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Knowledge, attitude and practice among Chinese acupuncturists receiving sham and/or placebo acupuncture: a cross-sectional survey Chunlan Jin,1 Xinyao Zhou,2 Ran Pang3
Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China 2 Division of Internal Medicine, Guang An Men Hospital, Beijing, China 3 Division of Urology, Guang An Men Hospital, China Academy of Chinese Medical Sciences, Beijing, China Correspondence to Dr Ran Pang, Division of Urology, Guang An Men Hospital, China Academy of Chinese Medical Sciences, No 5 Bei Xian Ge Street, Xicheng District, Beijing 100053, China; [email protected]
CJ and XZ contributed equally Received 18 January 2015 Revised 18 February 2015 Accepted 19 February 2015
To cite: Jin C, Zhou X, Pang R. Acupunct Med Published Online First: [ please include Day Month Year] doi:10.1136/acupmed-2015010772
ABSTRACT Background Placebo and sham acupuncture are common control strategies in acupuncture studies. However, the perception and practice of these approaches in acupuncturists are poorly documented. Objective To investigate knowledge of, attitude towards and practice of sham and/or placebo acupuncture among Chinese acupuncturists. Method A cross-sectional survey conducted in six different tertiary care hospitals of traditional Chinese medicine in Beijing, China. A total of 92 licensed acupuncturists were asked to complete a predesigned and structured questionnaire on-site. Results A response rate of 92.4% (n=85) was achieved. Almost all participants (99%, n=84) had moderate knowledge about sham and/or placebo acupuncture, but only a minority (27%, n=23) reported an excellent understanding. The general attitude towards sham and/or placebo acupuncture was positive. Most respondents (99%, n=84) thought such controls were necessary and the majority (81%, n=69) believed they were feasible in acupuncture research. More than two-thirds of participants (71%, n=60) had applied sham and/or placebo acupuncture, but only a few (8%, 5/60) used it as the most common control strategy in clinical trials. Conclusions The result of our survey suggests that Chinese acupuncturists have a moderate knowledge of, and a positive attitude towards, sham and/or placebo acupuncture. Research into sham and/or placebo acupuncture is limited in comparison with other control strategies. Therefore, an in-service education programme for acupuncturists and standardisation of sham and/ or placebo acupuncture need to be developed.
INTRODUCTION Acupuncture is a main branch of traditional Chinese medicine (TCM). Over recent decades, acupuncture has been
recognised by WHO1 and has gained popularity in the industrial world.2 3 A number of studies have shown its efficacy for various conditions, such as low back pain,4 5 migraine,6 cancerrelated fatigue7 8 and depression.9 However, other studies have found that acupuncture had no significant effect on some of these conditions.10 11 It has been suggested that controversy about the efficacy of acupuncture largely stems from bias in study design.12 The randomised controlled trial (RCT) is generally considered to be the ‘gold standard’, providing high-quality evidence for an intervention’s efficacy and safety,13 but selecting the appropriate control strategy for an RCT of acupuncture is a challenge.14 An appropriate control should be able to distinguish specific treatment effects from non-specific effects. Because acupuncture is a complex physical procedure, its non-specific effects include both physiological and psychological aspects, which make the design of a control strategy difficult.15 To identify specific effects and blind the patient to minimise response bias, two kinds of control strategies, including sham and placebo acupuncture, have been used in RCTs of acupuncture. Sham acupuncture is performed by inserting a real acupuncture needle into the skin either fully at a non-point or superficially at a point, whereas placebo acupuncture involves using a non-puncturing acupuncture device at a point or non-point.16 Although sham and placebo acupuncture have been applied in Western countries for more than 15 years, only a few studies in China have used these control strategies,17 and these are performed
Jin C, et al. Acupunct Med 2015;0:1–6. doi:10.1136/acupmed-2015-010772
Copyright 2015 by British Medical Journal Publishing Group.
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Original paper only in universities and institutes.17 The perception and attitude of Chinese clinical acupuncturists towards these control strategies have not been explored. It is also not clear whether these research tools are used in clinical trials by Chinese clinical acupuncturists. The specific objectives of our study were to investigate Chinese acupuncturists’ perception of sham and/or placebo acupuncture, understand their attitude towards placebo/sham-controlled RCTs of acupuncture and determine the application of sham and/or placebo acupuncture in China. Additionally, the study also aimed to obtain information to enable planning of an education programme for Chinese acupuncturists. METHODS This cross-sectional survey was carried out in May and June 2012 at six different tertiary care hospitals of TCM (Guang An Men hospital, Xi Yuan hospital, Dong Zhi Men hospital, Dong Fang hospital, Wang Jing hospital and Beijing hospital of TCM) in Beijing, China. The study received ethical approval from the institutional review board of the Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences. Instrument
Data were collected using a two-page questionnaire comprising 22 items. The draft questionnaire with closed-ended questions was developed based on a literature review and a structured interview with five doctoral candidates in acupuncture and five experienced acupuncturists from the China Academy of Chinese Medical Sciences. The questionnaire was then reviewed by four expert acupuncturists and two epidemiologists at the China Academy of Chinese Medical Sciences and modified according to their comments. Before the formal investigation, another five doctoral candidates in acupuncture and five acupuncturists were invited to complete the questionnaire. After 1 week, these subjects were asked to complete the same questionnaire with the questions in a different order. The results from the two pre-surveys were consistent. Each questionnaire began with the statement, ‘Completing this survey is voluntary and serves as your informed consent for the study. The survey is anonymous and not linked to any commercial purpose.’ The questionnaire consisted of three sections covering information about respondents’ knowledge, attitude and experience using sham and/or placebo acupuncture, as well as demographic information. The knowledge section included four singlechoice questions, while the attitude section contained six single-choice questions and one multiple-choice question. Additionally, two single-choice questions and three multiple-choice questions were used to assess the practice of sham and/or placebo acupuncture. 2
Our study targeted the licensed clinical acupuncturists who were working in the tertiary care hospital of TCM in Beijing. Inclusion criteria were clinical acupuncturists with practice of acupuncture for >1 year; age >21 years; and research experience of acupuncture. Retired acupuncturists and acupuncture researchers without clinical practice were excluded. Only acupuncturists who met the inclusion criteria could participate in this study. Procedure
The survey was carried out in six different hospitals. Questionnaires were distributed to all the participants on site by third-party assistants. The respondents were generally given 10 min to complete the questionnaires, which had proved adequate in pilot studies, though if needed, extra time could be provided. Completed questionnaires were collected by the assistants and returned to the principal investigators directly. During the procedure, the principal investigators did not meet any respondents and the third-party assistants were not involved in any data analysis. Data analysis
The data were double-entered into computer by two research assistants and analysed using SPSS, V.19.0 (SPSS Inc, Illinois, USA). Continuous variables were expressed as means±SD. Categorical variables were expressed as percentage and frequency. Descriptive analysis was performed to estimate the awareness for different questions. The proportion of participants who had applied sham and/or placebo acupuncture in a different educational background group, professional title group and medical centre was compared by a χ2 test. χ2 Analysis was also used to explore the association between the use of sham and/or placebo acupuncture and other demographic factors. All reported p values were two-sided, and p20 Medical centre, n (%) Guang An Men hospital Dong Fang hospital Beijing hospital of TCM Dong Zhi Men hospital Xi Yuan hospital Wang Jing hospital TCM, traditional Chinese medicine.
35.8±8.4 29 (34) 56 (66) 30 (35) 44 (52) 11 (13) 11 (13) 23 (27) 27 (32) 24 (28)
Table 2 Acupuncturists’ knowledge about sham and/or placebo acupuncture Questions
Have you heard of sham and/or placebo acupuncture? How would you describe your understanding of sham and/or placebo acupuncture? For how many years have you been aware of sham and/or placebo acupuncture? Where did you hear about sham and/or placebo acupuncture?
No Yes Poor Limited Good 10 Journal Academic conference Internet Other
Respondents, n (%) 1 (1) 84 (99) 1 (1) 61 (72) 23 (27) 46 (54) 29 (34) 10 (12) 40 (47) 22 (26) 9 (11) 13 (15)
33 (39) 14 (16) 21 (25) 17 (20)
acupuncture, most respondents deemed that these approaches could remove the effect of mental factors and confirm the real efficacy of acupuncture, as shown in table 3.
20 (23) 15 (18) 15 (18) 15 (18) 10 (11.5) 10 (11.5)
Almost all respondents had heard of sham and/or placebo acupuncture, but only 23 (27%) reported an excellent understanding of these research tools. Moreover, 46 respondents (54%) had been aware of these control approaches for only