Cross-Cultural Comparison of Visitors to CAM Practitioners in the United States and Norway

Abstract

Objectives:

The United States and Norway are among the countries that have the highest total expenditure on health per capita and also high utilization of complementary and alternative medicine (CAM). However, these countries have fundamentally different health care systems. The aim was therefore to compare characteristics of adults who have seen a CAM practitioner during the last year in the United States and Norway.

Methods:

Data from the National Health Interview Survey in the United States from 2002 and the Level of Living survey in Norway from 2002 were used. Both surveys were nationally representative household surveys of the noninstitutionalized civilian population. The data consist of 6612 individuals from Norway and 31,044 individuals from the United States.

Results:

In the United States, 7.4% of the population had seen a CAM practitioner during the last 12 months compared to 8.7% in Norway (p < 0.001 for difference). In both the United States and Norway, seeing a CAM practitioner was most strongly associated with seeing other health care practitioners and having experienced better or worse self-reported health in the last year. Being male and a daily smoker reduced the odds of seeing a CAM practitioner in both countries. In the United States, but not Norway, having higher education was strongly associated with seeing a CAM practitioner. Higher education was the variable with the biggest difference between the two countries.

Conclusions:

This study indicates that in a country that provides health care services for all based on need regardless of personal income (Norway), the utilization of CAM practitioners is higher and less associated with use of other health care providers than a country with low government expenditure on health (the United States).

Introduction

A lthough the use of complementary and alternative medicine (CAM) is widespread,¹ to date there are only a few studies comparing CAM use across countries in selected populations.^2
–4 There are no studies comparing visits to CAM practitioners in representative studies of the general population. Comparative or cross-cultural studies are important to further expand the knowledge of health service use in general and CAM utilization in particular. One important aspect is the potential influence of the health care system on CAM utilization.

Norway and the United States are two Western countries with high CAM utilization.^5,6 They are among the countries that have the highest total expenditure on health per capita, with $6,350 in the United States and $5,910 in Norway in 2005,⁷ but they have very different health care systems. The Norwegian health care system includes provision of health care services for all citizens based on need regardless of personal income.⁸ The United States is said to be the only wealthy, industrialized nation that does not ensure health care coverage for all citizens.⁹ The government's share of the expenditures on health, as a percentage of the total expenditure on health, is nearly twice as high in Norway, with 45.1% in the United States and 83.6% in Norway.⁷

Visits to a CAM practitioner have to be paid out of pocket in both countries. Prevalence of visits to general practitioners and CAM practitioners have been found to be similar in the United States and Norway in the mid 1990s.^6,10 Comparing visits to CAM practitioners in the two countries might therefore shed some light on whether different systems of conventional health care delivery influence the characteristics of those who visit CAM practitioners. The aim of this study is therefore to compare the characteristics of adults in the United States and Norway who have seen a CAM practitioner in the last year.

Materials and Methods

This was a comparison of two cross-sectional studies conducted in 2002: the National Health Interview Survey (NHIS) in the United States, which included an Alternative Health and Complementary and Alternative Medicine supplement, conducted by the Census Bureau for the National Center for Health Statistics,¹¹ and the Level of Living Survey (LOLS) conducted by Statistics Norway.¹² Both surveys were a nationally representative household survey of the noninstitutionalized civilian population using a multistage sampling design.

NHIS had an overall response rate of 74.3% and LOLS a rate of 70.4%. No financial incentives were offered for completion. Only those 18 years and older were included. The data in the current analysis consist of 6612 individuals from Norway and 31,044 individuals from the United States.

Variables

Visit to a CAM practitioner last year

In the LOLS the CAM use question was, “Have you during the last 12 months seen any type of CAM practitioner?”, without presenting any modalities. In the NHIS the question was “During the past 12 months, did you see a practitioner for [therapy]?”, and it was asked about the following 15 modalities: acupuncture, Ayurveda, biofeedback, chelation therapy, energy healing techniques/reiki, folk medicine, hypnosis, massage, naturopathy, herbs, homeopathy, special diets, vitamins, and relaxation techniques. Those who answered yes to any of these questions were characterized as having seen a CAM practitioner.

Chiropractic was listed both as one of the modalities in the USA Alternative Health and Complementary and Alternative Medicine supplement and in the main questionnaire regarding health care use. As chiropractic is an official recognized title in Norway and in some states in the United States, and is reimbursed in Norway, those seeing only a chiropractor were not regarded as having seen a CAM practitioner in either country.

Demographics

In addition to age and gender, variables on education, marital status, body–mass index, and employment status were included and recoded into categories as shown in Table 1. Education level was recoded from 9 levels in Norway and 11 levels in the United States. In both countries, graduation from high school is after attending school for 12/13 years, but in Norway it is only compulsory to complete 10 years. The label “currently working” was given when answering yes to the question “Having worked last week.”

Table 1.

Bivariate Analysis of Visits to Complementary and Alternative Medicine (CAM) Practitioners in the United States and Norway and Comparison Between the Two Countries

	United States			Norway			United States vs. Norway
Variable	N	% seen CAM	p-value 1	N	% seen CAM	p value ^a	Difference	p value ^b
Seen a CAM practitioner	31,044	7.4%		6612	8.7%		−1.3%	<0.001^**
Gender
Female	17,539	9.0%	<0.001^**	3318	11.7%	<0.001^**	−2.7%	<0.001^**
Male	13,505	5.7%		3294	5.6%		0.1%	0.824
Age (years)
18–29	6030	6.7%	<0.001^**	1270	8.0%	<0.001^**	−1.3%	0.097
30–39	6437	9.0%		1339	10.4%		−1.4%	0.108
40–49	6201	9.3%		1290	11.0%		−1.7%	0.059
50–59	4767	7.8%		1158	10.3%		−2.6%	0.004^**
60–69	3288	5.7%		757	7.1%		−1.4%	0.142
70–79	2735	4.5%		531	4.3%		0.2%	0.838
80 and over	1586	2.4%		267	2.1%		0.3%	0.765
Education
High school graduate or less	15,808	6.0%	<0.001^**	4796	8.7%	0.482	−2.7%	<0.001^**
College/bachelors	7434	11.7%		1356	9.3%		2.4%	0.010^**
Masters, doctorate, prof. degree	2378	13.1%		362	7.2%		5.9%	0.001^**
Marital
Never married	6600	7.5%	<0.001^**	1261	8.3%	0.001^**	−0.9%	0.270
Married	14,767	7.3%		3454	9.1%		−1.8%	<0.001^**
Cohabiting	1521	9.7%		1050	9.0%		0.7%	0.550
Separated/divorced	4919	9.0%		441	11.3%		−2.3%	0.109
Widowed	3098	4.1%		405	4.1%		0.1%	0.924
Currently working	19,249	8.2%	0.008^**	4562	9.7%	<0.001^**	−1.5%	0.001^**
Weight
Underweight (BMI under 18.5)	584	7.7%	<0.001^**	114	6.7%	0.255	0.9%	0.739
Healthy weight (BMI 18.5 to 25)	11,513	8.5%		3534	9.4%		−0.9%	0.097
Overweight (BMI 25–30)	10,249	7.2%		2282	8.2%		−1.0%	0.098
Obese (BMI over 30)	7071	6.7%		549	7.7%		−1.0%	0.369
Current lifestyle
Smokes daily	5577	5.5%	<0.001^**	1815	7.5%	0.032^*	−2.0%	0.002^**
Alcohol weekly	9144	9.5%	<0.001^**	2061	9.5%	0.129	0.0%	1.000
Moderate activity 3 hours or more weekly	3496	9.7%	<0.001^**	4045	9.0%	0.236	0.7%	0.297
Hard activity 3 hours or more weekly	3340	11.9%	<0.001^**	1975	9.6%	0.087	2.3%	0.010^**
Global health
Same compared to 1 year ago	22,706	6.3%	<0.001^**	5202	7.6%	<0.001^**	−1.3%	0.001^**
Better compared to 1 year ago	5439	10.9%		764	13.5%		−2.6%	0.033^*
Worse compared to 1 year ago	2899	9.9%		646	11.9%		−2.0%	0.130
Diseases
Allergy	5434	11.8%	<0.001^**	1794	12.5%	<0.001^**	−0.7%	0.428
Arthritis	6829	9.0%	<0.001^**	235	10.8%	0.179	−2.0%	0.294
Cancer	2262	9.5%	0.003^**	283	10.6%	0.207	−1.2%	0.519
Diabetes	2186	6.6%	0.182	300	6.5%	0.138	0.2%	0.896
Emphysema/COPD	522	4.5%	0.011^*	298	7.8%	0.600	−3.4%	0.044^*
Heart disease	8650	6.4%	<0.001^**	1253	7.3%	0.040^*	−0.9%	0.228
Seizures	432	12.5%	<0.001^**	113	5.5%	0.314	6.4%	0.055
Thyroid	2284	12.3%	<0.001^**	280	11.7%	0.058	0.5%	0.810
Ulcer	2414	9.2%	0.004^**	412	10.6%	0.150	−1.4%	0.368
Psychologic complaints last 30 days
So sad nothing cheers up	986	10.2%	0.006^**	120	16.2%	0.002^**	−6.0%	0.046^*
Nervous	1363	10.8%	<0.001^**	153	13.5%	0.026^*	−2.8%	0.295
Everything an effort	1551	10.8%	<0.001^**	2244	10.6%	<0.001^**	0.2%	0.845
Restless/fidgety	1541	12.7%	<0.001^**	1184	11.3%	<0.001^**	1.3%	0.303
Seen health care practitioner last year
Dentist	18,166	9.2%	<0.001^**	2370	10.0%	0.005^**	−0.8%	0.207
Mental health practitioner	2056	20.8%	<0.001^**	228	14.8%	<0.001^**	5.9%	0.035^*
Chiropractor	2467	23.2%	<0.001^**	477	20.8%	<0.001^**	2.4%	0.253
Physician	24,785	8.5%	<0.001^**	5130	9.7%	<0.001^**	−1.2%	0.006^**

χ² test.

Test of proportions.

p value <0.05.

p value <0.01.

COPD, chronic obstructive pulmonary disease.

Current lifestyle

The included lifestyle factors were the following:

Currently smoking; answering yes to “Smoking cigarettes every day.”

Drinking alcohol each week; yes to “Drinking alcohol at least once weekly during the last year.”

Moderate and hard activity at least 3 hours per week; yes to “Conducting moderate or hard activity for at least 1 hour 3 times a week.”

Global health change; “Compared to 12 months ago, would you say your health is better/same/worse?”. In Norway, there were five response categories: “much better” and “somewhat better” were recoded to “better” and “somewhat worse” and “much worse” to “worse.”

Diseases

For the diseases displayed in the tables, the respondents had to answer yes to a question on “Have you ever been told by a doctor or other health professional that you have …”. In Norway, the question was started with “Have you or have you ever had …”. Having heart diseases was defined as those who answered yes to having had hypertension, angina, heart attack (myocardial infarction), or stroke. For the United States, having an allergy was considered as answering yes to either a question about allergy to food/odor or allergy to medicines, while in Norway it was a question on allergy in general.

Psychologic complaints

Psychologic complaints were asked for through questions on “During the last 30 days, how often have you felt …”. Sad was “Feeling so sad nothing could cheer you up”; Nervous was “Feeling nervous,” restless was “Feeling restless or fidgety,” and Everything an effort was “Feeling that everything was an effort.” Those answering “All” or “Most of the time” were coded as yes and those answering “Some,” “A little,” or “None of the time” were coded as no. In Norway, there was an additional category between “All” and “Most of the time” called “Nearly all the time” and this was coded as yes. In Norway, two of the questions used positive formulation, so that the question on being restless was “Feeling calm and harmonic” and on effort it was “Feeling full of initiative”. The scoring for these two questions was reversed to match the U.S. data.

Visit to health care practitioner last year

Visits to a health care practitioner were elicited by asking “During the last 12 months, have you seen or talked to any of the following health care providers about your own health?”. In addition to specific question about contact with a dentist and a chiropractor, contact with a physician was defined as those answering yes to any of the questions about consulting different types of physicians (both specialists and general doctors). A mental health professional in the United States was consulting a psychiatrist, psychologist, psychiatric nurse, or clinical social worker, while in Norway it was seeing a psychiatrist or psychologist.

Statistical analysis

The U.S. data sets were analyzed with STATA v 10.0 (Stata Corporation, College Station, TX) using the Survey module. The analysis for Norway was done with SPSS 15.0 for Windows (SPSS Inc., Chicago, IL) with weighting for nonresponders as the Norwegian data do not include sampling units due to the availability of national registers of all inhabitants.

The datasets for each country were separately analyzed using χ² for the bivariate analyses and logistic regression for the multivariate analyses. To compare the results from each country, a test of proportions was used.¹³ To make it easier to identify the variables most strongly associated with visits to a CAM practitioner, the variables with a significance level below 5% (p < 0.05) and 1% (p < 0.01) are marked in the tables, and only variables that are associated with CAM visits at a p < 0.01 level are mentioned in the text.

Results

In the United States, 7.4% of the population had seen a CAM practitioner during the last 12 months compared to 8.7% in Norway (p < 0.001) (Table 1). The bivariate analysis showed that in both countries, a range of common variables was associated with more frequent visits to a CAM practitioner: being female, middle aged (30–59 years), working, having a change for better or worse in global health the last year, having physiologic complaints the last 30 days, and seeing other health care practitioners in the last year (Table 1).

Visitors to CAM practitioners in the United States

The multivariable logistic regression (Table 2) showed that when controlling all variables in Table 2 for each other, the odds that a person was a CAM visitor in the United States was significantly increased at a p < 0.01 level if the individual had a higher education (bachelor adjusted odds ratio (adjOR) 1.9, masters adjOR 2.2), drank alcohol weekly (adjOR 1.4), did hard activity 3 hours or more weekly (adjOR 1.4), experienced change in global health last year (better adjOR 1.4, worse adjOR 1.5), had allergy (adj OR 1.4), arthritis (adjOR 1.3), cancer (adjOR 1.4), thyroid disease (adjOR 1.5), and feeling restless (adjOR 1.5). They were less likely to see a CAM practitioner if they were male (adjOR 0.6), 70 years or older (70–79 adjOR 0.6, 80 and over adjOR 0.4), or smoked daily (adjOR 0.7).

Table 2.

Adjusted Odds Ratio (Adj OR) from Multivariate Logistic Regression Models for Visits to Complementary and Alternative Medicine (CAM) Practitioners in the United States and Norway, and Test of Difference Between the Two Countries with Ratio Odds Ratio (Ratio OR)

	United States (N = 24,420)			Norway (N = 6612)			United States vs. Norway
Variable	Adj OR	95% CI	p value ^a	Adj OR	95% CI	p value ^a	p value ^b	Ratio OR (95% CI)
Gender
Female	Ref			Ref
Male	0.6	(0.6–0.7)	<0.001^**	0.4	(0.4–0.5)	<0.001^**	0.004^**	1.4 (1.1–1.8)
Age (years)
18–29	Ref			Ref
30–39	1.2	(1.0–1.5)	0.029^*	1.4	(1.0–1.9)	0.040^*	0.541	0.9 (0.6–1.3)
40–49	1.2	(1.0–1.4)	0.130	1.5	(1.1–2.0)	0.024^*	0.243	0.8 (0.5–1.2)
50–59	0.9	(0.7–1.2)	0.581	1.3	(0.9–1.9)	0.138	0.123	0.7 (0.5–1.1)
60–69	0.8	(0.6–1.0)	0.076	0.9	(0.6–1.4)	0.614	0.566	0.9 (0.5–1.4)
70–79	0.6	(0.4–0.8)	0.004^**	0.5	(0.3–1.0)	0.037^*	0.771	1.1 (0.6–2.2)
80 and over	0.4	(0.2–0.7)	<0.001^**	0.3	(0.1–0.8)	0.010^**	0.666	1.3 (0.5–3.5)
Education
High school graduate or less	Ref			Ref
College/bachelors	1.9	(1.6–2.1)	<0.001^**	0.8	(0.6–1.0)	0.041^*	<0.001^**	2.4 (1.8–3.1)
Masters, doctorate, prof. degree	2.2	(1.8–2.5)	<0.001^**	0.8	(0.5–1.2)	0.232	<0.001^**	2.8 (1.8–4.6)
Marital
Never married	Ref			Ref
Married	0.8	(0.7–1.0)	0.011^*	0.9	(0.7–1.2)	0.521	0.506	0.9 (0.6–1.2)
Cohabiting	1.2	(1.0–1.6)	0.089	0.9	(0.7–1.2)	0.571	0.133	1.4 (0.9–2.0)
Separated/divorced	0.9	(0.8–1.1)	0.432	1.0	(0.7–1.5)	0.891	0.666	0.9 (0.6–1.4)
Widowed	0.7	(0.5–1.0)	0.045^*	0.7	(0.4–1.2)	0.196	0.824	1.1 (0.6–2.1)
Currently working	1.1	(0.9–1.2)	0.207	1.1	(0.9–1.4)	0.408	0.900	1.0 (0.7–1.3)
Weight
Underweight (BMI under 18.5)	Ref			Ref
Healthy weight (BMI 18.5–25)	1.1	(0.7–1.7)	0.771	1.4	(0.6–2.9)	0.411	0.570	0.8 (0.3–1.9)
Overweight (BMI 25–30)	1.0	(0.7–1.6)	0.995	1.3	(0.6–2.8)	0.510	0.570	0.8 (0.3–1.9)
Obese (BMI over 30)	0.9	(0.6–1.4)	0.574	1.0	(0.4–2.3)	0.982	0.771	0.9 (0.3–2.2)
Current lifestyle
Smokes daily	0.7	(0.6–0.8)	<0.001^**	0.6	(0.5–0.8)	<0.001^**	0.522	1.1 (0.8–1.5)
Alcohol weekly	1.4	(1.3–1.6)	<0.001^**	1.1	(0.9–1.3)	0.332	0.029^*	1.3 (1.0–1.6)
Moderate activity 3 hours or more weekly	1.1	(1.0–1.3)	0.108	1.0	(0.8–1.2)	0.673	0.177	1.2 (0.9–1.5)
Hard activity 3 hours or more weekly	1.5	(1.3–1.8)	<0.001^**	1.2	(0.9–1.4)	0.182	0.037^*	1.3 (1.0–1.7)
Global health
Same compared to 1 year ago	Ref			Ref
Better compared to 1 year ago	1.4	(1.3–1.6)	<0.001^**	1.6	(1.2–2.0)	0.001^**	0.583	0.9 (0.7–1.2)
Worse compared to 1 year ago	1.5	(1.2–1.8)	<0.001^**	1.5	(1.1–2.0)	0.005^**	0.836	1.0 (0.7–1.4)
Diseases
Allergy	1.4	(1.2–1.6)	<0.001^**	1.5	(1.2–1.8)	<0.001^**	0.667	1.0 (0.8–1.2)
Arthritis	1.3	(1.2–1.5)	<0.001^**	1.3	(0.8–2.0)	0.279	0.918	1.0 (0.6–1.7)
Cancer	1.4	(1.1–1.7)	0.009^**	1.4	(0.9–2.2)	0.094	0.807	0.9 (0.6–1.5)
Diabetes	1.2	(0.9–1.5)	0.138	0.8	(0.5–1.3)	0.422	0.171	1.5 (0.8–2.6)
Emphysema/COPD	0.8	(0.5–1.2)	0.293	0.8	(0.5–1.3)	0.314	0.985	1.0 (0.5–1.9)
Heart disease	0.9	(0.8–1.1)	0.424	0.9	(0.7–1.2)	0.523	0.875	1.0 (0.8–1.4)
Seizures	1.3	(0.9–1.9)	0.159	0.4	(0.2–1.1)	0.077	0.030^*	3.1 (1.1–8.5)
Thyroid	1.5	(1.2–1.8)	<0.001^**	1.0	(0.6–1.5)	0.909	0.079	1.5 (1.0–2.3)
Ulcer	1.0	(0.8–1.3)	0.673	1.5	(1.0–2.1)	0.032^*	0.105	0.7 (0.5–1.1)
Psychologic complaints last 30 days
So sad nothing cheers up	0.9	(0.6–1.4)	0.608	1.6	(0.9–2.9)	0.122	0.118	0.6 (0.3–1.2)
Nervous	1.0	(0.7–1.4)	0.858	1.1	(0.6–2.0)	0.741	0.708	0.9 (0.4–1.8)
Everything an effort	1.1	(0.8–1.6)	0.376	1.1	(0.9–1.4)	0.216	0.976	1.0 (0.7–1.5)
Restless/fidgety	1.5	(1.1–2.1)	0.008^**	1.0	(0.8–1.3)	0.876	0.049^*	1.5 (1.0–2.2)
Seen health care practitioner last year
Dentist	1.3	(1.1–1.5)	<0.001^**	1.2	(1.0–1.4)	0.068	0.468	1.1 (0.9–1.4)
Mental health practitioner	2.5	(2.1–3.0)	<0.001^**	1.4	(0.9–2.1)	0.097	0.023^*	1.4 (1.0–1.9)
Chiropractor	3.8	(3.3–4.4)	<0.001^**	2.7	(2.1–3.5)	<0.001^**	0.010^**	1.8 (1.1–2.8)
Physician	1.7	(1.4–2.0)	<0.001^**	1.6	(1.2–2.1)	<0.001^**	0.752	1.1 (0.8–1.5)

All variables for each country are controlled for each other.

Logistic regression.

Test of proportions.

Highlights a p value of <0.01.

Highlights a p value of <0.05.

CI, confidence interval; BMI, body–mass index; COPD, chronic obstructive pulmonary disease.

In the United States, having seen any other health care professionals the last year increased the odds for having seen a CAM practitioner at a p < 0.01 level, with an adjOR of 1.3 for visit to a dentist, adjOR 1.7 for physician, adjOR 2.5 for mental health practitioner, and adjOR 3.8 for visit to a chiropractor.

Visitors to CAM practitioners in Norway

The increased odds of seeing a CAM practitioner in Norway (Table 2) were associated at a p < 0.01 level with having experienced change in global health last year (better adjOR 1.6, worse adjOR 1.5) or having allergy (adjOR 1.5). Persons who were male (adjOR 0.4), 80 years or older (adjOR 0.3), and smoked daily (adjOR 0.6) had decreased odds of seeing a CAM practitioner at a p < 0.01 level.

In Norway, having seen a physician (adjOR 1.6) or a chiropractor (adjOR 2.7), was associated with increased odds of seeing a CAM practitioner at a p < 0.01 level.

Comparison between the United States and Norway

Of the 40 categories included in the logistic regression, 4 showed a statistical significant difference between the United States and Norway at a p < 0.01 level and 5 at a p < 0.05 level (Table 2). Eight (8) of these categories were associated with higher utilization of CAM practitioners in the United States and 1 in Norway.

The variables that were associated with increased odds of seeing a CAM practitioner in the United States compared to Norway at a p < 0.01 level were having a higher education (bachelor degree ratio OR 2.4, masters degree ratio OR 2.8), and feeling restless and fidgety (ratio OR 1.5). Compared to the United States, being male was associated with decreased odds of seeing a CAM practitioner in Norway (ratio OR 1.4).

Compared to Norway, having seen a chiropractor the last year was associated with increased odds of seeing a CAM practitioner in the United States at a p < 0.01 level (ratio OR 1.8). Visits to dentists and physicians were on the same level in the two countries.

Discussion

Summary of results

Characteristics of CAM visitors were mostly similar in the United States and Norway. In both countries, seeing a CAM practitioner was most strongly associated with visits to other health care practitioners, while being male and smoking reduced the odds of seeing a CAM practitioner. In the United States but not Norway, having higher education was strongly associated with being a CAM visitor. Having a higher education was the variable with the biggest difference between CAM visitors in the United States and Norway.

This is the first study conducting a cross-cultural comparison of visits to CAM practitioners between two Western countries. Furthermore, the size of the studies allowed for the inclusion of a comprehensive set of variables.

As seeing a CAM practitioner is the dependent variable, the difference in how the question was asked is crucial and a limitation. In the U.S. survey, a list of CAM practitioners was given. This could inflate the prevalence as respondents are cued by the list. A single closed question such as the one used in the Norwegian survey could conversely underestimate the prevalence because the respondents are not cued and thus could forget visits to practitioners they would have been prompted about if a list had been given. This indicates that the difference in prevalence found between the United States and Norway is on the smaller side. However, as the results of the separate analysis for each country go mainly in the same direction, our judgment is that the comparison is not hampered by this.

Another limitation is that the included independent variables are restricted to those variables in the datasets that are directly comparable. This means that a variable known to be associated with CAM use (e.g., in Norway) would be omitted if the same variable was not included in the U.S. survey. It turned out that this was no problem as the variables most frequently associated with CAM use^5,14 were comparable. There are nevertheless some notable differences, one being the inclusion of race, which is important in the United States but not in Norway due to a rather homogeneous white population.

The prevalence of CAM visitors was 18% (1.3 percentage points) higher in Norway (8.7%) compared to the United States (7.4%). Studies conducted some years earlier also indicate that the prevalence was higher in Norway than in the United States^10,14 and similar to that in the UK¹⁵ and Canada.¹⁶ This indicates that seeing a CAM practitioner in the United States is somewhat less frequent than in other Western countries.

A higher education level, which is usually associated with increased use of CAM,^17
–19 was only a significant association in the United States. Earlier studies in Norway have found that education was associated with being a CAM visitor but that this association was weakened from 1985 to 1995.²⁰ This study cannot give any answers to why there is a marked difference between the United States and Norway regarding education but indicates that the association between education and CAM use should be studied in more detail.

Change in global health the last year, both improvement and worsening, was associated with seeing a CAM practitioner. It would be expected that experiencing worse health would lead to use of health care services including CAM practitioners. However, as those who have experienced better health also do the same, it is difficult to make an assumption about possible causal relationships. Nevertheless, self-rated global health, which has been found to be more strongly associated with seeing CAM practitioners than sociodemographic variables in Norway,¹⁴ is an important factor. It reflects many aspects of health and lifestyle in addition to simply the purely physical²¹—aspects identified elsewhere as important to those using CAM.²²

Both in the United States and Norway, CAM visitors were also more frequent users of other health care providers. This can be expected, since those who have a health problem causing visits to a CAM practitioner are likely to use other services as well. This is also known from other studies.¹⁷ However, seeing other health care providers was more strongly associated with visits to CAM practitioners in the United States than in Norway. Visits to other health care providers in Norway are paid for by the social insurance system, managed by the National Insurance Scheme,⁸ while seeing a CAM practitioner is paid out of pocket. In the United States, a large part of the population has to pay out of pocket for both types. This indicates that there is a link between being able to pay for other health care providers and seeing CAM practitioners. This assumption is strengthened by the association in the United States between having a higher education—indicating higher income—and seeing a CAM practitioner, an association not seen in Norway.

Overall, this study indicates that in a country that provides health care services for all based on need regardless of personal income, the utilization of CAM practitioners is higher and less associated with use of other health care providers than a country with low government expenditure on health.

Conclusions

The prevalence of CAM visitors is 1.3 percentage points (18%) higher in Norway compared to the United States. The characteristics of adults who had seen a CAM practitioner the last year were very similar in the United States and Norway with a few exceptions, among which having higher education was prominent. There is a strong association between seeing a CAM practitioner and seeing other health care practitioners in both countries, but low government expenditure on health might be associated with higher use of CAM practitioners among those who can afford to see other health care providers.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Harris

, Rees

. The prevalence of complementary and alternative medicine use among the general population: A systematic review of the literature. Complement Ther Med, 2000; 8:88–96.

Flaherty

, Takahashi

, Teoh

et al. Use of alternative therapies in older outpatients in the United States and Japan: Prevalence, reporting patterns, and perceived effectiveness. J Gerontol A Biol Sci Med Sci, 2001; 56:M650–M655.

Molassiotis

, Fernadez-Ortega

, Pud

et al. Use of complementary and alternative medicine in cancer patients: A European survey. Ann Oncol, 2005; 16:655–663.

Chua

, Furnham

. Attitudes and beliefs towards complementary and alternative medicine (CAM): A cross-cultural approach comparing Singapore and the United Kingdom. Complement Ther Med, 2008; 16:247–253.

Barnes

, Powell-Griner

, McFann

, Nahin

. Complementary and alternative medicine use among adults: United States, 2002. Adv Data, 2004; 343:1–19.

Steinsbekk

, Adams

, Sibbritt

et al. The profiles of adults who consult alternative health practitioners and/or general practitioners. Scand J Prim Health Care, 2007; 25:86–92.

World Health Organization. World Health Statistics 2008. Geneva: World Health Organization, 2008.

Johnsen

. Health Systems in Transition: Norway, Vol. 8,No. 1 Copenhagen: WHO Regional Office for Europe on Behalf of the European Observatory on Health Systems and Policies, 2006.

Institute of Medicine of the National Academies. Insuring America's Health: Principles and Recommendations. Washington, DC: The National Academic Press, 2004.

10.

Druss

, Rosenheck

. Association between use of unconventional therapies and conventional medical services. JAMA, 1999; 282:651–656.

11.

National Center for Health Statistics. Data File Documentation, National Health Interview Survey, 2002 (machine readable data file and documentation) Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention, 2003.

12.

Statistics Norway. About the statistics. Survey of Living Conditions, cross-sectional survey (SLC) www.ssb.no/english/subjects/03/01/soskon_en/2008. 2008 October 21.

13.

Altman

, Bland

. Interaction revisited: The difference between two estimates. BMJ, 2003; 326:219.

14.

Steinsbekk

, Adams

, Sibbritt

et al. Socio-demographic characteristics and health perceptions among male and female visitors to CAM practitioners in a total population study. Forsch Komplementmed, 2008; 15:146–151.

15.

Thomas

, Nicholl

, Coleman

. Use and expenditure on complementary medicine in England: A population based survey. Complement Ther Med, 2001; 9:2–11.

16.

Wiles

, Rosenberg

. ‘Gentle caring experience’. Seeking alternative health care in Canada. Health Place, 2001; 7:209–224.

17.

MacLennan

, Myers

, Taylor

. The continuing use of complementary and alternative medicine in South Australia: Costs and beliefs in 2004. Med J Aust, 2006; 184:27–31.

18.

Lonroth

, Ekholm

. Alternative therapies in Denmark: Use, users and motives for the use [in Danish] Ugeskr Laeger, 2006; 168:682–686.

19.

Thomas

, Coleman

. Use of complementary or alternative medicine in a general population in Great Britain: Results from the National Omnibus survey. J Public Health (Oxf), 2004; 26:152–157.

20.

Steinsbekk

. Complementary and alternative medicine: An institution in Norway? [in Norwegian] Trondheim: Norwegian University of Science and Technology (NTNU), 2000.

21.

Fayers

, Sprangers

. Understanding self-rated health. Lancet, 2002; 359:187–188.

22.

Astin

. Why patients use alternative medicine: Results of a national study. JAMA, 1998; 279:1548–1553.