Percepção de médicos e enfermeiros da Estratégia de Saúde da Família sobre terapias complementares Family Health Strategy doctors and nurses ’ perceptions of complementary therapies

MÉTODOS: Estudo com 177 médicos e enfermeiros a partir de um questionário auto-aplicado em 2008. As variáveis desfecho foram “interesse pelas práticas integrativas e complementares” e “concordância com a Política Nacional de Práticas Integrativas e Complementares”. Sexo, idade, graduação, pósgraduação, tempo de formado e de trabalho, possuir fi lhos, oferta de práticas integrativas e complementares no local de trabalho e uso de homeopatia ou acupuntura compuseram as variáveis independentes. Os dados foram analisados pelo teste do qui-quadrado e teste exato de Fisher.


INTRODUCTION
The growing demand for complementary medicine and therapies and their increasing acceptance by health professionals is a relatively recent fact.Eisenberg et al 8 showed that a third of Americans used a certain type of complementary medicine or therayp in 1993, with an increase in research on such theme from this time on. 3,15,16In the last decades, techniques originated from different cultural and healing traditions such as acupuncture have slowly been tested and recognized by biomedicine and incorporated into medical specialties.
Social, academic and institutional recognition of these therapies emphasize the consensus that biomedicine exists among other types of care, in a cultural context characterized by therapeutic or health care pluralism (according to Helman 10 ) -although maintaining its hegemony in an increasingly medicalization. 1,18,21continuous growth in the number of medical consultations with specialists in homeopathy and acupuncture and in the search for complementary therapies can be observed in the context of private health care in Brazil.This growth is not occurring with the same intensity in public health services, thus suggesting socially unequal access to these therapies. 1cognizing the therapeutic pluralism of each country and refl ecting this in health care is a challenge when public policies are planned.Recommendations of the World Health Organization (WHO) Alma-Ata International Conference of 1978, updated in 2002, suggest strategies for the implementation of Traditional Medicine and Complementary and Alternative Types of Medicine (TM/CAM) in public health services of member countries.a Health care comprehensiveness, established as a directive by the 8 th Brazilian Health Conference and formalized as a doctrinal principle of the Sistema Único de Saúde (SUS -Unifi ed Health System), points to the offer of these therapies in Brazil.They can contribute to the partial de-medicalization on professional care, in addition to their being socially valued and expected.Decree 971, b passed in 2006, provides for the inclusion of homeopathy, medicinal plants/phytotherapy, acupuncture/Chinese medicine and thermal water therapy in the SUS, mainly in Primary Health Care (PHC).The objective is to promote an increase in the number of approaches to health and to make available promotion, preventive and therapeutic options to SUS users 14 that are different from biomedicine.The inclusion of these therapies in the SUS represents respect for system principles, 17,18 although in a controversial way.
Studies show that health professionals, especially doctors, are unaware of complementary therapies, despite their interest in learning about them and agreeing with their inclusion in public health services or courses in the health area. 3,4,18,19Similar results were obtained with medical students. 20ganized social movements were in favor of the implementation of Complementary and Integrative Therapies (CIT) in the SUS, in the city of Florianópolis, Southern Brazil.The demand for studies on this theme in Brazil can be observed, especially on the relationship between Primary Health Care professionals and complementary types of medicine and therapies.Studies of this nature could enable the observation of this relationship in Brazil, in addition to the construction of policies and projects of inclusion and the offer of such therapies in the cities.Doctors and nurses are key care agents in the context of the Estratégia Saúde da Família (ESF -Family Health Strategy) and important social participants in health care, with great responsibility in diagnostic actions and preventive and therapeutic guidance.
The present study aimed to analyze the ESF professionals' perception of complementary and integrative therapies.

METHODS
An exploratory study was conducted with ESF doctors and nurses of the city of Florianópolis, between September and November 2008.
Data were collected from 46 Health Centers (HC) of this city.Florianópolis showed a population coverage by the ESF of approximately 77%, with 94 family health teams.
A self-administered questionnaire was used, initially developed by researchers with closed-ended questions and one open-ended question.A pilot test was conducted with ten professionals, with characteristics similar to those of study subjects.Of all 188 professionals, 177 (94.2%) responded to the questionnaire: 82 doctors and 95 nurses.A total of 12 doctors refused to participate in the study and one nurse was included in it, in addition to those expected.
The outcome variables were "professionals' interest in CIT" and "opinion about the inclusion of CIT in the SUS".Interest in CIT was considered as "yes" (shows interest) when the professional pointed out that they would like to participate in a training course or obtain a specialization/qualifi cation in the area.In contrast, "no" (shows no interest) was considered when indicating no or little interest or that they would like to know more about this.Sex, age, graduate level of education, postgraduate level of education, length of time since graduation, having children (only for the variable "interest in CIT"), length of time of work in the SUS, offer of a certain CIT in the HC where one works, and use of CIT (homeopathy or acupuncture) for oneself or by the family comprised the independent variables.Use of CIT was categorized into "yes", when "many times/often" and "always" were indicated, and "no", when "never", "rarely" and "sometimes" were indicated.The choice to exclusively value the use of homeopathy and acupuncture resulted from the fact that these therapies are provided by the municipal health network and that they are the most well-known, in addition to phytotherapy.
Data on the follow-up of patients or their referral to a certain CIT were used to estimate the use or recommendation of a certain CIT during the professional activity for their users.The offer of CIT in HCs was analyzed in the questionnaires, a piece of information that was subsequently confi rmed by telephone.
Data were analyzed using Chi-square test and Fisher's exact test, when necessary.The database was formatted in the EpiData software and the results analyzed using the EpiData Analysisand Stata version 9.0 software programs.
The project was approved by the Municipal Department of Health in June 2008 and by the Human Research Ethics Committee of the Universidade Federal de Santa Catarina , on July 28 th , 2008 (protocol 181/08).

RESULTS
The professionals studied were predominantly females (70.6%), married (51.4%), without children (59.9%), young (mean of 35 years), and with up to fi ve years of length of time since graduation (40.5%).The majority of them (84.2%) had one or more specializations, 77 (43.5%) performed residency in Family and Community Medicine or specialization in Family Health, and 22 professionals (12.4%) had a specialization in homeopathy or acupuncture.Other courses in CIT areas (such as phytotherapy, fl orals and massage therapy) were reported by 39 professionals (22.0%).
The majority of professionals (59.9%) associated CIT with broader understanding of the health-disease process than in biomedicine, 5.1% associated them with the placebo effect, and 8.5% believed that only those CIT that had been proved by science should be used.
Among professionals, 88.7% did not know the directives of the Política Nacional de Práticas Integrativas e Complementares (PNPIC -National Policy on Complementary and Integrative Therapies), although 81.4% agreed with what it recommends (Table 1).The inclusion of CIT in the three levels of health care was accepted by 45.8% of individuals, while 51.3% believed that they could be provided in primary and/or secondary care.In addition, 59.9% were very interested in CIT, expecting to obtain training or a qualifi cation in the area; whereas 6.8% reported having no or little interest in these therapies.All professionals agreed that CIT should be approached in courses in the area of health.
A total of 17 HCs (36.7%) provided nine different therapies, ranging from medical rationalities (homeopathy, Chinese and Ayurvedic medicine) and therapeutic practices (acupuncture, auriculotherapy, massage, massage therapy, chiropractic and phytotherapy), among which acupuncture and homeopathy were those most frequently present.Groups with activities considered complementary (yoga, biodance, relaxation, meditation, dance, tai chi chuan) were offered in seven HCs.According to 55.4% of professionals, the community had an interest in these practices (Table 1).
Nurses showed slightly greater interest, when compared to doctors and individuals working in HCs that provide a certain type of CIT, those with greater length of time since graduation, and those without children, although there was no statistically signifi cant difference."Use of homeopathy for oneself" (p = 0.002) and "use of acupuncture by family members" (p = 0.013) had a statistically signifi cant association with interest in CIT."Use of homeopathy by family members" and "use of acupuncture by oneself" had a borderline statistical signifi cance (Table 2).
"Agreement with the inclusion of CIT in the SUS or not" was statistically associated with having a graduate level of education -nurses were more favorable to the PNPIC (p = 0.027) -and with the use of homeopathy as treatment for oneself (p = 0.019).
Some of the professionals reported not knowing or knowing little about CIT, especially about anthroposophic, ayurvedic and traditional Chinese medicine (Figure).An average level of knowledge was predominant for homeopathy and acupuncture, in contrast with higher lack of knowledge about phytotherapy and medicinal plants.
Professionals referred few patients to treatments that were not provided by the municipal health network, such as ayurvedic medicine, anthroposophic medicine, traditional Chinese medicine, and therapeutic touch.Homeopathy, massage, phytotherapy and medicinal  4).

DISCUSSION
Support for the inclusion of CIT from the doctors and nurses studied can become a more disseminated reality in Brazil, although other studies for comparison are practically inexistent.Studies support the hypothesis that there is growing interest in complementary therapies and sensitization of health professionals, especially those in primary care, at the same time that demand for such therapies increases. 3,4,16,19planations about the phenomenon include dissatisfaction with biomedicine (iatrogenia; expensive and invasive methods; focus on the disease, rather than the patient; and impersonality) and the qualities attributed to complementary types of medicine and therapies (comprehensiveness of care, humanism in the doctorpatient relationship, promotion of the body's healing forces, lower potential harm, more holistic approach to the health-disease-care process). 15,18The majority of professionals studied reported that CIT are based on a broader understanding of the health-disease process, which could be associated with their interest in these therapies.
The growth and institutionalization of these practices in Brazil was observed, causing corporative organizations to raise questions at the time the PNPIC was passed.
In 2006, the Conselho Federal de Medicina (Brazilian Medical Council) stated the following about the PNPIC in its newspaper: "The decree that authorizes the application of 'alternative' techniques by the SUS was rejected", d based on arguments of invasion of private medical activities by non-doctors and of lack of scientifi c proof of CIT.However, the results of the present study showed primary care doctors' openness towards and interest in this theme in the city of Florianópolis.This suggests that there may be divergences between the macro-political positions of this category and the doctors' attitude, especially those in primary care, unless this fi nding is an idiosyncrasy of the city studied, perhaps resulting from the proportion of specialists in Family and Community Medicine, Family Health, Public Health or a certain CIT.
Health professionals' lack of knowledge about complementary therapies can lead to incorrect concepts, which may cause diffi culties in the doctor-patient relationship and with colleagues who practice these specialties. 9,18Sales 18 observed the notion that homeopathy would only serve for simple and common, although prevalent, problems, held by non-homeopathic medical professionals and managers in contact with homeopathy in public services or in the university environment.The generalization of this fi nding to the remaining CIT can be hypothesized to understand the reason why approximately half of the professionals, although supporting CIT and showing interest in them, restrict their support for primary and/or secondary care.Results of the present study indicate the professionals' relative ignorance of this subject, thus suggesting the need for qualifi cation courses and promotion of these themes to implement PNPIC in the city.Promoting the introduction of the theme in the curricula of courses in the area of health would be a measure to be considered. 18,20n most cases, such courses do not provide knowledge about other types of medicine and therapies, including These data emphasize the current paradox, where a high level of social medicalization, belief in science and biomedicine and consistent growth in the search for other types of care coexist. 11,21Results of the present study do not provide in-depth analyses or explanations about the position of most professionals, although they suggest that there is sensitization to the social movement to revalue CIT.The patients' demand for healing practices that are not used by biomedicine and the professionals' search for specialization in these areas could represent a deep social change towards health care, including broader cultural transformations. 1,2,6,12,21ther medical rationalities, such as homeopathy and traditional Chinese medicine, and therapeutic practices centered on patient care and health promotion, which encourage their autonomy, facilitate better doctorpatient relationship and stimulate patients' self-healing mechanisms, have been valued. 9,12,18They can contribute for the family health strategy to strengthen its role in the art of healing and health care, disease prevention and health promotion.
The difference in medical professionals' and nurses' interest in CIT in the present study probably occurred due to the fact that doctors rely more on and justify their professional practice according to biomedicine and its great number of drugs, whereas nurses could expect to use non-biomedical therapies to better care for their patients.This fi nding is in accordance with other studies that emphasize nurses' greater openness towards CIT. 5,18meopathy and acupuncture are the most valued CIT present in the city's HCs, which is in accordance with other countries.However, qualifi ed professionals do not always have the time, space or authorization to perform such therapies, so that many do not do this in the ESF.In the open-ended question of the questionnaire, these professionals reported that acupuncture needles and homeopathic drugs had not been provided and professional qualifi cation had not been encouraged by the Municipal Department of Health.The inexistence of a municipal policy or institutional support for these practices, at the time of this study, partly explains the low level of CIT present in the ESF in the city of Florianópolis.
The use of medicinal plants is a disseminated popular practice, within reach of the majority of individuals.Professionals' lack of knowledge about these practices probably determines the absence of encouragement for their use.Qualifi cation of Family Health teams to use and handle medicinal plants seems to be a measure that should be taken by municipal managers (and the institutions that offer professional qualifi cation) to provide professionals with knowledge about their effi cacy and safety and to involve the communities to recover the cultural aspects of their use.This would enable other therapeutic options.
It was observed that 43.5% of the doctors studied were specialists in Family and Community Medicine and that 12.4% were specialists in homeopathy and/or acupuncture.These percentages are probably higher than those in the rest of the country (although researchers of the present study do not know any studies that deal with this).This may result from the fact that the specialization in Family and Community Medicine or Public Health is more valued in the city's public examinations, something that has been occurring for many years.This could be refl ected in the results, which may hardly be extended to other cities as a consequence.On the other hand, this suggests that a medical qualifi cation with a specialization in primary health care (Family and Community Medicine) can interfere with these results, because there seems to be an elective affi nity between CIT and this medical specialty.McWhiney 13 indicates that Family and Community Medicine provides access to CIT, because there is an overlapping of the values shared by both: an emphasis on an individual's diagnosis, rather than the disease alone; the search to understand the biological, psychological and social dimensions and their interactions; valuing of the health belief system; and emphasis on the development of a cooperative relationship with patients.
There could have been an induced effect of "politically correct" responses, once the theme of complementary therapies has a certain evidence in the media, due to positive social valuing and the PNPIC being passed.This could result in overestimation of professionals' openness towards and sympathy for the theme.Nonetheless, the internal consistency and convergence of results with international studies indicate coherence of the fi ndings of the present study.
The offer of multiple therapeutic and care options through complementary and integrative practices is a possibility in Brazilian cities and a reality in several of them, encouraged by the PNPIC. 7,14The results of the present study suggest that there is support from ESF doctors and nurses of the local health network of Florianópolis to implement CIT.Such support can exist on a signifi cant level in other Brazilian cities and an important fi rst step could be made if managers surveyed this to develop local policies in a sustainable way, as these can provide complementary therapies in the SUS.
New studies on this theme must be conducted in Brazil, and measures to implement the offer of CIT in the SUS must be taken in a democratic, participative and co-responsible way among managers, professionals and City Health Councils.

Table 1 .
Distribution of the sample according to ESF doctors' and nurses' position on complementary and integrative therapies.Florianópolis, Southern Brazil, 2008.

Table 2 .
Association between exposure variables and ESF doctors' and nurses' interest in complementary and integrative practices.Florianópolis, Southern Brazil, 2008.
ESF: Estratégia Saúde da Família (Family Health Strategy); CIT: Complementary and Integrative Therapies; HC: Health Center a Chi-square test b Fisher's exact test

Table 3 .
Association between exposure variables and agreement with the inclusion of complementary and integrative therapies in the SUS.Florianópolis, Southern Brazil, 2008.
SUS: Sistema Único de Saúde (Unifi ed Health System); CIT: Complementary and Integrative Therapies; HC: Health Center a Chi-square test b Fisher's exact test plants had similar proportions of referrals.Referring one to acupuncture was more prevalent than the other categories, when 2/3 of cases were sometimes or always referred (Table

Table 4 .
Distribution of the number and percentage of ESF professionals, according to the level of recommendation/referral or prescription of complementary and integrative therapies.Florianópolis, Southern Brazil, 2008.those about acupuncture and homeopathy, which are medical specialties.ESF professionals of Florianópolis recognize this reality and are in favor of the inclusion of CIT in courses in the area of health.