Complementary Health Practice Review

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Pediatric Health Care Providers' Attitudes and Referral Predictors for Therapeutic Massage and Acupuncture Mary C. McLellan, Ellen Silver Highfield and Alan D. Woolf Complementary Health Practice Review 2005 10: 119 DOI: 10.1177/1533210105280645 The online version of this article can be found at: http://chp.sagepub.com/content/10/2/119

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ARTICLE M. C. McLellan 10.1177/1533210105280645 Predictors for Therapeutic et al. Massage and Acupuncture

Pediatric Health Care Providers’ Attitudes and Referral Predictors for Therapeutic Massage and Acupuncture Mary C. McLellan, BSN, RN, CMT Ellen Silver Highfield, LicAc Alan D. Woolf, MD, MPH The objective of this study was to assess pediatric health providers’attitudes, experience, and referral patterns with respect to therapeutic massage and acupuncture (TM&A). A written survey of experience with and attitudes about TM&A was distributed to a convenience sample of pediatric health care providers attending a regional postgraduate course in April 2002. Bivariate analyses were performed using Fisher’s exact test and the chisquare statistic. Pediatric care providers’ practices of referring patients to TM&A were associated with their own familiarity with and prior use of TM&A as well as their professed comfort level in discussing these modalities. There were no significant differences by professional status, gender, or years in practice in 42% of the respondents who reported making TM&A referrals. Pediatric health care providers’ practices in referring patients for TM&A are positively associated with their familiarity with and personal use of TM&A. Keywords: massage; acupuncture; integrative medicine

BACKGROUND Studies over the past decade document increased use of complementary and alternative medicine (CAM) in pediatric populations (Armishaw & Grant, 1999; Chan, Rappaport, & Kemper, 2003; Field, 1999; Friedman et al., 1997; Hagen, Schneider, Stephens, Modrusan, & Feldman, 2003; Kemper et al., 2000; Kemper & Wornham, 2001; Ottolini et al., 2001; Sanders et al., 2003; Sawni-Sikand, Schubiner, & Thomas, 2002; Zeltzer et al., 2002), with multiple surveys showing average usage rates ranging between 20% and 40% and even higher numbers in chronic patient populations (Friedman et al., 1997; Ottolini et al., 2001; Sawni-Sikand et al., 2002). Children readily accept CAM therapies and report positively on their experience (Armishaw & Grant, 1999; Field, 1999; Fong & Fong, 2002; Kemper et al., Complementary Health Practice Review, Vol. 10 No. 2, April 2005 119-131 DOI: 10.1177/1533210105280645 © 2005 Sage Publications

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M. C. McLellan et al.

2000; Loman, 2003; Simpson & Roman, 2001; Zeltzer et al., 2002). Despite physicians’limited formal training in CAM, surveys from the late 1990s indicated that many primary care physicians use, make referrals to, and have positive attitudes toward CAM providers (Barnes, Plotnikoff, Fox, & Pendleton, 2000; Kemper, 2001; Ott, 2002). Providers in other surveys report they would like to offer acupuncture, biofeedback, chiropractic care, hydrotherapy, nutritional supplements, or massage to patients in the future (Rooney, Fiocco, Hughes, & Halter, 2001; Sikand & Laken, 1998). The proportion of medical schools in the United States offering CAM-related education increased from 37% to 60% between 1996 and 1998 (Graham-Pole, 2001; Wetzel, Kaptchuk, Haramati, & Eisenberg, 2003). Recent surveys of 302 pediatricians in Denver and 348 pediatricians in Michigan indicated that 76% and 84%, respectively, reported that their patients were using CAM; 48% and 50% would recommend CAM; and 24% and 37% reported self-use (Sikand & Laken, 1998; Winslow & Shapiro, 2002). In both surveys, female physicians were more apt to refer to and discuss CAM than their male counterparts. The Denver survey indicated that those physicians who used more than one CAM modality were seven times more likely to recommend CAM to their patients. Of the CAM modalities, massage (24%) and acupuncture (35%) were most often used and asked about, with primary care physicians reporting higher patient CAM use than specialists (Winslow & Shapiro, 2002). The objectives of this study were (a) to assess pediatric health care providers’ selfreported attitudes toward therapeutic massage and acupuncture and (b) to assess whether there were predictors of referral patterns or self-reported positive attitudes within this group. METHODS A written, anonymous survey of attitudes and self-described practices regarding acupuncture and massage was developed, piloted, refined, and approved by the Institutional Review Board at Children’s Hospital Boston. (See the appendix for a copy of the questionnaire.) The survey questionnaire was designed for an audience of pediatric health professionals for distribution at a regional, general pediatrics postgraduate conference. The questionnaire requested demographic information, including health care profession (pediatrician, other MD, nurse practitioner, nurse, resident student, social worker, or other), gender, age, years in practice, and number of patients seen weekly. Ethnicity was not assessed. The survey asked about personal use of acupuncture and/or massage by the respondent, the respondent’s family, and the perceived use of these modalities by the respondent’s patients. Using a 4-point Likert-type scale, the survey also asked about familiarity with massage and acupuncture, as well as comfort in discussing, referring, and using these modalities. Another question specifically asked whether the practitioner had ever personally referred a patient to acupuncture and/or massage. Those who answered yes were then asked about their clinical judgment as to the impact of these therapies on their patient’s health. Finally, a set of four questions used a Likert-type scale for assessing attitudes and beliefs regarding use of these therapies with children in both inpatient and outpatient settings, with 1 = strongly agree, 2 = agree, 3 = disagree, 4 = strongly disagree, and 5 = unsure. For the analysis, strongly agree and agree were classified as positive, and all other responses were classified as not positive. To compare groups, contingency tables analysis and Fisher’s exact test or the chi-square statistic were used for dichotomous variables, with 2-tailed alpha values set at .05 considered to be significant. Multiple logistic regression was

Predictors for Therapeutic Massage and Acupuncture

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used to determine the characteristics that predicted the practitioners most likely to refer patients for acupuncture and massage. Surveys with missing responses on a particular question were excluded from analysis requiring that variable. To compare responses based on professional status, nurses and nurse practitioners were combined into one category as there were no statistically significant differences between these two professions’ responses. Practitioners who were not nurses or physicians were excluded from the professional status comparisons and comprised less than 1% of the sample. The survey was distributed in April 2002 at a regional, general pediatric postgraduate course sponsored by Children’s Hospital Boston and Harvard Medical School. The course generally attracts pediatricians, nurses, and nurse practitioners primarily from Massachusetts and contiguous states. The topics for the course were as follows: Pediatric Dermatology, Surgical Updates, Basic Life Support (BLS) Techniques, Care of the Medically Complex Child, and Sports Safety. The conference contained no special emphasis on CAM topics. The surveys were distributed anonymously. RESULTS Of the 238 conference attendees, 175 (74%) returned the surveys. Demographic information for the sample is shown in Table 1. The mean age of the sample was 47.6 years, and mean years in practice was 18.8 years. In terms of professional status, 40.6% of the sample were doctors, 31.4% were nurse practitioners, 27.4% were nurses, and 0.6% were other. Approximately 17% of the sample were male, and 83% were female. There were no statistically significant differences between the nurses’ and nurse practitioners’ responses, so these professions were combined into the single “Nurse” category. Perceived Patient Usage, Referrals, and Attitudes Regarding Acupuncture and Massage Of the respondents, 6.2% believed that their patients had used acupuncture, 11.9% massage, 36.9% both modalities, 18.8% neither, and 26.2% were unsure (see Table 2). Only 42% of the respondents indicated that they had referred their patients for acupuncture and/or massage therapy (see Table 3). Specifically, 6.6% referred patients to acupuncture, 19.3% to massage, 15.7% to both therapies, and 58.4% did not refer their patients to either. There was no statistically significant difference in referral rates for acupuncture and/ or massage by gender, professional status, age, or years in practice. Respondents who indicated that they had referred patients for one or both of these therapies agreed more than those who did not refer that acupuncture and massage were appropriate therapies for children (See Table 4). Specifically, those who had referred patients to either or both therapies agreed more than those who did not refer that acupuncture was an appropriate inpatient (p = .002) and outpatient (p ≤ .001) therapy for children. Furthermore, those who had referred agreed more than those who did not refer that massage therapy was an appropriate inpatient (p = .023) and outpatient (p ≤ .001) therapy for children. In addition, respondents who referred patients to these modalities believed acupuncture (94%) and massage (96%) had positive effects on their patients’ health (see Table 4).

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TABLE 1. Demographic Characteristics of Respondents to the Acupuncture and Massage Survey at a Regional General Pediatric Postgraduate Course in Boston, April 2002

Respondent Characteristics Profession Physiciana Nurse practitioner Nurse Otherb Missing data Gender Male Female Missing data Years in practice 1-2 years 3-4 years 5-10 years 11 or more years Missing data Age 25-34 years 35-44 years 45-55 years 55 or more years Missing data Average patients seen per weekc 0-19 20-39 40-59 60 or more Retired Missing data

%

n

40.6 31.4 27.4 0.6 0

71 48 55 1 0

17.1 82.9 0

30 145 0

8.6 7 16.4 68

11 9 21 87 47

11.6 30 34.2 24.2

14 36 41 29 55

16.8 18.1 18.1 43.6 3.4

25 27 27 65 5 26

Note: All conference attendees received a copy of the survey. Return rate was 74%. a. Category includes pediatricians, other physicians, and residents. b. Category includes social workers and students. c. Self-reported average numbers of patients seen personally by the respondent in a typical week.

Personal Experience With Acupuncture and Massage Personal use of acupuncture only was reported by 1.8% of the respondents, 23.6% reported personal use of massage only, 12.7% used both therapies, and 61.8% had used neither (see Table 5). In addition, 5.4% reported that their family had used acupuncture only, 26.2% massage only, 13.1% both, and 55.4% neither (see Table 5). Overall, 37% of the respondents reported that they were familiar with acupuncture and massage, 46.8% reported that they were only slightly familiar, and 16.8% were not familiar with these therapies. Of the respondents, 36% expressed that they were very comfortable or comfortable in discussing


123

TABLE 2. Perceived Patient Usage of Massage and Acupuncture Among Health Professional Respondents to a Survey at a Regional General Pediatric Conference in Boston, April 2002

Respondents Who Believed Patients Were Using These Therapies Acupuncture Massage therapy Both therapies Neither therapy Unsure if their patients used either therapy Missing data Total (excluding missing data)

% 6.2 11.9 36.9 18.8 26.2

n 10 19 59 30 42 15 160

TABLE 3. Self-Reported Patient Referrals of Massage and Acupuncture Among Health Professional Respondents to a Survey at a Regional General Pediatric Conference in Boston, April 2002

Respondents Who Have Referred Patients to These Therapies Acupuncture Massage therapy Both therapies Neither therapy Missing data Total (excluding missing data)

% 6.6 19.3 15.7 58.4

n 11 32 26 97 9 166

these modalities with their patients, 41.7% were slightly comfortable, and 22.1% were not comfortable discussing these modalities. Correlations of Attitudes and Referrals With Personal Use Those respondents who had used acupuncture and/or massage were more likely to refer patients to these therapies (p ≤ .001) and to agree that acupuncture and massage are appropriate inpatient (p = .014 and p = .002, respectively) and outpatient therapies (p = .060 and p = .020, respectively) for children (see Table 6). They were also more likely to report being comfortable in discussing acupuncture and massage with their patients (p < .001) and referring their patients to professionals for acupuncture and massage (p < .001). Those having family members who had used such services also were more likely to refer patients to acupuncture and/or massage therapy (p = .020) and were more comfortable discussing (p = .001) and referring (p < .001) patients to acupuncture and massage (see Table 6). Those who were familiar with these modalities were more likely to make referrals (48% vs. 12%; p < .001), and those who reported a higher level of comfort in discussing these modalities with their patients were more likely to refer them for such services (48% vs. 18%; p < .002). Logistic regression analysis identified three attitudinal factors that predicted the practice behavior of referring pediatric patients for acupuncture and massage: agreement that acupuncture and massage are appropriate modalities for use in the outpatient care of children

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Perceived Patient Use of, Appropriateness of, and Health Effects of Acupuncture and Massage From Respondents Who Self-Reported Patient Referrals to These Modalities Compared to Those Who Did Not Refer Among Health Professional Respondents to a Survey at a Regional General Pediatric Conference in Boston, April 2002

TABLE 4.

Referred Patients Variable % Reported patients used a acupuncture or massage Yes 85 No 15 “Acupuncture is appropriate for children in an inpatient hospital setting.”b Agree 69 Disagree 31 “Massage is appropriate for children in an inpatient hospital setting.”b Agree 85 Disagree 15 “Acupuncture is appropriate for children in an outpatient setting.”b Agree 81 Disagree 19 “Massage is appropriate for children in an outpatient setting.”b Agree 96 Disagree 4 “In your clinical judgment, what effect did acupuncture have on your patient’s health?”c Positive 94 Neutral 6 Negative 0 “In your clinical judgment, what effect did massage have on your patient’s health?”c Positive 96 Neutral 4 Negative 0

(n)

Did Not Refer Patients %

(n)

p

Total

(55) (10)

34 66

(31) (59)

< .001

155

(46) (21)

43 57

(38) (51)

.002

156

(57) (10)

68 32

(60) (28)

.023

155

(54) (13)

52 48

(45) (42)

< .001

154

(65) (3)

72 27

(63) (24)

< .001

155

(29) (2) (0)

(47) (2) (0)

Note: Respondents reported personal patient referrals to acupuncture or massage. p values are derived from Fisher’s exact test comparing the percentage of those health professionals who referred patients to acupuncture and/or massage to the professionals who did not refer patients. a. Respondents reported perceived patient use of these therapies. b. Respondents chose from selections of strongly agree, agree, disagree, strongly disagree, and unsure. Strongly agree and agree were combined into agree, and strongly disagree, disagree, and unsure were combined into disagree. c. Respondents chose from selections of very positive, positive, no effect, negative, and very negative. Very positive and positive were combined into positive, negative and very negative were combined into negative, and no effect was categorized as neutral. Only respondents who had referred patients to these modalities were asked to answer these questions.


125

Self-Reported Personal and Family Use of Massage and Acupuncture Among Health Professional Respondents to a Survey at a Regional General Pediatric Conference in Boston, April 2002

TABLE 5.

Personal Use Variable Acupuncture Massage therapy Both therapies Neither therapy Missing data Total (excluding missing data)

% 2 24 13 62

Family Use

(n)

%

(n)

(3) (39) (21) (102) (10) 165

5 26 13 55

(9) (44) (22) (93) (7) 168

(odds ratio [OR] = 3.9; 95% confidence interval [CI] = 1.7-9.1), familiarity with these modalities (OR = 4.6; 95% CI = 2.1-10.2), and family use of acupuncture and/or massage (OR = 4.0; 95% CI = 1.8-8.7). Correlations of Gender and Profession With Attitudes and Referrals Overall, more women than men agreed that acupuncture is an appropriate inpatient therapy (p = .039) for children (see Table 7). There was no statistically significant difference between women and men as to whether massage is an appropriate inpatient or outpatient therapy or acupuncture as an outpatient therapy. Nurses were more likely than doctors to agree that massage (p = .004) is an appropriate inpatient therapy for children. There was no statistically significant difference between nurses and doctors regarding acupuncture as an inpatient therapy. There was no statistical difference between professions regarding the appropriateness of these modalities as outpatient therapies. Despite differences in opinions, there was no significant difference between genders or professions in reported patient referrals to massage and/or acupuncture. Female practitioners and nurses reported higher personal use of these therapies compared to male practitioners (p = .002) and doctors (p < .001) (see Table 7). DISCUSSION Pediatric health care providers’ practices in referring patients for acupuncture and massage are positively associated with their familiarity with and their personal use of these therapies. Personal use and family use were strongly associated with patient referrals, positive attitudes, and higher professed comfort levels in discussing these modalities with patients. Logistic regression analysis identified three attitudes that were highly correlated with the practice behavior of referring children for acupuncture and/or massage. Those practitioners who were familiar with these modalities, whose family had used them, and who agreed with the idea that these therapies are appropriate pediatric outpatient therapies were four times more likely to refer patients than those who did not share such attitudes. Nurses and women reported a higher percentage of personal use and positive attitudes about acupuncture and massage as pediatric therapies than did doctors and men. The gender and professional status results are consistent with the findings in previous studies (Sikand &

126 64 36 58 42 85 15 69 31 88 12 90 10 87 13

(158) (155) (155) (153) (155) (157) (152)

(61) (9)

(63) (7)

(64) (9)

(50) (22)

(61) (11)

(42) (30)

(47) (26)

(n)

62 38

67 33

79 21

61 39

67 33

49 51

25 75

%

.001

.203

.181

.016

.264

.017

p

(52) < .001 (32)

(60) (29)

(67) (18)

(51) (33)

(58) (28)

(42) (44)

(22) (66)

(n)

(n)

88 (154)

91 (159)

90 (158)

89 (156)

90 (158)

92 (158)

92 (161)

%

Total

Note: Respondents reported personal and family use of acupuncture and/or massage therapy. p values are derived from Fisher’s exact test comparing the percentage of those health professionals with personal or family use to those without. a. Respondents chose from selections of strongly agree, agree, disagree, strongly disagree, and unsure. Strongly agree and agree were combined into agree, and strongly disagree, disagree, and unsure were combined into disagree. b. Respondents chose from selections of very comfortable, comfortable, slightly comfortable, and not comfortable. Very comfortable and comfortable were combined into comfortable, whereas slightly comfortable and not comfortable were combined into not comfortable.

%

Family Use No Family Use

(n)

Total

Variable % (n) % (n) p % Referred patients for acupuncture and/or massage Yes 62 (37) 28 (28) < .001 90 No 38 (23) 71 (70) “Acupuncture is appropriate for children in an inpatient hospital setting.”a Agree 66 (40) 45 (42) .014 89 Disagree 34 (21) 55 (52) “Massage is appropriate for children in an inpatient hospital setting.”a Agree 89 (54) 66 (62) .002 89 Disagree 11 (7) 34 (32) “Acupuncture is appropriate for children in an outpatient setting.”a Agree 74 (45) 58 (53) .058 88 Disagree 26 (16) 42 (39) “Massage is appropriate for children in an outpatient setting.”a Agree 92 (56) 77 (72) .017 89 Disagree 8 (5) 23 (22) Comfort level discussing acupuncture and massage with patientsb Comfortable 90 (56) 68 (66) < .001 90 Not comfortable 7 (4) 32 (31) Comfortable referring patients to professionals offering acupuncture or massageb Comfortable 89 (54) 63 (57) < .001 87 Not comfortable 11 (7) 37 (34)

Personal Use No Personal Use

TABLE 6. Self-Reported Referral Practices and Attitudes Toward Acupuncture and Therapeutic Massage for Pediatric Patients as a Function of Personal and Family Use Among Health Professional Respondents to a Survey at a Regional Pediatric Conference in Boston, April 2002

127

Male

42 58 50 50 48 52 58 42 84 16 68 32 85 15 76 24 78 22

(166) (165) (168) (165) (163) (161) (163) (165) (158)

(71) (20)

(71) (22)

(82) (15)

(65) (30)

(81) (16)

(56) (40)

(47) (50)

(47) (47)

(40) (54)

(n)

69 31

80 20

80 20

61 39

65 35

46 54

40 60

23 77

41 59

% .874

p

(46) (21)

(55) (14)

(53) (13)

(40) (26)

(43) (25)

(31) (36)

(28) (42)

.202

.704

.529

.318

.004

.152

.344

(16) < .001 (54)

(29) (42)

(n)

Physician

(n)

90 (158)

93 (162)

93 (163)

92 (161)

93 (165)

93 (163)

95 (167)

94 (164)

94 (165)

%

Total

Note: Respondents reported personal use of acupuncture and/or massage as well as self-reported patient referrals. p values are derived from Fisher’s exact test comparing gender and professional status. a. Respondents chose from selections of strongly agree, agree, disagree, strongly disagree, and unsure. Strongly agree and agree were combined into agree, and strongly disagree, disagree, and unsure were combined into disagree. b. Respondents chose from selections of very comfortable, comfortable, slightly comfortable, and not comfortable. Very comfortable and comfortable were combined into comfortable, whereas slightly comfortable and not comfortable were combined into not comfortable.

%

Nurse

(n)

Total

Variable % (n) % (n) p % Referred patients for acupuncture and/or massage Yes 43 (58) 37 (11) .683 95 No 57 (78) 63 (19) Reported personal use of acupuncture and/or massage Yes 44 (59) 13 (4) .002 94 No 56 (76) 87 (26) Reported family use of acupuncture and/or massage Yes 46 (63) 40 (12) .003 96 No 54 (75) 60 (18) “Acupuncture is appropriate for children in an inpatient hospital setting.”a Agree 57 (77) 34 (10) .039 94 Disagree 42 (57) 66 (19) “Massage is appropriate for children in an inpatient hospital setting.”a Agree 79 (106) 62 (18) .059 93 Disagree 21 (28) 38 (11) “Acupuncture is appropriate for children in an outpatient setting.”a Agree 69 (91) 48 (14) .051 92 Disagree 31 (41) 52 (15) “Massage is appropriate for children in an outpatient setting.”a Agree 85 (114) 72 (21) .110 93 Disagree 15 (20) 28 (8) Comfort level discussing acupuncture and massage with patientsb Comfortable 76 (103) 86 (26) .328 93 Not comfortable 24 (32) 14 (4) Comfortable referring patients to professionals offering acupuncture or massageb Comfortable 75 (98) 68 (19) .477 90 Not comfortable 25 (32) 32 (9)

Female

TABLE 7. Self-Reported Referral Practices and Attitudes Toward Acupuncture and Massage for Children as a Function of Gender and Occupation Among Health Professional Respondents to a Survey at a Regional General Pediatric Conference in Boston, April 2002

128


Laken, 1998; Winslow & Shapiro, 2002). There was no association in our study between gender, profession, age, or years in practice and reported referral of acupuncture and massage. This finding differs from previous studies demonstrating females to have higher referral rates (Sikand & Laken, 1998; Winslow & Shapiro, 2002). A limitation of this study was sampling from a small geographic area, which may limit its ability to generalize the attitudes and practices of pediatric health professionals elsewhere. However, our data were consistent with other surveys of differing specificity and region (Sikand & Laken, 1998; Winslow & Shapiro, 2002). It is possible that the population of health care providers attending a postgraduate course may differ from the general populace of similar providers. The office practices of providers comprising the sample would typically include only children and adolescents, with very few young adults, although participants were not queried about the characteristics of the patient populations they serve. The results of this study may not be generalized to those practitioners who serve adults or the elderly. Finally, responses given on a written survey instrument may not reflect the actual practices of a clinician, so these results should be interpreted with appropriate caution. CONCLUSION Educational initiatives aimed at increasing pediatric health practitioners’ comfort in referring patients for acupuncture and massage should focus on increasing their knowledge about these modalities and include the opportunity for a participatory demonstration of these techniques. The current study indicates that a clinician’s experience with acupuncture and/or massage may positively influence the knowledge, attitudes, and practices of pediatric health care providers toward these two therapeutic modalities.

APPENDIX Acupuncture and Massage Survey 1. You are a/an: (Check one) ⵧ Pediatrician ⵧ Nurse Practitioner ⵧ Nurse ⵧ Student 2. Sex: ⵧ Male

ⵧ Female

ⵧ Resident ⵧ Social Worker ⵧ Other:___________

Years in Practice: _______

ⵧ Other MD

Age:_______

3. On average, how many patients do you personally see in your practice each WEEK? ⵧ 0-4 ⵧ 5-9 ⵧ 10-19 ⵧ 20-39 ⵧ 40-59 ⵧ > 59 4. Are any of your patients using or have ever used the following services? ⵧ Acupuncture ⵧ Massage Therapy ⵧ Both ⵧ Neither

ⵧ Unsure

5a. Have you personally ever used any of these therapies in your community? ⵧ Acupuncture ⵧ Massage Therapy ⵧ Both ⵧ Neither 5b. Has your family ever used any of these therapies in your community? ⵧ Acupuncture ⵧ Massage Therapy ⵧ Both ⵧ Neither 6. In your opinion . . . a. How familiar are you with the modalities: ACUPUNCTURE and MASSAGE, as adjunctive therapy to patient care?

Predictors for Therapeutic Massage and Acupuncture ⵧ Very Familiar

ⵧ Familiar

ⵧ Slightly Familiar

129 ⵧ Not Familiar

b. How comfortable are you in discussing these modalities with your patients? ⵧ Very Comfortable ⵧ Comfortable ⵧ Slightly Comfortable ⵧ Not Comfortable c. How comfortable are you in referring your patients to professionals offering these services? ⵧ Very Comfortable ⵧ Comfortable ⵧ Slightly Comfortable ⵧ Not Comfortable d. How comfortable are you in using these modalities for yourself or your family? ⵧ Very Comfortable ⵧ Comfortable ⵧ Slightly Comfortable ⵧ Not Comfortable 7. Have you ever personally referred a patient to ⵧ Acupuncture ⵧ Massage Therapy ⵧ Both If answer to #7 is YES then . . .

ⵧ Neither

8a. In your clinical judgment, what effect did acupuncture have on your patient’s health? ⵧ Very Positive ⵧ Positive ⵧ No Effect ⵧ Negative ⵧ Very Negative 8b. In your clinical judgment, what effect did massage have on your patient’s health? ⵧ Very Positive ⵧ Positive ⵧ No Effect ⵧ Negative ⵧ Very Negative Please tell us in your opinion whether you agree or not to the following statements: 9a. Massage therapy is an appropriate therapy to be offered to children in an INPATIENT HOSPITAL setting. ⵧ Strongly Agree ⵧ Agree ⵧ Disagree ⵧ Strongly Disagree ⵧ Unsure 9b. Acupuncture is an appropriate therapy to be offered to children in an INPATIENT HOSPITAL setting. ⵧ Strongly Agree ⵧ Agree ⵧ Disagree ⵧ Strongly Disagree ⵧ Unsure 9c. Massage therapy is an appropriate therapy to be offered to children in an OUTPATIENT setting. ⵧ Strongly Agree ⵧ Agree ⵧ Disagree ⵧ Strongly Disagree ⵧ Unsure 9d. Acupuncture is an appropriate therapy to be offered to children in an OUTPATIENT setting. ⵧ Strongly Agree ⵧ Agree ⵧ Disagree ⵧ Strongly Disagree ⵧ Unsure 10. Comments:________________________________________________________________ _____________________________________________________________________________ (Please do not include your name on this survey. Thank you.)

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Acknowledgments. The project described was supported by grant AT00538 from the National Center for Complementary and Alternative Medicine. The authors would like to express appreciative acknowledgment and gratitude to Hillel R. Alpert, ScM, for his valuable assistance with the statistical analysis of this article. Disclaimer. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Complementary & Alternative Medicine, National Institutes of Health. Biographical Data. Mary C. McLellan is a staff nurse III in the Cardiovascular Program at Children’s Hospital Boston. As a trained and certified massage therapist, she was recruited as a massage therapy director for CHPER in 1997. Ellen Silver Highfield is a licensed acupuncturist who was a consultant with the Children’s Hospital Boston Pain Treatment Service from 1995 to 2000. In 2000, she was recruited as the director of the Acupuncture Program for CHPER. She is an associate in pediatrics at Harvard Medical School. Alan D. Woolf, MD, MPH, is an associate professor of pediatrics at Harvard Medical School, a fellow of the Academy at Harvard Medical School, and director of the Program in Environmental Medicine, Children’s Hospital, Boston.

Address correspondence to: Mary C. McLellan, BSN, RN, CMT, Center for Holistic Pediatric Education and Research, Division of General Pediatrics, 1295 Boylston Street, Suite 100, Boston, MA 02115; e-mail: [email protected].