Received date: May 30, 2017; Accepted date: June 05, 2017; Published date: June 12, 2017
Citation: de Sousa LA, Braghetto GT, Pigari JO, Pereira MJB (2017) Acupuncturists in Primary Health Care: Knowing to Legitimate and to Expand. J Tradit Med Clin Natur 6:223.
Copyright: © 2017 de Sousa LA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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The present research takes a different approach to acupuncture. While most researches have studied aspects related to the treatments and effects of acupuncture use, which undoubtedly are of great importance, we are dedicated to studying aspects related to health policies 1. Therefore, we take Primary Health Care as a research field for acupuncture and other alternative and complementary medicines, which are denominated in Brazil, of Integrative and Complementary Practices.
Acupuncture is the fastest growing therapy in the world, including encouragement and recommendations from the World Health Organization for its inclusion in public health systems. In order for acupuncture to be offered in public health systems it is essential to have acupuncturists in sufficient quality and quantity, another aspect that is also discussed by WHO.
Given the relevance of these considerations, in this research, we seeked to map and identify the professionals specialized in acupuncture and who are interested in exercising the offer of this therapeutic practice in Primary Health Care. For this, we seeked to identify the number of acupuncturists; Describe socio-demographic profile of acupuncturists; Identify the different formations in acupuncture; to identify the interest and availability of acupuncturist professionals in acupuncture in primary health care services.
In order to collect data, we prepared a questionnaire and submitted it to a process for validating the appearance and semantics of the content, carried out by five judges with higher education in the health area, specialization in acupuncture and experience in Primary Health Care, which favored the accuracy of the instrument. Only after the validation by the judges the questionnaire was applied to the participants of the research in the online and printed format.
Acupuncture; Legitimate; Socio-demographic
The growing worldwide interest in inserting acupuncture in primary health care requires that national and international health authorities seek ways to ensure safety in their use. One of the aspects that the World Health Organization draws attention to is the importance of professional training for the practice of acupuncture, especially in countries where Western medicine ‘is the sole basis of the national health system [1,2].
Although the offer of acupuncture and other alternative and complementary medicines, called integrative and complementary practices in Primary Health Care in Brazil, are greatly encouraged by the WHO [1-3], has been expanding and has been happening for decades in different countries, there are still some needs in the process of implementation in regard to the available human resources for the practice of acupuncture [1,2]. In Brazil, such needs are evidenced by several difficulties, especially the low percentage of acupuncturists who work in public health services and because there is no formal work contract for acupuncturists in these services. However, there is interest among professionals to specialize in acupuncture and most of them are interested in acting in Primary Health Care services as an acupuncturist .
In the Brazilian context, there are still neither institutions nor actors in sufficient number that are at the same time well established and linked to integrative and complementary practices such as acupuncture and other medical rationalities, converging to the ideals of the Unified Health System, of health promotion and of health care integrality, and being immediately “partners to be recognized and valued as references”  for integrative and complementary practices and other medical rationalities .
A recent study shows that, although there are health professionals with specialization in acupuncture in the municipal public health network, there is no survey on the quantity of them, on which services they work and if they have an interest in acupuncture in Primary Health Care Health. There is good acceptance and demand from the population for acupuncture; however, because of the scarce amount of acupuncturists, the waiting list of people for this care is continuously growing .
The hiring of more acupuncturists is not yet a priority in the agenda of decisions of the health manager. Thus, the specific position for this hiring in the institutional personnel framework has not yet been given, either due to administrative, financial difficulties or health care model. So, the supply is restricted and the population is without this access . The incorporation of either unconventional practices or alternative and complementary medicines into national health systems, with new conceptions of the health-disease process, of the care and of the cure themselves depend on the conjuncture of central or local governments, social demand and political pressure in their favor . All these issues have an impact on the expansion and strengthening of the acupuncture offer and, consequently, on the National Policy on Integrative and Complementary Practices (created in 2016) in the Unified Health System . In this perspective, it is worth highlighting that the Integrative and Complementary Practices starts from the premise that acupuncture can be exercised in a multiprofessional manner by the professional categories present in the Unified Health System, and in consonance with the level of attention . This premise favors the broadening of the acupuncture practices. It is also important to mention that currently several professional councils recognize acupuncture as specialty , among them the physical therapy, nursing, occupational therapy, biomedicine, pharmacy, naturology, medicine and others. In addition, it is emphasized that the World Health Organization presents guidelines and recommendations for basic training according to the different professional categories . In view of this diversity of training possibilities, and also considering that in the context of the study, the Municipal Health Department adopted only medical professionals for acupuncture care, we questioned: how many university-level professionals working in the Health Units of the Unified Health System, has specialization in acupuncture, considering the recommendations of WHO and the National Policy on Integrative and Complementary Practices?
Based on these considerations, it is necessary to map and identify the professionals specialized in acupuncture and who have an interest in exercising the offer of this therapeutic practice in the Primary Health Care in the public health services network at the municipal level. Besides this, these were also the objectives of this investigation: To identify the amount of acupuncturists; to describe socio-demographic profile of acupuncturists; to identify training in acupuncture; and to identify the interest of acupuncturist professionals in acupuncture.
This is a descriptive study with a quantitative approach.
Place of Study
The study was carried out in the health units of the Primary Health Care Network at the municipal level, from June to July 2015. This health care network is organized into five health districts that are: the northern district, the eastern district, the central district, the southern district and the western district, consisting of one Emergency Care Unit, four Districtal Basic Health Units, 26 Basic Health Units and 14 Family Health Units, which serve about 604,682 people . There are several types of employment relationships within the framework of health professionals in this network. For this study, considering this variety of professional relationships and also considering the different levels of health care assistance, for this research only the health units of the primary level of care were included, regarding that the professionals have a municipal employment relationship, hired by contest. Thus, the total of units that participated in this study, according to health districts was: 12 units of the northern district, 6 units of the eastern district, 5 units of the central district, 4 units of the southern district and 12 units of the western district, totaling 39 health units.
In order to select the participants of the research, the inclusion criteria were defined as: to be a professional with a municipal employment relationship (hired by the City Hall); to work in the Primary Health Care Network of the Municipal Health Department; to exercise a contracted function requiring a higher education level; to work in the units participating in this study, described in the previous item. Participants who did not meet the inclusion criteria were excluded from the study. For example, participants who were on vacation, leave or who were not present at the health unit during the period of data collection and those who refused to participate. Professionals working in more than one health unit answered the questionnaire only once. Thus, the study included 156 participants.
In order to collect the data, we used the questionnaire, both in online format and in printed format, composed of three parts. In the first part of this questionnaire were the identification data, university education, position that the subject currently exercised in the public service and its duration. In the second part of the questionnaire were the data referring to the specialization in Integrative and Complementary Practices, requesting that it was specified if the answer was yes and whether or not there was an interest in carrying out a specialization in some of the types of Integrative and Complementary Practices. For those who did not have a specialization in acupuncture, the questionnaire was closed. However, for those with a specialization in acupuncture, there was the third part of the questionnaire, containing questions, whose objective was to identify the acupuncture specialization, whether the practitioner was currently practicing acupuncture and about the interest in acting in the different services of Primary Health Care as an acupuncturist. The collection was carried out in July 2015.
This questionnaire was submitted to a validation process for the appearance and semantics of the content . To this end, it counted with the participation of five judges with higher education in the area of health, specialization in acupuncture and experience of the professional practice in Primary Health Care, from different regions of the country. We first made phone calls to the judges to explain the research and invite them to participate in the questionnaire validation. Subsequently, we sent by e-mail the Informed Consent Form and the questionnaire for validation by the judges. For each question listed, we asked judges to assess the content for clarity, objectivity, organization, easy reading and understandable content. We accepted the suggestions of the questions regarding age and working time, providing the answers in intervals of years, as suggested by the judges, and in the question about specialization, we accepted the suggestion to write “Integrative and Complementary Practices” instead of keeping only the acronym “ICP”. The validation process favored the accuracy of the instrument. Only after the validation by the judges was the questionnaire applied to the participants of the research.
The questionnaire was sent in the online format, by email, to all health units in the municipality, making it accessible to all professionals participating in the survey. Online questionnaires have many advantages for those who fill them and for the researcher, such as speed, convenience and cost reduction. However, in spite of these advantages, there was a low adherence of the professionals, generating little participation in the questionnaire in the online format (less than 8%), even when the researchers contacted the unit managers explaining the importance, encouraging participation and resending the questionnaire. This was a difficulty for the researchers.
Faced with this obstacle, the researchers opted for a second alternative: to do the questionnaire in printed format and to go personally to the health units to apply it to professionals. The average time to answer the questionnaire ranged from three to 5 min. This experience showed that there is not yet an established habit for the participation in research questionnaires in the online format, and the presence of the researcher or research technicians applying the questionnaire made a significant difference for the participants’ adherence to the research. During the visits at the health units, the managers reported the updated staff group of each unit, describing the quantity of them who were hired, the quantity of them who were on vacation or maternity leave. From this description, it was expected the participation of 266 professionals. However, considering the professionals who were on vacation and health/maternity leave, the total number of professionals was 186.
Of these 186 participants, 141 answered the printed questionnaires that were distributed in the health units, which corresponds to 75.8%. As participation is voluntary and not compulsory, among the 45 individuals who did not respond to the questionnaire, which corresponds to 24.2%, the justifications alleged for non-participation were lack of interest, lack of time and overwork.
Considering the number of questionnaires printed and online answered, respectively, 141 and 15, the total number of participants that took part in this study was 156. That is, 90.4% answered the printed questionnaire and 9.6% answered the online questionnaire.
It is worth emphasizing that the process of validation of the questionnaire by the judges was fundamental to make it clearer and, consequently, faster to be answered by the interviewees. This was undoubtedly a positive aspect in this research development. Nevertheless, the online questionnaire has not yet proved to be a productive data collection instrument. We believe there is a need to change people’s habits to increase acceptance and adherence to respond online questionnaires, by the easiness itself. There is also time gain mainly related to the application of the online questionnaire in relation to the printed questionnaire.
After the collection, a descriptive statistical analysis of the data was performed.
The study was approved by the Ethics Committee of the University of São Paulo at Ribeirão Preto College of Nursing under no. 897.644/2014, according to the ethical standards required by National Health Council Resolution n. 466/2012. Since the research involved human beings, the study took place after every participant signed the Informed Consent Term.
Acupuncturists sociodemographic profile
Of the 156 participants of this study, 106 are female, corresponding to 67.9% and 50 males, which is equivalent to 32.1% of the total participants. It is noted that the participation of females is twice as large as the participation of males.
Regarding the participants’ age range, 36 (23.1%) reported being between 50 and 54 years old; 33 (21.1%) reported being between 55 and 60 years old; 20 (12.8%), between 45 and 49; 18 (11.5%), between 35 and 39 years old; 15 (9.6%), between 30 and 34 years old; 13(8.3%), between 40 and 44 years old; 11 (7.1% ) reported being over 60 years old and 10 (6.4%) reported being between the ages of 25 and 29. It can be concluded that the majority of the participants in the present study are between 50 and 54 years old. Regarding university education, 66 (42.3%) are physicians, 42 (26.9%) are nurses, 33 (21.1%) are dentists, 9 (5.8%) are pharmacists, 2 (1.2%) speech therapists, 2 (1.2%) psychologists and 2 participants (1.2%) did not identify their university education. It is identified that among the total of interviewees, medical and nursing studies predominated, respectively.
Regarding integrative and complementary practices, we consider as specializations acupuncture, homeopathy, herbal medicine/ phytotherapy, thermalism/crenotherapy and anthroposophic medicine, both contemplated by the National Policy of Integrative and Complementary Practices in the Unified Health System. When questioned if they had a specialization in Integrative and Complementary Practices, 139 participants, which corresponds to 89.1%, reported that they did not have any specialization in Integrative and Complementary Practices while 17, which is equivalent to 10.9%, refers having a specialization in one or more of the Integrative and Complementary Practices. This analysis led us to raise some questions: Does the high number of professionals without specialization in Integrative and Complementary Practices mean that there is “no interest” in these practices or does it mean lack of knowledge about Integrative and Complementary Practices?
Of the 17 participants with some specialization in Integrative and Complementary Practices, eight (47%) have specialization in homeopathy, five (29.4%) have specialization in acupuncture, two (11.7%) have specialization in acupuncture and homeopathy and 1 (5.8%) in herbal medicine/phytotherapy. According to the questionnaire, one participant (5.8%) was attending a specialization in phytotherapy.
Regarding the interest or not of specializing in Integrative and Complementary Practices, 55.2% (79 subjects) reported not having interest in any specialization in Integrative and Complementary Practices. In contrast, 44.8% (64 participants) referred having interest in doing some specialization in Integrative and Complementary Practices. It is observed that almost half of the subjects are interested in performing some specialization in Integrative and Complementary Practices, and from these:
• 39% are interested in specializing in acupuncture;
• 15.6% are interested in specializing in herbal medicine/ phytotherapy;
• 11% are interested in specializing in acupuncture and herbal medicine/phytotherapy;
• 4.7% are interested in specializing in acupuncture and homeopathy;
• 4.7% are interested in specializing in homeopathy and herbal medicine/phytotherapy;
• 3.1% are interested in specializing in homeopathy;
• 3.1% are interested in specializing in anthroposophic medicine;
• 3.1% are interested in specializing in anthroposophic medicine and herbal medicine/phytotherapy;
• 4.5% are interested in specializing in three or more Integrative and Complementary Practices;
• 1.5% are interested in specializing in some Integrative and Complementary Practices, however, without preferences, and 9.4% scored no response.
The considerable percentage of participants (39%) interested in specializing in Integrative and Complementary Practices/acupuncture is noteworthy.
Interest and availability of acupuncturists in practicing acupuncture
Of the six interviewees who have a specialization in acupuncture, five are interested in working as an acupuncturist in the health units of primary health care, corresponding to 83.3%; and one (16.7%) has no interest. Of the 83.3% of acupuncturists interested in working as acupuncturists in health units of primary health care, 60% reported availability in the morning and 40% did not mention the availability. It is worth mentioning an interesting data according to the questionnaire, which shows that a respondent with acupuncture specialization acts as an acupuncturist in the health unit but is not formally hired as an acupuncturist.
The study shows the low percentage of acupuncturists working in public health services and reveals that there is no formal working contract as acupuncturists in these services. However, there is interest among professionals in doing acupuncture specialization and most of them are interested in acting in Primary Health Care services as an acupuncturist.
Acupuncture is the fastest growing therapy in the world, including encouragement and recommendations from the World Health Organization for its inclusion in public health systems. In order for acupuncture to be offered in public health systems, it is essential to have acupuncturists in sufficient quality and quantity, another aspect that is also discussed by WHO. Given the relevance of these considerations, in this research, we sought to map and identify the professionals specialized in acupuncture and who are interested in providing the offer of this therapeutic practice in Primary Health Care. For this, we sought to identify the number of acupuncturists; to describe socio-demographic profile of acupuncturists; to identify the different formations in acupuncture; to identify the interest and availability of acupuncturist professionals in acupuncture in primary health care services. This survey contributed to increase the possibility of reshaping the staff and increasing acupuncturists in primary health care, meeting the pent-up demand and thus broadening and strengthening the offer of acupuncture. This strategy can also contribute to the health services of primary health care in different countries to articulate and trigger viable strategies for the implantation and implementation of acupuncture and other integrative and complementary practices in their different contexts and realities. It is recommended that the Primary Health Care services review the structure of their work contracts, formally inserting acupuncturists and other professionals with training in other integrative and complementary practices, thus materializing the legitimacy of these health professionals. It is also recommended that acupuncturists, who are interested in acting as acupuncturists in the Primary Health Care services, should express this interest and, together with the managers, seek strategies to formally institute this specialty within the framework of professionals in the Primary Health Care services, legitimating it. Acupuncture and other integrative and complementary practices can contribute to change the logic of the medical-care model focused on complaint and prompt care, since acupuncture not only favors treatment and recovery but also emphasizes the promotion of health and prevention of diseases, potentializing the materialization of the assistance integrality, of health as rightly and strengthening the health systems through primary health care. We defend health as a right, and above all, we argue that people have the right to choose the therapy they want to take care of their health and their illness. Therefore, we understand that acupuncture and other Integrative and Complementary Practices should be offered in the different health services of Primary Health Care. And, for this therapeutic option to be assured, it is fundamental that Primary Health Care services have such professionals. We believe that this research may contribute to other research aimed at implanting or expanding acupuncture and other integrative and complementary practices in the different health systems of Primary Health Care, pointing out specific human needs. Therefore, identifying practitioners of integrative and complementary practices in Primary Health Care, knowing their training and interest, is essential, since it is from this identification that it will be possible to make a concrete plan to implant or to expand the offer of acupuncture and other therapeutic approaches within the health systems of Primary Health Care.
The authors would like to acknowledge José Renato Gatto Júnior, doctorate student at the University of São Paulo, Postgraduation Program of Psychiatric Nursing, for the translation of this article.