Parents' and primary healthcare practitioners ...

care, health and development Child: Original Article

doi:10.1111/j.1365-2214.2010.01186.x

Parents’ and primary healthcare practitioners’ perspectives on the safety of honey and other traditional paediatric healthcare approaches cch_1186

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Raekha Kumar,* Ava Lorenc,† Nicola Robinson† and Mitch Blair* *River Island Paediatric and Child Health Academic Centre, Imperial College Northwick Park Hospital Campus, Harrow, and †Centre for Complementary Healthcare and Integrated Medicine, Faculty of Health and Human Sciences, Thames Valley University, Brentford, UK Accepted for publication 30 August 2010

Abstract

Keywords beliefs, botulism, child, complementary therapies, honey, traditional medicine Correspondence: Ava Lorenc, Thames Valley University, Paragon House, Boston Manor Road, Brentford TW8 9GA, UK E-mail: [email protected]

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Background Traditional and complementary healthcare approaches (TCA) are widely used for children, often because of perceived safety. Honey is a traditional remedy for upper respiratory tract symptoms in infants. Health officials currently advise limiting honey use because of the risk of botulism. Objective This paper discusses honey as a traditional healthcare approach for children in a multi-ethnic community, and parents’ and primary healthcare practitioners’ (PHPs) perceptions of its safety. Design As part of a larger study exploring beliefs about TCA, this paper focuses on perceived safety and use of honey, using data extracted for detailed analysis. Eleven parent focus groups (n = 92) and 30 interviews with PHPs were conducted. Qualitative data analysis used the Framework approach. Setting London Boroughs of Brent and Harrow Results TCA, particularly home remedies, dietary and religious approaches were popular for children. Honey was a particularly common TCA, reportedly used by 27 (29%) parents for their children. Honey was believed to be traditional, acceptable, accessible, natural and safe. It was most commonly used for respiratory tract symptoms and administered with hot water and lemon juice. PHPs were more concerned about the safety of TCA than parents. Almost half (40%) of PHPs mentioned the use of honey for children, few perceived it as a ‘treatment’ or were concerned about botulism. Others were aware of the risks and some reported challenges in communicating risk to parents. Conclusion TCA are commonly used for children, honey in particular for respiratory tract symptoms. Parents and some PHPs appear unaware of the risk of botulism from honey use in infants. Healthcare practitioners should ask routinely about the use of honey and other TCA, and consider different parental belief systems in ethnically diverse populations. Further research is required on the use and efficacy of honey for infants, to raise awareness of its benefits and risks.

© 2010 Blackwell Publishing Ltd

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Introduction Minor ailments are common in childhood, particularly cough which accounts for approximately one in 10 consultations in the first year of life (Birmingham Research Unit 2006; Cherry et al. 2007). Many parents use over the counter (OTC) medications for symptomatic relief of common childhood illnesses. However, recent advice from the Medicines and Healthcare products Regulatory Agency suggests that OTC medications, particularly for colds and coughs, should not be used for children, as they may be harmful and ineffective (MHRA 2009). Parents may instead turn to traditional and complementary healthcare approaches (TCA), which they perceive as safer (Fong & Fong 2002; Johnston et al. 2003; Lanski et al. 2003; Evans et al. 2010). These options are considered culturally traditional or ‘complementary’, i.e. outside of mainstream health care. TCA popular for children include dietary supplements (vitamins and minerals), homeopathy and herbal medicine (Simpson & Roman 2001; Johnston et al. 2003; Crawford et al. 2006; Robinson et al. 2008). Honey is one common TCA used for children, given traditionally to soothe crying infants, as a flavouring agent and for cough relief (Hocking et al. 1982; Ramenghi et al. 2001; Warren et al. 2007; Mulholland & Chang 2009). The World Health Organization (WHO) has suggested that honey is a potential treatment for coughs and colds, claiming it can soothe the throat perhaps because of possible antimicrobial and antibacterial properties and a topical demulcent affect (Subrahmanyam et al. 2001; World Health Organization 2001; Adeleye & Opiah 2003; Eccles 2006). A recent Cochrane review also stated that honey may have potential benefit for nonspecific childhood cough (Mulholland & Chang 2009). Further, evidence suggests honey alone is better than no treatment and the antitussives dextromethorphan and diphenhydramine for reducing nocturnal coughing and associated sleep difficulties (Paul et al. 2007; Warren et al. 2007; Axelsson 2008; Warren et al. 2008; Shadkam et al. 2010). Honey may also assist in treating burns, infantile gastroenteritis and infected surgical wounds (Haffejee & Moosa 1985; Subrahmanyam 1991; Vardi et al. 1998). The use of home remedies and herbal medicines, including honey, is largely based on cultural practices. In India, Pakistan, Nigeria and Ghana, honey is used to treat a variety of medical conditions from ear infections to upper respiratory tract infections (Kapil et al. 1990; Denno et al. 1994; Mishra et al. 1994; Iyun & Tomson 1996; Qidwai et al. 2003). Giving honey to children is also popular in the Middle East, Germany, Norway, Spain and Venezuela (Koepke 2008).

However, such TCA have caveats about ensuring their safe use, particularly in children (Chan 2008; Mulholland & Chang 2009). As with other healthcare therapies, they have the potential for adverse effects, particularly as they are often given unsupervised and parents may not be aware of safety issues (Snodgrass 2001; Ernst 2003a,b; Woolf 2003; Mansberg 2004). Safety issues include intrinsic effects (side effects of the product itself), interaction with pharmaceuticals and other TCA, and extrinsic effects (due to lack of standardization, contamination, substitution, adulteration, incorrect preparation/dosage or inappropriate labelling) (Chan 1994; Drew & Myers 1997; Choonara 2003). One of the most publicized safety issues with TCA is the association between infantile botulism (IB) and honey ingestion (Arnon et al. 1977). IB is an age-limited neuromuscular disease causing a symmetrical, flaccid paralysis, resulting from neurotoxins produced by the anaerobe Clostridium botulinum. Fifteen per cent of reported cases of IB have been attributed to honey contaminated by spores from this bacterium (Midura 1996). If left untreated, IB is fatal, but recovery with antitoxin is usually excellent. Almost 1500 cases have been reported to the Centre for Communicable Disease, and 95% have occurred between 6 weeks and 6 months of age (Shapiro et al. 1998). This has resulted in warning labels on packaging for honey brands in the UK, and advice to healthcare practitioners discouraging the use of honey in children under one year of age. Yet the potential dangers of honey use for infants may remain relatively unknown in the community, despite these precautionary measures. Cases of IB have been associated with the prolonged use of honey as a laxative or on pacifiers (Fenicia et al. 1993; McMaster et al. 2000; van der Vorst et al. 2006). The risks are also often not acknowledged (Ripa 1978; Ramenghi et al. 2001). An Italian study revealed that 25% of 270 women had given honey to their infants and all were unaware of the risks of IB (Aureli et al. 2002). Honey can also cause dental caries, hyperactivity, nervousness and insomnia (Ripa 1978; Paul et al. 2007). This highlights the need to explore in more detail perceptions of efficacy and safety.

Aims This paper discusses parents’ and primary healthcare practitioners’ (PHPs) perceptions of the safety of honey for children. This is part of a larger exploration of how TCA are used therapeutically in a multi-ethnic community, which included the role of tradition, culture and safe practice, which was previously published.

© 2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 5, 734–743

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Method The data on honey presented in this paper are part of a larger study on the use of TCA for children (Robinson et al. 2009; Lorenc et al. 2010). The study comprised focus groups with parents and one-on-one interviews with PHPs – general practitioners (GPs), nurses, health visitors (nurses with specialist community health qualifications who offer practical support and care to parents of young families) and midwives.

Sampling The study took place in the London Boroughs of Brent and Harrow. Sampling was purposive to access the ‘richest’ sources of data. Sampling was also iterative, whereby sampling units were chosen successively, focussing on extending data already collected in order to refine theories, in accordance with standardized qualitative research methodology (Kuzel 1999). Details of the sampling strategy were therefore not determined prior to data collection. Parents were recruited from: ethnic minority support groups, cultural associations, refugee groups, baby clinics, mother and toddler groups, baby massage classes, nurseries, schools, churches/temples, personal contacts and parenting websites. Parents were included if they had at least one child under 16 years, were residents in the London Boroughs of Brent or Harrow and able to provide informed consent. Focus group theory-based sampling used ethnic background as the demographic most likely to affect the variation in traditional medicine use, so ethnic diversity and a range of geographical locations were selected. For PHP interviews, a range of GP practices from both boroughs were sampled to obtain locations with diverse ethnic and socio-demographic distributions representative of the local population. Sampling also ensured representation from all four PHP groups: GPs, health visitors, midwives and nurses.

Focus groups In order to sample the wide range of ethnic groups in the area, 11 focus groups with parents took place, between May 2007 and June 2008. Groups aimed to define the range of TCA used for children, establish their prevalence and gain a deeper understanding about parent choice of TCA. Of the 11 groups conducted, five took place in Harrow and six in Brent, with between three and 12 participants (92 parents participated). Most groups were preformed (already regularly met as a group), which is thought to improve the group inter-


Table 1. Demographics of focus group participants Number (%) Age of parent (years)

Relationship to child

Education

Income (£)

Ethnicity

Born in UK

19–29 30–39 40–49 50–59 60+ Missing Mother Father Missing Grandmother Aunt None GCSEs A levels First degree Postgraduate Missing 0–10 000 10 000–14 999 15 000–19 999 20 000–29 999 30 000–39 000 40 000+ Missing On benefit Not working White* Asian† Black Mixed Other (mainly Iranian and Chinese) Yes No‡ Missing

9 50 22 5 2 4 62 3 24 2 1 11 15 17 25 13 7 8 8 6 11 9 22 25 1 2 32 32 11 4 13 29 52 11

(54%) (24%)

(67%) (26%)

(12%) (16%) (18%) (27%) (14%) (12%)

(12%) (24%) (27%)

(35%) (35%) (12%) (14%) (32%) (57%) (12%)

*47% White British, 16% Brazilian, 6% Irish and one each of Iraqi, Lithuanian, American, French, Polish, Scottish, Spanish, Yugoslav/Albanian, Swedish and European. †23% Sri Lankan, 17% Asian British, 13% Afghani, 13% Indian and under 10% Pakistani, Gujarati, Asian British (Indian/Pakistani/Gujarati), British Indian and Other Asian. ‡Average of 12 years in UK. GCSE, General Certificate of Secondary Education.

action and dynamics because of familiarity (Bloor et al. 2001). Table 1 gives the demographic details of participants. Seven groups consisted of participants from different ethnic backgrounds, and four groups were homogenous. Participants were given an information sheet (translated for non-English speakers) and signed a consent form. A book token was offered as an incentive to attend and as a gesture of thanks for participation. Parents also completed a short questionnaire including demographic data such as ethnic group and birth country.


Table 2. Focus group topic guide and prompts Research Aims • To define the range of traditional and complementary healthcare approaches (TCA) used in a multi-ethnic community. • To establish prevalence of the use of TCA in a multi-ethnic child population. • To gain a deeper understanding about parent choice of the TCA used. • To identify sources and types of TCA available in a multi-ethnic community and their impact. Questions 1 What are Traditional and Complementary healthcare Approaches? (‘Therapies and treatments other than those recommended by a doctor or nurse’) Prompts: a What treatments would you consider to be TCA? Music/dance, prayer, religious practices/ceremonies, food, medications? (Identify the range) b Are these treatments linked to your ethnic origin or culture? Do you have specific beliefs about the causation of illness, or a cultural understanding of illness? c What do you think of TCA? Do you think they work? Better than conventional medicine? 2 Do you use TCA for yourself? Have you ever used TCA for your children? ‘Are you doing anything special to keep your child healthy or to manage a health problem’‘Do you use any home remedies for your child?’ Prompts: a What was it? b Why did you use it? c What was the illness, treatment used, outcome? Minor ailments, chronic problems e.g. skin, asthma? d Did you see a practitioner? e If over the counter, Where was it obtained? Shop/ethnic grocer, pharmacy, home, abroad? What did it cost? f How often do you use them? 3 Where do you get information on TCA? Prompts: a Where would you be likely to get information on TCA or TCA practitioners from? b Would you be likely to get information from family/friends, doctor, pharmacist, other health professional, books, internet? c What effect do family/extended family, cultural traditions, religion media have? Are grandparents and female family members particularly important? d How do you decide who or what you trust related to healthcare information? 4 How and why do you choose to use TCA for your children? a What led you to use alternative medicine? b What were the things you have considered when deciding to use or not use alternative medicine for your children? E.g. cost, avoiding conventional medicine, safety, effectiveness of treatment, availability. c What are your expectations of the healthcare treatments you select? d Do you feel you are or you prefer to be actively involved in your child’s healthcare? How are you actively involved? e Do you use TCA to avoid using drugs/conventional medicine? 5 Do you think TCA are safe? Prompts: a Any experience of adverse effect, interaction, contraindications, contamination? b Do you think TCA can have adverse effects/interactions/contamination? c What precautions do you/should you take? d Do you think TCA are safer than conventional medicine? 6 Do/would you discuss TCA use for your children with their doctor? Prompts: a If not, why not? What would make you more likely to? b Do you discuss with another health professional? c Do you think health professionals know enough about TCA? d Who would you tell if you had a problem with a TCA? (Pharmacist, health visitor, nurse, doctor etc) 7 Do you think there are issues around TCA that are different for children? Prompts: a Safety, giving consent, getting them to take it? b Should children be able to choose? c Dose of medication.

The topic guide had seven questions with prompts for each question, open-ended to promote discussion (Table 2). Questions were asked in an order appropriate to the natural flow of the conversation. Groups were tape-recorded using a digital

multidirectional recorder, and a transcriber recorded the conversation and non-verbal communication. Where participants were non-English speaking, an interpreter was used. Focus groups lasted for approximately 1 h.


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Interviews

Data analysis

One-on-one, tape-recorded semi-structured interviews were conducted with 30 PHPs, between May 2007 and February 2008. Participants completed a consent form and a short demographic questionnaire. Interviews were conducted in the PHP’s workplace and at a time and date convenient for them. Questions followed a schedule covering their knowledge of TCA, whether they discussed TCA with patients, sources of information, personal TCA use and perceived effectiveness and safety of TCA (Table 3). Interviews lasted between 30 and 60 min.

All qualitative data were analysed using the Framework approach (Ritchie et al. 2003). Inter-rater coding was used to improve reliability. Statistical calculation of concordance was not carried out, rather the exercise focussed on discussion of disparities in coding, as a result of the ontological view of multiple realities (Viera & Garrett 2005). The researcher (AL) kept a reflective diary throughout the project, exploring potential influences on data including assumptions, theories, perspectives and cultural norms. Issues were discussed with the project team, aiming to improve dependability and transferability of findings. For this paper all data relating to the use of honey were extracted and summarized. A previous publication has detailed other data from the focus groups, which focuses on the influence of cultural beliefs and norms, and developing typologies of TCA use and a decision-making model (Robinson et al. 2009). Ethical approval was received from Harrow Research Ethics Committee. Questioning was limited to adults, thus minimizing the ethical impact on the children themselves. Participants were, in writing and verbally, given an overview of the project and their involvement and the researchers’ contact details, and assured of confidentiality and their right to withdraw.

Table 3. Primary healthcare practitioners’ schedule of questions and

prompts 1 What do you consider to be traditional and complementary healthcare approaches (TCA)? 2 Can you describe how you deal with TCA in consultations? Prompts: a Do parents tell you they are using TCA or ask your advice on TCA? b Do you ask parents about TCA? Why/why not? How? c Do you think TCA should be part of primary care? Why/why not? d How do you feel about your patients using TCA? e What affects your discussion? 3 What do you think about recording TCA use in patients notes? Do you record it? Prompts: a If yes, how and where do you record it? What do you record? b If not why not? And what would encourage you to? Suggest EMIS template. 4 What do you know about the local use of TCA in your community? 5 What sort of information about TCA do you use? Prompts: a Where do you get information on TCA? Journals: case studies/ efficacy studies/RCTs etc; Websites; Friends and family/colleagues b Do you have adequate access to reliable TCA information? c If no, how can this be improved? 6 Tell me about your personal experience with TCA Prompts: a Do you or have you ever used TCA? Which therapies? Did they help? b Do you think your use/non use of TCA affects your attitude to your patients’ use? How/how not? 7 What do you think are the main factors that inform your opinions and attitudes on TCA? 8 What do you feel about the safety of TCA? Do you report TCA adverse events? in children? Prompts: a Do you think TCA is safe for children? b What are your main safety concerns 9 What experience do you have of learning about TCA? Prompts: a Have you ever had training on TCA? Was this child-specific? Was it useful? b Was TCA part of your professional (medical/nursing etc) training? Do you think it should be? 10 How do you view the effectiveness of TCA? This is an abridged version.


Results Parent focus groups Perspectives on TCA Over 150 different TCA were cited as used for children. Many were ‘home remedies’, including honey and lemon, turmeric, mint tea and ginger. Dietary approaches were also popular, as were religious approaches including rituals and prayer. Many parents used baby massage (mostly at home rather than a class) and baby yoga. Bought products and practitioner-based TCA were less common, mainly cranial osteopathy and homeopathy. More details are available in a published paper (Robinson et al. 2009). A common belief across all ethnic groups was that TCA was ‘natural’, despite the term ‘natural’ rarely being used in research materials or focus group questions. Most parents felt that ‘natural’ medicines were better for children as they were safer. Some believed that being ‘natural’ meant TCA would work better and others had a preference for using ‘natural’ approaches.


Table 4. Parent focus group quotes Quotes on the safety of TCA and its connection with ‘natural’ and tradition. ‘[TCA] can’t do any harm’ (Chinese mother) ‘I don’t always expect it to work, but I don’t expect it to harm’ (White British mother) ‘they do say natural medicines are probably better for them’ (Asian British mother) ‘There’s somebody saying there’s nothing unnatural in it and it just gives you that sort of sense of security that it’s probably going to be better’ (Chinese mother) ‘Is from your parents, grandparents, because their views have been passed down and you know you can trust it’ (Iranian mother) ‘my family for example these things have been used for generations you know, it was used for me, it was, I’m using it for my child, we’ll be fine . . . These are kind of a standard protocol’ (Indian mother) Quotes illustrating honey as convenient and for minor symptoms ‘sometimes the later of the night, after midnight you’re very, very, very ill, high temperature, you don’t have the Calpol, you have the honey and lemon you use’ (Black African mother). ‘I mean a lot of it you think oh its old wives’ tales um but it was um, honey and lemon in hot water, you know, things like that’ (White British mother) ‘I think it depends on how severe, because if its for minor coughs and colds honey and lemon ease the cough’ (White British mother) ‘for coughs, the er, fresh ginger and honey they give it in the morning, one spoon, it’s good’ (Black African mother) Quotes on conflicting beliefs and honey as safe ‘no, here they say don’t give honey to children, but in my country they give little bit honey with it’ (Gujarati mother) ‘Because, yeah because I think that one is sugary and sweet, this one is the pure, the honey is, if they eat [honey] is pure, is not sugary, is just from the bees, honeycomb so it’s not side effect’ (Asian British Aunt) TCA, traditional and complementary healthcare approaches.

The majority of parents reported that TCA were safe, with few or no side effects and non-toxic, and could therefore be given routinely and long term. These beliefs were informed by personal experience or contacts. Information on TCA mainly came from family members and other mothers; some also used the internet, but family information was more trusted. Many parents felt that a tradition of use of TCA in their family and their wider culture ensured safety and efficacy (see Table 4).

Perspectives on honey Of the 92 parents, 27 (29%) spontaneously mentioned using honey for their children, despite not being asked specifically about honey. Use of honey was reported in families with children of various ages, 20 (74%) had children under 5 years old. Parents from all ethnic groups reported using honey. Honey and lemon juice in hot water (19 parents) was the most commonly reported remedy used, mainly for colds/coughs (13 parents), but also for constipation (one parent) and fever (one parent). Parents also reported adding honey to herbal

medicines, e.g. turmeric (so that children would take them) as well as combining with ginger (three parents) lime, pepper, beetroot and hot milk (mentioned separately by one parent each) to improve taste for children, but also because of perceived healing properties. Similar to other TCA, honey was considered to be a traditional home remedy which was convenient, easily accessible and could be used if symptoms were not severe (Table 4). Only two parents expressed concern with using honey for small children, whereas one parent felt it was safe because it was natural (especially compared with using sugar). Opinions regarding safety were also affected by conflicting cultural belief systems (Table 4).

Healthcare practitioners A total of 30 PHPs were interviewed: 13 GPs, nine health visitors, six nurses, one medical student and one midwife. Of these, 26 were female and four male, 11 were White (White British, Irish, South African), 11 Asian (Asian British, Indian, Malaysian, Sri Lankan), three Black (Ghanaian, Caribbean, Armenian), one Chinese and one Other (Mixed African/Asian).

Perspectives on TCA Primary healthcare practitioners also felt that most TCA were safe, but they expressed many more safety concerns than parents. By far the most common concern in all practitioner groups was being unable to identify ingredients of TCA and potential intentional adulteration. Cited adverse effects included: liver dysfunction/failure from herbal medicine and vitamin A; exacerbation of eczema and cataracts from Chinese creams; structural damage from baby yoga, laxative effects of black tea and eye infections from kohl1. In general, PHPs did not feel responsible for dealing with TCA in the primary care consultation. PHPs did feel a duty to inform and discuss use with the parent/patient because of safety concerns.

Perspectives on honey Twelve PHPs mentioned the use of honey for children. They identified honey as a common, popular approach for both treating cough and also skin conditions (cuts, burns, scar healing). Honey was also considered a legitimate component of existing OTC products (Strepsils and cough medicines) and it was appreciated that evidence existed for its therapeutic efficacy (Table 5). 1

A black cosmetic applied to the eyelids for protection, also called karjil.


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Table 5. Primary healthcare practitioners’ quotes Quotes on safety of TCA ‘If they use something which I really don’t know anything about and I consider to be dangerous like this woman then I will really kind of make sure that she has a good health education, I will stop her basically, using it, and I will document it. Because it comes almost under child protection, if something happened to the child. So then I will . . . explain the danger of, yeah, depends on the level yeah of, of, or my knowledge about this particular item or this, if I feel comfortable with it then maybe I won’t [interfere]’ (HV) ‘Unless I think it’s something that’s actually harmful for the child. But if it’s something that isn’t going to do them any harm then I’m not likely to stamp my foot and make a fuss about that’ (South African female, GP) Quote on efficacy of honey ‘I think it was the GMC said that honey does have some properties and they’ve looked at linctus, cough linctus and the cough linctus didn’t have as much goodness as honey will have for a cough’ (HV) Quotes on the safety of honey ‘because there is a Canadian research they did and find out its, children under one shouldn’t be given honey’ (HV) ‘Sometimes you have to be a little bit careful just to make sure that it’s safe for babies, some, some mothers for example might give a child honey or something to settle them down and that is not recommended for a child under a year so you just have to double check’ (HV). ‘honey is not harmful and neither is tumeric so I wouldn’t be worried about side effects for that’ (Midwife) Quote on belief systems ‘When it comes to sugar and honey, it’s very conceptually difficult for people to understand that honey should not be prescribed until, or advised, until one years of age, when your grandparents, everybody use honey, and honey is associated with nutrition and you know, all good things and suddenly somebody saying to you, it’s like somebody saying oh money’s not good or, it’s conceptually difficult to understand’(HV) Honey not considered as healthcare ‘[whether I record TCA in medical notes] depends on what it is, er, um, if it’s something that’s probably, you know, I don’t know, honey and lemon and that sort, no I won’t’ (GP) ‘whether it’s evidence-based or not I probably wouldn’t even consider . . . I just, you know, honey and lemon and ginger mixed together is good for colds and coughs’ (nurse) GP, general practitioner; HV, health visitor; TCA, traditional and complementary healthcare approaches.

Only health visitors (five), identified the issue of botulism and discouraged the use of honey for children under 1 year of age. One midwife and one GP specifically cited honey and lemon as safe for children (Table 5). There were views (cited by one GP, one HV, one nurse) that honey use may not even be recognized as healthcare, and therefore it was unlikely to be discussed or recorded in the medical notes (see final two quotes in Table 5). Primary healthcare practitioners tended to have different belief systems compared with parents, creating a potential conflict in the advice given (Table 5). Two health visitors described difficulties convincing parents not to use honey for young babies given the conflict with traditional practices and cultural beliefs that honey has strong healing properties.


Discussion This research has shown that parents report often using TCA for children because of a perception that they are ‘natural’ and therefore safe, and this is backed up by family, cultural and traditional use. A range of approaches were used, the majority being readily available at home, rather than bought products or practitioner-based TCA. Honey was one of the most commonly used TCA, which was similarly perceived as a ‘natural’, ‘safe’ and ‘traditional’ remedy. This emerged from the study without specific prompting on the subject of honey, highlighting its popularity. It was used especially for children under 5, for symptomatic relief and for perceived therapeutic qualities. Use appeared common in all cultural groups, especially for colds and coughs. Although PHPs also perceived TCA as generally safe, they were aware of a range of potential adverse effects, more so than parents. Despite its popularity, there appeared to be little awareness of the potential dangers of the use of honey in both groups. Only 2/92 parents and five PHPs (only health visitors) mentioned without prompting that it may be dangerous for small infants. One midwife and one GP even specifically cited honey and lemon as ‘safe’ for children. Other research investigating the use of honey for children similarly did not mention any health risks (Ramenghi et al. 2001). Furthermore, some PHPs do not consider its use a part of health care. If healthcare practitioners are unaware of the dangers and also fail to acknowledge the therapeutic use of honey, there may be health consequences ranging from, rarely, IB, to the more common dental caries. Inappropriate feeding practices and the consumption of sugary medications has ensured that tooth decay remains a health concern for infants and toddlers, making it one of the most common yet preventable chronic diseases of childhood (Krol 2003). Hence, although honey is generally regarded as safe over the age of one, its use, as with other TCA, should be acknowledged in order to investigate potential adverse affects. The data from both the focus groups and PHPs suggest that the therapeutic use of TCA, including honey, is often based on traditional cultural beliefs, which may cause difficulties when trying to raise awareness of potential dangers. PHPs strongly expressed feeling responsible for informing parents of potentially unsafe TCA, but appeared largely unaware of the dangers of honey. Previous studies have shown a lack of knowledge about TCA safety among PHPs (Zubek 1994; Suchard et al. 2004). It has been suggested that PHPs do not perceive TCA as having harmful effects, believing it works by the placebo effect (Shaw et al. 1997). It may also be because of lack of knowledge about TCA in general (Garner 2000). Because this study has also


shown that some PHPs may not even consider TCA as health care, inclusion in the medical curriculum may be desirable in order to improve safety awareness of these practices (Flannery et al. 2006). Healthcare practitioners need to be attentive to the use and dangers of TCA, particularly honey, in the community. Such remedies are appealing because they are relatively inexpensive compared with OTC medications. Many medications and foods targeted for children also use honey flavouring, giving the impression that honey consumption is a safe TCA. Healthcare practitioners should also acknowledge that TCA such as honey do appear to have some therapeutic properties and respect patients’ cultural beliefs, while remaining aware of the current state of evidence for efficacy and safety of honey (Haffejee & Moosa 1985; Subrahmanyam 1991; Vardi et al. 1998; Ramenghi et al. 2001; Eccles 2006; Paul et al. 2007; Warren et al. 2007; Basson & Grobler 2008; Warren et al. 2008; Evans et al. 2010). This study has a number of limitations. Firstly the focus groups and interviews were not specifically focussed on honey, so all views on honey may not have been captured. A population-based survey would reliably estimate its wider use. However, it is useful to use such an inductive approach to assess views on the relative importance of TCA to parents and PHPs, including the place of foods and other ingested substances in health care. Measures were taken to improve the reliability and validity of the data analysis and collection, including inter-rater coding, transparent data analysis, iterative sampling and a reflective diary. Framework analysis produces an ‘audit trail’ which promotes transparency in analysis, therefore improving reliability (Bowling 2002). However, there are always risks arising from the interactional nature of qualitative work, which may reduce generalizability. This study had a large sample size and used purposive sampling and translation services in order to capture the ethnic diversity. Although not representative of all cultures, findings are likely to be generalizable to the London Boroughs of Brent and Harrow and to some extent to populations with similar socio-demographics. Sampling of PHPs focused on capturing a range of geographical locations and practitioner groups, but nurses and midwives were under-represented. This study highlights the level of awareness of patients and healthcare practitioners about potential safety issues with TCA and in particular honey which is commonly used. Parents often prefer to use TCA because they are perceived as ‘natural’, sometimes cheaper and they fit with cultural beliefs but its risks need to be emphasized. As patients continue to use these holistic approaches, it is up to healthcare practitioners to acknowledge this and accustom themselves with these practices. They must

reinforce the useful approaches and educate parents about possible risks. There are reliable sources of information which healthcare practitioners can utilize, such as the Natural Medicines Database (http://www.naturaldatabase.com) and the NHS Evidence – CAM Specialist Collection (http://library.nhs.uk/ cam/). More research investigating the dangers of TCA use, and linkage with such reporting systems are vital in order to ensure the public are well advised. Such rigorous scientific scrutiny is required in order to protect the public and the healthcare provider (Qidwai et al. 2003). As parents increasingly use TCA, research needs to keep pace with patient choice. A recent Cochrane review (Mulholland & Chang 2009) and a further paper (Evans et al. 2010) concluded that further high-quality research on the efficacy of honey for acute cough is needed, as honey has potential as an inexpensive alternative to pharmacological intervention. Further research is also required regarding possible harm inflicted by the use of TCA, so that treatment decisions can be made on rational grounds. Ultimately the choice to use such resources becomes one governed by the prevailing belief systems of each party.

Key messages • Use of TCA, particularly honey for children is very common in families from a range of ethnic backgrounds. • In this sample of ethnically diverse parents, honey was perceived as natural and traditional and therefore safe, there was little awareness of the risk of botulism. • Primary healthcare practitioners are often concerned about the safety of TCA and feel responsible for advising parents, but appear to lack sufficient information to do so effectively. • Primary healthcare practitioners are aware of the use of honey. Health visitors spontaneously reported awareness of the recommendations against use for under 1-year-olds because of the risk of IB. • Use of TCA needs to be acknowledged by healthcare practitioners, and their efficacy and risks communicated to the community.

Acknowledgements We are very grateful to all the parents and PHPs who took part in the study and the King’s Fund (London) for financially supporting the project.


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