Aims: This study aimed to determine the use of complementary and alternative medicine (CAM) by mothers with a chronically ill child and their anxiety levels.
Methods: This study used a descriptive design. The study was conducted with 135 mothers of a chronically ill child at a general pediatric and oncology unit in Uludağ University Hospital, Bursa, Turkey. A questionnaire, including sociodemographic items and the State-Trait Anxiety Inventory, were given to the mothers.
Results: In the study, 42.29% of the mothers reported using one or more CAM therapies for their child with a chronic disease, including herbal medicine, taking the child to hodja (prayers), a special diet, and a special massage. The mothers experienced anxiety and the presence of a disease within the close family circle increased the anxiety level of the mothers.
Conclusion: Herbs and other alternative supplements were used by some children with a chronic disease in Turkey. The most commonly used CAM therapies included oral herbal medicine, taking the child to hodja, massage, and diets. Therefore, it is important to consider the implications of the popularity of complementary therapies. Most of the mothers used more than one of these therapies for their child and the anxiety level of the mothers was found to be moderate.
Families confronting illness experience fear, worry, and anxiety that are related to uncertainty about the course of the disease in their child during the treatment process, repeated operations, tests, the correct administration of medicines, the side-effects of medicines, and the rules and prohibitions (Fernandes & Souza, 2001; Lim et al., 2006; Meleksi, 2002; Özkaya, Çetin, Uğurad, & Samancı, 2010; Svavarsdottir & Rayens, 2005). Studies have found that some alternative medicine methods, such as massage and herbal medicine, can help to reduce both the symptoms in the children and anxiety in their parents. For example, the massage of children with cancer is feasible and appears to decrease the level of anxiety of parents and younger children (Post-White et al., 2009b).
Health personnel, including nurses, who are closely involved with families should be aware of the psychological problems and need for support of families who have ill children. They should define and evaluate the traditional treatment approaches that are used apart from medical treatment and, if necessary, intervene (Fernandes & Souza, 2001) and provide the best care with evidence-based treatments, in accordance with the principle of causing no harm (Post-White & Hawks, 2005).
This study was conducted in order to detect whether mothers of a child with a chronic disease resort to CAM therapies and to evaluate these mothers' anxiety levels.
The sample comprised the mothers of 135 children with a chronic disease who visited the child and adolescent oncology clinics of Uludağ University Medical Center Training, Treatment, and Research Hospital, Bursa, Turkey, on Thursdays and Fridays between February and April 2008. The ailments included respiratory conditions (e.g. asthma), endocrine diseases (e.g. diabetes), different types of cancer, nervous system conditions (e.g. cerebral palsy and epilepsy), and kidney diseases (e.g. chronic renal failure).
For the data collection, a questionnaire was used that captured the sociodemographic data of the children with a chronic disease and their mother and the State-Trait Anxiety Inventory (STAI). The questionnaire was given to the mothers at least 2 months after the diagnosis of the disease of their child.
The questionnaire consisted of three parts. The first part contained closed-ended questions that included the sociodemographic data of the mothers and children. The second part included open-ended questions that determined whether or not the mothers resorted to alternative treatments (Appendix I). In the third part, the STAI was used to determine the anxiety level of the mothers.
The Turkish adaptation of the STAI, which was developed by Spielberger in 1970, was carried out by Öner and Le Compte in 1982 (Öner & Le Compte, 1985; Spielberger, Gorsuch, & Lushene, 1970). The State Anxiety Inventory (SAI) requires individuals to define how they feel in a specific moment and under certain conditions, whereas the Trait Anxiety Inventory (TAI) requires individuals to define how they feel in general. The SAI can be conducted on the same individuals at different times in order to assess changes in the severity of their fear and anxiety levels. The TAI is not sensitive to feelings that change based on temporary conditions. For both scales, the weight values of the answer options change from one to four. In the scales, there are direct or smooth statements, indicating negative feelings, and reverse statements, indicating positive feelings. The total score value that is obtained from either scale is between 20 and 80. High scores indicate a high level of anxiety. The scoring is carried out by subtracting the total score of the direct statements from the total score of the reverse statements. A predetermined and unchanging value is added to this number. This value is 10 for the state of anxiety and 35 for the trait of anxiety. The final value that is obtained is the anxiety score of the individual. Subscale scores of 20–39 are considered to be indicative of low anxiety, scores of 40–59 are considered to be of moderate anxiety, and scores of 60–80 are considered to be of severe anxiety (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983).
Two researchers collected the data via face-to-face interviews with the mothers. Each interview lasted for 20 min.
The statistical analysis was carried out by using the Statistical Package for the Social Sciences version 10.0 for Windows (SPSS, Bursa, Turkey). Both parametric and non-parametric linkage analyses were made.
In the comparison of two independent groups, the t-test was used for the parametric values and the Mann–Whitney U-test was used for the non-parametric values. In the comparison of multiple independent groups, the Kruskal-Wallis test was used and Pearson's correlation analysis was used to assess the relationship between two averages. For all the analyses, P ≤ 0.05 was considered to be statistically significant.
Before starting the study, the necessary permission from the Uludağ University Faculty of Medicine Ethics Committee and written consent from the families that were participating in the study were received. The mothers of the children who were included in the study were informed about the study and their voluntary participation was ensured.
The average age of the mothers was 33.54 years (SD = 5.62). The age distribution of the children was as follows: 39.3% were 1–5 years old, 31.1% were 6–10 years old, and 29.6% were ≥11 years old.
In the study, 42.29% of the mothers reported using one or more CAM therapies for their chronically ill child, including herbal medicine, taking the child to hodja (prayers), a special diet, and a special massage (Fig. 1). The herbal medicines were used as follows: stinging nettle for cancer (three patients), cough tea for asthma (three patients), locust molasses for cancer (one patient), basil for renal failure (one patient), linden for nervous system diseases (one patient) and asthma (one patient), and zam-zam water for nervous system diseases (one patient) (Table 1).
Table 1. Type of herbal medicine used according to the type of chronic disease
Chronic renal failure
Figure 2 displays the mothers' use of CAM therapies by the type of chronic disease that was suffered by their child (Table 1):
1Taking the child to hodja: nervous system diseases (five patients, 31.3%); asthma (one patient, 20%); chronic renal failure (one patient, 11.1%); and cancer (three patients, 3.2%).
2Using herbal medicine: asthma (four patients, 80%); nervous system diseases (two patients, 12.5%); chronic renal failure (one patient, 11.1%); and cancer (four patients, 4.2%).
3Using a special massage: asthma (two patients, 40%); nervous system diseases (four patients, 25%); diabetes (two patients, 20%); cancer (17 patients, 17.9%); and chronic renal failure (one patient, 11.1%).
4Using a special diet: diabetes (eight patients, 80%); chronic renal failure (eight patients, 25.8%); asthma (one patient, 20%); cancer (12 patients, 12.6%); and nervous system diseases (two patients, 12.5%).
Moreover, only the mothers of four patients (3%) consulted with their nurses or doctors about CAM use.
The study found that the mothers of a child with a chronic disease recorded an average anxiety level score (SAI = 51.18 ± 11.13, TAI = 45.95 ± 8.61).
The mothers' anxiety scores were not statistically significantly different according to the type of disease that was affecting their child (Table 2). When the correlation between the mothers resorting to CAM therapies and the SAI-TAI average scores was considered, a statistically significant difference was discovered between the use of a special massage and the SAI-TAI score, between the use of a special diet and the TAI score, and between the use of herbal medicine and the TAI score.
Table 2. Demographic and treatment characteristics and the State Anxiety Inventory (SAI)–Trait Anxiety Inventory (TAI) levels of the complementary and alternative medicine therapy (CAM) users, compared to the non-users (n = 135)
A meaningful correlation was found between the existence of other diseases in the family and the SAI-TAI anxiety score and between the existence of the same disease in the family and the SAI score.
A statistically significant difference was found between the SAI scores and the TAI scores of the mothers (an average anxiety level score: SAI = 51.18 ± 11.13, TAI = 45.95 ± 8.61; P < 0.001).
Many (42.29%) of the mothers who participated in the study reported using one or more CAM therapies with their chronically ill child (Fig. 1). Studies that have been conducted in Turkey have found that the mothers reported varying use of traditional treatment approaches with their child: 57% for general pediatric conditions (Öztürk & Karayağız, 2008), 48.9% for children with cancer (Gözüm et al., 2007), and 66.8% for children with asthma (Kaya et al., 2009).
The results of this study revealed that cough tea and linden were used frequently for children with asthma and urtica urens was used for children with cancer. Herbal medicines were used to control asthma attacks and to treat respiratory problems for children with asthma (Kaya et al., 2009; Madsen et al., 2003; Oshikoya, Senbanjo, Njokanma, & Soipe, 2008). Cough tea and linden, which have expectorant qualities, are used frequently in Turkey. Stinging nettle is commonly used for the treatment of adults, as well as of children (Gözüm et al., 2007) (Fig. 2).
As displayed in Figure 2, a special massage and herbal medicine were the most frequently used CAM modalities by the mothers of a child with cancer. The herbal medicines that are used for patients with cancer might prevent chemotherapeutic agents from reaching an efficient dose or might cause toxic effects (Post-White & Hawks, 2005). It can be said that mothers who use herbal medicines have insufficient information about this issue.
The use of CAM varied by the type of disease. The chronic disease for which CAM therapies were used most frequently was asthma, followed by diabetes, nervous system diseases, chronic renal failure, and cancer. In keeping with the findings of this study, other studies have found that traditional therapies were used more frequently for asthma than for other chronic diseases (Madsen et al., 2003; Post-White et al., 2009a).
When all the CAM therapies were considered in the context of the various chronic conditions, the following results were the most salient: using herbal medicines for asthma, using special diets for diabetes, taking children to hodja for nervous system diseases, and using a special massage and special diets for cancer. The spiritual and religious approaches of mothers in Turkey contribute to the use of traditional approaches, such as taking the child to hodja and resorting to personal prayers for treatment (Özyazıcıoğlu & Polat, 2004; 2005). In this study, taking an ill child to hodja was practised most frequently by the mothers with a child who was suffering from a nervous system disorder, but it also was observed in relation to all the other chronic diseases that presented in this study. The literature shows that traditional healers (e.g. elite persons who are believed to have special powers) are sought out frequently throughout the world, especially for the treatment of epilepsy (Oshikoya et al., 2008; Yeh et al., 2000).
This study found that only a few mothers reported seeing their child's nurse or doctor about alternative therapy. The mothers refrained from disclosing to the medical personnel that they used CAM, probably because of their fear about negative feedback from the healthcare personnel. This result is supported by another study (Gözüm et al., 2007).
Repeated additional stresses, such as the health status of the child, financial problems, and unemployment, increase the demands on parents and decrease their self-confidence. The insecurity that is formed as a result of these strenuous experiences might cause anxiety and depression in parents (Hilton, 1993). This study found that the existence of the same chronic disease, as well as other chronic diseases, in close relatives resulted in an increase in the anxiety level of the mothers. The possibility of the genetic transfer of the disease also was considered and the mothers sometimes felt that they were responsible for their child's situation. In order to decrease parents' anxiety and to increase their ability to cope with stress, healthcare providers must establish open communication with parents who have similar disease patterns within their families and support them spiritually.
Additionally, the existence of chronic disease and the uncertainty that is felt by mothers and fathers could lead to stress. The results of this study revealed that a moderate level of anxiety was experienced by the mothers with a chronically ill child. In the study, the average anxiety scores of all the mothers were 51.18 ± 11.13 for the SAI and 45.95 ± 8.61 for the TAI. The maternal anxiety level that was reported by Aksu (2008) was less than that of our sample (SAI = 42.12, TAI = 46.85), but this level was defined as moderate anxiety in the study that was conducted on mothers with a child who was suffering from asthma, epilepsy, or a urinary tract condition in Turkey.
For the mothers of a child with cancer, the anxiety level in relation to the SAI was 50.75 ± 10.60, which is a moderate anxiety level. In the study by Arıkan and Çelebioğlu (1999), which was carried out on the mothers of a child with cancer in Turkey, the mothers' situational-permanent anxiety level was found to be more than that of our study (SAI = 56.1, TAI = 53.4), yet this study defined this anxiety level as “medium”. In another study on this issue, Boman et al. (2003) stated that, after a child was diagnosed with cancer, the anxiety and depression levels of the mother decreased with time, but it was not possible to entirely explain the reason for these decreases. In contrast, Rabineau et al. (2008) reported that most parental stress can be relatively transitory and can change in stages during the diagnosis and the treatment process.
In this study, the anxiety scores of the mothers of a child with epilepsy were 52.25 ± 11.85 for the SAI and 43.31 ± 10.43 for the TAI. In Aksu's (2008) study, the SAI score (44.20) was lower than that of this study and the TAI score (49.48) was higher than that of this study. The point average of the mothers of a child with epilepsy was found to be higher than that of the mothers in the control group (P < 0.05). In another study, the anxiety level of the parents of a child with epilepsy was within normal limits and it was found that good organization and strong support within the family might have played an influential part in this result (Baki et al., 2004; Williams et al., 2003). However, changes in the treatment period of chronic diseases and other stressful events (i.e. financial problems and the status of the disease) might increase the anxiety levels of mothers (Simonen et al., 2006).
The anxiety score of the mothers of a child with diabetes was determined to be at a medium level (SAI = 55.20 ± 12.95 and TAI = 45.20 ± 6.68). Streisand et al. (2008) detected that the anxiety level of the mothers was at a medium level (45.65) and that the anxiety level of the fathers was lower than that of the mothers in a study that was conducted on mothers within 4 months of their child's diagnosis. Multiple authors have reported lower parental anxiety levels than are reported here, including Mitchell et al. (2009) in their study of the fathers of a child with diabetes and Hood, Johnson, Baughcum, She, and Schatz (2006) in their study of mothers' anxiety scores.
In this study, the maternal anxiety levels in the context of asthma were 45.20 ± 9.42 (SAI) and 44.00 ± 6.60 (TAI). In a study on the mothers of a child with asthma, Aksu (2008) found that the SAI score (41.16) was lower than that of this study and that the TAI score (46.00) was higher than that of this study. In the study by Özkaya, Çetin, Uğurad, and Samancı (2010), the mean of both the state and trait anxiety scale scores was found to be 40 ± 4.54 in the case groups and 34 ± 3.17 in the control groups and the difference between them was statistically significant. Contrary to our findings, Akçakaya, Aydoğan, Hassanzadeh, Camcıoğlu, and Çokuğraş (2003) discovered that asthma caused no change in the anxiety level of the mothers in their study, which was conducted with the mothers of a child with asthma.
Results similar to those described above were found for the mothers of a child with chronic renal failure and nervous system disorders. Changes in the health condition of the child, poor control of the disease, and the isolation that was experienced by the child were effective in isolating the parents and increasing the anxiety of the mothers (Freidman, 2006; Williams et al., 2003).
In the context of all the chronic diseases that were examined in this study, the anxiety level of the mothers was found to be only at a moderate level. This result suggests that the mothers of a child with a chronic disease accept the disease and partially adapt to the new condition, apart from changes during the disease period. No significant relationship was observed in this study between the demographic data and the anxiety level of the mothers. In the findings of Arıkan and Çelebioğlu (1999), no statistically significant difference was found between the age and educational level of the parents and their anxiety level.
This study found that the anxiety level of the mothers who used massage for their child was low and a significant difference was detected between the SAI and TAI scores and the use of a special massage. Post-White and Hawks (2005) and Post-White et al. (2009b) stated that the mothers of a child with cancer had higher anxiety scores; however, the use of massage was considerably beneficial for the child, decreased the child's anxiety, and also decreased maternal anxiety (Table 2).
A statistically significant difference was found between the use of a special diet and herbal medicine and the TAI score. The SAI score of the mothers was found to be higher than their TAI score and the difference was statistically significant. Toros, Tot, and Düzovalı (2002) discovered that the parents of a child with a chronic disease had higher anxiety levels than the parents of a healthy child.
Limitations of the study
There were several limitations to this study. The mothers who were analyzed in this study had a child whose condition fell within one of five large chronic disease groupings. In addition, a paucity of research examining the relationship between maternal anxiety levels and CAM use limits the use of the guiding functions of the previous studies in the Discussion. The individualized nature of this study design forms a restriction in terms of human power and the resulting small sample size makes it difficult to determine a cause-and-effect relationship from the obtained data.
We found that families did resort to CAM therapies, although the use of them was at a relatively low level. In the context of all the chronic diseases that were examined in this study, the mothers of a child with a chronic disease only experienced a moderate level of anxiety. However, the frequency of the incidence of disease among close relatives increased their anxiety level.
Apart from the medical treatment that the hospital recommended for your child:
1Have you ever used herbal drugs? If Yes:
• Which herbs did you use?
• Have you experienced any benefit?
2Did you take your child to hodja?
3Have you used a special massage?
4Have you used a special diet?
5Which other treatments have you used
6Where did you learn these treatments?
7Were you applying these treatments before the diagnosis of the disease?
8Have you seen your doctor/nurse about these treatments?