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The Association between Socioeconomic Status and Traditional Chinese
Medicine Use among Children in Taiwan
BMC Health Services Research 2012, 12:27 doi:10.1186/1472-6963-12-27
Chun-Chuan Shih (et1125@iris.seed.net.tw) Chien-Chang Liao (jacky48863027@yahoo.com.tw)
Yi-Chang Su (sychang@mail.cmu.edu.tw) Tsu F. Yeh (master@mail.cmu.edu.tw) Jaung-Geng Lin (jglin@mail.cmu.edu.tw)
ISSN 1472-6963 Article type Research article Submission date 10 February 2011 Acceptance date 1 February 2012
Publication date 1 February 2012
Article URL http://www.biomedcentral.com/1472-6963/12/27
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The Association between Socioeconomic Status and Traditional Chinese Medicine Use among Children in Taiwan
Chun-Chuan Shih1,2, Chien-Chang Liao3,4,5,†, Yi-Chang Su2, Tsu F. Yeh6, Jaung-Geng Lin1,*
1 The School of Chinese Medicine for Post-Baccalaureate, I-Shou University,
Kaohsiung County 82445, Taiwan
2 Graduate Institute of Chinese Medicine, China Medical University, Taichung 404,
Taiwan
3 Department of Anesthesiology, Taipei Medical University Hospital, Taipei 110,
Taiwan
4 Health Policy Research Center, Taipei Medical University Hospital, Taipei 110,
Taiwan
5 Management Office for Health Data, China Medical University Hospital, Taichung
404, Taiwan
6 School of Medicine, College of Medicine, China Medical University, Taichung 404,
Taiwan
†Equal contribution with first author
Email address: CCS: hwathai@seed.net.tw CCL: jacky48863027@yahoo.com.tw ccliao@tmu.edu.tw YCS: sychang@mail.cmu.edu.tw TFY: master@mail.cmu.edu.tw JGL: jglin@mail.cmu.edu.tw *Corresponding author Jaung-Geng Lin, MD, PhD Professor
Graduate Institute of Chinese Medicine, China Medical University
91 Hsueh-Shih Road Taichung 404, Taiwan
Tel: +886-4-2205-3366 ext 3311 Fax: +886-4-2203-5192
Abstract
Background: Traditional Chinese medicine (TCM) utilization is common in Asian
countries. Limited studies are available on the socioeconomic status (SES) associated
with TCM use among the pediatric population. We report on the association between
SES and TCM use among children and adolescents in Taiwan.
Methods: A National Health Interview Survey was conducted in Taiwan in 2001 that
included 5,971 children and adolescents. We assessed the children’s SES using the
head of household’s education, occupation and income. This information was used to
calculate pediatric SES scores, which in turn were divided into quartiles. Children and
adolescents who visited TCM in the past month were defined as TCM users.
Results: Compared to children in the second SES quartile, children in the fourth SES
quartile had a higher average number of TCM visits (0.12 vs. 0.06 visits, p = 0.027)
and higher TCM use prevalence (5.0% vs. 3.6%, p = 0.024) within the past month.
The adjusted odds ratio (OR) for TCM use was higher for children in the fourth SES
quartile than for those in the first SES quartile (OR 1.49; 95% confidence interval [CI]
1.02-2.17). The corresponding OR was 2.17 for girls (95% CI 1.24-3.78). The
highest-SES girls (aged 10-18 years) were most likely to visit TCM practices (OR
2.47; 95% CI 1.25-4.90).
and especially girls aged 10-18 years. Our findings point to the high use of
Background
Complementary and alternative medicine (CAM) is an increasingly popular
therapeutic mode among adults and children all over the world [1-6]. CAM use and
expenditures among adults in the US increased substantially between 1990 and 1997.
This phenomenon has been attributed primarily to an increase in the proportion of the
population seeking alternative therapies rather than to an increase in the number of
visits per patient [1]. In 1997 it was estimated that 42% of US adults used CAM. At
629 million visits, CAM use by Americans in 1997 exceeded even the total number of
visits to primary care physicians [1]. The prevalence of CAM use remained stable
from 1997 to 2002 [7]. About 40% of parents in the US were CAM users during this
time, whereas 21% had treated their child with CAM over the preceding year [5].
The National Centre for Complementary and Alternative Medicine at the National
Institutes of Health defined CAM as a diverse group of medical and health systems,
practices and products that are not presently considered to be part of conventional
allopathic medicine (AM) [8]. In Taiwan, traditional Chinese medicine (TCM) is legal
and like AM, is covered by the National Health Insurance. TCM includes acupuncture,
herbal medicine, moxi-bustion, Tuina, Baguan and their techniques. TCM use is
common among Koreans and people in Taiwan [9-14]. Even among white-collar
45% [15].
While TCM and CAM are commonly used in Taiwan [10-13] and among
immigrant Chinese populations in Canada and the United States [16, 17], their use in
western countries is increasing [2, 3, 7]. It was estimated in 2005 that about 72 million
US adults had used CAM within the past year [7]. With such large numbers of people
using CAM, the context surrounding its use should not be ignored.
CAM use for children with special health care needs is also common (64%),
especially among children with chronic illnesses or disabilities in the United States [4,
8]. In San Diego, approximately 23% of parents reported that their child had seen a
CAM provider in the past 12 month [3]. Parents who use CAM therapies are often
accustomed to seeking medical treatment for their children. In the United States, large
proportions of children who take herbal supplements also take prescriptions or
over-the-counter medications concurrently [18]. Because CAM care can be sought for
both sick and routine care [3], children with chronic illnesses are at least three times
more likely to use CAM than healthy children [19].
CAM use among children has been reported in Hong Kong, Singapore and the
United States [5, 8, 18, 20-23]. In Taiwan, most studies reported TCM use patterns
focused on the adult population [10, 13-15, 24-28]. However, limited studies have
socioeconomic factors and TCM utilization among adults in Taiwan was investigated
in previous researches [14, 24-26, 28, 29]. The association between high
socioeconomic status (SES) and TCM use was also found in adult cancer patients in
Taiwan [26]. A study based on Taiwan’s National Health Insurance also showed that
high education and income were associated with TCM use among adults [25].
However, no study has demonstrated the relationship between SES and pediatric
TCM use in Taiwan. This study used data from the Taiwan National Health Interview
Survey (NHIS) to investigate the association between SES and TCM utilization
Methods
Study Design and Participants
Before interviews were conducted, the interviewers explained the program to the
parents/guardians of children and invited their participation. Informed (written)
consents were then obtained from the parents/guardians of children. This study was
approved by the Bureau of Health Promotion of Taiwan.
Taiwan has a population of approximately 23 million people distributed across 7
cities and 18 counties. In 2001 the National Health Research Institute and Bureau of
Health Promotion of Taiwan conducted a nation-wide NHIS survey using a
face-to-face interview questionnaire [14,30]. The 2001 NHIS included a
representative sample of 22,121 interviewees from the non-institutional population.
With a standardized face-to-face interview questionnaire, the NHIS used a multi-stage
stratified sampling scheme to collect a representative sample of Taiwan’s population.
Approximately 323 interviewers were trained to administer these interviews. These
interviewers explained the study’s purpose at the beginning of each interview. If the
interviewee was of eligible age, the interview was either initiated at that time or
scheduled for later. The 2001 NHIS was a cross-sectional survey with sampling and
measurement details similar to those described elsewhere [24]. The response rate for
Data Collection
The 2001 NHIS content included questions about sociodemographic factors, health
status, self-reported height and weight, medical services utilization, lifestyle and heath
behaviors. The questionnaire included several questions on the use of medical
services, including: (1) In the past month, excluding dental care, have you used AM
outpatient services (e.g., routine prenatal checks, health examinations, hospitalizations
or emergency room visits)? or (2) In the past month, have you been to any TCM
hospitals or clinics? Individuals who reported AM use were defined as AM users and
those reporting TCM use were defined as TCM users.
Definition and Variables
TCM includes the following treatments: herbal medicine, acupuncture, moxibustion,
bone reduction, traditional trauma treatment, traditional dislocation treatment,
traditional fracture treatment, Tuina, Baguan and other therapies. Its practitioners are
licensed TCM physicians and practice in a hospital or clinic. TCM is legal in Taiwan,
and according to Taiwanese medical law, TCM physicians are allowed to advertise
the medical benefits of TCM. At the end of 2001, there were 2 public and 42 private
TCM hospitals in Taiwan as well as 2,544 private TCM clinics providing TCM
ambulatory care [10].
the population density (persons/km2) for each of these administrative units by
dividing the population (persons) of the unit by its area (km2). The first, second and
third tertiles were considered to be areas of low, moderate and high urbanization,
respectively [31]. We calculated the density of physicians per administrative unit
using the number of physicians per 10,000 persons.
Statistical Analysis
The SES of the head of the household was taken as the SES of each child. We
calculated scores for the head of the household’s education and occupation in an
effort to calculate SES scores according to Kuppuswamy’s SES scale [32]. This
entailed summing the scores for education (profession or honors = 7, graduate or
postgraduate = 6, intermediate or post-high school diploma = 5, high school
certificate = 4, middle school certificate = 3, primary school certificate = 2, illiterate =
1), occupation (profession = 10, semi-profession = 6, clerical worker or shop owner or
farmer = 5, skilled worker = 4, semi-skilled worker = 3, unskilled worker = 2,
unemployed = 1) and income (New Taiwan Dollars [NTDs]: <10,000 = 1,
10,000-19,999 = 2, 20000-39,999 = 3, 40000-59999 = 4, 60,000-79,999 = 6,
80000-99,999 = 10, >100,000 = 12) to calculate an overall SES score [32]. Each head
of household’s occupation was assessed according to criteria from a local study of
(scores 3-9), second (scores 10-11), third (scores 12-14), and fourth (15-29 scores). In
2001, one US dollar was equal to 35 NTDs and one NTD was the equivalent of 1.47
Indian rupees.
We compared the children’s mean ages, body mass index and number of TCM
visits. Moreover, we compared the children with respect to their SES quartile scores
according to the following criteria: mean age, mean SES score, and the mean number
of children in the household. We used analysis of variance statistical methods to test
whether these factors varied by SES scores. Chi-square tests were then used to
compare children from different SES quartile scores with respect to the gender
distribution, living in high-density urban areas, and use of TCM, as well as the use of
AM.
Adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated for
the relationship between TCM use and SES scores using four different logistic
regression models. Model 1 employed a multivariate logistic regression to calculate a
crude OR, adjusting for the sex and age of the children. Model 2 adjusted for body
mass index, children’s use of AM and head of household’s smoking and alcohol
consumption. Model 3 adjusted for the covariates in model 2 as well as urbanization.
Model 4 adjusted for the covariates in model 3 and for the head of household’s use of
with SES scores separately for boys and girls. All analyses were performed using SAS
software, version 8.0 (SAS Institute Inc., Carey, NC). Two-tailed probability values
Results
This study found that 4.7% of the 5,971 eligible pediatric participants had used
TCM within the past month. Compared to children from the lowest SES quartile,
children in the highest SES quartile had higher average numbers of TCM visits
(0.12±0.64 vs. 0.09±0.53, p<0.0001), a higher prevalence of TCM usage (5.9% vs.
4.3%, p = 0.024) and greater use of AM (39.5% vs. 32.5%, p = 0.0005) (Table 1).
Children from high SES families were also more likely to live in high-urban areas
(27.2% vs. 14.8%, p<0.0001). In contrast, the average age (8.5±5.2 vs. 10.0±5.2,
p<0.0001) and body mass index (17.8±3.9 vs. 18.5±4.5, p<0.0001) were lower in
children from the highest SES quartile than those from the lowest SES quartile. A
U-shaped relationship was found between the prevalence of TCM use and the SES
quartiles among this pediatric population.
Heads of households from the highest SES quartile were older (39.2±6.6 vs.
41.9±11.1, p<0.0001) and had more children (2.3±1.1 vs. 2.5±1.1, p<0.0001)
compared with those from the lowest quartiles. Among the heads of households,
significant differences in smoking (p<0.0001), alcohol consumption (p<0.0001), and
TCM use (p<0.0001) were also found between the SES quartiles.
In the multivariate logistic regression (Table 2), the adjusted OR for TCM use was
SES quartile (see model 1). The adjusted ORs in models 2, 3, and 4 were 1.43 (95%
CI 0.99-2.06), 1.43 (95% CI 0.98-2.08), and 1.49 (95% CI 1.02-2.17), respectively. A
significant p value for the OR trend was found in each model.
In the sex-stratified analysis (Table 3), there was no association between SES and
TCM use among boys. However, among girls, the ORs for the relationship between
TCM use and SES were 2.02 (95% CI 1.20-3.39) in model 1, 1.82 (95% CI 1.14-3.38)
in model 2, and 2.17 (95% CI 1.24-3.78) in model 4. The U-shaped pattern between
SES and TCM use was investigated only for girls. As shown in Figure 1, the
prevalence of TCM use was 2.2% in girls between 0-2 years of age, 5.4% in girls
between 5-6 years of age, 3.5% in girls between 9-10 years of age, and 7.4% in girls
17-18 years of age. The age-stratified analysis in model 1 (Table 4) showed that
compared to girls in the lowest SES quartile, girls in the highest SES quartile had a
higher OR for TCM use (OR 1.95; 95% CI 1.04-3.67). In model 3 the corresponding
OR was 2.10 (95% CI 1.08-4.08). Compared to girls in the first SES quartile, girls in
the fourth SES quartile had the highest OR for TCM use (OR 2.47; 95% CI 1.25-4.90).
The U-shape relationship between SES and TCM use existed in girls aged 10-18 years.
Discussion
This study was designed to provide a comprehensive analysis of the influence of
SES on TCM utilization among children. The results of this large-scale NHIS study
found that, among children in Taiwan, a higher prevalence of TCM visits was
associated with higher SES. High-SES adolescent girls were more likely to visit TCM
practitioners than low-SES girls. A significant trend was found between SES and
TCM utilization, even after controlling for many of the relevant associated factors. To
the best of our knowledge, this study is the first to examine the association between
SES and TCM utilization.
Many studies have reported that high SES is associated with the use of medical
health services [15, 25, 26, 34, 35]. Higher income levels and the presence of private
insurance were associated with more TCM or AM consultations among people in
Hong Kong [35]. In addition, the association between high SES and TCM use was
also found in cancer patients in Taiwan [26]. Daly et al reported that both high
education and high income were associated with TCM use among Caucasian adults in
Taiwan [15]. A study based on Taiwan’s National Health Insurance also showed
similar conditions in Taiwan [25]. At present, no study has reported an association
between SES and the use of unconventional medical services such as CAM or TCM
respect to socioeconomic factors; they did not confirm an association between SES
and TCM use. However, in this study we found that children of high-SES households
were more likely to use TCM compared with children of low-SES households. In
Taiwan, parental socioeconomic factors are meaningfully related to children’s mental
and physical health [36].
Because people of lower SES have greater morbidity, higher mortality and higher
barriers to access to more advanced medical services, they tend to seek cheaper health
services that are covered by public health insurance [34]. General health care and
public health care are considered to be cheaper health care options that people of low
SES are more likely to utilize. Yu et al [34] found that in Hong Kong, socioeconomic
deprivation was associated with public health care use. Among patients with
osteoarthritis in Hong Kong, low education and SES were associated with greater
disease severity [31]. In general, socioeconomically disadvantaged populations
experience inferior mental and overall health. Moreover, they report health service
needs similar to or even greater than those of high-SES populations [37].
In Taiwan, TCM has frequently been used to treat diseases of the respiratory
system, musculoskeletal disorders, injury and poisoning, and signs, symptoms and
ill-defined conditions [25]. Menstrual discomfort is also a frequent reason for females
low-SES girls, high-SES girls were more likely to seek TCM. In addition, further
analysis found that girls between the ages of 10-18 years were more likely to visit a
TCM practitioner compared to girls aged between 0-10 years. It has been documented
that menarche can begin at 10 years of age (average = 13, 95% confidence interval =
11-15 years) in Taiwanese girls [42]. Wu found that the average age at menarche for
adolescent girls in Taiwan was 12.11 years (95% confidence interval = 10.07-14.15
years) [43]. Consequently, we assumed that possibly these girls used TCM for treating
menstrual problems [38-41]. High-SES adolescent girls were found more likely to
seek TCM compared low-SES adolescent girls. Thus, we assumed that perhaps
high-SES parents were capable of paying more for care for their adolescent girls’
menstrual problems. National Health Insurance in Taiwan covers AM and TCM
services. However, the types of Chinese herbal medicine covered by the NHI are
limited to extracted TCM powder preparations prescribed by TCM physicians.
Patients are required to pay out of their own pocket for crude drugs and other TCM
products produced according to traditional methods. For example, the decoction
method (boiling several prescribed crude drugs down to make a Chinese medicinal
soup) has been used for thousands of years [29]. For females with menstrual problems,
TCM is one of the choices. TCM treatments for menstruation problems included
National Health Insurance. The four-agent decoction (i.e., Si Wu Tang) therapy [38]
and other TCM herbal medicine formulas [44] demonstrate adequate effectiveness in
reducing the menstrual pain associated with primary dysmenorrhoea. TCM in Taiwan,
as in other countries, is not the principal source of medical care; however, the market
for and effectiveness of TCM should not be ignored [45]. Because of the association
between age at menarche and body mass index later in life, we adjusted the final
model for children’s body mass index [46].
Parents are care givers and guardians for children. They are also the decision
makers for children’s medicine-seeking behaviour. In Taiwan, medical doctors were
considered a population with high SES. A recent local study showed interesting
results that medical doctors with experience with TCM training had higher use of
TCM services, as well as their relatives [27]. We considered that knowledge, attitude,
and practice for parents have great impact on children’s medicine-seeking behaviour.
The concern about the health of children by parents pushes them to seek other choices
for medical treatment and may be an important factor associated with TCM use in
children. The high rate of CAM or TCM utilization among children is a source of
increasing concern among pediatricians in Hong Kong and Singapore [22, 23]. In
Taiwan, limited information is available regarding the patterns and utilization of TCM
SES and TCM use among children in Taiwan.
CAM use varies by sex, race, geographic region, health insurance status, smoking
habits and alcohol consumption [3]. CAM use by parents/caretakers is the best
predictor for CAM use among children [4]. In this study’s final model, we
investigated how parents’ SES influenced the TCM utilization by children, adjusting
for the parents’ own use of TCM. Because of the association between childhood
obesity and SES reported in previous research, we also adjusted for childhood body
mass index [47]. In Taiwan, people with low income, severe diseases, pregnancy,
veteran, or some important occupational diseases and injuries are remitted a
copayment for National Health Insurance. In this study, people with low income were
included in the first quartile of income. Because the medical copayment remission,
low-income people might have less barrier to medical economics compared with
people of moderate income. In addition low-SES people have more morbidities than
the general population. These reasons may explain why the U-shaped relationship
exists between SES and TCM use among children in this study.
The principal strength of this study lies in its use of a large, nationally
representative survey of a non-institutionalized pediatric population in Taiwan.
However, this study still has several limitations. First, the responses to questions
use accurately. Second, the results will also be biased if respondents misreport their
SES. Finally, because this is a cross-sectional study, we cannot determine for certain
whether parents’ SES is the real cause of TCM use in children.
Conclusion
Children from high-SES families were more likely to use TCM compared with
children from low-SES families, especially among adolescent girls aged 10-18 years.
We assumed that adolescent girls (10-18 years) visited TCM settings due to their
menstrual problems. We also assumed high-SES parents to be capable of paying more
money for care for their adolescent daughters’ menstrual problems and thus more
likely to visit TCM settings. Because of the high rate of TCM and CAM use among
the Chinese populations in Canada and the United States [16, 29], it is important that
pediatricians be informed about such treatments and their popularity. CAM is an
aspect of children’s health care that should not be ignored [48]. By being aware of
these alternative medical practices, physicians will be able to discuss CAM with
parents, ensuring the continuity of essential conventional treatments. Further research
is needed to better understand the nature of this finding and how it influences health
outcomes.
Abbreviations
National Health Interview Survey; SES: socioeconomic status; TCM: traditional
Chinese medicine
Competing Interests
The authors declare that they have no competing interests.
Authors’ Contributions
CCS, CCL, TFY, YCS and JGL were involved in the study concept, design, research
questions, data interpretation and data acquisition. CCS CCL JGL contributed to data
analysis and drafted the manuscript. All authors revised the article for intellectual
content and approved the final version.
Acknowledgements: We acknowledged the Taipei Chinese Medical Association,
Taiwan for funding support (CCC97-RD-001). This study was also supported in part
by a grant from Committee on Chinese Medicine and Pharmacy, Department of
Health, Taiwan (grant number CCMP98-RD-038), China Medical University Hospital
(grant number 1MS1), Taiwan Department of Health Clinical Trial and Research
Center for Excellence (grant number DOH100-TD-B-111-004) and Taiwan
Department of Health Cancer Research Center of Excellence (grant number
DOH100-TD-C-111-005). The funders had no role in study design, data collection
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Figure 1 Prevalence of traditional Chinese medicine utilization among the pediatric population by sex and age.
3 0 le 1 T h e c h ar ac te ri st ic s of s tu d y p ed iat ri c p op u lat ion b y s oc ioe con om ic s tat u s S oc ioe conom ic s ta tus , s cor es 1s t 2nd 3r d 4t h M ea n ± S D M ea n ± S D M ea n ± S D M ea n ± S D p-va lue um be r 1325 1370 1753 1523 hi ldr en A ge , y ea rs 10.0 ± 5.2 9.3 ± 5.1 8.9 ± 5.1 8.5 ± 5.2 < 0.0001 B od y m as s i nde x , kg /m 2 18.5 ± 4.5 18.3 ± 4.3 18.0 ± 4.0 17.8 ± 3.9 < 0.0001 U se of t ra di ti ona l C hi ne se m edi ci ne , vi si ts 0.09 ± 0.53 0.06 ± 0.38 0.08 ± 0.41 0.12 ± 0.64 0.027 B o y s, % 51.3 49.7 51.2 54.1 0.1 1 L ive i n hi g h ur b ani za ti on, % 14.8 14.4 16.6 27.2 < 0.0001 U se of t ra di ti ona l C hi ne se m edi ci ne , % 4.3 3.6 4.9 5.9 0.024 U se of a ll opa thi c m edi ci ne , % 32.5 36.4 38.6 39.5 0.0005 ous ehol d l ea de rs A ge , y ea rs 41.9 ± 1 1.1 38.0 ± 7.9 38.2 ± 7.4 39.2 ± 6.6 < 0.0001 S oc ioe conom ic s ta tus , s cor es 7.5 ± 1.6 10.5 ± 0.5 12.8 ± 0.8 18.9 ± 3.4 < 0.0001 O cc upa ti on, s co re s 0.3 ± 0.5 0.9 ± 0.7 1.7 ± 0.9 2.6 ± 0.8 < 0.0001 N um be rs of hous ehol d l ea de r' s c hi ldr en 2.5 ± 1.1 2.5 ± 1.0 2.4 ± 1.0 2.3 ± 1.1 < 0.0001 E duc at ion ≥ 13 y ea rs , % 2.2 2.9 20.8 78.9 < 0.0001 In com e 40,000-79.999 N T D , % 6.0 26.4 57.1 67.3 < 0.0001 S m oki ng , % 46.6 63.1 50.4 41.8 < 0.0001 A lc ohol dr inki ng , % 37.4 46.1 41.6 41.6 0.0001
3 1 U se of t ra di ti ona l C hi ne se m edi ci ne , % 8.6 8.8 9.1 6.1 0.008 , s ta nda rd de vi at ion; T C M , t ra di ti ona l C hi ne se m edi ci ne .
3 2 le 2 O d d s r at ios an d 95% c on fi d en ce i n te rval s of u se o f t rad it ion al C h in es e m ed ic in e a m on g c h il d re n i n as soc iat io n w it h ioe con o m ic s ta tu s S oc ioe conom ic s ta tus , s cor es 1s t 2nd 3r d 4t h O R ( 95% C I) O R ( 95% C I) O R ( 95% C I) O R ( 95% C I) p f or T re nd ode l 1 1.00 (r ef er en ce ) 0.84 (0.57-1.24) 1.18 (0.84-1.66) 1.45 (1.03-2.04) 0.007 ode l 2 1.00 (r ef er en ce ) 0.77 (0.50-1.19) 1.12 (0.77-1.62) 1.43 (0.99-2.06) 0.013 ode l 3 1.00 (r ef er en ce ) 0.77 (0.50-1.19) 1.12 (0.77-1.63) 1.43 (0.98-2.08) 0.015 ode l 4 1.00 (r ef er en ce ) 0.76 (0.49-1.17) 1.1 1 (0.76-1.61) 1.49 (1.02-2.17) 0.009 I, c on fi de nc e i nt er va l; O R , odds r at io. ode l 1: a dj us te d pe di at ri c s ex a nd a g e. ode l 2: a dj us te d pe di at ri c s ex , a ge , bod y m as s i nde x , us e of a ll opa thi c m edi ci ne , hous ehol d l ea d er ’s s m oki ng , al cohol dr ink ing . ode l 3: a dj us te d c ova ri at es i n m ode l 2 pl us ur ba ni za ti on. ode l 4: a dj us te d c ova ri at es i n m ode l 3 pl us hous ehol d l ea de r’ s us e of t ra d it iona l C hi ne se m edi ci ne .
3 3 le 3 O d d s r at ios an d 95% c on fi d en ce i n te rval s of u se o f t rad it ion al C h in es e m ed ic in e a m on g c h il d re n i n as soc iat io n w it h ioe con o m ic s ta tu s b y s ex S oc ioe conom ic s ta tus , s cor es 1s t 2nd 3r d 4t h O R ( 95% C I) O R ( 95% C I) O R ( 95% C I) O R ( 95% C I) P f or T re nd o y s M ode l 1 1.00 (r ef er en ce ) 0.91 (0.55-1.49) 0.93 (0.59-1.49) 1.10 (0.69-1.74) 0.65 M ode l 2 1.00 (r ef er en ce ) 0.82 (0.47-1.45) 0.98 (0.59-1.62) 1.13 (0.68-1.87) 0.49 M ode l 3 1.00 (r ef er en ce ) 0.82 (0.46-1.44) 0.96 (0.58-1.59) 1.04 (0.62-1.75) 0.71 M ode l 4 1.00 (r ef er en ce ) 0.80 (0.45-1.41) 0.95 (0.57-1.59) 1.07 (0.63-1.79) 0.64 ir ls M ode l 1 1.00 (r ef er en ce ) 0.76 (0.41-1.42) 1.57 (0.94-2.64) 2.02 (1.20-3.39) 0.0006 M ode l 2 1.00 (r ef er en ce ) 0.70 (0.36-1.36) 1.29 (0.75-2.23) 1.82 (1.06-3.10) 0.005 M ode l 3 1.00 (r ef er en ce ) 0.69 (0.36-1.34) 1.31 (0.76-2.25) 1.96 (1.14-3.38) 0.002 M ode l 4 1.00 (r ef er en ce ) 0.69 (0.35-1.35) 1.29 (0.74-2.24) 2.17 (1.24-3.78) 0.001 bbr evi at ions : C I, conf ide nc e i nt er v al ; O R , odds r at io. ode l 1: a dj us te d pe di at ri c s ex a nd a g e. ode l 2: a dj us te d pe di at ri c s ex , a ge , bod y m as s i nde x , us e of a ll opa thi c m edi ci ne , hous ehol d l ea d er ’s s m oki ng , al cohol dr ink ing . ode l 3: a dj us te d c ova ri at es i n m ode l 2 pl us ur ba ni za ti on. ode l 4: a dj us te d c ova ri at es i n m ode l 3 pl us hous ehol d l ea de r’ s us e of t ra d it iona l C hi ne se m edi ci ne .
3 4 le 4 O d d s r at ios an d 95% c on fi d en ce i n te rval s of u se o f t rad it ion al C h in es e m ed ic in e a m on g c h il d re n i n as soc iat io n w it h h ou se h ol d ad er s’ s oc ioe con o m ic s tat u s am on g gi rl s b y a ge S oc ioe conom ic S ta tus , S cor es 1s t 2nd 3r d 4t h P er 5 S cor es I n cr ea se O R ( 95% C I) O R ( 95% C I) O R ( 95% C I) O R ( 95% C I) P f or T re nd O R ( 95% C I) ge , y ea rs 0-9 M ode l 1 1.00 (r ef er en ce ) 1.16 (0.41-3.30) 1.92 (0.76-4.86) 2.20 (0.87-5.59) 0.041 1.28 (0.96-1.72) M ode l 2 1.00 (r ef er en ce ) 0.95 (0.32-2.82) 0.94 (0.35-2.55) 1.48 (0.57-3.85) 0.34 1.12 (0.79-1.58) M ode l 3 1.00 (r ef er en ce ) 0.92 (0.31-2.74) 0.95 (0.35-2.56) 1.53 (0.58-4.01) 0.30 1.14 (0.80-1.62) M ode l 4 1.00 (r ef er en ce ) 0.82 (0.27-2.48) 0.88 (0.32-2.39) 1.49 (0.57-3.94) 0.29 1.14 ( 0.80-1.62) 10-18 M ode l 1 1.00 (r ef er en ce ) 0.57 (0.25-1.30) 1.38 (0.73-2.60) 1.95 (1.04-3.67) 0.007 1.51 (1.21-1.88) M ode l 2 1.00 (r ef er en ce ) 0.52 (0.22-1.23) 1.34 (0.70-2.59) 1.87 (0.98-3.57) 0.01 1 1.50 (1.20-1.88) M ode l 3 1.00 (r ef er en ce ) 0.51 (0.21-1.21) 1.37 (0.71-2.64) 2.10 (1.08-4.08) 0.005 1.61 (1.27-2.05) M ode l 4 1.00 (r ef er en ce ) 0.53 (0.22-1.28) 1.39 (0.71-2.72) 2.47 (1.25-4.90) 0.002 1.69 (1.32-2.16) bbr evi at ions : C I, conf ide nc e i nt er v al ; O R , odds r at io. ode l 1: a dj us te d pe di at ri c s ex a nd a g e. ode l 2: a dj us te d pe di at ri c s ex , a ge , bod y m as s i nde x , us e of a ll opa thi c m edi ci ne , hous ehol d l ea d er ’s s m oki ng , al cohol dr ink ing . ode l 3: a dj us te d c ova ri at es i n m ode l 2 pl us ur ba ni za ti on. ode l 4: a dj us te d c ova ri at es i n m ode l 3 pl us hous ehol de r’ s us e of t ra di ti on al C hi ne se m edi ci ne .
