4-fold higher (Lin, 2012). Another threat to the local CM programs is decreased government funding compared to other clinical disciplines, such as conventional WM and dentistry. Although all of these programs are 6 years in length, public funding for CM is less than half of that for each of the others, resulting in staff shortages and decreased administrative support (Tam, 2013).

02 TCM Chapter 2.indd 25

13/3/2019 下午2:19

26

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

With regards to research, CM schools in Hong Kong face similar challenges to their Australian counterparts. A dedicated CM theme was established under the Hong Kong Health and Medical Research Fund in 2002, encouraging health services research and clinical trials on various CMs. However, with a cap of HK$1.2 million per project (Food and Health Bureau, 2017), only trials of modest size can be performed. The stringent requirements set by the Department of Health concerning the use of Chinese herbal medicines in clinical trial settings also pose difficulties for researchers. At the time of this publication, there are only a few Chinese herbal products approved for human trials, even though such herbs are already widely used in the community. Despite the government’s attempt to develop CM using an evidence-based approach, the largest share of research funding is often granted to laboratory-based research that does not inform clinical practice directly. Further, such funding is often channeled to departments that have no involvement in CM teaching. While the three Schools of Chinese Medicine were performing satisfactorily in the last research assessment exercise, it is uncertain how this may impact educational outcomes, as pedagogical research is minimal in all three schools. Thus, it appears that policies involving CM research and teaching in Hong Kong have been developed in an uncoordinated fashion and are not entirely concordant with the government’s initiative in building an evidence-based framework for CM practices (Food and Health Bureau, 2013a).

Regulation and clinical placement in healthcare Similarities in the statutory regulation of CM in Australia and Hong Kong largely reflect their British colonial histories. CM’s current regulatory status is also indicative of the more recently established government policies regarding both CM and WM.

02 TCM Chapter 2.indd 26

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

27

Australia In 2000, the State of Victoria, became the first Western state in the world to establish statutory regulations for CM (Xue, Wu, Zhou, Yang, & Story, 2006), which included the introduction of minimum education standards. This was followed in 2012 by the inclusion of CM in Australia’s National Registration and Accreditation Scheme, where it joined 13 other health professions. This process led to the application of national education and competency standards to CMPs, including the requirement of a recognized degree in CM to be able to register and practice. The degree programs themselves must be accredited by the CMBA in order for their graduates to be eligible for registration. This new accreditation process was only recently implemented, placing a significant administrative and financial burden on CM education providers. Furthermore, these accreditation standards have been developed and tailored specifically for CM degree programs. They include detailed requirements relating to the theory and practice of acupuncture and herbal medicine, the basic understanding of the Chinese language, and the mastery of the Pinyin system as well as basic scientific competencies and more generic health professional learning outcomes related to ethical conduct, communication, and risk management (CMBA, 2013). As of February 2018, there were nine active CM degree programs approved by the CMBA (CMBA, 2018b). Despite having joined the list of registered professions, CMPs remain largely excluded from publicly funded healthcare systems and hospitals in Australia, resulting in most CMPs operating as private businesspeople in the community. Similarly, rather than being integrated into the health system, CM students receive most of their clinical training in a single university-based clinic, limiting their exposure to clinical populations and presentations. Although it is also common for Australian-based CM students to complete their

02 TCM Chapter 2.indd 27

13/3/2019 下午2:19

28

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

clinical training in Mainland China, the predominant therapies, conditions, and clinical settings in the Chinese healthcare system are not necessarily equivalent to those in Australia. Unlike many other health professions (e.g., WM, pharmacy, psychology), there are currently no formal training pathways for CM graduates in Australia, aside from standard CME and professional development courses. Interestingly, the Australian Government has signaled its support of CM through the signing of a “Letter of Understanding” with the Chinese Government in June 2015 (in conjunction with a new free trade agreement) agreeing to promote cooperation between the two countries around CM research and the recognition of qualifications (Robb & Hucheng, 2015). Increasing Australia’s links to Asia will likely reap benefits for local CM education. Hong Kong Though now reunified with Mainland China, Hong Kong’s regulatory situation for CM is very similar to that of Australia and continues to reflect the region’s British colonial heritage. Despite statutory regulation and CM program accreditation, CMPs remain a parallel profession to conventional WMDs as well as other healthcare professionals. At the undergraduate level, while all CM programs include WM components, exposure to even basic CM principles is limited for medical, nursing, and pharmacy students. Further, at the postgraduate level, although local universities have collaborated with the Hospital Authority (the public healthcare service provider in the region) to organize a CM training course for practicing healthcare professionals, interprofessional learning has yet to be scaled up. Since CM is not provided in all publicly funded hospitals and clinics, teamwork across CM and WM is rare. Currently, there is no formal mechanism for facilitating referrals between CMPs and WMDs, and no publicly funded hospitals accept referrals from

02 TCM Chapter 2.indd 28

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

29

private CMPs. Given the limited interaction between them, the two professions are considered discrete entities in the public sector. To boost the perception of CM within the medical community and increase public use, the government has partially subsidized CM outpatient services by 20%. This is managed with a tripartite system by the schools of CM, nongovernment organizations (NGOs), and the Hospital Authority on a predominantly self-financed basis. The first tripartite CM clinic was established in 2003, and there are currently a total of 18 in the territory (Hospital Authority, 2015). Out-of-pocket payments from the patients are their main source of funding, although fees can be waived based on the patient’s financial status. These tripartite clinics are also the primary employer for local CM graduates and provide a structured 3-year training program. Therefore, the clinics must find a balance between maintaining financial sustainability and serving as clinical training sites for CM students. This implies that while the contribution of tripartite clinics to training junior CMPs should be recognized, training quality may be compromised due to financial pressures (Tam, 2014). CM hospitals in Mainland China are alternative sites for clinical training for Hong Kong-based CM students. At these clinics, CM students often spend their final year of study in environments where both CM and WM treatments are prescribed by the same clinician. However, as with Australian-based CM students, knowledge and skills gained from an integrative inpatient environment in Mainland China are not directly applicable to their likely future as a primary care clinician providing CM-only treatments in Hong Kong (Lin, 2011). In Hong Kong, continuous education (via CME programs) is mandatory for CMP license revalidation. However, these programs are often viewed negatively by local CM graduates as they are typically geared towards CMPs who previously received grandfathering licenses and have not been formally trained (Chung, Law, Wong,

02 TCM Chapter 2.indd 29

13/3/2019 下午2:19

30

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Mercer, & Griffiths, 2009). Thus, while these regulations have helped establish standards in the CM field, recognition, training, and career development of registered CMPs in the healthcare system in Hong Kong require further policy support.

Public and professional legitimacy While there are differences in public use and acceptance of CM in Australia and Hong Kong, issues regarding its legitimacy within public medicine and tertiary institutions exist in both. These concerns primarily stem from the unbalanced and unresolved relationship between the CM and WM fields. Australia Accompanying the uneven governmental support of CM practice and education in Australia are varying levels of acceptance among the public and other health professions. Acupuncture and Chinese herbal medicine are the most commonly used CMs, with 9.2% and 7% of national survey respondents reporting usage in the previous 12 months, respectively (Xue, Zhang, Lin, Da Costa, & Story, 2007). However, it has been argued that CM lacks a strong presence in Australia (Garvey, 2011) as well as an identifiable professional body (Bensoussan & Myers, 1996). With regards to CM education, Garvey (2011) suggests that because regulated and accredited CM training is a relatively new concept in Australia, the discipline will continue to be treated with skepticism by proponents of WM disciplines and will need to prove its legitimacy as a healthcare practice. Indeed, the same year in which CM was included in the national registration system also saw significant backlash against the teaching of complementary medicine in Australian universities. This campaign was led by the Friends of Science in Medicine, a lobbyist group primarily composed of academic doctors and scientists, who

02 TCM Chapter 2.indd 30

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

31

argued through the media that complementary medicine, including CM, was pseudoscience that should not be taught in publicly funded universities (Brosnan, 2015). Representatives of universities teaching CM and other types of complementary medicine responded to the campaign predominantly by asserting that such degree programs are, in fact, based on scientific foundations. This ongoing debate suggests that the legitimacy of CM within Australian universities largely hinges on its integration of bioscientific approaches. Hong Kong While current support for CM education and service within the public sector is limited, usage of CM among the Hong Kong population is high, with more than 60% of the general public having consulted a CMP at least once in their lifetime (Census and Statistics Department, 2013). One territory-wide survey suggested that the average 1-year prevalence of consulting a CMP was around 20%. Of this 20%, 17% sought care from both CMPs and WMDs, while the other 3% consulted only a CMP in the past year (Chung, Lau, Yeoh, & Griffiths, 2009). The former Chief Executive of Hong Kong, Mr. Leung Chun-ying, showed strong support for the further advancement of CM in an evidence-based manner, and in 2013 the Chinese Medicine Development Committee (CMDC) was established with the Secretary for Food and Health as Chairman (Food and Health Bureau, 2013b). Following recommendations from the Committee, three main policy initiatives were announced in 2015 (Food and Health Bureau, 2015). The first is the establishment of a testing center for CMs directly managed by the Department of Health. This center will establish reference standards for safety, quality, and testing methods of Chinese herbal medicines and provide upstream assurance on the safe use of these herbs. The other two policies are more service-oriented. A site has also been reserved for the establishment of a new CM hospital in the territory,

02 TCM Chapter 2.indd 31

13/3/2019 下午2:19

32

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

to provide inpatient care as well as teaching support. This is an entirely new initiative for the Hong Kong health system. To explore more feasible modes of operation, the government has launched the Integrated Chinese-Western Medicine Pilot Programme in multiple public hospitals. This includes three pilot integrative care projects on cancer palliative care, lower back pain, and stroke rehabilitation. Evaluation results from these pilots will help guide regulation of and operations in future CM hospitals. The CM treatments for all three conditions are based on protocols that were designed from existing evidence and consensus between CM and WM experts. One of the main issues this program addresses is the limited prescription flexibility for CMPs, which ultimately compromises the essential features of individualized treatment. These policy initiatives seem to suggest that the biomedicalization of CM is essential for its acceptance in a healthcare environment dominated by conventional medicine. Unlike the situation in Australia where CM’s legitimacy is being directly challenged, in Hong Kong, the patterns tend to favor the assimilation of CM with a gatekeeping role for WMDs and pharmacists. In response to this, the Hong Kong Government has issued a call for organizations that are interested in participating in the future operation of CM hospitals (Hong Kong Government, 2016), thus establishing better communication between the CM and WM platforms. Taken together, progress in the currently implemented programs will likely shape the operational models in the field and impact the interprofessional relationship between CMPs and WMDs.

CM education in Australia and Hong Kong: Key comparisons Comparing the factors impacting CM education in Hong Kong and Australia has revealed some striking similarities between the two

02 TCM Chapter 2.indd 32

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

33

regions, as well as some notable differences, highlighting the distinct roles of history, culture, and politics in the local evolution of CM. CM was integrated into the formal tertiary education sector much earlier in Australia than in Hong Kong, first via private colleges and later via universities. However, Hong Kong’s reunification with Mainland China acted as a catalyst for the development of CM education, and CM now has a comparatively larger presence in the university sector compared to Australia, with almost 38% and less than 10% of the public universities teaching CM, respectively. Postgraduate clinical training pathways in publicly funded CM clinics are also much more established in Hong Kong, while no such programs exist in Australia, where CM remains truly excluded from the public healthcare system. However, the rate of CM usage in Hong Kong is only 2- to 3-times higher than that in Australia, while the practitioner-to-population ratio is 5-times higher, indicating that the oversupply of CMPs is a more significant problem in Hong Kong. Beyond these differences, three key interrelated issues seem to stand out with regards to the status of CM education in both Australia and Hong Kong. The first is the impact of ongoing WM dominance within the healthcare system. In both Hong Kong and Australia, this imbalance has limited the CM clinical training opportunities available at both the undergraduate and postgraduate levels and has also curbed the development of interprofessional education, now recognized as crucial in other health disciplines (Reeves, Tassone, Parker, Wagner, & Simmons, 2012). This situation is, in turn, likely to perpetuate CM’s marginalization, as the understanding of CM theories and treatments by other health practitioners and patient referral to CMPs will remain limited. Furthermore, the relatively low profile of CM in these regions, compared to WM, means that the scale of CM education has remained small. As a university discipline, CM lacks the critical mass within these regions that is needed to develop into a robust professional field.

02 TCM Chapter 2.indd 33

13/3/2019 下午2:19

34

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

These ramifications are also related to the second issue, which is the possible detrimental impact of global competition between universities for students, status, and research funding on CM education. Schools of CM in Hong Kong compete for students with more affordable Mainland Chinese universities, while Australian CM university departments compete with private colleges. Programs in both regions compete with other disciplines for institutional resources. As CM student numbers are not large in either Hong Kong or Australia, any fluctuations in enrollment caused by policy changes or increased competition render these university programs vulnerable. In Australia, it is unlikely that new university programs will open soon, particularly as universities teaching complementary medicine are under the scrutiny of skeptic groups that target the universities’ reputations (Brosnan, 2015). While private college degree programs in Australia must go through a similar accreditation process as public universities, these colleges are less likely to have access to the same research facilities and high-tech teaching equipment available in public universities. Therefore, a move towards greater private provision will likely impact how CM is learned as well as the potential relationship between CM teaching and research. Notably, research provides another important source of income for universities, but research funding for CM is limited in both Hong Kong and Australia and is not always funneled into the same schools that teach CM clinical practices. The research funding that is available for CM is typically directed mostly to basic science involving standardized protocols. In general, research fitting a WM model attracts the most substantial funds and produces the most output for universities (Collyer, 2013). This factor, coupled with ongoing pressure for CM to prove its legitimacy within a context in which WM dominates, means that within universities, CM is likely to continue to become biomedicalized and tested through methods that do not necessarily allow for traditional knowledge

02 TCM Chapter 2.indd 34

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

35

or individualized approaches to be incorporated into the research framework. Whether this biomedicalization extends to how CM is taught within degree programs depends, at least in part, on how the relationship between teaching and research evolves. However, lack of alignment between the two domains is unlikely to be tenable in an environment where the scientific basis of CM degrees is under scrutiny. This points to an urgent need to evaluate the balance between research and education in the tertiary CM education sector. A third important observation is that the relationship with Mainland China exerts a significant influence on CM and CM education in both Australia and Hong Kong. This is interesting given that CM has been observed to have changed and adapted to the various transnational settings in which it is found (Pritzker, 2014; Zhan, 2009), and in the case of Australia, the extended period in which it has been established in local universities. Still, for both Australian and Hong Kong students, Mainland China remains a common clinical training destination, despite the more restricted scope of practice and position in the healthcare system for CM in these regions compared to Mainland China. Interestingly, in Hong Kong, the recent policy developments and the plan to establish a CM hospital signify increased alignment with the status of CM in Mainland China. For Australia, Mainland China already provides a useful source of CM research funding, and the formal agreement between the two countries around CM implies that such investments are likely to continue. This may help to consolidate CM’s position in Australian universities, although strengthened research programs will not necessarily impact the position of the courses.

Conclusion Cross-regional comparisons provide significant insights concerning influential factors that lie within and transcend national boundaries.

02 TCM Chapter 2.indd 35

13/3/2019 下午2:19

36

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

The similarities and differences in CM education in Australia and Hong Kong with regards to history, current context and position, regulation and acceptance in the healthcare system, and public and professional legitimacy highlight the current and future status of CM on a global scale. Furthermore, the significant issues identified may also influence CM education in other regions, particularly in terms of the impact of continued WM dominance within many healthcare systems and the increasing level of global competition between universities. The relationship between nations appears to be an increasingly important factor. While these relationships currently revolve around links with Mainland China, the global movement of the CM workforce may lead to connections developing between other regions in relation to CM and CM education. Taken together, while country-specific differences exist between CM education programs, the role of education in both professional integration/ legitimacy and public perception is undeniable.

02 TCM Chapter 2.indd 36

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

37

Acknowledgments This chapter is an edited version of a previously published paper by the same authors (Brosnan, C., Chung, V. C. H., Zhang, A. L., & Adams, J. (2016) Regional influences on Chinese medicine education: Comparing Australia and Hong Kong. Evidence-Based Complementary and Alternative Medicine, 2016, 6960207. https://doi.org/10.1155/2016/6960207). The text has been edited and reproduced with permission from the journal.

References Australian Bureau of Statistics. (2013). 4364.0.55.002 — Australian health survey: Health service usage and health related actions, 2011–12. Retrieved from www. abs.gov.au/ausstats/[email protected]/Lookup/4364.0.55.002main+features12011-12# Bensoussan, A., & Myers, S. P. (1996). Towards a safer choice: The practice of traditional Chinese medicine in Australia. Campbelltown: Faculty of Health, University of Western Sydney Macarthur. Brosnan, C. (2015). “Quackery” in the academy? Professional knowledge, autonomy and the debate over complementary medicine degrees. Sociology, 49(6), 1047–1064. https://doi.org/10.1177/0038038514557912 Census and Statistics Department. (2013). Thematic household survey report No. 50. Retrieved from www.censtatd.gov.hk/fd.jsp?file=B11302502013XXXXB0100. pdf&product_id=B1130201&lang=1 Chinese Medicine Board of Australia [CMBA]. (2013). Accreditation standards: Chinese medicine. Retrieved from www.chinesemedicineboard.gov.au/ Accreditation.aspx Chinese Medicine Board of Australia [CMBA]. (2018a). Registrant data: reporting period 1 July–30 September 2018. Retrieved from www.chinesemedicineboard. gov.au/About/Statistics.aspx Chinese Medicine Board of Australia [CMBA]. (2018b). Approved programs of study, profession: Chinese medicine practitioner. Retrieved from www. ahpra.gov.au/Education/Approved-Programs-of-Study.aspx?ref=Chinese%20 Medicine%20Practitioner Chinese Medicine Council of Hong Kong [CMCHK]. (2018a). List of Registered Chinese Medicine Practitioners. Retrieved from www.cmchk.org.hk/cmp/ eng/#main_rdoctor_choice.htm

02 TCM Chapter 2.indd 37

13/3/2019 下午2:19

38

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong Chinese Medicine Council of Hong Kong [CMCHK]. (2018b). Regulation of Chinese medicine practitioners, Licensing Examination. Retrieved from www. cmchk.org.hk/cmp/eng/#main_rcmp02.htm Chinese University of Hong Kong. (2018). Bachelor of Chinese Medicine. Retrieved from www.scm.cuhk.edu.hk/en-GB/programs/bachelor-of-chinese-medicine/ bachelor-of-chinese-medicine Chung, V. C. H., Lau, C. H., Yeoh, E. K., & Griffiths, S. M. (2009). Age, chronic non-communicable disease and choice of traditional Chinese and western medicine outpatient services in a Chinese population. BMC Health Services Research, 9(207), 1–8. https://doi.org/10.1186/1472-6963-9-207 Chung, V. C. H., Law, M. P. M., Wong, S. Y. S., Mercer, S. W., & Griffiths, S. M. (2009). Postgraduate education for Chinese medicine practitioners: A Hong Kong perspective. BMC Medical Education, 9(10), 1–10. https://doi. org/10.1186/1472-6920-9-10 Chung, V. C. H., Ma, P. H. X., Wang, H. H. X., Wang, J. J., Hong, L. C., Wei, X., Wong, S. Y., Tang, J. L., & Griffiths, S. M. (2013). Integrating traditional Chinese medicine services in community health centers: Insights into utilization patterns in the Pearl River region of China. Evidence-Based Complementary and Alternative Medicine, 2013, 426360. https://doi.org/10.1155/2013/426360 Collyer, F. (2013). The production of scholarly knowledge in the global market arena: University ranking systems, prestige and power. Critical Studies in Education, 54(3), 245–259. https://doi.org/10.1080/17508487.2013.788049 Department of Health. (2017). Health facts of Hong Kong. Retrieved from www. dh.gov.hk/english/statistics/statistics_hs/files/Health_Statistics_pamphlet_E. pdf Flesch, H. (2013). A foot in both worlds: Education and the transformation of Chinese medicine in the United States. Medical Anthropology, 32(1), 8–24. https://doi.org/10.1080/01459740.2012.694930 Food and Health Bureau. (2013a). Chinese Medicine Development Committee. Retrieved from www.fhb.gov.hk/en/committees/cmdc/cmdc.html Food and Health Bureau. (2013b). Press release of establishment of the Chinese Medicine Development Committee. Retrieved from www.info.gov.hk/gia/ general/201301/17/P201301170520.htm Food and Health Bureau. (2015). 2015 Policy Address policy initiatives of the Food and Health Bureau (extract on development of Chinese medicine). Retrieved from www.fhb.gov.hk/en/committees/cmdc/extract_2015_4.html

02 TCM Chapter 2.indd 38

13/3/2019 下午2:19

Comparing Regional Influences on Chinese Medicine Education

39

Food and Health Bureau. (2017). About HMRF (Health and Medical Research Fund). Retrieved from https://rfs2.fhb.gov.hk/english/funds/funds_hmrf/ funds_hmrf_abt/funds_hmrf_abt.html Garvey, M. (2011). The transmission of Chinese medicine in Australia. PORTAL Journal of Multidisciplinary International Studies, 8(2), 1–13. https://doi. org/10.5130/portal.v8i2.1652 Griffiths, S., & Chung, V. (2009). Development and regulation of traditional Chinese medicine practitioners in Hong Kong. Perspectives in Public Health, 129(2), 64–67. https://doi.org/10.1177/1757913908101611 Griffiths, S. M., Chung, V. C. H., & Tang, J. L. (2010). Integrating traditional Chinese medicine: Experiences from China. Australasian Medical Journal, 3(7), 385–396. https://doi.org/10.4066/AMJ.2010.411 Hong Kong Baptist University. (2018). Bachelor of Chinese Medicine and Bachelor of Science (Hons) in Biomedical Science. Retrieved from http://scm.hkbu.edu.hk/ en/education/undergraduate_programmes/bachelor_of_chinese_medicine_ and_bachelor_of_science_Hons_in_biomedical_science/index.html Hong Kong Government. (2016). Government invites expression of interest for development of Chinese medicine hospital. Retrieved from www.info.gov.hk/ gia/general/201601/15/P201601150397.htm Hospital Authority. (2015). Introduction to Hospital Authority Chinese Medicine Centres for Training and Research. Retrieved from www.ha.org.hk/ chinesemedicine/intro.asp?lan=en Huang, X. (2014, April 26). 未來中醫大學畢業生─學歷錯配的重災區？[Will graduates of Chinese medicine be especially plagued by mismatched qualifications?]. Mingpao, p. A24. Koo, L. (1998). Chinese medicine in colonial Hong Kong (Part I): Principles, usage, and status vis-a-vis Western medicine. Asia Pacific Biotech News, 1(33), 682–684. Lee, R. P. L. (1980). Perceptions and uses of Chinese medicine among the Chinese in Hong Kong. Culture, Medicine and Psychiatry, 4(4), 345–375. https://doi. org/10.1007/BF00051811 Lee, R. P. L. (1981). Chinese and western health care systems: Professional stratification in a modernizing society. In A. Y. C. King & R. P. L. Lee (Eds.), Social life and development in Hong Kong (pp. 255–273). Hong Kong: Chinese University Press.

02 TCM Chapter 2.indd 39

13/3/2019 下午2:19

40

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong Lin, Z. (2011, December 9). 扶持中醫教育政府有責 [The government should be responsible for supporting Chinese medicine education in Hong Kong]. Takungpao, p. A28. Lin, Z. (2012, August 24). 三三四學制下中醫教育的挑戰和對策 [Challenges and strategies of Chinese medicine education under the new academic structure for secondary and higher education in Hong Kong]. Takungpao, p. B10. Martyr, P. (2002). Paradise of quacks: An alternative history of medicine in Australia. Sydney: Macleay Press. Medical Board of Australia. (2018). Registrant Data: reporting period 1 July–30 September 2018. Retrieved from www.medicalboard.gov.au/News/Statistics. aspx Moore, A., Canaway, R., & O’Brien, K. A. (2010). Chinese medicine students’ preparedness for clinical practice: An Australian survey. The Journal of Alternative and Complementary Medicine, 16(7), 733–743. https://doi. org/10.1089/acm.2009.0244 Münch, R. (2014). Academic capitalism: Universities in the global struggle for excellence. London: Routledge. Parliament of Victoria. (1975). Report from the Osteopathy, Chiropractic and Naturopathy Committee. Retrieved from www.parliament.vic.gov.au/papers/ govpub/VPARL1974-76NoD27.pdf Pritzker, S. (2014). Living translation: Language and the search for resonance in U.S. Chinese medicine. New York, NY: Berghahn. Reeves, S., Tassone, M., Parker, K., Wagner, S. J., & Simmons, B. (2012). Interprofessional education: An overview of key developments in the past three decades. Work, 41(3), 233–245. https://doi.org/10.3233/WOR-2012-1298 Robb, A., & Hucheng, G. (2015). Side letter on traditional Chinese medicine. Canberra: Department of Foreign Affairs and Trade, Commonwealth Government of Australia. Scheid, V. (2002). Chinese medicine in contemporary China: Plurality and synthesis. Durham, NC: Duke University Press. Sinn, E. (1989). Power and charity: The early history of the Tung Wah Hospital. Hong Kong: Oxford University Press. Tam, Y. (2013, December 20). 香港中醫教育之淺見(一) [Opinions on Chinese medicine education in Hong Kong (Part one)]. Takungpao, p. B20. Tam, Y. (2014, January 3). 香港中醫教育之淺見(二) [Opinions on Chinese medicine education in Hong Kong (Part 2)]. Takungpao, p. B10.

02 TCM Chapter 2.indd 40

13/3/2019 下午2:19

.

Comparing Regional Influences on Chinese Medicine Education

41

Topley, M. (1975). Chinese and Western medicine in Hong Kong: Some social and cultural determinants of variation, interaction and change. Washington, DC: United States Government Printing Office. University Admissions Centre. (2016). Australian Tertiary Admissions Rank. Retrieved from www.uac.edu.au/atar/ University of Hong Kong. (2018). Admissions requirements: School of Chinese Medicine. Retrieved from www.aal.hku.hk/admissions/local/admissionsinformation?page=en/programme/bachelor-chinese-medicine Wardle, J., & Adams, J. (2013). Are the CAM professions engaging in high-level health and medical research? Trends in publicly funded complementary medicine research grants in Australia. Complementary Therapies in Medicine, 21(6), 746–749. https://doi.org/10.1016/j.ctim.2013.09.003 Wardle, J., Steel, A., & Adams, J. (2012). A review of tensions and risks in naturopathic education and training in Australia: A need for regulation. Journal of Alternative and Complementary Medicine, 18(4), 363–370. https:// doi.org/10.1089/acm.2011.0480 Xie, Y. G. (1998). 香港中醫藥史話 [A history of traditional Chinese medicine in Hong Kong]. Hong Kong: Joint Publishing. Xue, C. C. L., Zhang, A. L., Lin, V., Da Costa, C., & Story, D. F. (2007). Complementary and alternative medicine use in Australia: A national population-based survey. Journal of Alternative and Complementary Medicine, 13(6), 643–650. https://doi.org/10.1089/acm.2006.6355 Xue, C. C., & Story, D. (2004). Chinese medicine in Australia. Asia-Pacific Biotech News, 8(23), 1252–1256. https://doi.org/10.1142/S0219030304002137 Xue, C. C., Wu, Q., Zhou, W. Y., Yang, W. H., & Story, D. F. (2006). Comparison of Chinese medicine education and training in China and Australia. Annals of the Academy of Medicine Singapore, 35(11), 775–779. Zhan, M. (2009). Other-worldly: Making Chinese medicine through transnational frames. Durham, NC: Duke University Press.

02 TCM Chapter 2.indd 41

13/3/2019 下午2:19

02 TCM Chapter 2.indd 42

13/3/2019 下午2:19

3 Public Perception of Traditional Chinese Medicine in Hong Kong Kara Chan and Lennon Tsang

Medical decisions are influenced by a variety of factors. To understand the public’s attitude toward traditional Chinese medicine (CM) in Hong Kong compared to that toward Western biomedicine (WM), researchers have conducted various studies. These studies have helped elucidate the processes underlying an individual’s medical decisions in a region offering both CM and WM. In a recent survey (Chan & Tsang, 2018), we focused on three factors involved in the decision to consult a CM practitioner (CMP) or a conventional WM doctor (WMD) — namely, the perceived superiority of WM over CM, efficacy of CM, and differences in treatment costs between CM and WM. A patient’s attitude toward CM and WM, particularly with regard to these factors, greatly influences their choice of medical consultation and, in turn, the prevalence of CM.

CM and WM in Hong Kong The historical context of the CM and WM healthcare sectors, as well as their integration, has had a profound impact on people’s current

03 TCM Chapter 3.indd 43

13/3/2019 下午2:19

44

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

attitudes toward CM. While Hong Kong, a former British colony, has a medical system that is dominated by WM, CM also has a rich history in the region, thus truly exemplifying the “East meets West” paradigm (please see Chapters 2 and 3 for a more in-depth analysis of the history of CM and CM education in Hong Kong). Because of its practitioner friendliness, interpersonal sensitivity, and fewer perceived side effects, CM has recently become more popular worldwide (Barnes, Powell-Griner, McFann, & Nahin, 2004; Kelner & Wellman, 1997; Quan, Lai, Johnson, Verhoef, & Musto, 2008). For example, acupuncture, a branch of CM, is a popular alternative medical treatment in North America and Europe (MacPherson, Sinclair-Lian, & Thomas, 2006; Xue et al., 2008; and Zhang, Lao, Chen, & Ceballos, 2012). However, even with its recent increase in popularity, CM is still marginalized in the Hong Kong healthcare system. In addition, many WMDs are unwilling to recommend CM to their patients (Chung et al., 2011). This trend is highlighted in the following testimony from a 45-year-old high school teacher with breast cancer: Chemotherapy treatments were taking a lot out of me, and I considered using some herbs to boost my immune system. I was under the impression that they could improve my condition, but a discussion with my oncologist changed my mind. He told me about a few other cancer patients whose herbal remedies had caused harmful interactions with their Western drugs. Still, I was keen to try TCM [traditional Chinese medicine], so I consulted an acupuncturist. This really helped to relieve the anxiety and discomfort I was experiencing at the time (Gonzales, 2017).

Thus, while the patient above held a positive attitude toward CM, they were dissuaded from using it by their WMD. This patient ultimately decided to undergo treatment in conjunction with their prescribed

03 TCM Chapter 3.indd 44

13/3/2019 下午2:19

Public Perception of Traditional Chinese Medicine in Hong Kong

45

biomedical drug therapy, but many others may be deterred. The marginalization demonstrated here is reflected in a report published by the Census and Statistics Department (2017) showing that among the 1.61 million Hong Kong people who consulted a doctor in the 30 days before survey enumeration, 89% consulted a WMD and only 17% consulted a CMP. It is not altogether surprising that both individuals and healthcare systems view CM and WM differently as CMPs and WMDs use vastly different approaches to study and treat diseases. Their distinct methodologies differ in how they evaluate the inner structures of the body and how it operates, the nature of illness, and the strategies and techniques for medical intervention (Karchmer, 2013). Generally speaking, CM offers integrated treatment and personalized medicine, whereas WM is disease-targeted (Gu & Chen, 2014). WM has historically been the mainstream medical treatment in Hong Kong, but more people have recently started to consult CMPs as well. Indeed, the percentage of people who consulted a CMP in addition to a WMD during the 30 days before survey enumeration increased from 11% in 2013 to 17% in 2017 (Census and Statistics Department, 2013; 2017). Many scholars and practitioners also believe that the interactions between CM and WM provide significant treatment benefits. In fact, Gu and Chen (2014) proposed that certain biomedical phenomena can be used to explain basic CM theories, diagnostic principles, and treatment successes. In turn, CMPs can provide insight into the complex combination of herbal drugs to WMDs (Gu & Chen, 2014). To capitalize on this potential synergy, the Hong Kong Government initiated the Integrated ChineseWestern Medicine Pilot Programme in 2014 to provide integrated inpatient stroke care, cancer palliative care, and acute lower back pain care in three public hospitals (Hospital Authority, 2014) (see Chapter 8 for more details about the integration of CM into the public health system in Hong Kong).

03 TCM Chapter 3.indd 45

13/3/2019 下午2:19

46

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

General attitudes toward CM Previous studies have shown that Hong Kong people generally hold a positive attitude toward CM, and many also believe that CM has fewer side effects than WM therapies (Chung, Wong, Woo, Lo, & Griffiths, 2007). Citizens who consult both a WMD and CMP typically believe that although CM can cure the root causes of most diseases, it acts slowly (Lam, 2001). Interestingly, young people generally trust CM more than older generations (Chan et al., 2003). This trend has also been correlated with income, whereby older citizens have relatively lower incomes compared to their young counterparts. This same study also showed that a small proportion of the total population believes in both CM and WM. Notably, advertising campaigns implemented by some CMPs appear to positively affect attitudes toward CM (Chan, Tsang, & Ma, 2015). This previous study indicates that citizens find the advertisements useful in terms of providing information about the services offered, but they also worry the advertisements might be misleading or exaggerated and could lead to higher treatment costs.

Perceived inferiority, efficacy, and cost of CM While Hong Kong people generally seem to have positive attitudes toward CM, little is known about how these attitudes affect behavior when it comes to consulting a WMD or CMP. To predict the likelihood that a person who consults a WMD first will subsequently choose WM as their sole treatment, we propose a conceptual framework that utilizes three predictors: perceived superiority of WM over CM, perceived efficacy of CM, and perceived costs associated with CM treatment (Figure 3.1). Based on these parameters, people who perceive WM to be superior to CM and those who perceive CM treatment to cost more than WM treatment will be more likely to consult a WMD first and choose WM as their exclusive treatment.

03 TCM Chapter 3.indd 46

13/3/2019 下午2:19

Public Perception of Traditional Chinese Medicine in Hong Kong

Predictors

Predicted Variables

Perceived superiority of WM over CM

Perceived efficacy of CM

Perceived cost of CM

47

+

–

Will consult WM first Will consult WM exclusively

+

Figure 3.1 Conceptual framework showing the relationships between the Chinese medicine (CM)-related predictors and the likelihood that an individual will consult Western biomedicine (WM) first or exclusively. A "+" indicates a positive relationship, while a "–" indicates a negative relationship.

In contrast, those who perceive the efficacy of CM to be higher will be less likely to consult a WMD first and will be less likely to choose WM as their exclusive treatment. These theoretical predictions were subsequently tested using an online survey. The survey was conducted on a quota sampling of Hong Kong residents aged 15 or above in March 2016. For a detailed explanation of the data acquisition and analysis methods used in this study, please refer to Chan and Tsang (2018). A total of 1,321

03 TCM Chapter 3.indd 47

13/3/2019 下午2:19

48

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Table 3.1 Demographic and behavioral profiles of the respondents (N = 1,321) Demographic profile

Number

%

Sex Female

573

43.4

Male

748

56.6

15–29

386

29.2

30–49

478

36.2

50–59

232

17.6

60 or above

227

17.2

Primary school or below

88

6.7

Secondary school or high school

537

40.6

Post-secondary or university

697

52.7

248

18.9

HK$10,000–$29,999

569

43.3

HK$30,000 or above

496

37.8

Age

Education

Monthly household income HK$9,999 or below

Occupation 86

6.5

Office worker

Production worker

220

16.7

Professional/executive/managerial

270

20.4

Student

299

22.6

Housewife

149

11.3

Retired

195

14.8

Other

102

7.7

Public housing

352

26.6

Subsidized home ownership scheme housing

265

20.0

Housing

Private rental housing

179

13.5

Privately owned housing

486

36.8

40

3.0

Other

03 TCM Chapter 3.indd 48

13/3/2019 下午2:19

Public Perception of Traditional Chinese Medicine in Hong Kong

49

Table 3.1 (continued) Behavioral profile

Number

%

Consulted CMPs in the past 3 years

896

67.7

Did not consult CMPs in the past 3 years

427

32.3

valid questionnaires were received. Notably, this questionnaire was based on a previous survey evaluating attitudes toward acupuncture (reported in Chapter 5). Table 3.1 shows the demographic profile of the respondents. There were more male than female respondents, and 43% came from families with a monthly income between HK$10,000 and HK$29,999. The Information Services Department (2015) reported that 40% of the Hong Kong population had a monthly household income within this range. Thus, our study sample roughly represents the general population, at least in terms of income. Notably, two-thirds of the respondents reported that they had consulted a CMP at least once in the last 3 years. All the questions and descriptive statistics used in this study are shown in Table 3.2. Generally speaking, the respondents had positive beliefs about WM. They perceived WM to be more scientific and governed by rigorous rules. They also indicated that they trusted WM and WMDs more than CM and CMPs and expressed doubts about CMP qualifications. Most of the respondents believe that CM practices are not standardized and depend heavily on practitioner expertise and a patient’s characteristics. With regards to perceived efficacy, the respondents had mostly positive beliefs about CM. Most of them thought that CM provided effective preventive care and had fewer side effects than WM. Many also believed that CM could provide a permanent cure. However, the respondents found WM to be more convenient than CM. It is also important to note that a

03 TCM Chapter 3.indd 49

13/3/2019 下午2:19

50

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Table 3.2 Descriptive statistics of each predicting variable and the predictions made using the conceptual framework Statement

Agree Neutral Disagree (%) (%) (%)

Perceived superiority of WM over CM (α = 0.78)a

M

SD

3.3

0.6

WM is more scientific than CM.

65.4

22.4

12.2

3.6

0.9

CMP experience and practices vary. Thus, the consultation may not achieve the desired effect.

48.5

34.2

17.3

3.4

0.9

Patients’ body structure and responses to CM vary. Therefore, CM doctors may not be able to give a good prescription.

50.5

31.6

17.9

3.4

0.9

Rules governing WM are more rigorous than those governing CM.

47.8

30.5

21.7

3.3

1.0

The professional qualifications of CMPs are confusing.

46.1

30.6

23.3

3.3

0.9

I trust WMDs more than CMPs.

31.3

42.2

26.5

3.1

0.9

I trust WM more than CM.

31.0

41.8

27.2

3.0

0.9

3.4

0.6

Perceive efficacy of CM (α = 0.66) CM is useful for preventive care.

72.1

18.5

9.4

3.8

0.9

CM has fewer side effects than WM.

69.9

22.4

7.7

3.8

0.8

CM can achieve a permanent cure.

65.7

24.3

10.0

3.7

0.9

CM is better than WM for permanently curing disease.

51.1

35.2

13.7

3.5

0.9

Even when other medical treatments fail, CM may be able to cure a health problem.

32.9

42.5

24.6

3.1

0.9

CM is an alternative treatment for difficult and rare diseases.

26.5

27.1

46.4

2.7

1.0

03 TCM Chapter 3.indd 50

13/3/2019 下午2:19

Public Perception of Traditional Chinese Medicine in Hong Kong

51

Table 3.2 (continued)

Statement

Agree Neutral Disagree (%) (%) (%)

M

SD

Cost of CM and WM (α = 0.21)b WM is more convenient than CM.

77.4

12.7

9.8

3.9

0.9

CM treatment costs more than WM treatment.

21.4

40.6

38.0

2.8

0.9

If I am ill, I would first consult a WMD. When WM fails, I would consider CM.

53.2

23.9

22.9

3.4

1.0

When receiving WM treatment, one should not receive CM treatment at the same time.

48.6

23.6

27.8

3.3

1.1

Predictions

a

α represents the Cronbach alpha coefficient of the variable.

b

The Cronbach alpha coefficient for these statements was too low to combine.

A 5-point scale with 5 = strongly agree and 1 = strongly disagree was used. Abbreviations: CM, Chinese medicine; CMP, Chinese medicine practitioner; WM, Western biomedicine; WMD, Western biomedicine doctor; M, mean; SD, standard deviation.

high percentage (40.6%) of respondents had a neutral attitude toward the statement “CM treatment costs more than WM treatment”, indicating that cost may not be a significant factor for some people. Two multiple regression analyses were performed to test whether sex, age, education, perceived superiority of WM over CM, perceived efficacy, or the perceived treatment costs was a significant predictor of a respondent’s likelihood to consult a WMD first (Table 3.3) and their likelihood to use WM exclusively (Table 3.4) when ill. Compared to older respondents, younger respondents were more likely to consult a WMD first. Less educated respondents were

03 TCM Chapter 3.indd 51

13/3/2019 下午2:19

52

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Table 3.3 Regression analysis for variables predicting respondents’ likelihood to consult WM first when ill (N = 1,321) Variable

B

SE B

β

0.03

0.05

0.02

Age (1 = 15–19 years; 2 = 20–29; 3 = 30–39; 4 = 40–49; 5 = 50–59; 6 = 60–69; 7 = 70+)

−0.06

0.02

−0.11***

Education (1 = elementary; 2 = secondary; 3 = college)

−0.09

0.04

−0.05*

0.66

0.04

−0.01

0.04

CM costs more than WM treatment

0.11

0.03

0.10***

WM is more convenient than CM

0.12

0.03

0.11***

Sex (1 = M, 2 = F)

Perceived superiority of WM over CM Perceived efficacy of CM

0.40*** −0.00

R2 = 0.25 (p < 0.001); * p < 0.05; *** p < 0.001

Table 3.4 Regression analysis for variables predicting respondents’ likelihood to consult WM exclusively when ill (N = 1,321) Variable

B

SE B

β

0.03

0.06

0.02

−0.10 Age (1 = 15–19 years; 2 = 20–29; 3 = 30–39; 4 = 40–49; 5 = 50–59; 6 = 60–69; 7 = 70+)

0.02

−0.15***

Education −0.17 (1 = elementary; 2 = secondary; 3 = college)

0.05

−0.10***

Perceived superiority of WM over CM

0.30

0.05

0.16***

Perceived efficacy of CM

0.10

0.05

0.05

CM costs more than WM treatment

0.11

0.03

0.09***

WM is more convenient than CM

0.12

0.04

0.10***

Sex (1 = M, 2 = F)

R2

= 0.10 (p < 0.001); * p < 0.05; *** p < 0.001

03 TCM Chapter 3.indd 52

13/3/2019 下午2:19

Public Perception of Traditional Chinese Medicine in Hong Kong

53

also more likely to consult a WMD first. Furthermore, three other groups of respondents — those who had a more positive attitude toward WM, those who believed that CM is associated with higher costs, and those who believed that WM is more convenient than CM — were also more likely to consult WM first when ill. Not surprisingly, the predictive indicators for exclusively using WM when ill were almost the same as those that predict the respondent’s choice to consult a WMD first. Younger and less educated respondents as well as those who thought highly of WM, those who perceived CM to have higher costs, and those who believed WM to be more convenient than CM were more likely to use WM exclusively when ill. Notably, education played an important role in predicting the sole use of WM when ill. One puzzling result from this analysis is that, contrary to what might be expected, the perceived efficacy of CM is not positively correlated with the likelihood of consulting a CMP first or of using CM as a complementary medical treatment. Indeed, when other predictors were kept constant, a high score in the perceived efficacy of CM did not drive respondents to consult a CMP first.

Survey implications and recommendations: Trust, cost, and convenience The results of this study have a number of social and practical implications that may guide future strategies for promoting CM in Hong Kong. Based on our analyses, we recommend some changes in the system used to govern CM practices. These changes focus on enhancing trust between CMPs and patients, decrease the perceived costs (financial, etc.) as well as changes that can be made by the CMP to decrease the inconveniences perceived by patients.

03 TCM Chapter 3.indd 53

13/3/2019 下午2:19

54

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Increase trust in CM Overall, people are more likely to trust WM than CM. People generally think that WM is more scientific and more rigorously regulated than CM. The perception that CMPs vary greatly in experience also perpetuates this lack of trust in CM. The public has voiced doubts regarding their qualifications. In Hong Kong, WM has dominated the public health system, and CM regulation was only initiated two decades ago. Thus, it is necessary to build and reinforce public trust in CM to make it a more preferred choice of medical treatment. We propose four ways to mediate this change. First, scientific CM research and development as well as CM education should be strengthened, and government funding should be increased to support these changes. This particular goal can be achieved by establishing evidence-based teaching and learning programs, and universities with CM programs should actively promote the release and application of clinical evidence regarding CM treatments. These programs should instill students with the ability to write their clinical results in a jargon-free manner and that can be consolidated for easy access by reporters, news agencies, and the general public. University professors conducting CM research should also be trained to communicate their findings. Second, the professional standards and status of CMPs need to be enhanced. According to the Chinese Medicine Ordinance Cap. 549 (2018), all registered CMPs must fulfill the requirements of the Continuing Chinese Medicine Education (CME) program accredited by the Chinese Medicine Practitioners Board for renewal of their license (Food and Health Bureau, 2016). This CME program enables CMPs to upgrade their professional knowledge and skills as well as advance their techniques in response to the latest research. Under the current requirements, registered CMPs will not have their practicing certificates renewed if they do not fulfill the minimum CME requirements for a consecutive period of six years (Food

03 TCM Chapter 3.indd 54

13/3/2019 下午2:19

Public Perception of Traditional Chinese Medicine in Hong Kong

55

and Health Bureau, 2016). Tightening this requirement to ensure compliance and establishing additional professional standards (e.g., test score thresholds, accreditation, etc.) may help build trust in CMPs. The Hong Kong Government is also currently examining the possibility of further developing CM as a specialization with various stakeholder groups (Food and Health Bureau, 2016), a step that will also likely enhance the public’s trust in CM. Third, the Chinese Medical Council of Hong Kong should provide a transparent and credible channel to handle public complaint against CMPs. At present, the website of the Chinese Medical Council of Hong Kong only contains information about CMP regulation and the restricted use of certain CM herbs. In contrast, the Medical Council of Hong Kong, which regulates WM and WMDs, devotes a full section of its website to complaints and disciplinary inquiries. The website states that “doctors have a duty to maintain a good standard of practice and care and to show respect for human life” (The Medical Council of Hong Kong, 2017), thus highlighting their focus on high standards and respect for the patient. The website also shows how patients can lodge a complaint involving professional misconduct and what the Medical Council will do to investigate the complaint. Moreover, the website reports detailed information about previous disciplinary inquiries that the public can view. These items all act to instill trust in the system and in WMDs. The absence of such information on the website of the Chinese Medical Council of Hong Kong results in a lack of transparency that significantly limits the public’s trust in the system and individual CMPs. Thus, the Chinese Medical Council should follow the example of the Medical Council and include similar information on their website. Fourth, the public should be educated about the professional qualifications of CMPs as well as the philosophies underlying CM and the advantages of CM treatment. Many respondents in this study believed that individual differences would hamper the

03 TCM Chapter 3.indd 55

13/3/2019 下午2:19

56

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

desired medical effects of CM. Thus, providing a more thorough understanding of the philosophies of CM and its advantages for personalized medication is essential. This could be achieved via public forums and professional seminars. Furthermore, in the current study, we found that 46% of respondents expressed confusion about the CMP registration and accreditation process. According to the Chinese Medical Council of Hong Kong, only two types of practitioners (registered CMPs and listed CMPs) are allowed to practice CM in Hong Kong. These two groups are differentiated by their academic qualifications and years of practice before January 2000. Informing the public of these differences and the required qualifications will help to establish greater trust in CM and CMPs. This information should be properly presented to the public. Although advertisements distributed by some CMPs help to inform the public, the media should also be monitored to ensure that only legitimate claims are made concerning treatment results and that they are made by CMPs that are eligible to practice in Hong Kong. Decrease the cost of CM The cost of consultation for CM is also an issue. Based on the authors’ personal experience in 2018, the typical consultation costs for a visit to a private WMD (general practitioner) at Hong Kong Baptist Hospital plus 2–3 days of flu medications was approximately HK$400 (equivalent to US$50). The typical consultation fee for a CMP at a CM clinic associated with Hong Kong Baptist University (again, based on personal experience in 2018) was only HK$260 (equivalent to US$33). However, this fee does not include the cost of medication, which for the flu is about HK$300 (equivalent to US$38) for two to three days’ worth (including herbal decoction). Therefore, the cost of using CM is indeed slightly higher than that associated with WM, at least at the present time. Lowering these costs (or setting a combined fee that includes both the CM consultation and medication) needs to be explored to increase CM use in the region.

03 TCM Chapter 3.indd 56

13/3/2019 下午2:19

Public Perception of Traditional Chinese Medicine in Hong Kong

57

Reduce the inconveniences associated with CM Another barrier to CMP consultation and CM use is the perceived inconvenience of CM compared to WM. Some CMs take time to prepare, both in and out of the clinic, and may require longer visits for application, which does not fit into the busy and hectic lifestyle of many Hong Kong people. Making CM medication more convenient will facilitate use by the public. For example, making concentrated CM granules containing the prescribed herbal treatment would make it easier for patients to consume.

Conclusion While efforts are being made to integrate CM into the current public health system in Hong Kong (further discussed in Chapter 8), this process still has a long road ahead and requires continuous reflection and redirection. The survey discussed here focuses on the influence of three primary factors (the perceived superiority of WM over CM, efficacy of CM, and treatment costs) on an individual’s decision to consult a WMD or CMP. The results show that changes in the CM system to establish and increase trust, decrease costs, and decrease inconvenience would help to promote CM use and CMP consultation. The omission of CM from the current primary public healthcare system reflects the limited governmental and institutional effort in fostering integration of CM and WM. This has led to the fragmented treatment decisions among patients in this study and others (Templeman & Robinson, 2011). Hong Kong has a unique position as a global center of trade and finance (Chan & Yeung, 2002), and many scholars believe that Hong Kong has an essential role to play in building up the links between East and West with regards to CM. This role requires support from all sectors, including the government, the public, the media, and both WMDs and CMPs. Only when these groups work cooperatively will CM become a mainstream medical option for patients.

03 TCM Chapter 3.indd 57

13/3/2019 下午2:19

58

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Acknowledgments Part of this chapter was previously published in a paper authored by the authors in 2018 (Chan, K., & Tsang, L. (2018). Public attitudes toward traditional Chinese medicine and how they affect medical treatment choices in Hong Kong. International Journal of Pharmaceutical and Healthcare Marketing, 12(2) 113–125. https://doi.org/10.1108/IJPHM-02-2017-0009). This text has been edited and reproduced with the permission of the journal.

References Barnes, P., Powell-Griner, E., McFann, K., & Nahin, R. (2004). Complementary and alternative medicine use among adults: United States, 2002. Seminars in Integrative Medicine, 2(2), 54–71. https://doi.org/10.1016/j.sigm.2004.07.003 Census and Statistics Department. (2013). Thematic Household Survey Report No. 50: Doctor Consultation. Retrieved from www.statistics.gov.hk/pub/ B11302502013XXXXB0100.pdf Census and Statistics Department. (2017). Thematic Household Survey Report No. 63: Doctor Consultation. Retrieved from www.statistics.gov.hk/pub/ B11302632017XXXXB0100.pdf Chan, K., & Tsang, L. (2018). Public attitudes toward traditional Chinese medicine and how they affect medical treatment choices in Hong Kong. International Journal of Pharmaceutical and Healthcare Marketing, 12(2) 113–125. https:// doi.org/10.1108/IJPHM-02-2017-0009 Chan, K., Tsang, L., & Ma, Y. (2015). Consumers’ attitudes toward advertising by traditional Chinese medicine practitioners. Journal of Asian Pacific Communication, 25(2), 305–322. https://doi.org/10.1075/japc.25.2.11cha Chan, K., & Yeung, H. W. (2002). The progress of Chinese medicine in Hong Kong SAR, China. In Chan, K., & Lee, H. (Eds.), The Way Forward for Chinese Medicine (pp. 261–290). London: Taylor & Francis. Chan, M., Mok, E., Wong, Y., Tong, T., Day, M., & Tang, C. (2003). Attitudes of Hong Kong Chinese to traditional Chinese medicine and biomedicine: survey and cluster analysis. Complementary Therapies in Medicine, 11(2), 103–109. https://doi.org/10.1016/S0965-2299(03)00044-X Chinese Medicine Ordinance. (2018) Hong Kong e-Legislation, Cap. 549, Paragraph 76: Registered Chinese medicine practitioner not to practise without practising certificate. Retrieved from www.elegislation.gov.hk/hk/ cap549?xpid+ID_1438403426223_003

03 TCM Chapter 3.indd 58

13/3/2019 下午2:19

Public Perception of Traditional Chinese Medicine in Hong Kong

59

Chung, V. C. H., Hillier, S., Lau, C. H., Wong, S. Y. S., Yeoh, E. K., & Griffiths, S. M. (2011). Referral to and attitude towards traditional Chinese medicine amongst western medical doctors in postcolonial Hong Kong. Social Science Medicine, 72(2), 247–255. https://doi.org/10.1016/j.socscimed.2010.10.021 Chung, V., Wong, E., Woo, J., Lo, S. V., & Griffiths, S. (2007). Use of traditional Chinese medicine in the Hong Kong Special Administrative Region of China. The Journal of Alternative and Complementary Medicine, 13(3), 361–367. https:// doi.org/10.1089/acm.2006.6152 Food and Health Bureau. (2016). Continuing education for registered Chinese medicine practitioners and professional specialisation of Chinese medicine practitioners. Retrieved from www.legco.gov.hk/yr15-16/english/panels/hs/ hs_dcm/papers/hs_dcm20160114cb2-628-1-e.pdf Gonzales, S. (2017, February 27). Does traditional Chinese medicine have a role in helping patients fight cancer? South China Morning Post. Retrieved from www.scmp.com/lifestyle/health-beauty/article/2074400/does-traditionalchinese-medicine-have-role-helping-patients Gu, P., & Chen, H. (2014). Modern bioinformatics meets traditional Chinese medicine. Briefings in Bioinformatics, 15(6), 984–1003. https://doi.org/10.1093/ bib/bbt063 Hospital Authority. (2014). The Hospital Authority launches the Integrated Chinese-Western Medicine Pilot Program. Retrieved from www.ha.org.hk/ chinesemedicine/resources/ICWM.pdf Information Services Department. (2015). Hong Kong: The Facts — Population. Retrieved from www.gov.hk/en/about/abouthk/factsheets/docs/population. pdf Karchmer, E. I. (2013). The excitations and suppressions of the times: Locating the emotions in the liver in modern Chinese medicine. Culture, Medicine and Psychiatry, 37(1), 8–29. https://doi.org/10.1007/s11013-012-9289-4 Kelner, M., & Wellman, B. (1997). Health-care and consumer choice: medical and alternative therapies. Social Science & Medicine, 45(2), 203–212. https:// doi.org/10.1016/S0277-9536(96)00334-6 Lam, T. P. (2001). Strengths and weaknesses of traditional Chinese medicine and biomedicine in the eyes of some Hong Kong Chinese. Journal of Epidemiology and Community Health, 55(10), 762–765. https://doi.org/10.1136/jech.55.10.762 MacPherson, H., Sinclair-Lian, N., & Thomas, K. (2006). Patients seeking care from acupuncture practitioners in the UK: A national survey. Complementary Therapies in Medicine, 14(1), 20–30. https://doi.org/10.1016/j.ctim.2005.07.006

03 TCM Chapter 3.indd 59

13/3/2019 下午2:19

60

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong Quan, H., Lai, D., Johnson, D., Verhoef, M., & Musto, R. (2008). Complementary and alternative medicine use among Chinese and white Canadians. Canadian Family Physician, 54(11), 1563–1569. Templeman, K., & Robinson, A. (2011). Integrative medicine models in contemporary primary health care. Complementary Therapies in Medicine, 19(2), 84–92. https://doi.org/10.1016/j.ctim.2011.02.003 The Medical Council of Hong Kong. (2017). Complaints and Disciplinary Inquiries. Retrieved from www.mchk.org.hk/english/complaint/complaint.html Xue, C. C., Zhang, A. L., Lin, V., Myers, R., Polus, B., & Story, D. F. (2008). Acupuncture, chiropractic and osteopathy use in Australians: A national population survey. BMC Public Health, 8(105) 1–8. https://doi.org/10.1186/14712458-8-105 Zhang, Y., Lao, L., Chen, H., & Ceballos, R. (2012). Acupuncture use among American adults: What acupuncture practitioners can learn from national health interview survey 2007? Evidence-based Complementary and Alternative Medicine, 2012, 1–8. https://doi.org/10.1155/2012/710750

03 TCM Chapter 3.indd 60

13/3/2019 下午2:19

Part II Acupuncture as a Focus

04 TCM Chapter 4.indd 61

13/3/2019 下午2:19

04 TCM Chapter 4.indd 62

13/3/2019 下午2:19

4 How People Perceive Acupuncture: A Qualitative Study Kara Chan, Judy Y. M. Siu, and Timothy Fung

Hong Kong is a medically pluralistic society. The primary form of healthcare is Western biomedicine (WM), while forms of traditional, complementary, and integrative medicine (TCIM) exist alongside. Traditional Chinese medicine (CM) is the most common TCIM in Hong Kong, with CM practitioners (CMPs) providing about 22% of all medical care in the region (Chinese Medicine Council of Hong Kong [CMCHK], n.d.-a). In Hong Kong, CM is sometimes treated as a “second-class citizen” in terms of its professional status (Lai, Wong, & Lai, 2013). However, there has been significant advancement in its status since 1999, largely in response to the establishment of a statutory framework under the CMCHK that recognizes the professional status of CMPs. A CMP registration system has also been enforced since 2000 (CMCHK, n.d.-a; n.d.-b). Under this system, 9,956 CMPs were identified in 2016, as opposed to 14,013 WM doctors (WMDs; Department of Health, 2017). About 73% of CMPs are registered, while the rest are listed, a term used to identify CMPs who came into existence via practice experience and will

04 TCM Chapter 4.indd 63

13/3/2019 下午2:19

64

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

be gradually phased out. Notably, some WM hospitals under the management of Hospital Authority, a statutory body that manages Hong Kong’s public hospitals, also provide CM outpatient services (Kwong Wah Hospital, n.d.). CM encompasses multiple types of treatment. Acupuncture, for example, is a form of CM that has been practiced for over 2500 years (Unschuld, 1985). It has been used to treat patients with chronic conditions in Hong Kong, Mainland China, and many other countries (Cheuk, Yeung, Chung, & Wong, 2012; Tam, Leung, Li, Zhang, & Li, 2007; Wong & Wong, 2008; Wong, Cheuk, Lee, & Chu, 2012). Although acupuncture is widely used, we have a limited understanding of how people perceive acupuncture as a medical treatment and what underlying factors influence their decision to use this CM. Several previous studies have investigated the attitudes toward TCIM or CM in general (see Chapter 3), but few have focused on acupuncture. We sought to address this knowledge gap in our recently reported qualitative study focused on the perception of acupuncture in Hong Kong (Chan, Siu, & Fung, 2016).

Attitudes toward acupuncture Acupuncture has been institutionalized as part of the national healthcare systems in Mainland China, Hong Kong, and Taiwan (Chen, Kung, Chen, & Hwang, 2006; Chung, Wong, Woo, Lo, & Griffiths, 2007). It is the most widely known TCIM and is also regarded as a useful treatment in the West (Kaptchuk, Goldman, Stone, & Stason, 2000; Perkin, Pearcy, & Fraser, 1994). In the United States, for example, acupuncture users (including former and recent users) numbered 14.01 million in 2007 (Zhang, Lao, Chen, & Ceballos, 2012). Substantial use of acupuncture has also been observed in Australia (Xue et al., 2008), the United Kingdom (MacPherson,

04 TCM Chapter 4.indd 64

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

65

Sinclair-Lian, & Thomas, 2006; Ernst & White, 2000), Norway, and Denmark (Hanssen et al., 2005). This trend in acupuncture use in the West is expected to increase as TCIM practices become more widely understood and accepted. However, the relationship between this trend and treatment perception is not straightforward. Previous studies have sought to better define the attitudes toward acupuncture by focusing on three populations: medical students, medical professionals, and the general public. Medical students Acupuncture is well known among medical students in many countries, including Canada (Baugniet, Boon, & Østbye, 2000), Pakistan (Majeed, Mahmud, Khwaja, Mansoor, & Khimani, 2007), Singapore (Yeo et al., 2005), the United Kingdom (Perkin et al., 1994; Furnham & McGill, 2003), and the United States (Chez, Jonas, & Crawford, 2001). Medical students in the United Kingdom, for example, generally hold a positive attitude toward acupuncture (Perkin et al., 1994) and believe in its efficacy (Donald, Mackereth, & Tobin, 2010). Similarly, most Turkish medical students are familiar with acupuncture and believe it to be an effective treatment option (Akan et al., 2012). Nearly 50% of Israeli medical students also support the use of acupuncture and would consider referring their future patients for treatment (Shani-Gershoni, Freud, Press, & Peleg, 2008). Interestingly, the viewpoints of medical students in the United States have historically been more divergent, with 28% of students believing that acupuncture only induces a placebo effect and 37% believing treatment effectively cures ailments (Chez et al., 2001). Medical professionals A second group of studies has also been conducted among medical professionals, including both conventional WMDs and acupuncture-

04 TCM Chapter 4.indd 65

13/3/2019 下午2:19

66

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

trained CMPs. In the United Kingdom, all of the doctors included in a 1994 survey had heard about acupuncture, and nearly 95% of them said they understood its principles (Perkin et al., 1994). Another more recent study showed that 92.6% of the members of acupuncture associations in the United Kingdom agreed that traditional acupuncture was an effective treatment for patients (Shao, Borthwick, Lewith, & Hopwood, 2005). Norwegian physicians also hold similarly positive attitudes toward acupuncture, and a significant increase in use was previously noted in the country (Ytrehus, Norheim, Emaus, & Fønnebø, 2010). Furthermore, half of the doctors in a random sample taken in the Netherlands in 1990 considered acupuncture effective for patients with chronic pain (Knipschild, Kleijnen, & Riet, 1990), with 25% of them believing that acupuncture would also be helpful in treating asthma or smoking addiction (Knipschild et al., 1990). The general public A random sampling survey taken in Norway revealed that 19% of people suffering from musculoskeletal pain had tried acupuncture as a treatment option (Norheim & Fønnebø, 2000). Of these people, 66% benefited from the treatment, and 56% felt that doctors should also recommend it to migraine patients. However, 7% reported adverse effects. In Taiwan, 23% of the general public in 2002 had used acupuncture within the past 7 years (Chen et al., 2006). Musculoskeletal and neurologic disorders were the major symptoms prompting people to seek out acupuncture treatment. Similar findings were also recorded in the general public in the United States (Burke, Upchurch, Dye, & Chyu, 2006). Kemper et al. (2000) surveyed pediatric pain patients and their families in the United States and found that most parents considered acupuncture helpful as they could see notable improvement in their child’s health.

04 TCM Chapter 4.indd 66

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

67

Understanding the factors influencing attitudes toward acupuncture and its use In addition to documenting use and overall attitudes toward TCIMs, including acupuncture, previous studies have provided valuable insight concerning the factors influencing how therapy is perceived. Clinical or personal exposure to acupuncture treatment is a significant determinant. For example, Norwegian and American physicians that have personal experience with acupuncture tend to hold a more positive attitude towards treatment (Norheim & Fønnebø, 1998; Chaterji et al., 2007). Shani-Gershoni et al. (2008) found that Israeli medical students were more supportive of introducing acupuncture into hospitals if they had previous clinical exposure. In addition to exposure to acupuncture treatment, Norwegian doctors mentioned that unsuccessful conventional WM treatment is also a factor for personal acupuncture treatment or patient referral. Interestingly, patients have been shown to view acupuncture positively if those in their social circles had experience with it (Highfield, Barnes, Spellman, & Saper, 2008; Jastrowski Mano & Davies, 2009). Additional factors have also been noted when the patient is a child and treatment decisions are being made by their parents or guardians. The most frequently cited concern was the child’s fear of needles (Jastrowski Mano & Davies, 2009; Kemper et al., 2000). Another factor is expected effectiveness (Jastrowski Mano & Davies, 2009). Some parents also reported that the smell of moxa burning (Kemper et al., 2000), painful sensations (Shyu, Tsai, & Tsai, 2010), and financial barriers (Shyu et al., 2010) were their primary concerns when deciding if their child should be treated with acupuncture. Although these previous studies provide some insight into the factors underlying attitudes toward acupuncture, a review of the literature indicates that most of the current studies are quantitative. Thus, significant insight can be gained from a qualitative analysis of

04 TCM Chapter 4.indd 67

13/3/2019 下午2:19

68

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

the perceptions and beliefs among users and non-users of acupuncture. Additionally, there is currently very little published information about the factors considered when evaluating acupuncture as a possible treatment option or in selecting an acupuncturist.

A qualitative analysis to evaluate public perception of acupuncture in Hong Kong To address the gaps in our current understanding of how acupuncture is perceived, we employed an interpretivist approach using a qualitative methodology (Neuman, 2003). This qualitative approach was essential for two primary reasons. First, perceptions of acupuncture are very much context-, age-, and gender-specific. Qualitative techniques, whose strengths are to provide understanding and interpretation, are more appropriate than quantitative techniques, whose strengths are to describe and explain. Second, it is likely that the factors influencing the use of acupuncture are complex and interwoven. Therefore, using a set of closed-ended questions, such as those used in a quantitative survey, may limit the level of new insight into what draws people to or repels them from acupuncture. Focus group sessions were used as previously described (Silverman, 2005). For a detailed explanation of the data acquisition and analysis methods used in this study, please refer to Chan, Siu and Fung (2016). Using purposive sampling, 37 Chinese adults (35 years or older; 12 males, 25 females) who had visited any WMD or CMP in the previous six months were recruited through our social network. About two-thirds of the participants were employed in managerial, executive or clerical positions while the remaining one-third were manual workers. They were divided into four focus groups. Two groups (referred to as non-user groups) consisted of 17 members who had never used acupuncture. The two other groups

04 TCM Chapter 4.indd 68

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

69

(referred to as user groups) consisted of 20 members who had used acupuncture. Two authors of this book chapter acted as moderators in the focus groups. There was one moderator in each focus group session, which took 55 to 77 minutes to complete. Written consent was obtained from the participants before the focus group sessions. The sessions were conducted in Cantonese (the Chinese dialect spoken in Hong Kong) in February and March 2013. Bearing in mind that the accepted guideline for focus groups is that there should be fewer than 12 topics (Stewart & Shamdasani, 1990), a protocol of six carefully worded open-ended questions was used (Table 4.1). While some questions between the acupuncture users and non-users overlapped (questions 1–3), others were specific to that particular group. The order of the questions was not rigidly adhered to and was adjusted according to the flow of the discussion. Each session was recorded, and a research assistant later transcribed it into Chinese. The full transcripts were read through once without imposing any themes. The transcripts were then read through again, and notes were made of possible emerging themes. Marshall and Rossman’s (1999) comparison analysis method was used throughout the study to form linkages between statements (Strauss, 1987). The data obtained using this method were then compared to the themes. Once they were coded under a particular theme, the data were removed from the main pool. This process of reading and coding the data and refining the themes was continued until no further data remained in the main pool and the list of themes had stabilized. Selected quotes were translated into English by the authors. Using these methods, a total of five themes about acupuncture treatment emerged from the four focus group interviews conducted. These include the perceived benefits of acupuncture, reasons for using acupuncture as a treatment, satisfaction with treatment, barriers to using acupuncture, and factors in selecting an acupuncturist.

04 TCM Chapter 4.indd 69

13/3/2019 下午2:19

70

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Table 4.1 English translations of the questions asked of acupuncture users and non-users User group questions Q1

What do you think are the advantages of acupuncture?

Q2

What do you think are the disadvantages of acupuncture?

Q3

What illness do you think acupuncture is the most suitable treatment for?

Q4

What are the health reasons that caused you to receive acupuncture treatment last time? How long was the treatment? Are you satisfied with the treatment?

Q5

What made you try acupuncture treatment?

Q6

When you decided to receive acupuncture treatment, what factors (e.g., educational background, gender, and affiliation) did you consider when you chose an acupuncturist?

Non-user group questions Q1

What do you think are the advantages of acupuncture?

Q2

What do you think are the disadvantages of acupuncture?

Q3

What illness do you think acupuncture is the most suitable treatment for?

Q4

Did anyone suggest that you receive acupuncture treatment?

Q5

Why did you not try acupuncture treatment?

Q6

If you decide to receive acupuncture treatment, what factors (e.g., educational background, gender, and affiliation) will you consider when you choose an acupuncturist?

Perceived benefits of acupuncture In this study, acupuncture was perceived as having two types of benefits. The majority of users considered acupuncture effective, particularly for pain control. Some participants commented that acupuncture could be used to treat chronic headache, back pain, pain with unidentifiable cause, insomnia, and endocrine disorders. A few participants also noted that their pain was relieved promptly after acupuncture treatment, and others mentioned that their pain was cured permanently. Many participants pointed out that acupuncture

04 TCM Chapter 4.indd 70

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

71

was particularly effective for those who had suffered a stroke. A participant recalled a friend’s experience: She had suffered a stroke, and her condition was bad. She could not speak clearly and had difficulty moving on her own. She began to receive acupuncture after being discharged from the hospital. Since then, she has received acupuncture treatment every week. She gradually recovered. She now sleeps and eats well, and she can walk slowly by herself.

Another benefit described by the user group was the lack of serious side effects. Indeed, none of the participants reported side effects during or after acupuncture, while more than half of them reported side effects, such as fatigue and loss of appetite, after WM treatment. A few participants also pointed out that they believed acupuncture could treat ailments that could not be treated with WM. Reasons for using acupuncture as a treatment The user group participants had various motivations for engaging in acupuncture therapy. The most common of these was their perceived needs, which were related to their physical ailments. This was often described in relation to pain: I sprained my leg when I was young, and I still feel pain now. So I began to have acupuncture.

Acupuncture was also considered by some participants to be the best approach to relieve physical suffering. While treatment was not found to be effective in all cases, this CM was considered to be beneficial for treating joint and bone pain. In contrast, other participants only used acupuncture as a last resort. In many cases,

04 TCM Chapter 4.indd 71

13/3/2019 下午2:19

72

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

participants had tried other remedies, such as WM, physiotherapy, chiropractic alignment, and bonesetting. The failure of these remedies motivated them to try acupuncture: I had severe bone pain in my leg after the birth of my youngest son. It was so painful that I could hardly walk. I went to a bonesetter first, but he could not help me. Later, a friend of mine recommended that I try acupuncture, and it really worked! I recovered 60 or 70% just from the first treatment. … Western biomedicine and Chinese herbal medicine could not help me, so I had to try acupuncture.

Media reports of successful acupuncture treatments also offered hope to the participants: Sometimes I see reports in newspapers and magazines about successful acupuncture. This motivated me to try it.

Advice and referrals were also important in motivating participants to try acupuncture, with recommendations from friends being the most common: Recommendations from people who are trustworthy were important [for me to try acupuncture]. If no trustworthy people recommended it or if I did not know any successful cases, I would not have believed [in acupuncture]. But once you see successful cases among your friends and relatives and you see that their pain is greatly relieved, you start to believe in it.

Satisfaction with treatment Suffering from physical pain was the most common motivation for participants when seeking acupuncture treatment. In this study, physical pain was primarily noted in the patient’s joints and

04 TCM Chapter 4.indd 72

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

73

bones and included lower back pain, neck pain, and knee pain. Other participants underwent acupuncture for sciatica and nerve pain. Insomnia was another common physical complaint that led participants to use acupuncture. The majority of users were satisfied with the benefits of acupuncture: When I was young, my nose had a problem, and I had to blow my nose very often. It was really embarrassing. Then a friend told me that I probably had sinusitis and he took me to an acupuncturist. After only two times I was cured. It was really an amazing experience.

Belief and trust in the treatment and the acupuncturist were significant factors involved in the level of treatment satisfaction felt by the patient. A minority of the participants commented that although they were not sure about the efficacy of acupuncture, they still believed in it and the acupuncturist: You have to believe in the doctor [acupuncturist]. If you trust him, his treatment will be good. If you don’t, then the treatment won’t be very effective.

Barriers to using acupuncture Although there were many motivations for participants to seek acupuncture and user experiences were generally good, a number of participants in this study had never undergone acupuncture (non-users) and were not motivated to try it in the future. A few participants mentioned that their CMPs had recommended acupuncture for their condition. However, these recommendations were not supported by others in their social circles. This resulted in a lack of confidence in acupuncture for the non-users and greatly discouraged them from seeking treatment. Many non-users also

04 TCM Chapter 4.indd 73

13/3/2019 下午2:19

74

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

indicated that they think acupuncture lacks scientific basis, clinical evidence, and research supporting its efficacy: I know acupuncture has a long history. But there seems to be no concrete or international research [about acupuncture]. You know, the physical characteristics of everyone are different. If there’s no research, how can you ensure everyone has the same acupressure points?

In a WM-dominated society, it is natural for patients to consider acupuncture in the context of WM research, and they often hold both conventional and alternative medicines to the same criteria. Therefore, when promoting acupuncture, trust is more likely to be gained if related research and information are packaged in a way that highly resembles that used for WM treatments. Furthermore, non-users often doubted the qualifications of acupuncturists, and lack of CMP accreditation was a significant concern for them. Queries related to an acupuncturist’s qualifications were often raised during the interviews and included questions concerning who is eligible to practice acupuncture in Hong Kong. Many non-users had the impression that acupuncture was not regulated in Hong Kong. Some non-users even expressed suspicion of physiotherapists who provided acupuncture treatment. As they were unsure of the regulatory aspects of treatment, they were discouraged from using acupuncture: I am not sure about the qualifications of acupuncturists. I just know there are some registered Chinese medicine practitioners, but can they perform acupuncture as well? I am not sure. Also, do they need to take professional examinations? I am not sure about that either. ... I am not sure if Hong Kong has a system for regulating acupuncturists, like the system used for doctors who practice Western biomedicine.

04 TCM Chapter 4.indd 74

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

75

According to the Chinese Medicine Ordinance Cap. 549 (2018), any person involved in (a) the diagnosis, treatment, prevention, or alleviation of any disease or any symptom of a disease; (b) the prescription of Chinese herbal medicines or proprietary CMs; or (c) the regulation of the functional states of the human body on the basis of CM in general practice, acupuncture, or bonesetting is said to be practicing CM. To be practicing legally, this person will need to be registered as a CMP and their personal information, including their name, address, qualifications, and other particulars, must be submitted to the Registrar (Chinese Medicine Ordinance, 2018). The Registrar annually publishes a list of registered CMPs and their information in the Gazette. The key phrase in the ordinance is “on the basis of traditional Chinese medicine.” Thus, acupuncture, when being conducted based on CM theories, should be performed by a registered CMP. However, when acupuncture is not conducted on the basis of CM, the practitioner does not need to be registered. For example, a physiotherapist can also practice acupuncture provided that they perform the treatment according to a physiotherapeutic approach rather than a CM-based approach. This unspecific phrasing results in a large grey area in which the purpose of the treatment and how it is conducted require interpretation. The confusion described by the non-user participants in this study about the legal practice of acupuncture in Hong Kong is, therefore, not altogether surprising. Based on this, patient educational campaigns should be designed to more clearly explain the accreditation and registration systems of acupuncturists as a way to promote use. There should be a website on which the public can check the qualifications of individual acupuncturists. The regulatory body should also take a proactive role in cracking down on unqualified acupuncture practitioners. Promoting the recognition of certified CMPs should be an essential element in the campaign to build patient trust. Promotional materials can be distributed on various media platforms and in multiple formats (e.g., leaflets or broadcast materials) to help answer the

04 TCM Chapter 4.indd 75

13/3/2019 下午2:19

76

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

questions most frequently raised by the public concerning CMP qualifications. For example, the public should be informed if an acupuncturist qualified in Mainland China can assume practice in Hong Kong and how the accreditation processes overlap. Lack of positive experiences among friends was also a barrier to using acupuncture for the non-users. In fact, a number of the participants commented that none of their friends were cured or had prolonged alleviation of their condition after acupuncture: I did not see my friend improve after acupuncture. He often goes for treatment, several times a month. But his condition is almost the same. He is always tired. ... Maybe he gets a bit better just after the treatment, but it cannot cure him. ... So I would rather use Western biomedicine.

Because of their lack of confidence in acupuncture, several fears persisted among the non-users in this study. The most significant of these was the fear of treatment-induced pain: I am afraid of pain. The needles are stuck in your skin so I think acupuncture must be very painful. I dare not try it.

Another fear was related to their lack of knowledge, mainly with regards to the effects of treatment and adverse reactions. Notably, this fear was a concern among both users and non-users. More than half of all the participants enrolled in this study commented that they did not know what the natural response to the treatment would involve: I am more familiar with Western biomedicine, and I know what to expect. I don’t know what the natural responses to acupuncture are or what the effects of a good acupuncture treatment are like.

04 TCM Chapter 4.indd 76

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

77

Acupuncture may lead to serious consequences, but I do not know anything about them.

Needle hygiene was also a commonly debated topic among the participants. Many patients voiced concerns about the risk of contracting an infectious disease via the acupuncture needles, concerns that ultimately prevented many of them from seeking treatment: I am not sure if the needles used in acupuncture are hygienic enough. I know the syringes used in Western biomedicine are used once only. But my impression is that the needles used in acupuncture are reused many times. Also, newspapers reported that acupuncture can transmit diseases. I have lower back pain and have been thinking of trying [acupuncture]. I gave up on the idea because I was afraid of being infected during treatment.

More than half of the participants labeled acupuncture as an invasive procedure. They also believed that serious risks could arise from treatment if the acupuncturist was inexperienced. Knowledge about the possible risks associated with acupuncture, such as pneumothorax and paralysis, was mainly obtained from news stories reported in the media. Finally, the level of trust the participants had in WM and their habit of seeking help from WMDs also played a role in discouraging many of them from seeking non-WM treatment. The common perception of WM as providing quick effects and CM as being slower also limited their desire to try acupuncture: I trust Western biomedicine more. I rarely go to see Chinese medicine practitioners and dare not try acupuncture. I don’t have any confidence in Chinese medicine. I would rather see Western

04 TCM Chapter 4.indd 77

13/3/2019 下午2:19

78

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

biomedicine doctors when I am ill. Western doctors have gone to medical school and are registered. My impression of Chinese medicine is that [its knowledge is] transmitted from father to son. … Western biomedicine also works quickly. The effects of shots and medications are quick.

Factors in selecting an acupuncturist Participants identified word of mouth and other patients’ experiences as well as the experience level, educational background, and registration status of the CMP as the main factors in selecting an acupuncturist. Of these, word of mouth and the experiences of others were the most commonly mentioned. For example, if the participant had friends that had been successfully treated by a particular acupuncturist, they would have more confidence in that acupuncturist, but not necessarily more confidence in other CMPs. The importance of word of mouth was demonstrated by an interesting event that occurred after a session. The participants stayed to share the name and contact details of an acupuncturist who had cured a stroke patient. One of the other remaining participants commented on how the reputation of an acupuncturist was important to her: If my friends say they saw significant improvement after their acupuncture treatment, then that indicates the acupuncturist is trustworthy. I would have confidence in them.

Not unexpectedly, if an acupuncturist could relieve a patient’s problem, other participants would be more motivated to visit that acupuncturist. They considered it a waste of time and money if an acupuncturist could not treat their symptoms. A professional license was the second most frequently mentioned factor in the discussions about selecting an acupuncturist. Acupuncturists who have passed treatment-related examinations

04 TCM Chapter 4.indd 78

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

79

are considered more professional than those that have not. Although many participants did not fully understand the professional qualifications of an acupuncturist, they remarked that obtaining a professional license was a basic requirement. Some participants preferred acupuncturists who have a certificate indicating specialization in acupuncture, rather than general training in CM: If I go for acupuncture, I will definitely find someone who is a specialist. If no one introduces me to an acupuncturist, I will definitely see a doctor who has professional certificates in acupuncture. I have more confidence in doctors who are acupuncture specialists rather than the doctors who claim that they know various treatment techniques.

The experience of an acupuncturist was also important to the participants. Lack of confidence in recently graduated acupuncturists was prevalent. For most participants, they would only visit an acupuncturist that has several years of clinical experience. When participants were asked how many years of practice were necessary before the acupuncturist would be considered “experienced,” a participant in a non-user group replied, At least ten years, because an acupuncturist will need to stick needles into your skin. If he or she stimulates the wrong acupressure points, you may be harmed. I won’t choose an acupuncturist without a lot of clinical experience.

Similarly, the educational background of an acupuncturist also played a role in selection by participants. Acupuncturists who graduated from major universities, majoring in acupuncture were considered more credible. All participants cast doubt on secret acupuncture treatment formulas passed from mentors to mentees.

04 TCM Chapter 4.indd 79

13/3/2019 下午2:19

80

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Other factors, including the institutional affiliation, gender, and age of the CMP, were identified as important selection criteria. Acupuncturists who practice in or are affiliated with universities with CM schools were considered more credible than private CMPs. Female participants also preferred female acupuncturists, though the gender of the acupuncturist was not an important factor for male participants. Acupuncturists who seem very young or very old were considered undesirable. Limitations of the study The major limitation of this study was the use of convenience sampling. As the participants were recruited through personal social networks, the findings cannot be generalized to represent the general population. However, the study does highlight possible themes that should be considered by acupuncturists as well as the regulatory bodies of CM in Hong Kong.

Conclusion In this qualitative study on the perception of and attitudes toward acupuncture among users and non-users in Hong Kong, we have shown that users and non-users differed significantly in their perceptions of the efficacy and side effects of acupuncture, in their attitudes toward CM and WM in general, and in their responses to media reports of acupuncture malpractice. Among non-users, acupuncture was believed to lack clinical support, be highly risky, and rely heavily on the expertise of the CMP. Among users, acupuncture was considered to be effective, having few side effects, and generating a lasting impact. Both users and non-users believe that acupuncture is useful in treating pain and joint- or muscle-related problems. In choosing acupuncture practitioners, participants relied on word of mouth recommendations as well as the CMP’s experience and professional qualifications.

04 TCM Chapter 4.indd 80

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

81

Acknowledgements Part of this chapter was previously published as a journal article by the same authors in 2016 (Chan, K., Siu, J. Y. M., & Fung, T. K. F. (2016). Perception of acupuncture among users and non-users: a qualitative study. Health Marketing Quarterly, 33(1), 78–93. https://doi.org/10.1080/07359683.2016.1132051). This text has been edited and reproduced with the permission of the journal and publisher (Taylor & Francis Ltd).

References Akan, H., Izbirak, G., Kaspar, E. C., Kaya, C. A., Aydin, S., Demircan, N., Bucaktepe, P. G., Ozer, C., Sahin, H. A., & Hayran, O. (2012). Knowledge and attitudes towards complementary and alternative medicine among medical students in Turkey. BMC Complementary and Alternative Medicine, 12(1), 115–121. https://doi.org/10.1186/1472-6882-12-115 Baugniet, J., Boon, H., & Østbye, T. (2000). Complementary/alternative medicine: Comparing the views of medical students with students in other health care professions. Family Medicine, 32(3), 178–184. Burke, A., Upchurch, D. M., Dye, C., & Chyu, L. (2006). Acupuncture use in the United States: Findings from the National Health Interview Survey. The Journal of Alternative and Complementary Medicine, 12(7), 639–648. https:// doi.org/10.1089/acm.2006.12.639 Chan, K., Siu, J. Y. M., and Fung, T. K. F. (2016). Perception of acupuncture among users and non-users: a qualitative study. Health Marketing Quarterly, 33(1), 78–93. https://doi.org/10.1080/07359683.2016.1132051 Chaterji, R., Tractenberg, R., Amri, H., Lumpkin, M., Amorosi, S. B., & Haramati, A. (2007). A large-sample survey of first- and second-year medical student attitudes toward complementary and alternative medicine in the curriculum and in practice. Alternative Therapies in Health and Medicine, 13(1), 30–35. Chen, F. P., Kung, Y. Y., Chen, T. J., & Hwang, S. J. (2006). Demographics and patterns of acupuncture use in the Chinese population: The Taiwan experience. The Journal of Alternative and Complementary Medicine, 12(4), 379–387. https://doi.org/10.1089/acm.2006.12.379 Cheuk, D. K., Yeung, W. F., Chung, K. F., & Wong, V. (2012). Acupuncture for insomnia. Cochrane Database of Systematic Reviews, 9, 1–176. https://doi. org/10.1002/14651858.CD005472.pub3

04 TCM Chapter 4.indd 81

13/3/2019 下午2:19

82

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong Chez, R. A., Jonas, W. B., & Crawford, C. (2001). A survey of medical students’ opinions about complementary and alternative medicine. American Journal of Obstetrics and Gynecology, 185(3), 754–757. https://doi.org/10.1067/ mob.2001.117484 Chinese Medicine Council of Hong Kong [CMCHK]. (n.d.-a). Development of Chinese medicine in Hong Kong. Retrieved from www.cmchk.org.hk/cmp/ eng/#../../eng/main_deve.htm Chinese Medicine Council of Hong Kong [CMCHK]. (n.d.-b). List of Registered Chinese Medicine Practitioners. Retrieved from www.cmchk.org.hk/cmp/ eng/#main_rdoctor_choice.htm Chinese Medicine Ordinance. (2018) Hong Kong e-Legislation, Cap. 549, Paragraph 2: Interpretation. Retrieved from www.elegislation.gov.hk/hk/ cap549?xpid+ID_143840342516_001 Chung, V., Wong, E., Woo, J., Lo, S. V., & Griffiths, S. (2007). Use of traditional Chinese medicine in the Hong Kong Special Administrative Region of China. The Journal of Alternative and Complementary Medicine, 13(3), 361–367. https:// doi.org/10.1089/acm.2006.6152 Department of Health. (2017). Health facts of Hong Kong, 2017 edition. Retrieved from www.dh.gov.hk/english/statistics/statistics_hs/files/Health_Statistics_ pamphlet_E.pdf Donald, G. K., Mackereth, P., & Tobin, I. (2010). Medical students and acupuncture: A short sharp placement experience! Acupuncture in Medicine, 28(1), 12–15. https://doi.org/10.1136/aim.2009.001602 Ernst, E., & White, A. (2000). The BBC survey of complementary medicine use in the UK. Complementary Therapies in Medicine, 8(1), 32–36. https://doi. org/10.1016/S0965-2299(00)90833-1 Furnham, A., & McGill, C. (2003). Medical students’ attitudes about complementary and alternative medicine. The Journal of Alternative and Complementary Medicine, 9(2), 275–284. https://doi.org/10.1089/10755530360623392 Hanssen, B., Grimsgaard, S., Launsø, L., Fønnebø, V., Falkenberg, T., & Rasmussen, N. K. (2005). Use of complementary and alternative medicine in the Scandinavian countries. Scandinavian Journal of Primary Health Care, 23(1), 57–62. https://doi.org/10.1080/02813430510018419 Highfield, E. S., Barnes, L., Spellman, L., & Saper, R. B. (2008). If you build it, will they come? A free-care acupuncture clinic for minority adolescents in an urban hospital. The Journal of Alternative and Complementary Medicine, 14(6), 629–636. https://doi.org/10.1089/acm.2008.0021

04 TCM Chapter 4.indd 82

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

83

Jastrowski Mano, K. E., & Davies, W. H. (2009). Parental attitudes toward acupuncture in a community sample. The Journal of Alternative and Complementary Medicine, 15(6), 661–668. https://doi.org/10.1089/ acm.2008.0449 Kaptchuk, T. J., Goldman, P., Stone, D. A., & Stason, W. B. (2000). Do medical devices have enhanced placebo effects? Journal of Clinical Epidemiology, 53(8), 786–792. https://doi.org/10.1016/S0895-4356(00)00206-7 Kemper, K. J., Sarah, R., Silver-Highfield, E., Xiarhos, E., Barnes, L., & Berde, C. (2000). On pins and needles? Pediatric pain patients’ experience with acupuncture. Pediatrics, 105(4), 941–947. https://doi.org/10.1542/ peds.105.4.S1.941 Knipschild, P., Kleijnen, J., & Riet, G. (1990). Belief in the efficacy of alternative medicine among general practitioners in the Netherlands. Social Science and Medicine, 31(5), 625–626. https://doi.org/10.1016/0277-9536(90)90099-E Kwong Wah Hospital. (n.d.). Hospital service: The collaboration of traditional Chinese medicine and biomedicine service (In Chinese). Retrieved from www3.ha.org.hk/kwh/main/tc/service-integrative.asp Lai, G., Wong, O., & Lai, V. (2013). Social ties and use of Chinese medicine consultation services in Hong Kong. American Sociological Association 108th Annual Meeting. August 10–13, New York, USA. Retrieved from https:// repository.hkbu.edu.hk/hkbu_staff_publication/4335 MacPherson, H., Sinclair-Lian, N., & Thomas, K. (2006). Patients seeking care from acupuncture practitioners in the UK: A national survey. Complementary Therapies in Medicine, 14(1), 20–30. https://doi.org/10.1016/j.ctim.2005.07.006 Majeed, K., Mahmud, H., Khwaja, H. R., Mansoor, S., & Khimani, F. (2007). Complementary and alternative medicine: Perceptions of medical students from Pakistan. Medical Education Online, 12(1). https://doi.org/10.3402/meo. v12i.4469 Marshall, C., & Rossman, G. (1999). Designing qualitative research (3rd ed.). Thousand Oaks, CA: Sage. Neuman, W. L. (2003). Social research methods: Qualitative and quantitative approaches (5th ed.). Boston, MA: Allyn and Bacon. Norheim, A. J., & Fønnebø, V. (1998). Doctors’ attitudes to acupuncture: A Norwegian study. Social Science & Medicine, 47(4), 519–523. https://doi. org/10.1016/S0277-9536(98)00152-X

04 TCM Chapter 4.indd 83

13/3/2019 下午2:19

84

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong Norheim, A. J., & Fønnebø, V. (2000). A survey of acupuncture patients: Results from a questionnaire among a random sample in the general population in Norway. Complementary Therapies in Medicine, 8(3), 187–192. https://doi. org/10.1054/ctim.2000.0375 Perkin, M. R., Pearcy, R. M., & Fraser, J. S. (1994). A comparison of the attitudes shown by general practitioners, hospital doctors and medical students towards alternative medicine. Journal of the Royal Society of Medicine, 87(9), 523–525. Shani-Gershoni, Z., Freud, T., Press, Y., & Peleg, R. (2008). Knowledge and attitudes of internists compared to medical students regarding acupuncture. Israel Medical Association Journal, 10(3), 219–223. Shao, J. Y. J., Borthwick, A. M., Lewith, G. T., & Hopwood, V. (2005). Attitudes towards traditional acupuncture in the UK. Evidence-Based Integrative Medicine, 2(1), 37–45. https://doi.org/10.2165/01197065-200502010-00008 Shyu, Y. I. L., Tsai, J. L., & Tsai, W. C. (2010). Explaining and selecting treatments for autism: Parental explanatory models in Taiwan. Journal of Autism and Development Disorders, 40(11), 1323–1331. https://doi.org/10.1007/s10803-0100991-1 Silverman, D. (2005). Doing qualitative research (2nd ed.). London: Sage. Stewart, D. W., & Shamdasani, P. N. (1990). Focus groups: Theory and practice. Newbury Park, CA: Sage. Strauss, A. (1987). Qualitative analysis for social scientists. New York, NY: Cambridge University Press. Tam, L. S., Leung, P. C., Li, T. K., Zhang, L., & Li, E. K. (2007). Acupuncture in the treatment of rheumatoid arthritis: A double-blind controlled pilot study. BMC Complementary and Alternative Medicine, 7, 35. https://doi. org/10.1186/1472-6882-7-35 Unschuld, P. (1985). Medicine in China: A history of ideas. Berkeley, CA: University of California Press. Wong, C. L., & Wong, V. C. (2008). Effect of acupuncture in a patient with 7-yearhistory of Bell’s palsy. Journal of Alternative and Complementary Medicine, 14(7), 847–853. https://doi.org/10.1089/acm.2007.0780 Wong, V., Cheuk, D. K., Lee, S., & Chu, V. (2012). Acupuncture for acute management and rehabilitation of traumatic brain injury. European Journal of Physical and Rehabilitation Medicine, 48(1), 71–86. https://doi. org/10.1002/14651858.CD007700.pub2

04 TCM Chapter 4.indd 84

13/3/2019 下午2:19

How People Perceive Acupuncture: A Qualitative Study

85

Xue, C. C., Zhang, A. L., Lin, V., Myers, R., Polus, B., & Story, D. F. (2008). Acupuncture, chiropractic and osteopathy use in Australians: A national population survey. BMC Public Health, 8, 105. https://doi.org/10.1186/14712458-8-105 Yeo, A. S. H., Yeo, J. C. H., Yeo, C., Lee, C. H., Lim, L. F., & Lee, T. L. (2005). Perceptions of complementary and alternative medicine amongst medical students in Singapore: A survey. Acupuncture in Medicine, 23(1), 19–26. https:// doi.org/10.1136/aim.23.1.19 Ytrehus, I. A., Norheim, A. J., Emaus, N., & Fønnebø, V. (2010). Physicians become acupuncture patients — Not acupuncturists. The Journal of Alternative and Complementary Medicine, 16(4), 449–455. https://doi.org/10.1089/ acm.2008.0634 Zhang, Y., Lao, L., Chen, H., & Ceballos, R. (2012). Acupuncture use among American adults: What acupuncture practitioners can learn from National Health Interview Survey 2007? Evidence-based Complementary and Alternative Medicine, 2012, 710750. https://doi.org/10.1155/2012/710750

04 TCM Chapter 4.indd 85

13/3/2019 下午2:19

04 TCM Chapter 4.indd 86

13/3/2019 下午2:19

5 How People Perceive Acupuncture: A Quantitative Study Kara Chan, Lennon Tsang, and Timothy Fung

Acupuncture is a form of traditional Chinese medicine (CM) that involves inserting fine needles into precise points on the body, followed by manual manipulation or electrical stimulation. These processes alleviate pain and nausea by triggering an influx of calcium into the area that stimulates endorphin production in the surrounding white blood cells (Yang, Li, Nilius, & Li, 2011). In 2003, the World Health Organization (WHO) endorsed acupuncture as a treatment for migraines, chemotherapy-induced nausea and vomiting, and stroke as well as shoulder, knee, and back pain (WHO, 2003). Because of its effectiveness, acupuncture has become a popular medical treatment in North America and Europe (MacPherson, Sinclair-Lian, & Thomas, 2006; Xue et al., 2008; Zhang, Lao, Chen, & Ceballos, 2012) and has drawn considerable scholarly attention.

Acupuncture in Western societies In the West, acupuncture is widely acknowledged as a form of traditional, complementary, and integrative medicine (TCIM). In

05 TCM Chapter 5.indd 87

13/3/2019 下午2:18

88

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

a 2007 survey by the American Center for Disease Control, 6.5% of Americans said they had received acupuncture treatment (McKenzie, 2011). Similarly, around 2–3% of the population in Australia (MacLennan, Wilson, & Taylor, 1996), Italy (Menniti-Ippolito, Gargiulo, Bologna, Forcella, & Raschetti, 2002), and the United Kingdom (Ernst & White, 2000) have received treatment. Several European countries, including France, Germany, and Norway, also cover acupuncture in their national healthcare insurance systems. Survey findings show that acupuncture is most commonly used to treat chronic pain, migraines, arthritis, and fibromyalgia (Burke, Upchurch, Dye, & Chyu, 2006; Kemper et al., 2000; Norheim & Fønnebø, 2000; Patel, Gnitzwiller, Paccaud, & Marazzi, 1989). Despite some suggestions that acupuncture only induces a placebo effect (Chez, Jonas, & Crawford, 2001), medical professionals and the public in many Western countries generally have positive perceptions of acupuncture (Baugniet, Boon, & Østbye, 2000; Furnham & McGill, 2003; Perkin, Pearcy, & Fraser, 1994; Ytrehus, Norheim, Emaus, & Fønnebø, 2010). For some, these positive thoughts concerning acupuncture have been influenced by their personal experiences (Norheim & Fønnebø, 1998; Chaterji et al., 2007) or those of their relatives and friends (Highfield, Barnes, Spellman, & Saper, 2008; Jastrowski Mano & Davies, 2009). Others turned to acupuncture because their previous medical treatments failed or were contraindicated (Camp, 1986; Ytrehus et al., 2010). Using face-to-face interviews of 35 adults in the United Kingdom, a recent study identified four steps in the decision to try acupuncture: establish a need for treatment, establish a need for a new treatment, decide to try acupuncture, and find an acupuncturist (Bishop & Lewith, 2013). Notably, despite acupuncture’s relative popularity in Western countries, some patients have reported unfavorable views. These largely stem from painful sensations felt during treatment, its perceived high cost (Shyu, Tsai, & Tsai, 2010), and the patient’s fear

05 TCM Chapter 5.indd 88

13/3/2019 下午2:18

How People Perceive Acupuncture: A Quantitative Study

89

of needles (Highfield et al., 2008). The smell of moxa burning was also indicated as an annoyance when treatment was administered in a general-purpose CM clinic (Kemper et al., 2000). With regards to juvenile patients, some parents expressed concern because they do not think there is enough research on acupuncture in young patients (Jastrowski Mano & Davis, 2009).

CM and acupuncture in Chinese societies Acupuncture is widely used in Chinese communities. For example, in the Anhui and Hebei provinces in Mainland China, 30.6% (Chen, Hu, Wang, & Meng, 2003) and 50.8% (Yan et al., 2010) of survey respondents had received acupuncture, respectively. The respondents also noted few side effects and considered acupuncture to be a cure for difficult and rare diseases (Yan et al., 2010). Among non-users in Anhui, 36.7% reported that they did not understand acupuncture, and 25% reported that they did not have confidence in this form of treatment (Chen et al., 2003). A recent survey in Guangdong province found that fear of pain and delayed treatment effects were the main barriers preventing use (Zhao & Zhao, 2013). However, in this same study, acupuncture was perceived to be effective in the treatment of cervical spondylopathy, facioplegia, and insomnia. In Taiwan, acupuncture is part of the compulsory health insurance scheme, and a survey in 2006 showed that about 13.6% of the respondents had received acupuncture treatment in the previous year (Wu et al., 2012). Of these, two-thirds used acupuncture to treat illness, while one-third used it to maintain their health. In Hong Kong, acupuncture is primarily treated as a form of CM or TCIM. The latest figures show that among the people who consulted a doctor in the 30 days before the survey, 18.1% of them consulted a CM practitioner (CMP) (Census and Statistics Department, 2017). In this instance, CMPs include general practitioners, acupuncturists,

05 TCM Chapter 5.indd 89

13/3/2019 下午2:18

90

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

and bonesetters. Notably, many of the studies published about acupuncture in Hong Kong (and globally) focus on its clinical effects (Chen & Hsieh, 2012; Ernst, Pittler, Wider, & Boddy, 2007; Kaptchuk, 2002; Lee, LaRiccia, & Newberg, 2004; Sun, Chan, Lo, & Fong, 2001; Yeung, Chung, Leung, Zhang, & Law, 2009; Vickers et al., 2012). Further, the majority of the published social science research evaluates TCIM in general, and few studies have focused solely on acupuncture. Thus, little is known about the public’s attitudes toward this form of therapy. In chapter 4, we performed a qualitative study using focus groups to assess how the public views acupuncture in relation to Western biomedicine (WM) in Hong Kong. In the present chapter, we quantitatively evaluate public perception of acupuncture, focusing on how the public perceives it as a medical treatment, their understanding of the risks involved in treatment, and in what ways they view acupuncture differently from WM. It also investigates how attitudes toward acupuncture influence their medical treatment decisions.

Quantitative evaluation of public perception of acupuncture in Hong Kong We conducted an online survey in April 2012 among a quota sample of Hong Kong residents aged 20 or above. For a detailed explanation of the data acquisition and analysis methods used in this study, please refer to Chan, Tsang, and Fung (2015). A total of 879 questionnaires were used for this analysis. The questionnaire was developed from the results of a prior focus group study of public perception toward acupuncture (reported in Chapter 4). The demographics of the sample population are summarized in Table 5.1. The number of male respondents is approximately 11% greater than the number of female respondents. The 20 to 29 age group was the largest (34.4%). Further, more than half of the

05 TCM Chapter 5.indd 90

13/3/2019 下午2:18

How People Perceive Acupuncture: A Quantitative Study

91

respondents claimed to have post-secondary or university education, and about two-thirds claimed to have a monthly household income of HK$10,000 to HK$39,999. In comparison, the median monthly household income in Hong Kong in 2010 was HK$18,000 (Information Services Department, 2012). Slightly more than 25% of the respondents reported that they consulted an acupuncturist in the last three years. Perceptions of acupuncture as a medical treatment The respondents’ perceptions of acupuncture as a medical treatment are summarized in Table 5.2. Most respondents view acupuncture as a medical treatment that does not involve taking medicine. Similarly, most respondents also perceived acupuncture to be, at least to some extent, a preventive measure. They gave some credence to the idea that acupuncture can permanently cure diseases and that it can cure difficult and strange diseases as well as common illnesses. They had no strong views, however, on whether acupuncture could cure diseases when other medical treatments had failed. According to our survey, more than half of the respondents believed that acupuncture could effectively deal with problems with movement, various types of pain, paralysis, and insomnia (Table 5.3). On the other hand, less than one-fourth of the respondents believed that acupuncture could effectively deal with chronic diseases, Alzheimer’s disease, or autism. Comparing acupuncture and WM All eight of the statements comparing acupuncture and WM had mean scores significantly different from the mid-point (Table 5.4), indicating that the respondents perceived significant differences between them. They agreed with all of the statements except “Acupuncture cures faster than WM.” Their responses to these statements highlight their belief that acupuncture has fewer side

05 TCM Chapter 5.indd 91

13/3/2019 下午2:18

92

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Table 5.1 Demographic and acupuncture use profiles of the respondents (N = 879) Demographic profile

Number

%

Female

486

44.6

Male

391

55.4

Sex

Age 20–29

301

34.4

30–39

188

21.5

40–49

203

23.2

50 or above

184

21.0

53

6.1

Secondary school or high school

299

34.2

Post-secondary or university

521

59.7

HK$9,999 or below

88

10.1

HK$10,000–$19,999

236

27.0

HK$20,000–$39,999

334

38.2

HK$40,000 or above

216

24.7

Public housing

226

25.9

Subsidized home ownership scheme housing

190

21.7

Private rental housing

113

12.9

Private owned housing

327

37.4

18

2.1

68

7.8

White-collar worker

229

26.1

Professional/managerial

190

21.7

Student

218

24.9

Retired

94

10.7

Other

77

8.8

Education Primary school or below

Monthly household income

Housing

Other Occupation Blue-collar worker

05 TCM Chapter 5.indd 92

13/3/2019 下午2:18

How People Perceive Acupuncture: A Quantitative Study

93

Table 5.1 (continued) Acupuncture use profile

Number

%

Used acupuncture in the past 3 years

245

28.0

Has not used acupuncture in the past 3 years

631

72.0

Totals may not sum to N = 879 because of missing data for some respondents.

Table 5.2 Perceptions of acupuncture as a medical treatment

Statement

Agree Neutral Disagree (%) (%) (%)

M

SD

Acupuncture is a medical treatment that does not involve taking medicine.

52.1

24.5

23.4

3.4

1.0

Acupuncture is useful for preventative care.

50.8

31.8

17.4

3.4

0.9

Acupuncture can effect a permanent cure.

42.5

40.2

17.3

3.3

0.8

Acupuncture is an alternative medical treatment that can cure difficult and strange diseases.

40.5

31.7

27.8

3.2

1.0

Even when other medical treatment fails, acupuncture is able to cure a disease.

28.8

44.8

26.4

3.0

0.9

Acupuncture is not applicable to common illnesses, such as colds and flu.

30.7

30.1

39.2

2.9

1.0

A 5-point scale with 5 = strongly agree and 1 = strongly disagree was used. Abbreviations: M, mean; SD, standard deviation.

05 TCM Chapter 5.indd 93

13/3/2019 下午2:18

94

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Table 5.3 Percentages of participants who perceived that the specified conditions could be treated effectively by acupuncture Condition

%

Problems with movement, such as joint pain and hand/leg movement issues

83.6

Various types of pain

76.7

Nerve paralysis

65.6

Insomnia and other sleeping problems

53.1

Stroke

45.4

Female problems, such as menstrual pain and infertility

30.8

Various allergies, such as allergic rhinitis and skin irritations

26.6

Chronic diseases requiring long-term treatment, such as diabetes, kidney disease, and heart disease

23.8

Alzheimer’s disease

14.6

Autism

8.1

Other

0.2

effects than WM, but that WM is more scientific, governed by more rigorous rules, and cheaper. They expressed more trust in WM and WM doctors (WMDs) than acupuncture and acupuncturists or CMPs. Despite the fact that the statutory framework for CM and acupuncture in Hong Kong was established over 15 years ago, public confidence in acupuncture was not strong. These results suggest that to earn trust and recognition from the public, acupuncturists, CMPs, and the Hong Kong Government need to inform the public more about the professional qualifications, accreditation system, and the laws and rules governing acupuncture and CM practices. Acupuncturist groups and the Chinese Medicine Council of Hong Kong (CMCHK) should consider funding a consumer education program for this purpose. Notably, the perceived advantages of acupuncture over WM included having fewer side effects and being able to permanently

05 TCM Chapter 5.indd 94

13/3/2019 下午2:18

How People Perceive Acupuncture: A Quantitative Study

95

Table 5.4 Comparison of acupuncture and Western biomedicine (WM)

Statement

Agree Neutral Disagree (%) (%) (%)

M

SD

Acupuncture has fewer side effect than WM.

61.4

27.6

11.0

3.6

0.9

WM is more scientific than acupuncture.

60.5

25.8

13.7

3.6

0.9

Rules governing WM are more rigorous than those governing acupuncture.

53.9

29.8

16.3

3.5

0.9

I trust WM doctors more than acupuncture.

43.2

38.0

18.8

3.3

0.9

I trust WM more than acupuncture.

42.2

38.4

19.4

3.3

1.0

Compared with WM, acupuncture can better effect a permanent cure.

33.0

49.3

17.7

3.2

0.8

Acupuncture treatment costs more than WM

28.9

51.4

19.7

3.1

0.8

Acupuncture cures faster than WM.

12.6

43.8

43.6

2.7

0.8

A 5-point scale with 5 = strongly agree and 1 = strongly disagree was used. Abbreviations: M, mean; SD, standard deviation.

cure an illness. These advantages should be used as focal points in media messages to promote acupuncture use. Perceived risks of acupuncture The respondents’ perceptions of the risks associated with acupuncture are summarized in Table 5.5. All nine statements had mean scores significantly different from the mid-point, with the statement “With improper needle application, acupuncture can induce severe aftereffects” having the highest mean score (3.9).

05 TCM Chapter 5.indd 95

13/3/2019 下午2:18

96

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Table 5.5 Perceived risks of acupuncture

Statement

Agree Neutral Disagree (%) (%) (%)

M

SD

With improper needle application, acupuncture can induce severe aftereffects.

75.7

20.4

3.9

3.9

0.8

Professional qualifications of acupuncturists are ambiguous and the general public can be confused.

71.6

21.5

6.9

3.8

0.8

Acupuncturists’ needle application skills are not standardized. Expected treatment results may not be achieved.

72.9

21.6

5.5

3.8

0.8

Acupuncturists may not be able to accurately apply the needle since patients’ body structures are different and their acupuncture points may be different.

62.7

26.3

11.0

3.6

0.8

Acupuncture may cause pain sometimes and I am confused whether the pain is normal.

45.9

41.0

13.1

3.4

0.8

Media reports about medical errors of acupuncturists made me greatly concerned about acupuncture.

37.3

36.4

26.3

3.1

0.9

The effectiveness of acupuncture has been exaggerated. Expected results may not be achieved.

28.4

47.7

23.9

3.1

0.8

Acupuncture is an invasive procedure, which can hurt the patient.

25.7

40.5

33.8

2.9

0.9

Acupuncture can only generate short-term effectiveness and the effect of the same treatment will decline gradually.

16.8

38.8

44.4

2.7

0.8

A 5-point scale with 5 = strongly agree and 1 = strongly disagree was used. Abbreviations: M, mean; SD, standard deviation.

05 TCM Chapter 5.indd 96

13/3/2019 下午2:18

How People Perceive Acupuncture: A Quantitative Study

97

Notably, the perceived risks related to individual acupuncturists were higher than those related to acupuncture treatment itself. Many respondents seemed to doubt the professional qualifications and skills of acupuncturists, a trend that mimics that observed when comparing acupuncture and WM. The respondents were also unsure of how much pain to expect during acupuncture treatment. These findings suggest that acupuncturists should discuss all possible sensations with their patients before treatment. They should also help their patients identify any abnormal or alarming sensations and respond appropriately if they occur. Finally, the respondents did not generally agree with the statement “Acupuncture is an invasive procedure, which can hurt the patient” or that “Acupuncture can only generate short-term effectiveness and the effect of the same treatment will wear off gradually.” Factor analysis All of the perceptions and attitudes toward acupuncture evaluated here were also subjected to principal components analysis using the varimax rotation method. Our analysis shows that all of the questionnaire statements could be grouped into four factors that explain a total of 41.2% of the observed variance. Table 5.6 summarizes the factor loading for this four-component solution. The first factor was “doubt of acupuncture” and reflects the respondents’ concerns about acupuncture and its efficacy. The second factor was “efficacy of acupuncture.” It highlights the respondents’ perception of acupuncture as a medical treatment with regards to efficacy. The third factor was “trust in WM,” which reflects the perceived superiority of WM over acupuncture based on scientific evidence and rigorous regulation. The fourth factor was “ambiguity.” This factor reflects respondents’ concerns about the qualifications and skills of acupuncturists and CMPs. Notably, the Cronbach alpha coefficients for the first three factors (0.73, 0.70, and 0.81, respectively) were all greater than or equal to the minimum acceptable level of

05 TCM Chapter 5.indd 97

13/3/2019 下午2:18

98

Traditional Chinese Medicine: Professionalization and Integration in Hong Kong

Table 5.6 Factor loadings of the four-component analysis Component Factor and statement

1

2

3

4

Factor 1: doubt about acupuncture Acupuncture can only generate short-term effectiveness and the effect of the same treatment will decline gradually.

0.75

Acupuncture is an invasive procedure, which can hurt the patient.

0.69

The effectiveness of acupuncture has been exaggerated. Expected results may not be achieved.

0.67

Media reports about medical errors of acupuncturists made me greatly concerned about acupuncture.

0.52

Acupuncture may cause pain sometimes and I am confused whether the pain is normal.

0.52

Acupuncture is not applicable to common illnesses such as colds, flu, etc.

0.51

Acupuncture treatment costs more than WM.

0.26

Factor 2: trust in WM Even when other medical treatment fails, acupuncture is able to cure a disease.

0.70

Acupuncture can effect a permanent cure.

0.68

Compared with WM, acupuncture can better effect a permanent cure.

0.62

Acupuncture is an alternative medical treatment that can cure difficult and strange diseases.

0.61

Acupuncture is a medical treatment that does not involve taking medicine.

0.60

Acupuncture is useful for preventive care.

0.44

Acupuncture has fewer side effects than WM.

0.40

Acupuncture cures faster than WM.

0.37

05 TCM Chapter 5.indd 98

13/3/2019 下午2:18

How People Perceive Acupuncture: A Quantitative Study

99

Table 5.6 (continued) Component Factor and statement

1

2

3

4

Factor 3: efficacy of acupuncture I trust WM doctors more than acupuncturists.

0.81

I trust WM more than acupuncture.

0.79

WM is more scientific than acupuncture.

0.73

Rules governing WM are more rigorous than those governing acupuncture.

0.70

Factor 4: ambiguity of acupuncturists Acupuncturists’ needle application skills are not standardized. Expected treatment results may not be achieved.

0.71

Professional qualifications of acupuncturists are ambiguous and the general public can be confused.

0.69

With improper needle application, acupuncture can induce severe aftereffects.

0.56

Acupuncturists may not be able to accurately apply the needle since patients’ body structures are different and their acupuncture points may be different.

0.55

0.70 (Nunnally & Bernstein, 1994). In contrast, the Cronbach alpha coefficient of the ambiguity factor (0.62) was below the minimum acceptable level. Interestingly, the statement “Acupuncture treatment costs more than WM” demonstrates weak loading (