584867
research-article2015
CMSXXX10.1177/1203475415584867Journal of Cutaneous Medicine & SurgeryAlGhamdi et al
Basic/Clinical Science
Use of Complementary and Alternative Medicine Among Dermatology Outpatients: Results From a National Survey
Journal of Cutaneous Medicine and Surgery 2015, Vol. 19(6) 570–579 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1203475415584867 jcms.sagepub.com
Khalid M. AlGhamdi1,2, Huma Khurrum2, Sahar H. Al-Natour3, Waleed Alghamdi4, Thamer Mubki5, Abdulatif Alzolibani6, Dhafer Mohammed Y. Hafez7, and Mohammed AlDraibi8
Abstract Background: Little is known about the prevalence and practice of complementary and alternative medicine (CAM) among dermatology patients in the Arab world. The aim of this study was to determine knowledge and attitudes about CAM, prevalence of its use, reasons for its use, and types of CAM used in dermatology patients in Saudi Arabia. Methods: This was a national survey of various regions of Saudi Arabia. In this cross-sectional study, dermatology outpatients were interviewed using a questionnaire. Sociodemographic characteristics, acceptability, utilization pattern, and reasons for CAM use were elicited. Dermatology life quality index (DLQI) was obtained. Results: Overall, 1901 patients returned complete questionnaires out of 2500 distributed (76% response rate). Of these, 808 (40%) were CAM users, and the majority were woman (55.1%), with a mean age of 31.6 ± 12 years. Most were literate (71.2%) and just over half were married (51.9%). Patients with acute skin diseases were found to be more likely to use CAM (P = .027). The mean DLQI score was higher (worse quality of life) among CAM users than among nonusers (P = .002). The results showed that 315 of 801 (40%) and 250 of 601 (30%) CAM users agreed that CAM methods are safer and more effective than modern medicine, respectively, and 83% will continue to use CAM in future. The most commonly used CAM modalities were vitamins, prayers, natural products, and herbs. Responses indicated that 379 of 803 (47.2%) CAM users did not consult their doctor before using CAM, and 219 of 743 (30%) did not obtain sufficient answers regarding CAM use from their dermatologists. Conclusions: There is a significant use of CAM among dermatology outpatients in Saudi Arabia. In view of the common belief that CAM has fewer side effects than conventional medicine, dermatologists need to increase their awareness of CAM. Résumé Contexte et objectif : On n’en sait très peu au sujet de la prévalence, des connaissances, des attitudes et des pratiques à l’égard de la médecine non conventionnelle (MNC) chez les patients en dermatologie dans le monde arabe. Cette étude visait à déterminer la prévalence de l’utilisation de la MNC chez les patients en dermatologie, les types de MNC auxquels les patients ont recours, ainsi que les motifs de cette utilisation. Méthodes : Il s’agit d’un sondage national mené dans diverses régions de l’Arabie saoudite. Dans cette étude transversale, les patients externes en dermatologie ont été interrogés à l’aide d’un questionnaire. Les caractéristiques sociodémographiques des répondants, l’acceptabilité, les tendances et les motifs de l’utilisation de la MNC ont été relevés. On a obtenu un indice dermatologique de la qualité de vie (Dermatology Life Quality Index – DLQI). Résultats : Dans l’ensemble, 1901 patients ont rempli et retourné le questionnaire, sur les 2500 qui ont été distribués (taux de réponse de 76 %). 808 (40 %) étaient des utilisateurs de MNC et la majorité était des femmes (55,1 %) âgées en moyenne de 31,6 ±12 ans. La plupart des sujets étaient alphabétisés (71,2 %) et mariés (51,9 %). Les patients souffrant de maladies aiguës de la peau se sont révélés être de plus grands utilisateurs de MNC (P = 0,027). Le score DLQI moyen était plus élevé (qualité de vie moins bonne) chez les utilisateurs de MNC que chez les non-utilisateurs (P = 0,002). Parmi les utilisateurs de MNC, 315/801 (40 %) étaient d’avis que ces modalités sont plus sûres et 250/601 (30 %), qu’elles sont plus efficaces que la médecine moderne, et 83 % continueront à utiliser la MNC à l’avenir. Les modalités de MNC les plus fréquemment utilisées
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étaient les vitamines, la prière, les produits naturels et les plantes médicinales. Parmi les utilisateurs de MNC, 379/803 (47,2 %) n’avaient jamais consulté de médecin avant d’avoir recours à la MNC et 219/743 (30 %) n’avaient pas obtenu de leur dermatologue des réponses suffisantes au sujet de l’utilisation de ces modalités. Conclusion : On constate une utilisation importante de MNC chez les patients externes en dermatologie en Arabie saoudite. Étant donné la croyance répandue selon laquelle la MNC a peu d’effets secondaires, les dermatologues doivent se sensibiliser davantage à la MNC. Keywords dermatological conditions, complementary and alternative medicine, dermatologists, dermatology outpatients, Saudi Arabia, herbs, dermatology quality of life
Complementary and alternative medicine (CAM) is gaining popularity worldwide. The National Center for Complementary and Alternative Medicine (NCCAM) in the United States defines CAM as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine.”1 Patients suffering from skin conditions are significant users of CAM. UK survey data indicate that 35% to 69% of patients with skin disease have used CAM in their lifetime.2 No such study has been performed in the Arab world, so no regional data on the use of CAM among patients with dermatologic conditions are available. CAM and herbal remedies for diabetes and its ensuing complications are commonly used in Saudi Arabia.3 Herbal remedies are the most popular type of CAM. The most commonly used herbs are myrrh, black seed, fenugreek, and aloes.3 Limited types of CAM are practiced in Saudi Arabia, including acupuncture, chiropractic, naturopathy, and traditional Chinese treatment.4 Various CAM practices are associated with adverse reactions, including drug interactions between CAM and allopathic treatments. These practices have resulted in low adherence to prescription drugs and delays in establishing diagnoses. Regional data are lacking in terms of how dermatology patients practice CAM and their knowledge and attitudes about CAM. Therefore, we performed this study to explore CAM use in our dermatology patients, to assess reasons why dermatology patients use CAM, and to evaluate sociodemographic and clinical variables in relation to CAM use.
Methods The current study was based on a cross-sectional, descriptive, hospital-based survey. Subjects included male and female adult patients attending dermatology clinics at the main hospitals of each province. We divided the Kingdom of Saudi Arabia into 5 regions: northern, southern, eastern, western, and central. The main tertiary care hospitals in each region were selected. After we performed a pilot study on 50 patients, we used their comments regarding the clarity and comprehension of questions to produce a final version of the survey. Then 2500 dermatology outpatients were selected for interviews. Dermatology outpatients were approached in person and asked to complete a survey regarding their use of CAM therapies during the previous year.
Survey Instrument The survey addressed the use of various CAM domains, including treatments or techniques, vitamins, herbs, or other dietary supplements during the previous year. The survey also addressed the types of skin conditions for which CAM was being used. Data were gathered using a questionnaire composed of 22 questions. The questionnaire was prepared with the objective of determining the CAM methods applied to dermatological complaints and the sociodemographic characteristics of the individuals. After consent was obtained and the methods were explained to the individuals by a trained research assistant, questions related to the CAM method used by the individuals were asked.
1
Dermatology Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia Vitiligo Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia 3 Department of Dermatology, University of Dammam, Saudi Arabia 4 Department of Dermatology, Security Forces Hospital Riyadh, Saudi Arabia 5 Department of Dermatology, College of Medicine, Al-Imam University, Riyadh, Saudi Arabia 6 Department of Dermatology, College of Medicine, Qassim University, Saudi Arabia 7 Department of Dermatology, Asir Central Hospital, Abha, Saudi Arabia 8 Department of Dermatology, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia 2
Corresponding Author: Khalid M. AlGhamdi, MD, Dermatology Department, College of Medicine, King Saud University, PO Box 240997, Riyadh, 11322, Saudi Arabia. Email:
[email protected]
572 The questionnaire consisted of several sections. The first section included basic sociodemographic information. The second section consisted of specific questions about CAM use, including the types, reasons, sources, and duration of CAM use; attitudes toward CAM use; any side effects or complication after using CAM; and disclosure of CAM use to their dermatologist. The third section included types of dermatological conditions and the duration of illness. The fourth section focused on the patient’s perceived severity of the disease assessed by the validated patient-administered Dermatological Life Quality Index (DLQI). A higher DLQI score/band corresponds to a lower quality of life and greater self-perceived disease severity. The questionnaire also included questions about the negative impact of the patients’ dermatological conditions on daily life, personal relationships, emotional well-being, and physical health. Absolute confidentiality of participants was guaranteed, and ethical approval of the study protocol was obtained from our institutional review board (IRB).
Statistical Analysis All data management and statistical analysis were performed using SPSS, version 16.0 for Windows (SPSS Inc, Chicago, Illinois). Frequencies were tabulated for categorical data, such as sociodemographic features. CAM prevalence, CAM type, and mean ± SD were calculated for continuous data. CAM usage rates were assessed for the entire sample and then analyzed by sociodemographic categories. Participants were categorized into 2 groups: patients who used CAM and patients who did not use CAM. Chi-square tests and t test were used to determine which of the sociodemographic variables were related to CAM use. Multiple logistic regression analysis was performed to determine different associations between CAM use and various variables. Statistical significance was set as P < .05.
Results In total, 2500 questionnaires were distributed. The results from all 5 regions in Saudi Arabia were analyzed collectively. The questionnaire was completed by 1916 patients, including 25.6% (490 patients) from the central region, 16% from the northern region, 21% from the southern region, 23.4% from the eastern region, and 14% from the western region. Of the 1916 completed responses (response rate 76.6%), 15 were significantly incomplete. Therefore, data from 1901 questionnaires were analyzed. In all, 808 male (40%) and 1093 female (60%) patients completed questionnaires. The sociodemographic characteristics of the respondents are presented in Table 1. In total, 1901 dermatological patients participated in the study. Of the respondents, 808 (40%) were CAM users, and 1093 (60%) were nonusers. The mean age of study participants was 31.6 ± 12 years. Significant
Journal of Cutaneous Medicine and Surgery 19(6) differences were observed between CAM users and nonusers with regard to gender, marital status, education level, and occupation. A majority of CAM users were women (55.1%), were literate (71.2%), and were married (51.9%). No significant differences were noted between CAM users and nonusers in terms of monthly income and urban or rural residence (P > .05). The mean score on the DLQI was higher (indicating a poorer quality of life) among CAM users compared with CAM nonusers (P = .002). This suggests that patients with low quality of life have more motivation to use alternative medicine. With regard to the knowledge of and attitudes about CAM between users and nonusers, highly significant differences (P < .001) were observed (Table 2). For example, 340 (42%) CAM users reported researching CAM-related information occasionally, whereas 29% and 26% of nonusers rarely or never searched for information, respectively. Moreover, 315 of 801 (39.3%) and 250 of 801 (31%) CAM users agreed that CAM methods are safer and more effective than traditional Western medicine, respectively, and 83% of CAM users planned to continue to use CAM in the future. In addition, 379 (47.2%) CAM users did not consult a doctor before using CAM, and approximately 219 (30%) were unable to obtain a sufficient answer regarding CAM use. In total, 41.4% of CAM users reported some improvements in their symptoms after using CAM, and 71.4% (577/808) of patients were willing to use CAM together with modern medicine in the future. Figure 1 presents the distribution of various types of CAM and the methods used by different dermatological patients. In total, 50% to 70% of patients reported the use of herbs and spiritual healing, including the Quran (directly) and reading the Quran, as well as blowing air into water or oil and taking vitamins, to treat their skin illnesses. Massage was frequently used by patients with eczema (37.1%), dermatitis (40.4%), urticaria (32.3%), and melasma (27.3%), whereas cupping and acupuncture were more likely to be used by patients with psoriasis (32% and 18%, respectively). Henna (Lawsonia inermis), black seeds (Nigella sativa), and fenugreek (Trigonella foenum-graecum) were used more frequently. Rashad seeds (garden cress) or sanoot (mugwort) were frequently used to treat skin infections (35%) and urticaria (46%). The use of garden cress seeds to treat scars (31%) and cactus to treat skin infections (50%) was also noted. The use of myrrh (Commiphora molmol) was high among the CAM group (20%-55%). Vitiligo was mainly treated by black seeds, honey, and Zamzam water (holy water from Makkah). Honey, Zamzam water, and combinations of different methods were frequently used (Figure 1). Among the participants using CAM, the most cited reason was the preference for treatment using a natural source (73.5%) and to avoid the side effects associated with chemical drugs (61.5%) (Figure 2). Based on logistic regression analysis, sociodemographic characteristics of
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AlGhamdi et al Table 1. Sociodemographic Characteristics of CAM Users, Nonusers, and Total Sample. Variable Age, mean ± SD Gender, n (%) Female Male Marital status, n (%) Married Single Divorced Widowed Education level, n (%) Primary Secondary and above Occupation, n (%) Government employee Private sector Student Unemployed Monthly income in Saudi Riyal, n (%)b 20,000 Residence, n (%) Urban Rural Quality of Life Index score, mean ± SD
CAM Users
CAM Nonusers
Total Sample
P Value
31.6 ± 11.42
30.4 ± 12.45
31 ± 12.0
.035a
445 (55.1) 362 (44.9)
522 (47.8) 571 (52.2)
967 (50.9) 933 (49.1)
.002a
414 (51.9) 340 (42.6) 29 (3.6) 15 (1.9)
495 (45.8) 552 (51.1) 25 (2.3) 8 (0.7)
909 (48.4) 892 (47.5) 54 (2.9) 23 (1.2)
