part 3: original paper

Trends in the Use of Complementary and

Alternative Medicine in the United States: 2002–2007
Dejun Su, PhD
Lifeng Li, MPH

Abstract: In this study we seek to assess recent trends in complementary and alternative
medicine (CAM) use based on a comparative analysis of data from the 2002 and 2007
National Health Interview Survey (NHIS). The findings suggest that CAM use, in par-
ticular the use of provider-based CAM therapies such as chiropractic care, massage, and
acupuncture, have grown significantly in the U.S. This growth was more pronounced among
non-Hispanic Whites than among racial and ethnic minorities, increasing an already exist-
ing White-minority gap in CAM use. Findings from this study also reveal that CAM use
becomes more likely when access to conventional care has been restricted. In both 2002
and 2007, having unmet needs in medical care or having delayed care due to cost were
associated with a higher chance of CAM use.
Key words: Complementary and alternative medicine, trends, disparities, U.S.

C omplementary and alternative medicine (CAM) refers to a series of medical and

health care practices and products that are not an integral part of conventional
medicine due to insufficient proof of their safety and effectiveness.1 The use of CAM
increased substantially in the United States between 1990 and 2002. Survey data based
on nationally representative samples indicate that the proportion of adults using CAM
practices, therapies, and products within the last year increased from 34% in 1990 to
62% in 2002.2 Until the recent release of the 2007 National Health Interview Survey
(NHIS) data, little has been known about trends in CAM use in the U.S. since 2002.
In this study, we seek to assess the most recent trends in CAM use by conducting a
comparative analysis of data from the 2002 and 2007 NHIS. In particular, we hypoth-
esize that, in the five-year period between 2002 and 2007, as the cost of conventional
medical care was constantly escalating and an increasing proportion of Americans
were uninsured or underinsured, CAM use would become more prevalent among
Americans. Existing evidence shows that CAM use becomes more likely when access
to conventional care has been restricted. Using survey data from the 2002 NHIS, Pagán

Dejun Su is affiliated with the Department of Sociology and the South Texas Border Health Disparities
Center, both at the University of Texas–Pan American (UT-PA), in Edinburg, Texas. Lifeng Li is
affiliated with the Department of Economics and Finance, College of Business Administration, at UT-PA.
Please address correspondence to Dejun Su, PhD, Department of Sociology, University of Texas–Pan
American, 1201 West University Drive, Edinburg, TX 78541; (956) 380-8798; dsu@utpa.edu.

Journal of Health Care for the Poor and Underserved  22 (2011): 296–310.
 Su and Li 297

and Pauly examined the relation between access to conventional medical care and the
use of CAM.2 The results indicated that respondents who did not get or delayed getting
needed medical care due to cost in the 12 months prior to the survey were also more
likely than other adults to use CAM. This suggests, as Pagán and Pauly concluded, that
the recent growth in CAM use could well be related to increases in the relative cost
of conventional health care. In our study, we explicitly relate CAM use and its recent
trends to the experience of having unmet medical needs or delayed care due to cost
and assess whether and the extent to which the effect of access to conventional care
on CAM use changed from 2002 to 2007.
We further hypothesize that the growth in CAM use from 2002 to 2007 was uneven
across racial and ethnic groups. Previous studies have revealed that for most of the
major CAM therapies, the rate of use is higher among non-Hispanic Whites than
among racial and ethnic minorities,3 and higher among U.S.-born Americans than
among immigrants.4 These disparities in CAM use, in combination with the constantly
increasing share of racial and ethnic minority population in the U.S.,5 can have a pro-
found impact on the overall dynamics of CAM use in the U.S. and their trajectories
in the future.
To test these hypotheses, in this study we first assessed net changes in the prevalence
of CAM use in the U.S. from 2002 to 2007 by taking into account compositional changes
across the 2002 and 2007 NHIS. We then examined racial and ethnic disparities in CAM
use in both the 2002 and 2007 NHIS. By comparing corresponding findings across the
samples we were thus able to reveal whether and the extent to which the gaps in CAM
use across racial and ethnic groups were changing in the period. Finally, to determine
the trends in the relationship between access to conventional medical care and CAM
use, we correlated CAM use with the experience of having unmet medical needs or
delayed care due to cost in both NHIS samples.

Methods
Data and measures. The data used in this study come from the 2002 and 2007 NHIS.
The NHIS, conducted annually by the National Center for Health Statistics, is a nation-
ally representative, cross-sectional survey of the civilian non-institutionalized U.S.
population. It employs a multistage design and oversamples African Americans and
Hispanics. For each year, the NHIS contains similar core and variable supplemental
questionnaires. The core questionnaires provide information on demographics, health
status, health behaviors, and health care access and utilization. Both the 2002 and 2007
NHIS have a CAM supplement. The consistency in the sample design, weighting, and
CAM modalities covered in the 2002 and 2007 NHIS makes it straightforward to com-
pare across the two samples. The samples used in this study consist of 30,267 adults in
the 2002 NHIS and 20,769 adults in the 2007 NHIS.
Both 2002 and 2007 NHIS Adult CAM supplements contain questions on CAM use
in the 12 months prior to the survey. The 2002 CAM supplement includes questions
on 27 types of CAM therapies, and the 2007 CAM supplement covers 36 CAM thera-
pies. After matching the definitions of each CAM therapy in both years, we focused
our analysis on 15 major CAM therapies, including 11 provider-based (chiropractic
298 Complementary and alternative medicine

care, massage, homeopathy, acupuncture, energy healing therapy/Reiki, hypnosis,

naturopathy, biofeedback, folk medicine, ayurveda, and chelation therapy) and four
non-provider-based CAM therapies that do not necessarily require providers (relax-
ation techniques, yoga-taichi-qigong, special diets, and prayer for health reasons). The
definitions of these CAM therapies can be found in the appendix. Since prayer for
health reasons was excluded from some of previous CAM studies, we analyzed prayer
for health reasons separately to compare the difference in CAM uses with and without
including prayer for health reasons.6
Besides information on the use of CAM therapies, the 2002 and 2007 NHIS also
collected information on racial and ethnic background, health insurance coverage, and
unmet medical needs or delayed care due to cost during the 12 months prior to the
survey. In our study, we assessed differences in CAM use across four major racial and
ethnic groups in the U.S.: non-Hispanic Whites, African Americans, Hispanics, and
Asians. In terms of health insurance coverage, the NHIS asks respondents to select from
these categories: private health insurance, public health insurance including Medicaid,
Medicare, SCHIP, military, and other public insurance programs, and no health insur-
ance. We collapsed the classification into two major categories, including insured and
uninsured. Experience of unmet medical needs or delayed care due to cost during the
12 months prior to the survey was measured based on two questions in the NHIS: 1)
During the past 12 months, was there any time when {person} needed medical care, but
did not get it because {person} couldn’t afford it?; and 2) During the past 12 months, has
medical care been delayed for {person} because of worry about the cost? If a respondent
answered yes to either of the two questions, the respondent was coded in our study as
having unmet medical needs or delayed care due to cost.
We first computed the prevalence of CAM use among the sample adult respondents
in 2002 and 2007. The percentage change of CAM use from 2002 to 2007 and the Pear-
son’s chi-squared statistics were calculated to examine the magnitude of the changes.
Adjusting for compositional changes across the two NHIS samples is an important
issue in assessing changes in prevalence of CAM use from 2002 to 2007. It is important
because the differences in percentages of CAM use between the 2002 and 2007 NHIS
samples can be attributed to two factors: differences in sample composition and dif-
ferences in the actual prevalence of CAM use. Despite the fact that both the 2002 and
2007 NHIS consist of nationally representative samples, there are notable differences
in sample composition. For example, a comparison between the 2002 and 2007 NHIS
suggests that relative to the 2002 NHIS, the 2007 NHIS incorporates a higher proportion
of respondents who are older, who are of Hispanic or Asian origin, who have a family
income of over $75,000, and who report unmet needs for medical care or delayed care
due to cost. Therefore, a mere comparison between percentages of CAM use across the
two NHIS samples without considering changes in sample composition could lead to
biased or even misleading conclusions.
In our study, to adjust for compositional changes across the two NIHS samples, we
first ran logistic regressions in the 2007 NHIS to relate use of specific CAM therapies
to a set of explanatory variables including age, gender, race/ethnicity, marital status,
educational attainment, family income, employment status, region of residence, self-
reported health status, history of chronic diseases, health insurance status, and having
 Su and Li 299

had unmet medical needs or delayed care due to cost. The coefficients of these explana-
tory variables were then used to predict the level of CAM use in the 2002 NHIS. By
comparing the estimated and actual CAM use in the 2002 NHIS, we were able to
assess the extent to which the changes in CAM use from 2002 to 2007 was driven by
structural changes in sample composition such as the aging of the population and an
increasing share of immigrants. This allowed us to answer an important question: if
the respondents in the 2002 NHIS sample were subjected to the structural relation
between CAM use predictors and CAM use as observed in the 2007 sample, to what
extent would this change the level of CAM use in 2002?
We then examined racial and ethnic disparities in CAM use in both the 2002 and
2007 NHIS samples. For each racial and ethnic group, we estimated the percentage of
CAM use in each year and calculated whether the percentage change over time was
statistically significant based on the Pearson’s chi-squared test. Similar analyses of CAM
use were also conducted for groups that had or had not reported unmet medical needs
or delayed care due to cost.
All estimates of the study were calculated using Stata 10. A specific Stata program—
svy commands—was used to account for the complex multistage sample design by
NHIS.7 All estimates were also weighted using the sample adult record weight in order
to represent the civilian non-institutionalized U.S. population of 18 years or over.

Results
Changes in prevalence of CAM use in the U.S. from 2002 to 2007. For most of the
CAM therapies considered, respondents in the 2007 NHIS reported significantly more
use than those in the 2002 NHIS, as indicated in Table 1. Without counting prayer
for health reasons, the proportion of respondents reporting use of at least one CAM
therapy increased from 25.7% to 29.4%, a relative increase of 14.2%. The corresponding
relative increase becomes 10.4% when prayer for health reasons is counted.
A comparison between provider-based and non-provider-based CAM use suggests
that the growth in CAM use from 2002 to 2007 was more pronounced in the case of
provider-based CAM therapies. About 16% of the 2007 sample reported use of at least
one provider-based CAM therapy, compared with 12.5% in the 2002 sample. The cor-
responding gap in the case of non­provider-based CAM is 19.9% versus 18.5% when
prayer for health reasons has not been counted.
In terms of the use of specific CAM therapies, some experienced more significant
growth between the two periods than others. Among provider-based CAM therapies,
the increase in use is more significant in chiropractic care, massage, acupuncture, and
folk medicine. As for non­provider-based CAM therapies, modest increase was observed
for the use of yoga-taichi-qigong, relaxation techniques, and prayer for health reasons.
For instance, the proportion of the respondents reporting use of prayer for health
reasons increased from 44.6% in 2002 to 50.1% in 2007. Among all CAM therapies
considered in this study, the only one that experienced a significant decrease in use
is special diets.
We then estimated the extent to which the observed gap in CAM use across the two
samples can be attributed to differences in sample composition by using the regression
300 Complementary and alternative medicine

Table 1.
CHANGES IN PERCENTAGES OF CAM USE
BETWEEN THE 2002 AND 2007 NHIS SAMPLES

2002 CAM
use based on
2002 2007 % change 2007 regression
CAM therapies (%) (%) since 2002 coefficienta

At least one CAM (without prayer) 25.71 29.37 14.24*** 28.79

At least one CAM (with prayer) 55.26 60.98 10.35*** 63.19
Provider-based CAM
  At least one CAM 12.47 16.16 29.59*** 15.43
  Chiropractic care 7.53 8.62 14.48*** 8.32
  Massage 4.97 8.31 67.20*** 7.80
  Homeopathy 1.70 1.81 6.47 1.82
  Acupuncture 1.06 1.44 35.85*** 1.32
  Energy healing therapy/Reiki 0.53 0.56 5.66 0.58
  Hypnosis 0.25 0.26 4.00 0.30
  Naturopathy 0.25 0.34 36.00 0.36
  Biofeedback 0.14 0.17 21.43 0.17
  Folk medicine 0.12 0.37 208.33*** 0.45
  Ayurveda 0.08 0.10 25.00 0.11
  Chelation therapy 0.03 0.05 66.67 0.13
Non-providered-based CAM
(without prayer)
  At least one CAM 18.45 19.89 7.80*** 19.95
  Relaxation techniques 14.49 16.04 10.70*** 16.14
  Yoga-Taichi-Qigong 5.83 6.67 14.41*** 6.61
  Special diets 3.52 2.86 -18.75*** 2.94
Non-providered-based CAM
(with prayer)
  At least one CAM 51.54 56.36 9.35*** 58.90
Prayer for health reasons 44.59 50.07 12.29*** 52.74

*p,.1
**p,.05
***
p,.01
a
Estimated CAM use in 2002 was based on regression coefficients predicting CAM use in the 2007
NHIS sample.
CAM 5 Complementary and Alternative Medicine
NHIS 5 National Health Interview Survey
 Su and Li 301

coefficients on CAM use from the 2007 sample to predict CAM use in the 2002 sample.
A comparison between the predicted level of CAM use in 2002 and the observed level
of CAM use in 2007 suggests that had the respondents in the 2002 NHIS used CAM at
a rate similar to that of their counterparts in the 2007 NHIS, the overall gap in terms
of CAM use between the two samples would be substantially reduced. For instance, if
the respondents in the 2002 NHIS were subjected to the relation between predictors
of CAM use and the predicted likelihood of CAM use as indicated by the regression
coefficients based on the 2007 NHIS, the proportion that used at least one CAM (with-
out considering prayer for health reasons) would increase from the observed 25.7% to
the predicted 28.8%, which comes very close to the 29.4% reported in the 2007 NHIS.
This suggests that the observed differences in CAM use between the two samples are
not mainly caused by compositional differences in the two samples, but mostly by an
elevated prevalence of CAM use by respondents in the 2007 NHIS.
Racial/ethnic differences in CAM use in the U.S. from 2002 to 2007. Results in
Table 2 reveal a clear pattern in racial/ethnic differences in CAM use: excluding prayer
for health reasons, non-Hispanic Whites (NHWs) had the highest prevalence rate of
using at least one CAM therapy in both 2002 and 2007, followed by Asian Americans,
African Americans, and Hispanics. In 2007, 33% of NHWs reported using at least one
CAM therapy, compared with 31.8% for Asian Americans, 20.1% for African Americans,
and 16.9% for Hispanics. Thus, it appears that NHWs and Asian Americans used more
CAM therapies than African Americans and Hispanics did.
The elevated rate of CAM use by NHWs, relative to racial/ethnic minorities, becomes
even more salient in the use of provider-based CAM therapies. In terms of use of at
least one provider-based CAM therapy in 2007, rates of use among African Ameri-
cans and Hispanics are less than half of the rate of use among NHWs. Gaps of similar
magnitude between NHWs and African Americans as well as Hispanics can also be
observed in the use of chiropractic care, massage, and homeopathy.
When prayer for health reasons is included, however, the patterns detailed above
no longer hold. In both samples, African Americans used more prayer for health rea-
sons than NHWs did. As a result, when prayer for health reasons is included, African
Americans, rather than NHWs, had the highest rate of using at least one CAM in both
the 2002 and 2007 NHIS. It should also be noted that relative to NHWs, several other
CAM therapies are more commonly used by racial/ethnic minorities. For instance,
acupuncture was favored most by Asian Americans, whereas Hispanics had the highest
percentage in the use of folk medicine in 2007.
An important finding based on results from Table 2 is that growth in CAM use
from 2002 to 2007 was more pronounced among NHWs and Asian Americans than
among African Americans and Hispanics. Excluding prayer for health reasons, use
of at least one CAM therapy increased by 18.1% among NHWs from 2002 to 2007,
compared with 17.2% among Asian Americans, 6.6% among African Americans, and
1.01% among Hispanics. A similar patterned gap in growth in CAM use between
NHWs and racial/ethnic minorities can also be observed in the use of at least one
provider-based CAM therapy.
Having unmet medical needs or delayed care due to cost and CAM use. The per-
centage distribution in Table 3 unequivocally indicates that for both NHIS samples, and
Table 2.
PERCENTAGES OF CAM USE BY RACIAL/ETHNIC GROUPS IN THE U.S.: 2002 VS. 2007

Whites African Americans Hispanics Asians

% % % %
CAM therapies 2002 2007 Difference 2002 2007 Difference 2002 2007 Difference 2002 2007 Difference

At least one CAM 27.96 33.01 18.06*** 18.87 20.12 6.62 16.77 16.94 1.01 27.15 31.83 17.24*
(without prayer)
At least one CAM 54.14 60.05 10.92*** 65.56 70.78 7.96*** 53.59 58.65 9.44*** 48.57 55.62 14.52***
(with prayer)
Provider-based CAM
  At least one CAM 14.34 19.22 34.03*** 5.60 7.13 27.32** 7.45 8.68 16.51 10.70 14.08 31.59*
  Chiropractic care 8.98 10.72 19.38*** 2.73 3.05 11.72 3.86 3.81 21.30 4.14 4.39 6.04
  Massage 5.63 9.91 76.02*** 2.47 4.15 68.02*** 2.71 3.85 42.07** 5.52 7.87 42.57*
  Homeopathy 1.89 2.17 14.81 0.60 0.70 16.67 1.41 1.00 229.08 2.09 1.21 242.11
  Acupuncture 1.04 1.52 46.15*** 0.73 0.60 217.81 1.15 1.09 25.22 2.35 3.68 56.60
  Energy healing therapy/Reiki 0.57 0.73 28.07 0.38 0.17 255.26 0.36 0.10 272.22** 0.61 0.34 244.26
  Hypnosis 0.30 0.36 20.00 0.18 0.07 261.11 0.04 — — 0.14 0.03 278.57
  Naturopathy 0.27 0.40 48.15** 0.14 0.10 228.57* 0.17 0.16 25.88 0.48 0.40 216.67
  Biofeedback 0.16 0.19 18.75 0.10 0.12 20.00 0.10 0.10 0.00 — 0.16 —
  Folk medicine 0.08 0.18 125.00** 0.12 0.05 258.33 0.21 1.30 519.05*** 0.28 0.17 239.29
  Ayurveda 0.08 0.10 25.00 0.07 0.14 100.00 0.03 0.00 2100.00 0.28 0.30 7.14
  Chelation therapy 0.04 0.07 75.00 — — — 0.02 0.02 0.00 — 0.04 —
(Continued on p. 303)
Table 2. (continued)

Whites African Americans Hispanics Asians

% % % %
CAM therapies 2002 2007 Difference 2002 2007 Difference 2002 2007 Difference 2002 2007 Difference

Non-providered-based CAM (without prayer)

  At least one CAM 19.51 21.80 11.74*** 15.94 16.15 1.32 12.36 11.21 29.30 22.08 24.42 10.60
  Relaxation techniques 15.10 17.65 16.89*** 14.05 13.73 22.28 9.93 8.98 29.57 16.39 17.47 6.59
  Yoga-Taichi-Qigong 6.38 7.47 17.08*** 3.21 3.69 14.95 3.35 3.09 27.76 10.37 12.35 19.09
  Special diets 3.84 3.04 220.83*** 2.24 2.58 15.18 2.33 1.66 228.76** 4.32 3.41 221.06
Non-providered-based CAM (with prayer)
  At least one CAM 49.69 54.32 9.32*** 64.70 69.78 7.85*** 51.94 56.28 8.36*** 45.06 51.93 15.25***
Prayer for health reasons 41.64 46.43 11.50*** 63.05 69.94 10.93*** 48.29 54.56 12.98*** 34.07 40.36 18.46**

*p,.1
**p,.05
***p,.01
CAM 5 Complementary and Alternative Medicine
304 Complementary and alternative medicine

virtually for each of the CAM therapies considered, having unmet medical needs or
delayed care due to cost is associated with substantially elevated CAM use. Excluding
prayer for health reasons, the percentage of using at least one CAM therapy in 2007
among those who reported unmet medical needs or delayed care due to cost is 38.5%,
compared with 28.1% for those who did not report unmet medical needs or delayed
care. The relative gap between the two groups becomes most salient in the use of folk
medicine, energy healing therapy/Reiki, and homeopathy, with over 100% difference
in both years.
Although CAM use was growing for respondents both with and without unmet
medical needs or delayed care, the growth, in relative terms, was more pronounced
among respondents who did not report unmet medical needs or delayed care. As a
result, the relative gap between those reporting unmet medical needs or delayed care
and others was mitigated between 2002 and 2007. In terms of prevalence of using at
least one CAM therapy in 2002 (excluding prayer for health reasons), the rate was
43.4% higher among those who reported unmet or delayed care than among those who
did not. The corresponding gap was reduced to 36.8% in 2007. Similarly, the relative
gap in terms of using at least one provider-based CAM changed from 42.3% in 2002
to 27.2% in 2007.

Discussion
This study provides evidence that CAM use, in particular the use of provider-based
CAM therapies such as chiropractic care, massage, and acupuncture, experienced a
significant growth in the U.S. from 2002 to 2007. Moreover, this increasing use of
CAM therapies is not a result of compositional changes across the two NHIS samples,
but rather a clear indication of an elevated prevalence of CAM use. These findings, in
combination with previous findings on trends in CAM use,2,8 point to a steady increase
in CAM use in the U.S. over the past two decades.
In an attempt to explain the increase in use of several CAM therapies including
acupuncture, massage, and naturopathy between 2002 and 2007, a recently released
report by Centers for Disease Control and Prevention (CDC) singled out two possible
contributing factors. One is the greater number of states that license these CAM prac-
tices and a corresponding increase in the number of licensed practitioners between
2002 and 2007. The other factor relates to improved awareness of these CAM therapies
mainly as a result of the lay press extolling the benefits of CAM use.1
While the CDC explanations focus more on supply-side factors, findings from this
study underscore the importance of demand-side factors in the increasing prevalence
of provider-based CAM therapies in the U.S. The much elevated rate of use among
those reporting unmet medical needs or delayed care due to cost, as revealed by this
study, suggest that when financial barriers hamper or prevent individuals from access-
ing conventional care, they are more likely to resort to CAM therapies for health care.
This is consistent with the well-documented connection between affordability of con-
ventional care and CAM use.2,9,10
Growth in CAM use is taking place when health care costs have been escalating in the
U.S. and when an increasing proportion of Americans report going without or delaying
 Su and Li 305

Table 3.
PERCENTAGES OF CAM USE BY WHETHER OR NOT
HAVING UNMET MEDICAL NEEDS OR DELAYED CARE
DUE TO COST: 2002 VS. 2007

Whether or Not Having Unmet Medical Needs

or Delayed Care Due to Cost

2002 2007

Difference Difference
CAM therapies Yes No (%) Yes No (%)

At least one CAM 35.42 24.70 43.40*** 38.50 28.14 36.82***

(without prayer)
At least one CAM 66.35 54.10 22.64*** 71.74 59.53 20.51***
(with prayer)
Provider-based CAM
  At least one CAM 17.06 11.99 42.29*** 19.92 15.66 27.20***
  Chiropractic care 8.89 7.38 20.46** 10.23 8.40 21.79***
  Massage 6.95 4.76 46.01*** 9.88 8.10 21.98**
  Homeopathy 3.69 1.49 147.65*** 3.41 1.59 114.47***
  Acupuncture 1.92 0.97 97.94*** 2.13 1.35 57.78**
  Energy healing 1.62 0.42 285.71*** 1.10 0.49 124.49***
   therapy/Reiki
  Hypnosis 0.48 0.23 108.70* 0.44 0.23 91.30
  Naturopathy 0.50 0.22 127.27** 0.47 0.32 46.88
  Biofeedback 0.35 0.11 218.18* 0.26 0.15 73.33
  Folk medicine 0.35 0.09 288.89** 0.86 0.31 177.42**
  Ayurveda 0.16 0.07 128.57 0.04 0.11 263.64
  Chelation therapy 0.06 0.03 100.00 0.07 0.05 40.00
Non-providered-based CAM (without prayer)
  At least one CAM 28.00 17.45 60.46*** 28.46 18.72 52.03***
  Relaxation techniques 23.04 13.59 69.54*** 24.71 14.87 66.17***
  Yoga-Taichi-Qigong 8.68 5.53 56.96*** 8.12 6.47 25.50***
  Special diets 6.11 3.25 88.00*** 3.78 2.73 38.46**
Non-providered-based CAM (with prayer)
  At least one CAM 62.91 50.36 24.92*** 67.06 54.92 22.10***
Prayer for health reasons 53.58 43.65 22.75*** 59.72 48.75 22.50***

*p,.1
**p,.05
***p,.01
CAM 5 complementary and alternative medicine
306 Complementary and alternative medicine

medical care. From 2003 to 2007, the proportion of Americans reporting unmet need
in medical care increased from 5.2% to 8.0%. The increase for those reporting delayed
care was from 8.4% to 12.3%.11 When access to conventional care for many Americans
is increasingly restricted, some of them may well resort to CAM, particularly provider-
based CAM therapies, as an alternative to conventional care instead of a supplement.
Among respondents who reported CAM use in the 2002 NHIS, 13.2% singled out the
high cost of conventional medicine as an important reason for them to use CAM.12
Findings from this study also point to growing disparities in CAM use across racial
and ethnic groups in the U.S. from 2002 to 2007. Since the efficacy of most of the CAM
therapies remains to be verified, it would be premature to assess the impact of these
growing disparities in CAM use on racial and ethnic disparities in health status. If it
can be confirmed that certain CAM therapies are effective for a given condition (for
example, acupuncture has been proven effective for back and knee pain1) such a trend
in CAM use will contribute to an expanding gap in health status between NHWs and
racial and ethnic minorities.
The findings that Hispanics had the lowest rate of utilization of any CAM therapy and
that their use of CAM largely stagnated between 2002 and 2007 deserve attention. One
of the potential contributing factors is the lack of knowledge of CAM modalities in the
U.S. by Hispanic immigrants. The importance of cognitive resources in the utilization of
health care has been well documented in previous studies.13–15 Given that the majority
of immigrants to the U.S. now come from Latin America, it may well be the case that
many of them have not been exposed to some CAM modalities, in particular provider-
based CAM modalities, in their countries of origin that nonetheless are popular in the
U.S. Curanderismo, a holistic system of folk medicine that has long been practiced in
Latin America, is also popular among Hispanic immigrants in the U.S., which could
hamper the spread of other forms of CAM therapies in the group. As a result, when
these immigrants arrive in the U.S. they might not be aware of the existence of these
therapies. A recent study of CAM use based on data from the 2002 NHIS found that
as immigrants become more acculturated to the U.S. as indicated by a longer period of
residence or a more proficient use of English, their level of CAM use increases as well,
gradually approaching the level of CAM use by U.S.-born Americans.4
This study also provides evidence that the inclusion or exclusion of prayer for health
reasons can make a fundamental difference in the observed disparities in CAM use. For
instance, the racial and ethnic disparities in CAM use become far more salient when
prayer for health reasons has been excluded than otherwise. This is because if prayer
for health reasons can be regarded as a form of CAM therapy, it will be the most often
utilized one, which can easily blur or even reverse the observed disparities in CAM use
when it has not been included. Correspondingly, comparisons across samples in terms
of CAM use will not be meaningful if the definition of CAM with regard to prayer for
health reasons is not consistent.
 Su and Li 307

Conclusions and Directions for Future Research

Through a comparative analysis of data from the 2002 and 2007 NHIS, this study reveals
an increasing prevalence of CAM use in the United States in the period. This growth
in CAM use, however, was not evenly distributed across racial and ethnic groups in
the U.S. Excluding prayer for health reasons, non-Hispanic Whites experienced a more
rapid increase in CAM use than both African Americans and Hispanics. As a result,
the gap between non-Hispanic Whites and the two minority groups was expanding
from 2002 to 2007. While the current study provides evidence of this pattern, it touches
little on the why question, that is, why was the increase in CAM use, especially in
provider-based CAM therapies, more pronounced among non-Hispanic Whites than
among racial and ethnic minority groups? For example, was it the relative economic
advantage of non-Hispanic Whites that enabled them to better afford CAM therapies,
especially provider-based therapies? Or was there a relatively lower level of awareness
of CAM therapies among racial and ethnic minority groups than among non-Hispanic
Whites? Future studies can better address these questions in a multivariate framework
that incorporates these relevant factors.
One of the factors that we did not examine in our study but nonetheless could
potentially contribute to the observed trends in racial and ethnic disparities in CAM
use is gender. Results from previous studies suggested that the use of CAM therapies
was much more common among women than men.8,12 If this gender differences in CAM
use were not evenly distributed across racial and ethnic groups, it could then at least
partially determine racial and ethnic disparities in CAM use and their trends.
The increasing prevalence as well as the expanding gap in CAM use across racial
and ethnic groups highlights the urgent need for evaluating the health consequences
of CAM therapies. The majority of CAM therapy users did not inform their medical
doctors that they used CAM.16 So far little has been known about the efficacy and the
possible side effects associated with the use of any particular CAM therapy and its
interaction effects with conventional medicine. Such information will be necessary to
assess the extent to which CAM therapies can serve as an alternative or supplement
to conventional medical care. It is also crucial for assessing how disparities in CAM
use across racial and ethnic groups might be linked to health disparities between these
groups.
Findings from this study reinforce evidence on the connections between access to
conventional medical care and CAM use. They point to the importance of the escalating
cost of conventional medical care and the resulting increasingly restrictive access to
medical care in the period from 2002 to 2007 as a contributing factor to the increasing
prevalence of CAM use in the period. With the 2010 health care legislation starting to
come into effect, it would be interesting to evaluate its impact on CAM use as access
to conventional medical care gradually improves among low-income Americans.
308 Complementary and alternative medicine

Appendix 1—Terms of Complementary and

Alternative Medicine Used in the Studya,b

CAM therapies Definitions

Provider-based CAM Providers or practitioners are usually required to provide care

or advice on a specific CAM.
Chiropractic care This therapy involves the adjustment of the spine and joints
to influence the body’s nervous system and natural defense
mechanisms to relieve pain and improve general health.
Massage Practitioners manipulate muscle and connective tissue to
enhance function of those tissues and promote relaxation and
well-being.
Homeopathy Homeopathy is a system of medical practices based on
the theory that any substance that can produce symptoms
of disease or illness in a healthy person can cure those
symptoms in a sick person.
Acupuncture Acupuncture is a family of procedures involving stimulation
of anatomical points on the body by a variety of techniques.
Energy healing therapy/ Energy healing therapy involves the channeling of healing
Reiki energy through the hands of a practitioner into the client’s
body to restore a normal energy balance and, therefore,
health.
Hypnosis Hypnosis is an altered state of consciousness characterized by
increased responsiveness to suggestion.
Naturopathy Naturopathic practitioners work with the patient with a
goal of supporting a healing power that as they believe
can establish, maintain, and restore health through
treatments such as nutrition and lifestyle counseling, dietary
supplements, medicinal plants, exercise, homeopathy, and
treatments from traditional Chinese medicine.
Biofeedback Biofeedback uses simple electronic devices to teach clients
how to consciously regulate bodily functions, such as
breathing, heart rate, and blood pressure, in order to improve
overall health.
Folk medicine Folk healers usually participate in a training regimen of
observation and imitation, with healing often considered a
gift passed down through several generations of a family. Folk
healers may employ a range of remedies including prayer,
healing touch or laying on of hands, charms, herbal teas or
tinctures, magic rituals, and others.
 Su and Li 309

Ayurveda Ayurveda aims to integrate and balance the body, mind, and
spirit. This balance is believed to lead to contentment and
health and to help prevent illness. However, Ayurveda also
proposes treatments for specific health problems, whether
they are physical or mental. A chief aim of Ayurvedic
practices is to cleanse the body of substances that can cause
disease, and this is believed to help reestablish harmony and
balance.
Chelation therapy Chelation therapy is a chemical process in which a substance
is used to bind molecules, such as metals or minerals,
and hold them tightly so that they can be removed from a
system, such as the body. In medicine, chelation has been
scientifically proven to rid the body of excess or toxic metals.
Non-providered-based Providers or practitioners are not necessary for this type of
CAM CAM therapies.
Relaxation techniques A group of techniques aim to relax muscles or mind. In the
study, they include guided imagery, meditation, progressive
relaxation, and deep breathing exercises.
Yoga-Taichi-Qigong Qigong combines the use of gentle physical movements,
mental focus, and deep breathing designed to integrate the
mind, body, and spirit, and to stimulate the flow of vital life
energy (qi). Taichi refers to a type of Chinese self-defense
discipline and low-intensity, low-impact exercise regimen
that is used for health, relaxation, and self-exploration.
Yoga combines breathing exercises, physical postures, and
meditation. It aims to calm the nervous system and balances
body, mind, and spirit.
Special diets A group of diets include vegetarian diet, macrobiotic diet,
Atkins diet, Pritikin diets, Ornish diet, and Zone diet.
Prayer for health reasons Users pray for their own health or others pray for a user’s
health.
a
Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and
children: United States, 2007. Natl Health Stat Report. 2007;12.
b
Barnes PM, Bloom B, Powell-Griner E, et al. Complementary and alternative medicine use among
adults: United States, 2002. CDC Adv Data Rep. 2004;343:1–20.
CAM 5 complementary and alternative medicine

Acknowledgements
This research was supported in part by grants from the Agency for Healthcare Research
and Quality (grant number R24HS017003) and the Centers for Disease Control and
Prevention (grant number 1H75DP001812-01). The authors want to thank Daphne
Wang and anonymous reviewers designated by Journal of Health Care for the Poor and
Underserved for their comments.
310 Complementary and alternative medicine

Notes
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