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Can Fam Physician
Vol. 54, No. 11, November 2008, pp.1563 - 1569
Copyright © 2008 by The College of Family Physicians of Canada
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Research

Complementary and alternative medicine use among Chinese and white Canadians

Hude Quan, MD PhD
Associate Professor in the Department of Community Health Sciences and the Centre for Health and Policy Studies at the University of Calgary in Alberta

Daniel Lai, PhD
Professor in the Faculty of Social Work at the University of Calgary

Delaine Johnson, MScN
Manager, Healthy Diverse Populations for the Calgary Health Region

Marja Verhoef, PhD
Professor in the Department of Community Health Sciences at the University of Calgary

Richard Musto, MD
Clinical Associate Professor in the Department of Community Health Sciences at the University of Calgary and Executive Medical Director for the Southeast Community Portfolio and Deputy Medical Officer of Health for the Calgary Health Region

Correspondence: Dr Hude Quan, University of Calgary, Community Health Sciences, 3330 Hospital Dr NW, Calgary, AB T2N 4N1; e-mailhquan{at}ucalgary.ca

Complementary and alternative medicine (CAM) is widely used in Canada: according to 1 study, 50% of the population used CAM therapies and 22% visited CAM practitioners over a 12-month period.1 Cultural and health beliefs play an important role in making the decision to choose CAM.2–6 As the Chinese have a longer history of using traditional Chinese medicine (TCM), a common CAM system, and its components (including Chinese herbal therapies and acupuncture) than white Canadians, the level and type of CAM use and reasons for use might differ between Chinese and white Canadians.

Lai and Chappell7 surveyed 2167 Chinese immigrants 55 years of age or older in 6 Canadian cities and found that 50.3% used TCM. Tjam and Hirdes8 interviewed a convenience sample of 106 Chinese-Canadian seniors in Ontario and reported that 21.7% of these seniors used TCM. Wong et al9 surveyed 829 Chinese patients at family physician clinics in Vancouver, BC, and found that 32% visited herbalists and 8% saw acupuncturists. Zhang and Verhoef10 interviewed 19 Chinese Canadians with arthritis in Calgary, Alta, and found that the decision to use TCM was affected by personal beliefs about TCM and perceived barriers of cost and access to experienced practitioners. These studies mainly focused on specific age groups (mainly older people) or specific components of TCM and had no comparison groups or used non-random samples. This study addresses these limitations through surveying randomly selected Chinese (as case group) and white (as comparison group) residents in a large Canadian city to assess the extent of CAM use and to identify the factors associated with CAM use in each of these populations.


   METHODS
TOP
 METHODS
RESULTS
 DISCUSSION
 Footnotes
 References
 
Study population
A cross-sectional telephone survey was conducted among randomly selected Chinese and white Canadians in Calgary in 2005. The surnames listed in the 2005 Calgary telephone directory were screened using a validated list of Chinese surnames11 to form the Chinese-Canadian sampling frame from which a random sample was then extracted. After exclusion of screened Chinese names from the telephone directory, telephone numbers were randomly selected to screen for the white Canadian sample.

The randomly selected telephone numbers were called to identify eligible respondents (ie, those who identified themselves as Chinese or white, as 18 years of age or older, and as speaking English, Cantonese, or Mandarin). Ethnicity of respondents was determined using the following question: "People living in Canada come from many different cultural and racial backgrounds. How would you describe your ethnic origin (Caucasian or white, Chinese, or other)?" Only 1 respondent was interviewed in each household. If there was more than 1 eligible respondent in the household, the individual with his or her birthday coming up the soonest was selected for the interview. Each of the randomly selected telephone numbers was called at different times (weekdays and weekends, and various times of day) up to 10 times.

Survey questionnaire
The National Institutes of Health has defined CAM as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine."12 Our survey assessed use of 11 major and commonly studied therapies13,14 in the previous 12 months. (The questionnaire is available on request.)

Study variables that were selected based on Aday and Andersen’s health services utilization model15,16 included predisposing factors of demographic characteristics and beliefs rooted in TCM principles regarding causes of diseases; enabling factors, such as additional health insurance and household income; and need factors, such as the presence of chronic diseases (allergies, arthritis, back pain, cancer, depression, diabetes, headaches, heart disease, high blood pressure, kidney disease, liver disease, lung disease, neurological disorder including stroke, sleeping problems, and stomach diseases).

The questionnaire was initially developed in English. The questionnaire was tested and refined by interviewing 11 people. Forward-backward translation was used to ensure that the meaning of the questions in the Chinese and English versions was consistent.

Ethics approval was obtained from the Conjoint Health Research Ethics Board of the Faculty of Medicine of the University of Calgary and the Affiliated Teaching Institutions.

Data collection
Interviewers were trained and practised telephone interviews with one another. White respondents were interviewed in English and the Chinese respondents in English, Mandarin, or Cantonese.

Statistical analysis
Differences between these 2 groups were tested using {chi}2 tests. Parsimonious logistic regression models were fitted using the backward method to determine factors associated with overall CAM use and with individual therapies of herbal therapy, acupuncture, and massage.


   RESULTS
TOP
 METHODS
 RESULTS
DISCUSSION
 Footnotes
 References
 
Of the 1727 Chinese and 1948 white Canadians contacted by telephone, 850 Chinese and 805 white Canadians agreed to participate. Eighteen responses with missing values were excluded; responses from 835 (49.2%) Chinese and 802 (41.2%) white participants were analyzed. Compared with white participants, Chinese participants were more likely to be younger than 65 years old, male, have university or higher education, be married, or be in the low-income group (Table 1).


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  		Table 1 Characteristics of Chinese (n = 835) and white (n = 802) survey respondents

 
The proportion of respondents who had CAM in the past 12 months was similar between Chinese (59.9%) and white respondents (58.6%) but varied significantly across therapies (Table 2). Chinese respondents were more likely to use herbal therapy than white respondents were (48.7% vs 33.7%), equally likely to use acupuncture (8.3% vs 7.9%), and less likely to use the remaining 9 CAM therapies studied. More white than Chinese respondents used multiple CAM therapies (24.5% vs 11.2% for using 3 or more therapies).


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  		Table 2 Use of 11 complementary and alternative therapies in the past 12 months among Chinese and white survey respondents: A) Types of therapies used. B) Number of therapies used (P < .01).

 
Chinese and white respondents had significantly different beliefs about CAM (Table 3). More Chinese than white respondents believed that herbal therapy (66.0% vs 28.9%), acupuncture (46.2% vs 15.7%), and massage (24.7% vs 14.2%) could cure chronic diseases that prescription drugs were unable to cure and that herbal therapy had been scientifically tested and proven to be effective (70.4% vs 21.8%).


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  		Table 3 Beliefs about complementary and alternative medicine therapies and practitioners among Chinese (n = 835) and white (n = 802) survey respondents: P < .01.

 
Factors associated with CAM use varied by therapy and ethnicity (Table 4).* Receiving a recommendation to use CAM from a family member or friend was associated with herbal therapy, acupuncture, and massage therapy use in both groups. Chronic diseases were associated with herbal therapy, acupuncture, and massage therapy use among Chinese respondents and with acupuncture use among white respondents. Chinese respondents who had postsecondary education were less likely to use herbal therapy than those without postsecondary education, while those who believed that herbal therapy could cure chronic diseases that prescription drugs were unable to cure or who trusted herbal therapists were more likely to use herbal therapies. White respondents who believed that herbalists used a holistic approach (ie, taking the whole person, including mind, body, and spirit, into account for treatment) or that herbal therapies had fewer side effects than prescription medications were more likely to use the therapies than those without such beliefs. White respondents who perceived that acupuncture and massage could prevent chronic disease from getting worse were more likely to use them than those who did not share this perception.


   DISCUSSION
TOP
 METHODS
 RESULTS
 DISCUSSION
Footnotes
 References
 
About 60% of the Chinese and white respondents had used CAM within the previous year. The Chinese respondents predominantly used herbal therapies, while the white respondents used a range of CAM therapies. The common factor associated with CAM use among Chinese and white respondents was receiving a recommendation from a family member or friend. The unique factors associated with herbal therapy use for the Chinese respondents were beliefs about benefits of herbal therapy and trust in herbal therapy practitioners. The specific factors associated with CAM use among the white respondents were beliefs about fewer side effects or a holistic approach of herbal therapy and preventive effects of acupuncture and massage.

Our findings of the level of CAM use among Chinese Canadians (59.9%) could not be compared with previous reports because of heterogeneity in the study populations and variations in the definition of CAM. With respect to TCM use, previous studies reported 40.8% use among Chinese-American women,17 76% among residents of Singapore,18 and 22.1% among residents of Hong Kong.19 Consistent with previous studies,9,20–22 the Chinese Canadians in this study predominantly used herbal therapies, although they also infrequently used non-Chinese culturally related therapies, such as chiropractic care and naturopathy.

The high use of herbal therapies is related to Chinese respondents’ beliefs about the therapies. We found that 66% of Chinese respondents believed that herbal therapy could cure chronic diseases in contrast to 46% for acupuncture and 24% for massage. Chinese respondents who believed herbal therapy could cure chronic disease or deeply trusted herbal practitioners were more likely to use the therapy than those without such beliefs. These findings suggest that Chinese Canadians have stronger beliefs about the benefits of herbal therapy than of acupuncture and massage in the management of chronic disease. However, traditional Chinese beliefs about the causes of disease (including the Yin-Yang principle) were not related to CAM use among Chinese respondents. This indicates that Chinese people might be less concerned about the theoretical principles of diagnosis and treatment but more concerned about effects when choosing CAM.

Other studies in Western countries have consistently documented that CAM users tend to be female, be of middle age, have a high income or high education level, and have poorer physical or mental health compared with nonusers.13,23–28 We found that sociodemographic characteristics were not associated with the overall CAM use (Table 4D)* among Chinese respondents, while being younger or female were correlated with higher CAM use among the white respondents. This different pattern could indicate that CAM has been widely accepted by respondents, regardless of education, marital status, or income. However, within the groups, there is some variation, as Chinese respondents with more education were less likely to use herbal therapy compared with those with less education.

Our findings are important in the context of clinical practice, helping physicians to understand the differences in beliefs about CAM between cultural groups. For example, 70% of Chinese respondents in our study believed that herbal therapy had been scientifically tested and proven to be effective, which was much higher than among white respondents (21.8%). This large difference between the 2 populations is likely related to numerous factors. One possible factor is that the Chinese have historically used TCM and are more aware of herbal therapy than white Canadians. It is a common traditional Chinese belief that TCM is effective for treatment of chronic diseases but not effective for acute conditions. We found the presence of chronic disease was associated with use of herbal therapy, acupuncture, and massage among Chinese Canadians, while belief in the preventive effects of CAM was a significant factor for white Canadians. Knowing these differences would allow health care professionals to better connect with patients, opening up the opportunity for more accurate health assessment and more culturally appropriate health intervention strategies.

Limitations
As a local study, the generalizability of the findings to other locations is unknown. This cross-sectional study could not establish causal relationships between the correlates and the dependent variables. Our sample size is not large enough to allow further analyses of the factors associated with CAM use by medical condition.

Conclusion
While the percentage of CAM use was similar in both groups, Chinese Canadians mainly used herbal therapy and white Canadians used a range of CAM therapies. Factors associated with CAM use varied by ethnicity and type of CAM therapy. However, presence of chronic disease was an important factor for Chinese Canadians. If there is need (ie, presence of chronic disease) and recommendations from people they know well, Chinese Canadians are likely to use CAM. That finding suggests that Chinese Canadians use CAM for the treatment of chronic disease while white Canadians for disease treatment or health maintenance. The findings serve to better inform health care professionals about CAM use attitudes and preferences of Chinese and white Canadians.



   EDITOR’S KEY POINTS
 
  • This survey assessed randomly selected Chinese and white respondents’ use of 11 major and commonly studied therapies in the previous 12 months.
  • About 60% of the Chinese and white respondents had used CAM within the past year. More white than Chinese respondents had used multiple CAM therapies. No sociodemographic characteristics were associated with overall CAM use among Chinese respondents, whereas being younger or female were correlated with higher CAM use among the white respondents.
  • The common factor associated with herbal therapy, acupuncture, or massage use among Chinese and white respondents was receiving a CAM recommendation from a family member or friend.

 



   POINTS DE REPÈRE DU RÉDACTEUR
 
  • Cette enquête évaluait l’utilisation par des répondants chinois et caucasiens, au cours des 12 mois précédents, de 11 thérapies importantes fréquemment étudiées.
  • Environ 60% des répondants chinois et caucasiens avaient eu recours à des MCP durant l’année précédente. Plus de répondants caucasiens que de chinois avaient eu recours à des thérapies MCP multiples. Chez les Chinois, l’utilisation des MCP n’était associée à aucune caractéristique sociodémographique, alors que chez les caucasiens, le fait d’être plus jeune ou d’être une femme favorisait une plus forte utilisation.
  • Chez les Chinois comme chez les caucasiens, le facteur commun associé au recours aux herbes médicinales, à l’acupuncture ou aux massages était le fait de recevoir une recommandation en ce sens d’un membre de la famille ou d’un ami

 


   Footnotes
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
References
 
Competing interests

None declared

Contributors

Drs Quan, Lai, Verhoef, and Musto and Ms Johnson contributed to concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.

* Table 4 is available at www.cfp.ca. Go to the full text of this article on-line, then click on CFPlus in the menu at the top right-hand side of the page. Back

This article has been peer reviewed.


   References
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
 References
 

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