Research
Complementary and alternative medicine use among Chinese and white Canadians
Hude Quan
MD PhDDaniel Lai
PhDDelaine Johnson
MScNMarja Verhoef
PhDRichard Musto
MDABSTRACT
OBJECTIVE
This study aimed to describe the level of complementary and alternative medicine (CAM) use and the factors associated with CAM use among Chinese and white Canadians.DESIGN
A cross-sectional telephone survey conducted in English, Cantonese, and Mandarin.SETTING
Calgary, Alta.PARTICIPANTS
Chinese and white residents of Calgary aged 18 or older.MAIN OUTCOME MEASURES
Rates of use of 11 CAM therapies, particularly herbal therapy, massage, chiropractic care, and acupuncture; reasons for use of CAM therapies.RESULTS
Sixty percent of 835 Chinese respondents (95% confidence interval [CI] 56.5% to 63.2%) and 59%of 802 white respondents (95% CI 55.1% to 62.0%) had used CAM in the past year. Chinese respondents were more likely to use herbal therapy than white respondents were (48.7% vs 33.7%, P < .001), less likely to use massage (17.1% vs 30.4%, P < .001) and chiropractic care (8.4% vs 21.2%, P < .001), but equally likely to use acupuncture (8.3% vs 7.9%, P = .173). 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. Factors unique to either Chinese or white CAM users varied by therapy. For example, herbal therapy use for Chinese respondents was associated with the presence of chronic disease (adjusted odds ratio [AOR] 2.15, 95% CI 1.09 to 4.24 for having 3 diseases compared with those without chronic disease), beliefs about the effectiveness of herbal therapy (AOR 1.56, 95% CI 1.12 to 2.17), and trust in herbal therapy practitioners (AOR 1.72, 95% CI 1.24 to 2.37). Herbal
therapy use for white respondents was associated with the beliefs that herbal treatment had fewer side effects than prescription drugs (AOR 1.81, 95% CI 1.31 to 2.50) and that herbalists took a holistic approach (AOR 2.07, 95% CI 1.49 to 2.87).
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 with ethnicity and type of CAM therapy. Presence of chronic disease, however, was an important factor for Chinese Canadians. That finding suggests that Chinese Canadians use CAM for the treatment of chronic disease, while white Canadiansuse such therapies for disease treatment and health maintenance.
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 recommen- dation from a family member or friend.
This article has been peer reviewed.
Can Fam Physician 2008;54:1563-9
Recherche
Cet article a fait l’objet d’une révision par des pairs.
Can Fam Physician 2008;54:1563-9
Recours aux médecines complémentaires et parallèles par les Canadiens d’origine chinoise ou de race blanche
Hude Quan
MD PhDDaniel Lai
PhDDelaine Johnson
MScNMarja Verhoef
PhDRichard Musto
MDRéSUMé
OBJECTIF
Cette étude voulait décrire le degré d’utilisation des médecines complémentaires et parallèles (MCP) et les facteurs associés à cette utilisation chez des Canadiens chinois et caucasiens.TYPE D’éTUDE
Enquête téléphonique transversale effectuée en anglais, en cantonais et en mandarin.CONTEXTE
Calgary, Alberta.PARTICIPANTS
Résidants chinois et caucasiens de Calgary âgés de 18 ans et plus.PRINCIPAUX PARAMÈTRES éTUDIéS
Taux d’utilisation de 11 thérapies MCP, notamment les herbes médicinales, les massages, la chiropratique et l’acupuncture; raisons pour avoir recours à ces thérapies.RéSULTATS
Soixante pour-cent des 835 répondants chinois (intervalle de confiance [IC] à 95% 56,5 à 63,2%) et 59% des 802 répondants blancs (IC à 95% 55,1 à 62,0%) avaient eu recours à des MCP durant l’année précédente. Par rapport aux Blancs, les Chinois étaient plus susceptibles d’utiliser les herbes médicinales (48,7 vs 33,7%, P < ,001), moins susceptibles d’utiliser les massages (17,1 vs 30,4%, P < ,001) et la chiropraxie (8,4 vs 21,2%, P < ,001) mais également susceptibles d’utiliser l’acupuncture (8,3 vs 7,9%, P = ,173). Chez les Chinois comme chez les caucasiens, le facteur commun associé au recours auxherbes 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. Les facteurs spécifiques aux utilisateurs de MCP chinois ou caucasiens variaient selon les thérapies. Par exemple, l’utilisation d’herbes médicinales chez les Chinois était associée à la présence de maladies chroniques (rapport de cotes ajustées [RCA] 2,15, IC à 95% 1,09 à 4,24 pour avoir 3 maladies par comparaison avec ceux n’ayant aucune maladie chronique), au fait de croire en l’efficacité de ces herbes (RCA 1,56, IC à 95% 1,2 à 2,17) et à la confiance envers ceux qui dispensent cette thérapie (RCA 1,72, IC à 95% 1,24 à 2,37). Le recours aux herbes médicinales chez les répondants blancs était associé à la croyance que ce type de thérapie a moins d’effets indésirables que les médicaments de prescription (RCA 1,81, IC à 95% 1,31 à 2,50) et que les herboristes ont une approche holistique (RCA 2,07, IC à 95% 1,49 à 2,87).
CONCLUSION
Alors que le pourcentage d’utilisateurs de MCP était semblable dans les deux groupes, les Canadiens d’origine chinoise utilisaient principalement les herbes médicinales tandis que les caucasiens avaient recours à une variété de thérapies MCP. Les facteurs associés à l’utilisation des MCP variaient selon l’origine ethnique et le type de thérapie MCP. Pour les Chinois, toutefois, la présence d’une maladie chronique était un facteur important. Cette observation laisse croire que les Canadiens d’origine chinoise utilisent les MCP pour traiter des maladies chroniques alors que les Blancs les utilisent pour toutes sortes de maladies et pour préserver leur santé.POINTS DE REPÈRE DU RéDACTEUR
•
Cette enquête évaluait l’utilisation par des répon- dants chinois et caucasiens, au cours des 12 mois précédents, de 11 thérapies importantes fréquem- ment étudiées.
•
Environ 60% des répondants chinois et caucasiens avaient eu recours à des MCP durant l’année précé- dente. Plus de répondants caucasiens que de chinois avaient eu recours à des thérapies MCP multiples.
Chez les Chinois, l’utilisation des MCP n’était asso- ciée 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 fac-
teur commun associé au recours aux herbes médici-
nales, 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
CAM use among Chinese and white Canadians Research
C
omplementary 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 medi- cine (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 fam- ily 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 compo- nents of TCM and had no comparison groups or used non-random samples. This study addresses these limita- tions 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 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 vali- dated 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 num- bers 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 back- grounds. How would you describe your ethnic origin
(Caucasian or white, Chinese, or other)?” Only 1 respon- dent 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 soon- est 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 consid- ered to be part of conventional medicine.”12 Our survey assessed use of 11 major and commonly studied thera- pies13,14 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 dis- eases; enabling factors, such as additional health insur- ance and household income; and need factors, such as the presence of chronic diseases (allergies, arthri- tis, 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 interview- ing 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 inter- views 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 χ2 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
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 ana- lyzed. 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).
The proportion of respondents who had CAM in the past 12 months was sim- ilar between Chinese (59.9%) and white respondents (58.6%) but varied signifi- cantly 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 ther- apies studied. More white than Chinese respondents used multiple CAM therapies (24.5% vs 11.2% for using 3 or more thera- pies).
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 prescrip- tion drugs were unable to cure and that herbal therapy had been scientifically tested and proven to be effective (70.4%
vs 21.8%).
Factors associated with CAM use var- ied by therapy and ethnicity (Table 4).*
Receiving a recommendation to use CAM from a family member or friend was asso- ciated with herbal therapy, acupuncture, and massage therapy use in both groups.
Chronic diseases were associated with herbal therapy, acupuncture, and mas- sage therapy use among Chinese respon- dents 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
Table 1. Characteristics of Chinese (n = 835) and white (n = 802) survey respondents
VARiAbLeS
CHiNeSe ReSPONDeNTS
N (%)
WHiTe ReSPONDeNTS
N (%) P VALue
Age, y < .0001
• 18-34 224 (26.8) 217 (27.1)
• 35-64 549 (65.7) 478 (59.6)
• ≥ 65 62 (7.4) 107 (13.3)
Sex < .0001
• Male 406 (48.6) 307 (38.3)
• Female 429 (51.4) 495 (61.7)
Education < .0001
• Less than senior high school 93 (11.1) 50 (6.2)
• Senior high school 137 (16.4) 207 (25.8)
• Technical or professional college 162 (19.4) 259 (32.3)
• University or postgraduate 443 (53.1) 286 (35.7)
Marital status < .0001
• Married or common-law 647 (77.5) 469 (58.5)
• Never married 144 (17.2) 208 (25.9)
• Divorced or separated 44 (5.3) 125 (15.6)
Annual income, $ < .0001
• ≤ 30 000 238 (28.5) 97 (12.1)
• 30 001-50 000 181 (21.7) 144 (18.0)
• 50 001-70 000 128 (15.3) 113 (14.1)
• > 70 000 194 (23.2) 323 (40.3)
• Not provided 94 (11.3) 125 (15.6)
Language spoken at home < .0001
• English 87 (10.4) 773 (96.4)
• Chinese 612 (73.3) 0 (0)
• Both English and Chinese 133 (15.9) 0 (0)
• Other 3 (0.4) 29 (3.6)
Birthplace < .0001
• Canada 72 (8.6) 683 (85.2)
• Outside Canada 763 (91.4) 119 (14.8)
Length of stay in Canada for people
born out of Canada, y < .0001
• 1–4 328 (39.3) 12 (1.5)
• 5–9 152 (18.2) 17 (2.1)
• ≥ 10 283 (33.9) 90 (11.2)
No. of chronic disease present
(out of 15) < .0001
• 0 402 (48.1) 164 (20.4)
• 1 227 (27.2) 202 (25.2)
• 2 125 (15.0) 159 (19.8)
• 3 45 (5.4) 110 (13.7)
• ≥ 4 36 (4.3) 167 (20.8)
Extended health insurance besides government insurance
543 (65.0) 659 (82.2) < .0001 Family doctor visit in the past 12 mo 621 (74.4) 642 (80.0) < .0001 Specialist visit in the past 12 mo 236 (28.3) 303 (37.8) < .0001
Family member or friend recommended < .01
• Herbal therapy 529 (63.4) 430 (53.6)
• Acupuncture 388 (46.5) 268 (33.4)
• Massage 388 (46.5) 484 (60.3)
CFPlus
GO*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.
CAM use among Chinese and white Canadians Research
prescription drugs were unable to cure or who trusted herbal therapists were more likely to use herbal thera- pies. White respondents who believed that herbalists used a holistic approach (ie, taking the whole person, including mind, body, and spirit, into account for treat- ment) 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 mas- sage could prevent chronic disease from getting worse were more likely to use them than those who did not share this perception.
DISCUSSION
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 ther- apies. 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 previ- ous reports because of heterogeneity in the study pop- ulations 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 chiro- practic 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 ther- apy 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 acu- puncture 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 respon- dents. 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 over- all CAM use (Table 4D)* among Chinese respondents, while being younger or female were correlated with higher CAM use among the white respondents. This dif- ferent pattern could indicate that CAM has been widely accepted by respondents, regardless of education, mari- tal status, or income. However, within the groups, there is some variation, as Chinese respondents with more education were less likely to use herbal therapy com- pared with those with less education.
Our findings are important in the context of clini- cal practice, helping physicians to understand the
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).
A)
THeRAPy
CHiNeSe ReSPONDeNTS (N = 835) N (%)
WHiTe ReSPONDeNTS (N = 802) N (%) P VALue
Herbal remedies 407 (48.7) 270 (33.7) < .01 Massage therapy 143 (17.1) 244 (30.4) < .01 Chiropractic care 70 (8.4) 170 (21.2) < .01
Acupuncture 69 (8.3) 63 (7.9) .173
Amino acids or
enzymes 41 (4.9) 85 (10.6) < .01
Naturopathy 12 (1.4) 29 (3.6) < .01
Homeopathy 7 (0.8) 45 (5.6) < .01
Reiki 4 (0.5) 23 (2.9) < .01
Ayurvedic
medicine 2 (0.2) 8 (1.0) < .01
Biofeedback
training 2 (0.2) 5 (0.6) < .01
Hypnosis 1 (0.1) 8 (1.0) < .01
Any of the
therapies 500 (59.9) 470 (58.6) .599
b)
NO. OF THeRAPieS uSeD
CHiNeSe ReSPONDeNTS (N = 500) N (%)
WHiTe ReSPONDeNTS (N = 470) N (%)
1 318 (63.6) 205 (43.6)
2 126 (25.2) 150 (31.9)
3 40 (8.0) 59 (12.6)
≥ 4 16 (3.2) 56 (11.9)
differences in beliefs about CAM between cultural groups. For example, 70% of Chinese respondents in our study believed that herbal therapy had been scien- tifically 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 effec- tive 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, acu- puncture, and massage among Chinese Canadians, while belief in the preventive effects of CAM was a sig- nificant factor for white Canadians. Knowing these dif- ferences 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 fac- tors 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 dis- ease was an important factor for Chinese Canadians. If there is need (ie, presence of chronic disease) and rec- ommendations 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 treat- ment or health maintenance. The findings serve to better inform health care professionals about CAM use attitudes and preferences of Chinese and white Canadians.
Dr Quan is an Associate Professor in the Department of Community Health Sciences and the Centre for Health and Policy Studies at the University of Calgary in Alberta. Dr Lai is a Professor in the Faculty of Social Work at the University of Calgary. Ms Johnson is Manager, Healthy Diverse Populations for the Calgary Health Region. Dr Verhoef is a Professor in the Department of Community Health Sciences at the University of Calgary. Dr Musto is a 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.
Competing interests None declared Contributors
Drs Quan, Lai, Verhoef, and Musto and Ms Johnson contributed to con- cept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.
Table 3. beliefs about complementary and alternative medicine therapies and practitioners among Chinese (n = 835) and white (n = 802) survey respondents: P < .01.
beLieFS
CHiNeSe ReSPONDeNTS
N (%)
WHiTe ReSPONDeNTS
N (%)
Herbal therapies
Agreed that herbal therapies can cure chronic diseases that prescription drugs are unable to cure
551 (66.0) 232 (28.9)
Agreed that some herbal therapists have secret therapies that have been passed down from generation to generation
495 (59.3) 368 (45.9)
Agreed that herbal therapies in general have fewer bad side effects than prescription drugs
551 (66.0) 309 (38.5)
Agreed that herbal therapies have been scientifically tested and proved to be effective
588 (70.4) 175 (21.8)
Agreed that herbalists treat patients with a holistic approach
538 (64.4) 392 (48.9)
Trust herbalists very much or
quite a lot 381 (45.6) 131 (16.3)
Acupuncture
Agreed that acupuncture can prevent chronic diseases from getting worse
372 (44.6) 214 (26.7)
Agreed that acupuncture can cure chronic diseases that prescription drugs are unable to cure
386 (46.2) 126 (15.7)
Massage
Agreed that massage can prevent chronic diseases from getting worse
298 (35.7) 334 (41.6)
Agreed that massage can cure chronic diseases that prescription drugs are unable to cure
206 (24.7) 114 (14.2)
Disease causation
Agreed that disease is a result of “Yin and Yang” disharmony
402 (48.1) 139 (17.3) Agreed that one will get
arthritis if one sleeps on the cold floor too often
431 (51.6) NA
Agreed that one should avoid
eating seafood after surgery 336 (40.2) NA Agreed that one will get sick if
one goes to bed with wet hair 475 (56.9) NA Agreed that it is not advisable
for women to take a bath shortly after birth
290 (34.7) NA
CAM use among Chinese and white Canadians Research
Correspondence
Dr Hude Quan, University of Calgary, Community Health Sciences, 3330 Hospital Dr NW, Calgary, AB T2N 4N1; e-mail hquan@ucalgary.ca references
1. Boon HS, Verhoef MJ, Vanderheyden LC, Westlake KP. Complementary and alter- native medicine: a rising healthcare issue. Healthcare Policy 2006;1(3):19-30.
2. Hsiao AF, Wong MD, Goldstein MS, Yu HJ, Andersen RM, Brown ER, et al.
Variation in complementary and alternative medicine (CAM) use across racial/ethnic groups and the development of ethnic-specific measures of CAM use. J Altern Complement Med 2006;12(3):281-90.
3. Keith VM, Kronenfeld JJ, Rivers PA, Liang SY. Assessing the effects of race and ethnicity on use of complementary and alternative therapies in the USA.
Ethn Health 2005;10(1):19-32.
4. Mackenzie ER, Taylor L, Bloom BS, Hufford DJ, Johnson JC. Ethnic minority use of complementary and alternative medicine (CAM): a national probability survey of CAM utilizers. Altern Ther Health Med 2003;9(4):50-6.
5. Xu KT, Farrell TW. The complementarity and substitution between uncon- ventional and mainstream medicine among racial and ethnic groups in the United States. Health Serv Res 2007;42(2):811-26.
6. Kuo GM, Hawley ST, Weiss LT, Balkrishnan R, Volk RJ. Factors associ- ated with herbal use among urban multiethnic primary care patients: a cross-sectional survey. BMC Complement Altern Med 2004;4:18.
7. Lai D, Chappell N. Use of traditional Chinese medicine by older Chinese immigrants in Canada. Fam Pract 2007;24(1):56-64. Epub 2006 Nov 21.
8. Tjam EY, Hirdes JP. Health, psycho-social and cultural determinants of medi- cation use by Chinese-Canadian older persons. Can J Aging 2002;21(1):63-73.
9. Wong LK, Jue P, Lam A, Yeung W, Cham-Wah Y, Birtwhistle R. Chinese herbal medicine and acupuncture. How do patients who consult family physicians use these therapies? Can Fam Physician 1998;44:1009-15.
10. Zhang J, Verhoef MJ. Illness management strategies among Chinese immi- grants living with arthritis. Soc Sci Med 2002;55(10):1795-802.
11. Quan H, Wang F, Schopflocher D, Norris C, Galbraith PD, Faris P, et al.
Development and validation of a surname list to define Chinese ethnicity.
Med Care 2006;44(4):328-33.
12. National Center for Complementary and Alternative Medicine. What is CAM?
Bethesda, MD: National Center for Complementary and Alternative Medicine;
2007. Available from: www.nccam.nih.gov/health/whatiscam. Accessed 2008 Sep 25.
13. Druss BG, Rosenheck RA. Use of practitioner-based complementary thera- pies by persons reporting mental conditions in the United States. Arch Gen Psychiatry 2000;57(7):708-14.
14. Ni H, Simile C, Hardy AM. Utilization of complementary and alternative medicine by United States adults: results from the 1999 national health inter- view survey. Med Care 2002;40(4):353-8.
15. Aday LA, Andersen R. A framework for the study of access to medical care.
Health Serv Res 1974;9(3):208-20.
16. Andersen RM. Revisiting the behavioral model and access to medical care:
does it matter? J Health Soc Behav 1995;36(1):1-10.
17. Kronenberg F, Cushman LF, Wade CM, Kalmuss D, Chao MT. Race/ethnicity and women’s use of complementary and alternative medicine in the United States: results of a national survey. Am J Public Health 2006;96(7):1236-42.
Erratum in: Am J Public Health 2006;96(8):1340.
18. Lim MK, Sadarangani P, Chan HL, Heng JY. Complementary and alternative medicine use in multiracial Singapore. Complement Ther Med 2005;13(1):16-24.
19. Lau JT, Leung EM, Tsui HY. Predicting traditional Chinese medicine’s use and the marginalization of medical care in Hong Kong. Am J Chin Med 2001;29(3-4):547-58.
20. Bair YA, Gold EB, Greendale GA, Sternfeld B, Adler SR, Azari R, et al. Ethnic differences in use of complementary and alternative medicine at midlife: longi- tudinal results from SWAN participants. Am J Public Health 2002;92(11):1832-40.
21. Lee MM, Lin SS, Wrensch MR, Adler SR, Eisenberg D. Alternative therapies used by women with breast cancer in four ethnic populations. J Natl Cancer Inst 2000;92(1):42-7.
22. Maskarinec G, Shumay DM, Kakai H, Gotay CC. Ethnic differences in com- plementary and alternative medicine use among cancer patients. J Altern Complement Med 2000;6(6):531-8.
23. 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(18):1569-75.
24. Bausell RB, Lee WL, Berman BM. Demographic and health-related corre- lates to visits to complementary and alternative medical providers. Med Care 2001;39(2):190-6.
25. Blais R, Maiga A, Aboubacar A. How different are users and non-users of alternative medicine? Can J Public Health 1997;88(3):159-62.
26. Unutzer J, Klap R, Sturm R, Young AS, Marmon T, Shatkin J, al. Mental dis- orders and the use of alternative medicine: results from a national survey. Am J Psychiatry 2000;157(11):1851-7.
27. Burstein HJ, Gelber S, Guadagnoli E, Weeks JC. Use of alternative medicine by women with early-stage breast cancer. N Engl J Med 1999;340(22):1733-9.
28. Astin JA. Why patients use alternative medicine: results of a national study.
JAMA 1998;279(19):1548-53.
