Complementary and Alternative Medicine Use Among
Military Family Medicine Patients in Hawaii

This section is compiled by Frank M. Painter, D.C.
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FROM:   Military Medicine 2010 (Jul); 175 (7): 534–538 ~ FULL TEXT

Jeremy B. Kent, MC USA, Robert C. Oh, MC USA

Department of Family Medicine,
Tripler Army Medical Center,
1 Jarrett White Road,
Honolulu, HI 96859-5000, USA.

Complementary and alternative medicine (CAM) is a growing component of medicine within the U.S. civilian and military populations. Tripler Army Medical Center (TAMC) Family Medicine Clinic represents an overseas medical facility stationed among a diverse ethnic population. The impact that local cultures have on CAM utilization in the military population in overseas medical facilities is unknown.

METHODS:   Cross-sectional survey. The authors surveyed all volunteer soldiers, family members, and retirees 18 years old or greater enrolled at TAMC Family Medicine Clinic with appointments between September 1 and September 25, 2008.

RESULTS:   503 volunteers were surveyed with a response rate of 73% (n = 369). A total of 50.7% reported using at least one CAM therapy within the last year. CAM use was significantly higher among women, Caucasians, and a college level education or greater.

CONCLUSION:   Prevalence of CAM use is higher within a military family medicine clinic in Hawaii than the prevalence among mainland civilian or other military populations.

From the FULL TEXT Article:


Complementary and alternative medicine (CAM) is a growing aspect of health care within the United States (U.S.) population. CAM is a nonspecific and broad term to describe a large group of diverse health care modalities that are not commonly considered to be a part of conventional medicine. As a result, defining CAM is difficult. Generally, CAM is divided into four groups of therapies: mind–body medicine such as meditation, biologically based therapies such as herbal medications, manipulative and body-based practices such as chiropractics, and energy medicine such as therapeutic touch. A fifth group termed whole medical systems uses multiple CAM therapies. Whole medical systems include homeopathic medicine and traditional Chinese medicine. ( ). [1]

Studies show that CAM is used by approximately 38% of the U.S. population. [2–5] Studies also show that the prevalence of CAM use among active duty military personnel is very similar to the civilian population. [6, 7] Conversely, the use of CAM within the Hawaiian civilian population is significantly higher than mainland U.S. with a prevalence of 49.9%. [8, 9] The higher prevalence may be attributed to Hawaii’s diverse ethnicities that include Asian influence, local Hawaiian beliefs, and other South Pacific cultures within a state without a real majority. [10–14] The 2005 Hawaii Census shows that of those questioned, 57% considered themselves Asian, 42% White, 22% Pacific Islander, 3% Black, and 2% Native American. [9]

With the immigration of Japanese and Chinese people to Hawaii in the 1800s they brought with them many health care practices that are well known CAM therapies today, such as Reiki from Japan and acupuncture from China. Hawaii also has CAM that is distinctly Hawaiian. Native Hawaiian spiritual healers known as Kahuna have been practicing Lomilomi massage, giving spiritual healing, and offering herbal medicines since their migration to Hawaii. [15–17] Lomilomi means to press or massage in Hawaiian. Although there are now many different forms of Lomilomi massage, it has traditionally been a holistic healing technique that was brought with the fi rst Polynesians on their migration to Hawaii. The traditional form not only uses massage, but also incorporates prayer and herbal medicines. [15] The kava culture of the Pacific dates back hundreds of years in Hawaiian society. Kava is a plant of the Pacific of which the root has been used for anxiety, stress, and insomnia. It has played a role in certain medical, political, and social ceremonies in Pacific cultures. [17–19] This melting pot of beliefs and cultures may be why there is a higher prevalence of CAM use not seen in the continental U.S.

The U.S. military in Hawaii is exposed to these diverse cultures, which may lead to greater CAM use among the military. [10–14] Some of the soldiers and dependents have Hawaiian or Asian lineage. These same soldiers and family members are seen at Tripler Army Medical Center (TAMC) Family Medicine Clinic. As a full scope clinic taking care of every branch of the U.S. military, TAMC Family Medicine Clinic is a good representation of a diverse military population outside the continental United States (OCONUS).

As the prevalence of CAM use increases, there is more potential for interactions with conventional medicine. Providers need to be aware of CAM use among their patients to prevent these interactions. The goal of this study is to determine the prevalence and types of CAM use at an OCONUS military medical clinic among the distinctly different and ethnically diverse background of Hawaii.


      Study Population

The survey consisted of volunteers who were 18 years old or greater and enrolled at TAMC Family Medicine Clinic with scheduled appointments between the dates of September 1, 2008 to September 25, 2008. The TAMC Family Medicine Clinic consists of a patient population of approximately 10,000 active duty personnel, dependents, and retired service members from all branches of the military to include the U.S. Army, Navy, Air Force, and Coast Guard. The study protocol was approved by the human use committee at Tripler Army Medical Center. Investigators adhered to the policies for protection of human subjects as prescribed in 45 CFR46.


A modifi ed survey instrument fielded by Smith 7 in a study of CAM use among U.S. active duty Navy and Marine Corps personnel was used with the author’s permission. The survey queried the volunteer’s use of CAM, specific CAM therapies used, and demographic data. Volunteers were recruited when they checked in for their appointments at the TAMC Family Medicine Clinic. Volunteers were instructed to fill out the survey during the visit and leave it in one of three labeled drop boxes. The survey was coded with a nonidentifiable number to determine nonresponse rates. The three-page survey was designed to be completed in 5 minutes.

      CAM Definition

The definition of CAM that was used in this study is similar to the criteria used by Smith and Eisenberg. [1, 5, 7] Three CAM therapies were also added that were included in a Hawaii study. [8] These were chelation, naturopathy, and Ayrvedic medicine. CAM use was defined as any of the below therapies used within the last year: acupuncture, chiropractics/osteopathy, homeopathy, energy healing, spiritual/religious healing, folk remedies, massage therapy, biofeedback, hypnosis, high-dose megavitamins, art/music therapy, Ayrvedic medicine, Chinese medicine, herbal therapy, chelation, exercise/movement therapy, naturopathy, aromatherapy, and relaxation healing.

      Statistical Analysis and Power Analysis

Descriptive statistics using frequency, means, and standard deviation described our population studied. Education was collapsed and the highest level education completed was used (high school and college or greater) for bivariate and multivariate analysis. Bivariate analyses using c 2 tests assessed for significant associations between CAM use and demographic variables. A multivariate model using logistic regression assessed for independent associations of CAM use with signifi cant demographic variables. The enter method and forward stepwise regression were both utilized. All analyses were conducted using SPSS software version 13.0 Windows.

      Power Analysis

A power analysis was conducted and it was determined that 350–380 surveys were needed to estimate a prevalence of 45% (±5%) with a 95% confidence interval using the Family Medicine enrollment base of 10,000 beneficiaries.


Table 1

A total of 503 surveys were handed out. A total of 369 were returned for analysis with a response rate of 73%. Demographic data are presented in Table 1. In this study, the prevalence of CAM use was 50.7%. The therapies used the most were: massage therapy (58.3%, n = 109), relaxation (31.0%, n = 58), osteopathic manipulative treatments (OMT)/chiropractics (30.5%, n = 57), and herbals (29.4%, n = 55). The least used therapies were chelation, Ayrvedic medicine, and hypnosis (Figure 1). Of the 50% of participants who reported use of CAM therapy, 73% reported using two or more therapies. CAM therapies were used five or more times by 18% of the participants (Figure 2).

In bivariate analysis, White/non-Hispanics (p value = 0.025), women (p value = 0.002), and those completing a college degree or higher (p value = 0.015) were found to be significantly associated with CAM use. Similarly in multivariate analysis, these variables remained significantly associated with CAM use. Table 2 and Table 3 show bivariate and multivariate results.

Figure 1

Figure 2

Table 2

Table 3

The prevalence of CAM use among the active duty military population has been shown to be similar to the civilian population. [2, 4, 6, 7] Military personnel are stationed worldwide and are exposed to a number of different cultures and potential CAM therapies. Hawaii is a good representation of an OCONUS military site with a military population exposed to a multitude of mainstream and native CAM therapies.

The results of this study show a higher prevalence of CAM use compared to the general U.S. and mainland active duty population, but similar prevalence compared to the local Hawaiian population. [2, 7, 8] The greater CAM use suggests a local influence from a population of higher utilizers of CAM therapy. The authors speculate that this may be due to an increased availability or increased acceptance of CAM within Hawaii that leads to a greater use among our patient population. A higher prevalence was also noted among a population visiting a conventional medicine clinic as opposed to a general population survey. As such, the prevalence represents patients who will ultimately be seen at the TAMC Family Medicine Clinic. These are the same patients who need guidance and education about potential interactions between conventional and CAM therapies.

The data suggest that the odds of CAM use is significantly greater among women, White/non-Hispanics, and those with a completed education of college level or higher, which is consistent with previous National Institutes of Health-funded nationwide surveys. [2–4] Barnes et al. [2] surveyed a national sample of households by phone and showed that CAM use was also signifi cant among women, White/non-Hispanics, and those with a higher level of education. The study suggests that if a patient is going to use CAM therapy they are more likely to use more than one type and many will use multiple therapies. The more commonly used CAM therapies were consistent with previous studies. [2–4]

Our findings suggest that Asian and Polynesian ethnicities are less likely than Whites to use CAM therapies which are contradictory to the Hawaiian study. This is most likely the result of our patient selection. Those enrolled in the clinic are more likely to use conventional therapy even if they are ethnically similar to the local population. Secondly, our patient demographics surveyed fewer Asians and Polynesians. We likely did not have adequate power to detect a difference among the Asian and Polynesian population. Our findings suggest that the higher prevalence of CAM use is the result of the local civilian population’s influence on the military population and not due to military personnel who are ethnically similar to the local population. Health providers working in overseas medical facilities should be aware that their patient population may have a higher prevalence of CAM use compared to continental U.S. medical facilities. They should also be aware that if the patient is using CAM they are more likely using multiple therapies. As CAM use grows, lack of patients reporting its use continues to pose an increased risk for interaction with conventional medicine. [21–24] This study reaffirms the need to ask patients about CAM therapies used.

There are limitations to this study. The data were self-reported and are subject to reporting bias. Generalizability of this study to other nonmilitary populations may be limited. This study was limited to those patients who made appointments to the TAMC Family Medicine Clinic and may have selected for people who are not as healthy or are more likely to seek out conventional medicine. However, these are patients that physicians may encounter in a primary care setting and may represent those that are more likely to utilize CAM therapies. The study only surveyed prevalence of CAM use and did not study the reason volunteers used CAM, specific diseases they were trying to treat, or outcomes of CAM use.

Future studies should be done to help answer these questions. In spite of its limitations, this study has a number of distinct characteristics that contribute to our understanding of CAM use. The response rate of the study was excellent. This study gives a diverse representation of all services; Army, Navy, Air Force, and Coast Guard. Further studies are needed to help characterize CAM use among military medical installations outside the mainland United States.


This work was supported by Tripler Army Medical Center Family Medicine Department.


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