Perceptions about Complementary Therapies Relative to Conventional Therapies among Adults Who Use Both: Results from a National Survey

Complementary and alternative medical (CAM) therapies (also known as integrative or unconventional therapies) have been defined as those interventions neither taught widely at U.S. medical schools nor generally available in U.S. hospitals (1, 2). While imperfect, this definition has been used to identify representative CAM therapies, which have been studied for prevalence of use in two national random-household telephone surveys (1, 2). Data from these surveys indicate that CAM therapy use and expenditures increased substantially in the United States between 1990 and 1997 (1). Overall prevalence of use increased by 25%; total visits by an estimated 47%, from 427 to 629 million; and expenditures for CAM services by an estimated 45%, which totaled $21 billion (1). National surveys performed in other countries have suggested similar rates of CAM use throughout the industrialized world (3-7). Less well documented, however, are the reasons that adults typically use (and pay out of pocket for) these therapies, most of which have not been satisfactorily evaluated for relative effectiveness, safety, or mechanisms of action. Only one U.S. national survey published in a peer-reviewed journal has explored reasons for CAM use (8). Astin's survey, conducted in 1994 on a convenience sample of 1035 adults, found that reasons for CAM use included a holistic orientation to health; having had a transformational experience that changed the person's world view; and classification in a cultural group identifiable by their commitment to environmentalism, commitment to feminism, and interest in spirituality and personal growth psychology (8). National surveys in the United States of CAM use in 1990 and 1997 revealed that adults typically do not disclose their use of CAM therapies to their medical doctors (1, 2). In 1997, as in 1990 (1), fewer than 40% of CAM therapies used in the previous 12 months were discussed with a medical doctor. A recent analysis of data on U.S. national medical expenditures corroborated these findings and suggested that the percentage of CAM users who disclose their CAM visits to their medical doctors may be as low as 20% (9). This paper summarizes 1997 national survey data on respondents' perceptions about use and nondisclosure of CAM therapies relative to conventional medical care. Methods Sample We conducted a nationally representative telephone survey between November 1997 and February 1998. Survey methods were approved by the Beth Israel Deaconess Committee on Clinical Investigations, Boston, Massachusetts. The survey used random-digit dialing techniques to select households and random selection of one resident per household, age 18 years or older, as the respondent. Eligibility was limited to English-language speakers for whom cognitive or physical impairment did not prevent completion of the interview. The survey sample and weighting methods have been previously described (1). Interview The interview was presented as a survey by investigators from Harvard Medical School about the health care practices of persons in the United States. No mention was made of alternative, integrative, unproven, or complementary therapies in the introductory comments. The first substantive questions addressed perceived health, health worries, days spent in bed, and functional impairment due to health conditions. Next, respondents were asked about their interactions with a medical doctor, defined as a medical doctor, MD, or an osteopath, DOnot a chiropractor or other nonmedical doctor. The term medical doctor was used throughout the remainder of the interview. Respondents were asked if they had experienced any of a list of specified common medical conditions in the previous 12 months. Those who reported experiencing more than three conditions were asked to identify the three most bothersome or serious medical conditions. Respondents were then asked about seeing a medical doctor for these principal medical conditions and about perceptions of confidence in the medical doctor and the helpfulness and efficacy of their interactions. Next, respondents were asked about use of CAM therapies in the past 12 months and over their lifetime and whether each of these therapies was used for each of their principal medical conditions. We distinguished between use under the supervision of a professional (a provider of CAM therapy) and personal use without such supervision. Persons who reported having supervised use were asked about the number of visits during the past 12 months to providers of each therapy, perceptions of helpfulness and efficacy, and confidence in their CAM therapy providers. Respondents were asked whether they typically see a CAM provider before, after, or concurrent with their visits to a medical doctor. In addition, respondents were asked whether they agreed or disagreed with a list of thoughts about the use of alternative therapies (Figure 1). Each question was intended to elucidate perceptions about CAM therapy use relative to conventional care. All users of CAM therapies who had seen their medical doctor in the past year were asked if they had discussed use of each therapy with their medical doctor and if not, why they had not. They were then provided a list of possible reasons why people might not discuss certain therapies with a medical doctor and were asked to say yes to any number of items on the list that explained their own reasons for nondisclosure and no to items that did not. Additional details of the survey instrument are described elsewhere (1). Figure 1. Perceptions about complementary and alternative medical (CAM) therapy relative to conventional therapy. white bars shaded bars darkly shaded bars n n Statistical Analysis As previously described (1), we calculated sampling weights for each respondent to reflect the probability of selection and to parallel the aggregate distribution of demographic characteristics of the U.S. population. We used SUDAAN software (10) to compute weighted estimates of the proportion of respondents giving specific answers to study questions. We applied the McNemar test to compare respondents' evaluations of the helpfulness of CAM therapies and conventional care among respondents who used both for the same medical condition. Role of the Funding Sources This research was funded by grants from the National Institutes of Health, the John E. Fetzer Institute, and the American Society of Actuaries. Additional support for the completion of analyses and manuscript preparation was provided by unrestricted gifts from the Friends of Beth Israel Deaconess Medical Center, the Kenneth J. Germeshausen Foundation, the J.E. and Z.B. Butler Foundation, and The American Specialties Health Plan. None of the sponsors had access to the primary data, nor did they review the manuscript before submission. Results Characteristics of the Respondents The weighted survey response rate was 60% (1). The sociodemographic characteristics of the survey sample (n = 2055) were similar to the population distributions published by the U.S. Bureau of the Census (1). Among the 2055 survey participants, 1802 (87% weighted) reported seeing a medical doctor in the previous 12 months. Of these, 831 (45% weighted) reported using CAM therapy (excluding use of self-prayer alone) in the past 12 months, and 411 (23% weighted) reported seeing a CAM provider in the past 12 months (1). Perceptions of CAM Relative to Conventional Therapy Use Figure 1 summarizes responses among respondents who used conventional care and CAM therapies in the past 12 months. As a preface to these questions, the interview script read, I am going to read you some thoughts people have about their use of alternative therapies, like chiropractic, massage, acupuncture and the others I mentioned earlier. For each statement, please tell me if you agree or disagree. As shown in Figure 1, fewer than 1 in 4 (21%) CAM therapy users (n = 831) agreed with the statement, Alternative therapies are superior to conventional therapies, and roughly 4 of 5 (79%) respondents agreed that Using both conventional and alternative therapies is better than using either one alone [for your problems]. For respondents who saw a CAM therapy provider and a medical doctor (n = 411), we asked whether they agreed or disagreed that their CAM provider did a better job of listening or explaining their medical problems than their medical doctor. Forty-one percent agreed that their CAM provider was a better listener, and 52% disagreed; 42% agreed that their CAM provider did a better job of explaining their medical conditions, and 56% disagreed. Sequence of Seeking Care from CAM Providers and Medical Doctors We asked respondents who reported seeing both a medical doctor and a CAM provider during the past 12 months (n = 411) the following: The next questions are about your use of alternative therapies in general. People generally fall into one of three groups regarding their use of alternative medicine. Some people see an alternative provider before they consult a medical doctor; some see both alternative providers and conventional doctors at the same time; and some see an alternative provider after they have seen a medical doctor. Which of these best describes your pattern of seeing alternative providers? As summarized in Figure 2, 7 of 10 respondents reported typically seeking the services of a CAM provider after or concurrent with their visit to a medical doctor. Fewer than 1 in 6 (15%) said they saw a CAM therapy provider before seeing a medical doctor. Figure 2. Sequence of seeking care from complementary and alternative medical (CAM) providers and medical doctors. n Overall Helpfulness of Therapies The Table summarizes perceived relative helpfulness for 10 of the most commonly reported principal medical conditions identified in the 1997 national survey among respondents who used both conventional care and CAM therapies for each condition. The CAM therapies were judged more helpful th