The 2020 NAFKAM population survey

This edition of NAFKAM's monitoring survey of Norwegians' usage of complementary and alternative medicine (CAM) was carried out by Ipsos MMI in November/ December 2020.

It brought knowledge from telephone interviews with a total of 1,002 inhabitants aged 18 and over. These showed that after some years of decline, the use of CAM appeared to have stabilized by 2020:

Main results

In 2020, around 39% reported to having used one or more of the following categories of CAM for a specific health problem:

Having received one or more CAM therapies from a practitioner; used herbs/natural remedies; and/ or used self-help techniques, one or more times. On average, the cost per user of CAM in 2020 was NOK 3,440. Transferred to the total population level of people aged 18 years of age or older (According to Statistics Norway: 4,249,400 people), these costs added up to almost NOK 5.75 billion (regardless whether they used CAM or not). A closer look at the data shows that:

Some 20% of the respondents had received one or more CAM therapies from a practitioner; inside or outside the official healthcare system. Their patients' average cost for this was almost NOK 3,800.

About 9% stated having used herbs/natural remedies (such as ginseng, garlic, ginger, etc.) for a specific health problem. The average cost for this was just over NOK 1,000.

Almost 22% reported having used self-help techniques (yoga, mindfulness, meditation etc.) for a specific health problem. The average cost for this was NOK 535.

The most commonly used CAM therapies that Norwegians received from CAM practitioners that year were massage therapy, acupuncture, naprapathy, reiki healing, reflexology/zone therapy, osteopathy, cupping, homeopathy and kinesiology.

The respondents could also state if they had received other CAM therapies than the predefined. Among such reported, were quantum medicine, biophotone treatment, (biopathy), atlas correction, IKYA therapy, hypnotherapy, rosen therapy, aromatherapy and intercessory prayer.

The differences in usage of the predefined CAM therapies were minor, except for massage therapy, which also in 2020 constituted a significantly higher proportion than the others. From cross-checks in previous surveys, we know that Norwegian users of massage therapy mainly state health-related purposes over well-being or relaxation for using this. We see no reason indicating that this should be any different for the 2020 massage therapy-users.

Most commonly used CAM therapies in Norway, 2020

Therapy

Users (% of total)

Change from 2018 (pp)

Massage therapy

11,7

+0,6

Acupuncture

3,3

+0,4

Naprapathy

2,7

(-)

Other CAM therapy*)

1,5

-0,2

Reiki

1,4

-0,7

Zone therapy/ reflexology

1,2

(-)

Osteopathy

1,1

-0,1

Cupping

0,7

+0,4

Homeopathy

0,4

-0,3

Kinesiology

0,3

(-)

*) The alternative "Other CAM therapy" aims to record respondents' possible usage of other CAM therapies they may have received from a practitioner, than the 9 predefined therapies. Before reporting here, answers in this category are checked for potential school-medicinal therapies/ treatment from healthcare professionals representing the official healthcare system (eg eye surgery, physiotherapy, chiropractic treatment and the like); and such are thus removed.

Norwegians' use of dietary supplements in 2020

Regular use of dietary supplements is not considered as CAM, but NAFKAM has a special sub-task to monitor and report the population's use of dietary supplements. For practical reasons, this is investigated at the same time as the population's use of CAM.

In 2020, a total of 71% of the respondents stated that they had used supplements, with an average cost of NOK 1,037 per user. Transferred to the population level, Norwegians in 2020 spent approximately NOK 312.9 million on nutritional supplements. 

The CAM practitioners

Those respondents who reported having seen a CAM practitioner in 2020, were also asked if their practitioner was listed in the Norwegian official CAM Practitioners' Registry (Utøverregisteret):

Answer % of N (206)
Yes, the practitioner was listed 39,3%
No, not listed 13,4%
I don't know 47,3%
Total 100%

CAM users' experiences

The respondents who answered they had used CAM in 2020, also received three questions about their experiences from this.

  % of CAM users in 2020 Change from 2018 (pp)
Did you experience that your use of CAM negatively affected your state of health?    
Yes 2% (-)
No 93% (-3)
Unsure 5% (+3)
     
Did you experience any side- or adverse effects from this treatment?    
Yes 4% (-1)
No 91% (-3)
Unsure 5% (+4)
     
Did you experience that your use of CAM improved your state of health?    
Yes 59% (-3)
No 31% (-1)
Unsure 10% (+5)

Differences between men and women

The 1.002 respondents consisted of 52% men (521 individuals) and 48% women (481 individuals). The 2020 figures showed that women still use CAM and supplements more than men:

Share of respondents who...

% of the men in the survey

(change from 2018, in pp)

% of the women

(change from 2018)

% of all respondents

(change from 2018)

used one or more of the following forms for CAM: 30,7% (+1,3) 48,7% (+1,7) 39,4% (+1,9)
-treatment from a CAM provider 15,4% (-2,0) 26,2% (-3,0) 20,6% (-2,2)
-herbs/ natural remedies 8,8% (+0,4) 9,8% (-2,1) 9,3% (-0,7)
-self-help techniques 15,4% (+4,6) 28,7% (+4,3) 21,8% (+4,8)
       
used dietary supplements 70,1% (+7,1) 71,7% (-4,3) 70,9% (+1,9)

However: cost-wise, male users of CAM and supplements spent more money than female users: 

Average cost per user to...

Male users

(% change from 2018)

Female users 

(% change from 2018)

All users

(% change from 2018)

one or more of the following forms for CAM: NOK 3879,74 (-9,6%) NOK 3139,64 (-51,8%) NOK 3440,19 (-39,5%)
CAM providers NOK 3496,78 (+60,0%) NOK 3687,06 (+7,8%) NOK 3787,92 (+25,4%) 
herbs/ natural remedies NOK 1332,28 (+26,8%) NOK 706,36 (-17,3%) NOK 1015,96 (+7,6%) 
self-help techniques NOK 362,86 (-53,2%) NOK 634,70 (-71,7%) NOK 534,94 (-68,9%)
       
dietary supplements NOK 1124,87 (-28,2%) NOK 945,26 ( -22,2%) NOK 1037,59 (-23,1%)

Respondents' state of health in 2020

All respondents were asked how they perceived their own state of health; from "very good" to "very bad". Regardless of if they used CAM or not, more than 75 (77.3)% of the respondents rated their health as "good" or "very good". CAM users generally tended to rate their health as slightly worse than non-users.

The findings were mostly in line with previous editions of this survey.  

Consideration of own state of health CAM users in 2020 (change from 2018) Non-CAM users in 2020 (change from 2018)
Very good 28% (-4) 29% (-)
Good 46% (-) 50% (-3)
Neither good nor bad 17% (+3) 13% (-)
Bad 8% (+2) 6% (+2)
Very bad 1% (-1) 1% (-)
Don't know 0% (-) 1% (+1)

Occurence of long-term/ chronic illness

We also asked all respondents if they had a diagnosed long-term (chronic) disorder or disease. A total of 36.5% in the survey stated that they are diagnozed with such an illness/disease. The incidence of such health problems was slightly higher among users of CAM, than among those who did not use CAM:

  % of CAM users % of non-CAM users
Yes, I have such a disorder/ disease 38,3% 35,4%
No 61,2% 64,5%
Don't know/ prefer not to answer 0,5% 0,2%

Respondents' usage of the official healthcare system

All respondents were also asked about their potential usage and costs for school-medicinal treatment from the official healthcare system (e.g visits to their GP, the Emergency room, admittance to hospital, etc):

  among CAM users among non-CAM users
No.of consultations 7,51 4,86
Mean cost (for consultations, medicines, medical equipment, etc)  NOK 2790,86 NOK 1795,58

In 2020, Norwegian CAM users had approximately 2,65 more consultations with the official healthcare system, than non-CAM users; spending almost NOK 1000 per person more than non-CAM users. 

What does this mean, and why?

While Norwegians' total use of CAM was a little higher (+1,9 pp) in 2020 than 2018, users' costs were significantly lower (-40%). Several factors may have contributed to this: 
 
In 2020, treatment from CAM providers was 2.2 pp lower than in 2018. Use of such CAM has generally declined since 2012. Users' costs to CAM providers increased significantly, with more than 25% from 2018-20. In addition to the common, general raise in costs, this may be due to extraordinary conditions related to the corona situation in 2020; and/or that groups of CAM providers gradually increased their prices (to meet the order for full VAT liability from Jan 1, 2021). This may signify that mots CAM providers who were seen in 2020 were registered in the official Utøverregisteret; yet this assumption is not supported by the finding that merely 40% of those who had seen a CAM provider stated that the provider was registered.

CAM use in the form of herbs/natural remedies has been the most stable over time. However, the slight decline from 2016-18 seemed to continue into 2020: The share of people using such CAM fell further, from just above to just below 10%. In contrast to this relatively stable consumption, costs related to herbs and natural remedies have varied substantially: From 2018-2020, the average cost for users of herbs/ natural remedies increased by almost 8%. In addition to the common general raise in costs, users' purchasing preferences may have varied in the period (users do not specify what kind of herbs, at what price, or how much of they purchase at a given point in time). One hypothesis may be if prices for herbs and natural remedies rose extraordinary due to the total COVID situation and the lockdown of CAM providers specifically, though we have not measured this in the 2020 survey.

Use of self-help techniques (yoga, meditation, mindfulness etc) for specific health purposes was 4.8 pp higher in 2020 than in 2018, while the costs related to this were almost 70% lower. One explanation for this may be that costs related to instruction/training in self-help techniques are included in this category. Putting their knowledge and skills from such instruction into practise, is most probably free of charge. Thus, an increase in use and decrease in cost from 2018-20 for self-help techniques may be explained in that users of such CAM during the pandemic were also affected by lockdown of instructors and classes; thus the reported usage is linked to practising what they have learned previously, rather than attending new courses and instructional classes in self-help techniques.

Despite the pandemic's disease numbers and the population's possible fears of being infected by COVID-19, there was little in the respondents' self-assessment that indicate a general increase in need for treatment, neither among users nor non-users of CAM: The differences between these groups was in line with previous years.

Regarding other external factors, the general growth in wages and costs were slightly higher in 2020 than the year before. Also, access to CAM providers was lower in 2020 than usual, due to periodic forced lockdowns related to infection control. Some CAM providers started using digital solutions as a platform for treatment, and were thus able to follow up existing as well as attracting new customers.  In addition, we know that some groups of the CAM providers registered in the official Utøverregisteret, gradually increased their prices in order to meet the order for full VAT liability on CAM services from January 1, 2021.

All things considered, Norwegians' use of CAM was still high, and in line with comparable countries. CAM still accounted for a large part of Norwegian patients' total strategy for healthcare. The same can be said for the population's use of dietary supplements.

NB

The 2020 figures have not been corrected for any individual cases reporting very high usage and/or very high costs. Previous investigations have shown that these exist.
The development figures have not been corrected for the CPI (consumer price index).

Although the surveys' sample size has been approximately the same over the years (minimum 1,000 complete interviews; representative with regard to gender and geographical place of residence), the lower age limit may have had some significance for the answers:

While in the surveys from 2012-16 it was 15 years and in 2018 16 years, the lower age limit for responding in the 202 survey was set to 18 years; to better reflect the respondents' formal competence to consent, and their actual ability to make choices for their own health.

PS: In this survey, the term CAM includes health-related services (analysis, diagnosis, dietary or lifestyle advise, instructions as well as treatment, meant to maintain or improve health), provided mainly by non-authorised personnel outside the health care system, as well as patients' use of self-help strategies with herbs/ natural remedies and/or their use of self-help techniques for specific health problems. 

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Norway's National Research Center in Complementary and Alternative Medicine

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