Use of complementary and alternative medicine (CAM) has stimulated discussion in both Canada1–4 and the United States5–12 on topics such as who might benefit from CAM insurance coverage and the role of CAM as a substitute for use of conventional medical treatment vs a supplement to such treatment. In the United States, members of racial or ethnic minority groups are less likely to use CAM than are White people, and elevated income is a strong predictor of CAM use.5,6,8 In the United States (unlike in Canada), race and ethnicity are related closely to health insurance status.13 In both Canada4 and the United States,5,6,8 CAM use appears higher in western regions than in other areas. In Canada, western provinces are much more likely than those in the east to cover CAM in their health programs.1 In the United States, some 42 states mandate coverage of chiropractic care in private insurance,9 whereas federal legislation mandates coverage for all people older than 65 years (in the Medicare program) as well as for individuals whose health insurance is provided by large employers regulated under the Employee Retirement Income Security Act.14
This study examined relationships between race, geography, and conventional medical care and the use of acupuncture, chiropractic, homeopathy/naturopathy, and massage therapy.
Methods
Data were obtained from the 1996 Canadian National Population Health Survey, which had a response rate of 83%.15 Canadian CAM users in the first (1994) wave of this survey have been described previously.4 Information was also obtained from the 1996 United States Medical Expenditure Panel Survey, which had a response rate of 78%.16 Data from this survey have been employed in other studies on CAM use in the United States.8,10 Each country’s data set was analyzed by means of logistic regression with the SUDAAN computer program (release 7.5.4; Research Triangle Institute, Research Triangle Park, NC).
Results
Table 1 ▶ shows that Canadian respondents were slightly older, had slightly less education, were much more likely to be White, and had slightly worse self-reported health status than their counterparts in the United States. Both countries had the same percentages reporting problems with activities of daily living. Canadian and US respondents differed in reported problems with instrumental activities of daily living (e.g., shopping), but this item was worded differently in the 2 surveys. Canadians were more likely than US respondents to have seen a conventional physician (doctor of medicine or doctor of osteopathy) in the year prior to the interview.
TABLE 1.
—Demographics of Users of Complementary and Alternative Medicine in Canada and the United States
| Canada, No. (%) | United States, No. (%) | |
| N | 70 884 (100) | 16 400 (100) |
| Age, y | ||
| 15–19 | 4449 (6) | 1590 (10) |
| 20–44 | 34 053 (48) | 8026 (49) |
| 45–64 | 19 019 (27) | 4339 (27) |
| ≥ 65 | 13 363 (19) | 2445 (15) |
| Male | 32 981 (47) | 7709 (47) |
| White | 65 642 (93) | 13 486 (82) |
| High school or higher | 50 520 (72) | 12 010 (74) |
| Residencea | ||
| East | 3389 (5) | 8903 (54) |
| Central | 40 128 (57) | 3569 (22) |
| West | 27 367 (39) | 3687 (23) |
| Health status | ||
| Excellent | 16 437 (23) | 4951 (30) |
| Very good | 26 988 (38) | 4872 (30) |
| Good | 19 152 (27) | 4117 (25) |
| Fair | 6237 (9) | 1742 (11) |
| Poor | 2070 (3) | 658 (4) |
| Problem with instrumental ADLs | 8282 (12) | 632 (4) |
| Problem with ADLs | 1682 (2) | 316 (2) |
| Service use in past 12 mo | ||
| MD/DO | 56 035 (79) | 10 894 (66) |
| Acupuncturist | 800 (1) | 101 (1) |
| Chiropractor | 9074 (13) | 573 (4) |
| Homeopath/naturopath | 906 (1) | 73 (0.4) |
| Massage therapist | 2290 (3) | 318 (2) |
| Any CAM provider | 11 400 (16) | 862 (5) |
| Only physician (MD or DO) | 48 168 (68) | 10 316 (63) |
| Only CAM provider | 1412 (2) | 133 (1) |
| Both CAM and physician | 9979 (14) | 729 (4) |
Note. ADLs = activities of daily living; CAM = complementary and alternative medicine (acupuncture, chiropractic, homeopathy/naturopathy, massage therapy); MD = doctor of medicine; DO = doctor of osteopathy.
aEast = Atlantic Canada (including Nunavut) and Northeast and South US census divisions; Central = Quebec and Ontario and Midwest US census division; West = remaining Canadian provinces and territories and Western US census division.
In both countries, there was little use of acupuncture, homeopathy/naturopathy, or massage therapy. Chiropractic was the most frequently used CAM treatment in both countries, with Canadian use being 3 times that in the United States. Respondents in both countries were very unlikely to have seen only a CAM provider.
Table 2 ▶ shows that for both countries, CAM use was highest among persons aged 20 to 64 years, women, persons with a high school education or higher, and Whites. In both Canada and the United States, CAM use was much more prevalent among westerners than among other residents (even after adjustment for all other factors). In both countries, CAM users were slightly less likely to report “excellent” health than were nonusers. After adjustment for other factors, this relationship remained statistically significant in Canada but not in the United States. Both US and Canadian CAM users were more likely than nonusers to report problems with instrumental activities of daily living, but this relationship was not statistically significant in the United States. Conversely, CAM users in Canada were slightly less likely than nonusers to have problems with activities of daily living. In Canada and the United States, CAM users were more likely than nonusers to have seen a conventional physician in the previous year (even after adjustment for all other factors).
TABLE 2.
—Comparison of Users and Nonusers of Complementary and Alternative Medicine in Canada and the United States
| Canada | United States | |||||
| Users, % | Nonusers, % | Adjusted OR (95% CI) | Users, % | Nonusers, % | Adjusted OR (95% CI) | |
| Age, y | ||||||
| 15–19 | 4 | 7 | 1.00 | 4 | 10 | 1.00 |
| 20–44 | 53 | 47 | 1.43 (1.34, 1.53) | 50 | 49 | 1.77 (1.17, 2.66) |
| 45–64 | 30 | 26 | 1.42 (1.35, 1.50) | 35 | 26 | 2.04 (1.34, 3.11) |
| ≥ 65 | 13 | 20 | 0.68 (0.63, 0.74) | 12 | 15 | 1.29 (0.80, 2.08) |
| Male | 43 | 47 | 0.79 (0.77, 0.82) | 37 | 48 | 0.72 (0.62, 0.84) |
| White | 96 | 92 | 2.07 (1.95, 2.19) | 92 | 82 | 2.32 (1.71, 3.14) |
| High school or higher | 77 | 71 | 1.40 (1.35, 1.46) | 88 | 74 | 1.78 (1.30, 2.44) |
| Residencea | ||||||
| East | 2 | 5 | 1.00 | 38 | 56 | 1.00 |
| Central | 50 | 58 | 2.84 (2.69, 3.01) | 30 | 22 | 1.79 (1.41, 2.27) |
| West | 49 | 37 | 4.68 (4.36, 5.02) | 32 | 22 | 2.47 (2.00, 3.04) |
| Health status | ||||||
| Excellent | 20 | 24 | 1.11 (1.09, 1.13) | 28 | 30 | 1.03 (0.95, 1.12) |
| Very good | 39 | 38 | 33 | 30 | ||
| Good | 28 | 27 | 26 | 25 | ||
| Fair | 10 | 9 | 9 | 11 | ||
| Poor | 3 | 3 | 4 | 4 | ||
| Problem with instrumental ADLs | 14 | 11 | 1.73 (1.63, 1.83) | 3 | 4 | 0.63 (0.34, 1.17) |
| Problem with ADLs | 2 | 2 | 0.77 (0.71, 0.84) | 2 | 2 | 1.34 (0.63, 2.86) |
| Saw MD/DO in past 12 mo | 85 | 78 | 1.45 (1.39, 1.50) | 84 | 65 | 2.57 (2.11, 3.13) |
Note. OR = odds ratio; CI = confidence interval; ADLs = activities of daily living; CAM = complementary and alternative medicine (acupuncture, chiropractic, homeopathy/naturopathy, massage therapy); MD = doctor of medicine; DO = doctor of osteopathy.
aEast = Atlantic Canada (including Nunavut) and Northeast and South US census divisions; Central = Quebec and Ontario and Midwest US census division; West = remaining Canadian provinces and territories and West US census division.
Discussion
Despite notable differences between Canada and the United States,17–19 these countries seem rather similar with regard to CAM use. The racial/ethnic disparity in CAM use that has been found in the United States5,6,8 also is seen in Canada. The striking geographic differences in CAM use across Canada were also found in the United States. Whereas Canadian regional variation in CAM consumption might be explained by differences in provincial health insurance,4 such an explanation seems unlikely in the United States. In both countries, CAM appears to be an add-on rather than an alternative to conventional medical care.
This cross-sectional project’s limitations included inability to verify service use reports and difficulty in determining causality. Many of the survey items were identical in Canada and the United States, but there were a few differences. Nonetheless, as in other aspects of medical care,20,21 comparisons between Canada and the United States can stimulate fruitful discussion and investigation regarding optimal provision of complementary health care services.
Acknowledgments
This project was supported in part by grants from the Canadian Embassy and the US National Institute of Mental Health (R03 MH 59719) (to M. K.).
This analysis is based on Statistics Canada’s National Population Health Survey 1996–1997, Household Component, Public Use Microdata Files, which contain anonymous data, and on the US Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey, 1996. All computations on these data were prepared by Oregon Health and Science University and Portland State University. Responsibility for the use and interpretation of these data is entirely that of the authors.
Human Participant Protection This study was determined to be exempt from review by the Oregon Health and Science University Institutional Review Board.
B. McFarland, D. Bigelow, and M. Kaplan conceptualized the analysis. B. Zani and J. Newsom conducted the data analysis and produced the tables. B. McFarland, D. Bigelow, B. Zani, and M. Kaplan drafted the brief, which was reviewed and finalized by all of the authors.
Peer Reviewed
References
- 1.Achilles R, Adelson N, Antze P, et al. Complementary and Alternative Health Practices and Therapies. A Canadian Overview. Toronto, Ontario: York University Centre for Health Studies; 1999.
- 2.Shearer R, Simpson J, eds. Perspectives on Complementary and Alternative Health Care. Ottawa, Ontario: Health Canada; 2001.
- 3.Blais R, Maiga A, Aboubacar A. How different are users and non-users of alternative medicine? Can J Public Health. 1997;88:159–162. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Millar WJ. Use of alternative health care practitioners by Canadians. Can J Public Health. 1997;88:154–158. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.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;328:246–252. [DOI] [PubMed] [Google Scholar]
- 6.Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997. JAMA. 1998;280:1569–1575. [DOI] [PubMed] [Google Scholar]
- 7.Eskinazi DP. Factors that shape alternative medicine. JAMA. 1998;280:1621–1623. [DOI] [PubMed] [Google Scholar]
- 8.Druss BG, Rosenheck RA. Association between use of unconventional therapies and conventional medical services. JAMA. 1999;282:651–656. [DOI] [PubMed] [Google Scholar]
- 9.Sturm R, Unutzer J. State legislation and the use of complementary and alternative medicine. Inquiry. 2000/01;37:423–429. [PubMed] [Google Scholar]
- 10.Druss BG, Rosenheck RA. Use of practitioner-based complementary therapies by persons reporting mental conditions in the United States. Arch Gen Psychiatry. 2000;57:708–714. [DOI] [PubMed] [Google Scholar]
- 11.Unutzer J, Klap R, Sturm R, et al. Mental disorders and the use of alternative medicine: results from a national survey. Am J Psychiatry. 2000;157:1851–1857. [DOI] [PubMed] [Google Scholar]
- 12.Sturm R. Patient risk-taking attitude and the use of complementary and alternative medical services. J Altern Complement Med. 2000;6:445–448. [DOI] [PubMed] [Google Scholar]
- 13.Statistical Abstract of the United States: 2000. 120th ed. Washington, DC: US Bureau of the Census; 2000.
- 14.Talbott JA, Hales RE, eds. Textbook of Administrative Psychiatry: New Concepts for a Changing Behavioral Health System. 2nd ed. Washington, DC: American Psychiatric Publishing Inc; 2001.
- 15.Kaplan MS, Newsom JT, McFarland BH, Lu L. Demographic and psychosocial correlates of physical activity in late life. Am J Prev Med. 2001;21:306–312. [DOI] [PubMed] [Google Scholar]
- 16.Cohen JW, Monheit AC, Beauregard KM, et al. The Medical Expenditure Panel Survey: a national health information resource. Inquiry. 1996/97;33:373–389. [PubMed] [Google Scholar]
- 17.Lipset SM. Continental Divide: The Values and Institutions of the United States and Canada. New York, NY: Routledge; 1991.
- 18.Bigelow DA, McFarland BH. Comparative costs and impacts of Canadian and American payment systems for mental health services. Hosp Community Psychiatry. 1989;40:805–808. [DOI] [PubMed] [Google Scholar]
- 19.Bigelow DA, McFarland BH. Financing Canada’s mental health services. New Dir Men Health Serv. 1994;61:63–72. [DOI] [PubMed] [Google Scholar]
- 20.Kessler RC, Frank RG, Edlund M, Katz SJ, Lin E, Leaf P. Differences in the use of psychiatric outpatient services between the United States and Ontario. N Engl J Med. 1997;336:551–557. [DOI] [PubMed] [Google Scholar]
- 21.Katz SJ, Zemencuk JK, Hofer TP. Breast cancer screening in the United States and Canada, 1994: socioeconomic gradients persist. Am J Public Health. 2000;90:799–803. [DOI] [PMC free article] [PubMed] [Google Scholar]