A Summary of National Data on Complementary and Alternative Health Care - Current Status and Future Development: A Discussion Paper

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Table of Contents

• Executive Summary
• A Summary of Results from National Population Surveys on the Use of Complementary and Alternative Health Care
  • The Use of Alternative Practitioners
  • The Use of Natural Health Products (NHPs)
• Suggested Next Steps
• References
• Appendix A: National Population Surveys of the Use of Complementary and Alternative Health Care
  • i) National Population Health Survey
  • ii) Canadian Community Health Survey
  • iii) Berger Population Health Monitor
  • iv) Individual Surveys
  • v) Other Surveys and Studies
• Appendix B: Opportunities for Further Development of Population Surveys
  • i) Refinement of Survey Questions
  • ii) Potential Uses of the Canadian Community Health Survey
• Appendix C: Research Studies as an Adjunct to Population Surveys
• Appendix D: The Canadian Institute for Health Information
  • i) Mandate
  • ii) The Roadmap Initiative
  • iii) CIHI Databases of Health Care Providers
  • iv) Primary Health Care Indicators
  • v) 2001 Report on Health Care Providers
  • vi) 2001 Report on Health Care in Canada
• Appendix E: Challenges in Gathering National Data About Health Care Providers and Services
  • i) Limited Purposes of Existing Databases
  • ii) Development of Appropriate Indicators
  • iii) Need for a Collaborative Information Framework
  • iv) Access to Individual Practitioners
  • v) Multiple Providers of a Service
  • vi) Data-gathering Systems and Costs
  • vii) Protection of Privacy
• Appendix F: Opportunities for Further Development of National Data on Complementary and Alternative Health Care Providers and Services
  • i) Identifying Data to be Gathered
  • ii) Experience in Developing Professional Databases
  • iii) Inclusion in Health Information Systems and Reports
• Appendix G: Proposed HRDC Sector Study of Complementary and Alternative Health Care Providers
  • i) The Proposed Sector Study
  • ii) Information Needs Related to the Sector Study
  • iii) An Opportunity for Longer-Term Information Systems

Executive Summary

Canadians are making more and more use of complementary and alternative health care (CAHC). This growing use includes natural health products (NHPs), complementary and alternative practices, as well as consultations with complementary and alternative practitioners.

Despite its increasing role in the health care of Canadians, there is relatively limited national data on CAHC for a number of reasons. Since CAHC is not integrated into established health care delivery systems, data on the use of complementary and alternative practitioners, products and services are not generated by regulatory bodies, health care institutions and public health insurance plans. Health Canada only recently established a regulatory authority for NHPs - the Natural Health Products Directorate (NHPD) - and is now in the process of establishing a regulatory framework for NHPs. Many, but not all, CAHC professional associations are in relatively early stages of development and currently have limited capacity to provide national data. Furthermore, a significant proportion of people who use complementary and alternative practices or products do so as a form of self care, and this usage is not readily captured by information systems focused on health services.

In recent years, there has been a concerted effort by the federal and provincial/territorial governments to obtain better information about the health of Canadians and health care in Canada. At the national level, Statistics Canada has been gathering population data about health and health care through the National Population Health Survey (NPHS) and, more recently, through the Canadian Community Health Survey (CCHS). In an effort to provide a more complete picture of health care in Canada, the Canadian Institute for Health Information (CIHI) has been leading numerous projects under the Roadmap Initiative to develop or enhance data systems on health and health care, to develop and implement more complete indicators of health and health care, and to consolidate and analyze all available data. A series of labour market sector studies have been conducted or considered by Human Resources Development Canada (HRDC) among a number of health care sectors and professions including nursing, physicians, oral health practitioners, pharmacy, home care, and CAHC practitioners.

The following report summarizes national data currently gathered on CAHC in the context of these initiatives and suggests possible opportunities for gathering more complete data. The report focuses on national initiatives, specifically the population health surveys administered by Statistics Canada, the health information projects led by CIHI, and the employment sector studies facilitated by HRDC. A discussion of local studies is beyond the scope of this report.

A Summary of Results from National Population Surveys on the Use of Complementary and Alternative Health Care

The Use of Alternative Practitioners

i. The use of alternative practitioners is rising in Canada

According to the National Population Health Survey (NPHS), the use of alternative practitioners among Canadians aged 18 or older increased from an estimated 15 percent in 1994/95 to an estimated 19 percent in 1998/99. The use of chiropractors remained stable over this period. The increase in the use of other types of alternative practitioners (including massage therapists, acupuncturists, homeopaths or naturopaths, Feldenkrais or Alexander teachers, relaxation therapists, biofeedback teachers, rolfers, herbalists, reflexologists, spiritual healers, religious healers, and others) accounted for the increase over this period (Millar 2001: 12).

Other surveys also found an increasing use of alternative practitioners in Canada (Ipsos-Reid 1997a; Berger Monitor 1999: 55). Historically, chiropractors are used more often than other alternative practitioners (Ipsos-Reid 1997a; Ramsay et al. 1999).

ii. Consultation with alternative practitioners may be episodic rather than ongoing

Among people who reported consulting an alternative practitioner in any one of the three cycles of the NPHS, 54 percent did so in one cycle, 25 percent did so in two cycles, and 22 percent did so in three cycles (Millar 2001: 12-13).

iii. Women are more likely than men to consult alternative practitioners

In the 1998/99 NPHS survey, 19 percent of women reported that they consulted an alternative practitioner in the previous year, compared with 14 percent of men, or 2.2 million versus 1.6 million (Millar 2001: 13). When other factors (such as education, household income, number of chronic conditions, chronic pain, attitude toward self care, and perceived unmet health care needs) were taken into account, women still had higher odds of consulting an alternative practitioner (Millar 2001: 16). Men and women were equally likely to have reported consulting a chiropractor, but a much higher percentage of women than men reported that they had consulted another type of alternative practitioner (Millar 2001: 14).

Other surveys also found a greater use of alternative practitioners, with the exception of chiropractors, among women (Ipsos-Reid 1997a; Berger Monitor 1999: 55).

iv. The use of alternative practitioners (but not natural health products) appears to be a 'mid-life' phenomenon

In the 1998/99 NPHS survey, 19 percent (almost one in five) of people aged 25 to 44 and 45 to 64 reported consulting an alternative practitioner, compared with 11 percent (about one in 10) of people aged 18 to 24 and 65 and older. This pattern remained when other factors were taken into account (Millar 2001: 16).

Other surveys also found that the use of alternative practitioners was highest among the middle-aged group (Ispos-Reid 1997a; Ramsay et al. 1999), while the use of an alternative medicine was highest among people aged 18 to 24 (Ramsay et al. 1999). However, there is some evidence that the use of alternative practitioners is increasing among people under the age of 24 (Berger Monitor 1999: 61).

v. The use of alternative practitioners is higher in Western Canada

According to the 1998/99 NPHS, the use of alternative practitioners increases in Canada as one moves from East to West. Between three and nine percent of people in the Atlantic provinces consulted an alternative practitioner in 1998/99, compared with 15 percent in Quebec and Ontario, and 21 to 25 percent in the Western provinces. The rate of use was highest in Alberta. The higher use in Western Canada may partly reflect the four provinces' health care plans, which offer some coverage for chiropractic services (Millar 2001: 16).

The 1999 Berger Monitor survey found that the percentage of people who used an alternative practitioner was highest in Alberta and British Columbia (the provinces with the highest increase in use), and lowest in the Atlantic provinces. Chiropractors were most popular in the four Western provinces (Berger Monitor 1999: 56). The 1997 Angus Reid survey found that the percentage of people who used an alternative medicine or practice - the survey did not single out alternative practitioners - was higher than the national average in Western provinces and lower than the national average in the Atlantic provinces (Ipsos-Reid 1997a).

However, the 1997 Fraser Institute survey found that Ontarians consulted an alternative practitioner most often in the previous year, followed by Saskatchewan/Manitoba, British Columbia, Alberta, Quebec, and Atlantic Canada (Ramsay et al. 1999).

vi. The use of alternative practitioners rises with education and income

According to the 1998/99 NPHS, people with at least some post-secondary education have higher odds of consulting an alternative practitioner than people with less than high school graduation. People belonging to the three higher household income groups had higher odds of consulting an alternative practitioner than people in the low-income category (Millar 2001: 16-17).

Other surveys also found that the use of alternative practitioners was higher among people with greater income (Ipsos-Reid 1997a; Ramsay et al. 1999; Berger Monitor 1999: 61) and more education (Ramsay et al. 1999; Berger Monitor 1999: 61).

vii. The use of alternative practitioners is greater among people with chronic conditions or chronic pain

According to the 1998/99 NPHS, 25 percent of people with three or more chronic conditions consulted an alternative practitioner, compared with 11 percent of those who reported no chronic conditions. Twenty-six percent of people who reported chronic pain consulted an alternative practitioner, compared with 15 percent of those who did not report chronic pain. These patterns remained when other factors were taken into account. People with three or more chronic conditions had over twice the odds of consulting an alternative practitioner, compared with those with no chronic conditions. People with chronic pain had almost twice the odds of consulting an alternative practitioner, compared with those with no pain (Millar 2001: 17). The proportion of people who used alternative practitioners was highest among those with back problems. The proportions were also high among people with Crohn's disease, bronchitis/emphysema, migraine, asthma, and arthritis/rheumatism (Millar 2001: 17-18).

The 1997 Fraser Institute survey found that for the 10 most common ailments reported by respondents, many who reported the condition used an alternative therapy in the previous year (from 59 to 71 percent, varying according to the ailment). A substantial minority saw an alternative practitioner in the previous year (from 18 to 32 percent, varying according to the ailment), and a smaller percentage saw a physician in the previous year (from six to 11 percent, varying according to the ailment). However, almost half of the respondents saw a physician before turning to an alternative practitioner, compared with 17 percent who saw an alternative practitioner first. Back and neck problems, allergies, and arthritis/rheumatism were the most common ailments reported by respondents. Chiropractic care was most often used for neck and back problems (Ramsay et al. 1999).

viii. The use of alternative practitioners is associated with self care, certain health practices, and perceived unmet health care needs

According to the 1998/99 NPHS, 24 percent of people who believed strongly in self care consulted an alternative practitioner, compared with 12 percent of people who believed less strongly in self care. Higher percentages of people who were concerned about the role of nutrition in maintaining and improving health - as well as people taking vitamins and minerals and avoiding foods high in fat, salt, and sugar - reported consulting an alternative practitioner. Twenty-nine percent of people who thought that the mainstream health care system did not meet their needs consulted an alternative practitioner, compared with 16 percent who did not think so. These patterns remained when other factors were taken into account (Millar 2001: 17-18).

As regards self care, the 1997 Fraser Institute survey found that 81 percent of people who used alternative therapies - including self-administered as well as practitioner-provided therapies - did so for 'wellness.' However, there were significant variations according to the therapy. For example, 75 percent of people who used chiropractic care did so because of back or neck problems, versus four percent for general health. Prayer, yoga, lifestyle diets, imagery techniques, naturopathy, spiritual healing, high-dose megavitamin therapy, and chelation therapy were used mainly for general health.

As regards unmet health needs, the 1997 Angus Reid survey found that one-third of people who used alternative medicines and practices did so because conventional medicines were not working for them (Ipsos-Reid 1997a).

ix. The use of alternative practitioners accompanies, rather than supplants, the use of conventional health care

According to the 1998/99 NPHS, people who consulted an alternative practitioner were more likely than those who did not consult one to have a regular physician, to have seen a specialist in the past year, to have had 10 or more physician visits in that time, and to have had their blood pressure checked in the preceding two years. This use of conventional health care is not surprising, since those who consulted an alternative practitioner were more likely than non-users to have chronic conditions and chronic pain. However, even when these factors were taken into account, those who consulted an alternative practitioner still had higher odds of having seen a specialist, having had 10 or more physician visits, and having had their blood pressure checked (Millar 2001: 18-19).

The 1999 Berger Monitor survey found that people who made heavy use of alternative practitioners regarded the alternative practitioner as an adjunct to their physician. Still, a substantial percentage of those who saw a chiropractor, massage therapist, or other therapist did so instead of seeing a physician (Berger Monitor 1999: 60).

The 1997 Fraser Institute survey found that 45 percent of all people with a medical condition saw a physician in the previous year, six percent saw an alternative practitioner only, 14 percent saw both, and 35 percent saw neither. Among those who sought treatment for the top 10 medical conditions, 49 percent saw a physician first, 17 percent saw an alternative practitioner first, 27 percent saw a physician and an alternative practitioner concurrently, and, for eight percent, the provider they saw first depended on their medical condition. Among people who used alternative medicines and practices, 72 percent did so because they believed that using alternative medicine together with conventional medicine was better than using either alone, 37 percent of respondents thought that alternative practitioners spent more time with them than physicians, and 31 percent thought that alternative practitioners were better listeners (Ramsay et al. 1999).

The 1997 Angus Reid survey found that 23 percent of people who used alternative medicines and practices did so because they were worried about prescribed medicines and practices, 17 percent did so because they got better service from alternative practitioners, but only six percent did so because they did not trust modern medicine and practices (Ipsos-Reid 1997a).

The Use of Natural Health Products (NHPs)

i. The use of NHPs continues to grow

The 2001 Berger Population Health Monitor survey found that the proportion of people who had used one or more NHPs in the previous six months grew from 70 percent in 1999 to 75 percent in 2001. During the same period, the proportion of people who had used three or more NHPs increased from 26 to 31 percent. While the use of vitamins and minerals did not change in that period, there were significant increases in all other categories. The greatest increases were in herbal remedies (from 28 to 38 percent) and other NHPs (from one to 15 percent) (Berger Population Health Monitor 2001).

ii. The use of NHPs is highest in British Columbia and lowest in the Atlantic provinces

The 2001 Berger Population Health Monitor survey found that 41 percent of respondents in British Columbia had used three or more NHPs in the previous six months, compared with 15 percent in the Atlantic provinces, and between 27 and 34 percent in the remaining provinces. Between 1999 and 2001, the largest increases in people who had used three or more NHPs in the previous six months were in Quebec, Manitoba/Saskatchewan, and British Columbia (Berger Population Health Monitor 2001).

iii. Pharmacies are the main source of NHPs, followed by health food stores, but there are important regional and socio-demographic differences

The 2001 Berger Population Health Monitor found that 58 percent of respondents made their last purchase of an NHP at a pharmacy, followed by 22 percent at a health food store, and seven percent at a supermarket or discount store with a pharmacy. The proportion that made the purchase at a pharmacy remained stable since 1999, but the proportion that made the purchase at a health food store grew from 16 percent in 1999 (Berger Population Health Monitor 2001). As one moves west from the Atlantic provinces, purchases in pharmacies declined and purchases in health food stores increased (Berger Population Health Monitor 2000). In addition, among those aged 20 to 24 and those with more than a high school education, purchases in pharmacies declined and purchases in health food stores increased (Berger Population Health Monitor 2001). The number of people who purchase NHPs on the Internet remained low (Berger Population Health Monitor 2002, 2001).

iv. Substitution of an NHP for a prescription drug continues

The Berger Population Health Monitor found that the proportion of people who, in the previous six months, had received a prescription from a physician but instead had used an NHP increased from two percent in 1999 to seven percent in 2000; the proportion remained at that level in 2001. This represents about 1.5 million Canadians within a six-month period. Among people who used three or more NHPs, the proportion who substituted was greater, having increased from seven percent in 1999 to 14 percent in 2000, and having remained steady at that level in 2001 (Berger Population Health Monitor 2001).

v. Substitution of an NHP for non-prescription drugs has increased

The Berger Population Health Monitor found that the number of people who had taken an NHP instead of non-prescription or over-the-counter medication doubled, increasing from 15 percent in 1998 to 30 percent in 2000. Those most likely to substitute were people taking three or more NHPs, compared with those taking only vitamins; people aged 15 to 24, compared with those aged 65 and older; people in Alberta and British Columbia, compared with people in Quebec; and people in Vancouver and Toronto, compared with people in Montreal (Berger Population Health Monitor 2000).

vi. The number of people taking an NHP instead of seeing a physician has increased

The Berger Population Health Monitor found a substantial increase in the number of people who, in the previous six months, had used an NHP instead of seeing a physician for a prescription. The percentage among all respondents grew from 10 percent in 1998 to 24 percent in 2000. This number represents about four million Canadians over a six-month period. Among people who used three or more NHPs, the percentage grew from 21 percent in 1998 to 41 percent in 2000 (Berger Population Health Monitor 2000).

vii. More people are discussing their use of NHPs with their physician or pharmacist

Between 1998 and 2000, the Berger Population Health Monitor found a substantial increase in the number of people who discussed their use of NHPs with their physician or pharmacist. The percentage that discussed it with their physician grew from 31 to 38 percent, and the percentage that discussed it with their pharmacist grew even more, from 22 to 38 percent. However, there are important regional and socio-demographic differences. In Quebec, people were more likely to discuss their use of NHPs with their pharmacist than their physician, while in Alberta and British Columbia they were least likely to speak with their pharmacist. Moreover, women were more likely than men to discuss their use of NHPs with their physician or their pharmacist (Berger Population Health Monitor 2000).

Suggested Next Steps

The capacity to gather and report information about CAHC is relatively undeveloped and incomplete in Canada. Improvements in this capacity will likely be incremental and will involve a variety of systems and sources of information - broad population surveys, focused research studies, professional association databases, and health system databases. No one source or system of information can provide all the relevant data, and each one has its limitations.

There are a number of opportunities at present that could be used to gather and report more complete information about CAHC in Canada. These include:

• Statistics Canada's Canadian Community Health Survey (CCHS)
• CIHI's Roadmap Initiative
• HRDC's proposed sector study of CAHC providers.
  

To take advantage of these opportunities, the following activities might be considered:

• consultation on minimum data elements on CAHC to be used as part of the main content of the section on health care utilization in the CCHS
  
  This section will be undergoing review. To determine the questions to be included on the use of CAHC, it would be timely to have consultations between Statistics Canada, Health Canada, CIHI, and selected researchers on the utilization of CAHC (including the use of NHPs, complementary and alternative practices), as well as consultation with complementary and alternative practitioners and other informed participants (such as CAHC professional associations and distributors of NHPs).
  
  
• a working group on a supplementary survey to the CCHS
  
  The potential exists to develop and implement a supplementary survey to the CCHS to gather more detailed information about CAHC, including the use of NHPs, the use of complementary and alternative practices, and consultation with complementary and alternative practitioners. However, many issues would need to be addressed before moving forward: the design and content of the survey, the scope of data collection (health regions or provinces), the use of the survey over space and time, the comparability of data gathered, and cost, etc. Consideration should also be given to the benefits of surveys among populations known to make high use of CAHC (products, practices, and practitioners). It would be useful to have a working group involving Statistics Canada, Health Canada, CIHI, and researchers on the utilization of CAHC to explore these issues and to develop options with regard to a supplementary survey. Suggested areas of inquiry might include (see Appendix B):
  
  
  • the product, practice, or practitioner used (categories of products, forms of practice, types of practitioners)
  • the reasons for using a specific product, practice, or practitioner (a means to identify why a person used a specific form of care, distinguishing between health promotion, disease prevention, and treatment of illness)
  • sources of information about the specific product, practice, or practitioner used (friend, family, media, Internet, primary health care provider, information provider, etc.)
  • community settings in which people consulted a practitioner or received a service (sole practitioner, multidisciplinary practice, community health centres, community care access centres, home care, pharmacies, health food stores, etc.)
  • institutional settings in which people consulted a practitioner or received a service (acute care hospitals, ambulatory care, long-term care, rehabilitation facilities, palliative care facilities, etc.)
  • costs of services and sources of payment
  • self care (forms of self care, reasons for self care)
    
    
• consultation with CIHI on enhancing or developing the data-gathering capabilities of CAHC professional associations
  
  Health care professional associations are one of the principal sources of data about health care in Canada. As CAHC professional associations develop their capacity to gather and report information about their members and services, it would be opportune for them to consult with CIHI about:
  
  
  • the information that is being gathered or should be gathered as part of the larger picture of health care in Canada (see Appendix F i)
  • what is involved in developing or enhancing their data-gathering systems (see Appendix F ii)
  • alternative approaches to gathering more complete data (such as surveys of the profession). It is particularly timely for the national groups representing professional associations and training bodies involved in the development of the proposed HRDC sector study for CAHC practitioners to undertake such consultations with CIHI.
    
    
• consultation with CIHI on performance indicators in primary health care
  
  In the CIHI project on performance indicators in primary health care, provision is made for the further development of indicators. These include access to, utilization of, and referral to other primary care providers. As the project evolves beyond its present stage of development, it would be useful for CAHC professional associations to consult with CIHI on the inclusion of CAHC in the further development of indicators.
  

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Appendix A: National Population Surveys of the Use of Complementary and Alternative Health Care

i ) National Population Health Survey

Note: The NPHS provides longitudinal data and controls for the various factors being measured. It is not possible to make direct comparisons between the NPHS, which asked about the use of alternative practitioners, and the Fraser Institute and Angus Reid surveys, which asked about the use of alternative practitioners, practices, and products. When reporting the results of a survey, the terminology employed by the survey is used (e.g., 'alternative practitioner' as used by the NPHS).

Statistics Canada's National Population Health Survey (NPHS), begun in 1994/95, collects information about the health of the Canadian population every two years. It covers household and institutional residents in all provinces and territories, except persons living on Indian reserves, Canadian Forces bases, and those living in some remote areas. The first three cycles of the NPHS (1994/95, 1996/97, and 1998/99) had both a longitudinal and a cross-sectional component. The cross-sectional component is being superseded by the Canadian Community Health Survey (see below). The longitudinal component will continue. For further information on the design and sample size of the NPHS, see Catlin et al.1999, Tambay and Catlin 1995, and Swain et al. 1999.

The first three cycles of the household survey of the NPHS included questions on the use of 'alternative practitioners' in the section on health care utilization.

Specifically, the NPHS asked:

• whether, in the past 12 months, the respondent had seen or talked to a chiropractor
• whether, in the past 12 months, the respondent had seen or talked to an alternative practitioner
• if 'yes,' with whom (massage therapist, acupuncturist, homeopath or naturopath, Feldenkrais or Alexander teacher, relaxation therapist, biofeedback teacher, rolfer, herbalist, reflexologist, spiritual healer, religious healer, or other - specify)

The NPHS was able to correlate data gathered on the use of complementary and alternative practitioners with other data gathered from respondents in the survey, including socio-demographic characteristics, health behaviours, chronic conditions, and health care utilization. (For further information about the content of the NPHS questionnaires, see
 www.statcan.ca/english/concepts/nphs/index.htm.)

There are limitations to NPHS data (Millar 2001: 11). The data are self- or proxy-reported, and the degree to which they are inaccurate because of reporting error is unknown. With cross-sectional data, relationships between variables can be described, but causality cannot be inferred. Thus, although the NPHS collects information about the use of complementary and alternative practitioners and the prevalence of various chronic conditions, the data cannot be used to establish a direct link between the two. The NPHS does not categorize respondents according to the specific condition for which they are consulting a complementary and alternative practitioner, and it does not gather information on all factors that motivate individuals to consult complementary and alternative practitioners. The NPHS does not analyze data on the use of complementary and alternative practitioners at the level of health regions or specific populations. Therefore, analyses at the national or provincial/territorial level may conceal specific groups among whom the use of complementary and alternative practitioners is more prevalent. Provincial differences in the use of complementary and alternative practitioners may reflect differences in the funding of complementary and alternative health care (CAHC) services under provincial health care plans or employer-sponsored plans. Finally, the NPHS does not gather data on the use of NHPs or on complementary and alternative forms of self care.

Two analyses of the NPHS data have been published. The first report analyzed data from the first cycle (Millar 1997); the second report analyzed data from the first, second, and third cycles (Millar 2001).

ii ) Canadian Community Health Survey

The Canadian Community Health Survey (CCHS), introduced by Statistics Canada in 2000 as part of the Roadmap Initiative (see Appendix F ii), is replacing the cross-sectional household component of the NPHS. (The longitudinal household component of the NPHS will continue.) The CCHS differs from the NPHS in that it will gather data at the level of health regions as well as provinces/territories. (There are 136 health regions across the country.) Data are collected in a two-year cycle. Each two-year cycle is comprised of two distinct surveys: a health region-level survey in the first year with a total sample of 130,000, and a provincial-level survey in the second year with a total sample of 30,000.

The health region-level survey consists of common content to be asked of all respondents to meet basic health data requirements, and optional content determined by each health region from a pre-defined list of questionnaire modules. The provincial/territorial-level survey consists of some common content and an in-depth treatment of one focus topic. For further information about the content of the CCHS, see Statistics Canada's website at
 http://www.statcan.ca/english/concepts/health/cchsinfo.htm.

The common content of the CCHS includes a section on health care utilization. In the first cycle of the CCHS, this section asked the same questions about the use of chiropractors and alternative practitioners as the NPHS household survey (see (i) above). Questions about CAHC may not be included in every cycle. The entire section on health care utilization is expected to be reviewed in light of the current situation in health care.

The limitations of data gathered by the CCHS are in many ways the same as those for the NPHS, since both are self- or proxy-reported cross-sectional surveys (see (i) above). However, the CCHS will permit analysis at regional levels.

iii ) Berger Population Health Monitor

A continuation of the Canada Health Monitor, The Berger Population Health Monitor (BPHM) reports the results of random-sample telephone surveys on health issues. The surveys are conducted semi-annually among approximately 2,500 persons 15 years of age and older. They are conducted on behalf of Health Canada by private polling firms in association with the Hay Health Care Consulting Group under the direction of Earl Berger.

The June-July 1997 Canada Health Monitor survey included a component on "complementary remedies." Subsequently, the BPHM included questions about the use of natural health products (NHPs) in three surveys (March 1999, May 2000, and March 2001) and questions about the use of complementary and alternative practitioners in one survey (March 1999). While there is continuity in successive surveys, some questions are not carried forward and new questions are introduced. The areas of inquiry have included:

• the kinds of NHPs that people are using (vitamins; iron, calcium, or other mineral supplements apart from vitamins; nutritional and food supplements, dietary supplements/fortified foods; homeopathic remedies; herbal remedies; any other NHPs, alternative or complementary remedies)
• where people last purchased one or more NHPs
• how much people are spending on NHPs
• where people go for information about their health and health conditions
• whether people discussed their use of complementary and alternative therapies with a physician or a pharmacist
• whether people have substituted an NHP for a physician's prescription
• whether people have taken an NHP instead of going to a physician

Reports of the results of these surveys are available to subscribers, including Health Canada (Canada Health Monitor 1997; Berger Monitor 1999; Berger Population Health Monitor 2000; Berger Population Health Monitor 2001).

iv) Individual Surveys

There have been several random-sample telephone surveys of the use of complementary and alternative therapies in the Canadian population. These include a survey conducted in May-June 1997 by the Fraser Institute (Ramsay et al. 1999), and a survey conducted in August 1997 by Angus Reid in association with CTV (Ipsos-Reid 1997a and 1997b). Both surveys inquired about the prevalence, patterns, and costs of the use of complementary and alternative practitioners and products. The Fraser Institute survey interviewed a random sample of 1,500 Canadians aged 18 years and older in all provinces (but no territories). The Angus Reid survey interviewed a random sample of 508 Canadians aged 18 years and older in six regions: British Columbia, Alberta, Manitoba/Saskatchewan, Ontario, Quebec, and the Atlantic provinces (sample sizes in Alberta, Manitoba/Saskatchewan, and the Atlantic provinces were small).

These two surveys inquired about the use of practitioners, practices, and products (unlike the NPHS, which only asks about consultation with alternative practitioners, and the Berger Population Health Monitor, which to date has focused on the use of NHPs). The Fraser Institute survey used categories derived, with some modification, from David Eisenberg at the Center for Alternative Medicine and Education in two surveys in the United States (Eisenberg et al. 1993; Eisenberg et al. 1998): chiropractic, relaxation techniques, massage, prayer, herbal therapies, special diet programs, folk remedies, acupuncture, yoga, self-help group, lifestyle diet, homeopathy, imagery techniques, energy healing, naturopathy, aromatherapy, spiritual or religious healing by others, hypnosis, high-dose megavitamins, biofeedback, osteopathy, and chelation (Ramsay et al. 1999). The Angus Reid Survey asked about the use of acupuncture, homeopathy, herbology, macrobiotics, chiropractic, and others (Ipsos-Reid 1997a). As a result, the two surveys do not allow for direct comparison with each other or with the NPHS and the Berger Population Health Monitor.

v) Other Surveys and Studies

Quebec population

A study comparing users and non-users of complementary and alternative therapies in Quebec was conducted with data from the 1987 Quebec Health Survey and the Quebec Health Insurance Board. The two groups were compared in terms of demographic characteristics, health profile, and utilization of medical services (Blais et al. 1997).

People with particular medical conditions

Researchers have investigated the use of complementary and alternative therapies among Canadians with particular medical conditions, most often people with cancer and HIV/AIDS. The studies include:

• a retrospective survey of parents of children diagnosed with cancer in BC between 1989 and 1995 (Fernandez et al. 1998)
• a retrospective survey of parents of children diagnosed with cancer in Saskatchewan between 1994 and 1995 (Bold and Leis 2001)
• a prospective survey of cancer patients in six Canadian provinces during the first two years after diagnosis, beginning in 2000/01 (Leis et al. no date)
• various retrospective surveys of the use of complementary therapy by people with HIV/AIDS in the provincial HIV/AIDS drug treatment program in British Columbia (Ostrow et al. 1997; Heath et al. 1999; Braitstein et al. 2000; Kendall et al. 2000; Kendall 2001)
• various cross-sectional surveys of the use of complementary therapies by people with HIV/AIDS enrolled in the HIV Ontario Observational Database (Robinson 1998, Millson et al. 1999; Furler et al. 2000a; Furler et al. 2000b; Furler et al. 2001)
• a study, conducted in 1997/98, comparing the use of complementary therapies by people with HIV/AIDS in a Toronto clinic prior to the introduction of highly active anti-retroviral therapy and after the introduction of such therapy (Waring et al. 1998)
• a prospective study comparing the use of complementary and alternative therapies by people with HIV/AIDS in a Saskatoon clinic in 1996 and 2001 (Kamyab et al. 2001)
• several studies of the use of complementary and alternative therapies by people with inflammatory bowel disease (Hilsden et al. 1998; Hilsden et al. 1999; Verhoef et al. 1990; Sutherland and Verhoef 1994; Verhoef et al. 1998)
• a prospective survey of the use of alternative therapies by people with a brain tumor in Alberta (Verhoef et al. 1999)

Appendix B: Opportunities for Further Development of Population Surveys

i) Refinement of Survey Questions

The population surveys reviewed above have used a variety of definitions and categories. As is often the case, the definitions and categories used in early studies (such as Eisenberg et al. 1993) may be incorporated into later surveys, thereby establishing the terms for baseline data in the field. Subsequently, however, more precise, useful, or appropriate definitions and categories are identified as a result of further research, debate about data, or application of data.

In Canada there is growing momentum with regard to research into complementary and alternative health care (CAHC). The time is opportune to review the questions used in population surveys of the use of CAHC. While it is not possible to change the questions used in the NPHS, it is possible to develop questions for use in the CCHS, either in the main survey or in supplementary surveys. However, to permit a comparison of results between health regions and over time, it is especially important to have an appropriate, useful, and validated set of questions. In this regard, current research - such as the prospective survey by Leis et al. among cancer patients in six Canadian provinces during the first two years after diagnosis, or the survey and qualitative study conducted by Kendall among people with HIV - may offer guidance, although patterns of use among people with diseases or conditions may be different than those in the population as a whole. Consultation among all stakeholders - researchers, practitioners, policy-makers, and consumers - would also be instructive.

There is, of course, a direct relationship between what is asked in a survey and what the investigator wants to know. When refining or developing surveys on CAHC, the following areas of inquiry should be considered:

• the product, practice, or practitioner used (categories of products, forms of practice, types of practitioners)
• the reasons for using a specific product, practice, or practitioner (a means to identify why a person used a specific form of care, distinguishing between health promotion, disease prevention, and the treatment of illness)
• sources of information about the specific product, practice, or practitioner used (friend, family, media, Internet, primary health care provider, information provider, etc.)
• community settings in which people consulted a practitioner or received a service (sole practitioner, multidisciplinary practice, community health centres, community care access centres, home care, pharmacies, health food stores, etc.)
• institutional settings in which people consulted a practitioner or received a service (acute care hospitals, ambulatory care, long-term care, rehabilitation facilities, palliative care facilities, etc.)
• costs of services and sources of payment
• self care (forms of self care, reasons for self care)

 

ii) Potential Uses of the Canadian Community Health Survey

The CCHS can accommodate questions about CAHC in two ways. The questions can form part of the main content of a cycle, or the questions can form a supplement to the main content of a cycle. If the content of a supplementary survey is relatively brief (e.g., 10 minutes), the questions may be asked during the same interview as the main survey. If the content is longer, the questions may be asked in a follow-up interview. In both cases, it is possible to correlate data gathered in the main survey with data gathered in the supplemental survey. Supplementary surveys are conducted by Statistics Canada on a cost-recovery basis. When a second interview is involved, there are additional costs associated with the second round of contacts. Surveys can also be designed for and conducted in specific populations.

One of the advantages of the CCHS over the now discontinued cross-sectional survey of the NPHS is that it allows for surveys at the level of the health region. It is therefore possible to undertake a selective program of information gathering on the use of CAHC, focusing on regions in which the use of CAHC is relatively more prevalent.

Another important consideration with regard to the CCHS is that a microdata file will be produced for public use and released on compact disc, thereby making the data of the survey available to researchers.

Since the CCHS is a relatively new survey, it would be opportune to consider what questions might feasibly be included in the main survey at regular intervals (though not necessarily at every cycle), and what questions might be included in supplemental surveys (should the resources be available for them). It would also be appropriate to consider what the best strategy would be, given available resources, for selective surveys in health regions: where to survey and when to survey.

Appendix C: Research Studies as an Adjunct to Population Surveys

While population surveys can provide valuable information, they are also subject to limitations. The optimum length of an interview limits the number of questions that can be included. The questions are typically not open-ended and, as a result, may miss important areas of information or dimensions of meaning. When the survey is cross-sectional, it possible only to establish correlation between data, not causation. If the categories of information are not well suited to the subject under inquiry or are not well tested, the results might be misleading or might lack explanatory power.

Research studies are an important adjunct, therefore, to population surveys. When well designed and implemented, research studies have the capacity for more thorough and subtle investigation. They can validate or modify assumptions, instruments, and findings of population surveys. They can suggest new areas of inquiry for population surveys.

It is beyond the scope of this report to explore in detail the opportunities for research studies on the use of complementary and alternative health care. However, it should be noted that the NHPD of Health Canada has completed extensive consultations on ways to facilitate and promote research in natural health products and related areas of research, and is actively engaged with funding partners, including CIHR, to advance research in the field.

Appendix D: The Canadian Institute for Health Information

i) Mandate

The Canadian Institute for Health Information (CIHI) is a national, not-for-profit organization responsible for developing and maintaining a comprehensive health information system for Canada. CIHI delivers the knowledge and develops the tools to advance Canada's health policies, to improve the health of the population, to strengthen the health system, and to assist leaders in the health sector make informed decisions.

The core program functions of CIHI are to:

• identify health information needs and priorities
• conduct analysis and special studies and to participate in/support health care system research
• support the development of national health indicators
• coordinate and promote the development and maintenance of national health information standards
• develop and manage health databases and registries
• fund and facilitate population health research and analysis, to conduct policy analysis, and to develop policy options
• contribute to the development of population health information systems and infrastructure
• provide appropriate access to health data
• publish reports and to disseminate health information
• coordinate and conduct education sessions and conferences (relevant to CIHI's core functions)

For further information, see  www.cihi.ca.

ii) The Roadmap Initiative

CIHI is the lead agency of the Roadmap Initiative (Canadian Institute for Health Information 2001e). The Initiative was established in 1998 as a collaborative effort between CIHI, Statistics Canada, Health Canada, provincial/territorial ministries of health, and several other groups at the national, regional, and local levels. The Initiative consists of a variety of projects to develop better information about the health system and the health of Canadians. Some of the projects under the Initiative will result in the establishment of new databases being established, or the expansion of existing ones. Other projects will seek to foster better data and technical standards for gathering information and for data protection. Still others will focus on obtaining consensus on the indicators and determinants of good health. Almost all of these projects will involve collaborative efforts with key stakeholders at the local, regional, provincial/territorial, and national levels. For further information, see

 secure.cihi.ca/cihiweb/en/downloads/ profile_roadmap_e_ProgReport2001.pdf.

iii) CIHI Databases of Health Care Providers

CIHI maintains several databases of information about health care providers in Canada (Canadian Institute for Health Information 2001e):

• The Health Personnel Database contains information on a number of health professions in Canada. It includes data on the number of people with active memberships in professional associations and licenses to practice in various health fields, as well as the number of new graduates in these fields. The data are supplied by licensing authorities, professional associations, provincial ministries of health, universities, and Statistics Canada. See  secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=hhrdata_personnel_e.
• The National Physician Database contains socio-demographic data and billing data on fee-for-service physicians, as well as data on the sex and age of their patients. A unique identifier for each physician allows for the tracking of physicians across jurisdictions and over time. The data are supplied by provincial/territorial medical health care insurance plans. See
   secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=hhrdata_npdb_e
• The Registered Nurses Database contains demographic data on registered nurses, including age, sex, year and province of graduation, education, employment status, place of employment, location of residence, and position. Data are derived from the annual licensing/registration forms of all nurses registering or re-registering in a province or territory. See
   secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=hhrdata_rndb_e.
• The Southam Medical Database contains information on the supply, distribution, and migration of physicians in Canada. The data include information on demographic characteristics, specialty, activity status, postal code, primary interest, registration status, hospital affiliation, hospital appointment, country, university and year of graduation, and prescribing status. See
   secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=hhrdata_smdb_e .

While CIHI is aware of the need for databases of other health care providers, particularly allied health care providers and complementary and alternative health care (CAHC) providers, CIHI is not able to develop additional databases of health providers without additional resources.

iv) Primary Health Care Indicators

CIHI has begun a project to develop and implement a system of performance indicators in primary health care (Canadian Institute of Health Information 2001d). The purpose of these indicators will be to (p. 1):

• assist with continuous quality improvement activities at the local level
• support performance reporting at the regional and provincial levels
• track the effects of reform in primary health care across the country

For the purpose of the project, the following definition of primary health care, developed by the World Health Organization, has been adopted:

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part of both the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system, bringing health care as close as possible to where people live, work, and constitutes the first element of a continuing health care process. (World Health Organization 1978)

The objectives of the project are to:

• obtain agreement on an initial set of performance indicators for primary health care services
• identify the data elements required to support the calculation of the performance indicators
• standardize the data elements and definitions
• consult with key stakeholders to evaluate the performance indicators for relevance and face validity
• identify current data sources
• pilot the performance indicators from existing data sources using a variety of methodologies, which may include using existing administrative data, randomized chart audit, data from existing electronic health records in selected sites, and other means
• disseminate the findings

Draft performance indicators have been developed with regard to:

• access to care
• the comprehensiveness of care
• the continuity of care over time
• the coordination of care (continuity across systems)
• the family-centred nature of care
• the community-oriented nature of care
• the cultural responsiveness of care
• quality improvement processes
• the format of medical records
• patient-provider communication and relationships
• clinical quality
• advocacy
• the multidisciplinary aspects of care.

These draft indicators will be reviewed by provincial/territorial ministries of health, regional health authorities, health care providers, consumers, and national associations before being finalized.

Although many of the draft indicators relate to conventional primary health care, there are indicators that relate specifically to the use of CAHC providers. In addition, the indicators include categories that may be hospitable to complementary and alternative paradigms of health and health care, such as indicators that measure the types of health care providers involved in primary health care, the integration of primary health care services, the cultural responsiveness of primary health care services, patient-provider communication and relationships, and multidisciplinary health care services.

The project is scheduled for completion in March 2003.

v) 2001 Report on Health Care Providers

In 2001, CIHI published Canada's Health Care Providers (Canadian Institute for Health Information 2001a). The report presents a compilation of current research, historical trends, as well as new data, findings, and analysis on what we know and do not know about Canada's health care providers. The report includes information about:

• numbers and geographic distribution of physicians, nurses, and other health care providers
• education and training of health care providers: number of graduates, types of graduates, location of programs, cost of education
• regulation of health care providers
• supply of health care providers: modeling human resource needs; trends in health care needs; apportionment of health care spending; geographic, demographic, and gender distribution of providers; full-time, part-time, and casual work; migration and immigration of providers
• teamwork in health care: mix of skills required in current health care; shared and exclusive scopes of practice, learning to work together, trends in primary health care
• working in health care: proportion of Canadians employed in health care, unemployment levels in health care, overtime work in health care, reimbursement of physicians, job satisfaction in health care
• health of health care providers: lost days of work, injury and illness at work, stress and burnout in health care

The report provides information on a few aspects of CAHC. These include:

• the use of chiropractors, massage therapists, homeopaths/naturopaths, and acupuncturists (p. 11), drawing on data from the 1998/99 National Population Health Survey
• regulated health care providers by province/territory as of February 2000: data are provided on chiropractors, midwives, osteopathic physicians, acupuncturists, and massage therapists (p. 23)
• the number of chiropractors and midwives per 100,000 population (p. 10)
• graduates from schools of chiropractic in 1988 and 2000 (p. 17)
  

vi) 2001 Report on Health Care in Canada

In 2001, CIHI, in collaboration with Statistics Canada, published its second annual report on health care in Canada. The report, entitled Health Care in Canada (Canadian Institute for Health Information 2001b), includes chapters on:

• Canada's changing health care system
• health promotion, illness prevention, and primary care
• acute care hospitals
• special care (mental health care, institutional care, home care, telehealth)
• providers of care
• outcomes of care
• spending on health care
• future directions
  

The report includes data from the 1998/99 National Population Health Survey on the use of complementary and alternative practitioners, as well as data from several other smaller surveys on the use of complementary and alternative therapies in general (pp. 23-24).

Appendix E: Challenges in Gathering National Data About Health Care Providers and Services

It will be evident from the above summary of CIHI initiatives and reports that the data gathered and the information reported about complementary and alternative health care (CAHC) are relatively limited when compared with data and information about conventional health care. However, it is instructive to observe that data on many aspects of conventional health care are also far from complete.

The challenges faced in gathering more complete information about CAHC are often similar to challenges faced in gathering more complete information about conventional health care. It may be useful to review some of the main challenges, noting issues or opportunities related to CAHC.

i) Limited Purposes of Existing Databases

National data on health care providers and services are derived from existing databases. These include databases of various types of health services or conditions (such as the Discharge Abstract Database, the National Trauma Registry, the Canadian Cancer Registry); databases of professional associations or regulatory bodies; and databases of enrollment in and graduation from educational institutions.

These databases were developed for specific purposes, such as payment for services provided by a practitioner or in a hospital, or registration of accredited or licensed practitioners in a health care profession. As such, they do not necessarily provide the type of information that is needed for a comprehensive understanding of the health system and for deliberations about the direction of the health system. For instance, membership data from professional associations do not necessarily identify practising and non-practising members, members in full-time or part-time practice, members' specialties, the settings in which members practise, etc.

To remedy these types of limitations, the Roadmap Initiative is expanding existing databases and, in some instances, developing new databases. Since data-gathering systems in CAHC are in an early state of development, relative to other health information systems, it would be useful to learn from the lessons of the past and to anticipate the needs of the future with regard to health information.

ii) Development of Appropriate Indicators

Health care is a complex system of services. Measuring the performance or outcomes of these services is similarly complex. This is a challenge within the paradigm of conventional health care, let alone within the multiple paradigms of CAHC.

There are a number of frameworks within which it may be possible, over time, to incorporate indicators appropriate to complementary and alternative paradigms of health and health care. For instance, population health surveys include measures of personal health status and personal health practices (Federal, Provincial and Territorial Advisory Committee on Population Health 1999). Similarly, as already noted above, the proposed performance indicators in primary health care include categories that may be amenable to use in CAHC.

iii) Need for a Collaborative Information Framework

It is often beyond the scope of any one organization in the health care field - whether a provincial/territorial ministry of health, a professional association, a health care institution, or some other agency - to gather the information that is needed for a comprehensive understanding of the health system. Taking steps toward gathering more comprehensive or comparable data requires a collaborative information framework involving all the stakeholders in the field.

For instance, to gather complete and reliable data on practitioners of a given complementary and alternative therapy, it would be necessary for all stakeholders to agree on:

• the definition of the practitioner
• a basic set of information to be gathered about the practitioner (eg., demographic information, education, regulatory status, practicing or non-practicing, full-time or part-time, practice settings, scope of practice, specialization, cross-trained)
• the standards for the quality and processing of data
• the use of the data
• provisions for informed consent regarding use of the data

The stakeholders in an collaborative information framework can be many and diverse. They can include professional associations, employers of health care practitioners, health care insurers, and provincial/territorial ministries of health.

iv) Access to Individual Practitioners

It is easier to identify and gather data from individual practitioners when the health care profession is regulated by legislation than when it is unregulated. Many CAHC professions are not regulated by legislation, and rely on voluntary membership in professional associations. This increases the challenges that these associations face in gathering information about their profession and the practitioners who practice in the profession.

v) Multiple Providers of a Service

When there are multiple providers of a particular service, it is more difficult to gather complete data on the provision of the services. For instance, advice on the use of herbal products may be provided by naturopaths, herbal practitioners, pharmacists, and staff in health food stores. Similarly, acupuncture may be provided by conventional health care practitioners as well as complementary and alternative practitioners. An accurate picture of the provision of the service would need to capture information from all potential providers of the service. This challenge is not unique to CAHC. For example, many primary health care services may be provided by both physicians and nurse-practitioners (Canadian Institute for Health Information 2001a: 56). However, the challenge of identifying providers of a particular service is greater when the scope of practice is not defined, the service is not regulated by legislation, or the services are not billed to a single payer (such as a provincial public health insurance plan).

vi) Data-gathering Systems and Costs

The responsibility for gathering data about health care providers lies, in the first instance, with professional associations. Similarly, the responsibility for gathering data about health care services lies, in the first instance, with individuals or institutions that provide those services. The systems required to gather such data are costly in terms of time, human resources, tools (such as membership forms), data processing, and financial outlays. This entails a long-term commitment from the body or institution gathering the data. For instance, in the case of CAHC practitioners, there would have to be a long-term commitment on the part of the executive and membership of the professional association to support the data-gathering initiative, in terms of costs, time, and the provision of data.

vii) Protection of Privacy

The privacy of personal information - and particularly personal health information - is protected by legislation, professional codes of ethics, and voluntary codes of ethics in Canada. Protection of the privacy of personal information requires that data gatherers limit the collection, use, and disclosure of data. It obliges them to obtain informed consent for the collection, use, and disclosure of personal information, with certain specific exceptions. It requires that they take steps to ensure the integrity and security of personal information. Safeguards in all of these aspects of data gathering are most crucial when there is a potential for individuals or institutions to be identified.

Information about existing or proposed privacy legislation, as well as other measures to protect the privacy of information, is available from a number of sources. The Privacy Commissioner of Canada provides information on federal privacy legislation and offers links to numerous other resources on the privacy of health information (see
 www.privcom.gc.ca/information/02_03_02_e.asp). The Canadian Institutes of Health Research has published a Compendium of Canadian Legislation Respecting the Protection of Personal Information in Health (Kosseim 2000), and is sponsoring a number of initiatives on the privacy of health information in research (see  http://www.cihr-irsc.gc.ca/e/18542.html). CIHI has developed principles and policies for the protection of health information (Canadian Institute for Health Information 1999), as well as several other resources (Canadian Institute for Health Information 1995a and 1995b).

Appendix F: Opportunities for Further Development of National Data on Complementary and Alternative Health Care Providers and Services

Although the information that is currently gathered and included about complementary and alternative health care (CAHC) providers and services in the Roadmap Initiative is limited, the Roadmap Initiative and other CIHI projects can contribute, both indirectly and directly, to the development of more complete information systems about CAHC.

i) Identifying Data to be Gathered

The CIHI reports identify not just what we know, but also what we do not know about the health system. Together these two - what we know and what we do not know - establish terms of reference for more complete information about the health system. For instance, a number of categories of information can be derived from Canada's Health Care Providers (Canadian Institute for Health Information 2001a) and potentially applied in systems to gather information about CAHC providers:

• number of practitioners in a given category
• number of practitioners in practice
• settings in which the practitioners practise
• proportion in full-time and part-time practice
• proportion in solo or team/multi-disciplinary practice
• regulatory status of the practitioners
• types of services provided by the practitioner or, if regulated, the scope of practice/controlled acts of the profession
• educational requirements to practise
• number of educational and clinical training placements in a given year
• number of students enrolled in educational programs
• number of students graduating from educational programs.

ii) Experience in Developing Professional Databases

CIHI and its collaborators - particularly professional associations and regulatory bodies - have valuable experience in developing databases for health care providers. Professional associations of CAHC providers may be able to learn from that experience in order to determine, for example:

• the readiness of the profession and the professional association to develop and implement a data-gathering system
• the components of a data-gathering system, including standard definitions of data elements, common data elements across jurisdictions, privacy and security of information, obtaining individual informed consent for the use and sharing of information
• the practicalities of administering a data-gathering system, such as the information to be gathered on professional membership forms, entering information into databases, safeguards for databases

iii) Inclusion in Health Information Systems and Reports

CIHI is in a position to advise CAHC professional associations as to when and how data on CAHC might be incorporated into health information systems and reports, as these are enhanced or developed. While the relative lack of data gathered about CAHC is evidently a challenge, CIHI's initiatives nevertheless might afford opportunities whereby, gradually and incrementally, more and better data are gathered and incorporated in national reports on health care in Canada. For instance, as the performance indicators of primary health care are developed and utilized, it may be possible, over time, to develop and incorporate more indicators related to CAHC.

Appendix G: Proposed HRDC Sector Study of Complementary and Alternative Health Care Providers

i) The Proposed Sector Study

Human Resource Development Canada (HRDC), Health Canada, and a selected number of CAHC national professional associations and educational bodies have held preliminary discussions on a proposed sector study of complementary and alternative health care (CAHC) practitioners (HG Associates 2001a and 2001b).

A sector study is a comprehensive analysis of human resource issues and challenges facing the sector or occupation. The objectives of the study are to provide sectoral and occupational labour market information that may be lacking, to identify employment opportunities within the sector, and to support government policy (HG Associates 2001a: 6). Several health sector studies are currently underway (nursing, physicians, oral health care, home care) or are under consideration (pharmacy).

The key features of the sector study are as follows (HG Associates 2001a: 6-7):

• it is a sector and occupational needs assessment
• it is national in scope
• the process is facilitated by HRDC
• the study is led by the sector itself
• the study is directed by a national steering committee
• the outcome of the study is a consensus report that will outline a common understanding of human resource issues and challenges, along with recommendations and possible solutions for some of the issues and challenges

Professions participating in preliminary discussions identified the following key potential benefits of a sector study of CAHC practitioners (HG Associates 2001a: 14):

• communication and collaboration within the sector
• better understanding of, and potential acceptance of, the sector by policy/decision-makers and other health care participants, such as hospitals and third party payers
• monitoring of trends in the sector, such as supply of and demand for practitioners
• training needs, new opportunities
• demographic information for and on the participating professions

Typically, a sector study gathers information on (HG Associates 2001a: 7):

• demographics
• recruitment practices
• retention of personnel within the sector
• image of the sector
• training and development
• skill and knowledge gaps
• employer-employee-client relations

Data are collected using a variety of both qualitative and quantitative methodologies: literature reviews, interviews, surveys, focus groups, etc. (HG Associates 2001a: 7).

Six disciplines/practice areas are collaborating on preliminary work for a possible sector study (HG Associates 2001b: 19):

• acupuncture and Traditional Chinese Medicine
• chiropractic
• herbal medicine
• homeopathy
• massage therapy
• naturopathy
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ii) Information Needs Related to the Sector Study

The disciplines/practice areas involved in the sector study are at varying stages of development with regards to professional association, regulatory status or professional definition, and information-gathering from and about the practice area (HG Associates 2001b: 9-10). The sector study represents an opportunity for the disciplines/practice areas to develop better descriptive information and better data-gathering systems. It also represents an opportunity to identify human resource issues and to gather information on those issues.

In preliminary discussions, the participating disciplines/practice areas identified the following key human resource issues for the sector (HG Associates 2001b: 13-14):

1. Education and training

• consistency
• lack of funding
• minimal or variable standards/regulations

2. Regulation/professional identity

• self-regulation
• statutory regulation

3. Research and emerging technology

• lack of literacy and capacity
• knowledge transfer
• central database (practice profiles)
• impact of Internet

4. Demand

• market drivers
• funding issues
• awareness (within and outside sector)
• image
• access
• relationship with mainstream care
• confusion among providers and the public
• lack of team care and a referral network
• aging population
• greater demand for CAHC services and treatment
• overlap between therapies and potential 'turf' issues
• potential competition between different practice areas
• lack of limitations on scope of practice
• lack of information or clarity
• possibility of privatization
• cultural preferences

5. Supply

• education (see above)
• training (see above)
• research (see above)
• workplace (number of people practising and modalities used)
• overlapping scopes of practice; need for accurate statistics
• geographic and location distributions
• immigration and foreign credentials
• mobility
• overlap with mainstream medicine

6. Recruitment and retention

• lack of human resource planning
• youth of new practitioners - now may be a first career choice
• income levels
• differences in practitioner age by province/territory
• gender issues
• professional recognition
• self-actualization and job satisfaction
• differences among professional capabilities
• employer/employee issues
• split between junior and senior clinicians, differences in educational backgrounds
• recognition of older certification and education
• lack of awareness by entry-level practitioners of further careeroptions/directions after initial level of training/education
• continuing education

7. Health policy issues

• impact of health care system funding
• CAHC not at the decision-making table
• differing paradigms of health and well-being affecting policy decisions and directions
• lack of cohesiveness and a lack of voice for CAHC (communication at the policy level)

iii) An Opportunity for Longer-Term Information Systems

The sector study offers an opportunity for the participating professions to consider their requirements for data gathering over the long term. It would be useful for them to consult with CIHI on how the data gathering that they do in the course of the sector study could contribute to the enhancement or the development of enduring data systems. Such consultation could address:

• agreement and differences between complementary and alternative and conventional paradigms of health and health care, and the potential for a working relationship between or among paradigms in gathering data and reporting information
• the types of data that would be useful within the larger context of information about the health of Canadians and health care in Canada
• cost-effective but reliable means of gathering data, such as, for example, using periodic surveys of a representative sample of the profession rather than the membership database of the profession to gather more complete information about the profession)
• the realities of developing and maintaining data-gathering systems (see Appendix E i)