Use of Alternative Therapies in Older Outpatients in the United States and Japan: Prevalence, Reporting Patterns, and Perceived Effectiveness

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1 Journal of Gerontology: MEDICAL SCIENCES 2001, Vol. 56A, No. 10, M650 M655 Copyright 2001 by The Gerontological Society of America Use of Alternative Therapies in Older Outpatients in the United States and Japan: Prevalence, Reporting Patterns, and Perceived Effectiveness T Joseph H. Flaherty, 1,2 Ryutaro Takahashi, 3 JoAnne Teoh, 4 Jeung-Im Kim, 5 Shazia Habib, 6 Mio Ito, 3 and Satoru Matsushita 7 1 Geriatric Research, Education and Clinical Center, Saint Louis VA Medical Center, Missouri. 2 Division of Geriatrics, 6 Department of Internal Medicine, 4 Saint Louis University School of Medicine, Missouri. 3 Department of Nursing and Health Care, Tokyo Metropolitan Institute of Gerontology, Japan. 5 Department of Nursing, College of Medicine, Soonchunhyang University, Choongnam, Korea. 7 Department of Internal Medicine, Tokyo Metropolitan Geriatric Hospital, Japan. Background. The purpose of this study was to determine the prevalence, patterns of reporting, and perceived effectiveness of alternative medical therapies (ATs) among older white American, African American, and Japanese outpatients. Methods. This study used a questionnaire to interview participants (N 593; age, 59 y), who were outpatients of geriatric outpatient clinics in Saint Louis, Missouri, and Tokyo, Japan (white Americans, n 180; African Americans, n 106; and Japanese, n 307). Results. Use of 1 AT was greatest among older Japanese (74.3%), followed by white Americans (61.1%) and African Americans (47.2%; p.001). The most common ATs used among the Japanese (and significantly more than the white and African American groups) were lifestyle diet, herbal therapy, massage, acupressure, and acupuncture. The white and African American groups were more frequent users of relaxation techniques and spiritual healing compared with the Japanese group. Contrary to prior studies of the general population, the use of 1 AT did not correlate with any sociodemographic variables. Reported use of ATs to doctors was low but similar in all three groups (white Americans 48%, African Americans 42%, and Japanese 46%). Perceived effectiveness was high but similar in all three groups (white Americans 85%, African Americans 92%, and Japanese 84%). Although chronic conditions were common reasons for use of ATs, nonmedical reasons (e.g., general health or religious reasons) were also common. Conclusions. Use of ATs was greater in Japan than in the United States, but for both countries, use by older persons was greater than previous reports of the general population. Because sociodemographic variables do not predict use, and reported use to doctors is low and perceived effectiveness is high, increased awareness and understanding about ATs by health care professionals seems imperative. HE use of alternative medical therapies (ATs), also called unconventional medicine and complementary medicine, is prevalent throughout the industrialized world (1 7), despite a scarcity of randomized controlled trials that show efficacy (8). As the exchange of medical information and international communication continue to grow (e.g., via the World Wide Web), it would be important to learn the extent of use of ATs among different countries, especially those with similarly aging populations. Has East met West when it comes to ATs? Two industrialized countries of interest because of their presumed difference in the use of ATs (1) and growing elderly population are Japan and the United States. By the year 2020, persons older than 65 years will comprise 25% of the total population in Japan and 20% in the United States (9,10). Use of ATs among elderly persons is of particular interest: these individuals may be more likely to try ATs because of an increase in chronic conditions (11 13) and they may be more apt to suffer side effects because of age-related physiological changes and drug interactions associated with multiple medication use (14,15). Although there is one U.S. study that focused on AT use among elderly persons (16), the rest of the medical literature is inadequate concerning use of ATs among older persons. In two major U.S. prevalence studies (with 1539 and 2055 participants, respectively), only about one third of the subjects in each of these studies were older and the age cutoff was too low (50 years [y]) to capture the population that might be at most risk for side effects of some therapies (2,3). An Australian study defined older as greater than 55 years old (4). A Japanese study used the category of 65 years and older, but it only included 100 subjects of this age (5). In a Canadian study, there was a large study population aged 65 years and older ( 1000 subjects), but the study queried only about use of alternative health care practitioners, not about all types of alternative therapies (6). Another issue concerning ATs is how well physicians are informed by their patients about these other therapies. Ac- M650

2 ALTERNATIVE THERAPIES: OLDER JAPANESE AND AMERICANS M651 cording to one large survey of Americans in 1997, 96% of those patients interviewed who saw an alternative therapy practitioner also saw a physician for the same condition, but only one third of patients discussed these therapies with the physician (2). In Japan, physicians may also be unaware of the use of ATs or of AT practitioners. For example, herbal treatments, which form about 3% of the total drug budget, are freely available at pharmacies, with or without a prescription. And, there are approximately 95,000 acupressurists and 65,000 acupuncturists across Japan (1). The purpose of this study was to answer the following questions concerning use of ATs among older white Americans, African Americans, and Japanese: What is the extent of use of ATs? Are there any predictors of use (e.g., demographics)? To what extent are doctors informed about use of ATs? How do patients perceive the usefulness of these therapies compared with therapies prescribed by their physician? For what reasons do older Americans and Japanese use ATs? METHODS Sample In Japan, the interviews were conducted from March through July All interviewees were from the geriatric clinics that are part of Tokyo Metropolitan Geriatric Hospital, a 700-bed geriatric hospital in Tokyo, Japan. In the United States, the interviews were conducted from May through August All interviewees were from the outpatient geriatric clinics at Saint Louis University Health Sciences Center, a tertiary-care academic center. In both countries, over 95% of the patients in the clinics were seen on a continual basis (i.e., very few patients were seen as referrals or consults only). Survey methods were approved by the review board of Tokyo Metropolitan Geriatric Hospital and Saint Louis University s institutional review board. Patients younger than 60 years or with a diagnosis of dementia were excluded. The remaining patients were asked, The following questions are concerning your general health and health care practices. Do you agree to participate in this interview? In Japan, seven patients refused to participate, and eight patients did not complete the interview. In the United States, 12 patients refused to participate and two did not complete the interview. There were 593 completed interviews, 286 in the United States and 307 in Japan. Each participant was only interviewed once. The Interview In Japan, four nursing students were trained and did interviews during the clinic time. In the United States, two of the authors (JT, SH) did the interviews during the geriatric clinic time. The interview questionnaire was developed in English based on the interview used by Eisenberg and colleagues (3) so that consistency in methods would allow valid comparisons. The questionnaire was then translated into Japanese by one of the authors (RT) for use in Japan. As noted previously, we made no mention of alternative therapy while recruiting participants. If patients agreed to participate, full consent was obtained. After demographic characteristics were obtained, patients were asked, The following is a list of symptoms or conditions or medical problems. Please tell me (yes or no), have you experienced any of these in the past 12 months? The interviewer then asked about 27 medical conditions, 12 of which were taken from a previous prevalence study on use of ATs (3). The other 15 conditions included common symptoms and specific diagnoses known to exist among older patients. After all conditions were asked about, patients were asked, Of all the conditions or symptoms or medical problems above that you said you have experienced in the past 12 months, please tell me which three bother you the most? For each of these three (if that many), patients were asked to respond to the following, The therapy prescribed by my doctor helped with this problem. (Choices were as follows: strongly agree, agree, disagree, strongly disagree, or not applicable.) Not all patients had three conditions that bothered them the most. The Japanese sample had 348 responses, and the United States had 374 responses, to this part of the survey. Perceived effectiveness of medical therapy was based on these responses. Patients were then asked about the use of 15 different ATs: Now I would like to ask you about your use of some other kinds of therapies and treatments. Please tell me (yes or no), have you used any of the following in the past 12 months? Thirteen of the ATs were taken from a previous prevalence study on use of ATs (3). Acupressure and vitamins/minerals were added to the present study. Then, patients were asked to tell the interviewer five therapies (if that many) they had used frequently in the past 12 months. For each of these, the patients were asked three questions. (i) Have you told or discussed with your medical doctor about the use of the therapy? (ii) Tell me the main problem for which you have used the therapy. (iii) Please respond to the following: This therapy has helped me with this problem (strongly agree, agree, disagree, or strongly disagree). For this part of the data, not all patients listed every AT they used because frequently was subjectively defined (i.e., the interviewer did not define it, but left it up to the patient about what they thought was frequent ). Excluding prayer, vitamins/minerals, and others, the Japanese sample had 271 responses to this part of the survey and the U.S. sample had 255 responses. The reporting rate to doctors, reasons for use of ATs, and perceived effectiveness of ATs were based on these responses. Statistical Analysis Chi-square tests of independence were used for comparing proportions among white Americans, African Americans, and Japanese. For use, perceived effectiveness, and reporting use of ATs, the Bonferroni correction was applied because of the high number of comparisons. This was calculated as.05/, where is the number of tests or comparisons, and is the level of the new p value (17). Bivariate correlations between hypothesized predictors (demographics) and the dependent variable (use of ATs) were calculated in two ways for each of the three populations: (i) correlation with use of one or more AT and (ii) correlation with use of increasing number of ATs.

3 M652 FLAHERTY ET AL. Unless explicitly mentioned, all analyses excluded prayer, vitamins/minerals, and others. Statistical analyses were performed using a commercially available statistics package (Statistica, Statsoft, Tulsa, OK). RESULTS Table 1 summarizes the characteristics for the three groups of patients. The groups were similar in sex distribution, but were different in age, education, and income distribution. When the three groups were compared with national samples, the following was found. In the two U.S. groups, the percentage of women was slightly higher than that of the 1998 U.S. Census Bureau (age, 65 y; all races; women 59%). In the two U.S. groups, age distribution was skewed toward the oldest age group compared with national samples (all races; age, y 49.6%, y 33.8%, 80 y 16.7%). Educational distribution was skewed toward lower education (all races; 65 y; high school 33%). Income levels for our study were comparable to the 1998 U.S. Census Bureau data for white Americans and African Americans aged 65 years and older. Concerning race, since the geriatric clinics in Saint Louis draw patients from both the city and the greater metropolitan area, the percentage of patients represented who were African American (106 of 286, or 37%) was in between that of Saint Louis City (48%) and the Saint Louis greater metropolitan area (18%) (18). The Japanese group was similar to a national sample of older Japanese persons in age and income distribution (9,19). Education distribution was skewed slightly toward higher education compared with a previous epidemiological study (20). Excluding vitamins/minerals, self-prayer, and others, use of at least one AT was 74.3% among Japanese, 61.1% among white Americans, and 47.2% among African Americans (p.001; Table 2). Elderly Japanese were more frequent users of 5 of 13 ATs (lifestyle diet, herbal therapy, Characteristic Table 1. Characteristics of Patients WA, % (n 180) AA, % (n 106) Japanese, % (n 307) p Value Gender Women Men Age, y Education High school High school graduate College or beyond Annual Income, $ 20, ,000 50, , No answer Notes: Due to rounding, percentages do not always total 100. WA white Americans; AA African Americans. massage, acupressure, and acupuncture). White Americans and African Americans had similar rates of use of relaxation techniques, but these rates were significantly higher than those of the Japanese. African Americans had the highest rate of use of spiritual healing compared with the other two groups. When the total U.S. sample (white Americans African Americans) was compared with the Japanese sample, the same significant differences were found. Also, controlling for demographic variables (age, education, and income level) did not change the differences in use of 1 AT nor use of specific types of ATs. As seen in Table 3, no demographic variable in any of the three groups correlated with use of 1 AT. When the associations between the demographic variables and increasing number of ATs were looked at, still very few correlations were found. Among white Americans, younger age and higher income correlated with increasing number of ATs, and among the Japanese, only female gender correlated with increasing number of ATs. Because there were no differences between the white and African American groups in reported use and perceived effectiveness of ATs, these two groups were combined in Table 4. When comparing percentages of patients who reported use of ATs to their doctor, there were no differences between the two countries for use of 1 AT and for each specific AT, except for herbal therapy and vitamins/minerals, which were less often reported by the Japanese population (Table 4). Overall, the rate of reporting was low in each country (approximately 45%). Furthermore, for each AT and for use of 1 AT, there was no significant difference between the U.S. and Japanese samples in perceived effec- Type of Therapy Table 2. Use of Alternative Therapies by Patients WA, % (n 180) AA, % (n 106) Japanese, % (n 307) p Value Lifestyle diet *.001 Herbal therapy *.001 Massage *.001 Relaxation techniques *.001 Commercial diet Acupressure *.001 Acupuncture *.004 Self-help groups Chiropractic Spiritual healing *.001 Biofeedback Megavitamins Hypnosis AT *.001 Vitamins/minerals *.001 Self-prayer *.001 Other NA Note: WA white Americans; AA African Americans; AT alternative medical therapy; NA not applicable. Excluding self-prayer, vitamins/minerals, and others. For WA (15 of 19) and AA (9 of 10) other represented some form of exercise. For 134 of 170 Japanese, other represented some form of exercise; for 28 of 170, social activities; for 5 of 170, moxa cautery; and for 3 of 170, aroma therapy. *p.0033 (Bonferroni correction for 15 comparisons).

4 ALTERNATIVE THERAPIES: OLDER JAPANESE AND AMERICANS M653 Table 3. Bivariate Correlations of Independent Variables With Use of ATs WA (n 180) AA (n 106) Japanese (n 307) Variable r p Value r p Value r p Value Correlation With Use of AT Men Age Education Income Correlation With Increasing Use of ATs Men * Age * Education Income * Note: ATs alternative medical therapies; WA white Americans; AA African American. *p values significant at.05. tiveness, but the overall response was considerably positive ( 80%) for use of 1 AT. When perceived effectiveness of ATs was compared with perceived effectiveness of treatment prescribed by the physician, both groups had a significantly higher perception of ATs (Japan: ATs [83.5%] vs medical [54.0%], p.001; United States: ATs [89.0%] vs medical [81.8%], p.001). When perceived usefulness of treatment prescribed by the physician was compared between the two countries, the U.S. group had a significantly higher positive perception than the Japanese group (Japan [54.0%] vs United States [81.8%], p.001; data not shown). Table 4. Reported Use and Perceived Effectiveness of Alternative Therapies Reported Use, % Perceived Effectiveness, % Type of Therapy (WA AA) Japanese (WA AA) Japanese Lifestyle diet Herbal therapy * Massage Relaxation techniques Commercial diet Acupressure Acupuncture Self-help groups Chiropractic Spiritual healing Biofeedback Megavitamins Hypnosis AT Vitamins/minerals * Self-prayer Note: WA white Americans; AA African Americans; AT alternative medical therapy. Reported use is the percentage of patients who told their physician. Perceived effectiveness is the percentage of patients who responded strongly agree or agree to the question This therapy has helped me with this (specific) problem. Excluding self-prayer, vitamins/minerals, and others. *p.0033 (Bonferroni correction for 15 comparisons). As seen in Table 5, there were more similarities than differences when reasons for use of ATs were compared. Reasons other than the 27 medical conditions were the most common reasons (e.g., general health). Musculoskeletal reasons (back/hip problems and arthritis/joint problems) were the next most common reasons for use of ATs. DISCUSSION In this study of older Japanese and white and African American outpatients, we found that overall use of ATs was greatest among the Japanese population (74%). However, use among white and African Americans was also quite high (61% and 47%, respectively). This is in contrast to a 42% rate in a nationally represented sample of adults (age, 18 y) (2) and 41% in a sample of elderly persons residing in California (16). One explanation for such a discrepancy might be that the current study interviewed outpatients at the physician s office and not by telephone (2) or mail survey (16). As such, these outpatients would have been more likely to seek therapy, whether medical or alternative. Whatever the reason, it is still an important finding since those most at risk for problems with ATs (e.g., drug interactions) are those seeking medical care. Another reason for greater use may be dissatisfaction with medical care. One U.S. study of adult family-practice patients found that the use of ATs was greater in those who said they were not being helped by their physician (21). In the present study, this may be the case in both countries. Perceived effectiveness of medical therapy prescribed by patients physicians compared with that of ATs was significantly lower among both the Japanese and the U.S. population. Another difference in the current study, compared with other studies, is the lack of association with use of ATs and sociodemographic variables. In general population studies, higher education levels (3,4) and higher income (3,5) have been associated with greater use of ATs. In the study of elderly California residents, younger age and higher education levels were associated with greater use of ATs (16). The lack of association in the current study emphasizes that clinicians will need to ask all of their older patients about the use of ATs, not just the younger, well-educated patients with extra income to spend on therapies other than those prescribed. Another reason to ask all older patients about use of ATs is that, overall, only about 45% of the patients in both countries reported use of ATs to their physician. This seemingly low percentage in the U.S. population is consistent with what Astin and colleagues (16) found in their study of U.S. elderly persons, where only 42% discussed use of ATs with their physician or other health care practitioner, and a bit higher than what Eisenberg and colleagues (2) found (38.5%) in the general U.S. population. For the Japanese population, it is somewhat surprising that with such a high prevalence of use, and presumed acceptance of ATs in Japan, reporting of ATs by older Japanese patients was not greater than that in the United States. On the other hand, this pattern of underreporting may be because older Japanese patients are less vocal with their physician.

5 M654 FLAHERTY ET AL. Table 5. Most Common Reasons Patients Use Alternative Therapies Most Common Reasons Type of Therapy United States Japan Lifestyle diet General health, diabetes General health, diabetes Relaxation techniques Relax, anxiety problem Relax, general health Herbal therapy Memory problem, depression General health, bowel problem Massage Back/hip, arthritis/joint problem Back/hip, arthritis/joint problem Self-help groups Religious reasons, alcoholic Diabetes Spiritual healing Religious reasons, general health Back/hip problem Chiropractic Back/hip problem Back/hip problem Commercial diet Weight loss, weight gain General health Megavitamins General health No response Acupressure Back/hip problem, stomach problem Back/hip, arthritis/joint problem Acupuncture Back/hip, arthritis/joint problem Back/hip problem, headache Biofeedback Relax, bowel problem Bowel problem, paralysis Hypnosis No response No response Vitamins/minerals General health General health, fatigue Self-prayer General health, religious reasons General health Notes: Top two or fewer reasons (for at least 20% of respondents) are listed in order. Reasons in quotations were reasons other than the 27 medical conditions asked about. Although the expected differences between Japan and the United States were seen (e.g., therapies that are considered more Eastern than Western, such as herbal, massage, acupuncture, and acupressure, were more commonly used in Japan), the similarities between these two distant countries were striking. In addition to the low but similar reporting rate of AT use to physicians (both countries approximately 45%), and the high but similar perceived effectiveness of ATs (both 80%), Table 5 shows that the reasons for using the different ATs were more similar than different. For 10 of the 15 ATs, a similar common reason for use of the AT was given. The limitations of this study include the following: Patients may not have had a complete understanding of the different ATs. During the interviews, it was difficult to confirm professional (i.e., someone who provides care and is paid for his or her services) use of three ATs: massage, relaxation techniques, and spiritual healing. On the other hand, it is unlikely that patients were erroneous about the use of the other therapies. For example, similar to Eisenberg and colleagues studies (2,3), we did differentiate and try to clarify the differences between megavitamins and regular vitamins/minerals on our questionnaires ( megavitamin therapy does not include taking a daily vitamin or vitamin prescribed by a doctor ), and between lifestyle diet and commercial diet ( commercial diet is the kind you have to pay for; this does not include changing your diet to try to lose or gain weight on your own ). The strengths of this study are in its methods and its applicability for clinicians. Face-to-face interview questionnaires allowed for more complete and accurate data, compared with telephone interviews or mailed questionnaires. Also, the response rate was over 95% in both countries, compared with 60% 67% in Eisenberg and colleagues telephone-interview studies and 51% in Astin and colleagues mailed-questionnaire study (2,3,16). This study is applicable for clinicians because the study populations were taken from geriatric outpatient clinics. The use of ATs may be greater in our study because people attending clinics are more likely to have more chronic conditions and thus more likely to use ATs (11 13). However, for clinicians who are concerned about the use of ATs in their patients and whether they are being told about their use, the data here are quite relevant because this is the population that clinicians will see. In summary, a high percentage of older Japanese and Americans seeking medical help use some form of alternative medical therapy. In addition, sociodemographic variables do not predict use, and reported use to physicians is low and perceived effectiveness is high. Based on these results, it is important for health care professionals to increase their awareness and understanding about ATs. Acknowledgments This research was supported in part by the Geriatric Academic Career Award Grant from the Bureau of Health Professions. This study was presented at the American Geriatric Society meeting, May 2000, in Nashville, Tennessee. Address correspondence to Joseph H. Flaherty, MD, 1402 South Grand Boulevard, Room M238, St. Louis, MO flaherty@slu.edu References 1. Goldbeck-Wood S, Zinn C, Josefson D, Ingram M, Dorozynski A, Yamauchi M. Complementary medicine is booming worldwide. Br Med J. 1996;313: Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, Result of a follow-up national survey. JAMA. 1998;280: Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. 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