To the best of our knowledge, this is the first study that used multiple years of nationally representative data to examine the trends in Tai Chi and Qi Gong (TCQ) use over ten years. Overall, TCQ use has substantially increased, particularly in the last five years examined, from 2012 to 2017, and to a lesser degree from 2007 to 2012. While there is no single explanation for the marked increase in the use of TCQ among U.S. adults, the following several factors may contribute to the increase.
Firstly, for decades there has been growing global awareness of Traditional Chinese Medicine (TCM) practices that have been in use throughout China and some other Asian countries for centuries to promote health and prevent disease. As essential components of TCM, the practices of TCQ have also increased in Western countries, especially among older people, Asian race/ethnicities, and economically disadvantaged individuals searching for holistic and gentle, culturally appropriate, and cost-effective modalities for health, wellness, and medical conditions. Secondly, the increasing use of TCQ may be attributed to the increased complexity of age-related medical conditions (e.g., fear of falling, knee arthritis, fibromyalgia, and pain) as it has been evidenced that TCQ can effectively improve those conditions.[3–7] Thirdly, the increased visibility of TCQ in popular media (e.g., internet, books, TIME magazines, newspapers, radios, CDs, and DVDs) may be conducive to the increasing TCQ popularity as well. For instance, the notable use by celebrities may have stimulated people’s interest and increased people's acceptance in the U.S. This popularity can be reflected with the proliferation of TCQ organizations/associations, studios as well as TCQ classes offered in different settings ranging from self-practice to college classes. Fourthly, the other contributory factor in TCQ’s growing use may due to the increased aging population as researchers indicated that TCQ may represent a broader appeal to the elderly with regard to its gentle movement combined with breathing relaxation. The use of TCQ has also increased in prevalence as the elderly population has grown in the U.S. Research supporting the benefits of TCQ for age-related conditions might also explain the strong increase in prevalence with age in the current sample.[34–36] Lastly, the growing use of TCQ may be facilitated by the advanced scientific reports on the effectiveness of TCQ in improving well-being and treating various age-related medical conditions. At the same time, the promotion of these findings in non-professional media have speat scientific evidence and strengthens perceived benefits of these therapies, especially for the elderly. These reports have burgeoned, especially since 2007. For example, a Cumulative Index of Nursing and Allied Health Literature (CINAHL) search about the benefits of TCQ from 2007-2020 show more than 7,057 articles, while a similar search from 1983-2006 resulted in fewer than 2,071 articles. The increasing use of these therapies in American society, coupled with increased awareness of the benefits of TCQ, may explain most of the observed increase in TCQ use.
Previous studies have reported that a predominance of females used Yoga, while almost no gender differences have been reported for TCQ use in the U.S., mainly because TCQ was viewed as gender-neutral exercise.[1, 23, 37] However, our study found that the use of TCQ in the U.S. has significantly increased only among females but not males from 2012 to 2017. Further investigation is warranted as to why TCQ began attracting more female practitioners in the last few years, especially as Tai Chi traditionally may have been perceived as a more “masculine” practice in the U.S, given its origin in martial arts. It is also worth noting that our study showed that the highest increased use of TCQ was for economically disadvantaged individuals. There is limited research about why TCQ is becoming more attractive to this vulnerable subgroup of the U.S. population. One possible explanation may be because TCQ has been used as cost-effective healing/exercise therapies for health promotion and disease prevention.[39–41]
Another interesting finding in our study is that the more significant change is for people who have been physically inactive compared with people who have been doing some physical activities and/or regular physical activities from 2012 to 2017. This may be because more and more people are aware of the unique qualities of TCQ, as they involve the form of physical activity (i.e., graceful body movement). However, as a form of physical activity, the TCQ practices are unique because they are embedded in a comprehensive philosophy of overall well-being and therefore go beyond what is usually provided in exercise-oriented sessions. As a holistic exercise practice based on meditation, the TCQ practices include not only physical but also the mental and spiritual components.
Among the four healthcare-related factors examined in our study, we found that most of them were not significantly associated with TCQ use; however, having delayed access to conventional care was significantly associated with TCQ use for all three survey years from 2007 to 2017. In addition, our study found that TCQ use among U.S. adults is not statistically significantly associated with "having difficulty in affording prescription medications" across all the three points." "Medical treatments were too expensive" was reported as the second to the last reason people used TCQ in a previous study. Our findings differ from several previous studies that found general CAM use is associated with higher medical care utilization.[43–45] In fact, TCQ may be able to serve as an essential cost-effective holistic therapy in reducing health care costs, especially for some chronic medical conditions, such as hypertension, knee osteoarthritis, fibromyalgia, and fall prevention.[39–41]
Among the predictive factors for TCQ use from 2007 to 2017, our study indicates that the association between the sociodemographic factors and TCQ use have changed in the past ten years. For example, Birdee et al. (2008) reported TCQ users were evenly distributed from young adults to the elderly however; our study found that TCQ use was much more prevalent among people older than 45 years than younger in both 2012 and 2017. While previous studies reported that TCQ appeared to be gender-neutral,[1, 38] our study found that females were significantly more likely to practice TCQ than males before the 12 months of the 2017 NHIS was conducted. While non-Hispanic white adults were more likely to use Yoga, Asians were more likely to practice TCQ in 2007 and 2017. This result is consistent with previous findings and is not surprising, given that TCQ originated in Asia and, therefore its use in the Asian community might be expected. Another interesting finding from our study is that while Yoga is disproportionately practiced among high-income groups in the U.S., the use of TCQ in 2017 is significantly associated with people having low-income than higher incomes. Differences in practitioners' characteristics between Yoga and TCQ have been found for age, race/ethnicity, income, and physical activity level, all indicating that Yoga and TCQ attract somewhat different subpopulations, which may be a result of differences in the features of the practices themselves or differences in delivery-related parameters in the U.S. as they were all immigrated mind-body therapies from the Eastern medical tradition. Therefore, it is worth differentiating between Yoga and TCQ and finding how they would meet the needs for further dialogue and diffusion.
There are several limitations in the study. First, the measures of this study were based on self-reported questions in NHIS surveys; therefor respondents' memory and/or willingness to report their TCQ use may lead to recall bias. Second, for each of the three NHIS surveys, the data were collected at one point in time, which makes it impossible to provide consecutive estimates of annual prevalence. Third, NHIS data collection/sampling methods and survey design have undergone major changes overtime (i.e., from 2002 to 2017). For example, the number of questions assessing the use of TCQ were reduced in 2017, which may not be comparable to the questions in the ALT section of 2007 and 2012. As a result, these revisions precluded direct comparisons for some questions and restricted the trend analysis only to the questions which were asked consistently in the three survey years.
However, our study provided the most updated and detailed information about the changing trends of TCQ use among U.S. adults within 10 years from 2007 to 2017. The information we provided may help to better inform the future directions of TCQ application and clinical research. This information could also stimulate further dialogue among medical professionals, insurance companies, health policymakers, and patients to consider the unique features of TCQ and benefits that TCQ may offer, especially for racial/ethnic minorities, economically disadvantaged populations, older adults, and people who are physically inactive, therefore, to suggest practical strategies to integrate TCQ into the current health care system to help reduce health disparities among these vulnerable populations.