Who Uses Complementary and Alternative Medicine?by Lindsay Myers, MBA, MPH | June 9, 2014
The most recent National Health Interview Survey reports that in the preceding 12 months, 38% of Americans used complementary and alternative medicine (CAM); defined as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.” So why is interest in alternative therapies increasing?
In general, complementary medicine refers to the use of unconventional medical therapies in conjunction with conventional medical treatment, while alternative medicine implies substitution for conventional medical therapies. More often, CAM is used in addition to conventional Western medicine.
While definitions of CAM vary, they frequently include, but are not limited to, massage, acupuncture, deep breathing, chiropractic adjustment, meditation, yoga, qi gong, vitamins and supplements, and guided imagery. In the Journal of Clinical Psychology, Crystal Park points out that “demographics associated with CAM use are fairly well established, but less is known about their psychological characteristics.” Other studies suggest that CAM use is associated with positive health behaviors and behavioral change. Consequently, the psychology of CAM users has implications as healthcare reform and other industry shifts move conventional providers towards integrated, outcome-focused care where they are expected to exert greater influence on patient behavior.
Increasing use of CAM in the United States
Out of pocket expenditures on CAM for the preceding 12 months, based on the CDC’s 2007 National Health Interview Survey, were almost $34 billion. Park reports that: “In the United States in 2007, the most commonly used CAM modalities were nonvitamin, nonmineral, natural products (17.7%), deep breathing exercises (12.7%), meditation (9.4%), chiropractic and osteopathic manipulation (8.6%), massage (8.3%), and yoga (6.1%).”
There was a precipitous drop in the government’s report of CAM use by Americans between 2002 and 2010. The 2002 National Health Interview Survey reported that 62 percent of Americans used CAM in the past 12 months. Due to the subsequent decision to reclassify prayer, which was previously included as a CAM modality and is no longer included in the definition, the number declined to 38.3 percent, still a substantial portion of the population. Prayer remains on the survey, but is no longer part of the CAM definition.
Contemporary research has attempted to quantify CAM use by the population, identify demographic predictors of use, and assess perceived CAM effectiveness related to specific conditions. The National Health Interview Survey collects substantial information on CAM use, perceived efficacy, as well as a multitude of conditions for which CAM is used. Other data sources specific to certain conditions, such as arthritis, have been used to examine both the efficacy of treatments and demographic characteristics of patients. Park suggests that increasing interest in CAM in the U.S. may be due to “greater awareness of the critical role that psychological distress plays in many medical conditions and health outcomes along with increased acceptance of the biopsychosocial model.”
Several studies suggest that women and middle-aged people are more inclined to use CAM. While women in general tend to seek healthcare more often than men, Park cites studies which find an “amplified” tendency for CAM use among women relative to overall use of health services.
While much research has focused on minorities and CAM use, the findings have been mixed. CAM use has been shown to increase with education and income, with more consistent results supporting the association with increased education. Explanations offered have included the idea that more educated patients are more capable of identifying and researching possible alternative treatments.
Studies have found an inverse relationship between health status and CAM use, which is consistent with other studies finding that increases in CAM use accompany multiple chronic conditions. Willison et al. found that chronically ill people use CAM two to five times as much as those who are not chronically ill. Interestingly, in the NHIS, only 30 percent of users of mind-body types of CAM used it for a specific condition; general wellness is a frequent aim of patients utilizing CAM.
Psychological traits of users
Parks reports that “psychological characteristics associated with higher mind-body CAM use include higher levels of openness, extraversion, social support, and goal persistence,” and that “considering one’s illness as having more severe consequences and beliefs that one has control over one’s health are related to greater use of mind-body CAM. Study participants who have used CAM have voiced motivations including wanting greater control over one’s health and dissatisfaction with conventional medicine. Greater awareness and practice of healthy behaviors has been associated with CAM use.
In a study of 243 British adults, Furnham sought to determine whether certain “big 5” personality traits, “modern health worries”, and attitudes towards science predicted attitudes and beliefs about CAM, wondering whether CAM was associated with neuroticism, skepticism towards science, or high levels of modern health worries. Furnham found that regular and occasional CAM users have higher modern health worries relative to non-users. Young males with a positive attitude toward science were the least likely to turn to CAM, and positive attitudes towards science were associated with skepticism towards CAM. The personality traits measured in the study were not predictive of CAM use.
Another aspect of the behavior of CAM users which has been the subject of research is whether or not they tell their conventional medical providers that they are using complementary or alternative therapies.
One study looked at potential adverse reactions between commonly used conventional treatments and CAM treatments. A study of urban, under-served minority patients with rheumatoid arthritis determined that 71.6 percent of research participants were using CAM, and that 59 percent shared this information with their provider. This same study found that women were more likely to disclose their use of CAM to their providers, while Hispanics were less likely to mention their CAM use.
Other research has found that many patients do not discuss their CAM treatments with their doctors. The National Center on Complementary and Alternative Medicine (NCCAM) and AARP identified common reasons that patients withhold this information: 42 percent said their provider never asks, and 30 percent said they didn’t know if they should raise the issue. As a result, the NCCAM started an educational campaign to promote discussions between providers and patients about CAM use: “Considering this and other campaigns addressing patient-provider relations it is of interest that an individual’s self-efficacy and their level of participation in health decision making are both potent.”
CAM use in other parts of the world
CAM is popular throughout the world. A study of South Koreans found that nearly 75 percent of those surveyed had used CAM in the last 12 months. A large Australian study found that 52 percent were current CAM patients and that 85 percent had used CAM treatments in their lifetime. The lifetime CAM use estimate from one UK survey was nearly half of those surveyed.
However, motivations differ among cultures. For instance, Koreans indicated that disease prevention and health promotion were the principal motive for CAM, with 45.8 percent seeking increased energy, 9.1% hoping to prevent disease, and 12.7 percent seeking anti-aging effects or beauty. Treatment of medical problems was the reported as the motive for only 20.3 percent of Korean survey participants, whereas in America people suffering from chronic conditions, particularly musculoskeletal problems, most often seek CAM.
Despite the quantity of research on the subject, there are relatively few definitive findings. This is due to the high degree of variability in CAM definitions, as well as variability in application. Park notes that “the specific definition of CAM used in any particular study strongly shapes the results of its prevalence statistics,” citing the earlier example of prayer. CAM treatments are also characterized by a great degree of heterogeneity. Many are self-administered, while others involve various practitioners.
Yoga and meditation methods vary considerably, for example. With so many CAM users using it for overall health rather than specific conditions, it is difficult to draw conclusions from the NHIS and other surveys. Efficacy measures often rely on subjective scales and self-reporting. Further convoluting the matter is the fact that so many CAM users have multiple, coinciding conditions for which they may be using CAM. Park also notes that CAM modalities “differ in historical precedent, cultural acceptability, cost, safety, extent to which they are systematic and rooted in traditional or new age approaches and purported mechanism of effect and the plausibility of that mechanism.”
Implications for health professions
CAM use has significant implications for various healthcare stakeholders. Since most CAM expenditures represent out of pocket costs to patients, insurers stand to gain where patients opt for non-covered services they deem more effective that prescriptions or conventional treatments which tend to be covered. Many conventional providers, such as primary care physicians, have integrated certain types of CAM into their business models, as a source of cash business and in response to patient demand.
As CAM gains traction as a socially acceptable means of treating chronic conditions, research efforts will continue to expand. Crystal Park duly noted that: “Knowledge about CAM modalities and their integration into clinical health psychology can be useful for researchers interested in taking a broader perspective on stress and coping processes, health maintenance and illness behaviors, and culture, and for practitioners seeking to incorporate CAM perspectives and techniques into their work. The increasingly expanding and officially recognized use of CAM warrants greater attention by conventional health care practitioners, decision makers, and researchers.”
National Health Interview Survey (2010). National Center for Health Statistics, Centers for Disease Control and Prevention.
Furnham A (2007). Are modern health worries, personality and attitudes to science associated with the use of complementary and alternative medicine? British journal of health psychology, 12 (Pt 2), 229-43 PMID: 17456283
Park C (2013). Mind-body CAM interventions: current status and considerations for integration into clinical health psychology. Journal of clinical psychology, 69 (1), 45-63 PMID: 22936306
Wallen GR, & Brooks AT (2012). To Tell or Not to Tell: Shared Decision Making, CAM Use and Disclosure Among Underserved Patients with Rheumatic Diseases. Integrative medicine insights, 7, 15-22 PMID: 23071389
Mental Context – A Delicate Subject
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