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The Relationship Between Knowledge and Attitude of Patients with Chronic Diseases Regarding Complementary Medicine

AUTHORS

Alehe Seyyedrassoli 1 , Akram Ghahramanian 2 , Zhila Rahimlou 3 , *

1 Department of Medical-Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

2 Hematology and Oncology Research Center, Medical Surgical Department, Nursing and Midwifery Faculty, Tabriz University of Medical Sciences, Tabriz, Iran

3 Student Research Committee, Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

How to Cite: Seyyedrassoli A, Ghahramanian A, Rahimlou Z. The Relationship Between Knowledge and Attitude of Patients with Chronic Diseases Regarding Complementary Medicine, Iran Red Crescent Med J. 2017 ; 19(5):e46166. doi: 10.5812/ircmj.46166.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 19 (5); e46166
Published Online: May 7, 2017
Article Type: Research Article
Received: February 5, 2017
Revised: March 26, 2017
Accepted: April 6, 2017
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Abstract

Background: Evidence shows the effectiveness of complementary medicine and its use in the treatment of chronic diseases are increasing.

Objectives: This study aimed to determine the relationship between knowledge and attitude toward complementary medicine in patients with chronic disease and referred to a hospital in an urban area of Iran.

Methods: This cross-sectional correlation study was conducted with 400 patients with chronic diseases referred to a hospital in an urban area of Iran. The samples were chosen using convenience sampling. The patients’ knowledge and attitudes were assessed using a researcher-made questionnaire and the holistic complementary and complementary medicine questionnaire, respectively.

Results: The patients’ knowledge was the highest and lowest in the subscales of herbal medicine and energy therapy, respectively. Also, their attitudes mean regarding holistic health was better than attitude regarding scientific validity of complementary medicine (21.37 versus 15.88). There were statistically significant relationships between knowledge and attitude (r = 0.28, P < 0.001). While the relationship between knowledge regarding complementary medicine and attitude toward holistic health (r = 0.52, P < 0.001), its relationship with attitude toward the scientific validity of complementary medicine was reverse and negative (r = -.23, P < 0.001). Moreover, demographic variables such as the level of education, marital status, disease type, exercise habits, and information about the methods of complementary medicine had statistically significant relationships with the patients’ knowledge about complementary medicine. The frequency of consumption of vegetables per week (r = -0.18, P < 0.001) and the duration of disease (r = -0.16, P = 0.002) had a statistically significant reverse relationship with knowledge regarding complementary medicine.

Conclusions: Knowledge regarding herbal medicine was high in patients with chronic diseases. Given a lack of sufficient knowledge and poor attitudes about other aspects of complementary medicine, patients need more education about the significance of complementary medicine and its positive effects on their health.

Keywords

Knowledge Attitude Chronic Diseases Complementary Medicine

Copyright © 2017, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Complementary medicine, as an alternative to conventional medicine, assists the diagnosis, treatment and prevention of diseases or medical conditions (1, 2). Given many advances in the field of medical sciences and ease of access and effectiveness of the synthetic drugs. The use of complementary medicine has increased. However, a large portion of the human population, due to the unavailability and high costs, are not interested in the use of chemical drugs. More than 80% of people in developing countries hardly have access to most basic medical procedures, drugs, and vaccines (3). On the other hand, drugs’ side effects may have serious life threatening consequences (4, 5). The use of complementary medicine has dramatically increased in developed and developing countries for reasons such as ease of access, lower costs, and efficacy. Complementary therapies and traditional medicine are highlighted for improving the healthcare delivered to the patients (6). According to studies in the USA, 29% - 42% of Americans use complementary medicine in the forms of self-care or prescription by the physician (7). In Italy, Germany, Canada, and France, 70% - 90% of the complementary medicine is in the form of herbal medicine (8, 9). In Africa, 70% - 95% (8), Nigeria 84% (10), Japan and Singapore 76% (11), South Korea 8.74% (12, 13), China 60% (14), and 62.5% of people in Iran use complementary and alternative therapies (1).

Chronic diseases affect all populations across the world, 70% of the cases of patients’ death in the USA are related to chronic diseases, which are about 1.7 million deaths every year. Chronic diseases are often monitored, but are not fully treatable. Some of these diseases are life threatening such as a heart attack or stroke, and some others can be difficult to be managed (7, 15, 16).

The results of Siddiqui et al. (2003) showed that 83.2% of the population of Tehran had knowledge of the types of complementary medicine, 75% knew about herbal therapy, 43% about acupuncture, 39% about hypnotherapy, 28% about energy therapy 22% about Yoga, and less than 5% about homeopathy (17). The study on healthcare workers in Kashan (2012) shows that most participants had little knowledge of complementary medicine, but showed interest about it. This indicates that medical community should provide education and training about the benefits and side effects of the application of complementary medicine to people (18).

An appropriate understanding of complementary medicine cannot be achieved without having enough knowledge of the current condition, patients’ knowledge, and attitudes toward complementary medicine.

2. Objectives

This study was performed with the aim of determining the relationship between knowledge and attitude toward complementary medicine in patients with chronic diseases.

3. Methods

3.1. General Information

This cross-sectional correlation study was conducted from March 2 to May 28, 2016 with 400 chronic patients that were referred to the cardiology, rheumatology, nephrology, and endocrinology wards as well as clinics of traditional medicine at the Sina hospital located in Tabriz, Iran, which happens to be the only referred center for chronical patients. This article has been approved by the ethics committee of Tabriz University of Medical Sciences (TBZMED.REC.1394.605). The samples were recruited from a hospital after obtaining required permissions for authorities including ethical approval for the study and sampling in the research zone. Also, the samples were informed of the studys’ aim and their rights regarding the anonymity and confidentiality of data and the possibility of withdrawal from the study at any time without being penalized. Those patients who willingly agreed to participate in this study signed the written informed consent form. The samples were chosen using the convenient method according to the following inclusion criteria: age above 18 years, being diagnosed with the chronic disease at least for 1 year, and the confirmation of the diagnosis from the patient’s medical file. The exclusion criteria included a lack of willingness to take part in this study and the history of the use of synthetic opioid drugs based on the patient’s word.

3.2. Sample Size

The sample size was determined using a sampling formula considering the frequency of complementary medicine’s use = 50%, z = 1.96, and d = 0.05. Also, given the probability of 10% attrition of samples, the number of samples was determined on 400 people. We also performed a power analysis to ensure the sample size estimation, which we based on correlation statistical test, alpha (0.05), power (0.80), and effect size (because of absence of similar study in the target group, effect size small and equal. 1 - 0.2 was considered). The sample size was calculated in the G*power software version 3.1. The third author of the paper selected patients with chronic diseases that referred to the cardiology, rheumatology, nephrology, and endocrinology wards in the evening shifts as well as clinics of traditional medicine in the odd days of week.

3.3. Instrument

The socio-demographic data form was developed after the literature review and contained questions such as age, gender, marital status, occupation, income level, and the source of information about the complementary medicine. The patients’ knowledge regarding complementary medicine was a researcher-made instrument developed based on the literature review. Also, 10 faculty members in the fields of nursing and complementary medicine confirmed its validity. For construct validity, this questionnaire (complementary alternative medicine knowledge questionnaire) was filed out by 200 patients with chronic diseases and exploratory factor analysis (EFA) was performed. The reliability of the CAM-knowledge questionnaire, according to the Kuder-Richardson formula (KR-21), was 0.84. This 37-item questionnaire had a 3-choice response from correct = 1, wrong = 0, and I do not know = 0. Additionally, 4 items had reverse scoring with wrong = 1 and other answers = 0. The CAM-knowledge questionnaire consisted of 37 items and 4 subscales: (1) herbal therapy with 18 items, (2) energy therapy with seven items, (3) yoga with seven items, and (4) the guidance of the mind and emotions with 5 items.

The patients’ attitudes were assessed using the holistic complementary and complementary medicine questionnaire (HCAMQ), which was developed by Hyland et al. (19). The validity of the HCAMQ was assessed using content and construct validity. Its reliability was evaluated using the test-retest method that was 0.77 and 0.96 for the total scale and its subscales, respectively (19). The HCAMQ consisted of 11 items and 2 subscales: (1) attitudes toward the scientific validity of complementary medicine with 6 items and (2) beliefs about holistic health with 5 items. For attitudes toward the scientific validity of complementary medicine, a 5-point Likert scale from strongly agree = 1 to strongly disagree = 5 was applied. For beliefs about holistic health, the 5-point Likert scale had a reverse scoring from strongly agree = 5 to strongly disagree = 1.

3.4. Statistical Analysis

Collected data was analyzed using descriptive and inferential statistics via the SPSS software version 16. P < 0.05 was considered statistically significant. Considering the normal distribution of scores of knowledge and attitude, Pearson correlation coefficient was used for determining a relationship between knowledge and attitude toward complementary medicine in patients with chronic diseases. For assessing a relationship between knowledge and characteristics of participants, independent t-test and analysis of variance (ANOVA) were used.

4. Results

The samples were consisted of 400 patients with the mean age of 41.85 years. The majority of them (83%) were female, 43% and 73% of the patients had an academic degree education and were married, respectively. More information regarding the patients’ socio-demographic characteristics were presented in Table 1.

Table 1. Characteristics of the Patients and Their Relationships with Knowledge About Complementary Medicine
CharacteristicsN (%)Mean (SD) for KnowledgeP Value
Gender0.201
Male68 (17)19.64 (6.94)
Female332 (83)18.43 (7.18)
Educational level0.001
Illiterate20 (5)10.20 (6.16)
Elementary64 (16)17.18 (5.34)
Guidance school64 (16)10.86 (7.54)
High school80 (30)19.70 (6.41)
Academic173 (43)19.88 (7.29)
Marital status0.012
Single88 (22)17.59 (7.82)
Married292 (73)19.20 (7.03)
Widow12 (3)17.00 (2.95)
Divorced8 (2)12.00 (.00)
Occupation0.001
Unemployed28 (7)15.28 (7.19)
Worker12 (3)12.33 (4.20)
Employed124 (31)21.54 (7.16)
House wife196 (49)18.00 (6.49)
Self-employed40 (10)17.00 (7.53)
Income0.294
Income equal to expenditure240 (60)19.05 (6.98)
Income more than expenditure48 (12)17.66 (7.78)
Income less than expenditure76 (18)19.63 (5.79)
Mean (SD)Mean (SD) for Knowledger (P Value)
Age (year)41.85 (15.33)18.67 (7.14)0.05 (0.298)
The frequency of the consumption of vegetables in the week3.94 (2.14)18.64 (7.14)-0.18 (0.001)
The frequency of the consumption of vegetables in the day1.49 (0.95)18.64 (7.14)0.001 (0.982)

From patients participating in this study, 41%, 27%, 27.8%, and 4.2% suffered from rheumatoid, nephrology, endocrine, and cardiac disorders, respectively. Also, 9% of the patients were cigarette smokers and 39% were exercising in a routine manner. Moreover, 57% of the patients were performing routine blood tests and 39% were suffering from blood pressure (Table 2).

Table 2. The Characteristics Related to Chronic Diseases and Their Relationships with Knowledge About Complementary Medicine
CharacteristicsN (%)Mean Score of KnowledgeP Value
Type of the disease0.001
Cardiac17 (4.2)20.53 (3.12)
Endocrine111 (27.8)19.66 (7.62)
Rheumatoid164 (41)16.57 (7.08)
Nephrology108 (27)20.44 (6.42)
Cigarette smoking0.942
Yes36 (9)18.55 (8.47)
No356 (89)18.64 (7.07)
Exercise0.005
Yes156 (39)16.90 (8.04)
No232 (58)19.28 (6.67)
Performing blood tests in the routine manner0.283
Yes228 (57)18.80 (6.91)
No152 (35)19.57 (6.89)
Monitoring blood pressure0.071
Yes156 (39)19.51 (6.60)
No232 (58)18.18 (7.60)
Information about the types of complementary medicine0.001
Yes172 (43)20.74 (5.87)
No224 (56)17.30 (7.44)
Mean (SD)Mean (SD) for Knowledger (P Value)
The duration of the disease (Year)4.01 (3.46)18.64 (7.14)-0.16 (0.002)
Night sleep (hour)7.35 (1.47)18.64 (7.14)-0.43 (0.382)
Daily sleep (hour)1.60 (1.69)18.64 (7.14)-0.97 (0.079)

The mean score of the patients’ knowledge regarding complementary medicine was 18.64 ± 7.14. The patients’ knowledge was the highest in herbal medicine with the mean of 10.57 ± 5.08 and lowest in the subscales and energy therapy with the mean of 1.31 ± 1.74.

The mean score of the patients’ attitudes regarding complementary medicine were 37.25 ± 3.96. Also, their attitudes regarding holistic health with the mean of 21.37 ± 3.47 was better than their attitudes regarding scientific validity of complementary medicine with the mean of 15.88 ± 2.93.

There was a statistically significant relationship between knowledge regarding complementary medicine, attitude regarding complementary medicine, and attitude toward holistic health. The relationship between knowledge regarding complementary medicine and attitude toward the scientific validity of complementary medicine was reverse and negative (P < 0.001). Relationships between the attitudes toward complementary medicine and subscales of knowledge containing herbal therapy and guidance of the mind and emotions were statistically significant (P < 0.001).

Moreover, demographic variables such as the level of education, marital status, disease type, exercise habits, and information about the methods of complementary medicine had statistically significant relationships with knowledge regarding complementary medicine. The frequency of consumption of vegetables per week and the duration of disease had a statistically significant reverse relationship with knowledge regarding complementary medicine (P < 0.01).

Accordingly, illiterate, divorced, and unemployed patients had less knowledge regarding complementary medicine compared with other patients. Furthermore, the patients with rheumatoid diseases, patients who exercised, and received no data about complementary medicine from various sources had significantly less knowledge. With the increase of the consumption of vegetables per week and duration of the disease, knowledge about complementary medicine was decreased (Tables 1, and 2).

Table 3. Knowledge About Complementary Medicine
SubscalesMinimumMaximumMeanStandard Deviation
Herbal therapy0.0017.0010.575.08
Energy therapy0.007.001.311.74
Yoga0.007.001.812.40
The guidance of the mind and emotions0.005.004.171.33
Total knowledge3.0033.0018.647.14
Table 4. The Correlation Matrix Between Knowledge and Attitudes About Complementary Medicine
Variables2345678
Herbal therapy0.12a (0.011)0.10a (0.043)0.31b (P < 0.001)0.85b (P < 0.001)-0.22b (P < 0.001)0.49b (P < 0.001)0.26b (P < 0.001)
Energy therapy0.28b (P < 0.001)-0.10a (0.045)0.41b (P < 0.001)-0.10a (0.032)-0.02 (0.682)-0.09 (0.052)
Yoga0.21b (P < 0.001)0.52b (P < 0.001)-0.06 (0.235)0.16b (P < 0.001)0.10a (0.046)
The guidance of the mind and emotions0.49b (P < 0.001)-0.08 (0.085)0.53b (P < 0.001)0.40b (P < 0.001)
Total knowledge-0.23b (P < 0.001)0.52b (P < 0.001)0.28b (P < 0.001)
The scientific validity of complementary medicine-0.24b (P < 0.001)0.52b (P < 0.001)
Holistic health0.69b (P < 0.001)
Total attitude

aSignificant level of Pearson correlation coefficientis was less than 0.05.

bSignificant level of Pearson correlation coefficientis was less than 0.01.

5. Discussion

This study aimed to determine the relationship between knowledge and attitude toward complementary medicine in patients with chronic diseases. We found out that the patients had more knowledge regarding herbal therapy compared with other aspects of complementary medicine. They also had less knowledge regarding energy therapy compared with other aspects. The study done by Sadighi et al. showed that 83.2% of people had knowledge about at least 1 of the methods of complementary medicine and two thirds of them had knowledge about herbal therapy (18); these results were similar to the current study.

According to a study in Kuwait, herbal therapy was one of the priorities of participants (20). In the study done by Zimmerman, participants were often familiar with herbal medicines such as ginseng, St. John’s wort, garlic, Echinacea, and cinnamon (21). Also, these results were similar to the current study.

The patients in this study had a better attitude toward holistic health compared with the scientific validity of complementary medicine. A probable reason to this poor attitude is the experience of side effects or fear of its complications. In the study done by Awad and Al-Shaye, 18% of individuals experienced the side effects of complementary medicine. Also, two thirds of them believed that the Kuwaiti’s Ministry of Health supervised the production of complementary medicines indicating a lack of trust to the scientific validity of complementary medicine (20). In the study done by Gruber et al., two thirds of the parents were informed of the role of complementary medicine and recognized its role in the recovery of their own child (22). In the study done by Zimmerman, the majority of students were informed of complementary medicine, but were not optimistic toward its role in the prevention of diseases. Also, they had little knowledge regarding herbal medicine (21), which was in contradiction with our findings.

According to the findings of this study, relationships between the attitudes toward complementary medicine, knowledge regarding herbal therapy, and the guidance of the mind and emotions were statistically significant. The study done by Adib et al. showed that the majority of participants had little knowledge regarding complementary medicine, but were interested in learning it. It shows the importance of education provided by healthcare professionals regarding the advantages, disadvantages, and side effects of complementary medicine to the public (18).

In this study, demographic variables such as the level of education, marital status, disease type, exercise habits, and information regarding the methods of complementary medicine had statistically significant relationships with knowledge about complementary medicine. The frequency of consumption of vegetables per week and the duration of disease had a statistically significant reverse relationship with knowledge regarding complementary medicine. Our findings were confirmed by those of other studies stating that middle-aged women with higher levels of education were interested in complementary medicine (18, 23).

In a study done in Malaysia in 2009, 64% of patients with chronic diseases used complementary medicine, because patients believed in the effectiveness of complementary medicine (24). In a study done by Callahan et al. patients with rheumatoid diseases were looking for specialist and a few of them used complementary medicine for relieving their symptoms (25). Few studies found that the use of complementary therapies were subject to lower costs and are cheaper. In a study done in the United States of America by Barnes et al., it was found that families who had a good income used complementary therapies more than poor or low-income families. Nowadays, complementary medicine is used more than before due to an increase in the number of healthcare centers and specialists in the field of complementary medicine, the publication of more related articles, as well as an increase of public knowledge (26). A study in Iran (2015) showed that the frequency of physician visits, chronic diseases, and multiple complications increases the use of complementary medicine (27).

5.1. Conclusion

Knowledge regarding herbal medicine was high in patients with chronic diseases. Given a lack of sufficient knowledge and poor attitudes toward other aspects of complementary medicine, patients need more education regarding the significance of complementary medicine and its positive effects on their health.

Acknowledgements

Footnotes

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