Herbal Remedy Use as Health Self-Management
Among Older Adults
Thomas A. Arcury,
1Joseph G. Grzywacz,
1Ronny A. Bell,
2Rebecca H. Neiberg,
2Wei Lang,
2and Sara A. Quandt
21
Department of Family and Community Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina. 2
Divison of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
Objectives. Guided by the self-regulatory model, we describe the proportions of older adults who include herbal remedies in their health self-management, determining differences in herb use in terms of personal and health characteristics, indicators of culture, and personal resources.
Methods. Data were from the 2002 National Health Interview Survey, which included a supplement on the use of herbal remedies. We limited the present analysis to adults aged 65 and older who were Black, Hispanic, Asian, or White.
Results. Herbs were an important component of the health self-management of older adults. Whereas about one quarter of Asian and Hispanic elders used herbal remedies, about 10% of Black and White elders used them. Older adults differed by ethnicity in the herbs they used and their reasons for using herbs. Predictors of herb use included gender, age, and health status. Ethnicity and region of the country, indicators of culture, and education, a personal resource, were significant predictors of herb use when personal and health characteristics were controlled.
Discussion. A complex set of factors is associated with the inclusion of herbs in the health self-management of older adults, with cultural and personal resources being extremely important.
H
ERBS are the most commonly used category of com-plementary and alternative medicine (CAM) among U.S. residents other than prayer, and they are widely used among older adults (Barnes, Powell-Griner, McFann, & Nahin, 2004; Bruno & Ellis, 2005). Herbs are generally available; they can be gathered, grown at home, or purchased at supermarkets, pharmacies, and health food stores. They are available in their natural form, as extracts, and as pills. Herbs can be selected by any individual, but may also be prescribed by a conventional (allopathic) or alternative health care provider. People using herbs may be following cultural practices, engaging in the use of home remedies, acting on an alternative health care phi-losophy, or responding to media and marketing.Studies have documented the levels and predictors of herb use in different segments of the U.S. population (Barnes et al., 2004; Bruno & Ellis, 2005; Kelly et al., 2005; Raji, Kuo, Al Snih, Sharif, & Loera, 2005). Several studies have documented herb use in order to caution conventional physicians and phar-macists of potential interactions between herbs and prescription medicines among patients (Bruno & Ellis, 2005; Kelly et al., 2005). Typically, older adults do not report herb use to allo-pathic physicians (Kuo, Hawley, Weiss, Balkrishnan, & Volk, 2004; Zeilmann et al., 2003).
Although concerns about possible drug interaction effects are warranted, a focus on these possible effects does not address the most important issues surrounding herb use. Specifically, this focus lacks a conceptual framework that explains why indi-viduals use herbs. Models that explain indiindi-viduals’ use of herbs are essential because they provide insight into intervention strategies to change this health behavior. For example, if herb use confers legitimate health benefits, attempts to promote
widespread use of herbs will need to target the specific sociocultural (e.g., beliefs about the safety of herbs) or resource factors (e.g., insurance coverage) that enable the behavior to occur. Likewise, a solid understanding of why individuals are using these substances needs to inform attempts to reduce the use of those herbs that undermine health. Furthermore, strong conceptual models of specific health behaviors, like the use of herbs, can inform understanding of adults’ overall strategies for managing their health status and can be used to design programs that improve adults’ health self-management (Clark, 2003; Ory, DeFriese, & Duncker, 1998).
We view use of CAM like herbs as one type of health management activity. A basic premise of health self-management is that adults are actively involved in monitoring and making decisions about their health (Arcury, Bell, et al., 2006; Grzywacz et al., 2005). One might not consider all decisions to be positive within the framework of conventional medicine; for example, some individuals may decide to do nothing, to maintain behaviors that are detrimental to their health, or to use unproven alternative remedies. Although older adults perform some health self-management behaviors to prevent the onset of new disease or illness, their health self-management frequently focuses on treating symptoms (e.g., taking an aspirin or resting in a dimly lit room for a headache), states (e.g., starting a diet or increasing physical activity to reduce weight), or chronic conditions (e.g., taking insulin or testing blood glucose to control diabetes). Studying individual forms of complementary and alternative (nonallopathic) health care is important because distinct modalities likely have dif-ferent behavioral, sociocultural, and cognitive antecedents. For example, whereas herbs can be purchased at a variety of drug S142
and discount stores and taken without supervision, other modalities, such as acupuncture or use of biofeedback, require access to specialists, specialized equipment, or specific skills.
Leventhal’s self-regulatory model (SRM) provides one theoretical framework for understanding specific health self-management behaviors undertaken by older adults (Cameron & Leventhal, 2003; Leventhal, Halm, Horowitz, Leventhal, & Ozakinci, 2004). As with more general models of health self-management, the SRM framework posits that people are active in solving health-related problems and that they do so by con-structing self-regulatory or common-sense models of illness experiences within which they evaluate options for health self-management. The idea of common-sense models that individ-uals apply in selecting behaviors to respond to a symptom or state expands on the concept of explanatory models of illness proposed by Kleinman (1980). By highlighting individual perceptions and structural factors, the SRM posits that indi-viduals will select a self-management behavior, such as herb use, based on their beliefs (explanatory models) of a symptom, state, or illness; their perceptions and understanding of their health; their knowledge of treatments (to use an herb, indi-viduals need to know it exists); personal resources (indiindi-viduals cannot use herbs if they cannot afford to procure them); and structural factors that affect access to a therapy (individuals cannot use herbs if they cannot be obtained in the community). Although we cannot examine all of the components of SRMs with the data available for this analysis, this theory does direct us to consider several domains characterizing individuals that will differentiate their use of herbal remedies.
The first domain considered within the SRM for understand-ing alternative therapy use includes personal characteristics, such as gender and age. Women tend to have greater health knowledge and health concerns than do men (George, 2001). Women are often greater users of complementary and alter-native therapies, but not among older adults (Najm, Reinsch, Hoehler, & Tobis, 2003). Use of complementary and alternative therapies, including herbs, changes with age (Arcury, Bell, et al., 2006; Zeilmann et al., 2003). Herb use compared to use of other complementary and alternative remedies may also be particularly relevant to older adults as the health culture in which they were raised may have included the use of herbs and other home remedies (Cavender & Beck, 1995; Frate, Croom, Frate, Juergens, & Meydrech, 1996).
Ethnicity and culture are important in determining how a person implements health self-management, particularly how that person incorporates complementary and alternative health care, such as herbs, into a self-management regime. The SRM framework posits that shared beliefs (culture) about what is right or possible to do for health often dictate health behaviors. Members of an ethnic group share beliefs and common experiences that affect their willingness to use different forms of health care. The use of herbs for the prevention and treatment of ill health often has its roots in the traditional and contemporary cultures of the United States, including the cultures of people with European as well as Asian, African, Latino, and Native American heritage. Herb use differs by ethnicity; in the United States, it occurs most widely among Asians and Latinos (Arcury, Suerken, et al., 2006; Barnes et al., 2004; Kuo et al., 2004; Loera, Black, Markides, Espino, & Goodwin 2001; Raji et al., 2005).
Like with all self-management behaviors, greater use of herbs and other complementary and alternative therapies by those with health conditions may reflect the need to treat these conditions (Astin, Pelletier, Marie, & Haskell, 2000; Clark, 2003). However, the number of health conditions one has may limit his or her use of some therapies, as the conditions may be beyond that individual’s functional ability to manage.
Personal and financial resources, such as education or income, affect performance of health self-management behav-iors. These structural factors are important within the SRM framework as they facilitate or limit an individual’s ability to implement a behavior. For example, education is related to the use of complementary and alternative therapies (Astin et al., 2000; McMahan & Lutz, 2004; Najm et al., 2003). Having more education may result in having greater knowledge of complementary and alternative therapies like herbs, as well as having the ability to pay for them. However, the lack of formal education could result in greater use of traditional herbal remedies due to less access to, less ability to pay for, or less willingness to use conventional medical care (Arcury, Quandt, Bell, & Vitolins, 2002; Najm et al., 2003). Financial resources, whether income or health insurance status, can affect individuals’ relative access to conventional care and their ability to pay for herbal supplements (Astin et al., 2000; McMahan & Lutz, 2004; Najm et al., 2003).
This analysis has three aims. First, using data from the 2002 National Health Interview Survey (NHIS), we describe the proportions of older adults who use herbs. This includes specifying the herbs that these older adults use. We also describe characteristics of older adults related to herbal remedy use: their reasons for using herbs, the importance of herbs in maintaining their health and well-being, whether they go to an herbal provider, and whether they tell their conventional health care providers about their herb use. Because ethnicity is a major focus of our research program on CAM use, and due to the interest in the association of CAM with health disparities, we consider ethnic differences in the use of specific herbs and in the characteristics related to herbal remedy use. Second, guided by the SRM framework, we determine differences in herb use among older adults in terms of personal (gender, age) and health status characteristics, as well as indicators of culture (ethnicity, region of the country) and of resources (educational attainment, income, health insurance). Finally, we determine if indicators of culture and resources remain predictors of herb use after accounting for personal and health characteristics.
METHODS
Data Source
Data for this analysis came from the 2002 NHIS, a representative, population-based survey of the civilian, non-institutionalized U.S. population. Personnel of the U.S. Census Bureau conducted all interviews in English. The NHIS sampling plan used a multistage area probability design. The 2002 NHIS included a supplement assessing alternative health care that contained extensive questions on the use of alternative health providers, products, and practices, with reference to the use of these therapies to treat specific health conditions and the perceived benefit of these therapies.
We limited this analysis to adults aged 65 and older who were members of four ethnic groups: non-Hispanic Black (Black), Hispanic, Hispanic Asian (Asian), and non-Hispanic White (White). The Asian group included Asian Indian, Chinese, Filipino, and Other Asian. The NHIS over-sampled Black and Hispanic respondents but not Asian respon-dents. Therefore, with only 98 Asian elder respondents, we expect standard errors of percentages for this subpopulation to be relatively large. There was an insufficient number of Native American elders to include in this analysis.
Measures
We based the measure of herbal remedy use in the past year on two sets of items. First, we considered respondents to have used an herbal remedy if they answered the following question affirmatively: ‘‘Some people use natural herbs for a variety of health reasons. Some people drink an herbal tea to remedy a flu or cold. Others take a daily herb pill to help with a health condition or just to stay healthy. . .. During the past 12 months, did you use natural herbs for your own health or treatment?’’ Second, we considered individuals to have used an herbal remedy if they reported having used an herbal remedy to treat a specific health condition in the past 12 months.
The measures of specific types of herbs used were based on an item that listed 35 different herbs and asked respondents if they had used that herb in the past year. Three of the substances on this list were not herbs (i.e., fish oils, glusosamine, and melatonin); we excluded them from the study (unlike Bruno and Ellis, 2005). We coded respondents who reported any use of the remaining 32 items as having used herbs.
The study used five questions to elicit reasons why individuals had used herbs: (a) conventional treatment would not help, (b) conventional treatment was too expensive, (c) individual combined herbs and conventional treatment, (d) conventional provider suggested herbs, and (e) individual thought it would be interesting. If a respondent indicated yes to any of these questions, we considered that person to have had that reason for herb use. We based importance of herb use for maintaining health and well-being on an item that had the response categories very, somewhat, slightly, and not at all important. Items asking whether respondents had gone to natural herb practitioners in the past 12 months, and whether in the past 12 months they had told their conventional medical professionals that they were using a natural herb, had the values of yes or no.
Personal characteristics included in this analysis were gender and age (divided into 5-year cohorts). The first health status measure was self-rated health, which had values of excellent, very good, good, fair, and poor. Number of health conditions was the sum of 36 different conditions, grouped into the categories none, one or two, three or four, and five or more. Ethnicity had the values of Black, Hispanic, Asian, or White. The NHIS provided information on only the four major census regions (Northeast, Midwest, South, and West) in the public use data set. The first resource measure was educational attainment, divided into the categories of less than high school; high school, general equivalency diploma, and some college; or college graduate. Annual household income had the values of less than $20,000 per year, and at least $20,000 per year.
Additional paid health insurance indicated if the respondent had purchased health insurance in addition to Medicare.
Analysis
We performed all analyses using SAS (SAS Institute, Cary, NC) callable SUDAAN (Research Triangle Institute, Research Triangle Park, NC) software to account for the complex survey design. We used the Sample Adult Weight–Final Annual variable to produce population estimates. We used PROC CROSSTAB to generate descriptive statistics, including estimates for the weighted percentages of past year use of an herbal remedy and for herb users who had told a conventional provider about their herb use, as well as their corresponding standard errors for each of the demographic, health, and health care characteristics. We used the chi-square test to test for differences across ethnic groups for reasons and importance of herb use. We used PROC LOGIST to fit separate logistic regression models in order to examine the odds ratios for the effects of gender, age, race, educational attainment, income, additional paid health insurance status, U.S. census region, self-rated health, and number of chronic conditions on use of an herbal remedy in the past 12 months and on herb users who had told a conventional provider about their herb use. We used the Hosmer-Lemeshow chi-square test as a measure of goodness of fit for the logistic regression models.
RESULTS
Sample Characteristics
The sample contained more women than men (57.2% vs 42.8%, respectively; Table 1). The modal level of self-rated health was ‘‘good,’’ with more respondents stating that their health was excellent (13.8%) than poor (7.1%). Although 10.3% had no health conditions, 35.9% had five or more. Although the ethnic composition of the sample was over-whelmingly White (83.3%), there were sufficient numbers of the other three ethnic groups for analysis. The use of sampling weights ensured that the number of respondents in each region was proportionate to the size of the general population in those regions. The majority of the respondents (55.0%) had a high school degree or equivalent, with 16.3% having a college degree or greater. More than one third of the respondents had annual incomes of less than $20,000 per year, and 29.5% had additional paid health insurance beyond Medicare.
Herbal Remedy Use
Of the older adults included in this analysis, 11.9% had used an herbal remedy in the preceding year (Table 2). The herbs used by these older adults were diverse. The most widely used herbs were echinacea (3.0%), garlic supplements (2.9%), ginkgo biloba (2.0%), ginger supplements (1.3%), ginseng (1.3%), and saw palmetto (1.2%). Each of the other 27 specified herbs was used by less than 1.0% of the respondents, with 2 herbs having been used by no respondents.
Although Asian older adults were the most frequent users of herbal remedies (28.1%), their list of specific herbs used was the shortest. Ginger supplements (9.1%), ginseng (6.6%), and garlic supplements (6.0%) were Asian elders’ most widely used herbal remedies. However, 7.3% of Asian respondents
indicated that they did not know the name of an herb that they had used, and 6.4% indicated that they had used another herb not on the list. Almost one fourth (23.8%) of Hispanic older adults reported having used an herbal remedy. Ragweed/ chamomile (5.1%) and echinacea (3.6%) were Hispanic elders’ most widely used herbs. Of Hispanic respondents, 2.5% did not know the name of an herb that they had used, and 6.4% indicated that they had used an herb not on the list.
About 10.0% of Black and White older adults reported having used an herbal remedy. The most widely used herbal
remedies among White older adults were echinacea (3.2%), garlic supplements (2.9%), and ginkgo biloba (2.1%). The list of herbs used by White older adults contained 28 specific items. The most widely used herbs among Black older adults were garlic supplements (3.2%) and ginger supplements (1.8%); 2.5% indicated that they had used an herb not on the list.
Very few of the older respondents (n¼29, 4.2%) who had used herbs had used an herbal provider. About 2 in 5 (41.6%) individuals who had used an herbal remedy had told their conventional health care provider about this use. The reasons why the older respondents used herbal remedies varied (Table 3). The most common reasons were to supplement conventional treatment (31.7%), or because it would be interesting (27.2%). That conventional treatments were too expensive was a reason given by few (6.8%), as was the belief that conventional treatments would not help (12.1%). Conventional providers had suggested the use of herbs in a small number of cases (11.5%). Older adults differed significantly by ethnic group in some of their reasons for using herbs. More Asians (14.6%) and Whites (12.9%) than Blacks (2.9%) or Hispanics (4.5%) reported having used herbs because conventional treatment would not
Table 1. Personal and Health Characteristics Among Black, Hispanic, Asian, and White Adults Aged 65 Years and Older,
2002 National Health Interview Survey
Measure % SE na Nb Gender Female 57.2 0.70 3,670 18,838,189 Male 42.8 0.70 2,167 14,067,755 Age in years 65–69 28.3 0.73 1,532 9,328,660 70–74 25.5 0.69 1,421 8,405,813 75–79 22.1 0.67 1,305 7,277,705 80–84 14.3 0.51 912 4,691,845 85 or older 9.7 0.41 667 3,201,921 Self-rated health Excellent 13.8 0.50 774 4,500,324 Very good 24.6 0.72 1,438 8,020,712 Good 35.0 0.75 2,001 11,380,883 Fair 19.4 0.63 1,143 6,329,346 Poor 7.1 0.40 418 2,323,829 Health conditions None 10.3 0.46 592 3,348,574 1–2 28.2 0.68 1,629 9,191,011 3–4 25.6 0.65 1,468 8,352,318 5 or more 35.9 0.78 2,090 11,689,756 Ethnicity Black 8.3 0.45 642 2,735,166 Hispanic 6.4 0.42 536 2,111,235 Asian 2.0 0.28 98 655,660 White 83.3 0.65 4,561 27,403,883 Region Northeast 20.3 0.70 1,144 6,675,300 Midwest 24.1 0.76 1,406 7,940,457 South 37.4 1.04 2,169 12,292,687 West 18.2 0.89 1,118 5,997,500 Education
Less than high school 28.7 0.77 1,818 9,261,706 High school, general equivalency
diploma, and some college
55.0 0.84 3,044 17,758,281
College graduate 16.3 0.61 875 5,270,147
Income
Less than $20,000/year 34.2 0.82 2,268 9,988,120 At least $20,000/year 65.8 0.82 2,901 19,187,190 Additional paid health insurance
Yes 29.5 0.85 1,633 9,609,170
No 70.5 0.85 4,141 22,945,924
Notes:SE¼standard error. aUnweighted sample size. bNational estimate.
Table 2. Reported Herb Use by Ethnicity Among Black, Hispanic, Asian, and White Adults Aged 65 Years and
Older, 2002 National Health Interview
Total Black Asian Hispanic White
Herb % % Rank % Rank % Rank % Rank
Total 11.9 10.2 28.1 23.8 10.8 Echinacea 3.0 0.9 6 3.6 3 3.2 1 Garlic supplement 2.9 3.2 1 6.0 5 1.7 9 2.9 2 Other 2.2 2.5 2 6.4 4 6.4 1 1.8 4 Ginkgo biloba 2.0 1.2 4 2.5 6 1.2 11 2.1 3 Ginger supplements 1.3 1.8 3 9.1 1 1.1 13 1.1 7 Ginseng 1.3 0.7 7 6.6 3 1.2 11 1.2 6 Saw palmetto 1.2 0.1 17 1.8 7 1.3 5 Don’t know 1.2 0.6 8 7.3 2 2.5 5 1.1 7 Peppermint 0.9 1.1 5 0.4 10 3.0 4 0.7 11 Ragweed/chamomile 0.8 5.1 2 0.5 13 Soy supplement 0.9 0.3 12 1.7 7 0.9 14 1.0 9 St. John’s Wort 0.9 0.1 17 0.8 15 1.0 9 Bee pollen 0.6 0.2 15 1.4 10 0.6 12 Valerian 0.6 0.4 10 2.1 6 0.5 13 Comfrey 0.4 0.4 10 0.6 16 0.4 15 Evening primrose 0.4 0.2 15 0.6 9 0.1 20 Kava kava 0.4 0.2 19 0.4 15 Milk thistle 0.4 0.1 17 0.5 18 0.4 15 Black cohosh 0.3 0.1 17 0.6 16 0.3 18 Hawthorn 0.3 0.1 20 0.3 18 Licorice 0.3 0.6 8 0.2 19 0.3 18 Black wrack 0.2 0.1 17 0.2 19 0.2 21 Progesterone cream 0.2 0.2 21 Cascara sagrada 0.1 1.8 7 Chaparral 0.1 0.1 20 0.1 23 Chasteberry 0.1 0.1 23 Dong quai 0.1 0.3 12 0.7 8 0.1 23 Feverfew 0.1 0.2 19 0.1 23 SAMe 0.1 0.2 19 0.1 23 Senna 0.1 0.3 12 0.1 20 0.1 23 Yohimbe 0.1 0.1 20 0.1 23 Ma huang 0.1 0.1 17
Mexican yam cream 0.1 0.1 20
Chasteberry/virtex 0.0
help. A greater proportion of White older adults (13.2%) stated that they had used an herb because it was suggested by their conventional provider, compared with Hispanic (0.0%), Black (4.1%), or Asian older adults (7.6%). Among herb users, 72.9% considered the importance of herb use for maintaining health and well-being to be at least somewhat important; this pro-portion did not vary by ethnic group.
Table 4 presents weighted percentages, standard errors, and weighted sample sizes obtained from bivariate analyses; and odds ratios and associated 95% confidence intervals obtained from multivariate logistic regression models adjusted for all factors listed in the table. The use of herbal remedies was significantly associated with the personal (gender, age), health (self-rated health, health conditions), cultural (ethnicity, re-gion), and resource (education) characteristics of the older adults. Women were more likely to have used an herbal remedy than were men. Herbal remedy use declined with age; com-pared to individuals aged 85 and older, a significantly greater proportion of those aged 65 to 69 and 70 to 74 had used herbs. The decrease in the percentages of people aged 75 to 79 (10.5%) and 80 to 84 (8.7%) using herbs, compared to those aged 65 to 69 (14.5%) and 70 to 74 (13.8%) and with those 85 and older (7.5%), trended in an almost linear fashion, but the proportion of individuals in these age groups using herbs was not significantly different from that for those aged 85 and older.
Self-rated health was significantly related to herb use, with a higher percentage of people reporting excellent health having used an herb than those reporting poor health. However, the number of health conditions experienced by the older adults was also directly related to herb use. The percentages of people with no health conditions (8.8%) and with one or two health conditions (10.3%) who had used herbs were significantly lower than the percentage of those with five or more health conditions who had used herbs (14.0%).
Although the percentages of Blacks (10.2%) and Whites (10.8%) who had used herbs did not differ, significantly higher percentages of Hispanic (23.8%) and Asian (28.1%) older adults had used herbal remedies compared to their White counterparts. Significantly smaller percentages of northeastern (11.1%), midwestern (11.0%), and southern (9.6%) older adults
had used herbal remedies than had those living in the West (18.8%). A significantly smaller percentage of older adults with lower educational attainment (less than high school, 9.9%; less than college degree, 11.8%) had used herbs than had those who had graduated from college (16.3%).
Virtually none of the personal, health, cultural, and resource characteristics were associated with telling one’s conventional health care provider about herb use among those who had used herbs. The only significant association was that smaller percentages of individuals with no health conditions or with one or two health conditions had told their conventional provider about herb use than had those with five or more health conditions.
DISCUSSION
This analysis confirms that herbs are an important compo-nent of the health self-management of older adults. This is particularly the case among Asian and Hispanic older adults, more than one fourth of whom reported having used herbal remedies. However, even among Black and White older adults, 1 in 10 reported having used herbal remedies. At the same time, almost no old adult of any ethnic group had gone to an herbal provider. Therefore, their knowledge of herbs came from other sources. For many, it may have been tradition: herbal remedies are simply part of the health self-management knowledge that communities share and maintain. Others probably drew from popular contemporary sources, such as magazines and books, as well as informal sources like friends (Stoller, Pollow, & Forester, 1994); this may account for the more than one fourth of participants who indicated that they had used an herb because they ‘‘thought it would be interesting.’’ For others, particularly White older adults, the source included conven-tional providers; more White older adults reported that they had used herbs suggested by a conventional provider, and about half of those who had used herbs stated that they had told their conventional providers about this use. Older adults may justify unconventional remedy use by attributing it to a conventional provider’s recommendation (Arcury, Quandt, Bell, & Vitolins, 2005). This is consistent with other research showing that White patients prefer authoritative medical information sources
Table 3. Reasons for Herb Use and Importance of Herb Use Among Black, Hispanic, Asian, and White Adults Aged 65 Years and Older Who Use Herbal Remedies, 2002 National Health Interview Survey
All Adults Black Asian Hispanic White
Variable % SE n % SE n % SE n % SE n % SE n
Reasons for using herbs
Conventional treatment would not help* 12.1 1.72 58 2.9 1.90 2 14.6 5.32 11 4.5 4.39 1 12.9 2.03 44 Conventional treatment too expensive 6.8 1.33 33 5.8 3.35 3 16.3 5.61 10 17.5 10.56 2 5.1 1.37 18 Combined herbs and conventional treatment 31.7 2.63 144 20.2 7.39 7 34.3 7.22 24 37.5 11.40 6 32.1 3.02 107 Conventional provider suggested herbs* 11.5 1.69 52 4.1 4.07 1 7.6 2.95 9 0.0 — 0 13.2 2.07 42 Thought it would be interesting 27.2 2.34 126 20.1 7.63 9 27.8 6.50 23 15.3 8.24 4 28.2 2.79 90 Importance of herb use to maintaining health and well-being
Very important 39.2 2.39 194 39.4 7.49 21 39.3 6.56 36 41.2 12.08 6 39.0 2.71 131
Somewhat important 33.7 2.35 149 42.6 7.87 14 42.6 7.48 22 25.6 11.29 3 32.0 2.61 110
Slightly important 19.5 2.21 94 11.1 5.88 5 14.9 4.55 13 17.6 10.28 3 21.0 2.57 73
Not at all important 7.7 1.34 36 6.8 3.87 3 3.2 1.65 4 15.6 14.15 1 8.0 1.55 28
Notes:SE¼standard error.
about CAM remedies (Kakai, Maskarinec, Shumay, Tatsumura, & Tasaki, 2003).
As suggested by the SRM framework, ethnic heritage played an important part both in an individual’s decision to use herbs for health self-management and in the specific herbs that they
used. The gross measures of culture that were available in the 2002 NHIS—race/ethnicity and region—remained important predictors of herb use when controlling for personal, health, and resource characteristics. It is therefore important to understand the beliefs of older adults when considering their
Table 4. Logistic Regression Estimates for Herbal Remedy Use and Telling Conventional Provider About Herbal Remedy Use for Black, Hispanic, Asian, and White Adults Aged 65 Years and Older, 2002 National Health Interview Survey
Use an Herbal Remedya Tell Conventional Providerb,c
Characteristic %d SEd n OR (95% CI)e %b SEd n OR (95% CI)e
Total 11.9 0.50 696 41.6 2.17 277 Gender Female 13.1 0.65 478 1.51 (1.23–1.85) 44.9 3.81 102 0.96 (0.63–1.46) Malef 10.3 0.71 218 39.7 2.53 175 Age 65–69 14.5 1.06 236 1.97 (1.26–3.08) 41.7 3.74 96 1.47 (0.61–3.57) 70–74 13.8 1.01 198 1.70 (1.12–2.58) 48.8 3.99 93 2.08 (0.89–4.82) 75–79 10.5 0.88 145 1.29 (0.84–1.99) 34.4 4.62 46 1.24 (0.50–3.04) 80–84 8.7 1.00 76 1.16 (0.74–1.83) 42.0 6.69 29 1.60 (0.58–4.44) 85 or olderf 7.5 1.34 41 28.3 8.11 13 Self-rated health Excellent 13.8 1.36 108 1.71 (1.02–2.87) 45.9 5.30 48 1.97 (0.69–5.64) Very good 11.3 0.96 163 1.31 (0.83–2.09) 46.4 4.33 72 1.40 (0.56–3.52) Good 12.2 0.94 240 1.43 (0.91–2.27) 38.7 3.54 92 1.29 (0.53–3.16) Fair 11.8 1.11 145 1.30 (0.82–2.05) 40.9 5.07 54 1.22 (0.48–3.12) Poorf 9.3 1.63 40 30.1 8.24 11 Health conditions None 8.8 1.33 53 0.45 (0.30–0.67) 20.6 5.97 12 0.34 (0.15–0.76) 1–2 10.3 0.85 169 0.61 (0.46–0.80) 34.5 3.96 57 0.52 (0.31–0.89) 3–4 12.0 0.98 173 0.79 (0.61–1.03) 50.8 4.42 82 1.09 (0.66–1.81) 5 or moref 14.0 0.93 301 44.0 3.54 126 Ethnicity Black 10.2 1.35 65 1.12 (0.78–1.60) 23.3 5.82 18 0.59 (0.29–1.19) Hispanic 23.8 2.33 120 2.94 (2.11–4.10) 25.3 5.14 31 0.57 (0.29–1.09) Asian 28.1 6.01 27 2.95 (1.59–5.49) 12.1 6.36 3 0.29 (0.06–1.41) Whitef 10.8 0.51 484 47.9 2.59 225 Region Northeast 11.1 0.90 124 0.70 (0.53–0.93) 35.5 4.81 45 0.88 (0.49–1.59) Midwest 11.0 0.84 157 0.69 (0.52–0.92) 51.9 4.65 75 1.58 (0.89–2.81) South 9.6 0.75 215 0.56 (0.42–0.74) 40.7 3.73 79 1.05 (0.62–1.78) Westf 18.8 1.57 200 38.6 4.20 78 Education
Less than high school 9.9 0.86 195 0.51 (0.37–0.69) 29.8 3.85 51 0.68 (0.36–1.27)
High school, general equivalency diploma, and some college
11.8 0.67 350 0.70 (0.54–0.90) 45.8 3.08 162 1.06 (0.66–1.71)
College graduatef 16.3 1.37 144 45.7 4.30 63
Income
Less than $20,000/year 11.4 0.80 260 0.94 (0.76–1.17) 33.9 3.47 84 0.76 (0.48–1.18)
At least $20,000/yearf 12.9 0.68 388 45.4 2.78 176
Additional paid health insurance
Yes 11.4 0.84 191 1.00 (0.81–1.24) 50.2 3.78 95 1.25 (0.85–1.82)
Nof 12.1 0.63 505 38.2 2.47 182
Notes:SE¼standard deviation. OR¼odds ratio; CI¼confidence interval.
aHosmer–Lemeshow goodness-of-fit test indicated model was a good fit for the data,v2¼14.23,p¼.0759. b
Hosmer–Lemeshow goodness-of-fit test indicated model was a good fit for the data,v2¼
14.17,p¼.0774. c
Herb users only.
dWeighted percentages and standard errors obtained from bivariate analyses using PROC CROSSTAB.
eOdds ratios and 95% confidence interval estimates obtained from the multivariate logistic regression model adjusted for all factors listed in the table. fReference group.
use of herbs and their use of other components of health self-management, including other CAM modalities. White and Black older adults, compared to Asian and Hispanic older adults, were less likely to have used herbs, and they were less specific in the herbs that they had used. This may indicate that herbs are not part of the traditional health culture of many Black and White older adults.
The specific herbs that were included in the 2002 NHIS may indicate a bias toward those used by Whites. Although only about 1 in 10 White older adults reported having used herbs, their list of herbs used included 28 of the 32 items studied in this analysis; only 1.8% indicated ‘‘other,’’ and 1.1% indicated ‘‘don’t know.’’ Although more than one fourth of the Asian older adults reported having used an herbal remedy, they reported having used only 8 of the 32 specific herbs; 7.3% indicated ‘‘don’t know,’’ and 6.4% indicated ‘‘other.’’ The proportion of Asian and Hispanic older adults who would have reported herbal remedy use might have been substantially greater if the study had used culturally and linguistically appropriate lists of herbs. For example, in their analysis of Hispanic older adults, Loera and colleagues (2001) found that 9.8% had used an herbal remedy in the previous 2 weeks, and Zeilmann and colleagues (2003) reported that about 60% of their participants used herbs.
Within the SRM framework, resources are important in facilitating the transition from belief to behavior. Greater edu-cation, a personal resource, was associated with herb use, sug-gesting that factors other than tradition contribute to the incorporation of herbs and other alternative remedies into older adults’ health self-management regimes. That health insurance, another resource, was not associated with herbal remedy use is not surprising in that few, if any, health insurance plans pay for herbal remedies. Astin and colleagues (2000) did find high use of two forms of alternative therapies (chiropractic and acu-puncture) among older adults enrolled in a health maintenance organization that paid for these therapies, but most older adults are not enrolled in such plans. However, to the extent that one may purchase herbal remedies, it is surprising that income was not associated with herb use. The reported measure of income used was fairly crude, but it had few missing values. However, an additional analysis using a measure of income with five categories (less than $20,000; $20,000–$34,999; $35,000–$54,999; $55,000–$74,999; and $75,000 or greater), in which we replaced missing values using multiple imputation (Schenker et al., 2005), had no effect on the results. The cultural and educational factors leading to herb use may be so strong that older adults use them largely irrespective of cost. However, the cost of many herbs, particularly those that can be grown, gathered, or purchased at a supermarket or ethnic store, may be very low. Finally, to the extent that older adults are substituting herbs for prescription medications, the cost of the herbs may be lower than the cost of the prescription drugs (Pagan & Pauly, 2004). At the same time, few (6.8%; Table 3) of the older adults in this study indicated that they had specifically used herbs because conventional treatments were too expensive.
Gender is an important determinant in the use of herbal remedies, but not in the use of other CAM modalities. More older women than men included in this analysis reported having used herbal remedies. This is similar to the findings of other
analyses of herbal remedy use (Kuo et al., 2004; Loera et al., 2001; Raji et al., 2005). However, studies of general CAM use among older adults have reported no significant gender differences (Arcury, Bell, et al., 2006; Astin et al., 2000; Foster, Philips, Hamel, & Eisenberg, 2000; Najm et al., 2003). Researchers must consider how personal characteristics, such as gender, affect the use of specific CAM modalities.
Age is also an important determinant in the use of herbal remedies. The general literature on CAM use among older adults has reported a decline in alternative remedy use after age 65 (Astin, 1998; Bausell, Lee, & Berman, 2001; Ni, Simile, & Hardy, 2002). However, Barnes and colleagues (2004) reported the level of total CAM use at 24.7% among those aged 40 to 49, 26.2% among those aged 50 to 59, 21.3% among those aged 60 to 69, and 15.3% among those aged 70 to 84. Our analysis indicates that herbal remedy use remains relatively high among the young-old (i.e., 14.5% among those aged 65–69) and then declines among the old and the old-old (i.e., 7.5% among those aged 85 and older). This is the same pattern that Arcury, Suerken, and colleagues (2006) and Grzywacz and colleagues (2005) reported for general CAM use among older adults. More research is needed to examine how older adults come to use or stop using CAM modalities.
The association between health status and herbal remedy use is complex. Most older adults who used herbs stated that their use was important for maintaining health and well-being. More people who stated that their health was excellent used herbal remedies than those who stated that their health was very good to poor. This indicates that older adults use herbal remedies for health maintenance and prevention. However, using herbs is also associated with having more health conditions, indicating that older adults also use herbs for treatment. The association of greater herb use among those with more health conditions is similar to that found in other research on general CAM use and health status (Astin et al., 2000; Foster et al., 2000). This analysis shows that older adults may need to experience several health conditions before they affect their use of herbal remedies. Researchers need to measure better the use of herbs for treating specific diseases or symptoms, as opposed to the use of herbs for disease prevention or health maintenance.
This analysis has several limitations. The study had limited ability to operationalize the SRM framework because the NHIS was not designed to test hypotheses derived from this theory. The cross-sectional design limits the consideration of the causes of herb use among older adults. The sample did not include sufficient numbers of older adults from all ethnic groups. Therefore, we could not consider some ethnic groups, such as Native Americans. The ethnic categories of Hispanic and Asian combined individuals with very different cultural traditions. Furthermore, we did not know length of residence in the United States among immigrants in any ethnic group, so we could not discern the relationship of level of acculturation to CAM use. Finally, the data were limited to CAM use for the past year.
This analysis also has important strengths. The 2002 NHIS is a national probability sample that oversampled Black and Hispanic adults. It is the first national sample with sufficient numbers of ethnic older adults to allow some analysis of ethnic differences in CAM use. Although it does not include all herbs, its list of herbs is more inclusive than those used in most other studies.
This analysis shows that herbs are an important part of the health self-management of many older adults. It further shows that factors associated with herb use (including age, gender, and health status) are complex. More importantly, and consistent with the SRM framework, culture and personal resources differentiate older adults who include herbal remedies in their health self-management regimes. Health care providers who seek to implement culturally competent care must consider the cultural backgrounds of their patients when assessing their use of nonallopathic medicine. Research investigating how older adults manage their health must consider herbal remedies and other alternative modalities separately, and future research should more fully operationalize the SRM to identify factors related to each specific modality.
ACKNOWLEDGMENTS
Funding provided by Grant R21 AT002241 from the National Center for Complementary and Alternative Medicine.
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Received February 27, 2006 Accepted August 31, 2006
