Prevalence of Use of Complementary/alternative Medicine: A Systematic Review

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Research

Prevalence of use of complementary/alternative


medicine: a systematic review
E. Ernst1

Reported are the results of a systematic review of the prevalence of use of complementary/alternative medicine.
Computerized literature searches were carried out in four databases. Twelve surveys thus found were selected because
they dealt with the utilization of complementary/alternative medicine in random or representative samples of the
general population. Data were extracted in a predefined, standardized way. Prevalence of use of complementary/
alternative medicine ranged from 9% to 65%. Even for a given form of treatment such as chiropractic, as used in the
USA, considerable discrepancies emerged. The data suggest that complementary/alternative therapies are used
frequently and increasingly. Prevalence of use seemed to depend critically on factors that were poorly controlled in
surveys of complementary/alternative medicine. The true prevalence of use of complementary/alternative medicine in
the general population remains uncertain.

Keywords: alternative medicine, utilization, prevalence; review, literature.

Voir page 256 le résumé en français. En la página 256 figura un resumen en español.

Introduction ill but evidently employ CAM in order to prevent


illness (9). Reliable prevalence figures for the general
Complementary/alternative medicine (CAM) has population could form the basis for much discussion
been described as ‘‘diagnosis, treatment and/or on CAM, especially as regards its integration into
prevention which complements mainstream medi- routine health care.
cine by contributing to a common whole, satisfying a The present article reports the results of a
demand not met by orthodoxy, or diversifying the systematic review, summarizing the available data on
conceptual frameworks of medicine’’ (1). Approxi- the prevalence of CAM use among random or
mately 1500 articles on CAM are published annually representative samples of general populations.
in the literature covered by MEDLINE (2). In the
United Kingdom the market for herbal and homoeo-
pathic remedies and aromatherapy oils increased by
41% between 1992 and 1996 (3). In Germany a herbal
Methods
remedy (St John’s wort) is now the most frequently The MEDLINE, EMBASE, Cochrane Library and
prescribed drug for depression. In the USA, the sales CISCOM databases were searched covering the
of St. John’s wort rose by 2800% between 1997 and period from the dates of their inception to the end
1998, and the total market for medicinal botanicals of 1997. The following keywords were used:
was worth US$ 3.87 billion in 1998 (4). Most experts acupuncture, alternative medicine, aromatherapy,
agree that the interest in and practice of CAM are chiropractic, complementary medicine, herbalism,
driven mainly by consumer pressure. homoeopathy, hypnotherapy, massage therapy,
The prevalence of CAM use by defined naturopathy, osteopathy, phytomedicine, reflexol-
populations of patients, e.g. those suffering from ogy, relaxation therapy, surveys, yoga. In addition, the
rheumatic diseases (5), acquired immunodeficiency author’s own files and those of 12 other experts were
syndrome (AIDS) (6) or cancer (7), and paediatric consulted. Furthermore, the following journals not
patients (8), is fairly well established and relatively listed in or only recently admitted to electronic
easy to quantify. However, it may be more important databases were hand-searched for relevant publica-
to consider the use of CAM in the population at large, tions (1993–97): Acupuncture in Medicine, Alternative and
particularly as more than 50% of CAM users are not Complementary Medicine, Alternative Therapies in Health
and Medicine, British Journal of Homeopathy, Complemen-
tary Therapies in Medicine, Fitoterapı́a, Forschende Komple-
1
Professor, Department of Complementary Medicine, Postgraduate mentarmedizin, NaturaMed. The bibliographies of all
Medical School, University of Exeter, 25 Victoria Park Road, Exeter EX2 articles thus found were scanned for further relevant
4NT, England (e-mail: E.Ernst@exeter.ac.uk). publications.
Ref. No. 0143

252 # World Health Organization 2000 Bulletin of the World Health Organization, 2000, 78 (2)
Prevalence of use of complementary/alternative medicine

To qualify for inclusion, a survey had to address and prevalence data were not provided for specific
the prevalence of CAM, i.e. the percentage of people therapies. The results suggested a one-year preva-
using it. The surveys had to be based on random or lence of 8.5% for all forms of CAM use, a
representative samples of the general population of a considerably lower value than those reported else-
nation or a defined geographical area. ‘‘Representa- where. This was possibly because of national
tive’’ was taken to mean an unselected sample from differences or because the survey was conducted
the general public with no evidence of a systematic during a difficult economic period in the United
difference in demographics compared to the general Kingdom, where CAM is usually paid for privately.
population. Surveys on subpopulations (such as In Scotland, Emslie et al. (13) asked people
patients with a named condition, e.g. AIDS, or whether they would consider using CAM in the
individuals with a given characteristic, e.g. being future. There appeared to be a high potential demand,
vegetarian) were excluded. Publication in a language particularly for osteopathy, acupuncture and aroma-
other than English was not grounds for exclusion. All therapy. However, the sample size was relatively
identified surveys were read in full by the author and small.
their data were extracted and validated according to MacLennan et al. (14) employed a rigorous
standardized, predetermined criteria (Table 1). methodology to ensure that their random sample was
representative of the general population of South
Australia. They also evaluated the reliability of their
Results questionnaire by reinterviewing a subsample by
telephone. However, the questionnaire was some-
More than 100 papers on surveys of CAM use were what confusing as far as the categories of remedies
found, but most were excluded because the samples were concerned. For instance, vitamin or mineral
were neither random nor representative. Twelve supplementation may not be considered universally
surveys (9–20) met the criteria and were included in as CAM, while Chinese medicines, herbal medicines
the review. Although Fisher & Ward (20) mentioned and ginseng, mentioned as distinct categories, over-
several further surveys as being representative, none lap. The high prevalence of CAM use (48.5%)
of them fulfilled the present criteria. Most of the suggested by the survey may partly reflect the
included material refers to recent publications. The misclassification of treatments.
key data of all surveys are summarized in Table 1. Chi et al. (15) conducted interviews among
The survey by Haidinger & Gredler in Austria 1358 members of the National Household Sample in
(10) employed an unorthodox sampling method: China (Province of Taiwan), and asked the partici-
65% of the interviews were carried out in Vienna, pants whether they would use Chinese medicine. It
22% in Lower Austria and the rest elsewhere in the appeared that 10% were current users of this type of
country. Nevertheless, the demographic description CAM and that 31% would consider using it.
of the sample implied that it was representative of the Panamore sent questionnaires to 3450 US
Austrian population. The results of the survey citizens (16). This sample originated from the
suggested that acupressure was the most prevalent National Access to Care (NAC) Survey and was
form of CAM. Galvanic current treatment, the third representative of the country’s population. Partici-
most popular therapy, is not normally considered as a pants were asked whether, in the last year, they had
form of CAM. Generally speaking, lifetime preva- used chiropractic, massage, relaxation or acupunc-
lences of CAM use were low. This could have been ture, for which the prevalences were 6.8%, 3.1%,
because the country’s law does not permit non- 1.3% and 0.4% respectively.
medically trained complementary/alternative thera- An opinion poll commissioned by the German
pists to practise CAM. On the other hand, the survey Association of Pharmaceutical Manufacturers (17)
was carried out more than 10 years ago and may not indicated that the overall prevalence of CAM use was
reflect the current situation (6). 65% in 1996; in 1970 the corresponding figure had
The first survey by Eisenberg et al. (11) was been 52%. However, it was unclear whether lifetime
based on a sample from across the USA, obtained by or one-year prevalence was assessed. In all age groups,
random telephone dialling. It suggested that the one- women used CAM more frequently than men. In
year prevalence of CAM use was 34%. On average, cases of serious disease, only 3% of the population
each user made 19 visits a year to CAM providers, said they would rely exclusively on CAM. Only 22%
involving costs exceeding US $500 per head; middle- had obtained CAM through prescriptions from their
aged, female, well-educated whites were the most physicians. People seemed to be motivated to use
frequent users; 72% of users did not inform their CAM largely because they had misgivings about
physicians about their use of CAM. It was deduced pharmacotherapy: 84% considered that the risk of
that visits to CAM providers outnumbered visits to adverse effects of synthetic drugs was moderate or
primary care physicians and that the total costs great. It was considered important or very important
amounted to around US$ 14 billion. The data also by 75% that the cost of CAM should be reimbursed
suggested that 18% of CAM use was for psychiatric by the German health insurance system.
indications (10% for anxiety, 8% for depression). In the Canadian National Population Health
In Vickers’ survey, in the United Kingdom Survey, 17 626 individuals aged 515 years were
(12), the description of the sample was insufficient asked about their use of CAM during the preceding

Bulletin of the World Health Organization, 2000, 78 (2) 253


Research

Table 1. Results of selected surveys on the use of complementary/alternative medicine in general populations

First author Nature of Response Description of sample Question(s) asked Prevalence figures by therapy
(year) sample/survey rate (%)

Haidinger Representative, 99.6 53% female Have you ever used any 19.5% acupressure
(1988) n = 1620, 33% aged 430 years of the following therapies? 17.3% autosuggestion
personal 35% aged 31–50 years (21 named) 13.3% galvanic currents
interview 32% aged > 50 years 12.4% yoga
From across Austria 12.1% homoeopathy
11.3% reflexology
9.6% acupuncture
9.5% chiropractic
Eisenberg Random, 67 Random sample from USA Have you ever used any Used in the last 12 months:
(1993) n = 1539, 48% female of the following therapies? 34% at least one CAM
telephone 34% aged > 50 years (16 named) If so, have you done 13% relaxation techniques
interview 82% white so within the last 12 months? 10% chiropractic
Sample recruited through 7% massage
random digit dialling
Vickers Random, 78 Adults from UK electoral Have you consulted a Combined one-year prevalence of
(1994) n = 921, registers practitioner of any of the acupuncture, chiropractic, osteopathy,
postal following therapies (6 named) homoeopathy, herbal medicine and
questionnaire or any other specialist in hypnotherapy was 8.5%.
complementary medicine in Lifetime use of some form of CAM was
the past 12 months? estimated to be 33%.
Emslie Random, 70 Individuals aged 518 years Would you ever consider using any 45% osteopathy
(1996) n = 500, from Grampian Region, Scot- of the following therapies? 44% acupuncture
postal land, stratified by age, sex, (8 named) 40% aromatherapy
questionnaire and district of residence 33% chiropractic
32% reflexology
32% homoeopathy
30% hypnotherapy
25% herbalism
MacLennan Random and 73 Multistage systematic area Which of the following have you used Remedies bought Therapists visited
(1996) representative, sample of persons aged in the past year: evening primrose 37.7% non- 15% chiropractor
n = 3004, 515 years living in oil, ginseng, herbal medicines, prescribed vitamins 5% naturopath
personal Adelaide (Australia) vitamins, homoeopathic remedies, 9.9% herbal 2% acupuncturist
interview and major country centres Chinese medicines, aromatherapy medicines 1.2% homoeopath
(over 1000 inhabitants) oils, mineral supplements, other 9.2% mineral 0.8% iridologist
health products (not calcium, iron supplements 0.7% reflexologist
or prescribed vitamins)? 7.8% evening 0.6% aromatherapist
primrose oil 0.4% herbalist
4.4% homoeopathic
remedies
3.5% aromatherapy oils
3.0% ginseng
1.8% Chinese medicine
Chi Random, 53 48% female Do you use or would you 9.6% current users and 31% would
(1997) n = 1358, 30% aged 18–29 years use Chinese medicine? consider using Chinese medicine.
national 46% aged 30–49 years
household 16% aged 50–64 years
sample, 8% aged 5 65 years
personal From across China
interview (Province of Taiwan)
Paramore Representative, 75 Sample from the National In the last year, did you 6.8% chiropractic
(1997) n = 3450 Access to Care Survey. use any of the following 3.1% therapeutic massage
From across the USA. therapies? (4 named) 1.3% relaxation techniques
0.4% acupuncture
Häussermann Representative n.m.a German citizens n.m. Overall prevalence was 65% (55% for men,
(1997) sample of the aged > 16 years 74% for women)
German population,
n = 2647
Millar Representative, n.m. The National Population In the last 12 months, have you seen 15% had used some form of CAM; the middle-
(1997) n = 17 626, Health Survey, Canada. One an alternative health care provider age group made most use, women more than
personal interview person was selected at ran- such as an acupuncturist, naturopath, men, higher-educated individuals more than
dom from each household. homoeopath or massage therapist? lower.
Landmark Random sample of n.m. US citizens aged >18 years n.m. 42% had used CAM in the past year
Report (19) adults in the USA who were covered by health 17% herbal therapy
(1998) insurance. 16% chiropractic
14% massage
Astin Random sample of 69 National Family Opinion Have you used any of the following 40% had used CAM in the past year
(1998) adults in the USA, Survey (USA), age 418, forms of CAM within the past year? 16% chiropractic
n = 1500, 80% white, 51% female, (17 named) 8% lifestyle diet
representative of the 30% high school or less, 12% 7% exercise
population of the 4US$ 12 500 yearly income 7% relaxation
USA
Eisenberg Random, 60 Random sample of population As in 1990 survey (11) Used in the last 12 months:
(1998) n = 2055, of USA, 52% female, age 42% at least one CAM
telephone interview distribution and recruitment 13% relaxation technique
of sample as in 1990 survey 12% herbal medicine
(11), 77% white 11% massage
11% chiropractic
a
n.m. = not mentioned.

254 Bulletin of the World Health Organization, 2000, 78 (2)


Prevalence of use of complementary/alternative medicine

year (18). A total of 15% had seen a CAM provider. This degree of variance is not easily explained.
Usage was disproportionately high among women, There is no indication that in the USA or anywhere
people who had received higher education, and else the popularity of CAM in general or chiropractic
people in the age range 25–64 years. The relatively in particular has decreased during the period
low prevalence is probably because the study only concerned. Indeed, there is evidence from the USA
considered CAM provided by practitioners rather that the prevalence of CAM use increased, while that
than including self-prescribed use. of chiropractic remained stable between 1990 and
In the USA a study on public perceptions of 1997 (9, 11). Furthermore, there is good evidence
alternative care (19) was based on telephone inter- from Germany (14) and elsewhere that the popularity
views with 1500 adults in a random sample of of CAM has risen steadily since 1945.
households throughout the country during Novem- With the exceptions of Paramore’s study (16),
ber 1997. Respondents were required to be dealing with only four named forms of CAM, and the
518 years of age and had to be currently covered investigation by Chi et al. (15), focusing on only
by some type of health insurance or health care plan. Chinese medicine, the surveys were affected by the
The results suggested a one-year prevalence of CAM complex problem of defining CAM. This was bound
use amounting to 42%. The four most popular to lead to considerable variance in prevalences. Most
therapies were herbal therapy (17%), chiropractic experts would probably agree that electrotherapy
(16%), massage therapy (14%) and vitamin therapy (10), exercise (11, 21), mineral supplementation (14)
(13%); 74% of CAM users said they used these and psychotherapy (21) are mainstream forms of
treatments as an adjunct to mainstream medicine. therapy that should not come under the umbrella of
Astin reported a survey of 1035 randomly CAM. In the interest of clarity, therefore, future
selected individuals in the USA who responded to a studies should assess specifically named therapies
postal questionnaire (20). Some type of CAM had rather than CAM in general.
been used by 40% of the respondents during the Some surveys were aimed at determining
previous year. The most popular therapies were lifetime prevalence of CAM use (10, 15), while
chiropractic (15.7%), lifestyle diet (8.0%), exercise others used one-year prevalence data (11, 12, 14, 16,
(7.2%) and relaxation (6.9%), which were used most 18, 19, 21). It could be argued that the telephone
frequently for the following conditions: chronic pain, surveys (9, 11) were biased in favour of the affluent,
anxiety, chronic fatigue syndrome, sprains, strains, and that this could have inflated the prevalence
addictions, rheumatic diseases, headaches, depres- values. One survey (13) assessed whether participants
sion, digestive problems and diabetes. The three would consider CAM, while all the others asked
most powerful predictors of CAM use were high whether CAM had actually been used. Response rates
educational level, poor health status, and a holistic were reported as ranging from 100% (10) to 53%
approach to matters of health. (15), but in some surveys none were given (17, 18,
The only reliable longitudinal data derive from 19). Clearly, future surveys should:
the 1997 update (9) of the survey conducted by – deal with named therapies rather than with CAM
Eisenberg et al. in 1990 (11). Over this period the in general;
one-year prevalence of CAM use increased from – be based on samples representative of general
33.8% to 42.1%. Medical herbalism was the therapy populations;
showing the largest increase (380%). In both surveys – assess point and one-year prevalences;
about 40% of users disclosed CAM use to their – be based on adequate response rates.
physicians. Expenditure for CAM increased by 45%,
reaching US$ 21 billion in 1997. The most popular On the basis of the data outlined in this review it is
CAM modalities in 1997 were relaxation techniques, problematic to speak of true prevalences of CAM use
herbal medicine, massage and chiropractic. within the general population of any country. Despite
the unreliability of the data, however, several
interesting and consistent trends emerge. All the
Discussion surveys agree that the most likely users of CAM are
female, affluent, middle-aged, well-educated and
These data show that there are considerable white. It should be pointed out, however, that most
uncertainties about the true prevalence of CAM of the surveys were conducted in industrialized
among the general populations of countries. The countries. No surveys conducted in developing
prevalences reported above varied from 9% (9) to countries matched the inclusion criteria. The typical
65% (14). The investigations included in the present user of traditional medicines in developing countries
review differed markedly in their methodologies, would almost certainly have different characteristics.
origins and results. There were marked discrepancies A substantial proportion of CAM users do not inform
in prevalences even within particular countries. In the their doctors of this fact. The majority employ CAM
USA, for example, prevalences in the range 10–16% as an adjunct to mainstream medicine for the
(9, 11, 19, 20) contrasted with a figure of only 6.8% prevention rather than the treatment of illness. The
for chiropractic revealed by a comparatively large costs of CAM can be considerable, yet its popularity
survey reporting on named therapies (16). seems to be increasing.

Bulletin of the World Health Organization, 2000, 78 (2) 255


Research

Why do people turn towards CAM? Which strongly suggests that more research of increased
forms of CAM are helpful for which conditions? rigour is required into all aspects of CAM.
What is the role of the placebo effect and the The prevalence of the use of CAM is likely to
therapeutic relationship? What risks are associated vary according to factors that are not fully under-
with the use of CAM? None of these questions can be stood. The available data are both contradictory and
answered conclusively at present (22–26) because the unreliable. In order to generate more valuable
evidence is too patchy and often contradictory. This information, future surveys should exclude the
drawbacks of the investigations published to date. n

Résumé
La place des médecines parallèles : analyse systématique
Il semble que les médecines parallèles soient de plus en Douze enquêtes ont satisfait aux critères retenus.
plus populaires. Cette analyse systématique récapitule La fréquence du recours aux médecines parallèles a
les connaissances actuelles concernant la fréquence de montré des variations marquées, allant de 9 % à 65 %.
leur utilisation dans la population générale de divers Même pour une forme donnée de traitement, telle la
pays. chiropractie aux Etats-Unis d’Amérique, des disparités
On a effectué des recherches bibliographiques importantes sont apparues. Néanmoins, les données
dans quatre bases de données informatiques (MEDLINE, disponibles laissent à penser que ces médecines sont
EMBASE, bibliothèque Cochrane et CISCOM). Ont été employées fréquemment et de plus en plus.
incluses dans l’étude les enquêtes qui faisaient état d’un L’importance de ces dernières semble reposer sur
recours aux médecines parallèles dans des échantillons un certain nombre de facteurs décisifs mal contrôlés dans
randomisés ou représentatifs de la population générale. les enquêtes. A l’heure actuelle, la fréquence réelle du
Les données ont été extraites de ces articles par une recours aux médecines parallèles dans la population
méthode définie à l’avance et normalisée. générale est mal connue.

Resumen
Examen sistemático de la prevalencia de las medicinas complementarias/alternativas
Al parecer las medicinas complementarias/alternativas complementarias/alternativas fue muy variada: entre un
gozan de creciente aceptación. En la presente revisión 9% y un 65%. Incluso para una misma modalidad de
sistemática se resumen los conocimientos actuales sobre tratamiento como la quiropráctica, según se emplea en
la prevalencia de su uso en la población general de los Estados Unidos, se observaron considerables
diversos paı́ses. discrepancias. No obstante los datos disponibles indican
Se llevaron a cabo búsquedas computadorizadas en que las terapias complementarias/alternativas se utilizan
la literatura contenida en cuatro bases de datos (MEDLINE, con frecuencia y de forma creciente.
EMBASE, la Biblioteca Cochrane y CISCOM), teniéndose Las estimaciones de la prevalencia de las
en cuenta los estudios en que se hablaba del uso de las medicinas complementarias/alternativas parecen de-
medicinas complementarias/alternativas en muestras pender de forma crucial de varios factores que no se
aleatorias o representativas de la población general. Se controlan bien en las encuestas. Por el momento es
empleó un procedimiento predefinido y normalizado para difı́cil establecer la verdadera prevalencia de las
seleccionar los datos de esos documentos. medicinas complementarias/alternativas en la población
En total satisficieron los criterios precitados general.
12 estudios. La prevalencia del recurso a medicinas

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