3. Methodology
3.2 Analysis methods
The data collected though questionnaire were entered to Microsoft Excel then exported and analysed through SPSS.
Descriptive statistics
We first analysed the data using simple descriptive statistics. The results are reported through the analyses of frequencies and we used valid percent to present the data in the figures and tables.
Comparative statistics
Our aim was to understand how the physician, his Chinese medicine education course and the environment influenced his acupuncture practice.
Therefore we chose six groups of factors, which were the age of the physician, his years of clinical practice, his education course, the type of hospital he works in, the geographical situation of the hospital and the density of urbanisation.
The different groups were subdivided into different variables and we performed the chi-square test to determine if there were notable differences between the variables into each group with regards to acupuncture practice.
Table 3.2.1 Factor 1: Education course
Variable 1 School of Chinese medicine
Variable 2 School of Post baccalaureate Chinese medicine Variable 3 Special license qualification examination
Table 3.2.2 Factor 2: Age of the Chinese medicine physicians
Variable 1 Under 30 years
Variable 2 30 to 39 years
Variable 3 40 to 49 years
Variable 4 50 and more years
Table 3.2.3 Factor 3: Years of practice
Variable 1 1 to 5 years
Variable 2 6 to10 years
Variable 3 11 to 20 years
Variable 4 More than 20 years
Table 3.2.4 Factor 4: Type of hospitals
Variable 1 Teaching hospital
Variable 2 Regional hospital
Variable 3 Rural hospital
Variable 4 Chinese medicine hospital
Table 3.2.5 Factor 5: Geographical situation
Variable 1 North
Variable 2 Centre
Variable 3 South
For the distinction between North, Centre and South, we used the National Health Insurance district boundaries that divided the countries in six regions30. The North referred to the northern region and the Taipei area, the Centre to the central region and the South to the southern region and the Kaoping region. We didn’t include the eastern region because the sample was too small to be computed in the statistics.
Table 3.2.6 Factor 6: Urbanisation
Variable 1 Cities area
Variable 2 Districts area
The cities and districts areas are administrative boundaries planned out by the Taiwanese government. We assumed that cities areas were more urbanized than districts areas. The cities areas included Taipei city, Keelung city, Hsinchu city, Taichung city, Chiayi city, Tainan city and Kaohsiung city. The districts areas included all the districts in the north, central and south part of the island.
For the questions 2.1 and 2.2 in the second part of the questionnaire, which included a frequency rating (Never used=0; Rarely=1; Occasionally=2;
Frequently=3; Very frequently=4), we also performed the one-way Anova test (the T test for the comparison between cities and districts areas) to determine the differences of frequencies between the different variables.
Then we used the post hoc analysis Tukey’s test to determine which variable were significantly different and which were not.
Finally in order to test the potential association of the different groups of factors with the items of our questionnaire we performed a multiple linear regression analysis for the questions concerning the treatment methods (question 2.1), the diseases categories treated by acupuncture (question 2.2), the importance accorded to the diagnosis tools (question 3A1), the importance accorded to the pattern identifications (question 3A2), questions about needles techniques (questions 3B4 and 3B5) and the rational for choosing acupuncture points as well as the importance accorded to acupuncture points categories (question 3B6).
Questionnaire reliability
We tested the validity of the questionnaire on 14 physicians. After of the reception of the first questionnaire we sent back two weeks later the same questionnaire and analysed the reliability of the answers. We tested the main questions of the questionnaire: 2.1 (15 items); 2.2 (16 items); 3A1 (16 items); 3A2 (4 items); 3B4 (4 items); 3B5(6 items) and 3B6 (12 items). If
we reported the average measure of ICC (Intraclass correlation) we obtained an average of 0.7 that signify a very good reproducibility. If we reported the single measure of ICC, we obtained an average of 0.53, which still indicate a fair reproducibility31. The two main questions which obtained the lower alpha value were the question 3A1 (Alpha= 0.49) and 3A2 (Alpha= 0.46), which concerned the diagnosis tools.
4.1 Questionnaire distribution
The questionnaire was send to 403 Chinese medicine physicians working in hospitals. We selected Chinese medicine hospitals and Western medicine hospitals32 with a department of Chinese medicine. The physicians that received the questionnaire were asked to carefully fill it, in return they will obtain 2 credit points from the Chinese Medical Association of Acupuncture33 (中華針灸醫學會). From the 403 questionnaire sent, 177 physicians returned the questionnaire (44%). However, only 160 questionnaires were used for this study (39.9%). We excluded 17 questionnaires because 11 were blank with sometimes a note explaining that the Chinese medicine physician didn’t use acupuncture as a therapeutic method. The 6 other questionnaires were excluded because they contained too much missing data.
4.2 Profile of the questionnaire respondents
The age range of the respondents of the questionnaire was from 28 to 75 years, the average age was 39 years.
Table 4.2.1 Age of the respondents Age of the respondents (n=159)
Under 30 years 6.9%
30 to 39 years 44.7%
40 to 49 years 43.0%
50 years and more 14.5%
A majority of respondents were male (67%). The results showed a female predominance in younger physicians (group age: “under 30 years”
and “30 to 39 years”). This result was also correlated with the years of clinical practice where we found less female physicians with a long clinical experience.
Most of the physicians obtained a bachelor degree in Taiwan. A lot of them also had a master degree. A few possessed a PhD but one third of these PhD were issued from mainland China.
Figure 4.2.1 Degree obtained by the physicians
A majority of the respondents were graduated from the school of Chinese medicine and the school of Post baccalaureate Chinese medicine.
Table 4.2.2 Chinese medicine course Chinese medicine course (n=160)
School of Chinese medicine 51.3%
School of Post baccalaureate Chinese medicine 44.4%
Special licence qualification 4.4%
In the school of Post baccalaureate Chinese medicine, we found a larger proportion of female physicians (41.5%) than in the other groups (25.7% for
the school of Chinese medicine and 14.3% for the special licence qualification group). The special licence qualified physicians were older than the physicians in the two other groups, 86% of them fell in the categories of
“40 to 49 years” and “50 and more years” (49% for the physicians of the school of Chinese medicine and 45% for the physicians of the school of Post baccalaureate Chinese medicine). Furthermore, they were working only in regional hospitals (71.4%) and teaching hospitals (28.6%). For the two other groups, the physicians were distributed in all the different hospitals.
The majority of the respondents didn’t have a lot of clinical experience.
Their average years of practice was 7 years (from 1 to 36 years). A large proportion of the physicians of the school of Chinese medicine and the school of Post baccalaureate Chinese medicine fell in the category of “1 to 5 years” of clinical practice. In comparison the special licence qualified physicians had more clinical experience, 43% of them had more than 10 years of clinical experience (37% for the physicians of the school of Chinese medicine and 19% for the physicians of the school of Post baccalaureate Chinese medicine).
Figure 4.2.2 Years of practice
Most of the physicians worked in a teaching hospital or a regional hospital. The location of the hospitals within cities areas or a districts areas was well balanced. 56% of the hospitals were situated in cities areas and 46% in districts areas.
Figure 4.2.3 Place of practice
Figure 4.2.4 Hospitals geographical situation
There were a majority of hospitals situated in the North, but the three regions were well represented. The teaching hospitals were distributed in the three parts of the island. A majority of rural hospitals were located in the central part of the island and the Chinese medicine hospitals were mainly situated in the North and in the South. The rural hospitals were more likely to be located in districts areas and the Chinese medicine hospitals were mainly located in cities areas. Teaching and regional hospitals were almost equally distributed between cities and districts areas.
We found a high rate of teaching experience as well as publication that showed an active participation and contribution of the physicians to the medical field. 60.6% of the physicians had teaching experience and 60% of the physicians published articles. Most of the publications were in Chinese.
Table 4.2.3 Publications
Publication Chinese journal SCI journal Chinese & SCI journals
48.8% 6.9% 4.4%
This participation was related to the age, the years of practice and the education background. In general, teaching experience, publications and participation of international meeting showed a higher rate for the older physicians and for physicians with a long clinical practice. Statistical evidences demonstrated that the teaching experience was correlated to the age and years of practice of the physicians and that the age was also related to the publication’s rate.
Table 4.2.4 Participation and contribution regarding the age of the physicians
Age Under 30
years
30 to 39 years
40 to 49 years
50 years and more
Teaching experience* 18.2% 53.5% 78.2% 60.9%
Publication* 18.2% 49.3% 78.2% 69.6%
Participation to international meetings
27.3% 20.3% 31.5% 36.4%
Table 4.2.5 Participation and contribution regarding the years of practice of the physicians
Years of practice 1 to 5 years
6 to 10 years
11 to 20 years
More than 20 years
Teaching experience* 44.1% 68.9% 79.4% 77.8%
Publication 50.0% 62.2% 73.5% 77.8%
Participation to international meetings
27.9% 16.7% 35.3% 37.5%
It is interesting to note that younger physicians and physicians with less years of clinical practice were more used to teach in students or public associations as older physicians and physicians with more years of clinical practice were teaching in universities, hospitals, medical associations or opening their own classes.
The education background also played a role even there was no statistical evidence for it. Special licence qualified physicians showed a higher rate of participation and contribution. They were mainly teaching in medical associations, student or public associations or having their own class.
Physicians from the school of Chinese Medicine were more likely to teach in the universities and finally physicians of school of Post baccalaureate
Table 4.2.6 Participation and contribution regarding education course of the physicians
Education background School of Chinese medicine
School of Post baccalaureate Chinese medicine
Special licence qualification
Teaching experience 66.2% 53.7% 85.7%
Publication 67.6% 52.4 71.4%
Participation to international meetings
30.0% 22.8% 49.2%
4.3 Use of acupuncture in general
Acupuncture in Chinese Medicine practice
Chinese Medicine is characterized by its multiplicity of therapeutic methods, the main ones are the medicinal treatment and the acupuncture and moxibustion treatments, besides comes the manipulations techniques 34 including massage or tuina and the prevention techniques that optimize the circulation of Qi like Qigong. Finally other minor techniques as cupping, guasha, bloodletting, the application of plasters and fumigations are also frequently used. In Taiwan, one Chinese medicine physician usually relies on many therapeutic methods35. Nevertheless some choose to specialize only in the field of medicinal treatment, some others use both acupuncture and medicinal treatment and add others techniques like manipulation, cupping, guasha and so on. Therefore acupuncture is one of the therapeutic methods used by Chinese Medicine physicians.
The data obtained through the questionnaire showed that the most used therapeutic method was the powdered Chinese medicinal, followed by life style advices and then acupuncture.
Figure 4.3.1 Therapeutic methods used
75.5% of the physicians used “very frequently” powdered Chinese medicinal and 65% of them used “very frequently” acupuncture. We can also note the high importance of life style advice (68.4% “very frequently”) that includes recommendations about diet, sleep and exercises.
Statistical evidence demonstrated that the different therapeutic methods were strongly correlated with geographical and urban environment.
There were evidences that acupuncture was more widely used in the North than in the centre of Taiwan. The manipulations methods and the use of red lamp were also more popular in the North of the island. On the contrary, moxibustion and scalp acupuncture are more used in the south than in the centre of the country. A similar trend was also observed for the fumigations, which were more used in the south of the island, even there was
no statistical evidence. There were no differences of the frequency uses of powdered Chinese medicinal and raw Chinese medicinal between the different geographical locations.
0=Never used; 1=Rarely; 2=Occasionally; 3=Frequently; 4=Very frequently
Figure 4.3.2 Frequency of the therapeutic methods used according the geographical situation
The division between cities areas and districts areas also showed some differences in the use of therapeutics method.
Statistical evidence showed that acupuncture, moxibustion, scalp acupuncture and knife acupuncture were more used in districts areas than in cities areas. By contrast, life style advices were more important into cities areas. In general we found a larger use of therapeutics methods in districts areas than in cities areas.
0=Never used; 1=Rarely; 2=Occasionally; 3=Frequently; 4=Very frequently
Figure 4.3.3 Frequency of the therapeutic methods used regarding the cities and districts areas
Regarding the therapeutic methods there was only one statistical evidence related to the years of clinical practice. Statistics demonstrated that raw Chinese medicinal were more used by physicians with a longer clinical experience. We found the same tendencies for the bloodletting technique. In contrast, the use of powdered Chinese medicinal was more frequently use by the physician with 6 to 10 years of clinical experience.
The use of raw Chinese medicinal and bloodletting technique was also correlated with age. Older physicians favoured more the use of these two therapeutic methods than younger physicians. That also was the case for the use of ear acupuncture, which was more popular for the group age between 40 to 49 years and 50 and more years. The use of powdered Chinese medicinal was predominant for the physicians between 30 to 49 years old.
Statistical evidences also showed that the bloodletting technique was correlated to educational background. Special licence qualified physicians used considerably more this techniques than the two other groups. The
special licence qualified physicians also stand out of the other groups by the fact they used more raw Chinese medicinal and didn’t used at all knife acupuncture nor Qigong techniques. We can note that if bloodletting technique and the use of raw Chinese medicinal were strongly correlated with special licence qualified physicians that could be due to the fact that in this group the physicians were older than the physicians from the school of Chinese medicine and the school of Post baccalaureate Chinese medicine (see profile of the respondent p. 20-1).
There were no evidences for the correlation between the different hospitals and the therapeutics methods. However we can distinguish some tendencies especially concerning rural hospitals and Chinese medicine hospitals. In the rural hospitals we found a higher rate of moxibustion and fumigation use. On the contrary, we found less use of raw Chinese medicinal and knife acupuncture than in the other type of hospitals. We also found some similarity between rural hospitals and Chinese medicine hospitals were the use of manipulations and plasters were higher than in teaching and regional hospitals.
Through the multiple linear regression analysis, we found that the group of factors that influenced strongly the use of the treatment methods was those correlated with the environment. There were four evidence of association related to geographical areas (moxibustion, knife acupuncture, manipulations and the use of red lamp). Two evidences were related to the cities/districts areas (manipulations and life style advice) and finally one was related to the type of hospitals (manipulations). The age was also influencing the choice of therapeutic methods (two evidences for the use of acupuncture and the use of red lamp). Finally, one evidence was related to the education background of the physicians and it concerned the use of the bloodletting technique.
Table 4.3.1 Factors associated with the treatment methods (1st Page)
Data were analysed through Multiple Linear Model analysis and we chose to represent only the factors that attained statistical evidences.
The factors didn't showed a difference with the following treatment methods: ear acupuncture, scalp acupuncture, raw Chinese medicinal, powdered Chinese medicinal, plaster, fumigations, cupping, guasha, qigong
a. This parameter is set to zero because it is redundant
* P<.05
**P<.001
Acupuncture Moxibustion Manipulation Bloodletting
95% Special licence
-.03 Under 30 years old
30 to 39 years old 40 to 49 years old More than 50 years old
-.59 11 to 20 years of practice More than 20 years of practice
.37 Teaching hospital
Regional hospital Rural hospital
Chinese medicine hospital
-.11 North of Taiwan
Centre of Taiwan South of Taiwan
.12 Cities areas
Districts areas
-.30
Table 4.3.1 Factors associated with the treatment methods (Page 2)
Data were analysed through Multiple Linear Model analysis and we chose to represent only the factors that attained statistical evidences.
The factors didn't showed a difference with the following treatment methods: ear acupuncture, scalp acupuncture, raw Chinese medicinal, powdered Chinese medicinal, plaster, fumigations, cupping, guasha, qigong
a. This parameter is set to zero because it is redundant
* P<.05
**P<.001
Knife acupuncture Life style advices Redlamp
95% Special licence
.34 Under 30 years old
30 to 39 years old 40 to 49 years old More than 50 years old
-.07 11 to 20 years of practice More than 20 years of practice
-.16 Teaching hospital
Regional hospital Rural hospital
Chinese medicine hospital
-.03 North of Taiwan
Centre of Taiwan South of Taiwan
-.12 Cities areas
Districts areas
-.02
Diseases treated by acupuncture
Acupuncture is used to improve the communication and circulation between the meridians and regulate the flow of the Qi and the blood in the meridians36. Therefore it can treat many diseases.
Results issued from the questionnaire data showed that the most common kind of diseases treated by acupuncture were mainly diseases of the musculoskeletal system and nervous and vascular system37. Then came the ear, throat and nose diseases, digestive system disease and rheumatoid and immune diseases.
Figure 4.3.4 Diseases categories treated by acupuncture
Besides the ten major diseases picked up among the list of 64 diseases recommended by the WHO for acupuncture treatment were: low back pain, sciatica, sprain and strain, scapulo humeral periarthritis, headache, myopia of children, chronic pain of the locomotor system, dysmenorrhea, backache and facial paralysis38.
Figure 4.3.5 Most common diseases treated by acupuncture
Apart these ten first common diseases commonly treat with acupuncture, Chinese medicine physicians are also used to treat cervical spondylopathy (60 physicians), hemiplegia (58 physicians), tennis elbow (55 physicians), insomnia (55 physicians), rhinallergosis (53 physicians), migraine (36 physicians), tonic headache (32 physicians), nausea and vomiting (32 physicians), oppilation (27 physicians), prosopalgia (25 physicians)and simple obesity (20 physicians).
Comparative statistics showed some interesting features on how diseases categories treated by acupuncture were related to the physicians educational background, age and years of clinical practice as well as to the geographical environment. Furthermore some evidences also showed some links between the different kind of hospitals and the diseases treated.
The most striking statistical evidences were linked to the educational background. The special licence qualified physicians used acupuncture for a lager scope of diseases than physician graduated from the school of Chinese medicine and the school of Post baccalaureate Chinese medicine. For the 16 different diseases categories mentionned in the questionnaire, 10 showed evidences of the differences between the special licence qualified physicians with the two other groups (table 4.3) and 3 showed evidences of the differences between the special licence qualified physicians and one of the other groups. Special licence qualified physicians displayed always a higher rate of acupuncture use except for musculoskeletal, neurological diseases and poisoning where there were no differences between the three groups.
0=Never used; 1=Rarely; 2=Occasionally; 3=Frequently; 4=Very frequently
Figure 4.3.6 Diseases categories treated by acupuncture according to the education course
The age of the physician was also strongly correlated with the categories of diseases treated by acupuncture. The older the physicians were, they used acupuncture for a larger scope of diseases. We obtained statistical evidences for four categories: Rheumatoid and immune diseases, neoplasm, diseases of the respiratory system and diseases of the blood. We observed two kinds of tendencies. The first one was a progressive increase of the
The age of the physician was also strongly correlated with the categories of diseases treated by acupuncture. The older the physicians were, they used acupuncture for a larger scope of diseases. We obtained statistical evidences for four categories: Rheumatoid and immune diseases, neoplasm, diseases of the respiratory system and diseases of the blood. We observed two kinds of tendencies. The first one was a progressive increase of the