Military Medicine 2010 (Jul); 175 (7): 534–538 ~ FULL TEXT
Jeremy B. Kent, MC USA, Robert C. Oh, MC USA
Department of Family Medicine,
Tripler Army Medical Center,
1 Jarrett White Road,
Honolulu, HI 96859-5000, USA.
Complementary and alternative medicine (CAM) is a growing component of medicine within the U.S. civilian and military populations. Tripler Army Medical Center (TAMC) Family Medicine Clinic represents an overseas medical facility stationed among a diverse ethnic population. The impact that local cultures have on CAM utilization in the military population in overseas medical facilities is unknown.
METHODS: Cross-sectional survey. The authors surveyed all volunteer soldiers, family members, and retirees 18 years old or greater enrolled at TAMC Family Medicine Clinic with appointments between September 1 and September 25, 2008.
RESULTS: 503 volunteers were surveyed with a response rate of 73% (n = 369). A total of 50.7% reported using at least one CAM therapy within the last year. CAM use was significantly higher among women, Caucasians, and a college level education or greater.
CONCLUSION: Prevalence of CAM use is higher within a military family medicine clinic in Hawaii than the prevalence among mainland civilian or other military populations.
From the FULL TEXT Article:
Complementary and alternative medicine (CAM) is a growing
aspect of health care within the United States (U.S.) population.
CAM is a nonspecific and broad term to describe a
large group of diverse health care modalities that are not commonly
considered to be a part of conventional medicine. As a
result, defining CAM is difficult. Generally, CAM is divided
into four groups of therapies: mind–body medicine such as
meditation, biologically based therapies such as herbal medications,
manipulative and body-based practices such as chiropractics,
and energy medicine such as therapeutic touch.
A fifth group termed whole medical systems uses multiple
CAM therapies. Whole medical systems include homeopathic
medicine and traditional Chinese medicine. ( http://nccam.nih.gov/ ). 
Studies show that CAM is used by approximately 38% of
the U.S. population. [2–5] Studies also show that the prevalence
of CAM use among active duty military personnel is very similar
to the civilian population. [6, 7] Conversely, the use of CAM
within the Hawaiian civilian population is significantly higher
than mainland U.S. with a prevalence of 49.9%. [8, 9] The higher
prevalence may be attributed to Hawaii’s diverse ethnicities
that include Asian influence, local Hawaiian beliefs, and other
South Pacific cultures within a state without a real majority. [10–14]
The 2005 Hawaii Census shows that of those questioned,
57% considered themselves Asian, 42% White, 22% Pacific
Islander, 3% Black, and 2% Native American. 
With the immigration of Japanese and Chinese people to
Hawaii in the 1800s they brought with them many health care
practices that are well known CAM therapies today, such as
Reiki from Japan and acupuncture from China. Hawaii also
has CAM that is distinctly Hawaiian. Native Hawaiian spiritual
healers known as Kahuna have been practicing Lomilomi
massage, giving spiritual healing, and offering herbal medicines
since their migration to Hawaii. [15–17] Lomilomi means to
press or massage in Hawaiian. Although there are now many
different forms of Lomilomi massage, it has traditionally
been a holistic healing technique that was brought with the
fi rst Polynesians on their migration to Hawaii. The traditional
form not only uses massage, but also incorporates prayer and
herbal medicines.  The kava culture of the Pacific dates back
hundreds of years in Hawaiian society. Kava is a plant of the
Pacific of which the root has been used for anxiety, stress, and
insomnia. It has played a role in certain medical, political, and
social ceremonies in Pacific cultures. [17–19] This melting pot of
beliefs and cultures may be why there is a higher prevalence
of CAM use not seen in the continental U.S.
The U.S. military in Hawaii is exposed to these diverse cultures,
which may lead to greater CAM use among the military. [10–14] Some of the soldiers and dependents have Hawaiian
or Asian lineage. These same soldiers and family members
are seen at Tripler Army Medical Center (TAMC) Family
Medicine Clinic. As a full scope clinic taking care of every
branch of the U.S. military, TAMC Family Medicine Clinic is
a good representation of a diverse military population outside
the continental United States (OCONUS).
As the prevalence of CAM use increases, there is more
potential for interactions with conventional medicine. Providers
need to be aware of CAM use among their patients to
prevent these interactions. The goal of this study is to determine
the prevalence and types of CAM use at an OCONUS
military medical clinic among the distinctly different and ethnically
diverse background of Hawaii.
The survey consisted of volunteers who were 18 years old or
greater and enrolled at TAMC Family Medicine Clinic with
scheduled appointments between the dates of September 1,
2008 to September 25, 2008. The TAMC Family Medicine
Clinic consists of a patient population of approximately
10,000 active duty personnel, dependents, and retired service
members from all branches of the military to include the U.S.
Army, Navy, Air Force, and Coast Guard. The study protocol
was approved by the human use committee at Tripler Army
Medical Center. Investigators adhered to the policies for protection
of human subjects as prescribed in 45 CFR46.
A modifi ed survey instrument fielded by Smith 7 in a study of
CAM use among U.S. active duty Navy and Marine Corps
personnel was used with the author’s permission. The survey
queried the volunteer’s use of CAM, specific CAM therapies
used, and demographic data. Volunteers were recruited when
they checked in for their appointments at the TAMC Family
Medicine Clinic. Volunteers were instructed to fill out the survey
during the visit and leave it in one of three labeled drop
boxes. The survey was coded with a nonidentifiable number
to determine nonresponse rates. The three-page survey was
designed to be completed in 5 minutes.
The definition of CAM that was used in this study is similar to
the criteria used by Smith and Eisenberg. [1, 5, 7] Three CAM therapies
were also added that were included in a Hawaii study. 
These were chelation, naturopathy, and Ayrvedic medicine.
CAM use was defined as any of the below therapies used
within the last year: acupuncture, chiropractics/osteopathy,
homeopathy, energy healing, spiritual/religious healing, folk
remedies, massage therapy, biofeedback, hypnosis, high-dose
megavitamins, art/music therapy, Ayrvedic medicine, Chinese
medicine, herbal therapy, chelation, exercise/movement therapy,
naturopathy, aromatherapy, and relaxation healing.
Statistical Analysis and Power Analysis
Descriptive statistics using frequency, means, and standard
deviation described our population studied. Education was
collapsed and the highest level education completed was used
(high school and college or greater) for bivariate and multivariate
analysis. Bivariate analyses using c 2 tests assessed
for significant associations between CAM use and demographic
variables. A multivariate model using logistic regression
assessed for independent associations of CAM use with
signifi cant demographic variables. The enter method and forward
stepwise regression were both utilized.
All analyses were conducted using SPSS software version
A power analysis was conducted and it was determined that
350–380 surveys were needed to estimate a prevalence of
45% (±5%) with a 95% confidence interval using the Family
Medicine enrollment base of 10,000 beneficiaries.
A total of 503 surveys were handed out. A total of 369 were
returned for analysis with a response rate of 73%. Demographic
data are presented in Table 1. In this study, the prevalence
of CAM use was 50.7%. The therapies used the most
were: massage therapy (58.3%, n = 109), relaxation (31.0%,
n = 58), osteopathic manipulative treatments (OMT)/chiropractics
(30.5%, n = 57), and herbals (29.4%, n = 55). The
least used therapies were chelation, Ayrvedic medicine, and
hypnosis (Figure 1). Of the 50% of participants who reported use
of CAM therapy, 73% reported using two or more therapies.
CAM therapies were used five or more times by 18% of the
participants (Figure 2).
In bivariate analysis, White/non-Hispanics (p value = 0.025),
women (p value = 0.002), and those completing a college
degree or higher (p value = 0.015) were found to be significantly
associated with CAM use. Similarly in multivariate
analysis, these variables remained significantly associated
with CAM use. Table 2 and Table 3 show bivariate and multivariate
The prevalence of CAM use among the active duty military
population has been shown to be similar to the civilian population. [2, 4, 6, 7]
Military personnel are stationed worldwide and are
exposed to a number of different cultures and potential CAM
therapies. Hawaii is a good representation of an OCONUS
military site with a military population exposed to a multitude
of mainstream and native CAM therapies.
The results of this study show a higher prevalence of CAM
use compared to the general U.S. and mainland active duty
population, but similar prevalence compared to the local
Hawaiian population. [2, 7, 8] The greater CAM use suggests a
local influence from a population of higher utilizers of CAM
therapy. The authors speculate that this may be due to an
increased availability or increased acceptance of CAM within
Hawaii that leads to a greater use among our patient population.
A higher prevalence was also noted among a population
visiting a conventional medicine clinic as opposed to a general
population survey. As such, the prevalence represents patients
who will ultimately be seen at the TAMC Family Medicine
Clinic. These are the same patients who need guidance and
education about potential interactions between conventional
and CAM therapies.
The data suggest that the odds of CAM use is significantly
greater among women, White/non-Hispanics, and those with
a completed education of college level or higher, which is
consistent with previous National Institutes of Health-funded
nationwide surveys. [2–4] Barnes et al.  surveyed a national sample
of households by phone and showed that CAM use was
also signifi cant among women, White/non-Hispanics, and
those with a higher level of education. The study suggests that
if a patient is going to use CAM therapy they are more likely
to use more than one type and many will use multiple therapies.
The more commonly used CAM therapies were consistent
with previous studies. [2–4]
Our findings suggest that Asian and Polynesian ethnicities
are less likely than Whites to use CAM therapies which are
contradictory to the Hawaiian study. This is most likely the
result of our patient selection. Those enrolled in the clinic are
more likely to use conventional therapy even if they are ethnically
similar to the local population. Secondly, our patient
demographics surveyed fewer Asians and Polynesians. We
likely did not have adequate power to detect a difference
among the Asian and Polynesian population. Our findings
suggest that the higher prevalence of CAM use is the result of
the local civilian population’s influence on the military population
and not due to military personnel who are ethnically
similar to the local population. Health providers working in
overseas medical facilities should be aware that their patient
population may have a higher prevalence of CAM use compared
to continental U.S. medical facilities. They should also
be aware that if the patient is using CAM they are more likely
using multiple therapies. As CAM use grows, lack of patients
reporting its use continues to pose an increased risk for interaction
with conventional medicine. [21–24] This study reaffirms
the need to ask patients about CAM therapies used.
There are limitations to this study. The data were self-reported
and are subject to reporting bias. Generalizability of
this study to other nonmilitary populations may be limited.
This study was limited to those patients who made appointments
to the TAMC Family Medicine Clinic and may have
selected for people who are not as healthy or are more likely
to seek out conventional medicine. However, these are patients
that physicians may encounter in a primary care setting and
may represent those that are more likely to utilize CAM
therapies. The study only surveyed prevalence of CAM use
and did not study the reason volunteers used CAM, specific
diseases they were trying to treat, or outcomes of CAM use.
Future studies should be done to help answer these questions.
In spite of its limitations, this study has a number of distinct
characteristics that contribute to our understanding of CAM
use. The response rate of the study was excellent. This study
gives a diverse representation of all services; Army, Navy, Air
Force, and Coast Guard. Further studies are needed to help
characterize CAM use among military medical installations
outside the mainland United States.
This work was supported by Tripler Army Medical Center Family Medicine
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