Growing public interest in complementary therapies has led to an increase in the use of unqualified contributors writing and recommending various therapies
Fiona Mantle, BSc, Cert Ed, RHV, RNT, RN, is a freelance writer, researcher and lecturer in complementary and alternative medicine.
Mantle F (2009) The risks associated with consumer magazines giving advice on complementary therapies. Nursing Times; 105: 48, early online publication.
Background The increased popularity of complementary and alternative medicine (CAM) has led to increased demand for information on it, giving rise to the concept of “new experts”. However, there is concern about the quality and accuracy of this information, much of which is published in popular magazines and written by contributors with no medical qualifications.
Aim To examine the extent of CAM product advice in women’s and health magazines, and the potential for adverse drug/herbal interaction.
Method Fifteen women’s magazines were examined over one month.
Results and discussion A total of 150 articles were identified, of which 131 were written by non medically qualified contributors, mainly journalists. Out of the 150, 95 discussed ingested herbs which had the potential for adverse interactions and are contraindicated for certain groups.
Conclusion The findings have legal and ethical implications. The re-evaluation of the journalists’ code of conduct to reflect this new development in journalism should be considered.
Keywords: Complementary and alternative medicine, CAM, Herbal remedies
- This article has been double blind peer reviewed
As a result of these findings, nurses need to be aware of the following issues:
- Patients may access many and varied sources of medical information;
- Patients may use CAM therapies either on their own or in combination with concurrent orthodox medication;
- There is a growing group of “new experts”, who may have minimal or no relevant training.
With higher expectations of healthcare provision and general disenchantment with its delivery, many people are turning to complementary and alternative medicine (CAM). This has led to a significant increase in the amount of information about its use being made available in traditional media and on the internet (Ong and Banks, 2003). Giddons (1990) coined the phrase “new experts’ on health and wellbeing (old experts being proponents of orthodox and mainstream knowledge). For those who are dissatisfied with their current healthcare system, these modalities can provide a welcome source of information.
However, the quality of advice given and the qualifications of “new experts” cannot be guaranteed. Of particular concern is the plethora of lay advice available about CAM in popular magazines. Some are specifically devoted to CAM while others, primarily focusing on women’s issues, often contain information about using CAM for medical conditions. This may take the form of readers’ contributions, celebrity endorsement, feature articles promoting CAM, product placement in response to specific conditions and information about therapies in general. A common format is columns in which new experts offer advice about CAM interventions for medical problems, ostensibly sent in by readers.
Observation of a selection of these magazines indicates that, although some of this information is written by medically qualified writers, the majority is by contributors whose key remit appears to be new product placement. This raises legal, ethical and safety issues regarding the potential use of CAM by uninformed members of the public and its sequelae in terms of latent harm to both adults and children.
One side effect of the increase in health information via the media is the worrying trend towards self medication, either with orthodox medication or with CAM.
The scope of self medication
Proprietary drugs sold over the counter (OTC) include analgesics (including those containing codeine), antihistamines, vitamins, tonics, antacids, statins and cough medicines. The World Medical Association (2002) stated that individuals have primary responsibility for using OTC products, but if they choose to self medicate, they should be able to:
- Recognise the symptoms they are treating;
- Determine that their condition is suitable for self medication;
- Choose a suitable product;
- Follow the directions for use.
Self medicating for a diagnosis of cold or flu is well within most people’s capability. However, the seriousness of other symptoms may be less obvious and result in delays in seeking appropriate treatment.
Sihvo and Hemminki (1999) highlighted the dangers of self medication, in this instance, to treat dyspepsia. This research discussed a common remedy for a common problem but indicated the potential for serious misdiagnosis. A survey conducted on 50 consecutive customers in 10 pharmacies (response rate 53%) showed 88% were self medicating for heart burn, 31% for gastrointestinal pain, and 32% for acid regurgitation. Of these, 75% had been using the drugs for over a year, while 6% had symptoms which contraindicated self medication but had not consulted a doctor. Although this was a small study, the level of continuous self medication was high and could indicate cause for concern.
More recently, Bardia et al (2007) conducted a survey among 30,600 adults, finding that 3,315 used herbs to treat a specific medical condition and, of these, two thirds did not do so in accordance with evidence based indications.
Risks related to self medication with CAM products include:
- The appropriateness of the intervention for the condition;
- Failure to appreciate the significance of the presenting symptoms and incorrect self diagnoses being made;
- The possibility of a delay in seeking orthodox treatment, or the refusal of more appropriate orthodox treatment.
One perennial problem regarding safety and CAM is the enduring perspective that, since these medicines are perceived as “gentle” and “natural”, they are intrinsically safe and have no side effects. This can be wrong but may it prove difficult to change patient perceptions.
Mintel (2003) noted that annual retail expenditure on homeopathic remedies, herbal remedies and essential oils was £126m.
Thomas et al (2001) noted that the purchase of OTC remedies was highest in the 18-44 age bands for both men and women, and that in every age band women were twice as likely as men to use OTC products.
Sources of health information
We now receive, and are exposed to, many sources of health information either from healthcare professionals or, increasingly, from consumer media. This desire for health information is a natural consequence of the move away from the “doctor as expert” attitude towards the more modern desire for self help and wellness.
One source of information on CAM is the media, specifically through consumer magazines, books and periodicals available in high street shops.
The role of women’s magazines
Women’s magazines have a long history of supplying a range of information, including health information (Moyer et al, 2001). A key format is the advice column, which typically follows a question and answer format. This might include legal, veterinary care, maternity, and childcare advice, as well as answers to emotional problems. In general it is given by appropriately qualified professionals such as lawyers, midwives, nurses, health visitors or doctors, who have professional accountability. It is extremely unlikely that this sort of advice would be offered by unqualified lay contributors. However, this level of qualified expertise does not appear to extend to information on the subject of CAM. Occasionally, it does include warnings to consult a doctor before following the advice given. Eriksson et al (2005) investigated the role of general health information in the media on patients’ contact with GPs and noted that media health messages rarely directly cause patients to consult their GP. However, the extent to which patients contact their doctors in relation to CAM information has not been investigated.
Larsson et al (2003) interviewed 148 medical journalists from 37 countries, who all agreed that the validity of medical reporting in mass media is important. Key issues that mitigated against the dissemination of safe medical information were reported by medical journalists as:
- Lack of time;
- Space available in the publication;
- Their background knowledge;
- Problems with editors and commercialism;
- Difficulties with terminology;
- Problems with finding and using reliable sources.
The Press Complaints Commission’s code of practice and the National Union of Journalists’ code of conduct emphasise the need for accuracy and to avoid misleading or distorted material.
The study’s aim was to determine the extent of CAM advice on OTC products in women’s or other popular magazines, specifically on the use of herbal remedies and the potential for adverse drug/herbal interaction. This would be particularly important for people with diabetes, hypertension, cardiac conditions, blood dyscrasias, liver disease or who take blood thinning agents such as warfarin.
The key research question was: is there any evidence to indicate cause for concern in relation to the potential for harm in popular magazines relating to CAM advice by determining:
- How many articles promoting CAM interventions were observed in the sample over one month?
- What did they include?
- Who wrote them?
- Were contraindications/interactions included in the information?
- Were there any potential contraindications/interactions with orthodox medication?
- Does the content of the articles/information contravene the journalists’ code of conduct?
Descriptive content analysis within the qualitative paradigm was carried out on five sources of CAM information available to the public:
- Information given as replies to readers’ letters;
- Information from readers’ contributions;
- Feature articles promoting CAM;
- Product placement in response to specific conditions;
- Information about therapies in general, including food supplements.
I carried out the analysis, ensuring that categories elicited should be theoretically relevant, exhaustive, mutually exclusive and independent.
Fifteen consumer magazines published in the UK, aimed at women and/or covering health topics, were identified as having one or more of the above features and were deemed to be a rich source of data. Information from the publishers indicated the magazines were aimed at social groups AB with an age range of 20–50, with one aimed at the over 50s. Median circulation figures were 300,000.
This was any editorial which identified, promoted, described or advocated the use of a CAM intervention that does not require an intermediary for its use, to address a particular condition or a set of symptoms. The following are examples of CAM interventions that are available OTC or by mail order: herbal remedies; homeopathic remedies; dietary supplements; or a therapy used as a self help intervention. Examples of this included self massage, acupressure or reflexology techniques.
Editorial covers content written by any contributor, since all published material is the responsibility of the relevant editor, who is subject to the Press Complaints Commission and National Union of Journalists’ code of conduct.
Contributor: these include: journalists, “gurus”, medically qualified doctors, CAM therapists, celebrities or readers.
Sample frame: examination of a relevant sample of a range of women and/or health focused weekly and monthly publications available in an outlet of a chain of high street newsagents and stationers. This yielded a sample of 15 magazines with editorial promoting or advocating the use of CAM for clinical conditions. These magazines were analysed over one month using descriptive content analysis to determine the content, veracity and safety of information provided for the general public on health issues.
Analysis of the 15 magazines yielded a total of 150 articles, of which 95 were on ingested (as opposed to topical) herbal remedies, 25 on nutritional supplements, 10 on homeopathic remedies, and 20 related to essential oils.
Other therapies suggested as useful for indicated medical conditions included: reflexology (two), yoga (two), t’ai chi (one), Bach Flower remedies (four), topical use of honey (four), topical use of a herbal remedy (three), osteopathy (two), cranial osteopathy (two), acupuncture (seven), massage (two) and the Bates eye exercises (one). Of these, one reflexology article was a “how to” rather than a general recommendation. Of particular concern was a self help leg massage feature for “heavy legs”, which failed to offer any contraindications in relation to varicose veins, previous or suspected DVT, or localised dermatological conditions.
Of the articles on herbal remedies, the most frequently mentioned were: black cohosh (five); liquorice; ginger; garlic (four on each); St John’s wort; echinacea; chamomile; aloe vera (three on each); and seven Ayurveda herbal remedies.
In no instance were any contraindications/interactions indicated in the use of these herbs in relation to any medical conditions. Of particular concern was the recommendation for a woman aged 33 to take ginseng, which should not be taken by people under 40 [Baldwin, 1986).
Of the contributors, seven were CAM therapists, of whom two advised further consultation with a medical herbalist or a homeopath. Five were medically qualified (in this instance doctors) and were responsible for 19 articles. None of the doctors highlighted any herb/drug interaction, with two prescribing liquorice without any reference to existing cardiac pathology, diabetes or hypertension. There was one celebrity feature and 14 articles comprised suggestions by readers.
Of the 150 articles, 131 remedies were proposed by contributors with no medical qualifications.
Although this study is small, involving only 15 women’s and/or health focused popular magazines, it has highlighted an issue of considerable concern in relation to the proliferation of potentially dangerous information. Extrapolation of these results over a year indicates the potential to elicit 1,800 such articles.
In spite of the dangers of drug/herb interactions being well documented (Woodward, 2005), there has been no reported investigation into the extent to which unqualified contributors are publicly advocating the use of herbal, homeopathic or essential oil remedies as a medical intervention. This might be in response to reported medical conditions or to address signs and symptoms but without any knowledge of either the reader’s medical history or that of any reader to whom the medical scenario might apply.
When orthodox medical issues are raised in consumer media, these tend to be dealt with by medically qualified staff. However, when the topic includes advice relating to the use of CAM this does not necessarily apply, with advice mainly given by contributors such as journalists, therapists, readers or celebrities, demonstrated by the 131 articles identified in this study. Even if the information is evidence based, it does not necessarily follow that this would be appropriate to the reader’s situation. As Slowther et al (2004) pointed out in relation to primary care, symptoms presented may be non specific and reflect a social or psychological aetiology not apparent in the printed article.
It could be suggested that, by promoting the use of a product without being aware of the reader’s full medical history and by making a “diagnosis” on the basis of a few symptoms, the contributor is failing in their duty of care and may cause the reader harm. It could also be argued that the reader is unable to make an informed decision on the product’s use if its contraindications and interactions are not indicated in the article. This would appear to contravene the Press Complaints Commission’s code of practice and the NUJ’s code of conduct, which emphasise the need for accuracy and to avoid misleading or distorted material.
The use of CAM OTC products by the general public is well established. However, the extent of the promotion of such remedies by the media has not been identified nor investigated. This study has addressed both issues and has indicated potential for harm.
Further exploration is needed regarding the legal and ethical implications of these findings. The re-evaluation of the journalists’ code of conduct to reflect this new development in journalism should be considered.
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