J Complement Integr Med. 2015; 12(1): 89–94
Yasuhiro Ujiie* and Hiroki Okada
Factors affecting the use of complementary and alternative medicine among Japanese university students Abstract Background: Patients suffering from intractable diseases and individuals seeking relief from mild symptoms resort to treatments outside the modern medical paradigm, such as complementary and alternative medicine (CAM). In order to improve doctor–patient communication about CAM, it is essential to evaluate CAM usage among social groups likely to choose it in the future. Therefore, we aimed to evaluate how university students – individuals highly subject to future CAM usage – perceive CAM and the factors affecting their choice of CAM use. Methods: We conducted a questionnaire survey with 1,096 Japanese university students not studying medical subjects. Results: The term CAM was known to 11 % of the subjects. Modalities they most associated with CAM were art therapy (353 subjects), hot spring therapy (349), and aromatherapy (345). They had experience taking vitamins, trace elements, other supplements (498), and nutritional drinks (483). Several subjects wanted to experience shiatsu massage (373) and hot spring therapy (303). Multiple regression analysis of the modalities that the subjects wanted to experience revealed a 42 % multiple coefficient of determination for prioritizing modalities that the subject associated with CAM, showing a large contribution of this deciding factor. Conclusions: Although most subjects were not familiar with the term CAM, many of them had decided to ingest substances in the CAM category on the basis of selfjudgment and without adequate knowledge. Because such behavior can be detrimental to health, medical professionals should be aware of CAM usage among their patients and seek effective communication with them in order to enable safe CAM practice.
*Corresponding author: Yasuhiro Ujiie, Faculty of Human Sciences, Sendai Shirayuri Women’s College, 6-1 Honda-cho, Izumi-ku Sendaicity, Miyagi 9813107, Japan, E-mail: [email protected] Hiroki Okada, Faculty of Medicine, Kagawa University, Japan
Keywords: aromatherapy, art therapy, complementary and alternative medicine modality, hot spring therapy, shiatsu massage DOI 10.1515/jcim-2014-0003 Received January 23, 2014; accepted September 14, 2014; previously published online October 21, 2014
Introduction Health care has, in many ways, transitioned from an age in which medical professionals take the lead to an era of patient self-determination and citizen participation. Particularly, medical education in Japan has transformed from physician-led to patient-guided treatment. Compared to western countries, this was a fairly rapid change [1–4]. The reasons for this include informed consent requirements, greater use of second opinions, increasing awareness of health management, easy access to medical information, and the diversification in treatment choices. This change and the increase in medical costs have resulted in patients resorting to preventive medicine and alternative therapies. We evaluated therapies other than conventional (Western) medicine taught in university medical departments. These therapies include traditional or folk medicine. These thought systems and the methods used in these systems for disease prevention and treatment are known as complementary medicine in Europe and alternative medicine in the United States, or collectively as complementary and alternative medicine (CAM). CAM is a general term used for systems of medical science and treatment modalities that are not used clinically or have not been scientifically verified within the range of modern Western medicine [5]. The US government has established a National Center for Complementary and Alternative Medicine, where intensive and well-funded research into CAM is pursued. We aimed to identify the psychological and societal factors responsible for the growing interest in CAM. A US study revealed that most CAM practitioners used CAM
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90
Ujiie and Okada: Prevalence of CAM use among Japanese students
because it was consistent with their values, beliefs, and philosophical orientations toward life and health, such as an interest in environmental protection or spirituality, whereas very few CAM users used it because they were dissatisfied with conventional medicine [6]. Conclusions drawn based on this report alone might imply that people’s outlook toward life affects their interest level in CAM. However, it is possible that the above reasons are after-the-fact rationalizations, when in reality CAM usage may be prompted by a belief that these modalities could improve health or relieve disease symptoms, even if only to a limited extent. According to Eisenberg et al., 38.5 % of CAM users admit its usage to their doctors, and one in every two CAM users turns to such therapies solely on the basis of self-judgment [7, 8]. Thus, these studies indicate a lack of communication about CAM between doctors and patients. In a study of 143 cancer patients who used CAM, 93 said communication with their doctors was difficult. These patients said they wanted to talk about CAM, but they expected their doctors to be indifferent or hostile toward CAM or to insist on therapies having a scientific basis [9]. Considering the above findings, we aimed to clarify the characteristics of people who intend to use CAM in order to improve medical communication. Eisenberg et al. [7, 8] demonstrated that the social strata that use CAM are usually college graduated. In a survey of ≥18-year-old Americans, a significantly greater percentage of people with higher education (50.6 %) were CAM users compared to people without higher education (36.4 %). Furthermore, CAM was most likely to be supported by people in the 25- to 49-year-old age group. Thus, we chose students at universities, graduate schools, and vocational schools, with a presumably a high latent possibility of actively seeking out CAM in the future, as the subjects for this study. People who consider using CAM are not necessarily ill. Thus, this study did not investigate patients with any evident diseases, as has been done in surveys limited to cancer patients or elderly outpatients [9, 10]. However, unlike random telephone surveys of unselected adults, this study sought to examine a group thought likely to use CAM in the near future [11, 12].
Materials and methods The objectives and methods of this study were explained orally to 1,096 higher education students without using the term CAM.
Among these, 1,087 students agreed to participate in the survey and were given a questionnaire. For the actual survey, we first explained the aim of our research to the students, distributed a questionnaire to the students who provided consent, and asked the students to answer the questions themselves. They were given ample time to complete them. The survey was performed in December 2006. Questions on the participant’s familiarity with the term “complementary and alternative medicine,” rate of CAM usage, and the criteria for selecting a therapy that is categorized as CAM were included in the survey. Furthermore, the selected students were ones opting for nonmedical majors and were not systematically studying CAM or any other type of medicine. Recording the subjects’ disease or hospitalization history would have complicated the survey questionnaire; therefore, questions regarding the participants’ medical history were excluded. While some of the participants probably had minor illnesses, most appeared healthy. The study design was approved by the Ethics Review Board of Sendai Shirayuri Women’s College. This study investigated 26 CAM categories listed in Table 1. The subjects were first asked whether they were familiar with the term CAM. Next, they were asked to select the modalities in Table 1 that they thought were part of CAM. The next question pertained to the modalities in Table 1 that the participants had experienced, regardless of whether they thought of the modality as CAM. Finally, they were asked which of the modalities in Table 1 they would like to experience in the future.
Table 1
Respondent attributes. Men
Women
Total
Type of school University, undergraduate Graduate Vocational Subtotal
219 8 172 399
311 13 364 688
530 21 536 1,087
Age, years 18 19 20 21 22 23 24 and older
35 89 126 50 27 15 57
91 256 157 75 21 19 69
126 345 283 125 48 34 126
Subtotal
399
688
1,087
Multiple regression analysis was used to investigate the factors that affected the choice of CAM modalities that the subjects wanted to experience in the future. The possible factors were whether the modalities were associated with CAM or whether subjects had already experienced the modalities. The statistical analysis package IBM SPSS Statistics 20 was used for data processing.
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Ujiie and Okada: Prevalence of CAM use among Japanese students
Results
91
Table 3 Modalities that subjects had experienced (top 5 in descending order).
Responses were received from 1,087 people with a mean age (SD) of 21.2 (5.5) years. A response rate of 99.2 % was possible because missing values or mistakes in the forms were circumvented by repeatedly explaining how to fill out the questionnaire and allowing ample time to complete the survey. The subjects’ attributes are shown in Table 1. The term CAM was known to 120 (11 %) respondents. A χ2-test was performed to determine the association between sex and knowledge of the term CAM, but a significant difference was not observed. The higher the recognition rate of the term CAM, the higher will be the use of CAM. Table 2 shows the actual number of respondents who supported various CAM categories. Table 3 shows the modalities the subjects had experienced, regardless of whether they thought of them as CAM, and Table 4 shows the
No. Modality
1 2 3 4 5
No. of respondents
Vitamins, trace elements, and other supplements Nutritional drinks Personally selected OTC drugs Medicinal foods, health-boosting foods Shiatsu massage
498 483 465 412 292
Table 4 Modalities that subjects wanted to experience in the future (top 5 in descending order). No.
Modality
1 2 3 4 5
Shiatsu massage Hot spring therapy Aromatherapy Herbal therapy Animal therapy
No. of responses 373 303 300 220 199
Table 2 The investigated CAM modalities and the actual number of supporters (units are in people, multiple answers n ¼ 1,087). No. Category
1 2 3 4 5
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
No. of respondents
Herbal therapy Vitamins, trace elements, and other supplements Medicinal foods, health-boosting foods Aromatherapy Chinese medicine (Kampo medicinal/dietary prescriptions, acupuncture, and moxibustion) Indian therapy (Ayurveda) Dietary therapy Immunotherapy Spiritual psychotherapy Art therapy (music, drawing) Hot spring therapy Chiropractic Shiatsu massage Dance therapy Yoga Qi gong (breathing exercises) Oxygen therapy Fortune-telling Nutritional drinks Religion (prayer) Animal therapy Horse-riding therapy Fasting Treatment by changing climate Personally selected OTC drugs Thalassotherapy
328 265 243 345 286
130 289 119 343 353 349 117 202 243 188 221 152 91 109 120 343 196 109 128 119 107
modalities the subjects wanted to experience in the future regardless of whether they thought of them as CAM. Table 5 shows the results of a multiple regression analysis to determine the factors that predicted what CAM modalities a subject would like to experience in the future. When subjects considered what CAM modalities they might use in the future, the absolute value of the standardized partial regression coefficient was larger for modalities the subjects thought of as CAM than for modalities they had experienced. This difference was significant, showing the large statistical impact of this factor. This suggests that participants preferred modalities that they associated with CAM for potential future use over modalities they had already experienced. The multiple coefficient of determination was 42 %. Table 5 Results of multiple regression analysis to predict modalities that students would like to experience in the future. Variable
Think of as CAM Have experienced CAM Regression constant Multiple correlation coefficient Multiple coefficient of determination a
p < 0.05.
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Partial regression coefficient
Standardized partial regression coefficient
0.656 –0.026 –10.365
0.646a –0.045
0.651 0.424
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Ujiie and Okada: Prevalence of CAM use among Japanese students
Discussion Opportunities to use substances and techniques associated with CAM with the intention of preventing disease or maintaining and promoting health have become commonplace. There exist hot spring recuperation facilities that employ resident medical staff, though the main purpose of these places is travel or leisure. Low-priced health massages can be had near train stations, in airports, and in large shopping malls, and the shelves of 24-h convenience stores are packed with health foods, functional nutritional foods, and health supplements. Moreover, people are exposed to a huge amount of information via television, the Internet, newspapers, weekly magazines, and other media. Frequently, this information is in the form of advertisements, such as commercials for exercise DVDs to facilitate dieting or for orally ingestible products that claim to have some beneficial effects on health or to assist in slimming. Thus, CAM users are not patients, and the usage of CAM is not a purely medical issue, but also concerns ethics, politics, and economics [13]. In modern society, information about CAM has become easily accessible. Thus, even healthy young people could rapidly become CAM users. In addition, easy accessibility of CAM information could prompt patients with diseases to decide and receive a CAM treatment of their choice without adequate knowledge [14]. There is a difference between knowing the term and actually using it, but the rate of knowing the term could be a predictor of the rate of spread of CAM use. In our study targeting students who were not majoring in medicine, 11 % knew the term CAM, which was lower than the 29 % of students at a medical school who knew the term [15]. In a 1992 survey conducted by a medial association, 45 % of respondents said they had heard of the term, yet the percentage of people using CAM without having heard the term was no less than 73 % [16]. Among hospital staff, the recognition rate varied according to their jobs; 67 % of doctors had heard of the term, yet 0 % nutritionists, cooks, and administrative staff had [17]. Great disparities still exist in the extent of knowledge of CAM as a comprehensive concept. In our study, no significant association was found between sex and rate of knowledge of the term, even though women generally exhibit significantly higher rates of knowledge [18]. In Europe, CAM is dealt with as a part of the national exam for medical practitioners; therefore, comparison of our study findings with those from Europe would not be yield relevant results. In North America, in the late 1990s,
it was reported that 42.2 % of the population had an understanding and awareness of the term CAM [7, 8]. Recent reports indicate that over 70 % of CAM users in the US Midwest are aware of the term CAM [3], and 83 % of the staff in a hospital in Canada used CAM [4]. Thus, the relative awareness about CAM in Japan is low in comparison to western countries, even though it has grown in recent years. Several of the modalities that the subjects in this study associated with CAM might be considered “fashionable” therapies, such as art therapy, aromatherapy, and herbal therapy. Rather than associating these modalities with preventing or treating particular illnesses, healthy people more likely see them as leisure activities. Moreover, frequent use of the term “heart care” in Japanese society has made spiritual psychotherapy a familiar topic, and modalities such as hot spring or animal therapy are associated with ideas of leisure or the “healing boom” and other popular topics in the mass media. The low ranking of modalities directly associated with diseases or symptoms, such as shiatsu massage, which can relieve muscle pain, or over-the-counter (OTC) medicine, which can alleviate subjective symptoms, was considered appropriate for a study of university students. Modalities the subjects had experienced, regardless of whether they associated them with CAM, included those that students can use casually on an everyday basis. About half the subjects reported using easily obtainable supplements or nutritional drinks, suggesting they had little resistance to some orally ingestible products, despite associating them with CAM. Further, four of the top five modalities that the subjects wanted to experience, regardless of whether they associated them with CAM, were “spa” modalities such as shiatsu massage and hot spring therapy. While aromatherapy and herbal therapy can be experienced with products purchased for home use, it is possible that these five modalities were most desired because they are often available at clinics. There was a tendency among the university students in our study to consider casual supplements and modalities with recreational effects as CAM. It is possible that discrepancies in ideas can appear because of differences in study populations, even when the same survey is used. It has proved difficult to grasp the actual situation in Europe because of differences between countries in medical systems, history, and culture [19]. Although multiple regression analysis on deciding factors involved in what modalities the subjects wanted to experience in the future showed that subjects gave
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Ujiie and Okada: Prevalence of CAM use among Japanese students
precedence to modalities they associated with CAM, the multiple coefficient of determination was 42 %, which is not high for an explanation rate. We speculate that this result can be accounted for by the wide range of modalities that CAM encompasses, as well as by the fact that the university students who were the subjects of this study did not have much need for CAM, compared to people who are actually sick. CAM modalities likely to be major health risks should also be investigated. We believe that the mass media should practice restraint when providing information that causes people to see CAM as able to prevent, treat, and heal diseases. Users, too, must be aware in order to effectively evaluate information. The percentage of CAM users who admitted its use to their primary physicians was low, that is, 21.1 % [15] and 38.5 % in previously reported studies [7, 8]. Medical professionals need to be aware that their patients may be using CAM and need to consider the possible interactions between orally administered CAM products and standard allopathic medicines [20]. CAM has become an important component of health care [21, 22]. In today’s information-oriented society, it is easy for people to post accounts of their experiences with CAM. If readers place too much trust in these accounts, unintended health problems may occur. Indeed, reports exist of health damage due to CAM use [22]. Of 235 reported cases, 95 were caused by health food products (after excluding cases involving products such as unapproved or unlicensed drugs). More than 30 different products were used in these 95 cases, with easily available diet foods and health teas making up about 25 % of the 30 products. One example is spirulina – a health food product with a good balance of many nutrients that has received attention from the governing body of the United Nations as a nutrient source for poor or malnourished children in developing countries. In one case, an adult with no history of illness developed an inflammatory muscular disease accompanied by wide-ranging skin symptoms after taking spirulina for about 1 month [23]. The patient required long-term hospitalization. This case illustrates the possible risks faced by consumers who feel that a substance or modality is safe to use without professional medical advice just because it is in the CAM category. Both consumers and medical professionals need to be sensitive to the possibility that ingesting just one wrong substance or engaging in an improper exercise can cause disease or injury and secondary damage such as financial difficulty. While many healthy people utilize CAM modalities for health enhancement or leisure, patients sometimes turn to CAM out of desperation when conventional
93
medicine does not yield expected results. With the amount of advertising for CAM products in the media, it is not surprising that many patients secretly start using CAM even while continuing to trust their medical care provider. Patients might expect CAM to alleviate their suffering, even if medical professionals judge that further alleviation may not be possible. In reality, some patients are likely suffering because of interactions between CAM treatments and prescribed pharmaceuticals. As people’s desire to be more involved in their medical care continues to grow, the role of CAM can be expected to grow as well. Because CAM modalities can be beneficial or detrimental, we hope that medical professionals will increase their knowledge of CAM so that they can provide their patients with appropriate information. Further, it is possible that CAM users are in some way dissatisfied with their medical care. Thus, CAM should not be ignored or repudiated; rather, medical professionals should discuss with patients the possible benefits and potential risks of CAM modalities.
Conclusions In this study, 11 % of subjects knew the term CAM, and there was no difference between the sexes. Modalities the subjects most associated with CAM were art therapy, hot spring therapy, and aromatherapy. Modalities they had experienced most frequently were vitamins and other supplements, nutritional drinks, and OTC drugs. Modalities they most wished to experience in the future were shiatsu massage, hot spring therapy, and aromatherapy. These results suggest that university students are very familiar with CAM. Thus, medical professionals should be aware of the possibility that their patients must be regular CAM users.
Acknowledgments: We would like to thank the students who participated in the survey. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission. Research funding: None declared. Employment or leadership: None declared. Honorarium: None declared. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
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Ujiie and Okada: Prevalence of CAM use among Japanese students
References 1. Onishi H. Rapid change in Japanese medical education. Med Teach 2004;26:403–8. 2. Murray C. Why is Japanese life expectancy so high? The Lancet 2011;378:1124–5. 3. Peregoy J, Clarke T, Jones L, Stussman B, Nahin R. Regional variation in use of complementary health approaches by U.S. adults. NCHS Data Brief 2014;146:1–8. 4. Adams D, Schiffgen M, Kundu A, Dagenais S, Clifford T, Baydala L, et al. Patterns of utilization of complementary and alternative medicine in two pediatric gastroenterology clinics. J Pediatr Gastroenterol Nutr 2014. Epub ahead of print. 5. Hyodo I. Complementary and alternative medicine in cancer treatment. Jpn J Complement Altern Med 2004;1:7–15. 6. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548–53. 7. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the united states, 1990-1997: results of a follow-up national survey. JAMA 1998;280:1569–75. 8. 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;328:246–52. 9. Tasaki K, Maskarinec G, Shumay DM, Tatsumura Y, Kakai H. Communication between physicians and cancer patients about complementary and alternative medicine: exploring patients’ perspectives. Psychooncology 2002;11:212–20. 10. Flaherty JH, Takahashi R, Teoh J, Kim JI, Habib S, Ito M, et al. Use of alternative therapies in older outpatients in the united states and Japan: prevalence, reporting patterns, and perceived effectiveness. J Gerontol Biol Sci Med Sci 2001;56: M650–5.
11. Ernst E, White A. The BBC survey of complementary medicine use in the UK. Complement Ther Med 2000;8:32–6. 12. Yamashita H, Tsukayama H, Sugishita C. Popularity of complementary and alternative medicine in Japan: A telephone survey. Complement Ther Med 2002;10:84–93. 13. Spencer JW. Essential issues in complementary and alternative medicine. In: Spencer JW, Jacobs JJ, editors. Complementary and alternative medicine: an evidence-based approach, 2nd ed. St. Louis, MO: Mosby, 2003:2–39. 14. Brody JE, GD. The New York Times guide to alternative health: a consumer reference. New York: Times Books, 2001. 15. Wada T. Students recognize alternative medicine more rather than a doctor. Tokyo Jikeikai Med J 2000;115:628. 16. Watanabe S, Imanishi J, Satoh M, Ozasa K. Unique place of Kampo (Japanese traditional medicine) in complementary and alternative medicine: A survey of doctors belonging to the regional medical association in Japan. Tohoku J Exp Med 2001;194:55–63. 17. Yaegashi H. A survey regarding attitudes toward complementary and alternative medicine among hospital staffs. Jpn J Complement Altern Med 2004:86. 18. Imanishi J, Watanabe S, Satoh M, Ozasa K. Japanese doctors’ attitudes to complementary medicine. Lancet 1999;354:1735–6. 19. Fisher P, Ward A. Complementary medicine in Europe. BMJ 1994;309:107–11. 20. World Health Organization. Legal status of traditional medicine and complementary/alternative medicine: a worldwide review. Geneva: World Health Organization, 2001. 21. World Health Organization. WHO traditional medicine strategy 2002–2005. Geneva: World Health Organization, 2002. 22. Ishikawa T, Ayada J. Drug-induced liver injury. J Ther 2007;89:3198–203. 23. Konno T, Umeda Y, Umeda M, et al. A case of inflammatory myopathy with widely skin rash following use of supplements containing Spirulina. Rinsho Shinkeigaku 2011;51:330–3.
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Yasuhiro Ujiie* and Hiroki Okada
Factors affecting the use of complementary and alternative medicine among Japanese university students Abstract Background: Patients suffering from intractable diseases and individuals seeking relief from mild symptoms resort to treatments outside the modern medical paradigm, such as complementary and alternative medicine (CAM). In order to improve doctor–patient communication about CAM, it is essential to evaluate CAM usage among social groups likely to choose it in the future. Therefore, we aimed to evaluate how university students – individuals highly subject to future CAM usage – perceive CAM and the factors affecting their choice of CAM use. Methods: We conducted a questionnaire survey with 1,096 Japanese university students not studying medical subjects. Results: The term CAM was known to 11 % of the subjects. Modalities they most associated with CAM were art therapy (353 subjects), hot spring therapy (349), and aromatherapy (345). They had experience taking vitamins, trace elements, other supplements (498), and nutritional drinks (483). Several subjects wanted to experience shiatsu massage (373) and hot spring therapy (303). Multiple regression analysis of the modalities that the subjects wanted to experience revealed a 42 % multiple coefficient of determination for prioritizing modalities that the subject associated with CAM, showing a large contribution of this deciding factor. Conclusions: Although most subjects were not familiar with the term CAM, many of them had decided to ingest substances in the CAM category on the basis of selfjudgment and without adequate knowledge. Because such behavior can be detrimental to health, medical professionals should be aware of CAM usage among their patients and seek effective communication with them in order to enable safe CAM practice.
*Corresponding author: Yasuhiro Ujiie, Faculty of Human Sciences, Sendai Shirayuri Women’s College, 6-1 Honda-cho, Izumi-ku Sendaicity, Miyagi 9813107, Japan, E-mail: [email protected] Hiroki Okada, Faculty of Medicine, Kagawa University, Japan
Keywords: aromatherapy, art therapy, complementary and alternative medicine modality, hot spring therapy, shiatsu massage DOI 10.1515/jcim-2014-0003 Received January 23, 2014; accepted September 14, 2014; previously published online October 21, 2014
Introduction Health care has, in many ways, transitioned from an age in which medical professionals take the lead to an era of patient self-determination and citizen participation. Particularly, medical education in Japan has transformed from physician-led to patient-guided treatment. Compared to western countries, this was a fairly rapid change [1–4]. The reasons for this include informed consent requirements, greater use of second opinions, increasing awareness of health management, easy access to medical information, and the diversification in treatment choices. This change and the increase in medical costs have resulted in patients resorting to preventive medicine and alternative therapies. We evaluated therapies other than conventional (Western) medicine taught in university medical departments. These therapies include traditional or folk medicine. These thought systems and the methods used in these systems for disease prevention and treatment are known as complementary medicine in Europe and alternative medicine in the United States, or collectively as complementary and alternative medicine (CAM). CAM is a general term used for systems of medical science and treatment modalities that are not used clinically or have not been scientifically verified within the range of modern Western medicine [5]. The US government has established a National Center for Complementary and Alternative Medicine, where intensive and well-funded research into CAM is pursued. We aimed to identify the psychological and societal factors responsible for the growing interest in CAM. A US study revealed that most CAM practitioners used CAM
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90
Ujiie and Okada: Prevalence of CAM use among Japanese students
because it was consistent with their values, beliefs, and philosophical orientations toward life and health, such as an interest in environmental protection or spirituality, whereas very few CAM users used it because they were dissatisfied with conventional medicine [6]. Conclusions drawn based on this report alone might imply that people’s outlook toward life affects their interest level in CAM. However, it is possible that the above reasons are after-the-fact rationalizations, when in reality CAM usage may be prompted by a belief that these modalities could improve health or relieve disease symptoms, even if only to a limited extent. According to Eisenberg et al., 38.5 % of CAM users admit its usage to their doctors, and one in every two CAM users turns to such therapies solely on the basis of self-judgment [7, 8]. Thus, these studies indicate a lack of communication about CAM between doctors and patients. In a study of 143 cancer patients who used CAM, 93 said communication with their doctors was difficult. These patients said they wanted to talk about CAM, but they expected their doctors to be indifferent or hostile toward CAM or to insist on therapies having a scientific basis [9]. Considering the above findings, we aimed to clarify the characteristics of people who intend to use CAM in order to improve medical communication. Eisenberg et al. [7, 8] demonstrated that the social strata that use CAM are usually college graduated. In a survey of ≥18-year-old Americans, a significantly greater percentage of people with higher education (50.6 %) were CAM users compared to people without higher education (36.4 %). Furthermore, CAM was most likely to be supported by people in the 25- to 49-year-old age group. Thus, we chose students at universities, graduate schools, and vocational schools, with a presumably a high latent possibility of actively seeking out CAM in the future, as the subjects for this study. People who consider using CAM are not necessarily ill. Thus, this study did not investigate patients with any evident diseases, as has been done in surveys limited to cancer patients or elderly outpatients [9, 10]. However, unlike random telephone surveys of unselected adults, this study sought to examine a group thought likely to use CAM in the near future [11, 12].
Materials and methods The objectives and methods of this study were explained orally to 1,096 higher education students without using the term CAM.
Among these, 1,087 students agreed to participate in the survey and were given a questionnaire. For the actual survey, we first explained the aim of our research to the students, distributed a questionnaire to the students who provided consent, and asked the students to answer the questions themselves. They were given ample time to complete them. The survey was performed in December 2006. Questions on the participant’s familiarity with the term “complementary and alternative medicine,” rate of CAM usage, and the criteria for selecting a therapy that is categorized as CAM were included in the survey. Furthermore, the selected students were ones opting for nonmedical majors and were not systematically studying CAM or any other type of medicine. Recording the subjects’ disease or hospitalization history would have complicated the survey questionnaire; therefore, questions regarding the participants’ medical history were excluded. While some of the participants probably had minor illnesses, most appeared healthy. The study design was approved by the Ethics Review Board of Sendai Shirayuri Women’s College. This study investigated 26 CAM categories listed in Table 1. The subjects were first asked whether they were familiar with the term CAM. Next, they were asked to select the modalities in Table 1 that they thought were part of CAM. The next question pertained to the modalities in Table 1 that the participants had experienced, regardless of whether they thought of the modality as CAM. Finally, they were asked which of the modalities in Table 1 they would like to experience in the future.
Table 1
Respondent attributes. Men
Women
Total
Type of school University, undergraduate Graduate Vocational Subtotal
219 8 172 399
311 13 364 688
530 21 536 1,087
Age, years 18 19 20 21 22 23 24 and older
35 89 126 50 27 15 57
91 256 157 75 21 19 69
126 345 283 125 48 34 126
Subtotal
399
688
1,087
Multiple regression analysis was used to investigate the factors that affected the choice of CAM modalities that the subjects wanted to experience in the future. The possible factors were whether the modalities were associated with CAM or whether subjects had already experienced the modalities. The statistical analysis package IBM SPSS Statistics 20 was used for data processing.
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Ujiie and Okada: Prevalence of CAM use among Japanese students
Results
91
Table 3 Modalities that subjects had experienced (top 5 in descending order).
Responses were received from 1,087 people with a mean age (SD) of 21.2 (5.5) years. A response rate of 99.2 % was possible because missing values or mistakes in the forms were circumvented by repeatedly explaining how to fill out the questionnaire and allowing ample time to complete the survey. The subjects’ attributes are shown in Table 1. The term CAM was known to 120 (11 %) respondents. A χ2-test was performed to determine the association between sex and knowledge of the term CAM, but a significant difference was not observed. The higher the recognition rate of the term CAM, the higher will be the use of CAM. Table 2 shows the actual number of respondents who supported various CAM categories. Table 3 shows the modalities the subjects had experienced, regardless of whether they thought of them as CAM, and Table 4 shows the
No. Modality
1 2 3 4 5
No. of respondents
Vitamins, trace elements, and other supplements Nutritional drinks Personally selected OTC drugs Medicinal foods, health-boosting foods Shiatsu massage
498 483 465 412 292
Table 4 Modalities that subjects wanted to experience in the future (top 5 in descending order). No.
Modality
1 2 3 4 5
Shiatsu massage Hot spring therapy Aromatherapy Herbal therapy Animal therapy
No. of responses 373 303 300 220 199
Table 2 The investigated CAM modalities and the actual number of supporters (units are in people, multiple answers n ¼ 1,087). No. Category
1 2 3 4 5
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
No. of respondents
Herbal therapy Vitamins, trace elements, and other supplements Medicinal foods, health-boosting foods Aromatherapy Chinese medicine (Kampo medicinal/dietary prescriptions, acupuncture, and moxibustion) Indian therapy (Ayurveda) Dietary therapy Immunotherapy Spiritual psychotherapy Art therapy (music, drawing) Hot spring therapy Chiropractic Shiatsu massage Dance therapy Yoga Qi gong (breathing exercises) Oxygen therapy Fortune-telling Nutritional drinks Religion (prayer) Animal therapy Horse-riding therapy Fasting Treatment by changing climate Personally selected OTC drugs Thalassotherapy
328 265 243 345 286
130 289 119 343 353 349 117 202 243 188 221 152 91 109 120 343 196 109 128 119 107
modalities the subjects wanted to experience in the future regardless of whether they thought of them as CAM. Table 5 shows the results of a multiple regression analysis to determine the factors that predicted what CAM modalities a subject would like to experience in the future. When subjects considered what CAM modalities they might use in the future, the absolute value of the standardized partial regression coefficient was larger for modalities the subjects thought of as CAM than for modalities they had experienced. This difference was significant, showing the large statistical impact of this factor. This suggests that participants preferred modalities that they associated with CAM for potential future use over modalities they had already experienced. The multiple coefficient of determination was 42 %. Table 5 Results of multiple regression analysis to predict modalities that students would like to experience in the future. Variable
Think of as CAM Have experienced CAM Regression constant Multiple correlation coefficient Multiple coefficient of determination a
p < 0.05.
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Partial regression coefficient
Standardized partial regression coefficient
0.656 –0.026 –10.365
0.646a –0.045
0.651 0.424
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Ujiie and Okada: Prevalence of CAM use among Japanese students
Discussion Opportunities to use substances and techniques associated with CAM with the intention of preventing disease or maintaining and promoting health have become commonplace. There exist hot spring recuperation facilities that employ resident medical staff, though the main purpose of these places is travel or leisure. Low-priced health massages can be had near train stations, in airports, and in large shopping malls, and the shelves of 24-h convenience stores are packed with health foods, functional nutritional foods, and health supplements. Moreover, people are exposed to a huge amount of information via television, the Internet, newspapers, weekly magazines, and other media. Frequently, this information is in the form of advertisements, such as commercials for exercise DVDs to facilitate dieting or for orally ingestible products that claim to have some beneficial effects on health or to assist in slimming. Thus, CAM users are not patients, and the usage of CAM is not a purely medical issue, but also concerns ethics, politics, and economics [13]. In modern society, information about CAM has become easily accessible. Thus, even healthy young people could rapidly become CAM users. In addition, easy accessibility of CAM information could prompt patients with diseases to decide and receive a CAM treatment of their choice without adequate knowledge [14]. There is a difference between knowing the term and actually using it, but the rate of knowing the term could be a predictor of the rate of spread of CAM use. In our study targeting students who were not majoring in medicine, 11 % knew the term CAM, which was lower than the 29 % of students at a medical school who knew the term [15]. In a 1992 survey conducted by a medial association, 45 % of respondents said they had heard of the term, yet the percentage of people using CAM without having heard the term was no less than 73 % [16]. Among hospital staff, the recognition rate varied according to their jobs; 67 % of doctors had heard of the term, yet 0 % nutritionists, cooks, and administrative staff had [17]. Great disparities still exist in the extent of knowledge of CAM as a comprehensive concept. In our study, no significant association was found between sex and rate of knowledge of the term, even though women generally exhibit significantly higher rates of knowledge [18]. In Europe, CAM is dealt with as a part of the national exam for medical practitioners; therefore, comparison of our study findings with those from Europe would not be yield relevant results. In North America, in the late 1990s,
it was reported that 42.2 % of the population had an understanding and awareness of the term CAM [7, 8]. Recent reports indicate that over 70 % of CAM users in the US Midwest are aware of the term CAM [3], and 83 % of the staff in a hospital in Canada used CAM [4]. Thus, the relative awareness about CAM in Japan is low in comparison to western countries, even though it has grown in recent years. Several of the modalities that the subjects in this study associated with CAM might be considered “fashionable” therapies, such as art therapy, aromatherapy, and herbal therapy. Rather than associating these modalities with preventing or treating particular illnesses, healthy people more likely see them as leisure activities. Moreover, frequent use of the term “heart care” in Japanese society has made spiritual psychotherapy a familiar topic, and modalities such as hot spring or animal therapy are associated with ideas of leisure or the “healing boom” and other popular topics in the mass media. The low ranking of modalities directly associated with diseases or symptoms, such as shiatsu massage, which can relieve muscle pain, or over-the-counter (OTC) medicine, which can alleviate subjective symptoms, was considered appropriate for a study of university students. Modalities the subjects had experienced, regardless of whether they associated them with CAM, included those that students can use casually on an everyday basis. About half the subjects reported using easily obtainable supplements or nutritional drinks, suggesting they had little resistance to some orally ingestible products, despite associating them with CAM. Further, four of the top five modalities that the subjects wanted to experience, regardless of whether they associated them with CAM, were “spa” modalities such as shiatsu massage and hot spring therapy. While aromatherapy and herbal therapy can be experienced with products purchased for home use, it is possible that these five modalities were most desired because they are often available at clinics. There was a tendency among the university students in our study to consider casual supplements and modalities with recreational effects as CAM. It is possible that discrepancies in ideas can appear because of differences in study populations, even when the same survey is used. It has proved difficult to grasp the actual situation in Europe because of differences between countries in medical systems, history, and culture [19]. Although multiple regression analysis on deciding factors involved in what modalities the subjects wanted to experience in the future showed that subjects gave
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Ujiie and Okada: Prevalence of CAM use among Japanese students
precedence to modalities they associated with CAM, the multiple coefficient of determination was 42 %, which is not high for an explanation rate. We speculate that this result can be accounted for by the wide range of modalities that CAM encompasses, as well as by the fact that the university students who were the subjects of this study did not have much need for CAM, compared to people who are actually sick. CAM modalities likely to be major health risks should also be investigated. We believe that the mass media should practice restraint when providing information that causes people to see CAM as able to prevent, treat, and heal diseases. Users, too, must be aware in order to effectively evaluate information. The percentage of CAM users who admitted its use to their primary physicians was low, that is, 21.1 % [15] and 38.5 % in previously reported studies [7, 8]. Medical professionals need to be aware that their patients may be using CAM and need to consider the possible interactions between orally administered CAM products and standard allopathic medicines [20]. CAM has become an important component of health care [21, 22]. In today’s information-oriented society, it is easy for people to post accounts of their experiences with CAM. If readers place too much trust in these accounts, unintended health problems may occur. Indeed, reports exist of health damage due to CAM use [22]. Of 235 reported cases, 95 were caused by health food products (after excluding cases involving products such as unapproved or unlicensed drugs). More than 30 different products were used in these 95 cases, with easily available diet foods and health teas making up about 25 % of the 30 products. One example is spirulina – a health food product with a good balance of many nutrients that has received attention from the governing body of the United Nations as a nutrient source for poor or malnourished children in developing countries. In one case, an adult with no history of illness developed an inflammatory muscular disease accompanied by wide-ranging skin symptoms after taking spirulina for about 1 month [23]. The patient required long-term hospitalization. This case illustrates the possible risks faced by consumers who feel that a substance or modality is safe to use without professional medical advice just because it is in the CAM category. Both consumers and medical professionals need to be sensitive to the possibility that ingesting just one wrong substance or engaging in an improper exercise can cause disease or injury and secondary damage such as financial difficulty. While many healthy people utilize CAM modalities for health enhancement or leisure, patients sometimes turn to CAM out of desperation when conventional
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medicine does not yield expected results. With the amount of advertising for CAM products in the media, it is not surprising that many patients secretly start using CAM even while continuing to trust their medical care provider. Patients might expect CAM to alleviate their suffering, even if medical professionals judge that further alleviation may not be possible. In reality, some patients are likely suffering because of interactions between CAM treatments and prescribed pharmaceuticals. As people’s desire to be more involved in their medical care continues to grow, the role of CAM can be expected to grow as well. Because CAM modalities can be beneficial or detrimental, we hope that medical professionals will increase their knowledge of CAM so that they can provide their patients with appropriate information. Further, it is possible that CAM users are in some way dissatisfied with their medical care. Thus, CAM should not be ignored or repudiated; rather, medical professionals should discuss with patients the possible benefits and potential risks of CAM modalities.
Conclusions In this study, 11 % of subjects knew the term CAM, and there was no difference between the sexes. Modalities the subjects most associated with CAM were art therapy, hot spring therapy, and aromatherapy. Modalities they had experienced most frequently were vitamins and other supplements, nutritional drinks, and OTC drugs. Modalities they most wished to experience in the future were shiatsu massage, hot spring therapy, and aromatherapy. These results suggest that university students are very familiar with CAM. Thus, medical professionals should be aware of the possibility that their patients must be regular CAM users.
Acknowledgments: We would like to thank the students who participated in the survey. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission. Research funding: None declared. Employment or leadership: None declared. Honorarium: None declared. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
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Ujiie and Okada: Prevalence of CAM use among Japanese students
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