Respondent characteristics
Respondent characteristics are reported in Table 1. Women accounted for 87.7% of the total sample (n = 6802) and brief text writers (n = 342). Respondents in the sample of brief text writers were younger than those in the total sample. Slightly less than half of all respondents (46.5%) and a third (32.5%) of brief text writers indicated that they almost always told the physician about their CT use. Of all respondents, 37.1% and the brief texts writers, 57.6% reported only rarely telling physicians about their use of CT, while 8.4% of all respondents and 9.9% of brief texts writers reported never telling.
Table 1
The respondents’ characteristics, including the total sample (n = 6802) and the sample of brief text writers (n = 342), gender, age, and frequency of disclosing CT use to a physician.
Gender and age | All % (n) | Number of respondents who reported always, only rarely and never disclosing their CT use to a physician (%, n) |
Total sample (n = 6802) | Sample of brief texts writers (n = 342 |
Almost always % (n) | Only rarely % (n) | Never % (n) | No answer % (n) | All % (n) | Almost always % (n) | Only rarely % (n) | Never % (n) |
100 (6802) | 46.5 (3160) | 37.1 (2522) | 8.4 (570) | 8.0 (546) | 100 (342) | 32.5 (111) | 57.6 (197) | 9.9 (34) |
Gender* | | | | | | | | | |
Women | 87.7 (7968) | 47.1 (2808) | 37.4 (2232 | 7.6 (452) | 8.0 (476) | 87.7 (300) | 32.3 (97) | 57.3 (172) | 10.3 (31) |
Men | 10.3 (700) | 42.3 (296) | 34.3 (240) | 14.7 (103) | 8.7 (61) | 9.4 (32) | 37.5 (12) | 53.1 (17) | 9.4 (3) |
Other | 2.0 (134) | 44.8 (60) | 37.3 (50) | 11.2 (15) | 6.7 (9) | 2.9 (10) | 20.0 (2) | 80.0 (8) | 0 (0) |
Age groups* | | | | | | | | | |
44 years and below | 35.8 (2438) | 44.3 (1079) | 41.8 (1018) | 9.3 (226) | 4.7 (115) | 42.1 (144) | 32.6 (47) | 61.8 (89) | 5.6 (8) |
45–59 years | 39.6 (2692) | 48.9 (1316) | 35.3 (951) | 7.7 (208) | 8.1 (217) | 34.8 (199) | 32.8 (39) | 49.6 (59) | 17.6 (21) |
60 years and over | 24.0 (1632) | 45.9 (749) | 33.0 (539) | 8.1 (132) | 13.0 (212) | 21.6 (74) | 33.8 (25) | 59.5 (44) | 6.8 (5) |
No answer | 0.6 (40) | 50.0 (20) | 35.0 (14) | 10.0 (4) | 5.0. (2) | 1.5 (5) | 0 (0) | 1.5 (5) | 0 (0) |
*Gender and age groups in the total sample (6802) < 0.001, age groups in the sample of brief texts writers (n = 342) p = 0.013 |
The seven themes of reasons for nondisclosure of CT use
The structured tabular thematic analysis of the selected 342 brief texts revealed seven themes of reasons for the nondisclosure of CT use (Table 2).
Table 2
Themes of reported reasons for nondisclosure of CT use to a physician in respondents´ brief texts and reported frequency of disclosure. (n = 342).
| Reported frequency of CT disclosure |
Theme of reported reasons for nondisclosure of CT use | All n = 342 % (n) | Almost always n = 111 % (n) | Rarely or never n = 231 % (n) | p |
1. Expectations of physician’s attitudes and response | 47.4 (162) | 34.2 (38) | 53.7(124) | < 0.001 |
2. Expectation of physician’s knowledge of CT | 31.0 (106) | 28.8 (32) | 32.0 (74) | 0.548 |
3. Previous experiences with CT disclosure | 20.8 (71) | 15.3 (17) | 23.4 (54) | 0.085 |
4. CT use not related to medical care/disclosure not considered necessary | 32.0 (109) | 40.5 (45) | 27.8 (64) | 0.018 |
5. Shortness of time/did not come to mind | 14.4 (49) | 10.8 (12) | 16.1 (37) | 0.193 |
6. Case-by-case assessment of the medical encounter | 15.2 (52) | 24.3 (27) | 10.8 (25) | 0.001 |
7. Safety, risks and adverse effects of CT | 4.4 (15) | 4.5 (5) | 4.4 (10) | 0.960 |
Theme 1: Nearly half of the respondents (47.4%) mentioned in their brief texts that they expected physicians to show a negative attitude towards CT or respond inappropriately if they were told about CT use. Those with expectations of physicians´ negative responses were significantly higher among rarely or never disclosers (53.7%) than among almost always disclosers (34.2%). Respondents reported being afraid that the physician would demean the CT user or might even forbid them from using certain CT modalities. (Quote 1).
Quote 1. I suppose the doctor might consider me a nutter [if I told him]. I am afraid that the doctor might even forbid me from using natural therapies, which I would not accept. (Woman, 30–44 years, disclosed only rarely.).
Others reminded that physicians’ expected unwillingness to encounter patients as emotional and communicative human beings hindered disclosure (Quote 2).
Quote 2. I can´t bear to listen to arrogant disrespect and name-calling as a gullible fool who puts their health in danger by eating something that has no effect yet is still dangerous. I’d rather be silent so I won’t feel as bad after seeing the doctor. (Woman 30–44 years, disclosed only rarely.).
Theme 2: Slightly less than a third of respondents (31%) wrote about physician´s insufficient knowledge or understanding of CT. No significant difference were found between the groups of almost always and rarely or never disclosers. Nondisclosure was described in the brief texts by proactively emphasising that physicians could not understand that CT could positively impact patients’ lives. Respondents referred to differences between physicians and their own understanding of healing concepts, such as ‘energy’ and ‘holism’, to discrepancies in world views and to criticism of Western medical practices. (Quote 3).
Quote 3: They do not have the knowledge and understanding to evaluate the benefits of energy healing or their meaning to a person´s well-being, for example. Generally, world views do not meet, and doctors are strictly captive to their Western education and thinking. (Woman, 45–59 years, never disclosed.).
The physician´s medical knowledge and expertise seemed incompatible with the respondent´s own knowledge. Their lived experience indicates that nondisclosure might reflect a shying away from worldview -dissonances that could potentially undermine core belief systems for both parties. This point may mean different ideological positions(22) concerning health and healing. The critique of Western medicine was targeted at the pharmaceutical industry's power in health care. (Quote 4)
Quote 4. It is a common knowledge that medics are very strongly under the obligation to pharmaceutical industry. When a doctor graduates, he can only make a prescription. Doctors are specialized on ophthalmology, orthopaedics, gynecology etc. but they are not seeing a patient as whole. Doctors see themselves above the patient, they make prescription and re-schedule new appointment in few weeks. If one medication is not working then it is changed to another. (Woman, over 70 years, disclosed almost always.).
Theme 3: Every fifth brief text writer (20.8%) referred to the previous experiences with CT disclosure as a reason for nondisclosure. The number of those who wrote about their previous disclosure experiences was higher among rarely or never disclosers (23.4%) than among almost always disclosers (15.3%). Feelings of disappointment and frustration as a result of previous communication experiences were reflected in responses about getting inadequate responses when disclosing CT use to a physician. Some said that disclosure could negatively influence the quality of medical care. (Quote 5).
Quote 5. I have noticed that the medical professionals attitude towards me changes when I have mentioned the use of natural treatments or health products. It has had a negative effect to the treatment I’ve received. I no longer tell about using natural treatments or health products. (Man, 45–59 years, disclosed only rarely.).
Others emphasised that because they had previously experienced that physicians did not see or hear them as CT users, they did not want again to receive belittling or other negative comments about healing methods they themselves considered helpful. (Quote 6).
Quote 6. [I don´t tell the doctor] because I don’t think that doctors understand about these treatments. Mainly because, in my experience, doctors look down on these treatments. I don’t need to hear despicable comments about the treatments that had helped my family and decreased the need of seeing the doctor or use of medicine. (Woman, 30–44 years, disclosed only rarely.).
Theme 4: A third of respondents (32%) wrote that CT use was unrelated to medical care or that disclosure was not considered necessary. The number of those who reported CT use unrelated to medical care or disclosure not considered necessary was higher among almost always disclosers (40.5%) than among rarely or never disclosers (27.8%).
The difference between the groups of almost always disclosers (40.5%) and rarely or never disclosers (27.8%) was statistically significant. According to respondents, CT use was not discussed in medical consultations because CT use was not related to the ailment, disease, or problem for which respondents sought help from physicians. They indicated that they did not expect CT use to have much bearing on the type of treatments prescribed by their physicians or regarded CT as health promotion rather than medical care (Quote 7).
Quote 7. I usually go [to the doctor] just for a specific illness or ailment, like eczema or an infection. With natural treatments, I maintain my health by reducing stress and increasing the relaxation and well-being of the body and mind with various massages or other procedures. And I also support my health by utilising the long-known effect of plants and food on well-being. (Woman, 30–44 years, disclosed only rarely.).
Respondents who considered disclosure of CT use irrelevant or unnecessary seemed to consciously navigate between the worlds of medical care and CT therapies. A woman 45–59 years old, who reported disclosing CT use only rarely, noted that it is not necessary to disclose, because, in her opinion, ‘nutritional supplements do not affect healing of a sprain or removal of a fat pad’. Another woman emphasised the importance of her own knowledge and mentioned that she would not allow physicians to decide what kind of therapies she uses. (Quote 8)
Quote 8. [I do not tell because] I know better what treatments and health products work for me. I decide what I do and what products I use. I am not giving the power of decision to doctor. (Woman, 45–59 years, disclosed only rarely.).
Theme 5: Respondents (14.4%) referred in their brief texts to lack of time during consultations or forgetting to bring up their CT use. They mentioned that physicians did not ask and commented that the patient would not tell if the physician would not ask (Quote 9). The difference between the groups of almost always (10.8%) and rarely or never (16.1%) disclosers was not statistically significant.
Quote 9. I would tell if I remember or if the doctor asks. Nowadays doctors don’t ask anything. Patient doesn’t know what he should tell and doctor doesn’t ask… (Woman, 30–44 years, disclosed almost always.).
Theme 6: Those respondents (15.2%) who wrote about case-by-case assessment of the medical encounter pointed out that each encounter with a physician was weighed and re-evaluated separately. They reported that raising the subject of CT use in a discussion with a physician depended on the physician or the quality of the encounter. The number of those who reported their case-by-case assessments was significantly higher among almost always disclosers (24.3%) than among rarely or never disclosers (10.8%). Responses on the reasons for nondisclosure typically started with a phrase: ‘It depends on…’ (Quote 10).
Quote 10. It depends on doctor. For some doctors you can tell about the treatments and products you’ve tried and they might fully agree if I’ve found them helpful. Some doctors, especially young ones, deny alternatives so strongly that I’d rather say nothing. (Woman, 60–69 years, disclosed almost always.).
The decision depended on the assessment of the individual encounter with a physician. If the interaction was felt to be conducive to open dialogue, the respondents said they would disclose (Quote 11).
Quote 11. I would tell if I feel that it matters on that situation and if I feel (my intuition) that the doctor is a person to whom I want to tell this kind of matter. I need to feel that I will be heard openly without judgement or being despiced. (Man 45–59, disclosed only rearly, mentioned thirteen modalities helpful).
Depending on each encounter, these people chose to disclose or not to disclose their CT use. They seemed to be able to easily navigate between speaking and silence. The respondent´s decisions to discuss specific CT modalities were based on the physician´s assumed reaction to the modality in question (Quote 12).
Quote 12. I talk about acupuncture, bone setting and health products, but not often about energy healing and homeopathy, for example. Especially energy healing seems to be like a curse. When you talk about energy healing you will be underminded and classified to second-class citizen, you even face nearly hostile attitude. (Woman 30–44 years, disclosed only rarely.).
Theme 7: Safety, risks, and adverse effects did not emerge as a prominent topic for the respondents, with 4.4% of writers mentioning them as a reason for nondisclosure. There was no difference between discloser groups. Drug-herb interactions were mentioned concerning respondents’ reliance on the physicians’ expertise and their responsibility to ask about CT use. (Quote 13).
Quote 13: If I was prescribed a medicine that has effects when using with health products I would thell about the use. Patients can’t be expected to know when to bring up these issues. Doctors should always ask about the use of health products if there is a known combine effects with medicine. (Woman, 30–44 years, disclosed almost always.).
The three types of patient silence: avoidant, precautionary and conditional
In the final model of the backward stepwise logistic regression, the likelihood of disclosing CT use to a physician was associated with three themes of reasons for nondisclosure of CT use (Table 3).
Table 3
The associations between variables for the CT nondisclosure and the disclosure status (almost always vs. rarely or never). The binary logistic backward regression analysis, the final model, p < 0.05, Odds ratios (OR) and 95% confidence. (n = 342).
Themes on reasons for nondisclosure of CT use that entered into the final model | Respondents disclosing almost always (n = 342) % (n) | OR | 95% CI |
From | To |
Expectations of physician’s attitudes and response (Theme 1) | 47.4 (162) | 0.43 | 0.27 | 0.70 |
Previous experiences with CT disclosure (Theme 3) | 20.8 (71) | 0.52 | 0.28 | 0.97 |
Case-by-case assessment of the medical encounter (Theme 6) | 15.2 (52) | 2.35 | 1.27 | 4.35 |
Those who indicated assessing on a case-by-case-basis whether to disclose were more than twice as likely to disclose their CT use to a physician (OR 2.35, 95%, CI from 1.27 to 4.35) compared to those who did not mention a case-by-case assessment in their brief texts. Those who reported their expectations of physician´s attitudes and responses (OR 0.43, 95%, CI from 0.27 to 0.70) and those who wrote about their previous experiences with CT disclosure (OR 0.52, 95%, CI from 0.28 to 0.97) were slightly less likely to disclose their CT use to physicians compared to those who did not mention these themes. (Table 3). See Supplementary Materials for more details on regression analysis.
Based on the regression analysis results we concluded that there are three types of patient silence that are significant in our data. Based on our interpretations of how the respondents justified CT nondisclosure to be right or reasonable for themselves, we named silences as avoidant, precautionary, and conditional. (Fig. 1).
Avoidant silence
The logic here is that if physicians do not know that patients use CT, patients need not be afraid of feeling hurt or ashamed, which the physician´s negative response was expected to bring along. The silence was thus justified by a reluctance to face unpleasant feelings and expected inconvenient and unwanted consequences (Quote 1). Avoidant silence was used to evade undesirable events. It helped respondents cope with the fear of unwanted response from a physician and avoid the expected negative consequences of CT disclosure. Fear of the assumed consequences led to the decision to avoid undesirable, unpleasant emotions caused by hurt feelings due to the assumed physician´s future negative attitude and response to CT disclosure.
Respondents´ reluctance to listen to the expected physician’s judgemental response to the CT disclosure, as portrayed in Quote 2 (‘I can´t bear to listen…’), illustrates the communicative distance between the patient and physician, which may reflect a power imbalance between them. According to our data, unwillingness to speak can be interpreted as a sign of respondents´ fearful inability to communicate with physicians, which results in the choice of silence instead of articulating their own experiences and views on CT use.
Another critical approach to justify avoidant silence was targeted not so much at individual physicians´ possible negative response but at society's dominant social norms. Quote 14 below refers to public discourse, where many CT modalities are located outside or at the margin of health care, and are interpreted as odd or not fully socially acceptable in society and tend to be viewed with suspicion (66, 68).
Quote 14. [I do not tell] because treatments have been condemned ‘demonized‘ or people using them are declared delusional or stupid like frail and retarded. I consider myself an ‘intelligent‘ person with academic education, I don’t take well suhc a strong critic on decisions one makes. (Woman 45–59 years, disclosed only rarely.).
Precautionary silence
Precautionary silence, according to our data, allowed respondents to prevent previously felt frustration of wishes to be seen and heard as CT users. It may help maintain respect for one’s personal values as well as protect one's integrity, self-esteem, and identity as a person who has chosen to use CT (Quotes 5 and 6). Frustration combined with a reluctance to face a similar medical encounter in the future as in the past explains the choice of silence. (Quote 15).
Quote 15. [I do not tell because] my choices have been judged and my feelings been invalidated before. I don’t want to be despised anymore, I know how I feel and about my health better than a doctor. (Woman 30–44 years, disclosed only rarely.).
A patient´s previous experiences may become an obstacle to discussing CT use with a physician. If the respondents previously disclosed their experienced benefits of CT to physicians but received unaccepting and dismissing responses, obviously, during the next medical consultation, they would stay silent to prevent a similar situation. Precautionary silence in our data also refers to possible taboos regarding unwritten rules and unspoken social norms that define what is suitable and acceptable to discuss in health care (Quote 16).
Quote 16: [I do not tell because…] many [doctors] have had a negative attitude since they don´t have enough information. Doctors fear the consequences since above mentioned issues [CT] are not part of contemporary medicine and therefore, they are not allowed subjects to discuss. (Woman, 60–69 years, disclosed only rarely.).
Conditional silence
According to our data, conditional silence can be interpreted as a selective patient approach to exercising self-confidence in choosing between disclosure and nondisclosure of CT use to a physician. Trust and belief in one´s own ability to make the right choices were reflected in justifications for both disclosure and nondisclosure, indicating that respondents´ own assessments of the quality of medical encounters were used as a guide for decision-making on disclosure (10–12).
Freedom to choose one´s GP was emphasised when referring to quality of encounters. In case the physician´s behaviour did not allow respondents to freely discuss their CT use, for example due to different values and views on CT, respondents might even change physicians (Quote 17), which is however challenging in publicly funded health care in Finland (61, 62).
Quote 17. If a physician expresses opposition to the treatments in question [CT], I would go to another physician. Luckily, some physicians have a holistic view of the matter. (Woman, 60–69 years, disclosed almost always.).
Conditional silence illustrates respondents´ proactive health behaviour, sense of control over health and care options, and the will to make independent decisions on CT disclosure.