Cupping Therapy (Al-Hijama) Qualification Program for Health Practitioners in Saudi Arabia

Introduction

More than 70% of people worldwide use health care approaches developed outside of mainstream western or conventional medicine [1]. Yet, despite increased complementary and alternative medicine (CAM) use by the patients, allopathic health care providers often lack sufficient knowledge of CAM therapies and products and their role in health and healing. They are unaware about the safety and effectiveness of CAM therapies. They lack the requisite expertise to collaborate with CAM practitioners to provide patients with an integrated health care [2,3]. CAM therapies have been associated with serious and even life-threatening adverse events [4]. Thus, conventional health care providers need to understand the safety and efficacy issues pertinent to widely used CAM therapies, incorporate assessment of CAM use into their history and physical examinations of their patients, and collaborate efficiently with CAM practitioners [5].

Cupping therapy (Al-Hijamah) is a traditional folk therapy practiced mostly by traditional healers worldwide since ancient times [6,7]. Initial reports of cupping had been found in Egyptian and Chinese scriptures; however, the first description of cupping is traced in Ebers Papyrus, the oldest medical textbook written in 1550 BC. Subsequently, cupping was passed on to the Greeks, Romans and western countries [7,8]. Over centuries, the cups and cupping techniques have changed; however, its beneficial effects were increasingly recognized both by the cupping practitioners and users [9] along with keen interest in research on cupping therapy.

Medical education has undergone major transformation along with the change in concept of health and disease. It is becoming increasingly community oriented, learner-centered, self-learning, and self-peer assessing process [10]. Educational institutions, particularly those in developing countries such as Saudi Arabia, face sorts of challenges in the implementation of change via the introduction of new systems and procedures. This is the more common type of organizational change they encounter, as they become more global in their perspectives and face performance-based assessments such as accreditation [11-17].

Properly conducted and well-planned need-oriented qualification programs tend to create extremely efficient, competent, better quality and cost-effective health care services, improve compliance with regulatory measures and enhance satisfaction level without wasting resources [18-20]. However, planning and implementing effective training is not always easy due to qualification programs unsupportive of a true business goal, unclear vision and purposes and loaded with complex information [19, 20]. Overall, training is undergoing innovative changes in all fields for developing highly competitive workforce around the world. A model of structured teaching, training and assessment by peers has replaced the traditional education system where the teacher is the sole provider of knowledge and the learner is a passive receiver [21]. Trainees and students are now given equal opportunities for curriculum development, active interactive learning, decision making and evaluation [22]. Evaluation of qualification courses is an integral part of qualification program specifically intended to demonstrate its effectiveness and provide feedback to the evaluators and attendees on how the implementation of a program has progressed [23]. Accordingly, qualification programs may need modifications for further improvement. In addition, evaluation of training is a process of assessing its potential value, benefits, effectiveness, impact on trainees, performance of trainers, suitability of course contents and delivery methods [24].

Cupping therapy trainers need to give the detailed pertinent knowledge along with practical skills of cupping therapy (Al-Hijamah) to the trainees [25]. An important quality of healthcare professional is to instill a strong will to provide the best training services to the trainees and the willingness to periodically evaluate themselves for improvement [26]. Healthcare practitioners intending to practice cupping therapy need to take a comprehensive qualification course [27]. Qualification courses for cupping therapy are often tailored taking into account evidence based practice of safety and efficacy and philosophy of community oriented, people centered teaching [28,29].

Vision of the program:

Knowledgeable, highly skilled, research oriented hijama practitioner, with high level of professionalism based on safe, and evidence-based practice.

Concepts of the program:

Adoption of the concept of professionalism, concept of safe cupping technique, concept of evidence-based cupping and research oriented practitioners.

Overall Aims and Objectives

Upon successful completion of the qualification program, health practitioners should be able to:

a) Define what is traditional, complementary and alternative medicine, integrative health, other synonyms and related terminologies, and how do they differ from each other and from that of conventional medicine.

b) Define cupping therapy and describe history and hadiths on cupping.

c) Discuss the classifications and types of cupping.

d) Identify indications, advantages and disadvantages of tools and equipment used for cupping.

e) Assess evidence of safety, efficacy, cost effectiveness and mechanism of action of cupping therapy.

f) Access and search the literature and critically evaluate researches on cupping.

g) Adopt medical ethics and research ethics related to cupping.

h) Take a positive attitude towards evidence based cupping.

i) Identify common frauds, misconceptions and wrong beliefs related to cupping therapy

j) Acquire skills of history taking, examination, putting treatment plan, selection of points, scarification and applying different types of cupping.

k) Adopt infection control measures in cupping clinics and proper use of personal protective measures.

l) Discuss indications, contraindications and precautions in cupping practice.

m) Clarify the role of the National Center for Complementary and Alternative Medicine (NCCAM) in KSA as a national reference for all CAM concerns including cupping regulations, licensing and accreditation.

Intended Learning Outcome of the program (ILOs)

Knowledge and understanding

Upon successful completion of the program, health practitioner should be able to A-1) Describe the characteristics of Complementary and Integrative Medicine. A-2) Learn about safety, efficacy, cost effectiveness and mechanism of action of cupping. A-3) Learn about the history of cupping, and Hadiths on cupping. A-4) Enumerate side effects and complications of different types of cupping. A-5) Describe the uses, indications and contraindications of the different types of cupping. A-6) Learn about evidence based cupping therapy. A-7) Judge medical ethics and research ethics related to cupping. And A-8) Define trusted CAM resources especially for cupping.

Intellectual skills

Upon successful completion of the program, health practitioner should be able to B-1) Suggest the right type of cupping for a particular health problem. B-2) Summarize common diseases where cupping therapy can be included in the management plan. B-3) Design suitable plan for management of particular cases using cupping. B-4) Communicate efficiently with patient seeking cupping. B-5) Suggest health education message regarding proper use of cupping and conventional medicine. And B-6) Deal with misconceptions and wrong beliefs of cupping therapy.

Professional and practical skills

At the end of the program, health practitioner should be able to C-1) Discuss the assignments of different cases in the practical notes concerning type of cupping used, theories, side effects and contraindications and suggest the disease(s) that can be managed using cupping based on evidence based medicine. C-2) Do interpretation of a research project including different cases treated by the use of cupping therapy, effectiveness and recommendations. C-3) Acquire practical skills related to different types of cupping. And C-4) Acquire practical skills of scarification.

General and transferrable skills

At the end of the program, health practitioner should be able to D-1) Communicate within the team work in the cupping clinics and centers. D-2) Plan and conduct a research task related to cupping. D-3) Basic information/ health technology literacy.

Course Description

NCCAM is the national reference for all activities related to CAM in Saudi Arabia. It started regulation of cupping therapy since 2015. Cupping therapy was mostly practiced by non-qualified and unlicensed traditional healers. Hence, NCCAM planned, organized, standardized, and implemented health practitioner qualification program for cupping therapy. Physicians, physiotherapists, nurses, and CAM practitioners are only allowed to attend the program. The program implemented in five days course included both theoretical and practical parts for eight hours daily. Health practitioners were assessed at the end of the program through oral, practical, written and OSCE exams.

Topics to be covered

Topics to be covered during the program include 1) Introduction, characteristics and comparison of CAM vs. conventional medicine. 2) history of cupping. 3) Hadiths on cupping. 4) types of cupping techniques. 5) tools and equipment used for cupping. 6) theories that could explain mechanism of action of cupping. 7) cupping session. 8) side effects and complications of cupping. 9) precautions, absolute and relative contraindications. 10) infection control measures in cupping clinics. 11) wrong beliefs associated with cupping. 12) points of cupping and different systems for choosing them. 13) research methods used in cupping. 14) evidence based cupping. 15) Simulation in cupping training 16) How to deal with patient before, during and after cupping 17) Medical ethics and research ethics of cupping therapy. In addition to practical training on different cupping techniques with special emphasis on wet cupping, the most prevalent type in Saudi Arabia (table 1).

Methods of teaching

• Brainstorming.

• Interactive lectures.

• Simulation.

• Small group discussion.

• Case based learning.

• Role play.

• Problem based learning.

• Self-directed learning.

• Team based learning.

• Video display and Criticism.

• Demonstrations.

• Learning by doing.

• Assignments.

1) Introduction, characteristics and comparison of CAM vs. Conventional Medicine. At the end of the lecture, health practitioners should be able to define Traditional Medicine, Alternative, Complementary Medicine, Integrative Health and other names and related terminologies, and how do they differ from each other and from that of conventional medicine. Compare between conventional medicine and CAM as regards safety, efficacy, research problems, evidence based medicine, medical ethics, qualification, regulation,….etc. Discuss different classifications of CAM modalities and therapies, describe the common CAM practices used worldwide and in KSA and define National Center for Complementary and Alternative Medicine.

2) History of cupping. At the end of the lecture, health practitioners should be able to describe how cupping transmitted through different generations, famous scientists wrote about cupping benefits, specifications and development of tools used.

3) Hadiths on cupping. At the end of the lecture, health practitioners should be able to benefit from true hadiths of prophet Mohammed related to cupping therapy and practice. Plane certain guidelines based on hadiths.

4) Types of cupping. At the end of session, health practitioners should be able to define different classifications and types of cupping, indication and contraindication and advantage and disadvantage of each one.

5) Tools and equipment used for cupping. At the end of the session, health practitioners should be able to know advantage and disadvantage, indications and contraindications of different types of cups according to the material of cups, function, shape, size and set inside the cup. Tools used for scarifications and historical sets.

6) Theories that could explain mechanism of action of cupping. At the end of the session, health practitioners should be able to discuss different theories that could explain how the patient can benefit from cupping according to diagnosis and type of cupping used and apply this on different scenarios.

7) How to deal with patient before, during and after cupping. At the end of the session, health practitioners should be able to give instructions for patients before and after cupping, proper history taking, laboratory work up and investigations required to reach to the proper diagnosis. Also, how to follow up the patient.

8) Cupping session. At the end of session, health practitioners should be able to suggest the proper management plan including treatment principles; conventional medicine required, other complementary medicine modalities, physiotherapy, health education, nutrition education, change of lifestyle….etc. Treatment plan for cupping including, type(s) of cupping used, number of sessions, frequency between sessions and points of cupping. Decide the proper position of patient. Steps of cupping starting from disinfection till the end of session.

9) Side effects and complications of cupping. At the end of the lecture, health practitioners should be able to know different side effects and complications that may be related to cupping and how to deal with them to minimize their effects.

10) Precautions, absolute and relative contraindications. At the end of the lecture, health practitioners should be able to take all precautions required for safety of cupping, to prevent any suspected adverse events. These are precautions related to the tools and equipment, precautions related to the patient, practitioners, disinfection and sterilizations and precautions relation to the practice itself. Aware of absolute and relative contraindications for cupping and contraindications of cupping in sports injuries.

11) Infection control measures in cupping clinics. At the end of the lecture, health practitioners should be able to do routine hand washing properly, use of personal protective measures and take universal precautions for infection control in health care facilities. Also, measures for proper waste disposal in cupping clinics.

12) Wrong beliefs associated with cupping. At the end of session, health practitioners should be able to define and deal with wrong beliefs prevalent in our community from the traditional healer who practice cupping hundred years ago.

13) Points of cupping and different systems for choosing points. At the end of session, health practitioners should be able to discuss general guidelines for selecting points of cupping, different systems used for selecting points, points mentioned in hadiths of prophet Mohammed and to detect their sites on the skin. Study different points mentioned in researches of cupping and how to benefit from them.

14) Research methods used in cupping. At the end of the lecture, health practitioners should be able to differentiate between research methods used in conventional medicine and those in CAM especially cupping, difficulties of research in cupping and how to solve them and know the importance of control group and placebo in research. Define reverse strategy and choose the proper research methods suitable for cupping.

15) Evidence based cupping. At the end of the lecture, health practitioners should be able to discuss the concept of evidence based cupping and the criteria for rating strength of evidence and how they differ from conventional medicine. Define circular approach for evidence in CAM and know simply how to reach for evidence of cupping in management of any disease within reasonable time.

16) Medical ethics and research ethics of cupping therapy. At the end of the lecture, health practitioners should be able to discuss the ethical issues of CAM especially for cupping; the ethics of the CAM practitioner towards patients, himself, the public and his colleagues and towards his job. Discuss the ethics of the cupping practitioners towards advertisement of CAM practices and products. Signing medical consent and patient rights.

17) Simulation in cupping training. At the end of session, health practitioners should be able to practice cupping on artificial skin, acquire skills of scarification before working on human being. Take a confidence in doing cupping in proper way.

18) Interactive lectures. Interactive lectures will involve the health practitioner in active discussion, and may provide brief learning activities during the lecture to achieve the learning objectives stated under each topic.

19) Practical sessions. Daily practical session was applied. In the first session, health practitioners start to apply cupping on artificial skin. In the second session, they practice dry, flash, moving and wet cupping on a human volunteer. In the following sessions they do preventive wet cupping on kahel (area below 7th cervical spine) and two respiratory windows (in the inter-scapular area) on volunteers.

Quality Assurance and Evaluation Process

This qualification program needs constant reviewing and monitoring to ensure that it meets the demands placed on it. Hence, there will be a number of assessment strategies for evaluation of the program. They are: 1) Health practitioner feedback at the end of the program, seeking practitioner comments on both teaching, learning, and assessment of the program along with the practitioner views on the general course organization and implementation. 2) Practitioner feedback on a sample of teaching and learning activities, obtained at the end of each activity. 3) Tutor feedback. 4) Examiner feedback. 5) Peer evaluation, where a staff member may visit a particular teaching and learning activity and provide formative feedback about its conduct. 6) Analysis of the practitioner' examination results. 7) External reviews.

Discussion

Survey study of the status of CAM education in health colleges in Saudi Arabia, in 2012, revealed that there is no specialized track or postgraduate education on CAM in any health college in Saudi Arabia. Eleven (12.2%) colleges were teaching CAM courses in their curricula not including cupping [30]. Hence, health practitioners’ qualification program for cupping was planned and implemented for increasing awareness, improving knowledge, and acquiring skills of cupping therapy (hijama) for health practitioners.

This practitioner qualification program is the first governmental program worldwide. There is not any qualification degree of cupping, bachelor’s degree or higher. National surveys done in Saudi Arabia reported that cupping ranked forth CAM modality used by the public (35%) after herbal therapy (59%), spiritual healing and honey and bee products (55%) each [27]. Health professionals and policymakers in Saudi Arabia reported 25% of population used cupping [28]. Another survey on patients attending primary health care centers revealed 13% of them used cupping before. Also, 11.4% used cupping for the same disease before requesting conventional medicine [29].

This qualification program covers one week of teaching in NCCAM, Riyadh, KSA. It located in the north part of Riyadh city, the capital of Saudi Arabia. Such many qualification courses, many and different methods of teaching and learning were used to improve quality and interest in the course, gain knowledge and acquire skills. The program coveres most of topics related to cupping based on literature review and health practitioners’ expectations to satisfy all needs of attendances. This in accordance with many authors who stated that use different methods have a great impact on knowledge and skills retention [31-33].

There is no approved and trusted source or guidelines for the educational material of the cupping qualification course. Published textbooks on cupping therapy, gray literature of unpublished data and information were reviewed. Most of the research published on cupping in different sources, data basis and journals were reviewed especially systematic reviews and meta-analysis, randomized and non-randomized controlled trials and analytical and descriptive studies. Also, we contacted famous and respected cupping health practitioners in Saudi Arabia, Middle East, Asia and Europe to benefit from their experience in the field. At the same time, we attended many private training courses in different countries. All of these activities were practiced to prepare scientific and standardized training material based on evidence based medicine.

This training material approved and updated regularly and frequently based on scientific basis. It was approved by 15 experts in the field after doing some modifications according to their recommendations and request. Also, the program has been tested and methods of teaching were approved by cupping experts, experts in training and education, and public health, community medicine and family medicine consultants. They attended three days course for auditing, evaluation, and approval of the program. Regular and continuous auditing and assessment of the course done by NCCAM. Updates based on results of recent published research are regularly added to the training material.

More than 25 trainers shared in implementation of the program under supervision and control of the author to ensure high quality performance of the course.

All health practitioners attended the course passed the assessment exams. The feedback received was most supportive of the program and appreciative of the facilitators, the information provided and skills gained and the way in which it was delivered. This practitioners’ satisfaction with the course may have a good impact on retention. Most of health practitioners expressed that studying of cupping needs to be integrated into medical school curriculum, and this trend is consistent with other studies [34-36]. The long-term implications of this finding are many, including cupping capacity building in relation to clinical practice, research, teaching, and training [37].

According to many studies, there are many barriers against integration of cupping and use of CAM therapies exist across the world [38-40]. In the context of western medical settings, lack of evidence for cupping, lack of staff training, lack of reimbursement, legal issues raised by medical schools and institutions, relative lack of competent cupping providers, lack of appropriate equipment, and cupping therapy being too time consuming, were the main barriers [38,39,41].

Limitations of the program

Navigating the information landscape and obtaining reliable information is challenging due to presence of disinformation, false claims or outright discouragement of cupping. Preserving updated knowledge and philosophies, while protecting them from inappropriate regulation is crucial especially for cupping therapy that rooted in tradition and distinct from modern education systems. Lack of research in cupping with poor quality due to difficulty in blindness and placebo.

Summary and Conclusion

The Qualification program for cupping has been planned and implemented during the year 2015 for Health practitioners at NCCAM, Riyadh, KSA. The Methods of teaching and learning included interactive lectures, practical sessions, assignments, simulation, learning by doing, case studies, problem based learning and self-directed learning. Topics covered during the course included; Introduction, characteristics and comparison of CAM vs. Conventional Medicine, history of cupping, Hadiths on cupping, types of cupping techniques, tools and equipment used for cupping, theories that could explain mechanism of action of cupping, cupping session, side effects and complications of cupping, precautions, absolute and relative contraindications, infection control measures in cupping clinics, wrong beliefs associated with cupping, points of cupping and different systems for choosing them, research methods used in cupping, evidence based cupping, simulation in cupping training, How to deal with patient before, during and after cupping and Medical ethics and research ethics of cupping therapy. In addition to practical training on different cupping techniques with special emphasis on wet cupping, the most prevalent type in Saudi Arabia. At the end of the program, attendance were assessed using oral, practical, written and OSCE exams.

Recommendations

1) Reliable information is crucial for consumer safety, informed choices and shared decision-making in health care. 2) Significant investment and prioritization of cupping research are imperative. 3) Need for more research data to advance its use and integration. 4) Conduct rigorous scientific studies to support the evidence base regarding the safety, quality, effectiveness, cost-effectiveness and mechanism of action of cupping. 5) Explore innovative approaches for research appropriate to the unique characteristics of traditional, complementary and integrative medicine (TCIM) knowledge and practices especially cupping. 6) Contribute to developing/implementing electronic patient record systems accessible by TCIM health practitioners and promote interoperability. 7) Regularly monitor and report on the implementation of the program.

Acknowledgment

The author is grateful to all the staff members of National Center for Complementary and Alternative Medicine who has participated in the delivery of the program, assessment and final evaluation of the practitioners. This program is dedicated to the soul of Dr. AbdelGawwad El-Sawi who shared in planning, assessment and implementation of the program.

COMPETING INTERESTS

Authors have declared that no competing interests exist.

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