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Complementary and alternative medicine is the term that has officially been introduced by the World Health Organization (WHO). It implies "Health practices, approaches, knowledge and beliefs that are concerned with preparation of plant, mineral or animal origin, spiritual therapies, and manual techniques and exercises that are persued individually and/or in combination for the purpose of healing, diagnostics and disease prevention i.e. the preservation of well-being" [1, 2]. The abbreviation CAM--complementary and alternative medicine is used by the professional public and it entails the following: "Group of systems and products that are used for the purpose of providing health care together with conventional medicine but are not currently considered a part of it" [1, 2]. Apart from complementary and alternative medicine the WHO uses the term traditional medicine (TM). The term of traditional medicine includes things that have their own tradition and history (for instance Chinese traditional medicine, Indian Ayurveda, Tibetan medicine, Unani-Arabic medicine and so on). It is a general term and it is related to the culture of a specific nation [1, 2]. On the territory of the Rublic of Serbia TM and CAM are integrated in the healthcare system in accordance with the Healthcare Law of Serbia (Legal Gazette no. 107/05) [3]. The law has equated TM and CAM with conventional medicine and given the patients the right to be informed about alternative treatment methods, thus obliging healthcare workers to give respective information. All TM and CAM that can be used on all three levels of health care on the territory of the Republic of Serbia are divided into two categories: Diagnostic methods and treatments and Rehabilitation methods (for the advancement of health) [3].

Information about the attitudes of nurses on the utilization of TM and CAM come foremost from the developed parts of the world [4-10]. In our country, the knowledge about the attitudes of healthcare workers, especially nurses and technicians, towards TM and CAM is limited. According to our literature review only one research has been done on attitudes toward CAM (which was published in 2013), but the participation of nurses in that research was limited to only six participants [11]. Therefore, it is the aim of our paper to determine the attitudes and beliefs of nurses and medical technicians about the application of CAM and TM, personal application of CAM and their recommendations to the patients about the usage of CAM at the General Hospital in Subotica.

Material and Methods

The study, planned as a cross-sectional survey, was performed at the General Hospital in Subotica from November 2016 to July 2017. A hundred and twenty-six nurses and medical technicians participated in the research. The survey was performed on the voluntary basis irrespectively of years of service and education levels. Nurses and medical technicians that were on their residency or volunteering at the General Hospital in Subotica were excluded from the survey. The study was approved by the Ethics Board of the General Hospital in Subotica and the Ethics Committee of the Faculty of Medicine Novi Sad, University of Novi Sad.

Study Instruments

We used the CAM Health Belief Questionnaire --CHBQ instrument to determine the attitudes of nurses and medical technician about CAM. This questionnaire is widely applied by the population of health workers in hospital conditions. It consists of 10 items that are answered by a seven-point Likert scale (from 1--I absolutely disagree, to 7--I absolutely agree). Items 6, 7 and 8 are reverse scored in order to minimize the influence of disinterest in participants. By adding up points from each item we get the general score that represents the attitudes of a participant. It can be positive, neutral and negative. The maximum and the minimal possible score that can be achieved is 70 and 10, respectively. The authors have defined the value of 35 as an indicator of a neutral stance, scores above 35 point to a positive attitude and those under 35 go towards a negative attitude [12]. The authors of this paper redesigned this questionnaire for the purposes of this study in order to determine which CAM modality were recommended by the nurses and medical technicians to their patients and used themselves.

Statistical Data Analysis

The indicators of descriptive statistics used in this study were calculated by means of univariate analysis, measures of central tendency, variability measures and methods of bivariate analysis (correlation and regression coefficients). The following comparative statistics methods were used: Student's t-test to determine the gender differences between mean values of two samples and the Z-test to determine the significance of proportion differences between two samples. The obtained results were interpreted as statistically significant if p values were lower than 0.05 or highly significant if lower than 0.01.

Test validity was proved by analyzing the correlations between the scores of the CHBQ questionnaire and answers regarding the usage and recommendations of modalities. Statistical processing was performed by using the IBM SPSS Statistics 22 package.


Out of 123 distributed questionnaires, 83 were returned to be processed, which means that the response rate was 65.87%. Table 1 presents the sociodemographic characteristics of the participants. Most of the answers were given by nurses (91.6%) aged between 35 and 39 years, with 11 do 16 years of service (26.5%) and high school education level (79.5%). The youngest and the oldest participant were 20 and 56 years old, respectively. The average age of nurses and medical technicians that participated in the survey was 37.3[+ or -]9.89(SD) with the average length of service of 14.10[+ or -]8.37(SD) years.

According to the data presented in Table 2 the nurses and medical technicians most often used local traditional medicine (56.6%), then phytotherapy (43.4%) and homeopathy (19.3%) from the group Diagnostics methods and treatments group. In addition, they recommended their patients the very same methods they used themselves. By analyzing the socio-demographic characteristics of the participants it was observed that the nurses and medical technicians aged 38 and older recommended diagnostic and treatment methods more readily than the younger participants (Z=2.15; p=0.03).

As for Rehabilitation methods, most of the nurses used apitherapy in personal life (54.22%), 37.35% of them practiced yoga, 36.14% used aromatherapy and 21.69% applied constellation work. Besides, most of the participants recommended the same methods to their patients.

On average 15.42% of the participants used some of diagnostic and treatment methods and 20.36% of them applied some of the methods for rehabilitation and health improvement. The participants chose methods of rehabilitation and health improvement more frequently (Z=2.91; p=0.03).

The highest positive value with respect to the CAM effects was achieved on the item 5 of the questionnaire (4.9[+ or -]1.4(SD)) while the lowest one was recorded for the item 7 (3.8[+ or -]1.5(SD)). Other results can be seen in Table 3. The mean score value of the participants on the CAM attitude evaluation questionnaire was 44.8[+ or -]1.3 (SD), which suggests the positive attitude. The regression correlation coefficient was calculated to assess the correlation between the attitudes and recommendations of nurses and medical technicians towards CAM. The obtained value of regression coefficient (r=0.413; t=4.21; p=0.00) was suggestive of the positive correlation; the increased score on CHBQ questionnaire increases the average number of YES responses regarding the recommendation of CAM methods by 0.413. The scree plot and the regression line are shown in Graph 1.


The interest for and the availability of traditional medication and complementary--alternative methods make them more and more appealing, as shown by the results from many studies which reported that TM and CAM usage was continuously on the rise in the last decade of the 20th century. The reasons for the increased use of CAM in the general population differ in literature and include the improvement function of the immune system [13-15], decrease of adverse effects [15, 16], pain control [17], belief that CAM is safer than conventional medication [17]. Personal experience, knowledge and education have been pointed out as factors that contribute most to forming attitudes towards CAM in the population of nurses and medical technicians, and to their willingness to recommend them to the patients [5-11, 14]. The results of our study show that more than half of the nurses and technicians themselves use the methods of local traditional medicine and apitherapy (56.6% vs 54.2%), then homeopathy (19.3%), phytotherapy (43.4%), yoga (37.5%), constellation work (21.7%) and aromatherapy (36.1%). The analysis of sociodemographic predictors for the personal use and professional recommendation of CAM in the category of Diagnostic and treatment methods and Rehabilitation methods revealed that the personal use of CAM dominated among the nurses and medical technicians aged 38 and older, who worked for 15 years or longer. With regards to the recommendations given to patients, a little less than half of the nurses and technicians (43.3%) recommended CAM methods of diagnostics and treatment. Such results are in accordance with a study published in 2016 where the authors pointed out that the nurses did not often use CAM in practice [17]. The results obtained in our study are not surprising, given the fact that there are many obstacles for including CAM into clinical practice on the nursing level. One of the obstacles is the absence of education opportunities for nurses and medical technicians in the field of applied CAM modalities and the insufficient number of nurses licensed to perform CAM according to the current standards and rulebooks. It is also worth noting that only homeopathy out of all Methods of diagnostics and treatment and Methods of rehabilitation approved by the Ministry for Health of the Republic of Serbia has found its application in clinical-hospital situations at the General Hospital in Subotica, where this research was conducted.

The methods most recommended to patients by nurses and technicians are those that they themselves have used. The results of a study performed in the United States of America have also shown that the CAM modalities used by nurses themselves are those that are most recommended to patients by nurses, which further corroborates our claims [4]. A significant number of experts claim that the personal use of CAM by healthcare workers is the main determinant in moving towards integrative care, the fusion of CAM and allopathic medicine [4-8, 17].

Nevertheless, considering the average score of the CHBQ questionnaire (44.8[+ or -]1.38 (SD)), it can be said that the attitude of nurses and technicians in our country toward CAM is positive. Research results suggest that nurses and technicians are aware of the fact that patients should be viewed as a union of the body, mind and soul, and that the integration of the patients' expectations, beliefs and values is crucial for adequate healthcare.

The highest communality among the participants was achieved on the CHBQ 5 item 5 (4.9[+ or -]1.4(SD)), and the lowest was on the CHBQ item 7 (3.8[+ or -]1.5 (SD)). Such results are in accordance with the results obtained by previous studies and they suggest that the majority of nurses and medical technicians respect the expectations and beliefs of their patients. However, they also suggest that the absence of scientific evidence to prove the efficiency and safety of certain CAM can be the reason for the low communality on the item 7 [16-18].

When comparing the results of our study and the studies performed in eight cities in Serbia during 2010 and 2011 we can conclude that the nurses and technicians in the General Hospital in Subotica have lower average scores on CHBQ when compared with medicine and dentistry students (50.26 [+ or -] 7.92(SD) vs 50.26 [+ or -] 7.92(SD)) and university professors (50.29 [+ or -] 9.50(SD)) [11]. Nevertheless, the participants in both studies have shown positive attitudes towards CAM on the whole.


Most of the nurses and medical technicians have the positive attitude towards CAM, and this is a consequence of positive personal experience. Their experience is also the reason for making recommendations to patients. The results show that nurses and technicians are ready for further integration of CAM categorized as Methods of diagnostics and treatment and Methods of rehabilitation in the clinical-hospital practice in the General Hospital in Subotica.


[1.] World Health Organization, Traditional medicine strategy 2014-2023 [Internet]. 2017 [cited 2017 Jun 14]. Available from:

[2.] National Center for Complementary and Integrative health, Complementary, Alternative, or Integrative Health: What's In a Name? [Internet]. 2017 [cited 2017 Jun 14]. Available from:

[3.] Ministry of Health of Serbia. Traditional (complementary and alternative) medicine [Internet]. 2017 [cited 2017 Jun 14]. Available from:

[4.] Johnson PJ, Ward A, Knutson L, Sendelbach S. Personal use of complementary and alternative medicine (CAM) by U.S. healthcare workers. Health Serv Res. 2012;47(1 Pt 1):211-27.

[5.] Shorofi SA, Arbon P. Nurses' knowledge, attitudes, and professional use of complementary and alternative medicine (CAM): a survey at five metropolitan hospitals in Adelaide. Complement Ther Clin Pract. 2010;16(4):229-34.

[6.] Holroyd E, Zhang AL, Suen LK, Xue CC. Beliefs and attitudes towards complementary medicine among registered nurses in Hong Kong. Int J Nurs Stud. 2008;45(11):1660-6.

[7.] Shorofi AS, Arbon P. Complementary and alternative medicine (CAM) among Australian hospital-based nurses: knowledge, attitude, personal and professional use, reasons for use, CAM referrals, and socio-demographic predictors of CAM users. Complement Ther Clin Pract. 2017;27:37-45.

[8.] Trail-Mahan T, Mao CL, Bawel-Brinkley K. Complementary and alternative medicine: nurses' attitudes and knowledge. Pain Manag Nurs. 2013;14(4):277-86.

[9.] Johannessen B, Garvik G. Experiences with the use of complementary and alternative medicine in nursing homes: a focus group study. Complement Ther Clin Pract. 2016;23:136-40.

[10.] Orkaby B, Greenberger C. Israeli nurses' attitudes to the holistic approach to health and their use of complementary and alternative therapies. J Holist Nurs. 2015;33(1):19-26.

[11.] Jakovljevic MB, Djordjevic V, Markovic V, Milovanovic O, Rancic NK, Cupara SM. Cross-sectional survey on complementary and alternative medicine awareness among health care professionals and students using CHBQ questionnaire in a Balkan country. Chin J Integr Med. 2013;19(9):650-5.

[12.] Lie D, Boker J. Development and validation of the CAM Health Belief Questionnaire (CHBQ) and CAM use attitudes amongst medical students. BMC Med Educ. 2004;4:2.

[13.] Oyunchimeg B, Hwang JH, Ahmed M, Choi S, Han D. Complementary and alternative medicine use among patients with cancer in Mongolia: a National hospital survey. BMC Complement Altern Med. 2017;17(1):58.

[14.] Lettner S, Kessel KA, Combs SE. Complementary and alternative medicine in radiation oncology: survey of patients' attitudes. Strahlenther Onkol. 2017;193(5):419-25.

[15.] Teo TY, Yap J, Shen T, Yeo KK. Complementary and alternative medicine use amongst patients with cardiovascular disease in Singapore. BMC Complement Altern Med. 2016;16 (1):446.

[16.] Marshik PL, Kharat AA, Jakeman B, Borrego ME, Dodd MA, Bachyrycz A, et al. Complementary and alternative medicine and therapy use in a diverse new Mexican population. J Altern Complement Med. 2016;22(1):45-51.

[17.] Balouchi A, Rahnama M, Hastings-Tolsma M, Shoja MM, Bolaydehyi E. Knowledge, attitude and use of complementary and integrative health strategies: a preliminary survey of Iranian nurses. J Integr Med. 2016;14(2):121-7.

[18.] Ernst E. How nurses can be misled about complementary and alternative medicine. J Adv Nurs. 2015;71(2):235-6.

Sanja TOMIC (1), Goran MALENKOVIC (1), Ivica LALIC (1,2), Slobodan TOMIC (3) and Nensi LALIC (1)

(1) University of Novi Sad, Faculty of Medicine, Department of Nursing

(2) Clinical Center of Vojvodina, Novi Sad, Department of Orthopedic Surgery and Traumatology

(3) University of Novi Sad, Faculty of Medicine

Corresponding Author: Doc. dr Sanja Tomic, Univerzitet u Novom Sadu, Medicinski fakultet, Katedra za zdravstvnu negu, 21000 Novi Sad, Hajduk Veljkova 3, E-mail:


WHO--World Health Organization

CAM--Complementary and alternative medicine

TM--traditional medicine

CHBQ--CAM Health Belief Questionnaire

Rad je primljen 3. IX 2018.

Recenziran 5. IX 2018.

Prihvacen za stampu 10. IX 2018.

BIBLID.0025-8105:(2018):Suppl 1:53-58.
Table 1. Socio-demographic characteristics of participants
Tabela 1. Socio-demografske karakteristike uzorka

                                                                n (%)

Female/Zenski                                                 76 (90.1)
Male/Muski                                                     7 (9.9)
Lifetime intervals in years/Intervali zivotnog doba u
20-29                                                         19 (22.9)
30-39                                                         31 (37.3)
40-49                                                         19 (22.9)
55-59                                                         14 (16.9)
Years of service in yearly intervals/Intervali duzine radnog
staza u godinama
0-4                                                           19 (22.9)
5-10                                                           7 (8.5)
11-16                                                         22 (26.5)
17-22                                                         16 (19.4)
23 i vise                                                     18 (21.7)
Education levels/Stepen obazovanja
High school/Srednja skola                                     66 (79.5)
Vocational school/Graduate degree Visa skola/fakultet         17 (20.4)
Total/Ukupno                                                  83 (100)

n = Absolute frequency/Apsolutna ucestalost; % = Relative frequency
/Relativna ucestalost

Table 2. The frequency of usage and recommending of the most commonly
practiced complementary-alternative methods.
Tabela 2. Distribucija primene i preporuka najcescih
komplementarno-alternativnih metoda

CAM accordance with the            Use/Primena         Recommendation
Healthcare Law of Serbia                                /Preporuka
CAM prema Ministarstvu
zdravlja Republike Srbije
                                Da/Yes     Ne/No     Da/Yes    Ne/No
                                n (%)      n (%)     n (%)     n (%)

Diagnostic and treatment
methods/Metode dijagnostike
Homeopathy/Homeopatija        16 (56.6)  67 (80.7)  45 (54.2)  67 (32.5)
Phytotherapy/Fitoterapija     36 (43.4)  47 (56.6)  52 (62.7)  47 (37.3)
Local traditional medicine    47 (19.3)  36 (43.4)  56 (67.5)  36 (45.8)
/Tradicionalna domaca
Rehabilitation methods
/Metode rehabilitacije
Apitherapy/Apiterapija        45 (54.2)  38 (78.5)  57 (68.7)  26 (31.3)
Aromatherapy/Aromaterapija    30 (37.5)  53 (63.9)  39 (47)    44 (53)
Yoga exercises/Joga vezbe     31 (36.1)  52 (62.5)  45 (54.2)  38 (45.8)
Constellation Work/Porodicni  18 (21.7)  65 (45.8)  44 (53)    39 (47)

n = Absolute frequency/Apsolutna ucestalost; % = Relative frequency
/Relativna ucestalost

Table 3. Distribution of answers of the nurses on statements from CHBQ
Tabela 3. Distribucija odgovora medicinskih sestara na tvrdnje iz CHBQ

CAM Health Belief Questionnaire/CHBQ/Upitnik CHBQ
Items/Stavke                                             Mean[+ or -]SD
                                                        Prosek[+ or -]SD

1. The physical and mental health are maintained by an   4.5[+ or -]1.5
underlying energy or vital force Fizicko i mentalno
zdravlje su odraz vitalne energije tj. vitalne sile.
2. Health and disease are a reflection of balance        4.6[+ or -]1.5
between positive life-enhancing forces and negative
destructive forces/Zdravlje i bolest su odraz
(narusene) ravnoteze izmedu pozitivnog stava o zivotu
njegovim promenama i negativne destruktivne sile.
3. The body is essentially self-healing and the task     4.4[+ or -]1.6
of a health care provider is to assist in the healing
process/Telo je u sustini samoisceljujuce i zadatak
zdravstvenog radnika je da ucestvuje u procesu
4. A patient's symptoms should be regarded as a          4.7[+ or -]1.6
manifestation of general imbalance of dysfunction
affecting the whole body/Simptome pacijenta treba
posmatrati kao generalnu neravnotezu funkcija koje
zahvataju ceo organizam.
5. A patient's expectations, health beliefs and values   4.9[+ or -]1.4
should be integrated into the patient care process
Ocekivanja pacijenta, zdravstvena uverenja i vrednosti
treba da budu integrisani u proces zdravstvene nege
6. Complementary therapies are a threat to public        4.6[+ or -]1.2
health/CAM terapije ugrozavaju javno zdravlje.
7. Treatments not tested in a scientifically             3.8[+ or -]1.5
recognized manner should be discouraged
/Komplementarno-alternativne terapije koje nisu
testirane na naucno priznat nacin treba zabraniti.
8. Effects of complementary therapies are usually the    4.3[+ or -]1.3
result of a placebo effect/Efekti CAM i terapija su
uglavnom rezultati placebo efekta.
9. Complementary therapies include ideas and methods     4.5[+ or -]1.0
from which conventional medicine could benefit/ CAM i
terapije ukljucuju ideje i metode iz kojih bi
konvencionalna medicina mogla imati koristi.
10. Most complementary therapies stimulate the body's    4.6[+ or -]1.1
natural therapeutic powers/Vecina CAM i terapija
stimulise prirodnu terapijsku moc tela.

Mean score value/Ukupna prosecna vrednost skora         44.8[+ or -]1.3
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Author:Tomic, Sanja; Malenkovic, Goran; Lalic, Ivica; Tomic, Slobodan; Lalic, Nensi
Publication:Medicinski Pregled
Article Type:Report
Date:Aug 15, 2018

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