Use of Complementary and Alternative Medicine by Older Adults: An Exploratory Study

Transcription

1 Use of Complementary and Alternative Medicine by Older Adults: An Exploratory Study Catherine P. Montalto, PhD Vibha Bhargava Gong Soog Hong, PhD Determinants of complementary and alternative medicine (CAM) use and characteristics of users are examined using a sample of 848 adults aged 50 and older from the 2000 Health and Retirement Survey. Logistic regression is used to identify the factors associated with the likelihood of using CAM. Nearly 70% of the respondents use at least one CAM modality, with 44% reporting use of curative CAM and 58% reporting use of preventive/curative CAM. Whites, relative to Blacks, were more likely to use curative and less likely to use preventive/curative CAM. Widowed older adults were more likely to use preventive/curative CAM. Number of limitations in activities of daily living was positively associated with use of both types of CAM. Recommendations are made for improving research on alternative health care utilization, for educating CAM users, and for qualitative studies to gain further insight into factors affecting the use of specific CAM modalities. Keywords: complementary and alternative medicine; preventive and curative modalities; older adults Use of complementary and alternative medicine (CAM) has increased in recent years in the U.S. health care system (Barnes, Powell-Griner, McFann, & Nahin, 2004). A survey of prevalence, cost, and patterns of CAM use suggests that these modalities have significant presence in the U.S. health care system (Astin, 1998). In a nationally representative survey of 2,055 respondents by Eisenberg et al. (1998), 42% of the respondents reported using CAM in the previous year. The 2002 National Health Interview Survey showed a higher use (62%) of CAM (Barnes et al., 2004). Eisenberg et al. (1993) reported that approximately $27 billion was spent on CAM by American health care consumers, with an additional $3 to $4 billion spent on herbal supplements. Expenditures on CAM are one of the largest nonreimbursed health care expenditures, increasing from about $14 billion in 1990 to about $21 billion in 1998 (Eisenberg et al., 1998). This figure is considerably higher than that of nonreimbursed conventional health care expenditures. The increase in prevalence of CAM in the existing health care system, despite developments in conventional medicine, is noteworthy. Complementary Health Practice Review, Vol. 11 No. 1, January DOI: / Sage Publications 27

2 28 C. P. Montalto et al. One aspect of CAM that has not been appropriately addressed in previous studies is the definition and classification of various CAM modalities. Studies examining the predictors of CAM use have commonly combined the different modalities into one group. Kelner and Wellman (1997) found that patients using different types of CAM differed from each other. Aggregating the different CAM modalities into one category does not allow the identification of predictors of use of different modalities. Given that the individual CAM modalities such as acupuncture and meditation differ from each other in various aspects including price and the purpose of use, it is reasonable to expect that the predictors of use of individual CAM modalities may also differ. According to Siahpush (1999), biomedicine, with its narrow biological focus, is not equipped to deal with chronic illnesses whose proper treatment requires taking into account social, psychological, and environmental factors. The author posits that CAM is more responsive to the requirements of chronic conditions and more in touch with consumer demands than conventional medicine is. Therefore, those who are affected by chronic illness might try CAM for relief from these conditions (Loera, Black, Markides, Espino, & Goodwin, 2001). Prevalence of chronic illnesses increases with age, and older individuals are often affected by multiple chronic conditions, making older adults more likely users of CAM. According to health self-management theory proposed by Quandt, Arcury, and Bell (1998), older individuals choose among self-care, informal support, formal support, and medical care as resources for managing their health. The choice depends on factors including life course events, knowledge, culture, society and economy factors, personal situations and barriers to learning, household situations and barriers, and community situations and barriers. On the basis of this theory, it can be argued that individuals have different motives for using CAM based on the attributes of different modalities. To gain an understanding of different uses of CAM by older adults, this study classifies CAM into two categories. The first category includes CAM modalities that are more likely to be used for curative purposes, including chiropractic services and acupuncture. These two types of CAM are provider-based formal services and have an associated monetary cost (Barnes et al., 2004). The second category includes modalities that can be classified as either curative or preventive, including herbs, massage therapy, meditation, and breathing exercise. Based on the classification, this study first examines CAM as one group and then more specifically as curative and preventive/curative CAM modalities. Each modality is also analyzed individually. The objectives of this study are (a) to provide a descriptive analysis of older adults who use CAM in general, those who use curative modalities, and those who use preventive/ curative modalities and (b) to explore factors affecting the use of CAM in general, as well as curative and preventive/curative CAM modalities. FACTORS AFFECTING USE OF CAM MODALITIES: REVIEW OF THE LITERATURE The increase in CAM use has motivated researchers to identify the market for CAM and the factors associated with the choice of CAM modalities. Eisenberg et al. (1993) conducted a national survey in 1990 to determine the prevalence, costs, and patterns of use of CAM. Nearly one third of the respondents reported using at least one CAM modality. More educated, higher income, non-black, and 25- to 49-year-old respondents reported the highest use. Most of the respondents used CAM for chronic rather than acute medical conditions. Among all the health conditions included in the study, frequency of CAM use was

3 Use of CAM by Older Adults 29 highest for back problems, anxiety, headaches, chronic pain, and cancer or tumors. Of all the modalities, relaxation techniques, chiropractic, and massage were used most often. Astin (1998) found that use increased with deterioration of health. Back problems, chronic pain, anxiety, and urinary tract problems were predictive of CAM use. Wellman, Kelner, and Wigdor (2001) found that musculoskeletal and emotional conditions were the more frequently cited reasons for seeking CAM. McGregor and Peay (1996) examined some of the factors associated with the choice of CAM modalities and found that users of CAM were less satisfied with the ability of conventional medicine to provide relief. However, Astin (1998) showed that negative attitude toward or experience with conventional care did not predict CAM use. Several studies have focused on the use of CAM by older individuals. Wellman et al. (2001) reported that older adults who were consulting alternative practitioners were more likely to be female, to have graduated from a university, to be in managerial or professional occupations, and to have higher household incomes. Astin, Pelletier, Marie, and Haskell (2000) studied CAM use among elderly persons enrolled in Blue Shield Medicare supplement plans. Younger, more educated elderly, who experienced depression/anxiety and/or arthritis pain, exercised, and practiced meditation, were more likely to use CAM, whereas hypertension was negatively associated with use. In a comparison of CAM use between persons younger than 65 years and persons aged 65 and older, Foster, Phillips, Hamel, and Eisenberg (2000) reported that persons 65 and older were less likely to use any type of CAM. Loera et al. (2001) found that among Mexican American elderly, being female, being aged 75 and older compared to 65 to 74 years, living alone, being an immigrant, and reporting financial strain were positively associated with use of herbal medicines. Arthritis, hip fracture, urinary incontinence, and asthma were positively associated whereas myocardial infarction was negatively associated with use of herbal medicines. McMahan and Lutz (2004) examined CAM use in a sample of 335 individuals aged 65 to 74. Higher levels of education and income, being female, greater importance of spirituality, greater control over health, and poor self-perceived health status were positively associated with CAM use. Kelner and Wellman (1997) reported that compared to users of conventional medicine, users of CAM were more likely to be urban residents, female, younger, married, more highly educated, employed full-time, in higher level occupations, and to have higher incomes. Similar findings were reported by Barnes et al. (2004), who found that CAM use was positively associated with education, age, urban residence, and being female. In a review of results from national surveys on CAM use, Wootton and Sparber (2001) found a higher use of CAM among middle-aged, better educated, and higher income consumers. Astin (1998) also found that education was positively associated with the likelihood of use of CAM. Conboy et al. (2005) reported that CAM users were more likely to be divorced, single, or living with someone than married. Contradicting these studies, McGregor and Peay (1996) concluded that the users and nonusers of CAM did not differ significantly on demographic characteristics including gender, age, marital status, education, and occupation. Several studies have examined racial/ethnic differences in CAM use. Eisenberg et al. (1998) found that CAM use was less common among African Americans compared to other racial groups. Cappuccio, Duneclift, Atkinson, and Cook (2001) found that Black people of African origin were more likely than Whites to use CAM and South Asians were the least common users. Arcury, Quandt, Bell, and Vitolins (2002) reported significant ethnic differences in CAM use in a sample of 108 individuals aged 70 and older. In a convenience sample of adults older than 50 years, Cuellar, Aycock, Cahill, and Ford (2003) reported a higher use of alternative modalities among Caucasian Americans than African Americans.

4 30 C. P. Montalto et al. Barnes et al. (2004) found that compared to White and Asian adults, Black adults were more likely to use mind-body therapies including prayer. In a convenience sample of 525 elderly, Najm, Reinsch, Hoehler, and Tobis (2003) reported racial and ethnic differences in use rates and predictors of use of different types of CAM modalities. Schoenberg, Stoller, Kart, Perzynski, and Chapleski (2004) reported a higher use of CAM for diabetes management among Hispanics than other racial and ethnic groups. Tindle, Davis, Phillips, and Eisenberg (2005) found a higher use of CAM among non-hispanics and non-blacks compared to other racial/ethnic groups. Use of selfadministered modalities such as prayer was higher in the Black racial group. Mackenzie, Taylor, Bloom, Hufford, and Johnson (2003) did not find any differences in use of different CAM modalities by ethnic groups. Wolsko, Eisenberg, Davis, Ettner, and Phillips (2002) also concluded that race was not a significant predictor of CAM use. Health insurance is also a vital determinant of use of health care services. A few recent studies have shown that the uninsured are more likely to use at least one CAM modality (e.g., Graham et al., 2005; Mackenzie et al., 2003). Druss and Rosenheck (1999) found that those who have health insurance were more likely to use conventional medicine as well as CAM. Wolsko et al. (2002) found that insurance coverage is strongly correlated with CAM utilization. On the other hand, Burg, Hatch, and Neims (1998) did not find an association between health insurance coverage or type and CAM use. Ritchie, Gohmann, and McKinney (2005) also found that health insurance was not a significant predictor of CAM use. However, health maintenance organization insurance decreased the likelihood of using herbs and spiritual therapy. Studies looking at use of CAM among older adults also did not find significant association between CAM use and health insurance (Hong, Montalto, & Bhargava, 2004; Montalto, Bhargava, & Hong, 2005). Astin (1998) examined whether need for personal control over health care decisions and philosophical congruence with the use of CAM motivated people to seek alternative care. Holistic philosophy of health was a significant predictor of use of CAM. Kelner and Wellman (1997) examined the motivations of patients who choose to seek care from five types of practitioners: family physicians, chiropractors, acupuncturists/traditional Chinese doctors, naturopaths, and Reiki practitioners. Users of CAM were more likely to have no religious affiliation; however, they considered spirituality an important factor in life. The study suggested that an alternative ideology (i.e., health beliefs) influenced individuals willingness to seek CAM. Arcury, Bell, Vitolins, and Quandt (2005) examined the belief systems of CAM users among the rural elderly within the health self-management theory proposed by Quandt et al. (1998). The authors found that most of the rural elderly use some type of CAM, mostly home and folk remedies, and vitamin and mineral supplements, and the use is largely complementary rather than alternative to conventional medicine. The complementary use of CAM in this group was motivated by positive life course experiences related to development of conventional medicine. A review of the CAM literature by Moss (2002) indicated that the characteristics of CAM modalities that were of interest to CAM users include a holistic view of mind, body, and spirit; a personal supportive relationship between the healer and patient; active participation of the patient in the healing process; lifestyle and habit changes as tools to optimize health; and aversion toward the adverse side effects of conventional medicine. The studies reviewed above indicate that various factors determine CAM use. However, one should be cautious in drawing conclusions because the forms of CAM that are examined differ across these studies. Given the heterogeneity of CAM, it may not be appropriate to generalize the determinants of use across all forms of CAM. None of the studies reviewed above have attempted to classify the alternative modalities on the basis of purpose of use. This study explores whether the factors affecting the use of CAM vary when the CAM modalities are classified according to the purpose of use.

5 Use of CAM by Older Adults 31 METHODS Data and Sample The primary source of data for this analysis is the 2000 Health and Retirement Survey (HRS), an ongoing national longitudinal survey conducted every 2 years by the Survey Research Center at the University of Michigan. The data collection is funded mainly by the National Institute on Aging (Juster & Suzman, 1995). HRS is a rich source of information on the economic, health, marital, family, public, and private support systems of older Americans. HRS includes different experimental modules in each of its waves, and these modules are administered to randomly selected subsamples of all HRS respondents. The specific modules are not disclosed to the selected respondents when they are asked to participate. The respondents in the main sample are not required to participate in any module and can refuse to answer questions in the module to which they are randomly assigned. This study uses the module on CAM included in the 2000 HRS. This module contains information on respondents use of CAM modalities such as herbs, chiropractic, massage, acupuncture, meditation, and breathing exercises. Respondents were asked if they ever use any herbal products including pills or tinctures for health reasons, if they have ever been treated by a chiropractor, if they have ever received massage therapy, if they have ever been treated by acupuncture or acupressure, if they ever do regular breathing exercises, and if they ever meditate. Respondents were allowed to report use of more than one modality but were able to report the frequency of use only for breathing exercise and meditation. Of 1,160 respondents who participated in the CAM module as well as the main HRS survey, 848 respondents 50 years and older and with complete information were used in this study. Statistical Methods In this study, logistic regression was used to identify the factors associated with the likelihood of CAM use. The CAM modalities considered in this study included acupuncture, chiropractic, massage therapy, breathing exercise, use of herbs, and meditation. Chiropractic and acupuncture are provider-based modalities requiring out-of-pocket payments by users with no or limited health insurance coverage. These modalities are more likely to be used in response to health problems or symptoms rather than for prevention purposes and are labeled as curative. Modalities such as massage, herbal products, breathing exercises, and meditation could be provided by a practitioner and used for curative purposes such as treating pain and mental problems or be self-administered for prevention or health promotion reasons. These modalities are labeled as preventive/curative. Descriptive data analysis was used to examine differences in use rates by sample characteristics. Variables Three outcome variables were analyzed. The first outcome variable was an indicator variable equal to 1 if the respondent used any of the forms of CAM and 0 otherwise. The second outcome variable was an indicator variable equal to 1 if the respondent used curative CAM (i.e., acupuncture and/or chiropractic) and 0 otherwise. The third outcome variable was an indicator variable equal to 1 if the respondent used at least one of the CAM modalities classified under the preventive/curative category (i.e., breathing exercise, meditation, massage, and/or herbs) and 0 otherwise. Of 607 users of CAM, 256 (42%) used both curative and preventive/curative modalities. Twenty percent of the CAM users used only curative and about 38% used only preventive/curative modalities.

6 32 C. P. Montalto et al. Possible predictors were drawn from previous studies, and they included sociodemographic factors such as age, education, marital status, gender, race, and employment status of the respondent; economic factors such as financial variables and health insurance coverage; factors indicating health status and health behaviors of the respondent; and preference indicators such as importance of religion and satisfaction with health care. Age is measured as a categorical variable with two levels: 50 to 64 years and 65 years and older. Education is measured as a categorical variable and has four levels: less than high school education, high school education, some college education, and college education. Employment status reflects whether the respondent is presently working, retired, or unemployed. Gender is a dichotomous variable indicating whether the respondent is male or female. On the basis of self-identified race, respondents are classified as White, Black, or other racial group. Marital status is measured with three dichotomous variables: married, widowed, or other (i.e., separated, divorced, or never married). Importance of religion is a dichotomous variable indicating whether or not the respondent considers religion important. Physical health is measured by number of chronic illnesses, number of limitations in activities of daily living (LADL), and number of limitations in instrumental activities of daily life (LIADL). Activities of daily living include walking, sitting for more than 2 hours, getting up from a chair, climbing stairs, stooping, kneeling or crouching, and picking up a dime. Instrumental activities of daily living include preparing a hot meal, shopping for groceries, making a phone call, taking medications, and managing money. Chronic illnesses include high blood pressure, diabetes, cancer, lung problem, heart problem, and arthritis. Psychiatric problem is a dichotomous variable indicating whether the respondent has an emotional, nervous, or psychiatric problem. Self-perceived health status is measured as a categorical variable with five levels: excellent, very good, good, fair, and poor. Satisfaction with health care is a categorical variable with three levels: fully satisfied with health care, somewhat satisfied, and not satisfied. Health behaviors are measured by three dichotomous variables: indicator of whether the respondent participates in vigorous physical activity or exercises three times a week or more, indicator of whether the respondent currently smokes, and indicator of whether the respondent drinks any alcoholic beverages. Health insurance plans are measured using three dichotomous variables indicating whether the respondent has Medicare, Medicaid, and/or private health insurance. Household income, liquid assets, and nonliquid assets are indicators of resources available to the respondent. Household income is the total household income in the year Liquid assets are measured as the sum of balances in checking and saving accounts, CDs, savings bonds, treasury bills, and money market funds. Nonliquid assets include the market value of trusts, stocks, mutual funds, bonds, individual retirement accounts, Keogh, vehicles, business equity, annuities, real estate (excluding home equity), and land after subtracting associated liabilities. RESULTS Characteristics of Users and Nonusers Characteristics of the sample used in this study are summarized in Table 1. The majority of the sample was aged 65 and older. Approximately one third of the sample reported a high school diploma as the highest level of education, and nearly half of the respondents were retired. The majority of the respondents were White (77%). Nearly two thirds of the respondents were married (63%). The majority of the older adults considered religion (text continued on page 36)

7 TABLE 1. Sample Characteristics Total Sample (N = 848) % Preventive/ % Users % Nonusers % Curative Curative Frequency Column % (n = 607) (n = 241) (n = 374) (n = 489) Age (years) 65 and older Education Less than high school High school Some college College Employment status Working Retired Unemployed Gender Male Female Race White Black Others (continued) 33

8 TABLE 1 (continued) Total Sample (N = 848) % Preventive/ % Users % Nonusers % Curative Curative Frequency Column % (n = 607) (n = 241) (n = 374) (n = 489) Marital status Married Widowed Others Importance of religion Important Not important Satisfaction with health care Satisfied Somewhat satisfied Not satisfied Health insurance a Medicare Medicaid Private Health status Psychiatric problem Self-perceived health status Excellent Very good Good Fair Poor

9 Health behavior a Exercise Smoke Alcohol Continuous variables, median b Financial variables (in 10,000 dollars) Household income (1.67, 5.83) (1.75, 6.12) (1.53, 5.50) (1.00, 6.32) (1.64, 6.90) Assets Liquid assets (0.10, 3.50) (0.10, 3.60) (0.10, 3.30) (0.10, 4.00) (0.08, 3.60) Nonliquid assets (0.47, 18.85) (0.5, 22.1) (0.30, 15.25) (0.80, 25.00) (0.4, 19.7) a. Column percentages for the variable will not add to a 100%. b. Numbers in parentheses are the 25th and 75th quartiles, respectively. 35

10 36 C. P. Montalto et al. TABLE 2. Users of Complementary and Alternative Medicine (CAM; n = 607) CAM Frequency % Massage Acupuncture Herbs Chiropractic Breathing exercise Meditate important (90%). The median household income for 1999 was about $33,000. Approximately 72% of the respondents used at least one of the CAM modalities included in this study. The users and nonusers of CAM have very similar sociodemographic characteristics. A higher percentage of users than nonusers were White (79% vs. 74%). A slightly higher percentage of users than nonusers were not satisfied with health care (10% vs. 8%). A higher percentage of users than nonusers reported a psychiatric problem (17% vs. 12%). The median number of chronic illnesses, LADLs, and LIADLs for the users and nonusers were identical (2, 1, and 0, respectively). The characteristics of users of curative and preventive/curative CAM modalities are also very similar (see Table 1). About 60% of the users of curative and preventive/curative modalities were 65 years and older. Nearly one third of the users of curative and preventive/ curative CAM had at least a high school diploma. Nearly half of the users of curative as well as preventive/curative modalities were retired. However, a higher percentage of users of curative modalities compared to users of preventive/curative modalities were White (88% and 75%, respectively). The percentage of users who used each type of CAM modality is presented in Table 2. Chiropractic was found to be the most used form of CAM, with nearly 60% of the older adults reported using chiropractic. About 47% of the users reported use of meditation. Only about 26% of the users reported use of massage, herbs, or breathing exercise. The least reported CAM was acupuncture (10%). The characteristics of users of different types of CAM are reported in Table 3. A much higher percentage of the users of acupuncture, herbs, breathing exercise, and meditation were women. The majority of the users of all types of CAM modalities considered religion important. Overall, the characteristics of users of all types of CAM were very similar. Multivariate Analysis Three logistic models were estimated to identify the predictors of use of at least one CAM modality, use of curative modalities, and use of preventive/curative modalities (Table 4). The models were estimated separately to identify differences in the determinants of CAM use when classified by purpose of use. The logistic model for use of CAM in general did not perform well. None of the possible predictors were statistically significant. Grouping the heterogeneous CAM modalities together may be inappropriate and may reduce the ability to identify predictors of CAM use. The logistic models for use of curative modalities and use of preventive/curative modalities performed slightly better (Table 4). The log likelihood ratio test for the curative model was significant, and three of the predictors had statistically significant coeffi- (text continued on page 42)

11 TABLE 3. Sample Characteristics of Users of Complementary and Alternative Medicine (in percentages) Breathing Massage Acupuncture Herbs Chiropractic Exercise Meditation Variable (n = 160) (n = 58) (n = 151) (n = 366) (n = 148) (n = 285) Age (years) 65 and older Education Less than high school High school Some college College Employment status Working Retired Unemployed Gender Male Female Race White Black Others Marital status Married Widowed Others (continued) 37

12 TABLE 3 (continued) Breathing Massage Acupuncture Herbs Chiropractic Exercise Meditation Variable (n = 160) (n = 58) (n = 151) (n = 366) (n = 148) (n = 285) Importance of religion Important Not important Satisfaction with health care Satisfied Somewhat satisfied Not satisfied Health insurance a Medicare Medicaid Private Health status Psychiatric problem Self-perceived health status Excellent Very good Good Fair Poor Health behavior b Exercise Smoke Alcohol

13 Continuous variables, median b Financial variables (in 10,000 dollars) Household income (1.9, 6.3) (1.8, 5.7) (1.9, 6.8) (1.9, 6.3) (1.5, 4.3) (0.7, 5.5) Assets Liquid assets (0.1, 3.6) (0.2, 3.3) (0.2, 4.0) (0.1, 4.0) (0.1, 3.0) (0.1, 3.6) Nonliquid assets (0.4, 23.7) (0.5, 24.4) (1.0, 34.3) (0.8, 25.6) (0.3, 19.6) (0.3, 17.5) a. Column percentages for the variable will not add to 100%. b. Numbers in parentheses are the 25th and 75th quartiles, respectively. 39

14 TABLE 4. Results of Logistic Regression for Users of Complementary and Alternative Medicine User-Nonuser Curative Preventive/Curative Variable OR 95% CI OR 95% CI OR 95% CI Age (years; 65 and older) , , , 1.02 Education (less than high school) High school , , , 1.55 Some college , , , 1.98 College , , , 1.91 Financial variables (in 10,000 dollars) Household income , , , 1.03 Assets Liquid assets , , , 1.01 Nonliquid assets , , , 1.00 Employment status (retired) Working , , , 1.63 Unemployed , , , 1.08 Gender (female) Male , , , 1.17 Race (Black) White , , , 0.81 Others , , , 1.16 Marital status (others) Married , , , 21.4 Widowed , , , 3.23 Importance of religion (not important) Important , , ,

15 Satisfaction with health care (not satisfied) Satisfied , , , 1.31 Somewhat satisfied , , , 1.45 Health insurance Medicare , , , 1.54 Medicaid , , , 1.67 Private , , , 1.82 Health status Number of chronic illnesses , , , 1.20 Number of LADLs , , , 1.24 Number of LIADLs , , , 1.55 Psychiatric problem , , , 2.18 Self-perceived health status (excellent) Very good , , , 0.97 Good , , , 1.30 Fair , , , 1.20 Poor , , , 1.47 Health behavior Exercise , , , 1.65 Smoke , , , 1.23 Alcohol , , , 1.22 Likelihood ratio * Note. OR = odds ratio; CI = confidence interval; LADLs = limitations in activities of daily living; LIADLs = limitations in instrumental activities of daily life. Statistically significant odds ratios are in bold. *.001 level of significance. 41

16 42 C. P. Montalto et al. cients. White older adults were nearly 4 times as likely to use curative CAM as the Black older adults (odds ratio = 3.95). Respondents who were somewhat satisfied with health care were about half (odds ratio = 0.5) as likely to use curative CAM modalities as respondents who were not satisfied with health care. Number of LADLs was positively associated with likelihood of use of curative CAM modalities. The odds ratio (1.16) suggests that an additional LADL increased the odds of using curative CAM by a factor of about one sixth. The model test for the preventive/curative model was not significant, but 4 of the 20 possible predictors were statistically significant. The odds of use of preventive/curative modalities were one half as large for Whites as for Blacks (odds ratio = 0.5). In other words, Whites were less likely to use preventive/curative modalities. Widowed older adults were nearly twice as likely as older adults in other marital status groups to use preventive/ curative CAM modalities (odds ratio = 1.87). Among the health status variables, the number of LADLs was positively associated with the likelihood of use of preventive/curative CAM modalities. The odds ratio (odds ratio = 1.12) suggests that additional LADLs increased the odds of using preventive/curative CAM by a factor of about one eighth. Compared to respondents in excellent health, respondents in very good health were less likely to use preventive/curative CAM. The odds of preventive/curative CAM use were nearly two thirds (odds ratio = 0.60) as large for respondents reporting good health than those reporting excellent health. Separate logistic regression models were also estimated to identify the predictors of use of each CAM modality with the exception of acupuncture because of the small number of older adults reporting acupuncture use. Results of this analysis are available by request from the authors. DISCUSSION More than half of older adults use CAM. The percentage of users among older adults is higher than the rates of 41% reported by Astin et al. (2000) and 43% reported by McMahan and Lutz (2004). This may be caused by differences in the populations sampled. Astin et al. (2000) examined CAM use among respondents age 65 years and older, whereas McMahan and Lutz (2004) examined adults aged 65 to 74 years. The present study includes adults aged 50 and older. Chiropractic was the most commonly used form of CAM in this study, a finding consistent with a study of adults aged 65 and older by Foster et al. (2000). The usage rate of herbs found in this study is higher than the percentage reported by Eisenberg et al. (1998) and Foster et al. (2000). Previous research has reported acupuncture use by about 14% of users of CAM among older individuals (Astin et al., 2000; Najm et al., 2003). Older adults belonging to the Black racial group, those who are widowed, and those reporting more LADLs are more likely to use CAM compared to their comparison groups. Previous studies have reported a higher use of CAM among Whites compared to other racial and ethnic groups (Ni, Simile, & Hardy, 2002). This study shows that Whites are more likely to use curative modalities whereas Blacks are more likely to use preventive/ curative modalities that include self-administered modalities. This result might reflect access issues as well as cultural significance of some CAM modalities among the racial and ethnic subpopulations. Conboy et al. (2005) found that widowed individuals were less likely than married individuals to use most of the CAM modalities included in the study. However, widowed individuals were more likely to use self-prayer compared to married individuals.

17 Use of CAM by Older Adults 43 Loera et al. (2001) reported a positive association between LADLs and use of herbal medicines by older Mexican Americans. The lack of association between number of chronic illnesses and use of CAM is consistent with McGregor and Peay (1996). Examining chronic illnesses such as arthritis, cancer, and heart disease separately rather than controlling for the total number of chronic illnesses might better decipher the relationship between chronic illnesses and CAM use. For example, Eisenberg et al. (1998) found a positive association between arthritis and CAM use. The finding that those who are in excellent health compared to those in good health are more likely to use CAM partially contradicts the hypothesis that use of CAM increases with deterioration in health and may suggest that respondents in excellent health use alternative health care for preventive purposes. There are differences between the predictors of use of curative and preventive/curative modalities. Differences also exist in the predictors of use of specific types of CAM modalities. Although previous studies consistently indicate that Whites are more likely to use CAM, separate analysis of each CAM modality in this study indicates that Whites are less likely to use meditation compared to Blacks. This indicates that grouping heterogeneous CAM into one category might hide some of the important differences in patterns of use. The empirical results suggest that to accurately identify determinants of CAM use, it is necessary to classify CAM on the basis of use and other dimensions such as complexity of the modalities. One of the limitations of this study is the overlap of respondents in the sample of users of curative and preventive/curative CAM. This limits the identification of unique factors affecting the use of these two types of CAM. The results do suggest that predictors of use differ across types of CAM. A qualitative study of purposes of use of CAM would provide more insight into factors associated with use. IMPLICATIONS AND CONCLUSIONS A high percentage of older adults are using CAM, and this has significant implications for health care providers. Compared to the conventional health care market, the market for alternative health care products, such as herbal medicines, and services, such as acupuncture and chiropractic, is relatively new for consumers. The majority of the users of CAM do not disclose CAM use to their physicians (Tindle et al., 2005). Providers should question older adults about their CAM use to avoid adverse consequences of interaction between conventional care and CAM. The heavy use of CAM among these older adults calls for reliable scientific information about the effectiveness and safety of these modalities. There is also a need for increased monitoring of the information regarding the effectiveness of CAM modalities disseminated through Web sites and other media sources. From the public health perspective, a high use of CAM among older adults calls for targeting CAM education to these groups as well as the health care providers, especially if CAM is used along with conventional medicine. The use of CAM by older adults increases the demand on their financial resources and might have an effect on the ability to purchase other recommended and necessary health care. With the growing popularity of CAM, consumers are likely to demand health insurance coverage of CAM. According to Harris, Ripperger, and Horn (2000), the managed care industry expanded the coverage of CAM in health plans to increase access to the health care system. Consequences of providing CAM coverage have not yet been assessed. Given the likely impact of health insurance coverage of CAM on the cost of health care, this area needs to be explored.

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20 46 C. P. Montalto et al. alternative medicine and economics of obesity. Gong Soog Hong, PhD, is a consumer economist and professor and chair in the Department of Consumer Sciences at Ohio State University. Her research focuses on health care of the elderly and children and out-ofpocket health care expenditures across the life span. Address correspondence to: Catherine P. Montalto, PhD, Department of Consumer Sciences, The Ohio State University, 1787 Neil Avenue, #265 J, Columbus, OH