We give Nutrilon to our babies, but strict people, they still believe in full milk : traditional and complementary medicine use in a multi-ethnic paediatric clinic in Amsterdam, the Netherlands

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‘We give Nutrilon to our babies,

but strict people,

they still believe in full milk.’

Traditional and Complementary Medicine use

in a multi-ethnic paediatric clinic in Amsterdam,

The Netherlands

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‘We give Nutrilon to our babies,

but strict people,

they still believe in full milk.’

Traditional and Complementary Medicine use

in a multi-ethnic paediatric clinic in Amsterdam,

The Netherlands

Master Thesis Medical Anthropology and Sociology,

University of Amsterdam

Amsterdam, 6 April 2017

Student: Judy Hoomans Supervisor: mw. Prof. Dr. Amade M’Charek

Student number: 5699940 Second reader: Dr. Maarten Bode

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Figures and tables

Table 1.1

Percentages of ehnic groups under treatment of TCA practitioners, 2010-2013 19

Table 1.2

Percentage children by age groups under treatment of TCA practitioners, 2010-2013 21

Table 2.1

Binary oppositions operating in premises of the research questions of the umbrella project

and current study 28

Table 2.2

Examples of in-between categories to the underlying binary oppositions in current study 29

Table 3.1

The ‘Five pillars of the Islam’ 36

Figure 4.1

Announcements of the study in the corridor 42

Table 5.1 TCA

Remedies used 53

Table 6.1

Parents’ motivations for not participating in the survey 64

Table 6.2

Demographic characteristics respondents 65

Table 6.2a

Motivations for TCA use within the total population, calculated to equal groups sizes 66

Table 6.3

Therapists consulted by the total population and by subgroups 67

Table 6.5

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Table 6.4

TCA remedies used as reported by parents at the outpatient paediatrics department 70 by cultural background of respondent

Table 6.6

Most reported health complaints of children visiting the hospital and amount of remedies 72 in total population used for that condition

Table 6.7

TCA, biomedical OTC (between brackets) and panacea used for main health complaints 73 and fever (in alphabetic order).

Annex 9 132

Table 6.8 Motivations for TCA use

Annex 10 134

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Abbreviations

(including names of Dutch organisations) ADHD Attention Deficit Hyperactive Disorder

CAM Complementary and Alternative Medicine

CBS Centraal Bureau voor de Statistiek (Statistics Netherlands)

EBM Evidence Based Medicine FGD Focus Group Discussion GP General Practitioner (huisarts)

GBA Gemeentelijke Basis Administratie (Municipal Basis Administration)

IM Integrative Medicine

LBI Louis Bolk Institute

NCCAM National Center for Complementary and Alternative Medicine, part of the National Institute of Health, old name for the NCCIH

NCCIH National Centre for Complementary and Integrative Health, part of the National Institute of Health, new name for the NCCAM

NGD Natural Group Discussion

RMO Raad voor Maatschappelijke Ontwikkeling (Dutch Council for Social development)

SBM Sociobehavioural Model

SIZIN Stichting Interculturele Zorgconsulenten in Nederland (Foundation of Intercultural Care

Consultancy in the Netherlands)

SLZ Slotervaart Ziekenhuis (Slotervaart Hospital)

UvA Universiteit van Amsterdam (University of Amsterdam)

TCA Traditional and Complementary health care Approaches

TVCN Tolk- en Vertaalcentrum Nederland (Dutch Interprete and Translate Centre)

TVU Thames Valley University (now the University of West London)

UK United Kingdom

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Glossary

Baraka aolutiferous powers ascribed to the Prophet Muhammad, his descendants, the Qur’an and Holy persons

Dua supplication

Roqia acquisition of cure by praying and dua

Hadith tradition and legends about the life and sayings of the Prophet Muhammad

Halal clean according to Islamic laws on fare

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Acknowledgements

While working out research data, spending daily and nightly hours sitting at a desk behind a computer, studying may seem a time abandoned enterprise. However, many people, both before as well as behind the scenes, have put their efforts to make this study possible, to steer it into good channels, to provide it from marginal notes or encouragement, or to keep me in optimal condition during the period of collection and elaboration of data.

In the first place my sincere gratitude goes to all parents who co-operated with this study, by completing a questionnaire, by expressing their knowledge, experiences, hope and concerns during interviews, by assisting in focus group discussions or by inviting me at their homes hospitably.

I express my thanks also to the team of the paediatrics clinic of the Slotervaart hospital and other departments involved in this study. In especially I express my gratefulness to Ines von Rosenstiel of the Integrative Medicine Clinic, who made it possible to carry this study into effect and who supported this study whenever this was possible for her. I also thank the Governing Council of the hospital, who provided funding for the translations of the questionnaires and for the focus group discussions. Winnie Schats, for her contributions of several relevant background articles for this study. The staff of the paediatrics clinics, who provided some background information about the populations involved. I also thank Jantsje Reitsma for her sincere interest in the project and her active support in approaching parents with questionnaires. Hanane Algozor en Nevin Cam for their help with the translations of Arabic and Turkish answers written by parents on the questionnaires, and their supplementary information. Candida Marten, for her good care and many cups of coffee. Mirjam Baruch for borrowing me the book written by her father. Furthermore I express my thanks to Hans Dorrestijn, Fiena Hamers en Marja Groenendaal of the Public Relations department for their contributions for the translations of the questionnaire and their care for publicity about this study.

There are various persons outside the hospital I would like to thank here for their involvement in this study also. The supervisor of the fieldwork, Miek Jong of the Louis Bolk Institute, for her recommendations for chapter 6. Martine de Rooij of the University of Amsterdam and Lucy van de Vijver of the Bolk Institute, for their support in the elaboration of statistical data for the umbrella project. Nicola Robinson and Ava Lorenc of the Thames Valley University, to place their questionnaire design at the disposal of this study.

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Raci Topal of the Foundation of Intercultural Care Consultancy in the Netherlands (Stichting

Interculturele Zorgconsulenten in Nederland) for bringing participants of the focus groups together, for

the food for participants and for his efforts to arrange translators for each meeting.

My sincere gratefulness also goes to Amade M’Charek of the University of Amsterdam and supervisor of this thesis, and to Maarten Bode, who constituted himself last-minute as the second reader of current thesis. Also thanks to Cor Hoffer of the Parnassia-Bavo group for his

recommendations elaborated in chapter 2. Many thanks for the recommendations and support during the realization of this thesis to all three, and Amade especially also for her inspiring contribution of relevant literature about whatever topic of this thesis I spoke about with her.

Furthermore my acknowledgements go to my father Arie Hoomans, for his spontaneous

contribution to the funding of a part of the travelcosts made for this project. Pierre Baetings, for a control of the made calculations and co-operation during the preliminary elaboration of questionnaire data in Excel.

Finally I express my sincere gratitude to Brigit Hoomans, for her support in so many ways and for the revision of my texts. Peter Hoomans, because he made the project logistically possible for me. He put everything at my disposal what I needed during my stay in Amsterdam: a room, a bicycle, a laptop, a recorder and delicious meals. And Gerard Dijkstra, my husband, because he always leaves me room to follow my heart in projects I want to realize, also when this is not in his favour. He accepted to be at home alone for many weeks, and took much work out of my hands that was not directly related to this study. Thanks to his hospitableness and space he gives I became to be who I am now.

All people related with this study in one or another way: thank you very much!

Judy Hoomans April 2017

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Summary

Current thesis explores the use of traditional and complementary remedies and therapies (TCA), and motivations for its use or non-use of Turkish, Moroccan and Dutch parents of children visiting the paediatrics clinic of the Slotervaart Hospital (SLZ) in Amsterdam, The Netherlands from March to June 2010.

Thus far, little is known about the use of TCA in a multi-ethnic population in Dutch paediatric, whereas the is a growing concern about safety issues related to TCA use. It was therefore considered by the SLZ to be of importance to explore TCA use in this population.

Objectives

The main purpose of current study is to explore TCA remedies and therapies used for children in a multi-ethnic population. And parental motivations for its use or non-use. The prevalence of TCA usage or its non-usage and sociodemographic background of the target-population are explored. More generally, this explorative study aims to provide data regarding TCA use and motivations to use it in an multi-ethnic paediatric population in The Netherlands, which are scarce so far.

Methods

A parent-completed questionnaire survey was held Qualitative Natural Group Discussions were used to further explore the different types of traditional and complementary therapies used by the parents and to explore illness conceptions regarding to asthma and diabetes.

Semi-structured interviews were held with individual parents of children about motivations and patterns for complementary use and to obtain more insight into parental motivations related to health and illness of their children.

Results and conclusions

 32 semi-structured interviews with individual parents were included in the analysis;  4 natural group discussions were held with parents of children suffering from asthma and

diabetes;

 160 questionnaires were included in the analysis

There was a high ambivalence (36%) found in answers to the questions about remedies applied, or the use of ‘TCA’. Also, the population appeared to be more heterogeneous than estimated on forehand.

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The main purposes for all three groups to use TCA were to treat sensory perceived symptoms, and the consideration that TCA is ‘natural’ and helps the child, especially in case of mild complaints. Most respondents combined biomedicine with TCA. Identity was more related to TCA use than ethnicity.

Main motivations for respondents in all groups not to use TCA were no need; automatically consulting the doctor, and the motivation that biomedicine was safer. Respondents of the Turkish and Moroccan group indicated to have insufficient knowledge as another main motivation not to use TCA.

Comparing TCA use of the three target groups shows a high overlap in categories of remedies. Differences between the groups were found mainly in used products within these categories. Herbals were the most reported category. Honey, massage, olive oil and hot water bottles were most reported single remedies. One seed not asked about in the survey appeared to be used by 6% of the population: black caraway. 14% of Moroccan respondents, 2% of Turkish and none of the Dutch respondents reported spontaneously to use it. Both Turkish and Moroccan

respondents more frequently used TCA than the total population’s average, and Dutch parents less. Moroccan parents were the most frequent TCA users, and used the highest number of remedies; Dutch parents the lowest. Dutch respondents used TCA for fewer purposes than the other respondents.

Various respiratory infections, bowel complaints, fever and problems with weight, growth and behaviour were the most frequently reported motivations to visit the clinic. Moreover, these were the conditions where TCA was most frequently reported to be used. The amount of remedies varied both between sample sizes and health complaints. Panaceas were reported to be used for ‘every disease’.

Differences in organization of sensory data was found to play a role in the parental motivation to use TCA. There appears to be a relation with prevention of the child against perceived or feared damage caused by the symptoms (found mainly in Turkish and Moroccan parents) or from concerns about acceptance and career of the child. Parents try to influence physicians, Allah, energies or atmospheres to protect their children against disadvantageous effects for the development of the child, either physical or social by treatments chosen.

Discussion

When asked whether respondents used TCA, they referred not always to things which were ‘TCA’ according to the dichotomy biomedicine versus TCA. Overall, they cross borders and change of paradigms and identities with ease. The found ambivalence concerning TCA makes it delicate to draw firm conclusions, although this explorative study may give a first general impression about TCA use among Turkish, Moroccan and Dutch parents in a paediatric outpatient clinic.

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According to answers of parents themselves, 21% stated to have used TCA for their children. This is the prevalence of TCA use as seen by respondents.

When people were asked about products used, the prevalence of TCA use is much higher. When remedies used on the first page of the questionnaire are considered as ‘TCA’ and reinterpreted to the definition of current study, the prevalence of TCA is much higher: 65% in the Turkish group, 80% in the Moroccan group, and 40% in the Dutch group.

For open communication in daily practice about TCA use, it is therefore recommended to ask questions about TCA by asking open questions or by asking about concrete, specified products instead of the use of overarching categories or an uncommon term or definition. Specific

remedies can be asked for furthermore by remedies used for specific diseases or disordered organ (-systems).

Regarding to ethnicity, people showed to identify with multiple and changing identities. Turkish and Moroccan respondents referred more with their national groups identity than Dutch ones, but they also referred to personal identities. The high overlap seems to be related with the levels of acculturation. Of the Turkish group, 22% is born in The Netherlands and 74% lives there more than 10 years; of the Moroccan group, this percentages are 28% and 66% respectively. As environment contributes to acculturation, their long stay in The Netherlands may have

contributed to mutual adaptations.

It is recommended either to identify ethnicity and health concerns related with it more specifically, or to supersede ethnic boundaries in order to identify specific health risks related with TCA use. The question raises, whether ethicizing parents and the way this is done is the most effective to meet the stated aims. The strict ethnic boundaries appeared not to coincide with the highly heterogeneous population of the clinic. It may therefore be more effective to approach safety issues and TCA use by disease categories which may be considered to be a point of concern at the paediatric department, rather than by ethnicity, even more so when the concept ‘ethnicity’ is used in the found loose way, based on phenotypical representations.

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1. Introduction and outline

Background

Current thesis explores the use of traditional and complementary remedies and therapies, and motivations for its use or non-use among a multi-ethnic population of parents visiting a

paediatrics clinic with their children. The study includes parents of Turkish, Moroccan and Dutch origin and was held in the paediatrics clinic of the Slotervaart Hospital (Slotervaart Ziekenhuis, SLZ) in Amsterdam, The Netherlands.

This study was carried out at the request of the SLZ Paediatric clinic under the direction of the Louis Bolk Institute (LBI) in Driebergen-Zeist, The Netherlands. The research proposal and thesis supervision was provided bij the University of Amsterdan (UvA).

The study includes parents visiting the SLZ with their children, as part of a multi-stage parallel research done in several countries. The overarching project design is developed in the United Kingdom (UK) in name of the Thames Valley University (TVU,1 now the University of West London). Main aims of this umbrella project are ‘to provide a greater understanding of

Traditional and Complementary health care Approaches’(TCA) […] and [to] raise awareness of the safety implications’2 internationally.

A survey in London, held in 2005,3_{explored the use of TCA among multi-ethnic populations of}

parents who visited paediatric clinics with their children. A higher percentage of parents than expected appeared to use remedies considered as Complementary or Alternative Medicine (CAM). Also, the use of traditional remedies as part of the care for children appeared to be common.4

In 2007, an international TVU project started. It included Focus Group Discussions (FGD’s) and the development of a questionnaire. The FGDs were used ‘[t]o explore why parents use TCA for their children, particularly the cultural beliefs and norms’.5 (For more about the use of the terms ‘CAM’ and ‘TCA’, see chapter 2.)

In London, the questionnaire was used as a postal survey including 400 children in two London boroughs. The questionnaires ‘determine the prevalence and determinants of TCA use in the general practice population.’6 They also ‘[…] evaluate the generalization of the focus group findings to the broader population’ (ibid.), and include socio-geographic data as well as an

exploration of used remedies, therapies and consulted therapists for children. That questionnaire, with some adaptations to the Dutch situation and involved groups (chapter 4), is also used for current study (see chapter 4, 6, and appendices 1-3).

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Other stages of the international project are the investigation of attitudes and knowledge of primary health care practitioners on TCA and the views of pharmacists on over the counter (OTC) TCA products and pharmacists’ involvement in advice to parents.7 Both views were explored with the use of questionnaires, also in The Netherlands.8 This stage is followed by the exploration of the recording of TCA use by general practitioners, guidelines and an educational programme for practitioners to implement in daily practice, and is expected to result in an increased awareness among practitioners internationally regarding TCA use among parents, and in a more open communication between doctors and parents about its use.9

The project initiated in the UK has been repeated in several countries by partners of the TVU, among which the LBI and the SLZ. Current thesis concerns the first stage: It includes the questionnaire, interviews and NGD’s to explore which TCA parents of different ethnicity use or do not use for their children when their children have health complaints and why parents do so, with the aim to improve treatment strategies for multi-ethnic communities.10

Data found in current study were aimed to be compared in a later stage with data obtained by participating partners in other countries, under the auspices of the TVU. This further elaboration aims to identify predisposing, enabling and need factors that contribute to the use of TCA among several multi-ethnic populations. During that stage, decision making processes of TCA users will be analyzed with the help of Andersen’s Sociobehavioural Model (SBM)11_{, as presented by}

Lorenc12_,13_{The SBM model is used, for example, to clarify relations between ethnic origin and}

the use of health care.14 The model and discussion of implications of its use for the development of health care politics, treatment- and marketing strategies are out of the scope of current study, as do comparisons of data gathered internationally. Also examination of safety- and evidence issues of used TCA is a next step in the process, and is not included in current presentation.

Rationale for the study

Safety concerns

The WHO regards traditional use of herbal medicines as ‘[…] well established and widely

acknowledged to be safe and effective’.15 However, in biomedicine and health politics in the USA and Europe, the use of herbs and other TCA approaches is nowadays perceived either as a growing concern or as of interest because of safety and efficacy issues, and a growing (potential) market.16

In the politically dominant health care system of biomedicine, safety-issues of non-biomedical therapies are usually considered from a biomedical perspective. Currently, there is an ongoing call in biomedicine for a heightened awareness of TCA use and considerations about safety issues. Considerations cover a wide domain of topics, such as safety of TCA use in general,17

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interactions with biomedicine18,

absence of evidence regarding efficacy and safety of non request for biomedical intervention

others.

This call to heighten attention for safety issues is also found regarding TCA use in

paediatrics.33,34,35,36 This is also the case in the mentioned project in London and in relation to the evaluation of forms of TCA in the care for children.

to investigate ‘[…] whether TCA pose a risk to patients, in particular children, and how conventional medicine may be affected as a result.’

applied TCA in their conclusions

the main aims is ‘[to] raise awareness of the safety implications’ of TCA internationally.

TCA use

According to Statistics Netherlands

6% of citizens in The Netherlands consulted a TCA practitioner.

consulting a TCA practitioner varied between people with parents born in The Netherlands and parents born elsewhere. According to the CBS, people with paren

Turkey and Morocco (‘non-Western allochtoon’; frequent (table 1.1):

Table 1.1 Percentages of ehnic groups under treatment of TCA practitioners, 2010

Furthermore, the use of TCA for children is prevalent in many countries. According to Kemper et al.39 in 2002 there were worldwide 47 systematic reviews published on its use, and 1

,19,20,21 adverse or side-effects of remedies,22,23 toxicity, absence of evidence regarding efficacy and safety of non-biomedical therapies, request for biomedical intervention28,29 and risks of contamination of used products,

This is also the case in the mentioned project in London and in relation to the evaluation of forms of TCA in the care for children. The rationale for the study in London was to investigate ‘[…] whether TCA pose a risk to patients, in particular children, and how

conventional medicine may be affected as a result.’37 The authors also question the safety of applied TCA in their conclusions on the research outcomes. Also in the umbrella project one of the main aims is ‘[to] raise awareness of the safety implications’ of TCA internationally.

According to Statistics Netherlands (Centraal Bureau voor de Statistiek, CBS), between

6% of citizens in The Netherlands consulted a TCA practitioner.38 The percentage of people a TCA practitioner varied between people with parents born in The Netherlands and parents born elsewhere. According to the CBS, people with parents from Surinam, the Antilles,

Western allochtoon’; see chapter 3) visited a TCA practitioner

Table 1.1 Percentages of ehnic groups under treatment of TCA practitioners, 2010

the use of TCA for children is prevalent in many countries. According to Kemper worldwide 47 systematic reviews published on its use, and 1

toxicity,24 the biomedical therapies,25_,26_,27_{delay in the}

and risks of contamination of used products,30,31,32 among

This is also the case in the mentioned project in London and in relation to the he rationale for the study in London was to investigate ‘[…] whether TCA pose a risk to patients, in particular children, and how

The authors also question the safety of on the research outcomes. Also in the umbrella project one of the main aims is ‘[to] raise awareness of the safety implications’ of TCA internationally.

), between 2010-2013 The percentage of people a TCA practitioner varied between people with parents born in The Netherlands and

ts from Surinam, the Antilles, a TCA practitioner less

Table 1.1 Percentages of ehnic groups under treatment of TCA practitioners, 2010-2013

the use of TCA for children is prevalent in many countries. According to Kemper worldwide 47 systematic reviews published on its use, and 1,400 articles

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considered randomised clinical trials (RCT’s).The amount of research has even grown since, with varying outcomes and big differences in found rates of use, also within countries (see for

differences within Turkey for example40,41,42,43).

In the US, Canada and Europe user rates in paediatrics vary from 544_{to 70%}45_{but are generally}

considered to be considerable.46,47 Not much is known about ranges and motivations for use of TCA for children in The Netherlands, and even less is known about its use among children whose parents came from abroad, especially from countries influenced by Arabic-Islamic traditions.

Heterogeneity

Immigrants cannot be isolated as one homogeneous group that differs totally from other Dutch citizens. However, cultural influences may have impact on the choices people make when choosing remedies or therapies. According to Van Dijk48_{, in 2004 the number of 404 different}

non-biomedical therapies was distinguished in The Netherlands. Traditional and folk therapies of immigrants are a considerable part of a broad range of these therapies.49 Van Dijk stated that the most consulted therapies in The Netherlands are homeopathy, paranormal healing,

anthroposophy, acupuncture and other foreign healing systems (ibid.) such as Ayurvedic and Islamic therapies.

Traditional and folk medicine changes over time and place. Different Islamic societies and traditions for example developed different Islamic healing systems. Turkish and Moroccan immigrants, considered to belong to ‘ethnic minorities’ in the Netherlands, brought elements of their own healing systems with them to Dutch society. Elements of these therapies were

introduced in Dutch society but are not taken into account so far in the discussion on TCA therapies in paediatrics in the Netherlands, while both immigrants and native Dutch citizens search for the support of alternative healers.50

Parents of different ethnic background may use partially the same, and partially different remedies and therapies for their children’s complaints. Patterns of TCA use may differ by ethnicity. These differences may for example be based on different ideas of health and disease, different knowledge and traditions, and by social economic circumstances. It is expected that homeopathy, dietary supplements and manual therapies, that are mainly found to be applied to Dutch children, are also used for children with a other cultural backgrounds. Furthermore, other remedies and therapies known in the parents’ countries of origin are expected to be used for children in the heterogeneous, international population that visits the SLZ paediatric clinic. Turkish people with asthma may use for example more commonly herbal preparations, quail eggs, honey or prayer healing, while Dutch parents may more tend to the use of homeopathy or eucalyptus inhalers for their children for the same complaints.

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Paediatrics

According to the CBS51, the average for children who visited a TCA practitioner from 2010 to 2013 lies around 6% and varies by age (table 1.2):

Table 1.2 Percentage children by age groups

A study done in a Dutch general paediatrics clinic in 2009 demonstrated that nearly 30% of children visiting the clinic was treated with TCA by their parents.

indicate that in The Netherlands, TCA is used for 30 to 40% of children.

2013 the most used forms of TCA for children are homeopathy, dietary, supplements and manual therapies.54

As these populations, however, expected to be representative fo youth is of a multi-ethnic background. included in studies so far.

Formulation of the problem

Safety of non-biomedical therapies is considered to be a matter of concern in paediatrics in The Netherlands.56_{In the SLZ paediatrics}

of colloidal silver could not be excluded as being the cause for kidney damage in a c

Rosenstiel, personal communication). It is not known whether this case represents an incident or is part of a structural problem due to TCA use and

concern.

, the average for children who visited a TCA practitioner from 2010 to 2013 lies around 6% and varies by age (table 1.2):

Table 1.2 Percentage children by age groups under treatment of TCA practitioners, 2010 udy done in a Dutch general paediatrics clinic in 2009 demonstrated that nearly 30% of children visiting the clinic was treated with TCA by their parents.52 A few more recent studies indicate that in The Netherlands, TCA is used for 30 to 40% of children.53 It is estimated that in 2013 the most used forms of TCA for children are homeopathy, dietary, supplements and

however, were predominantly of Dutch family origin, the TCA use is expected to be representative for paediatrics in the Netherlands overall, as nearly a quarter of all

ethnic background.55 Moreover, several foreign therapies and remedies are not

Formulation of the problem

therapies is considered to be a matter of concern in paediatrics in The In the SLZ paediatrics it is stated that there is one reported case in which the use of colloidal silver could not be excluded as being the cause for kidney damage in a c

Rosenstiel, personal communication). It is not known whether this case represents an incident or part of a structural problem due to TCA use and, therefore, whether there is reason for

, the average for children who visited a TCA practitioner from 2010 to

under treatment of TCA practitioners, 2010-2013 udy done in a Dutch general paediatrics clinic in 2009 demonstrated that nearly 30% of

A few more recent studies It is estimated that in 2013 the most used forms of TCA for children are homeopathy, dietary, supplements and

the TCA use is not , as nearly a quarter of all everal foreign therapies and remedies are not

therapies is considered to be a matter of concern in paediatrics in The there is one reported case in which the use of colloidal silver could not be excluded as being the cause for kidney damage in a child (Von Rosenstiel, personal communication). It is not known whether this case represents an incident or

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As mentioned above, not much is known yet about the use of TCA for children in multi-ethnic populations in The Netherlands, because paediatric populations studied in The Netherlands so far in relation to TCA use are predominantly of Dutch family origin. Because of heterogeneity in ethnicity and health complaints, definitions and research outcomes, research findings so far cannot be extrapolated to— and may not be representative for the use of TCA in multi-ethnic paediatrics in The Netherlands. Research outcomes so far, therefore, may also not be

representative for the SLZ paediatrics clinic, including the Integrative Medicine clinic. Therefore, no conclusions about risk exposure or safety issues for children of different origin can be drawn so far.

Which therapies are frequent used in the SLZ outpatient clinics is not determined yet. Frequent used therapies may involve both commonly used complementary therapies in the Netherlands, Turkey and Morocco (such as acupuncture or herbal therapies) and also Turkish and Moroccan folk beliefs and visits to traditional Islamic healers. The expectation is that remedies and therapies known in the parents’ countries of origin may be used for children in such a heterogeneous population as well.

Main health complaints seen in the clinic are chronic complaints such as chronic respiratory infections, asthma, chronic abdominal pain, urinary tract infections, delay in growth, obesity and chronic fatigue and malaise in adolescents (Von Rosenstiel, personal communication). It is expected, that TCA is used for several of these complaints, as TCA for children seems to be related to the prevalence of chronic diseases, of which the symptoms are not reduced by biomedical treatment.57_,58

According to the SLZ paediatric clinic, 2,000 children are seen annually (Von Rosenstiel, personal communication). Ethnic background is not registered because of Dutch regulation. Children of Turkish and Moroccan parents are estimated to be 60 to 70% of the paediatrics clinic (Von Rosenstiel, personal communication), in all 1,200 to 1,400 patients annually. 25% of the patients, are children from parents born in The Netherlands (Von Rosenstiel, personal communication), being 500 children annually. Remaining parents come from countries all over the world. So on forehand it is estimated 85 to 95% of the population originates from Turkey, Morocco and The Netherlands. Most TCA use in the clinic will therefore be covered by these three main groups.

Because the use of TCA for children is widespread and is often used for chronic complaints as seen in de paediatrics clinic, SLZ expected that the use of TCA is widespread at its paediatric department as well. It is expected that remedies and therapies known in the parents’ countries of origin, but probably not generally reported in Dutch paediatrics so far, are used for children as well.

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This lack of data that can be extrapolated to the clinic, in combination with the information that use of TCA for children seems to be related to the prevalence of chronic diseases, and the fact that mainly these diseases are seen in the clinic, contributed to the request of the SLZ for a parallel research as done in London. The SLZ’s objective was to increase awareness among pediatricians regarding TCA use and its safety for children, and to facilitate a more open communication between doctors and parents about its use. The objective of the Integrative medicine department of the paediatrics clinic was to include evidence based elements of these approaches in the treatment of children.

Outline of the thesis

In current section, the introduction and outline of this study is given.

Chapter 2 describes the theoretical framework, research context and reflection on the use of binary oppositions in a pluralistic setting. In chapter 3, concepts used and ethical considerations to these concepts are found. Research aims, methods and research questions are described. Chapter 5 presents the qualitative research outcomes, and chapter 6 the quantitative findings. Chapter 7 is dedicated to the conclusions, discussion and recommendations of this study. Research materials, preliminary results and two tables are included in the annexes.

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2. Theoretical framework, /research context/

and reflection on the use of binary oppositions

in a pluralistic setting

As parental perspectives of TCA within a biomedical setting are explored in current study, is worth to be aware of premises that frame the research questions which possibly influence understanding which limit legitimation of other perspectives. Theoretical perspectives and premises regarding the integration of biomedicine and elements of other therapies influence both the research questions in this study and the legitimacy of given answers. They also influence communication about these questions and answers, both scientifically and in daily medical practice. Continuous critical reflection of the influence of own premises is a requisite for good qualitative analysis,59 so it is important to be aware of them.

Biomedicine and TCA can be considered from from a wide range of perspectives, such as biomedical, ethno-medicine, anthropologic and sociologic perspectives, parental and native ones, modern insights and insights from tradition, ‘Dutch’ perceptions compared to others, and so on. This study, however, focusses on the use of dichotomies as premises underlying used concepts from a anthropologic-sociologic viewpoint.

In this chapter, medical pluralism, and premises underlying to dichotomies and binary oppositions in the umbrella project and thus underlying current study are brought under attention. Anthropologic-sociologic framings of their restrictions are discussed shortly. Finally, the concept of underlying in-between categories in binary oppositions is introduced to come to a more dynamic concept.

Medical pluralism

In many countries, people combine traditional medicine and/or complementary therapies with biomedical care, also when biomedicine is widely available.60 This simultaneous use of different kinds of therapies by patients and caregivers, even when these therapies have mutually

incompatible explanations for the health complaints at stake, is nothing new. During history, this common phenomenon, called medical pluralism, ‘has been the norm rather than the exception’.61 The self-evident use of several therapies at the same time can be seen as ‘a structural

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Medical pluralism, however, from a biomedical and political perspective became two separate, static categories: biomedicine (or ‘conventional medicine’, ‘mainstream medicine’ or ‘Western medicine’) and CAM (or TCA, or ‘Complementary Health Approaches’, which are

interchangeable terms). In The Netherlands, this distinction became official in 1865, when Thorbecke introduced the Law on Practicing Medicine. This distinction, and with it its static binary oppositions and underlying premises, nowadays results in an effort by some biomedical orientated professionals to combine and integrate elements of non-biomedical categories in

evidence based medicine (EBM).

There are several definitions of EBM. According to Verbrugh and Kips,63 the definition is as follows:

‘The conscientious, explicit and judicious use of the best current evidence available to make decisions for individual patients. The practice of evidence based medicine implicates the integration of individual clinical expertise with the best extern evidence available from systematic research. Preferences, wishes and expectations of a patient play a central role in this decision-making process.’ (Italics in the original text.)

This effort to combine and integrate non-biomedical categories into biomedicine is named Integrative Medicine. It is framed by the National Center for Complementary and Alternative Medicine (NCCAM) as a growing ‘[…] integrative trend […] among providers and health care systems. Driving factors include marketing of integrative care by health care providers to consumers who perceive benefits to health or well-being, and emerging evidence that some of the perceived benefits are real or meaningful.’64

As a part of TCA, the definition of Traditional medicine is included in this distinction. Traditional medicine is described by the World Health Organization as

‘[t]he sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or

treatment of physical and mental illness.’65

This sum total is not fixed, but changes over time and place.66 Different Arabic societies and traditions, for example, developed different Islamic healing systems67,68,69 which among others may be based on official Islamic traditions or local folk beliefs.70_{Elements of biomedicine}71_or

contemporary society may be incorporated in what people consider being ‘traditional’ and vice versa. Users, however, do not necessarily experience tradition therapies as ‘complementary’ or ‘traditional’ and may combine or alternate elements from several paradigms with ease.

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Binary oppositions

As stated, medical pluralism became divided into two separate, static categories: biomedicine and TCA. This division is based on the use of dichotomies, also named binary oppositions. Binary oppositions are ‘a division into two, mutually exclusive, theoretical opposites’72 in language and thought, which are set off against one another. These oppositions are easy to handle because they simplify complexity to only two opposed categories that exclude each other. However, they may be misleading because they may be incomplete,73 as there are often more categories than just two, and also because the opposite categories may be based on only one difference out of several features which are characteristic for the topic at stake.

Several binary oppositions and their premises underlie this study’s aims (cf. chapter 1). For example, that biomedicine and TCA are two separate categories, that biomedicine for children is safe and that safety of TCA for children is not self-evident but a (potential) risk, that

understanding of the use of biomedicine is self-evident whereas understanding of TCA use is not, that children differ from adults and that Dutch children belong to another category than children from parents with a migration background.

In the following, the main binary oppositions underlying this study will be discussed. However, instead of discussing each dichotomy separately, or giving a historical overview of dualistic thinking from Descartes onwards via Marx and Hegel, in the following, attention is paid to overlooked categories by thinking in static dichotomies about dynamic practice, with

consequences for the research questions asked, the answers, analysis and communication about the findings in science and daily practice. The use of binary oppositions, and its static

simplification of daily practice will be relativized in the following. This will be done from an anthropologic-sociologic viewpoint.

Binary oppositions in anthropology and sociology

Binary oppositions are used ‘to find specific assumptions, practices and beliefs of particular people.’74_{In anthropology, these oppositions, from the structuralist Lévi-Strauss onwards, are}

considered to represent collective representations of a culture, in current study design

representations of biomedical culture. From this perspective, the ‘other’, TCA use of multi-ethnic parents, is explored.

Structuralists in anthropology consider the division of reality in binary oppositions as ‘a

fundamental operation of the human mind based on the production of meaning.’ 75_{Lévi-Strauss}

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in complications on another level,76 such as daily practice. Also, binary categories are static, whereas daily practice is more dynamic.

Poststructuralists such as Bateson,77on the other hand, recognize pluralism and the dynamics of relations. Bateson pleads for multiplicity instead of thinking in traditional dualistic binary

categories. This poststructuralist approach enables a synergy of ideas from divergent backgrounds and traditions.

Geertz reacted also upon the ideas of Lévi-Strauss and other structuralists. He was not mainly interested in the categories and its production of meaning, but in their dynamics to explain social processes and changes.78 He also elaborated on the concept of ‘thick prescription’, 79 an

ethnographic methodology often used in social sciences to explain the behavior of people in their context, in a way that both the behavior as well as its origins become understandable to others. Or, in current study: that the choices made by parents become understandable for biomedical oriented persons in The Netherlands, who do not share traditional knowledge, and were not trained in TCA during their education.

Geertz’ work itself is stated to have contributed to the dichotomy of great Islamic traditions80 (true Islam) and little Islamic traditions (false Islam). However, in his approach, both the static- as well as the dynamic side of social processes have their influence on culture. Both the static

reduction of the individual to traditions and cultural habits, as well as the individual’s dynamic social context in which he shapes his culture by making autonomic choices play a role in the culture of people.81

Binary oppositions underlying current study

The dichotomy between biomedicine and TCA is the central binary opposition, but at the same time only one of several underlying binary oppositions in the aims of the umbrella project and underlying current study (table 2.1). The table below illustrates these binary oppositions.

Binary categories are opposed to each other and cannot be combined to one category by definition, because each category has its own given meaning, static characteristics and simplifications. As a consequence of Dutch biomedical thinking about medical pluralism in binary oppositions and the given meanings to the categories ‘biomedicine’ and’ TCA’ for

example, ‘evidence-based use of CAM’ is considered to be ‘an oxymoron’.82_{Underlying concepts}

are relevant for example because ‘a static biomedical vision on culture or religion is fatal for the communication and interaction with some patients with a migrant background’ (Hoffer, personal communication), whereas the improvement of communication between pediatricians and parents is one of the aims of the SLZ.

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Biomedicine / pharmaceuticals TCA / remedies Safe (potential) risk physician lay public/ parents

Adult child

‘autochtoon’ / ‘Dutch’ ‘allochtoon’ / ‘Turkish’, ‘Moroccan’ Modern traditional

evidence based experience based nature nurture

biophysical / biology sociocultural / culture Signs / disease Symptoms / illness medical disorder social construct body / material mind / energetic secular religious / Islamic

knowledge /rationality / real belief /superstition / irrational /unreal individual identity group identity

Table 2.1 Binary oppositions operating in premises of the research questions of the umbrella project and current study

Because biomedicine, TCA, the population of the SLZ, definitions and other concepts are rather pluralistic and dynamic, it is considered to be appropriate for current study not to restrict analysis and presentation of findings to the classic dualistic way of thinking in dichotomies and in static concepts of peoples and their cultures, but to use a more dynamic approach. In a scientific enterprise such as current study, however, dichotomies cannot be abandoned completely, simply because ‘[…] the sovereign perspective of abstract reason is a product of the compounding of two dichotomies: between humanity and nature, and between modernity and tradition.’ 83_The

main research questions (‘Which TCA do parents use for their children?’; ‘Why do parents (not) use TCA for their children?’) implicate thinking in dichotomies and its static reduction of individuals to traditions and habits of its culture as well. Also, the design of the questionnaire (chapters 4 and 6) is based on thinking in these static reductions, as is the estimation of the three involved target groups.

Therefore, the dynamic social context of parents who shape their culture by making autonomic choices influenced by several cultures and health systems, alternating or at the same time, and often without considering dichotomies as used in biomedicine and in current study, are taken into consideration in the presentation and description of findings. Table 2.2 explains they may fall in an ‘in-between’ category. This ‘in-between’-category shows overlooked options when thinking in dichotomies, which are helpful to take into consideration when exploring TCA use from

biomedical perspective. Its qualitatively different examples, however, are not brought into view to fund a new theory, nor is it aimed to be complete.

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Examples of in-between categories in underlying binary oppositions

Biomedicine / pharmaceuticals integrative medicine / licensed medicinal natural products / patents and property rights on medicinal plants and animal products / cultural re-interpretation of pharmaceuticals / traditional medicinal substances as ingredient in

pharmaceuticals

TCA / remedies

Safe unsafe use of safe products / unsafety by contamination of safe products / risky bioactive components prescribed in a safe dosage or in a safe combination

(potential) risk

Physician proto professionalization / parents who are physician or medically educated otherwise / physician as layman (TCA)

lay public/ parents Adult adolescent child

‘autochtoon’ / ‘Dutch’ acculturalisation / more nationalities for one person / redefining definitions and categories by CBS / ethnic minorities within national borders (Kurds, Berbers/ immigrants) / migrant background with acquired nationality or identity of the host country

‘allochtoon’ / ‘Moroccan’, ‘Turkish’

Modern inclusion of traditional elements in modernity / inclusion of modern elements in tradition

traditional evidence based evidence through experience experience based nature combination of nature and nurture nurture

biophysical / biology ecological psychology (Gibson) sociocultural / culture Signs / disease symptoms confirmed by signs / signs

not confirmed by symptoms / symptoms not confirmed by signs

Symptoms / illness disease as medical disorder both a medical disorder and a social

construct at the same time

Disease as social construct Body / material psycho-neuroendocrinology /

mind-body therapies / psychosomatic disturbances

Mind / energetic Secular Alternation of categories / praying

physicians/ parents consulting physician and Imam or priest

Religious / Islamic / Christian Knowledge /rationality /

Real

Alternation and combination of diverse paradigms

belief /superstition / irrational / unreal

Individual cultural identity Changing identities Group cultural identity

Table 2.2 examples of in-between categories to the underlying binary oppositions in current study

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The research population exists of parents who may share biomedical paradigms and concepts to varying degrees, but who not necessarily do so. Parents may have different perspectives or combine elements of several paradigms without problem or without considering that they cross borders of distinguishable categories, whereas medical professionals may adhere with more emphasis to the paradigm they are educated in. The idea that TCA and biomedicine can be separated as binary oppositions may therefore be self-evident from a strict biomedical perspective, but this may not necessarily be so when approached from other perspectives.

The categorization in three categories instead of two enables an ‘in-between’ category between the so far underlying opposite categories, which enables a more dynamic perspective and autonomy of individuals, influences by the society in which they live. Recognition of the ‘in-between’ category and the exchange between these categories may resemble the actual Dutch society more than binary oppositions do.

Also, this recognition may ease understanding and communication, both scientific as in daily medical practice. Also, it may ease integration of elements of TCA within biomedicine, the goal of the Integrative Medicine clinic of the paediatrics department.

Based on the aforesaid, the combination of static reduction of people and their cultures as a result of dichotomies and used definitions, as well as the dynamic side of social processes and adaptations within the population of parents that visits the clinic is enhanced in the description and presentation of the research findings, and is considered to be an appropriate approach of the research objectives and questions.

However, findings and descriptions may neither be from a ‘typical biomedical perspective’ when thought in the dichotomy ‘biomedicine-TCA’, nor represent the ‘typical anthropological

perspective’ which includes the researcher as a reflective observer who introduces her individuality in personal reflections. Because current presentation is written both for

anthropologist-sociologists as well as for biomedically-oriented readers, personal reflections, such as considering used definitions and binary classifications, are presented against scientific

backgrounds. Current study may therefore belong to the ‘in-between’ category as well.

Nevertheless this combination is applied to explore and explain the dynamics and adaptations of used concepts and autonomic choices made by parents regarding the use of ‘TCA’ for their children, as part of a pluralistic and dynamic whole that includes ‘in-between’ categories as well.

Considerationsto the use of binary oppositions

Thinking about people in separate categories may lead to stigmatisation of the compared groups. Therefore, a more dynamic approach of analysis is chosen to reduce this risk.

Used concepts implicate the risk of what Kleinman named category fallacy, ‘a phenomenon that categories established for one group is applied to a group to which the categories do not have

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valid significance.’ 84 ‘TCA’ is not a common term for lay public. Therefore, it is important to be aware of respondent’s interpretations in the analysis, compared to the biomedical framing.

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3. Concepts used and ethical considerations

The research questions in current study (chapter 4) depart from the premises stated in chapter 2 and 3, for example that parents visiting the clinic can be distinguished as separate ethnic groups, that children can be identified as a category that needs medical care in a dedicated department (annex 4), and that TCA and biomedicine are binary categories.

Several concepts and their varying definitions are a source of infinite and ongoing controversy and confusion. For example, TCA has been defined in several ways, also in The

Netherlands85,86,87, and these different definitions have been a source of continuing controversy and discussion to no end (Verbrugh and Kips 200488). Also other concepts, such as ‘culture’, ‘ethnicity’, ‘biomedicine’, ‘traditional’, or ‘Islam’ are food for discussion. As unclear definitions may limit the legitimation of this study, in this chapter attention is paid to the framings of biomedicine, TCA, culture, and ethnicity, with the aim to clarify their interpretation in current study. It is necessary to be aware of the presence of these underlying premises, as in SLZ’s daily practice as well as in current study several perspectives meet.

Framings of biomedicine

In The Netherlands, biomedicine, including paediatrics, is the politically dominant health care system.89,90 This system can be considered as a part of the shared dominant Dutch culture, for example because biomedical ideas about anatomy, health and disease are taught in schools and at universities (Verbrugh and Kips91). One of the characteristics of actual biomedicine in The Netherlands is, that natural factors are considered to cause disease. Social and supra-natural or metaphysical causes as disease factors are out of scope of biomedical epistemology.

However, biomedical thinking is diverse and it is not necessarily identical in different places or over time. Also, biomedicine is influenced by cultural and local norms, values and habits.92,93, 94 For example, on entering the elevator of any Dutch hospital, some of the general, actual and historically grown influences can be identified.

The elevator reveals a central paradigm of biomedical thinking, i.e. that pathology is seen as a deviation of an organ. The hospital organises its specializations mainly according to separate anatomic divisions, organs and their systems and accordingly departments.

The concept that pathology can be brought back to anatomic unities and physiologic

disturbances started in the dissecting room and anatomy classes from the late sixteenth century onwards. Nowadays, not only medical specialists, but also ‘lay people have come to see the body as a machine consisting of parts which –when damaged or failing-- can be repaired or replaced.’95

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This mechanistic idea of disease as separated anatomic unities is still represented in the separated departments for each organ or organ system, with specialised diagnostic methods, tools and treatments: respiratory system, digestive system, circulatory system, nervous system and so on. As a representation of the dualistic separation in body and mind, psychology has its own department for psychological disturbances with somatic signs. There is no elevator button for symptoms classified as psychiatric disturbances, though.

Biomedicine was re-introduced from the nineteenth century onwards into Islamic societies.96_In

the Arabic world, biomedicine is commonly the accepted health care paradigm.97 Morocco and Turkey the first biomedical faculties were established in 195798 and 194699 respectively.

Considerations

The elevator buttons may seem self-evident from a biomedical point of view, but these ideas are influenced by historical and political events in Europe. The development of disease concepts in varying political and historical circumstances may have been different in other countries. People coming from areas with other historical or political events, not necessarily share (all) mechanical concepts of biomedicine. According to Kleinman,100 ‘biomedicine differs from other forms of medicine by its extreme insistence on materialism as the grounds of knowledge, by its discomfort with dialectical modes of thought, […] its requirement of single causal chains used to specify pathogenesis […] and particularly because its peculiar powerful commitment of nature that includes the teleological.’ This is characteristic of biomedicine and its historical and political background in Western Europe during certain periods. People from countries with a different political and historical background, however, may share or not share all epistemology

forthcoming from these circumstances. For example, migrants or their descendants do not necessarily make the - exclusively in biomedicine existing - ‘split’ between psyche and body. The latter is for example also the case in Islamic traditions and folk beliefs, which partially origins in and differs from several concepts from the secular, mechanistic approach current in biomedicine.

Patients’ autonomy and personal meaning associated with diverse health beliefs and practices, may be worthy of attention in a hospital setting when popular health beliefs do not coincide with biomedical ideas. Extreme dilutions used in homeopathy may be hard to accept for biomedical trained health care providers, as well as the influence of God or Allah, magical practices, influences of the evil eye or the belief in spirits in folk belief may be. However, different social-economic circumstances, expectations, idioms of distress, norms, beliefs and perceptions about health and health care of patients may cause misunderstandings between physicians and (ethnic minority) patients, whereas treatment success depends partially on bridging these differences.101 Current study hopes to facilitate a this bridging, although it may be seen as ‘different’ also because of the chosen perspective.

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Considerations self-reported diseases

At the SLZ paediatrics clinic, parents’ participation to current research was anonymous and confidential. For that reason, there was no access to medical files or biomedical diagnoses. The interviews therefore rely on the participants’ perceptions and choice of words. Names of diseases used by parents may coincide with the medical diagnoses in the files, but not necessarily so. Names used by respondents for the health complaints of their children were used instead. As a consequence, ‘inflammation of the lungs’ is not necessarily the same as ‘pneumonia’. Names used by parents may coincide with biomedical nomenclature, but does not necessarily do so.

Heterogeneity in definitions and framings of TCA

The in Europe and the USA leading NCCAM defines TCA as ‘the array of health care

approaches with a history of use or origins outside of mainstream medicine.’ This description is followed by the remark that non-mainstream therapies as a category ‘are actually hard to define and may mean different things to different people.’102

That ‘mainstream medicine’ and (some) TCA approaches may well be rooted in shared

history103,104 at least in Europe, including The Netherlands,105 but also in Turkey106 and Morocco, is left out of the scope in this definition. Furthermore, that the category ‘mainstream medicine’ may also mean different things to different people is not included in this definition. For example, it is stated that more than 70% of the population in low industrialised countries relies primarily on TCA.107_{In these areas, traditional healthcare is often the main resource — and only access to}

healthcare, especially so in rural areas.108_{Also, in several countries, different ‘mainstream’ forms}

of medicine are practised in state supported hospitals, because of the simultaneous occurrence of different recognised ‘mainstream’ methods by the state at the same time. Therefore, in current study, the term ‘biomedicine’ is used instead of ‘mainstream’, ‘conventional’, or ‘Western’ medicine, although biomedicine is heterogenic in itself to some degree also.

Definition of TCA used in current study

Furthermore, the definition of ‘TCA’ varies among studies.109_,110_,111_,112_{Research findings are not}

only inconsistent and contradictory because of different definitions of TCA,113,114 they may vary for example also by ethnicity115,116,117,118,119,120, country121,122,123,124,125 health

complaints126_,127_,128_,129_,130_{, and differences in methodology,}131_{among others. So research findings}

cannot simply be generalised, compared or extrapolated to specific populations or different countries. Because of the need of some description to clarify what is meant in current study with CAM or TCA, the definition of Zollman and Vickers (1999) is used here:

‘A broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health care system of a particular society or culture in a given

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historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being. Boundaries within CAM and between the CAM domain and the dominant health system are not always sharp and fixed.’132

In current study both complementary as well as traditional therapies are included in the terms ‘TCA’ and ‘CAM’. In the following only the term TCA will be used, unless in citations the word CAM is used in the original text.

Considerations self-reported TCA use

Self-reported information on TCA use may be influenced by bias of several kind. For example, acceptations of folk belief and remedies may not be accepted by people who adhere to official Islamic doctrines. Also, people may withhold information when they expect to be opinionated because of it, of give socially desirable or accepted answers.

The survey was based on self-reported measures by parents and not on –or compared with— dossier files of patients. Also no observations of application were done at the homes of the children. Application of TCA and its administration for children by parents may differ to the answers of parents.

TCA brought from Turkey and Morocco

Health care systems in Turkey and Morocco are not only influenced by concepts of biomedicine, but for example also by political and historical background originating in Arabic-Islamic Medicine and Prophetic Medicine (for more information see Hoffer 2000133_{). People may also be}

influenced by folk beliefs and social-economic circumstances. Islamic traditions differ between migrants from Turkey and Morocco as well, as they do between people from these countries. As a result, migrants and their descendants and their (Dutch) brides may include several influences in their explanations of disease which are not own to people from other areas. Elements of brought traditions may well be ‘mainstream’ in Turkey or Morocco, but considered to be ‘TCA’ in the Netherlands.

As a pragmatic result of these diverging backgrounds, with their diverse definitions and influences which will not be considered here, people from Morocco and Turkey may generally consider natural factors to cause disease. These diseases are generally considered to be a natural, self-evident phenomenon, either or not in the need for biomedical, herbal or bodily treatment such as massage and dietary adaptations. Children’s diseases are commonly perceived as natural diseases.

However, social, metaphysical or supra-natural causes as disease factors or Allah’s will as the supreme influence underlying all diseases may be part of the perception of parents as well. Allah’s will may considered to be the supreme influence underlying all diseases, their cures, the efficacy

We give Nutrilon to our babies, but strict people, they still believe in full milk : traditional and complementary medicine use in a multi-ethnic paediatric clinic in Amsterdam, the Netherlands

‘We give Nutrilon to our babies,

but strict people,

they still believe in full milk.’

Traditional and Complementary Medicine use

in a multi-ethnic paediatric clinic in Amsterdam,

The Netherlands

‘We give Nutrilon to our babies,

but strict people,

they still believe in full milk.’

Traditional and Complementary Medicine use

in a multi-ethnic paediatric clinic in Amsterdam,

The Netherlands

Master Thesis Medical Anthropology and Sociology,

University of Amsterdam

Figures and tables

Abbreviations

Glossary

Acknowledgements

Table of contents

Summary

Results and conclusions

1. Introduction and outline

Background

Rationale for the study

Formulation of the problem

Formulation of the problem

Outline of the thesis

2. Theoretical framework, /research context/

and reflection on the use of binary oppositions

in a pluralistic setting

Medical pluralism

Binary oppositions

Binary oppositions in anthropology and sociology

Binary oppositions underlying current study

3. Concepts used and ethical considerations

Framings of biomedicine

Heterogeneity in definitions and framings of TCA