Complementary and alternative medicine (CAM) describes a broad category of health care practices that are not currently a part of conventional Western medicine (1). From 1990 to 1997, the number of individuals reporting the use of CAM within the previous year increased from 34% to 42% (2), and a recent national study found that 62% of telephone survey respondents had used some CAM therapy within 12 months of the survey (3). Several explanations have been proposed for the apparent surge in CAM popularity, including dissatisfaction with our current health care system, a failure of conventional treatments or an attempt to avoid drug side effects, a desire for more personal control over health care decisions, the influence of our society's recent focus on health promotion and disease prevention, and the impact of family or cultural background (2-7).

Although some studies of primary care patients have charted increased CAM use among young, white, well-educated, and more economically secure populations (2-4,8-10), other research has pointed out that CAM use is also high among low-income or rural groups, highlighting again the variety of reasons for which individuals may use CAM (2,3,5,11). Wootton and Sparber suggested a bimodal distribution of CAM use, in which higher-income groups use disposable income for CAM products and services that supplement their standard health care and ethnic minority and lower-income groups use traditional healing as a substitute for conventional care (11). The evolution of medical practices among ethnic minorities is seen as part of the larger process of socialization within U.S. culture; the socialization process has also been labeled acculturation as the values, behaviors, and norms of individuals within ethnic minorities are gradually modified through exposure to a new culture. Degree of acculturation may potentially influence patterns of medical care (12). Folk remedies, defined loosely as layperson's medicine, seem to be used largely in ethnic minority populations, with frequency of use related inversely to level of acculturation (4,12). Among ethnic minority populations, Hispanics appear to use traditional or folk remedies — most commonly home or self-care practices — significantly more often than other minority groups (4,12). Still, in light of the scarcity of research on patterns of CAM use among ethnic minorities, it has been difficult to determine trends and CAM modalities specific to Hispanic populations.

It has been suggested that chronic musculoskeletal conditions provide an ideal framework in which to research CAM use because they are prevalent, have no known cure, are characterized by chronic pain, and often adversely affect normal function (13); they are also among the most frequently cited reasons for using CAM (2-4,7,8,14,15). Osteoarthritis  is the most prevalent of these conditions (16). Few studies, however, have surveyed patterns of CAM use among the osteoarthritis population, and fewer still have investigated variations of CAM use among different groups within the osteoarthritis population (8,15,17-20).

This study documented patterns of use of CAM therapies among adults with osteoarthritis in a New Mexico primary care clinic population to assess whether there were significant differences in CAM use between Hispanics and non-Hispanic whites (NHWs) and whether ethnic variations were influenced by level of acculturation, socioeconomic status, and education.

One of the most striking findings of this survey was the confirmation of high rates of overall use of CAM therapies for managing osteoarthritis among both Hispanics and NHWs with low- to mid-level incomes in a primary care setting. Most (89.4%) participants reported ever having used CAM, and 66.7% reported current use of CAM for osteoarthritis management, even after excluding high-response items, such as prayer, from the analyses. These rates are higher than most that have been reported in the literature. Barnes et al showed current rates of CAM use (for any purpose, including prayer) close to 62%, with lifetime use rates of 75% (3). Other surveys of CAM use have reported rates of current CAM use from 21% to 43% (4,7,9,33); higher rates of current use (34% to 66%) have been found in surveys of individuals with arthritis (8,13,14,17-20,34). New Mexico has a reputation for being alternative-health care friendly, which may help explain the numbers reported in this study. There are many alternative medicine practitioners in the Albuquerque area, and many people of different backgrounds and health care philosophies reside in this region. The environment also may contribute to the normalization of CAM practices and subsequent openness in discussing use of CAM therapies with primary care providers. Finally, the personal nature of the one-on-one interviews in this study may also have contributed to a more comfortable atmosphere and thus more honest revelations of CAM use.

Both Hispanics and NHWs in this population had similar rates of overall CAM use. Previous research has shown a range of 41% to 58% in overall rates of current CAM use among Hispanics (33,35-37). The high rates of use among Hispanics in this study can be explained in part by recognizing that our research focused on individuals with arthritis, who tend to report higher rates of CAM use overall. In contrast to our data, recent studies have shown higher rates of CAM use among Hispanics than among other ethnic groups, leading investigators to conclude that folk remedies or traditional healing practices are used more often in the Hispanic community (35,36). The similarity in rates of use of any type of CAM that we observed between the two ethnic groups may reflect higher than usual rates of CAM use among the NHW population.

Despite similar overall rates of CAM use, patterns of CAM use varied by ethnicity. After modeling to account for ethnic differences in demographics and disease status, we found that more low-acculturated Hispanics used oral herbs and wore items to manage their osteoarthritis than NHWs and that more high-acculturated Hispanics used energy therapies than NHWs. Previous research found that Hispanics were more likely to use traditional healing methods, often in the form of herbal preparations (33,35,36). It would make sense that degree of proximity to a parent culture would affect the degree of parent cultural influence on health care practices. This idea is supported by our findings that patterns of CAM use among high-acculturated Hispanics largely mirrored patterns among NHWs. On the other end of the spectrum, low-acculturated Hispanics were more likely than NHWs to use herbs, magnets, and copper jewelry. Although we controlled for the influence of age, sex, income, education, and disease status on CAM use, we did not control for other aspects influencing CAM use such as access to CAM services and products. Higher rates of use of herbal preparations and items worn among Spanish-speakers may be supported by a tradition of self-medication practices common in Central America, easy access to CAM products across the border in Mexico, the traditionally lower cost of gathered herbs, and the high degree of influence of family members and oral tradition on Hispanic health care practices (4,11,35,36). However, rates of overall CAM use among Hispanics in this study were not influenced by level of acculturation. Few studies have examined the influence of acculturation on CAM use; in Najm's study of the ethnic elderly, however, recent immigration status was predictive of CAM use among Hispanics (35).

Finally, these data reinforce the idea that communication between patients and primary care providers about the use of complementary therapies depends largely on whether the providers directly ask about CAM use. Although most participants from both ethnic groups reported telling their primary care provider about their CAM use, significantly fewer Hispanics (52.2%) did so than NHWs (75.2%). Furthermore, although Hispanics were less likely to communicate their CAM use to their primary care provider, they were also less likely to view their provider's response as supportive. These findings are fairly consistent with previous research showing that up to 66% of Hispanics never discuss their CAM use with their primary care provider (37). However, communication is not a problem limited to the Hispanic population; 25% of NHWs in this study and up to 83% of participants in other studies did not reveal their CAM use to their primary care provider (2,35,38). To a large extent, this lack of communication may be attributed to a don't-ask–don't-tell attitude, as first suggested by Eisenberg in 1998 and supported in subsequent literature (2,38). It is possible that patient–provider communication practices about CAM use may have shifted in the 4 years since these data were collected.

This study is not without its weaknesses or limitations. The data were derived from personal recollections of CAM use and are thus subject to recall bias. Recall bias may affect the accuracy of memory for types and frequency of use of CAM modalities, but more importantly it may blur the distinction between CAM use for arthritis and CAM use for general health maintenance or treatment of concurrent ailments. We hope that a focus on current use of CAM therapies may have avoided some of this effect. Also, osteoarthritis diagnosis was not confirmed by medical record review, so it is possible the sample included some individuals with chronic joint pain but without true osteoarthritis. The question may be raised of whether the five-question language-use scale, selected for a balance of convenience and validity, represents a true measure of acculturation. A process as complex and multifactorial as the assimilation of new cultural practices into an older tradition would be difficult to condense into any survey, let alone a short scale that only assessed use of the Spanish and English languages.

Generalizability of the study is limited for several reasons. As stated above, Albuquerque is a CAM-friendly area, so CAM use is likely to be higher in Albuquerque than in other regions. The information presented here was collected from a clinic-based population recruited from a single health care organization and may not be representative of other clinic populations. We do not know language acculturation levels in the regional Hispanic population and so cannot compare the acculturation results to a larger Hispanic population. We had low response rates overall, with a moderate difference in response rates between Hispanics and NHWs. However, nonparticipants were statistically similar to participants in sex and age. Finally, as is true of any research conducted regionally, findings gleaned from this Hispanic population are not necessarily applicable to Hispanics elsewhere because of the wide heterogeneity of Hispanic populations in this country. Even if generalizability were compromised, the conclusion stands that patterns of CAM use for osteoarthritis management may vary among subgroups in ways that cannot be assumed, and therefore it is important for providers to directly ask about CAM use, regardless of the patient's background.

These data analyses reinforce the understanding that individuals of different ethnic and socioeconomic backgrounds are using CAM at high rates. Although in the current study, acculturation and ethnicity appear to influence the forms of CAM that might be used, they do not seem to influence overall rates of use. In other words, we cannot make assumptions about who is and is not using alternative therapies based solely on an individual's cultural background. We are now seeing more research into the safety and efficacy of various CAM modalities. This research is allowing us to formulate increasingly clear-cut recommendations and treatment guidelines for CAM modalities. However, even if we are not able to provide our patients with specific recommendations, we must continue to monitor which therapies they are using on their own. It is clear that individuals are still not likely to disclose their use of CAM therapies in the absence of a direct question, and Hispanics may be more reluctant than NHWs to discuss their CAM use. In the end, it is the ethical obligation of the health care provider to ask patients about their use of CAM not only to facilitate an open patient–provider relationship but also to avoid possible drug–herb interactions and to provide guidance. Finally, as suggested in the 2004 summary on patterns of CAM use in the United States (6), we should continue to investigate where people are learning about CAM and take steps to improve the completeness and reliability of available information about CAM therapies.