The Sample is Highly Diverse
The completed CHIS-CAM sample contains 9187 respondents, of whom 1844 reported a diagnosis of cancer in either CHIS 2001 or during the period between the two studies. Selected characteristics of both the CHIS 2001 and CHIS-CAM samples are shown in . The sample is highly diverse in terms of ethnicity with about 24% of the respondents identifying as Latino, 11% as Asian-American, 6% as African-American and 3% as ‘other’. Almost a third of the respondents lived in families where the annual income was less than twice the poverty line, and can thus be considered as ‘low income’, and 15% were uninsured at the time of the interview. Although slightly more than one-third had graduated from college, 39% had no more than a high school diploma. Just under two-thirds of the group reported having a chronic condition (including cancer). In terms of most characteristics the sample is almost identical to the CHIS 2001 sample which itself was very similar to the California population in the 2000 Census in terms of urban–rural residence, ethnicity. For example, 5.9% of the CHIS sample was African-American as opposed to 5.8% of the state's population as reported in the Census. In no instance did the absolute difference between the CHIS sample and the Census exceed 2% for any racial/ethnic or income category (21
). Overall, the major difference between our sample and both the CHIS 2001 samples as well as the California population is in terms of health status where we have only about 35% reporting no chronic illness as opposed to over 55% of the CHIS 2001 sample. This is due to our deliberate selection of individuals diagnosed with cancer and is reflected in that our respondents are older and thus more economically secure. Despite this oversampling of individuals with cancer, CHIS-CAM respondents appear to be diverse and similar to the broader California adult population. Thus, the sample is suitable for examining issues surrounding the relationship of sociodemographic factors and health status to the use of CAM.
CHIS-CAM and CHIS 2001 sample characteristics (unweighted n, weighted %)
The Use of CAM in California is High
shows the percentage of the respondents who reported using various CAM providers and other CAM modalities (both ‘ever’ and ‘over the past 12 months’). The utilization of specific CAM providers among our respondents is substantial. A full quarter of our respondents had seen a CAM provider in the past 12 months and almost half the group had done so at some time in the past. More specifically, almost 13% of the CHIS-CAM respondents reported visiting a chiropractor in the past 12 months before the interview. Slightly over 14% reported using a massage therapist, whereas 3.0% visited an acupuncturist or practitioner of TCM. The vast majority of visits to CAM providers were concentrated among this limited range of providers. Relatively few respondents reported visiting practitioners such as homeopaths (0.9%), naturopaths (1.1%), Reiki practitioners (1.0%) or curanderos (0.3%).
The use of CAM modalities that do not require visiting a practitioner was considerably greater than the use of those forms that required a visit. For example, in the 12 months before the interview almost 21% used a mind–body intervention to deal with a health problem and 6.6% attended a support group. Very high proportions of the sample reported using some form of dietary therapy to deal with a specific health problem (41.3%), and even more (62.4%) reported using two or more dietary supplements (in addition to any use of a regular multivitamin) to deal with a health problem. Ever praying for one's own health was reported by 45.4% of the sample.
As there is disagreement about how use of ‘any CAM’ should be operationally defined, ascertaining the rate with which respondents used any form of CAM is difficult. Using a broad definition which includes the use of any of the providers we asked about, as well as mind–body techniques, dietary interventions, two or more dietary supplements in addition to a multivitamin and participation in support groups (but not self-directed prayer, which we measured only for lifetime use), 65.9% of our respondents had used some form of CAM in the year before the interview. This is only modestly lower than the 72.7% of our respondents who have ever used such approaches (again, prayer is excluded). Thus, the vast majority of Californians who ever used CAM have used it recently. Eliminating the use of (2+) dietary supplements from the definition of ‘any CAM’ results in a proportion of 57.8% of our respondents who have used CAM in the past 12 months.
shows the relation of selected sociodemographic factors, health insurance and health status to the use of CAM providers, whereas presents the relation of these factors to the use of other, non-provider based, forms of CAM (weighted percentages, 95% CIs, adjusted odds ratios, 95% CIs). The odds ratios are adjusted to show the impact of the variable in question on the use of a specific type of CAM while controlling for the impact of all other variables in the model.
Demographic and health characteristics and the prevalence of selected CAM providers within the past 12 months (weighted %, adjusted odds ratiosa, 95% CI)
Demographic and health characteristics and the prevalence of selected CAM modalities within the past 12 months (weighted %, adjusted odds ratiosa, 95% CI)
Overall, Women Use CAM More Than Men
As expected, the results show that being ‘female’ has a positive relation with the use of most CAM providers (chiropractors are the single exception), as well as with the use of special diets, dietary supplements, mind–body interventions, prayer and support groups. The positive relation of CAM use and being female is independent of age, ethnicity, income, education or health status. That women in California visit chiropractors at about the same rate as men is itself striking, as the use of chiropractic has been associated with males (24
Regardless of Their Health, Those Over 65 years Are Least Likely to Use CAM
The relation between ‘age’ and CAM provider use is not as clear as that of gender. In general, use rises gradually with age and then declines more sharply among the oldest (65+) respondents. This pattern can be seen for those using each type of CAM provider. But when health status and the other demographic are taken into account the impact of age is less clear with only those over age 65 showing a drop off in use. A similar pattern can be seen in the case of both dietary therapies and mind–body techniques. However, the use of dietary supplements, prayer and support groups appear largely unrelated to age.
The Impact of Racial and Ethnic Identity on CAM Use Differs for Each Type of CAM
Among Californians, identification with a particular ‘racial/ethnic group’ has a somewhat distinct relation to the utilization of CAM. Our findings do not support the oft stated view that CAM utilization among whites is consistently higher than that found among other groups. Although whites do report greater use of some types of CAM such as chiropractors and massage therapists, this elevated level of use is not found for many other CAM modalities. For example, Asian/Pacific Islanders have the highest use of acupuncture/TCM, and African-Americans are most likely to report praying for their health. In other instances, the differences between whites and other groups are minimal. Latinos consistently report a lower level of use than whites and other racial/ethnic groups on every measure of CAM utilization except self-directed prayer, where they report more use than any other group except for African-Americans. Although other relations between race/ethnicity and CAM use can be described (e.g. African-Americans use some non-provider based forms of CAM such as special diets, dietary supplements and support groups at the same rate as whites, while using others such as mind–body techniques less often, Asian/Pacific Islanders are less likely to report using prayer or support groups), it is difficult to find a consistent pattern. At least among our respondents, it appears that the relation of race/ethnicity and CAM use is complex and varies considerably by group as well as by what type of CAM is being used.
Those With More Money Make Greater Use of CAM Providers, But Not Other Forms of CAM
The relationship of family ‘income’ to utilization is consistent for most forms of CAM. The utilization of every type of CAM provider increases as family income rises. The same trend is evident for every measure of non-provider based CAM with the exception of self-directed prayer. However, once the other variables in the model are included, the impact of income on CAM use vanishes for the non-provider based forms of CAM. Again, the exception is self-directed prayer where use clearly declines as income goes up, even when other variables in the model are included. The use of CAM providers in California is positively associated with economic security, whereas the use of most other forms of CAM is not.
The More Education People Have, the More Likely They are to Use CAM
‘Educational attainment’ is another factor showing a consistent relation to the use of ‘any’ CAM provider as well most specific provider types. Respondents having the lowest levels of education are least likely to use CAM, and use typically rises with educational level. For example, even when income, race/ethnicity and other factors are taken into account, those with a college degree are almost twice as likely to have used a massage therapist in the past year, and more than twice as likely to have used an acupuncture/TCM practitioner, or other type of CAM provider than those without a high school diploma. The pattern is similar for the use of therapeutic diets, dietary supplements and especially pronounced for mind–body techniques. The exceptions to this pattern are the use of self-directed prayer and attendance at support groups which appear unrelated to education.
Having ‘health insurance’ coverage at the time of the interview appears to have a very modest association with the use of CAM providers among our respondents. For example, although 26.2% of those with insurance have seen a provider in the past year, only 18.9% of those without insurance have done so. But once the other factors are included in the analysis the impact of insurance coverage disappears. Given this lack of association for the use of CAM providers, it is not surprising to find that current insurance coverage has no impact on the non-provider based forms of CAM.
Suffering from a Chronic Condition is the Key Factor Associated with CAM Use
‘Health status’, here defined as either not having a chronic illness, having been diagnosed with cancer, or having been diagnosed with at least 1 of 10 other chronic conditions, but not cancer, is clearly related to CAM use. As expected, the use of every form of CAM is considerably lower among those not reporting cancer or another chronic condition. The utilization of CAM providers, dietary supplements and mind–body techniques among those with cancer is not distinctly different than that of those reporting other chronic conditions. However, those in the cancer group are considerably less apt (36.1% versus 48.3%) to report employing dietary therapies, and more apt to report self-directed prayer (58.4% versus 49.9%), and attending support groups (11.3% versus 7.9%). These differences in CAM utilization by health status remain after accounting for all of the other sociodemographic factors.