The 2020 NAFKAM population survey

The 2020-edition of NAFKAMs national survey was carried out by Ipsos at the turn of the month November/December 2020. Original analysis and reporting was done by Frauke Musial and Ola Lillenes.

In November 2022, the data were re-analysed by Agnete E. Kristoffersen, for increased comparison with the other editions of this survey. This report was therefore upgraded in January 2023, due to this and requirements for universal design and accessibility.

The 2020 survey provided knowledge from 1,002 telephone interviews with residents aged 18 and over. At the end of 2020, the total population for this age group, according to Statistics Norway, was 4,248,972 people, consisting of 2,132,477 men (50.2%) and 2,116,495 women (49.8%). In our survey, the proportion of male respondents was slightly higher (51.9%) and the proportion of female respondents correspondingly lower (48.1%).

Total CAM use

This year, 39.3% reported having used complementary and alternative medicine (CAM) treatment for health purposes, ie one or more of the following forms for CAM:

  1. Received one or more CAM therapies from a provider (20,6%), and/or
  2. Herbs/natural remedies (9,3%), and/or
  3. and/or used self-help techniques (21,8%)

Overall, use of CAM was most common among women: 48.6% of the women in the survey reported having used one or more of the above, compared to 30.7% of the men. The user group thus consisted of 41% men and 59% women.

The average cost for those who used CAM in 2020 was NOK 2,561.50. The average cost for male users was NOK 2,579.70, and among female users it was NOK 2,549.00. Transferred to population level, these figures correspond to 1.6 million Norwegians aged 18 or older using CAM in 2020, at a total cost of NOK 4.3 billion.

A closer look at the data shows the following:

CAM treatment from providers in 2020

20.6% of all respondents stated that they had received one or more CAM therapies from a provider inside or outside the public health care system. This was more common among women (26.2%) than among the men in the survey (15.5%). The user group was thus divided into 39% men and 61% women.

The average cost to CAM providers was NOK 3,769.60 per user. Transferred to population level, these figures correspond to 879,537 people receiving CAM treatment from a provider in 2020, at a total cost of NOK 3.3 billion.

Most commonly used CAM therapies in 2020 (Table):

CAM Therapy % who used
Massage therapy 14,0
Acupuncture 4,8
Naprapathy 2,9
Osteopathy 1,4
Reiki healing 1,4
Zone therapy/ reflexology 1,2
Cupping 0,7
Homeopathy 0,4
Other*) 1,5

Among the "other" CAM therapies reported than those predefined, were quantum medicine, biophotone therapy, biopathy, Atlas correction, IKYA therapy, hypnotherapy, Rosen therapy, aromatherapy and intercessory prayer.

The differences in the use of the predefined therapies were small, except for massage therapy, which also in 2020 constituted a significantly higher proportion than the others. You can read more about this in our general article on NAFKAM's population survey, or in the report from the 2014 survey.

The CAM providers in 2020

Respondents who had seen a CAM provider in 2020, were also asked if their provider was listed in the Norwegian official CAM Practitioners' Registry (Utøverregisteret):

Use of herbs/natural remedies in 2020

9.3% reported having used herbs/natural remedies (for example ginseng, garlic, ginger or the like) for health purposes in 2020. This  was more common among the women (9.8%) than among the men in the survey (8.8%). The user group was thus divided into 49.5% men and 50.5% women.

The average cost for this was NOK 1,016.00 per user. The average cost for male users was NOK 1,332.30, and among female users it was NOK 706.40. Transferred to population level, these figures correspond to 395,154 people using herbs/ natural remedies in 2020, at a total cost of NOK 401.4 million.

Use of self-help techniques in 2020

21.8% reported having used self-help techniques (for example yoga, mindfulness, meditation or similar) for health purposes in 2020. This was more common among the women (28.7%) than among the men in the survey (15.4%). The user group was thus divided into 37% men and 73% women.

The average cost for this was NOK 534.90 per user. The average cost for male users was NOK 362.90 and among female users it was NOK 634.70. Transferred to the population level, these figures correspond to 926,276 people using self-help techniques for health purposes in 2020, at a total cost of NOK 495.5 million.

CAM users' experiences

The 39.3% who stated having used CAM in 2020 were asked three follow-up questions about their experiences with CAM. These were related to perceived side effects, worsening or improvement of their health situation.

Almost six out of ten users (59%) perceived that their health improved from such treatment. Only 4% of users reported side effects, and 2% reported poorer health after using CAM. Transferred to the population level, these percentages still represent 66,800 and 33,400 people respectively.

In NAFKAMs view, this indicates that patient safety must still be taken seriously within CAM. Only a few reported both, i.e. having noticed both health improvement and -deterioration. This can be interpreted to apply to several different treatment situations (different therapies, practitioners and/or different episodes of the same treatment).

Gender differences in CAM use in 2020

The 1,002 respondents consisted of 521 men and 481 women. The 2020 data showed that women still used CAM more than men:

However, male users' costs were generally on average NOK 30.7 higher than female users' in 2020:

Norwegians' state of health in 2020

The respondents were asked to evaluate their own health situation, by rating it from "very good" to "very bad":

More than 75% rated their health as good or very good, regardless of whether they were CAM users or not (CAM users generally rated their health slightly worse than non-users).

The incidence of long-term/ chronic illness in Norway in 2020

The respondents were also asked if they had any long-term (chronic) disorder or illness, diagnosed by a Medical Doctor. A total of 36.5% reported having such an illness/disease. The incidence of such health problems was slightly higher among CAM users than among non-users:

Usage of medical treatment and the official healthcare system

The respondents were also asked about their use of and costs for medical treatment in/ from the public healthcare system (such as a GP/MD, emergency room, hospital, specialist health service and more):

In 2020, CAM users had on average 2.7 more consultations in the health care system than non-users, and on average CAM users' costs related to this were almost NOK 1,000 higher than those who did not use CAM.

Norwegians' use of dietary supplements in 2020

NAFKAM does not consider ordinary use (in line with the declaration) of dietary supplements (e.g vitamins, minerals, trace elements etc) to strengthen one's health as CAM, but we measure the populations' use of such on behalf of the Norwegian health authorities.

A total of 70.9% reported having used dietary supplements in 2020. The use of supplements was slightly more common among the women (71.7%) than among the men in the survey (70.1%). The user group was thus divided into 51% men and 49% women.

The average cost for supplements was NOK 1,037.60 per user. The average cost for male users was NOK 1,124.90 and among female users it was NOK 945.30. Transferred to the population level, this corresponds to 3.0 million Norwegians using dietary supplements in 2020, at a total cost of NOK 3.1 billion.

What does this mean, and why?

While the populations' use of CAM was slightly higher (+1.9 pp) in 2020 than in 2018, CAM uses' costs were significantly lower (-40%). This may seem strange, but there are several reasons for this which can be commented on:

The proportion who received CAM treatment from practitioners was 2.2 pp lower in 2020 than in our previous survey (2018). This may partly be due to the periodic shutdown during the  corona situation in 2020, but the use of practitioners has been declining since 2012. At the same time, this user group's costs increased by more than 25% from 2018-20. This, in contrast to the fact that the number of providers in the official CAM Provider Registry increased from 2018-20 by 13% to 4,041. Registered CAM providers were still exempt from VAT on their treatment services in 2020, and could thus charge a lower price than non-registered providers. In 2020, we know that approximately 40% of the providers seen by the user group, were listed in this registry. In addition to a slightly higher general price increase in 2020 than in previous years; higher costs could be caused by both an extraordinary price increase following CAM providers conversion to digital consultations during the pandemic, and/or that the performers in the CAM Provider Registry gradually increased their prices in order to meet the order for full VAT obligation from 2021. 

The proportion who used herbs/natural remedies for health purposes has been relatively stable over the years, but the proportion who used herbs fell from just over 10% in 2018 to just below 10% in 2020, and the average cost to herbs fell in the same period by almost 8%. Differences and variations in these figures can partly be explained by the fact that purchase volume and market trends can vary from one survey to the next (users do not state the type of herbs, the unit price or the quantity they buy). An almost unchanged share in use and a simultaneous increase in costs may thus indicate that herbal users bought more and/or more expensive herbs in 2020 than before.

The use of self-help techniques for health purposes rose with 4.8 pp from 2018-20, while the costs to this fell dramatically: -69% lower than in 2018. Such a gap or mismatch between the development in use and costs of self-help techniques may be due to that costs are mainly linked to instruction/training; not to usage after classes, practising what one has learned. Increased use and lower costs from 2018-20 may mean that the user group increasingly used what they have learned previously, instead of spending money on new courses in the pandemic year of 2020.

Bottom line

Despite the pandemic's disease numbers and people's fear of being infected by COVID-19, there was little in the respondents' self-assessment of their health that indicated a generally increased need for treatment in 2020; neither among CAM users nor non-users. The differences between these groups were in line with previous years.

The decrease in the use of CAM practitioners continued, the use of herbs was virtually unchanged, and the use of self-help techniques increased somewhat. Self-treatment seemed to continue to dominate the population's use of CAM, at the expense of treatment from a CAM practitioner. The absence of treatment responsibilities associated with self-treatment can mean new aspects to consider in patient safety.

From May 2022, naprapaths and osteopaths are subject to the Health Personnel Act, and their therapies to be considered medical treatment provided inside the official health care system. It is too early to say whether the industry of CAM providers is under reduction, as a result of lost income base during the pandemic and/or lower competitiveness as a result of the order for full VAT from 2021 onwards. On the basis of 2020's users of CAM providers, the majority of them (60%) may theoretically have consulted CAM providers who were not in the official CAM Provider Registry - and were thus already subject to requirements for full VAT by 2021.

Overall, Norwegians' use of CAM was still high by 2020 and in line with comparable countries. CAM still makes up a large part of Norwegian patients' total healthcare. The same goes for the population's use of dietary supplements. Norwegians' use of this is still probably linked mostly to cod liver oil, vitamins, fish oil and the like, for which we have long traditions as a strategy for the general maintenance of good health; not for preventing or treating specific health problems.

PS:

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

In this survey, the term "CAM" encompasses a wide range of health-related services (analysis, diagnosis, dietary or lifestyle advise, instruction as well as actual treatment, meant to maintain or improve health), provided mainly by non-authorised personnel outside the health care system; as well as patients' self-initiated use of self-help strategies with herbs/ natural remedies and/or self-help techniques for specific health problems. 

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