Patients’ Attitudes towards Complementary and Alternative Medicine: A Cross-Sectional Study among Hypertensive Patients in Baghdad, Iraq- Juniper Publishers
Juniper Publishers- Journal of Complementary Medicine
Abstract
The use of complementary and alternative medicine
(CAM) in the management of hypertension (HTN) is evident. This
necessitates the need to investigate the prevalent attitudes that drive
the patient to pursue this practice. This study aimed to assess HTN
patients’ attitudes towards CAM; patient-doctor communication about CAM
and attitudes towards disclosing it to the physician. A cross-sectional
study was conducted among HTN patients attending out-patient clinics of
two major teaching hospitals in Baghdad, Iraq. A convenience sampling
method was adopted for the recruitment, and a validated CAM-attitude
questionnaire was used for gathering the information. CAM was used by
65.5% of respondents. A significant difference in patients’ attitudes
towards CAM was found between CAM-users (mean=4.34+1.67, median=5.0)
versus non-users (mean=1.31+0.93, median=1.0), P<0.001. The highest
favorable attitude towards CAM was seem among females patients
(mean=3.73+2.22, median=4.0, P<0.001) and patients holding an
elementary level of education (mean=5.01+1.7, median=5.0, P<0.001). A
poor patient-doctor communication about CAM was found and a
non-favorable attitude towards disclosing CAM to the physician was
detected among users of this practice. In addition, an inverse
relationship was found between attitudes towards CAM and attitudes
towards disclosing it to the physician (rho=-0.355, P<0.001). In
conclusion, CAM was a common practice among Iraqi HTN patients. Users of
CAM showed a favorable attitude towards it which was associated with
gender and patient’s educational level. Patient-doctor communication
about CAM was poor and characterized by poor attitudes towards
disclosing it to the physician. An inverse relationship between
attitudes towards CAM and attitudes towards disclosing it to the
physicians was detected.
Keywords: Complementary medicine; Attitudes; Disclosing CAM; Iraq; HypertensionAbbrevations: CAM: Complementary and Alternative Medicine; HTN: Management of Hypertension; IMOH: Iraqi Ministry of Health; CAMAQ: CAM-Attitudes Questionnaire; NCCIM: National Centre for Complementary and Integrative Medicine; SPSS: Statistical Package for Social Science; ROS: Reactive Oxygen Species
General Perception about Pneumonia
The trend of using CAM in the control of blood
pressure is growing. CAM constitutes therapies that are not classified
as standard pharmacological treatment [1]. It contains domains of
healing resources linked with individual beliefs and cultural treatment
practices like the use of crude herbs, meditation, massage, biofeedback,
reflexology, acupuncture, spirituality, homeopathy, hypnosis, and
cupping. Notably, therapies of CAM are differ according to the cultural
diversity around the world. Information on the guidelines for
preparation, doses, and dispensing is still insufficient and
inconvenient [2]. Previous
studies have reported the use of variety of herbal, non-herbal, and
other approaches in the control of blood pressure [3-6]. The rate of
using CAM in the management of blood pressure was as high as 85.7% [7].
However, the difference in the definition of CAM from country to country
make this rate varied from study to study.
The considerable use of CAM among HTN patients gives
an indication of a distinct attitude towards it. Previous studies have
found that users of CAM were characterized by a positive attitudes
towards this practice [8-10]. Patient’s attitude towards any treatment
is the overall assessment and evaluation of
patient’s beliefs and the outcome associated with that treatment
[11]. However, it remains unclear what attitude drives the HTN
patient to choose and maintain the use of CAM. Several notions
have been proposed that collectively explained patient’s attitude
towards CAM. These include a belief in nature and natural
remedy [12]. Adherents to natural remedy hold a strong belief
in the effectiveness of nature to cure the illness; as well as, a
belief that natural composition is always free from any side
effect resulted from the industrialized treatment [10]. Another
notion proposed that the favorable attitude towards CAM is a
factor of psychological agreement between patient’s philosophy
about CAM and the concept of health [13]. Rejection of science
(anti-science feeling) was found as another contributing factor
in the favorable attitude towards CAM. Users of CAM tend to
perceive that health as a comprehension of the body parts which
are intimately interconnected. Hence they reject the scientific
authority and hold a holistic opinion of health to cure from illness
[14]. Moreover, a belief in personal ability in contributing to good
health was found to be related with the positive attitude towards
CAM [15]. This means that faith in being able to contribute to
the health rather than referring it to the doctors or other health
professionals may affect the behavior of seeking a treatment.
The steady gain in using CAM was explained as a reason of
dissatisfaction with the standard treatment [16]. However, the
model suggested by Siahpush confirmed that discontent with
patient-doctor communication was the significant contributor
in searching CAM; whereas, dissatisfaction with the medical
treatment itself was not a significant predictor [17]. This
motivated the researchers to investigate patients’ disclosure
of CAM to the health professionals which was found to be very
poor [2,7,18]. As such, the current study will be more effective
in exploring an important issue related to patient-doctor
communication about CAM which is the attitudes towards
disclosing CAM to the physicians.
A recent qualitative scenario from Iraq reported that CAM
is prevalent among HTN characterized by using some kinds of
herbs; cupping; reflexology; and acupuncture in the control
of blood pressure [19]. Hence, the question that come into
investigation here is what the attitude and the associated factors
underlying Iraqi patient’s motivation to use CAM in the control
of blood pressure. This study was sought to determine the use
of CAM among HTN population; assess the prevalent attitudes
towards CAM and the associated factors; assess patient-doctor
communication about CAM and attitudes towards disclosing it to
the doctor; and find the relationship between patients’ attitudes
towards disclosing CAM to the doctor and attitudes towards
CAM.
Methods
Study design
A cross sectional study was conducted at outpatient clinics
of two major teaching hospitals in Baghdad, the capital of Iraq.
The duration of the study extended from Oct 2015 to July 2016.
Baghdad is divided by the river Tigris into two parts Karkh (the
west part) and Rusafa (the east part). Therefore; Ibn Al-Nafees
hospital (from Rusafa side) and Al-Karama hospital (from Karkh
side) were chosen as the study setting. Both hospitals are major
teaching and public hospitals in Baghdad affiliated to the Iraqi
Ministry of Health (IMOH) and providing healthcare at a very
low charge. The two hospitals are well-maintained with various
specialties of in-patient and out-patient services. They were
selected to
a) Allow a fair representation of hypertensive patients
from the city
b) To adhere to the instructions of IMOH that do not
permit conducting any type of research in more than two
hospitals of the city and
c) The outpatient clinics of both hospitals are frequently
visited by a considerable number of patients every day.
A convenience sampling technique was used for recruiting
HTN patients. A validated CAM-attitudes questionnaire (CAMAQ)
was used for the purpose of gathering the data. Ethical approval
to conduct the study was obtained from IMOH (#74633). The
study was conducted upon patients’ approval, and after obtaining
a signed informed consent. Monetary payment or other forms of
compensation were not offered.
Sample size: Calculation of the sample size was based on the
prevalence sampling technique [20]. Prevalence of hypertension
in Iraq is 38.5%, a confidence interval of 95%, an allowable
margin of error 5%. Assuming dropout rate of 20%; the target
sample size was 436 patients.
Participants: A total of 218 patients from each selected
hospital were invited to insure a fair representation of crosssectional
sample. Where patients were more than 18years old;
both genders; diagnosed with hypertension for at least one
year; and not too ill to communicate with the researcher. Newly
diagnosed patients were not included to avoid the confusion that
might be understood as suggesting more therapeutic options and
prevent creating additional stress that often accompaniesa new
diagnosis. Patients were informed about the study objectives
and protocols prior to participation. They were also assured that
their answers would be kept confidential, and no information
that could reflect their identity will be disclosed.
Assessment tool: The four sections CAMAQ was developed
based on previous literatures to achieve the aim of the study.
The first section contained the demographic characteristics
(gender, age, education, marital status, monthly income,
duration of hypertension, and co-morbidity). The second section
encompasses questions about the use of CAM. Participants were
questioned to report CAM usage by noting on a list of different
CAM products if they had used in the past or currently using
it to control their blood pressure. The list of CAM products
was based on a standard classification by the National Centre for Complementary and Integrative Medicine (NCCIM) [1].
Questions of the first and second sections were either multiple
choice responses (multiple options could be ticked) or openended
answers filled by the participants. Section three of the
questionnaire encompasses assessment of patient’s attitudes
towards CAM. Items of this domain reflected the following
dimensions: effectiveness, protection, safety, naturalist, personal
responsibility, and philosophy of health. These dimensions were
identified from previous literatures as potentially assessing
attitude towards CAM [10,15,21]. Responses to this domain
were measured using “Yes”, “No”, and “Do not know” answers.
The last section, section four, contained questions to assess
patient-doctor communication about CAM and the attitudes
towards disclosing CAM to the physician. Questions of this part
were obtained and amended from previous literatures [7,18].
The domain attitudes towards disclosing CAM use was also
measured using “Yes”, “No”, and “Do not know” answers. Face
validity of the questionnaire was assessed by consulting a panel
of experts for reasonableness, appropriateness, and sequence of
the items. While content validity was established by adopting the
same validated questions of the previous mentioned literatures.
Reliability analysis of the domains “attitude towards CAM” and
“attitude towards disclosing CAM” revealed a good internal
consistency (Cronbach alpha) of 0.68 and 0.69, respectively.
Statistical Analysis
The collected data was coded and entered to the program
Statistical Package for Social Science version 16 (SPSS Inc.,
Chicago, USA) for statistical analysis. Descriptive statics were
presented as frequencies, percentages, mean (+SD), and median
(IQR). For subsequent analysis, respondents were categorized as
either CAM users or non-users. Regarding the domain attitudes
towards CAM, a dichotomous measure was created from the
responses of its eight items. That is coded 1 for agreement
response and 0 otherwise. In consequence, this dichotomous
coding can be envisioned as indication of agreement to the items
of the domain. The overall higher score would be indicative of
favorable attitudes [22]. The same dichotomous measure was
created for the five items under the domain “attitudes towards
disclosing CAM to the physician”. A favorable attitude towards
this domain is a reflection of an overall higher score. Users of
CAM and non-users were compared in their attitudes by their
agreements proportion to each item. In addition, their overall
scores on both domains were compared by Mann-Whitney U test
to detect the significant differences between them. A priori level
of significance was accepted at 0.05. Further, Mann-Whitney
and Kruskal Wallis tests were used to detect the significant
differences in patients’ characteristics on attitudes towards CAM.
Added to this, Post-hoc analysis was performed to compare the
significant effect among the three groups of patient’s educational
level. For this type of analysis, a Bonferroni adjustment to the
alpha value of 0.05 was applied to control for type 1 error. The
adjustment was done by dividing the alpha value by 3 (the
number of tests that used to assess the significant differences
among three subgroups). In consequence, a stricter alpha value
of 0.017 was adopted. Lastly, Spearman rank order coefficient
was used to assess the relationship between the two domains
“attitudes towards CAM” and “attitudes towards disclosing CAM
to the physician”.
Result
Characteristics of respondents
A total of 400 valid responses were obtained recorded a
response rate of 91.7%. The values of systolic blood pressure
reading ranged from 155 to 230 mmHg (mean=187.5+15.9).
While, for diastolic blood pressure ranged from 80 to 110
(mean=93.4+5.6). The percentage of male was slightly higher
(55.2%) than that of females. Age of respondent ranged from
35 to 84 years old; patients > 65 years recorded the highest
percentage (54.8%). Other highest characteristics were
intermediate level of education (41.8%); intermediate monthly
income level (41.2%); patients who were in a relation (61.0%);
patients with HTN for more than five years (56.5%); and patients
with co-morbidity (72.5%). Details of patients’ characteristics
are presented in Table 1.
aEach 1 US Dollar = 1164 Iraqi Dinar.
bIn a relation involved the married respondents; while, not in a relation
involved the single, divorced, and widow respondents.
The use and attitudes towards CAM
The use of CAM was recognized by around two thirds
(65.5%) of respondents. Different products of CAM were used by
HTN patients to control the blood pressure. These were herbs;
cupping (“Alhijama” in Arab society); reflexology; acupuncture;
and some dietary supplements. The most used herbs were garlic;
flaxseeds; dried lime; rosella tea; green tea; saffron; ginger;
peppermint tea; and chines herbs.
*Mann-Whitney U test detected a significance level of P< 0.001.
Responses to the domain “attitudes towards CAM” revealed a
distinct favorable attitude towards some perceived characteristics
of CAM. These attitudes were recognized considerably among
patients who were using CAM to control their elevated blood
pressure as shown in Table 2. The first two items of the domain
reflected patients’ considerations towards effectiveness of CAM.
The proportion of patients’ agreements to the first (63.5%)
and second (47.3%) items were higher among CAM users than
non-users. The third item reflects patients’ considerations
towards the ability of CAM in protecting HTN patients from the
cardiovascular consequences. Nearly half (48.9%) of CAM users
responded with agreements to this item. However, none of CAM
non-users agreed to this item. The dimension safety of CAM was
reflected by patients’ responses to the fourth and fifth items
of the domain. It was noticed that three quarters (74.8%) and
more than three quarters (85.5%) of CAM users showed their
agreements to the fourth and fifth items respectively. In contrast,
a very low percentages of agreements were reported by nonusers
of CAM on the same items. The sixth item of the domain
reflected patients’ believes in the natural therapy. More than
half (55.0%) of CAM users were in agreements that CAM is more
natural form of healing than conventional medicine. While, nonusers
of CAM reported a low percentage of agreements (33.3%)
on this item. Concerning the dimension individual responsibility
(item number seven); more than half (59.2%) of CAM users
agreed that CAM enables them to take more active part in
maintaining the health. however, the agreement percentages of
CAM non-users on this item was very low (26.1%). In the last
item of the domain that reflected patients’ philosophy of health;
more than half of CAM users (59.5%) were also in agreement
that health is a about harmonizing the body, mind, and spirit.
However, a very low percentage (15.9%) was reported from nonusers
of CAM on the same item.
aaEach 1 US Dollar=1164 Iraqi Dinar.
bIn a relation involved the married respondents; while, not in a relation involved the single, divorced, and
The total score of the domain “attitudes towards CAM” for
CAM users extended from zero to 7; while it was ranged from
zero to 4 for CAM non-users. The mean of the total score for
CAM users was fairly higher (4.34+1.67) than that of CAM nonusers
(1.31+0.93). The medians were statistically different from
each other by Mann-Whitney U test, P<0.001. That is, patients’
who are using CAM in the management of HTN have a favorable
attitude toward CAM than non-users.
The analysis also assessed whether the score of attitude
towards CAM was a function of patients’ characteristics as
seen in Table 3. Female patients were higher in their favorable
attitudes towards CAM (mean=3.73+2.22) than male patients
(mean=2.94+1.83). A significant difference between genders
was obtained by Mann-Whitney U test, P<0.001. Patients’
with elementary level of education had favorable attitudes
(mean=5.01+1.71) greater than intermediate (2.83+1.60)
and high (1.55+1.14) levels of education. The medians were
statistically different among the three levels by Kruskal-Wallis
test, P<0.001. Post-hoc analysis of patient’s educational levels
showed that the medians were significantly different among
all the three subgroups. Patients’ with elementary level of
education had more favorable attitudes towards CAM higher
(median=5.0) than patients’ with intermediate (median=3.0)
and high (median=1.0) levels; P<0.017. Furthermore, patients’
with intermediate level of education had more favorable
attitudes towards CAM (median=3.0) than patients with high
(median=1.0) level of education, P<0.017. There were no effect
of age, income, marital status, duration of HTN, and co-morbidity
on attitudes towards CAM scores.
Patients-doctor communication about CAM
Patients were questioned whether they had been assessed
by their doctors about CAM usage. Notably, all of them reported
that they had never been asked by their doctors about any
treatment with CAM. They were then questioned whether they
had disclosed their CAM use to the doctor. Responses showed
that very few (11.5%, n=46) of CAM users had told their doctors
about their use of CAM to control the blood pressure.
*Mann-Whitney U test detected a significance level of P< 0.001.
Analysis were also performed to assess patients’ attitudes
towards disclosing CAM to the doctor as shown in Table 4.
Patients’ responses to the first item of this domain showed that
very few proportion (8.8%) of CAM users agreed that asking the
doctor about CAM is important. In contrary, more than three
quarters of CAM non-users responded with their agreement to
this item. In the second item, responses showed that very few
proportion (8.4%) of CAM users agreed that the doctor has good
information about CAM. Whereas; more than three quarters
of CAM non-users showed agreement on the same item. In the third item, half of CAM users responded that the doctor will
reject their usage of CAM; however less than half (40.6%) of
CAM non-users showed agreement on this item. Notably, both
types of respondents (users and non-users) reported with high
percentages their agreements on the fourth item of the domain.
The majority of CAM users (82.8%) agreed that the doctor did
not have enough time to discuss about CAM, and more than three
quarters (78.3%) of CAM non-users showed the same response.
Lastly, less than half (49.2%) of CAM users found it difficult to
talk to their doctors about CAM. However, a very low percentage
(19.6%) of CAM non-users showed agreement on this item.
Notably, attitudes towards disclosing CAM use to the
physician was significantly correlated with attitudes towards
using CAM as seen in Table 5. A negative medium correlation was
found via Spearman rank order coefficient (rho= -0.35, P<0.001).
This means that increased attitudes towards using CAM is
associated with deceased attitudes in disclosing this practice to
the doctor.
Discussion
The study revealed an important information within the area
of how attitudes towards CAM drive the HTN patients to pursue
this practice in the control of blood pressure. Despite previous
studies has discussed attitudes towards CAM among university
students and healthcare providers; the present study involved
HTN patients recruited from a hospital setting. Hence, this study
was capable of addressing attitudes towards CAM permitting
better generizability to HTN patients seeking CAM for prevention
and treatment. Up to this date, information explored from this
scenario is the first of its kind from Iraq.
The study showed that CAM users were in favorable
attitudes towards this practice; whereas, CAM non-users were
not. This was in line with previous studies that conducted in
the developed and developing countries [10,15,23]. Analysis of
the dimensions that composed this domain (attitudes towards
CAM) showed that CAM users were more likely to consider this
practice as effective treatment in the control of blood pressure.
Previous investigations also reported that the use of CAM is often
underpinned by a strong belief in effectiveness of CAM for various
illness[9,24]. Meanwhile, respondents also perceived that CAM
efficacy is equivalent or better than the standard conventional
treatment. This perception added evidence to the previous
reported data where CAM perceived to work in the same way and
sometimes better than the standard treatment [25]. A belief that
CAM treatment protects the HTN patients from cardiovascular
consequences was also predominant among CAM users. This
may explain why HTP patients maintain the use of CAM alongside
their conventional treatment as endorsed previously [24,26].
Interestingly, some species of herbs (flavonoids as an example)
are able to protect the heart from the damaging effect of reactive
oxygen species (ROS) contributing to the antioxidant defense
mechanism [27]. The analysis also showed that a large segment
of CAM users perceived CAM as safe products and not interact
with the conventional treatment. Variation in the safety and
CAM-drug interaction is yet a questionable issue of high concern
[22]. Pursuing CAM especially ingestion of herbs without proper
counselling may indirectly affect the treatment plane through
interactions with the components of the pharmacological
treatment [18]. Safety of CAM is still a global concern especially
when consumed in case of chronic diseases where multiple drug
therapy is required [4,28]. Serious interactions are reported
between cardiovascular treatment and some consumed herbs
for HTN like hawthorn, ginger, green tea, and peppers [29,30].
The only evident fact is that CAM with encouraging benefits and
safety for HTN condition encompasses garlic, biofeedback, yoga,
and message [31-33]. The perception of “natural effect” was also
prevalent among users of CAM in this scenario. Attitudes towards
using CAM have always been linked with the belief that CAM is
derived from nature resulting in natural cure from illness without
toxic effect to human body [2,13]. The natural composition of
CAM was found as the main reason of attraction to this practice
and often linked with the cultural beliefs of the society [4,13,34].
In addition, a philosophy of personal responsibility to take part
in maintaining the health was also prevalent among CAM users.
Personal responsibility for good health was assigned for the
favorable attitudes towards CAM [18,15]. The last dimension
of attitudes towards CAM revealed that users of this practice
considered health as a harmony between the body, mind and
spirit. A philosophy that health is the intimate interconnection
between body parts, mind and the spirit was indicated as a
significant predictor of favorable attitudes towards CAM [8,17].
Based on this result, it could be explained why those engaged
with CAM treatment showed high agreements to the attitude
items that reflect the predominant believes pertaining CAM;
whereas, those not pursuing CAM showed non-agreements to
the attitudes items.
One of the largest subgroup of respondents holding favorable
attitudes towards CAM were female and patients with elementary
level of education. Other demographic factors did not contribute
to the differences in attitudes towards CAM. This finding was
contradicted with the models suggested previously where age
of patients was the only predictor of positive attitudes towards
CAM [8,10]. This contradictory result may be attributed to the
differences in the population sample where university students
were recruited in previous studies in assessing attitudes towards
CAM. Further exploration is needed in this regard.
It was not surprising that patients of this study were never
assessed by their physicians about the use of CAM. Information
obtained from previous studies often revealed lack of patient’s
assessment within the context of CAM [5,6,9]. At the same
time, a considerable number of participants had not disclosed
their use of CAM to the physician. Similar finding was often
reported from related researches [2,7,35-36]. This revealed a
lack of awareness of patients and health professionals about
the dangerous associated with the unsupervised use of CAM.
Serious consequences were noted due the concomitant use of CAM (especially herbals) with the standard pharmacological
treatment like missed diagnoses, adverse effect, toxicity, and
failure of the HTN management plane [29,30,37]. This fact
necessitate the need to obtain a carful patient’s history on
CAM usage during the routine clinical assessment. This kind of
information is important for health care providers to give the
proper advice in the management of HTN; as well as, preventing
the risk of developing cardiovascular consequences.
Notably in this study, users of CAM showed poor attitudes
towards disclosing CAM use to the health professionals. A large
segment of CAM users denied the importance of asking the doctor
about CAM and disagreed that the doctor has a good information
related to CAM. Studies have suggested that non-favorable
attitudes towards disclosing CAM is associated with a rejection
of authority and a belief in personal responsibility toward health
[8,38]. However, CAM users were in agreement that the doctor
will reject their self-practice of CAM. Fear of doctor-rejection
and disapproval of CAM usage were often reported as reasons
of non-disclosure [2,9,38]. Noticeably, a considerable number of
both users and non-users of CAM were in agreement that doctors
did not have enough time for counselling about CAM. Insufficient
consultation time was found to be a barrier for many patients
to disclose their use of CAM to the physicians [39-40]. Lack of
interest shown by the doctors in assessing their patients about
CAM was found to be problematic in the communication flow
between the patients and the health professionals [2,39]. In
general, the interest with CAM among health professionals is not
encouraging. It was found that they prefer the standard validated
treatment, and most of them have a concern towards the safety
or efficacy of CAM therapy [41-42]. Hence, the disparate attitudes
between patients and their physicians may reduce the patients’
motives to disclose CAM usage to the health professionals.
The correlation analysis of this study has revealed an inverse
relationship between patients’ attitudes towards disclosing
CAM to the health professionals and the attitudes towards CAM.
That is, patients with favorable attitudes towards CAM are
less motivated to disclose this practice to their physicians. In
consequence, this may impose the risk of inaccurate diagnosis
and serious CAM-drug interactions. Therefore, an open dialog
with the patients is encouraged as long as patients are usually
consulting physicians who are the best informed in the field of
medical treatment.
Conclusion
The use of CAM for the control of blood pressure was
a common practice among Iraqi HTN patients. A favorable
attitude towards CAM was noted among users of this therapy
and was associated with gender and patient’s educational
level. Poor patient-doctor communication about CAM was
noted characterized by low disclosure of CAM usage to the
physicians. Added to this, poor attitudes towards disclosing
CAM use was prevalent among users of CAM. Moreover, patient’s
attitude towards disclosing CAM to the physician was inversely
correlated with their attitudes towards this practice. Therefore,
it became necessary that health professionals must inquire their
patients about the self-use of CAM to prevent the problems
associated with CAM-drug interaction and failure of therapeutic
management of hypertension.
Acknowledgment
The authors would like to thank all participants in Iraq for
their time and responses to this study.
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