Diplomarbeit

Use of Complementary and Alternative Medical Methods in Turkey

zur Erlangung des akademischen Grades Doktorin der gesamten Heilkunde (Dr.med.univ.)

an der Medizinischen Universität Wien

ausgeführt am Universitätsklinik für Innere Medizin I

unter der Anleitung von Ao.Univ.-Prof. Dr.med.univ. Michael FRASS

eingereicht von

Ebru Yalcin

0109368 ______Wien, Juni /2019

Contents

Contents ...... i

List of Figures ...... iv

List of Tables ...... iv

Zusammenfassung ...... 5

Abstract ...... 6

1. Introduction ...... 7

Complementary and Alternative Medicine: Definition and terminology...... 8

2. Background ...... 11

2.1. Healthcare in Turkey ...... 11

2.1.1. Development of healthcare system in Turkey ...... 11

2.1.2. Current healthcare system in Turkey ...... 14

2.2. Official regulations on CAM ...... 18

2.2.1. Official regulations on CAM around the world ...... 18

European Union and related countries ...... 18

United States of America ...... 19

China ...... 20

2.2.2. Official CAM regulations in Turkey ...... 22

2.3. CAM Methods ...... 24

CAM Methods Under Regulation ...... 26

2.3.1. Acupuncture...... 26

2.3.2. Apitherapy ...... 28

2.3.3. Hypnosis ...... 30

2.3.4. Phytotherapy ...... 31

2.3.5. Leech application ...... 34

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2.3.6. Homeopathy ...... 35

2.3.7. Chiropractic ...... 38

2.3.8. Cupping ...... 40

2.3.9. Maggot application ...... 41

2.3.10. Mesotherapy ...... 42

2.3.11. Osteopathy ...... 43

2.3.12. Ozone therapy ...... 44

2.3.13. Proloterapi ...... 46

2.3.14. Reflexology ...... 46

2.3.15. Musicotherapy ...... 47

Some other CAM methods ...... 49

2.3.16. Bioresonance ...... 49

2.3.17. Emotional Freedom Technique ...... 49

2.3.18. Hot Springs ...... 51

2.3.19. Massage ...... 52

2.3.20. Neural Therapy ...... 52

3. A County in the Aegean Region of Turkey: Akhisar ...... 52

General characteristics of Akhisar ...... 53

Health services in Akhisar ...... 53

4. Methods ...... 55

Sample ...... 55

Data Acquisition and data analysis ...... 55

Ethical approach ...... 56

5. Findings ...... 57

5.1. Prevention of diseases and approach to the diseases ...... 57

5.2. Current conditions of the participants ...... 58

5.3. Past experiences or indirect experiences of participants with CAM ...... 61

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5.4. How participants approach to CAM methods and their habits of use ...... 74

5.5. Ways to learn about CAM ...... 75

5.6. CAM and money/finance/insurance ...... 75

5.7. Satisfaction with CAM methods ...... 76

5.8. Recommending CAM methods ...... 77

5.9. CAM and modern medical methods ...... 77

5.10. Some CAM methods used by participants ...... 77

Phytotherapy ...... 77

Neural therapy ...... 82

5.11. Views of Professionals on CAM ...... 84

E-13: Internist ...... 84

E-14: Manipulation and orientation specialist ...... 92

E-15: Family practitioner ...... 97

6. Results ...... 100

7. Discussion ...... 102

8. References ...... 107

9. Acronyms and Abbreviations ...... 122

10. Appendix ...... 124

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List of Figures

Figure 1 Diagram of Healthcare services.12(P-21) ...... 15 Figure 2 Shifts in Health and Healthcare Services.22(P-46) ...... 16 Figure 3 The EFT Tapping Points179(P-How to do the EFT Tapping Basics - The Basic Recipe-The EFT Tapping Points) ...... 50

List of Tables

Table 1 Disease-Treatment ...... 59 Table 2 CAM/Satisfaction ...... 62 Table 3 Characteristics of Participants (2014) ...... 106

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Zusammenfassung

Das Ziel der Studie ist das Wissen und Verhalten der Menschen in der Türkei in Bezug auf komplementäre und alternative Medizin (CAM) zu bestimmen.

In dieser qualitativen Studie wurde eine Umfrage zu den Meinungen der Teilnehmern über CAM-Methoden und Anwendungsgewohnheiten für diese Methoden in der Türkei durchgeführt. Die Personen mit verschiedenen sozioökonomischen Niveau aus Zentrum von Akhisar-Manisa sind eingeschlossen. Den Teilnehmern (6 Frauen, 6 Männer im Alter von 19-64 Jahren; 3 Angehörige der Gesundheitsberufe) wurden Fragen aus einem halbstrukturierten Fragebogen in türkischer Sprache während eines Interviews von Angesicht zu Angesicht gestellt und das Interview wurde als Audiodatei aufgezeichnet. Anschließend wurden diese Audiodateien transkribiert, mit Hilfe einer Software (MAXQDA 11, Demo Version, erreichbar auf http://www.maxqda.com) analysiert und die relevanten Teile ins Englische übersetzt.

Die zu Hause anwendbare und traditionelle Methoden, insbesondere Kräuterrezepte, sind sehr beliebt. Das Beten wird in jeder Phase von Gesundheitsproblemen angewendet.

Höheres Bildungsniveau und Internetnutzung erhöhen die Kenntnis und Verwendung vielfältiger CAM-Methoden.

Frauen interessieren sich für CAM mehr als Männer.

Die Kosten beeinflussen Bevorzugung oder Beendigung einer CAM-Methode.

Das CAM-Wissen und die CAM-Nutzung der Teilnehmern unter 20 ist sehr begrenzt.

Personen mit chronischen oder ungelösten Gesundheitsproblemen verwenden mehr CAM- Methoden als diejenigen ohne. Diese Patienten mit chronischen oder ungelösten Gesundheitsproblemen sind auch die am meisten Unzufriedenen.

Die meisten Menschen, die zu Hause CAM-Methoden verwenden, sind in der Regel zufrieden.

Alle an dieser Studie teilgenommene Experten sind der Meinung, dass CAM im Lehrplan der medizinischen Fakultäten einen Plaz haben sollten.

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Abstract

The aim of the study is to determine the knowledge and behavior of people in Turkey for complementary and alternative medicine (CAM).

In this qualitative study, a survey was conducted on participants’ opinions on CAM methods and usage habits for these methods in Turkey. The persons of different socioeconomic level from the center of Akhisar-Manisa are included. Participants (6 women, 6 men aged 19-64, 3 health professionals) were asked questions from a semi- structured Turkish questionnaire during a face-to-face interview, and the interview recorded as an audio file. Subsequently, these audio files were transcribed, analyzed using software (MAXQDA 11, demo version, accessible on http://www.maxqda.com) and the relevant parts translated into English.

The home-usable and traditional methods, especially herbal recipes, are very popular. Praying is used in every phase of the health problems.

Higher education level and Internet usage, increase the acquaintance and use of diverse CAM methods.

Women are more interested in CAM than men.

The costs affect preference or termination of a CAM method.

The CAM knowledge and the CAM usage of participants under 20 is very limited.

People with chronic or unresolved health problems use more CAM methods than those without. The Patients with chronic or unresolved health problems are also the most dissatisfied reported. Most people who use CAM methods at home are usually satisfied.

All experts participating in this study believe that CAM should have a place in the medical faculty curriculum.

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1. Introduction The aim of this study is to determine the knowledge and behavior of the individuals in Turkey about complementary and alternative medicine (CAM).

Every civilization has created their own solutions to live healthy or heal disease, in accordance with their own social characteristics, beliefs, and geographical, cultural and financial potentials.1 And Turkish people have an old tradition of folk medicine. Folk medicine was the first option for Turkish people against illness, especially before the modern structuring of the health system. As a result, sometimes they apply what they have learned from the elder members of the family, and sometimes they ask for help from individuals called herbalist, bone setter or folk healer.2

In today’s conditions, besides visiting a hospital or a physician, obtaining the prescribed medicine from the pharmacy, and using it, Turkish people also try methods they have learned from before, or have heard from someone or have read somewhere.1

According to Alptekin, folk medicine is a healing method used from the very beginning of human existence and today it steps in and offers its own healing when solutions of the modern medicine are consumed. There are many folk literature works such as epics, legends, jokes, and stories that talk about stories and even recipes of folk medicine and thus, the fund of knowledge about folk medicine continues to pass to future generations.3

Along with the value Turkish people bestow upon their own folk medicine, they are also interested in the knowledge accessed from the folk medicine heritage of other cultures, and new methods formed by combining scientific methods with these ancient methods. An example for the former is the Traditional Chinese Medicine (TCM), and examples for the latter are homeopathy and neural therapy.

This study combined all this variety under the term CAM, and investigated how these methods are perceived and used by individuals in Turkey. In the first part discussed how CAM is described and named around the world and in Turkey.

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Complementary and Alternative Medicine: Definition and terminology

Today, the term Complimentary and Alternative Medicine refers to all practices and schools that are related to health, excluding the main medical education offered in the universities of developed countries, and the healthcare services offered by professionals that have undergone that education.

CAM definition of National Center for Complementary and Integrative Medicine (NCCIH) is: “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”4

As mentioned in the introduction, the most part of the CAM usage among Turkish people consists of the folk medicine practices. Therefore, in this study, the term complementary and alternative medicine (CAM) -as in the World Health Organisation’s (WHO) description-:

“refers to a broad set of health care practices that are not part of that country’s own tradition and are not integrated into the dominant health care system. (And)… used inter-changeably with traditional medicine.”5

The term complementary refers to the methods that are used in parallel/along with the modern medical practices, while the term alternative refers to the medical practices that are used in place of the modern medical practices.4,6

Belbez states that the term alternative medicine refers to the rebellious movement in the 1960s against the scientific medicine, and to the methods that are used for this purpose.7 However, she points out that although people used these methods, they did not adopt that rebellious movement and therefore the term alternative medicine has gone through a change in the meaning throughout time. According to Belbez, the academic medicine, which does not accept any alternative in its place, has preferred to use the term complementary medicine, on the basis of people’s tendency to use the alternative medicine methods together with the modern medicine methods. As a result, as people continue to use the term alternative medicine, and the academia continues to use the term complementary medicine, the most commonly used term CAM was formed.7

The academic/modern medicine that was formed with scientific methods did not emerge in one day. In fact, compared to the ancient methods humans have developed or discovered

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throughout centuries from the very first day when they searched for cures for their illnesses, that is for thousands of years, modern medicine that has a history of only 300 years and has many methods which have not been tested enough yet can be, according to a point of view, described as an alternative medicine.8

In recent years, as some of the CAM methods are being included in the system by the conventional medicine, the term integrative medicine is also being used frequently. For example, National Center for Complementary and Alternative Medicine (NCCAM) has changed its name as National Center for Complementary and Integrative Health (NCCIH) on November 17, 2014. The explanation on the website regarding this change is as follows:

“Since the Center’s inception, complementary approaches have grown in use to the point that Americans no longer consider them an alternative to medical care… The goal of an integrative approach is to enhance overall health, prevent disease, and to alleviate debilitating symptoms such as pain and stress and anxiety management that often affects patients coping with complex and chronic disease, among others.”9

Stanway explains when the 'turning point' for integrative medicine will be achieved as follows:

“when the alternative therapies are accepted as the first class therapies in their own fields, and when they are no longer the meeting point of people who could not be treated and thus were given up on by the modern medicine.”8

And he supports that just as the developing countries are beginning to utilize the modern medicine along with folk medicine, the western people should also be able to utilize the alternative medicine.8

In Turkey where modern medicine has become more easily accessible because of the development of the institutional structure, the increasing interest to CAM methods among both health care professionals and the public seem to be a contradiction. Similar trends can also be observed in developed Western societies. In view of the Porter and McWhinney’s views that “the scientific paradigm shift -defined by Kuhn- is happening also in medical science”7, Belbez in her work titled 'The CAM Movement' associates the increased interest to CAM methods with this paradigm shift.7 Kuhn suggests that science advances with

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radical changes and ruptures countering to the view that “science progresses in a linear fashion” which was commonly-held until then, and explains these ruptures by “the paradigm shift”.10 According to Kuhn, a scientific paradigm that cannot respond to certain problems gradually displaces itself to another paradigm.10 From this point of view, the search for alternative solutions of individuals who cannot find solutions from the modern medicine within the current system or does not prefer modern medical solutions for some reason, and that this search is becoming widespread throughout society may also point to a paradigm shift.

The reason the term CAM has been used in this study is that, it is commonly being used by the practitioners and academicians around the world and in Turkey in general. Some researchers are concerned that the term alternative therapy could be misunderstood as “two different methods bringing out more or less the same result with equal success”11, and they prefer to use the term non-proven instead of the term alternative. Despite academia is hesitant regarding adopting the term alternative, many studies in Turkish use the term TAT that is the literal translation of the term CAM because it is the term that is commonly being used.

Based on the statements used by the individuals who participated in this study during interview, we can conclude that people use the term modern medicine for the conventional medicine or academic medicine and as in Stanway’s definition, for all other methods apart from this main school, they use the term alternative medicine 8. Again, even though people use the alternative methods together with and to complement the therapies of the modern medicine, they do not use the term complementary method much.

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2. Background

2.1. Healthcare in Turkey

Before studying the CAM methods more closely, understanding the development and current state of the healthcare system in Turkey will help to understand Turkish people’s attitude towards CAM, and the reasons of changes in this attitude, if any.

2.1.1. Development of healthcare system in Turkey

According to Top, along with the practices for diagnosis, treatment, and rehabilitation of diseases, Healthcare services also covers all activities towards preventing disease and improving the health of the society and individuals. To eliminate the factors that are harmful to human health, to protect the society from these factors, rehabilitation of the individuals with reduced physical and psychological skills and abilities are also within the scope of Healthcare.12

According to the 'Health Transformation Program Report' published by the Ministry of Health in 2008 healthcare policies enforced in Turkey can be studied in six periods:

“1920-1923: Post-war structuring.

1923-1946: “Vertical organization period” where the main regulations were developed.

1946-1960: The period when the number of institutions were increased and centralization started, and the medical profession laws were established.

1960-1980: Structuring period when welfare centers, community clinics, district and city hospitals were built (Socialization)

1980-2002: The period of theoretical reform efforts.

2003-2011: The period of “Health Transformation Program in Turkey.”13

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Historical development of Healthcare in Turkey can be summarized as follows according to the publication of Ministry of Health titled 'Health Transformation Program in Turkey and Basic Healthcare Services'14:

Shortly after the establishment of Turkish Grand National Assembly, the Ministry of Health was established with the law number 3 on May 3, 1920 and as a main task, the Ministry worked to eliminate the post-war health problems; therefore no orderly records could be kept during this period. In 1923, healthcare in Turkey was very limited, being provided in government, municipality and quarantine offices, small health offices etc., with a treatment facility of 86 beds, and a total of 6,437 sickbeds, 554 physicians, 69 pharmacists, 4 nurses, 560 health officers and 136 midwives.

On December 12, 1946, the 'First Decennary National Health Plan' which was considered as the first written health plan of the Turkish Republic was approved by the Supreme Council of Health, however it could not be legislated and enforced for political reasons.

On December 8, 1954, 'National Health Program and Studies on Health Bank' was announced and with this plan, structuring of 16 health regions with a medical faculty in each, and increasing the number of healthcare personnel was aimed.14

Here are some numbers regarding the development of healthcare in Turkey from the same source:

“Compared to 1950, in 1960 the number of physicians increased from 3,020 to 8,214, the number of nurses increased from 721 to 1658, and the number of midwives increased from 1,285 to 3,219.

In 1950, there were 14,581 beds in 118 institutions connected to the Ministry of Health, while in 1960 this number increased to 32,398 in 442 institutions. In 1950 there were 9 beds for every 100,000 people, and in 1960 this number increased to 16.6.”14

During these years, improvements were observed in the general health indicators of Turkey. In 1946, 'the Directorate of Workers’ Insurance (Social Security Institution)' was established, and beginning 1952, health institutions and hospitals started to be founded for the insured workers.14

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Also, some regulations forming the basis of the legal structure of healthcare were established during this period:

“Law of Turkish Medical Association (1953/6023) Law of Pharmacists and Pharmacies (1953/6197) Nursing Law (1954/6283) Law of Turkish Pharmacists’ Association (1956/6643).”14 In 1961, 'Law on Socialization of Healthcare Services' was made however the work on this subject started in 1963 and was spread to the whole country in 1983.14

“With an approach of a widespread, continuous, integrated and gradual structure that is integrated within the city, welfare centers, community clinics, municipality and city hospitals were constructed.”14

In 1967, a draft law was prepared for the 'General Health Insurance'. However, even though it was brought to the Parliament’s agenda many times, it could not be actualized until 2000 for political reasons.14

At the beginning of 2003, the Ministry of Health prepared and announced the Health Transformation Program. The goals of this program were to reconstruct the general health insurance, establish the family practice system, offer high quality healthcare services that are widespread and easily accessible, increase the number of educational and scientific institutions to provide enough healthcare professionals, a rational management system for pharmaceuticals and materials, and to establish the health knowledge base system.14

When evaluating the community health, three important parameters are: life expectancy at birth, life expectancy at the age of 65, and infant death rate. In order to evaluate the evolution of community health in Turkey, we can look at the changes of these values in years. According to the related 'Organisation for Economic Co-operation and Development' (OECD) indicator, life expectancy at birth has increased from 48.3 in 1960 to 78 in 2014. The upsurge of 1.8 points between 1989-1990 and 3.4 points between 2012- 2014 are remarkable.15 Again according to another OECD indicator, life expectancy at the age of 65 was increased steadily between 1960 and 2012, and for men it increased from 11.4 to 14.1, for women it increased from 12.1 to 16.1. This parameter has seen a remarkable increase in the following two years, and increased to 16.2 for men and 19.4 for

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women in 2014.16 Infant mortality rate was, according to World Health Organisation (WHO) statistics, 55.7 in 1000 live births in 1990, while it decreased to 16.5 in 1000 live births in 2013.17 Maternal death rate, another important parameter, was 48 in 100,000 live births in 1990, 33 in 2000, while it decreased to 20 in 2014.17

Here some other indicators from the '2014 Health Statistics Yearbook of Turkish Republic Ministry of Health' are:18

Vaccination rate for third dose of combined vaccine (DaBT+IPA+Hib) in Turkey increased to 96% in 2014 from 78% in 2002. Measles incidence was found to be 11.8 in 100,000 in 2002 and 0.5 in 100,000 in 2012. Tuberculosis incidence was 33 in 100,000 in 2002, while in 2013, it is 20 in 100,000.18 In 2002, malaria incidence was 15.4 in 100,000 while in 2012 it is 0,5 in 100,000.

Along with these positive indicators, non-infectious diseases (NCDs) are estimated to account for 89% of total deaths.19

In 2014, 19.9% of individuals over 15 were obese (Body Mass Index (BMI) ≥30kg/m2), and 33.7% were overweight (BMI ≥25 kg/m2).20

Satisfaction rate, one of the important parameters in evaluating the improvements in the healthcare in Turkey was 39.5% in 2003, while in 2015 it increased to 72.3%.21

2.1.2. Current healthcare system in Turkey

In Top’s study, the main type of Turkish healthcare system was described as the healthcare system type of developing/middle income country. According to Top, in Turkey,

“public sector is the main player in supply and demand of healthcare services. Private health insurance businesses and private sector is working to play a bigger part in the system. Supply and demand of healthcare services has a complicated structure and multi-headedness. General Health Insurance has been put into practice.”22

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The institutions providing health care services in the study of Top12 are shown as follows:

Types of Healthcare Services and Institutions Providing These Services

HEALTHCARE SERVICES

PREVENTIVE REHABILITATION IMPROVEMENT OF TREATMENT SERVICES HEALTHCARE SERVICES SERVICES HEALTH

Rehabilitation Center Health Education Inpatient Treatment For Individuals For Environment Same-day Outpatient Center Services Nursing Care Center Home Care Community Clinic Hospital Maternal and Infant Health Welfare Center Department of Private Practice Sport Facilities Environmental Health Hospital Nursing Community Clinic Hospital Clinic Fittness Club Community Health Lab. Care Center Center for Maternal and Emergency Department Terminal Period Care Infant Health Community Clinic of Hospital Ambulatory healthcare School Health Outpatient Surgery Ser. Service Ambulatory Healthcare Home Care Dep. Infirmary Dialysis Center Hospital Hospital

Institutions Providing Holistic Health Care: (Managed Care) (Health Maintenance Organizations HMO, Preferred Provider Organizations PPO, Physician Hospital Organizations)

Figure 1 Diagram of Healthcare services.12(P-21)

After the changes implemented with the Health Transformation Program between 2003- 2011, today all population under 18 and students are covered by the General Health Insurance. Primary Healthcare, 112 emergency services and emergency and intensive care treatments in all hospitals are provided free of charge. With the Green Card given to poor citizens, healthcare services and medication within the scope of outpatient treatments are provided free of charge by the government. Also, Green Card holders can receive dental canal and filling services for free, and can get medication from common pharmacies.13

“All Turkish citizens whose contribution is not paid by the government (unlike Green Card) have to get registered in the social insurance system and make contributions”.13

In order to perform the tasks of manufacturing of pharmaceuticals, their storage, and supply to the consumers in a safe and reliable manner, the Ministry of Health is deploying

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the Pharmaceuticals Tracking System (ITS) to monitor every step the drugs go through and to prevent fraud and release of fake and illegal drugs into the market.13

With the Central Hospital Appointment System, patients can make appointments with public hospitals and family practitioners via telephone or the internet. In accordance with Full-Day Law, physicians work full day in public and training hospitals and they cannot work in private institutions or offices. With this law, the necessity of the patient to visit the doctor’s private office or the private hospital he works in order to receive a better service is eliminated. To ensure fair access to health services, 2 years government service is obligatory for all physicians.13

The change in concepts related to healthcare services throughout this process was demonstrated as follows in Top’s study:12(P-46)

Shifts in Health and Healthcare Service Concepts

Old New

Paternal Fellowship

Personal service Team approach

Intervention Prevention

Clinical service Clinical service + education / social missions

Hospital Home care, etc. Priority for elites Justice

Figure 2 Shifts in Health and Healthcare Services.22(P-46)

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According to the report on health sector of an association, “there are over 1,400 hospitals serving in Turkey, 34% of which being private hospitals.”23

According to other figures we learn from this report 48% of private hospitals and 56% of private beds are in one of the cities of Istanbul, Ankara or Izmir. 59% of working doctors in Turkey work in public hospitals under the Ministry of Health and 20% work in private sector. Again, according to the evaluation in this report, private initiative investments in health sector increases and the health system is liberalized.23

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2.2. Official regulations on CAM

2.2.1. Official regulations on CAM around the world

This section covers the CAM regulations around the world. As reviewing official regulations in every country is outside the scope and aim of this study, some select countries were studied. Since Turkey is an European Union (EU) candidate, general information regarding CAM regulations in EU and related countries were presented. Regulations USA, where the modern medicine is quite developed and besides, some of the CAM methods take place in their health systems according to the integrative medicine approach. Finally, because TCM is widely known and used around the world, general information about regulations on CAM in China were presented.

European Union and related countries

In CAMbrella’s database, it is possible to access current and detailed information on CAM in European Union and related countries. CAMbrella is “A pan-European research network for Complementary and Alternative Medicine (CAM).”24 CAMbrella Work Package 2 reviews the legal status of CAM in all 27 EU member states and in 12 associated states (later expanded with two additional countries).

According to this study:

“From EU member countries, Belgium, Denmark, Germany, Portugal, Hungary, Slovenia and Romania, the EFTA [European Free Trade Association] countries Iceland, Lichtenstein and Norway, and from candidate countries, Serbia have CAM laws.”24

From EU member countries Malta and Bulgaria, EFTA country Switzerland, the EU candidate countries Macedonia and Albania and potential EU candidate country Bosnia & Herzegovina have general CAM legislation in their health laws.24

According to the same study:

Belgium, Germany, Portugal and Denmark, in addition to CAM law, have regulations on specific CAM treatments.

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The EU members Austria, Finland, France, Greece, Italy, Luxembourg, Spain, Sweden, UK (United Kingdom), Cyprus, Czech Republic, Estonia, Latvia, Lithuania, Poland and Slovakia have regulations on specific CAM treatments.

From EU member countries, Ireland; from candidate EU member countries, Croatia and Montenegro have no CAM regulations. However, Bosnia & Herzegovina and Montenegro have CAM laws in progress.24

In Denmark, a volunteer registration system for CAM practitioners who do not have medical certification was established with a law accepted in 2004. According to this system, a CAM practitioner who is a member of one the officially recognized CAM institutions can use the title registered alternative practitioner along with his/her own CAM title. Professional communities of CAM practitioners can have the authority to offer certificates provided they meet the specific requirements of the members, supreme court of the CAM method and educational system.25

United States of America

In the United States of America, licensing schemes, laws, regulations, courts and juridical documents that interpret all, differ from state to state.26

Cohen says that these differences are related to “who gets the license, what the practitioners are legally allowed to do, the training required for each profession, and the license type for each practitioner.”26

The options to become a legal CAM applicant in the USA (United States of America) can be summarized from Cohen’s presentation as follows:27

Mandatory licensure: practitioners have to get a license for providing a service and, practicing the profession without a license is prohibited. Title licensure: practitioners have to get credentials before using a professional title. Also, practicing the profession without a license is permitted, but one may not use the designated title without a license. For example, no one may use the title “massage therapist” without a license. Registration: practitioners have to provide the details of name, address, training and experience to a state consumer protection agency.

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Exemption: A certain class of providers may not need any licensure or registration. For example, religious healers can practice without any official labeling as long as they are practicing under the roof of an officially recognized church. Shiatsu practitioners and reflexologists may not be subject to any license to perform massage therapy. 27

Cohen mentions Minnesota model in this presentation too:

“In Minnesota CAM practices are not licensed, however there is an 'Office of Unlicensed Complementary and Alternative Health Care Practice' (OCAP).”27

The unlicensed CAM practitioners in Minnesota may not provide a medical diagnosis, perform surgery, give or dispense prescription drugs or controlled substances, set fractures, give injections, draw blood, or otherwise puncture the skin, use certain medical devices, perform x-ray radiation, manipulate or adjust joints or the spine and any practice included in dentistry. There are more detailed regulations about unlicensed CAM practitioners in '2016 Minnesota Statutes CHAPTER 146A’.28

Acupuncturists, chiropractors, traditional midwifes, nutritionists, osteopaths are licenced, naturopathic doctors, and doulas are registered practitions in Minnesota.28

China

In China, traditional Chinese medicine co-exists with modern medicine.29

As cited from the State Council Information Office in the study of Meng Q et al. : “Some 75.6% of community health centres, 51.6% of community health stations, 66.5% of township hospitals and 57.5% of village clinics are able to deliver TCM services.”30

Again, in the same study, the following information was provided about regulations:

“by end of 2014, there have been 11 health laws and 38 administrative regulations promulgated by the State Council. The major health authorities at the state level in China are the 'National Health and Family Planning Commission' (NHFPC) and the 'State Administration of Traditional Chinese Medicine' (SATCM) overseen by the NHFPC.”30

The SATCM is responsible for the development of traditional Chinese medicine.30

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'State Council of the People’s Republic of China' defines tasks for the state, as to give equal weight to TCM and western medicine, to support and to develop multi-faceted TCM, to encourage both medical schools to learn from each other and complement each other, and to ensure the integration of these two medical systems, in Article 3 of the regulation dated 7 April 2003.31

Also, according to the Article 9, when TCM becomes a resident institution in health services, it shall use the characteristics and advantages of traditional Chinese medicine fully and will monitor its development and combine traditional theories and practices with modern science and technology. TCM will launch its role in preventive medicine, health care and rehabilitation and will provide high quality TCM services to people at affordable cost.31

And according to the Article 11, a TCM practitioner or a person who has learned TCM through master-apprentice relationship or who can prove his / her competence in TCM must complete the license examination and registration procedures required by the government to practice TCM.31

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2.2.2. Official CAM regulations in Turkey

Scientific researches on CAM in Turkey first started in 2003, in the 'Complementary and Alternative Medicine Department' opened within the body of 'University of Istanbul Oncology Institution'.32

In 2011, because of the need of official regulations on this subject, 'Ministry of Health' was authorized under a delegated legislation. According to that legislation, 'Ministry of Health' makes the regulations related to traditional, complementary and alternative medicine, grants permission to all practices with a health claim and inspects them, stops all activities and promotions that do not comply with the regulations and permissions.33

Again, according to the same delegated legislation, the ministry and subsidiaries can make administrative arrangements that fall within their work, authority and responsibility areas.33

On the basis of this delegated legislation, the 'Department of Traditional, Complementary and Alternative Medicine Practices' was founded within the body of 'Directorate General for Healthcare Services'.

As a result of the efforts of this institution, the aim of the 'Traditional and Complementary Medicine (GETAT) Practices Regulation' published in the official gazette on 27 October 2014 is:

“to identify traditional and complementary medicine practice methods for human health, to arrange training and authorization for the individuals who will practice these methods and establish the working principles and procedures of the healthcare institutions where these methods will be applied.”34 'The Ministry of Health' has also published a translated version of this regulation on its website.35 If we quote from this version, this regulation, as stated in 'ARTICLE 2-(1)', covers the healthcare institutions that belong to the public and private legal persons and the natural persons and the institutions where traditional and complementary medicine practices will be practiced, and the individuals who will apply the methods in these institutions.35 Again, according to the related article '(ARTICLE 10-(2))' of this regulation:

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“A department can be founded, within the scope of planning, for the practices approved by the Ministry on condition that they will be applied to those who stay in the facility and have only received acute treatment in the accommodation facilities licensed by the Ministry of Culture and Tourism.”35

Following this clause and in the other clauses of the same article, regulations were made on recording CAM practices applied in these facilities by creating a patient file, reporting adverse events to the Provincial Directorate of Health every month, having informed consent forms and information forms signed.35

Again, inspection of the institutions who practice CAM methods also regulated in detain in the articles 16, 17 and 20 of the same 'GETAT Regulation’.35

According to the related article '(ARTICLE 13-(1))' of the 'GETAT Regulation', certified trainings under the scope of this regulation are provided by the centers who are authorized by the Ministry to provide these trainings.35

Also, a circular has issued by 'Turkey Pharmaceuticals and Medical Devices Agency' which affiliated with the 'Ministry of Health' to regulate the herbal product sales. In this circular, the terms of sale and preservation of these generic herbal products are specified.36 In addition, has issued a list of 38 plants, 33 inorganic, organic and other substances prohibited to be sold in seller of medicinal herbs, spice store and similar stores.36

As of 2017, the 'Ministry of Health' published a website at 'http://getatportal.saglik.gov.tr/' where all information regarding CAM were released. Also, training standards for 15 CAM methods that are covered in the 'GETAT Regulation' were determined and published in this same portal.37

Efforts for integrating CAM methods to the healthcare services nationwide continue in Turkey. During this process, possible collaboration with South Korea, one of the countries in the world that has integrated CAM methods into their healthcare system and using them effectively was raised and some meetings were held for this purpose.38

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2.3. CAM Methods

According to Stanway, since the modern medicine education mandates a diagnosis to heal diseases, a doctor who cannot name what he faces cannot treat that disease, he can only reduces the symptoms and feels inadequate.8 However, most of the alternative medicine systems do not necessarily need to diagnose the disease, but take the problems of the person as the starting point, and by applying the methods, aim to help body to find its own balance and heal.

Among physicians who studied modern medicine, there has always been the ones who are interested in CAM methods and folk medicine and placed them at the center of their work. For example, Tombak has compiled the natural methods he believed are the most effective among the treatments he applied during his practice as a physician in his book called 'With the Pharmacy of Nature, There Is No Illness That Can’t be Healed'.39 As the first information, just as the modern medicine advises, he mentioned that no one died from eating moderately, but contrarily, eating too much causes many early deaths. The author emphasizes that having a simple and natural diet is the key to the health.39

CAM methods are used by most individuals to heal or to help heal their illnesses or conditions. In fact some of these methods center around preserving the health. Some of the alternative methods aim to remove the blockages preventing the individual to heal physically and/or spiritually, therefore preserving/regaining the healthy state.

For example, the main assumption of the Traditional Chinese Medicine (TCM) is that every person is born with the ability to heal himself/herself and according to the TCM, human body, as an organic whole, has an indivisible relationship with the nature and the universe.40

If we have a closer look at the CAM methods, evaluating the methods most widely known and used will offer a good starting point. According to 'CAMbrella WP 2 final report part 2'24, numbers regarding CAM methods that are regulated in countries are as follows:

“Acupuncture is regulated in 26 countries, anthroposophic medicine in 7 countries, Ayurveda in 5 countries, chiropractic in 26 countries, herbal medicine/phytotherapy in 10 countries, homeopathy in 24 countries, massage in 20 countries, naprapathy in

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2 countries, naturopathy in 8 countries, neural therapy in 3 countries, osteopathy in 15 countries, and finally traditional Chinese medicine in 10 countries.”24

If we look at the classification of CAM methods by NCCIH, we see a classification of 5 in the previous years as “alternative medical systems, biologically based therapies, manipulative and body-based therapies, mind-body therapies and energy healing therapies.”4 At present, NCCIH has a classification of three for the complementary and integrative medicine methods: “mind and body practices”, “natural products”, and “other complementary health approaches.”4

According to 'National Health Statistics Reports 2012', with a rate of % 17,7, nonvitamin, nonmineral dietary supplements were the most commonly used complementary health approach durig the past 12 months. Deep breath therapy takes the second place with 10.9%. Yoga, tai chi and qi gong together is the third most frequently used complementary health approach with 10.1%. The methods following the first three are: chiropractic or osteopathic manipulation with 8.4%, meditation with 8.0%, massage therapy with 6.9%, special diets with 3.0%, homeopathic treatment with 2.2%, progressive relaxation with 2,1%, guided imagery with 1.7%, acupuncture with 1.5%, energy healing therapy with 0.5%, naturopathy with 0.4% and hypnosis, biofeedback and Ayurveda with 0.1% each.41

As the subject of this qualitative study is the use of CAM methods in Turkey, detailed explanation of all CAM methods applied around the world does not comply with the scope and purpose of the study. Therefore, presenting general information primarily about methods that are covered by the 'GETAT Regulation' and also some methods mentioned during the interviews is found appropriate. The methods mentioned more frequently during the interviews are covered in more detail. The researcher believes that having CAM methods that are evidence-based, whose trainings are offered and that could be applied by the specialists widespread and supported by the health authority, will offer a safe option for the public’s quest for alternative methods in health practices. Some traditional applications and religious rituals the participants consider within the scope of CAM but are mostly used in the ancient times are considered as subject of another study, however they were mentioned when giving the experiences of the participants.

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CAM Methods Under Regulation

CAM methods covered by 'GETAT Regulation' are acupuncture, apitherapy, phytotherapy, and hypnosis. In Appendix 3 of this regulation, the 'Health Department' offers descriptions of fifteen methods including acupuncture, apitherapy, phytotherapy, hypnosis, leeching, homeopathy, chiropractic, cupping, maggot therapy, mesotherapy, prolotherapy, osteopathy, ozone treatment, reflexology and musicotherapy; provides information on areas of practice, inapplicable situations and equipment centers that use these methods may or should have.35

2.3.1. Acupuncture

Acupuncture is a Latin word and derived from the words acus which means needle and punctura which means to prick.42 Acupuncture which is part of TCM is known to be applied since 2500 years ago.43 The most important and the oldest work on acupuncture is called 'Neijing' (The Yellow Emperor’s Classic of Internal Medicine) which is considered to be dated from 100 B.C. This historical book is still considered an important reference on acupuncture.44

Chinese physicians of ancient times believed that a life force energy called qi circulates around the channels between certain points they assumed to exist in the human body.45 According to this concept that constitutes the core of TCM, in all living beings, healthy state is maintained with the balanced flow of the qi energy in the body. And illnesses develop if this flow be blocked at certain points.46 Qi flows through the meridians that are assumed to exist in the organs and between the organs and the body. And the acupuncture points can be considered as the junction points of these meridians. Stimulation of these points stimulates and regulates the flow of qi and restores the yin-yang balance in the body.44 As well as needles, electric current, laser, heat, pressure or moxibustion can be used to stimulate these points.45

Some scientists conducted studies to prove the existence of meridians that represent the channels between the acupuncture points.46

The Western medicine approached the existence of meridians that the qi flows through with suspicion and rather than trying to prove their existence, it focused on the areas where acupuncture is effective. Thus, the Western doctors began to use this method whose

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effectiveness was observed over time, without sticking to any ancient ideology but with an understanding of stimulating the nervous system at different points. As a result, the phenomenon of the western medicine acupuncture (WMA), which is a different phenomenon from the TCM emerged.47

Researches found that acupuncture has a positive effect on emesis which occurs after chemotherapy, nausea related to pregnancy and toothache. Again, based on some studies, acupuncture is considered to stimulate the endogenous opioid mechanism and have specific effects on some areas of the brain.48 And there are findings showing that it can be helpful as a complimentary application for situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma.43

The presentation of the Ministry of Health lists the effects of acupuncture as findings from a good number of studies:

“analgesic effect, sedation, psychiatric-neurological effects, strengthening the immune-system, homeostasis, regeneration and motor improvement, regulatory effect on the digestive system, soothing effects on the respiratory system and allergic conditions.”42

Indications of Acupuncture topic of WHO says “clinical experience shows that acupuncture has positive effects on several diseases, however it is not possible to list indications or contraindications of acupuncture since there are no controlled clinical trials on each.”49

NCCIH has a similar approach to the indications of acupuncture as WHO. Accordingly, Acupuncture can be a helpful option for pain situations such as low-back pain, neck pain, osteoarthritis/knee pain, tension headaches and migraine headaches, most of which are chronic.50

As we look at all these data, in conclusion acupuncture is being used as a standalone or complementary therapy for several pain situations, nausea, digestive system diseases, addiction, asthma, COPD (chronic obstructive pulmonary disease), gulosity and obesity, infertility, stroke, and some psychiatric-neurologicaldiseases.

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Adverse reactions related to Acupuncture are usually complications develop because of non-sterile needle use or improper applications: infections, punctured organs, collapsed lungs, and injury to the central nervous system.50

In the 1999 publication of WHO, contraindications of acupuncture were listed as follows: pregnancy, medical emergencies and surgical conditions, malignant tumours, and bleeding disorders.51

2.3.2. Apitherapy

The application of bee venom is the first method that comes to mind when talk from apitherapy. The prevalent component in bee venom is melittin, which has anti- inflammatory anti-bacterial and anti-viral properties. Other components that might have pharmacological effects are apamin that improves the neural transmission, adolapin with its anti-inflammatory and analgesic properties, noradrenaline and other neurotransmitters such as dopamine and serotonin.52

According to the knowledge present, 6000 years ago people of Egypt used bee products for health purposes.53 “The Greeks and Romans also used bee products for medical purposes.” 53

Dogaroglu describes the following properties of honey in his article titled 'Arı Ürünleri ve Saglık' (Bee Products and Health): Honey has an anti-bacterial property because of the components it has. The sugar in honey can be directly used by the organs and cells without the need for digestion, and therefore it is an ideal energy source. Also, honey accelerates the metabolic events in the liver and has a detox effect.54

In another part of the same book, the authors Akcicek and Selek listed the medicinal properties of honey as follows:

“•Antioxidant • Anti-inflammatory (against temptation) • Antiatherogenic (Against the hardness of the vessel) • Antimutagenic (protective against genetic damage in the cell) • Antitumor (against the tumor) • Immunomodulator

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• Antimicrobial (against microbes) • Antiparasitic (against parasite).”55 In Teichfischer’s opinion, apitherapy is in an institutionalization process for the last forty years and developed as a method that centers around bee venom therapy.56

In PubMed, the search for the keyword apitherapy brought 181 results.57 In the search the names of specific bee products as honey (11067), bee venom (6350), propolis (2930), bee pollen (1384), and royal jelly (783), were more frequent than the word apitherapy.57

According to the experiences of beekeepers who participated in a study, the most potent and favored healing property was obtained from honey, propolis, pollen and royal jelly, as listed from the most potent to the least. Beekeepers used propolis to treat colds, wounds and burns, sore throats, gum disorders and also as a general prophylactic. They used pollen as a general protective product and sometimes they used it for prostate conditions.52

Yucel and Ceylan mentioned the Beehive Air Therapy which is a new form of Apitherapy and they said that this method was first discovered by the beekeeper Hans Musch in Germany.58 According to this study, this therapy involves slow and systematic inhalation of the 36 Celsius beehive air that contains several volatile substances and aerosols. The beehive air is conveyed to the person with the help of a fan, using a hose and a mask.58

According to the news report in Die Welt on 21.11.2015, this therapy practiced by the healers in Germany was prohibited by the Federal state of Türingen.59 The report cites Arno Bruder from the 'German Apitherapy Association (Deutschen Apitherapie-Bund)' about the beehive air:

“The essential oils, phyto chemicals and alcohols contained in this air creates an antibacterial and soothing effect on the upper respiratory tract… Therefore, this therapy is used particularly in patients who have inflammatory diseases in the respiratory tract.”59

The same report conveys that the 'Jena Health Office' banned an apiair-therapy healer to practice the method and the report of the 'Health Office' had the following explanation:

“During inhalation of the beehive air by the patient, allergen substances are directly and deeply absorbed by the body. This can lead to the development of serious reactions and allergic complications.”59

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Bee products, particularly honey as a food product, and also bee pollen have been commonly consumed by the Turkish people from ancient times to present for the purposes of living healthy, working up the appetite, and increasing the strength of the body. In recent years, use of more special and rare bee products such as royal jelly and propolis for the purpose of healing diseases has become more common. Also, according to the personal experience of the author of this study, even though it is colloquially said that bee sting is good for rheumatism, Turkish people are mostly unaware of the word apitherapy and its meaning.

2.3.3. Hypnosis

Hypnosis is an altered state of consciousness that allows the person to relax deeply and to focus inward easily.60 The therapeutic effect of hypnosis can be attributed to the fact that while under hypnosis most people are, more open to recommendations than they usually are.61

In his study 'De influxu planetarum in corpus humanum' in 1766, Franz Anton Mesmer (1734 - 1815)62, who is also known as the father of modern hypnosis raised the idea that the rays coming from the planets in our solar system has effects on the human body. Mesmer called this effect the animal magnetism and the rays he presumed to come from the planets as magnetic fluid and he offered therapeutic sessions to his patients using the effects of these rays.63

The term hypnosis was first used by the English scientist James Braid (1795-1860) was inspired by Hypnos, the Greek god of sleep and who did not want the similiar applications to be associated with Mesmer’s animal magnetism concept which he found ridiculous.64

Entering into states of consciousness such as hypnosis and trance has been known and practiced since ancient times, by Egyptian, Chinese, Greek and Roman people. However, these ancient practices were mostly related to magic and mystical applications rather than healing.63

The hypnosis which is being practiced by healthcare professionals for treatment purposes today is of course very different than all those historical antecedents. The hypnosis of today is a form of communication with a background that is established at verbal and non- verbal levels with the patient. The effects of hypnosis include increasing the self-help

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potential, creative skills and self-healing ability of the individual. Healthcare professionals working in all medical and dental areas may use hypnosis to facilitate all types of application routines.65

Quoting the related article from Encyclopedia.com:

“Hypnotherapy involves achieving a psychological state of awareness that is different from the ordinary state of consciousness… This state of awareness can be achieved by relaxing the body, focusing on one’s breathing, and shifting attention away from the external environment. In this state, the patient has a heightened receptivity to suggestion. The usual procedure for inducing a hypnotic trance in another person is by a direct command repeated in a soothing, monotonous tone of voice.”66

A healthcare professional, by using hypnosis, verbal and non-verbal interventions, can help to lower the patient’s level of anxiety, having the patient calm down and relax, so that conquering the fear of operation or injection and controlling the pain becomes easier.65 One of the areas that use hypnosis is psychotherapy. Psychotherapy with hypnosis is successfully applied for various psychic and psychosomatic disorders such as anxiety, depression, personality disorders, eating disorders, chronic illnesses, pain conditions, trauma therapy etc.67

In conclusion, hypnosis today can be used particularly in anaesthesia, dentistry, addiction treatments and psychological illnesses.

2.3.4. Phytotherapy

As described in the related article of Encyclopaedia Britannica: “Phytotherapy, the use of plant-derived medications in the treatment and prevention of disease.”68

The concept of pyhtotherapy was first used in 1913 by the French doctor Henri Leclerc. It got into the literature with his book 'Handbook of Phytotherapy' published in 1922.68

Of course humans have been using herbs to heal illnesses since the ancient times. The first written document on this subject is from 3000 BC.69 Sumerian, Assyria and Akkadians which are ancient civilizations of Mesopotamia used herbs for medicinal purposes. Chinese

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and Indian medicine also uses herbs a lot. Scientists such as Hippocrates, Avicenna and Al- Gafini mentioned uses of herbs in their books.70

Phytotherapy transforms herbs into different forms such as teas, tinctures, saps, ointments, respirable essential oils, baths or bandages, in order to use them in the most effective way.71

According to Krenn, in countries such as Austria, Germany, Sweden where herbal preparations are officially classified as herbal medicine, studies on phytotherapy are more frequent than other countries. Therefore, a great deal of updated information on quality, reliability and efficacy of herbal preparations is available.72

In Austria, Univ.Prof. Dr. W. Kubelka and Ao. Univ.Prof. Dr. R. Laenger from the Pharmacognosy department published the Phytokodex (Phyto-pharmacopoeia) in 1996. The Phytokodex which can also be accessed online provides the users information on all herbal drugs registered in Austria.73

Phytotherapy that has been developed with scientific methods, researched with controlled clinical trials, studied as the subject of various scientific publications differs from the medicinal herbalism which is mostly based on traditional knowledge.68

However, with regard to treatment with herbs, Turkish people consider phytotherapy together with the traditional herbalism. That is, with regard to herbal medicine, both scientific-based approaches and traditional approaches come to mind. Academically, phytotherapy is the subject of the Pharmacognosy department of Pharmaceutics.

Yesilada argues that today’s treatment methods are more advantageous compared to the therapeutic use of herbs throughout the history, as they can consistently provide the dosage required for efficacy.74 According to Yesilada, it is not possible to provide the same efficacy with the herbal medicines used before the modern era because their content varies greatly according to the region and the climate where the herbs were grown, how they are grown and processed. Another important finding of Yesilada is that the isolated active ingredient may not always provide the desired result because when the active ingredients in the herbs are isolated, their efficacy can decrease or disappear or sometimes some adverse reactions can occur with the use of the herbal essence. In such situations, rather than using the active ingredient alone, it is applied either as a raw herbal essence or a partly

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purified fraction.74 That is, using the modern methods or making drugs by extracting active ingredients from herbs may be disadvantageous as well as advantageous.

Ersoz has presented a list for important points to pay attention during preparation of products from herbs for treatment purposes or as a treatment aid. The entries in the list can be summarized as:75

 Difference of types: Different strains of the same species can have different chemical structures, very different effects or they can have the same effect in greatly different strengths.  Condition for growth: Climate, rainfall and soil structure in the geographical location where the herbs are grown and the time of the harvest change chemical structures of the herbs.  Production method: The method to be used when preparing a herbal product should follow the scientific data and should be an internationally relevant method.  Environmental factors: Herbs grown in areas with heavy traffic may contain heavy metals and those grown in areas where pesticides are used may contain residues of pesticides.  Storage conditions: Herbs harvested for preparing herbal products should be dried rapidly and accurately. If this is not observed, enzymatic reactions that could occur may disrupt the active ingredients of the herb or may cause formation of harmful ingredients.  Confusions of names and herbs: Herbs confused with each other because of their appearance may have totally different effects. For example, “Tanacetum cinerariaefolium”, which can be confused with daisy, a herb that is safe to use may pose serious problems because of the compounds with insecticide effects in its chemical structure.75

Another point with regard to use of herbs for health, for therapeutic or protective purposes is the economical aspect. Basaran says that use of communication facilities widely without observing ethics may cause situations that are harmful to individuals and communities.76 According to him again, herbal products are commonly used especially for weight loss, sexual drive and cancer treatment without consulting with a physician and these products are misused for financial profit by persons who are not experts in the field.76

Mesir paste which was mentioned by the participants in this study is a product specific to Manisa city and is particularly important in the area among herbal products used for health.

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Mesir paste was first made by Merkez Efendi, the head physician of Sultan Mosque Madrassa in Manisa, during the reign of Suleiman the Magnificent.77 Rumour has it that Hafsa Sultan, the mother of the Sultan catches an unknown disease. Merkez Efendi prepares a paste mixing 41 types of herbs and spices with the intention to cure this disease. Hafsa Sultan, after having this paste recovers from the disease and wants her people to benefit from this cure. Upon her request, every year between March 21-24, during the Nowruz festival, Mesir paste is prepared, wrapped in small papers and tossed to the public from the Sultan Mosque. The Mesir Paste which is tossed to the people is mixed and boiled with prayers. This tradition which has a history of 400 years is still celebrated as Manisa Mesir Festival with various activities.77

Some of the spices in the Mesir Paste which is prepared in accordance with the traditional knowledge passed from generation to generation are: aniseed, black seed, mustard seed, coconut, cardamom, black pepper, clove, cummin, coriander, rhubarb, saffron, gum, cinnamon, vanilla, pimento, ginger, galangal, orange peel, senna, fennel.77

2.3.5. Leech application

We can summarize the history of leech therapy with the help of Whitaker et al. study on the history of leech therapy:78

The term Leech comes from the Anglo-Saxon word laece which means physician. It is known that leeches are used therapeutically in Ancient Egypt and it is accepted that the leech therapy is used from the beginning of civilizations. Leech therapy is mentioned in Chinese, Sanskrit, Farsi and Arabic resources of 1st Century. At the same period, Romans used leech therapy and called leeches Hirudo. Plinius, Galen, Hippocrates, Alexander de Tralles and Avicenna used leech therapy and mentioned that in their Works. Leech therapy which had the most popular period between 1825-1850 and become almost a fashion in Europe lost that popularity at the end of 19th Century. After the discovery of anticoagulant effect of Hirudin in 1986, leeches began to be used in microsurgery. Today leech application is used specifically in microsurgery, to save the microvascular tissue transfers that are problematic because of venous occlusion.78 According to the study of Abdualkader AM et al., some of the other areas of use for leech application supported by scientific study are: cardiovascular diseases, diabetes mellitus and its complications, infectious diseases, in cancer treatment especially to prevent metastasis, in arthritis treatment especially as a

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painkiller. Other than these, there are applications where leech therapy is successfully used and became the subject of publications. For example leech application is used in dentistry, in the management of traumatic and postoperative macroglossia, treatment of sublingual hematoma and massive lingual hematoma, treatment of gum diseases like abscess and inflammation. In audiology and ear abnormalities like tinnitus, acute and chronic otitis and in some skin disorders.79

In Germany, medical leeches (Hirudo medicinalis, Hirudo verbana and Hirudo orientalis) are regarded as finished medicinal products since 2004 and are authorized for sale.80 In Austrian drug legislation § 1 Abs. 4 Z 3, leeches are regarded as drugs as a product that meets the description of purpose.81 Again in the USA, Food and Drug Administration (FDA) authorized leeches for sale for use in treatments.82

Risks and adverse reactions of leech application are relatively low. These are infections, allergic reactions, blood loss, disappearance of leeches in body cavities and gaps and adverse psychological responses.83,84 Infections can occur because of Aeromonas Hidrophila that naturally occurs in the normal flora of digestive system of leeches. Therefore, antibiotics are recommended as a prophylactic for leech therapies.85

2.3.6. Homeopathy

Homeopathy is a medical system based on the principle of “like cures like”.86 This principle was first mentioned by Hippocrates, the physician of ancient Greece.86,87 And although Paracelsus in 16th Century; Fleming, Sydenham and other physicians in 17th and 18th Centuries supported the like cures like principle, the founder of the medical system based on this principle is German Doctor Samuel Hahnemann (1755-1843).87

The explanation in the relevant article of the 'General Health Encyclopedia Medicana' is in epitome as follows:88 In consequence of his observations and experiments, Hahnemann explained in 1796 the idea that diseases can be cured with drugs that cause similar symptoms with those diseases on healthy people. According to the first principle of treatment which Hahnemann explained in his book titled 'The Organon of the Healing Art' (1810) every condition of living beings can be cured with a more potent condition that has similar symptoms, if not the same symptoms. The second principle is to know the area of work very well. Thus, with a completely personalized diagnosis and treatment approach, a

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homeopath practices a long examination of the patient taking into account the patient’s life habits and unique symptoms.88

The process to identification of homeopathic preparations is described in the web page of the European Committee for Homeopathy:

“Hahnemann spent several years experimenting on himself, his family and a group of followers, testing a wide range of natural substances, such as plants, minerals, metals, etc. In fact, he was the 'father' of experimental pharmacology. He and his colleagues catalogued over 200 medicines, primarily of plant, mineral and animal origin. Each substance was tested, i.e. taken by healthy volunteers who kept detailed records of their physical, mental and emotional reactions. The reported symptoms of these experiments –'homeopathic pharmacodynamics'– were compiled in a Materia Medica Pura. Repeating this type of experiment led him to observe and describe the basic principles of homeopathy.”86

The most criticized aspect of homeopathy by the modern medical school is that homeopathic drugs are prepared with a high level of dilution. Hahnemann aimed to avoid the adverse reactions of drugs by using the active ingredient causing the symptoms at very low doses. Again in the related article of 'General Health Encyclopedia Medicana’, preparation of homeopathic drugs are described as:

“According to the homeopathy theory, the effect of a drug is inversely proportional to the amount of the drug. According to the principle set by Hahnemann, the amount of a drug in the weight of a wheat kernel (0,0648 g) is combined with 10 parts of a neutral substance such as absolute alcohol, water, or sugar. This mixture is called “the first potency”. The “second potency” is obtained by combining 10 parts of a neutral substance with one part of the first potency. When this process is repeated six times, the amount of the sixth potency equals to one in a million of active ingredient in the solution. According to the homeopathy theory, as the amount of drug in the mixture decreases, the potency of the mixture increases equally. Use of homeopathic drugs at very low doses is the third foundational principle of homeotherapy.”88

The potentiation process, after the substance solved in a tincture, is -from Croce’s detailed description on the 'National Homeopathy Center' website - as follows: After each dilution,

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the mixture is agitated vigorously (succussion) and used to prepare the next potency. In this process, if 1 part of homeopathic tincture is mixed with 9 parts of diluent, this is called 1X (X for Roman numeral 10) or 1D (D for decimal) potency; if mixed with 99 parts of diluent, this is called 1C (C for Roman numeral 100 or centesimal) potency. In the following steps, potencies produced with the scale used goes as 2X or 2C, 3X or 3C... In general, potencies up to 30C are used for home use, but experts use 200C or above.89

The essential point in preparation of homeopathic drugs is that they should be easy to use for the physician and for the patient. This way, medicated powders or pellets (globules), tablets, triturates, cones could be prepared. It can be prepared in a topically applicable form such as tinctures, liquid attenuations or triturations, suppositories, ointments, cerates, gels or lotions. Other dosages and modes of administration are: capsules, liquids for oral or sublingual administration, liquids and semi-solids for oromuscular administration, nasal, ophtalmic and otic solutions.90

Homeopathic drugs that are highly diluted and anticipated to have no original active ingredient left in the final form are investigated in some clinical studies with different measurement methods to determine if they are different from controls. In the study of Klein and Wolf, 3 out of 6 different starting materials showed significant statistical differences between 30C, 200C and 200CF potencies and controls in terms of UV absorbances.91 Also, some studies researched the effectiveness of personalized homeopathy. In Mathi’s 'Controlled clinical studies of homeopathy’, he re-evaluated the controlled clinical studies evaluated by Max Haidvogl in 1994 in his book 'Ultra High Dilution', with addition of an updated comprehensive literature review and a systematic review literature. According to Mathi, 81 out of 105 trials in the original work had positive findings regarding the effectiveness of homeopathy, while as personally stated by Haidvogl, methodological inadequacies of some of these trials overshadow the reliability of the evidences.92 This study and similar studies show that, in order for homeopathy to develop and be understood in the world of medicine, more randomized controlled clinical trials at scientific grade should be conducted.

In his article titled 'A Re-Examination of Homeopathic Philosophy and A Simplified Approach to Practice', Cartwright93 states that the fact that the philosophy of homeopathy has not been fully understood is not a reason to fully ignore the subject. According to Cartwright, the increase in the number of different homeopathic applications and their

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different success rates results from the unclear philosophical background. In his study based on his 13 years of homeopathy practice, he describes witnessing many patients who gets well as soon as the drug touches his/her lip and who explains this as “it’s as if I never had the illness - it’s as if it never existed.” When looking for the answer to the question of how homeopathy works, he emphasizes that this phenomenon should be also taken into account. According to Cartwright, the reason might be that homeopathic drugs somehow shift the patient’s reality.93 Another possible explanation is that homeopathic drugs contain nanoparticles of the source material.94

The following explanation of the American academician Croce89 regarding the working philosophy of homeopathy is worth considering:

Croce says:

“Potentized remedy speaks the same language as the vital force. Instead of acting directly on the material body as material medicines do, potentized medicines stimulate the vital force to create material results. Measurable changes such as normalized white cell count, improved hormone levels, and shrinking cysts may follow the administration of a remedy, but not because the remedy has produced them directly. The remedy addresses the vital force, which is the power that animates the whole organism and which is no more “material” than the remedy itself.”89

Croce takes this view even one step further by articulating the idea that potentiated drugs may constitute a bridge between the physical and the metaphysical.89

Taking into account all of these, even though the how of homeopathy has not been answered yet, it can be concluded that it is a CAM method whose healing effects has been experienced by a good number of physicians and patients for 200 years.

2.3.7. Chiropractic

According to the definition in 'Who Guidelines on basic training and safety in chiropractic':

“A health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on

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general health. There is an emphasis on manual techniques, including joint adjustment and/or manipulation, with a particular focus on subluxations.”95

According to the website of International Federation of Chiropractors and Organisations (IFCO):

“Chiropractic is a vitalistic philosophy, science, and art which consists solely of the non-therapeutic objective of locating, analyzing, and assisting in the correction of vertebral subluxations, because they are detrimental to the expression of innate intelligence.”96

The inventor of chiropractic is Palmer. Harvey Lillard, who was a doorman in the building where Palmer worked as a magnetic healer, said that Palmer healed his deafness of 17 years with two spinal manipulation sessions. After this event, Palmer defined himself as a magnetic manipulator.97 Later he derived the term chiropractic from the Greek words 'cheir' -hand- and 'praxis' -practice-.98

According to Kaptchuk and Eisenberg, chiropractic: “creatively synthesized 4 previously distinct health care traditions: bone setting, magnetic healing, orthodox science, and popular health reform.”99

This healing method is based on the assumption that conditions and diseases stem from the disruptions in the neural system and aims to heal individuals and keep them healthy as a whole by eliminating the disruptions in the neuromusculoskeletal system using physical interventions.100

The mystical aspect of chiropractic creates both the suspicious approach of the modern medicine and also the difference of opinions among chiropractors.101

Chiropractors may use some other methods along with the manual interventions:

Heat and ice, electrical stimulation, relaxation techniques, rehabilitative and general exercise, counseling about diet, weight loss, and other lifestyle factors, dietary supplements.98

According to studies, patients most often visit chiropractors for upper and lower back pain. On the other hand, some patients who seek different treatment options other than drugs and surgery also prefer chiropractic for different complaints.102 However, although studies exist

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to demonstrate the effectiveness -or ineffectiveness- of chiropractic in treating the back pain as good as other methods, its effectiveness in indications listed by some chiropractors and organizations, including asthma, digestion problems, migraine, infantile colic, dysmenorrhoea is not proven with scientific research.101

2.3.8. Cupping

The British Cupping Society describes Cupping as follows: “Cupping Therapy is an ancient medical treatment that re1ies upon creating a local suction to mobilise blood flow in order to promote healing.”103

Information regarding where and when cupping was first used is contradictory in different resources. While some resources104 state that cupping was used in China 2000 years ago, Arabic authors105 claim that their ancestors applied cupping using animal horns and bamboo cups 5500 years ago. In conclusion, cupping is known to be used in ancient Greek, Chinese and Middle Eastern medicine.106

Cupping therapy uses heat or suction to create a partial vacuum effect on the skin. Thus, a subdermal blood flow occurs in the application area. The goal of this application is to activate the static blood under the skin103 and eliminate the harmful substances and toxins accumulated there.107 There are 12 types of cupping therapy: weak/light cupping, medium cupping, strong cupping, moving cupping, light moving cupping, needle cupping, moxa/hot needle cupping, empty/flash cupping, full/bleeding cupping, herbal cupping, water cupping, ice cupping (cooling) method.103 Two methods most commonly used are dry cupping and wet cupping.108 Dry cupping creates vacuum on the skin, however there is no cutting and blood-letting. Therefore dry cupping is an easier method and is suitable for home applications. In wet cupping on the other hand, small incisions are made on the surface of the application area and the cupping is applied. With the vacuum effect, blood is collected in the cup.104 Wet cupping is used worldwide while it’s widespread particularly in the Middle East and the surrounding areas.109,110

Wet cupping has a special place in the world of Muslims because it’s part of the prophet medicine.106 In the Muslim world, unlike wet cupping applications in other parts of the world, dry cupping is applied first to draw the blood onto the area. The procedure continues with the typical wet cupping application.106

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Cupping therapy is considered useful and applied by Hippocratic physicians for gynecological purposes, earaches, affections and pain in the extremities, infections from contaminated water, sciatica, angina, tonsillitis, erysipelas in the lungs, and eye diseases.108

The effectiveness of cupping in treating the pain especially with musculoskeletal conditions was demonstrated by scientific researches.109–111

Adverse events of cupping therapy mostly occur as a result of improper applications. When cupping is applied by authorized individuals, the unwanted side effects could be reduced if the rules are observed.112 The adverse events of cupping therapy are commonly caused by improper manipulation of medical practitioners, ignoring contraindication and patient’s constitution. The most frequent adverse effects of cupping are, anemia, factitial panniculitis and herpes viral infection.113 Also, cupping-related post-inflammatory hyperpigmentation114 and keloid115 are observed. It is reported that cupping could be hazardous for eczema.116

2.3.9. Maggot application

The definition of maggot therapy in the DocCheck online dictionary:

“The maggot therapy describes a special process from the wound care, in which specially germ-free bred maggots are introduced into a (often necrotizing and strongly inflamed) wound, in order to selectively break down the diseased tissue and allow a gentle healing.”117

The history of maggot therapy from Bucher’s article is as follows: Australian Aborigines and Maya Indians are known to use maggots to heal wounds. The effects of maggots on open wounds were often observed at times of war. In the Western world, it was Ambroise Paré (1510 –1590) who first discovered that the wounds with maggots on them heal more rapidly. However,Paré thought that these maggots happened spontaneously on the wound with the impairment of the tissue. French surgeon Baron Larrey (1766–1842) also realized the rapid healing of wounds on which flies landed. However,the first Westerner who consciously used maggots for wound healing was surgeon John Forney Zacharias (1861- 1885).118

In maggot therapy, usually maggots of sterile greenbottle Lucilia sericata are used.119

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Use of maggots in wound healing is a low-cost, easy to use method which is almost riskless if medical maggots are used.120 Along with positive studies regarding the effectiveness of the maggot therapy121–123 there is one study which demonstrated that the maggot therapy has no superiority over hydrogel administration in terms of effectiveness.124 According to the results of this last study, even though maggot therapy shortens the duration of debridement, it showed no superiority over hydrogel therapy in terms of total healing time. Again there were no significant difference between the two methods in terms of bacterial load. However, patients who received maggot therapy had more pain complaints compared to the patients who received hydrogel therapy.124

2.3.10. Mesotherapy

Ihrisky SA, defined mesotherapy in his study as follows:

“Mesotherapy (from Greek meso = in between, therapeia = treat) is a non-surgical, mostly cosmetic therapy, where active substances are injected intradermally into a depth of about 4 mm.”125

As stated by International Society of Mesotherapy on official website, mesotherapy was first used in 1952 by French physician Michel Pistor and in 1958, the term mesotherapy was used in a medical publication.126 A brief research on the Internet about mesotherapy first reveals aesthetic interventions. For example therapy of androgenetic alopecia and telogen effluvium,125 cellulite reduction,127 chemical peeling and facial rejuvenation,128 for weight loss/fat loss, flaccid skin, stretch marks, hyper pigmentation etc..129 Other uses of mesotherapy than aesthetics are local pain management130 e.g. chronic spinal pain131 and therapy of burns.132

Most common uses of mesotherapy From website of Austrian Society for Mesotherapy are: Circulatory and wound healing problems such as ulcus cruris, dekubitus, keloid or stretch marks; Rheumatic diseases, arthroses of all kinds; Sports injuries and overload damage e.g. tennis elbow, tendinitis of Achilles tendon, sprained ankles, bruises and strains, joint pain, back pain, herniated disc, chronic back pain, knee pain; Micro-Immunmodulation; Stress, fatigue, sleep disorders; Headache and migraine; Quitting smoking; Gynecological disorders e.g. dysmenorrhea, pelvipathia spastica, irritable bladder, recurrent infections or female infertility; in dentistry for diseases of the gums or the periodontium.133

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Some studies on the effectiveness of mesotherapy revealed different results in terms of the effectiveness and side effects of this method. For example, it was found in androgenetic alopecia therapy that mesotherapy paradoxically could cause hair loss or scarring at the injection site.134 Again, another study mentions that mesotherapy could rarely cause panniculitis.135

2.3.11. Osteopathy

According to the Canadian College of Osteopathy, the definition of traditional osteopathy is:

“A natural medicine which aims to restore function in the body by treating the causes of pain and imbalance. To achieve this goal the Osteopathic Manual Practitioner relies on the quality and finesse of his/her palpation and works with the position, mobility and quality of the tissues.”136

Osteopathic medical principles were first suggested by Doctor Andrew Taylor Stil in 1874.136 According to the philosophy of traditional osteopathy, human body has the capacity to heal itself and osteopathy applications help to regulate this capability of the body.136 Osteopathic manipulative medicine (OMM) uses manual techniques such as stretching, gentle pressure, and resistance.

The conditions osteopathy is most often used for are back and neck pain, shoulder pain; problems with the pelvis, hips and legs; postural problems caused by driving, work or pregnancy; sporting injuries, muscle and joint deterioration, arthritis, restricted mobility and occupational ill-health.137,138

In a randomized, double-blind, placebo-controlled trial, patients with chronic lower back pain received 6 osteopathic manipulative therapy (OMT) sessions over 8 weeks and the results were evaluated at Week 12 by using the visual analog scale and Roland-Morris Disability Questionnaire. According to the results of this study, 95% of the patients were recovered with OMT.139

In another study, patients received OMT for 25 minutes for postpartum lower back pain, abdominal pain and vaginal pain. VAS score before and after OMT was measured and the mean VAS score for pain was 5.0 before OMT and 2.9 after OMT.140

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In a single-blind randomized placebo-controlled pilot study conducted to evaluate the efficacy of OMT for treatment of frequent episodic tension-type headache (TTH), the OMT group had 33% lower frequency of headache compared to the second group and OMT was considered as the preferred option for this type of patients.141

According to the definition of Canadian College of Osteopathy, techniques of the following 4 sub-disciplines are combined and used: Osteo-articular adjustments, cranial- sacral application, visceral normalization and fascial release. Firstly, the tissue to be treated is touched lightly. Depending on the technique used, the contact of the osteopath with the tissue is as light as the patient cannot feel or as strong as the patient can clearly feel. The Osteopath can use one of the direct treatment or indirect treatment methods. The former moves the tissue to a more natural or correct position, while the latter moves the tissue to a direction with a problem or strain pattern. With the indirect therapy, the goal is to achieve a relaxation while moving the tissue towards a problem area. Thus, blocked vital fluid flow around the tissue is normalized and recovery is achieved.142

Osteopathy is confused by people with some other methods that use similar techniques. Chiropractic, one of these methods, focuses on the nerves around the spine for diagnosis and treatment of conditions while osteopathy considers the whole body. Especially people who have discomfort from the popping or clicking sounds created by the bones may prefer osteopathy instead of chiropractic.143

2.3.12. Ozone therapy

Ozone was discovered by Dutch physicist Martinus Van Marum in 1785 and was synthesized by German Chemist Cristian Friedrich Schönbein.144 As stated in the study of International Scientific Committee of Ozone therapy (ISCO3), 'Ozone Therapy and Its Scientific Foundations'145, research on biological effects of ozone began in the second half of 19th Century in Russia, and in 1876, Dr. Chemezov V.V published a doctoral dissertation titled 'Effects of ozone on animals'. And in the same period, Razenberg in Crimea, used ozone in the treatment of allergies which were especially active in the respiratory tract. For this, he took his patients to the open sea after a storm and allowed them to breathe an ample amount of ozone.145 Quintero R et al.144 tell in their study 'The African Contribution to Ozone Therapy Dr. George Stoker (1854-1920)' that Dr. George Stoker saw in 1879 that Zulus took the injured to high mountains for one or two weeks.

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These injured people recovered, even though they had more pain at the beginning. Based on these observations, after returning Europe he began to treat the injured patients with a mixture of oxygen and fresh air and he built and used a precursor of the device what we call hyperbaric chambers today.144 In 1898, Thauerkauf and Luth began to work on ozone administration in the form of injections in the institute they founded in Berlin. At the beginning of the 20th Century, with the ozone generators having been produced, many doctors in the Western world used ozone for medical purposes, conducted studies and wrote books about it.145 In 1953, Dr. Hans Wolf who founded the first ozone therapy school presented the major and minor autohemotherapy in 1962.145

Ozone is attributed to effects such as strengthening the immune system, increasing the oxygen transmission into the tissues and cells, killing bacteria and viruses it comes into contact with, increasing the energy efficiency of cells, decreasing oxidation, killing cancer cells it contacts with. Ozone can be administered externally or systemically for medical purposes; can be used for disinfecting and treating burns and wounds, strengthening the immune system, as a primary or supportive therapy to treat all kinds of conditions such as internal systemic diseases, colds, flu, chronic degenerative diseases.146,147

Medical ozone administration modes are: Major autohemotherapy, minor autohemotherapy, rectal ozone administration, extracorporeal blood oxygenation and ozonation (EBOO).148 In major autohemotherapy, a certain amount of blood (50-100 ml) is drawn from the person and is treated with a certain amount of anticoagulant and afterwards with a mixture of O2-O3. The mixture is reinfused IV to the patient at the rate of one drop per minute.149 According to the Madrid declaration, the rate of ozone in the O2-O3 mixture should not exceed 78 µgN/ml.145

In minor autohemotherapy, 2-10 ml blood is drawn from the patient and is mixed with the same amount of medical ozone. As ozone can interact with the whole blood in seconds, the mixture of blood-ozone is injected to the patient by intramuscular (IM) or rarely subcutaneous (SC) route.150

In rectal ozone administration, rectal insufflation of 300 ml of ozone-oxygen gas mixture at a concentration of 60 μg/ml is performed.151

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In extracorporeal whole body ozone (EBOO) method, O2-O3 mixture is delivered to the blood during extracorporeal circulation and with this method, 4800 ml heparinized blood can be ozonated in 1 hour. EBOO can be administered easily during haemodialysis.152

Ozone is also used in dentistry, in the treatment of oral infections and also in surgery.147

According to Bocci, ozone properly administered with a dose of 70 µg/ml per gram of blood, up to 60 sessions, does not present acute or chronic toxic effect.153 Su and Gordon showed in their study with guinea pigs that, ozone administered in vivo increased the expression of Heath Shock Protein (HSP).154 According to another study with rats, HSP’s may be playing a role in strengthening the T-cell response against tumors.155 Although these studies show that ozone therapy has a potential role as an adjuvant in cancer treatment, further studies such as randomized clinical trials are required.156

Besides, breathing ozone may create the following toxic effects: Irritation of the upper respiratory tract, rhinitis, coughing, headache, epiphora, occasional nausea and vomiting.157

To undesirable side- effects, in the study of Vanni et al., hard adhesions were discovered between soft tissues and bony structures during lumbar disc surgery with patients who previously received intraforaminal ozone injection and these were associated with the ozone injection.158

2.3.13. Proloterapi

Proliferative therapy or prolotherapy is the therapy based on triggering the wound healing mechanisms of the body by causing local cell death in deformed tissues.159,160 It is mainly used in the treatment of chronic musculoskeletal system diseases such as osteoarthritis or tendinopathy.161 In prolotherapy, mostly hyperosmolar dextrose or another irritant and a certain amount of local anaesthetic is injected into the effected area.162 Positive effects of prolotherapy in the treatment of osteoarthritis is demonstrated and it is considered to be an option for the treatment of painful musculoskeletal system conditions when other standard therapies fall short.163

2.3.14. Reflexology

Reflexology Association of America’s definition of reflexology:

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“Reflexology is a protocol of manual techniques, such as thumb and finger- walking, hook and backup and rotating-on-a-point, applied to specific reflex areas predominantly on the feet and hands. These techniques stimulate the complex neural pathways linking body systems, supporting the body’s efforts to function optimally.”164

According to the presupposition of reflexology, some points in the hands and feet correspond to all the organs, systems and structures of the body. The method was called 'reflexology' because the stimulus applied to one point (massage in this context) creates a response at another point in the body.165

In current literature, the use of reflexology in pain management is more prevalent. In a study, vaccine-induced pain was reduced when reflexology was applied to infants for 20 to 30 minutes.166 In other studies, it has been shown that reflexology applied to prenatal women is effective in reducing pain and anxiety and increases vaginal delivery frequency.167

Reflexology sessions can also reduce symptoms in situations such as stress, insomnia, and irritable bowel syndrome.168

2.3.15. Musicotherapy

According to the information in the book titled “The Origins of Turkey Folk Culture” of Oguz, healing effects of music has been accepted since ancient times. As is the case in Greek medical texts, Islamic medical texts have also recommended therapy applied with music. The scholars who best studied and explained the Greek philosophy in the Islamic world, namely ar-Razi (854-932), al-Farabi (870-950) and Ibn Sina (980- 1037), have formed the scientific foundations of the use of music in the treatment of psychic diseases in particular.169

Dr. Osman Sevki Uludag In his book titled “The Five and a Half Century History of Turkish Medicine” mentions the music therapy under the heading of Special Turkish Cures as follows:

“Music therapy was not the invention of Turkish physicians. However, this treatment method saw developments in the hands of Turkish physicians. It was

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already known that music was related to medicine. Ottoman hospitals in Fatih, Istanbul and Bayezid, Edirne were applying psychotherapy with music.

A separate musical mode was used for each of the unsteady states, such as the fall, the rise and the width of the heartbeat, and the music therapy began in this way.”170

As far as we learn from Turabi’s work on the work of Dr. Suuri Hasan Efendi, 'Ta’dîlü’l- Emzice', the major music modes considered to be good for diseases until the 19th century were:171

Buselik Mode: Offers benefits in the treatment of shoulder pain and back pain.

Büzürg Mode: It helps with the brain, shoulder pain and eliminates the weakness.

Hicaz Mode: It plays a supporting role in the treatment of urologic diseases.

Hüseyni Mode: It refreshes the person. It helps to increase the the person’s self-confidence and relief. It helps with autistic and spastic diseases.

Irak Mode: It’s good to the people with a temper and palpitation.

Isfahan Mode: It opens the mind, sharpens the intelligence, refreshes the memories.

Neva Mode: It is used in the treatment of women’s diseases and sadness.

Rast Mode: It is a helping and supportive mode for the relief of mental illness and paralysis.

Rehavi Mode: It is good for all headaches, nosebleeds, deformed mouth, paralysis and sputum diseases.

Ussak Mode: It is a helpful method for the treatment of heart, liver, malaria and stomach diseases.

Zengule Mode: It’s good for heart, brain diseases, meningitis, stomach fever, liver fever.

Zirefkend Mode: It is good for paralysis and back pain, offers a feeling of strength.171

Moreover, as Kazancıgil mentions in one of his speeches, “which nations, which races (according to their colors) enjoy which music modes, and which modes are more pleasurable and peaceful at what time of the day were also determined.”172

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In the medical literature, it can be seen that the practice of music therapy was examined for psychological disorders, reduction of anxiety and pain, and treatment of epilepsy. In one of these studies, changes that music creates in the human brain have been examined by various imaging methods.173

In another study, the positive effects of Mozart’s compositions were demonstrated in epileptic patients.174

Some other CAM methods

2.3.16. Bioresonance

“In addition to physiological vibrations, pathogenic vibrations occur in the human body and these play a significant role in the emergence of diseases. In the bioresonance method, the diseased frequency sample of cellular communication is transformed into a therapeutically effective, healing frequency sample.

For this, the body’s own electromagnetic vibrations are transmitted to the bioresonance device through a high-ohm signal input by means of electrodes. Frequencies modulated and prepared as desired with the help of the device are returned to the human body using the electronic protective circuits.”175

Bioresonance therapy is often preferred by patients for treating allergies.176 People also prefer this method to quit smoking and treat gastrointestinal problems.

2.3.17. Emotional Freedom Technique

Emotional Freedom Technique (EFT), also known as tapping, is applied to certain acupuncture points by gentle tapping. The critical point of this technique is that when these tappings are done, the person focuses on a specific problem using formulated sentences.177

EFT was first introduced in 1995 by Gary Craig, who worked with other methods preceding this method up to that point.178

One of these methods is, Roger Callahan’s Thought Field Therapy (TFT) which was developed in the late 1970s. In Callahan’s method, the points to be tapped must be identified. 177 Craig, on the other hand, has developed a procedure that makes it possible to tap without having to identify the point by creating a compilation of the points to be

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tapped. The person/practitioner formulates a sentence about the specific problem experienced and gently taps each tapping point 5-6 times as he/she repeats the sentence: “Even though I have I completely love and accept myself”178

Tapping points used during EFT are shown on the web page of Gary Craig as follows:

Figure 3 The EFT Tapping Points179(P-How to do the EFT Tapping Basics - The Basic Recipe-The EFT Tapping Points) KC: The Karate Chop point TOH: Top of the head EB: EyeBrow SE: Side of the Eye UE: Under the Eye UN: Under the Nose Ch: Chin CB: CollarBone UA: Under the Arm In a study on the effectiveness of EFT in the treatment of Post-Traumatic Stress Disorder (PTSD), EFT showed important treatment effectiveness compared to usual care treatment or a waiting list. In the same study, the effectiveness of EFT in the treatment of PTSD showed no difference from the two other evidence-based methods, Eye Movement Desensitization and Reprocessing (EMDR) and Cognitive Behavioral Therapy (CBT).180

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Another randomized controlled study found that EFT application twice a day for 2 months showed improvements in reducing the frequency and intensity of Tension-Type Headaches.181

2.3.18. Hot Springs

Therapy with hot springs (Spa) or broadly Balneotherapy has a long history of 5000 years.182 Within the scope of spa treatments, soil, earth and marine based mineral waters, gases, peloids (mud) and climatic factors, along with other climate features and other treatments as required are utilized in the form of cures. Thermal waters can be used as baths, drinking and inhalation.183

According to European Spas Association, usage areas of spa are: musculoskeletal disorders, respiratory and ear-nose-throat conditions, vascular and cardiac conditions, diseases of digestive tract, metabolic conditions, neurological diseases, diseases of kidney and urinary tract, stress related disorders, skin diseases, gynecological diseases, post-acute stages after oncological treatment.184

“Baths are classified as cold (hypothermal, below 34ºC), warm (isothermal, 34- 35ºC), hot (thermal, 36-40ºC) and extremely hot (hyperthermal; 40-42ºC). Duration of baths are usually 20 minutes. Bath applications are full baths, half baths, and hip baths. Baths are usually taken for 2-4 weeks, either once a day (one day break a week) or every other day. The frequency of baths is adjusted by the spa doctor. The number of baths in a hot-spring course is between 15 and 20.”183

Ministry of Health has regulated the conditions for the application of these therapies in Spa Regulation, 2001.185 In addition, spa treatments were included in the General Health Insurance coverage and the conditions of reimbursement were determined with the Communique on Health Practices.186

The effectiveness of spa treatments has been studied in some scientific studies. In a study on patients with knee osteoarthritis and knee pain, bathing with sulfuric and non-sulfur thermal waters has been shown to reduce pain and pain medication and improve physical function.187 A systematic review also reported that, in osteoarthritis, thermal baths applied for 3-6 months, sometimes for 9 months reduced pain and improved function; but the impact on quality of life and use of medication was controversial.188

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2.3.19. Massage

Massage is a method applied to soft tissues and muscles by applying pressure with hands, rubbing, kneading and tapping and has been used by many societies for medical purposes.189 People frequently ask their close connections to massage them for situations like fatigue, painful muscles and joints, tension, etc. Even though it is not considered as a treatment in this form, in fact it is one of the most frequently used CAM methods among folks. Massage therapies can be applied by trained personnel upon doctor’s advice, primarily for situations such as fibromyalgia, cancer pains and headache, and also for pains, mind health, baby care, HIV/AIDS.189 The therapeutic effects of massage is investigated by scientific studies. According to NCCIH, massage applications bring out positive effects in patients but these effects are mostly short-term.190

2.3.20. Neural Therapy

Ferdinand and Walter Huneke brothers from Germany used nerve block first as a specific therapy in 80s and called it 'neural therapy'.191

“Neural therapy is a medical approach that diagnoses and treats local disturbances of the autonomic nervous system. The foci of disturbance, called interference fields, are electrophysiologically unstable and emit abnormal neurological signals to which the autonomic nervous system reacts.”192

Any part of the body such as teeth, tonsils, paranasal sinuses and scar tissue can be an interference field. In Neural therapy, usually 0.5-1% of procaine or lidocaine is as anesthetic injected, depending on the application, to intravenous, subcutaneous or other tissues such as ganglia, trigger points.193,194 Some scientific studies demonstrated therapeutic effects of neural therapy on conditions such as vulvodynia, articular and periarticular pain, Bell’s Palsy, multiple sclerosis, however it was also reported that the effectiveness of neural therapy should be supported by some other qualified scientific studies.193–196 Although practitioners of neural therapy support that when applied properly and carefully, neural therapy does not cause any side effects, it should be taken into account that this CAM method may cause significant side effects.197

3. A County in the Aegean Region of Turkey: Akhisar

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It was considered meaningful to briefly provide the characteristics of Akhisar District of Manisa Province in order to ensure accurate evaluation of the findings of this study and compare them with the findings of similar studies conducted or to be conducted in other regions of Turkey that have different characteristics.

General characteristics of Akhisar

Akhisar was established on the plain with the same name in the Aegean region and is the biggest town of Manisa Province, and the eighth biggest town of Turkey. Akhisar is 52 km distance to Manisa, 92 km distance to the Aegean Sea.198

“The population of Akhisar District is... approximately 171 thousand (2018). More than 100,000 of the population lives in the center. This number is higher than the population of many cities in Turkey. The male/female rate of the population is almost half-and-half. The primary reason for such a high population is the geographical location of Akhisar. Also, the county received significant immigration after the Turkish War of Independence.”199

Akhisar has approximately 80,000 hectares of agricultural land. The main industrial plants grown are olive and tobacco. A large part of table olive of Turkey is grown in Akhisar. Also, wheat, barley, corn, cotton, legumes and garden plants are among the plants grown in Akhisar. While the economy of Akhisar depends on agriculture, Akhisar Organized Industrial Site is home to select Ceramic fabrication facilities of Europe and Turkey. Again the biggest Broiler and Egg production facilities are in Akhisar.199

Akhisar is located on significant roads. Izmir-Istanbul main road, Izmir-Ankara and Izmir- Bandırma railroads pass through Akhisar. This significant location allowed Akhisar to become a lively trade center and added economical strength to the county.

Health services in Akhisar

“There are 1 State Hospital with 200 Beds, 1 Oral and Dental Health Center, 2 112 Emergency Assistance Station, 1 Tuberculosis Dispensary, 1 Community Health Center, and 48 family physicians, 34 of which are in the district center and 14 in villages and towns.

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Also, 2 private hospitals,... 1 private outpatient clinic, 20 specialist practice (4 of which are free), 21 dental practitioner (16 of which are free), 1 pharmacy warehouse, 56 pharmacies 9 of which are in burghs, 11 opticians, 2 beauty parlors, 4 private laboratories 1 of which being bacteriology, 1 being biochemistry, 1 radiology and 1 pathology.”200

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4. Methods

Sample

Snowball or chain sampling method was used. However, at the final stage of the participant selection, variety of sociocultural characteristics, age and gender was observed. To avoid legal and ethical confusion, participants were selected among people who were not hospitalized and were over 18 at the time of the study.

Also, presenting views and experiences of some health professionals regarding use of CAM methods is regarded useful to allow the study to be evaluated from different angles. To this end, “expert interviews” were held with three health professionals. These are: an internist offering CAM methods in his private practice (E-13), an independent manipulation and orientation expert (E-14) and a family practitioner working in a center of family health (E-15).

Data Acquisition and data analysis

This qualitative study used face to face interviewing technique in order to investigate the habit of of Turkish people to use the Complementary and Alternative Medicine and to provide information for this purpose. The interviews used the semi-structured interview method and all interviews were held in Turkish.

Interviews were made in May and June 2014. The shortest interview lasted 7 minutes, the longest interview lasted 60 minutes and the average interview duration was 25 minutes. Houses or workplaces of participants were preferred as the venue for interviews. Before the interviews, all participants were informed about the subject, scope and course of the interview. At the beginning of the interview, the participants were asked to mark the CAM methods they have used or heard in the list (APPENDIX-1). Next, open-ended questions were asked from a pre-prepared questionnaire (APPENDIX-2) and the rest of the interview was detailed based on the answers of the participants. Interviews were audiotaped and afterwards these tapes were transcribed verbatim. Parts that are of significance for the study and parts that were used in the study text were translated into English language. Statements of participants that are of no value for the study have not been translated but were preserved in the original documents by author.

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Next, the interviews were categorized and coded according to the method described by Mayring, utilizing the demo version of the software named MAXQDA11.

The literature work to create the structure of the study includes resources in Turkish, English and German languages. Most of the actual studies related to the subject were accessed through the PUBMED database.

Ethical approach

All participants were informed about the privacy of personal information and the right to withdraw at any given moment and they signed the informed consent form prepared in Turkish and German languages. In order to ensure anonymity, participants were coded with 'IP' which is the abbreviation of 'Interview Partner' followed by a number between 1- 12. With the same principle, the experts were coded with the letter 'E' as the abbreviation of the term 'Expert' followed by a number between 13-15.

For this study, approval of Ethical Commission of Vienna Medical University was obtained. (EK-Nr. 1274/2014)

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5. Findings During one-on-one interviews with participants in this study, the methods of homeopathy, chiropractic, larva application, mesotherapy, prolotherapy, osteopathy were not mentioned by name; while the methods of leeching, acupuncture, hypnosis, ozone therapy and musicotherapy were mentioned by name. Even though the term apitherapy was not mentioned, some of the participants used honey as a CAM method. Among these 15 methods, only phytotherapy and cupping were used by the participants, while reflexology was applied by the manual therapy specialist. Other than these, some methods applied by another person such as neural therapy, bioresonance, blood-letting, massage, religious rituals and some self-applied methods such as praying, dancing, going to the spa, using nutrition supplements were used by the participants.

Religious applications such as praying, getting someone else pray, reciting the Quran, drinking zam-zam are frequently used applications by individuals in Turkey, where the majority is Muslim.

Methods such as neural therapy, bioresonance which are just beginning to become widespread are methods which especially appeal to those who could not find a solution to their problems from the modern medicine methods. The fact that these methods are being applied by doctors of medicine gives reassurance to the persons who want to receive these therapies and it becomes the reason for preference.

5.1. Prevention of diseases and approach to the diseases

Within the study, the participants were asked 'do you use any methods to prevent diseases or methods you use before visiting a doctor when you become sick, if yes what are they?' during the one-on-one interviews. 4 of the participants said they take care of their diets, 10 said they use herbal teas/products, 2 said they try to avoid pollen exposure, 2 said they use cupping, 2 said they use massage, 2 said they recite Quran, one said they avoid having alcohol, one said they take care of the shifts in weather from hot-cold and vice versa, one said they work out, one said they use from the medicines at home, one said they use eucalyptus pomade. Most of the participants answered this question with colds, influenza, flu, allergy or mild pain or stiffness in mind, while 4 of the participants stated that they visit a doctor for more severe conditions or if the condition does not disappear despite of these applications. One participant said that they try not to get sick, and if they do, they

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first visit a doctor and then turn to the alternative medicine if they do not heal. However, as the same participant said that they treat conditions such as flu, coughs, sore throat using home remedies and they do not like using drugs in the first place, it is understood that the participant uses CAM methods before seeing a doctor for these conditions.

5.2. Current conditions of the participants

4 of the participants reported to have herniated disc/cervical disc hernia, 1 reported to have meniscal tear, one reported Chiari type1, and one reported to have a severe muscle stiffness. From this information, it can be concluded that in this sample group, the most commonly seen diseases are musculoskeletal conditions. The second most common condition is the pollen allergy, which was reported by 3 participants. Other than these, actual complaints of participants and the modern medicine methods applied/recommended for them provided in the 'Table 1-Disease-Treatment' as follows:

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Table 1 Disease-Treatment

Participant Disease/Condition Applied/recommended modern medical treatment

IP-1 Allergy, chronic sinusitis, overactive bladder. Sinusitis surgery. Drug therapy for allergies. 2 times IVF administration.

IP-2 Neck hernia, associated neck stiffness, strains and pain. Drug therapy with myorelaxants for neck pain, home exercises for neck and arm.

IP-3 Herniated disc, coronary heart disease, high blood pressure, Drug therapy for high blood pressure. Stent in the heart, drug therapy. Drug meniscal tear in the left knee, edema in the bone marrow in the therapy for asthma. Knee surgery is recommended. Knee was previously right knee, tear in the left arm, asthma. administered pain relief injection, cortisone injection. Drug therapy for the knee pain.

IP-4 Allergic asthma. Drug therapy for allergic asthma. Burning treatment was recommended for the cervical wound.

IP-5 Nerve compression in the neck, associated trembling in the Surgery on the cervical vertebrae was recommended. Drug therapy for hands, and occasional imbalance in the body, blackouts. Parkinson’s. Parkinson’s.

IP-6 Myoma, pruritus and redness of skin, pain in the arm, Chiari Drug treatment with injection for myoma, induced menopause. Psychiatric Type 1 Malformation (cerebellar prolapse/cerebellar tonsillar drug treatment for arm pain. Thyroid replacement. herniation), digestive problems, hypothyroidism.

IP-7 High blood pressure, osteoporosis, psoriasis, frequent angina. Drug treatment for high blood pressure, osteoporosis and psoriasis.

IP-8 Wounds on the back, on the feet. Drug treatment for skin wounds.

IP-9 Seasonal allergy, pollen allergy. Drug treatment for seasonal allergy.

IP-10 None. None

IP-11 Respiratory distress during foggy weather, blurred vision, cyst Surgery was recommended for the cyst in the brain. Surgery was in the left brain, herniated disc in the lower back. recommended for hernia.

IP-12 Ulcer, gastritis. Ulcer surgery, diet.

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In this section, to help us understand the important factors causing individuals turn to CAM methods, the experiences of some of the participants with doctors, hospitals and treatments for their long-term conditions were cited. These factors are factors such as contradicting or different diagnoses or treatments offered by different hospitals and doctors, risky operations advised, treatments that are not successful enough, the patient being totally passive during treatment, etc.

IP-1 who is a tradeswoman at 40 has allergies for house dust and some foods, and chronic sinusitis. She also complains about thamuria. She was advised drugs for her allergies and has been using them but she stops using the drugs when pollens are less. IP-1 stated that allergies can only be treated with tablets and she uses her tablets. The fact that the patient is unaware of hyposensitisation makes one think that she was not provided enough information about the treatment options and was not offered different alternatives to choose from during the treatment.

IP-1 had an operation for her chronic sinusitis three years ago, she found relief for three- four months but later her complaints about sinusitis returned. IP-1 and her husband received therapy to have children, her husband for male infertility. Because the studies of infertility involved both partners, the processes of diagnosis and treatment were difficult for IP-1. The couple did not get any result from these therapies and could not have a baby yet. Also, the spouse of IP-1 has severe vision loss related to macular degeneration.

Another participant, IP-5, has complaints of nerve entrapment because of narrowing of the cervical vertebrae and related shivering and blackout for 12 years. Especially in 2012, because his complaints began to restrict his daily life, he was examined in three university hospitals and one government hospital in the neurology and neurosurgery departments. He decided not to have operations he was described as “removing the vertebrae and relieving the nerves and supporting with plastic if needed” by one university hospital, and as “removing the vertebrae and replacing with vertebrae from a cadaver or with artificial vertebrae” by another university hospital. His decision was influenced by statements of different neurosurgeons as “as long as his illness does not advance and because he can maintain his life like this, he does not yet have to have this serious operation”. IP-5 tried many CAM methods for these conditions. Finally, he received neural therapy from a neuro surgeon in Izmir in his private practice.

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IP-6 who is a housewife of 49 has arm pain for 25 years. For this condition doctors have been diagnosing as calcification for years, she was at some point referred to a neuro surgeon. She then got examined by two different neuro surgeon professors. One said she needs neuro surgery, another said she needs cervical disk surgery, yet another said she needs no operation. Because IP-6 had hesitations about the recommended operations, she felt the need to see other doctors. In her final examination, the neuro surgeon who examined her diagnosed her illness as Chiari Type 1 Malformation, which he said is congenital and currently does not advance, but if it does in the future she may need an operation and recommended her to see a psychiatrist for her complaints. The professor of orthopedics, then she also saw, referred her to psychiatry. As a result, IP-6 received psychiatric medication therapy for 3 years (Mirtazapine, Venlafaxine HCl, Diazepam) and she found a big relief at that time. She applied various traditional methods with her parents’ guidance and finally she used the diet an internist in Akhisar gave for wheat and rice allergy (bioresonance therapy).

5.3. Past experiences or indirect experiences of participants with CAM

The participants of the study were asked about their past illnesses or conditions and CAM methods they used for them. Also, they were encouraged to share the experiences acquired from their families and acquaintances. This section presents the responses of participants to this question, respectively.

We can see the CAM experiences and satisfaction states of participants at a glance in the 'Table 2- CAM/Satisfaction Table’:

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Table 2 CAM/Satisfaction

Participant Reason to use From whom/where CAM method Effect Satisfaction

IP-1 Indigestion From media/at home Finished herbal product Recovered Satisfied

Infertility of the Spouse (Couples therapy) Specialist Phytotherapy Did not have a child Dissatisfied

Infertility of the Spouse (Couples therapy) Doctor Electrosomatography/Phytotherapy Did not have a child Dissatisfied

Infertility of the Spouse (Couples therapy) Doctor Neural therapy Did not have a child Dissatisfied

Allergy/sinusitis Doctor Neural therapy No recovery Dissatisfied

For anaemia At home Used locus-bean molasses It helps Satisfied

IP-2 Rheumatism From local practitioner Folk medicine/praying No recovery Dissatisfied

Small conditions At home Herbal teas It helps Satisfied

Straightening of the neck At home Homemade pillow It helps Satisfied

IP-3 Joint pain From herbalist/at home Phytotherapy No recovery Dissatisfied

Joint pain Doctor Cupping therapy No recovery Dissatisfied

Arm fracture as a child Bone setter Fracture healing Trapezoid bone Dissatisfied

Warts on hands as a child From local practitioner Folk medicine Recovered Satisfied

Mumps as a child From local practitioner Folk medicine Recovered Satisfied

IP-4 Simple fever conditions At home Sweating It helps Satisfied

Applying pomade and wrapping Tonsillitis At home the throat It helps Satisfied

Cervical wound At home Herbal application Recovered Satisfied

Cholesterol Increase in cholesterol At home Having walnut normalized Satisfied

Various mild conditions At home Herbal application It helps Satisfied

Depression At home Reading Quran/praying It helps Satisfied

IP-5 Neurological conditions From local practitioner Bioenergy No recovery Dissatisfied

Neurological conditions From local practitioner Praying /(Bioenergy?) Slightly improved Satisfied

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Neurological conditions Doctor Neural therapy Slight recovery Dissatisfied

Spinal disc herniation From local practitioner Massage Recovered Satisfied

Kid: Spinal disc herniation From local practitioner Bioenergy No recovery Dissatisfied

Kid: Spinal disc herniation From local practitioner Massage No recovery Dissatisfied

Kid: Spinal disc herniation At the resort Hot spring cure No recovery Dissatisfied

IP-6 Chronic arm pain From local practitioner Folk medicine practices/praying No recovery Dissatisfied

Chronic arm pain At home Breathing exercises It helps Satisfied

Chronic arm pain At home/At the course Drawing, dancing It helps Satisfied

Chronic arm pain At home Reading Quran/praying It helps Satisfied

Good during the Chronic arm pain Doctor Bioresonance and diet therapies application Satisfied

Shrinked (concurrent with other CAM Myoma At home Onion cure methods) Uncertain

Small conditions At home Herbal teas It helps Satisfied

IP-7 Psoriasis From local practitioner Blood-letting No recovery Dissatisfied

Chills At home Cupping It helped Satisfied

It helped (synchronized with Osteolysis At home Homemade medicine medical treatment) Satisfied

Kid: Too much crying From local practitioner Folk medicine It helped Satisfied

Evil eye From local practitioner Praying, pouring lead It helped Satisfied

IP-8 Scars on the skin At home Herbal application No recovery Dissatisfied

Small conditions At home Herbal teas It helps Satisfied

IP-9 Pollen allergy From herbalist/at home Phytotherapy It helps Satisfied

Severe muscle stiffness From Physiotherapists Massage therapy Recovered Satisfied

Muscle stiffness At the resort Hot spring cure Recovered Satisfied

Fatigue, exhaustion At home Nutritional supplements It helps Satisfied

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Small conditions At home Herbal teas It helps Satisfied

Nephew: big tonsils At home Herbal application Shrinkage in tonsils Satisfied

IP-10 Acne At home Herbal application Recovered Satisfied

Small conditions At home Herbal teas It helps Satisfied

IP-11 Spinal disc herniation At home Herbal application Recovered Satisfied

Hemorrhoids At home Herbal application Recovered Satisfied

IP-12 Gastritis At home Herbal application It helps Satisfied

Table 3 CAM/Satisfaction

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IP-1: IP-1 uses tablets for her allergies but in order to avoid the side effects of the tablets, she stops using them when the allergens are less. She is unaware of the hyposensitization method but she turned to neural therapy with the search for an alternative and received neural therapy. But she did not get relief for her allergies from this therapy. She still uses tablets for her allergies.

IP-1 did not have a baby in her marriage of 11 years and they used all diagnostic methods offered by the academic medicine. In this process, IP-1’s husband was diagnosed with infertility and they received therapy, however it was not successful. They also used various CAM methods for his infertility in the last ten years. The first method she remembers is the examination of a physician in Izmir with a pen-like device that stimulates hands and feet and according to his evaluation, giving them herbal capsules and herbal teas. IP-1 who reported to have seen various certificates obtained from abroad (Germany and Far East) and her husband received this therapy for 1.5-2 years. The husband of IP-1 had tests in a private and independent laboratory during this process and his sperm count reached the top-level of all treatment processes. However, they quit this method because they could not achieve real success. IP-1 received treatment from the same physician for her indigestion. Later she used a garlic capsule she heard from the media for her indigestion and after that her complaints stopped.

Later they used products of a herbalist who is not a physician but they communicated through the phone because he lives in Ankara, however they did not help at all and they were disappointed.

IP-1 received neural therapy for her chronic conditions from a physician in Akhisar, which she had heard from her friend. However, this therapy did not help with her allergies and thamuria much. It only helped for very rapid healing of the wounds from sinusitis operation. At first her husband received neural therapy from this physician and after he received some benefit, IP-1 wanted it for herself too.

When asked 'Are there any CAM methods you wanted to try but somehow could not access?', IP-1 said she wants to use acupuncture and leeching therapies. She did not use this method because she heard from the media that there are a lot of dabblers in this area and it is hard to find a good practitioner who applies acupuncture properly. IP-1 heard in a TV show that her husband’s macula degeneration that 'has no medical cure' can be helped

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by leech therapy. She wanted to access that physician which appeared in that show with his patients for her husband but because the physician was in Ankara and asked a lot of money, they did not use this method. IP-1 who has an interest in the alternative methods and does researches, read that the leeches used were called 'doctor leeches' in European countries (Sweden or Germany), and the secretions of these leeches were very beneficial.

IP-2: IP-2 who is a building contractor at 43 said that he saw a hodja for his condition which was called 'yilancik' (a.n. a local word for rheumatism) and was told to be rheumatic pain, at the age of 17-18, and he shares his experience as below:

“IP-2: when I was 17-18 in the past I had pain in my legs... rheumatism in the feet, is known as rheumatism in medicine but colloquially it’s called 'yilancik' (a.n. a local word for rheumatism. I visited the hodja, there were natural stones, the hodja was praying, putting stones on my knees, if the stones stick on the knees they consider it to be erysipelas and they pray about it for a while... he says the prayers he knows, we don’t know those prayers he says. But later he gives a diet, that is we shouldn’t eat dough based foods, for about 15-20 days. We don’t eat for that time. We see some benefit.”

IP-2 whose complaints persisted after this application visited a doctor and his condition was diagnosed as rheumatism and he was told he could have a surgery. He did not want to have a surgery because his complaints were not too severe. IP-2 said he accompanied an acquaintance when they received acupuncture for losing weight, and that constitutes his only experience other than herbs and praying.

IP-3: This participant is a housewife of 59 that has many conditions such as herniated disc, hypertension, meniscal tear, etc. When IP-3 had a broken arm when she was young, they did not take her to the doctor but instead took her to a bone setter in the neighborhood:

“IP-3: When I was in the primary school I had my arm broken and at that time, there are these bone setters in the neighborhood, they took me to him and he broke my arm and then set my arm again. He grated hand soap, mixed that with egg, he made a mash with them and wrapped that onto my arm. He cut 'karve' (a.n. means something like stick) into many bands and he wrapped that onto my arm with tape, my arm was on the sling.... For a long time, like 2 months or so.”

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Even though IP-3’s arm was a little skewed, she did not have any pain or complaint. Again when she was 16-17 she had warts in her hands and they were not cured after seeing a dermatologist and using the medicine he prescribed. They used the following CAM method for that:

“IP-3: I was at sixteen or seventeen. I had a lot of warts on my hands.… Our neighbor told my mom 'find a fig stick and come to me, I will pray and mark with the stick every day'. I went to her, she prayed for about a week and they disappeared, nothing was left on my hands.

Again when she was young, when she had mumps, they obtained soot from bakeries and put that on the back of the ear and it offered relief. (a.n: this method is widely used among folks.)

IP-4: When they found she has high cholesterol at a laboratory test some time ago, IP-4 solved this problem by eating one walnut on an empty stomach in the morning for a while and later her cholesterol (LDL?) was normal.

IP-4 who was diagnosed with cervical opening wound a few years ago and when she did not heal by the medicine prescribed by the doctor, they decided to burn the wound. They told her to come back after her period but at that time IP-4 entered the menopause and therefore she did not return. Even though the patient have not heard this use, she thought “if that works for other wounds, it can work for this too” and she applied common centaury oil with the help of a syringe and a style a few times. In IP-4’s next gynaecological examination, they saw that the wound was healed. According to the accounts of this participant, there were people who use this oil for warts, mouth ulcers and even for stomach ulcers.

IP-4 applied black cumin oil to her nose when she had a nasal congestion and she saw that it was very effective in relieving the congestion. IP-4 also told about her neighbor who has sinusitis for forty years treated herself with this method. IP-4 applied the same method to her husband who could not sleep one night because of nasal congestion. She told his reaction as follows:

“IP-4: Again, my husband doesn’t believe these things, but. He went to bed, and tells me 'I cannot breathe'. I told him that there’s something like this, let’s try it, I

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ran and brought it and we tried. 'Oh, how quickly it opened my nose, I breathe so well, what kind of miracle is this' he said. At the same time his sinuses were opened and his breathing became easy.”

IP-5: IP-5 has complaints of tremors in hands, blackout and sitting unrest because of the nerve entrapment in the neck vertebrae for 12 years. Because the illness is not very progressive, after a long history of examination he decided not to have the high-risk operation. IP-5 who is quite open to using the alternative methods, received neural therapy for his condition in 2013. IP-5’s experience will be given in detail in section 5.4, 'Neural therapy'.

IP-5 also thinks 'jinn' which are held responsible of diseases in the society can be used to treat psychological conditions that are not organic-based. IP-5 said that this method can be beneficial especially when the person believes the method told about his experience on the subject. He said that during the time when he had first examinations for his complaints in 1997-98, a woman in the next village whom he heard from his friends and visited gave him information about his illness accurately and she knew his complaints without him telling her. Later the woman put her hand on his head and began to say prayers he could not hear clearly and both the woman and IP-5 sweated extremely during this practice. At the same time, IP-5 had a feeling like thousands of ants were walking from her neck to her head and were being pulled by the five hands of the woman. When sweating and the feeling of tingling ended, the woman said 'teacher, get well soon' and terminated the application. IP-5 said that she had a relief and the imbalances were disappeared after this application but in time, especially when she was nervous and tense the complaints reappeared.

IP-5 thinks that applications such as wear an amulet or get someone pray and blow which are called as 'ufurukculuk' (quack to claim to cure by praying and blowing) can be helpful provided the person believes they will work, and he shared her experience of a friend. The old mother of his friend had headaches and she asked his son to go to the next village and have the hodja there to write an amulet. The man thought it’s unnecessary to do that and he found three pieces of paper and wrote things resembling Arabic language, folded them and gave them to his mother. He told her to wear one of them on her neck, to put one of them into the water and drink it, and to bury the third into the ground. The mother who have been having headaches for days got well after doing this. IP-5 thinks that it works when the person totally trusts and surrenders to the method.

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Son of IP-5 who is 19 and plays soccer had a surgery for the hernia in the back. He tried some other methods when he started to feel discomfort in the back. IP-5 herself had back pain before and she were healed from the massage performed by a young woman in a nearby village. He took his son who has back pain to the same woman and had him receive massage too but his son did not heal. IP-5 knew that the people who offer these massages for the purpose of treating a health issue are usually seniors, so he asked the woman who did the massage whether she had a training about this and where did she receive it. Upon his questions, the woman got nervous because she was scared to be reported to the police. IP-5 told her who was confused with the fear of being reported that he has no such intention, then he learned that this young lady learned the therapy massage from her grandmother. (a.n. Initiation)

Again IP-5 took his son to a nearby small town (Yatagan) where a man who is rumored to heal people by using energy and he also received the same application. When the practitioner put his hand next to the problem area his hand began to shake and he claimed to heal the problems by giving energy. He also witnessed some people who were there and could not walk got healed after the application. People who had this application before and waiting for another session also said that they got benefit from it. His son stayed there for 3 days and received 3-4 sessions but did not get benefit. However,when the practitioner said his son has problems in his kidneys and heart, IP-5’s trust was shaken and they returned home. He thinks that the practitioner mentioned different conditions and made them nervous and thus he tried to to keep them coming. The son of IP-5 later wanted to go to the spa and spent a few days in the spa but there was no healing. IP-5 thinks that if it’s a slipped disc, it can be healed with massage etc. but if it’s a hernia, it does not heal. After that IP-5 told his son that he now needs to have surgery because other methods did not work and thus they had the operation. After a successful operation in Izmir that used microsurgery method his son healed now and after one year from the surgery he resumed doing sports again.

IP-6: IP-6 used onion course for the myoma the gynecologist diagnosed and reduced the size using medication causing menopause. IP-6 said she had a wound at the cervical opening at the same time, and during the exam it was also healed. She also received bioresonance therapy from an internist who uses CAM methods and even though she does not know which one helped her heal, she thinks the doctor’s therapy was more effective in

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her healing. Because of sensitivity and rash in her skin she was referred to the government hospital in Manisa (big city) from Akhisar (a town) and there she was told that it was caused by goiter and that she needs to have surgery. IP-6 told that she did not have that maybe because she did not believe that and later she visited the internist who uses CAM methods after hearing about him from her friends. From her definition of “He did a checkup”, it is understood that it was a bioresonance device but IP-6 never used the term 'bioresonance'.

“IP-6: With checkup, I mean he had me place my feet and hands onto some metal things and checked from the computer, he scanned my body like that.”

The doctor said IP-6 has rice and flour allergy and when IP-6 had a 3 weeks diet without them, that helped. Also, IP-6 who had a pain in her right arm that can be severe enough to wake her up at night for many years felt the pain in her arm decreased during that time. Also, her complaints which was diagnosed as 'bladder syndrome' when she was examined in the hospital disappeared during that diet.

She recommended her elder sister to see the same doctor. Her elder sister who had upper and lower back pain also received neural therapy as it is understood from the definition of IP-6 but IP-6 did not used the term 'neural therapy' neither.

IP-7: IP-7, who is a homemaker at 56 and who is also a farmer said that she has cupping application when she catches a cold and it helps. IP-7 had blood-letting long ago for her psoriasis:

“IP-7: I had that blood-letting once long ago. I had that for the psoriasis, they said it will help but it did not help much. At that time there was a man in Akhisar and he was doing that continuously. He had a shop, and there was a room in his office, he did that there. At the front it’s a tailor’s shop and at the back there was a room for this. They said he knows that and I went there because he is well-known in Akhisar.... he drew blood from my arm using a machine-like thing. But I was a little scared, I cannot say I wasn’t scared when he drew lots of blood. He drew from the vein. He drew from here, this area (a.n. the cubital areal).”

IP-7 tells that she let pour lead, when be coveted, when the child cries too much and becomes ill, and described the way to do this:

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“IP-7: Well, they cover a cloth over the child or over the grown-up, whoever the lead will be poured to. They melt the lead and throw it into the water, and they evaluate the shape of that lead in the water. If there is an evil eye, an eye shape forms they say.”

IP-8: 20-year-old IP-8, who is a university student and also an employee, have not used any CAM methods except a local herbal oil (balsam oil: St. John’s Wort oil) for wounds in the legs, and thyme or linden tea for the flu. However, her aunt who suffers from back pain due to herniated discs and has difficulty walking has recovered after she applied the mixtures she bought from someone who prepares herbal oils.

“IP-8: my aunt suffered from low back pain a lot. They visited that person, they gave her some (herbal) oils there,... it really worked. She was about to undergo surgery but she didn’t. Her low back recovered.

INTERVIEWER: Does she still use the product, or did she use it for a while and then recovered?

IP-8: She used a while then recovered.... they said she needs surgery, said she has herniated disk, you see... My aunt used them, and they helped, you see, she goes up the hill well. She healed, auntie is good right now. Before, she was laying in the bed, she could not get up for 1-2 weeks.”

IP-8 added that her mother, who had low back pain, also used the same oils, but she did not recover.

IP-9: IP-9 is 43 years old, working as a retiree and farmer. When he was working in Switzerland, one time when he had his summer vacation in Turkey, he was exposed to the air condition for a long time when he fell asleep when he was sweaty and had a serious stiffness in the back. When he visited the emergency department, they administered muscle relaxants and painkillers and received strong pain relief pills, but the problem was not resolved. When he returned to Switzerland, the family doctor said that some of the patients had similar illnesses during the summer vacation, and recommended him physical therapy and massage.

“IP-9: I went to receive physiotherapy, he said to me 'this is a summer sickness, there are 3 gripes on your back'. They massaged them with a machine, about ten

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session, you see, it does good. But my wife also massaged with olive oil about every two days. It lasted for 3 months, but I was healed after 3 months. Normally it heals within 2-3 days but it took 3 months to heal.”

The tonsils of the nephew of IP-9 who is interested in herbal cures were very large and caused breathing problems. The nephew had been recommended to have surgery for this and the appointment was taken. IP-9 used a method he learned on his nephew until the time of surgery:

“IP-9: My sister’s daughter also had the problem with the tonsils. She’d have trouble breathing. If I had read it before, for example, if the child used it regularly, perhaps she would not have to get operation. I can not remember at the moment, but the barley or oat is boiled with nettle and if the child drinks it regularly, one glass in the morning, one in the afternoon and one in the evening, it has a good taste when it is sweetened with honey or sugar, it becomes like tea, we saw that it was very effective in downsizing the tonsils. Even the doctor noticed that.... Since the doctor’s appointment was set, her family said 'let’s not risk it, have the surgery, relieve the child' But I have seen the difference with my own eyes and even my sister saw it. We saw that before it had a gap of 2 to 3 millimeters, and it expanded like that, expanded to 6-7 millimeters.”

IP-9 also stated that he relaxes by going to the spa when he has muscle strain, and he uses fish oil capsule, vitamin tablets or freshly squeezed orange juice when he has a busy schedule.

IP-10: 19 years old IP-10 who is a university student stated that they use herbal remedies for their mild diseases. He told that he applied lemon crust to his face for puberty pimples and he had a positive results. Because he was a young and generally healthy person, his experience with CAM methods was little.

IP-11: 55 years old IP-11 did not want to have surgery recommended for diagnosed herniated disc, because he thought the surgery was risky. Instead, he used a traditional method he had heard from his grandmother:

“IP-11: I had made my wife wrap the settling... that is the acid of olive oil, wrap on my back. Made her rub one hundred grams of it to my waist, down from here my

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back bone, then… I wrapped it with stretch film for forty-eight hours. Have wrapped five or six layers. Forty-eight hours without taking it off. When I took it off... Look, it has been a little more than one and a half year now, I feel noting anymore. There’s nothing left. It has been one and a half year since I used it. I had an MRI again, and there is nothing now. I have nothing.”

IP-11 had hemorrhoid surgery two years ago, but his doctor told that the surgery was failed. Then his aunt’s son-in-law brought him a seed called the bitter bean and he swallowed five or six times a day for fifteen days and learned that the hemorrhoid had been healed when he went to check.

“IP-11: I went to see the doctor, to err, I went to Celal Bayar (a.n. university hospital). I went to see the doctor and the doctor himself could not even believe it. I had a check in a month. The doctor examined, even he was surprised. He said 'Mister', said 'there is nothing left', said 'there is nothing'.”

IP-11 has also recommended this method which he has benefited to many other people, and they used it and they too received positive results. Mother and father of IP-11 who had died because of different types of cancer did not use any CAM methods and only applied the treatment offered in the hospital.

IP-11 heard that there was a sauna in a nearby province Salihli, where massage was applied for the herniated disc. He explained that the ones gone there felt good for a while but then they were worse:

“IP-11: we had a friend who worked here, he went to Salihli, he had a good week, after a week he couldn’t hold his waist straight, walked doubled up all around.”

IP-12: 46-year-old IP-12, who worked as a janitor at school and said he was doing the jobs like sweeping, with a sporting intent, went to the hot spring to accompany a friend who had a backache. He did not have a personal experience with a CAM method other than the well-known herbal teas that he drinks for flu etc. and the distilled thyme juice he used after gastric ulcer surgery. IP-12 stated that he feels positive about traditional methods. He explained that a friend who had a malignant diagnosed wound on the lips didn’t have operation as recommended by the surgeon, instead he used the preparation made by someone who prepares herbal ointments for such cases in a nearby city and healed

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completely. He narrated that, then his friend wanted to talk about the recovery with the diagnosing surgeon, but he got the negative reaction from the surgeon, as follows:

“IP-12: He recovered without surgery. He went to see the doctor, so he wanted to tell him that 'I’ve healed because of this'. The doctor said him 'go' 'and tell the one whoever healed you'. They weren’t interested at all.”

5.4. How participants approach to CAM methods and their habits of use

While the majority of individuals participating in the study, consider using the alternative methods only for mild illnesses that can be dealt with at home, they stated that they immediately consult a physician for illnesses they think which are serious. One of the most common reasons for using CAM methods is patients’ wish to avoid surgery recommended by the doctor, especially for complaints of musculoskeletal system. For this reason, IP-5 tried to get resolution for his neurological disorders using some CAM methods, and tried a variety of CAM methods for his son who has a herniated disc. However, those who used all the possibilities of modern medicine to solve their health problems but are not able to achieve adequate recovery or satisfactory results also make a serious search for CAM methods. One of the most obvious examples of such searches is the desire to have a child, and infertility treatments, as in the case of IP-1.

According to the information and observations obtained in this research, young people get to know and use the alternative methods more with the lead of their parents. The community structure of Turkey, where young people stay with their families until they get married or study at college in another city has an important role in this. Both young people participating in this study were observed to have limited knowledge and experience in health and CAM subjects. The fact that health problems increase with age may be a reason why young people are less interested in this subject. It is clear that older participants have more experiences and share more examples of their acquaintances about these subjects. Level of education is a factor that influences the interest in CAM methods in Turkey where these methods are not so common yet. Individuals who are primary school graduates use traditional methods, but often are not interested in other CAM methods. The observation that participants who are high school graduates were more interested in CAM methods

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apart from the traditional methods and do researches about these methods was one of the notable findings during this study.

While the interest about and use of CAM methods increase both among the public and healthcare professionals in Turkey, a large segment of the society considers alternative medicine as herbs. Another segment includes medical systems that belong to other cultures and are newly recognized in Turkey into this definition, along with phytotherapy and traditional methods.

5.5. Ways to learn about CAM

Individuals who want to use other methods besides or instead of modern medical treatments for various reasons tend to seek information from the sources they can access. The most common way of getting informed in the public on this subject is by people who use a method to tell or recommend it to others. The number of people who learn and practice the methods they consider would be good for health at TV health shows also should not be underestimated. Also, some investigate the methods of interest from books or sources on the internet.

5.6. CAM and money/finance/insurance

Those participants who saw physician CAM practitioners said that their rates were high and they had difficulty in paying the fees. Those who used herbal products they bought from herbalists or pharmacies said this method was affordable. There were also participants who picked the locally grown herbs themselves. Some participants who paid for some traditional local practices indicated that the money they paid was not too much. One participant said that an acquaintance of her did not recommend her a herbal method she used and got some benefit, because it was too expensive and has not fully cured the problem.

Almost all of the participants said that they would view it positively when asked “How would you view it if some of the CAM methods are reimbursed?”

However, the participants’ behaviour of trying and recommending, especially the traditional methods, even if they do not heal is remarkable. The reason for this is that it is easy to access these methods and they do not require much money. This situation supports

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the comment of E-13, who is an internist on this issue. E-13 stated that the full reimbursement of CAM methods would be wrong, it would decrease the quality of service, and lead people to some methods even if they do not benefit from them. He emphasized that the patient takes responsibility when using CAM methods whose benefit is not fully proven, and that one way to show that is to pay for it. However, he added that it would be appropriate if the CAM preparations or applications prescribed by the physicians are reimbursed.

5.7. Satisfaction with CAM methods

5 of the 12 people who participated in the study stated that they were satisfied with all of the CAM experiences they mentioned during the interview. Only one of these 5 people reported using CAM methods applied outside the home. Among all other participants who said they were satisfied with every method they used, none of them mentioned any method other than herbs and praying. Even tough one of these people had herniated disc and hemorrhoids, one had gastritis and two had a history of allergies, it could be stated that these 5 people do not have complicated diseases and histories.

IP-1 and IP-5 who used various CAM methods without any results were the participants indicating the most dissatisfaction. Even though IP-1 had some benefit from some methods with her spouse, she was not satisfied with the CAM methods she used because she ultimately could not fulfill her desire to have a child, and because of the financial burden these methods incurred. IP-5 was dissatisfied because he did not get any benefit from the CAM methods he used to avoid surgery, other than slight relief, and because these methods were costly. Likewise, he was not satisfied with the methods they tried to avoid surgery of his son. Whether or not people are satisfied with the CAM methods they used or not is, like in modern medicinal methods, mostly related to whether they see positive results or not. However, when people use CAM methods and do something themselves, that is, when they take an active role in recovery, the satisfaction levels increase subjectively. This could be observed in the attitude of IP-4, IP-9 and IP-10 when they talk about herbs, or in the attitude of IP-6 when she talks about dancing and painting.

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5.8. Recommending CAM methods

Most of the participants heard the methods they used with the recommendation of someone who has used or benefited from that method. Again, most of the participants recommend the methods they use and benefit from to others.

Most of the participants stated they would be happy to hear recommendations of a doctor about a CAM method, and they said they would confidently use this method. IP-4 however thinks it may not be very appropriate because as a society, we are not ready for it yet.

5.9. CAM and modern medical methods

Participants were asked whether they used CAM methods along with modern medical methods. Two participants expressed that they did not use CAM products simultaneously with the medications because they were concerned about interaction. Two participants used the CAM method together with the medications simultaneously, and when evaluating the positive result, they believe that they benefited more from the CAM method than the medical method.

5.10. Some CAM methods used by participants

The researcher considers including some CAM methods used and explained by participants in another chapter would be useful in that it will allow evaluation of the public knowledge about these methods. The following pages include these experiences under the names of these CAM methods, and especially the descriptions given by the participants.

Phytotherapy

Herbs and herbal products are the most frequently used and popular method among the CAM methods used. In this study, herbal CAM methods are those the participants have the most experience with and provided the recipes of. However, when it comes to treatment with herbs, Turkish people perceive phytotherapy together with the traditional herbalism. That is, when it comes to herbal CAM method, both scientific-based approaches and traditional approaches come to mind under this concept.

One of the reasons why herbal products are used as a CAM method is the belief that 'that which is natural is harmless’.

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The opinions and experiences about herbal products of some of the participants in our study are as follows:

“IP-10: the herbal products would be such as beneficial, you now, harmless, because they are organic, I think they would be benefical without side effects.”

“IP-1: we take antibiotics etcetera when we go to modern medicine, but well on the harms they do to other organs, I do researches, I am curious, I look at it from the internet, I follow from newspapers or from the media.... while it heals somewhere, at the other side it can cause other damages. Well, there are the side effects of herbs, of alternative methods, but it seems to me like, it’s my opinion, that these heavy drugs we use, the heavy medicines of modern medicine that intensively used, like a chemotherapy for example. Okay, it’s applied to a serious health problem, but on the other hand it takes some things away, as far as I can observe... if the harm to get can be reduced with the alternative methods, if they also heal without you get the harm that you would get with the drugs, can be leaned to them.”

“IP-9: Get thyme, sage, they have side effects like this, I heard there is, thyme for example can be given to small children, but it has to stay short in water, in hot water. I heard that, it is not good for children, for pregnant women, when it stays 8 or 10 minutes, that a preliminary study had to be done in advance. For example, that the sage is very strong, can cause low blood pressure, to be careful when used by children and pregnant women.”

“IP-4: (a.n. referring home remedies) maybe it should be countered them, but some medicines do too much harm, so I’m not really into drugs. I lean to alternative because of that.

INTERVIEWER: Do you think in this way because you used and got harm, or based on your observations? Just you said some of the medicines are harmful.

IP-4: Some of the medicines are harmful, for example some of the headache medicines can harm my stomach very much, so I do not like to drink too much medicine, I do not normally like it.”

IP-4, who is a science teacher, from those who think herbs when called CAM method:

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“INTERVIEWER: Where are you usually getting these informations, you... said 'I’m interested in?

IP-4: It’s, I don’t know, let’s say my field of interest, I also love to working with herbs too much....

Now I lean more to herbs....

Yes I find it useful. I like the herbs....

As getting through the flu too.... For the medicines that I prepare about flu, of course, I also primarily leaning to the herbs. that I prepare about flu, of course, I also primarily leaning to the herbs. I really like alternative medicine too much.”

Indeed, IP-4 has also put into practice the information she won as a result of this interest and has got a lot of recipes and experiences. She made the same compound, as her mother made and put on the wounds of her children when she was a child, and she described this as follows:

“IP-4: For example, I had a medicine, made at home. With olive oil and centaury, we put the flowers in olive oil for forty days in a warm environment. We use red centaury for this, after forty days it takes a color like tincture of iodine and it becomes really a chemical interaction and it is effective in closing the wounds. Let’s just say that our finger is cut, we have a cut off any place, both it relieves the pain and the second you forget your wound, has a so strong healing effect.”

IP-4 also described a mixture, which she heard that it is good for stomach discomfort. IP-4 has prepared this mixture, which obtained by chopping the bitter squash and holding it for forty days in pure olive oil, in her own home. Along with not being used until now, she thinks to use it when needed.

IP-4 said that for flu, she rubs a pomade (a.n. a brand with eucalyptus) on the back and chest while massaging. Participant also said that she doesn’t like to use antibiotics in throat infections, that she wind a cheesecloth around the throat after putting on this pomade, that she changes it frequently when sweaty, and it comes to recovery by sweat the toxins out in this way. One more example of IP-4’s wide home-care knowledge is the application of apple vinegar by spraying into the upper part of the throat and upper palate with the help of

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an empty spray box, which is applied at the onset of throat infections without infection. And the other one is, to put a sweet spoon salt in a glass of boiled chilled water and mix it, then sniff it in and clean the nose. She thinks that sweating has a healing effect by diseases like flu and cough, and she prepares and uses a mixture like this:

“IP-4: if it’s a flu, if there is also cough, if there is need to sweat, if there is need to sweating out, there is a mixture like this. This mixture, a glass of boiled hot water, it should be quite hot, one or two tablespoons honey, one aspirin, we use a lemon, black pepper, we mix them. It is such a beautiful mixture that it is lightly spicy, wonderful, hot. He drinks it so hot, he made drink. After that, we drink it and then we sweating so beautifully during the rest, that it is very good for the throat and for coughing is also very good. And it’s also ideal for sweating.

INTERVIEWER: You think sweating is useful.

IP-4: I think it’s helpful, I think it’s been eliminated out of the body. I mean, I think those toxins were removed out of the body, removed by sweating. And it comforts us, we feel really better at the end of sweating.”

IP-4 also cares about take nourishment rich of vitamins and when they get sick, especially to her children, she cooks and serve a lot of chicken soup. She read that this is in America recommended for children because it is as effective as antibiotics.

IP-9 had lived in Switzerland before, and when he was there, he bought a tea which 'stomach ache' written on the package, from the supermarket and drunk it for his abdominal pain, and after a while his abdominal pain ceased. After that, he began to show interest in herbal teas for therapeutic purposes. Later, he tried chamomile, anise tea for sleeping problems, and drunk in the morning with honey sweetened thyme tea to feel vigorous. IP-9, who has pollen allergies since childhood and uses pills for it, has used stinger a lot to help his allergies. In a shop selling herbal products, he bought a tea with 4-5 kinds of herbs inclusive stinger, honey and sugar. In the time he used this tea, he needed less allergy medicines.

“IP-9: For example, I have been using since about 15-20 years 20 pills, in April, May, this time I used 5 or 6 pills. I think it does me good.... 15-20 years, as I used,

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20 times and sometimes even more pills, in two months, this time I had a nice, comfortable period using pills 5-6 times.”

IP-9, who stated that herbal teas should be used regularly as a cure, expressed the following opinion in this regard:

“IP-9: People do not know cure. So when I drink two glasses, 'this is good for me' or 'it did not work for me'. But if you have a problem, or even if you have any, these herbal teas, to use regularly. For example, one week morning and evening a glass to drink, with a water glass. Scientists say it is more beneficial to the body if rested for 3-4 days and then tested again for a week. After drink 2-3 cups, 'I took some herbal tea' and such like.”

IP-2 tells that he uses yarrow, which colloquially known as 'kokarotu' (a.n. yarrow) and answers questions about CAM methods, often thinking of this herb:

“IP-2: We call colloquially 'kokarotu' (a.n. yarrow), I drink some herbs like this, this herbs do good to abdominal pain. I also benefit much from this. But if it doesn’t be better, then I go to the doctor.

INTERVIEWER: Are there any other methods that you apply to other people in your family?

IP-2: In our family, my wife uses like this, so we see the benefit of it.

INTERVIEWER: I understand. Is there anything you obviously use? You say 'I used it at this time’?

IP-2: I used that herb a lot. It’s a little psychologicall I guess, it becomes a habit psichologically. But when I use it, it gets better, so there is a little bit of a stomachache, it’s like a swollen abdomen, and that gets better when I use them.”

Another participant is who stated that she use herbal teas, is IP-6:

“IP-6: I already drink green tea. They said it’s good for both my body and so to get rid of edema. Then, for example, cinnamon, cherry stalk, turmeric, I boil and drink them.

INTERVIEWER: For what?

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IP-6: It’s just to make my body more comfortable. It’s mostly because of edema- relieving, because it’s appetite-reducing and because it’s beneficial to lose weight. But I see the benefit. I used that. Like I said, I use herbal remedies when I got the flu. Linden, sage.... I brew separate. We use black pepper and all of them, boil and drink them.”

IP-7 also states that they use the most common herbal teas as family by mild illness:

“IP-7: As I said already, from herbs, we drink tea, herbal teas. For example, like linden tea, sage, because I am a person with a very sore throat, and instantly my throat suddenly gets sick.... Related to blood pressure, sometimes we drink lemon or something we wonder if it’s helpful, we don’t know also it’s effect.... For bone tinning, I melted the egg crumbs with lemon and drank a tablespoon on an empty stomach in the morning. For 15 days. I took a break for 15 days and drank again.”

For the wounds that occurred on the feet of IP-8, used the herb known as 'balsama' (a.n. centaury) which her neighbor picks and prepared an oil, but she didn’t benefit. The participant stated that she and her family were boiling and drinking the herbs such as thyme, linden when they have flu.

Neural therapy

Two people who participated in the study have personally received neural therapy, and it is understood from the statements of one of the participants that her sibling also received neural therapy. The accounts of one of the participants who has received neural therapy, described the therapy he received as neural therapy, but he did not know the exact name.

Neural therapy is a method that requires special training. It is applied by injection of nettle extract and local anesthetic, and is practiced by trained doctors. The fact that the practitioner has mastered the modern methods of medicine also has a very important role in creating a feeling of confidence in the patients who use it. Although this TAT method does not bring out the same positive result in every patient, patients do not react negatively when they are informed properly from the beginning, even if the improvement is unsatisfactory. However, if the patient gets high expectations from the beginning through promises such as 'this method will solve your problem', the patient experiences a bigger disappointment if the result is not satisfactory.

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The allergy problem of IP-1, who received neural therapy for the allergy problem, was not completely disappeared after the therapy; but the wound after sinusitis surgery improved very well when receiving neural therapy. She did not blame the doctor even though she was disappointed from the result, because the doctor explained from the beginning that the method might not be effective for him/her, and left the choice to use the method to him/her eventually that he left the choice to use the method.

IP-5 has been suffering from trembling of the hands, blackout, and restlessness while sitting for about 12 years as a result of the nerve compression. The neural therapy he received a year ago did not prove to be as beneficial as his expectation, and he has a more negative reaction against the doctor because the doctor kept his expectations high from the beginning.

“IP-5: He said 'I’ll give you a treatment and as a result of this treatment you will heal'. Well, that sounded good to me too. I said okay doctor, what shall we do?”

Initially, IP-5 traveled to Izmir from Akhisar where he resided three days a week for the first 12 sessions, and it was a two-hour journey. After session 13, he received sessions every one or two weeks and they completed the treatment with 17 sessions. When he visited the doctor for follow-up one month after the treatment was completed, he said that he did not get much benefit from this treatment. The doctor said that it might take time for the herbal product used during the treatment to take effect, which could take up to six months. There was no major improvement in the situation of IP-5 when this specified period ended in April. During this time, complaints of IP-5, who continued to use Pramipexol dihydrochloride monohydrate and Escitalopram preparations, which were prescribed by the neurology doctor at Akhisar State Hospital before the neural therapy, were slightly relieved after these medications and neural therapy. He can have coffee when he is relaxed, and he is not as restless as before when sitting.

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5.11. Views of Professionals on CAM

In this study, an internist who uses some CAM methods he was trained on in his treatments, a manual therapy specialist who was trained on manual therapy in Russia, and a family practitioner who works in a community clinic has been interviewed as professionals.

Considering the versatility of the subject, obtaining views of a family practitioner besides two specialists who uses CAM methods was considered beneficial.

E-13: Internist

E-13, who is an internist accepted to participate in this study has completed his education on internal medicine in 1999 and has been working in his private practice since 2000. He has not worked in a governmental institution; however he worked as a dialysis physician outside his office for 12 years. For the last two years he is working only in his practice and is interested in the CAM methods for about 7 years.

E-13 said that a physician working in an office faces the outcome for every patient he/she has seen, while a physician working in an hospital, a medical center or a university mostly does not know what happens after the patient goes home, and therefore, the best place to practice medicine is the private office. According to E-13, a patient who visits the private practice of a professional at his own expense comes back and lets the physician know every instance he failed at treating his condition. And therefore, the best working manner in terms of receiving feedback is the private practice. E-13, who knows the subsequent states of his patients he sees for years realized that, for some conditions which resulted from pain, hormonal imbalances, and mental and physical dysfunction, the service he offers as a doctor of what he calls 'Anglo-Saxon' medicine was insufficient. According to E-13, the biggest handicap of the doctors of today is, when faced with situations they cannot solve, they are unable to say 'I don’t know' and instead they describe the situation as 'this patient is a psychological case, he has a benefit from the illness or there is somatisation, etc.' Therefore, because he believed that, when the medicine he prescribed does not work, or when the patient does not respond to the therapy there must be some other solutions, he turned to CAM. At the same time, E-13 believes that “in the universe, everything takes up its own space and nothing can take up the space of another” and, while

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he uses the methods of the modern medicine for the suitable patients, for patients who does not respond to them, he uses the CAM method he thinks the best fit for that patient.

When asked what methods he follows for the health problems of himself and his family, E- 13 said that he decides according to the diagnosed condition. For example, if his child was diagnosed with cryptic tonsillitis, he uses the classical method; however if it is a pain syndrome, he prefers the CAM method.

E-13 stated that the method he likes most among CAM methods is neural therapy and he could solve more problems with this method compared to other CAM methods. However, he said that nothing is as effective as EFT when it comes to the post-traumatic stress syndrome, and he emphasized that the compulsion of solving every problem with the same method is wrong. E-13 uses CAM methods such as bioresonance, ozone therapy, neural therapy ad EFT. He received his training on bioresonance therapy in a foundation in Istanbul, where he practiced the technique for 3-4 years. And during this process, he was introduced to other CAM methods. He received his EFT training from a doctor who was an EFT master, and also a biochemist. He received his neural therapy training from a physician working on neural therapy in Istanbul, and he worked with him for over two years. Again, he received trainings on detox therapies and chelations from this same physician, and received 3 levels of manual therapy training from his group of professionals. Regarding ozone therapy, he studied over one year in an on ozone therapy foudation in Turkey.

According to E-13, half of his patients see him as an internist and other half visits him for the CAM methods he uses. Most of the latter are referred by people who visited E-13 and benefited from the methods he uses, and come with prior knowledge about his methods. Having said that, E-13 observed that eight of ten patients who visited him especially in the last 5-6 years had visited 3-4 doctors before seeing him. E-13 thinks this is due to the fact that, as a result of the general health insurance, people now can receive free medical service from institutions such as community clinics, government hospitals, university hospitals; and for a fraction of the cost, from most private hospitals. E-13 says that in Akhisar where the economical status is at moderate levels, people first prefer to use these services and come to visit him only when they cannot solve their problem there.

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According to E-13, patients in Turkey definitely have a big inclination to CAM, however physicians in Turkey definitely have not. E-13 who said that most doctors in Turkey have not even heard some CAM methods widely used around the world, gave the example of 'Bach flowers' and said that nine out of ten doctors have not heard of Bach flowers method.

E-13 cited one of his teacher’s statement on this topic: “Someone who only has a hammer in his toolkit sees everything as a nail and hits on its head.” With this understanding, according to E-13, each CAM method is an instrument that works for the specific cases and increases the problem solving capacity and, it is necessarry to combine the western medicine with CAM somehow and thus to use the suitable methods for the specific cases.

E-13 said that all institutions offering CAM trainings give participants a 'certificate of participation' for the course which does not have any official recognition, and he added that their only value could be to hang them on the wall of the office to impress clients. He emphasized that he practices the methods he was trained on to his clients within a relationship of mutual trust. E-13 said that those who will issue the certificates or hold exams must have mastery in that area and, for example, for a professor who has not heard of neural therapy before to do these things would be meaningless. According to E-13, the problem about certification comes from the lack of knowledge regarding CAM methods in the universities and their curriculum that will be counseled when making these regulations. E-13, who said he does not believe there is autonomy of education in the universities and that he sees the universities as 'the courses of the medical equipment industry' has some recommendations for solution regarding regulations.

“E-13: In Turkey, not all practitioners of alternative methods are doctors. Some of them are doctors, some of them are not. If in Turkey doctors don’t use manual therapy, then bone setters in the society do that. If in Turkey doctors don’t have knowledge of herbal therapies, then the herbalists do that. If doctors in Turkey don’t know how to do bloodletting by cupping, then the cupper will do that. No space will stay empty. Someone definitely fills in that space. Well, here, to me, all the complimentary methods and the basis they work on should be taught at universities in the first place. For example, homeopathy is being practiced in the world for 250 years, however there are physicians who graduated from the medical school but have never heard of the term 'homeopathy'. Is this normal? No. I even think that a person who graduated from the medical school should have on her/his

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diploma this statement: 'medical doctor of British-American school'. So that the patient can say 'Hmm, this man is a medical doctor of British-American school, they couldn’t solve my problem. Is there a doctor who is not from British-American school?'”

E-13 believes that having information on methods that are practiced around the world is the responsibility of a doctor, and he gave the following example:

“E-13: A simple example: hyperbaric oxygen therapy has a history of 15 years in Turkey. A Russian doctor discovered it in 70s. Diabetic feet they used to cut 15 years ago can now be treated with hyperbaric oxygen therapy. However, 25-30 years ago they were being treated in Russian block. So, don’t you think that professor who cut that diabetic foot because he didn’t know a method that existed in the world is ethically responsible?”

E-13 thinks that, in order to gain knowledge about all CAM methods, medical faculties do not have to support the use of CAM. In fact, he supports that these methods should be integrated during the education process and when listing treatment options, it should be stated that these methods can be used for cases that do not respond or cases that are suitable. According to E-13, CAM is the knowledge accumulated throughout human history and even a professor does not have the right to curse this knowledge. E-13 who has witnessed patients who saw 4-5 doctors but could not heal, then found cure from someone who uses traditional methods, thinks that excluding these practitioners, even if they have not received medical education, is inappropriate and supports a formula that encompasses these practitioners. His suggestion regarding this formula is that, the patient who will receive the CAM method will be given a document. With this document, the practitioner will inform the patient as following:

“E-13: Dear patient, this is the procedure you need. This procedure is not a procedure voted for by the general health authorities in the world. Not accepted by all. The person practicing it in Turkey believes in it but this is not a method that has been commonly accepted. Therefore, since this is not a commonly accepted method, in the application of this method, the patient and the practitioner are equally responsible for choosing this method.”

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His suggestion for solution includes that those practitioners who are not doctors or specialists should be able to have an office as members of various associations that will be established on CAM fields, to register at the health department and pay taxes. When these associations can give training and/or authorization for practice, that area will be under supervision. The expert’s taught in this subject resembles the self-regulated registration system for alternative practitioners in Denmark (see 2.2.1)

According to E-13, those who practice CAM methods without a legal authorization will continue doing that despite all the regulations, and therefore prohibition will not be sufficient to ensure supervision. However, as especially those who received medical education learn these methods, people will in time eliminate those who are not good in practicing the method.

E-13 said that no government or association on the earth has the right to say 'you will be content with the knowledge I have' and added:

“E-13: Can we say 'Dear patient, you will get rid of the pain as much as the British/American medicine allows you to and please don’t seek other solutions', can we say that? We cannot have the right to say that. We cannot have the right to say that. But right now, that is what they say to the patients. When you say 'Why did you visit that person, why did you visit the massage therapist, why did you do cupping', in fact what you mean is 'why didn’t you content yourself with what I’ve provided to you, ungrateful person.' That is a dead-end.”

E-13, who said that some patients who visit him have amulets is quite open-minded on this subject:

“E-13: Sometimes I see, the patient has an amulet. If I was the Minister of Health, I would allow those who prepare amulets to make it freely. I would say, 'Establish an association, all of you get your certificate from the association and hang it on your walls. Issue your invoices, pay your taxes, hang it on your wall. Get signature from everyone who visits you. State if you haven’t studied theology at college, state if you studied. State what you have done and haven’t done.' If people have faith in that, that can be done. But the more you push them away from the cities, the more you push them to the suburbs, the more misuse occurs.”

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According to E-13, natural methods, methods of Anatolian medicine such as cupping, leech therapies, the methods that we adopted from Chinese medicine or Indian medicine, and methods such as energy therapies, EFT, affirmation therapies that we have recently adopted from the West, all should be regulated and made available to the public.

E-13 said that the biggest problem of practitioners of alternative methods is they do not have the culture of following-up patients because they have not received a medical education. He have this example:

“E-13: Someone in Alasehir, who is a truck mechanic... is doing manipulation, manual therapy. But is that manual therapy a one-time application or should he do follow-up exams and follow-up applications? But that man is doing it only once.... Because he doesn’t have this information: 'first check the iliosacral joint, correct it and if the problem persists, make sure to check the temporomandibular joint too.' But he is making applications to 50 people all day. And all 50 say 'I feel very good' after 15 minutes. And the patients and companions who watch them say 'hey, he looks so good now' and the practitioner sends them away. He knows nothing about those patients who feel bad after 1 day.”

In order to solve this follow-up problem, E-13 suggests that the Government should set the main rules and create a template for people who do healing work. According to this template, the CAM practitioner should, as a legal obligation, make follow-up calls after 1 day, 5 days, 15 days, 3 months, 6 months and 1 year and fill up the required documents. To do this, according to E-13 CAM applications should be priced a little bit higher than they are now. For example, someone who sees a phytotherapist or a herbalist should pay 150 to 200 TL, no matter what kind of product they get and also they should know that 50 of that 200 TL is for calling this patient 6 times in one year and fill a form in 15 minutes on the phone. E-13 thinks that when they receive such feedback, most practitioners will conclude 'what I am doing is not working' and will quit that practice. Also, E-13 believes that with this type of record-keeping, many good drugs and methods will come out from Anatolia and he says Statistics departments or psychology or parapsychology departments or medical faculties of universities should perform studies over those records. He continued:

“E-13: I mean, if the government will get involved in this, it should be that way. Well, for example a herbalist recommends a herb, and a physician declares him a

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fraud. But dear physician, you couldn’t solve my problem.… If you are such a skilled man, such a holy man, then solve the patient’s problem so that he doesn’t see another person. But on one hand you cannot solve the patient’s problem, on the other hand you are saying 'you must content yourself with what I’ve provided to you, you are being ungrateful by visiting someone else'.”

E-13 also believes that a CAM method that solves a problem should be made known to the physician or physicians who could not solve that problem before, and this communication should be established by the Government. He thinks that universities must have CAM professorships and these should must include local-traditional practitioners who do not have a diploma or certification and their fund of knowledge must be put into use.

E-13 said that sometimes relatives of patients consult him asking 'my father has cancer, our uncle also had cancer and he received treatment for 6 months, then he died. We don’t have any trust in modern medicine now. They say there’s a man in Tire (a town), or a man in Odemis (a town) who treats patients, shall we see him?' and he explained his approach to these situations:

“E-13: What is the illness of your father? Colon cancer. For how long that man is doing this job? Ten years. Then see him and say: 'give me the names of colon cancer patients you treated 3 years, 5 years, 7 years, 10 years ago. I’ll visit them and then we’ll follow your way.' If he can give you the names of patients who were treated 1, 2, 3, 4 years ago, if he can enable you to contact them, then you can use those herbs, those stems with peace of mind. But if he cannot, then be careful, because he might be deceiving you. I mean, how they will test the method when they first see a method? There’s no university that validates that method. But the university doesn’t suggest a solution for that disease either. The patient is hesitating.”

E-13 stated that along with practicing CAM methods, he is an internist and he spends approximately 30 minutes with one patient and the current healthcare system ignores those doctors like him and does not reimburse the exams or prescriptions of them. E-13 supports that, even if it did, he would prefer patients pay their own fees and he explained it as follows:

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“E-13: When you approach the patients with complementary methods, you must work with the patient two to three times longer. When a chakra examination with Kirlian scan take 15 to 20 minutes, homeopathic examination can take 3 hours…. Therefore, if the government… gets involved in the complementary methods, it won’t have a positive impact on the health system in Turkey. And also, … people save money for bad times. And today, he will use those savings.… One of the ways people save money is paying premiums. Now here I think that, especially with the complementary medicine, the fact that the patient pays for the treatment shows his/her trust for the treatment. That is, when you say the Government will fund it, then there will be a lot of practitioners who don’t do it properly or patients who don’t believe it but have it done. To me, in complementary medicine, the fact that the patient pays for the treatment is in fact part of the treatment. Therefore, would I make a contract with the Government, no.

INTERVIEWER: Do you think it’s good for the patient?

E-13: Would it be good for the patient? No.... If the Government decides to fund them, there will be a lot of corruption. The massage that was 45 minutes becomes 10 minutes. That is, there are things that the Government cannot fund.… especially for the complementary medicine, I believe the patient should be able to understand what’s being done…. The patient must make an effort to be healed.... That’s the other aspect. And another one is that, patients can use methods even if they don’t benefit.… I believe the monetary exchange between the physician and the patient brings discipline both for the physician and the patient. And I believe there should be an exchange…. Therefore, I don’t think the monetary exchange between the patient and the physician is… pathological. On the contrary, if the patient keeps paying, it means he keeps benefiting or trusting the physician. I mean, I view that parameter differently… And it’s a fact that all of us must save for bad times in the future. And even that need to save for bad times in the future is something that keeps us connected to life and keeps us healthy. I mean, I see it that way.”

E-13 said that, for example if the Government pays 80 of the 100 TL session fee, that practitioner will receive 40 patients a day while in normal conditions he/she can find 10-15 patients a day and this will decrease the quality of service, therefore he definitely objects to the reimbursement for the session fees by the general health insurance. However, he

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supports that the prescriptions he writes spending more time than doctors in other institutions or some CAM preparations should be reimbursed by the general health insurance.

E-14: Manipulation and orientation specialist

E-14, who is a manipulation and orientation specialist received his training in Russia, at the University of St. Petersburg and, his title in Russia is manipulation and orientation physician. However, because there is no equivalent of his license here in Turkey, he had to participate in certification programs on massage therapies etc. and obtain certificates and he now works under the regulation of manipulation by hand. E-14 said that the methods such as chiropractic, osteopathy, lymph drainage, breath techniques, reflexology, acupressure should be mastered by a manipulation and orientation specialist are considered separately in Turkey and even though there is not a clear definition, he presented his documents to the Ministry of Health and local health authority, and practices these methods in clinics or under the supervision of physicians. However, he complains about not being able to explain his profession to doctors and patients who are closed to everything other than the medical education in Turkey, and he thinks there is a strong reaction to non habitual areas. E-14 lives in Akhisar but he travels to big cities such as Izmir, Istanbul, Bursa and works with groups of patients in those cities.

E-14 said that, the important thing in manipulation and orientation practices is to strive to keep the healthy parts intact before healing the sick parts. As an example, in cancer patients, he said he performs applications to prevent development of metastasis, to strengten the immune system, to increase the oxygen efficiency of the body.

The conditions E-14 face most are mostly musculoskeletal system issues, herniated discs, cervical disc hernia, kyphoses, scoliosis, chronic pain and muscular degenerations, tears, spinal degenerations, strokes or lymphatic system and breath problems where there is malfunction of lymphatic system.

E-14 explained how he deals with cases as a manipulation specialist as follows:

“E-14: When I see a patient, I ask three questions: 'Have you had a traffic accident?' If the answer is no, I move to the second question: 'Have you had a surgery?' If the answer is no, I move to the third question: 'Do you have a chronic

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pain that’s diagnosed, or do you have a diagnosed illness?' If he says I had a traffic accident, then I ask: 'Did you have a bone fracture or bone dislocation and if so, where? How was the bleeding, did you have any?' I ask. Second, I had a surgery. 'Where did you have the surgery?' 'Do you have a pacemaker?' I ask all the procedures he has had. I mean I have to do this. If, on someone who has a pacemaker, I perform a procedure at the trocar, then I would create a muscle contraction which is no good. I can’t do the same procedure on someone who had a surgery in the neck, who has had his thyroid removed, and because of that whose neck muscle has half removed. I mean in terms of herbal remedies, example, I mean blood-letting, it’s famous in Turkey, and if you do that to someone who has a neuropathy, I mean, who has a diabetes, who has varicosity, you can’t be of help, it’s hundred percent harmful. I mean 15 percent of the population in Turkey has diabetes, forty percent of the population in Turkey has varicosity.”

E-14 told that he decides whether to continue the therapy or not and the time schedule after the first 5 sessions, because if the patient does not respond in the first five sessions, he will most probably not respond later too. According to the response to these initial 5 sessions, he can decide how long and at what frequency the therapy will continue.

When asked if there were patients who quit therapy because of financial difficulties because CAM therapies are not covered by the general health insurance, E-14 answered yes, and said that sometimes he completes the 30 sessions himself for the price of 10 sessions, thus trying to achieve a balance.

E-14 said that he never directs patients regarding the modern therapies they receive such as 'do this, don’t do that' etc. however he thinks the practitioners of modern medicine can negatively guide patients regarding CAM methods.

However, according to the accounts of E-14, doctors whose patients benefited from E-14’s applications can refer their patients to him:

“E-14: For example, let’s say an oncology patient receives lymphatic drainage treatment many times because they have dysfunction in their lymphatic glands and after seeing some results, there’s recurrence but after they start working with me, after seeing the permanent results, they share it with their doctor. Their doctor refers patients to me. Or with spinal cord diagnoses, when certain spasticity is

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eliminated, constipation is eliminated to some degree, after seeing that they refer patients to me. Or physical therapists, neurologists, when they see problems in cervical disk hernia removed, when they witness it they refer patients.”

E-14 who practices both in big cities and in Akhisar explained the differences of patient profile between these two:

“E-14: The patient profile here is generally chronic, that is, they have a history of agriculture in their background. Mainly tobacco.... Generally there’s a hunchback group that we call kyphos. Because they work bent over to hoe, and work differently in tobacco and cotton, the fixed posture, because they use postures that deteriorate the anatomic structure. In big cities, generally cervical disc hernia, flattenings and pathological conditions such as cancer types that fall within oncology. If we look at the patient profile in Akhisar, it’s a good, healthy county.”

INTERVIEWER: Is there a difference in their approach?

“E-14: In terms of approach, in the big city, because they are under the surveillance of a doctor, they can express their problems very comfortably after a few sessions and they don’t object to your applications. But no matter where we are, whether in Istanbul, Bursa, Akhisar, Izmir, it doesn’t matter where, and even if you work within the body of a hospital, in the first one or two sessions they are very nervous, they have a prejudiced approach. After two sessions and one or two weeks, after seeing the benefits of the application, seeing the scientific aspect of it and the skill of the specialist, they start to feel comfortable. But at the beginning all of them have some nervousness.

INTERVIEWER: Why do you think is this nervousness?

E-14: Lack of knowledge. That is, because they dictate people that: 'everyone else other than doctors are fraud, a jester.' Yes, unfortunately they exist, lots of frauds, lots of jesters, and those who say I am the one who knows best. But people always keep this prejudice in their minds because they don’t research themselves.”

When asked when do the patients come to him, E-14 answered 'when they cannot get adequate response from other treatments' and he said that at that point patients start to develop consciousness themselves.

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E-14 said that patients who cannot find a solution in public hospitals can visit other doctors but sometimes those who cannot find a solution with him can blame him with fraud, and he explained that he takes precautions by informing the patients at the beginning and following the principle of deciding in the first 5 sessions.

E-14 mentioned the drawbacks of self-application of CAM methods by patients and he gave the example of a patient with stomach ulcer using the onion course he heard from somewhere and can get damaged.

E-14 has used CAM methods such as ozone therapy, neural therapy, osteopathy and he does not visit doctors much.

E-14 also criticizes the CAM trainings offered in Turkey:

“E-14: To me, unfortunately because everything is linked to finances, people go for people who come from India, United States, England, Canada, because it’s trendy, and they say he comes for this time only, they collect quite a lot of money under the name of seminars of one week or two weeks. Those who come from abroad tell, tell, tell. To make people dependent... Is that all? No, there’s the second level, third level, I don’t know, it has fifteen levels.”

E-14 received a training on bioenergetics in the ACMOS academy in France, and he said that the first principle they teach there is 'You cannot give energy to anyone, you cannot receive energy from anyone. But you can help people balance their energy with certain rituals and colors.' E-14 said that bioenergetics is a CAM method anyone can learn and it has nothing to do with an endowment, and he thinks that those who claim they heal others with his/her own energy can only be liars.

E-14 thinks that before 1960s, smoking addiction and illnesses such as heart disease, high cholesterol, stroke and tuberculosis were at a low level but after this period, with economical and political changes the population became less and less healthy. He emphasized that, after this period, Turkey was used as a market and instead of natural products, industrial products (fabricated eggs instead of natural village eggs, fabricated milk instead of village milk) were promoted, and the natural olive oil and natural butter were discredited while margarine consumption was encouraged, olive fields were removed and instead tobacco fields were planted, soldiers were given free cigarettes and smoking

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was increased intentionally. He added that until 2002, commercials of drugs were free in Turkey and doctors could advertise drugs. E-14 who said that in 1970, also faculties offering education on aromatics and herbs were closed and classes or education programs about manual physical manipulation were removed and Turkey has become an area of guinea pigs and consumption, and he thinks that these practices enforced by political authority in order to establish the modern medicine had a negative impact both on medical education and community health.

E-14 who criticized the healthcare system in Turkey said that the patients first go to the community clinic, when they do not heal using the medication given there they go to the public hospital, and if they do not get well there they go to the research hospital, and then the university hospital, and that makes a long path, makes the illness chronic, creates unnecessary use of medication and economical burden. He thinks that if the necessary tests were made when the person first goes to the community clinic this would not happen and he believes that every health institution must work as a research hospital. He gave the example of a patient with cervical hernia receiving painkiller and neuromuscular blocker prescription, but in case this person continues to work with a head leaning forward, the issue will worsen and requires surgery…

Just as E-13, E-14 also thinks that people who will make the regulations and inspections on CAM must be knowledgeable and experts on this area. E-14 who said that he objects to be inspected by people who are not familiar with his methods and the trainings he received, thinks that until faculties are established and education is offered on CAM practices, official regulations only will not solve the problems on this area.

E-14 said that he could have opened a massage parlor that would enable him make much more money but stated that he prefers to work with doctors, and this way he can practice his profession better and he can be much more helpful to people medically. To him, with this working style, he can help people more about how they will deal with their condition at home, at work and what they should be pay attention to. E-14 says that in only 100 patients out of 2000 he worked with until now they had recurrence. He also emphasized that he later calls his patients and learns about their state, and strives to make the patient independent.

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E-14, who criticized the health shows airing frequently on TV in Turkey said that the doctors appearing on these shows are buying show times from televisions and are using them for advertisement purposes. The reason for this, he thinks, is that people perceive those appearing on TV as 'the best in their field'. He thinks that in other countries only the real experts can appear on TV shows but in Turkey it is the contrary. He said that these doctors charge much higher fees per exam than normal (1500 TL) and moreover they refer their patients to other specialists which is something any family practitioner can do. He also said that there are many private hospitals in Turkey and therefore patients are seen as clients and this causes healthcare services to decrease in quality. E-14 said that private hospitals request unnecessary tests and use unnecessary methods to make more money, they diagnose diseases that are non-existent, and they even make free check-up campaigns to reach their money-making goals. E-14 who thinks that the whole reason causing these things are the healthcare is bound by the political laws and he believes that the healthcare system should be governed by the jurisdiction rather than the political system. He also thinks that the reason why being a pharmacist is such a popular profession is because this profession is executed as opening a drug shop. He thinks that someone who gets their pharmacist diploma never have to work hard much and can relax for the rest of his/her life after opening their pharmacy, without doing any work.

E-14 said that the consumption of drugs per person per year is 1.5-2 kg and the Health Department pays about $150 per person per year for drugs, and that inpatient care, surgeries, medical device costs are not included in this price. E-14 believes that if the government can create a good health policy and can separate healthcare from politics and establishes a good inspection system, many complementary medicinal methods will take place in the healthcare naturally

E-15: Family practitioner

E-15 is a family practitioner and working in a community clinic in Akhisar. She takes sage tea, linden tea, etc. when she catches a cold, and applies massages using local soothing ointments. Even though she finds some herbal methods helpful when used along with the medical treatment, she thinks that herbal methods alone cannot bring a total or rapid healing. She advises her patients who caught a cold, or have bronchitis or pharyngitis to use sage tea, linden tea, have warm drinks and foods, take lots of Vitamin C.

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However, she also witnesses some CAM methods used by her patients:

“E-15: There are some methods they use outside the modern medicine. For example, some patients use blood-letting, leeches, etc. I tell them that the blood- letting or using leeches are not good, they can cause some illnesses. In terms of vitamins, I think they have a positive impact.

E-15: Sometimes, sometimes, not always, sometimes they talk among themselves and go have it done.”

E-15 had patients who used some CAM methods and then experienced stomach issues or allergic reactions but in terms of blood-letting and leeches, because their impact can only be determined by tests and time, she has no precise knowledge about them. She thinks that in order to create awareness about unconscious use of CAM methods in the public, public service announcements can be broadcast on TV’s, or screens in the community clinics, brochures can be printed and distributed at some places.

When asked whether she had positive or negative experiences about CAM methods, E-15 replied that:

“E-15: I think it changes from disease to disease. My personal opinion is that, I don’t think a cancer patient can be healed with an alternative medicinal method. Because I saw it with my own relatives. But with a back pain, a cold, and a sore throat, I mean with less serious cases they can be more beneficial. But as I said, for a cancer patient or a cardiac patient, let’s use alternative therapy, I don’t think they can be healed.”

E-15 answered the question whether she is familiar with CAM methods that are applied by doctors or trained specialists as follows:

“E-15: Now, we haven’t received any education on alternative medicine during our professional training. But in my own personal life, there were a few cancer patients in some relatives. Because they haven’t seen any positive results from the alternative medical methods they used, and because we didn’t have any information at school, I didn’t have much interest in alternative medicinal methods, especially for malign diseases. I mean, seeing a negative example in my own life, not having

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any information about these during my education, I mean I keep a distance from alternative medicinal methods especially for severe diseases.

INTERVIEWER: How do you approach to the idea of having them in the educational system? For example as an elective course?

E-15: I mean of course, of course, not as an elective course, I think it should be one of the main classes. I think everyone should have knowledge about them. I mean, at least our uneasiness decreases in some areas then. We can think more positively and approach it more positively.”

The Internist E-13 has a positive approach towards CAM methods provided that the right methods are used for the right patient believes that why people incline towards CAM methods could be because of hopelessness, search for a hope, and not getting any benefit from the conventional therapy they received. She thinks that methods such as yoga and meditation can be beneficial for psychological illnesses, though with the organic or malign diseases, they would not.

E-15, thinks that, provided that they are inspected regularly, some CAM methods can be covered by the general health insurance. However,she has a hesitation about some methods or products being used unnecessarily or for purposes that are not intended.

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6. Results 11 of the participants mentioned that they use CAM methods at home. Those that can be applied at home and traditional methods, especially herbal recipes, are the most commonly used CAM methods by the participants. These can be used before they see the doctor, at the same time as modern medical treatments, or when these treatments do not give any results. Praying/reading the Quran or getting someone else pray are also ways that many participants turn to at every stage of their health problems.

3 of the participants mentioned neural therapy. The fact that in such a small sample of research, 25% of the participants mentioned neural therapy may be due to the presence of neural therapy doctors in the area and the use of the snowball method as the sampling method.

When we evaluate participants’ attitudes to CAM according to their education, we can say that those who are educated below the high school level do not know and are not interested in CAM methods other than traditional methods. These individuals mostly indicate their circles/acquaintances, television and newspaper as their ways of getting information. It has also been observed that those who use the Internet as a way of obtaining information are familiar with more methods than others. The convenience the Internet offers for accessing the information increases the familiarity with CAM methods. Participants who have a high school or higher education level are familiar with more CAM methods in addition to traditional methods.

In our study, it was observed that women are more interested in CAM than men.

With the findings we have, it was not possible to make a tangible assessment between income levels and CAM applications. Some participants mentioned that they did not use CAM methods (Interview-1, Interview-3) or discontinued the CAM therapy (Interview-5, Interview-6) due to their fees. Based on these statements, we can easily say that the cost to be paid plays a role for preferring a CAM method or discontinuing a CAM therapy.

When we consider the familiarity and use of CAM methods according to the age of the participants, we see that the knowledge of the two participants aged 18-19 about CAM methods is very limited. However, because the age distribution of the participants was not balanced and there were no participants between the ages of 20-40, it is not possible to

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make a sound assessment about the relationship between the age and CAM use in our study.

The fact that those with chronic or unresolved health problems use more CAM methods than those without is also clear in our research. When these individuals can not find a solution to their problems in modern medicine, they turn to CAM methods. If the CAM methods applied by the experts or by local practitioners do not give satisfactory results, they turn to another CAM method. In other words, they use of a wide variety of CAM methods not because they primarily prefer these methods, but because they cannot achieve the desired end result.

When we look at Satisfaction Column in Table-2, we see that these people are at the same time who reported the most dissatisfaction. The dissatisfaction with CAM methods seems to be related to the complication of the health problem. Most people who use home/self- applied CAM methods, which are mostly traditional methods, are usually satisfied.

Regarding CAM training, all of the experts who have participated in this research have expressed the opinion that CAM methods should be included in the medical faculty curriculum. Family physician E-15 thinks that a class in the curriculum that provides general information about CAM methods will help physicians to overcome their prejudices and, if necessary, help them approach these methods correctly. Manipulation and orientation specialist E-14 thinks that faculties with individual CAM method trainings should be established. According to the internist E-13, students studying medicine should be provided classes about complementary methods, even if they are elective courses, and students should be informed about these methods. In addition, there should be chairs of complementary medicine in the universities, and these should include people who are local-traditional practitioners but have no medical training and their fund of knowledge should be utilized.

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7. Discussion With the paradigm shift7,10 seen in the medical field, the traditional and complementary methods which were previously completely outside the official health system in the Republic of Turkey now can have a place in the system with the GETAT regulation. Again, courses are opened for healthcare professionals in university hospitals about CAM methods. Healthcare services are going through a very dynamic process and it seems that this change will continue afterwards with more developments.

People have always tried to heal themselves using traditional or well-known CAM methods for the common mild conditions. Nowadays, as the awareness about health increases, efforts to research, learn and apply various methods in order to protect from diseases and to lead a healthy life also becomes widespread. On the other hand, some doctors and other healthcare professionals who feel that they cannot adequately meet the needs of their patients with modern methods of the medical education they have received form the other pier of this shift. These health professionals are on the lookout for further examination and treatment methods. In the section where we cover the individual CAM methods, we have seen that some methods have been developed by Western physicians who lived in recent years. It can be said that at a point in their careers, these physicians felt inadequate with the knowledge and skills they had, and they have turned to new quests. Recently developed methods such as homeopathy, EFT and neural therapy have been developed by these scientists and physicians who were inspired by some traditional methods. CAM methods or medical systems, which seem contradictory to the mainstream, have received reaction and were excluded by the established medical circles. However, some methods popularized with observed positive results among the public could be accepted by these circles over time.

We would like to cite that wise saying of Abraham Maslow, expressed by E-15 on the interview once more: “If you have only a hammer in your hand, you tend to see every problem as a nail.” A physician who is aware of various methods that can be used in different situations will have more treatment options for his or her patient’s situation and preferences. Any method by which a physician is capable of practicing will be a tool that can be used at select proper situations. The health and quality of life of societies will be able to move to a higher level when the resources provided by technology, the trust the

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scientific methods offer, and the health experiences people have accumulated and accumulated throughout history are combined.

Modern medicine, which is often referred to as mainstream medicine, academic medicine, orthodox medicine, conventional medicine, can include some of the alternative methods as a complement in the areas where it cannot fulfill the needs. In a similar vein, alternative methods based solely on experience and tradition are sought to be supported by modern scientific research methods. The place of the modern medicine in the last centuries and the interruption it caused in the medical tradition seems to have caused the society to approach the traditional methods the same way as they approach the modern medicine. For this reason, people today may seek scientific proof or, more often, the recommendation of a health care professional for the ancient methods that formerly practiced by folk physicians and whose effectiveness was not questioned by the public. For the circles in the world of science that are open to CAM, quality and objective scientific studies conducted in this area are important. Research on the effectiveness of a CAM method will help a health care professional when deciding to learn and implement the method. In this study, examples of these types of scientific publications are provided in the section where individual methods are examined.

There are many studies in the world studying CAM use habits too. Some of the most important findings of the health statistics report of the (American) National Center for Health Statistics in 2007, which is one of the most comprehensive of these studies, are as follows:

“In 2007, almost 4 out of 10 adults had used CAM therapy in the past 12 months, with the most commonly used therapies being nonvitamin, nonmineral, natural products (17.7%) and deep breathing exercises (12.7%).”4

According to the same research, CAM was used by adults most often (33.5%) for the treatment of various musculoskeletal problems.

In both 2002 and 2007 NHIS, it was found that women, adults between 30-69, well- educated adults, adults who are not poor, adults who live in the West, ex-smokers, and adults who were hospitalized in the past year have used CAM methods more than other groups.

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Again, according to the results of both years, adults are using CAM more often than otherwise, when they can not afford conventional medical care.4

Seo et al. has reported in their systematic review of 11 different studies in South Korea, the use of CAM to increase with female gender, older age and higher education. It has been observed that the CAM use frequency is between 29% and 83%. It is stated that this wide range of frequency may depend on whether conventional treatments are accepted as CAM in the study. It is therefore necessary to develop a standardized questionnaire that identifies and classifies CAM methods to ensure that scientific studies yield more reliable results.201

In recent years, academic work has also been carried out on health professionals’ views, behaviors and tendencies about CAM. According to findings from Bal’s202 study, 9.6% of nurses and 18.9% of physicians are not interested in CAM at all. 71.4% of the nurses and 61.3% of the physicians support that CAM methods should be included in the curriculum and/or the training program. 43.6% of physicians stated that they wanted CAM methods to be used in patient care and treatment. Only 32.3% of the nurses in the study believed that CAM methods are effective and beneficial and expressed that they believe massage, hydrotherapy / hot springs and vitamins are the most effective and beneficial. 33.6% of physicians believe that CAM methods do not threaten public health.202

One of the groups most frequently turn to CAM methods is cancer patients and their relatives. In this study, we aimed to examine the general tendencies in the society about CAM, therefore individuals who are not hospitalized are interviewed. There are no cancer patients among the participants. Participants with cancer stories in their families also stated that they did not resort to alternative methods. However, in the literature screened during the research, among the scientific researches on the use of CAM, the ones related to the use of CAM for cancer patients are quite extensive. From these studies, women have used more TAT methods than males, according to the findings obtained in the literature review performed by Kav, Hanoglu and Algier.203 Summarized from the same study: Factors such as duration of illness, advanced stage cancer, socioeconomic level, education level (low educational level except for one study), place of birth and family type also influence the frequency of CAM use other than gender. The most commonly used CAM methods are herbal mixtures and the most commonly used one is 'nettle grass'. Other methods used other than herbs are prayer, religious practices and vitamins/special diets.203

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Another finding of this literature study is that the most common reason for using CAM is the intention to do everything against the disease, to believe in the benefits of the cancer treatment and the method.203 The effectiveness of the methods varies according to the studies. In the same study, it was stated that “the source of information is often friends, relatives and other patients/their relatives.” And one of the most important findings of this study is that: “In the studies, it was reported that the majority of patients and/or relatives using CAM did not inform the doctor/nurse.”203

Some of the individuals who participated in our study stated that they did not talk to their doctors about the CAM methods they used because they had reservations about their reaction. The exclusivist and restraining approach of the doctors about alternative methods could have created this reservation. This leads to a lack of confidence in the relationship between the patient and the doctor. If physicians, especially family physicians, are familiar with the alternative methods commonly used in the area where they work, and are able to explain to their patients about the risks of these methods that may be detrimental to their health, and have a wealth of knowledge to suggest them safe alternatives could be very helpful in solving this problem.

There is a need for more scientific studies in this area in order to be able to reveal and understand the CAM usage habits of individuals.

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Table 4 Characteristics of Participants (2014)

Participant Gender Age Education Level Job Income/Month

IP-1 F 40 High School Graduate Artisan 1000 TL - 3000 TL

IP-2 M 43 Primary School Business owner 1000 TL - 3000 TL Graduate

IP-3 F 59 Primary School Homemaker <1000 TL Graduate

IP-4 F 56 Educational institute Science teacher >3000 TL graduate

IP-5 M 61 Educational institute Retired teacher >3000 TL graduate

IP-6 F 49 Primary School Homemaker 1000 TL - 3000 TL Graduate

IP-7 F 56 Primary School Homemaker, farming <1000 TL Graduate

IP-8 F 20 University student Student and worker 1000 TL - 3000 TL

IP-9 M 43 High school graduate Retired worker, farmer 1000 TL - 3000 TL

IP-10 M 19 University student University student 1000 TL - 3000 TL

IP-11 M 55 Secondary school, Security at school. 1000 TL - 3000 TL second year

IP-12 M 46 High school graduate Attendant at school. 1000 TL - 3000 TL

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9. Acronyms and Abbreviations CAM Complementary and Alternative Medicine MAXQDA Qualitative Data Analysis Software for MacOS and Windows. TCM Traditional Chinese Medicine NCCIH National Center for Complementary and Integrative Medicine NCCAM National Center for Complementary and Alternative Medicine OECD Organisation for Economic Co-operation and Development WHO World Health Organisation NID Non-Infectious Disease BMI Body Mass Index İTS İlaç Takip Sistemi (transl. Pharmaceuticals Tracking System) EU European Union CAMbrella CAMbrella is an European research network for complementary and alternative medicine (CAM) EFTA European Free Trade Assosiation UK United Kingdom USA United States of America OCAP Office of Unlicensed Complementary and Alternative Health Care Practice NHFPC National Health and Family Planning Commission SATCM State Administration of Traditional Chinese Medicine GETAT Geleneksel ve Tamamlayıcı Tıp (transl. Traditional and Complementary Medicine) WMA Western Medicine Acupuncture COPD Chronic obstructive pulmonary disease PubMed PubMed is a free online resource developed and maintained by the National Biotechnology Information (NCBI) at the National Library of Medicine® (NLM). FDA Food and Drug Administration IFCO International Federation of Chiropractors and Organisations

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OMM Osteopathic manipulative medicine OMT Osteopathic manipulative therapy TTH Tension-type headache ISCO3 International Scientific Committee of Ozonetherapy EBOO Extracorporeal blood oxygenation and ozonation HSP Heath Shock Protein EFT Emotional Freedom Technique TFT Thought Field Therapy PTSD Post Traumatic Stress Disorder EMDR Eye Movement Desensitization and Reporcessing CBT Cognitive Behavioral Therapy ACMOS Analysis of the Compatibility of Matter on the Organism and its Synergy

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10. Appendix

Appendix-1 CAM Methods heard/used Please select the ones which you have ever From the CAM Methods that listed used. below which ones have you ever heard? o 1 □ Acupuncture o 1 □ Acupuncture o 2 □ Acupressure o 2 □ Acupressure o 3 □ Aromatherapy o 3 □ Aromatherapy o 4 □ Art therapy o 4 □ Art therapy o 5 □ Ayurveda o 5 □ Ayurveda o 6 □ Bach Flower remedies o 6 □ Bach Flower remedies o 7 □ Chiropractic o 7 □ Chiropractic o 8 □ Colour therapy o 8 □ Colour therapy o 9 □ Dance Movement therapy o 9 □ Dance Movement therapy o 10 □ Spiritual Healing o 10 □ Spiritual Healing o 11 □ Herbal medicine o 11 □ Herbal medicine o 12 □ Homeopathy o 12 □ Homeopathy o 13 □ Hypnosis o 13 □ Hypnosis o 14 □ Magnetic therapy o 14 □ Magnetic therapy o 15 □ Massage o 15 □ Massage o 16 □ Meditation o 16 □ Meditation o 17□Transcendental Meditation o 17 □ Transcendental Meditation o 18 □ Music therapy o 18 □ Music therapy o 19 □ Naturopathy o 19 □ Naturopathy o 20 □ Osteopathy o 20 □ Osteopathy o 21 □ Reiki o 21 □ Reiki o 22 □ Reflexology o 22 □ Reflexology o 23□Relaxation/Breathing technique o 23 □ Relaxation/Breathing technique o 24 □ Shiatsu o 24 □ Shiatsu o 25□Traditional Chinese Medicine o 25 □ Traditional Chinese Medicine o 26 □ Therapeutic Touch o 26 □ Therapeutic Touch o 27 □ Visualization o 27 □ Visualization o 28 □ Vitamins and minerals o 28 □ Vitamins and minerals o 29 □ Yoga o 29 □ Yoga o 30 □ Other______o 30 □ Other______

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Appendix-2 Questionare

1. What is your surname, name and age? What is your education, profession and location (City center, village, town)?

2. What is your approximate monthly houshold income? a) Less than 1000 TL b)Between 1000 TL-3000 TL c) More than 3000 TL 3. Please read the CAM Methods in Appendix-1 and mark those which you have heard and used. 4. Do you currently have a condition or a disease that has been diagnosed? 5. If yes, which modern medical treatments have you recieved for them? 6. Are there any methods that you use to protect yourself from illness or you use before you go to a physician when you get sick. 7. Have you ever used any CAM Method for yourself, your first degree relatives (mother, father, partner, child, sibling ) or for anyone whose care under your responsiblity.

If any CAM Method has been used continiue whit Part A, if not continue with Part B.

Part A

If the answer to question 7 is yes:

8. When did you use this CAM Method/s? 9. How have you came to know the CAM Method/s? 10. Did you use this CAM Method under the supervision of a practitioner / specialist or on your own? 11. What was your reason to use this CAM Method? ( - Against the adverse effects of the modern medical treatment you received; - To support the treatment you recieved; To cure your illness; To rehabilitate or cure some ailments ( disease symptoms); to reinforce your immunsystem and your general physical condition, etc. 12. Have you used this CAM Method instead of modern medical treatments or whit theese? 13. Have you any benefit (or loss) from the CAM Method/s that you used? 14. Why do you think that you recieved a benefit (or damage) (or didn’t recieve any benefits/damages) from the CAM Method/s that you used. 15. Have you recommended / would you recommend the CAM Method/s that you used to other patients who have similar situation? 16. Did you make any payments to access to the CAM Method/s? 17. What do you think abot the fee you paid to access to the CAM Method/s? (Expensive, cheap, reasonable, worth the money, must be more affordable,etc.) 18. Have you ever wanted to use a CAM Method that you could’t because of it’s high fee?

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19. Have you ever visited a center where the CAM Methods are applied by the practitioner /specialist (Hospital, private practice, beauty center, residence, office, etc. ? 20. What would you think CAM centers were established and widespread? 21. What would you think if your family physician or another specialialized physician provided you information about CAM Methods or recommended you these kinds of methods? 22. In some countries, some of CAM Methods ( Acupuncture, Homeopathy, Massage, Chiropractic etc.) are covered by the health insurance. What would you think if some of CAM Methods were covered by the healht insurance in Turkey, can you explain with reasons? 23. Is tehere anything else that you want to say about CAM Methods?

Thank you.

Part B

If the answer to question 7 is no:

8. Please explain your reason for not using any CAM Method? (- Because you find the modern medical methods sufficient; - Because you don’t have any information about any CAM Method; - Because you don’t trust CAM Methods; - Because you can not afford to pay extra fees to CAM Methods, etc.)

9. Have you recommended / would you recommend your acquaintances not to use CAM Methods?

10. What would you think if your family physician or another specialized physician informed you about CAM Methods or recommended you these kind of methods?

11.What would you think if CAM centers were established and widespread?

12. In some countries, some of CAM Methods ( Acupuncture, Homeopathy, Massage, Chiropractic etc.) are covered by the health insurance. What would you think if some of CAM Methods were covered by the healht insurance in our country, can you explain with reasons?

13. Is tehere anything else that you want to say about CAM Methods?

Thank you.

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