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a Geriatric Research, Education and Clinical Center, Saint Louis VA Medical Center, Missouri
b Division of Geriatrics, Missouri
c Department of Internal Medicine, Missouri
d Saint Louis University School of Medicine, Missouri
e Department of Nursing and Health Care, Tokyo Metropolitan Institute of Gerontology, Japan
f Department of Nursing, College of Medicine, Soonchunhyang University, Choongnam, Korea
g Department of Internal Medicine, Tokyo Metropolitan Geriatric Hospital, Japan
Joseph H. Flaherty, 1402 South Grand Boulevard, Room M238, St. Louis, MO 63104 E-mail: flaherty{at}slu.edu.
Decision Editor: Larry E. Johnson, MD, PhD
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Abstract |
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Methods. This study used a questionnaire to interview participants (N = 593; age, >59 y), who were outpatients of geriatric outpatient clinics in Saint Louis, Missouri, and Tokyo, Japan (white Americans, n = 180; African Americans, n = 106; and Japanese, n = 307).
Results. Use of >1 AT was greatest among older Japanese (74.3%), followed by white Americans (61.1%) and African Americans (47.2%; p < .001). The most common ATs used among the Japanese (and significantly more than the white and African American groups) were lifestyle diet, herbal therapy, massage, acupressure, and acupuncture. The white and African American groups were more frequent users of relaxation techniques and spiritual healing compared with the Japanese group. Contrary to prior studies of the general population, the use of >1 AT did not correlate with any sociodemographic variables. Reported use of ATs to doctors was low but similar in all three groups (white Americans = 48%, African Americans = 42%, and Japanese = 46%). Perceived effectiveness was high but similar in all three groups (white Americans = 85%, African Americans = 92%, and Japanese = 84%). Although chronic conditions were common reasons for use of ATs, nonmedical reasons (e.g., general health or religious reasons) were also common.
Conclusions. Use of ATs was greater in Japan than in the United States, but for both countries, use by older persons was greater than previous reports of the general population. Because sociodemographic variables do not predict use, and reported use to doctors is low and perceived effectiveness is high, increased awareness and understanding about ATs by health care professionals seems imperative.
THE use of alternative medical therapies (ATs), also called unconventional medicine and complementary medicine, is prevalent throughout the industrialized world (1) (2) (3) (4) (5) (6) (7), despite a scarcity of randomized controlled trials that show efficacy (8). As the exchange of medical information and international communication continue to grow (e.g., via the World Wide Web), it would be important to learn the extent of use of ATs among different countries, especially those with similarly aging populations. Has East met West when it comes to ATs?
Two industrialized countries of interest because of their presumed difference in the use of ATs (1) and growing elderly population are Japan and the United States. By the year 2020, persons older than 65 years will comprise 25% of the total population in Japan and 20% in the United States (9) (10). Use of ATs among elderly persons is of particular interest: these individuals may be more likely to try ATs because of an increase in chronic conditions (11) (12) (13) and they may be more apt to suffer side effects because of age-related physiological changes and drug interactions associated with multiple medication use (14) (15). Although there is one U.S. study that focused on AT use among elderly persons (16), the rest of the medical literature is inadequate concerning use of ATs among older persons. In two major U.S. prevalence studies (with 1539 and 2055 participants, respectively), only about one third of the subjects in each of these studies were "older" and the age cutoff was too low (50 years [y]) to capture the population that might be at most risk for side effects of some therapies (2) (3). An Australian study defined "older" as greater than 55 years old (4). A Japanese study used the category of 65 years and older, but it only included 100 subjects of this age (5). In a Canadian study, there was a large study population aged 65 years and older (>1000 subjects), but the study queried only about use of alternative health care practitioners, not about all types of alternative therapies (6).
Another issue concerning ATs is how well physicians are informed by their patients about these other therapies. According to one large survey of Americans in 1997, 96% of those patients interviewed who saw an alternative therapy practitioner also saw a physician for the same condition, but only one third of patients discussed these therapies with the physician (2). In Japan, physicians may also be unaware of the use of ATs or of AT practitioners. For example, herbal treatments, which form about 3% of the total drug budget, are freely available at pharmacies, with or without a prescription. And, there are approximately 95,000 acupressurists and 65,000 acupuncturists across Japan (1).
The purpose of this study was to answer the following questions concerning use of ATs among older white Americans, African Americans, and Japanese: What is the extent of use of ATs? Are there any predictors of use (e.g., demographics)? To what extent are doctors informed about use of ATs? How do patients perceive the usefulness of these therapies compared with therapies prescribed by their physician? For what reasons do older Americans and Japanese use ATs?
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Methods |
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Patients younger than 60 years or with a diagnosis of dementia were excluded. The remaining patients were asked, "The following questions are concerning your general health and health care practices. Do you agree to participate in this interview?" In Japan, seven patients refused to participate, and eight patients did not complete the interview. In the United States, 12 patients refused to participate and two did not complete the interview. There were 593 completed interviews, 286 in the United States and 307 in Japan. Each participant was only interviewed once.
The Interview
In Japan, four nursing students were trained and did interviews during the clinic time. In the United States, two of the authors (JT, SH) did the interviews during the geriatric clinic time.
The interview questionnaire was developed in English based on the interview used by Eisenberg and colleagues (3) so that consistency in methods would allow valid comparisons. The questionnaire was then translated into Japanese by one of the authors (RT) for use in Japan.
As noted previously, we made no mention of alternative therapy while recruiting participants. If patients agreed to participate, full consent was obtained. After demographic characteristics were obtained, patients were asked, "The following is a list of symptoms or conditions or medical problems. Please tell me (yes or no), have you experienced any of these in the past 12 months?" The interviewer then asked about 27 medical conditions, 12 of which were taken from a previous prevalence study on use of ATs (3). The other 15 conditions included common symptoms and specific diagnoses known to exist among older patients. After all conditions were asked about, patients were asked, "Of all the conditions or symptoms or medical problems above that you said you have experienced in the past 12 months, please tell me which three bother you the most?" For each of these three (if that many), patients were asked to respond to the following, "The therapy prescribed by my doctor helped with this problem." (Choices were as follows: strongly agree, agree, disagree, strongly disagree, or not applicable.) Not all patients had three conditions that "bothered them the most." The Japanese sample had 348 responses, and the United States had 374 responses, to this part of the survey. Perceived effectiveness of medical therapy was based on these responses.
Patients were then asked about the use of 15 different ATs: "Now I would like to ask you about your use of some other kinds of therapies and treatments. Please tell me (yes or no), have you used any of the following in the past 12 months?" Thirteen of the ATs were taken from a previous prevalence study on use of ATs (3). Acupressure and vitamins/minerals were added to the present study. Then, patients were asked to tell the interviewer five therapies (if that many) they had used "frequently" in the past 12 months. For each of these, the patients were asked three questions. (i) "Have you told or discussed with your medical doctor about the use of the therapy?" (ii) "Tell me the main problem for which you have used the therapy." (iii) "Please respond to the following: ‘This therapy has helped me with this problem’ (strongly agree, agree, disagree, or strongly disagree)." For this part of the data, not all patients listed every AT they used because "frequently" was subjectively defined (i.e., the interviewer did not define it, but left it up to the patient about what they thought was "frequent"). Excluding prayer, vitamins/minerals, and "others," the Japanese sample had 271 responses to this part of the survey and the U.S. sample had 255 responses. The reporting rate to doctors, reasons for use of ATs, and perceived effectiveness of ATs were based on these responses.
Statistical Analysis
Chi-square tests of independence were used for comparing proportions among white Americans, African Americans, and Japanese. For use, perceived effectiveness, and reporting use of ATs, the Bonferroni correction was applied because of the high number of comparisons. This was calculated as 
= .05/
, where is the number of tests or comparisons, and is the level of the new p value
(17).
Bivariate correlations between hypothesized predictors (demographics) and the dependent variable (use of ATs) were calculated in two ways for each of the three populations: (i) correlation with use of one or more AT and (ii) correlation with use of increasing number of ATs.
Unless explicitly mentioned, all analyses excluded prayer, vitamins/minerals, and "others." Statistical analyses were performed using a commercially available statistics package (Statistica, Statsoft, Tulsa, OK).
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Results |
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The Japanese group was similar to a national sample of older Japanese persons in age and income distribution (9) (19). Education distribution was skewed slightly toward higher education compared with a previous epidemiological study (20).
Excluding vitamins/minerals, self-prayer, and "others," use of at least one AT was 74.3% among Japanese, 61.1% among white Americans, and 47.2% among African Americans (p < .001; Table 2 ). Elderly Japanese were more frequent users of 5 of 13 ATs (lifestyle diet, herbal therapy, massage, acupressure, and acupuncture). White Americans and African Americans had similar rates of use of relaxation techniques, but these rates were significantly higher than those of the Japanese. African Americans had the highest rate of use of spiritual healing compared with the other two groups. When the total U.S. sample (white Americans + African Americans) was compared with the Japanese sample, the same significant differences were found. Also, controlling for demographic variables (age, education, and income level) did not change the differences in use of >1 AT nor use of specific types of ATs.
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As seen in Table 5 , there were more similarities than differences when reasons for use of ATs were compared. Reasons other than the 27 medical conditions were the most common reasons (e.g., general health). Musculoskeletal reasons (back/hip problems and arthritis/joint problems) were the next most common reasons for use of ATs.
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Discussion |
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Another reason for greater use may be dissatisfaction with medical care. One U.S. study of adult family-practice patients found that the use of ATs was greater in those who said they were not being helped by their physician (21). In the present study, this may be the case in both countries. Perceived effectiveness of medical therapy prescribed by patients' physicians compared with that of ATs was significantly lower among both the Japanese and the U.S. population.
Another difference in the current study, compared with other studies, is the lack of association with use of ATs and sociodemographic variables. In general population studies, higher education levels (3) (4) and higher income (3) (5) have been associated with greater use of ATs. In the study of elderly California residents, younger age and higher education levels were associated with greater use of ATs (16). The lack of association in the current study emphasizes that clinicians will need to ask all of their older patients about the use of ATs, not just the younger, well-educated patients with extra income to spend on therapies other than those prescribed.
Another reason to ask all older patients about use of ATs is that, overall, only about 45% of the patients in both countries reported use of ATs to their physician. This seemingly low percentage in the U.S. population is consistent with what Astin and colleagues (16) found in their study of U.S. elderly persons, where only 42% discussed use of ATs with their physician or other health care practitioner, and a bit higher than what Eisenberg and colleagues (2) found (38.5%) in the general U.S. population. For the Japanese population, it is somewhat surprising that with such a high prevalence of use, and presumed acceptance of ATs in Japan, reporting of ATs by older Japanese patients was not greater than that in the United States. On the other hand, this pattern of underreporting may be because older Japanese patients are less vocal with their physician.
Although the expected differences between Japan and the United States were seen (e.g., therapies that are considered more Eastern than Western, such as herbal, massage, acupuncture, and acupressure, were more commonly used in Japan), the similarities between these two distant countries were striking. In addition to the low but similar reporting rate of AT use to physicians (both countries approximately 45%), and the high but similar perceived effectiveness of ATs (both >80%), Table 5 shows that the reasons for using the different ATs were more similar than different. For 10 of the 15 ATs, a similar common reason for use of the AT was given.
The limitations of this study include the following: Patients may not have had a complete understanding of the different ATs. During the interviews, it was difficult to confirm "professional" (i.e., someone who provides care and is paid for his or her services) use of three ATs: massage, relaxation techniques, and spiritual healing. On the other hand, it is unlikely that patients were erroneous about the use of the other therapies. For example, similar to Eisenberg and colleagues' studies (2) (3), we did differentiate and try to clarify the differences between megavitamins and regular vitamins/minerals on our questionnaires ("megavitamin therapy does not include taking a daily vitamin or vitamin prescribed by a doctor"), and between lifestyle diet and commercial diet ("commercial diet is the kind you have to pay for; this does not include changing your diet to try to lose or gain weight on your own").
The strengths of this study are in its methods and its applicability for clinicians. Face-to-face interview questionnaires allowed for more complete and accurate data, compared with telephone interviews or mailed questionnaires. Also, the response rate was over 95% in both countries, compared with 60%–67% in Eisenberg and colleagues' telephone-interview studies and 51% in Astin and colleagues' mailed-questionnaire study (2) (3) (16).
This study is applicable for clinicians because the study populations were taken from geriatric outpatient clinics. The use of ATs may be greater in our study because people attending clinics are more likely to have more chronic conditions and thus more likely to use ATs (11) (12) (13). However, for clinicians who are concerned about the use of ATs in their patients and whether they are being told about their use, the data here are quite relevant because this is the population that clinicians will see.
In summary, a high percentage of older Japanese and Americans seeking medical help use some form of alternative medical therapy. In addition, sociodemographic variables do not predict use, and reported use to physicians is low and perceived effectiveness is high. Based on these results, it is important for health care professionals to increase their awareness and understanding about ATs.
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Acknowledgments |
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Received September 21, 2000
Accepted November 6, 2000
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