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Conteúdo (article):

Prevalence of lifestyle habits following the use of integrative and complementary practices in Brazil’s adult population: National Health Survey 2019.

AUTHORS: Nogueira, Mário Círio¹; Cerqueira, Larissa Valdier²; Ozório, Sarah Rachid³; Rodrigues, Iasminn Gomes⁴.

1- Departamento e Programa de Pós-Graduação em Saúde Coletiva, Faculdade de Medicina, UFJF, mario.cirio.nogueira@gmail.com, ORCID: https://orcid.org/0000-0001-9688-4557.

2- Universidade Federal de Juiz de Fora, UFJF, larissavaldier@gmail.com, ORCID: https://orcid.org/0009-0002-9658-8322.

3- Universidade Federal de Juiz de Fora, UFJF, sarahrozorio@gmail.com.

4- Universidade Federal de Juiz de Fora, UFJF, iasminngomesdocs@gmail.com.


ABSTRACT

Introduction: Integrative and Complementary Practices (ICPs) comprise complex medical systems and therapeutic resources that seek to stimulate natural disease prevention and health recovery mechanisms by promoting changes in lifestyle habits.

Objective: to investigate the association between the use of ICPs and the prevalence of healthy eating habits in Brazil’s population.

Methodology: this cross-sectional study used data on adult and older adult participants in Brazil’s 2019 National Health Survey. Prevalence of habits was estimated by categories of ICP use, together with prevalence ratios adjusted by sociodemographic characteristics and chronic disease, using Poisson regression models with robust variance and 95% confidence intervals.

Results: ICP use was 5.5% prevalent. Interviewees who used some ICP during the period, returned a higher prevalence of regular consumption of fruits and vegetables and a lower prevalence of consumption of soft drinks, ultra-processed foods and beans.

Conclusions: ICP users reported a higher prevalence of healthy eating habits, which is consistent with the approach the practices foster. Expanding access to ICPs can contribute to a healthier lifestyle.

Keywords: complementary and integrative practices; lifestyle; eating behaviour.


INTRODUCTION

A healthy lifestyle includes having diversified daily meals, good quality sleep, not smoking, not drinking alcohol (or doing so in moderation) and engaging in regular physical activity. Taken together, these actions are associated with lower risk of developing chronic diseases¹. These lifestyle habits thus influence individual health and are related to risk factors for pathologies in general. Factors related to individual behaviour, such as high body mass index, elevated fasting glucose and inappropriate diet, contribute significantly to deaths from noncommunicable chronic diseases².

In Brazil, the national health survey (Pesquisa Nacional de Saúde, PNS) is notable for conducting a significant number of lifestyle studies. The PNS is a population-based survey conducted most recently in 2013 and 2019 by Brazil’s official bureau of statistics, the Instituto Brasileiro de Geografia e Estatística (IBGE), in partnership with the Ministry of Health, to characterise the population’s conditions of health and life, evaluate national health system performance as regards service access and preventive measures, and to provide data on which to base surveillance of diseases and their determinants. In that way, the PNS provides a frame of reference for public health in Brazil and the information collected makes it possible to formulate measures to assist in policy making, evaluation and monitoring³.

In the most recent two surveys, those of 2013 and 2019, the information on Brazilians’ lifestyle habits shows that certain healthy habits, such as eating beans and fish⁴, have decreased, while the prevalence of drinking alcohol has increased⁵. This points to a need to investigate lifestyle, given that some of these factors are directly connected with increasing obesity and a number of other chronic diseases⁶ and a decrease in the numbers of individuals who self-assess their health as good⁷.

Integrative and complementary practices (ICPs), which the World Health Organisation (WHO) terms Traditional, Alternative and Complementary Medicine (TACM), comprise complex medical systems and therapeutic resources that seek to stimulate natural disease prevention and health recovery mechanisms. Their approach involves the use of safe, effective technologies, particularly sympathetic listening, therapeutic bonding and integration of the human person with the environment and society. They also operate on an expanded view of the health-disease process and promotion of comprehensive human care, especially self-care⁸.

With a view introducing, regulating and administering TACM at the world level, the WHO issued a first Traditional Medicine Strategy (2002-2005). The significant resulting impact and mounting pressure to encourage the use of TACM, particularly in association with conventional medicine, led to the development of a new strategy (WHO Traditional Medicine Strategy 2014-2023). The key goals are to harness the potential contribution of TACM to health, wellbeing and person-centred care and promote the safe, effective use of TACM by regulating, researching and integrating TACM products, practitioners and practices into health systems, where appropriate⁹.

In Brazil, ICPs were instituted in the national health system (Sistema Único de Saúde, SUS) by the national integrative and complementary practices policy (Política Nacional de Práticas Integrativas e Complementares, PNICPs) sanctioned by Ministerial Order GM/MS No. 971, of 3 May 2006¹⁰. The PNICPs sets out guidelines and institutional responsibilities for the supply of services and products in homeopathy, traditional Chinese medicine/acupuncture, medicinal plants and phytotherapy, as well as instituting observatories on anthroposophic medicine, social thermalism/crenotherapy and others.

These practices broaden approaches to care and the therapeutic possibilities open to users, guaranteeing greater comprehensiveness and resolution in health care. The PNICPs is recognised internationally by the WHO and a number of countries as exemplary in the introduction of traditional and complementary medicines into a national health system, which is one of the main reasons these practices are integrated into health care in the SUS¹¹.

The PNS provides data on the use in Brazil of ICPs, including acupuncture, homeopathy, medicinal plants and phytotherapy, meditation, yoga, taijiquan, lian gong and others. In 2013 and 2019, it estimated the percentage of Brazilian’s who used any ICP in the prior 12 months. The figures obtained were, respectively, about 3.8% (IC: 3.50-4.10) and 4.6% (IC: 4.3-4.80) of interviewees had used an ICP in the 12 months prior to the survey12,13,14,15. While the PNS estimated those prevalences in the general population, ICP use among primary care users in Brazil is far more widespread16.

Studies in other countries, e.g., the United States, have found ICP users to be more motivated to make positive changes in their health-related behaviour, both as regards taking physical exercise and eating appropriately, and in their use of alcohol and tobacco¹⁷.

Despite this evidence, no recent studies were found that explored the relationship between ICP use and lifestyle habits in a representative sample of the Brazilian population. Accordingly, this study investigated the association between ICP use and prevalence of healthy habits in the population of Brazil, using data from the 2019 national health survey.

METHODS

This cross-sectional study used data from the 2019 PNS, a three-stage survey of a representative sample of Brazil’s adult population¹⁸. Data for 87,187 respondents aged 18 years or more was drawn from the questionnaires of the selected resident in each household, after exclusion of persons who self-declared their skin colour to be yellow or indigenous, following IBGE guidance, because of the small number of respondents in those categories and the high coefficient of variation¹⁹. The PNS microdata base, questionnaire, dictionary of variables and R software codes, with guidance on how to treat the data and create new variables, were all downloaded from the PNS website (https://www.pns.icict.fiocruz.br/).

From the extensive questionnaire, the variables used here (alphanumerical codes from the dictionary of variables) were developed from questions in the modules C (residents’ general characteristics), J (health service use), P (lifestyle) and Q (chronic diseases):

- C006: sex (categorised into: male or female).

- C008: age (excluding the under-18s and categorised into: 18 to 29 years; 30 to 44 years; 45 to 59 years; 60 to 74 years; 75 years or more).

- C009: colour or race (categorised into: white, black, yellow, brown or indigenous; the yellow and indigenous categories were excluded from the analysis).

- J05301: ICP use in prior 12 months.

- J05402/J05403/J05404/J05405/J05406/J05407/J05408/J05409/J054010: use of specific ICPs in the prior 12 months (respectively: acupuncture; homeopathy; medicinal plants and phytotherapy; auriculotherapy; meditation; yoga; taijiquan, lian gong and qigong; integrative community therapy; and other ICPs).

- P00901 and P018: appropriate consumption of fruits, legumes and vegetables (at least 5 portions per day, 5 times a week).

- P006: regular consumption of beans (at least 5 days a week).

- P015: consumption of fish at least 1 day a week.

- P02002: regular consumption of soft drinks (at least 5 days a week).

- P02501: regular consumption of sweets (at least 5 days a week).

- P02602: regularly replacing lunch by snacks (at least 5 days a week).

- P02601: high salt intake.

- P00607, P00608 and P00609: consumption of a vegetable on the day prior to the survey.

- P00610 and P00611: consumption of at least one fruit on the day prior to the survey.

- P00614/P00615/P00616/P00617/P00618/P00619/P00620/P00621/P00622/P00623: not consuming any ultra-processed food on the day prior to the survey.

- P03201: abusive consumption of alcohol in the prior 30 days.

- P050: current tobacco smoking.

- P04501: 3 hours or more television time per day.

- P04502: 3 hours or more screen use (computer, mobile phone or tablet) per day.

- Q00201: medical diagnosis of arterial hypertension.

- Q03001: medical diagnosis of diabetes.

- Q063306: medical diagnosis of heart disease.

- Q068: medical diagnosis of stroke.

- Q074: medical diagnosis of asthma.

- Q079: medical diagnosis of arthritis or rheumatism.

- Q088: medical diagnosis of WMSDs.

- Q084: medical diagnosis of a chronic spinal problem.

- Q092: medical diagnosis of depression.

- Q11007/Q11008/Q11009: medical diagnosis of other mental disease.

- Q11604: medical diagnosis of chronic lung disease.

- Q120: medical diagnosis of cancer.

- Q124: medical diagnosis of chronic kidney failure.

An “Any chronic disease” variable was created, with the categories “Yes” (if the person had any of the diseases or conditions listed above) or “No”.

In addition to these three modules, the following socioeconomic and location variables were used:

- VDF004: per capita household income (categorised by minimum wages: up to half; from half to one; one to two; two to three; more than three).

- VDD004A: schooling (categorised into: incomplete lower secondary or equivalent; incomplete upper secondary or equivalent; incomplete higher; and complete higher).

- V0026: place of residence (categorised into: urban or rural).

- V0001: federative unit of residence (aggregated by major subnational regions: North, Northeast, Southeast, South and Mid-West).

Prevalences of habits were estimated with 95% confidence intervals (95%CI), by ICP use category, as well as prevalence ratios adjusted for sociodemographic and location characteristics (Rpa1) and adjusted for sociodemographic and location characteristics and having any chronic disease (Rpa2), also with 95% confidence intervals (95%CI), using Poisson regression models.

The survey library of the R software was used for the statistical analyses, in order to take account of the complex study sampling.

This study needed no research ethics committee approval, because it was based on data drawn from the freely accessible PNS website. The PNS was approved by Brazil’s national research ethics committee (Comissão Nacional de Ética em Pesquisa, CONEP)/ national health council (Conselho Nacional de Saúde, CNS), as in Opinion No. 3.529.376, issued on 23 August 2019.

RESULTS

The study sample contained a slightly higher proportion of women, of individuals in the 30-44 year and 45-59 year age ranges, most predominantly of brown race/colour, nearly 80% with monthly per capita income of less than 2 minimum wages, most commonly with incomplete lower secondary schooling or equivalent, 77% resident in urban areas, the largest proportion living in the Northeast and just under half with some chronic disease. In addition to the simple percentages, weighted percentages were also calculated, to take account of the participants’ weight , as this was a complex sample (Table 1).

Of those who reported having used an ICP in the prior 12 months, only 46.1% (95%CI: 43.6-48.7) reported regularly eating fruits, vegetables and legumes, although that prevalence was 16.0% (RPa2 95%CI: 1.10-1.22) greater than among non-ICP users. On the other hand, 11% (RPa2 95%CI 0.85-0.93) fewer ICP users regularly ate beans, a prevalence of 54.1% (95%CI: 51.5-56.7). No association was found between ICP use and eating fish, regularly replacing lunch with snacks or high salt intake. ICP users regularly consumed 35.0% (RPa2 95%CI: 0.47-0.88) less soft drinks . On the day before the interview, 5.0% (RPa2 95%CI: 1.03-1.07; 1.02-1.08) more ICP users consumed fruits and vegetables and 12% (RPa2 95%CI: 1.01-1.25) more did not consume ultraprocessed foods. No association was found between ICP use and abusive consumption of alcohol or current tobacco smoking, but negative associations were found with more than 3 hours’ TV time (RPa2 95%CI: 0.79-0.95) and screen time (RPa2 95%CI: 0.78-0.96) (Table 2).

Among interviewees who reported having used phytotherapy or medicinal plants in the prior 12 months, there was 16% (RPa2 95%CI: 1.08-1.26) higher prevalence of regular consumption of fruits, vegetables and legumes; on the other hand, regular consumption of beans was 9% (RPa2 95%CI: 0.87-0.96) lower. Eating fish, high salt intake, not having eaten ultraprocessed food the previous day, abusive consumption of alcohol, current tobacco smoking and more than 3 hours of TV time showed no association with ICP use. Also, regular consumption of soft drinks was 41% (RPa2 95%CI: 0.43-0.82) lower in ICP users, while regularly eating of sweets was 29% (RPa2 95%CI: 1.11-1.49) higher. Replacing lunch with snacks was 50% (RPa2 95%CI: 0.33-0.75) lower among those who reported ICP use, while eating vegetables and fruit on the day before the interview was 5% (RPa2 95%CI: 1.02-1.09) more prevalent. More than 3 hours’ screen use was 20% (RPa2 95%CI: 0.69-0.93) lower among users of phytotherapy and medicinal plants (Table 3).

Among interviewees who reported having used acupuncture in the prior 12 months, there was 13% (RPa2 95%CI: 1.03-1.24) higher prevalence of consumption of fruits, vegetables and legumes, but the prevalence of regularly eating beans was 13% (RPa2 95%CI: 0.79-0.96) lower among those who used acupuncture. Meanwhile, eating fish once a week was 13% (RPa2 95%CI: 1.04-1.23) more prevalent among interviewees who used acupuncture. No differences were found between ICP users and non-users as regards regularly eating sweets, regularly replacing lunch with snacks and high salt intake, eating a vegetable on the day prior to the survey, abusive consumption of alcohol in the prior 30 days and more than 3 hours’ TV time. Eating fruit on the day before the interview was reported 8% (RPa2 95%CI: 1.03-1.13) more by users of acupuncture. As association was also found between current smoking and use of acupuncture: 34% (RPa2 95%CI: 0.49-0.89) fewer of those who used acupuncture were current smokers (Table 4).

Interviewees who reported using homeopathy in the prior 12 months returned 21% (RPa2 95%CI: 1.10-1.33) higher prevalence of consumption of fruits, vegetables and legumes, although only 45.8% (RPa2 95%CI: 39.0-52.7) reported regularly eating beans, a prevalence ratio (RPa2) 15% (95%CI: 0.74-0.98) lower than for non-users of ICPs. Regularly eating sweets was 31% (RPa2 95%CI: 1.00-1.71) greater in the group of users of homeopathy. Users and non-users of homeopathy were found not to differ significantly in their eating fish, regular consumption of soft drinks, regularly replacing lunch with snacks and high salt intake, nor in eating vegetables, fruits and ultraprocessed foods the day before the interview. There was no association between using homeopathy and abusive drinking in the prior 30 days nor with being a current tobacco smoker.

No substantial association was found between TV time and screen time of more than 3 hours each (Table 5).

Table 1 – Demographic, socioeconomic, location and chronic disease characteristics of adults and older adults selected by the Pesquisa Nacional de Saúde, Brazil, 2019.

Table 2 – Prevalence of lifestyle habits, by integrative and complementary practices, Brazil, 2019.

Table 3 – Prevalence of lifestyle habits, by use of medicinal plants and phytotherapy, Brazil, 2019.

Table 4 – Prevalence of lifestyle habits, by use of acupuncture, Brazil, 2019.

Table 5 – Prevalence of lifestyle habits, by use of homeopathy, Brazil, 2019.

DISCUSSION

The main findings of this study, which investigated the association between ICP use and prevalence of healthy habits in Brazil’s population, include:
- prevalence of engaging in some ICP in the prior 12 months was 5.5%;
- of those who reported engaging in some ICP in the prior 12 months, 46.1% reported consuming fruits, legumes and vegetables, that is, a 16% higher prevalence than among non-ICP users;
- consumption of soft drinks was 41% lower among ICP users and not consuming ultraprocessed foods, 12% higher;
- a negative association was found with more than 3 hours’ TV time and screen time among ICP users;
- replacing lunch with snacks was 50% less common among in ICP users; and
- smoking was 34% less prevalent among those who used acupuncture.

Studies seeking to correlate Brazilian eating habits with engagement in integrative and complementary practices are rare, but they have touched on a positive relation between engaging in ICPs and healthy eating. The literature review by Araújo et al. (2021)²⁰ addressed a series of Brazilian studies that reported a beneficial relation between treatment for obesity and ICP use, which was directly connected with reducing binge eating, body weight, anxiety and other determinants of obesity. Although evidencing that relationship, the studies selected did not include measures evaluating changes in specific lifestyle habits, such as consumption of healthy foods, smoking or reducing screen time, which are shown by the study reported here.

In another exploratory, descriptive, qualitative study, using semi-structured interviews as its data production technique with a sample of eight, 18 to 64 year old, males and females with a diagnosis of obesity, Araújo et al. (2023)²¹ found that ICPs occupy a dynamic, hybrid place in the flow of care and seem to collaborate with the comprehensiveness of care, acting as mediators of the process of body acceptance. In that study, the approach to evidence was qualitative and subjective, so that no direct quantitative parallel can be drawn with our findings from the 2019 PNS. Nonetheless, that conclusion shows the need to encourage quantitative studies to investigate the health care proposal suggested by ICPs.

The study “Práticas integrativas e complementares em saúde entre estudantes universitários: motivos de uso e de não uso” (Integrative and complementary health care practices among university students: reasons for use and non-use), published recently (2024), examined a selection of 667 questionnaires answered by students. Prominent among the reasons given for engaging in ICPs were "wellbeing", "health", "quality of life" and "balance". Those results once again corroborate aspects of the ICPs studied, revealing the public’s perception linking ICP use with good lifestyle habits, which could raise a hypothesis for the findings of this study²². In the same way, Ornela et al. (2016)²³ found acupuncture to assist in the process of weight loss which includes a specific diet monitored by a nutritionist, as well as regular physical activity. Improved aspects of patients’ quality of life and degree of satisfaction were reported. Menegotte et al., 202424 also found less anxious and more mindful behaviour associated with dietary re-education and new habit formation in nutrition patients who engaged in ICPs.

A study using 2015 and 2016 data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil) showed that consumption of fruits and vegetables was only 12.9% prevalent in the older adult population25, posing the need to strengthen existing food and nutrition policies and programmes. Meanwhile, in the general population, a VIGITEL-based study in Brazilian state capitals found consumption of fruits and vegetables 35.2% prevalent in 2016, which is nonetheless less than the 46.1% the 2019 PNS found among ICP users²⁶. Thus, one contribution to strengthening and encouraging healthy diet could come from incentives for implementing ICPs within the scope of primary health care.

VIGITEL 2014 found 10.8% prevalence of smoking in the adult population of Brazil’s state capitals, a figure that parallels the 12.7% (95%CI: 12.3-13.1) among non-ICP users in the 2019 PNS and contrasts with the 6.0% (95%CI: 4.2-7.7) of acupuncture users found to be currently smoking in this study. VIGITEL 2014 also found that soft drinks were regularly consumed by 20.8% of adults in Brazilian state capitals and the Federal District, while this study found 5.0% (95%CI: 3.5-6.5) among users of any ICP in the 2019 PNS²⁷.

In the international context, meanwhile, the 2012 National Health Interview Survey (NHIS), a periodically conducted cross-sectional household interview survey targeting the non-institutionalized civilian population of the United States, asked interviewees to specify up to three ICPs that had been most important to their health in the prior 12 months. These included: chiropractic or osteopathic manipulation; massage; acupuncture; energy healing therapy; naturopathy; hypnosis; biofeedback; craniosacral therapy; traditional healers; herbs; homeopathy; meditation; yoga/tai chi/qi gong; special diets; and movement or exercise therapies. From that survey, the study correlated ICP use with lifestyle habits, finding that 45.4% of interviewees reported being motivated to make at least one behavioural change after using ICPs. Approximately one third reported feeling motivated to practice physical exercise more regularly (34.9%) or to eat more healthily (31.4%); while 17.2% reported being motivated to eat more organic foods. The prevalence of healthy diet was similar to that among ICP users in the study reported here, in that 46.1% of those who reported having used an ICP in the prior 12 months also reported regularly eating fruits, vegetables and legumes. On the other hand, unlike this study, which found no association between lower consumption of alcohol and tobacco, the study cited found that 16.6% of smokers reported being motivated to cut down or stop smoking and 8.7% of those who drank alcohol reported being motivated to cut down or stop drinking alcohol. All individual modalities of ICP inspired health behaviour change in some users. For instance, 66.7% of those who used movement or exercise techniques, 61.5% of those who used yoga or tai chi/qigong and 39.5% of those who followed a special diet reported being motivated to exercise more regularly. Meanwhile, 77.3% of those who followed a special diet, 43.4% of those using movement or exercise techniques and 41.2% of those using yoga or tai chi/qigong reported being motivated to eat more healthily. Accordingly, about half of ICP users were motivated by their practices to change their lifestyle habits for the better, especially as regards physical exercise and diet. The same was found in the study reported here, in addition to reductions in consumption of tobacco and alcohol¹⁷.

Another study analysed data from the Australian Longitudinal Study on Women’s Health (ALSWH), a nationally representative study designed to assess health and wellbeing in Australian women. Three random age cohorts selected from the national Medicare database yielded a total sample of 28696 women of ages 62-67 years, 31-36 years and 19-25 years. Interviewees were asked whether they had consulted a naturopath or herbalist in the prior 12 months, whether they smoked or had smoked, whether they drank alcohol, whether and how they engaged in physical activity and what their eating habits were. The women who consulted naturopaths/herbalists were more likely to report healthy behaviour, such as not smoking, engaging in at least moderate physical activity – similarly to the study based on the National Health Interview Survey (NHIS)¹⁷ – and following a vegetarian or vegan diet. Alcohol was consumed by most of the women who consulted a naturopath, although only a minority displayed high risk or risk consumption behaviour²⁸. Although it is unknown whether consulting a naturopath/herbalist prompts women to adopt the kinds of health behaviour discussed in the article or whether personal characteristics and psychosocial factors behind these kinds of health behaviour also predict an intention and openness to seek naturopathic/herbalist care, nonetheless, that association was found to exist.

Another exploratory, cross-sectional study by online survey of adults in Germany evaluated the use of self-care interventions, lifestyle and ICP use, as well as mental/emotional state during the COVID-19 pandemic²⁹. The questionnaire was directed to adults who considered themselves to have an affinity for ICPs and/or lifestyle interventions. More than half the participants followed a plant-based diet and declared themselves vegetarians or vegans, an association that was also found in the NHIS-based study cited above²⁸. Also, participants in a positive emotional state reported consuming a higher proportion of organically grown products and an overall healthier diet, with an emphasis on raw, plant-based and less-processed foods. Despite the study’s limitations, correlations were found between lifestyle habits and ICP use, as in the study reported here and those cited above, such as the preference for a healthier diet among ICP users.

From the findings of the questionnaires applied by the 2019 PNS, it can be said that ICP users returned a higher prevalence of healthy eating habits, such as eating more fruits, vegetables and legumes, to the detriment of ultraprocessed foods. That claim is also supported by the results of Tesser³⁰, who addressed ICPs as a toolset that could be introduced into the health care model, because of their strategic role in individual and collective health promotion conceived in terms of four interrelated axes. One of the rationales for this influence is that various complementary practices address health in an integrated manner and their practitioners have lived experiences that enabled them to develop health knowledge that extends beyond their individual choices in forming eating habits.

In addition, the positive relationship between ICP use and healthy habits is corroborated by other studies, including the literature review by Araújo et al. (2021)²⁰, which found that ICPs play an important role in comprehensive individual care by acting as mediators of the process of body acceptance. In that way, ICPs are not limited solely to addressing physical issues, but foster a holistic approach to health that takes account of its emotional and psychological aspects. These aspects are fundamental to making more aware eating choices and maintaining healthy habits.

It is important to stress, however, that the main limitation of this study is that it is cross-sectional and, accordingly, cannot establish a causal relationship between ICP use and the habits studied. That issue should be investigated in longitudinal studies, such as cohort studies, that can trace individual characteristics and behaviour over a period and thus establish a time relationship between the start of ICP use and any modification of lifestyle habits.

CONCLUSION

This study found that ICP users returned greater prevalence of healthy eating habits, such as higher consumption of fruits, vegetables and legumes, to the detriment of consumption of ultraprocessed foods, as well as a negative relationship with harmful lifestyle habits, such as tobacco smoking and prolonged screen time. As this is constituted as a cross-sectional observational study, no conclusions can be drawn as to whether ICP users tended to include healthier lifestyle habits as part of their treatment or whether ICP users already had a prior interest in changing their lifestyle habits.

However, it is evident that ICPs constitute a set of tools that can be introduced into Brazil’s model of health care, because of their strategic role in health promotion and their having been regulated in the 2006 National Integrative and Complementary Practices Policy. A number of qualitative studies have demonstrated the positive relationship of valuing self-care, autonomy and empowerment with health, as well as health promotion and better lifestyle habits, which supports the hypotheses and rationales mentioned in this study . Accordingly, broader access to ICPs could contribute to healthier lifestyles.

Accordingly, note that the subject needs more attention from health care practitioners, particularly those in primary health care, and from health managers and researchers, because quantitative studies and research remain scarce in this field.

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