key: cord-0938742-invh1t98
authors: Stub, Trine; Jong, Miek C.; Kristoffersen, Agnete E.
title: The impact of COVID-19 on complementary and alternative medicine providers: a cross-sectional survey in Norway
date: 2021-08-11
journal: Adv Integr Med
DOI: 10.1016/j.aimed.2021.08.001
sha: 85fa6705b90916507a6516dbdc665aa963342148
doc_id: 938742
cord_uid: invh1t98

BACKGROUND: The Norwegian authorities decided in March 2020 to implement a nationwide lockdown to prevent spread of the COVID-19 virus. The lockdown had vast socioeconomic consequences for the society. The aim of this study was to investigate how COVID-19 affected Complementary and Alternative Medicine (CAM) providers’ practice, financial situation, recommendations to patients, and how they perceived their future practice as CAM providers. METHOD: Data were collected in this cross-sectional survey using a self-administrated electronic questionnaire. A total of 581 CAM providers completed the questionnaire, which was designed to describe consequences for CAM providers and their clinical practice caused by the nationwide lockdown. Descriptive statistics were carried out using frequency analyses to describe the demographics and consequences of the lockdown. Between group differences (gender and age) were analyzed using Pearson chi-square tests and Fisher’s exact tests for categorical variables, and ANOVA tests and t-tests for continuous variables. Significance level was defined as p < 0.05 without adjustment for multiple comparisons. RESULT: During the nationwide lockdown of Norway, 38.4% of the respondents were able to provide CAM treatment to their patients. Of those, the majority (96.4%) had reorganized their clinical practice in accordance with COVID-19 hygiene regulations, offered video consultations (57.4%) or telephone consultations (46.6%). To manage financially during the lockdown, half of the providers spent their savings (48.7%). More than one third (35.1%) was supported by their partner, and 26.7% received compensation from the Norwegian state. A total of 26.3% of the CAM providers had other paid work that provided them with income. Nearly a fifth (18.6%) borrowed money from friends and family, changed their loan terms, or took out new bank loans. More than half (62.7%) expressed uncertainty about the future of their practice. CAM providers who had reorganized their practice to online consultations were more optimistic. CONCLUSION: The impact of COVID-19 on CAM providers was considerable. It adversely affected their clinical practice, financial situation, and view on their future practice. To ensure that the health needs of the Norwegian population regarding CAM use are met during pandemic times like COVID-19, it is recommended to support and train CAM providers in the development of online CAM services, as well as efficient implementation of infection prevention and control measures.

(gender and age) were analyzed using Pearson chi-square tests and Fisher's exact tests for categorical variables, and ANOVA tests and t-tests for continuous variables. Significance level was defined as p < 0.05 without adjustment for multiple comparisons.

During the nationwide lockdown of Norway, 38.4% of the respondents were able to provide CAM treatment to their patients. Of those, the majority (96.4%) had reorganized their clinical practice in accordance with COVID-19 hygiene regulations, offered video consultations (57.4%) or telephone consultations (46.6%). To manage financially during the lockdown, half of the providers spent their savings (48.7%). More than one third (35.1%) was supported by their partner, and 26.7% received compensation from the Norwegian state. A total of 26.3% of the CAM providers had other paid work that provided them with income. Nearly a fifth (18.6%) borrowed money from friends and family, changed their loan terms, or took out new bank loans. More than half (62.7%) expressed uncertainty about the future of their practice. CAM providers who had reorganized their practice to online consultations were more optimistic.

The impact of COVID-19 on CAM providers was considerable. It adversely affected their clinical practice, financial situation, and view on their future practice. To ensure that the health needs of the Norwegian population regarding CAM use are met during pandemic times like COVID-19, it is recommended to support and train CAM providers in the development of online CAM services, as well as efficient implementation of infection prevention and control measures.

Complementary and Alternative Medicine (CAM); COVID-19; Pandemic; Finance management

The outbreak of a novel coronavirus disease (COVID-19; previously known as 2019-nCoV) (1) was first reported in Wuhan in December 2019 (2) . On January 7 2020, the Chinese health authorities identified the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) that rapidly spread to other parts of China and globally, including Norway (3). On March 11 2020, the World Health Organization (WHO) declared COVID-19 a pandemic (4). By July 2020, the disease was confirmed in 14,043,176 people worldwide (5).

In general, COVID-19 is an acute resolved disease. However, in severe cases COVID-19 might result in death as a result of massive alveolar damage and progressive respiratory failure (6) . COVID-19 carries a mortality of approximately 3-7% (7) compared with a mortality rate of less than 1% from influenza. Currently, there is no effective treatment against COVID-19. Until vaccines are widely available, public health strategies focus on preventing or slowing down further transmission of the virus. Suggested strategies are frequent hand-washing, face masks, social distancing, and home-quarantine. Other measures that have been implemented by governments on a national level are closure of schools and universities, working from home, minimizing the use of public transport in peak hours, and refraining from nonessential traveling (4).

On March 12 2020, the Norwegian government held a press conference presenting the most drastic nationwide restrictions since World War II. The Minister of Health and Care Services (Høie) stated that "working together will slow down and limit the transmission of the virus that is harmless to most people, but extremely dangerous to a few. By participating in this voluntary work, we can all help saving lives". Voluntary work is a concept characterizing the Norwegian corona discourse (encouraging people to follow the national guidelines to prevent the spread of the virus) (8) . It is like the nation has entered a warlike situation, appealing to unity, responsibility, voluntary work, and the national feelings of its citizens.

On 16 March 2020, the Norwegian authorities decided on a nationwide lockdown, including the closure of kindergartens and schools (9) . Where possible, employees were instructed to work from home. From one day to the next, health care providers such as physiotherapists, psychologists and ophthalmologists closed down their physical consultation practices if infection control and hygiene measureses could not be met (physical contact with less than two meters distance and with a duration of more than 15 minutes) (10, 11) . This also applied to providers of Complementary and Alternative Medicine (CAM).

CAM is defined as a group of diverse medical and health care symptoms, practices, and products that are not generally considered part of conventional medicine (12). If CAM is used together with conventional medicine, it is considered complementary, and if used in place of conventional medicine, it is considered alternative (12). In a study from 2018 (13) , we reported that a little over one third (37%) of the Norwegian population has used one or several CAM modalities at least once during the previous year. The individual average cost for CAM was about NOK 5,700.Twenty three percent received CAM from a CAM provider and/or authorized health personnel, within or outside the official healthcare system (13). The five most frequently applied CAM modalities were massage, acupuncture, naprapathy, healing, and reflexology (13). According to the latest survey (14) , the use of CAM is even higher in specific patient groups. More than one third (33.4%) of the Norwegian cancer patients used some form of CAM, and 14% had visited a CAM provider. Cancer patients who used CAM applied these modalities complementary to conventional cancer treatment.

In Norway, the majority of CAM providers are members of a professional organization that demands ethical and professional standards among their members. Many of these organizations are registered in the Brønnøysund Register (15). A national register for CAM practitioners was established in 2004 with the purpose of increasing patient safety, quality, seriousness, and professionalism in the CAM field. Today 40 CAM organizations with a total of 4,130 providers are registered in Brønnøysund (15). J o u r n a l P r e -p r o o f

Based on knowledge from respiratory illness pandemics in the last century, and the current situation in the USA and South America, it appears that the COVID-19 pandemic recurs in waves (16) . This might also very well be the case in Norway. Furthermore, sporadic increase of cases in connection with local outbreaks and clusters are likely to occur (3) . Therefore, it is of high importance to gain knowledge on how CAM providers in Norway are coping during the COVID-19 pandemic and how it has affected their clinical practice. This will provide essential information that is needed to ensure that the health needs of the Norwegian population regarding CAM use are met during pandemic times.

The present study was initiated to investigate the impact of COVID-19 on CAM providers in Norway. We investigated how COVID-19 affected their practice and consultations with patients, their recommendations to patients, their financial situation, and how CAM providers perceived their future practice.

A national cross-sectional survey was carried out in Norway from April to June 2020. The study protocol was reviewed by the Norwegian Centre for Research Data (NSD) and approved in April 2020 (NSD/ 287191). A modified version of the International Questionnaire to Measure Use of Complementary and Alternative Medicine (I-CAM-Q) was surveyed (17, 18) .

Norwegian residents receive healthcare within the public health care system, in which licensed conventional health care professionals treat and care for the patients (19) . CAM modalities are practiced outside this system, and are unregulated. Anyone can use the term CAM provider and treat patients (20) . However, most CAM providers are members of professional organizations. To ensure patient safety in cases of intervention-related health issues, CAM providers are required to obtain professional liability insurance. Generally, patients themselves pay for the visits to CAM providers.

Inclusion criteria for participation in the study were being a practicing CAM provider at the time the survey was completed and member of a professional CAM organization. Thirty-five CAM organizations received an email with a link to the questionnaire and were asked to forward the link to their members. Thirteen organizations did not respond to the invitation, but 22 organizations did. They forwarded the link to 2,215 CAM providers that were a member of their organization. A total of 581 CAM providers (response rate 26%) completed and returned the questionnaire (Fig. 1) . 

This study was a self-administered questionnaire-based cross-sectional survey.

The modified I-CAM-Q consisted of four parts, and all parts related to CAM practices during the past three COVID-19 pandemic months (March-May 2020). The first part included demographics. The second part included questions related to clinical practice and financial consequences of the COVID-19 situation. The third part included questions related to what modalities these providers recommended, such as dietary supplements, vitamins, herbals, and other over-the-counter remedies. The fourth part included questions related to the recommendation of self-care techniques. The last part of the survey included questions on the fear that CAM providers may have of getting infected with COVID-19, or that a family member gets infected, and how they evaluated the danger of COVID-19 compared to other influenza viruses. An open-ended question invited the respondents to give a final remark about the study. All data was anonymously collected and reported.

The data collection was based on the Dillman survey procedure (21) . By email, the CAM organizations were invited to participate in the study and informed that a new-email with a link to the online survey would be sent a week later. One week after the email with the link, a second email was sent as a reminder to the non-respondents and as a thank you to those that had already responded. Finally, after an additional week, a reminder with the link to the survey was sent to the non-respondents. The CAM organizations forwarded these emails following the same procedure subsequently to their members.

Household income was collected using the following categories (NOK <100,000, 100,000-199,000, 200,000-299,000, 300,000-399,000, 400,000-499,000, 500,000-599,000, 600,000-799,000, 800,000-999,000, 1000,000-1500,000 and more than NOK 1500,000). These were categorized into low (< NOK 400,000), middle (NOK 400,000 -799,000) and high (NOK ≥ 800,000) household income.

Level of education was recorded using six values; Primary education (up to 8 years); Lower secondary education (from 9-10 years); upper secondary education (from 11-13 years); lower levels at university/college (up to 4 years); higher levels at university/college (more than 4 years): and do not want to reply. These were merged into a measure with four categories (compulsive level; middle level; college/university less than 4 years; and college/university 4 years or more).

Age was obtained as an open question and assessed as a continuous variable. In the analysis, this was categorized into three levels (25-39 years; 40-59 years; and 60-83 years).

Other personal characteristics included sex (female, male), postal code (merged into the Norwegian regions East, South, West, Mid (Trøndelag), and North), location (city, town, village, rural area), and number in the household with income or responsible for the economy.

How the clinical practices were organized was surveyed using five categories: Individual practice organized as sole proprietorship; individual practice organized as private limited company; salaried employee in a practice without employer responsibility; other mode of operational business and other.

Whether the respondents had worked as a CAM provider after March 12, 2020 was measured by the dichotomous variable yes/no. In case the respondents responded yes to this question, they were asked if they had made any changes in the way their practice was organized during COVID-19 and what the changes included. This question had four response options: Video consultations; telephone consultations; physical consultations with patients with or without infection control measures; other.

To assess how the COVID-19 situation had affected their income had four response options: More than expected; as expected; less than expected; the practice is closed. Further, in case of decreased income, the respondents were asked how they managed financially. This measure had ten response options: using life savings; support from NAV (Norwegian Labour and Welfare Administration); live on the income of my spouse/cohabitant; other paid work; compensation from the state; borrow money from friends and family; take out loan from the bank; change terms on bank loans; other; do not want to reply. In the analysis, this was categorized into a measure of finances with seven levels: Savings; supported by my partner/cohabitant; compensation from the state/support from NAV; other paid work; loan, other, and did not answer.

The respondents were asked what the future prospects were for their practice. This variable had four response options: Optimistic about the future due to minimal impacts on my practice; unsure about the future, do not know what will happen to my practice; pessimistic about the future due to devastating impacts on my practice.

The respondents were asked what CAM modalities they had recommended to patients to prevent COVID-19 infection after the national lockdown. The section included six CAM groups, with the following response options: self-care techniques included 13 modalities such as mindfulness, yoga, and coaching; Herbs included 12 different herbs, such as garlic, ginger and, turmeric; Diets included nine different regimes such as low carb diet, fasting, and macrobiotic diet; Homeopathy included two options such as individual homeopathic remedies, and complex remedies; vitamins and minerals had 11 response options such as Cvitamin, magnesium, and zinc; dietary supplements included five products such as omega 3, 6, and 9, cod-liver oil, and protein drink.

Whether the respondents forwarded patients to their general practitioner (GP) on suspicion of COVID-19 was recorded by the dichotomous variable yes/no. One question measured whether the respondents were afraid of becoming infected with COVID-19. This variable had four response options: Not at all, somewhat, absolutely, and do not want to answer. Finally, the respondents were asked whether they perceived COVID-19 to be more dangerous than the common influenza virus. This variable had four response options: Not at all, somewhat, absolutely, and do not want to answer.

We used descriptive analyses (frequency analyses) to characterize the demographic and work conditions for the CAM providers in the study. Pearson's Chi-square test and Fisher exact tests (if expected count were less than 5 in any of the cells) were performed to identify differences between men and women and between different age groups in categorical factors, while ANOVA tests and t-tests were used for continuous variables. All analyses were carried out using Statistical Package for Social Sciences (SPSS) v. 26.0.

The open-ended question that invited the respondents to give a final remark about the study was analyzed by means of a content analysis (22) . A content analysis is a systematic examination of text by identifying and categorizing themes (23) . In addition, it classifies and develops categories, and performs the coding (24) . In this study, the codes were grouped according to the questions in the survey. The quotations were analyzed in Norwegian before being translated into English by a professional service. The first author read the data several times and performed the content analysis.

The average respondent was middle aged (65.4%), female (80.3%), and lived nearby the capital in the southeastern part of Norway (53.8%). They held a university degree (87.9%) and had high income (46%). The majority of the respondents lived with a spouse/cohabitant (69%), had children (31.3%) or both (22.4%). Twenty-one percent had a single person household (Table 1) .

A higher percentage of female CAM providers had their practice in rural areas (9% vs. 5.5%), whereas men were more likely to practice in the city (45.5% vs. 40.6%, p<0.001). The youngest age group (25-39 years) was more likely to have high income compared to the middle and higher age groups (68% vs. 58 and 49%, respectively, p=0.05). An explanation for this finding may be that the majority of the respondents in the younger age group lived together with someone else who contributed to the household income (13% vs. 20% and 29%, respectively, p=0.023). Respondents in the oldest age group (60-83 years) were more likely to live together with children compared to respondents in the younger and middle age groups (3.8% vs. 41.3% and 38.9%, respectively p<0.001). J o u r n a l P r e -p r o o f

A total of 134 CAM providers (27.3%) responded to the open question and wrote a remark that explained their current situation. Five themes were identified in these qualitative data: CAM modalities, reorganization of clinical practice, finance management, vision of the future, and perceptions of COVID-19 infection.

These themes are further explained and presented together with the quantitative data below.

A wide range of CAM providers responded to the survey. Their clinical practice mostly included acupuncture/acupressure/ear acupuncture/cupping (30.1%). Other frequent CAM modalities reported were massage (24.6%), gestalt therapy (19.6%), reflexology (19.6%), muscle therapy (11.7%), coaching (11.5%), and conversation/psychotherapy/psychosynthesis (10%) ( Table 2) .

To prevent COVID-19 infection, the respondents recommended several CAM modalities to their patients. The most recommended modality was vitamin C (high and normal doses). This modality was recommended by 6.9% of the respondents. Other frequently CAM modalities recommended were relaxation techniques (3.1%), prayer for own health (2.1%), psychotherapy/counseling (1.9%), Ginger (1.9%), and Omega 3, 6, and 9 (1.2%).

In the free text, respondents emphasized the importance for their patients to take good care of themselves, as one respondent added: During this period, I advised my patients about exercise, health, and diet.

Another respondent wrote: I am engaged in the clients' increased awareness of how they sleep, eat, and are physically active, and how this relates to mental health and their energy level. I am concerned about how they take care of themselves and others, and that there is a balance between these two factors. J o u r n a l P r e -p r o o f

The majority of the responding CAM providers had a sole proprietorship practice (84.3%) followed by a private limited company practice (12%), and other modes of operation (1.7%). 

The majority of the respondents (91.6%) experienced that the income was less than expected during the lockdown. Only 1% responded to have increased their income. To manage financially, half of the CAM providers spent their savings (48.7%). Male CAM providers made use of their savings to a higher degree than female providers (60% vs. 46%, p=0.029). More than one third (35.1%) was supported by their partner, and 26.7% received compensation from the state (including support from NAV). A total of 26.3% had other paid work that provided them with income. Nearly a fifth (18.6%) borrowed money from friends and family, changed the loan terms, or took out new bank loans ( 

The majority of the respondents (62.7%) expressed uncertainty about the future and did not know what would happen to their practice. Nevertheless, 27.4% were optimistic about their future, mostly because they continue to see patients by means of video/telephone consultations. A minority (7.6%) was pessimistic due to devastating impacts on their practice (Table 3) , illustrated by this note: This does not look good. The clients are worried or broke, and it will be a long time before we can return to "normal". Considering finding another job.

Another respondent was more optimistic: I have not had income since the virus outbreak, but ongoing expenses. Small businesses will not receive compensation from the state, as far as I know. So this job is just a bad project now. However, I think this will pass and that the business will flourish again. Did not answer 61 10.5 * Respondents could check all that applied (more than one)

A total of 43.3% of the respondents did not refer patients to their GP on suspicion of COVID-19, probably because most CAM providers did not consult with patients during the lockdown. A total of 45.1% wanted updated information about infection control and hygiene measures. However, the majority (54%) did not see the need for such an update. One participant pointed out: I assess the clients from a professional nursing perspective. I urge them to obey national guidelines. I also discuss good hygiene measures with the client, safe hygiene.

A total of 42.3% of the respondents perceived COVID-19 to be absolutely more dangerous than common influenza. A total of 41% perceived COVID-19 to be somewhat more dangerous than common influenza (Table 3) , which was illustrated by the following comment from one respondent: I think COVID-19 is more dangerous than common influenza for those at risk. Not for those who are healthy, have a good diet, and a good nutritional status.

The more than half of the respondents (57.7%) were not very concerned about becoming infected with COVID-19 themselves, as noted by one respondent: I'm not worried for my own sake, but of infecting others.

Another added: I am mostly worried that someone will be infected in my practice, even though all hygiene measures have been followed.

The present study revealed that the majority of the CAM providers organized their clinics as sole proprietorships. They were uncertain or pessimistic about the future for their practice due to the financial impact of the pandemic. This is in line with current research suggests that also conventional health care providers encountered a considerable degree of stress, anxiety, depression, and insomnia due to the COVID-19 pandemic (26) . Results from a study conducted among 344 health care professionals in Sudan confirmed that most of the participants had minimal to mild anxiety, (35.2%) and (29.9%), respectively. More than half of healthcare professionals (54.9%) showed high levels of stress. The most common coping strategies used by healthcare professionals during the COVID-19 pandemic were "Praying more than usual and looking for something good in the situation (27) .

A small number of CAM providers express the use of vitamin C, Ginger, and Omega 3, 6, and 9 in COVID management, however this may not represent the CAM population due to the small response in this study. To date, there is no evidence of effect for any CAM modality regarding the prevention or treatment of COVID-19 infections (28) . Natural medicine (29) recommends CAM providers to inform patients that there is no good data to support using any natural medicines for COVID-19 treatment or prevention. Additionally, López-Alcalde et al. (30) concluded in a recent overview that there is no current evidence to recommend any specific CAM modality for the treatment of patients with COVID-19. However, CAM may be used for several subjective symptoms such as discomfort before and after the infection, which is in accordance with the respondents in this study, who advised patients to practice relaxation techniques, pray for own health and to use psychotherapy/counseling using online consultations.

In this study, CAM providers also advised patients to take healthy life-style measures such as ensure sufficient sleep, stay physically active, and ensure healthy diets. These measures are in line with recommendations from the national health authorities (31) and trustworthy online resources, as to advice patients to focus on healthy lifestyle choices such as getting eight hours of proper sleep each night, eating a well-balanced diet, and exercising regularly (28, 29, 32 ).

More than 70% of the respondents were uncertain or pessimistic about the future for their practice due to the financial impact of the pandemic. This seems to be a serious problem for the provision of CAM to patients in Norway. The respondents in the present study experienced that the income was less than expected during the lockdown, and only 1% reported increased income. To manage financially, the majority employed savings or was supported by their partner. Overall, respondents had high expectations regarding compensation from the state. However, less than one third received compensation from the state or support from NAV. The reason for this was that many businesses did not meet the compensation criteria (33) . Many respondents had small-scale businesses with low turnovers and therefore placed below the financial limit of compensation. For example, expenses below NOK 5,000 were not covered by the system and the first NOK 10,000 was withdrawn from the total sum of compensation (33) . The current compensation criteria thus hit hard on small businesses with low turnovers. It is recommended that authorities consider removing the lower limit of compensation for health care providers and CAM practitioners, should a similar situation arise in the future.

In order for CAM practices to survive such a pandemic, this study demonstrates how important it is for CAM providers to be able to adapt their practice both to effectively implement infection control and hygiene measures, and also to shift their consultation online or via telephone, whenever possible. Online consultations have been a part of the official health care service in Norway now for some time. According to HelseNnorge (The official health care services' web page for inhabitants in Norway) (34) , online consultation is understood as consultation conducted via the web using audio, video, or text conversation. Patients can only use this service when it does not require physical attendance. The service should not be used for immediate help or emergency situations. The health care provider is responsible for ensuring patient rights and safety, confidentiality, privacy, and providing necessary information security throughout the web solution (35) .

Many health care providers want to offer online consultations to patients, and HelseNorge provides information on how to facilitate this in collaboration with helsenorge.no. (36) . New online approaches for consultation of patients have improved practice in many ways, and is regarded an advantage for a specific group of CAM providers as it allows them to expand their practice by not only serving local patients but also patients across the country. The present study demonstrated that the latter contributed to an improved turnover for business for some CAM providers that responded to the survey. This was illustrated by one of the respondents who claimed that online consultations was the reason for perceiving the future relatively bright. This approach may also benefit CAM provision for chronically ill and elderly patients, since they are able to receive CAM care while staying at home. In addition, these consultations are timesaving for both CAM providers and patients. Online consultations are however not suitable for CAM providers who offer physical treatments, such as massage and acupuncture. Since the majority of the respondents in this study offered patients acupuncture, massage, reflexology, and muscle therapy, online consultations were not an option.

Based on the findings from this study, CAM organizations are recommended to facilitate online consultation options for their members, where applicable, with support from HelseNorge. Such consultations should ensure patient rights and safety, confidentiality, privacy and secure that the information obtained is safely stored. CAM organizations are also recommended to provide updated knowledge on infection control and hygiene in daily practice by offering seminars on the theme in collaboration with for example the National Institute of Public Health.

Hygiene control is a global issue. It is the responsibility of professional CAM organizations worldwide and their members to facilitate the accessibility of CAM services for patients in a therapeutic environment without the risk of being exposed to the COVID-19 virus for both patients and CAM providers.

CAM providers in this study contributed to the national discourse by promoting healthy life style advice to patients. As such, CAM providers can have a role as health promoters during these pandemic times. Further research is necessary to investigate the role of CAM in preventing and treating COVID-19 symptoms.

The results of this study should be interpreted in light of its limitations. A limitation was the low response rate of 26%, which may hamper the generalizability of the findings. Even though, organizations were reassured by the researchers that CAM providers are allowed to advise patients on possible prevention of COVID-19 infection, some organizations did not want to participate in the study because according to Norwegian law (37), CAM providers are not allowed to treat infections. Other CAM practitioner organizations had decided to perform their own survey among members and did not want to bother them with another survey related to COVID-19. Although the findings from this study give a good indication of the impact of the national lockdown, it may not represent the situation for all CAM providers in Norway. However, the risk of non-response bias depends not on the response rate per se, but to what extent respondents differ from non-respondents (38, 39) . Nonresponse bias can be assessed by examining changes in the prevalence of outcomes before and after, including late responders in the sample. In this study the outcomes from late responders did not differ significantly from the outcome of early responders with respect to age, education, income, organization of clinics, and how to manage financially. This finding suggests that the non-response bias may be limited (38, 40) . Another limitation of this study J o u r n a l P r e -p r o o f was that CAM providers were surveyed during the first three months of the COVID-19 pandemic in Norway. The long-term effects of the lockdown are therefore not known, and should be further investigated.

The impact of COVID-19 on CAM providers was considerable. It adversely affected their clinical practice, financial situation, and view on their future practice. The majority of the providers did not meet the criteria for compensation. Consequently, the authorities should consider removing the lower limit of compensation should a similar situation arise in the future. To ensure that health care needs of the Norwegian population regarding CAM use are met during pandemic times like COVID-19, it is recommended to support and train CAM providers in the development of online CAM services, as well as efficient implementation of infection prevention and control measures. 

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We acknowledge the CAM organizations and CAM providers who completed the questionnaire and participated in this study. We are also grateful to Jane Ekelund and Tine Lillegård Bergli, Ola Lillenes and Solveig Johansson for technical support.

Authors' information TS (research professor) is a trained CAM provider. She holds a PhD in Medical science and is specialized in both qualitative and quantitative research methodology. AEK (senior researcher) is a language sociologist and a CAM provider. She holds a PhD in Medical science and is trained in quantitative research design. MCJ (professor) holds a PhD in Medicine and has considerable expertise in understanding the use of complementary modalities, and patient-provider communication about complementary therapy use.

TS conceived the study and designed the Norwegian part of the questionnaire. She also collected the data, performed qualitative analysis and interpretation of data, and drafted the initial version of the manuscript. AEK was involved in the conception and design of the study, and performed quantitative analyses and interpretation of data. MCJ was involved in the conception and design of the study, interpretation of data, and critically revised the manuscript for important intellectual content. All authors reviewed subsequent versions and read and approved the final manuscript.

The publication charges for this paper have been funded by a grant from the publication fund of UiT The Arctic University of Norway. No additional funding was received.Authors' contributions TS conceived the study and designed the Norwegian part of the questionnaire. She also collected the data, performed qualitative analysis and interpretation of data, and drafted the initial version of the manuscript. AEK was involved in the conception and design of the study, and performed quantitative analyses and interpretation of data. MCJ was involved in the conception and design of the study, interpretation of data, and critically revised the manuscript for important intellectual content. All authors reviewed subsequent versions and read and approved the final manuscript. 

The publication charges for this paper have been funded by a grant from the publication fund of UiT The Arctic University of Norway. No additional funding was received.

The dataset this paper has been based on has not been deposited in any repository. All dataset and materials are available from the corresponding author upon reasonable request.

The study protocol was reviewed, and the Norwegian Centre for Research Data (NSD) approved the study in April 2020 (NSD/ 287191). Written informed consent was obtained from the respondents' by means of completed and returned questionnaire.

Consent to publication was obtained from the respondents.

The authors declare that they have no competing interests.

The study protocol was reviewed and the Norwegian Centre for Research Data (NSD) approved the study in April 2020 (NSD/ 287191). Written informed consent was obtained from the respondents' by means of completed and returned questionnaire.