Nationally, herbs, relaxation, chiropractic, yoga/tai chi/qi gong, and massage are the five top specific CAM therapies used among midlife women.³ Beyond prevalence, little is known with respect to the factors associated with use of specific CAM therapies among midlife women, using nationally representative data. However, some evidence suggests racial, ethnic, socioeconomic status (SES), and other differences in use exist based on broad CAM domains, as defined by the National Center for Complementary and Alternative Medicine (NCCAM), for midlife women.³ The NCCAM domains are (1) whole medical systems, (2) mind-body medicine, (3) biologically based practices, (4) manipulative and body-based practices, and (5) energy medicine. Each domain comprises several specific CAM therapies (nccam.nih.gov/health/whatiscam/). Findings from the Study of Women's Health Across the Nation (SWAN), a multisite sample of midlife women, show that the effects of race, SES, and health-related variables depend on the specific CAM therapy under consideration.^5,10 Examining these potential differences in a national sample of midlife women would allow for greater generalizability of the findings.

Women's motivations for using CAM can be regarded as one aspect of self-management of their health and healthcare,^11,12 and recent research has examined the specific health conditions for which CAM is used.^1–3 However, CAM is also used for general illness prevention and to promote health and well-being.^11,12 The distinction between CAM use for treatment of an existing health condition and CAM use for illness prevention and wellness is especially relevant when examining the reasons for use of different CAM therapies. The extent to which midlife women use specific types of CAM for treatment of health conditions vs. for overall health and wellness is still an open question. Also, interest is ongoing in characterizing the ways in which midlife women are using CAM therapies for menopausal symptoms. Menopausal symptoms are positively associated with CAM use,^5–7 but the percentages of women who report using CAM specifically for menopausal symptoms is relatively low^3,7 and depends on the particular CAM therapy.^5,7

Controlling for other factors, there were no racial/ethnic differences in use of herbs or relaxation, but compared with whites, blacks were less likely to use yoga/tai chi/qi gong, chiropractic care, and massage (Table 2). In contrast, black and Hispanic women were more likely than white women to use prayer for health. Foreign-born women were more likely to use herbs and less likely to use chiropractic care than U.S.-born women. No variation by age was observed in CAM use or prayer. Except for chiropractic care, greater educational attainment was associated with higher odds of use for all other types of CAM and prayer for health. Family income was not associated with use, except massage was more likely to be used and prayer for health less likely to be used among the most affluent women. Employment status was not associated with CAM use, but employed women were less likely to use prayer than unemployed/retired women. The relation of union status depended on the specific CAM type under consideration. Compared with married women, cohabiting women were more likely to use herbs, relaxation, and massage; divorced/separated women were more likely to use relaxation, yoga/tai chi/qi gong, and massage; never married women were less likely to use prayer for health. Compared with women living in the South, those living in the West were more likely to use each type of CAM; those living in the Midwest were more likely to use relaxation and chiropractic care, and women living in the Northeast were more likely to use chiropractic care only. In contrast, compared with women in the South, those living in other regions were less likely to use prayer for health. Women who were insured were less likely to use herbs.

Little difference was observed in CAM use by self-rated health status, except for relaxation techniques. Women with poorer health were more likely to use relaxation; only women reporting the poorest health were more likely to use massage. In contrast, poorer health status was associated with significant increases in use of prayer for health. Compared with never smokers, former smokers were more likely to use herbs, relaxation, and yoga/tai chi/qi gong; current smokers were less likely to use yoga/tai chi/qi gong or massage and were less likely to pray for health. Compared with current infrequent or light drinkers, abstainers were less likely to use all types of CAM; former drinkers were less likely to use massage. Women who were moderate or heavy drinkers were less likely to use prayer for health, whereas former drinkers were more likely to do so.

The total percentage of women who mentioned any specific health condition for each type of CAM is provided in the first row of Table 3. Women who used chiropractic care had the highest percentage reporting a specific health condition, and women who used yoga/tai chi/qi gong had the lowest. Midlife women used CAM for a variety of health conditions, with clear differences in the health conditions mentioned according to specific CAM used. For example, among midlife women who used herbs, 14.2% reported they did so for treatment of menopausal symptoms. No other CAM type had menopausal symptoms mentioned in the top 10 conditions.

Moreover, we found that women use a diversity of CAM therapies, and, importantly, the relations of many demographic, health, and behavioral factors to CAM use depended on the specific CAM type under consideration. For example, in the multivariate analyses, no racial or ethnic differences were observed in use of herbs or relaxation, but blacks were less likely than whites to use yoga/tai chi/qi gong, chiropractic care, and massage; blacks and Hispanics were more likely to use prayer for health. These racial and ethnic differences in specific types of CAM use are likely due to unmeasured group differences in knowledge, attitudes, and preferences about CAM use and health and health behaviors more generally. Being foreign born was positively associated with use of herbs, which may be because of continued adherence to traditional medicines of countries of origin.²⁰ Except for chiropractic care, increases in education were associated with increases in use for each type of CAM and prayer. Increases in income had little independent effect on CAM use, except for massage. It may be that differences in knowledge and attitudes about CAM and health and wellness that arise from increased education are important.²¹ Although the effects of union status also depended on the specific type of CAM considered, explanations are somewhat more speculative but are consistent with other research.¹ It may be, for example, that divorced women have fewer social supports than married women and, thus, are more likely to seek CAM therapies as coping strategies (e.g., relaxation techniques, yoga/tai chi/qi gong, massage).²² As expected, we found regional variability in CAM use, with women residing in the West more likely to use every type of CAM and less likely to use prayer than women residing in the South. These regional differences reflect the combined effects of availability of CAM therapies and services as well as regional normative differences in acceptability and utility of CAM.

Compared with studies that included women of all ages,¹ the effect of self-reported health status on CAM use was less pronounced among midlife women. Only relaxation techniques and prayer showed increasing use with poorer health; it may be that these women are using these practices as part of their overall management of their poorer health. Self-reported health status, although a useful measure, captures only one aspect of women's overall health. Other studies of midlife women found that those with a greater number of chronic health conditions (e.g., heart disease, high blood pressure, arthritis, among others) were more likely to use flaxseed, glucosamine, and soy supplements,⁵ CAM types that were not explicitly considered here. The effects of smoking and alcohol use on CAM use have also been found by others,^1,2 but testable explanations are still needed. For example, it may be that women who are former smokers have become more health conscious and, thus, more likely to use herbs, relaxation, and yoga/tai chi/qi gong as part of their health maintenance. Former drinkers may be using prayer as part of a sobriety program, which is commonly done in 12-step-type programs. In sum, our findings underscore the importance of analyzing individual CAM therapies separately because of the differences in the effects of demographic, health, and behavioral factors. Although “any use of CAM” is an important summary measure to assess overall prevalence, the exclusive use of this general measure masks important differences in the correlates of use of specific CAM types.

Our findings show substantial variability in the percentages of women who use a specific CAM type to treat a specific health condition vs. for general health and wellness. The highest percentage reported for treatment of specific health conditions was among women using chiropractic care, and the lowest was among women who used yoga/qi gong/tai chi and relaxation techniques. Herbs, massage, and prayer were used both for health conditions and for wellness. These findings also underscore the importance, particularly in the clinical setting, of asking women about their use of individual CAM therapies because reasons for use (curative vs. preventive) vary substantially by type of CAM. Moreover, for women who reported a health condition, substantial variability was observed in the particular health conditions mentioned across specific CAM types. For example, high percentages of women reported using relaxation techniques for stress-related conditions, whereas those using chiropractic care reported pain-related conditions. Importantly, only 14% of women who reported using herbs said they used herbs for menopausal symptoms; menopause was not a frequently mentioned condition for any other CAM therapy. This is significant because although the research is not very promising regarding the efficacy of various herbs and natural products for the treatment of one of the more bothersome menopausal symptoms, hot flashes,²³ evidence is increasing that other CAM strategies, including relaxation techniques and deep breathing exercises, may ameliorate vasomotor symptoms.²⁴ Thus, opportunities exist for education among menopausal women who might be interested in behavioral alternatives to hormone therapy for vasomotor symptoms.