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BMC Complementary and
Alternative Medicine
Open Access
Research article
The potential of complementary and alternative medicine in
promoting well-being and critical health literacy: a prospective,
observational study of shiatsu
Andrew F Long
Address: School of Healthcare, University of Leeds, Room 3.10, Baines Wing, Leeds, LS2 9UT, UK
Email: Andrew F Long - a.f.long@leeds.ac.uk
Abstract
Background: The potential contribution of complementary and alternative medicine (CAM)
modalities to promote and support critical health literacy has not received substantial attention
within either the health promotion or the CAM literature. This paper explores the potential of one
CAM modality, shiatsu, in promoting well-being and critical health literacy.
Methods: Data are drawn from a longitudinal, 6 months observational, pragmatic study of the
effects and experience of shiatsu within three European countries (Austria, Spain and the UK).
Client postal questionnaires included: advice received, changes made 6 months later, clients 'hopes'
from having shiatsu and features of the client-practitioner relationship.
Result: At baseline, three-quarters of clients (n = 633) received advice, on exercise, diet, posture,
points to work on at home or other ways of self-care. At 6 months follow-up, about four-fifths
reported making changes to their lifestyle 'as a result of having shiatsu treatment', including taking
more rest and relaxation or exercise, changing their diet, reducing time at work and other changes
such as increased body/mind awareness and levels of confidence and resolve. Building on the
findings, an explanatory model of possible ways that a CAM therapy could contribute to health
promotion is presented to guide future research, both within and beyond CAM.
Conclusion: Supporting individuals to take control of their self-care requires advice-giving within
a supportive treatment context and practitioner relationship, with clients who are open to change
and committed to maintaining their health. CAM modalities may have an important role to play in
this endeavour.
Background
There are a variety of ways to achieve health promotion's
goal of increasing 'people's control over their health and
its determinants' [1,2]. Within a population health
approach, interventions would target not just strategies to
enable healthier living and treatment of presenting symp-
toms, but also factors 'upstream', the primary causes of ill-
health, within the wider socio-politico-economic envi-
ronment in which people live [3,4]. In contrast, within
routine health and medical care, interventions target indi-
vidual patients, looking towards optimum strategies to
promote and support individuals to modify their behav-
iour. Examples include use of motivational interviewing
[5], applications of the stages of change model [6] and the
notion of 'readiness to change' [7]. Other literature exam-
ines the manner in which treatment and care is provided,
Published: 18 June 2009
BMC Complementary and Alternative Medicine 2009, 9:19 doi:10.1186/1472-6882-9-19
Received: 8 April 2009
Accepted: 18 June 2009
This article is available from: http://www.biomedcentral.com/1472-6882/9/19
© 2009 Long; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
BMC Complementary and Alternative Medicine 2009, 9:19 http://www.biomedcentral.com/1472-6882/9/19
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in particular, for example, shared decision making [8,9]
and patient-centred care [10]. While (individual) patient
empowerment [11] and self-efficacy [12] may be the ulti-
mate goal, discussions focus on adherence to prescribed
programmes and ways to support persons to manage their
own ill-health. Left implicit, and thus outside the clinical
gaze is the need to move beyond the individual, to con-
sider the individual within their family and wider social
network and socio-economic circumstances.
A central concept within health promotion is health liter-
acy. Nutbeam's influential framework [13] differentiates
three levels: functional health literacy (sufficient basic
skills in reading and writing to function effectively); com-
municative/interactive health literacy (ability to extract
information and to apply the information); and critical
health literacy (ability to critically analyse information
and to use it to exert greater control over life events). From
a behavioural change perspective, critical health literacy is
akin to a person heeding and acting on the advice given
(after implicit or explicit reflection) and modifying their
behaviour. Health literacy becomes an asset [14] and the
intervention aims at enhancing individuals' control. The
clinical or health promotion intention would be to move
from providing information on, for example, healthy eat-
ing or healthier lifestyles (with an outcome focus on
adherence with expert prescribed behaviour) to develop-
ing personal skills within a supportive (individual, family,
community) environment (with an outcome focus on
self-care in partnership with health care professionals)
and onto individuals (and communities) taking control
for self-care, with the self as the expert and manager
[13,14]. Taking this a stage further, public health literacy
embraces critical health literacy needed to make public
health decisions that benefit the community [15] and
effective actions at a political and social level to prevent
ill-health or support health [13,16].
The potential contribution of complementary and alter-
native medicine (CAM) modalities to promote and sup-
port critical health literacy has not received substantial
attention within either health promotion, CAM or the
sociology of CAM literatures. Indeed, Hill [17] com-
mented that UK health promotion texts rarely include ref-
erence to CAM and contain little in-depth discussion over
their potential role in collaborative alliances to promote
health. This is despite the increasing consumer user of
CAM [18-20].
Core features of the philosophy and practice-based com-
mitments of CAM and reasons for its use suggest a prima
facie case for consideration of its role. Firstly, CAM modal-
ities centre attention on health and healing. As Fulder [21]
valuably enumerates, characteristics of alternative medi-
cine include: restoring vital forces and self-healing energy
(to awaken the immune system/response); working with,
and not against, symptoms; seeking out the root of the
problem [22]; exploring individualised paths for treat-
ment; and, adopting a holistic approach to diagnosis and
treatment. Secondly, characteristics of the practitioner-cli-
ent encounter include: a more egalitarian relationship
between client and practitioner in order to sustain and
strengthen the client's commitment to taking (some)
responsibility for health, well-being and self-care [23,24];
the practitioner listening [25] and providing a safe, 'pro-
tected' space [26]; and, seeing the presenting reasons/
symptoms within the person's wider life and lifestyle
[18,27]. The practitioner may act as teacher and consult-
ant, as well as healer. Thirdly, while some access CAM to
help to resolve a long standing condition [28,29], others
talk explicitly about wanting to be proactive in order to
prevent further ill health [30], engaging in active health
maintenance and avoiding health-risk behaviours
[29,31,32]. As Sointu [33] concludes from her analysis of
interviews with practitioners and users of a variety of CAM
practices, people may turn to CAM to 'seek a subjective
sense of well-being rather than mere health .... The con-
cept of well-being encapsulates a demand for being recog-
nised as an active, empowered and knowledgeable agent'
(pp. 345–346).
Such philosophical commitments find representation
within the practice of CAM therapies. Energy medicine
works 'more with what is felt than measured' [34]. Touch-
ing clients enables diagnosis, the delivery of the treatment
and feedback as to how the treatment is received; it also
creates a relationship between the practitioner and client.
Classical (TCM) acupuncture's attempts to treat the 'root'
(the underlying central disharmony) and 'branch' (the
specific presenting symptoms) of the patient [22,35].
Some of the 'active ingredients' in homoeopathy, drawn
out from case studies of individual packages of care by
Thompson and Weiss [36] include the role of patient
expectations (the expectation of potential benefit/belief in
the treatment), openness to the mind-body connection,
the expression of empathy within the consultation and
the co-construction of the homoeopathic care, all apart
from the remedy itself. More generally, in a study of CAM
use, personality and coping strategies, Jacobson and
Honda [37] suggest that 'openness to experience' may be
a personality trait of persons who use body-mind, energy
and other biologically-based CAM therapies. Finally, in
the context of CAM education provision, Rakel et al [38]
revisit the notion of salutogenesis, arguing for the neces-
sity of health education to include a core understanding of
healing and prevention. They illustrate their discussion
through a review of evidence of CAM therapies for low-
back pain. Areas of influence include mind-body, nutri-
tion (sustaining food choices), spirituality (helping the
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patient to connect with things that give their life meaning)
and the bio-energetic dimension.
Against this background, this paper seeks to explore the
role of one CAM modality, shiatsu, to enhance critical
health literacy and thus wider population health. Shiatsu,
a body-based life-energy therapy, is a holistic health care
method developed in Japan and influenced by Western
knowledge. It is also inherently a safe modality [39]. Shi-
atsu uses Oriental energetic diagnosis and body energy
techniques to correct imbalances in the body and focuses
on the whole person, mind, body and spirit, as an inter-
connected whole, together with the environment in which
the person lives [40]. All aspects of the client's life-energy
system are addressed in understanding the condition,
making an energetic diagnosis and giving a treatment. A
highly developed sensitivity of touch enables the practi-
tioner to feel and interpret the quality and flow of ki, the
body's life-force. Treatment thus embraces both the appli-
cation of gentle pressure to the energy channels on the
body surface and commonly includes advice-giving, cen-
tred on raising self-awareness, modes of living and life-
style to sustain good health. While there are many
different styles of shiatsu, variations in theoretical content
[40] and cultural dimensions surrounding its delivery
[41], shiatsu training in Europe is grounded most com-
monly in the fundamentals of Traditional Chinese Medi-
cine (TCM) philosophy and theory and by the approach
of Shizuto Masunaga (Zen shiatsu).
Methods
The study from which the data are drawn comprised a lon-
gitudinal, 6 months observational, pragmatic design of
client experiences and effects of shiatsu as delivered and
received in normal practice [42]. Following a pre-defined
study protocol, clients were recruited by accredited and
experienced shiatsu practitioners registered with one of
three shiatsu national Societies: Österreichischen Dachver-
bands für Shiatsu (Austria); Asociación de Profesionales
de Shiatsu de España (Spain); and the Shiatsu Society UK
(UK). To be eligible for the study, practitioners had to be
on the register for at least two years prior to the start date
(Autumn 2005) and see an average minimum of 20 cli-
ents per month. Common characteristics of the training of
the accredited practitioners included: part-time study over
three years, with 500 to 700 teaching contact hours; simi-
lar energetic diagnosis and body energy techniques; super-
vised clinical practice; and, exploration of two of the three
or four theoretical models of shiatsu.
All clients were 18 years or over and receiving shiatsu for
whatever reason. Treatment was individualised for the cli-
ent, often including advice-giving on lifestyle and other
factors as well as direct energy-based bodywork. Data were
collected by self-administered, postal questionnaires at
four time-points: at initial ('baseline') recruitment, subse-
quent to the shiatsu session; four to six days after the
recruiting shiatsu session; and, 3 and 6 months later. The
content of the questionnaires was grounded in an inter-
view-based, two country (Germany and the UK) study
[32], exploring a range of shiatsu-specific and more gen-
eral areas (Appendix 1). To provide data on factors associ-
ated with advice-giving, questions included: what clients
'hoped to get from having shiatsu' (at baseline), features of
the client-practitioner relationship and advice-giving 'in
the (recruiting) session', and changes made 'in their life as
a result of having these shiatsu treatments' (at 3 and 6
months). If they had made any changes, they were asked
to indicate in what area(s), choosing from a list of possi-
bilities (for example, diet, exercise, rest and relaxation)
and to describe 'any other changes' in the space provided.
A postal questionnaire was completed towards the end of
the study by the practitioners who took part in the study
to provide insight into how they practised shiatsu. This
included a question on whether they commonly gave
'other advice and/or recommendations to the client' and
to indicate in which areas, ticking from a list (for example,
diet, points/meridians to work on at home, exercises, life-
style habits and posture/how to use your body).
All data were coded and analysed using SPSS 13.0 for
Windows. Data analysis was restricted to clients who com-
pleted all four study questionnaires in each of the three
countries. As the study was hypothesis-forming, simple
descriptive statistics are reported here. For the client writ-
ten comments, a thematic approach was used, involving
close reading and re-reading of the comments, identifying
categories/themes to cover these, comparing categories
and, finally, generating more abstract, theoretical labels
[43]. Ethical approval for the study was obtained from the
University of Leeds Faculty of Medicine and Health
Research Ethics Committee.
Results
Participant Characteristics
Over an eleven month period (February-December 2006),
948 clients were recruited by 85 practitioners; 633 clients
completed all four questionnaires, from baseline to six-
month follow-up, an overall response rate of 67%. This
varied from 49% (Spain, n = 93) to 70% (Austria, n = 261)
and 72% (the UK, n = 279). A typical client was a woman
(80–84%), aged in her 40s, in paid employment, either
full- or part-time, who had used shiatsu before (84–88%)
and described her overall health status as being 'good' or
better. She was continuing to use shiatsu at three months
(79–96%) and at six months (76–81%), having an aver-
age of 2–3 sessions during each three-month period. She
also paid for her own treatment. There were some country
variations. The UK sample was typically older on average
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(a median age of 50 years) and included a larger propor-
tion of persons aged 65 and over (21% vs. 7–10% in Spain
and Austria) and/or retired people.
Seventy-five practitioners completed the practitioner
questionnaire, a response rate of 88%. A typical recruited
practitioner was female and in her mid-40s, with formal
education to at least Baccalaureate or A level standard, and
was as likely to be working full- as part-time and involved
in teaching shiatsu or not. She had been giving shiatsu for
around nine years. Masunaga/Zen shiatsu on its own or in
combination with TCM theory and practice was the most
common practice style (84–89%). All the practitioners
indicated that they commonly gave advice, where appro-
priate, relating to exercise, diet, lifestyle habits and/or pos-
ture or how to use one's body. There were a number of
country differences. For example, Austrian practitioners
on average had been in practice for 7 years compared to
12–13 years for the UK practitioners. UK practitioners
were also more likely have a part-time shiatsu practice, to
be involved in teaching shiatsu and least likely to be
trained or qualified in another CAM therapy (although
two-thirds were).
Reasons for Accessing Shiatsu and Hopes from Treatment
At baseline, the main reason for accessing shiatsu 'today',
mentioned by 48% of respondents, was 'to maintain or
improve their health.' When asked what they hoped to get
from having shiatsu treatment, the second most men-
tioned was 'to enhance their health', quality of life or per-
sonal growth. The ways that these hopes were expressed
were illustrative of a 'desire to change' (Appendix 2), and
in many cases an implicit recognition of their own role in
achieving change (for example, 'to get to know myself better'
S95; '...a positive attitude' UK237; '... to know my body and its
weak areas better so I can work on them' S110; '... to gain
insights through connection' A104; and, '... with the exercises
recommended' UK200).
Advice-Giving
At baseline, around three-quarters of clients indicated that
their shiatsu practitioner gave them self-care advice or rec-
ommendations (Table 1). This picture was replicated by
the practitioners; at least 80% indicated that they com-
monly gave such advice. 'Other' areas of advice included:
ways to enable self-care, including stress management,
self-massage, meditation, visualisation and use of herbal
remedies (24%); emotional advice (21%) ('about my atti-
tude in facing life' S56; 'make think about how I feel about
myself' UK98; 'positive attitude about my body ...mind' A115);
and preventive advice (16%) ('pacing [myself] so as not to
overtax my [body's] resources' UK391; 'to pay attention to
when my back is hurting' S95; or, 'to listen to my own body, to
look after myself more' A258). Practitioners talked in similar
terms, such as: '(to) investigate pastimes that may fulfil (the)
client's necessities' (SP62) or 'meditation, growth work,
emphasise their strengths and abilities' (UKP14). The advice
or recommendations were overwhelmingly perceived as
relevant by the clients (99%).
Advice-Taking and Lifestyle and Awareness Changes
By six months follow-up, around four-fifths of the clients
reported making changes to their lifestyle 'as a result of
having shiatsu treatment' (Table 1). Substantial propor-
tions had increased the amount of 'rest and relaxation'
and 'exercise' they took (43–80%). Working less was also
evident, interpretable from the verbatim comments in
terms of 'time at work' or 'time devoted to work outside of
work hours'. A third or more indicated making 'other'
changes; the most mentioned areas were 'body/mind
awareness' and changes in 'levels of confidence and
resolve' (Appendix 3). Changes in self-perceptions over
levels of confidence, levels of awareness and wider atti-
tudes to health were reported; around two-thirds or more
(64–87%) agreed or agreed strongly with statements
about, for example, 'greater confidence', being 'more in
touch with my emotions', changes in 'understanding and
experience of my body' and 'more able to cope with
things.' (Table 2)
Features of the Client-Practitioner Interaction
Clients were overwhelmingly positive about their rela-
tionship with the practitioner. Around 70% or more of
the clients 'strongly agreed' that their practitioner 'lis-
tened' or 'accepted' them (Table 3). While there was
greater variation about their joint working, 75–93%
expressed agreement that they did (30–46% 'strongly
agreed'). The practitioner was also perceived by four-fifths
of the clients as being 'trustworthy' and 'skilful' and as
'warm' by around two-thirds.
Discussion
Shiatsu and Advice-Taking
Examining these findings from a health literacy perspec-
tive suggests a valuable role for shiatsu in promoting
healthier behaviours. At a basic, functional level, develop-
ing awareness and knowledge arose within advice-giving
(diet, exercise, how to use your body and self-care) occur-
ring in the baseline treatment session. It raised the possi-
bility for the client to utilise this information in their
everyday life. Such advice-giving occurred in the context
of a client-practitioner consultation which was positively
perceived by clients as involving 'listening' and 'accepting'
the client and treatment by a skilful, warm and trusted
practitioner. The fact that, six months later, around four-
fifths of clients reported making substantial changes in
their lifestyle 'as a result of having the shiatsu treatments'
is indicative of their acting on the knowledge (interactive
health literacy) and onto critical health literacy. Clients
reported changes in exercise and diet, enhanced confi-
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Table 1: Areas of Advice Received and Given and Their Update
Austria Spain UK
Advice Received by Clients (1) (% yes)
Advice or Recommendation given 76 76 74
Advice given in the following areas:
- Exercise 65 48 48
- Diet 49 30 42
- Posture or how to use your body 27 51 29
- Points or meridians to work on at home 29 26 26
- Other 34 20 24
Areas of Advice Given by Practitioners(2) (% yes)
Exercise 94 100 96
Diet 87 83 96
Lifestyle habits 84 83 96
Posture or how to use your body 81 78 77
Points or meridians to work on at home 74 72 92
Recommend to consult another practitioner 65 89 85
Other 32 17 35
Client Uptake of Advice(3)
Made lifestyle changes 'as a result of having shiatsu treatment' (% yes) 77 80 80
- Rest and relaxation (% take more) 75 80 54
- Exercise (% take more) 64 53 43
- Diet (% changed) 58 45 56
- Work (% reduce) 32 15 19
- Other (% yes) 33 48 40
Key: These data draw on three sources: (1) baseline client questionnaire; (2) practitioner questionnaire; and (3) six month follow-up client
questionnaire
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dence about their health, being 'more able to help myself'
and having a changed understanding and experience of
their body. Overall, the lifestyle changes were suggestive
of a tendency to adopt a more relaxed, healthier and more
balanced approach to life.
One of the strengths of the study is its pragmatic nature,
studying shiatsu as delivered and received in normal prac-
tice. While it is notable that the study findings were con-
sistent across countries, there remains a possibility of
inter- and intra-country variation, in particular in relation
to the practitioners' style of practice. Despite similar train-
ing and use of Zen shiatsu on its own or in combination
with TCM theory, practitioners will be at different stages
in their own personal development, both within shiatsu
and more broadly, leading to possible variations in how
they practise. This is an important area for further research
[44]. It is also important to note that the sample group
were relatively socially and economically advantaged. The
latter issue does not however affect the wider argument of
the potential contribution of shiatsu to critical health liter-
acy.
It is instructive to reflect on why shiatsu might result in so
large a lifestyle change. At the level of theory, all present-
ing reasons, symptoms, responses during and after treat-
ment would be understood and evaluated in terms of the
person as an 'energetic' being. Its holistic philosophy is
enacted in the holistic nature of shiatsu practice, treating
mind body and spirit as an interconnected whole together
with the environment in which they find themselves. This
concept of holism pervades the shiatsu encounter; ener-
getic diagnosis includes questions pertaining to all aspects
of a person's life. Clients' reasons for using shiatsu (health
maintenance and health enhancement) and changes in
lifestyle resonate with Antonovsky's concepts of a sense of
coherence and generalised resistance resources [3,45]. Cli-
ents were seeking support in order to enable better health
and living a good life, along with or as a consequence of,
greater mind/body awareness.
A different explanation could relate to the nature of the
client group per se. The typical user had chosen to access
shiatsu, paid for by herself, had used shiatsu before and
commonly was looking to maintain or improve her own
health. From a social psychological, behavioural change
Table 2: Self-Perceived Awareness Changes (% 'agree' or 'agree strongly' at six months follow-up)
Austria Spain UK
Overall Effects
I feel more confident about my health 87 80 79
General Awareness
I feel more able to help myself 69 87 83
I am more in touch with my emotions 60 70 57
I think about things differently 68 64 63
My understanding and experience of my body have changed 82 66 72
Attitudinal and Personal
I feel more hopeful that my problems can be helped 76 81 83
I am more able to cope with things 68 77 70
I feel I have developed as a person 67 61 52
Table 3: The Client-Practitioner Relationship (% 'strongly agree'/
% 'very much so')
Client-Practitioner Relationship Austria Spain UK
The practitioner accepted me 76 68 72
The practitioner listened to me 84 70 69
The practitioner and I worked together*463034
I felt the shiatsu practitioner was trustworthy 89 87 86
I felt the shiatsu practitioner was skilful 86 82 81
I felt the shiatsu practitioner was warm 62 69 66
I liked the treatment environment 68 85 57
* These percentages increase to 92%, 75% and 85% respectively if %
'agree' is included
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perspective, the sample group was already motivated or
ready to change and expectant of particular forms of ben-
efit. At the same time, this may be only a part of the rea-
son. Indeed, in-depth interviews with acupuncturists
taking part in a pragmatic randomised controlled trial of
acupuncture for low back pain drew attention to the inte-
gral role of self-help advice within the delivery of tradi-
tional acupuncture [46]. Other possible factors include
the features of the client-practitioner interaction and the
context and practice of care-giving. For example, studies
within homoeopathy [47] and acupuncture [48,49] point
to the importance of an empathic consultation and rela-
tional style of the practitioner, its influence on enabling
the client, for example, to understand and cope with their
illness, and a potential relationship with changes in per-
ceptions of well-being.
At a methodological level, however, there is the possibility
that the findings are an artefact, brought about by social
desirability. Clients might have wanted to be supportive
to the practitioner and thus were over-optimistic in their
judgement of changes 'as a result of shiatsu'. It is however
unclear why clients would not be honest, as typical users
were continuing with shiatsu, it providing 'ongoing sup-
port' as one part of their approach to well-being and living
healthily. Indeed, for the one or two clients who indicated
that they had experienced 'a potentially adverse event or
effect', none ceased using shiatsu [39]. Moreover, the study
findings were consistent across the three countries [42].
Nevertheless, a social desirability effect remains a possi-
bility. A future study might consider incorporating a spe-
cific measure to address this possibility [50].
A Possible Explanatory Model for Research
To provide further insight into possible ways that a CAM
could contribute to critical health literacy, self-care and
promoting healthier behaviours, an explanatory model is
presented in Figure 1. It is based on the logic of realist
evaluation [51], in which causal outcomes (O) are seen as
following from mechanisms (M) acting in particular con-
texts (C). The intention is to set up a number of plausible
and testable hypotheses for further research both within
and beyond CAM, drawing on the study's findings.
Three features of context are identified: client reasons for
accessing the CAM, their expressed hopes from the treat-
ment sessions and the treatment environment. Firstly, for
this CAM, the main reason underlying why clients
accessed it was 'maintaining or improving their health'.
While the typical shiatsu user was in 'good' (or better)
C-M-O Configuration for Critical Health LiteracyFigure 1
C-M-O Configuration for Critical Health Literacy.
Context Mechanism Outcome
Reasons for Seeking
‘Treatment’
Expressed Hopes from
Having the ‘Treatment’
N
ature and Style of
Treatment Sessions
Finding Ways to
Remain Healthy
Openness to Change
Readiness to Change
Treatment Environment
Reasons for Seeking
‘Treatment’
Relationship Building Critical Health Literacy
Working Together Sense of Control
Previously Experienced
Treatment Benefits
Experienced Symptom
Changes / Benefits
from the ‘Treatment’
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health, this is consistent with seeking help both to 'main-
tain health' and for pain or other symptoms. It also
implies at least an interest in, if not commitment to, find-
ing ways to remain healthy. Potentially implicit are
notions of self-responsibility and an openness to change.
Secondly, the ways that the clients expressed their hopes
for the treatments were highly suggestive of not just an
openness to change [37], but also a readiness to change,
for example, in terms of 'getting to know myself better' or 'to
know my body.' As Dalton and Gottlieb [7] observe, readi-
ness is linked to learning, and learning to empowerment,
trying out new approaches and self-efficacy. In addition,
many previous shiatsu users often linked their hopes to
previously experienced benefits from earlier shiatsu treat-
ments. It was also noticeable that the language used by
some clients, including new shiatsu users, suggested a
(growing) awareness of the theoretical underpinnings of
an energy-based therapy, for example, talking in terms of
'to clear blockages' or 'to become grounded'.
Thirdly, the treatment environment plays an important
contextual role, in terms of its ambience and atmosphere
as well as features that may support its perception as a safe
and caring environment [52,53]. The majority of the shi-
atsu clients strongly agreed that they 'liked' the treatment
environment. Data from the practitioner questionnaires
detailed how practitioners tried to make this environment
a safe physical space (confidential and quiet) and a pro-
tected space (a 'no rush' treatment approach, a space for
the client to talk, 'their space').
Possible mechanisms relate to the client-practitioner rela-
tionship and experienced benefit from the treatments;
readiness to change is also important here retranslated as
acting to change. The significance of the nature and qual-
ity of the client-practitioner relationship and relational
style is widely reported in the CAM field as a therapeutic
factor in achieved outcomes [47,48,54-56]. Initial percep-
tions of benefit, for example, in terms of symptom change
and meeting prior expectations, is another possible mech-
anism, reflecting classic placebo theory [57,58]. Perceived
benefits may become translated into ongoing self-care to
maintain achieved (better) health and well-being. At the
same time, experiencing positive symptom changes from
treatment may not lead to changes in self-behaviour; the
opposite effect could occur, as the 'problem' is seen to be
resolved.
In summary, the model elucidates a set of factors that may
account for, or be predictive of, seeking and taking advice.
Engagement with the CAM modality, through an open-
ness to change, taking responsibility for one's own health
and enhancing potential control, coheres with the active
realisation of critical health literacy by users. Thus, there
are particular features of CAM (its philosophy and mode
of practice), the way it is delivered (features of the client-
practitioner encounter and environment of care) and
characteristics of its users (seeking help, choice in access,
openness and readiness to change) that interact to facili-
tate advice-taking and critical health literacy. While focus
has lain on shiatsu, advice-giving is common within other
CAM modalities, for example, acupuncture, ayurverdic
medicine, herbal medicine, homoeopathy and traditional
Chinese medicine.
The model suggests a number of areas for further research,
in relation to shiatsu and other CAM modalities. Firstly,
the C-M-O configuration requires further exploration,
using measuring tools appropriate to each of its compo-
nents. Secondly, it would be instructive to gain insight
into how advice is actually delivered, who instigates it,
effects on the relationship, especially the power dimen-
sion, and any possible variation by practice style. Thirdly,
examination of the way that shiatsu and other CAM thera-
pies might contribute to the client's sense of coherence
and coping strategies, and its inter-linkage with critical
health literacy, would be valuable in order to provide fur-
ther evidence of the potential of CAM for population
health. Fourthly, in this as in many other studies, reliance
is placed on client reports. How perceived self-efficacy is
in fact translated into lifestyle changes and/or whether or
not individuals do in fact do what they say they do con-
tinue to be important areas to explore.
Conclusion
This article has examined the role of CAM to enhance crit-
ical health literacy and health promotion, through a case
study of shiatsu. The explanatory model arising has poten-
tial to aid understand of how critical health literacy may
be enhanced both within and beyond CAM. The findings
reinforce other research on the importance of an openness
or readiness to change, advice-giving as part of an integral
feature of some CAM practices and the continuing need
for other initiatives around 'raising awareness' about
healthy living, whilst exploring 'upstream' at an individ-
ual level, to their root and branch and wider socio-eco-
nomic environment. At the least, the findings are strongly
suggestive of a potentially powerful contribution of shi-
atsu to population health, particularly when used as part
of ongoing support to maintain health, pursued on the
initiative of users, albeit those who may be socially or eco-
nomically advantaged.
Key Points
• The potential contribution that complementary and
alternative medicine (CAM) can make to promoting
good health and developing critical health literacy is
poorly understood
BMC Complementary and Alternative Medicine 2009, 9:19 http://www.biomedcentral.com/1472-6882/9/19
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• Core philosophical and practice-based commit-
ments of CAM modalities and reasons for its use sug-
gest a prima facie case for consideration of their role
• Evidence from a large longitudinal, observational
and practice study of one CAM, shiatsu, demonstrated
both high rates of advice-giving and uptake six months
later
• An explanatory model is developed to provide
insight into why a CAM therapy could contribute to
health promotion and enhanced health literacy and to
guide future research both within and beyond CAM
Competing interests
The author declares that they have no competing interests.
Appendix 1
Overview of Client Questionnaires
• Questionnaire One – Baseline: Socio-demographic charac-
teristics of the client; previous use of shiatsu; how pay for
shiatsu; reasons for use; severity of symptoms; use of other
CAM and non-CAM for symptoms, use of medication and
time-off work; hopes from shiatsu treatment; current
health status
• Questionnaire Two – Immediate Experiences and Effects:
experience, immediate positive effects and negative
responses shortly after the recruiting shiatsu session; cli-
ent-practitioner relationship; advice/recommendations
given at initial session; immediate improvement; satisfac-
tion with treatment; expectations met
• Questionnaire Three – Positive and Negative Effects at Three
Months: continued use of shiatsu; symptom improvement,
changed use of other CAM and non-CAM for symptoms,
use of medication and time-off work; positive effects of
having shiatsu; lifestyle changes; negative responses, if any;
satisfaction with treatment; expectations met; current
health status
• Questionnaire Four – Positive and Negative Effects at Six
Months: continued use of shiatsu; symptom improvement,
changed use of other CAM and non-CAM for symptoms,
use of medication and time-off work; positive effects of
having shiatsu; lifestyle changes; negative responses, if any;
satisfaction with treatment; expectations met; current
health status
Appendix 2
Hopes from Shiatsu: Illustrative Extracts for Enhancing
Health
Physical and Psychological Health
Generally improved physical well-being, to become more
balanced (tranquil). (A 281)
Improvement of health, physical and mental well-being.
(A288)
To increase general well-being, control the physical com-
plaints which are due to the mental problems according to
my GP. (A100)
I hope to maintain my (physical and emotional) health,
so I can get to know myself better. (S95)
To keep improving my physical condition, know myself
better and improve my attitude in facing life and the
world. (S94)
Having Parkinson's disease the shiatsu treatment helps
slow down the progress of the disease, a positive attitude.
(UK237)
Health in General
To improve my health, my tension, my back pain. To acti-
vate and harmonise my energy flow. (A171)
To maintain the level (of health/well-being) that I have
reached through regular shiatsu. (A312)
To improve my health condition. To know my body and
its weak areas better so I can work on them in order to
improve. (S110)
To maintain general well being. To nip in the bud any
potential stresses that could escalate if left untreated.
(UK195)
I go once a month to keep me healthy and in a positive
frame of mind. (UK238)
Personal Development
Enrichment in relation to self development. To gain
insights through connection: emotion and body. (A104)
I want to do something for myself, to increase my capabil-
ity for relaxation, to improve my health and sense of well-
being. (A177)
Symptom Specific
To have less tension, especially in the back. Better well-
being. (A234)
I hope to continue having good physical health, control-
ling problems with muscles, joints. (S3)
Keep physical problems at bay and keep symptoms to
minimum ...some personal space and time for me to relax
(UK209)
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Appendix 3
Illustrative 'Changes' Extracts: Mind-Body Awareness and
Confidence and Resolve
Mind/Body Awareness
Paying more attention to my body and its signals ... trust-
ing in my senses. (A23)
When it comes to physical complaints I am more aware
and take more responsibility. (A8)
More body awareness and more mindfulness, therefore
more resting phases. (A22)
It reminds me that I am a living body and I am in control
of my body. (S128)
I am more self-aware, I am more in touch with my emo-
tions. I am more positive. (S138)
More body awareness which allows me to take better care
of myself. (S186)
An overall awareness of what impacts my mind and body,
negative and positive. (UK15)
I have developed a keener awareness of how thoughts and
feelings are connected to and express themselves through
the body. This awareness allows me to be more self sus-
taining through my healing process. (UK181)
Levels of Confidence and Resolve
Change in my self-image. (A154)
I'm better able to draw boundaries in my life. (A80)
Self-awareness, more courageous, more determined.
(A210)
I regained control over my life; it's not my "knees" any-
more. (A142)
Better control of emotions, greater self-reliance, fewer
external needs. (S6)
Increase of self-confidence and awareness of my emo-
tions. (S30)
My frame of mind has improved. (S45)
My ability to assimilate changes in my life, like situations
where I do not feel comfortable, is more positive. (S129)
I'm changing my way of living. Shiatsu has opened that
door to me. (S86)
Feel a greater sense of direction and what I want to do with
the rest of my life. (UK110)
Ability to relax and approach problems more positively.
(UK301)
Have learnt to like/respect myself for the first time. Pace
myself. Aware of needs. (UK70)
Feel a lot more confident, lost a lot of weight, became a
stronger person. (UK98)
I am much more content. I do not get so "up tight" about
irrelevant things. I now am qualified to do Indian head
massage plus reiki. My perspective on life has altered.
(UK224)
Acknowledgements
This study was funded by the European Shiatsu Federation. The views
expressed in this article are those of the author and do not necessarily
reflect those of the funder. Grateful acknowledgement is made to the par-
ticipants who took part in this study, to the German and Spanish translators
of the questionnaires and to Seamus Connolly, as research coordinator for
the ESF.
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