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August 2012, Volume 62, Issue 8

Student's Corner

Attitude and Practice of Patients and Doctors towards Complementary and Alternative Medicine

Rabyyan Junaid  ( Third Year Students, Dow Medical College Campus, Dow University of Health Sciences, Karachi. )
Mustafa Abaas  ( Third Year Students, Dow Medical College Campus, Dow University of Health Sciences, Karachi. )
Batool Fatima  ( Third Year Students, Dow Medical College Campus, Dow University of Health Sciences, Karachi. )
Irma Anis  ( Third Year Students, Dow Medical College Campus, Dow University of Health Sciences, Karachi. )
Mehwish Hussain  ( Department of Research, Dow University of Health Sciences, Karachi. )

Abstract

Objectives: To determine the attitude towards complementary and alternative medicine among the doctors and patients.
Methods: The study was carried out at Civil Hospital Karachi and Liaquat National University Hospital, Karachi during April to September 2010. Two sets of questionnaires were developed separately for doctors and patients. Each set consisted of queries regarding demographic data of patients and doctors. The questionnaire for the patients contained questions reflecting the general attitude, mode of complimentary and alternative medicine usage, disease referred and the underlined reasons behind pricking the options. The questionnaires for doctors in general laid focus on the personal opinion about the practice not only for their own use, but also related to their concern towards those patients who used complimentary and alternative medicine. Predictive analysis software statistics 18 was used for statistical analysis.
Results: Of the patients, 237 (59.3%) used complimentary and alternative medicine. Herbal medicine followed by homeopathic medicine were the most commonly used therapies. Fever and cough were the most common diseases for which patients used the options. The preference was mainly based on inter-personal communications, reliance on complimentary and alternative medicine, and financial restriction. Concealing from the doctors was common in patients. Only 62 (34.4%) out of 180 doctors used complimentary and alternative medicine themselves. Refusal by other doctors was because they considered the option ineffective, obsolete and unsatisfactory. About half of the doctors forbade the patients to use such therapies, but 31% (n=73) patients ignored the doctor\\\'s advice.
Conclusion: The use of complimentary and alternative medicine is highly prevalent in our society by patients irrespective of their social class. Preference for such therapies, on the other hand, is quite low among medical doctors as they consider allopathic medicine to be effective.
Keywords: CAM, Homeopathic medicine, Alternative medicine. (JPMA 62: 865; 2012).

Introduction

Complementary and Alternative Medicine (CAM) is usually disregarded by regular physicians.1 But there has been an unprecedented increase of CAM usage globally.2 These medications have always been an invisible mainstream within the healthcare delivery system.3 CAM therapy has been prevalent for a long time among Asian populations.1,2 The primary reason for using CAM is socio-cultural background of the people. The second most reported reason is cheaper treatment than allopathic medicine.1-3 The other reasons are fewer side effects, family pressure, disappointment from modern medicine and local advertisements.1,4 Some studies have acknowledged that religious beliefs and prayers improved morbidity and mortality.5
However, allopathic doctors usually prohibited their patients to use CAM. But studies stated that patients usually try to conceal their use of CAM from their physicians.6,7 On the other hand, a study on paediatricians\\\' attitudes and practices stipulated that a notable amount of physicians not only use CAM, but also refer patients for the same.8
Much of the population of Pakistan is characterised to be living below the poverty line, where society is dominated by religious and spiritual beliefs. The majority of population follows old traditions and is dominated by religious and spiritual beliefs. It is known that CAM therapy has been prevalent over a long period of time. A review article discussed prospects and limitations of CAM in Pakistan.3 A study at a private-sector tertiary care hospital of Pakistan determined the knowledge, attitude and practice {KAP) of their students.9 But, still data is not available stating the prevalence of CAM users of general population and doctors. This study was, thus, designed to get an in-depth analysis about not only the use but also the attitude of patients and doctors towards CAM.

Subjects and Methods

The descriptive study was carried out from April to September 2010 in two different hospitals of Karachi, Pakistan; Civil Hospital, Karachi (CHK), a public-sector tertiary care hospital; and Liaquat National University Hospital, Karachi, a private-sector hospital. The choice of hospitals reflects the two different sectors of our society; hence ruling out the social status factor. Permission to conduct survey was taken from the relevant authorities.
Two sets of questionnaires were developed separately for patients and doctors. Each set consisted of queries regarding demographic data of the two segments.
The questionnaire devised for the patients contained questions reflecting the general attitude, and range from mode of CAM usage to duration of usage. The disease diagnosed and the reasons were also included. The questionnaires developed for doctors in general laid focus on the acceptance of CAM therapy by them. Questions ranged from personal opinion about CAM usage to whether a patient was referred to CAM therapy.
While computing the sample size, the proportion of CAM use by the general population of Pakistan was found to be 51.7%10 and 34.8% for the doctors.11 So, with 90% power of the test, 98% confidence interval and 2:1 for patients and doctors, the computed sample size was 527 (351 patients and 176 doctors). The reason for taking this ratio is that in our societal settings, contacting this many number of doctors is an arduous task. Thus, these samples were collected on equal proportional stratified sampling for both the institutions.
Data were entered and analysed using Predictive Analysis Software Statistics (PASW Statistics 18). Frequencies (percentages) were computed for qualitative variables like gender, marital status, educational status, religion and CAM use and preferences etc). Harvard Graphics v. 4.0 was used for graphical representation.

Results

A total of 400 patients were interviewed from Civil Hospital Karachi (CHK) and Liaquat National Hospital (LNH) Karachi. Among them, 170 42.5%) were males and (n=100; 25%) of the respondents were illiterate; 117 (29.3%) were living below the poverty line; and only 46 (11.5%) had high income level.
Of the total, 237 (59.3%) patients used CAM (Figure-1).

Fever was the most common disease for which they used CAM (n= 101; 42.5%); cough was the second most common disease (n= 49; 20.6%). Herbal medicine was the most commonly used CAM among the patients, followed by homeopathy and faith-based treatment. Eighty nine (37.5%) patients were instructed by the family members or sibling for using CAM and five out of six had heard from people about CAM. Around 208 (88%) patients acknowledged that their physicians were aware of their CAM usage, and 102 (43.2%) confessed that their physicians forbade them to use CAM. However, 89 (37.6%) did not stop using CAM, assuming that their doctors were unaware of the CAM effectiveness. Every two out of five preferred to use CAM therapy (n=118; 50%). In all 118 (50%) acquiesced due to family advice, and 59 (25%) considered their disease incurable by allopathic medicine while very few of them did due to financial constraints. Every two out of five CAM users decreed to recommend CAM usage to others too.


Also part of the study were 180 doctors: 100 (55.5%) from the CHK; and 60 (33.3%) were males. More than half of them were only medical graduates. Of the total, 167 (92.8%) doctors were aware of CAM therapy; and 37 (22.1%) of them considered that there were no side effects of using CAM. However, 100 (55.5%) doctors refuted the idea that CAM should be part of the MBBS curricula. The idea of devoting any journal for CAM therapy was rejected by 54 (30%).
On the question, "Which CAM therapy is the most effective in your viewpoint?" 69 (41.3%) doctors chose herbal medicine; 48 (28.4%) homeopathy; whereas acupuncture and religious treatment were also preferred by 38 (23%) doctors. The sources of information of CAM for these doctors were people (n=103 57.2%); newspaper (n= 58; 33.1%), patients (n=51; 29.3%), television (n=45; 25.7%), family members (n=42; 23.3%), internet (n=30; 16.6%), journal article (n=29\\\' 16.11%), and seminar/workshop (n=18; 10%). Radio and roadside advertisements were also sources of information the rest of the doctors.
Of the total, 62 (34.4%) used CAM themselves. Homeopathy 31 (51.7%) and herbal medicine by 28 (46.7%) were the most commonly used CAM. Besides, 49 (29.34%) doctors indicated media advertisement as the strengthening factor for their CAM usage whereas 12 (19%) used CAM due to financial constraints. Thirty (50%) were satisfied with the use of CAM therapy.
In contrast, of the doctors who didn\\\'t use CAM, 37 (31.9%) did not prefer due to the awareness of effectiveness of modern medicine, 25 (21.6%) considered CAM as obsolete therapy, 20 (17.2%) were unsatisfied, 18 (15.5%) did not used due to slow recovery and 9 (8%) of them were forbidden by someone.
Forty five (25%) doctors referred their patients to use CAM. Cough, joint pain and obesity were the most common diseases in this regard. On the other hand, 87 (49.7%) of the doctors forbade their patients to use CAM.

Discussion

To our knowledge, this is the first multicentre study conducted in Pakistan to elaborate on the attitude and practices of CAM by Pakistani urban resident patients and doctors. Pakistan is considered less educated, low-income and old-world country. This may be the reason behind the high use of CAM therapy by the people. As the study stipulated, about 60% patients and 35% of doctors use CAM besides using allopathic medicine. A population-based study of Pakistan indicated 50% use of CAM by the general population. Among them, 20% also used biomedicine.10 CAM use by Singaporean patients was found to be nearly similar at 56%,12 but was slightly less at 50% in Japan.13,14 Though similar proportion of CAM users was found in a hospital emergency department of Switzerland,15 CAM usage in Canada was less than our findings.14
Herbal medicine followed by homeopathic medicine was the preferable CAM in the study. However, in the population-based study, homeopathy was the preferable CAM.10 This can be compared with a German study in which among the preferred CAM used by doctors, homeopathy followed by acupuncture topped the list.16
Three-quarter of our doctors did not like to refer CAM to their patients. Nonetheless, a study revealed that 91% of the Australian physicians used CAM for themselves. Not only this, 93% recommended or treated their patients with CAM.17 In Russia, a very high proportion of doctors not only used CAM themselves, but also referred their patients to use the same.18 In Italy, 58% of the doctors recommended CAM to their patients; though only 13% used CAM themselves. In the current study, 42% of the physicians did not recommend CAM to their patients due to insufficient evidence of its effectiveness.19 The US physicians also gave positive response on using and referring CAM with very high proportions.20
The trend of not disclosing the use of CAM to physicians was also found in Canadian and Japanese patients.13 Even in Singapore, 75% population did not disclose to their western-trained doctors about their use of CAM.21 This proportion was low in our study, which may be due to the cultural background of our society. In Canada, about 30% did not consider it important to inform the physicians; 13.5% thought that doctors were not interested; and 8.2% assumed that surgeons were not aware about the efficacy of CAM.14 These proportions in our society were quite high, which again, may be due to the culture factor. In our study, media was the strengthening factor. On the other side, friends, fellow patients and media were the main sources of information found by studies done in Singapore and Europe.12,22

Conclusion

The use of CAM is highly prevalent in our society; more so among the general population than among medical practitioners.

Acknowledgement

Prof. Dr. Junaid Ashraf, Principal, Dow Medical College Campus, DUHS, and Prof. Dr. Nazeer Khan, Director of Research Department, DUHS deserve special gratitude on our part for their help in completion of this project.
We are also obliged to all the doctors and patients of Civil Hospital Karachi and Liaquat National Hospital, Karachi who participated in this study.

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