Complementary and Alternative Medicine Use Among Military Family Medicine Patients in Hawaii

Transcription

1 MILITARY MEDICINE, 175, 7:534, 2010 Complementary and Alternative Medicine Use Among Military Family Medicine Patients in Hawaii CPT Jeremy B. Kent, MC USA ; MAJ Robert C. Oh, MC USA ABSTRACT Complementary and alternative medicine (CAM) is a growing component of medicine within the U.S. civilian and military populations. Tripler Army Medical Center (TAMC) Family Medicine Clinic represents an overseas medical facility stationed among a diverse ethnic population. The impact that local cultures have on CAM utilization in the military population in overseas medical facilities is unknown. Methods: Cross-sectional survey. The authors surveyed all volunteer soldiers, family members, and retirees 18 years old or greater enrolled at TAMC Family Medicine Clinic with appointments between September 1 and September 25, Results: 503 volunteers were surveyed with a response rate of 73% ( n = 369). A total of 50.7% reported using at least one CAM therapy within the last year. CAM use was significantly higher among women, Caucasians, and a college level education or greater. Conclusion: Prevalence of CAM use is higher within a military family medicine clinic in Hawaii than the prevalence among mainland civilian or other military populations. INTRODUCTION Complementary and alternative medicine (CAM) is a growing aspect of health care within the United States (U.S.) population. CAM is a nonspecific and broad term to describe a large group of diverse health care modalities that are not commonly considered to be a part of conventional medicine. As a result, defining CAM is difficult. Generally, CAM is divided into four groups of therapies: mind body medicine such as meditation, biologically based therapies such as herbal medications, manipulative and body-based practices such as chiropractics, and energy medicine such as therapeutic touch. A fifth group termed whole medical systems uses multiple CAM therapies. Whole medical systems include homeopathic medicine and traditional Chinese medicine. ( nccam.nih.gov/ ). 1 Studies show that CAM is used by approximately 38% of the U.S. population. 2 5 Studies also show that the prevalence of CAM use among active duty military personnel is very similar to the civilian population. 6,7 Conversely, the use of CAM within the Hawaiian civilian population is significantly higher than mainland U.S. with a prevalence of 49.9%. 8,9 The higher prevalence may be attributed to Hawaii s diverse ethnicities that include Asian influence, local Hawaiian beliefs, and other South Pacific cultures within a state without a real majority The 2005 Hawaii Census shows that of those questioned, 57% considered themselves Asian, 42% White, 22% Pacific Islander, 3% Black, and 2% Native American. 9 Department of Family Medicine, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI Presentation: Bass Competition, Department of Clinical Investigation, Tripler Army Medical Center, May 27, The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. Army Medical Command, Department of the Army (paragraph 6-8 AR 360-1), Department of the Defense, or the U.S. government. With the immigration of Japanese and Chinese people to Hawaii in the 1800s they brought with them many health care practices that are well known CAM therapies today, such as Reiki from Japan and acupuncture from China. Hawaii also has CAM that is distinctly Hawaiian. Native Hawaiian spiritual healers known as Kahuna have been practicing Lomilomi massage, giving spiritual healing, and offering herbal medicines since their migration to Hawaii Lomilomi means to press or massage in Hawaiian. Although there are now many different forms of Lomilomi massage, it has traditionally been a holistic healing technique that was brought with the first Polynesians on their migration to Hawaii. The traditional form not only uses massage, but also incorporates prayer and herbal medicines. 15 The kava culture of the Pacific dates back hundreds of years in Hawaiian society. Kava is a plant of the Pacific of which the root has been used for anxiety, stress, and insomnia. It has played a role in certain medical, political, and social ceremonies in Pacific cultures This melting pot of beliefs and cultures may be why there is a higher prevalence of CAM use not seen in the continental U.S. The U.S. military in Hawaii is exposed to these diverse cultures, which may lead to greater CAM use among the military Some of the soldiers and dependents have Hawaiian or Asian lineage. These same soldiers and family members are seen at Tripler Army Medical Center (TAMC) Family Medicine Clinic. As a full scope clinic taking care of every branch of the U.S. military, TAMC Family Medicine Clinic is a good representation of a diverse military population outside the continental United States (OCONUS). As the prevalence of CAM use increases, there is more potential for interactions with conventional medicine. Providers need to be aware of CAM use among their patients to prevent these interactions. The goal of this study is to determine the prevalence and types of CAM use at an OCONUS military medical clinic among the distinctly different and ethnically diverse background of Hawaii. 534 MILITARY MEDICINE, Vol. 175, July 2010

2 METHODS Study Population The survey consisted of volunteers who were 18 years old or greater and enrolled at TAMC Family Medicine Clinic with scheduled appointments between the dates of September 1, 2008 to September 25, The TAMC Family Medicine Clinic consists of a patient population of approximately 10,000 active duty personnel, dependents, and retired service members from all branches of the military to include the U.S. Army, Navy, Air Force, and Coast Guard. The study protocol was approved by the human use committee at Tripler Army Medical Center. Investigators adhered to the policies for protection of human subjects as prescribed in 45 CFR46. Survey A modified survey instrument fielded by Smith 7 in a study of CAM use among U.S. active duty Navy and Marine Corps personnel was used with the author s permission. The survey queried the volunteer s use of CAM, specific CAM therapies used, and demographic data. Volunteers were recruited when they checked in for their appointments at the TAMC Family Medicine Clinic. Volunteers were instructed to fill out the survey during the visit and leave it in one of three labeled drop boxes. The survey was coded with a nonidentifiable number to determine nonresponse rates. The three-page survey was designed to be completed in 5 minutes. CAM Definition The definition of CAM that was used in this study is similar to the criteria used by Smith and Eisenberg. 1,5,7 Three CAM therapies were also added that were included in a Hawaii study. 8 These were chelation, naturopathy, and Ayrvedic medicine. CAM use was defined as any of the below therapies used within the last year: acupuncture, chiropractics/osteopathy, homeopathy, energy healing, spiritual/religious healing, folk remedies, massage therapy, biofeedback, hypnosis, high-dose megavitamins, art/music therapy, Ayrvedic medicine, Chinese medicine, herbal therapy, chelation, exercise/movement therapy, naturopathy, aromatherapy, and relaxation healing. Statistical Analysis and Power Analysis Descriptive statistics using frequency, means, and standard deviation described our population studied. Education was collapsed and the highest level education completed was used (high school and college or greater) for bivariate and multivariate analysis. Bivariate analyses using c 2 tests assessed for significant associations between CAM use and demographic variables. A multivariate model using logistic regression assessed for independent associations of CAM use with significant demographic variables. The enter method and forward stepwise regression were both utilized. All analyses were conducted using SPSS software version 13.0 Windows. Power Analysis A power analysis was conducted and it was determined that surveys were needed to estimate a prevalence of 45% (±5%) with a 95% confidence interval using the Family Medicine enrollment base of 10,000 beneficiaries. RESULTS A total of 503 surveys were handed out. A total of 369 were returned for analysis with a response rate of 73%. Demographic data are presented in Table I. In this study, the prevalence of CAM use was 50.7%. The therapies used the most were: massage therapy (58.3%, n = 109), relaxation (31.0%, n = 58), osteopathic manipulative treatments (OMT)/chiropractics (30.5%, n = 57), and herbals (29.4%, n = 55). The least used therapies were chelation, Ayrvedic medicine, and TABLE I. Demographics of Complementary and Alternative Medicine Survey Volunteers Characteristic N = 369 (% Total) Gender Male 101 (28.5) Female 254 (71.5) Race/Ethnicity Caucasian(non-Hispanic) 179 (48.8) Hispanic 26 (7.1) African-American/Black 48 (13.1) Asian 60 (16.3) Pacific Islander 37 (10.1) Other 17 (4.6) Education Level Completed High School 192 (52.2) College Degree 136 (37.0) Graduate Degree or Higher 36 (9.8) Other 4 (1.1) Total Household Income <19,000 8 (2.2) 20,000 34, (13.3) 35,000 49, (19.6) 50,000 74, (26.5) 75,000 99, (14.9) 100,000 or More 52 (14.4) Don t Know 33 (9.1) Marital Status Single 26 (7.1) Married 297 (81.6) Separated 7 (1.9) Divorced 22 (6.0) Widowed 12 (3.3) Military Status Active Duty/Reserve 100 (28.3) Dependent 200 (56.7) Retired 53 (15.0) Age (19.9) (35.9) (19.9) (12.7) (5.5) >65 22 (6.1) MILITARY MEDICINE, Vol. 175, July

3 hypnosis ( Fig. 1 ). Of the 50% of participants who reported use of CAM therapy, 73% reported using two or more therapies. CAM therapies were used five or more times by 18% of the participants (Fig. 2 ). In bivariate analysis, White/non-Hispanics ( p value = 0.025), women ( p value = 0.002), and those completing a college degree or higher ( p value = 0.015) were found to be significantly associated with CAM use. Similarly in multivariate analysis, these variables remained significantly associated with CAM use. Table II and Table III show bivariate and multivariate results. DISCUSSION The prevalence of CAM use among the active duty military population has been shown to be similar to the civilian population. 2,4,6,7 Military personnel are stationed worldwide and are FIGURE 1. Percentage of CAM use. FIGURE 2. Level of CAM use. 536 MILITARY MEDICINE, Vol. 175, July 2010

4 TABLE II. Bivariate Results and P Values of CAM Use Characteristic CAM Use, N = 186 (% of Total) p value Gender Male 38 (37.6) Female 140 (55.1) Race/Ethnicity Caucasian (Non-Hispanic) 105 (58.7) Hispanic 14 (53.8) African-American/Black 15 (31.1) Asian 27 (45.0) Pacific Islander 16 (43.2) Other 8 (47.1) Level of Education High School 82 (42.7) College Degree 80 (58.8) Graduate Degree or Higher 20 (55.6) Other 4 (100.0) Total Househould Income <19,000 3 (37.5) 20,000 34, (41.7) 35,000 49, (49.3) 50,000 74, (13.3) 75,000 99, (53.7) 100,000 or More 31 (59.6) Don t Know 13 (39.4) Marital Status Single 10 (38.5) Married 150 (50.5) Separated 3 (42.9) Divorced 15 (68.2) Widowed 6 (50.0) Military Status Active Duty/Reserve 49 (49.0) Dependent 100 (50.0) Retired 28 (52.8) Age (47.2) (46.2) (61.1) (52.2) (50.0) >65 9 (40.9) exposed to a number of different cultures and potential CAM therapies. Hawaii is a good representation of an OCONUS military site with a military population exposed to a multitude of mainstream and native CAM therapies. The results of this study show a higher prevalence of CAM use compared to the general U.S. and mainland active duty population, but similar prevalence compared to the local Hawaiian population. 2,7,8 The greater CAM use suggests a local influence from a population of higher utilizers of CAM therapy. The authors speculate that this may be due to an increased availability or increased acceptance of CAM within Hawaii that leads to a greater use among our patient population. A higher prevalence was also noted among a population visiting a conventional medicine clinic as opposed to a general population survey. As such, the prevalence represents patients who will ultimately be seen at the TAMC Family Medicine TABLE III. Multivariate Analysis With Adjusted Odds Ratios and Confidence Intervals of Significant Variables of CAM Use Variable CAM Use (% of Total) OR 95% CI Caucasian (Non-Hispanic) 105 (58.7) Education (Completed 100 (58.1) College Level or Greater) Female 140 (55.1) Clinic. These are the same patients who need guidance and education about potential interactions between conventional and CAM therapies. The data suggest that the odds of CAM use is significantly greater among women, White/non-Hispanics, and those with a completed education of college level or higher, which is consistent with previous National Institutes of Health-funded nationwide surveys. 2 4 Barnes et al. 2 surveyed a national sample of households by phone and showed that CAM use was also significant among women, White/non-Hispanics, and those with a higher level of education. The study suggests that if a patient is going to use CAM therapy they are more likely to use more than one type and many will use multiple therapies. The more commonly used CAM therapies were consistent with previous studies. 2 4 Our findings suggest that Asian and Polynesian ethnicities are less likely than Whites to use CAM therapies which are contradictory to the Hawaiian study. This is most likely the result of our patient selection. Those enrolled in the clinic are more likely to use conventional therapy even if they are ethnically similar to the local population. Secondly, our patient demographics surveyed fewer Asians and Polynesians. We likely did not have adequate power to detect a difference among the Asian and Polynesian population. Our findings suggest that the higher prevalence of CAM use is the result of the local civilian population s influence on the military population and not due to military personnel who are ethnically similar to the local population. Health providers working in overseas medical facilities should be aware that their patient population may have a higher prevalence of CAM use compared to continental U.S. medical facilities. They should also be aware that if the patient is using CAM they are more likely using multiple therapies. As CAM use grows, lack of patients reporting its use continues to pose an increased risk for interaction with conventional medicine This study reaffirms the need to ask patients about CAM therapies used. There are limitations to this study. The data were selfreported and are subject to reporting bias. Generalizability of this study to other nonmilitary populations may be limited. This study was limited to those patients who made appointments to the TAMC Family Medicine Clinic and may have selected for people who are not as healthy or are more likely to seek out conventional medicine. However, these are patients that physicians may encounter in a primary care setting and may represent those that are more likely to utilize CAM MILITARY MEDICINE, Vol. 175, July

5 therapies. The study only surveyed prevalence of CAM use and did not study the reason volunteers used CAM, specific diseases they were trying to treat, or outcomes of CAM use. Future studies should be done to help answer these questions. In spite of its limitations, this study has a number of distinct characteristics that contribute to our understanding of CAM use. The response rate of the study was excellent. This study gives a diverse representation of all services; Army, Navy, Air Force, and Coast Guard. Further studies are needed to help characterize CAM use among military medical installations outside the mainland United States. ACKNOWLEDGMENTS This work was supported by Tripler Army Medical Center Family Medicine Department. REFERENCES 1. NIH : What is Complementary and Alternative Medicine? National Center for Complementary and Alternative Medicine. Bethesda, MD, National Institutes of Health, Available at ; accessed November 1, Barnes PM, Bloom B, Nahin RL : Complementary and Alterantive Medicine Use Among Adults and Children: United States, National Health Statistics Report, No 12, December 10, Barnes PM, Powell-Griner E, McFann K, Nahin RL : Complementary and Alternative Medicine Use Among Adults: United States, Adv Data 2004; Eisenberg DM, Davis RB, Ettner SL, et al : Trends in alternative medicine use in the United States, : results of a follow-up national survey. JAMA 1998 ; 280 (18) : Eisenberg DM, Kessler RC, Foster C, et al : Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993 ; 328 (4) : Arsenault J, Kennedy J : Dietary supplement use in U.S. Army Special Operations candidates. Mil Med 1999 ; 64 (7) : Smith TC, Ryan MAK, Smith B, et al : Complementary and alternative medicine use among US Navy and Marine Corps personnel. BMC Complement Altern Med 2007 ; 7: Harrigan R, Thomas J, Easa D, et al : Use of provider delivered complementary and alternative therapies in Hawai i: results of the Hawai i Healthy Survey. Hawaii Med J 2006 ; 65 (5) : State of Hawaii : Hawaii Census 2005 Data. The State of Hawaii Business Resource Web site. Available at ; accessed May 15, Baldwin CM, Long K, Kroesen K, Brooks AJ, Bell IR : A profile of military veterans in the southwestern United States who use complementary and alternative medicine: implications for integrated care. Arch Intern Med 2002 ; 162 (15) : Mackenzie ER, Taylor L, Bloom BS, et al : Ethnic minority use of complementary and alternative medicine (CAM): a national probability survey of CAM utilizers. Altern Ther Health Med 2003 ; 9 (4) : Maskarinec G, Shumay D, Kakai H, Gotay CC : Ethnic differences in complementary and alternative medicine use among cancer patients. J Altern Complement Med 2000 ; 6 (6) : McEachrane-Gross FP, Liebschutz JM, Berlowitz D : Use of selected complementary and alternative medicine (CAM) treatments in veterans with cancer or chronic pain: a cross-sectional survey. BMC Complement Altern Med 2006 ; 6: Katz P, Lee F : Racial/ethnic differences in the use of complementary and alternative medicine in patients with arthritis. J Clin Rheumatol 2007 ; 13 (1) : Chai MR : Na Mo olelo Lomilomi: Traditions of Hawaiian Massage and Healing, pp Korea, Bishop Museum, Daws G : Shoal of Time: A History of the Hawaiian Islands, pp xi xiii. Honolulu, HI, University of Hawaii Press, Gutmanin J, Monden SG : Kahuna La au Lapa au: Hawaiian Herbal Medicine. Australia, Island Heritage Publishing, Lindstrom L, Lebot V, Merlin MD : Kava: The Pacific drug. New Haven, CT, Yale University Press, Mathews JM, Etheridge AS, Valentine JL, et al : Pharmacokinetics and disposition of the kavalactone kawain: interaction with kava extract and kavalactones in vivo and in vitro. Drug Metab Dispos 2005 ; 33 (10) : Singh YN : Kava: From Ethnology to Pharmacology, pp New York, Taylor and Francis, Ernst E : Complementary medicine: its hidden risks. Diabetes Care 2001 ; 24 (8) : Ernst E : Risks associated with complementary therapies. In: Meyler s Side Effects of Drugs, Ed 14, pp Edited by Dukes MNG, Aronson JK. Amsterdam, The Netherlands, Elsevier Science, Elmer GW, Lafferty WE, Tyree PT, Lind BK : Potential interactions between complementary/alternative products and conventional medicines in a Medicare population. Ann Pharmacother 2007 ; 41 (10) : Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST : Use of prescripation and over the counter medications and dietary supplements among older adults in the United States. JAMA 2008 ; 300 (24) : MILITARY MEDICINE, Vol. 175, July 2010