Use of Complementary and Alternative Medical Therapies
Among Racial and Ethnic Minority Adults: Results From
the 2002 National Health Interview SurveyThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Natl Med Assoc 2005 (Apr); 97 (4): 535–545 ~ FULL TEXT
OPEN ACCESS Robert E Graham • Andrew C Ahn • Roger B Davis • Bonnie B O'Connor
David M Eisenberg • Russell S Phillips
Division for Research and Education in Complementary
and Integrative Medical Therapies,
Osher Institute, Harvard Medical School,
401 Park Drive, Suite 22A-West,
Boston, MA 02215Purpose: Complementary and alternative medicine (CAM) use among ethnic minority populations is poorly understood. We sought to examine CAM use in Hispanics, non-Hispanic blacks and non-Hispanic whites.
Methods: We analyzed data from the Alternative Health Supplement to the 2002 National Health Interview Survey (NHIS), including information on 19 different CAM therapies used in the past 12 months.
Results: An estimated 34% of Hispanic, non-Hispanic black and non-Hispanic white adults in the United States used at least one CAM therapy (excluding prayer) during the prior 12 months (2002). CAM use was highest for non-Hispanic whites (36%), followed by Hispanics (27%) and non-Hispanic blacks (26%). Non-Hispanic whites were more likely to use herbal medicine, relaxation techniques and chiropractic more frequently than Hispanics and non-Hispanic blacks. After controlling for other sociodemographic factors, Hispanic and non-Hispanic black races/ethnicities were associated with less CAM use, with adjusted odds ratios (95% confidence intervals) of 0.78 (0.70, 0.87) and 0.71 (0.65, 0.78), respectively. Hispanics cited using CAM because conventional medical treatments were too expensive more frequently than non-Hispanic blacks or whites. Hispanics had the highest provider nondisclosure rates (68.5%), followed by non-Hispanic blacks (65.1%) and non-Hispanic whites (58.1%).
Conclusions: Excluding prayer, Hispanics and non-Hispanic blacks used CAM less frequently than non-Hispanic whites and were less likely to disclose their use to their healthcare provider. Further research is needed to improve our understanding of the disparities in CAM use.
From the Full-Text Article:
INTRODUCTION
A large number of people use complementary and alternative medicine (CAM) in the United States. In 1997, 42% of the American population used some form of CAM. [1] Patterns of CAM use in minority populations have not been extensively studied. Few surveys have reported on CAM use among adults within non-Anglo/white groups using national probability data. With the increase in the minority population, there has been a demand for research on CAM use by minority populations and by specific minority subgroups. [2] Additionally, an improved understanding of CAM use among non-Anglo/white populations will enable clinicians to provide more culturally sensitive care to the full range of their culturally diverse patient population.
According to the 2000 U.S. Census, Hispanic and black adults make up over 25% of the total population. [3] Unfortunately, previous national CAM surveys" [4] have not oversampled racial and ethnic minorities, resulting in numbers that are too small to permit accurate subset analyses of non-Hispanic blacks and Hispanics using national estimates. Recently, a report was issued on CAM use among U.S. adults, using data from the 2002 National Health Interview Survey (NHIS). The report noted that 36% of adults used some form of CAM therapy during the past 12 months when prayer for health reasons was not considered. Although the use of CAM varied according to race/ethnicity, differences by race/ethnicity were not evaluated using adjusted analyses. [5] Prior to this report on the 2002 NHIS results, one other CAM study provided nationally representative ethnic minority population estimates. However, that study was restricted to the use of five CAM modalities and was based on data collected in 1995. [6] Surveys of ethnic minorities have been performed in specific clinics serving minority communities, but have limited generalizability. [7–9] Race/ethnicity has been reported to affect the specific choices of CAM based on cultural and traditional preferences. [10] Results of a single study suggest that 83% of minority patients who use it do not disclose this information to their physician. [11]
Despite the population growth of minorities, there is a gap in the current literature available on CAM use by adults of nonwhite racial backgrounds. In this context, our aims were to determine the prevalence of CAM use in ethnic minority populations; to identify how race/ethnicity influences the use of CAM; and to examine the reasons for use and rates of disclosure to medical professionals.
METHODS
Data Source
We analyzed data from the Sample Core component and the Alternative Health Supplement to the 2002 NHIS. The alternative medicine supplement was administered as part of the sample adult questionnaire of the 2002 NHIS. The NHIS is an in-person household survey conducted by the Census Bureau for the National Center for Health Statistics, and it is the principal source of information in the United States on the health of the civilian, noninstitutionalized household population. Using computerassisted personal interviews, the survey was administered in-person in English and/or Spanish.
One adult (aged 18 years or older) was randomly selected from each household to complete this portion of the survey. There were 31,044 completed interviews with a 73.4% final-weighted response rate. Non-Hispanic blacks and Hispanics were oversampled.
Use of Complementary and Alternative Medicine
The Alternative Medicine Supplement elicited information from U.S. adults on 19 nonconventional health therapies. The NHIS categorized these 19 CAM therapies into two groups: provider-/practitioner- and self-care-based. The interviewer began this section of the survey by asking:“Now, I am going to ask you about some other health services you may have used. First, I will ask you about some services for which you may have seen a practitioner. Later, I will ask you about some other health practices you may have done on your own.”
The ten “provider - or practitioner-based therapies” were identified as
acupuncture,
Ayurveda,
biofeedback,
chelation,
chiropractic,
energy healing therapy/reiki,
folk medicine,
hypnosis,
massage and
naturopathy.All respondents were asked
“Have you EVER seen a provider or practitioner for any of the following for your own health?”
Respondents who answered yes were then asked,
“During the past 12 months, did you see a practitioner for [therapy]?”
The eight “self-care-based” therapies included
(i.e., meditation, guided imagery, progressive relaxation, deep breathing exercises).herbal medicine;
homeopathy;
special diets;
mega-/high-dose vitamins;
yoga;
tai chi;
qi gong; and
relaxation techniquesThe respondents were asked:
“During the past 12 months, did you use [therapy] for your own health or treatment?”
The prayer category included self-prayer, sacrament, prayer chain and/or prayer by others.
The respondents were asked:
“During the past 12 months, did you pray specifically for the purpose of your OWN health; did you ask or have others pray for your OWN health; did you participate in prayer chain or prayer group for your OWN health; and/or did you have a healing ritual or sacrament performed for your OWN health or treatment?”
Other Health-Related Factors
We included information on the respondents' age (<25, 25–34, 35–44, 45–54, 55–64, ≥65); gender; marital status (defined as married or not married); educational attainment (< high school, high-school graduate, some college, college graduate); annual family income (< $15,000, $15,000–$34,999, $35,000–$64,999, ≥ $65,000); race/ethnicity (Hispanic, non-Hispanic white, non-Hispanic black); and region of U.S. residence (Northeast, Midwest, South, West).We also analyzed data on the following: health insurance status (insured or not insured), availability of professional healthcare:
“Is there a place that you usually go to when you are sick or need advice about your health — a clinic or health center, doctor's office or HMO, hospital emergency room, hospital outpatient department or some other place?”
A follow-up question also asked:
“Is that place the same place you usually go when you need routine or preventive care, such as a physical exam or check-up?”
and utilization of health services (last visit to health professional). We also included self-perceived health status (excellent, very good, good, fair and poor). We used data on reasons for use of CAM and disclosure rates to medical professionals.
These questions offered respondents five distinct reasons for using a CAM therapy, which included:
“Did you choose [modality] for any of the following reasons? — Conventional treatments would not help you, conventional treatments were too expensive, [modality] with conventional medical treatments would help you, a conventional medical professional suggested you try [modality], or you thought it would be interesting to try [modality]?”
Disclosure rates for a certain modality were ascertained by asking the question:
“During the past 12 months, did you let any of these conventional medical professionals know about the use of [modality]?”
Statistical Analyses
All analyses used SUDAAN, version 8.1 (Research Triangle Institute, Research Triangle Park, NC), [12] to account for the complex sample design ofthe NHIS. Population estimates were calculated using NHIS weights, which are calibrated to census totals for gender, age and race/ethnicity of the 2002 U.S. population. SUDAAN uses Taylor series linearization to compute standard errors and test statistics. Descriptive analytic techniques were used to examine the prevalence of CAM use; the most common modality used; insurance coverage; reasons for use; and disclosure rates to a medical professional. Within each of the racial/ethnic categories (Hispanic, non-Hispanic blacks and non-Hispanic whites), we used Chi-squared tests of independence to compare characteristics of CAM users and nonusers. We used multivariable logistic regression analysis to assess the association between race/ethnicity as an independent variable and the use of CAM, after controlling for all other background variables. We selected variables for testing in our model based upon the results of previous national studies, as well as our own clinical experience and entered all ofthese variables into the final model simultaneously. Variables tested in our model are listed in Table 1. We constructed two separate models, the first defining the dependent variable as the use of CAM excluding prayer, and the second the use of CAM including prayer.
To avoid any inconsistencies caused by different definitions of CAM, we will present our data with and without prayer.
RESULTS
There were 31,044 completed interviews, with a 73.4% final weighted response rate. Non-Hispanic blacks and Hispanics were oversampled. Ofthe 31,044 respondents, 29,990 were self-identified as Hispanics, non-Hispanic blacks and non-Hispanic whites and were the subjects of further analysis. Ofthese, 10,1 13 (34% weighted) reported using at least one CAM therapy, excluding prayer, during the past year.
Characteristics of the population shown in Table 1 are categorized by race/ethnicity. The racial/ethnic groups were compared to one another. Differences among the groups were all significant at p<0.005. In our sample, non-Hispanic blacks and Hispanics each accounted for approximately 12% of the total population.
Table 2 compares CAM users to nonusers. Across groups, users tended to be between 35 and 54 years old, female, have an educational level beyond high school, have higher incomes, have a usual source of medical care and had visited a health professional within the past six months. Among non-Hispanic blacks and non-Hispanic whites, worsening health status was associated with less CAM use. Among Hispanics, worsening health status appeared to be associated with increased use. Hispanics and nonHispanic blacks with medical insurance tended to use CAM more, while insurance status appeared to have little effect on CAM use among non-Hispanic whites.
Table 3 demonstrates the 12–month prevalence of use of CAM therapies. Among the three groups, CAM use (excluding prayer) was highest in non-Hispanic whites (36%), followed by Hispanics (27%) and non-Hispanic blacks (26%). Prayer use was highest among non-Hispanic blacks (67%) and lowest among non-Hispanics whites (59%) and Hispanics (57%). Excluding prayer, which was used by 44% of the population, the most commonly used therapies among the three groups were herbal medicine (19%), relaxation techniques (14%), chiropractic (7%), yoga (5%) and massage (5%). Non-Hispanic whites tended to use herbal medicine, relaxation techniques and chiropractic more frequently than Hispanics and non-Hispanic blacks.
Table 4 compares the reasons for CAM use and nondisclosure rates among the three groups. Across the three groups, approximately 30% of respondents reported that one reason to use CAM was that:“it would be interesting to try CAM”
and there were no significant differences by ethnicity. A similar percentage of respondents overall reported believing that
“CAM with conventional medicine would help,”
with non-Hispanic whites citing this reason more commonly than Hispanics and non-Hispanic blacks. Hispanics were more likely than non-Hispanic whites and non-Hispanic blacks to believe that
“conventional medical treatments were too expensive.”
Hispanics had the highest nondisclosure rates (68.5%), followed by non-Hispanic blacks (65.1%) and non-Hispanic whites (58.1%).
Table 5 shows the results from multivariable analysis. After controlling for sociodemographic factors, we found that CAM use (excluding prayer) was most common among women, persons with higher education, higher levels of income, those without insurance, persons with fair-poor health status and western U.S. residents. CAM use was least common among non-Hispanic blacks, Hispanics and those who had not seen a health professional within the past six months. However, if the definition of CAM included prayer, CAM use was most common in non-Hispanic blacks 1.62 (1.48, 1.77) and Hispanics 1.22 (1.11, 1.34), compared to non-Hispanic whites.
DISCUSSION
The overall use of CAM was common within the NHIS study population. Approximately 34% of respondents used at least one CAM therapy (excluding prayer) within the past 12 months. Hispanics, as well as non-Hispanic blacks, used CAM less frequently than non-Hispanic whites. Prayer use was highest among non-Hispanic blacks. One-third of all of the participants responded that their reason for CAM use was that “CAM with conventional medical treatments would help” and “it would be interesting to try CAM.” Hispanics were more likely to report using CAM because “conventional medical treatments were too expensive.” Hispanics and nonHispanic blacks had higher rates of nondisclosure to their healthcare provider than non-Hispanic whites.
Our findings are inconsistent with those reported by Mackenzie et al. [6] They studied 3,789 persons from the 1995 National Comparative Survey of Minority Health Care of the Commonwealth Fund. While we found that 34% of respondents used CAM in the past year, they reported that 43.1% of the respondents reported using one or more CAM modalities(defined by five items:
herbal medicine,
acupuncture,
chiropractic,
traditional healer and
home remedy )within the past 12 months. Although they reported a prevalence of herb use similar to our findings, they reported higher herb use in Hispanics and African Americans compared to our findings. For chiropractic, they reported a similar overall prevalence to our findings, but reported higher use among African Americans and Hispanics compared to our findings. Acupuncture was used similarly in both studies. We were unable to make direct comparisons for use of traditional healers and home remedies, as NHIS did not ask about these therapies. For folk medicine, we found that 0.1% of the populations used folk medicine, while Mackenzie et al. reported 3% overall use. Their study revealed that the use of CAM overall was similar among all ethnic groups, however, differences occurred among modalities. Possibly, these inconsistencies between studies are attributable to differences in wording of questions, sample selection or secular trends.
In 2002, using the 1999 NHIS, Ni et al. estimated lower overall use of CAM (28.9%) and reported that non-Hispanic whites had the highest use compared to other groups, [13] consistent with our findings.
Smaller studies in minority populations are limited by the lack of national generalizability. One study concluded that 77% of Mexican Americans (n=547) in the El Paso, Texas region used CAM. [8] A study conducted in New Mexico found that herbal remedies were used by 61% of the population. Hispanics used herbs more than whites (77% vs. 47%). The authors concluded that ethnicity (Hispanic culture) was related to the use of herbal remedies. [14] A study comparing the use of CAM among whites, African Americans and Hispanics was conducted in New York City. The study revealed that more than half of the sample had used a CAM treatment or remedy. Racial and ethnic differences in CAM use were minimal. [7] The variability and inconsistency of CAM use estimates may be attributable to discrepant definitions of CAM, [1, 4, 6, 14, 15] geographic variation of use, [6–8, 13, 16–18] exclusion of nonEnglish-speaking populations [1, 4, 7, 14] and exclusion of those without a telephone. [1, 4, 6, 14]
The correlates of CAM use we identified were consistent with previous studies. [1, 4, 6, 13, 14] Being female, having more years of formal education, higher-income status, living in the west and being ages 25–64 have all been associated with higher rates of CAM use. These associations are similar to findings for CAM use in non-Hispanic whites.' The association between worsening self-perceived health and CAM use has been documented repeatedly in studies involving non-Hispanic whites. [4, 11, 13, 14] Hispanics with a worsening self-perceived health status used CAM more often than whites. Respondents were also more likely to use CAM if they had visited a health professional within the last six months. [13]
We found that prayer, herbal medicine, relaxation techniques and chiropractic were used most commonly. These findings are also consistent with previous studies. [1, 4, 13] The significant differences we observed in the rates of certain therapies by ethnicity were of interest. For example, chiropractors were used by 8.8% of non-Hispanic whites, in contrast to 3.8% of Hispanics and 2.7% of non-Hispanic blacks. A number of possible explanations may account for these differences, such as the lack of diversity among chiropractors, [19] location of chiropractors' offices or cultural beliefs about chiropractors.
There was a surprisingly low rate of folk medicine (0.2%) use among Hispanics in the NHIS survey. This is contradictory to three decades of anthropological research. [20, 21] By contrast, previous surveys of Hispanic patients have estimated the use of folk medicine (curanderos and other traditional practitioners) at rates ranging between 4% and 7%. [15, 16]
Since 1998, the use of prayer for health concerns has increased. Recently, McCaffrey et al. [22] demonstrated that 35% of respondents used prayer for health concerns in a national study conducted in 1997. We estimate that 44.5% of respondents used prayer, with non-Hispanic blacks and Hispanics having the highest rates, 60.8% and 47.3%, respectively. For several decades, the influence of religion and prayer among African Americans [23, 24] and Hispanics [25, 26] has been well-documented, although less is known about prayer for health concerns. Recently, Dessio et al. concluded that African-American women were more likely to utilize religion/spirituality for health reasons than women of other races/ethnicities. [27] The high use of prayer may be attributed to the central theme of religious and spiritual beliefs as an integral part of many traditional health systems. [28]
Hispanics were more likely to choose CAM, "because conventional treatments were too expensive." This finding is consistent with observations of The White House Commission that reported that underserved populations use CAM therapies because they cannot afford access to conventional care. [29] Hispanics have less access to professional medical care than non-Hispanic whites and many may turn to alternative forms of medical care (folk/home remedies, family and community healers). [30] Despite equal rates of participation in the workforce, only 43% of Latinos are covered by employment-based health insurance, compared to 73% coverage of non-Hispanic whites. [31] Our survey revealed that Hispanics were least likely to have medical coverage, followed by non-Hispanic blacks and whites. Hispanics and non-Hispanic blacks with medical insurance tended to use CAM more, yet insurance status had no influence among whites in bivariable analyses. Insurance status has been examined by two studies with contradictory results. [5, 12] In our regression model, we found that respondents who were uninsured were more likely to use CAM.
Several studies have suggested that CAM therapies are used in conjunction with conventional medicine. [1, 4, 12, 14] We found that seeing a health professional within the past six months was associated with the use of CAM. This may suggest either that CAM users tend to be active in promoting their own health'9 or that sicker people see their health professionals and use CAM more often.
Despite the frequent use of CAM in these populations, discussion about CAM with conventional health providers is infrequent, particularly among Hispanics and non-Hispanic blacks. Previous studies have consistently shown nondisclosure rates at about 63–72%. [32] To our knowledge, this is the first study to show ethnic differences in disclosure rates. It is possible that subjects avoided discussion of CAM out of fear of criticism from the doctor, or the medical staff did not think to ask about CAM use due to time constraints. [17] Additionally, even without the language barriers that certain minorities face in the medical encounter, English-speaking, nonwhite patients may not inform their doctors of nonconventional treatments because they may think them irrelevant, are embarrassed to discuss them, feel the doctor will object or want to avoid being viewed as unsophisticated. [19, 20] This underscores the need for proactive inquiry on the part of physicians to ask all patients, especially minority patients, about their CAM use.
There are several limitations to this study. First, the survey is based on self-reported data, making it subject to recall bias. Second, and most significantly, despite the improved sampling and collection strategies employed by the NHIS to capture ethnic minority responses, there appears to be both ethnocentric and medico-centric bias in the survey instrument, which may have contributed to an underestimation of the prevalence of CAM, especially among nonwhite ethnic groups. [33] For example, in the herbal medicine questions, the instrument sought information regarding the use of 35 specifically named herbs, but failed to ask about the herbs more commonly used by ethnic minorities. Among Hispanics, cat's claw, rue, aloe vera and eucalyptus are frequently used, [7, 14] but these were not named in the questionnaire. Herbs named in the NHIS survey questions tended to be those widely used by middle class, non-Hispanic whites and those to be marketed as manufactured products; yet, Hispanics and nonHispanic blacks commonly use nonprocessed and often home-grown herbs, in addition to or instead of, manufactured herbal products.
Additionally, in the folk medicine category, the NHIS asked about only two systems in particular – curanderismo (a traditional Latin-/Mexican-American folk healing system) [34] and Native-American (nontribally differentiated). It failed to ask about other folk medicine systems, such as Espiritismo (translation: Spiritism), shamanism, Santeria (the "way of the saints") or about the use of community healers, such as bonesetters, midwives and sobadores (massagers). Espiritismo is a system in which mental and spiritual healing is carried out by healers, using energy and/or trance and has been described as a community healing resource in a variety of Latino populations. [35, 36] Santeria is a magico-religious system combining historical spiritual traditions of the Yoruba of West Africa with selected elements of European Catholicism. Santeria was developed in Cuba in the decades following the Spanish importation of African slaves; it came to the United States with Cuban and Puerto Rican immigrants. [37, 38] Sobadores (massagers) are lay healers who specialize in the use of manual massage techniques to treat symptoms and putative physical causes of both conventionally recognized ailments and culture-specific folk illnesses. [34, 39, 40] Contrary to our results, several convenience sample studies have estimated that Hispanics were higher users of herbal and home remedies [14, 41–43] and curanderos. [14, 41]
These limitations suggest that multi/interdisciplinary (e.g., anthropology, folklore, botany, ethnobotany and sociology) collaboration is critical to designing culturally appropriate survey instruments to avoid unconscious ethnocentric bias in categorization and definitions. A further limitation, since NHIS is largely restricted to a multiple-choice format, is that little information was available on items such as health beliefs, customs and attitudes towards CAM. This too suggests the value of interdisciplinary collaboration and multimethod studies to obtain a fuller picture of CAM use and rationales across populations. [43]
In summary, our results demonstrate that the rates of CAM use in ethnic minorities are considerably less than in non-Hispanic whites. Excluding prayer, most racial/ethnic minorities do not use CAM as commonly as non-Hispanic whites. Racial/ethnic minorities are less likely to disclose their use of CAM to their healthcare professional. The successful delivery of health services to minorities must include an increased awareness and appreciation for the cultural context of their CAM use by examining health belief systems and their potential effect on health behaviors and outcomes. An improved understanding of their use of CAM may also help address health disparities and inequalities in the United States. Further research is needed among minority populations to provide us with a greater understanding of their use of CAM to serve their needs within the current health system. Understanding the barriers that minorities face regarding nondisclosure of CAM use to their healthcare providers is necessary. Research is also needed to develop more culturally sensitive questionnaires.
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