plementary and alternative medicine (CAM) has increased signicantly tary/alternative medicine by consumers, Alternative and Complementary Medicine, …
Why Patients Use Alternative Medicine: Results of a National Study
John A Astin
Online article and related content current as of November 13, 2008 JAMA 1998;27919:1548-1553 doi:101001/jama279191548 http://jamaama-assnorg/cgi/content/full/279/19/1548
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Why Patients Use Alternative Medicine
Results of a National Study
John A Astin, PhD
Context–Research both in the United States and abroad suggests that significant numbers of people are involved with various forms of alternative medicine However, the reasons for such use are, at present, poorly understood Objective–To investigate possible
predictors of alternative health care use Methods–Three primary hypotheses were tested People seek out these alternatives because 1 they are dissatisfied in some way with conventional treatment; 2 they see alternative treatments as offering more personal autonomy and control over health care decisions; and 3 the alternatives are seen as more compatible with the patients values, worldview, or beliefs regarding the nature and meaning of health and illness Additional predictor variables explored included demographics and health status Design–A written survey examining use of alternative health care, health status, values, and attitudes toward conventional medicine Multiple logistic regression analyses were used in an effort to identify predictors of alternative health care use Setting and Participants–A total of 1035 individuals randomly selected from a panel who had agreed to participate in mail surveys and who live throughout the United States Main Outcome Measure–Use of alternative
medicine within the previous year Results–The response rate was 69The following variables emerged as predictors of alternative health care use: more education odds ratio [OR], 12; 95 confidence interval [CI], 11-13; poorer health status OR, 13; 95 CI, 11-15; a holistic orientation to health OR, 14; 95 CI, 11-19; having had a transformational experience that changed the persons worldview OR, 18; 95 CI, 13-25; any of the following health problems: anxiety OR, 31; 95 CI, 16-60; back problems OR, 23; 95 CI, 17-32; chronic pain OR, 20; 95 CI, 11-35; urinary tract problems OR, 22; 95 CI, 13-35; and classification in a cultural group identifiable by their commitment to environmentalism, commitment to feminism, and interest in spirituality and personal growth psychology OR, 20; 95 CI, 14-27 Dissatisfaction with conventional medicine did not predict use of alternative medicine Only 44 of those surveyed reported relying primarily on alternative therapies Conclusion–Along with being more
educated and reporting poorer health status, the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life
JAMA 1998;279:1548-1553
IN 1993 Eisenberg and colleagues1 reported that 34 of adults in the United States used at least 1 unconventional form of health care defined as those practices neither taught widely in US medical schools nor generally available in US hospitals during the previous year The most frequently used alterna-
From the Stanford Center for Research in Disease Prevention, Stanford University School of Medicine, Palo Alto, Calif Reprints: John A Astin, PhD, Stanford Center for Research in Disease Prevention, 730 Welch Rd, Palo Alto, CA 94304-1583 e-mail: astin@scrdpstanfordedu
tives to conventional medicine were relaxation
techniques, chiropractic, and massage Although educated, middleclass white persons between the ages of 25 and 49 years were the most likely ones to use alternative medicine, use was not confined to any particular segment of the population These researchers estimated that Americans made 425 million visits to alternative health care providers in 1990, a figure that exceeded the number of visits to allopathic primary care physicians during the same period Recent studies in the United States2 and abroad3,4 support the prevalent use of
alternative health care For example, a 1994 survey of physicians from a wide array of medical specialties in Washington State, New Mexico, and Israel revealed that more than 60 recommended alternative therapies to their patients at least once in the preceding year, while 38 had done so in the previous month2 Fortyseven percent of these physicians also reported using alternative therapies themselves, while 23 incorporated them into their practices When faced
with the apparent popularity of unconventional medical practices and the fact that people seem quite willing to pay out-of-pocket for these services,1 the question arises: What are the sociocultural and personal factors health status, beliefs, attitudes, motivations underlying a persons decision to use alternative therapies? At present, there is no clear or comprehensive theoretical model to account for the increasing use of alternative forms of health care Accordingly, the goal of the present study was to develop some tentative explanatory models that might account for this phenomenon Three theories that have been proposed to explain the use of alternative medicine were tested: 1 Dissatisfaction: Patients are dissatisfied with conventional treatment because it has been ineffective,5,6 has produced adverse effects,6,7 or is seen as impersonal, too technologically oriented, and/or too costly6-15 2 Need for personal control: Patients seek alternative therapies because they see them as
less authoritarian16 and more empowering and as offering them more personal autonomy and control over their health care decisions14,16-19 3 Philosophical congruence: Alternative therapies are attractive because they areseenasmorecompatiblewithpatients values, worldview, spiritual/religious philosophy, or beliefs regarding the nature and meaning of health and illness19-24 In addition to testing the validity of these 3 theoretical perspectives, this study also sought to determine on an exploratory basis how the decision to seek alternative therapies is affected by patients health status and demographic factors
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METHODS Participants completed an extensive mail survey that gathered information on use of alternative health care, perceived benefits and risks of these therapies, health beliefs and attitudes,
views toward and experiences with conventional medicine, political beliefs, and worldview The original survey instrument was developed by Ray,24 and the survey was conducted through National Family Opinion, Inc, which maintains a panel of persons who have agreed to be participants in mail surveys This panel constitutes a representativenationalsamplefromwhichsubsamples can be drawn A random sample of 1500 individuals was drawn from this panel, with 1035 people completing the questionnaire a response rate of 69 Dependent Variable Following Eisenberg et al,1 the dependent variable, alternative health care use, a dichotomous measure, was operationalized as used within the previous year of any of the following treatments: acupuncture, homeopathy, herbal therapies, chiropractic, massage, exercise/movement, high-dose megavitamins, spiritual healing, lifestyle diet, relaxation, imagery, energy healing, folk remedies, biofeedback, hypnosis, psychotherapy, and art/music therapy Several of these
treatments, however, were deemed not to be alternativeorunconventionaliftheywere used to treat particular health-related problems: 1 exercise for lung problems, high blood pressure, heart problems, obesity, muscle strains, or back problems; 2 psychotherapy for depression or anxiety; and 3 self-help groups for depression or anxiety The category alternative medicine was thus delimited to exclude those practices that are already part of standard medical care and recommendations such as exercise to treat hypertensionorpsychotherapytotreatdepression The category lifestyle diet could include more standard or conventional dietary recommendations such as a low-fat or low-salt regimen for treating cardiovascular disease or hypertension Analyses were repeated using a second dependent variable, primary reliance on alternative medicine, a dichotomous measure defined by those respondents who reported using primarily alternative therapies to treat health-related problems Independent Variables Table
1 lists the independent variables considered possible predictors of alternative health care use Since constructs like satisfaction with conventional medicine arehighlygeneralized,multiplemeasures of these variables were used Using prinJAMA, May 20, 1998–Vol 279, No 19
Table 1–Independent Variables
Satisfaction with conventional medicine General satisfaction: Thinking about the last time you went to see a medical doctor, how satisfied were you with the care you received? 4-point scale Satisfaction with practitioners The last time you had important questions about your health care, and you asked a medical doctor about them, did you understand the answers? 4-point scale How much confidence do you have in the medical doctor you see most often for your health care? 4-point scale How much trust do you have in the medical doctor you see most often for your health care? 5-point scale Lack of trust: I dont trust doctors and hospitals, so I use them as little as possible yes/no Need for
control What do you prefer for involvement in decisions about your health care? Would you prefer to Keep control in your own hands? Have an equal partnership with the doctor? Leave it in the doctors hands? Philosophical/value congruence Belief in the power of religion When I have health problems, I try prayer first, then go to the doctor if I get really sick yes/no When I have health problems, I depend primarily on prayer and Gods help yes/no Holistic philosophy The health of my body, mind, and spirit are related, and whoever cares for my health should take that into account yes/no Classification in the value subculture cultural creatives, those who are at the leading edge of cultural change and tend to be interested in psychology, spiritual life, self-actualization, self-expression, like the foreign and exotic, and enjoy mastering new ideas Experiences of and/or beliefs about religion and spirituality 19 questions: yes/no/not sure Participation in a nontraditional religious or
spiritual group yes/no Belief in the efficacy of conventional medicine I put myself into my doctors hands, to take care of things for me, and to tell me whats best for my health yes/no I take my body to the doctors office, and I expect the doctor to fix it yes/no I trust my medical doctor to do the best that Western medicine can do for me regardless of cost yes/no Health factors Health problems 26 specific health problems dichotomous measures: lung; hypertension; heart; diabetes; cancer; digestive; urinary tract; gynecologic; neurological; sprains; dermatological; allergies; dizziness; anxiety; depression; insomnia; acquired immunodeficiency syndrome; addiction; obesity; chronic dental; arthritis; back; headaches; chronic pain; chronic fatigue; other condition Health status Would you say that your health in general is excellent, very good, good, fair, poor? During the past 12 months, about how many days did illness or injury keep you in bed more than half the day? How much bodily pain
have you had during the past 4 weeks? 5-point scale Demographic factors Education, sex, income, race, and age
All such multiple-point questions used standard Likert checkoff scales Multi-item variable derived from factor analysis of selected questionnaire items Ray24,29 has identified 3 value subcultures in the US population, termed the cultural creatives, the moderns who represent mainstream popular culture and values, and the heartlanders, a subculture characterized by fundamentalist and traditional values and beliefs
cipal components analysis with varimax rotation of selected questionnaire items, 4 multi-item factors were identified: satisfaction with conventional practitioners; health status; belief in the power of religious faith to heal; and belief in the efficacy of conventional medicine Since the dependent variable was dichotomous, logistic regression analyses were carried out Demographic variables were entered in a first block with the remaining variables entered in a second
block These variables were entered together in the second block because their precise causal ordering was not readily apparent ie, there was no clear theoretical rationale for entering them in separate blocks The variables that then remained significant P 05 in the logistic regression analyses constituted the final multivariate model Hypotheses The following hypothesized relationships were tested in the multiple logistic regression:
1 Users of alternative health care will be distinguished from nonusers in that they will a report less satisfaction with conventional medicine; b demonstrate a greater desire to exercise personal control over health-related matters; and c subscribe to a holistic philosophical orientation to health 2 Since the majority of health care alternativesarenotcoveredbyinsurers,having access to more financial resources will predict use of alternative medicine25,26 3 As suggested by previous research,1,26-28 higher levels of education will be predictive of
alternative medical use 4 Users of alternative health care will be more likely to be part of a cultural group, described by Ray24,29 as cultural creatives, and identifiable by the following values: commitment to environmentalism; commitment to feminism; involvement with esoteric forms of spirituality and personal growth psychology, self-actualization, and self-expression; and love of the foreign and exotic These individuals tend to be at the leading edge of culAlternative Medicine–Astin
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tural change and innovation, coming up with the most new ideas in the society, andarethereforehypothesizedtobemore inclined to use alternative health care Ray developed his value classifications, what he termed value subcultures, empirically using factor analysis and multidimensional scaling to create orthogonal value dimensions K-means clustering was then used to cluster respondents
into the different value groupings According to Ray,24 the cultural creative group has been steadily growing in the culture at large since the late 1960s and now represents approximately 44 million Americans [236 of the adult population] While there is likely some crossover in terms of values and orientation with those identified by the popular media as New Agers, the latter term has no operational definition while the categorization of cultural creative is based on empirical research examining specific values held by individuals in the culture at large 5 Those who report relying primarily on alternative forms of health care will be more likely to subscribe to a holistic philosophy of health their greater commitment to these health practices being reflected in a set of health beliefs that are more congruent with many forms of alternative medicine RESULTS Demographic Characteristics Survey respondents were comparable to census data from the same time period with the exception of a
slight underrepresentation of younger, less educated, and poor persons Table 2 Health Problems Respondents were asked whether they had experienced any of a list of 26 healthrelated problems within the past year Table 1 They were then asked to list the 3 most bothersome or serious ones The top 5 problems listed were 1 back problems 197; 2 allergies 166; 3 sprains/muscle strains 157; 4 digestive problems 145; and 5 lung problems, pneumonia, or respiratory infections 13 Frequency of Use of Alternative Medicine Forty percent of respondents reported using some form of alternative health care during the past year The top 4 treatment categories were chiropractic 157; lifestyle diet 80; exercise/movement 72; and relaxation 69 The most frequently cited health problems treated with alternative therapies were chronic pain 37; anxiety, chronic fatigue syndrome, and other health condition 31 each; sprains/muscle strains 26; ad1550
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Table 2–Demographic
Characteristics of Survey Sample N1035
Users of Alternative Medicine, 35 41 42 44 35 41 29 40 44 71 44 39 41 31 47 45 50 33 42 36 44 44
Table 3–Most Frequently Used Alternative Therapies for Specific Health Problems
Most Frequently Used Alternatives No Exercise 12 Chiropractic 7 Massage 6 Relaxation 11 Exercise 8 Herbs 3 Art/music therapy 3 Massage 3 Massage 3 Exercise 3 Self-help group 2 Megavitamins 2 Chiropractic 38 Exercise 22 Massage 10 Relaxation 6 Herbs 6 Psychotherapy 2 Self-help groups 2 Exercise 17 Chiropractic 12 Homeopathy 5 Herbs 5 Other 5 Chiropractic 20 Massage 5 Exercise 5 Relaxation 4 Relaxation 9 Exercise 5 Herbs 4 Lifestyle diet 7 Other 6 Relaxation 6 Herbs 5 Chiropractic 5 Lifestyle diet 8 Exercise 7 Other 2
Variables Age, y 18-24 25-34 35-49 50-64 64 Race/ethnicity White Black Hispanic Asian/Pacific Islander Native American Other Sex Male Female Education High school or less Some college Bachelors degree Graduate degree Household income, 12 500 12 500-24 999
25 000-39 999 40 000-59 999 60 000
Sample, 79 215 348 180 179 795 83 75 09 07 31 486 514 302 263 153 87 119 153 253 229 247
Health Problems Chronic pain
Anxiety
Chronic fatigue syndrome
Sprains/muscle strains
Addictive problems Arthritis or rheumatism
Severe headaches
Depression
dictive problems and arthritis both 25; and headaches 24 Analyses were also carried out to determine which specific treatments were being used for which therapeutic modalities Table 3 lists the top 10 health problems in terms of percentage who treated them with alternative medicine and the most frequently used alternative therapies for each Although certain alternative therapies tended to be used more frequently, a broad range of alternatives were, in fact, being used for the majority of health problems For example, although chiropractic care represented close to 50 of all alternative treatments used for headaches, individuals also reported using acupuncture, homeopathy, megavitamins, spiritual
healing, lifestyle diets, relaxation, massage, folk medicine, exercise, psychotherapy, and art/music therapy to treat this health problem A similar pattern is evident across many of the health problems listed on the survey; ie, although particular alternative treatments may predominate, use is by no means confined to any particular therapy or even a few therapies Multivariate Statistics The following variables predicted use of alternative medicine in the multiple logistic regression criterion for entering was P 05: 1 being more educated; 2 being classified in the value subculture of cultural creatives; 3 having a transformationalexperience that changed the persons worldview; 4 having poorer overall health; 5 believing in the importance of
Digestive problems
Diabetes
body, mind, and spirit in treating health problems holistic health philosophy; and 6 reporting any of the following health problems: anxiety, back problems, chronic pain, or urinary tract problems Table 4 presents the
intercorrelations of all hypothesized predictors and use of alternative medicine Table 5 presents the adjusted odds ratios and 95 confidence intervals for the independent variables that emerged as significant predictors Contrary to a number of previous findings6-13,27 and the present studys hypothesis, negative attitudes toward or experiences with conventional medicine were not predictive of alternative health care use Among those who reported being highly satisfied with their conventional practitioners 54, 39 used alternative therapies, while 40 of those reporting high levels of dissatisfaction 9 of respondents were users of alternative medicine Although there was a trend in the direction of those desiring to keep control in their own hands being more likely to use alternative medicine, this variable was also not a significant predictor of alternative medicine use as hypothesized Racial/ethnic differences also did not predict use of alternative medicine Use was found across all groups
eg, whites,
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Table 4–Intercorrelations of Hypothesized Predictor Variables and Use of Alternative Medicine
Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Use of alternative medicine Being a cultural creative Having desire for control over health More education Belief in efficacy of conventional care Poorer health status Higher income Dissatisfaction with conventional care Urinary tract problems Chronic pain Back problems Anxiety Transformational experience Holistic philosophy 1 017 003 013 -008 013 006 001 007 010 015 012 012 013 2 004 012 -017 -001 018 003 001 006 003 006 002 018 3 4 5 6 7 8 9 10 11 12 13 14
007 -017 -011 016 012 -001 000 003 000 004 007
-017 -014 041 -011 -003 001 -002 003 001 007
010 -016 -014 003 002 -003 -001 -002 004
-019 011 002 013 010 002 006 000
-005 -005 003 002 010 -005 007
-001 008 011 -004 003 -002
-001
-008 -003 -002 -002
001 -004 003 005
-002 -001 -002
001 011
011
P 001 P 05 P 01
Table 5–Significant Predictors in the Multiple Logistic Regression N1035
Adjusted Odds Ratio 95 Confidence Interval 120 110-131 132 115-152 195 143-267 142 108-186 176 126-248 313 164-596 230 166-320 216 132-352 198 113-348
Variables Education Health status Cultural creative Holistic philosophy Had transformational experience Anxiety Back problems Urinary tract problems Chronic pain
P 001 001 001 02 005
001 001 005 02
These variables were coded on a 5-point Likert scale all other independent variables were dichotomous
41; blacks, 29; Hispanics, 40 Percentages of Asian and Native American respondents who used alternative medicine are not reported here as their overall numbers in the sample are too small Also, the fact that certain ethnic groups had relatively low representation in the sample may explain why they did not emerge as predictors in the regression No significant differences were
found with respect to sex with 41 of women and 39 of men reporting use of alternative health care Finally, neither income nor age predicted use of alternative medicine in the regression The results do, however, provide strong support for the philosophical/value congruence theory in several ways First, as hypothesized, having a holistic philosophy of health The health of my body, mind, and spirit are related, and whoever cares for my health should take that into account was predictive of alternative health care use Among those subscribing to this philosophy, 46 reported being users of alternative medicine, while only 33 of those not endorsing the item were users This finding suggests that use of alternative medicine may, in part, reflect shifting cultural paradigms, particularly with respect to recognizing the importance of spiritual factors in health Second, the statement, Ive had a transformational experience that causes me to
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see the world
differently than before, also emerged as a significant predictor Of those who answered yes 183, 53 reported use of alternative health care compared with 37 of those who responded no or not sure Third, those categorized as cultural creatives were significantly more likely to use alternative health care Among this subcultural group, 55 reported using alternative health care compared with only 35 of those not in this group Education emerged as the 1 sociodemographic variable that predicted use of alternative medicine; individuals with higher educational attainment were more likely to use alternative forms of health care eg, 31 of those with high school education or less reported use compared with 50 of those with graduate degrees The 3-item factor, health status, also emerged as a significant predictor of alternative health care use, with use increasing as health status declined A number of specific health problems ie, back problems, chronic pain, anxiety, and urinary tract problems were
also predictive of alternative health care use These results suggest that experiencing certain health problems increases the likelihood that one will be a user of alternative medicine in a general sense ie, not simply to treat that particular disorder For example, those individuals citing anxiety as 1 of their 3 most serious health problems were almost twice as likely as nonanxiety sufferers 67 vs 39 to be users of alternative health care To test the validity of the logistic regression model, 2 techniques were used First, predicted values from the multivariate equation were divided into quintiles The percentage of respondents within each quintile who used alternative medicine was then calculated This analysis is typically used to assess the extent to which there is any clinical or policy relevance to the predictor variables beyond their being statistically significant30 Within the quintile of lowest predicted
value scores, 17 used alternative medicine;withinthehighestquintile,68were
users These results suggest that the model is fairly strong and has practical not merely statistical significance To further examine the models validity, the sample was randomly split into 2 evensubsamples,andseparatelogisticregressions were run for each These multivariatemodelswerethencompared,and there were no significant differences observed in the coefficients of each model Finally, predicted values were again divided into quintiles in each subsample, andthespreadofprobabilitiesacross each group was quite consistent between each model and in comparison with the overall regression model Primary Reliance on Alternative Medicine To test whether individuals who report relying primarily on alternative forms of health care show a different profile from those who use alternative medicine more in conjunction with conventional means, separate logistic analyses were carried out This exploratory analysis suggests that primary reliance on alternative forms of medicine is explained by a
considerably different set of variables The following independent variables were significant predictors in the multiple logistic regression: 1 distrust of conventional physicians and hospitals; 2 desire for control over health matters; 3 dissatisfaction with conventional practitioners; and 4 belief in the importance and value of ones inner life and experiences The fact that only 44 n45 of the sample was categorized as relying primarily on alternative forms of health care is consistent with previous findings 1 suggesting that the vast majority of individuals appear to use alternative therapies in conjunction with, rather than instead of, more conventional treatment In contrast to individuals who use alternative therapies in conjunction with conventional medicine, for whom dissatisfaction with conventional medicine was
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not a significant
predictor of alternative health care use, 2 of the 4 predictors of primary reliance on alternative medicine reflect a general lack of trust in and satisfaction with conventional medical care It is also individuals who report a desire to keep control in their own hands who are more likely to report relying primarily on unconventional forms of health care Education and health status did not predict primary reliance on alternative medicine Neither being a cultural creative nor holding a holistic philosophy of health was a significant predictor in this model These findings suggest that, contrary to my hypothesis, those evidencing a greater commitment to orrelianceonalternativehealth care may be doing so primarily as a result of their dissatisfaction with conventional medicine rather than on ideological or philosophical grounds Because of the small sample size in the above analyses and the relatively imprecise measure of the dependent variable ie, one can only infer that respondents who
report relying primarily on these alternatives tend to use them more as a replacement than as a complement to conventionalapproaches,onemustinterpret these findings with caution Perceived Benefits of Alternative Medicine Perceivedbenefitsofalternativetherapies were considered as potential determinants of use eg, if someone reports receiving some benefit from a given treatment, this could in turn serve as an important determining factor in future health care decisions The 2 most frequently endorsed benefits were, I get relief for my symptoms, the pain or discomfort is less or goes away, I feel better, and The treatment works better for my particular health problem than standard medicines These responses suggest that the most influential or salient factor in peoples decision to use alternative health care may be its perceived efficacy The response, The treatment promotes health rather than just focusing on illness, was the third most frequently reported benefit and offers further support
for the philosophical congruence theory COMMENT The present study was designed to provide a comprehensive analysis of factors influencing the decision to use various forms of alternative health care Based on the results from the multiple logistic regression, users of alternative medicine 40 of those surveyed can generally be characterized as follows: Users tend to be better educated and to hold a philosophical orientation toward health that can be described as holistic ie, they believe in the importance of body, mind, and spirit in
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health They are more likely to have had some type of transformational experience that has changed their worldview in some significant way, and they tend to be classified in a value subculture as cultural creatives Users of alternative health care are also more likely to report poorer health status than nonusers Relief of symptoms is the main benefit reported the perceived efficacy of alternative medicine being cited
nearly twice asoftenasotherreportedbenefitsAcentral finding is that users of alternative health care are no more dissatisfied with or distrustful of conventional care than nonusers are Among those categorized as primarily reliant on alternative health care–fewer than 5 of the surveyed population–a different pattern emerged Unlike those who used alternative therapies in conjunction with or as a supplement to conventional forms of medical care, these individuals were more likely to be dissatisfied with and distrustful of standard care as well as desirous of maintaining exclusive control over their health care decisions They were also more likely to report being interested in their inner life and experiences, suggesting some crossover with the set of spiritually relevant variables that predicted nonexclusive use of alternative health care These results suggest that future studies examining predictors of alternative health care use need to more carefully measure this phenomenon so that
individuals who use these therapies in conjunction with or as a supplement to conventional means can be clearly distinguished from those who use them predominantly or more exclusively Several possible interpretations can be offered for certain variables that emerged as predictors of alternative health care use Education, for example, may increase the likelihood that people will 1 be exposed to various nontraditional forms of health care through their own reading of popular or academic books on the subject; 2 educate themselves about their illnesses and the variety of treatments available to them; and/or 3 question the authority of conventional practitioners ie, be less inclined simply to accept unquestionably the physicians knowledge and expertise There are also at least 2 possible explanations for the finding that poorer health status predicts alternative medical use First, since those who are in poor health have, by definition, had less success in treating their health problems,
their continued suffering may have prompted them to seek out alternatives Second, a significant number of individuals who report poor health, more pain, disability, and physical symptoms may be somatizers Somatization has been defined as the propensity to experience and report somatic symp-
toms that have no pathophysiological explanation, to misattribute them to disease, and to seek medical attention for them31 Since research suggests that somatizers are disproportionately high users of medical services, get more medical tests, and tend to experiment with shop around for different health care practitioners, it seems reasonable that they would be more likely to seek out various health care alternatives32 It would be useful to design future studies examining predictors of alternative health care use in such a way that somatizers and nonsomatizers can be differentiated more clearly There are also several possible explanations for the finding that alternative medicine users are more
likely to subscribe to a holistic philosophy of health People who hold this philosophical orientation may be attracted to alternative forms of health care because they see in these therapeutic systems a greater acknowledgment of the role of nonphysical mind/spirit factors in creating health and illness An alternate explanation which would reverse the direction of causation is that people who have been involved with alternative medicine have had their belief systems influenced by these therapeutic modalities and the philosophies underlying them That users of alternative health care are more likely to report having had a transformational experience that changed the way they saw the world lends partial support to the hypothesis that involvement with alternative medicine may be reflective of shifting cultural paradigms regarding beliefs about the nature of life, spirituality, and the world in general As suggested by Charlton,20 a subset of individuals may be attracted to these
nontraditional therapies because they find in them an acknowledgment of the importance of treating illness within a larger context of spirituality and life meaning The apparent effect of ones spiritual/ philosophical orientation on involvement with alternative health practices is further supported by the finding that being a cultural creative is a significant predictor of use This suggests that the growing interest in alternative medicine may not simply represent a shift in individual beliefs about the nature of health and illness, but is rather a phenomenon that is transmitted through and influenced by the culture This interpretation is supported by the finding that the effect of membership in this value subculture is not accounted for simply by holding a holistic philosophy of health; that is, both of these variables contributed independently in the logistic regression equation As with other studies that attempt to explain complex human behavioral phenomena, a significant amount of
variance
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is not explained by the regression equation There are obviously unaccounted for variables such as a general openness to novelty and experimentation, or curiosity, that need to be examined in future studies Another possibility is measurement error associated with the independent variables; for example, the variable belief in the importance of body, mind, and spirit might be interpreted differently depending on ones religious background Moreover, the decision to use alternative medicine is sufficiently context or situation dependent eg, influence of significant others who have used or not used various alternatives to make prediction quite difficult Another limitation to this study is its cross-sectional nature, which precludes drawing any definitive conclusions regarding cause-and-effect relationships For example, it is unclear whether
holding a holistic philosophical orientation has led certain individuals to seek out alternative therapies, whether exposure to these therapies has somehow influenced the way they view health and illness, or whetherbotheffectsoccurMoreover,the reliance on self-report may weaken the internal validity of the study as retrospective accounts of ones health status, health practices, and reasons for making certain health care decisions may be subject to distortion and inaccuracy Since the sample underrepresented the poorer, less educated, and nonEnglishspeaking segments of the population, it is unclear if and how the results would be different had these groups been better represented It is possible that the modest overrepresentation of more educated respondents in the study sample may have slightly inflated the estimates of use of alternative therapies Finally, since information could not be obtained on nonrespondents, there remains the possibility of some self-selection bias in the study
sample Despite these limitations, the study results make several contributions to our understanding of alternative health care use First, the results provide useful information to conventional practitioners about the health beliefs and practices of many of their patients and may suggest areas where practitioners and the present health care system may be failing to meet peoples health care needs adequately This seems particularly important given research suggesting that the vast majority of medical symptoms are self-diagnosed and selftreated33 and that a significant portion of alternative medical use eg, use of herbal therapies and nutritional supplements falls into the realm of self-care1 Subsequently, if health care professionals are to effectively support individuals in making informed, safe, and appropriate choices, it
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is critical that they develop greater awareness of the nature of, potential efficacy of, and reasons for patients use of
unconventional self-care approaches Second, the results can help identify and clarify prevailing cultural conceptions about and attitudes toward health and illness and examine the degree to which the growing interest in alternative medicine may represent a type of cultural Kuhnian34 paradigm shift regarding health beliefs and practices Results from the present study lend support to the notion that for many individuals, the use of alternative health care is part of a broader value orientation and set of cultural beliefs, one that embraces a holistic, spiritual orientation to life Third, the information derived from this and similar studies can serve as a usefuladjuncttodataderivedfromcontrolled studies of the clinical efficacy of alternative therapies These combined research efforts not only have the potential to changesomeofthewaysconventionalbiomedicine is practiced, but can also serve to stimulate further dialogue among the biomedical community, governmental agencies, insurance
companies, and managed care organizations regarding the potential value of alternative treatments Finally, as policymakers and health care professionals continue to debate reforms of the present health care system, it seems important to understand why a significant portion of the population is going outside mainstream biomedicine to treat a variety of illnesses and to maintain their general health and well-being
I would like to thank Paul Ray, PhD, for making available the data set that was used in the present study, Helena Kraemer, PhD, for her statistical consultation, and Helen Astin, PhD, and Alexander Astin, PhD, for their very helpful comments and suggestions on earlier drafts of the manuscript References 1 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL Unconventional medicine in the United States: prevalence, costs, and patterns of use N Engl J Med 1993;328:246252 2 Borkan J, Neher JO, Anson O, Smoker B Referrals for alternative therapies J Fam Pract
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