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Is complementary and alternative medicine use associated with cancer screening rates for women with functional disabilities?
Complementary Therapies in Medicine 24 (2016) 73–79
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Complementary Therapies in Medicine journal homepage: www.elsevierhealth.com/journals/ctim
Is complementary and alternative medicine use associated with cancer screening rates for women with functional disabilities? Rie Suzuki a,∗ , Eusebius Small b , Melissa Makled a a b
School of Health Professions and Studies, University of Michigan—Flint, United States School of Social Work, University of Texas at Arlington, United States
a r t i c l e
i n f o
Article history: Received 16 June 2015 Received in revised form 29 September 2015 Accepted 28 November 2015 Available online 18 December 2015 Keywords: Complementary and alternative medicine Disability Cancer screenings
a b s t r a c t Objectives: The purpose of this study was to examine the associations of complementary and alternative medicine (CAM) use with mammogram and Pap test rates and functional disabilities (FDs). Design: Cross-sectional study. Setting: Data were derived from the 2012 National Health Interview Survey (n = 6576). Analysis: FDs was defined as physical and/or social limitations. The weighted logistic regression models were performed using SAS software. Study covariates were age, race, education, marital status, usual source of care, and insurance. Results: Of 6576 women, a majority were Caucasian (87%), with GED or less (40%), married (50%), having usual source of care (96%) and health insurance (91%), and with FDs (56%). The results indicated that some CAM practices were negatively associated with increased mammogram and Pap test rates while other CAM practices were positively associated. The results indicated that CAM practices that contribute to musculoskeletal problems such as acupuncture and massage were associated with the increased mammogram and Pap test rates. Contrary, women who used chiropractic manipulation, biofeedback, guided imagery, and energy hearing therapy were less likely to obtain cancer screenings regularly regardless of having FDs. Conclusions: The use of several CAM therapies was more likely to be associated with mammogram and Pap test frequency, indicating that the CAM use may be associated with better screening rates due to the improvement of musculoskeletal problems. It is important to determine how each CAM therapy improves secondary health conditions in clinical trials to increase cancer screening rates for women with FDs. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Cancer is the second leading cause of death among Americans1 and represents a major public health concern for all women, including women with functional disabilities (FDs). Breast cancer is one of the most frequently occurring types of cancer among women, and ranks second in cancer-related deaths among Americans.2 The objectives of Healthy People 20203 suggest that clinical preventive services are needed to reduce cancer mortality. The U.S. Preventive Services Task Force4 recommends regular mammography for women aged 50–75 years. However, research consistently indicates that women with FDs have a lower rate of routine cancer screening exams than their counterparts5 (83% vs. 78%).6
∗ Corresponding author at: 3124 William S. White Building, 303 E. Kearsley St. Flint, MI 48502-1950, United States. E-mail address: rsuzuki@umflint.edu (R. Suzuki). http://dx.doi.org/10.1016/j.ctim.2015.11.008 0965-2299/© 2015 Elsevier Ltd. All rights reserved.
Previous studies revealed that the lower mammography rates may reflect barriers for screening in women with FDs. The World Health Organization (WHO) defines FDs as conditions entailing disruptions to normal functioning of movement, vision, hearing, or social relationships and interactions.7,8 Self-reported barriers reflect the WHO definition of FDs such as increased discomfort during mammography,9 low income status,10 age,10 insurance availability,9 multiple comorbidities,11 negative attitudes from health care providers,12 focusing on other health issues,13 inconsistent usage of breast cancer screening guidelines,14 difficulty scheduling appointments,9 and lack of transportation.15 Physical secondary conditions are health conditions that people with FDs experience at higher rates than the general population,16,17 and are generally regarded as preventable.18,19 Many adults with FDs experience a range of physical secondary conditions such as fatigue20 joint pain,21 obesity,16 depression,22 and falls or unintentional injuries.23 The most common physical secondary condition among people with FDs is chronic pain,24
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and these patients are at the risk of developing chronic pain with greater severity.25,26 Chronic pain is associated with low physical functioning,27 depressive symptoms,28 poor quality of life,29 and social isolation,30 often resulting from the difficulty in getting out into the community.24 Severe physical secondary health conditions typically decrease the utilization of treatment services and preventive health care services among women with FDs.9,31 Chronic pain, particularly back pain and musculoskeletal pain, is the most frequently cited physical secondary condition among women with FDs.24,32 Research has also found that chronic pain prevented women with FDs from following the recommended mammogram guidelines.9 For example, Suzuki et al. found that women with FDs expressed the physical secondary conditions such as pain and fatigue became the major barriers to obtain the regular cancer screenings.9 Further, Ravesloot et al. found that the improvements of secondary conditions was associated with engaging in healthy behaviors.33 Therefore, the management of physical secondary conditions could improve their engagement in health-promoting activities. Complementary and alternative medicine (CAM) is a group of therapy, practice and products that are not included in conventional medical practice.34 Chronic pain is one of the major fields where CAM therapies have been utilized in the U.S.35,36 Chronic muscle pain is often associated with deep tissue muscle pain with occasional resting pain and the perception of trigger points.37 The 2005 Institution of Medicine report suggested that there were multiple facilitators to CAM therapy use such as, the treatment for an existing disease, mistrust of the health care system, dissatisfaction of doctor and patient relationship, and one is wellness or improvement.35 Typically women with FDs, those who have received higher education,38 those who are hospitalized,38 those with chronic pain36 and those who are difficulty with physical functioning39 use CAM therapies. A growing body of studies suggests that manipulative therapies (i.e., massage, chiropractic manipulation, and acupuncture) could help manage chronic pain.40–43 Okoro et al.38 further found that women with FDs often used manipulative therapies and mindfulness meditation (i.e., relaxation or hypnosis) in a nationally representative population because these therapies are typically effective for pain managements.44,45 Adults with perceived cancer risks significant utilize CAM therapies.46,47 One study found that women with a high genetic risk of developing breast cancer were more likely to use CAM therapies.48 Furthermore, cancer survivors who were at a genetically higher risk of breast cancer recurrence significantly used physiological and dietary CAM therapies for risk reduction.49 However, relatively few studies have examined the direct association of CAM use with cancer screening rates among women with FDs. It is not known if women with FDs would significantly differ from women without FDs with regard to this relationship. Therefore, the purpose of this study was to examine the association between CAM use and mammography and Pap tests rates, and to identify whether FDs had a particular influence on this relationship. Research has argued that the management of physical secondary conditions increases health-promoting behaviors among people with FDs. We thus expect that CAM use increases the cancer screening rates because CAM therapies manage physical secondary conditions especially chronic pain among women with FDs. This reasoning led to our hypotheses: H1. Women who used CAM therapies would be more likely to obtain regular mammography and Pap tests. H2. CAM use would be associated with cancer screening adherence among women with FDs.
If CAM use is associated with mammogram and Pap test compliance rates, this indirectly suggests that the improvement of physical secondary conditions by CAM therapies relates to cancer screening rates. Recognizing the impact of CAM use will guide intervention strategies that might address poor physical secondary conditions; prior studies have not examined this interaction in women with FDs. 2. Methods The Institutional Review Board of the University of Michigan approved the study. Data were derived from a nationally representative sample in the National Health Interview Survey (NHIS) 2012, a non-institutionalized U.S. civilian’s survey. The National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention conducted the survey. A multistage cluster sample design identified a representative sample of households. The U.S. Census Bureau conducted the survey interviews. A randomly selected adult from each family who was 18 years or older, answered the Sample Adult file and the Adult Complementary and Alternative Medicine (ATL) items. The 2012 Sample Adult file and ALT supplements included 34,525 respondents with a total household response rate of 76.8%.50 The current study only analyzed 6576 women aged 50–75 years because mammogram screening is recommended at 50 years of age.4 Additionally, only those who answered the questions on cancer screenings were included to meet the purpose of this study. 2.1. Measures Variables used in this study are listed in Table 1. All variables were self-reported. 2.1.1. Mammogram use The following question assessed mammogram use, “Have you had a mammogram during the past 12 months?” The original response consisted of Yes (1) or No (2). The scale was reverse-coded, making Yes (1) and No (0). 2.1.2. Pap test use Pap test rate was assessed by the following question, “Have you had a pap smear/test during the past 12 months?” The original response consisted of Yes (1) or No (2). The scale was reverse-coded, making Yes (1) and No (0). 2.1.3. CAM use CAM use was assessed by ten items; “Have you ever used chiropractic or osteopathic manipulation for your health?”, “Have you ever used massage for your health?”, “Have you ever used acupuncture for your health?”, “Have you ever used hypnosis for your health?”, “Have you ever used biofeedback for your health?”, “Have you ever used guided imagery or progressive relaxation for your health?”, “Have you ever used energy healing therapy for your health?”, “Have you ever used naturopathy for your health?”, “Have you ever used Ayurveda for your health?”, and “Have you ever used homeopathic treatment for your health?”. The original response consisted of Yes (1) or No (2). The scale was reversed, making Yes (1) and No (0). These therapies have been shown to yield improvement in chronic pain.51 2.1.4. Functional disability FD was assessed by considering the difficulty in performing the following 12 items without using special equipment: (1) walking one-quarter mile, (2) climbing 10 steps, (3) standing for two hours, (4) sitting for two hours, (5) stooping, bending, or kneeling,
R. Suzuki et al. / Complementary Therapies in Medicine 24 (2016) 73–79
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Table 1 Weighted characteristics of the female participants by screening compliance. Mammogram screening
Pap test screening
Compliant
Not compliant
Compliant
Not compliant
Total raw sample
4065
2511
2978
3598
Pap test in past 12 months 1 = Yes 0 = No
62% 38%
18%* 82% 86% 14%
44%* 56%
Mammogram in past 12 months 1 = Yes 0 = No Functional limitations 1 = Yes 0 = No
54% 46%
58%* 42%
50% 50%
60%* 40%
Covariates Age 1 = 50–59 2 = 60–69 3 = 70–75 Weighted mean (years old)
42% 41% 17% 61.47
45%* 39% 16% 60.95*
52% 38% 10% 59.61
36%* 42% 22% 62.52
Race 1 = Caucasians 0 = African American
86% 13%
88%* 12%
85% 15%
88%* 12%
Education 1 = GED/high School and less 2 = Some college 3 = Bachelor’s degree 4 = Graduate degree
36% 31% 19% 14%
48%* 32% 13% 8%
35% 31% 20% 14%
45%* 32% 14% 10%
Marital status 1 = Married or committed relationship 0 = Single or divorced
52% 48%
45%* 55%
53% 47%
47%* 53%
Usual source of care 1 = Yes 0 = No
99% 1%
91%* 9%
99% 1%
94%* 6%
Health insurance 1 = No coverage 0 = Coverage
4% 96%
19%* 81%
5% 95%
13%* 87%
*
p > 0.05 on the weighted chi square test/the analysis of variance between compliant and non-compliant.
(6) reaching over the head, (7) grasping small objects, (8) lifting/carrying 10 lbs., (9) pushing large objects (10), going out to events, (11) relaxing at home, and (12) participating in social activities. The original response consisted of limited (1), not limited (2), or unknown if limited (3). We coded the responses as Yes (1) if a respondent reported any difficulty with one or more of the functional activities or No (0) if a respondent reported no difficulty. The sum of the responses to these items was used to assess FD. 2.1.5. Covariates Demographic variables included gender, race, age, education level, marital status, health insurance coverage, and availability of the usual source of care. All variables, except age and education level, were dichotomized. 2.2. Statistical analysis Weighted descriptive analyses, weighted PROC LOGISTIC for logistic regression analyses, and logistic regression analyses with interaction effects were performed using SAS 9.4 for Windows.52 Weighted frequencies, means, and standard deviations were calculated for demographic information, mammography and Pap test rates, CAM therapies, and FD items. All the mammography and Pap test rates, CAM therapies, and FD items were reverse-scored. Higher scores on all these items indicated the presence of a condition (undergoing mammography or Pap test, experiencing a CAM therapy, or having a FD).
3. Results Of the total 34,525 participants on the initial data file, 5478, were out of the targeted age range (50–75 years old), 21,974 did not answer the question on their Pap test experience, 9 did not answer questions on their mammogram use, 2 did not answer questions on FD status, and 486 did not answer questions related to the covariates. Therefore, a sample of 6576 participants was analyzed in this study. Demographic information and cancer screening rates are shown in Tables 1 and 2. The first hypothesis was that women who used CAM therapies were more likely to obtain regular cancer screenings. As expected, women who used massage, acupuncture, and hypnosis as well as naturopathy and homeopathic treatment were more likely to have had mammogram and Pap test screenings in the past 12 months. Contrary to our hypothesis, women who used chiropractic manipulation, biofeedback, guided imagery, energy healing therapy, and Ayurveda were less likely to meet the cancer screening guidelines (Table 3). Our second hypothesis was that the FD status was a moderator of the relationship between CAM use and cancer screening rates. As expected, the interactions between each CAM therapy and the presence of FDs had significant effects on cancer screening compliance rates (p < 0.05). The significant interaction effects indicated that the odds ratios of obtaining mammography in the past 12 months for women with FDs were significantly greater than the odds ratio for those without FDs in the massage, acupuncture, and hypnosis as
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Table 2 Weighted characteristics of the complementary and alternative medicine use by screening compliance. Mammogram screening Compliant
Pap test screening Not compliant
Compliant
Not compliant
Manipulative and body-based practices Chiropractic or osteopathic manipulation 35% 1 = Yes 0 = No 65%
33%* 67%
35% 65%
34%* 66%
Massage 1 = Yes 0 = No
23% 77%
17%* 83%
23% 77%
18%* 82%
Acupuncture 1 = Yes 0 = No
12% 88%
9%* 91%
13% 87%
10%* 90%
Mind–body medicine Hypnosis 1 = Yes 0 = No
4% 96%
3%* 97%
4% 96%
4%* 96%
Biofeedback 1 = Yes 0 = No
3% 98%
3%* 97%
3% 97%
3%* 98%
Guided imagery, or progressive relaxation 1 = Yes 11% 0 = No 89%
11%* 89%
12% 88%
10%* 90%
Energy medicine Energy healing therapy 1 = Yes 0 = No
3% 97%
3%* 97%
3% 97%
3%* 97%
Whole medical systems Naturopathy 1 = Yes 0 = No
3% 97%
3%* 97%
3% 97%
2%* 98%
Ayurveda 1 = Yes 0 = No
1% 99%
1%* 99%
1% 99%
1%* 99%
Homeopathic treatment 1 = Yes 0 = No
8% 92%
7%* 93%
8% 92%
6%* 94%
*
p > 0.05 on the weighted chi square test between compliant and non-compliant.
well as naturopathy and homeopathic treatment groups. We also found different effects of the CAM therapies on mammography and Pap test rates. Similar to the findings for mammogram frequency, women with FDs who used massage, acupuncture, naturopathy, and homeopathic treatment were more likely to have obtained a Pap test in the last 12 months. However, women with FDs who practiced biofeedback and guided imagery were more likely to have had an annual Pap test and less likely to have undergone mammography (Table 4). 4. Discussion The aim of this study was to investigate the effects of CAM use on cancer screening rates and to identify the influence of FDs on the relationship between the two. Although it was not indicated that all CAM therapies were related to cancer screening rates in women with FDs, several CAM therapies were independently associated with increased likelihoods of receiving mammography and Pap tests. Additionally, the results showed that women who used chiropractic manipulation, biofeedback, guided imagery, and energy healing therapy were less likely to obtain annual cancer screenings. Evidence of these negative associations was robust and persisted in the interaction between the presence of FDs and mammogram frequency. Our findings are similar to those from a previous analysis in a nationally representative sample. Women who used manipula-
tive and body-based practices and mind–body medicine techniques such as massage, acupuncture, and hypnosis were more likely to receive preventive health care. For example, a previous study identified that CAM users were more likely to visit primary care and preventive health services than other adults with chronic health conditions.53 Additionally, because the participants had a relatively higher income and were more educated, CAM users in this survey may be able to afford these therapies. Furthermore, because of their higher socioeconomic status (SES), these participants may have been more motivated to manage their health conditions by using CAM therapies that exceed conventional medicines because they may not have faced the same financial burdens as those with lower SES. In contrast to our hypothesis, our study found that women who used chiropractic manipulation, biofeedback, guided imagery, and energy healing therapy were less likely to meet the cancer screening guidelines. It is possible that they were sicker than those who used other CAM therapies. Previous evidence indicated that these therapies are often used to manage severe chronic pain.54 However, the use of CAM therapies may not reduce chronic pain drastically during physical rehabilitation. In fact, some studies argue that CAM therapies only provide short-term pain relief.40 CAM therapies could not have a strong influence on the utilization of preventive care services, due to the necessity of treating physical and secondary conditions in these patients.
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Table 3 Main effects in logistic regressions for the frequency of mammogram and pap test. Mammogram screening Adjusted OR (95% Cl)
Pap test screening p
Adjusted OR (95% Cl)
p
Manipulative and body-based practices Chiropractic or osteopathic manipulation 1.00 1 = Yes 0 = No 1.032 (1.030–1.034)
<0.001
1.00 1.049 (1.047–1.052)
<0.001
Massage 1 = Yes 0 = No
1.00 0.812 (0.809–0.814)
<0.001
1.00 0.835 (0.832–0.837)
<0.001
Acupuncture 1 = Yes 0 = No
1.00 0.820 (0.817–0.823)
<0.001
1.00 0.853 (0.850–0.856)
<0.001
Mind–body medicine Hypnosis 1 = Yes 0 = No
1.00 0.767 (0.763–0.772)
<0.001
1.00 0.995 (0.990–1.000)
n.s
Biofeedback 1 = Yes 0 = No
1.00 1.236 (1.228–1.244)
<0.001
1.00 1.034 (1.027–1.040)
<0.001
Guided imagery, or progressive relaxation 1 = Yes 1.00 1.225 (1.221–1.230) 0 = No
<0.001
1.00 1.008 (1.004–1.011)
<0.001
Energy medicine Energy healing therapy 1 = Yes 0 = No
1.00 1.123 (1.115–1.130)
<0.001
1.00 1.569 (1.559–1.579)
<0.001
Whole medical systems Naturopathy 1 = Yes 0 = No
1.00 0.908 (0.902–0.914)
1.00 0.791 (0.786–0.796)
<0.001
Ayurveda 1 = Yes 0 = No
1.00 1.258 (1.244–1.272)
1.00 1.190 (1.178–1.202)
<0.001
Homeopathic treatment 1 = Yes 0 = No
1.00 0.964 (0.960–0.969)
1.00 0.887(0.882–0.890)
<0.001
Raw sample size AIC
6434 8557.95
6434 8865.38
Note. OR = adds ratio; Cl = confidence interval; AIC = akaike information criterion. All analyses were adjusted for age, race, education, marital status, usual source of care and health insurance status.
As expected, the interactions between each CAM therapy and the occurrence of FDs had significant effects on cancer screening compliances. We found that, overall, the use of CAM therapies was associated with cancer screening rates if the patients had FDs. The significant interaction indicated that among subjects who utilized massage, acupuncture, and hypnosis as well as naturopathy and homeopathic treatment, women with FDs underwent mammography more frequently than those without FDs. These findings may be associated with the fact that these therapies have been used by those with non-life invasive chronic pain, indicating that they have limited impact on the improvement of physical functioning or chronic pain. In fact, the use of these therapies could influence the sub-behavior of engaging in health maintenance activities. For instance, using a nationally representative sample, Hawk and colleagues identified that people who used CAM therapies were more likely to connect with the improvement of wellness.55 It is important to further investigate the mechanisms linking pain tolerance and the effects of each CAM therapy on the degree of chronic pain to understand the factors associated with cancer screening rates. Surprisingly, contrary to mammography results, women with FDs who practiced biofeedback and guided imaginary were more likely to receive an annual Pap test. The findings of this study could be due to the locations of centers performing mammography and
Pap tests. If women with FDs are sicker than those without FDs, they may be more likely to meet their conventional doctors to treat their main and secondary conditions. Their frequent visits to conventional medical facilities would increase their Pap test rate because the Pap test is typically performed at the doctor’s office. Barriers to mammography in women with FDs include their perception of insensitivity or negative attitudes of clinicians,56 mammography technicians’ lack of knowledge about the needs of women with disabilities,57 limitations of health insurance coverage,9 and no family history.11 Barriers unique to women with FDs include the physical inaccessibility of mammography equipment and examining tables.58 Participants in our study may have experienced barriers in receiving mammography. Finally both biofeedback and guided imaginary let women with FDs focus on their thoughts to their health conditions. It could be possible that two CAM therapies increase their health conscious and support the utilization of Pap test over these barriers. Unfortunately, compared to our expectations based on previous findings that secondary health conditions result in poor cancer screening rates, we could not find a consistent positive association linking all CAM therapies improving secondary health conditions with higher cancer screening rates. This is because some CAM therapies may not have strong treatment effects on secondary health
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R. Suzuki et al. / Complementary Therapies in Medicine 24 (2016) 73–79
Table 4 Interaction effects of complementary and alternative medicine use and functional disability status for cancer screening rates. Mammogram screening Adjusted OR (95% Cl)
Pap test screening p
Adjusted OR (95% Cl)
p
Manipulative and body-based practices Chiropractic or osteopathic manipulation 1 = Yes 1.00 1.024 (1.020–1.027) 0 = No
<0.001
1.00 1.051 (1.048–1.054)
<0.001
Massage 1 = Yes 0 = No
1.00 0.825 (0.822–0.828)
<0.001
1.00 0.817 (0.814–0.820)
<0.001
Acupuncture 1 = Yes 0 = No
1.00 0.810 (0.807–0.814)
<0.001
1.00 0.852 (0.848–0.855)
<0.001
Mind–body medicine Hypnosis 1 = Yes 0 = No
1.00 0.703 (0.698–0.708)
<0.001
1.00 1.184 (1.177–1.192)
<0.001
Biofeedback 1 = Yes 0 = No
1.00 1.273 (1.263–1.283)
<0.001
1.00 0.932 (0.925–0.939)
<0.001
Guided imagery, or progressive relaxation 1 = Yes 1.00 1.230(1.224–1.236) 0 = No
<0.001
1.00 0.992(0.998–0.997)
<0.001
When functional disabilities = 1 (Yes)
Whole medical systems Naturopathy 1 = Yes 0 = No
1.00 0.898 (0.890–0.906)
1.00 0.565 (0.560–0.570)
<0.001
Ayurveda 1 = Yes 0 = No
1.00 1.129 (1.112–1.146)
1.00 2.370 (2.333–2.407)
<0.001
Homeopathic treatment 1 = Yes 0 = No
1.00 0.902 (0.897–0.908)
1.00 0.902 (0.897–0.907)
<0.001
Note. OR = adds ratio; Cl = confidence interval. All analyses were adjusted for age, race, education, marital status, usual source of care, health insurance status and main effects of CAM therapies.
conditions among women with FDs. Alternatively, pain and other secondary health conditions may not be strong predictors of noncompliance to cancer screening guidelines because evidence has shown that barriers to cancer screening among women with FDs include not only secondary health conditions but also interpersonal and community factors such as lack of knowledge about cancer screenings, health care providers’ attitude to disability, rural/urban differences, and physical accessibility of the buildings and the communities where healthcare is provided.9 Additionally, our statistical models could not examine the mediational effects of secondary health conditions between CAM use and cancer-related behaviors because the NHIS did not have pain scales. Future studies need to focus on the direct associations among each CAM therapy, secondary health conditions, and cancer screening frequency in women with FDs. Our study has several additional limitations. First, because of the cross-sectional nature of the study, we cannot claim any causal links or relationships. Although the investigated CAM therapies have known the improvement of major health conditions,35 our analyses represented an indirect association of the pain management with mammogram and Pap test adherence rates. Because of the secondary nature of our data (NHIS dataset), we were unable to identify pain related variables that show the association of pain and CAM use as well as the actual effects of CAM therapies on physical secondary conditions. Additionally, because the CAM variables did not directly measure pain management, it is difficult to ascertain whether or not CAM therapies were associated with physical secondary conditions. The NHIS data consist of self-reported
responses, which are prone to social desirability biases. The WHO definition on disability includes individuals with neuromuscular diseases, as well as those with obesity, diabetes, and stroke, thereby limiting the generalizability of our findings to a population with a single chronic condition. In conclusion, CAM therapies use was more likely to be associated with mammogram and Pap test frequency. This finding is not at all surprising because people often seek alternative solutions such as conventional medicine and CAM to manage their own health conditions to improve their quality of life. In fact, women with FDs use more CAM therapies than those without FDs to manage pain and physical functioning. In order to support the statement that women with FDs were less likely to undergo cancer screening due to poor secondary health conditions, further research is needed to determine whether CAM therapy improves secondary health conditions among women with FDs in clinical trials or not. It is important for health care providers, researchers, community workers, and policy makers to understand how people with FDs manage secondary health conditions to promote a healthy lifestyle. References 1. Kochanek K, Murphy S, Xu J, Arias E. Mortality in the United States, 2013. NCHS Data Brief, No 178. vol. 2014. Hyattsville, MD: National Center for Health Statistics; 2014. 2. American Cancer Society. Breast Cancer Facts & Figures 2013–2014. Atlanta, GA: American Cancer Society, Inc.; 2013. 3. U.S. Department of Health and Human Services. Healthy People 2020.; 2014 Accessed 09.09.14.
R. Suzuki et al. / Complementary Therapies in Medicine 24 (2016) 73–79 4. U.S. Preventive Services Task Force. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151(10):716. 5. Andresen EM, Peterson-Besse JJ, Krahn GL, Walsh ES, Horner-Johnson W, Iezzoni LI. Pap, mammography, and clinical breast examination screening among women with disabilities: a systematic review. Women’s Health Issues. 2013;23(4):e205–e214. 6. Courtney-Long E, Armour B, Frammartino B, Miller J. Factors associated with self-reported mammography use for women with and women without a disability. J Women’s Health. 2011;20(9):1279–1286. 7. World Health Organization. International Classification of Functioning, Disability and Health. Geneva. 2001. http://www.who.int/classifications/icf/ en/ (Accessed 29.12.15). 8. Centers for Disease Control and Prevention. Types of Disabilities. 2014.
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32. Gailey R, Allen K, Castles J, Kucharik J, Roeder M. Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use. J Rehabil Res Dev. 2008;45(1):15. 33. Ravesloot C, Seekins T, Cahill T, Lindgren S, Nary D, White G. Health promotion for people with disabilities: development and evaluation of the living well with a disability program. Health Educ Res. 2007;22(4):522–531. 34. U.S. Department of Health and Human Services. National Cancer for Complementary and Integrative Health.
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Complementary Therapies in Medicine journal homepage: www.elsevierhealth.com/journals/ctim
Is complementary and alternative medicine use associated with cancer screening rates for women with functional disabilities? Rie Suzuki a,∗ , Eusebius Small b , Melissa Makled a a b
School of Health Professions and Studies, University of Michigan—Flint, United States School of Social Work, University of Texas at Arlington, United States
a r t i c l e
i n f o
Article history: Received 16 June 2015 Received in revised form 29 September 2015 Accepted 28 November 2015 Available online 18 December 2015 Keywords: Complementary and alternative medicine Disability Cancer screenings
a b s t r a c t Objectives: The purpose of this study was to examine the associations of complementary and alternative medicine (CAM) use with mammogram and Pap test rates and functional disabilities (FDs). Design: Cross-sectional study. Setting: Data were derived from the 2012 National Health Interview Survey (n = 6576). Analysis: FDs was defined as physical and/or social limitations. The weighted logistic regression models were performed using SAS software. Study covariates were age, race, education, marital status, usual source of care, and insurance. Results: Of 6576 women, a majority were Caucasian (87%), with GED or less (40%), married (50%), having usual source of care (96%) and health insurance (91%), and with FDs (56%). The results indicated that some CAM practices were negatively associated with increased mammogram and Pap test rates while other CAM practices were positively associated. The results indicated that CAM practices that contribute to musculoskeletal problems such as acupuncture and massage were associated with the increased mammogram and Pap test rates. Contrary, women who used chiropractic manipulation, biofeedback, guided imagery, and energy hearing therapy were less likely to obtain cancer screenings regularly regardless of having FDs. Conclusions: The use of several CAM therapies was more likely to be associated with mammogram and Pap test frequency, indicating that the CAM use may be associated with better screening rates due to the improvement of musculoskeletal problems. It is important to determine how each CAM therapy improves secondary health conditions in clinical trials to increase cancer screening rates for women with FDs. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Cancer is the second leading cause of death among Americans1 and represents a major public health concern for all women, including women with functional disabilities (FDs). Breast cancer is one of the most frequently occurring types of cancer among women, and ranks second in cancer-related deaths among Americans.2 The objectives of Healthy People 20203 suggest that clinical preventive services are needed to reduce cancer mortality. The U.S. Preventive Services Task Force4 recommends regular mammography for women aged 50–75 years. However, research consistently indicates that women with FDs have a lower rate of routine cancer screening exams than their counterparts5 (83% vs. 78%).6
∗ Corresponding author at: 3124 William S. White Building, 303 E. Kearsley St. Flint, MI 48502-1950, United States. E-mail address: rsuzuki@umflint.edu (R. Suzuki). http://dx.doi.org/10.1016/j.ctim.2015.11.008 0965-2299/© 2015 Elsevier Ltd. All rights reserved.
Previous studies revealed that the lower mammography rates may reflect barriers for screening in women with FDs. The World Health Organization (WHO) defines FDs as conditions entailing disruptions to normal functioning of movement, vision, hearing, or social relationships and interactions.7,8 Self-reported barriers reflect the WHO definition of FDs such as increased discomfort during mammography,9 low income status,10 age,10 insurance availability,9 multiple comorbidities,11 negative attitudes from health care providers,12 focusing on other health issues,13 inconsistent usage of breast cancer screening guidelines,14 difficulty scheduling appointments,9 and lack of transportation.15 Physical secondary conditions are health conditions that people with FDs experience at higher rates than the general population,16,17 and are generally regarded as preventable.18,19 Many adults with FDs experience a range of physical secondary conditions such as fatigue20 joint pain,21 obesity,16 depression,22 and falls or unintentional injuries.23 The most common physical secondary condition among people with FDs is chronic pain,24
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and these patients are at the risk of developing chronic pain with greater severity.25,26 Chronic pain is associated with low physical functioning,27 depressive symptoms,28 poor quality of life,29 and social isolation,30 often resulting from the difficulty in getting out into the community.24 Severe physical secondary health conditions typically decrease the utilization of treatment services and preventive health care services among women with FDs.9,31 Chronic pain, particularly back pain and musculoskeletal pain, is the most frequently cited physical secondary condition among women with FDs.24,32 Research has also found that chronic pain prevented women with FDs from following the recommended mammogram guidelines.9 For example, Suzuki et al. found that women with FDs expressed the physical secondary conditions such as pain and fatigue became the major barriers to obtain the regular cancer screenings.9 Further, Ravesloot et al. found that the improvements of secondary conditions was associated with engaging in healthy behaviors.33 Therefore, the management of physical secondary conditions could improve their engagement in health-promoting activities. Complementary and alternative medicine (CAM) is a group of therapy, practice and products that are not included in conventional medical practice.34 Chronic pain is one of the major fields where CAM therapies have been utilized in the U.S.35,36 Chronic muscle pain is often associated with deep tissue muscle pain with occasional resting pain and the perception of trigger points.37 The 2005 Institution of Medicine report suggested that there were multiple facilitators to CAM therapy use such as, the treatment for an existing disease, mistrust of the health care system, dissatisfaction of doctor and patient relationship, and one is wellness or improvement.35 Typically women with FDs, those who have received higher education,38 those who are hospitalized,38 those with chronic pain36 and those who are difficulty with physical functioning39 use CAM therapies. A growing body of studies suggests that manipulative therapies (i.e., massage, chiropractic manipulation, and acupuncture) could help manage chronic pain.40–43 Okoro et al.38 further found that women with FDs often used manipulative therapies and mindfulness meditation (i.e., relaxation or hypnosis) in a nationally representative population because these therapies are typically effective for pain managements.44,45 Adults with perceived cancer risks significant utilize CAM therapies.46,47 One study found that women with a high genetic risk of developing breast cancer were more likely to use CAM therapies.48 Furthermore, cancer survivors who were at a genetically higher risk of breast cancer recurrence significantly used physiological and dietary CAM therapies for risk reduction.49 However, relatively few studies have examined the direct association of CAM use with cancer screening rates among women with FDs. It is not known if women with FDs would significantly differ from women without FDs with regard to this relationship. Therefore, the purpose of this study was to examine the association between CAM use and mammography and Pap tests rates, and to identify whether FDs had a particular influence on this relationship. Research has argued that the management of physical secondary conditions increases health-promoting behaviors among people with FDs. We thus expect that CAM use increases the cancer screening rates because CAM therapies manage physical secondary conditions especially chronic pain among women with FDs. This reasoning led to our hypotheses: H1. Women who used CAM therapies would be more likely to obtain regular mammography and Pap tests. H2. CAM use would be associated with cancer screening adherence among women with FDs.
If CAM use is associated with mammogram and Pap test compliance rates, this indirectly suggests that the improvement of physical secondary conditions by CAM therapies relates to cancer screening rates. Recognizing the impact of CAM use will guide intervention strategies that might address poor physical secondary conditions; prior studies have not examined this interaction in women with FDs. 2. Methods The Institutional Review Board of the University of Michigan approved the study. Data were derived from a nationally representative sample in the National Health Interview Survey (NHIS) 2012, a non-institutionalized U.S. civilian’s survey. The National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention conducted the survey. A multistage cluster sample design identified a representative sample of households. The U.S. Census Bureau conducted the survey interviews. A randomly selected adult from each family who was 18 years or older, answered the Sample Adult file and the Adult Complementary and Alternative Medicine (ATL) items. The 2012 Sample Adult file and ALT supplements included 34,525 respondents with a total household response rate of 76.8%.50 The current study only analyzed 6576 women aged 50–75 years because mammogram screening is recommended at 50 years of age.4 Additionally, only those who answered the questions on cancer screenings were included to meet the purpose of this study. 2.1. Measures Variables used in this study are listed in Table 1. All variables were self-reported. 2.1.1. Mammogram use The following question assessed mammogram use, “Have you had a mammogram during the past 12 months?” The original response consisted of Yes (1) or No (2). The scale was reverse-coded, making Yes (1) and No (0). 2.1.2. Pap test use Pap test rate was assessed by the following question, “Have you had a pap smear/test during the past 12 months?” The original response consisted of Yes (1) or No (2). The scale was reverse-coded, making Yes (1) and No (0). 2.1.3. CAM use CAM use was assessed by ten items; “Have you ever used chiropractic or osteopathic manipulation for your health?”, “Have you ever used massage for your health?”, “Have you ever used acupuncture for your health?”, “Have you ever used hypnosis for your health?”, “Have you ever used biofeedback for your health?”, “Have you ever used guided imagery or progressive relaxation for your health?”, “Have you ever used energy healing therapy for your health?”, “Have you ever used naturopathy for your health?”, “Have you ever used Ayurveda for your health?”, and “Have you ever used homeopathic treatment for your health?”. The original response consisted of Yes (1) or No (2). The scale was reversed, making Yes (1) and No (0). These therapies have been shown to yield improvement in chronic pain.51 2.1.4. Functional disability FD was assessed by considering the difficulty in performing the following 12 items without using special equipment: (1) walking one-quarter mile, (2) climbing 10 steps, (3) standing for two hours, (4) sitting for two hours, (5) stooping, bending, or kneeling,
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Table 1 Weighted characteristics of the female participants by screening compliance. Mammogram screening
Pap test screening
Compliant
Not compliant
Compliant
Not compliant
Total raw sample
4065
2511
2978
3598
Pap test in past 12 months 1 = Yes 0 = No
62% 38%
18%* 82% 86% 14%
44%* 56%
Mammogram in past 12 months 1 = Yes 0 = No Functional limitations 1 = Yes 0 = No
54% 46%
58%* 42%
50% 50%
60%* 40%
Covariates Age 1 = 50–59 2 = 60–69 3 = 70–75 Weighted mean (years old)
42% 41% 17% 61.47
45%* 39% 16% 60.95*
52% 38% 10% 59.61
36%* 42% 22% 62.52
Race 1 = Caucasians 0 = African American
86% 13%
88%* 12%
85% 15%
88%* 12%
Education 1 = GED/high School and less 2 = Some college 3 = Bachelor’s degree 4 = Graduate degree
36% 31% 19% 14%
48%* 32% 13% 8%
35% 31% 20% 14%
45%* 32% 14% 10%
Marital status 1 = Married or committed relationship 0 = Single or divorced
52% 48%
45%* 55%
53% 47%
47%* 53%
Usual source of care 1 = Yes 0 = No
99% 1%
91%* 9%
99% 1%
94%* 6%
Health insurance 1 = No coverage 0 = Coverage
4% 96%
19%* 81%
5% 95%
13%* 87%
*
p > 0.05 on the weighted chi square test/the analysis of variance between compliant and non-compliant.
(6) reaching over the head, (7) grasping small objects, (8) lifting/carrying 10 lbs., (9) pushing large objects (10), going out to events, (11) relaxing at home, and (12) participating in social activities. The original response consisted of limited (1), not limited (2), or unknown if limited (3). We coded the responses as Yes (1) if a respondent reported any difficulty with one or more of the functional activities or No (0) if a respondent reported no difficulty. The sum of the responses to these items was used to assess FD. 2.1.5. Covariates Demographic variables included gender, race, age, education level, marital status, health insurance coverage, and availability of the usual source of care. All variables, except age and education level, were dichotomized. 2.2. Statistical analysis Weighted descriptive analyses, weighted PROC LOGISTIC for logistic regression analyses, and logistic regression analyses with interaction effects were performed using SAS 9.4 for Windows.52 Weighted frequencies, means, and standard deviations were calculated for demographic information, mammography and Pap test rates, CAM therapies, and FD items. All the mammography and Pap test rates, CAM therapies, and FD items were reverse-scored. Higher scores on all these items indicated the presence of a condition (undergoing mammography or Pap test, experiencing a CAM therapy, or having a FD).
3. Results Of the total 34,525 participants on the initial data file, 5478, were out of the targeted age range (50–75 years old), 21,974 did not answer the question on their Pap test experience, 9 did not answer questions on their mammogram use, 2 did not answer questions on FD status, and 486 did not answer questions related to the covariates. Therefore, a sample of 6576 participants was analyzed in this study. Demographic information and cancer screening rates are shown in Tables 1 and 2. The first hypothesis was that women who used CAM therapies were more likely to obtain regular cancer screenings. As expected, women who used massage, acupuncture, and hypnosis as well as naturopathy and homeopathic treatment were more likely to have had mammogram and Pap test screenings in the past 12 months. Contrary to our hypothesis, women who used chiropractic manipulation, biofeedback, guided imagery, energy healing therapy, and Ayurveda were less likely to meet the cancer screening guidelines (Table 3). Our second hypothesis was that the FD status was a moderator of the relationship between CAM use and cancer screening rates. As expected, the interactions between each CAM therapy and the presence of FDs had significant effects on cancer screening compliance rates (p < 0.05). The significant interaction effects indicated that the odds ratios of obtaining mammography in the past 12 months for women with FDs were significantly greater than the odds ratio for those without FDs in the massage, acupuncture, and hypnosis as
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Table 2 Weighted characteristics of the complementary and alternative medicine use by screening compliance. Mammogram screening Compliant
Pap test screening Not compliant
Compliant
Not compliant
Manipulative and body-based practices Chiropractic or osteopathic manipulation 35% 1 = Yes 0 = No 65%
33%* 67%
35% 65%
34%* 66%
Massage 1 = Yes 0 = No
23% 77%
17%* 83%
23% 77%
18%* 82%
Acupuncture 1 = Yes 0 = No
12% 88%
9%* 91%
13% 87%
10%* 90%
Mind–body medicine Hypnosis 1 = Yes 0 = No
4% 96%
3%* 97%
4% 96%
4%* 96%
Biofeedback 1 = Yes 0 = No
3% 98%
3%* 97%
3% 97%
3%* 98%
Guided imagery, or progressive relaxation 1 = Yes 11% 0 = No 89%
11%* 89%
12% 88%
10%* 90%
Energy medicine Energy healing therapy 1 = Yes 0 = No
3% 97%
3%* 97%
3% 97%
3%* 97%
Whole medical systems Naturopathy 1 = Yes 0 = No
3% 97%
3%* 97%
3% 97%
2%* 98%
Ayurveda 1 = Yes 0 = No
1% 99%
1%* 99%
1% 99%
1%* 99%
Homeopathic treatment 1 = Yes 0 = No
8% 92%
7%* 93%
8% 92%
6%* 94%
*
p > 0.05 on the weighted chi square test between compliant and non-compliant.
well as naturopathy and homeopathic treatment groups. We also found different effects of the CAM therapies on mammography and Pap test rates. Similar to the findings for mammogram frequency, women with FDs who used massage, acupuncture, naturopathy, and homeopathic treatment were more likely to have obtained a Pap test in the last 12 months. However, women with FDs who practiced biofeedback and guided imagery were more likely to have had an annual Pap test and less likely to have undergone mammography (Table 4). 4. Discussion The aim of this study was to investigate the effects of CAM use on cancer screening rates and to identify the influence of FDs on the relationship between the two. Although it was not indicated that all CAM therapies were related to cancer screening rates in women with FDs, several CAM therapies were independently associated with increased likelihoods of receiving mammography and Pap tests. Additionally, the results showed that women who used chiropractic manipulation, biofeedback, guided imagery, and energy healing therapy were less likely to obtain annual cancer screenings. Evidence of these negative associations was robust and persisted in the interaction between the presence of FDs and mammogram frequency. Our findings are similar to those from a previous analysis in a nationally representative sample. Women who used manipula-
tive and body-based practices and mind–body medicine techniques such as massage, acupuncture, and hypnosis were more likely to receive preventive health care. For example, a previous study identified that CAM users were more likely to visit primary care and preventive health services than other adults with chronic health conditions.53 Additionally, because the participants had a relatively higher income and were more educated, CAM users in this survey may be able to afford these therapies. Furthermore, because of their higher socioeconomic status (SES), these participants may have been more motivated to manage their health conditions by using CAM therapies that exceed conventional medicines because they may not have faced the same financial burdens as those with lower SES. In contrast to our hypothesis, our study found that women who used chiropractic manipulation, biofeedback, guided imagery, and energy healing therapy were less likely to meet the cancer screening guidelines. It is possible that they were sicker than those who used other CAM therapies. Previous evidence indicated that these therapies are often used to manage severe chronic pain.54 However, the use of CAM therapies may not reduce chronic pain drastically during physical rehabilitation. In fact, some studies argue that CAM therapies only provide short-term pain relief.40 CAM therapies could not have a strong influence on the utilization of preventive care services, due to the necessity of treating physical and secondary conditions in these patients.
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Table 3 Main effects in logistic regressions for the frequency of mammogram and pap test. Mammogram screening Adjusted OR (95% Cl)
Pap test screening p
Adjusted OR (95% Cl)
p
Manipulative and body-based practices Chiropractic or osteopathic manipulation 1.00 1 = Yes 0 = No 1.032 (1.030–1.034)
<0.001
1.00 1.049 (1.047–1.052)
<0.001
Massage 1 = Yes 0 = No
1.00 0.812 (0.809–0.814)
<0.001
1.00 0.835 (0.832–0.837)
<0.001
Acupuncture 1 = Yes 0 = No
1.00 0.820 (0.817–0.823)
<0.001
1.00 0.853 (0.850–0.856)
<0.001
Mind–body medicine Hypnosis 1 = Yes 0 = No
1.00 0.767 (0.763–0.772)
<0.001
1.00 0.995 (0.990–1.000)
n.s
Biofeedback 1 = Yes 0 = No
1.00 1.236 (1.228–1.244)
<0.001
1.00 1.034 (1.027–1.040)
<0.001
Guided imagery, or progressive relaxation 1 = Yes 1.00 1.225 (1.221–1.230) 0 = No
<0.001
1.00 1.008 (1.004–1.011)
<0.001
Energy medicine Energy healing therapy 1 = Yes 0 = No
1.00 1.123 (1.115–1.130)
<0.001
1.00 1.569 (1.559–1.579)
<0.001
Whole medical systems Naturopathy 1 = Yes 0 = No
1.00 0.908 (0.902–0.914)
1.00 0.791 (0.786–0.796)
<0.001
Ayurveda 1 = Yes 0 = No
1.00 1.258 (1.244–1.272)
1.00 1.190 (1.178–1.202)
<0.001
Homeopathic treatment 1 = Yes 0 = No
1.00 0.964 (0.960–0.969)
1.00 0.887(0.882–0.890)
<0.001
Raw sample size AIC
6434 8557.95
6434 8865.38
Note. OR = adds ratio; Cl = confidence interval; AIC = akaike information criterion. All analyses were adjusted for age, race, education, marital status, usual source of care and health insurance status.
As expected, the interactions between each CAM therapy and the occurrence of FDs had significant effects on cancer screening compliances. We found that, overall, the use of CAM therapies was associated with cancer screening rates if the patients had FDs. The significant interaction indicated that among subjects who utilized massage, acupuncture, and hypnosis as well as naturopathy and homeopathic treatment, women with FDs underwent mammography more frequently than those without FDs. These findings may be associated with the fact that these therapies have been used by those with non-life invasive chronic pain, indicating that they have limited impact on the improvement of physical functioning or chronic pain. In fact, the use of these therapies could influence the sub-behavior of engaging in health maintenance activities. For instance, using a nationally representative sample, Hawk and colleagues identified that people who used CAM therapies were more likely to connect with the improvement of wellness.55 It is important to further investigate the mechanisms linking pain tolerance and the effects of each CAM therapy on the degree of chronic pain to understand the factors associated with cancer screening rates. Surprisingly, contrary to mammography results, women with FDs who practiced biofeedback and guided imaginary were more likely to receive an annual Pap test. The findings of this study could be due to the locations of centers performing mammography and
Pap tests. If women with FDs are sicker than those without FDs, they may be more likely to meet their conventional doctors to treat their main and secondary conditions. Their frequent visits to conventional medical facilities would increase their Pap test rate because the Pap test is typically performed at the doctor’s office. Barriers to mammography in women with FDs include their perception of insensitivity or negative attitudes of clinicians,56 mammography technicians’ lack of knowledge about the needs of women with disabilities,57 limitations of health insurance coverage,9 and no family history.11 Barriers unique to women with FDs include the physical inaccessibility of mammography equipment and examining tables.58 Participants in our study may have experienced barriers in receiving mammography. Finally both biofeedback and guided imaginary let women with FDs focus on their thoughts to their health conditions. It could be possible that two CAM therapies increase their health conscious and support the utilization of Pap test over these barriers. Unfortunately, compared to our expectations based on previous findings that secondary health conditions result in poor cancer screening rates, we could not find a consistent positive association linking all CAM therapies improving secondary health conditions with higher cancer screening rates. This is because some CAM therapies may not have strong treatment effects on secondary health
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Table 4 Interaction effects of complementary and alternative medicine use and functional disability status for cancer screening rates. Mammogram screening Adjusted OR (95% Cl)
Pap test screening p
Adjusted OR (95% Cl)
p
Manipulative and body-based practices Chiropractic or osteopathic manipulation 1 = Yes 1.00 1.024 (1.020–1.027) 0 = No
<0.001
1.00 1.051 (1.048–1.054)
<0.001
Massage 1 = Yes 0 = No
1.00 0.825 (0.822–0.828)
<0.001
1.00 0.817 (0.814–0.820)
<0.001
Acupuncture 1 = Yes 0 = No
1.00 0.810 (0.807–0.814)
<0.001
1.00 0.852 (0.848–0.855)
<0.001
Mind–body medicine Hypnosis 1 = Yes 0 = No
1.00 0.703 (0.698–0.708)
<0.001
1.00 1.184 (1.177–1.192)
<0.001
Biofeedback 1 = Yes 0 = No
1.00 1.273 (1.263–1.283)
<0.001
1.00 0.932 (0.925–0.939)
<0.001
Guided imagery, or progressive relaxation 1 = Yes 1.00 1.230(1.224–1.236) 0 = No
<0.001
1.00 0.992(0.998–0.997)
<0.001
When functional disabilities = 1 (Yes)
Whole medical systems Naturopathy 1 = Yes 0 = No
1.00 0.898 (0.890–0.906)
1.00 0.565 (0.560–0.570)
<0.001
Ayurveda 1 = Yes 0 = No
1.00 1.129 (1.112–1.146)
1.00 2.370 (2.333–2.407)
<0.001
Homeopathic treatment 1 = Yes 0 = No
1.00 0.902 (0.897–0.908)
1.00 0.902 (0.897–0.907)
<0.001
Note. OR = adds ratio; Cl = confidence interval. All analyses were adjusted for age, race, education, marital status, usual source of care, health insurance status and main effects of CAM therapies.
conditions among women with FDs. Alternatively, pain and other secondary health conditions may not be strong predictors of noncompliance to cancer screening guidelines because evidence has shown that barriers to cancer screening among women with FDs include not only secondary health conditions but also interpersonal and community factors such as lack of knowledge about cancer screenings, health care providers’ attitude to disability, rural/urban differences, and physical accessibility of the buildings and the communities where healthcare is provided.9 Additionally, our statistical models could not examine the mediational effects of secondary health conditions between CAM use and cancer-related behaviors because the NHIS did not have pain scales. Future studies need to focus on the direct associations among each CAM therapy, secondary health conditions, and cancer screening frequency in women with FDs. Our study has several additional limitations. First, because of the cross-sectional nature of the study, we cannot claim any causal links or relationships. Although the investigated CAM therapies have known the improvement of major health conditions,35 our analyses represented an indirect association of the pain management with mammogram and Pap test adherence rates. Because of the secondary nature of our data (NHIS dataset), we were unable to identify pain related variables that show the association of pain and CAM use as well as the actual effects of CAM therapies on physical secondary conditions. Additionally, because the CAM variables did not directly measure pain management, it is difficult to ascertain whether or not CAM therapies were associated with physical secondary conditions. The NHIS data consist of self-reported
responses, which are prone to social desirability biases. The WHO definition on disability includes individuals with neuromuscular diseases, as well as those with obesity, diabetes, and stroke, thereby limiting the generalizability of our findings to a population with a single chronic condition. In conclusion, CAM therapies use was more likely to be associated with mammogram and Pap test frequency. This finding is not at all surprising because people often seek alternative solutions such as conventional medicine and CAM to manage their own health conditions to improve their quality of life. In fact, women with FDs use more CAM therapies than those without FDs to manage pain and physical functioning. In order to support the statement that women with FDs were less likely to undergo cancer screening due to poor secondary health conditions, further research is needed to determine whether CAM therapy improves secondary health conditions among women with FDs in clinical trials or not. It is important for health care providers, researchers, community workers, and policy makers to understand how people with FDs manage secondary health conditions to promote a healthy lifestyle. References 1. Kochanek K, Murphy S, Xu J, Arias E. Mortality in the United States, 2013. NCHS Data Brief, No 178. vol. 2014. Hyattsville, MD: National Center for Health Statistics; 2014. 2. American Cancer Society. Breast Cancer Facts & Figures 2013–2014. Atlanta, GA: American Cancer Society, Inc.; 2013. 3. U.S. Department of Health and Human Services. Healthy People 2020.
R. Suzuki et al. / Complementary Therapies in Medicine 24 (2016) 73–79 4. U.S. Preventive Services Task Force. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151(10):716. 5. Andresen EM, Peterson-Besse JJ, Krahn GL, Walsh ES, Horner-Johnson W, Iezzoni LI. Pap, mammography, and clinical breast examination screening among women with disabilities: a systematic review. Women’s Health Issues. 2013;23(4):e205–e214. 6. Courtney-Long E, Armour B, Frammartino B, Miller J. Factors associated with self-reported mammography use for women with and women without a disability. J Women’s Health. 2011;20(9):1279–1286. 7. World Health Organization. International Classification of Functioning, Disability and Health. Geneva. 2001. http://www.who.int/classifications/icf/ en/ (Accessed 29.12.15). 8. Centers for Disease Control and Prevention. Types of Disabilities. 2014.
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32. Gailey R, Allen K, Castles J, Kucharik J, Roeder M. Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use. J Rehabil Res Dev. 2008;45(1):15. 33. Ravesloot C, Seekins T, Cahill T, Lindgren S, Nary D, White G. Health promotion for people with disabilities: development and evaluation of the living well with a disability program. Health Educ Res. 2007;22(4):522–531. 34. U.S. Department of Health and Human Services. National Cancer for Complementary and Integrative Health.