The findings from this study demonstrate a low prevalence of recent acupuncture use among American women, that multiple characteristics are associated with use, and that women use acupuncture for a variety of health conditions and reasons. Although the prevalence is low, it translates to over 1.2 million women nationwide. The prevalence of other provider-administered CAM therapies included in NHIS is widely variable. For example, 7.5 percent of adults used chiropractic services in the past 12 months and 5.0 percent used massage; in contrast, only 0.2 percent used naturopathy and 0.1 percent used biofeedback (Barnes et al., 2004
). The reasons for these differences in provider-based CAM therapies are complex and undoubtedly reflect variability in the numbers of providers, the geographic distribution of different CAM providers, and women's preferences and knowledge with respect to these therapies. However, recent trends in CAM use, including acupuncture, show that rates of use are stable or increasing (Tindle, Davis, Philips, & Eisenberg, 2005
), and with the growing research supporting the usefulness of acupuncture for a variety of health conditions (IOM, 2005
), acupuncture may be a viable alternative for some women.
Our results demonstrate that multiple factors are associated with women's recent use of acupuncture services, including several that are also associated with conventional health services. Characteristics from all three individual domains of the sociobehavioral model — predisposing, enabling, and medical need and personal health practices — were significantly associated with recent acupuncture use. We found that the effects of race and ethnicity on acupuncture use are contingent upon women's educational attainment. In particular, somewhat contrary to our expectations, Asian women with similar education as the white comparison group, as well as those with higher levels, were more likely to use acupuncture. It may be that these effects reflect differences in country of origin and nativity status among Asian subgroups. Also, Asian women with lower levels of education may be more likely to use acupuncture because of adherence or familiarity with this traditional medical system. Other studies focusing specifically on Asians of Chinese and Vietnamese ancestry found that those with lower levels of education or who had poor English proficiency were more likely to use traditional East Asian therapies (Ahn, et al., 2006
; Wu, Burke, LeBaron, 2007
). Because of data limitations we were not able to include relevant attitudes that have been shown to distinguish CAM users from non-users (Astin, 1998
; Furnham & Beard, 1995
). The sustained race and ethnicity-by-education interaction effects are probably due to unexplained differences in these attitudes and beliefs. Nevertheless, our findings point to continued importance of better understanding racial and ethnic differences in CAM use, especially with respect to group norms and knowledge and attitudes about health and health care services.
The only enabling resource that was significantly associated with acupuncture use was the region where women reside, with women in the West and Northeast having higher odds of use compared to those in the South. Although these are rather gross measures, they are proxies for differences in local access to services and normative differences regarding the acceptability of acupuncture. For example, of the over 16,000 licensed acupuncturists in the US in 2006, over half reside in the West (Acupuncture Today, 2006
). The NHIS does not contain state-level information so it is not possible to examine these general patterns more precisely, but our findings suggest additional research of this type would be fruitful. Surprisingly, income, employment and insurance status were not associated with use. It may be, however, that these factors are not necessarily predictive of having any
acupuncture in the recent past, but rather, the number
of treatments and the specific conditions
covered by insurers. For example, almost one-quarter of women reported only one treatment, a pattern of use which may not be overly economically burdensome for most women. And while health insurers are increasingly covering CAM therapies, including acupuncture, the majority of payments for these treatments are still out of pocket (Burke et al., 2006
; Sturm & Unutzer, 2000
), as we also demonstrated.
Medical need and personal health practices were also associated with acupuncture use. The effect of health status is in the expected direction, although the magnitude of the effect was less than anticipated. Other CAM studies have found more marked differences in CAM use by health status (Barnes et al., 2004
; Upchurch & Chyu, 2005
; Upchurch et al., 2007
). The more modest findings may be due to the lower prevalence of acupuncture use, and more imprecisely estimated coefficients. Former smokers, moderate to heavy drinkers, or women who were overweight, however, were more likely to use acupuncture than their “healthier” counterparts as we anticipated. It appears that these personal health practices are capturing other dimensions of health not picked up by the global measure of health status, but a more comprehensive interpretation requires additional information on beliefs and attitudes towards health and wellness.
The majority of women reported they used acupuncture for treatment of a specific health condition (rather than for “health and wellness”), and most were treated for only one condition. Moreover, women tended to use acupuncture for conditions not well treated by conventional medicine and include pain, musculoskeletal, and autoimmune disorders. The use of CAM for chronic conditions and for conditions difficult to treat with conventional medicine has been found by others (Barnes et al., 2004
; Burke et al., 2006
; Upchurch et al., 2007
). Acupuncture may be a viable option for these women (Berman et al., 2004; Smith, Crowther, & Beilby, 2007; White, 2003
). Although most acupuncture treatment requires multiple visits, many women only had a single treatment; it may be that these women were simply curious or had a negative reaction to this first treatment. Also, most women said that acupuncture was at least somewhat helpful in treating their condition. Close to half of women felt conventional medicine was not helpful for their condition, but close to two-thirds reported using acupuncture with conventional medicine. CAM users often express both pragmatic and ideological/lifestyle reasons for using these therapies (Astin, 1998
; Vincent & Furnham, 1996
), and our findings support a somewhat more pragmatic interpretation for reasons for use. Further investigation into the motivations for use, factors that influence initiating and sustaining use, as well as use of acupuncture and other CAM therapies for health and wellness is warranted.
Although this study provides one of the first comprehensive assessments of women's acupuncture use in the US, there are limitations beyond those already described. Importantly, our analysis was based on cross-sectional data and, as such, we were unable to model the contours and patterns of acupuncture use over time. In particular, there was no information available regarding the training of the acupuncturists (e.g., licensed acupuncturist or MD), the clinical setting, and other aspects of women's acupuncture experience. And while our findings suggest the sociobehavioral model of health care utilization is a productive theoretical approach to investigate acupuncture, we did not have an exhaustive set of variables necessary to fully operationalize each of the major domains in the model. Of particular concern is the lack of any psychosocial measures. Nor were we able to more comprehensively contextualize acupuncture use by including macro-level factors, such as state-level acupuncture resources or other CAM (and conventional medicine) resources that may compete with acupuncturists. Our expressed purpose was to characterize women who use acupuncture and to provide some descriptive information about patterns of use. The overall low prevalence of American women who have used acupuncture precluded any more detail than what is here. Women are higher users of health care services generally, higher users of CAM and acupuncture specifically, and primary agents in family health care utilization decisions. As acupuncture and CAM become more integrated into healthcare services, learning more about usage attitudes and behaviors by women is essential.