1. Use of Traditional, Complementary and Alternative Medicine (TCAM): A Case Study of Indian Cancer Patients Prem Chhetri RMIT University & Dr Alex Broom the University of Newcastle

2. Content ► Background ► Concept of TCAM ► Research Methodology ► Data collection ► Results and Interpretation ► Discussion

3. Background ► In 2005 cancer killed approximately 826,000 people in India; 519,000 under the age of 70 (WHO, 2005). ► This is predicted to rise disproportionally compared with cardiovascular and communicable diseases by 2030 to nearly 1.5 million deaths annually.

4. Background ► The Indian subcontinent is home to 16.5 percent of the world’s population and at any one time it is estimated that there are over 2 million people with cancer (Kishore et al 2008). ► The majority of Indian cancer patients have late stage incurable disease (75% to 80%) when first diagnosed (Jones, 1999; Kishore et al, 2008; Kumar & Mittal, 2004; Pal, 2002). ► ► At present, out of one million newly diagnosed Indian cancer patients each year, more than 50 percent will die within 12 months of diagnosis and another one million cancer survivors (within 5 years of diagnosis) will show progressive disease (Pal & Mittal, 2004).

5. Background: TCAM and global health (source: WHO, 2001) ► ► Global health policy emphasising the importance of promoting traditional medicines (TM) to help address the range of health concerns facing poorer countries ► ► Traditional medicines could (and do) play a role in reducing excess mortality and morbidity in poor and marginalised populations ► ► Recent policy trajectory has been toward a melding of traditional and biomedical systems ► ► But are there implications of the promotion of TM?

6. Many traditional, complementary and alternative practices ► ► Examples in South Asia:   Ayurveda (Hindu)   Unani medicine - Hakim (Islamic)   Spiritual healers, Dam - Pirs (Islamic)   Traditional Chinese Medicine (China and used throughout Asia)   Homeopathy (imported from Europe, popular in India) ► ► Participants shifted between alternative and traditional, few used complementary.

7. Traditional Medicines ► TCAM generally refers to health care practices not offered within orthodox facilities (or by their practitioners). ► Traditional medicine (TM) refers to local indigenous practices and belief systems that are used in developing countries for health-related purposes (Bodeker & Kronenberg, 2002). ► TMs have often been the dominant means of treatment for health problems for centuries (e.g. Ayurveda and Unani in India), and in some cases, they continue to dominate health care beliefs and practices.

8. Complementary and Alternative Medicine ► ► Complementary and alternative medicine (CAM) is generally used to refer to a range of non-indigenous, unorthodox practices including homeopathy, naturopathy, herbalism and so on (Broom and Tovey, 2008).

9. Purpose ► The aim of this project is two fold:  i) first to identify socio-demographic and disease status differences between the TCAM and non-TCAM users among cancer patients in India and  ii) second to assess whether there is a difference in seeking help from ‘orthodox medicine’ between the groups.

10. Data Collection ► Survey of 825 cancer patients in public and private hospitals in Delhi. The survey was conducted over the course of four months and the response rate was 80%. ► Recruitment sites:  All India Institute of Medical Sciences  Rajiv Ghandi Cancer Institute ► Using four interviewers, we used list sampling to interview every second patient over this four month period. ► 90 percent of the interviews were done in Hindi and 10 percent in English.

11. Data Collection

13. Results ► ► Of the entire sample, 34.3% used TCAM representing a significant proportion of the population. ► ► The most common types of practices used in this cohort of patients were Ayurveda, Homeopathy, Meditation, Acupuncture and Reiki. ► ► 22.8% had used local TM practices (e.g. Ayurveda) and 25.5% used CAM (e.g. Homeopathy). ► ► Of the 34.3% of TCAM users, 13.9% used both local TM and non-indigenous CAM.

14. TCAM User’s Profile ► TCAM users are more likely to be relatively older private patients, they are tended to be married upper caste Hindu, generally residing in Delhi or its surrounding states. ► Non-users of TCAM are more likely to be male. Furthermore, non-users were more likely to be single, public patients and non-Hindu in comparison to TCAM users. ► Non-users also tend to travel longer distance for their treatment (14.8% for TCAM users as compare to 21.6% for non-users).

15. Delay in seeking help from orthodox medicine ► ► 35.2% of respondents using TCAM sought help immediately after onset of symptoms whereas 50% of non-users immediately sought help from orthodox medicine. ► ► 12.8% of TCAM users waited 3 months or more after noticing symptoms whereas only 4.3% of non-users waited this long.

16. delay in seeking help from orthodox medicine Delays in seeking help:TCAM Users Non-Users One week35.2%50.0%0.000* * One month9.7%6.8% Three months30.8%36.8% More than 3 months12.8%4.3%

17. ► ► Are women more likely to be treated with TCAM?

18. ► ► Do women more likely to use public or private hospitals? For TCAM Users For Non TCAM Users

19. ► ► Is there a difference between the treatment received by non-upper caste women? For TCAM Users

20. Conclusion ► ► We found that TCAM and Non-TCAM users are different in terms of their socio- demographic characteristics ► ► We also found that TCAM users tend to delay in Orthodox medicinal treatment that might have strong implication in treatment. ► ► Female participants are more likely to be treated with TCAM, but they are more likely to be presented at private hospitals

21. What next What next? ► ► Requires more advanced statistical analysis and modelling to ascertain the factors affecting the use of TCAM ► ► Combining the results of qualitative data analysis and cross validation. ► ► Comparing results from different parts of South Asia ► ► Establishing a broader theoretical framework of the analysis