Artigos

Conteúdo (article):

IMPLEMENTATION, ACCESS AND USE OF INTEGRATIVE AND COMPLEMENTARY PRACTICES IN THE UNIFIED HEALTH SYSTEM: A LITERATURE REVIEW

IMPLEMENTAÇÃO, ACESSO E USO DAS PRÁTICAS INTEGRATIVAS E COMPLEMENTARES NO SISTEMA ÚNICO DE SAÚDE: REVISÃO DA LITERATURA

Ludmila de Oliveira Ruela. Programa de Pós-Graduação em Enfermagem em Saúde Pública, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. ludmilaoliveira@usp.br
Caroline de Castro Moura. Programa de Pós-Graduação em Enfermagem, Escola de Enfermagem, Universidade Federal de Minas Gerais. carol_castro_m@hotmail.com
Clícia Valim Côrtes Gradim. Escola de Enfermagem, Universidade Federal de Alfenas. cliciagradim@gmail.com
Juliana Stefanello. Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. julianas@eerp.usp.br
Denise Hollanda Iunes. Escola de Enfermagem, Universidade Federal de Alfenas. deniseiunes@unifal-mg.edu.br
Rogério Ramos do Prado. Diretoria de Extensão e Assuntos Comunitários, Universidade José do Rosário Vellano. rogerio.prado@unifenas.br

RESUMO
No Brasil, as Práticas Integrativas e Complementares (PIC) tiveram maior visibilidade após a criação da Política Nacional de Práticas Integrativas e Complementares, em 2006. Contudo, ainda existem lacunas sobre o cenário geral dessas práticas. O objetivo desse estudo foi analisar a implementação, o acesso e o uso das PIC no Sistema Único de Saúde (SUS) após a implantação da política. Foi realizada uma revisão integrativa da literatura, guiada pela questão: “Qual o atual cenário de implementação, acesso e utilização das PIC no âmbito do SUS?”, na Biblioteca Virtual em Saúde, na USNational Library of Medicine e na Web of Science, com os descritores “Sistema Único de Saúde”/“Unified Health System” AND “Terapias complementares”/“Complementary Therapies”. Da análise dos artigos, emergiram quatro categorias de discussão: “A abordagem das PIC no SUS: principais práticas usadas”; “O acesso às PIC: a Atenção Básica à Saúde como porta de entrada”; “Atual cenário de implementação das PIC: o preparo dos serviços e dos profissionais da saúde para a realização das PIC”; “Principais avanços no uso das PIC e desafios futuros”. Observa-se que as PIC são oferecidas de forma tímida e os dados disponíveis são escassos, apesar dos reflexos positivos para os usuários e para os serviços que aderiram à sua utilização.
Palavras-chave: Sistema Único de Saúde; Terapias Complementares.

ABSTRACT
In Brazil, the Integrative and Complementary Practices (ICP) achieved greater visibility after the establishment of the National Integrative and Complementary Practices Policy (NICPP) in 2006. However, there are still gaps in the general setting of these practices. Thus, this study aimed to analyze the implementation, access and use of ICPs in the Brazilian Unified Health System (SUS) after the establishment of this policy. We performed an integrative literature review, guided by the question: “What is the current setting of implementation, access and use of ICPs within the SUS?”, in the Virtual Health Library (BVS), the U.S. National Library of Medicine and in the Web of Science, with descriptors “Sistema Único de Saúde” / “Unified Health System” AND “Terapias Complementares” / “Complementary Therapies”. The analysis of papers gave rise to four categories for discussion: “The ICP approach in the SUS: main practices used”; “Access to ICPs: Primary Health Care as a gateway”; “Current implementation scenario of ICPs: the preparation of health services and professionals for to implement ICPs”; “Main advances in the use of ICPs and future challenges”. We have observed that ICPs are bashfully offered and that data available are scarce, despite the positive impacts on users and services that have embraced their use.
Keywords: Unified Health System; Complementary Therapies.

INTRODUCTION
Since the 1990s, the use of Integrative and Complementary Practices (ICPs) has increased in global proportions1. Its growth and visibility occurred mainly with incentive from the World Health Organization (WHO) in 2002, through the elaboration of a normative document to its member countries, which aims to develop and regulate such practices in health services, as well as increase access, rational use and evaluation of the efficacy and safety of such techniques from scientific studies2.
In this setting, in 2006, through Ordinance Nº 971/2006, the Ministry of Health published the National Integrative and Complementary Practices Policy (NICPP) in the Unified Health System (SUS), with the aim of ensuring integrality in health services3. From then on, the provision and incentive to use ICPs, such as herbal medicine, homeopathy, acupuncture, among others, was legitimized in the SUS, increasing the use of these practices4.
It is worth emphasizing that the implantation of the NICPP was of a political, technical, economic, social and cultural nature since it established national guidelines for the use of ICPs based on experiences and practices already adopted in the health services, which obtained satisfactory results3.This fact further facilitated the dissemination of these practices in different parts of the country.
In this context, Brazil has emerged as one of the 69 WHO Member States with specific policies and strategies for the use of ICPs. After the NICPP was established, 30% of Brazilian municipalities adopted their regulations for the use of these therapies, which indicates significant growth in healthcare practices, and PHC is one of the primary environments for their application4.
Therefore, it is imperative to analyze the current setting of the provision of these treatments in the country, as well as access to them and their use in public health services. Thus, this study aimed to analyze the implementation, access and use of ICPs in the SUS through a review of the national literature published after the implementation of the NICPP.
METHODS
This is an integrative review of the literature, based on the steps proposed by Whittemore and Knafl6, with the following guiding question: “What is the current setting of implementation, access and use of Integrative and Complementary Practices within the Unified Health System?”
We searched the Latin American & Caribbean Health Sciences Literature (LILACS), Nursing Database (BDENF), HomeoIndex and the Spanish Bibliographic Index of Health Sciences (IBECS) via the Virtual Health Library (BVS); in the Medical Literature Analysis and Retrieval System Online (MEDLINE) via the US National Library of Medicine (PubMed) and the Web of Science, by two independent researchers, with standardized descriptors extracted from the Health Sciences Descriptors (DeCS) and the Boolean operator AND, which resulted in the combination “Sistema Único de Saúde’ / “Unified Health System” AND “Terapias Complementares”/ “Complementary Therapies”.
Papers published in the 2006-2017 period, in Portuguese, English and Spanish languages, with abstract available in the database, and which were conducted in a national setting were the inclusion criteria. Studies that did not respond to the guiding question were excluded.
Firstly, papers were selected by two independent researchers, who read the title and abstract, according to the guiding question and the eligibility criteria. After the selection, they were read in full and, for data collection and evaluation, a tool elaborated by researchers adapted from Ursi7 was applied. This tool consisted of the following items: title of paper; authors and year of publication; objective (s) of the study; methodological characteristics; level of health care (primary, secondary and tertiary) where the study was conducted; results; and conclusions.
Figure 1
RESULTS
Table 1 shows the main information extracted from the selected papers.
(TABLE 1)
Concerning the type of ICP used, 23.52% of the studies addressed herbal medicine11,16,19,20, 17.64% homeopathy9,12,21, 5.90% acupuncture22 and 52,94% of the studies have evaluated ICPs in general8,10,13-15,17-18,23-24.
Regarding the level of care where practice was performed, 52.94% occurred at the primary care level8-9,11,14-15,17,19-20,24 and 17.65% at the primary/secondary level18,22-23. Other authors (29.41%) addressed practice in the general SUS scenario10,12-13,16,21. It was also identified that all the analyzed papers showed level IV of evidence. Also, the main topics covered were the main ICPs adopted in the SUS, access to these practices, and preparedness of health services and professionals for their implementation and use. The categories of discussion were elaborated from these themes.
DISCUSSION
The ICPs’ approach in the SUS: main practices
Initially, the NICPP only included five ICPs in its guidelines to be employed in the SUS in order to promote the recovery, maintenance and prevention of users’ health, besides the cure of some diseases, and they are: Traditional Chinese Medicine/Acupuncture; Homeopathy; Medicinal Plants/Herbal Medicine; Thermalism/Cryotherapy; and Anthroposophical Medicine25. However, in recognizing the increasing use of other practices based on traditional knowledge by the population in general, the MoH included, between 2017 and 2018, new therapeutic resources in the NICPP, through Ordinances No. 849/201726 and No. 702/201827. With these measures, the SUS currently provides 29 of these practices.
Given the ICPs options fostered by the policy, the results of this study show that many of these were not addressed by the authors or were merely cited without further elaboration. Therefore, studies that analyzed several practices in the same research prevailed, such as: acupuncture, homeopathy, herbal medicine, among others, analyzing their implantation and organization and the knowledge of users and professionals about ICPs8,14-15,18,23-24; as well as those studies that pointed out a general context of therapies in the SUS, without specifying the practices used10,13,17. Thus, it was possible to observe the lack of studies that investigated the use of some practices, such as Thermalism/Crenotherapy and Anthroposophical Medicine, pointing out a gap for their use in the SUS. However, this may be a reflection of the low supply of such therapies in services, which precludes the discussion of these practices in the studies analyzed.
Among the studies that addressed specifically practices, we highlight the use of herbal medicine11,16,19-20 and homeopathy9,12,21. Acupuncture was investigated in isolation by Silva and Tesser22. However, both homeopathy and acupuncture, even in the studies that analyzed several practices together, emerged as those with higher adherence by users and greater provision of services17-18,22. This is in line with data presented by the MoH in 2008, which show keen interest on the part of the government and the population in these therapies when compared to the others28.
While mechanisms of action of acupuncture29-30 and homeopathy31-32 are still not entirely clear and sometimes inconclusive, their benefits have been demonstrated in different studies for different diseases33-36. As a result, adherence to these treatments is increasingly progressive, so that 80% of the 129 WHO member countries already recognize acupuncture as a health treatment5, and homeopathy is one of the most indicated ICPs in European countries, as in France37.
In general, ICPs can be seen as an essential healthcare strategy, especially considering the person as a whole, differing from the biomedical model23. Demand for ICPs is mostly due to complicated reasons, ranging from factors such as low profile of adverse effects, to the natural consequence of incentive towards inside-out healing, search for complementation of allopathic treatment, reception and active listening performed during the consultation, as well as compatibility of such practices with values, beliefs and philosophy of health and life of the user10,38. Also, they may be perceived as a potential drug consumption reducer22.
Tesser39 also points out that the reasons that lead users to seek such treatments may be associated with critical socioeconomic factors. In developing countries, local culture, easy access to alternative practices, the high cost of conventional medicine, and the limited availability of biomedical resources facilitate the search for complementary medicine. However, in rich countries, dissatisfaction with the biomedical model and the benefits of ICPs are the factors that foster this demand.
Access to ICPs: Primary Health Care (PHC) as a gateway
Since PHC should be the user’s first contact and gateway to the healthcare network, according to the National Primary Healthcare Policy (PNAB)40, it is possible to infer that this level of care is a privileged locus for the implementation of ICPs in the Brazilian public health system. In fact, data from the MoH indicate that ICPs are mostly provided in PHC services41.
A recent study42 conducted in Florianópolis indicated that PHC professionals usually encouraged ICP use during the consultation with the patient and started treatment as soon as possible, often during the consultation itself. Thus, treatment with ICPs can be in some cases the initial approach, where conventional therapy is the second option, if necessary, or complementing the ICPs approach. Also, the availability of ICPs in PHC services may promote increased dialogue between practitioners and users about which therapy to use, namely, conventional therapy or ICPs, and this may have a positive effect on this contact42.
In this study, some authors point to secondary care services18,22-23 as access to ICPs. However, in order to achieve these sites as a field of care and provision of complementary treatments, it is necessary to approach professionals at both the primary and secondary levels so that they can be consolidated as a network of comprehensive care and universal access, taking into account the principles and foundations of each of the practices23.
Although the use of ICPs in secondary and tertiary care environments is more restricted, there is an albeit bashful tendency for their use at these levels, since 1,708 Brazilian municipalities provide ICPs, 78% in PHC, 18% in secondary care and 4% in tertiary care43. However, when considering PHC as the level of care with the highest capacity to develop health prevention and recovery actions, the use of ICPs in these services is the most appropriate. Furthermore, such practices do not require sophisticated technological resources, they provide lower risks of side effects when compared to conventional treatments, and demand fewer financial resources, making health care more affordable and of high quality, besides providing satisfactory results2,44.
However, the difficult of access to ICPs at the various levels of care, especially in the secondary and tertiary sectors, may be related to the lack of knowledge by professionals about the use of these practices. Also, it is emphasized that many of these workers do not understand the importance or do not have the adequate ability to indicate or apply such practices8,13.
Despite this obstacle, their availability in services is accepted and expected, especially by users10,14. Thus, a movement of Brazilian municipalities to implement the use of ICPs in the last years is observed16. However, local management should encourage the strengthening and use of these practices and provide conditions for their provision to the population, through dissemination and support, following recommendations of the NICPP18,20.
Current scenario of implementation of ICPs: preparedness of health services and practitioners for ICPs
Human resources are essential for the use of ICPs in the SUS. In this context, vocational training is a significant gap for the successful implementation of the practices8,12,18. The lack of knowledge of the NICPP, as well as of therapies addressed in the policy hinders professionals’ and services’ participation in the provision of practices12,21.
In Brazil, in addition to physicians, other health professionals, such as nurses, physiotherapists, pharmacists, among others, are qualified to use various practices fostered by the policy3. However, the low adherence to specializations in the area of complementary interventions and poor education about the purposes of using ICPs during training prevent more significant improvement of health professionals16, although many show an interest in training and agreement with the use of practices in services17.
One of the main difficulties pointed out by the managers for the implementation of these therapies is the resistance by some health professionals attributed to scarce scientific evidence and lack of logistical and structural support of the local management20. This is therefore considered an important problem since the positive attitude of professionals vis-à-vis these practices is relevant to motivate users towards adopting ICPs22.
Another fact that causes a stir is related to increased ICPs in the SUS. However, this was more significant from the application of practices by non-medical professionals45, which requires that other team members expand their knowledge about complementary treatments and gain space for the use of such practices11. Thus, managers should provide support and incentives in the supply of these resources to revive the humanistic realm of health care12.
In this context, greater knowledge about the policy and ICPs, as well as, for example, encouraging professionals through lifelong learning can be effective strategies for implementing and expanding the implementation of NICPP and improving access to health services within the SUS.
Although there are still few Brazilian studies on continuing education geared to these practices, Santos and Tesser46 show a method of implementation and promotion of access to ICPs in PHC based on previous experiences, consisting of four sequential stages. The first stage establishes the people responsible, who will spearhead this process (preferably, professionals with expertise in ICPs). In the second stage, a situational analysis will be carried out, in which these professionals, whether active or not, will be mapped and recruited so that, through implementation and access discussions, they conduct a survey on issues that hinder access to ICPs, on the organization of actions, the attendance flow of services and the formalization of activities developed, making a local situational analysis of ICPs. Regulations will be set during the third stage, establishing standards and adaptations for the development of ICPs in line with the current policy (NICPP) and, finally, during the fourth stage, the implementation takes place cyclically and continuously, which will be influenced by the productive capacity of the responsible staff46.
This model can help managers and professionals strategically expand existing services or implement new services that will facilitate and allow the general population’s access to ICPs. Thus, it is likely that initial investments and continuous training of network professionals will be necessary to meet demand in a qualified and decisive manner. However, over time, there may be lower values and higher service quality in services, since most practices require low operational costs and have fast and satisfactory results.
Significant advances in the use of ICPs and future challenges
Despite the increase in ICPs use in recent years, its therapeutic potential and its contributions to health are still poorly explored in the SUS11,16. Although the MoH has positively evaluated this increase47, there are gaps such as assessments of ICPs in services and better monitoring of the policy’s impact.
Moreover, the preeminence of the current biomedical model coupled with the market trend in health care, which transforms knowledge and practices into commodities, can be a substantial limitation in the expected advances for these practices. Thus, one challenge is the further analysis of care in a comprehensive care model, surpassing the supremacy of the rationale of biomedicine-based services13.
Other vital challenges are related to the training of and incentive to the health team members, support to non-medical professionals, as well as awareness and understanding of ICPs’ perspectives. These factors are essential for the successful introduction of ICPs into the SUS15 and to ensure the principles of the NICPP, contributing to the promotion of health throughout the care network18.
STUDY LIMITATIONS AND SUGGESTIONS FOR FUTURE STUDIES
The use of only two controlled descriptors (“Unified Health System” and “Complementary Therapies”) may have reduced the number of papers evaluated as to the eligibility criteria of the study. Thus, for future studies, we would suggest to include other more specific descriptors, such as, for example, “Healthcare levels” or “Primary Health Care”, besides specifying ICPs, especially the most prevalent ones, in the search fields (such as herbal medicine, homeopathy, acupuncture, bodily practices, among others) in order to expand the range of results obtained.
FINAL CONSIDERATIONS
After a decade of policy implementation, we can consider that ICPs are provided incipiently in the SUS and scarce data on specific practices are a limitation to the current scenario of this approach. However, positive reflexes can be observed for users and services that have adhered to their use, although there are still challenges in their implementation, in their access and use and the education of trained professionals.
Thus, new studies with a historical approach to complementary practices are required following the creation of the NICPP and on the impacts on the Brazilian public health, as well as incentives for professional improvement, mainly for PHC workers, as a fundamental tool for the implementation, access and use of ICPs in the SUS.
BIBLIOGRAPHY
1. Frass M, Strassl RP, Friehs H, Müllner M, Kundi M, Kaye AD. Use and acceptance of Complementary and Alternative Medicine among the general population and medical personnel: A Systematic Review. Ochsner J. 2012; 12(1):45–56.
2. World Health Organization (WHO). WHO Traditional Medicine Strategy 2002 – 2005. Geneva: WHO; 2002.
3. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Práticas Integrativas e Complementares no SUS. Brasília: MS; 2006.
4. Brasil. Ministério da Saúde. Revista Brasileira Saúde da Família. Práticas Integrativas e Complementares em Saúde: uma realidade no SUS. Brasília: MS; 2008.
5. World Health Organization (WHO). WHO traditional medicine strategy: 2014-2023. Geneva: WHO; 2013.
6. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005 dez; 52(5):546-553.
7. Ursi ES. Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura [dissertação]. Ribeirão Preto (SP): Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; 2005.
8. Fontanella F, Speck FP, Piovezan AP, Kulkamp IC. Conhecimento, acesso e aceitação das práticas integrativas e complementares em saúde por uma comunidade usuária do Sistema Único de Saúde na cidade de Tubarão/SC. ACM. 2007; 36(2):69-74.
9. Monteiro DA, Iriart JAB. Homeopatia no Sistema Único de Saúde: representações dos usuários sobre o tratamento homeopático. Cad. Saúde Pública. 2007 ago; 23(8):1903-1912.
10. Tesser CD, Barros NF. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Rev Saúde Pública. 2008; 42(5):914-920.
11. Ceolin T, Heck RM, Pereira DB, Martins AR, Coimbra VCC, Silveira DSS. A inserção das terapias complementares no sistema único de saúde visando o cuidado integral na assistência. Enferm. glob. 2009 jun; 16:1-10.
12. Salles SAC, Schraiber LB. Gestores do SUS: apoio e resistências à Homeopatia. Cad. Saúde Pública. 2009 jan; 25(1):195-202.
13. Andrade JT, Costa LFA. Medicina Complementar no SUS: práticas integrativas sob a luz da Antropologia médica. Saude soc. 2010; 19(3):497-508.
14. Marques LAM, Vale FVVR, Nogueira VAS, Mialhe FL, Silva LC. Atenção farmacêutica e práticas integrativas e complementares no SUS: conhecimento e aceitação por parte da população sãojoanense. Physis. 2011; 21(2):663-674.
15. Nagai SC, Queiroz MS. Medicina complementar e alternativa na rede básica de serviços de saúde: uma aproximação qualitativa. Ciênc. saúde coletiva. 2011; 16(3):1793-1800.
16. Santos RL, Guimaraes GP, Nobre MSC, Portela AS. Análise sobre a fitoterapia como prática integrativa no Sistema Único de Saúde. Rev. Bras. Pl. Med. 2011; 13(4):486-491.
17. Thiago SCS, Tesser CD. Percepção de médicos e enfermeiros da Estratégia de Saúde da Família sobre terapias complementares. Rev Saúde Pública. 2011; 45(2):249-257.
18. Ischkanian PC, Pelicioni MCF. Desafios das práticas integrativas e complementares no SUS visando a promoção da saúde. Rev Brasileira de Crescimento Desenvolvimento Humano. 2012; 22(2):233-238.
19. Oliveira SGD, Moura FRR, Demarco FF, Nascente PS, Del Pino FAB, Lund RG. An ethnomedicinal survey on phytotherapy with professionals and patients from Basic Care Units in the Brazilian Unified Health System. J Ethnopharmacol. 2012; 140:428-437.
20. Fontenele RP, Sousa DMP, Carvalho ALM, Oliveira FA. Fitoterapia na Atenção Básica: olhares dos gestores e profissionais da Estratégia Saúde da Família de Teresina (PI), Brasil. Ciênc. saúde coletiva. 2013; 18(8):2385-2394.
21. Galhardi WMP, Barros NF, Leite-Mor ACMB. O conhecimento de gestores municipais de saúde sobre a Política Nacional de Prática Integrativa e Complementar e sua influência para a oferta de homeopatia no Sistema Único de Saúde local. Ciênc. saúde coletiva. 2013; 18(1):213-220.
22. Silva EDC, Tesser CD. Experiência de pacientes com acupuntura no Sistema Único de Saúde em diferentes ambientes de cuidado e (des)medicalização social. Cad. saúde pública. 2013 nov; 29(11):2186-2196.
23. Lima KMSV, Silva KL, Tesser CD. Práticas integrativas e complementares e relação com promoção da saúde: experiência de um serviço municipal de saúde. Interface. 2014; 18(49):261-272.
24. Sousa IMC, Tesser CD. Medicina Tradicional e Complementar no Brasil: inserção no Sistema Único de Saúde e integração com a atenção primária. Cad. Saúde Pública. 2017; 33(1):e00150215.
25. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria nº 145, de 11 de janeiro de 2017. Altera procedimentos na Tabela de Procedimentos, Medicamentos, Órteses, Próteses e Materiais Especiais do SUS para atendimento na Atenção Básica. Diário Oficial da União 2017; 13 jan.
26. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portara nº 849, de 27 de março de 2017. Inclui a Arteterapia, Ayurveda, Biodança, Dança Circular, Meditação, Musicoterapia, Neturopatia, Osteopatia, Quiropraxia, Reflexologia, Reiki, Shantala, Terapia Comunitária Integrativa e Yoga à Política Nacional de Práticas Integrativas e Complementares. Diário Oficial da União 2017; 28 mar.
27. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria nº 702, de 21 de março de 2018. Altera a Portaria de Consolidação nº 2/GM/MS, de 28 de setembro de 2017, para incluir novas práticas na Política Nacional de Práticas Integrativas e Complementares – PNPIC. Diário Oficial da União 2018; 22 mar.
28. Brasil. Ministério da Saúde. Informes da Atenção Básica Nº 53. Práticas Integrativas e Complementares no SUS: ampliação do acesso. Brasília: MS; 2009.
29. Kawakita K, Okada K. Acupuncture therapy: mechanism of action, efficacy, and safety: a potential intervention for psychogenic disorders? Biopsychosoc Med. 2014; 8(4).
30. Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol. 2008; 85:355-375.
31. Carpenter JS, Neal JG. Other complementary and alternative medicine modalities: acupuncture, magnets, reflexology, and homeopathy. Am J Med. 2005 dec; 118(12B):109S-117S.
32. Cucherat M, Haugh MC, Gooch M, Boissel JP. Evidence of clinical efficacy of homeopathy. A meta-analysis of clinical trials. Eur J Clin Pharmacol. 2000; 56:27-33.
33. Iunes DH, Chaves ECL, Moura CC, Côrrea B, Carvalho LC, Silva AM et al. Role of Auriculotherapy in the treatment of temporomandibular disorders with anxiety in university students. Evid Based Complement Alternat Med. 2015; 2015:1-9.
34. Kurebayashi LFS, Gnatta JR, Borges TP, Belisse G, Coca S, Minami A et al. Aplicabilidade da auriculoterapia com agulhas ou sementes para diminuição de estresse em profissionais de enfermagem. Rev Esc Enferm USP. 2012; 46(1):89-95.
35. Macías-Cortés EC, Llanes-González L, Aguilar-Faisal L, Asbun-Bojalil J. Individualized Homeopathic Treatment and Fluoxetine for Moderate to Severe Depression in Peri- and Postmenopausal Women (HOMDEP-MENOP Study): A Randomized, Double-Dummy, Double-Blind, Placebo-Controlled Trial. PLoS One. 2015; 10(3):e0118440.
36. Toca-Villegas J, Esmer-Sánchez D, García-Narváez J, Sánchez-Aguilar M, Hernández-Sierra JF. Eficacia de la auriculoterapia modificada como tratamento para el control del dolor post operatorio em pacientes intervenidos mediante colecistectomía laparoscópica. Cir Cir. 2016.
37. Rossignol M, Bégaud B, Avouac B, Lert F, Rouillon F, Bénichou J et al. Who seeks primary care for musculoskeletal disorders (MSDs) with physicians prescribing homeopathic and other complementary medicine? Results from the EPI3-LASER survey in France. BMC Musculoskelet Disord. 2011; 12(21).
38. Astin JA. Why patients use alternative medicine: results of a national study. JAMA. 1998; 279(19):1548-1553.
39. Tesser CD. Práticas complementares, racionalidades médicas e promoção da saúde: contribuições poucos exploradas. Cad. Saúde Pública. 2009; 25(8)1732-1742.
40. Brasil. Ministério da Saúde. Política Nacional de Atenção Básica. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília: MS; 2012.
41. Brasil. Ministério da Saúde. Política Nacional de Práticas Integrativas e Complementares. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Informe – maio de 2017 [Internet]. 2017 Maio [acessado 2018 Mar 06]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/Informe_Maio_2017.pdf
42. Faqueti A, Tesser CD. Utilização de Medicinas Alternativas e Complementares na atenção primária à saúde de Florianópolis/SC: percepção de usuários. Ciênc. saúde coletiva. [periódico na Internet]. 2016 Ago [acessado 2017 Out 26]. Disponível em: http://www.cienciaesaudecoletiva.com.br/artigos/utilizacao-de-medicinas-alternativas-e-complementares-na-atencao-primaria-a-saude-de-florianopolissc-percepcao-de-usuarios/15829?id=15829
43. Brasil. Ministério da Saúde. Departamento de Atenção Básica. Portal da Saúde SUS. Portaria amplia oferta de PICS [Internet]. 2017 Jan [acessado 2017 Jul 09]. Disponível em: http://dab.saude.gov.br/portaldab/noticias.php?conteudo=_&cod=2297
44. Spadacio C, Castellanos MEP, Barros NF, Alegre SM, Tovey P, Broom A. Medicinas Alternativas e Complementares: uma metassíntese. Cad. Saúde Pública. 2010 jan; 26(1):7-13.
45. Sousa IMC, Bodstein RCA, Tesser CD, Santos FAZ, Hortale VA. Práticas integrativas e complementares: oferta produção de atendimentos no SUS e em municípios selecionados. Cad. Saúde Pública. 2012 nov; 28(11):2143-2154.
46. Santos MC, Tesser CD. Um método para a implantação e promoção de acesso às Práticas Integrativas e Complementares na Atenção Primária à Saúde. Ciênc. saúde coletiva. 2012; 17(11):3011-3024.
47. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde Departamento de Atenção Básica Coordenação Nacional de Práticas Integrativas e Complementares. Relatório de Gestão 2006/2010 - Práticas Integrativas e Complementares no SUS. Brasília: MS; 2011.