This paper draws on a mixed methods study that examined the feasibility of conducting a randomised controlled trial of individualisedhomeopathy plus usual care, compared to usual care alone, for children aged 7–14 with moderate to severe asthma recruited from secondary care.It draws on qualitative interviews with participants in the feasibility study that investigated families’ and professionals’ views and experiences ofasthma, homeopathy and study participation

1. Available online at www.sciencedirect.com
European Journal of Integrative Medicine 5 (2013) 418–426
Original article
Health professionals’ and families’ understanding of the role of
individualised homeopathy in asthma management for children requiring
secondary care: Qualitative findings from a mixed methods feasibility study
James Nichola, Elizabeth A. Thompsonb,∗, Alison Shawa
a School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, United Kingdom
b Bristol Homeopathic Hospital at South Bristol Community Hospital, Hengrove Promenade,
University Hospitals Bristol NHS Foundation Trust, Bristol BS14 0DE, United Kingdom
Received 30 July 2012; received in revised form 27 June 2013; accepted 27 June 2013
Abstract
Background: This paper draws on a mixed methods study that examined the feasibility of conducting a randomised controlled trial of individualised
homeopathy plus usual care, compared to usual care alone, for children aged 7–14 with moderate to severe asthma recruited from secondary care.
It draws on qualitative interviews with participants in the feasibility study that investigated families’ and professionals’ views and experiences of
asthma, homeopathy and study participation.
Methods: Semi-structured interviews were conducted with nine families from the homeopathy arm of the feasibility study and eight health
professionals from diverse disciplines involved in the study. Data analysis was thematic, guided by the constant comparative method and questions
of interest to the feasibility study.
Results: Three key themes were identified: the complexities of asthma and asthma management; the potential for homeopathy to improve asthma
management; and perceptions and experiences of the research process. All participant groups agreed that asthma was a complex condition that was
difficult to manage, but they voiced varied concerns and different perspectives regarding the ‘added value’ of homeopathy alongside usual care.
Conclusions: This qualitative study shows how participants in a feasibility study can hold different priorities and perspectives about an intervention
for severe childhood asthma. Differences in valued outcomes that reflect holistic practice should be considered when designing future research in
this field.
© 2013 Published by Elsevier GmbH.
Keywords: Homeopathy; Children; Asthma
Background
AsthmaisthemostcommonchronicdiseaseintheUK[1]and
there is some dissonance between the strategies of professionals
[2] and the aspirations of patients [3–5] about how best to man-
age it. The hopes and concerns of adult patients may be shared
by the parents of children with asthma [6] who seek greater con-
trol over a condition that can seem ‘out of control’ and may
look to complementary therapies as an option for achieving this.
The use of complementary therapies, including homeopathy, as
a non-pharmaceutical approach to the management of asthma
∗ Corresponding author. Tel.: +44 1179731231.
E-mail address: elizabeth.thompson@UHBristol.nhs.uk (E.A. Thompson).
is increasing [7] with a reported prevalence of 14.5% among
asthma patients (adults and children) in a primary care survey
in England [8]. Asthma is one of the ten most common reasons
for referral to one of the UK’s NHS homeopathic hospitals [9].
A previous trial of individualised homeopathy as an adjunct
in the treatment of childhood asthma included a high proportion
of children with very mild asthma, and it was reported as diffi-
cult to demonstrate any potential benefit from the intervention
due to ceiling effects [10]. A Cochrane review of homeopathy
for asthma suggested available evidence was inconclusive and
recommended observational studies to inform well designed
trials [11]. Having observational data from the clinic setting
at the Bristol Homeopathic Hospital suggestive of benefit for
children with asthma [12] and in an effort to carry out well
designed trials that avoided a ceiling effect, our aim was to
1876-3820/$ – see front matter © 2013 Published by Elsevier GmbH.
http://dx.doi.org/10.1016/j.eujim.2013.06.007

2. J. Nichol et al. / European Journal of Integrative Medicine 5 (2013) 418–426 419
conduct a feasibility study of a homeopathic package plus usual
care, versus usual care alone, for children with more severe
asthma (Step 2 or above on the British Thoracic Guidelines [2])
who required specialist care, in order to inform the design of a
future pragmatic randomised controlled trial.
A combination of quantitative and qualitative methods was
used to explore the appropriateness of the study design, out-
come measures, and acceptability of the intervention and study
process. The importance of using integrated quantitative and
qualitative methods to improve trial quality and conduct is well
recognised [13]. Qualitative methods were used to explore fam-
ilies’ and healthcare professionals’ experience of asthma, the
homeopathic package and study participation. For the purpose of
the feasibility study, homeopathic care comprised one long con-
sultation (1 h) and four shorter follow up appointments (20 min),
along with the prescription of an individualised homeopathic
remedy for the child. Those receiving homeopathic care also
received their usual care from clinicians at a respiratory outpa-
tient clinic for children and in primary care. Usual care varied
depending on the needs of the individual.
The results of the feasibility study using a mixed methods
approach has been published [14], with the conclusion that ‘a
future trial of similar design was not feasible’ for a population of
children with such severe asthma. Quantitative data suggested
thatintegratinghomeopathyintoexistingmedicalcarewouldnot
confer additional benefit either medically or financially. How-
ever, qualitative data from the feasibility study suggested ‘added
value to some individuals’. Previous literature has suggested that
it is useful to consider the ‘added value’ provided by comple-
mentary approaches’ [15], pointing to the development of new
outcome measures ‘with a broader view of holistic care in their
design allowing deeper changes at the emotional and psycho-
logical level to be viewed’ [16]. The present paper addresses
this issue of ‘added value’ of homeopathy in addition to usual
care, through examining the perspectives of different partici-
pants engaged in receiving or delivering care for children with
severe asthma as part of a feasibility study, and articulating the
implications for future research.
Methods
The study had ethics approval from the Oxfordshire Ethics
Committee (05/Q1605/126 November 2005) and approval from
the Medicines and Healthcare Products Regulatory Agency
(MHRA).
Recruitment to the feasibility study
The inclusion criteria for the feasibility study were that the
children were aged 7–14 years, were being seen in a secondary
care respiratory clinic and were at Step 2 or above on the British
Thoracic Society Guidelines [2]. Exclusion criteria were cur-
rent use of homeopathy and being too unwell to take part (as
judged by their respiratory physician). A total of 226 eligi-
ble children were identified from outpatient clinics and patient
databases held by respiratory nurses at outpatient clinics at
two secondary care sites. Those identified at the clinics were
approached by a research nurse and given information about the
study, a consent form and baseline questionnaires, to return to
the research team if they consented to participate. Those iden-
tified via a database were sent the information sheet, consent
form and baseline questionnaires through the post and invited
to participate. Subsequently 67 families showed an initial inter-
est in taking part and received the baseline questionnaires, 39
children returned the questionnaires and were randomised, 18
to the usual care plus homeopathy care (HC) and 21 to the usual
care arm (UC). Reasons for declining to participate given by
families included practical concerns (e.g. about parking their
car at the homeopathic hospital and taking their child out of
school when they already had multiple medical appointments)
and more ‘philosophical’ concerns, notably a lack of interest or
belief in homeopathy.
Sampling for the qualitative study
For the qualitative aspect of the study, a purposeful sampling
strategy targeted 10 children and their carers from the home-
opathy arm and 9 families were subsequently interviewed. (The
tenth family declined an interview being too pressured to par-
ticipate.) Sampling for variation was used to include patients of
varying age (range 7–14 years) gender (3 girls and 6 boys) and
asthma severity (from Step 2–4 on the British Thoracic Guide-
lines [2]). Although fathers played a role in some interviews,
mothers were the main parental participants. In addition, 8 health
professionalsfromthethreesettingsthathadbeeninvolvedinthe
feasibility study (two respiratory outpatient clinics and home-
opathic hospital) were interviewed to explore their attitudes to
homeopathy alongside usual care as an intervention for severe
childhood asthma. These included: 2 consultant paediatricians; 2
paediatric nurses specialising in respiratory medicine; 1 consul-
tant respiratory physician now working in paediatric respiratory
medicine; 2 homeopathic physicians (one of whom also worked
as a GP); and 1 paediatric nurse who was the research nurse who
recruited families to the feasibility study.
Data collection for the qualitative study
Qualitative data were collected using semi-structured inter-
views. Parents and children were interviewed together as family
views were important to us and extended knowledge from previ-
ous research carried out [17]. 8 families were interviewed at their
homesand1familywasinterviewedatthehomeopathichospital.
Professionalswereinterviewedintheirworkplace.JNconducted
the interviews using a flexible topic guide which allowed par-
ticipants to introduce new issues, incorporating new lines of
questioning in response to issues arising during data collection
and early analysis [18]. Broad topics covered in the interviews
are shown in Table 1. Interviews lasted between 20 and 50 min,
were recorded using a digital voice recorder and transcribed
verbatim by a professional transcriber.
Data analysis for the qualitative study
Data analysis was thematic and guided by the constant com-
parative method and issues relevant to the wider feasibility study,

3. 420 J. Nichol et al. / European Journal of Integrative Medicine 5 (2013) 418–426
Table 1
Interview topic guides for families and health professionals.
Families Part A: interview with child regarding homeopathy for
asthma
• Experiences of having asthma; how it affects life/activities.
• Views and experiences of conventional asthma treatment; feelings
about medication
• Any current impressions/knowledge of homeopathy
• Any expectations regarding the homeopathic hospital compared to
their usual doctors
• Experiences of homeopathic treatment including consultations and
remedies
• Views on impact of homeopathy on asthma; any changes in their
asthma during homeopathic treatment
• Would they want to continue using homeopathy for their asthma;
why or why not?
Families Part B: interview with parent regarding homeopathy for
asthma
• Experiences of being a parent of a child with asthma
• Views and experiences of conventional asthma treatment, e.g.
conventional medication, experiences of care
• Views of complementary medicine in general and any experience
of use
• Any views/expectations/experiences of homeopathy; any previous
consideration of homeopathy use
• Views on acceptability of homeopathy as a complementary
treatment for managing poorly controlled childhood asthma
• Expectations of attending the homeopathic hospital/homeopathic
treatment for their child’s asthma
• Experiences of homeopathic treatment - consultations, perceptions
regarding any impact on their child’s asthma, specific aspects of
homeopathy seen as helpful or otherwise
• Views on future use of homeopathy for asthma
• Views on the role of homeopathy within NHS asthma care
• Views on NHS health professionals’ attitudes/knowledge of
homeopathy
Families Part C: interview with parent and child on experiences of
participating in the study
• The parent’s views about taking part in the study
• The child’s view of taking part in the study (if appropriate and child
available) e.g. did they want to take part or was it the parent’s choice?
• Views about completing the questionnaires e.g. frequency, number,
questions asked (relevance, etc.), ease of completion (e.g. for child)
• Views about recruitment process
• Views about the practicalities of the treatment process e.g. ease of
attendance/access, time off school, timing of appointments
• Anything they would change about the study to make it more
acceptable to parents/children
Health professionals
• Experiences of treating childhood asthma; views of the
effectiveness of conventional treatments
• Views of complementary therapies in general
• Views of homeopathy: how it may/may not work, effectiveness for
asthma, safety, acceptability as adjunctive treatment for asthma
• Prior experience of referral to homeopathy, who initiated referral,
feelings about referral
• Views of the study: views of referring children with asthma for the
study, study process
• Expectations of how homeopathy might help or not
• Views of type and level of evidence they would require to routinely
refer patients for homeopathic treatment
• Views on the role of homeopathy within NHS care and whether it
should be funded
while incorporating flexibility to allow new perspectives and
issues raised by participants to be included. Analysis was led
by JN and began with detailed reading of each transcript, not-
ing initial emerging issues. Following this familiarisation phase,
open coding of individual transcripts led to the development of
a thematic coding framework [19] that was refined with input
from ET and AS. Data within the themes were scrutinised for
disconfirming and confirming views across the range of partici-
pants [19]. JN led the analysis. ET and AS coded a sub-sample
of transcripts and met with JN at regular intervals to discuss the
coding framework and check that the data were accounted for
by the three main themes.
Results
Three broad themes emerged from the data and reflected a
full range of expressed views. [See Tables 2–4, FM (mother),
FF (father) FC (child) or HP (health professional).]
Theme 1 – Complexities of asthma and asthma management
Family experiences
Parents were highly conscious of the impact of asthma on
the whole family and used language of fear and worry to
describe their experience of acute episodes and hospitalisations
(Table 2). They had to organise family and school life to deal
with these health crises and regular medical appointments and
felt responsible for managing treatment regimes in the home.
Some commented on the social impact of asthma on their child,
for example, in terms of peer relations. Others acknowledged
that their children do not always remember to take their medica-
tion or that they do not always appreciate the prevention aspect,
tending not to take medication when they feel well. At other
times, their children were perceived to more consciously resist
using their medication. One parent said that she had not fully
acknowledged and engaged with the level of her step-child’s
feelings about his asthma and his medication until he disclosed
them during a homeopathic consultation as part of the feasibility
study.
In their interview accounts, children themselves focused on
physical impairment and restrictions in daily life, such as losing
energy, getting out of breath, not being able to run or play
games like football and netball (Table 2). Children were acutely
conscious of the social impact of having asthma and how this
shaped peer relations, for example having to be ‘at the back’
(FC3) and therefore ‘not with my friends’ when walking up a
hill in school. One boy said that his friends ‘didn’t understand’
(FC5) the way in which he had to limit his participation in
football. For a girl of 11, a sleepover with friends triggered
severe symptoms and an emergency hospitalisation. One of
the children interviewed was experiencing severe bullying
and was considering changing schools as the bullying was
perceived to be related to her condition and perhaps in turn to
have exacerbated it. Another reported being glad that he could
use his inhaler discreetly at the school reception rather than in
front of his peers. Children who were stoical in their accounts

4. J. Nichol et al. / European Journal of Integrative Medicine 5 (2013) 418–426 421
Table 2
Complexities of asthma and asthma management.
Parents’ views Geared to keeping around him, trying to keep him healthy all of the time (FM1)
It is a bit of a nightmare. It really is a bit of a nightmare. (FM6)
There are times when he uses his inhalers as, almost like a weapon . . . I’m not doing this, I’ve had enough of this
and I don’t want to do it. (FM7)
At the moment we can’t see any end to where he can stop having it [medication]. This worries me the most.
(FM1)
She’s the only one with the asthma at her little school, it’s only such a tiny little school . . . So what, you know,
it’s just the stigma, isn’t it, it’s just the standing out, which can’t be good for kids, anyhow (FM3).
Children’s views I can’t run as fast because I get tired and I have to always stop. (FC3)
Don’t spin and not spin around fast, don’t jump up high. (FC5)
It’s really hard to have asthma because you can’t do as much things as other people can do because you end up in
hospital when you try and do the things that you want to. . . . Not long ago, I was in hospital because I was trying
to do something that my friends were trying to do. (FC4)
Professionals’ views I think traditionally, we’ve always gone into conventional medicine, but I really feel that there’s a really big
component in asthma where it’s to do with relaxation and those sort of different ways of actually dealing with it
. . . and we don’t actually look at the whole person, we just look at the asthma and we don’t look at the family
dynamics and all that because they’re all very, very pertinent to how they manage their asthma. (HP5, nurse)
They work very well but there’s a trade-off and in homeopathic philosophy, we would understand that because
it’s not a balancing effect . . . so therefore the body will react and respond . . . by trying to re-establish and
equilibrium, and that creates friction, whereas with homeopathy what you’re trying to do is just stimulate the
body to self-regulate. (HP7, homeopathic physician)
That small group of children that I said is more difficult to control that we’re using either tablet steroids or other
medications then the risk of side effects is very significant. Yeah and it’s always then a balance between what
side effects you get and how much control you’ve tried to get. (HP8, respiratory physician)
of their asthma symptoms appeared willing to be more openly
concerned about social issues like these within interviews.
Both parents and children said that conventional medica-
tion helped to control the asthma, at least to an extent, most
of the time. In the words of one parent: ‘it keeps it at a level’
(FM1). However, some were worried that the levels of medica-
tion prescribed by their doctors seemed to get higher with limited
additional benefits. The family who was most concerned was
facing an escalation to injections or continuous steroid tablets
at the time of interview. A mother was concerned about the
impact of long term treatment on her son’s body and growth.
A mother who was a pharmacist commented that her daugh-
ter had been taking medication since she was very young and
wondered about possible long-term effects of newer medications
on her daughter’s lungs – ‘these things haven’t been around all
that long’ (FM8). At the same time, comments about service
delivery within usual care were generally favourable, especially
in relation to the children’s hospital, described by one parent
as ‘absolutely brilliant’ (FM9). Parents expressed confidence in
the consultants and appreciated the contact with the respiratory
Table 3
Potential of homeopathy to improve asthma and asthma management.
Families’ views It did make you sort of stop and think about it a little bit more about how it’s affecting your life and perhaps well, if it’s
doing this, is there anything we can do to make it better or change that? (FM7)
It wasn’t something I particularly believed in. but you tend to get to a stage anything’s worth a try . . . I didn’t think it would
work, to be honest. (FM2)
I thought there’d be big gardens with loads of flowers and everything. (FC7, re expectations of Homeopathic Hospital)
Respiratory physicians’ views I would suppose that even bizarre concoctions are probably safe because they have minute molecular quantities. Although if
I put my scepticism aside, if these solutions have some [unclear 10:20] then you are applying a, some compound or material
which hasn’t been otherwise tested and that would not pass, you know current, you know regulations for a new medicine. So
on the one hand if it’s effective in someway how do I really know that it’s safe. But the reason why I am probably confident
is that my scepticism says that there’s not much there. (HP8)
Homeopathic physicians’ views I mean, sometimes you find a child who’s asthma has developed since some sort of emotional crisis, you know, like a loss of
a beloved grandparent or, you know, moving to a different country or something, and homeopathy provides a context for
giving meaning to that connection and our remedies are very much understood in terms of these aetiological factors. So, for
instance, if somebody has asthma ever since they got a terrible fright, you know, they came downstairs and there’s a burglar
in their living room or something, you know, and the child’s been petrified and asthmatic ever since, you know, we have
remedies like aconite that we prescribe for that. Whereas in conventional medicine there’s no . . . the treatment is the same
more or less regardless of the aetiology, unless the child’s like really psychiatrically ill. If they’re just a normal child with a
few hang ups that usually won’t come into the doctor’s formulation. So I think that’s really, you know, even that you’re
interested in that I think is something which people value. (HP1)
Nurses’ views It was the monsoon, we had no supplies, so we had to go back to the grass roots level of homeopathy and plants medicine or
whatever, and I was cynical at first but they were there with their plants and whatever, grinding them up and whatever and
the kids actually improved and you couldn’t say it was - the first time you think oh, it’s just luck and whatever, but after a
couple of times, it wasn’t luck, there is definitely something there and it’s just because we don’t understand it. (HP5)

5. 422 J. Nichol et al. / European Journal of Integrative Medicine 5 (2013) 418–426
Table 4
Perceptions and experiences of the research process.
Families’ views About halfway through, I sort of started to realise why they were asking these questions, because if you have like . . . if you
. . . they said if you have nightmares more than what you do normal dreams, there’s different medication which you need for
it, sort of . . . then it sort of clicked and I sort of realised. (FC2)
It was a lot more about finding out about your life and about your personality and stuff . . . it was quite interesting to how
they linked stuff that I just thought, like normal things, but are linked up with my asthma. (FC8)
And because she’s very quiet and he sort of helped her to talk about things, whereas normally they’ll go past her, because
she doesn’t answer, and they just go straight to me, when what she came out with, some of it we didn’t even know, [yeah] so
it was good. It was good, yeah. (FM3)
Homeopathic physicians’ views Several children . . . were on . . . pretty high doses of inhaled stuff, so they didn’t really have any symptoms. So if a child has
no asthma symptoms and no real suffering to talk about, then you’re digging around to look for things to make your remedy
on and you just . . . sometimes find it impossible to individualise the case. So that’s working against it. (HP1)
Nurses’ views It should have been recruitment for a whole year maybe, because then you’d probably get more because they wouldn’t be so
worried about exams. Too many hospital appointments . . . things like missing the post, frequently . . . Now I never sent out
that many questionnaires, each family for five questionnaires and about forty families. A high percentage of them have
apparently gone missing in the post. Hm. So I think they probably never got posted. (HP3)
Respiratory physicians’ views I think the problem in many studies like this is that you just have such a huge range of severity and I don’t think it will pick
up an effect . . . and it’s about targeting a group where there may be an effect. But it’s very difficult with homeopathy
because we don’t know what the best clinical effect is and I think there will always be a problem with studies that recruit
patients by asking a group of patients, ‘who wants to be in the study?’. You already have a self-selected group who may
have particular influences or beliefs which draw them into the trial . . . And the fact that they were on a variety of treatments,
medications, it wasn’t honed down . . . so I don’t think the populations were particularly well selected. (HP4)
nurses. They felt that the hospital was there for them when they
needed it. In particular, parents valued explanations about what
the different medications are designed to achieve and appreci-
ated the increasing use of language that stresses ‘management’
as a realistic goal for severe asthma.
Professional views
Professionals across all the groups represented in the fea-
sibility study also acknowledged the complexities of asthma
and asthma management (Table 2). A consultant paediatrician
viewed asthma as complicated by other co-existing conditions
and ‘variables such as anxiety that predispose them to a wors-
ening of their asthma’ (HP4). Respiratory physicians felt that
current medications achieve good results for 80–90% of the
children they see, although control were thought to be com-
promised by inadequate adherence to treatment regimes. They
also thought that current medications had limitations. One saw
inhaled steroids as a ‘disappointment’ because they do not pre-
vent acute viral induced episodes ‘or people’s struggle with their
daytodaywheezingillnesses’(HP4).Anothersuggestedthatthe
evidence base for anti-inflammatories was not ‘really a strong’
one and also had concerns about ‘more potent drugs’ with a
greater risk of ‘serious adverse effects’ (HP6). A third talked
about the need to balance control and side effects for children
with the most difficult problems, especially amongst children
with hard to control asthma who might require steroids.
Nurses recognised the challenges of maintaining patient’s
adherence to medication regimes, and commented that it was dif-
ficult, especially for adolescents, to remember to take medicines.
Inhaler or spacer routines were characterised as ‘a bit fiddly and
time consuming’ (HP2). Nurses also believed that patients made
the mistake of not taking their medication when feeling well
(as acknowledged by some parents who were interviewed). For
one nurse, part of the problem lay in limited opportunities for
discussions between patients or parents and their doctors, who
did not have time to find out how patients were feeling about
their asthma or address the negative impact of their medication
on their quality of life. One nurse emphasised the role of ‘family
dynamics’ in the management of children’s asthma (Table 2).
As well as recognising the complexity of managing asthma,
including the challenges of adherence to medication regimes,
homeopathic physicians’ understanding of complexity focused
on the whole person and what they needed to create opti-
mal health (Table 2). Both of the homeopathic physicians
interviewed acknowledged the power of conventional asthma
medication and argued that they were not in favour of replac-
ing patients’ conventional medication with homeopathy, in an
unsafe way. However, from a homeopathic perspective, conven-
tional medications create imbalances and friction in the body’s
attempts to achieve equilibrium. They suggested that powerful
technologies like steroids carry their own risks and we ‘need to
be wise’ with them (HP7).
Theme 2 – Potential of homeopathy to improve asthma
management
Family experiences
Five of the nine parents interviewed had a pre-existing inter-
est in homeopathy or complementary therapies more generally,
while others had no idea what homeopathy was. However all
entered the feasibility study with carefully moderated expec-
tations, describing being ‘open-minded’ and willing to try
anything that potentially offered their child reduced depen-
dency on conventional medication, especially steroids (FM7).
For some, homeopathy was a last resort (Table 3).
After experiencing the homeopathy plus usual care package
as part of the feasibility study, six of the nine families inter-
viewed thought that there had been an improvement in the child’s
asthma symptoms. Of these, one child had moved from steroid
inhalers to tablets during the study period and the parent could
not decipher whether it was this change of regime or the home-
opathy, if either, that had made a difference. In the other five

6. J. Nichol et al. / European Journal of Integrative Medicine 5 (2013) 418–426 423
cases, families reported favourable changes in breathing, run-
ning and sports which they were inclined to attribute, more or
less strongly, to the homeopathic remedies. For example, they
either made statements like ‘the powders helped a lot’ (FM4) or
more provisionally noted that the improvements happened at the
same time as taking the remedies and there was no other obvious
reason for a change. Three families believed that the homeo-
pathic package had made no difference to the child’s asthma
symptoms.
Some families thought that the homeopathy had made a
difference to other health problems that the child was expe-
riencing. One child and parent reported that the homeopathic
remedy seemed to be controlling the child’s eczema without
any improvement to her asthma symptoms. Another (child and
step mother) reported the relief of allergic symptoms and felt
that the homeopathic ‘allergy stuff’ (FM7) might have played a
role. Homeopathic treatment was also perceived to have brought
about broader quality of life benefits for some of the children.
Accordingtoamother,thechild‘hascomeoutofherself’(FM3),
is now in the school netball team and has increased her school
attendance. Both mother and child had a strong belief that the
homeopathic remedy was influential in this change.
Family members thought that the package of homeopathic
treatment was well organised and appreciated their contact with
homeopathic hospital staff. One of the children said, ‘the peo-
ple there were very, very helpful. The people who worked there
were just great really’ (FC2). One mother of a child with multiple
health problems described how she valued the ‘whole person’
(FM3) approach of homeopathy, given her own perception that
her daughter’s illnesses are interconnected. She liked the com-
bination of the remedy itself, attention to feelings and dietary
advice that was offered: ‘I think it’s her whole person we need
to concentrate on and the only way I’m going to get that done is
to go homeopathic’. Another parent was excited by the process
of remedy matching that is a part of individualised homeopathy.
Parents generally valued the longer consultations offered by the
homeopathic hospital and in some cases heard their children
say things about their feelings during homeopathic consulta-
tions that they hadn’t heard before. One mother described that
as ‘almost an additional service on its own’ (FM7). Another
described how the initial consultation had given her more insight
into daughter’s condition. Seven of the nine families interviewed
had an interest in continuing or resuming homeopathy use and
two did not. Six families wanted homeopathy to be available and
funded within the NHS.
There was some concern about lack of integration of conven-
tional and homeopathic care with one parent stating ‘it would be
nice if both sets of doctors could work together’ (FM2) and felt
that the use of homeopathy as an additional treatment might have
been more effective if ‘the consultants at the (children’s hospi-
tal)’ had been more positively engaged. Outside the context of
the feasibility study, doctors at the children’s hospital were per-
ceived to not proactively recommend homeopathy although also
not ‘shutting the door on it’ (FF1). One parent recalled, ‘they said
you can try if you trust them (FM5)’. Another reported that the
consultant had said, ‘if that’s how you feel about it, then it’s, you
know, it’s not a problem with them that we were going that path’
(FM9). A doctor ‘not the consultant’ in another specialist service
was seen ‘rolling up his eyes’ (FM3) in response to the patient’s
desire to try homeopathy. Reported responses from families’
GPs were more mixed: some ‘pooh-poohed’ (FM2) it, while
others were described as supportive of complementary therapies.
Professional views
The paediatricians and respiratory consultants interviewed
conveyed a guarded view of homeopathic care. None said that
they would block a patient’s attempts to access homeopathy
through their GP but none proactively referred patients them-
selves. Some reported being more persuaded by other forms of
complementary therapy such as chiropractic and acupuncture.
For such therapies, there was a degree of willingness to accept
their benefits, even if one could not necessarily understand how
they worked. One said, ‘I go to a chiropractor if I have back
problems and it’s done me a lot of good . . . I think I have to
accept that some things work, and I don’t know why’ (HP6).
Another said, ‘I’d be less skeptical about . . . physical therapies’
because he had friends who are GPs and have them in their
practice’ (HP8). However, this willingness to accept that thera-
pies can work even if one cannot understand the mechanism of
action did not necessarily extend to homeopathy. For example,
the latter interviewee had specific concerns about homeopathy
both because of ‘the minute molecular quantities’ in homeo-
pathic remedies and about what he believed to be inadequately
tested ingredients, which would have worried him if used in
larger quantities as a herbal medicine (Table 3). There was also
a perception that any benefits of homeopathic care could be due
to the time and attention given to patients within a homeopathic
consultation. A consultant paediatrician speculated whether if
he spent an hour with people ‘chatting through their problems
and just making them feel good about themselves’ (HP6), this
would make a difference in his own work.
The physicians were somewhat reassured by homeopaths
who are medically qualified, such as those providing homeo-
pathic care within the context of the feasibility study. All were
clear that homeopathy should be an adjunct and not influence
conventional treatment for asthma. They were concerned that
homeopathy could be used as a tool for reducing conventional
medication,whichtheyperceivedmightputpatientsatrisk.They
had mixed feelings about the place of homeopathy within the
NHS overall. One physician thought that the present level of
service should be maintained as a way of being ‘patient respon-
sive’ (HP4), but not expanded in the absence of better evidence.
Another was less certain. ‘The scientist in me says no’ (HP6),
but he conceded that if the NHS was funding psychotherapy, and
homeopathy relieved suffering, then perhaps it had a place. A
third doctor found it acceptable to fund NHS homeopathy cur-
rently, but highlighted that questions remain, and possibly are
increasing, regarding the continuation of NHS homeopathy as
the demand for evidence based medicine grows ever stronger.
The nurses interviewed had varying personal views of com-
plementary therapies, but all saw the provision of homeopathic
treatment as safe, and supportive of patient empowerment
and choice. They suggested that enabling people to have a
homeopathy referral ‘encourages people to take an interest in

7. 424 J. Nichol et al. / European Journal of Integrative Medicine 5 (2013) 418–426
their own health’ (HP2). One nurse saw the relative absence of
complementary options in NHS as penalising the less well-off.
Drawing on her experiences of traditional remedies in a
refugee camp where she had worked, she reflected that Western
medicine is overly concerned with explanation and not open
to alternatives (Table 3). In relation to the feasibility study, she
believed that asthma is so complex that neither homeopathy nor
conventional medicine should be seen as ‘watertight’ or ‘100%’
(HP5). Homeopathy’s value was seen to lie in its engagement
with the whole person as well as the specific health problem
and consequent ability to match the treatment to the person.
The nurses interviewed all wanted homeopathy to be funded
through the NHS. One argued that even if the benefits of home-
opathy are due to a placebo effect (which she doubted), she had
witnessed many patients with chronic problems who seemed
to have been helped. She suggested that access to homeopathy
might free up other parts of the health service: patients who
might be ‘clogging up’ (HP3) hospitals in other ways would
have access to non-toxic and inexpensive treatment. Another
wanted to see the service expanded so that the NHS became the
major provider of homeopathy, not only making it accessible to
more patients but also ensuring consistently high standards of
practice.
Homeopathic physicians believed that the homeopathic con-
sultation process could pick up on wider life events involving
crisis, loss and trauma that are significant in the person’s ill-
ness but not usually uncovered and discussed within usual care
(Table 3). They suggested that the role of the homeopathic rem-
edy within a patient’s wider treatment varied with the presenting
problem. In certain contexts such as chronic fatigue, homeopa-
thy might be the primary intervention whereas with cancer, it
could only be complementary. They felt that asthma could in
principle be viewed as lying somewhere between these two ends
of the treatment spectrum. They suggested that some children
with asthma might be able to cope without inhalers if home-
opathy was the initial treatment. If the main problem was not
the asthma, the homeopathic intervention might mean that ‘you
do not see an improvement in the asthma but you do see an
improvement in the child, in ways that maybe do not relate to
the asthma’ (HP1).
Homeopathic physicians described homeopathy as a com-
plex intervention with many active ingredients that should not
be conceptualised as a drug. In this feasibility study, where the
patient’s asthma was being controlled by significant amounts
of conventional medicine, matching the remedy to the individ-
ual child was experienced as challenging. For the homeopathic
physicians, both the consultative process and the remedies were
part of an overall package of individualised treatment. The con-
sultation was not a ‘chat’ or psychotherapy, because it attempted
to‘gatherthetotalityofsymptoms’(HP7).Theprocessofmatch-
ing the individual to a remedy was described as ‘absolutely key
. . . and if you look at the consultation process, it’s very, very
driven by that . . . task’ (HP7).
A homeopathic physician said that it was essential for the
NHS to fund non-pharmaceutical approaches. They suggested
that the term ‘evidence based’ needed to be used with care given
that there are many areas of conventional medicine without
a solid scientific evidence base. One example given was the
widespread use of anaesthetics, without detailed understanding
of how they work. They argued that homeopathy had its own
specific frameworks for understanding its mechanism of action,
which deserved proper consideration.
Theme 3 – Perceptions and experiences of the research
process
This theme had two aspects, namely practical (practical expe-
riences of participating in the feasibility study) and ‘theoretical’
(views about research design issues more widely). The fami-
lies focused primarily on practical issues while the professionals
also reflected on broader theoretical issues regarding conducting
research in this field.
Family experiences
Most of the families interviewed were recruited to the feasi-
bility study via asthma outpatient clinics and thought it was a
good setting in which to be invited to participate, adding that the
research was well explained by the research nurse. Two families
were contacted at home via databases held at the clinics. Fam-
ilies characterised the study as well organised, interesting and
as providing a good personal service for participants, although
some parents said they would have preferred their homeopathic
provision via a local health centre. They had concerns about
taking their child out of school for homeopathic appointments
when their attendance was already poor and about problems with
parking at the homeopathic hospital. Late afternoon appoint-
ments were therefore provided within the study and for children
who struggled to walk the distance to the homeopathic hospi-
tal from their car, telephone consultations were made after the
initial appointment.
Motivations to participate included both altruistic concerns
to help others in the future and a desire to improve their child’s
health, or one’s own health. In the words of one child, he didn’t
mind being involved ‘as long as I get better’ (FC9). Some fam-
ilies enjoyed questionnaires whilst others found it hard to cope
with in addition to everything else in their lives. Older children
who remembered the homeopathic consultations found them
interesting in terms of how links were made between differ-
ent dimensions of their life and health (Table 3). The learning
aspects of the homeopathic process were reflected in descrip-
tions of how it ‘made you stop and think about things a little
bit more’ (FM7), provided educational benefit within the family
and gave insight into how different homeopathy was from the
rest of the NHS.
Professional views
The nurses all noted some limitations in the recruitment pro-
cess for the feasibility study. One felt that participants were
a highly self-selected sample, due to family concerns about
travelling to the homeopathic hospital for extra consultations
particularly during exam time and to recruitment during the
spring and summer when patients feel better and are therefore
less interested in seeking additional help. Factors perceived to
facilitate families’ participation were an existing openness to

8. J. Nichol et al. / European Journal of Integrative Medicine 5 (2013) 418–426 425
complementary therapies or use of homeopathy as a last resort
for families who were ‘desperate’ and willing ‘to try anything’
(HP5). One research nurse had concerns about the number of
questionnaires apparently lost in the post (Table 3).
The homeopathic physicians identified two challenges: firstly
a ‘significant’ minority of families didn’t stay committed to
the homeopathic process, which they acknowledged was ‘very
understandable because they didn’t really have any expecta-
tion of what was coming’ (HP1). The second was that the
sample included children who were well controlled by high
doses of conventional medication and asymptomatic, making
it hard to individualise the case and match a homeopathic rem-
edy (Table 2). Reflecting on research more widely in this area,
the homeopathic physicians argued that the appropriate evidence
base for homeopathy should not just be confined to double blind
placebo randomised controlled trials. It should also incorporate
observational methods, and be able to take personal and individ-
ual experience into account. Improvement in a patient’s overall
quality of life was seen as an important measure of success.
While they recognised that benefits self-reported by patients
could not simply be taken at face value, they felt that observ-
able changes in social behaviour such as school attendance and
performance could act as markers for health gain.
The respiratory physicians pointed out that medicine was
becoming more demanding in terms of providing evidence of
effectiveness and cost effectiveness of treatments. The acknowl-
edged difficulties with the asthma syndrome meant that new drug
trials had to work with tens of thousands of people over several
years. In the view of one, the feasibility study had targeted a
group of children with severe asthma in order to see potential
effects more clearly but with homeopathy there was no agree-
ment on ‘best effect’ and the study had not been ‘honed down’
adequately (Table 3). Another said, ‘I don’t believe we will see
any patho-physiological outcome change as a result that could
be ascribed only to the homeopathic remedy’ (HP6). Yet, he
acknowledged that homeopathy could make a difference to the
patient and their quality of life, which ‘in that sort of holistic
sense’ is what matters to them. He said that if there was evi-
dence of a ‘true effect’, it would probably be ‘one of those road
to Damascus moments’.
Discussion
Three broad themes emerged from the data: complexities of
asthma and asthma management, the potential of homeopathy
to improve asthma care, and perceptions and experiences of
the research process. Families’ perspectives on the challenges
of asthma and asthma management, including concerns about
medication, resonate with existing understandings of asthma
patients’ experiences of living with asthma [5,20,21] as does
a ‘pragmatic’ use of CAM as an available strategy in response
to these challenges [22]. Two previous studies have suggested
typologies of CAM user and non-user in the specific con-
text of asthma [23,24]. Each identified a group of ‘pragmatic’
users (in contrast to ‘committed’ users), who employ conven-
tional and complementary therapies side by side, without strong
philosophical preferences. Self-selection and the context of the
feasibility study meant that participants were probably reflective
of this ‘pragmatic’ complementary therapy user group, rather
than either ‘committed’ complementary therapy users or asthma
patients and their families as a whole. ‘Push’ factors – i.e. con-
cerns about their conventional treatment – played a role in their
decisions to participate in the feasibility study. Having partic-
ipated in the trial, these users reported their experience of the
package as exceeding their expectations. Concerns about con-
ventional medication are in line with previous research findings
on asthma patients, including those who turn to complementary
therapies [20]. Even though parents valued the conventional care
being provided and no-one wanted to abandon it, they aspired
both to better control over the child’s condition and a reduced
dependency on medication [21].
In this way the qualitative data from the overall study serve to
bring out differences in the treatment outcomes sought by fami-
lies, respiratory physicians, homeopathic physicians and nurses
involved in the research. All shared the view of asthma as com-
plex and difficult to manage, but they had varying assessments
of the potential of homeopathy to improve asthma management,
partly at least because of somewhat divergent criteria regarding
outcomes – and hence about what counts as an ‘improvement’.
Nurses and participating families, as well as homeopathic physi-
cians, were more willing to identify a wider range of criteria
for successful intervention, like reductions in family stress or
improved school attendance and participation. Nurses specif-
ically wanted to support patient empowerment and choice,
perceived as a value of itself, through the provision of com-
plementary options. In this respect they were in line with trends
in health policy [25–27] which support greater patient responsi-
bility for health and treatment choices. Homeopathic physicians
had a particular commitment to the body’s attempts to achieve
equilibrium and a concern about the potential disadvantages of
powerful drugs.
These differing views have implications for future research
design regarding appropriate outcomes. Thus a respiratory
physician (HP6) described a ‘patho-physiological outcome
change’ as a ‘true effect’ and the bottom line for a research result
concerning asthma. Such an effect was distinguished from qual-
ity of life changes, which were perceived to be a separate issue,
and where the homeopathic package might possibly have a role
to play. By contrast, homeopathic physicians were equally clear
that the appropriate evidence base for homeopathy should not
just be confined to double blind placebo randomised controlled
trials, should allow for broader outcomes such quality of life, and
be able to take personal and individual experience into account.
Nurses saw psycho-social and quality of life issues as integral to
asthma management, though their comments on research design
were chiefly procedural. Families did not theorise about research
design, but intuitively leant towards a more ‘holistic’ approach
to intervention.
Conclusion
Whereas respiratory physicians caring for children with
severe childhood asthma may primarily focus on physi-
cal improvements for their patients, families, homeopathic

9. 426 J. Nichol et al. / European Journal of Integrative Medicine 5 (2013) 418–426
physicians and nurses appear to give equal weight to broader
health and quality of life issues. While this study was a small
qualitative study nested within a feasibility study, the findings
indicate that the complexities of the asthma syndrome and
its management bring out diverse priorities and different
perspectives amongst those receiving and giving care for
children with severe asthma. One implication of this qualitative
study is that if patients and families are to be encouraged to be
responsible for their own health and treatment choices, and to
develop their own voice in health service development [25,26],
then ways should be found to recognise that voice during the
research process including research design to include the use
of outcome measures that reflect important aspects of holistic
care such as well being and quality of life.
Competing interests
EAT is a consultant homeopathic physician at the setting used
to deliver homeopathy in the feasibility study but was not the
prescribing homoeopath. The authors have no other competing
interests.
Authors’ contributions
All authors contributed to the design, analysis and writing-up
ofthisstudy.JNwasresponsibleforday-to-daymanagementand
conduct of the study, conducted the interviews, led the analysis
and produced the first draft of the manuscript. All authors have
read and approved the final manuscript.
Acknowledgements
The authors wish to acknowledge the children, parents and
health professionals who gave their time to take part in this study.
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