Question 1: The rationale for this study is – due to increased interest of complementary and alternative medicine (CAM) in inflammatory bowel movements patients, a study needs to be conducted for patients with chronic disease who opt for (CAM). The researchers found that patients opt for complementary and alternative medicine (CAM) when conventional therapies are unable to relieve their health issues. So, this study is conducted for the following research questions - to explore the use of complementary and alternative medicine (CAM) and its effects on inflammatory bowel movements patients. Therefore, the researchers conducted a multi-centered, cross-sectional, and controlled study. The cross-sectional studies are used to get more insights about the health needs of the population or the burden of the disease. The advantage of using such a study is the data is obtained at a faster rate.
Question 2: Yes, the groups were comparable. In this study, the main groups and the control were comparable in various factors, these factors are listed below: They all were Swedish in origin and factors of sex, age, and geographic areas were also considered. Moreover, other factors like rural or urban were also performed for a better comparable group. The questionnaire in the study was sent to all the participants and returned letters are considered as written consent.
Question 3: Yes, the cases and the groups matched appropriately. The characteristics of this topic are briefly stated in the initial part of the article so that the reader gets a clear idea for the groups and study as well. They were all from Sweden and were the patients in Swedish hospitals. It was found that for this study the control group was selected from a residence registry, Statens Person Address Register (SPAR), whereas the inflammatory bowel disease (IBD) patients from the IBD centers of Sweden were invited. Moreover, the matching was performed for various factors like age, rural, urban, sex, marital status, education, or geographic areas.
Question 4: Yes, the same criterion was used for the identification of cases and control. For identification, there was the use of various key characteristics like geographic region, the inflammatory bowel disease patients, the groups were compared on the basis of factors like alcohol or tobacco use, age, sex, education, marital status, annual income, diet, urban, or rural residence. These factors are clearly stated in the article for a clear understanding of the reader.
Question 5: Yes, the exposure was measured in a reliable, standard, and valid way. The study clearly showed that it conducted statistical considerations for the data collected for both the groups of cases and control as well. It is stated in the study that for dichotomous variables the authors used Fisher’s exact test; for ordered categorical variables, the authors used the Mantel–Haenszel χ 2 –test; for continuous variables, the authors used the Mann–Whitney U-test. Moreover, the authors conducted a two-tailed test for their study, and only who’s P - values were considered to be significant on statistical grounds. The ethical considerations were taken in great importance for the reliability or credibility of the study. All these factors show that the study measured exposure in an effective manner.
Question 6: It is clearly stated in the article that the study conducted statistical and ethical considerations for the data that increases its validity and reliability of the study. There was a use of questionnaires and the results for the cases and control group were compared in each case and for each factor with the overall calculation of positive and negative effects. It was compared that how much percentage of the patients use which type of relieving material like Aloe vera, omega 3, herbal products, yoga, acupuncture, or others, for their health issues. The various factors that were used for outcome measurement were pain, healing, relaxation, and others. So, there was a standardized manner for effective outcome measurement.
Question 7: The confounding factors are those which are other than those discussed as the main focus of the study. These factors have the potential to change the results of the study so the authors focused on them as well in this study. In this study, the confounding factors were very well discussed like smoking, alcohol, use of different types of natural products or healing factors to have a positive impact on the health issue. These factors were measured, calculated, and compared with case groups and the control groups to explore their effects on the health and health outcome of the patients.
Question 8: The study did not mention clearly anywhere how long the exposure period of interest was given. The authors already used those participants who were the patients of inflammatory bowel movements (IBM) disease and preferred the use of complementary and alternative medicine (CAM). For any study, to get reliable and credible results it is suggested to have enough long time for the exposure period so that effective data collection with more information can be conducted for the study, which could reduce the biases or discrepancies.
Question 9: Yes, the study used effective and appropriate statistical analysis for the study. The authors used two-tailed tests, considered P values, confidence interval, odd ratios, performed univariable logistic regression, Mann–Whitney U-test, Mantel–Haenszel χ 2 –test, and Fisher’s exact test. Moreover, they took ethical considerations as well and the study got approval from the ethical committee as well. They conducted a comparative study between the two groups and compared almost every aspect in form of a percentage. The use of proper statistical analysis helps the authors to ensure that the data is collected in an appropriate manner and the method is significant.
Question 10: Yes, there was only one biases or error that crept into the study. Bias in any research study can result in wrong or distorted conclusions and results. It can further lead to unnecessary costs or harm to the patients. The bias is a selection bias of the participants. A selection bias occurs when there is no conduction of randomized trials. As in this study, the authors did not mention in the study that they conducted randomized control trials, however, it is clearly mentioned in the study that they randomly selected the participants for the sample of data collection. It is found that a random selection unable the author to make casual claims about the treatment impacts so that the results are generalized for the population. It was found that in the study the authors did not use a face-to-face manner for their questionnaire. If there is no face-to-face questionnaire, then the interviewer cannot observe the body language and other non-verbal aspects of the participants. The participants that are used in the study and those who answered the questionnaires might be among those who had suffered from serious side effects or other complications due to the use of conventional methods or other approaches. Another reason could be those participants might be among those who were more interested only in the use of complementary and alternative medicine (CAM) for their health issue of inflammatory bowel movements (IBM) disease. This is so because it was found that nearly 93 % of the participants reported the use of conventional medicine but 42 % of them reported the side effects of it. In the study, it was found that the majority of the participants showed positive effects of the use of CAM with a reduction in pain and other benefits of healing. The study also stated at the end that the attitude of the health professionals was not satisfactory, that is, they showed disapproving attitudes when the patients were observed for receiving the complementary and alternative medicine (CAM). The attitude of health professionals is very effective and influential in health care. Their attitude and behavior can either result in stigmatization or improvement in the health of the patent. They should always depict a positive attitude towards the patients, their treatment or medication preferences, and their care services. Moreover, it is found that there is the use of controls in the study which minimizes the effects of variables. This helps in increasing the credibility and reliability of the study. The P values used in this study are very significant in decision-making in medical researches as they help the researcher to conclude the significance of the research in statistical terminology. The Fisher’s exact test is used in this study which is more accurate than the chi-square or G-test and is used more often when the sample size is less than 1000. Furthermore, it was found that some participants did not complete the questionnaire, few did the incomplete questionnaires, few did not revert back at all, and few declined participation. These points might lead to less or insufficient data collection of biases in the study at later stages. Moreover, it was found that the authors used ethical considerations and approval for this study to ensure that there is the presence of either least or no errors and biases in the study.
Question 11: The study found that 83 % of the IBM patients stated that CAM offers positive effects on the health; 14.4 % observed to have negative impacts on their health due to the use of CAM; the majority of the patients found it for pain relief, relaxing, and for well-being; 5.8 % experienced illness and pain; patients who used acupressure experienced no pain, relaxation, and improved health; the patients found that the use of CAM reduced symptoms related to the disease, pain, and depression as well; 18.7 % of the IBM patients used natural products for the treatment; 0.3 % used Ayurveda; 2.3 % used homeopathy; 0.5 % used traditional Chinese medicine. Overall it was found that 48.3 % of the IBM Swedish patients are using different kinds of CAM approaches for their treatments (48.3 %); the control group is using CAM at a comparatively higher rate (53.1 %); one-fifth of the patients are using natural products but controls are found to use them more. It is found that research is going on for the use of vitamin D as a CAM for IBD patients and patients may be recommended with products like probiotics, omega-3, vitamins, or others. These products are considered as CAM forms in this study, but they were never recommended for any of these products by their physicians. Therefore, there is a high need to focus on this study as these products which are in the category of CAM are found to have improved effects on the health of the patients with minimum side-effects. In the case of IBD, the patients were found to have effective and improved results. Moreover, the study stated that there was no conflict of interest so it is important that such a study must be focused on. As the CAM is officially approved within the educational system and in health care, but there is no policy development for it. If such a study will be focused on then it will soon lead to policy development as well. CAM therapies like yoga, various forms of exercises, massage therapies, or others are not only useful in IBD patents but are also useful in various other health issues like diabetes, cancer, its side-effects, pain, nausea, or others. Thus, these points made another important reason for focusing on this study. Another reason can be – such practices ensure culturally safe and holistic care which will also increase the doctor-patient interaction. An increased interaction will affect the health of the patient in a positive manner resulting in patient satisfaction and fast recovery. Complementary and alternative medicine (CAM) includes practices such as drinking green tea, tai-chi, acupuncture, massage, naturopathy, homeopathy, the use of traditional Chinese medicine, and many others.
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