Complementary and alternative medicine use by visitors to rural Japanese family medicine clinics: results from the international complementary and alternative medicine survey

Complementary and alternative medicine (CAM) is defined by the National Center for Complementary and Alternative Medicine (NCCAM) as “a group of diverse medical and health care systems, practices, and products that are not considered part of conventional medicine” [1]. Examples of commonly used types of CAM include manual medicine such as massage therapy and spinal manipulation, traditional Chinese medicine such as tai chi, qi gong, and Chinese herbal medicine, and mind-body medicine such as mindfulness meditation, guided imagery, and relaxation techniques [1].

The use of CAM modalities is common in certain populations, and gaining popularity in others [2]. While CAM use is common, it has proven to be difficult to compare across populations due to varying study designs and different definitions of CAM [3, 4]. For example, when exercise and prayer are included in the definition of CAM, the prevalence of CAM use not surprisingly increases dramatically [4]. However, most research studies do not include prayer and exercise in the definition of CAM. The percentage of people using at least one form of CAM in cross-sectional nation-wide studies that did not include prayer or exercise in their definitions of CAM was found to be 26.3% in the UK in 2005, 38.3% in the USA in 2007, 42.3% in Germany in 2008, and 68.9% in Australia in 2005 [5‐8]. Available data also suggests that CAM use is more prevalent in rural areas than in urban areas [3].

While the use of CAM is common in multiple populations, previous research also shows that patients who use CAM commonly do not communicate this use with their primary care providers [2, 9‐11]. In order to understand the scope of this problem, it is necessary to quantify the use of CAM in various populations. In 2006, an international workshop was held in Norway to create a standardized survey quantifying the use of CAM, and the resulting instrument is the International Complementary and Alternative Medicine Questionnaire (I-CAM-Q) [12]. A key rationale for the development of the survey is to have a standardized approach to measuring CAM use that will allow comparisons among various populations and countries.

Use of CAM in Japan is of particular interest because several well-known types of CAM, such as herbal medicine – known in Japan as kampo – and acupuncture, have existed there for hundreds of years, and have experienced a recent revival in popularity and use [13‐15]. Moreover, there is a higher level of integration between CAM and conventional medicine in Japan than in most developed countries, with modern Western medicine often coexisting with certain types of traditional Asian medicine, such as kampo and acupuncture, that are commonly classified as CAM [14]. Specifically, kampo can be prescribed by physicians, and has been covered by the public health insurance system in Japan since 1976 [15]. Kampo use is common – a study in 1999 conducted by interviews with Japanese physicians found that 70% integrated the use of kampo into their patient care [16].

Given the apparent high frequency of kampo prescribing by Japanese physicians, previous researchers have explored the prevalence of CAM education – with a specific focus on kampo education - in Japanese medical schools. One study found that 86% of Japanese medical schools include kampo in their pharmacology curriculum, and 17% include broader CAM education beyond kampo [17]. A 2012 study surveyed all 80 Japanese medical schools, and found that 98% of schools offered at least one kampo course, 84% offered four or more kampo courses, and 29% employed full-time kampo medicine instructors [18]. A survey of physician graduates from Jichi Medical University supports the notion that kampo is commonly prescribed by Japanese physicians, with 30% of respondents prescribing kampo formulae daily, 45% occasionally, 22% rarely, and only 3% never [19].

Despite the historical origins of certain types of CAM, coverage under the national health insurance system since 1976, and the high frequency of CAM prescribing by physicians, there has been little research done on the prevalence of actual CAM use by patients in Japan. One large, nationwide study examined CAM use in the context of oncology patients, and indicated that 44.6% of cancer patients used CAM, with the majority (96.2%) using products such as mushrooms, herbs, and shark cartilage, and most (60.7%) using CAM without consulting a physician [20].

To date there have been only two studies about CAM use in general populations in Japan, one through a telephone survey of the general population, and the other a survey in urban clinics. The nation-wide telephone survey conducted in 2001 showed that 76.0% of respondents had used at least one type of CAM in the past 12 months, with the most commonly used modalities being nutritional and tonic drinks (43.1%), dietary supplements (43.1%), health-related appliances (21.5%), herbs or over-the-counter kampo (17.2%), and massage or acupressure (14.8%) [13]. In the 2002 study in Tokyo outpatient clinics, 49.6% of participants had used at least one type of CAM in the past 12 months, with the most common types being massage (21.4%), vitamins (17.1%), health foods and dietary supplements (11.3%), acupressure (10.3%), and kampo (9.3%) [21].

While it appears that CAM is commonly utilized in Japan, no study has focused on its use in rural Japanese settings. The purpose of this study was to develop and distribute a Japanese version of the I-CAM-Q to assess the use of CAM among people who visit rural Japanese family medicine clinics.

These data illustrate widespread use of and positive attitudes about CAM in these rural Japanese primary care populations. They also reveal important differences regarding gender, education, and health status in relation to CAM use. Female respondents, respondents with higher levels of education, and respondents with poorer overall health statuses were more likely to use certain types of CAM than those without these characteristics. Specifically, respondents with musculoskeletal, neurologic, gastrointestinal, allergic, and psychological illnesses were more likely to use certain types of CAM than respondents without these illnesses.

These data delineate commonly used CAM treatments and practitioners in rural Japan. Specifically, about a third of respondents reported use of pain relief pads, massage by self or family, and dietary supplements/herbs. In addition, about 1 of 13 respondents are using massage therapists and chiropractors, and one in 11 participants reported receiving kampo from a primary care physician. This seemed surprisingly low to the authors since the research was conducted during the winter months, when kampo formulations for the common cold are often used.

Over three quarters of participants said that they did not report their use of CAM therapies to physicians. A nationwide oncology survey showed similar results, with 60.7% of CAM users indicating that they did not consult a physician about CAM use [20]. A large review article investigated this issue as well, and found that rates of non-disclosure of CAM use to physicians ranged from 12-77% in 12 selected studies from various countries. In this review, the top three reasons that respondents listed for not revealing their CAM use to medical providers were concerns about a negative response, beliefs that the practitioner did not need to know, and the fact that the practitioner did not ask [11]. The reasons for not disclosing to physicians in our study may be similar, and may also be that rural Japanese patients feel there is not enough time in their brief encounter to discuss their use of CAM. Regardless of the reasons, physicians in rural Japan would benefit from familiarizing themselves with the most common types of CAM modalities, and inquiring about CAM use during patient encounters.

These data indicate that CAM modalities such as massage, dietary supplements, and kampo use among patients, and family members accompanying them to clinics, in rural Japan are common. These data are highly consistent with previous research in Japan using random telephone sampling and higher than the prevalence of 49.6% use in urban clinics. The results also indicate that pain relief pads are commonly used in this population, which has not been demonstrated in previous research. Being female, having higher education, and suffering from chronic health problems were predictors of higher likelihood of CAM use, which is highly consistent with previous research in rural communities and nation-wide studies from Australia, England, Germany, and the USA. Importantly, over three-quarters of CAM therapies used were not reported by CAM users to their primary care physicians. Given the high prevalence of CAM use in this population, we conclude that physicians in rural Japan would benefit by familiarizing themselves with the benefits and risks of commonly used CAM modalities, and may be able to provide better care by routinely inquiring about CAM use with patients. Finally, the findings elicited using the I-CAM-Q, and their consistency with previous research, suggests that the I-CAM-Q is a robust instrument for assessing CAM use.