utilization of complementary and alternative medicine (CAM) in the community and alternative medicine (CAM) is and Alternative Medicine …
Preventive Medicine 40 2005 46 53 wwwelseviercom/locate/ypmed
Use of complementary and alternative medicine among United States adults: the influences of personality, coping strategies, and social support
Keiko Honda, PhD, MPH and Judith S Jacobson, DrPH
Department of Epidemiology, Columbia University, New York, NY 10032, USA Available online 26 June 2004
Abstract Background Although patterns of utilization of complementary and alternative medicine CAM in the community have begun to be described, few studies have addressed the relationships between dispositional psychological factors and the use of CAM The aim of this study was to examine the associations between CAM use and personality, coping strategies, and perceived social support in a representative sample of adults in the United States Methods Data were drawn from the Midlife Development in the United States Survey MIDUS, a representative sample of 3,032 adults aged 25 74 in the US population We analyzed use of acupuncture,
biofeedback, chiropractic, energy healing, exercise/movement therapy, herbal medicine, high-dose megavitamins, homeopathy, hypnosis, imagery techniques, massage, prayer/spiritual practice, relaxation/ mediation, and special diet within the last year Multiple logistic regression analyses were used to evaluate the association of personality, dispositional coping strategies primary and secondary control, and perceived social support and strain with CAM use, controlling for sociodemographic factors, medical care access, and physical and mental disorders Results Openness was positively associated with the use of all types of CAM except manipulative body-based methods Extroversion was inversely correlated with the use of mind body therapies Primary control was inversely and secondary control directly correlated with the use of CAM Perceived friend support was positively associated with the use of mind body therapies, manipulative body-based methods, and alternative medical systems
Perceived partner strain was positively associated with the use of biologically based therapies, and family strain increased the odds of manipulative body-based methods Conclusions This study is the first to document a significant association between specific domains of personality, coping strategies, and social support, and the use of CAM among adults in the general population Understanding the relationships between psychological factors and CAM use may help researchers and health care providers to address patients needs more effectively and to achieve better adherence to treatment recommendations D 2004 The Institute For Cancer Prevention and Elsevier Inc All rights reserved
Keywords: Complementary and alternative medicine; Coping style; Psychological; Social support; Personality
Introduction Complementary and alternative medicine CAM is increasingly accepted in the United States both as treatment for illness and as self-care to promote health and well-being [1 3] Many mainstream
physicians are either referring patients to or practicing CAM modalities, and appear to understand the potential usefulness of CAM [4 6] However, little is known about the dispositional personal factors
Corresponding author Department of Epidemiology, Columbia University, Room 719, 722 West 168th Street, New York, NY 10032 Fax: 1-212-305-9413 E-mail address: kh2086@columbiaedu K Honda
associated with CAM use and CAM choices in the general population Understanding these associations may facilitate the development of evidence-based CAM and enhance adherence to therapeutic recommendations The National Center for Complementary and Alternative Medicine NCCAM has supported research on how health is related to cognition, personality, and social ties [3], but studies of how CAM use is related to these factors may also be worthwhile Clinical observations [7 9] suggest that several psychological factors may be relevant to CAM use: 1 dispositional coping strategies ie, optimism and pessimism; 2
congruence between the patients personal values and beliefs about CAM and the physicians perspective; and
0091-7435/ - see front matter D 2004 The Institute For Cancer Prevention and Elsevier Inc All rights reserved doi:101016/jypmed200405001
K Honda, JS Jacobson / Preventive Medicine 40 2005 4653
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3 previous experiences of the patient, family members, and friends with the medical system Several investigators [10 13] have quantitatively or qualitatively examined the relationship of CAM use with personality, coping styles, ethnicity/culture, and the influence of family and friends For example, in a study of cancer patients [13], active coping style and religiousness, but not lack of social support or information, were significantly associated with increased use of CAM Using the Tellgen Absorption Scale TAS, another study conducted among clinical and community samples [10] found absorption,1 which is known to be positively correlated with the trait of openness to experience [14],
to be an independent predictor of CAM use Because most patients make choices about CAM use without guidance from a conventional care provider, their own psychosocial characteristics may play a much greater role in their CAM use than in their conventional medical care Three features of previous studies have limited our understanding of the roles of psychological factors in CAM use in the community: 1 studies using convenience samples drawn from treatment settings have had limited generalizability; 2 studies of community-based samples have focused on demographic factors and medical conditions and have not explored psychological factors; and 3 few studies have assessed the predictors of specific types of CAM use The aim of this study is to evaluate the association of personality, coping strategies, and perceived social support with CAM use and their relative importance in CAM choices
4,242 subjects unweighted corresponds to 3,032, weighted for selection probabilities and non-response to
permit generalizability to the US population on age, gender, race, and education [15] Measures CAM use Respondents were asked whether they had received any of the following 14 CAM modalities in the past 12 months: acupuncture, biofeedback, chiropractic, energy healing, exercise/movement therapy, herbal medicine, high-dose megavitamins, homeopathy, hypnosis, imagery techniques, massage, prayer/spiritual practice, relaxation/meditation, special diet We grouped these practices into the five domains proposed by the NCCAM: alternative medical systems eg, acupuncture, homeopathy; body mind therapies eg, biofeedback, hypnosis, relaxation/meditation, imagery techniques, and prayer/spiritual practice; biologically based therapies eg, herbal medicine, high-dose megavitamins, special diets; energy therapies eg, healing touch, Reiki; and manipulative/body-based methods eg, massage therapy, exercise/movement therapies, chiropractic [3] Personality traits Assessment of personality traits in the
MIDUS was based on the big five factor model [17], which was tested in a pilot study conducted in 1994 with a probability sample of 1,000 men and women, age 30 70 574 valid cases were usable for item analysis Respondents were given a list of adjectives representing aspects of personality and asked to use a four-level Likert-scale to describe how much of the time all, most, some, or a little each word described them The adjectives were interpreted as comprising five traits or scales: Agreeableness helpful, warm, caring, softhearted, sympathetic a 080 five-item scale; Openness to experience creative, imaginative, intelligent, curious, sophisticated, adventurous a 077 seven-item scale; Conscientiousness [organized, responsible, hardworking, not careless] a 057 four-item scale; Extroversion outgoing, friendly, lively, active, talkative a 078 five-item scale; and Neuroticism moody, worrying, nervous, not calm a 074 four-item scale The alphas are based on the MIDUS national sample For
each respondent who provided valid values for at least half the adjectives comprising a trait, the trait was scored as the mean of the responses for that trait Primary and secondary control strategies The two-process model of primary and secondary control is a conceptualization that proposes two main coping strategies by which people may develop a sense of control [18 20] Primary control refers to individuals attempts to make external social and physical or behavioral circumstances conform to their personal needs and desires, whereas secondary control refers to individuals efforts to adapt
Methods Sample The Midlife Development in the United States Survey MIDUS is a nationally representative survey of 4,242 persons aged 25 74 years in the noninstitutionalized civilian population of the 48 coterminous United States [15] The MIDUS Survey was carried out by the John D and Catherine T MacArthur Foundation Network on Successful Midlife Development between January 1995 and January 1996 All
respondents completed a 30-min telephone interview and filled out two mailed questionnaires estimated to take a total of about 90 min to complete 868 conditional response rate in the subsample of telephone respondents The overall response rate was 608 More details on the MIDUS Survey design, filed procedures, and representativeness are provided elsewhere [15] The total sample of
Absorption refers to the disposition to display episodes of total attention during which the available representational apparatus seems to be entirely dedicated to experiencing and modeling the attentional object, be it a landscape, a human being, a sound, a remembered incident, or an aspect of ones self [16], p 274
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K Honda, JS Jacobson / Preventive Medicine 40 2005 4653
their cognitive and affective states in response to stressful life events [20] Respondents were asked to indicate how well each of 14 items described them, using a four-point Likert scale 1 not at all, 4 a lot [21] Assessment of
control strategies in the MIDUS used a three-factor model developed from a study conducted by Wrosch et al [21] Scales included a primary control persistence in goal striving a 077 five-item scale, a secondary control positive reappraisals a 078 four-item scale; and a secondary control lowering aspiration a 063 fiveitem scale Items were recoded so that higher scores indicated higher primary or secondary control Perceived social support and strain In the MIDUS, social support and social strain were evaluated as emanating from family members other than the spouse/partner, friends, and spouse/partner Supportive network exchanges were measured through four items that were parallel for spouse/partner, family members, and friends The four items were:
included in the model because it is known to affect health care utilization Data analysis First, F-based tests for independence were conducted to compare the sociodemographic, clinical, and psychosocial personality, coping, and social
support characteristics of respondents who had and had not used any CAM in the past 12 months Next, descriptive analyses were used to assess the prevalence of each CAM modality by presence and absence of mental and physical disorders Finally, multiple logistic regression analyses were used to examine the relationships between psychological factors personality, control strategies, and perceived social support and strain, and CAM use, controlling for sociodemographics age, gender, race, education, and marital status, health care access, and physical and mental health conditions major depression, anxiety disorders, panic disorders, heart-related problems, cancer, and obesity All psychological factors were measured on a continuous four-point scale We calculated the mean by summing the scales and dividing by the number of scales for each factor Hence, these associations reflect the increase in CAM use associated with every 1-point increase in the mean score for each psychological factor All
results reported here are based on weighted data, adjusted for differential probabilities of selection within households and for differences between the sample distribution and the census population distribution on a range of sociodemographic variables
How much do they family members, not including your spouse or partner; friends; spouse/partner understand the way you feel about things? How much do they really care about you? How much can you rely on them for help if you have a serious problem? And, how much can you open up to them if you need to talk about your worries? Strained network exchanges were also measured through four parallel items that read:
How often do they criticize you? How often do they make too many demands on you? How often do they let you down when you are counting on them? And, how often do they get on your nerves? All items were answered on a four-point Likert-type scale support items: 1 a lot; 4 not at all; strain items: 1 often, 4 never Items were
recoded so that higher scores indicated higher support or strain Cronbachs alpha scores were: Family support 082, Family strain 080, Friend support 088, Friend strain 079, Partner support 086, and Partner strain 081 [22] Covariates Based on previous studies [1,2,7,13,23,24], certain sociodemographic and health-related factors were hypothesized to predispose to CAM use Health factors including major depression, panic attacks, generalized anxiety disorder as well as heart-related problems, cancer, and obesity were assessed and included in the regression model Age, gender, marital status, race/ethnicity, and education were included in the model Health insurance coverage was also
Results Overall, 54 of the sample n 3,032 reported having used any kind of CAM in the past 12 months Individuals who reported CAM use were more likely to be female, white, or college educated than, but were similar in age and marital status to, those who did not use any CAM see Table 1 Users of CAM were more
likely to report mental disorders major depression and panic disorders than nonusers Users were also more likely than nonusers to report physical disorders, but the associations did not reach statistical significance Users of CAM were more likely than nonusers to be neurotic, to be open, to receive support from friends, and to experience strain from all social ties measured see Table 1 Table 2 shows the percentage of individuals with and without mental and physical disorders who reported using the 14 CAM modalities Among all respondent groups, the most commonly used CAM modality was prayer/spiritual practice, which was used by about 28 of all respondents Among those with no mental or physical disorders n 1,540, the second most commonly used CAM modality was exercise/movement therapy, and the third was relaxa-
K Honda, JS Jacobson / Preventive Medicine 40 2005 4653 Table 1 Clinical, sociodemographic, and psychosocial characteristics associated with use of CAM past 12 months among
adults in the community N 3,032 Characteristic Age [mean SD] Gender Male Female Education Less than GED High school diploma Some college Bachelors degree Graduate degree s Race White Ethnic Marital status Married Separated Divorced Widowed Never married Mental/emotional disorders Major depression ref no Anxiety disorders ref no Panic disorders ref no Physical disorders Heart-related conditions ref no Cancer ref no Obese ref no Personality traits [mean SD] Agreeableness continuous Neuroticism continuous Openness continuous Extroversion continuous Conscientiousness continuous Control strategies [mean SD] Persistence continuous Positive reappraisals continuous Lowering aspirations continuous Social support and strain [mean SD] Partner support continuous Family support continuous Friend support continuous Partner strain continuous Family strain continuous Friend strain continuous No use of CAM n 1,392 weighted 448 038 498 502 170 422 225 110 74 797 207 687 34 123 50 106 107 26 35
114 59 258 349 225 298 323 339 001 002 002 002 001 Use of ANY CAM n 1,640 weighted 458 044 375 625 96 346 284 161 113 841 159 676 21 137 43 124 174 39 100 130 69 261 352 231 305 320 341 001 002 001 002 001 F, P value ns
49
F 375, P 00001
F 169, P 00001
F 632, P 0012
ns
F 205, P 00001 ns F 382, P 00001 ns ns ns ns F 449, P 005 F 759, P 001 ns ns ns ns F 682, P 001 ns ns F F F F
326 002 314 002 263 002 353 340 314 217 208 191 002 002 002 002 002 002
322 002 317 002 255 002 352 341 328 225 220 199 002 002 002 002 002 001
2286, P 00001 507, P 005 2008, P 00001 1054, P 001
tion/meditation The leading two modalities among individuals with mental disorders n 322 and with physical disorders n 943, were similar to those of healthy individuals, but the third most commonly used modality was special diets Among individuals with both mental and physical disorders n 227, the second and third most common modalities were special diets and exercise/movement therapy
Those with both mental and physical disorders were more likely than the other respondent groups to use all types of CAM except energy healing Those with both mental and physical disorders were nearly twice as likely as healthy individuals to use herbal medicine and acupuncture and more than twice as likely to use biofeedback and high-dose megavitamins
Table 3 presents multiple logistic regression results for models in which the dependent variables were the five domains of CAM use and any CAM use In the prediction of mind body intervention use, female gender, more education, and mental disorders were associated with significantly increased likelihood of use Higher levels of openness were associated with the use of all domains of CAM except manipulative body-based methods The strongest association was that between openness and energy therapies Positive reappraisals and friend support were associated with a significantly increased likelihood of using mind body modalities Higher levels
of extroversion and primary control were associated with reduced likelihood of use of such modalities Having a physical disorder was associated with the use of
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Table 2 Use of different methods of CAM N 3,032 Method Use of CAM weighted No mental and physical only n 1,540 Body/mind therapies Biofeedback Hypnosis Relaxation/meditation Imagery technique Prayer/spiritual practice Biologically based therapies Herbal medicine High-dose megavitamins Special diet Manipulative/body-based methods Massage therapy Exercise therapy Chiropractic Alternative medical system Acupuncture Homeopathy Energy therapies Energy healing 06 16 132 27 279 Mental disorders only n 322 06 11 122 25 287 Physical disorders only n 943 03 12 86 19 276 Both mental and physical disorders n 227 19 16 192 35 382 Total
08 13 134 29 296
49 36 78
49 39 114
36 30 146
97 95 222
53 42 117
78 155 94
75 163 101
57 165 105
122 202 136
82 175 109
08
21
09 20
09 16
16 35
11 24
16
13
07
14
17
biologically based and manipulative body-based therapies, but having a mental disorder was associated with use of body mind interventions Partner strain was associated with a significantly increased likelihood of use of biologically based therapies, while primary control was associated with a significantly decreased likelihood of use of such therapies White respondents were about twice as likely as nonwhites to use manipulative/body-based methods The use of alternative medical systems and energy therapies were not associated with sociodemographic or health factors but with high levels of openness and secondary control and with low level of primary control
Discussion These results suggest that individual psychological characteristics such as personality, coping, and perceived social support may influence CAM use Assessment of personality and beliefs may therefore provide insight into CAM-seeking behaviors that may affect clinical and
research outcomes For example, openness to experience appeared to be associated with use of almost all types of CAM Individuals who are open to experience may be more likely than others to use CAM, even when it is not recommended or appropriate Extroversion was associated with a low frequency of use of mind body interventions Extroverted individuals appeared to favor more concrete or active types of CAM From a practical point of view, extroverted people may be
more likely than others to reject therapeutic recommendations or to be non-adherent to mind body interventions in trials or treatment We hypothesized that coping style might also be associated with CAM choices Specifically, we hypothesized that those who exercise primary control, which involves modifying the environment, and those who exercise secondary control, which involves modifying the self, might make different choices among CAM modalities Psychologists differ as to whether coping style is an internal attribute trait or a
transient state brought about by external life circumstances [25] However, a study of a large number of normal male and female twins [26] found a strong genetic influence on coping strategies including defense, emotional coping, substitution, and active coping, supporting the notion of coping style itself as a partially heritable trait On the other hand, some evidence [27] suggests that secondary control strategies become increasingly common in late life Cross-sectional studies [28,29] also suggest that the predominance of secondary control vs primary control is associated with culture eg, traditional Japanese culture as compared to Western culture These observations suggest that sense of control is not a fixed aspect of coping style However, adjusting for age and ethnicity as a proxy for culture, we observed that those with high levels of primary control were significantly less likely to use all types of CAM, except for manipulative body-based methods, than those with lower levels On
the other hand, secondary control appeared to be associated with use of mind body
K Honda, JS Jacobson / Preventive Medicine 40 2005 4653 Table 3 Predictors of any CAM and five domains of CAM use past 12 months among adults in the community Predictors Odds ratio 95 CI Body/mind intervention Sociodemographic Age continuous Gender ref male Race ref ethnic Marital status ref nonmarried Education ref no college Healthcare access Insurance coverage ref no Medical comorbidities Psychiatric disorders ref no Physical disorders ref no Personality traits Agreeableness continuous Neuroticism continuous Openness continuous Extraversion continuous Conscientiousness continuous Control strategies Persistence continuous Positive reappraisals continuous Lowering aspirations continuous Social support and strain Partner support continuous Family support continuous Friend support continuous Partner strain continuous Family strain continuous Friend strain continuous Predictors 100 184 134 134 169
098 101 131 257 084 215 080 223 122 232 Biologically based therapies 100 190 115 098 159 099 102 126 286 066 201 054 178 108 234
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Manipulative/body-based methods 101 095 202 085 107 100 103 067 134 108 378 050 145 076 149
104 073 148
109 070 171
121 081 180
164 109 248 080 058 109
142 089 226 170 117 247
132 084 199 144 104 200
113 092 152 064 092
073 174 070 120 106 217 045 093 064 133
115 126 220 094 071
072 183 090 176 143 339 062 143 046 110
085 107 138 097 124
056 131 081 141 095 199 068 140 082 186
059 041 085 186 134 257 100 073 136
056 037 084 152 097 237 101 070 145
094 064 137 091 065 129 085 061 118
100 115 140 104 134 116
073 137 085 155 107 182 078 140 098 182 082 163
138 099 105 151 114 115
096 199 069 141 075 146 107 215 079 164 078 168
119 099 145 099 158 098
086 164 074 134 109 192 071 138 113 222 070 137
Odds ratio 95 CI Alternative medical systems Energy therapies 099 167 085
028 419 096 103 032 877 017 411 007 119 097 1818 Any CAM 100 161 150 126 157 098 101 118 221 095 237 078 202 115 215
Sociodemographic Age continuous Gender ref male Race ref ethnic Marital status ref nonmarried Education ref no college Health care access Insurance coverage ref no Medical comorbidities Psychiatric disorders ref no Physical disorders ref no Personality traits Agreeableness continuous Neuroticism continuous Openness continuous Extraversion continuous Conscientiousness continuous Predictors
102 198 065 050 189
098 106 080 489 025 170 017 144 081 439
052 028 152
109 028 418
102 072 144
260 099 679 091 039 209
139 030 637 053 012 233
170 113 254 113 083 153
169 040 718 130 051 333 355 133 944 085 031 228 090 035 232 Odds ratio 95 CI
241 034 1708 079 033 190 1577 286 8687 096 026 360 164 035 779
106 088 165 065 094
073 156 069 113 118 231 046 091 065 135
continued on next page
52 Table 3 continued
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Jacobson / Preventive Medicine 40 2005 4653
Alternative medical systems Control strategies Persistence continuous Positive reappraisals continuous Lowering aspirations continuous Social support and strain Partner support continuous Family support continuous Friend support continuous Partner strain continuous Family strain continuous Friend strain continuous 024 011 051 341 119 934 090 048 170
Energy therapies 018 003 093 307 077 1233 262 101 677
Any CAM 067 047 095 120 089 162 086 064 116
111 054 228 086 046 200 281 123 641 117 061 225 089 051 158 133 062 285
141 071 353 072 190 026
044 445 022 226 095 1312 029 178 078 462 006 111
111 082 149 127 096 169 137 107 174 111 084 146 154 115 206 115 082 159
interventions and alternative medical systems Assessing individual differences in coping strategies may help us understand how to tailor patient education The effects of social support or strain from friends, family, and partner on the use of CAM are
important because they are amenable to psychological interventions Although these social support measures are self-reported and may not be a true reflection of social support received, we found that social support from friends was associated with most CAM modalities such as mind body interventions, manipulative bodybased methods, and alternative medical systems Future research could further examine the structural aspects eg, size and kind of friend network and actual support exchanges eg, informational, decisional in relation to CAM use Partner strain and family strain were associated with increased use of biologically based therapies and manipulative body-based methods, respectively Although the reasons for these associations are beyond the scope of this study, it is possible that some individuals respond to familial strain by using certain types of CAM modalities Future research is needed on the pathways that link social strain, potentially comorbid psychological distress, personal
resources, and CAM use This study has several limitations Our theoretical model proposes that individuals trait- and cognitive-oriented characteristics affect their CAM use The cross-sectional design, however, does not allow us to assess causality For example, as a result of using mind/body CAM, individuals may become more tolerant of a difficult situation and may therefore appear in the MIDUS data to have high secondary control Similarly, using CAM without adverse effects, at least in the short term, may encourage greater openness to experience However, personality traits are believed to develop early in life and to remain relatively stable over a persons life span [30,31] The questions in the MIDUS instrument focus on CAM use during the past 12 months We therefore doubt that CAM use is the causal agent in most of the associations we observed However, longitudinal research is needed to test the hypothesis that aspects of personality are predictors of CAM choices Another limitation is
that the survey instrument was not specifically
designed to assess determinants of CAM use For example, specific mental and physical disorders that the MIDUS instrument does not measure may also have played a role in CAM use The survey used a dichotomous measure of CAM use Data on dose or frequency of CAM use might shed additional light on CAM seeking behavior The MIDUS sample included only individuals aged 25 74 years Some studies have found that older people are less likely to use CAM than younger people We found no association of CAM use with age, but we cannot generalize our findings to very old or very young adults Despite these limitations, the current study has identified direct relationships between trait-oriented and cognitiveoriented characteristics and CAM choices in a sample of the general population If these factors do affect CAM choices, they may also predict adherence to and outcomes of treatment recommendations in general Psychosocial data might help providers and
patients select treatments for their compatibility with a patients psychosocial profile Even now, psychosocial testing is sometimes used to assess the eligibility of candidates for participation in clinical trials It may be also have the potential to provide not just a general judgment of emotional stability but also an assessment of the fit between the intervention and the subject In studies of treatments that are expected not to have dramatic short-term effects, small variations in adherence may have important consequences for the interpretability of results We therefore suggest that future trials, especially in but not limited to CAM, incorporate measurements of psychosocial factors and evaluate them as predictors of adherence Key points Individual psychosocial characteristics such as personality, coping, and perceived social support may influence CAM use Policy implications Assessment of personality and coping style has the potential to provide not just a general judgment of
emotional
K Honda, JS Jacobson / Preventive Medicine 40 2005 4653
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stability but also an assessment of the fit between the intervention and the subject
[14]
Acknowledgments
[15]
KH is supported by a postdoctoral fellowship from the National Cancer Institute CA09529
[16]
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