In the current survey, most Dutch YHC physicians were familiar with the concept of IM. The majority of the respondents regarded the three major components of IM, e.g. health care provider-client relationship, prevention strategies and the healing environment of importance to their daily practice. The fact that most YHC physicians were familiar with these three components of IM, may explain their rather neutral or negative opinion to regard IM as a new innovation in healthcare. Overall, determinants of a positive attitude toward IM were familiarity with IM, self-practising of CAM, self-use of CAM and high knowledge level of CAM. Remarkably, the use of CAM by YHC physicians themselves was relatively high (56% of respondents), much higher than the CAM use recently reported for paediatricians (39%) . Despite their high rate of self-medicated herbal and/or homeopathic medications, the majority (63%) of YHC physicians did not discuss CAM use with parents or children. A survey among parents of children visiting an outpatient paediatric clinic, demonstrated that there is a high need under parents to discuss CAM treatment options with their physician . Thus from a clients perspective, it should be recommended that every physician asks about CAM use as part of their regular medical examination. Although most YHC physicians do not discuss CAM use with their clients, they do see the need to accurately inform the client about all possible preventive interventions, including those that CAM has to offer. A possible explanation why YHC physicians do not routinely talk to clients about CAM may be that at present CAM is not part of their standard screening and monitoring and that they work under enormous time restraints.
Of the YHC physicians' one third recommended CAM therapies to their clients. The CAM practitioners most referred to were homeopaths, manual therapists and acupuncturists. In the three clinical cases, dietary advice was mostly recommended. Many YCH physicians commented at the end of the survey that they did not regard dietary advice as a CAM therapy. CAM is defined as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine . Since at present, dietary advice is still not part of routine every day care provided by family physicians and paediatricians, it was decided to include dietary advice and dietary supplements in the survey as part of CAM, in line with previous surveys among paediatricians in the USA [16, 17].
YHC physicians exhibited most knowledge on probiotics, homeopathy and dietary supplements. The high knowledge level on homeopathy could be explained by the fact that during their residency, YHC physicians follow an introductory course on homeopathy. Another explanation may be that self-care homeopathic remedies are frequently used by small children  and that parents may mention this more often to YHC physicians than other CAM therapies. In general, YHC physicians were not so familiar with acupuncture or anthroposophy. Furthermore, only one quarter of the respondents reported to have knowledge on mind-body therapies. A recent survey showed a high interest among paediatricians to refer their clients to mind-body therapies . Apparently mind-body therapies are not yet embedded in YHC. An interesting finding is that YHC physicians would like more training on subjects that they actually report to have the highest knowledge level on. About half of the respondents wanted additional training about probiotics, nutritional supplements and manual therapies. This indicated that YHC physicians are open to learn more about CAM therapies.
YHC physicians had little concern with safety aspects of CAM therapies. The majority was of the opinion that CAM therapies do not cause additional side effects nor interfere negatively with conventional medical care. Compared with surveys among paediatricians in the USA, these findings are very different. There, most of the health care professionals shared the opinion that CAM therapy may cause additional side effects and can be harmful [16, 17]. A recent pharmacoviligance study in Australia has demonstrated that CAM use can be associated with serious adverse event . Therefore, it is of importance for YHC physicians to be informed about CAM therapies so that they are also able to address safety issues of CAM therapies in communication with clients.
YHC physicians were very outspoken with respect to practising of CAM within their own community healthcare centre. More than half of the respondents thought that it will have a negative impact on the name of their organisation and their reputation if they advise CAM and that their organisation should not even advise CAM. This attitude can be explained by the fact that CAM does not fit into the concepts of their organisation. Another explanation can be the lively discussions in the Royal Dutch Association of Healthcare on the subject of CAM between advocates and opponents. Outside the organisation YHC physicians seem to have a relatively positive toward IM and CAM. The majority uses some form of CAM themselves, more than one third recommend CAM therapies to their clients and some practise one or more forms of CAM therapy.
This national survey among YHC physicians found that overall respondents have a relatively positive attitude towards IP, including CAM therapies. However, the present study also has its limitations. The percentage of respondents, a little over a quarter (27%), makes it insufficient to draw firm conclusions about the fact that the positive attitude towards IP counts for all YHC physicians in the Netherlands. There is a potential for response bias. Those who participated may have had an interest in CAM and were therefore more willing to invest time in filling out the questionnaire. Upon the assumption that all non-respondents to the present survey were anti-CAM, the percentage of YHC physicians referring clients to CAM therapies would drop to 9% and the number using CAM themselves to 16%. This assumption, however, does not seem realistic since a large survey among patients in the Netherlands showed that healthcare professionals react neutral (54%) or positive (41%) to disclosure of CAM use . Furthermore, the average characteristics of respondents in the present study were very similar to another, non-CAM related published survey among members of the AJN . It should be noted that in the Netherlands, YHC physicians are mostly women, leaving male YHC physicians a minority (about 8%). Within Europe, Belgium and the Netherlands represent particular examples where YHC is provided by specialized YHC physicians. In other European countries the paediatrician and/or family physician play a central role in providing YHC . To our knowledge, the present study is the first one to assess the attitudes of health care providers about IP and CAM in YHC specifically. Therefore, it is difficult to translate the current findings to other European countries and the USA. However, world-wide several studies have reported on the positive attitudes of paediatricians towards CAM [10, 15, 16, 21], suggesting that there is openness to further communicate and educate about possible implementation of IP healthcare programs in child health care.