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Use of unconventional therapies by primary care patients – Religious resources vs. complementary or alternative medicine services
Complementary Therapies in Medicine (2013) 21, 517—524
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/ctim
Use of unconventional therapies by primary care patients — Religious resources vs. complementary or alternative medicine services Tzipi Hornik-Lurie a,b,∗, Julie Cwikel b,c, Marjorie C. Feinson a, Yaacov Lerner a, Nelly Zilber a a
The Falk Institute for Mental Health Studies, Kfar Shaul Hospital, Givat Shaul, 91060 Jerusalem, Israel Social Work Department, Ben Gurion University of the Negev, 84105 Beer Sheva, Israel c Center for Women’s Health Studies and Promotion, Ben Gurion University of the Negev, POB 653, 84105 Beer Sheva, Israel Available online 22 August 2013 b
KEYWORDS Primary care patients; Religious resources for medical purposes; Complementary or alternative medicine
Summary Objectives: The study examines the difference in characteristics between primary care patients who turn to ‘‘religious resources for medical purposes’’ (RRMP) and those who turn to ‘‘complementary or alternative medicine’’ (CAM) services to cope with a physical or mental health problem. Design and setting: Data were collected from eight primary care clinics in Israel and included 905 Jewish patients aged 25—75. Main outcome measure: A self-report questionnaire with a battery of validated mental health assessment instruments and two questionnaires regarding use of unconventional therapies (RRMP and CAM services) were administered to the participants. The association of various variables with type of ‘service use’ was examined through logistic regression analysis. Results: Primary care patients suffering from emotional problems have a propensity to utilize unconventional therapies in addition to conventional medical treatment. However, differences exist between patients who turn to RRMP and to CAM. The risk factors for turning to RRMP are North African, Middle Eastern or Israeli origin, low SES, religious observance, and high use of primary care clinics. For using CAM services the risk factor is high SES. Conclusions: In the present study, a quarter of primary care patients also use additional resources for their medical problems. While all segments of the population use unconventional resources, our study reveals that two types of unconventional therapies — RRMP and CAM — tend to be used by two different population sectors. It is noteworthy that those suffering from mental health problems are more likely to utilize unconventional resources. © 2013 Elsevier Ltd. All rights reserved.
∗ Corresponding author at: The Falk Institute for Mental Health Studies, Kfar Shaul Hospital, Givat Shaul, 91060 Jerusalem, Israel. Tel.: +972 50 5893324; fax: +972 57 7941745. E-mail addresses: [email protected], [email protected] (T. Hornik-Lurie).
0965-2299/$ — see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctim.2013.08.010
518 It is well established that users of primary care services also turn to other resources for health care. For example, in 2001 a national survey in the United States1 revealed that, among those who used conventional medical treatment, 23% also used complementary or alternative medicine (CAM) services. Our definition of CAM follows that of the National Center of Complementary and Alternative Medicine: ‘‘a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period’’.2 Following the growing use of CAM, some studies have been published regarding the characteristics of the patients who use CAM services for medical or mental health problems.3—8 There are also many studies which indicate the importance of religiosity and spirituality in coping with mental and somatic health problems,9—12 and some physicians even claimed that ‘‘the medicine of the future is going to be prayer and Prozac’’.13 However, relatively little research has been performed on primary care patients who turn to religious resources for medical purposes (RRMP), like consulting a religious authority or pilgrimages to tombs of Jewish saints. To the best of our knowledge, there is no study on the difference in characteristics between primary care patients who turn to religious resources and those who use CAM services to cope with medical problems. The present study was conducted on Jewish primary care patients in Israel. Jewish religious observance is an integral part of the Jewish national identity, even among those who define themselves as secular.14 A significant segment of the Jewish population consults a rabbi for a variety of personal issues including medical problems (13%) and even a greater proportion of them see benefit in visiting the tombs of Jewish saints (24%).15 This phenomenon is similar to pilgrimages to shrines and graves found in Christanity16 and Islam.17 In the current study, turning to RRMP as well as CAM were considered as ‘unconventional therapies’. In the present study we described and compared the characteristics of primary care patients who turn to RRMP and of those who turn to CAM services, while also examining the impact of mental health problems on the type of unconventional services used.
Methods Sample The study population consisted of primary care patients who, at the time of the study (2002—2003), were between ages 25 and 75 and visited one of eight selected clinics in Israel’s largest HMO1 during the year prior to the interview. In the present study, which is part of a larger study on rates of utilization of the primary clinics,18 younger adults (<25) were excluded because they usually utilize army medical services and older adults (>75) because they generally have higher utilization rates due to increased somatic problems. The clinics were selected to represent a crosssection of the Israeli population on the basis of geographic,
1
Clalit Health Services HMO, which insures 60% of the Israelis.
T. Hornik-Lurie et al. socioeconomic and ethnic diversity. Although the sample included Israeli Arabs (7% of the sample), the present analysis focuses only on Jewish patients (N = 905) since a main variable is religious behavior, which differs in the two population groups. The sample was constructed by interviewing consecutive patients who were screened by a short questionnaire in order to select those who met the study criteria (age 25—75 and at least one visit during the year prior to the interview). Respondents were recruited by specially trained interviewers. The nature of the study (research about use of primary clinics by patients) was explained and only those who signed informed consent forms (77% of those eligible) were included. Patients were fully interviewed at home in Hebrew or Russian, according to respondents’ request. The study protocol and instruments were reviewed and approved by the medical director of the HMO as well as the medical directors of the eight selected clinics.
Measures Three self-rating mental health assessment instruments, with previously established reliability and validity, were administered: 1. The Brief Symptom Inventory — 18 (BSI-18) a shortened version of the BSI, a self-report scale for identifying psychological distress, which includes subscales for somatization, depression, and anxiety, as well as an overall index, the Global Severity Index (GSI). The BSI-18 internal consistency estimates are quite satisfactory.19 Cronbach’s alpha in our study was .88. The instrument is scored by converting total scores on each of the scales into T scores based on Israeli normative data from the community.20 A score of 63 or higher on the GSI or at least on two of the three subscales indicates clinical ‘‘caseness’’. 2. The Composite International Diagnostic Interview — Short Form (CIDI-SF), a diagnostic instrument developed by the WHO specifically for diagnosing mental health problems in epidemiological studies.21 This instrument diagnosed patients with depression or with anxiety (general anxiety, panic disorder or obsessive compulsive disorder — OCD). For depression, panic disorder and OCD, the CIDI-SF algorithm does not give a precise cut-off point for diagnosis, but provides the probability of a diagnosis for different scores. In our study, a score of 4—7 defines a diagnosis of depression (probability of 81—91%); for panic disorder, a score of 3—6 is required (probability of 87—100%) and for OCD, a score of 3 (probability of 84%). 3. The somatization subscale of the Symptom Checklist90 (SCL-90) questionnaire: 12 questions on symptoms of somatization, each one with a five-category response: not at all (0), a little bit (1), moderately (2), quite a lot (3) and extremely (4).22 A score of 3 or higher on at least six of the twelve symptoms was considered as indicating possible somatization. The somatization questionnaire was found to be highly reliable (Cronbach’s alpha = 84). Two self-report questionnaires concerned the use of unconventional therapies in addition to primary care services:
Use of unconventional therapies • 2-Items assessing use of RRMP: (a) ‘‘Did you consult a religious person (a Rabbi or a Kabbalist — Jewish mystic) for medical purposes in the last 12 months?’’; (b) ‘‘Did you visit tombs of saints for medical purposes in the last 12 months?’’ Patients were categorized as using RRMP if they answered ‘‘yes’’ to at least one of these questions. • A list of 11 various services of complementary or alternative medicine (CAM). The respondents were asked to specify what types of CAM they utilized in the last 12 months: reflexology, Bach flower remedies, naturopathy (nutritional therapy, herbal medicines), chiropractics, biofeedback, hypnosis, Chinese acupuncture, Chinese herbal medicine, homeopathic medicine, Shiatsu, other type of CAM. Those who indicated using at least one of these services were categorized as using CAM services. Socio-demographic questions included gender, ethnic origin2 (Israel — if the respondent and his/her two parents were Israeli-born, other countries in the Middle East, North Africa, Eastern Europe or Western Countries3 ), age (25—34, 35—44, 45—54, 55—64 or 65—75 years), years of education (0—8, 9—12 or 13+ years), marital status (married, widowed, separated/divorced or never married), religious observance (secular, traditional/observant, modern-orthodox or ultraorthodox), sufficiency of family income to cover the costs of daily living (sufficient, partly sufficient or insufficient) and work status — measured only for the working age population (unemployed, part-time employed or full-time employed). Utilization of primary care clinics (high vs. average) was defined by the number of visits in the last 12 months according to patients’ report. High utilization was defined as an annual number of visits exceeding the 70th percentile. Because of the increase in utilization with age, the definition changed with age: 7+ visits for ages 25—44, 13+ visits for ages 45—64 and 16+ visits per year for ages 65+. Less frequent utilization was defined as ‘Average’. Patients with high utilization were over-sampled because the present study is part of a larger study in which the relationship between high utilization of primary care clinics and psychopathology was studied.18
Data analysis Demographic variables, frequency of visits to primary health clinics and psychopathology were assessed for significant bivariate associations with (i) the type of unconventional medical practice used (RRMP vs. CAM services); (ii) use of RRMP vs. no use of unconventional therapies; (iii) use of CAM services vs. no use of unconventional therapies (crosstab procedure). Pairwise tests of the equality of row proportions were performed. The results were based on two-sided z tests
2 Ethnic origin was defined according to patient’s place of birth, with two exceptions: (a) if the patient was born in Israel, it was defined according to mother’s place of birth; if she was also born in Israel: according to father’s place of birth; (b) if the patient was not born in Israel and both parents were born in the same country, different from that of the patient: according to parents’ place of birth. 3 Western countries were defined as: Western Europe, United States and South Africa.
519 with a significance level of 0.05. The p values of the tests were adjusted using the Bonferroni method. Those independent variables with significant associations (p ≤ 0.05) with service use were entered together into a logistic regression in order to check their association with service use after controlling for the effect of all other variables entered into the model. In this analysis, because of the population size, some categories of the independent variables were combined into a single category. Data analyses were performed using SPSS/PC version 19.0. Two-sided tests of significance were used in all analyses.
Results The sociodemographic and clinical characteristics of the study population are provided in Table 1. Overall, 25% of respondents used unconventional services for medical treatment: 14% turned to RRMP only, 9% used CAM services only and just under 2% used both RRMP and CAM resources. Among RRMP users, 16% consulted religious authorities, 29% visited the tombs of Jewish saints and 55% turned to both of them. Half of the CAM users applied for one service, 27% two services, 13% three and the rest four and more. Among CAM users, the Chinese acupuncture was the most popular therapy (36%); 24% utilized reflexology, 20% Shiatsu, 19% naturopathy, 19% homeopathic medicine, 18% Chinese herbal medicine, 12% chiropractics, 10% Bach flower remedies, 3% hypnosis. Other CAM services were used by 22% of CAM users. When we compared primary care patients who turned to RRMP (Table 1, column A) with those who utilized CAM services (Table 1, column B), we found that they come from two different sectors. They differ in their demographic characteristics, such as ethnic origin, education and SES, in their religious observance and in some clinical characteristics like frequency of utilization of primary care clinics and diagnosis of depression (Table 2, first set of results). When we compared primary care patients who turned to RRMP to those who do not use any unconventional therapy (Table 2, second set of results), use of RRMP was found to be significantly associated with all study variables, except gender, age, marital status and somatization. As seen in Table 1 (superscript letters in column A), utilization of RRMP was significantly higher among patients of North African origin, patients from the Middle East and patients of Israeli origin than among patients from Eastern Europe, for whom the use of RRMP was the lowest. Utilization of RRMP among patients of North African origin was also significantly higher than among patients from Western countries. The use of these resources decreases with increased level of education, the differences between the three levels of education being statistically significant. As expected, secular respondents used significantly less RRMP than religious people, regardless of their level of religious observance. Regarding income, patients with insufficient income turned to RRMP significantly more often than those with partly sufficient or with sufficient income, with no significant difference between the two latter groups. This parallels the finding that unemployed patients turn significantly more often to RRMP than those employed parttime or full-time, with no significant difference between the two latter groups. High use of primary care medical
520 Table 1
T. Hornik-Lurie et al. Use of unconventional therapies according to patients’ characteristics.
Independent variables
Total
N
%
Total 905 100.0 Gender Male 312 34.5 Female 593 65.5 Ethnic origin Middle Eastc 202 23.4 North Africad 306 35.5 Eastern Europee 266 30.9 Western countriesf 48 5.6 Israelg 40 4.6 Age (years) 25—34 129 14.4 35—44 134 15.0 45—54 195 21.8 55—64 188 21.1 65—75 247 27.7 Education (years) 0—8 190 21.1 9—12 413 45.9 13+ 296 32.9 Marital status Married 636 70.4 Widowed 97 10.7 Separated/divorced 78 8.6 Never married 93 10.3 Religious observance Secular 303 33.6 Traditional/observant 408 45.2 Modern-orthodox 153 16.9 Ultra-orthodox 39 4.3 Sufficiency of family income Sufficient 390 43.8 Partly sufficient 261 29.3 Insufficient 239 26.9 Work statush Unemployed 188 34.4 Part-time employed 93 17.0 Full-time employed 266 48.6 Utilization of primary care clinics Highi 385 42.7 Averagej 516 57.3 Psychological distressk No 787 87.0 Yes 118 13.0 Diagnosis of depression No 722 79.8 Yes 183 20.2 Diagnosis of anxietyl No 734 81.1 Yes 171 18.9
Only use of RRMPa ‘column A’
Only use of CAMb services ‘column B’
Use of both RRMP and CAM services’ ‘column C’
Use of neither RRMP nor CAM services ‘column D’
N
%
N
N
%
N
%
127
14.0
82
9.1
16
1.8
680
75.1
45 82
14.4a 13.8a
22 60
10.1a 9.4a
5 11
1.9a 2.5a
240 440
76.9a 74.2a
25 84 7 3 5
12.4b 27.5a 2.6c 6.3bc 12.5ab
19 16 28 6 7
9.4ab 5.2b 10.5ab 12.5ab 17.5a
5 9 1 0 0
2.5ab 2.9a 0.4b 0.0 0.0
153 197 230 39 28
75.7b 64.4b 86.5a 81.3ab 70.0ab
13 17 27 33 37
10.1a 12.7a 13.8a 17.6a 15.0a
10 7 21 25 18
7.8a 5.2a 10.8a 13.3a 7.3a
4 2 5 3 2
3.1a 1.5a 2.6a 1.6a 0.8a
102 108 142 127 190
79.1a 80.6a 72.8a 67.6a 76.9a
56 57 14
29.5a 13.8b 4.7c
8 26 48
4.2b 6.3b 16.2a
3 7 6
1.6a 1.7a 2.0a
123 323 228
64.7b 78.2a 77.0a
91 14 14 8
14.3a 14.4a 17.9a 8.6a
61 9 3 9
9.6a 9.3a 3.8a 9.7a
10 0 2 4
1.6a 0.0 2.6a 4.3a
474 74 59 72
74.5a 76.3a 75.6a 77.4a
14 71 30 12
4.6b 17.4a 19.6a 30.8a
41 26 12 3
13.5a 6.4a 7.8a 7.7a
2 5 8 1
0.7b 1.2b 5.2a 2.6a
246 306 103 23
81.2a 75.0ab 67.3b 59.0b
36 31 60
9.2b 11.9b 25.1a
50 17 14
12.8a 6.5b 5.9b
7 2 7
1.8a 0.8a 2.9a
297 211 158
76.2a 80.8a 66.1b
38 8 27
20.2a 8.6b 10.2b
9 8 35
4.8b 8.6ab 13.2a
5 1 5
2.7a 1.1a 1.9a
136 76 199
72.3a 81.7a 74.8a
79 46
8.9b 20.5a
29 52
10.1a 7.5a
6 10
1.9a 1.6a
271 408
79.1a 70.4b
97 30
12.3b 25.4a
71 11
9.0a 9.3a
12 4
1.5a 3.4a
607 73
77.1a 61.9b
87 40
12.0b 21.9a
67 15
9.3a 8.2a
9 7
1.2a 3.8a
559 121
77.4a 66.1b
87 40
11.9b 23.4a
63 19
8.6a 11.1a
11 5
1.5a 2.9a
573 107
78.1a 62.6b
%
Use of unconventional therapies
521
Table 1 (Continued) Independent variables
Total
N Somatization No Yes
%
794 108
88.0 12.0
Only use of RRMPa ‘column A’
Only use of CAMb services ‘column B’
Use of both RRMP and CAM services’ ‘column C’
Use of neither RRMP nor CAM services ‘column D’
N
%
N
N
%
N
%
105 22
13.2b 20.4a
74 8
14 2
1.8a 1.9a
601 76
75.7a 70.4a
% 9.3a 7.4a
Missing cases. Ethnic origin: N = 43; age: N = 12; education: N = 6; marital status: N = 1; religious observance: N = 2; sufficiency of family income: N = 15; work status: N = 33; utilization of primary care clinics: N = 4; somatization: N = 3. Letters (a—c) indicate significant differences (at the level of 0.05) between row proportions. If two values are significantly different, those values display different letters. a RRMP (religious resources for medical purposes): consultation with a religious authority and/or visiting the tombs of saints for medical purposes. b CAM (complementary or alternative medicine). c Middle East (Iran, Iraq, Saudi Arabia, Syria, Turkey, Yemen). d North Africa (Algeria, Egypt, Ethiopia, Kenya, Libya, Morocco, Somalia, Sudan, Tanzania, Tunisia, Uganda, Zimbabwe). e Eastern Europe (Bulgaria, Czechoslovakia, Former Soviet Union, Hungary, Poland, Romania). f Western countries (Andorra, France, Germany, Gibraltar, Greece, Italy, Monaco, South Africa, Spain, United Kingdom, United States). g Israel = participant and both parents are Israeli-born. h Work status (only for women up to age 60 and men up to age 65); total N = 580. i High use was defined according to the following criteria: more than 6 visits per year for ages 25—44; more than 12 visits per year for ages 45—64; more than 15 visits per year for ages 65+. j All those who did not meet the above criteria were defined as having ‘average use’. k A T-score of 63 or higher in the overall index BSI-18 (GSI) or at least on two of the three subscales indicates psychological distress. l Anxiety (general anxiety, panic attacks or obsessive-compulsive disorder).
services was significantly associated with more use of RRMP. Use of RRMP was also significantly more frequent among patients suffering from psychological distress, depression, anxiety or somatization. With regard to the use of CAM services, it was found to be significantly associated with age,
Table 2
education, family income and anxiety (Table 2, third set of results). Specifically, (Table 1, column B) utilization of CAM was significantly more frequent among patients of Israeli origin than among patients from North Africa, for whom the use of CAM was the lowest. Utilization of CAM services
Association of use of different unconventional therapies with patients’ characteristics.
Independent variables
Gender Ethnic origin Age Education Marital status Religious observance Sufficiency of family income Work status Utilization of primary care clinics Psychological distress Diagnosis of depression Diagnosis of anxiety Somatization
Association of type of unconventional therapies used (RRMP or CAM services) with patients’ characteristics Table 1 columns A vs. B
Association of use of RRMP with patients’ characteristics Table 1 columns A + C vs. D
Association of use of CAM services with patients’ characteristics Table 1 columns B + C vs. D
2
df
p
2
df
p
2
df
p
1.69 52.49 2.94 59.28 4.71 39.38 26.06 15.84 14.79 3.29 4.48 1.70 2.32
1 4 4 2 3 3 2 2 1 1 1 1 1
.193 <.001 .567 <.001 .194 <.001 <.001 <.001 <.001 .070 .034 .192 .128
0.01 78.32 3.90 43.59 1.52 42.59 31.44 10.37 19.72 17.76 16.52 19.42 3.40
1 4 4 2 3 3 2 2 1 1 1 1 1
.940 <.001 .420 <.001 .677 <.001 <.001 .006 <.001 <.001 <.001 <.001 .065
2.28 2.74 9.81 16.80 2.21 6.51 7.93 5.04 0.52 1.78 1.24 4.69 0.09
1 4 4 2 3 3 2 2 1 1 1 1 1
.131 .603 .044 <.001 .529 .089 .019 .080 .470 .182 .266 .030 .763
p values inferior to 0.05 are indicated in bold.
522 Table 3
T. Hornik-Lurie et al. Predictors of use of RRMPa and of use of CAMb services vs. no use of unconventional therapies (logistic regression).
Use of RRMPa (total N = 766) Variables in the model Gender Male (Female) Ethnic origin Middle Easte North Africaf Western countriesg Israelh (Eastern Europei )
Education (years) 0—12 (13+) Religious observance (Secular) Religiousj Sufficiency of family income (Sufficient or partly sufficient) Insufficient Utilization of primary care clinics Highk (Averagel ) Diagnosis (3 categories) (Neither depression nor anxietym ) Depression or anxietym Depression and anxietym
Use of CAMb services (total N = 732) O.R.c 95% C.I.d 1.00 1.00
0.65—1.55
2.90 6.53 1.53 4.02 1.00
1.25—6.73 3.00—14.19 0.37—6.34 1.18—13.69
p
Variables in the model
O.R.c 95% C.I.d
.991
Gender Male (Female)
0.78 1.00
.327 0.47—1.28
<.001 .014 <.001 .559 .026
.001 2.11 1.00
p
1.36—3.28
Age (years) 25—44 45—64 (65—75) Education (years) (0—12) 13+
1.11 1.96 1.00
.026 0.57—2.14 .761 1.09—3.50 .024 <.001
1.00 2.39
1.52—3.77
<.001 1.00 3.09
1.69—5.65 .003
1.00 1.93
1.25—2.98
Sufficiency of family income Sufficient (Partly sufficient or insufficient)
.023 1.72 1.00
1.08—2.75
.016 1.68 1.00
1.10—2.56 .013
1.00 1.75 2.16
1.06—2.90 1.18—3.96
.030 .012
Diagnosis (3 categories) (Neither depression nor anxietym ) 1.00 Depression or anxietym 1.06 Depression and anxietym 2.60
.018 0.58—1.95 .848 1.33—5.08 .005
p values inferior to 0.05 are indicated in bold. a RRMP (religious resources for medical purposes): consultation with a religious authority and/or visiting the tombs of saints for medical purpose. b CAM (complementary or alternative medicine). c O.R.: odds ratio. d 95% C.I. of O.R.: 95% confidence interval of odds ratio. e Middle East (Iran, Iraq, Saudi Arabia, Syria, Turkey, Yemen). f North Africa (Algeria, Egypt, Ethiopia, Kenya, Libya, Morocco, Somalia, Sudan, Tanzania, Tunisia, Uganda, Zimbabwe). g Western countries (Andorra, France, Germany, Gibraltar, Greece, Italy, Monaco, South Africa, Spain, United Kingdom, United States). h Israel = participant and both parents are Israeli-born. i Eastern Europe (Bulgaria, Czechoslovakia, Former Soviet Union, Hungary, Poland, Romania). j Religious (traditional/observant, modern-orthodox, ultra-orthodox). k High use was defined based on the following criteria: more than 6 visits per year for ages 25—44; more than 12 visits per year for ages 45—64 and more than 15 visits per year for ages 65+. l All those who did not meet the above criteria were defined as having ‘average use’. m Anxiety (general anxiety, panic attacks or obsessive-compulsive disorder).
was also found to be more frequent among patients aged 45—64 than among the younger (age 25—44) and the older patients (age 65—75). Regarding education, those with the highest education (13+ years) turned to CAM services significantly more often than those with less education (0—8 and 9—12 years). There was no significant difference between the two latter groups. Use of CAM services was more frequent among patients with sufficient income than among those with partly sufficient or insufficient income. There was no significant difference between the two latter groups.
Concerning mental health status, use of CAM services was more frequent among patients suffering from anxiety, while no significant association was found with psychological distress, depression and somatization. Many significant associations were found between the study’s independent variables. Specifically, religious observance is associated with ethnic origin, education and income sufficiency: patients from North African and Middle Eastern origins are more likely to be religious (traditional/observant, modern orthodox or ultra-orthodox); less educated are more likely to
Use of unconventional therapies be religious while highly educated are more likely to be secular; and patients with insufficient income are more likely to be religious than those with partly sufficient or sufficient income (data available upon request). SES variables (education, family income, work status) are significantly associated with almost all demographic variables, with utilization of primary care services and with psychopathology variables. As already described in a previous article,18 psychopathology (psychological distress and psychiatric diagnoses) is significantly more prevalent among women, among those ages 45—64, with less education and insufficient income, the unmarried and the unemployed. No significant differences in diagnosis were found between the secular and the religious sectors of the population. Separate logistic regressions were done for use of RRMP and CAM services, controlling for the variables associated with these dependent variables. Although gender was not significantly associated with either type of ‘service use’, it was included because the known differences that exist in the utilization of health services between the two genders. Since ‘work status’ was measured only for the working age population while income sufficiency was measured for the entire population and the two variables are highly correlated, only ‘sufficiency of family income’ was included in the logistic regressions. The two variables of ‘diagnosis of depression’ and ‘diagnosis of anxiety’ were combined into a three-category variable (neither depression nor anxiety; depression or anxiety; depression and anxiety). As shown in Table 3, the results are consistent with those found in the univariate analyses. Even though many independent variables were associated with each other, after controlling for the other variables in the model, all of them remained significant in predicting the probability of using either RRMP or CAM services, except psychological distress.
Discussion In the present study, we examined the population characteristics of primary care patients who also use unconventional therapies, RRMP and/or CAM. One of the most important findings is the striking difference between patients who turn to RRMP compared to those who use CAM, difference in many demographic aspects, such as ethnic origin and SES, in religious observance and in the frequency of utilization of primary care clinics. The 1995 National Health Insurance (NHI) Law23 provides medical care to all citizens at no cost for visits to primary care physicians and negligible costs for visits to specialists; however, CAM is not included in the services provided.24 The costs of consulting a religious figure for health advice vary and often payment is left up to the patient, and visiting the tombs of Jewish saints involves minimal travel expenses. This may explain why use of RRMP is correlated with a lower socioeconomic level,25 while use of CAM services, which is generally expensive, is associated with a higher socioeconomic level, as also shown in other studies.5—8,24,26 One may expect that high users of primary care clinic will look for additional helping agents for medical purposes. As high users of primary care clinics have a higher probability of being of a low socioeconomic level,27 this may partially explain why seeking religious solutions are significantly associated with high use of primary care
523 clinics. Jews of North African and Middle East origins generally are more traditional and religious.28 Thus, it is not surprising that they consistently use RRMP more than patients of Eastern European and Western origin. Our results also indicate that primary care patients suffering from emotional problems have a propensity to utilize unconventional therapies in addition to conventional medical treatment, as also found in previous studies.3,4,7,10,12,29 The choice of the patients of either RRMP or CAM is, as mentioned previously, largely dependent on their socio-demographic characteristics, cultural background, and their level of religious observance. It should be noted that, while the rate of CAM utilization by primary care patients in Israel is relatively lower than in other Western countries, it has risen considerably over the last few years,7,30 a trend which is likely to continue in the future.24 A methodological limitation of our survey is that only patients in primary care clinics were included, which excluded those using only religious or CAM resources. An additional limitation is that the small number of patients using CAM services did not permit an examination of the use of various types of CAM separately. In contrast, a major advantage of this study is that it broadens the scope of alternative resources by including specific religious behaviors; this provides a perspective not available in other studies of alternative sources of medical care.
Conclusion The study shows that a significant number of primary care patients also use additional resources for their medical problems, but the two types of unconventional therapies examined in the study — RRMP and CAM — tend to be used by two different population sectors. It is noteworthy that those suffering from mental health problems are more likely to utilize unconventional resources, especially RRMP. It would be of interest in a further study to explore the sociological and anthropological factors responsible for the use by two different population sectors.
Conflict of interest statement None declared.
Acknowledgment This research was supported by a grant from The National Institute for Health Policy and Health Services Research (# 83656101).
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T. Hornik-Lurie et al. a survey of gender and cultural patterns in Israel. Gender Med 2009;6:384—97. Druss BG, Rosenheck RA. Association between use of unconventional therapies and conventional medical services. JAMA 1999;282:651—6. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990—1997. JAMA 1998;280:1569—75. Niskar AS, Peled-Leviatan T, Garty-Sandalon N. Who uses complementary and alternative medicine in Israel? J Altern Complement Med (New York, NY) 2007;13:989—95. Shmueli A, Igudin I, Shuval J. Change and stability: use of complementary and alternative medicine in Israel: 1993, 2000 and 2007. Eur J Public Health 2011;21:254—9. Woodward AT, Bullard KM, Taylor RJ, et al. Complementary and alternative medicine for mental disorders among African Americans, Black Caribbeans, and Whites. Psychiatr Serv 2009;60:1342—9. Bilu Y, Witztum E. Culturally sensitive therapy with ultraorthodox patients: the strategic employment of religious idioms of distress. In: Hoffman S, Feldman B, editors. Case studies of unorthodox therapy of orthodox patients. New York: Golden Sky; 2012. p. 1—22. Ferraro KF, Kelley-Moore JA. Religious consolation among men and women: do health problems spur seeking? J Sci Study Religion 2000;39:220—34. George LK, Larson DB, Koenig HG, McCullough ME. Spirituality and health: what we know, what we need to know. J Soc Clin Psychol 2000;19:102—16. Koenig HG. Religion, spirituality, and medicine: research findings and implications for clinical practice. South Med J 2004;97:1194—200. Sides H. The calibration of belief. New York Times Magazine 1997;(December):92—5. Levy S. Selective observance as a component of Jewish identity in contemporary Israeli society. Contemp Jewry 2001;22:18—36. Arian A, Keissar-Sugarmen A. A portrait of Israeli Jews: beliefs, observance, and values of Israeli Jews, 2009. The AVI CHAI — Israel Foundation, The Israel Democracy Institute; 2012, January. Talbot AM. Pilgrimage to healing shrines: the evidence of miracle accounts. Dumbarton Oaks Pap 2002;56:153—73.
17. Pirani FM, Papadopoulos IR, Foster J, Leavey G. I will accept whatever is meant for us. I wait for that — day and night: the search for healing at a Muslim shrine in Pakistan. Ment Health Religion Cult 2008;11:375—86. 18. Cwikel J, Zilber N, Feinson M, Lerner Y. Prevalence and risk factors of threshold and sub-threshold psychiatric disorders in primary care. Soc Psychiatry Psychiatr Epidemiol 2008;43:184—91. 19. Derogatis LR. The brief symptom inventory-18 (BSI-18): administration, scoring and procedures manual. Minneapolis: National Computer Systems; 2000. 20. Gilbar O, Ben-Zur H. Adult Israeli Community Norms for the Brief Symptom Inventory (BSI). Int J Stress Manage 2002;9:1—10. 21. Kessler RC, Andrews G, Mroczek D, Ustun B, Wittchen H-U. The world health organization composite international diagnostic interview short-form (CIDI-SF). Int J Methods Psychiatr Res 1998;7:171—85. 22. Derogatis L. SCL-90R (revised version) manual. I. Baltimore, MD: Johns Hopkins School of Medicine; 1977. 23. The State of Israel. The national health insurance law of 1994 (NHI). Jerusalem: Ministry of Justice; 1995 [Hebrew]. 24. Shuval JT, Averbuch E. Complementary and alternative health care in Israel. Israel J Health Policy Res 2012;1:7. 25. Schieman S. Socioeconomic status and beliefs about God’s influence in everyday life. Sociol Religion 2010;71:25—51. 26. Druss BG, Rosenheck RA. Association between use of unconventional therapies and conventional medical services. JAMA — J Am Med Assoc 1999;282:651—6. 27. Vedsted P, Christensen MB. Frequent attenders in general practice care: a literature review with special reference to methodological considerations. Public Health 2005;119: 118—37. 28. Goldscheider C, Friedlander D. Religiosity patterns in Israel. In: Himmelfarb M, Singer D, editors. American Jewish Year Book 1983. New York and Philadelphia: American Jewish Committee and The Jewish Publication Society of America; 1982. p. 3—39. 29. Gatz M, Fiske A. Aging women and depression. Profession Psychol: Res Pract 2003;34:3—9. 30. Gross R, Brammli-Greenberg S, Waitzberg R. Public opinion on the level of service and performance of the health-care system in 2007 and in comparison with previous years. Jerusalem: Myers-JDC-Brookdale Institute Center for Research on Disability and Special Populations; 2009.
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/ctim
Use of unconventional therapies by primary care patients — Religious resources vs. complementary or alternative medicine services Tzipi Hornik-Lurie a,b,∗, Julie Cwikel b,c, Marjorie C. Feinson a, Yaacov Lerner a, Nelly Zilber a a
The Falk Institute for Mental Health Studies, Kfar Shaul Hospital, Givat Shaul, 91060 Jerusalem, Israel Social Work Department, Ben Gurion University of the Negev, 84105 Beer Sheva, Israel c Center for Women’s Health Studies and Promotion, Ben Gurion University of the Negev, POB 653, 84105 Beer Sheva, Israel Available online 22 August 2013 b
KEYWORDS Primary care patients; Religious resources for medical purposes; Complementary or alternative medicine
Summary Objectives: The study examines the difference in characteristics between primary care patients who turn to ‘‘religious resources for medical purposes’’ (RRMP) and those who turn to ‘‘complementary or alternative medicine’’ (CAM) services to cope with a physical or mental health problem. Design and setting: Data were collected from eight primary care clinics in Israel and included 905 Jewish patients aged 25—75. Main outcome measure: A self-report questionnaire with a battery of validated mental health assessment instruments and two questionnaires regarding use of unconventional therapies (RRMP and CAM services) were administered to the participants. The association of various variables with type of ‘service use’ was examined through logistic regression analysis. Results: Primary care patients suffering from emotional problems have a propensity to utilize unconventional therapies in addition to conventional medical treatment. However, differences exist between patients who turn to RRMP and to CAM. The risk factors for turning to RRMP are North African, Middle Eastern or Israeli origin, low SES, religious observance, and high use of primary care clinics. For using CAM services the risk factor is high SES. Conclusions: In the present study, a quarter of primary care patients also use additional resources for their medical problems. While all segments of the population use unconventional resources, our study reveals that two types of unconventional therapies — RRMP and CAM — tend to be used by two different population sectors. It is noteworthy that those suffering from mental health problems are more likely to utilize unconventional resources. © 2013 Elsevier Ltd. All rights reserved.
∗ Corresponding author at: The Falk Institute for Mental Health Studies, Kfar Shaul Hospital, Givat Shaul, 91060 Jerusalem, Israel. Tel.: +972 50 5893324; fax: +972 57 7941745. E-mail addresses: [email protected], [email protected] (T. Hornik-Lurie).
0965-2299/$ — see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctim.2013.08.010
518 It is well established that users of primary care services also turn to other resources for health care. For example, in 2001 a national survey in the United States1 revealed that, among those who used conventional medical treatment, 23% also used complementary or alternative medicine (CAM) services. Our definition of CAM follows that of the National Center of Complementary and Alternative Medicine: ‘‘a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period’’.2 Following the growing use of CAM, some studies have been published regarding the characteristics of the patients who use CAM services for medical or mental health problems.3—8 There are also many studies which indicate the importance of religiosity and spirituality in coping with mental and somatic health problems,9—12 and some physicians even claimed that ‘‘the medicine of the future is going to be prayer and Prozac’’.13 However, relatively little research has been performed on primary care patients who turn to religious resources for medical purposes (RRMP), like consulting a religious authority or pilgrimages to tombs of Jewish saints. To the best of our knowledge, there is no study on the difference in characteristics between primary care patients who turn to religious resources and those who use CAM services to cope with medical problems. The present study was conducted on Jewish primary care patients in Israel. Jewish religious observance is an integral part of the Jewish national identity, even among those who define themselves as secular.14 A significant segment of the Jewish population consults a rabbi for a variety of personal issues including medical problems (13%) and even a greater proportion of them see benefit in visiting the tombs of Jewish saints (24%).15 This phenomenon is similar to pilgrimages to shrines and graves found in Christanity16 and Islam.17 In the current study, turning to RRMP as well as CAM were considered as ‘unconventional therapies’. In the present study we described and compared the characteristics of primary care patients who turn to RRMP and of those who turn to CAM services, while also examining the impact of mental health problems on the type of unconventional services used.
Methods Sample The study population consisted of primary care patients who, at the time of the study (2002—2003), were between ages 25 and 75 and visited one of eight selected clinics in Israel’s largest HMO1 during the year prior to the interview. In the present study, which is part of a larger study on rates of utilization of the primary clinics,18 younger adults (<25) were excluded because they usually utilize army medical services and older adults (>75) because they generally have higher utilization rates due to increased somatic problems. The clinics were selected to represent a crosssection of the Israeli population on the basis of geographic,
1
Clalit Health Services HMO, which insures 60% of the Israelis.
T. Hornik-Lurie et al. socioeconomic and ethnic diversity. Although the sample included Israeli Arabs (7% of the sample), the present analysis focuses only on Jewish patients (N = 905) since a main variable is religious behavior, which differs in the two population groups. The sample was constructed by interviewing consecutive patients who were screened by a short questionnaire in order to select those who met the study criteria (age 25—75 and at least one visit during the year prior to the interview). Respondents were recruited by specially trained interviewers. The nature of the study (research about use of primary clinics by patients) was explained and only those who signed informed consent forms (77% of those eligible) were included. Patients were fully interviewed at home in Hebrew or Russian, according to respondents’ request. The study protocol and instruments were reviewed and approved by the medical director of the HMO as well as the medical directors of the eight selected clinics.
Measures Three self-rating mental health assessment instruments, with previously established reliability and validity, were administered: 1. The Brief Symptom Inventory — 18 (BSI-18) a shortened version of the BSI, a self-report scale for identifying psychological distress, which includes subscales for somatization, depression, and anxiety, as well as an overall index, the Global Severity Index (GSI). The BSI-18 internal consistency estimates are quite satisfactory.19 Cronbach’s alpha in our study was .88. The instrument is scored by converting total scores on each of the scales into T scores based on Israeli normative data from the community.20 A score of 63 or higher on the GSI or at least on two of the three subscales indicates clinical ‘‘caseness’’. 2. The Composite International Diagnostic Interview — Short Form (CIDI-SF), a diagnostic instrument developed by the WHO specifically for diagnosing mental health problems in epidemiological studies.21 This instrument diagnosed patients with depression or with anxiety (general anxiety, panic disorder or obsessive compulsive disorder — OCD). For depression, panic disorder and OCD, the CIDI-SF algorithm does not give a precise cut-off point for diagnosis, but provides the probability of a diagnosis for different scores. In our study, a score of 4—7 defines a diagnosis of depression (probability of 81—91%); for panic disorder, a score of 3—6 is required (probability of 87—100%) and for OCD, a score of 3 (probability of 84%). 3. The somatization subscale of the Symptom Checklist90 (SCL-90) questionnaire: 12 questions on symptoms of somatization, each one with a five-category response: not at all (0), a little bit (1), moderately (2), quite a lot (3) and extremely (4).22 A score of 3 or higher on at least six of the twelve symptoms was considered as indicating possible somatization. The somatization questionnaire was found to be highly reliable (Cronbach’s alpha = 84). Two self-report questionnaires concerned the use of unconventional therapies in addition to primary care services:
Use of unconventional therapies • 2-Items assessing use of RRMP: (a) ‘‘Did you consult a religious person (a Rabbi or a Kabbalist — Jewish mystic) for medical purposes in the last 12 months?’’; (b) ‘‘Did you visit tombs of saints for medical purposes in the last 12 months?’’ Patients were categorized as using RRMP if they answered ‘‘yes’’ to at least one of these questions. • A list of 11 various services of complementary or alternative medicine (CAM). The respondents were asked to specify what types of CAM they utilized in the last 12 months: reflexology, Bach flower remedies, naturopathy (nutritional therapy, herbal medicines), chiropractics, biofeedback, hypnosis, Chinese acupuncture, Chinese herbal medicine, homeopathic medicine, Shiatsu, other type of CAM. Those who indicated using at least one of these services were categorized as using CAM services. Socio-demographic questions included gender, ethnic origin2 (Israel — if the respondent and his/her two parents were Israeli-born, other countries in the Middle East, North Africa, Eastern Europe or Western Countries3 ), age (25—34, 35—44, 45—54, 55—64 or 65—75 years), years of education (0—8, 9—12 or 13+ years), marital status (married, widowed, separated/divorced or never married), religious observance (secular, traditional/observant, modern-orthodox or ultraorthodox), sufficiency of family income to cover the costs of daily living (sufficient, partly sufficient or insufficient) and work status — measured only for the working age population (unemployed, part-time employed or full-time employed). Utilization of primary care clinics (high vs. average) was defined by the number of visits in the last 12 months according to patients’ report. High utilization was defined as an annual number of visits exceeding the 70th percentile. Because of the increase in utilization with age, the definition changed with age: 7+ visits for ages 25—44, 13+ visits for ages 45—64 and 16+ visits per year for ages 65+. Less frequent utilization was defined as ‘Average’. Patients with high utilization were over-sampled because the present study is part of a larger study in which the relationship between high utilization of primary care clinics and psychopathology was studied.18
Data analysis Demographic variables, frequency of visits to primary health clinics and psychopathology were assessed for significant bivariate associations with (i) the type of unconventional medical practice used (RRMP vs. CAM services); (ii) use of RRMP vs. no use of unconventional therapies; (iii) use of CAM services vs. no use of unconventional therapies (crosstab procedure). Pairwise tests of the equality of row proportions were performed. The results were based on two-sided z tests
2 Ethnic origin was defined according to patient’s place of birth, with two exceptions: (a) if the patient was born in Israel, it was defined according to mother’s place of birth; if she was also born in Israel: according to father’s place of birth; (b) if the patient was not born in Israel and both parents were born in the same country, different from that of the patient: according to parents’ place of birth. 3 Western countries were defined as: Western Europe, United States and South Africa.
519 with a significance level of 0.05. The p values of the tests were adjusted using the Bonferroni method. Those independent variables with significant associations (p ≤ 0.05) with service use were entered together into a logistic regression in order to check their association with service use after controlling for the effect of all other variables entered into the model. In this analysis, because of the population size, some categories of the independent variables were combined into a single category. Data analyses were performed using SPSS/PC version 19.0. Two-sided tests of significance were used in all analyses.
Results The sociodemographic and clinical characteristics of the study population are provided in Table 1. Overall, 25% of respondents used unconventional services for medical treatment: 14% turned to RRMP only, 9% used CAM services only and just under 2% used both RRMP and CAM resources. Among RRMP users, 16% consulted religious authorities, 29% visited the tombs of Jewish saints and 55% turned to both of them. Half of the CAM users applied for one service, 27% two services, 13% three and the rest four and more. Among CAM users, the Chinese acupuncture was the most popular therapy (36%); 24% utilized reflexology, 20% Shiatsu, 19% naturopathy, 19% homeopathic medicine, 18% Chinese herbal medicine, 12% chiropractics, 10% Bach flower remedies, 3% hypnosis. Other CAM services were used by 22% of CAM users. When we compared primary care patients who turned to RRMP (Table 1, column A) with those who utilized CAM services (Table 1, column B), we found that they come from two different sectors. They differ in their demographic characteristics, such as ethnic origin, education and SES, in their religious observance and in some clinical characteristics like frequency of utilization of primary care clinics and diagnosis of depression (Table 2, first set of results). When we compared primary care patients who turned to RRMP to those who do not use any unconventional therapy (Table 2, second set of results), use of RRMP was found to be significantly associated with all study variables, except gender, age, marital status and somatization. As seen in Table 1 (superscript letters in column A), utilization of RRMP was significantly higher among patients of North African origin, patients from the Middle East and patients of Israeli origin than among patients from Eastern Europe, for whom the use of RRMP was the lowest. Utilization of RRMP among patients of North African origin was also significantly higher than among patients from Western countries. The use of these resources decreases with increased level of education, the differences between the three levels of education being statistically significant. As expected, secular respondents used significantly less RRMP than religious people, regardless of their level of religious observance. Regarding income, patients with insufficient income turned to RRMP significantly more often than those with partly sufficient or with sufficient income, with no significant difference between the two latter groups. This parallels the finding that unemployed patients turn significantly more often to RRMP than those employed parttime or full-time, with no significant difference between the two latter groups. High use of primary care medical
520 Table 1
T. Hornik-Lurie et al. Use of unconventional therapies according to patients’ characteristics.
Independent variables
Total
N
%
Total 905 100.0 Gender Male 312 34.5 Female 593 65.5 Ethnic origin Middle Eastc 202 23.4 North Africad 306 35.5 Eastern Europee 266 30.9 Western countriesf 48 5.6 Israelg 40 4.6 Age (years) 25—34 129 14.4 35—44 134 15.0 45—54 195 21.8 55—64 188 21.1 65—75 247 27.7 Education (years) 0—8 190 21.1 9—12 413 45.9 13+ 296 32.9 Marital status Married 636 70.4 Widowed 97 10.7 Separated/divorced 78 8.6 Never married 93 10.3 Religious observance Secular 303 33.6 Traditional/observant 408 45.2 Modern-orthodox 153 16.9 Ultra-orthodox 39 4.3 Sufficiency of family income Sufficient 390 43.8 Partly sufficient 261 29.3 Insufficient 239 26.9 Work statush Unemployed 188 34.4 Part-time employed 93 17.0 Full-time employed 266 48.6 Utilization of primary care clinics Highi 385 42.7 Averagej 516 57.3 Psychological distressk No 787 87.0 Yes 118 13.0 Diagnosis of depression No 722 79.8 Yes 183 20.2 Diagnosis of anxietyl No 734 81.1 Yes 171 18.9
Only use of RRMPa ‘column A’
Only use of CAMb services ‘column B’
Use of both RRMP and CAM services’ ‘column C’
Use of neither RRMP nor CAM services ‘column D’
N
%
N
N
%
N
%
127
14.0
82
9.1
16
1.8
680
75.1
45 82
14.4a 13.8a
22 60
10.1a 9.4a
5 11
1.9a 2.5a
240 440
76.9a 74.2a
25 84 7 3 5
12.4b 27.5a 2.6c 6.3bc 12.5ab
19 16 28 6 7
9.4ab 5.2b 10.5ab 12.5ab 17.5a
5 9 1 0 0
2.5ab 2.9a 0.4b 0.0 0.0
153 197 230 39 28
75.7b 64.4b 86.5a 81.3ab 70.0ab
13 17 27 33 37
10.1a 12.7a 13.8a 17.6a 15.0a
10 7 21 25 18
7.8a 5.2a 10.8a 13.3a 7.3a
4 2 5 3 2
3.1a 1.5a 2.6a 1.6a 0.8a
102 108 142 127 190
79.1a 80.6a 72.8a 67.6a 76.9a
56 57 14
29.5a 13.8b 4.7c
8 26 48
4.2b 6.3b 16.2a
3 7 6
1.6a 1.7a 2.0a
123 323 228
64.7b 78.2a 77.0a
91 14 14 8
14.3a 14.4a 17.9a 8.6a
61 9 3 9
9.6a 9.3a 3.8a 9.7a
10 0 2 4
1.6a 0.0 2.6a 4.3a
474 74 59 72
74.5a 76.3a 75.6a 77.4a
14 71 30 12
4.6b 17.4a 19.6a 30.8a
41 26 12 3
13.5a 6.4a 7.8a 7.7a
2 5 8 1
0.7b 1.2b 5.2a 2.6a
246 306 103 23
81.2a 75.0ab 67.3b 59.0b
36 31 60
9.2b 11.9b 25.1a
50 17 14
12.8a 6.5b 5.9b
7 2 7
1.8a 0.8a 2.9a
297 211 158
76.2a 80.8a 66.1b
38 8 27
20.2a 8.6b 10.2b
9 8 35
4.8b 8.6ab 13.2a
5 1 5
2.7a 1.1a 1.9a
136 76 199
72.3a 81.7a 74.8a
79 46
8.9b 20.5a
29 52
10.1a 7.5a
6 10
1.9a 1.6a
271 408
79.1a 70.4b
97 30
12.3b 25.4a
71 11
9.0a 9.3a
12 4
1.5a 3.4a
607 73
77.1a 61.9b
87 40
12.0b 21.9a
67 15
9.3a 8.2a
9 7
1.2a 3.8a
559 121
77.4a 66.1b
87 40
11.9b 23.4a
63 19
8.6a 11.1a
11 5
1.5a 2.9a
573 107
78.1a 62.6b
%
Use of unconventional therapies
521
Table 1 (Continued) Independent variables
Total
N Somatization No Yes
%
794 108
88.0 12.0
Only use of RRMPa ‘column A’
Only use of CAMb services ‘column B’
Use of both RRMP and CAM services’ ‘column C’
Use of neither RRMP nor CAM services ‘column D’
N
%
N
N
%
N
%
105 22
13.2b 20.4a
74 8
14 2
1.8a 1.9a
601 76
75.7a 70.4a
% 9.3a 7.4a
Missing cases. Ethnic origin: N = 43; age: N = 12; education: N = 6; marital status: N = 1; religious observance: N = 2; sufficiency of family income: N = 15; work status: N = 33; utilization of primary care clinics: N = 4; somatization: N = 3. Letters (a—c) indicate significant differences (at the level of 0.05) between row proportions. If two values are significantly different, those values display different letters. a RRMP (religious resources for medical purposes): consultation with a religious authority and/or visiting the tombs of saints for medical purposes. b CAM (complementary or alternative medicine). c Middle East (Iran, Iraq, Saudi Arabia, Syria, Turkey, Yemen). d North Africa (Algeria, Egypt, Ethiopia, Kenya, Libya, Morocco, Somalia, Sudan, Tanzania, Tunisia, Uganda, Zimbabwe). e Eastern Europe (Bulgaria, Czechoslovakia, Former Soviet Union, Hungary, Poland, Romania). f Western countries (Andorra, France, Germany, Gibraltar, Greece, Italy, Monaco, South Africa, Spain, United Kingdom, United States). g Israel = participant and both parents are Israeli-born. h Work status (only for women up to age 60 and men up to age 65); total N = 580. i High use was defined according to the following criteria: more than 6 visits per year for ages 25—44; more than 12 visits per year for ages 45—64; more than 15 visits per year for ages 65+. j All those who did not meet the above criteria were defined as having ‘average use’. k A T-score of 63 or higher in the overall index BSI-18 (GSI) or at least on two of the three subscales indicates psychological distress. l Anxiety (general anxiety, panic attacks or obsessive-compulsive disorder).
services was significantly associated with more use of RRMP. Use of RRMP was also significantly more frequent among patients suffering from psychological distress, depression, anxiety or somatization. With regard to the use of CAM services, it was found to be significantly associated with age,
Table 2
education, family income and anxiety (Table 2, third set of results). Specifically, (Table 1, column B) utilization of CAM was significantly more frequent among patients of Israeli origin than among patients from North Africa, for whom the use of CAM was the lowest. Utilization of CAM services
Association of use of different unconventional therapies with patients’ characteristics.
Independent variables
Gender Ethnic origin Age Education Marital status Religious observance Sufficiency of family income Work status Utilization of primary care clinics Psychological distress Diagnosis of depression Diagnosis of anxiety Somatization
Association of type of unconventional therapies used (RRMP or CAM services) with patients’ characteristics Table 1 columns A vs. B
Association of use of RRMP with patients’ characteristics Table 1 columns A + C vs. D
Association of use of CAM services with patients’ characteristics Table 1 columns B + C vs. D
2
df
p
2
df
p
2
df
p
1.69 52.49 2.94 59.28 4.71 39.38 26.06 15.84 14.79 3.29 4.48 1.70 2.32
1 4 4 2 3 3 2 2 1 1 1 1 1
.193 <.001 .567 <.001 .194 <.001 <.001 <.001 <.001 .070 .034 .192 .128
0.01 78.32 3.90 43.59 1.52 42.59 31.44 10.37 19.72 17.76 16.52 19.42 3.40
1 4 4 2 3 3 2 2 1 1 1 1 1
.940 <.001 .420 <.001 .677 <.001 <.001 .006 <.001 <.001 <.001 <.001 .065
2.28 2.74 9.81 16.80 2.21 6.51 7.93 5.04 0.52 1.78 1.24 4.69 0.09
1 4 4 2 3 3 2 2 1 1 1 1 1
.131 .603 .044 <.001 .529 .089 .019 .080 .470 .182 .266 .030 .763
p values inferior to 0.05 are indicated in bold.
522 Table 3
T. Hornik-Lurie et al. Predictors of use of RRMPa and of use of CAMb services vs. no use of unconventional therapies (logistic regression).
Use of RRMPa (total N = 766) Variables in the model Gender Male (Female) Ethnic origin Middle Easte North Africaf Western countriesg Israelh (Eastern Europei )
Education (years) 0—12 (13+) Religious observance (Secular) Religiousj Sufficiency of family income (Sufficient or partly sufficient) Insufficient Utilization of primary care clinics Highk (Averagel ) Diagnosis (3 categories) (Neither depression nor anxietym ) Depression or anxietym Depression and anxietym
Use of CAMb services (total N = 732) O.R.c 95% C.I.d 1.00 1.00
0.65—1.55
2.90 6.53 1.53 4.02 1.00
1.25—6.73 3.00—14.19 0.37—6.34 1.18—13.69
p
Variables in the model
O.R.c 95% C.I.d
.991
Gender Male (Female)
0.78 1.00
.327 0.47—1.28
<.001 .014 <.001 .559 .026
.001 2.11 1.00
p
1.36—3.28
Age (years) 25—44 45—64 (65—75) Education (years) (0—12) 13+
1.11 1.96 1.00
.026 0.57—2.14 .761 1.09—3.50 .024 <.001
1.00 2.39
1.52—3.77
<.001 1.00 3.09
1.69—5.65 .003
1.00 1.93
1.25—2.98
Sufficiency of family income Sufficient (Partly sufficient or insufficient)
.023 1.72 1.00
1.08—2.75
.016 1.68 1.00
1.10—2.56 .013
1.00 1.75 2.16
1.06—2.90 1.18—3.96
.030 .012
Diagnosis (3 categories) (Neither depression nor anxietym ) 1.00 Depression or anxietym 1.06 Depression and anxietym 2.60
.018 0.58—1.95 .848 1.33—5.08 .005
p values inferior to 0.05 are indicated in bold. a RRMP (religious resources for medical purposes): consultation with a religious authority and/or visiting the tombs of saints for medical purpose. b CAM (complementary or alternative medicine). c O.R.: odds ratio. d 95% C.I. of O.R.: 95% confidence interval of odds ratio. e Middle East (Iran, Iraq, Saudi Arabia, Syria, Turkey, Yemen). f North Africa (Algeria, Egypt, Ethiopia, Kenya, Libya, Morocco, Somalia, Sudan, Tanzania, Tunisia, Uganda, Zimbabwe). g Western countries (Andorra, France, Germany, Gibraltar, Greece, Italy, Monaco, South Africa, Spain, United Kingdom, United States). h Israel = participant and both parents are Israeli-born. i Eastern Europe (Bulgaria, Czechoslovakia, Former Soviet Union, Hungary, Poland, Romania). j Religious (traditional/observant, modern-orthodox, ultra-orthodox). k High use was defined based on the following criteria: more than 6 visits per year for ages 25—44; more than 12 visits per year for ages 45—64 and more than 15 visits per year for ages 65+. l All those who did not meet the above criteria were defined as having ‘average use’. m Anxiety (general anxiety, panic attacks or obsessive-compulsive disorder).
was also found to be more frequent among patients aged 45—64 than among the younger (age 25—44) and the older patients (age 65—75). Regarding education, those with the highest education (13+ years) turned to CAM services significantly more often than those with less education (0—8 and 9—12 years). There was no significant difference between the two latter groups. Use of CAM services was more frequent among patients with sufficient income than among those with partly sufficient or insufficient income. There was no significant difference between the two latter groups.
Concerning mental health status, use of CAM services was more frequent among patients suffering from anxiety, while no significant association was found with psychological distress, depression and somatization. Many significant associations were found between the study’s independent variables. Specifically, religious observance is associated with ethnic origin, education and income sufficiency: patients from North African and Middle Eastern origins are more likely to be religious (traditional/observant, modern orthodox or ultra-orthodox); less educated are more likely to
Use of unconventional therapies be religious while highly educated are more likely to be secular; and patients with insufficient income are more likely to be religious than those with partly sufficient or sufficient income (data available upon request). SES variables (education, family income, work status) are significantly associated with almost all demographic variables, with utilization of primary care services and with psychopathology variables. As already described in a previous article,18 psychopathology (psychological distress and psychiatric diagnoses) is significantly more prevalent among women, among those ages 45—64, with less education and insufficient income, the unmarried and the unemployed. No significant differences in diagnosis were found between the secular and the religious sectors of the population. Separate logistic regressions were done for use of RRMP and CAM services, controlling for the variables associated with these dependent variables. Although gender was not significantly associated with either type of ‘service use’, it was included because the known differences that exist in the utilization of health services between the two genders. Since ‘work status’ was measured only for the working age population while income sufficiency was measured for the entire population and the two variables are highly correlated, only ‘sufficiency of family income’ was included in the logistic regressions. The two variables of ‘diagnosis of depression’ and ‘diagnosis of anxiety’ were combined into a three-category variable (neither depression nor anxiety; depression or anxiety; depression and anxiety). As shown in Table 3, the results are consistent with those found in the univariate analyses. Even though many independent variables were associated with each other, after controlling for the other variables in the model, all of them remained significant in predicting the probability of using either RRMP or CAM services, except psychological distress.
Discussion In the present study, we examined the population characteristics of primary care patients who also use unconventional therapies, RRMP and/or CAM. One of the most important findings is the striking difference between patients who turn to RRMP compared to those who use CAM, difference in many demographic aspects, such as ethnic origin and SES, in religious observance and in the frequency of utilization of primary care clinics. The 1995 National Health Insurance (NHI) Law23 provides medical care to all citizens at no cost for visits to primary care physicians and negligible costs for visits to specialists; however, CAM is not included in the services provided.24 The costs of consulting a religious figure for health advice vary and often payment is left up to the patient, and visiting the tombs of Jewish saints involves minimal travel expenses. This may explain why use of RRMP is correlated with a lower socioeconomic level,25 while use of CAM services, which is generally expensive, is associated with a higher socioeconomic level, as also shown in other studies.5—8,24,26 One may expect that high users of primary care clinic will look for additional helping agents for medical purposes. As high users of primary care clinics have a higher probability of being of a low socioeconomic level,27 this may partially explain why seeking religious solutions are significantly associated with high use of primary care
523 clinics. Jews of North African and Middle East origins generally are more traditional and religious.28 Thus, it is not surprising that they consistently use RRMP more than patients of Eastern European and Western origin. Our results also indicate that primary care patients suffering from emotional problems have a propensity to utilize unconventional therapies in addition to conventional medical treatment, as also found in previous studies.3,4,7,10,12,29 The choice of the patients of either RRMP or CAM is, as mentioned previously, largely dependent on their socio-demographic characteristics, cultural background, and their level of religious observance. It should be noted that, while the rate of CAM utilization by primary care patients in Israel is relatively lower than in other Western countries, it has risen considerably over the last few years,7,30 a trend which is likely to continue in the future.24 A methodological limitation of our survey is that only patients in primary care clinics were included, which excluded those using only religious or CAM resources. An additional limitation is that the small number of patients using CAM services did not permit an examination of the use of various types of CAM separately. In contrast, a major advantage of this study is that it broadens the scope of alternative resources by including specific religious behaviors; this provides a perspective not available in other studies of alternative sources of medical care.
Conclusion The study shows that a significant number of primary care patients also use additional resources for their medical problems, but the two types of unconventional therapies examined in the study — RRMP and CAM — tend to be used by two different population sectors. It is noteworthy that those suffering from mental health problems are more likely to utilize unconventional resources, especially RRMP. It would be of interest in a further study to explore the sociological and anthropological factors responsible for the use by two different population sectors.
Conflict of interest statement None declared.
Acknowledgment This research was supported by a grant from The National Institute for Health Policy and Health Services Research (# 83656101).
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