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Background The use of complementary and alternative medicine (CAM) is growing. However the factors contributing to changes over time and to birth cohort differences in CAM use are not well understood. Setting We used data from 10186 participants, who were aged 20–69 years at the first cycle of data collection in the longitudinal component of the Canadian National Population Health Survey (1994/95-2010/11). We examined chiropractic and other practitioner-based CAM use with a focus on five birth cohorts: pre-World War II (born 1925–1934); World War II (born 1935–1944); older baby boomers (born 1945–1954); younger baby boomers (born 1955–1964); and Gen Xers (born 1965–1974). The survey collected data every two years on predisposing (e.g., sex, education), enabling (e.g., income), behavior-related factors (e.g., obesity), need (e.g., chronic conditions), and use of conventional care (primary care and specialists). Results The findings suggest that, at corresponding ages, more recent cohorts reported greater CAM (OR = 25.9, 95% CI: 20.0; 33.6 for Gen Xers vs. pre-World War) and chiropractic use than their predecessors (OR = 2.2, 95% CI: 1.7; 2.8 for Gen Xers vs. pre-World War). There was also a secular trend of increasing CAM use, but not chiropractic use, over time (period effect) across all ages. Factors associated with cohort differences were different for CAM and chiropractic use. Cohort differences in CAM use were partially related to a period effect of increasing CAM use over time across all ages while cohort differences in chiropractic use were related to the higher prevalence of chronic conditions among recent cohorts. The use of conventional care was positively related to greater CAM use (OR = 1.8, 95% CI: 1.6; 2.0) and chiropractic use (OR = 1.2, 95% CI: 1.1; 1.4) but did not contribute to changes over time or to cohort differences in CAM and chiropractic use. Conclusion The higher CAM use over time and in recent cohorts could reflect how recent generations are approaching their healthcare needs by expanding conventional care to include CAM therapies and practice for treatment and health promotion. The findings also underscore the importance of doctors discussing CAM use with their patients.
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RESEARCH ARTICLE
Changes in the use practitioner-based
complementary and alternative medicine over
time in Canada: Cohort and period effects
Mayilee Canizares
1,2
*, Sheilah Hogg-Johnson
3,4
, Monique A. M. Gignac
2,3,4
, Richard
H. Glazier
3,5,6,7
, Elizabeth M. Badley
2,3
1Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada, 2Krembil Research Institute,
University Health Network, Toronto, Ontario, Canada, 3Dalla Lana School of Public Health, University of
Toronto, Toronto, Ontario, Canada, 4Institute for Work and Health, Toronto, Ontario, Canada, 5Institute for
Clinical Evaluative Sciences, Toronto, Ontario, Canada, 6Department of Family and Community Medicine,
University of Toronto, Toronto, Ontario, Canada, 7Department of Family and Community Medicine,
St. Michael’s Hospital, Toronto, Ontario, Canada
*mcanizar@uhnres.utoronto.ca
Abstract
Background
The use of complementary and alternative medicine (CAM) is growing. However the factors
contributing to changes over time and to birth cohort differences in CAM use are not well
understood.
Setting
We used data from 10186 participants, who were aged 20–69 years at the first cycle of data
collection in the longitudinal component of the Canadian National Population Health Survey
(1994/95-2010/11). We examined chiropractic and other practitioner-based CAM use with a
focus on five birth cohorts: pre-World War II (born 1925–1934); World War II (born 1935–
1944); older baby boomers (born 1945–1954); younger baby boomers (born 1955–1964);
and Gen Xers (born 1965–1974). The survey collected data every two years on predispos-
ing (e.g., sex, education), enabling (e.g., income), behavior-related factors (e.g., obesity),
need (e.g., chronic conditions), and use of conventional care (primary care and specialists).
Results
The findings suggest that, at corresponding ages, more recent cohorts reported greater
CAM (OR = 25.9, 95% CI: 20.0; 33.6 for Gen Xers vs. pre-World War) and chiropractic use
than their predecessors (OR = 2.2, 95% CI: 1.7; 2.8 for Gen Xers vs. pre-World War). There
was also a secular trend of increasing CAM use, but not chiropractic use, over time (period
effect) across all ages. Factors associated with cohort differences were different for CAM
and chiropractic use. Cohort differences in CAM use were partially related to a period effect
of increasing CAM use over time across all ages while cohort differences in chiropractic use
were related to the higher prevalence of chronic conditions among recent cohorts. The use
of conventional care was positively related to greater CAM use (OR = 1.8, 95% CI: 1.6; 2.0)
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 1 / 17
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OPEN ACCESS
Citation: Canizares M, Hogg-Johnson S, Gignac
MAM, Glazier RH, Badley EM (2017) Changes in
the use practitioner-based complementary and
alternative medicine over time in Canada: Cohort
and period effects. PLoS ONE 12(5): e0177307.
https://doi.org/10.1371/journal.pone.0177307
Editor: Russell Jude de Souza, McMaster
University, CANADA
Received: October 26, 2016
Accepted: April 25, 2017
Published: May 11, 2017
Copyright: ©2017 Canizares et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: Access to the data is
through the Statistics Canada Research Data
Centres (RDC) Program. RDCs are operated under
the provisions of the Statistics Act in accordance
with all the confidentiality rules. Researchers with
approved projects by Statistics Canada can access
the data. For more information on how to access
the data see http://www.statcan.gc.ca/eng/rdc/
process.
Funding: Access to the data is through the
Statistics Canada Research Data Centres (RDC)
and chiropractic use (OR = 1.2, 95% CI: 1.1; 1.4) but did not contribute to changes over time
or to cohort differences in CAM and chiropractic use.
Conclusion
The higher CAM use over time and in recent cohorts could reflect how recent generations
are approaching their healthcare needs by expanding conventional care to include CAM
therapies and practice for treatment and health promotion. The findings also underscore the
importance of doctors discussing CAM use with their patients.
Introduction
Conventional or mainstream medicine continues to be the main source of healthcare in Can-
ada and elsewhere. However, a significant number of people choose complementary and alter-
native medicine (CAM) for wellness and/or treatment [1,2]. The increasing demand for CAM
may reflect a diversification of preferences for different types of healthcare services and an
increasing emphasis on health promotion and self-care by the public [3]. For example, studies
show that while many adults use CAM therapies to treat specific symptoms such as chronic
pain, others also report using CAM for general health maintenance [46]. Therefore, the grow-
ing interest in CAM raises questions about the patterns of CAM use over time in the context
of use of conventional medicine in the population. Understanding the changes in patterns of
CAM and conventional care use has important implications for planning and improving the
healthcare system as well as for medical education.
Age has been found to be strongly related to CAM use, but studies show an inconsistent pat-
tern. Some studies suggest CAM use peaks at middle age [710] while others show that CAM
use increases with increasing age [11,12]. It is not clear if these findings reflect true age effects or
if they are related to birth cohort effects. Cohort effects arise from differences in the experiences
of groups born and growing up in different time periods. These may be differences that are
unique to a particular birth cohort or that accumulate over the lifetime. Only two studies have
examined cohort differences in CAM use [13,14]. Both reported greater CAM use in more
recent cohorts, but used cross-sectional data and could not distinguish cohort effects from age
and period effects (secular changes over time). Period effects are changes in CAM use across all
age groups resulting from widespread societal changes or from events that took place at a partic-
ular point in time. Changes in government policies are often cited as examples of period effects.
Findings from studies examining changes over time in CAM use are not consistent across
CAM therapies and practices. For example, data from the U.S. on national estimates of CAM
use for 2002, 2007, and 2012 found large variability across types of CAM used and over time
[15]. The study found an increased use of acupuncture and homeopathy over time, but no sig-
nificance change in chiropractic use. A Canadian study showed that use of publicly subsidized
chiropractic services by adults over the age of 50 decreased over the decade of the 1990s in one
Canadian province [16]. Several hypotheses related to period differences have been put for-
ward to explain why CAM use may be growing, including the rise of the consumer movement
in healthcare since the 1970’s and the growing use of the Internet [1719]. The consumer
movement has empowered individuals and encouraged them to take a proactive role towards
healthcare decisions and selection of services [18,20,21]. Additionally, as health information
becomes more readily available online, more individuals are seeking and finding information
about CAM treatments, which they may incorporate into their general healthcare practices
[19].
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 2 / 17
Program. RDCs are operated under the provisions
of the Statistics Act in accordance with all the
confidentiality rules. The findings and conclusions
of this paper are those of the authors and do not
represent the official position of Statistics Canada.
This study was partially supported by a CIHR
Operating Grant–Secondary Analysis of Databases
(SEC 117113). The funder had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
The aging of the population has been proposed as another possible explanation for variations
in CAM use over time. Notably, age effects alone do not appear to explain these changes since
analyses adjusting for age continue to indicate variability across time [22,23]. These variations
may also be related to changes in other factors. For example, cross-sectional studies have found
that CAM use is greater among those with high income and/or educational levels [2,7,9,24].
Yet, the few studies that have controlled for these factors while comparing CAM use across peri-
ods of time have found that changes in income and education were not associated with time
trends in CAM use [23]. Health variables are also important. Studies consistently indicate that
chronic conditions and pain are significantly related to CAM use [7,13,2527]. Therefore, it is
reasonable to hypothesize that the growing number of people living with chronic conditions
may also underlie the growing trend in CAM use [2830]. Lastly, the use of CAM in relation to
conventional care has also been examined with inconsistent findings. Some studies suggest that
conventional care users supplement their care with CAM services [31,32]. Others have sug-
gested that patients having difficulties accessing conventional care turn to CAM to meet their
healthcare needs [33,34]. No study, however, has examined changes in CAM use over time in
the context of changing patterns of need for care and of conventional care use.
We drew on 16 years of longitudinal population data to examine variations in CAM use
from 1994 to 2011 We focused on five birth cohorts of Canadians: pre-World War II (born
1925–1934), World War II (born 1935–1944), older baby boomers (born 1945–1954), younger
baby boomers (born 1955–1964), and Generation X (Gen Xers, born 1965–1974). We also
controlled for other factors associated with CAM use that have been reported in the literature
(e.g. chronic conditions, pain). Our goals were to determine 1) whether, in addition to age
effects, there were birth cohort and/or period effects in CAM use, and 2) whether changes in
need for care and changes in the use of conventional medicine contributed to any cohort and/
or period effects, controlling for other factors. We hypothesized that changes in CAM use over
time were, at least partially, related to cohort and period effects, independent of changes over
time in the factors predicting CAM use.
Materials and methods
Canadian National Population Health Survey
We used data from the longitudinal component of the Canadian National Population Health
Survey (NPHS) spanning 16 years (1994–2011) [35]. The target population of the NPHS
included household residents in the ten Canadian provinces in 1994/1995. The survey
excluded persons living on Indian Reserves and Crown Lands, residents of health institutions,
full-time members of the Canadian Forces Bases and some remote areas in Ontario and Que
´-
bec. The survey used a complex sampling design with a multi-stage stratified and cluster selec-
tion (geographic and/or socio-economic strata, geographic clusters, and then dwellings within
each cluster). The NPHS retained individuals who moved to long-term care institutions and
those who died over the course of the survey. The death of a respondent was confirmed against
the Canadian Vital Statistics Database, and the cause and date of death were captured. More
details on the NPHS sampling plan and survey questions is available from Statistics Canada
[35].We restricted the sample to 10186 individuals aged 20–69 years in 1994 who provided at
least three cycles of data.
This paper is based on secondary analyses of data collected by Statistics Canada; as such we
did not obtained direct consent from the survey participants. However, participation in the
survey was voluntary and respondents consented that their data may be used by third parties
upon approval from Statistics Canada. In addition, the University of Toronto Ethics Commit-
tee approved the study.
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 3 / 17
Measures
CAM use. CAM use was defined as consulting with any of the following CAM practition-
ers (Yes/No) in the past 12 months: massage therapist, acupuncturist, homeopath or naturo-
path, Feldenkrais or Alexander teacher, relaxation therapist, biofeedback teacher, rolfer,
herbalist, reflexologist, spiritual healer, or religious healer. As in other studies we also included
chiropractors [36]. Because chiropractors exhibit characteristics of both conventional medi-
cine and CAM [37,38], we examined chiropractic use separately from other CAM use. Chiro-
practic use was derived from a separate question: “In the past 12 months, how many times
have you seen or talked on the telephone with a chiropractor about your physical, emotional
or mental health?” Chiropractic use was defined as reporting 1 or more visits.
Age, period, and cohort. We used participants’ date of birth to calculate age for each
cycle and to allocate participants to the five birth cohorts previously noted. The year of the
interview was used as an indicator of period.
Need for care. We used two factors to assess need for care: chronic conditions and pain
that prevents activities. The NPHS collected data on up to 17 individual chronic conditions
that had been diagnosed by a healthcare professional: arthritis, back problems, asthma, aller-
gies (excluding food allergies), bronchitis, emphysema, diabetes, high blood pressure, heart
conditions, stroke, cancer, ulcers, urinary incontinency, dementia, migraine, glaucoma, and
cataracts. We calculated the number of chronic conditions and grouped them as: none, 1, and
2+. For the variable “pain that prevents activities” responses were grouped as: no pain/pain
does not prevent activity or pain prevents activity (few/sometimes/always).
Use of conventional care. At each survey cycle participants reported whether they con-
tacted primary care physicians/general practitioners (PCP) or specialists (excluding eye care)
in the 12 months prior to their interview. An indicator combining use of PCPs and of special-
ists was created: visited both, only PCP, only specialists, none.
Other predictors of CAM use. We included other factors grouped as predisposing,
enabling and behavior-related that previously have been found to be associated with CAM use
[7]: predisposing (sex and education), enabling (household income and having a regular
source of care), and behavior-related (obesity, smoking status, physical activity, and sedentary
lifestyle). Education was measured as years of schooling and was grouped for analyses as: <12
years, 12–15 years, and 16+ years. At each cycle, participants reported if they had a regular
doctor. Household income was categorized into quartiles of the distribution within each sur-
vey year and a separate category representing unknown values was retained for analyses. Obe-
sity was ascertained by using body mass index (BMI) categorized as: underweight (<18.5),
normal weight (18.5–24.9), overweight (25.0–29.9), moderate obese (30.0–34.9), and severe
obese (35.0). Smoking status was assessed by a Statistics Canada derived variable which
grouped participants as current smoker, former smoker, and non-smoker (those who never
smoked) [35]. Responses to a series of questions about participation in leisure time physical
activities such as, walking for exercise, running, gardening, etc. combined with data on walk-
ing or bicycling for commuting were used to group individuals as physically active (during lei-
sure time or active commuting) vs. inactive. Lastly, sedentary lifestyle was defined as those
who reported that they “usually sit during the day and don’t walk around very much.”
Statistical analysis
There is ongoing debate as to the best way to examine the unique effects of age, period, and
cohort [3941]. Because age, period and cohort are linearly related, the linear effects of the
three factors cannot be modeled simultaneous without imposing restrictions on at least one of
the parameters. For this study, we conceptualized the models within a multilevel framework
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 4 / 17
[42,43]. We estimated age and cohort as fixed effects with period as a random effect. We
started with a model unadjusted by period (Model 1). This was a two-level model where
repeated observations were nested within individuals, and age and cohort effects were esti-
mated as fixed effects. We then extended this model by adding another level to account for var-
iability across periods of times (Model 2). This was a hierarchical age-period-cohort (HAPC)
model in which repeated observations were nested within individuals and individuals were
nested within time periods. In subsequent models we added need for care and use of conven-
tional care while adjusting for the other predictors of CAM previously listed. In addition to
examining the effect of need for care and use of conventional care on CAM use, we also exam-
ined whether these factors affected the cohort, age, and period estimates.
We used the SAS/STAT software for all data analyses and the GLIMMIX procedure to esti-
mate the HAPC model [44]. The procedure uses maximum likelihood estimators that adjust
for non-response assuming the data are missing at random. It also uses all available data for
incomplete cases [44]. Although the NPHS uses weights to compensate for the complex multi-
stage sample design, the results of this paper are based on un-weighted analyses. The reason
for this is that the HAPC model cannot incorporate sampling weights at cross-classified levels.
We centered age at 39 years (the mean of the distribution for the five cohorts at baseline (1994/
95)). We used Wald tests to assess the significance of the variables.
Sub-analyses. About 39% of eligible participants died or dropped-out before the end of
the study. To examine the effect of attrition in our findings we compared our main results
with the results of two additional analyses: 1) including indicator variables identifying partici-
pants who dropped-out or died before the end of the study in all models; and 2) analyses with
a restricted sample of participants with complete data in the nine cycles.
Previous studies have suggested that analyses grouping CAM practitioners have the poten-
tial of missing differing patterns of use across practitioners [45]. We, therefore, repeated our
analyses for the CAM practitioners with >1% of use: massage therapy, acupuncture, and
homeopathy/naturopathy.
We also repeated the analyses to examine the contribution of specific chronic conditions to
the results. We chose the conditions that have been reported in the literature to be associated
with CAM use. These conditions were: back pain, arthritis, respiratory (asthma, allergies,
bronchitis, or emphysema), migraine, diabetes, high blood pressure, cardiovascular (heart con-
ditions or stroke), cancer, and other (ulcers, urinary incontinency, dementia, glaucoma,
cataracts).
Nahin et al [46] found that about 25% of individuals who do not use conventional care use
CAM in subsequent years. We, therefore, fitted the final model for CAM use with an addi-
tional variable indicating the use of conventional medicine in the previous cycle of data collec-
tion. This way we could examined whether those not using conventional care had increased
odds of using CAM in the following year.
Results
Descriptive
There were 10186 participants with at least three years of data (13.6% in the pre-World War II
cohort, 15.7% in the World War II, 21.6% in the older baby boomer, 27.3% in the younger
baby boomer, and 21.8% in the Generation X). Overall, 10.0% of the initial sample died and
27.3% dropped-out during follow-up. Between 1994/95 and 2010/11, CAM use increased from
4.8% to 11.2%. In contrast, overall chiropractic use remained virtually constant (9.0% in 1994/
95 vs. 10.2% in 2010/11, respectively). Similar patterns were seen in all birth cohorts. Chiro-
practors were the most common type of practitioner consulted across all cohorts followed by
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 5 / 17
massage therapists (Table 1). Generally, users of all types of CAM practitioners had higher
education and/or income. They were less likely to be current smokers, were more physically
active, and more likely to have a sedentary lifestyle. Obese individuals were less likely to con-
sult with other CAM practitioners and more likely to consult with chiropractors. CAM users
also had more chronic conditions and a higher proportion reported pain. In addition, CAM
users reported higher use of conventional care (visits to PCPs and/or specialists) than non
CAM users (Table 2).
CAM use
Changes over time and birth cohort differences. Table 3 presents the results of the
modeling for CAM use. There were significant age differences in CAM use (Table 3, Model 1,
Fig 1A). After accounting for the effects of aging, cohort differences were large and significant;
that is, there was a trend of greater CAM use in each succeeding recent cohort, particularly for
Gen Xers and baby boomers (Table 3, Model 1). Results from the model adjusting for period
effects (Table 3, Model 2) indicated that there was significant variability in CAM use over this
period of time. As illustrated in Fig 1B, there was a trend of increasing CAM use over the years
irrespective of age and cohort. In addition, compared to the unadjusted model, the age and
cohort effects were substantially reduced, although they remained significant. This suggests
that broad societal changes were at least partially manifesting as increases in CAM use over the
lifecourse.
Model 2 was then extended to include predisposing, enabling, and behavior-related factors
(S1 Table, Model 2a). CAM users were more likely to be women, have higher education/
income, to not have a regular source of care, to be current smokers, have normal weight, be
physically active, and to have a sedentary lifestyle. The estimates of the age and cohort effects
remained significant in this model, but were slightly reduced. The model was further extended
by adding need factors (Table 3, Model 3). (Only the estimates for age, cohort, need factors,
and period are presented in the table with the full model presented in S1 Table, Model 3.)
Cohort differences remained significant after accounting for need factors suggesting that there
were cohort differences in CAM use over and above need for care. In addition, the estimate for
the random effect for period was reduced but remained significant. This suggests that the
trend of increasing chronic conditions over time partially underlies the growing CAM use.
The inclusion of use of conventional care did not alter the age and cohort estimates (Table 3,
Model 4).
Role of need for care and use of conventional care. As shown in Table 3 Model 4,
chronic conditions and pain were strong predictors of CAM use. Those with two or more
chronic conditions were more likely to use CAM than those with no chronic conditions
(OR = 1.79, 95% CI (1.64; 1.96)). Similarly, those reporting pain were more likely to use CAM
(OR = 1.81, 95% CI (1.66; 1.98)). The use of conventional care was also a significant and strong
predictor of CAM use. The results indicate that CAM users were also users of conventional
medicine: those consulting with primary care physicians and with specialists had higher odds
of consulting with CAM practitioners.
Chiropractic use
Changes over time and birth cohort differences. Results from the model unadjusted by
period (Table 4, Model 1) showed that the age-trajectory of chiropractic use increased around
middle age, then declined (Fig 2A). In addition to age effects, large and significant cohort dif-
ferences were found (Table 4, Model 1, Fig 2A). Comparing cohorts at corresponding ages
indicates that there was higher chiropractic use for Gen Xers, followed by younger boomers,
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 6 / 17
and older boomers when compared to pre-boomers (World War II and pre-World War II
cohorts). As shown by the estimate of the random effect for period, variability across years for
chiropractor use was small and non-significant (Table 4, Model 2, Fig 2B). In addition, com-
pared to the unadjusted model (Model 1), the age and cohort effects were virtually unchanged.
As with CAM use, we included predisposing, enabling, and behavior-related factors to
Model 2 (S2 Table, Model 2a). There were no significant differences in chiropractic use
between men and women. Those with higher income, who were overweight or obese, current
smokers, and physically active were more likely to consult with chiropractors. When these var-
iables were considered, the estimates of the age and cohort effects were reduced but remained
significant.
Model 3 in Table 4 shows the estimates for age, cohort, need factors, and period with the
full model presented in S2 Table, Model 3. The estimates of age effects were slightly reduced,
although they remained significant, while the cohort effect estimates were no longer signifi-
cant. Lastly, Model 4 shows the results of adding the use of conventional care to Model 3.
Although significant, the inclusion of use of conventional care did not alter the age and cohort
estimates.
Role of need for care and use of conventional care. Findings from the fully adjusted
model (Table 4, Model 4) indicate that need for care factors (i.e. chronic conditions and pain)
were significantly associated with chiropractic use, such that having more chronic conditions
and/or pain affecting activities were strong positive predictors of chiropractic use. Further-
more, the use of conventional care was a significant and strong predictor of chiropractic use.
Those consulting with primary care physicians and/or with specialists had higher odds of con-
sulting with chiropractors.
Table 1. Use (%) of practitioners-based complementary and alternative medicine in 1994/95 and 2010/11 by birth cohort. Canadian National Popula-
tion Health Survey (NPHS), 1994–2011.
ALL
(1925–1974)
PRE-WORLD WAR
II
(1925–1934)
WORLD
WAR II
(1935–1944)
OLDER
BABY
BOOMER
(1945–1954)
YOUNGER BABY
BOOMER
(1955–1964)
GENERATION
X
(1965–1974)
CYCLE
1:
1994/
95
CYCLE 9:
2010/11
CYCLE1:
1994/95
CYCLE 9:
2010/11
CYCLE1:
1994/95
CYCLE 9:
2010/11
CYCLE1:
1994/95
CYCLE 9:
2010/11
CYCLE1:
1994/95
CYCLE 9:
2010/11
CYCLE1:
1994/95
CYCLE 9:
2010/11
n10186 6562 1384 665 1596 1061 2205 1577 2778 1886 2223 1373
CAM use
(all practitioners)
14.6 24.5 12.1 11.5 15.4 16.1 17.4 24.1 16.3 29.5 10.8 31.0
Chiropractors 10.7 13.4 9.5 8.4 11.8 9.0 13.0 13.8 11.2 15.7 8.2 15.6
CAM use
a
(other
practitioners)
5.6 15.8 3.8 5.3 5.2 9.2 6.6 14.6 7.3 19.6 3.9 21.8
Massage
therapist
2.4 7.6 1.0 3.5 3.1 5.6 3.2 9.1 4.0 14.2 2.3 15.6
Acupuncturist 0.8 2.4 1.2 1.5 0.8 2.5 1.0 3.4 1.0 3.6 0.3 3.8
Homeopath/
Naturopath
1.2 1.9 0.9 0.4 1.3 1.3 1.7 2.8 2.0 3.4 0.9 2.8
Abbreviations: CAM, Complementary and Alternative Medicine
a
Massage therapist, Acupuncturist, Homeopath/Naturopath, Feldenkrais or Alexander teacher, relaxation therapist, biofeedback teacher, rolfer, herbalist,
reflexologist, spiritual healer, or religious healer
https://doi.org/10.1371/journal.pone.0177307.t001
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 7 / 17
Sub-analyses
Our models adjusting for attrition showed no significant differences in CAM use between
those who died, dropped-out, or remained for the duration of the study. Estimates for the fac-
tors associated with CAM use were similar to those obtained in the main analyses. Further
analyses restricted to those who remained for the duration of the study showed that cohort dif-
ferences in CAM use and the relationships of the factors examined remained unchanged.
These analyses did not alter our conclusions.
Table 2. Characteristics of users and non-users of CAM and chiropractic services. Canadian National Population Health Survey (NPHS), 1994–2011.
CAM CHIROPRACTIC
CYCLE 1:
1994/95
CYCLE 9:
2010/11
CYCLE 1:
1994/95
CYCLE 9:
2010/11
USERS NON-USERS USERS NON-USERS USERS NON-USERS USERS NON-USERS
n570 9616 1035 5362 1100 9086 882 5705
Mean number of chronic conditions 1.3 0.9 2.0 1.9 1.4 0.9 2.1 1.9
% with back pain 26.9 15.1 29.2 19.7 41.7 12.6 37.5 18.7
% with arthritis 15.1 13.1 29.2 30.8 17.6 12.6 31.2 30.5
% with migraine 12.1 8.3 13.5 8.5 11.3 8.2 11.8 8.5
% with respiratory 27.8 22.0 44.8 34.4 27.8 21.6 42.3 35.0
% with diabetes 3.5 2.5 5.4 10.3 2.9 2.5 7.1 10.0
% with high blood pressure 7.4 8.9 19.3 30.6 8.6 8.9 23.4 29.6
% with cancer 1.8 1.2 1.5 2.3 1.1 1.3 1.7 2.2
% with cardiovascular 4.2 3.1 5.8 9.5 3.0 3.6 7.8 9.0
% with other
a
17.8 13.2 29.5 31.2 16.0 13.2 28.5 31.3
% with no chronic conditions 34.7 47.6 21.1 22.7 37.0 22.2 19.4 22.9
% with pain 21.9 10.9 21.6 14.8 19.4 10.5 20.1 15.3
Use of conventional care
% consulting with PCP 89.1 77.4 86.1 78.0 85.8 77.1 83.8 78.6
Mean visits to PCP 5.1 3.6 3.7 3.2 4.5 3.6 3.5 3.2
% consulting with specialists 40.0 25.8 37.2 31.9 30.6 26.1 35.0 32.4
Mean visits to specialists 1.8 0.9 1.2 1.0 1.3 1.0 1.0 1.0
Other factors
Predisposing
% women 70.4 53.1 71.5 53.1 54.7 54.0 56.7 55.9
Mean years of education 13.6 12.5 14.4 13.0 12.9 12.5 13.8 13.1
Enabling
Mean household income
b
53.4 50.4 87.4 73.5 53.1 50.2 84.1 74.4
% with regular source of care 87.5 85.7 92.2 90.9 90.3 85.2 92.5 90.9
Behavior-related factors
% obese (BMI 30.0) 45.3 52.0 57.6 67.6 51.5 46.0 66.1 66.1
Smoking status
% Current smokers 30.7 34.8 12.6 20.1 29.5 35.1 15.1 19.6
% Former smokers 34.6 30.2 53.9 49.2 36.7 29.7 54.0 49.3
% physical inactive 52.0 54.3 34.9 40.6 49.5 54.7 36.8 40.1
% with sedentary lifestyle 25.3 19.5 31.1 24.8 21.0 19.7 24.9 25.9
Abbreviations: CAM, complementary and alternative medicine; BMI, Body Mass Index; PCP, Primary Care Physician.
a
ulcers, urinary incontinency, dementia, glaucoma, or cataracts.
b
in Canadian dollars and expressed in thousands.
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The analyses for use of massage therapy, acupuncture, and homeopathy/naturopathy sepa-
rately showed similar patterns and predictors of use over time to those of all CAM use. Fur-
thermore, results from the models including individual chronic conditions suggested that
although back pain was the most common chronic condition reported associated with chiro-
practic use, cohort differences were not explain by cohort differences in back pain. Lastly, the
analyses controlling for use of conventional medicine in the previous cycle of data collection
yielded findings comparable to the main analyses. Results from these analyses are available
upon request.
Discussion
Using data from a large longitudinal national population survey spanning 16 years, this study
examined CAM and chiropractic use among baby boomers, Gen Xers, and pre-boomers in the
Table 3. Results from logistic two-level growth model (1) and hierarchical age-period-cohort models (2–4) for CAM use. Canadian National Popula-
tion Health Survey, 1994–2011.
MODEL 1 MODEL 2 MODEL 3
a
MODEL 4
a
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Fixed Effects
Age and Cohort
Linear Age
b
1.09 (1.09;1.10)*** 1.02 (1.01;1.03)*** 1.02 (1.00;1.03)*1.02 (0.99;1.08)
Birth Cohort
(Ref: Pre-World War)
Generation X 25.90 (19.95;33.64)*** 1.70 (1.02;3.00)*** 1.78 (1.03;3.07)*** 1.51 (1.14;2.00)**
Younger Baby Boomer 10.18 (8.00;12.95)*** 1.34 (0.85;2.10) 1.36 (1.01;2.10)*1.25 (1.01;1.61)*
Older Baby Boomer 4.46 (3.58; 5.56)*** 1.17 (0.83;1.63) 1.13 (0.99;1.57)
1.12 (0.99;1.40)
World War II 1.74 (1.42; 2.12)*** 0.89 (0.70;1.13) 0.87 (0.69;1.10) 0.94 (0.77;1.15)
Need for Healthcare
Chronic Conditions
(Ref: None)
2+ 1.91 (1.75;2.08)*** 1.79 (1.64;1.96)***
1 1.45 (1.34;1.58)*** 1.40 (1.29;1.52)***
Pain Prevents Activity 1.91 (1.75;2.08)*** 1.81 (1.66;1.98)***
Conventional Care
Physician Visits
(Ref: No visits)
Both 1.78 (1.60;1.97)***
Primary Care Only 1.44 (1.30;1.58)***
Specialists Only 1.21 (1.00;1.47)*
Random Effects
c
Individual 2.17 (2.06;2.28)*** 2.14 (2.04;2.24)*** 1.92 (1.82;2.02)*** 1.92 (1.82;2.02)***
Period 0.20 (0.04;0.35)*** 0.11 (0.01;0.20)*** 0.11 (0.01;0.20)***
Abbreviations: OR, Odd Ratio; 95% CI, 95% Confidence Interval.
*** p<0.0001
** p<0.01
*p<0.05
p<0.1.
a
Models also included, predisposing, enabling, and behaviour-related factors. Full models are shown in S1 Table.
b
Age was centered at the mean of the distribution in 1994/95 (39 years). All models also included a quadratic age term.
c
Estimates are variances.
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context of need for care (i.e. chronic conditions and pain) and the use of conventional care
(i.e. visits to physicians). There were substantial cohort differences in CAM and chiropractic
use, with each succeeding recent cohort reporting higher use of these practitioners (e.g. Gen
Xers reported greater CAM use than younger boomers and so on). In addition to cohort differ-
ences there was an increase in CAM use, but not chiropractic use, over time (period effect)
across all ages. Of interest was that different factors underlay cohort differences in CAM and
chiropractic use. Cohort differences in CAM use were partly related to period effects with
greater CAM use over time, whereas differences in chiropractic use were related to differences
in need for care. The use of conventional care was positively related to greater use of CAM and
chiropractic, but was not related to changes over time or cohort differences.
Higher CAM use over time, independent of changes in the individual factors examined, is
in keeping with studies suggesting that the growing interest in CAM reflects societal changes
that have been happening for several decades. These include the rise in medical consumerism,
the self-care movement, and the resurgence of holistic health in the 1970s [17,18,47,48]. In
addition, many physicians are more engaged with CAM practices and therapies than previ-
ously, which may explain some of the findings. For example, a survey of Canadian primary
care physicians found that 12% offered CAM services in their practice [49] and a literature
review found that 40% of physicians referred patients to chiropractors for the management of
chronic pain and back problems [50].
That chiropractic use remained relatively stable between 1994 through 2011 is in accord
with two smaller studies focused on healthcare use in provinces within Canada [16,51]. The
trend is of interest given that there has been an increase in the number of chiropractors during
this time period (15.9 vs. 24.3 per 100000 population in 1997 and 2011, respectively) [52]. The
reasons why use of chiropractic services is not noticeably changing are unknown. It is possible
that, as other CAM therapies and practices have become more widely accepted and used, as
Fig 1. Age, period, and cohort effects for CAM use: Results fromlogistic growth models. Canadian National Population Health Survey, 1994–
2011. Notes: CAM, Complementary and Alternative Medicine; GenX, Generation X; YBB, Younger Baby Boomer; OBB, Older Baby Boomer; WW2, World
War II; pre-WW, pre-World War II. Values for a) are predictions from the fixed partof model 1 in Table 3 and values for b) are predictions from the solution of
the random effects in model 2 in Table 3.
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was found in these data, it has created competition from other healthcare providers [51,53].
Future research would benefit from asking individuals directly about CAM preferences and
choices in care.
In our study, although chronic conditions and pain were strongly associated with higher
CAM use overall, the higher CAM use in Gen Xers and baby boomers was not related to
cohort differences in these factors. Cohort differences in CAM use were partly related to
period effects of increasing CAM use over time. As noted, there have been significant changes
in healthcare consumers’ values and expectations that appear to have had an impact on how
more recent cohorts approach their healthcare choices. The greater CAM use in Gen Xers and
boomers may be because they have been exposed, from an early age, to alternative treatments
as a more normalized part of the healthcare culture. It may also reflect that members of recent
generations share beliefs that are align with the holistic principles of CAM towards healthcare.
Table 4. Results from logistic two-level growth model (1) and hierarchical age-period-cohort models (2–4) for chiropractic use. Canadian National
Population Health Survey, 1994–2011.
MODEL 1 MODEL 2 MODEL 3
a
MODEL 4
a
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Fixed Effects
Age and Cohort
Linear Age
b
1.04 (1.03;1.04)*** 1.03 (1.03;1.04)*** 1.01 (1.01;1.02)*** 1.01 (1.01;1.02)***
Birth Cohort
(Ref: Pre-World War)
Generation X 2.16 (1.68;2.77)*** 2.08 (1.58;2.75)*** 1.12 (0.85;1.46) 1.15 (0.88;1.51)
Younger Baby Boomer 1.68 (1.34;2.11)*** 1.64 (1.28;2.09)*** 1.02 (0.80;1.29) 1.04 (0.82;1.32)
Older Baby Boomer 1.25 (1.01;1.53)*** 1.23 (0.99;1.52) 0.87 (0.70;1.08) 0.88 (0.71;1.09)
World War II 1.03 (0.85;1.24) 1.02 (0.84;1.23) 0.83 (0.68;1.01)
0.83 (0.69;1.01)
Need for Healthcare
Chronic Conditions
(Ref: None)
2+ 2.37 (2.17;2.58)*** 2.31 (2.11;2.52)***
1 1.61 (1.49;1.75)*** 1.58 (1.46;1.72)***
Pain Prevents Activity 1.44 (1.32;1.58)*** 1.43 (1.31;1.57)***
Conventional Care
Physician Visits
(Ref: No visits)
Both 1.22 (1.11;1.35)***
Primary Care Only 1.25 (1.14;1.36)***
Specialists Only 1.01 (0.84;1.23)
Random Effects
c
Individual 2.66 (2.54;2.78)*** 2.66 (2.54;2.78)*** 2.59 (2.47;2.71)*** 2.59 (2.47;2.71)***
Period 0.01(0.00;0.04) 0.01 (-0.02;0.03) 0.01 (-0.01;0.04)
Abbreviations: OR, Odd Ratio; 95% CI, 95% Confidence Interval.
*** p<0.0001
** p<0.01
*p<0.05
p<0.1.
a
Models also included, predisposing, enabling, and behaviour-related factors. Full models are shown in S2 Table.
b
Age was centered at the mean of the distribution in 1994/95 (39 years). All models also included a quadratic age term
c
Estimates are variances.
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As such, these generations may use CAM not only for treatment purposes but for health pro-
motion, supporting the idea that CAM is beneficial in maintaining well-being and preventing
illness. It is important for health services researchers and policy makers to understand the rea-
sons why individuals from different generations use CAM to develop appropriate policies. In
contrast, although back pain was the most common chronic condition reported by those using
chiropractic services, back pain alone did not explain cohort differences in chiropractic use.
The greater number of chronic conditions in recent cohorts contributed to the greater chiro-
practic use in these cohorts.
Our finding that use of conventional care did not reduce CAM consumption align with pre-
vious research suggesting that CAM users do not abandon conventional care [11,54,55].
Some proponents of CAM therapies and practices have speculated that since CAM focuses on
preventive care and is less expensive than conventional care, promoting the use of CAM may
help control increasing healthcare costs [34,56]. However, research in this area is too scant to
inform policy decisions. Since in our study we found that CAM users not only use conven-
tional care more frequently but they also use more services, widespread CAM use may not
reduce healthcare costs in this context. As CAM is not covered by the provincial health plans
in Canada, it is likely that growing CAM use will translate into increased out-of-pocket costs
for CAM users. This joint use of conventional care and CAM is also important in light of stud-
ies showing that more than 50% of CAM users do not disclose their CAM use to their conven-
tional healthcare providers [5,57,58]. Studies have shown that when patients disclose CAM
use to their physicians they experience a better patient–physician relationship and improve
quality of care [59,60]. From a policy perspective, understanding more about the patterns of
use of multiple healthcare services in the population is particularly important because the evi-
dence base about the safety and efficacy of CAM is limited. Future research is warranted to dis-
tinguish those who use CAM for treatment and/or for health promotion, as this will have
implications for determining whether, and how CAM or specific forms of CAM can be inte-
grated within the current healthcare delivery system.
Fig 2. Age, period, and cohort effects for chiropractic use: Results from logistic growth models. Canadian National Population Health Survey,
1994–2011. Notes: GenX, Generation X; YBB, Younger Baby Boomer; OBB, Older Baby Boomer; WW2, World War II; pre-WW, pre-World War II. Values
for a) are predictions from the fixed part of model 1 in Table 4 and values for b) are predictions from the solution of the random effects in model 2 in Table 4.
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Strengths and limitations
This study enhances the current literature by drawing upon panel data from a large population
longitudinal survey, providing the most current and comprehensive data available in Canada
describing CAM use. We were able to compare CAM use across different cohorts at the same
chronological age over a period of 16 years. However, the study is not without limitations. The
analyses focused on practitioner-based CAM use and did not include alternative therapies. As
a result, it may under-represent CAM use as people may be using a wide range of alternative
therapies (e.g. taking herbal supplements) without consulting CAM practitioners. Although
the survey collected information on the presence of chronic conditions and pain, it did not
link these conditions and CAM use. Consequently, we were unable to identify the specific con-
ditions for which individuals consulted with CAM practitioners. Also, information is not avail-
able on all the factors that motivate individuals to consult with CAM practitioners. For
example, it is unknown if seeking care from CAM practitioners was by referral from physi-
cians, related to lifestyle and general health and well-being, or if the decision was motivated by
disenchantment with the conventional healthcare system. Lastly, given the longitudinal nature
of the study and the long follow-up time, almost two-fifths of the sample died or dropped-out
during follow-up. However, we were able to examine the impact of these losses on the results
and these did not change our conclusions.
The analyses presented in this paper did not use sample weights. Although it has been sug-
gested that failing to account for the complex design in multilevel analyses can produce biased
parameter estimates, using a single weight combining level-1 and level-2 sampling design ele-
ments––as is the case for the NPHS––can also produce bias results [61]. In keeping with this
notion, a simulation study comparing different methods for incorporating sampling weights
into multilevel models suggested that unless weights are included properly (e.g. properly re-
scale weights at each level) in the estimation, the un-weighted analysis yielded results similar
to those that accounted for the complex design. More specifically, the study found that overall
weighted and un-weighted parameter estimates and standard errors were generally compara-
ble [62]. Furthermore, we fit the two-level models for CAM and chiropractic use adjusting for
the individual level predictors with and without weights. The findings from the weighted anal-
yses were not appreciable different to those from the un-weighted analyses. Taken all these
together we do not expect that the un-weighted analyses presented in this paper affected the
results and conclusions substantially.
Conclusions
Our study adds to the literature by examining the lifecourse trajectories of practitioner-based
CAM use using longitudinal data from a large national population survey. The findings indi-
cate that Gen Xers and younger and older boomers were more likely to consult with CAM
practitioners than pre-boomers, and that CAM use, excluding chiropractors, has increased
over time across all ages (period effect). We also found that CAM users are also users of con-
ventional care. This underscores the importance of doctors asking their patients about their
CAM use. Finally, the increasing trend of CAM use over time highlights the need for continu-
ing efforts to rigorously evaluate the safety, mechanisms, and cost-effectiveness of CAM thera-
pies and practices.
Supporting information
S1 Table. CAM use: Results from logistic growth models a. Canadian National Population
Health Survey, 1994–2011
(DOCX)
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 13 / 17
S2 Table. Chiropractic use: Results from logistic growth models a. Canadian National Pop-
ulation Health Survey, 1994–2011
(DOCX)
Acknowledgments
Richard Glazier is supported as a Clinician Scientist in the Department of Family and Commu-
nity Medicine at the University of Toronto and at St. Michael’s Hospital. Access to the data is
through the Statistics Canada Research Data Centres (RDC) Program. RDCs are operated
under the provisions of the Statistics Act in accordance with all the confidentiality rules. For
more information on how to access the data see http://www.statcan.gc.ca/eng/rdc/process.
The findings and conclusions of this paper are those of the authors and do not represent the
official position of Statistics Canada.
Author Contributions
Conceptualization: MC SHJ MAMG RHG EMB.
Data curation: MC.
Formal analysis: MC SHJ.
Funding acquisition: EMB.
Methodology: MC SHJ.
Project administration: MC.
Resources: MC.
Software: MC.
Supervision: SHJ MAMG RHG EMB.
Validation: MC SHJ MAMG RHG EMB.
Visualization: MC SHJ MAMG RHG EMB.
Writing original draft: MC.
Writing review & editing: MC SHJ MAMG RHG EMB.
References
1. Lawrence DJ, Meeker WC. Chiropractic and CAM utilization: a descriptive review. Chiropractic & oste-
opathy. 2007; 15:2.
2. Bishop FL, Lewith GT. Who Uses CAM? A Narrative Review of Demographic Characteristics and
Health Factors Associated with CAM Use. Evid Based Complement Alternat Med. 2010; 7(1):11–28.
https://doi.org/10.1093/ecam/nen023 PMID: 18955327
3. Ventola CL. Current Issues Regarding Complementary and Alternative Medicine (CAM) in the United
States: Part 1: The Widespread Use of CAM and the Need for Better-Informed Health Care Profession-
als to Provide Patient Counseling. Pharmacy and Therapeutics. 2010; 35(8):461–8. PMID: 20844696
4. Murthy V, Sibbritt D, Adams J, Broom A, Kirby E, Refshauge KM. Consultations with complementary
and alternative medicine practitioners amongst wider care options for back pain: a study of a nationally
representative sample of 1,310 Australian women aged 60–65 years. Clin Rheumatol. 2014; 33
(2):253–62. https://doi.org/10.1007/s10067-013-2357-5 PMID: 23949636
5. Vallerand AH, Fouladbakhsh JM, Templin T. The use of complementary/alternative medicine therapies
for the self-treatment of pain among residents of urban, suburban, and rural communities. American
Journal of Public Health. 2003; 93(6):923–5. PMID: 12773356
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 14 / 17
6. Fries CJ. Self-care and complementary and alternative medicine as care for the self: An embodied
basis for distinction. Health Sociology Review. 2013; 22(1):37–51.
7. Brown C, Barner J, Bohman T, Richards K. A multivariate test of an expanded Andersen Health Care
utilization model for complementary and alternative medicine (CAM) use in African Americans. J Altern
Complement Med. 2009; 15(8):911–9. https://doi.org/10.1089/acm.2008.0561 PMID: 19678783
8. Fries CJ, Kronenfeld, J. J. Ethnicity and the use of" accepted" and" rejected" complementary/alternative
medical therapies in Canada: evidence from the Canadian Community Health Survey. Issues in health
and health care related to race/ethnicity, immigration, SES and gender. 2012:113–31.
9. McFarland B, Bigelow D, Zani B, Newsom J, Kaplan M. Complementary and alternative medicine use in
Canada and the United States. American Journal of Public Health. 2002; 92(10):1616–8. PMID:
12356610
10. Neiberg RH, Aickin M, Grzywacz JG, Lang W, Quandt SA, Bell RA, et al. Occurrence and co-occur-
rence of types of complementary and alternative medicine use by age, gender, ethnicity, and education
among adults in the United States: The 2002 national health interview survey (NHIS). Journal of Alter-
native and Complementary Medicine. 2011; 17(4):363–70. https://doi.org/10.1089/acm.2009.0157
PMID: 21495904
11. Grzywacz JG, Quandt SA, Neiberg R, Lang W, Bell RA, Arcury TA. Age-related differences in the con-
ventional health care-complementary and alternative medicine link. American Journal of Health Behav-
ior. 2008; 32(6):650–63. https://doi.org/10.5555/ajhb.2008.32.6.650 PMID: 18442344
12. Grzywacz JG, Suerken CK, Neiberg RH, Wei L, Bell RA, Quandt SA, et al. Age, ethnicity, and use of
complementary and alternative medicine in health self-management. Journal of Health and Social
Behavior. 2007; 48(1):84–98. https://doi.org/10.1177/002214650704800106 PMID: 17476925
13. Ho TF, Rowland-Seymour A, Frankel ES, Li SQ, Mao JJ. Generational differences in complementary
and alternative medicine (CAM) use in the context of chronic diseases and pain: baby boomers versus
the silent generation. J Am Board Fam Med. 2014; 27(4):465–73. https://doi.org/10.3122/jabfm.2014.
04.130238 PMID: 25002001
14. Kessler RC, Davis RB, Foster DF, Van Rompay MI, Walters EE, Wilkey SA, et al. Long-term trends in
the use of complementary and alternative medical therapies in the United States. Ann Intern Med.
2001; 135(4):262–8. PMID: 11511141
15. Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of complementary health
approaches among adults: United States, 2002–2012. Natl Health Stat Report. 2015;(79):1–16. PMID:
25671660
16. Votova K, Penning MJ, Zheng C, Brackley ME. Trends and predictors of publicly subsidized chiropractic
service use among adults age 50+. J Altern Complement Med. 2010; 16(9):995–1001. https://doi.org/
10.1089/acm.2009.0628 PMID: 20809808
17. Kelner M, Wellman B. Health care and consumer choice: Medical and alternative therapies. Social Sci-
ence and Medicine. 1997; 45(2):203–12. PMID: 9225408
18. Sulik GA, Eich-Krohm A. No longer a patient: The social construction of the medical consumer. In: Gold-
ner M, Chambre
´SM, editors. Bingley, UK: Emerald Group Publishing Limited; 2008. p. 3–28.
19. Coulter ID, Willis EM. The rise and rise of complementary and alternative medicine: a sociological per-
spective. Med J Aust. 2004; 180(11):587–9. PMID: 15174992
20. Foster MM, Earl PE, Haines TP, Mitchell GK. Unravelling the concept of consumer preference: implica-
tions for health policy and optimal planning in primary care. Health policy. 2010; 97(2–3):105–12.
https://doi.org/10.1016/j.healthpol.2010.04.005 PMID: 20466449
21. Rosenthal M, Schlesinger M. Not Afraid to Blame: The Neglected Role of Blame Attribution in Medical
Consumerism and Some Implications for Health Policy. Milbank Quarterly. 2002; 80(1):41–94. https://
doi.org/10.1111/1468-0009.00003 PMID: 11933793
22. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the united states,
1990–1997: Results of a follow-up national survey. JAMA. 1998; 280(18):1569–75. PMID: 9820257
23. Esmail N. Complementary and alternative medicine in Canada: Trends in use and public attitudes,
1997–2006. Vancouver: Fraser Institute., 2007.
24. Metcalfe A, Williams J, McChesney J, Patten SB, Jette
´N. Use of complementary and alternative medi-
cine by those with a chronic disease and the general population—results of a national population based
survey. BMC Complementary and Alternative Medicine. 2010; 10(1):1–6.
25. Feinglass J, Lee C, Rogers M, Temple LM, Nelson C, Chang RW. Complementary and alternative med-
icine use for arthritis pain in 2 Chicago community areas. Clin J Pain. 2007; 23(9):744–9. https://doi.org/
10.1097/AJP.0b013e31815349d4 PMID: 18075399
26. Weigel P, Hockenberry JM, Bentler SE, Obrizan M, Kaskie B, Jones MP, et al. A longitudinal study of
chiropractic use among older adults in the United States. Chiropractic & osteopathy. 2010; 18(1):1.
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 15 / 17
27. Yang S, Dube CE, Eaton CB, McAlindon TE, Lapane KL. Longitudinal use of complementary and alter-
native medicine among older adults with radiographic knee osteoarthritis. Clin Ther. 2013; 35
(11):1690–702. https://doi.org/10.1016/j.clinthera.2013.09.022 PMID: 24145044
28. Afshar S, Roderick PJ, Kowal P, Dimitrov BD, Hill AG. Multimorbidity and the inequalities of global age-
ing: A cross-sectional study of 28 countries using the World Health Surveys. BMC Public Health. 2015;
15(1).
29. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and
implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;
380(9836):37–43. https://doi.org/10.1016/S0140-6736(12)60240-2 PMID: 22579043
30. Canizares M, Hogg-Johnson S, Gignac MA, Glazier RH, Badley EM. Increasing Trajectories of Multi-
morbidity Over Time: Birth Cohort Differences and the Role of Changes in Obesity and Income. J Ger-
ontol B Psychol Sci Soc Sci. 2017.
31. Davis MA, West AN, Weeks WB, Sirovich BE. Health behaviors and utilization among users of comple-
mentary and alternative medicine for treatment versus health promotion. Health Serv Res. 2011; 46
(5):1402–16. https://doi.org/10.1111/j.1475-6773.2011.01270.x PMID: 21554272
32. Rochelle TL, Marks DF. Medical pluralism of the Chinese in London: An exploratory study. British Jour-
nal of Health Psychology. 2010; 15(4):715–28.
33. Ayers SL, Kronenfeld JJ. Delays in seeking conventional medical care and complementary and alterna-
tive medicine utilization. Health Serv Res. 2012; 47(5):2081–96. https://doi.org/10.1111/j.1475-6773.
2012.01406.x PMID: 22985034
34. Pagan JA, Pauly MV. Access to conventional medical care and the use of complementary and alterna-
tive medicine. Health Aff(Millwood). 2005; 24(1):255–62.
35. Statistics Canada. Information about the national population health survey. Ottawa: Statistics Canada;
2011. Available from: http://www.statcan.gc.ca/pub/82f0068x/82f0068x1997001-eng.htm.
36. Harris PE, Cooper KL, Relton C, Thomas KJ. Prevalence of complementary and alternative medicine
(CAM) use by the general population: a systematic review and update. Int J Clin Pract. 2012; 66
(10):924–39. https://doi.org/10.1111/j.1742-1241.2012.02945.x PMID: 22994327
37. Redwood D, Hawk C, Cambron J, Vinjamury SP, Bedard J. Do chiropractors identifywith complemen-
tary and alternative medicine? Results of a survey. The Journal of Alternative and Complementary Med-
icine. 2008; 14(4):361–8. https://doi.org/10.1089/acm.2007.0766 PMID: 18435599
38. Villanueva-Russell Y. Caught in the crosshairs: Identity and cultural authority within chiropractic. Social
Science & Medicine. 2011; 72(11):1826–37.
39. Yang Y, Land KC. Age-Period-Cohort Analysis: New Models, Methods, and Empirical Applications.
Boca Raton, FL: CRC Press/Taylor & Francis Group; 2013. xiii, 338 p. p.
40. Bell A, Jones K. The impossibility of separating age, period and cohort effects. Social Science and Med-
icine. 2013; 93:163–5. https://doi.org/10.1016/j.socscimed.2013.04.029 PMID: 23701919
41. Reither E. N., Masters R. K., Yang Y. C., Powers D. A., Zheng H., & Land K. C. (2015). Should age-
period-cohort studies return to the methodologies of the 1970s? Social Science and Medicine, 128,
356–365. https://doi.org/10.1016/j.socscimed.2015.01.011 PMID: 25617033
42. Suzuki E. Time changes, so do people. Soc Sci Med. 2012; 75(3):452–6; Discussion 7–8. https://doi.
org/10.1016/j.socscimed.2012.03.036 PMID: 22591827
43. Bell A. Life-course and cohort trajectories of mental health in the UK, 1991–2008—A multilevel age-
period-cohort analysis. Social Science and Medicine. 2014; 120:21–30. https://doi.org/10.1016/j.
socscimed.2014.09.008 PMID: 25215933
44. SAS Institute Inc. The GLIMMIX Procedure (Chapter 43). SAS/STAT 93 User’s Guide. Cary: NC: SAS
Institute Inc.; 2013.
45. Ayers SL, Kronenfeld JJ. Using factor analysis to create complementary and alternative medicine
domains: an examination of patterns of use. Health. 2010; 14(3):234–52. https://doi.org/10.1177/
1363459309347491 PMID: 20427632
46. Nahin RL, Dahlhamer JM, Stussman BJ. Health need and the use of alternative medicine among adults
who do not use conventional medicine. BMC Health Services Research. 2010; 10.
47. Deloitte Center for Health Solutions. The Quest for Value in Health Care: A Place for Consumers 2014.
48. Moffatt S, Higgs P, Rummery K, Jones IR. Choice, consumerism and devolution: growing old in the wel-
fare state (s) of Scotland, Wales and England. Ageing and society. 2012; 32(05):725–46.
49. Hirschkorn KA, Andersen R, Bourgeault IL. Canadian family physicians and complementary/alternative
medicine: the role of practice setting, medical training, and province of practice. Can Rev Sociol. 2009;
46(2):143–59. PMID: 19831238
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
PLOS ONE | https://doi.org/10.1371/journal.pone.0177307 May 11, 2017 16 / 17
50. Astin JA, Marie A, Pelletier KR, Hansen E, Haskell WL. A review of the incorporation of complementary
and alternative medicine by mainstream physicians. Arch Intern Med. 1998; 158(21):2303–10. PMID:
9827781
51. Mior SA, Laporte A. Economic and resource status of the chiropractic profession in Ontario, Canada: a
challenge or an opportunity. J Manipulative Physiol Ther. 2008; 31(2):104–14. https://doi.org/10.1016/j.
jmpt.2007.12.007 PMID: 18328936
52. Canadian Institute for Health Information. Canada’s Health Care Providers—1997 to 2011: A Reference
Guide 2013. Available from: https://secure.cihi.ca/estore/productSeries.htm?pc=PCC56.
53. Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of complementary and alternative medi-
cine by US adults: 1997–2002. AlternTher Health Med. 2005; 11(1):42–9.
54. Lapane KL, Sands MR, Yang S, McAlindon TE, Eaton CB. Use of complementary and alternative medi-
cine among patients with radiographic-confirmed knee osteoarthritis. Osteoarthritis Cartilage. 2012; 20
(1):22–8. https://doi.org/10.1016/j.joca.2011.10.005 PMID: 22033041
55. Sirois FM. Motivations for consulting complementary and alternative medicine practitioners: a compari-
son of consumers from 1997–8 and 2005. BMC Complement Altern Med. 2008; 8:16. https://doi.org/10.
1186/1472-6882-8-16 PMID: 18442414
56. Lind BK, Lafferty WE, Tyree PT, Diehr PK. Comparison of Health Care Expenditures Among Insured
Users and Nonusers of Complementary and Alternative Medicine in Washington State: A Cost Minimi-
zation Analysis. J Altern Complement Med. 2010; 16(4):411–7. https://doi.org/10.1089/acm.2009.0261
PMID: 20423210
57. Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S, et al. Perceptions
about complementary therapies relative to conventional therapies among adults who use both: results
from a national survey. Annals of internal medicine. 2001; 135(5):344–51. Epub 2001/09/01. PMID:
11529698
58. Busse JW, Heaton G, Wu P, Wilson KR, Mills EJ. Disclosure of natural product use to primary care phy-
sicians: a cross-sectional survey of naturopathic clinic attendees. Mayo Clin Proc. 2005;80.
59. Ahn AC, Ngo-Metzger Q, Legedza AT, Massagli MP, Clarridge BR, Phillips RS. Complementary and
alternative medical therapy use among Chinese and Vietnamese Americans: prevalence, associated
factors, and effects of patient-clinician communication. Am J Public Health. 2006; 96(4):647–53. Epub
2005/12/29. https://doi.org/10.2105/AJPH.2004.048496 PMID: 16380575
60. Thorburn S. Examining the association between patient-centered communication and provider avoid-
ance, CAM use, and CAM-use disclosure. Alternative therapies in health and medicine. 2015; 21(2):30.
PMID: 25830278
61. Rabe-Hesketh S, Skrondal A. Multilevel modelling of complex survey data. Journal of the Royal Statisti-
cal Society: Series A (Statistics in Society). 2006; 169(4):805–27.
62. Carle AC. Fitting multilevel models in complex survey data with design weights: Recommendations.
BMC Med Res Methodol. 2009; 9:49. https://doi.org/10.1186/1471-2288-9-49 PMID: 19602263
Changes in the use practitioner-based complementary and alternative medicine over time in Canada
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... In 2000/2001, Lim et al. reported that 26% of adults with back pain consulted chiropractors in Canada, compared to 9% among those with no back pain [17], which is similar to the 24% in 2009/2010 [12]. Canizares et al. examined changes in utilization of chiropractic services over time and by birth cohorts from 1994 to 2011 and reported differences in chiropractic utilization by birth cohort but relatively stable national utilization in Canada [18]. Previous studies have assessed a range of variables perceived to impact the utilization of chiropractic services, either at a point in time [12,17], or over time [18], but are now dated nor did they consider year over year changes in trend. ...
... Canizares et al. examined changes in utilization of chiropractic services over time and by birth cohorts from 1994 to 2011 and reported differences in chiropractic utilization by birth cohort but relatively stable national utilization in Canada [18]. Previous studies have assessed a range of variables perceived to impact the utilization of chiropractic services, either at a point in time [12,17], or over time [18], but are now dated nor did they consider year over year changes in trend. ...
... We found a small increasing trend in Canadians reporting consulting a chiropractor in the preceding 12 months between 2001 and 2010, and for those reporting receiving regular health care from a chiropractor from 2015 to 2018. These findings are the same as those reported most recently by Wong et al. who also used CCHS data [19], similar to those of Canizares et al. who reported an increase in surveyed Canadians consulting a chiropractor from 10.7% in 1994-95 to 13.4% in 2010-11 [18], and to the estimated linear increase in utilization in Canada reported by Beliveau et al. [16]. The reported differences between studies are likely related to different methodological approaches and data availability; for example, Canizares et al. used the longitudinal component of the Canadian National Population Health Survey [18], while Beliveau et al. conducted a scoping review of global studies [16]. ...
Article
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Background Despite increases in musculoskeletal disorders (MSD) in Canada, evidence suggests utilization of chiropractic services has remained relatively stable over time. Understanding the extent to which chiropractors are consulted and factors associated with their utilization may suggest factors related to accessing care. We assessed the change in prevalence and characteristics of Canadians seeking chiropractic care across two time periods 2001–2010 and 2015–2018. Methods We used national cross-sectional data from seven cycles of the Canadian Community Health Survey between 2001 and 2018. The survey included Canadians aged 12 years and older living in private dwellings in all provinces and territories. National annual weighted prevalence and age-standardized weighted prevalence (and 95% confidence intervals) of chiropractic utilization were calculated. We calculated prevalence of chiropractic utilization stratified by demographic, socioeconomic, lifestyle and health-related variables. Crude linear trends and change in prevalence from 2001 to 2010 were assessed using linear regression models. Results The national annual prevalence of Canadians consulting a chiropractor in the previous 12 months slightly increased from 11.0% (95% CI 10.8, 11.3) in 2001 to 11.4% (95%CI 11.1, 11.7) in 2010, and in those reporting receiving regular health care from a chiropractor from 7.5% (95%CI 7.2, 7.7) in 2015 to 7.9% (95%CI 7.7, 8.2) in 2018. Prevalence of utilization varied by province, highest in the Western provinces but lowest in Atlantic provinces. The age-specific prevalence of chiropractic utilization was highest in those aged 35–49 years and remained stable over time, except for slight increase in those aged 65–79 years. A higher percentage of Canadians identifying as white, Canadian-born, in the highest quintile of household income, overweight, physically active and in excellent health reported seeking chiropractic services. The most common reported chronic conditions measured in the survey among Canadians consulting chiropractors were chronic back problems, arthritis, fibromyalgia and headaches. Conclusion The national prevalence of utilization of chiropractic services among Canadians slightly increased over time but varied by province and respondents’ socioeconomic and health characteristics. Chronic back problems were the most common reported chronic condition. This comprehensive population-based study on chiropractic utilization in Canada can be used to inform decisions concerning health human resources and access to rehabilitation care for MSD.
... Complementary and alternative medicine (CAM) has been defined by the World Health Organization as a broad set of health care practices that are not part of a given country's own traditional or conventional medicine and are not fully integrated into the dominant health care system [1]. During the past decades CAM has been widely and increasingly used in most Western countries [2][3][4][5][6]. ...
... However, some general patterns can still be highlighted here. For instance, Canizares and colleagues assessed the prevalence of provider-based CAMs within the past 12 months in Canada in 1994/1995 and 2010/2011 using longitudinal data from a large national population survey [5]. Canizares and colleagues found a prevalence of 14.6% of overall provider-based CAM use in 1994/1995, which had increased to 24.5% in 2010/2011. ...
... In our study, the highest prevalences of CAM use were found in the groups with 13-14 years and ≥ 15 years of education. This is in accordance with the findings of several other studies that has equally found higher prevalence's among those with higher levels of education [2,5,6,8,9,20,[22][23][24]. For instance, Hanssen and colleagues, found a higher prevalence of CAM use among respondents with a higher educational level [9]. ...
Article
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Background Complementary and alternative medicine (CAM) has been widely and increasingly used worldwide during the past decades. Nevertheless, studies in long-term trends of CAM use are limited. The aim of this study was to assess long-term trends in the prevalence of CAM use (both overall and for specific CAMs) between 1987 and 2021 in the adult Danish population and to examine certain sociodemographic characteristics of CAM users. Methods Data derived from nationally representative health surveys in the general adult population (≥ 16 years) in Denmark (the Danish Health and Morbidity Surveys) conducted in 1987, 1994, 2000, 2005, 2010, 2013, 2017, and 2021. The response proportion declined from 79.9% in 1987 to 45.4% in 2021. CAM use was assessed by questions on ever use of specific types of CAMs and overall use within the past 12 months. Differences in use of CAMs across educational levels were assessed using the Slope Index of Inequality (SII). Results An overall increase in the prevalence of CAM use within the past 12 months was found between 1987 (10.0%) and 2021 (24.0%). However, a stagnation was observed between 2010 and 2017, after which the prevalence decreased in 2021. In all survey waves, the prevalence was higher among women than men. For both sexes, the prevalence tended to be highest among respondents aged 25–44 years and 45–64 years. The group with 13–14 years of education had the highest prevalence of CAM use compared to the other educational groups (< 10 years, 10–12 years, and ≥ 15 years). SII values for both men and women increased between 1987 and 2021, which indicates an increase in differences of CAM use across educational groups. In all survey waves the most frequently used CAMs included massage and other manipulative therapies, acupuncture, and reflexology. Conclusions The use of CAM has increased markedly within the last decades and recently stagnated at high levels, which underlines the importance of securing high quality information and education for the public, health professionals, and legislators to ensure and promote safe use of CAMs.
... Furthermore, various follow-up studies indicate that the utilization of complementary and alternative medicine (CAM) in many countries worldwide has either shown an upward trend or has remained stable in recent years (Canizares et al., 2017;Esmail, 2017;Gunnarsdottir et al., 2020;MacLennan et al., 2006;Pokladnikova and Selke-Krulichova, 2018;Thomas et al., 2003). Not surprisingly, the usage of CAM has been recognized as a potential contributor to the emergence of scepticism (Fasce et al., 2023;Frawley et al., 2018) and some works have proved that antivaccination sentiment within CAM practitioners is significant (Wardle et al., 2016). ...
... Similar to the research conducted by Duan et al. (4), there has been a noticeable increase in the utilization of cohort studies in CAM in recent years. Cohort studies are valuable for tracking patterns and shifts in CAM usage over time (23), which is why they have become a significant tool in CAM research in recent years. Several studies have highlighted the global use of CAM for treating various diseases over the past decade (24)(25)(26). ...
Article
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Background We aimed to investigate the subject matters and the quality of publications detailing the findings of cohort studies within the realm of complementary and alternative medicine (CAM). Methods A scoping review was conducted on cohort studies in the CAM field up to the conclusion of 2023. The evaluation of their quality was carried out utilizing the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) checklist. Moreover, an analysis of their research settings and associated variables, including publication year, type of disease, intervention method, and study field, was conducted. Results Overall, 215 articles were identified. The majority of these cohorts, approximately 42.3%, originated from Taiwan, with stroke and cardiovascular diseases emerging as the most prevalent outcomes of interest. The mean STROBE score was 1.38 (SD=0.57) out of 2. The lowest scores were associated with the methods and funding sections. Methodologically, the principal weaknesses were linked to sample size, loss to follow-up, and bias control. Conclusion The frequency of cohort studies in CAM was limited, predominantly concentrated in a few countries. Chinese medicine and acupuncture were the main intervention methods, while other CAM interventions received less focus. Furthermore, the quality of these studies was deemed unsatisfactory in most cases.
... Na Alemanha, em 2009, verificou-se que 60% dos médicos clínicos gerais ofereciam algum procedimento, sendo que em 2015 constatou-se que mais de 67.000 médicos já tinham algum treinamento envolvendo Medicina Alternativa e complementar, na qual a Acupuntura era o procedimento mais utilizado para as queixas musculoesqueléticas (13) . No Canadá, na comparação entre diferentes gerações de pessoas, observou-se aumento na procura (1994/95, 14,6%), (2010/11, 24,5%) por PICS e Quiropraxia para dores nas costas (14) . Nesse sentido, no Reino Unido, em 2005, reportou-se que 12% da população geral havia passado por atendimentos com PICS, sendo em 2015 relatado Atendimentos uma taxa de 16% para procura nos últimos 12 meses, principalmente com massagem (19%), Osteopatia (12%) e Acupuntura (11%), para os quais apenas 4% vieram de prescrição ou recomendação de médicos da AB, abarcando 68% para condições musculoesqueléticas e 12% saúde mental (15) . ...
Article
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Este artigo está publicado em acesso aberto (Open Access) sob a licença Creative Commons, que permite uso, distribuição e reprodução em qualquer meio, sem restrições, desde que o trabalho seja corretamente citado. RESUMO Objetivo: Analisar a distribuição espacial das Práticas Integrativas e Complementares em Saúde (PICS) na Atenção Básica (AB) brasileira para a ampliação da discussão sobre sua oferta. Métodos: Estudo ecológico transversal realizado em 2020, a partir do sistema público brasileiro de informação em saúde do ano de 2019. Para análise, analisou-se a variável dependente quantidade de atendimentos, enquanto as variáveis independentes deram-se por território, Índice de Desenvolvimento Humano (IDH) e a cobertura da AB. Para as comparações estatísticas utilizaram-se os testes de qui-quadrado de Pearson e correlação de Spearman. Resultados: Considerando AB, secundária e terciária do Sistema Único de Saúde (SUS), a prevalência total de atendimentos em 2019 apresentou-se por 1.593.128. Separando e analisando exclusivamente a AB (n=51.352; 3.2%), a maior prevalência de atendimentos apresentou-se nas regiões Sudeste (n=15.210; 29,7%) e Nordeste (n=12.559; 24.4%), com ocorrências maiores de sessões de eletroestimulação (n=6.397; 12,4%) e de práticas corporais em Medicina Tradicional Chinesa (n=4.588; 8,9%). As correlações deram-se positivas entre atendimentos e população (r=0,62), e entre atendimentos e IDH (r=0,24). Conclusão: Evidenciou-se que a distribuição espacial das PICS na AB é desigual ao se considerar as prevalências de cada região. Já as correlações positivas podem representar a procura por alternativas de cuidado frente a condições crônicas, queixas musculoesqueléticas e insatisfação com a Medicina Moderna; fatores que geralmente provocam o aumento pela procura de PICS, principalmente em regiões onde o desenvolvimento social mais elevado favorece a autonomia da pessoa.
... 29 40 Additionally and notably, workers with less experiencewho tend to be younger-had higher odds of using CBT, mindful breathing and meditation to address pain, which may be attributed to documented generational differences in acceptance of approaches attitudes toward CAM. 41,42 Healthcare workers-another worker population that encounters physical and mental exertion albeit at differing levels than construction workers-have self-reported use of CAM for effective pain management. [43][44][45] Lastly, we found here that NH Black workers and workers of other ethnicities and races more frequently reported using spiritual/religious healing approaches to manage their pain than did their NH White counterparts. ...
Article
Background U.S. construction workers experience high rates of injury that can lead to chronic pain. This pilot study examined nonpharmacological (without medication prescribed by healthcare provider) and pharmacological (e.g., prescription opioids) pain management approaches used by construction workers. Methods A convenience sample of U.S. construction workers was surveyed, in partnership with the U.S. National Institute for Occupational Safety and Health (NIOSH) Construction Sector Program. Differences in familiarity and use of nonpharmacological and pharmacological pain management approaches, by demographics, were assessed using logistic regression models. A boosted regression tree model examined the most influential factors related to pharmacological pain management use, and potential reductions in use were counterfactually modeled. Results Of 166 (85%) of 195 participants reporting pain/discomfort in the last year, 72% reported using pharmacological pain management approaches, including 19% using opioids. There were significant differences in familiarity with nonpharmacological approaches by gender, education, work experience, and job title. Among 37 factors that predicted using pharmacological and non‐pharmacological pain management approaches, training on the risks of opioids, job benefits for unpaid leave and paid disability, and familiarity with music therapy, meditation or mindful breathing, and body scans were among the most important predictors of potentially reducing use of pharmacological approaches. Providing these nonpharmacological approaches to workers could result in an estimated 23% (95% CI: 16%–30%) reduction in pharmacological pain management approaches. Conclusion This pilot study suggests specific factors related to training, job benefits, and worker familiarity with nonpharmacological pain management approaches influence use of these approaches.
... In contrast, Japan has 186,000 licensed acupuncturists as of 2021 [16]. The annual utilization rates of acupuncture were reported as 1.7% in the United States in 2012 [17], 1.6% in the United Kingdom in 2004 [18], and 2.4% in Canada in 2010 [19]. In contrast, the reported rate was 5.7% in Japan in 2022 [20]. ...
Article
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Background With the growth of social media, there has been an increase in health-related studies utilizing data obtained from such sites and applications. Although acupuncture is used as a complementary alternative medicine worldwide, there is little research on acupuncture utilizing social media data. This study investigates the topics related to acupuncture on Twitter, currently known as X, in English and Japanese. Methods We collected tweets containing the English word “acupuncture” and its Japanese equivalent using Twitter's application programming interface from January 1, 2022 to December 31, 2022. After extracting the top 50 frequently occurring words from the collected tweet texts separately for each language, we conducted a co-occurrence network analysis for those words, in order to evaluate the patterns of their occurrence. Results A total of 70,435 English tweets from 41,939 users and 188,671 Japanese tweets from 81,093 users were analyzed after excluding retweets and duplicate tweets. The co-occurrence network analysis revealed that topics related to pain, other complementary and alternative medicines, and acupuncture-related experiences were common in both languages. However, explanatory topics such as needle use, Chinese medicine, and body points were specific to English tweets, while those about beauty care were specific to Japanese tweets. Conclusion The number of tweets regarding acupuncture and the number of users who posted them were both higher in Japanese than in English. Some acupuncture topics were common in both languages, while other topics were specific to each language. The findings of this study provide valuable insights into understanding information about acupuncture on social media.
... The use of unconventional therapeutic protocols, as alternative or support to conventional medical methods, is a muchdiscussed issue in literature [2,3,6,7]. Among CAM, TCM is certainly the most widespread in the world, as well as the only one to remain intact in the principles up to now and, therefore, the best systematized [6,[26][27][28]. ...
Article
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Traditional Chinese medicine (TCM) and acupuncture (AT) are widely used for treating acute and chronic pain conditions, including pain related to temporomandibular disorders (TMD). This review highlights the current knowledge about the use of AT and TCM in orofacial pain field, in particular for TMD-related pain management, exploring acupuncture potential benefits, its mechanisms of action on pain and the more suitable clinical application techniques and methods of point stimulation. The literature reviewed showed growing evidence supporting the use of AT and TCM-related techniques for the management of orofacial pain, especially associated with TMD. AT presents great potential for treating orofacial pain, especially for muscle pain and headache, and when applied on patients with systemic pain conditions. Different AT techniques and methods of point stimulation, including the traditional and the innovative ones, can be safely used as alternative or to support conventional treatments. The use of AT for the management of pain in oro-craniofacial district may have great potential, especially for chronic condition and for pain of muscular origin. Despite the growing interest for TCM and AT as therapeutic tool in musculoskeletal pain conditions, in orofacial pain field the evidence is still few and fragmentary, and there are no specific protocols or clinical and therapeutic indications.
... 61 Overall, there is a trend of increasing CAIM use over time across all ages. 62 ...
Article
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The definition of complementary, alternative, and integrative medicine (CAIM) remains dynamic and complex despite a steady increase in the popularity/usage of CAIM therapies across the globe. A lack of consistency in how these terms are defined remains a challenge for researchers, clinicians, and national and international organizations (e.g., World Health Organization, National Center for Complementary and Integrative Health) alike. In the present article, we provide a brief history of the use of these terminologies, and then outline the process we took to develop and create an operational definition of complementary, alternative, and integrative medicine. Our operational definition is the first to be informed by a systematic search of four quality-assessed information resource types, ultimately yielding 604 unique CAIM therapies. We then developed a single search string for the most common bibliographic databases using the finalized operational definition list of CAIM therapies. These CAIM therapies were searched against the Therapeutic Research Center's “Natural Medicines” database for all 604 therapies, whereby each item's scientific name and/or synonym was included as a keyword or phrase in the search string. While the current definition is not without limitations and ongoing debates still surround the field, this work is arguably a steppingstone towards enabling increased collaboration and communication amongst healthcare clinicians, researchers, and the public. This operational definition provides a foundation for developing well-coordinated research efforts that will assist in the acceptance and understanding of this field, while also focusing on adopting knowledge translation techniques and efforts for further research advancement and use.
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Age-Period-Cohort Analysis: New Models, Methods, and Empirical Applications is based on a decade of the authors’ collaborative work in age-period-cohort (APC) analysis. Within a single, consistent HAPC-GLMM statistical modeling framework, the authors synthesize APC models and methods for three research designs: age-by-time period tables of population rates or proportions, repeated cross-section sample surveys, and accelerated longitudinal panel studies. The authors show how the empirical application of the models to various problems leads to many fascinating findings on how outcome variables develop along the age, period, and cohort dimensions. The book makes two essential contributions to quantitative studies of time-related change. Through the introduction of the GLMM framework, it shows how innovative estimation methods and new model specifications can be used to tackle the "model identification problem" that has hampered the development and empirical application of APC analysis. The book also addresses the major criticism against APC analysis by explaining the use of new models within the GLMM framework to uncover mechanisms underlying age patterns and temporal trends. Encompassing both methodological expositions and empirical studies, this book explores the ways in which statistical models, methods, and research designs can be used to open new possibilities for APC analysis. It compares new and existing models and methods and provides useful guidelines on how to conduct APC analysis. For empirical illustrations, the text incorporates examples from a variety of disciplines, such as sociology, demography, and epidemiology. Along with details on empirical analyses, software and programs to estimate the models are available on the book’s web page.
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Multimorbidity defined as the "the coexistence of two or more chronic diseases" in one individual, is increasing in prevalence globally. The aim of this study is to compare the prevalence of multimorbidity across low and middle-income countries (LMICs), and to investigate patterns by age and education, as a proxy for socio-economic status (SES). Chronic disease data from 28 countries of the World Health Survey (2003) were extracted and inter-country socio-economic differences were examined by gross domestic product (GDP). Regression analyses were applied to examine associations of education with multimorbidity by region adjusted for age and sex distributions. The mean world standardized multimorbidity prevalence for LMICs was 7.8 % (95 % CI, 7.79 % - 7.83 %). In all countries, multimorbidity increased significantly with age. A positive but non-linear relationship was found between country GDP and multimorbidity prevalence. Trend analyses of multimorbidity by education suggest that there are intergenerational differences, with a more inverse education gradient for younger adults compared to older adults. Higher education was significantly associated with a decreased risk of multimorbidity in the all-region analyses. Multimorbidity is a global phenomenon, not just affecting older adults in HICs. Policy makers worldwide need to address these health inequalities, and support the complex service needs of a growing multimorbid population.
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Objectives: Chronic conditions and multimorbidity are increasing worldwide. Yet, understanding longitudinal changes in multimorbidity over the lifecourse is limited. We compared the age-trajectory of multimorbidity by birth cohort and examined effects of socio-demographic (e.g., sex, income) and behavioral risk (e.g., obesity) factors in multimorbidity. Methods: Using data from the Canadian Longitudinal National Population Health Survey (1994-2010), we examined 10,186 participants born 1925-1974 grouped in 5 birth cohorts. Data on the number of chronic conditions (up to 17), income, education, and behavioral risk factors were collected biannually. We used multilevel logistic growth modeling techniques for analyses of multimorbidity defined as the presence of 2+ chronic conditions versus 1 or none. Results: We found significant cohort differences in the age-trajectory of multimorbidity: at corresponding ages, each succeeding recent cohort had higher odds of reporting multimorbidity than their predecessors. Access to healthcare did not fully explain these differences. Women, having lower income, being obese, smoking, and a sedentary lifestyle had increased odds of reporting multimorbidity. Obese individuals, particularly Gen Xers and younger boomers, reported multimorbidity at an earlier age than those of normal weight. We observed divergent trajectories of greater multimorbidity for lower than higher income individuals. Furthermore, after accounting for age and risk factors there was an apparent increase in reporting multimorbidity over time (period effect) across all ages. Discussion: Our findings indicate that multimorbidity is not only becoming the norm, but is emerging earlier in the lifecourse and particularly for low income and obese individuals from more recent cohorts. The findings point to the importance of planning interventions and policies to deal with more recent birth cohorts entering into older age with worse health than their predecessors.
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Complementary and Alternative Medicines (CAM) are used by an extensive number of patients in the UK and elsewhere. In order to understand this pattern of behavior, it is helpful to examine the characteristics of people who use CAM. This narrative review collates and evaluates the evidence concerning the demographic characteristics and health status factors associated with CAM use in community-based non-clinical populations. A systematic literature search of computerized databases was conducted, and published research papers which present evidence concerning associations between CAM use and demographic and health characteristics are discussed and evaluated. The evidence suggests that people who use CAM tend to be female, of middle age and have more education. In terms of their health, CAM users tend to have more than one medical condition, but might not be more likely than non-users to have specific conditions such as cancer or to rate their own general health as poor. The multivariate studies that have been conducted suggest that both demographic and health characteristics contribute independently to CAM use. In conclusion, demographic characteristics and factors related to an individual's health status are associated with CAM use. Future research is needed to address methodological limitations in existing studies.
Article
Background: Little is known about perceptions of complementary and alternative medical (CAM) therapy relative to conventional therapy among patients who use both. Objective: To document perceptions about CAM therapies among persons who use CAM and conventional therapies. Design: Nationally representative, random-household telephone survey. Setting: The 48 contiguous U.S. states. Participants: 831 adults who saw a medical doctor and used CAM therapies in 1997. Measurements: Perceptions about helpfulness and patterns of CAM therapy use relative to conventional therapy use and reasons for nondisclosure of CAM therapies. Results: Of 831 respondents who saw a medical doctor and used CAM therapies in the previous 12 months, 79% perceived the combination to be superior to either one alone. Of 411 respondents who reported seeing both a medical doctor and a CAM provider, 70% typically saw a medical doctor before or concurrent with their visits to a CAM provider; 15% typically saw a CAM provider before seeing a medical doctor. Perceived confidence in CAM providers was not substantially different from confidence in medical doctors. Among the 831 respondents who in the past year had used a CAM therapy and seen a medical doctor, 63% to 72% did not disclose at least one type of CAM therapy to the medical doctor. Among 507 respondents who reported their reasons for nondisclosure of use of 726 alternative therapies, common reasons for nondisclosure were "It wasn't important for the doctor to know" (61%), "The doctor never asked" (60%), "It was none of the doctor's business" (31%), and "The doctor would not understand" (20%). Fewer respondents (14%) thought their doctor would disapprove of or discourage CAM use, and 2% thought their doctor might not continue as their provider. Respondents judged CAM therapies to be more helpful than conventional care for the treatment of headache and neck and back conditions but considered conventional care to be more helpful than CAM therapy for treatment of hypertension. Conclusions: National survey data do not support the view that use of CAM therapy in the United States primarily reflects dissatisfaction with conventional care. Adults who use both appear to value both and tend to be less concerned about their medical doctor's disapproval than about their doctor's inability to understand or incorporate CAM therapy use within the context of their medical management.
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Research is needed that uses large enough samples to facilitate disaggregation of users by specific types of complementary/alternative medical (CAM) practices and by ethnicity in order to examine possible patterns in the use of CAM therapies not accorded efficacy by family physicians. The objective of this study is too use data from a large population health survey to determine the relationship ethnicity, measured with multiple indicators, has with the use of CAM therapies classified as "accepted" or "rejected" by family physicians in terms of efficacy. Using data from the Canadian Community Health Survey (CCHS) Cycle 1.1, logistic regression models estimate the factors influencing the use of the two binary categories of CAM therapy. Measures of ethnicity available in the CCHS are used to focus on ethnic origin, comparing North American and Foreign born, and on ethnic identification, comparing Whites with Asians, South Asians, Blacks, Latin Americans, Aboriginals, and others. Whites and North American born had higher odds of using "accepted" therapies, whereas immigrant visible minorities and those with Asian ethnic identities were more likely to use "rejected" therapies. This research confirms that ethnicity constitutes a cultural resource upon which users of CAM draw as they make their health-care decisions, sometimes despite the recommendations of family physicians.
Article
Background: Little is known about perceptions of complementary and alternative medical (CAM) therapy relative to conventional therapy among patients who use both. Objective: To document perceptions about CAM therapies among persons who use CAM and conventional therapies. Design: Nationally representative, random-household telephone survey. Setting: The 48 contiguous U.S. states. Participants: 831 adults who saw a medical doctor and used CAM therapies in 1997. Measurements: Perceptions about helpfulness and patterns of CAM therapy use relative to conventional therapy use and reasons for nondisclosure of CAM therapies. Results: Of 831 respondents who saw a medical doctor and used CAM therapies in the previous 12 months, 79% perceived the combination to be superior to either one alone. Of 411 respondents who reported seeing both a medical doctor and a CAM provider, 70% typically saw a medical doctor before or concurrent with their visits to a CAM provider; 15% typically saw a CAM provider before seeing a medical doctor. Perceived confidence in CAM providers was not substantially different from confidence in medical doctors. Among the 831 respondents who in the past year had used a CAM therapy and seen a medical doctor, 63% to 72% did not disclose at least one type of CAM therapy to the medical doctor. Among 507 respondents who reported their reasons for nondisclosure of use of 726 alternative therapies, common reasons for nondisclosure were It wasn't important for the doctor to know (61%), The doctor never asked (60%), It was none of the doctor's business (31%), and The doctor would not understand (20%). Fewer respondents (14%) thought their doctor would disapprove of or discourage CAM use, and 2% thought their doctor might not continue as their provider. Respondents judged CAM therapies to be more helpful than conventional care for the treatment of headache and neck and back conditions but considered conventional care to be more helpful than CAM therapy for treatment of hypertension. Conclusions: National survey data do not support the view that use of CAM therapy in the United States primarily reflects dissatisfaction with conventional care. Adults who use both appear to value both and tend to be less concerned about their medical doctor's disapproval than about their doctor's inability to understand or incorporate CAM therapy use within the context of their medical management.
Article
Context: Patients' perceptions of the quality of their relationships with health care providers may influence their health care-seeking behaviors and future interactions with providers, including use of conventional health care, use of complementary and alternative medicine (CAM), and disclosure of CAM use. Objective: The study examined the associations between perceived patient-centered communication and provider avoidance, CAM use, and CAM-use disclosure. Design: This study used cross-sectional survey data from the Health Information National Trends Survey (HINTS) 3, a nationally representative survey of US adults collected between January 2008 and May 2008. Outcome measures: Two questions asked about CAM use and CAM-use disclosure, and another asked about avoidance of doctors. For the independent variable, responses from 6 questions on patient-centered communication were averaged to create a scale score ranging from 1-4. The research team conducted multiple logistic regressions of the 3 primary outcome measures, adjusting for sociodemographic characteristics, presence or absence of a regular source of care, insurance status, frequency of visits to providers, and health status. All analyses were weighted to make the results representative of the US population aged ≥18 y. Results: Approximately one-third of respondents (36%) had avoided seeing their doctors within the 12 mo prior to the survey. Approximately 24% had used CAM within the prior 12 mo, and 51.7% of CAM users had discussed their CAM use with their doctors. Higher levels of patient-centered communication were significantly associated with lower odds of provider avoidance (AOR=0.63; 95% CI=0.52, 0.76) and CAM use (AOR=0.60; 95% CI=0.46, 0.78) but were not associated with CAM-use disclosure. Conclusions: Findings suggest that patients may be more likely to avoid seeing their doctors and more likely to use CAM when they perceive low levels of patient-centered communication. Further research to understand the role of the characteristics of patient-provider relationships on provider avoidance, CAM use, and CAM-use disclosure is warranted.