Herbal medicines: Saudi population knowledge, attitude, and practice at a glance.

Herbal medicines are widely used in many countries in preventing and treating health disorders. In this study, a multiregional cross-sectional survey, a random sample of 809 adults from Saudi Arabia and territories were used to explore the participants' knowledge, attitude, and practice regarding the use of tradition medicines in Saudi society. Data were collected through direct simple observation, interviews, and structured questionnaires. Observations were made and interviews conducted in public places such as markets and popular schools. The questionnaire included data on sociodemographic such as age and gender and was drafted with optional questions and predefined answer. Data were collected from May 1st to the end of July 2014. Most of the respondents were female (85%). Approximately 70% of participants were found to be highly knowledgeable about the use of herbal medicine. The study found that 88.4% of the respondents stated to have used herbal medicines and 84.3% were interested in traditional recipes. Most of the participants used it for therapeutic reason (88.7%), with a successful effectiveness of 61.2%. In addition, the study found that 48.2% of the participants were taking information from friends and 76% stated that they do not trust the published information in commercial channels. Statistical analysis showed an association between the perception and the demographic data, with an increase in the use of herbal medicines. Because of the increased use of herbal medicine in Saudi Arabia facilitated by perceptions and attitudes of the population, it is important to ensure standardization, stability, and quality control of the use of medicine in Saudi Arabia.

Introduction

Herbal medicine refers to the use of roots, leaves, flowers, bark, berries, and seeds, among other parts of a plant for treatment or prevention of a disease. Some of the most widely used herbal medicinal plants include devil's claw, kava, Echinacea, ginseng, ginger, St. John's wort, black and blue cohosh, red raspberry leaf, and castor oil, among others.[1] The use of herbal medicines for the prevention and treatment of several health disorders has been in practice a long time worldwide.[2] Herbal medicines have a long history in the manufacture of several drugs such as aspirin, morphine, and digoxin, among others. Herbal medicines are used in the treatment of many ailments, including microbial and viral infections, reproductive health issues, psychiatric and immune disorders, and noncommunicable diseases such malaria, cancer, and injuries.[1]

Despite the gradual acceptance of modern medicine across societies, herbal medicines are still widely used in developed and developing countries. According to World Health Organization, approximately 80% of African and Asian populations are relying on traditional medicines for primary healthcare needs.[3] In addition, studies indicate that 70%–80% of the population in developed countries use alternative and some form of contemporary medicine at some stage.[145] According to Thomford et al.,[5] the increased use of herbal medicines in the past few decades has been partly because of the elusive cure for HIV/AIDS which prompted many countries to start refocusing attention in medicines. Also, some of the factors facilitating the increased usage of herbal medicines include local acceptance, history of known efficacy, dissatisfaction with conventional medicines, inexpensive procurement compared with modern medicines, and local abundance. People also perceive traditional medicines to be safe and free from side effects.[13]

The use of herbal medicine in Saudi Arabia is fairly common. For instance, a literature review study found that herbal medication during pregnancy in Middle East ranges between 22.3% and 82.3%.[1] The study by Al-Ghamdi et al.[1] involved 612 participants, of whom 48.9%, 33.7%, and 25.3% reported to have used herbal medicine after delivery, during labor, and during pregnancy. The main motives for using the medicines after delivery, during labor, and during pregnancy were to clean the womb, to accelerate and ease labor, and to boost general health, respectively. According to Al-Ghamdi et al., the prevalence of using herbal medication by Saudi women during pregnancy is relatively high. Musaiger and Abahussain[4] conducted a study investigating the attitudes and usage of complementary and alternative medicine (CAM) among Saudi Arabian adolescents. The study found that the use of CAM by adolescents in their lifetime ranged between 1.6% and 58.6%. The females were more likely to use herbal medicines than males in treating cough, cold and flu, and abdominal pains. The friends and family members were the main source of CAM than media. The study also found out that medicinal herb healers and religious leaders were the CAM healers who were mostly visited. In addition, approximately 21%–43% of the adolescents had positive attitudes toward the use of CAM. According to Musaiger and Abahussain,[4] the use of complementary therapies which include herbal medicine is highly prevalent among Saudi Arabian patients suffering from cancer and other chronic diseases.

Although herbal medicine could be effective, there is need for addressing issues related to safety and quality. The quality of herbal medicines is compromised because of the use of raw materials that are substandard and lack effective controls. In addition, herbal medicines are considered because they are natural and pure, thus are perceived to have low risk compared with conventional medicines. However, the medicines cannot be said to be completely free from issues related to adverse effects and toxicity. For instance, some herbal medicines interfere with cytochrome P450 enzyme systems which are important in drug metabolism and some increase the effects of anticoagulants.[6] According to Thomford et al.,[5] there are also some reports of people who died after taking herbal medicines. Teschke and Eickhoff[7] stated that plants used as herbal medicines are natural producers of chemical substances, which may have risk of herb-induced liver injury that has a severe or potentially lethal health outcome and requirement for liver transplant. As a result, some herbal traditional healers withhold some medicine from their patients and prescribe them under their supervision to avoid overdoses.[5]

Thomford et al.[5] stated that the abundance of herbal medicines has facilitated the increase in fake herbals in the market. According to Teschke and Eickhoff,[7] herbal medicines need to be marketed as herbal drugs under regulatory surveillance. Herbal medicines should be approved as safe for use after assessing the risks and benefits. Despite the potential risks associated with herbal medicines and existence of regulations, the products are still widely used in Saudi Arabia. The prevalence of using herbal medicines in the country is influenced by the philosophy, culture, and perspectives of the people of the country.[14] This study is conducted on the presumption that no research has been conducted to explore the use of herbal medicine among Saudi population. Thus, the aim of this study is to explore the knowledge, attitude, and practice of using tradition medicines among Saudi population.

Materials and Methods

This multiregional cross-sectional survey study was conducted in Saudi Arabia from May 1st to the end of July 2014. The study involved 1,067 adults who were randomly selected from various territories of Saudi Arabia. The inclusion criteria were adults age 18 years or older and included both sexes. The main objective of the study was to explore the knowledge, attitude, and practice of using tradition medicines by Saudi population. Potential participants were provided with a description of the study and asked to voluntarily provide consent to be involved in the study. In all, 809 participants who provided consent were presented the questionnaires.

The methods of collecting data were direct observation, interviews, and questionnaires. The interviews were conducted and observations were made in the markets and popular schools. In cases where the respondents did not understand the questions, the research team elaborated to them. Referrals to friends, neighbors, and colleagues by the interviewees enabled generation of more ideas about the study. The research team also visited public places that sell herbal medicines such as women markets, Attar also known as herbal and spice shop, to observe the process of marketing the products.

A structured questionnaire had been drafted with optional questions and predefined answers. The respondents chose to answer questions based on their preferences. The answers were simple, objective, and concise and addressed all segments of society issue. Some of the questionnaires were personally administered to participants in Riyadh at a Public Security Training City, schools, shopping malls, and popular markets. Some questionnaires were distributed electronically through email by making an electronic link that directly sent the questionnaires to participants who were acquired from social networking platforms such as Twitter, Facebook, and WhatsApp, after accepting to enrol in the study. In addition, some questionnaires were sent to participants in far regions of the Kingdom of Saudi Arabia through Saudimail.

Statistical analyses

Data analysis was performed using International Business Machines (IBM) Statistical Package for Social Sciences (SPSS) Statistics 20 (SPSS, Chicago, IL, USA). Descriptive statistics, percentages n (%), was used to describe categorical variables of patients’ characteristics. Chi-square test was used for bivariate analysis to assess the associations between the demographic data and the questionnaire items. Fisher's exact test was also used in testing statistical significance during analysis of data on contingency tables. For multivariate analysis, binary logistic regression was used to identify important factors that affect the use of traditional recipe. P < 0.05 was considered significant.

Results

The study was conducted over a period of 3 months. A total of 1067 adults were sampled, but only 809 adults participated. A majority of the participants were female (84.9%). Age was categorized into three groups: ≤30, 31–40, and ≥40 years old. Fifty percent of the participants were 40 years of age or older. The sample was taken from different parts of Saudi Arabia: Approximately 70% of the participants were from the central region, 3.4% were from rural areas, and the remaining were from urban region. About 70% of the participants were highly educated. Also, 60% of the participants had jobs in several governmental sectors including education, healthcare, administration, among others, but 40% were not working. Salary was categorized into three groups, in which half of the participants were in the middle group which earned between 3,000 and 10,000 Saudi Riyals. The information about the distribution of the sample according to sociodemographic data is shown in Table 1.

Table 1

Distribution of the sample according to sociodemographic data

The questionnaire contained 13 questions which were categorized into three themes. The first category is related to perception and involves two questions as shown in Table 2. The first question was “What are the reasons of using traditional therapy?” Four answers were to be chosen from the following: not confident in manufactured medicine (12.5%), take herbal medicine based on inherited beliefs (57.5%), both reasons (27.8%), and other reasons (2.2%). The second question was “Do the recipes keep you from taking manufactured medicine?” Three answers were found as follows: yes (10.6%), no (38.4%), and sometimes (51%).

Table 2

Perception of using traditional recipes and manufactured medicine

The second category is related to attitude which involved four questions as shown in Table 3. The first question was “Are you interested in traditional recipes?” The majority of the responses were for yes (85%) and the rest for no. The second question was “What do you think is the correct description of traditional recipe?” The answers were as follows: recipes based on long experience (16.1%); inherited believes (61.7%), and others (22.2%). The third question was “Do you think traditional recipes are safer than manufactured medicine?” The answers were as follows: 40.8% of the participants said no, 32.3% said yes, and 26.9% said that they do not know. Fourth question was “Do you trust the published information on commercial channels?” The majority of the participants said no (76%), 17.9% were neutral, and 6.1% said affirmed.

Table 3

Attitude toward traditional recipes

The third group of questions related to practice as shown in Table 4. The first question was “Have you ever used traditional recipes?” The participants who admitted were 88.4% and the rest stated no. The second question was “What is the source of information regarding traditional recipes?” Friends and neighbors got almost half of the answers, the rest were about web, TV, practitioner, Attar, and others. The third question was about the reason for using the traditional recipes. The participants who stated therapeutic were 88.7%, those who stated cosmetic were 8.2%, and 3.1% stated other reasons. With regard to the fourth question about the frequency of using herbal medicine, 43% of the participants stated as much as needed, 32.1% stated weekly, and 25% reported to use the products daily. The fifth question was about the experience of the participants with traditional therapy, in which 61.2% admitted that their experience was successful and 18.6% said that it was partially successful. In addition, 18.5% claimed that it did not have any effect and 1.7% of participants said that it has side effects.

Table 4

Practice of using traditional recipes

Relationship between questions and demographic data

Chi-square test was conducted to assess the association between perceptions’ answers and demographic data. Fisher's exact test was used in analyzing the contingency tables. Data on the association are shown in Tables 5–9.

Table 5

Sociodemographic data and perception relations

Table 9

Regression analysis between Question 1 and demographic data

The first category of questions is related to perceptions. There is a strong association between the perception of using traditional recipes and gender with P value < 0.000. Also, there is an association between the same question and the occupation with P value of 0.006. Education and occupation show a strong association with second perception question about whether a traditional recipe can keep a person from using manufactured medicine [Figure 1] with P values of 0.019 and 0.001.

Figure 1

The perception percentages of using traditional recipes and manufactured medicines

The questions related to attitude are four. With regard to the first question on whether a person is interested in traditional recipes, age, gender, area, education, and occupation have a strong association with this question by P values of 0.014, 0.042, 0.032, 0.000, and 0.003, respectively. In the second question about the source of information, no association between the given answers and demographic data is found. In the third question on whether a person thinks whether herbal medicines are safer than manufactured pharmaceuticals, only age and occupation have a significant association with P values of 0.049 and 0.000, respectively. Age categories are the only characteristics that are found to have an association with trust in the published information about traditional recipes [Figure 2].

Figure 2

The attitude percentages of using traditional recipes and manufactured medicines

The questions categorized under practice are seven. With regard to the question about the general use of traditional recipe, there was an association between gender, age, and occupation with P values of 0.00, 0.012, and 0.040, respectively. On the question on whether the source of information is very important, an association is found with almost all the demographic data. Gender, age, area, residency, and occupation showed a positive relation with P values of 0.002, 0.021, 0.049, 0.046, and 0.019, respectively. A reason for use is also an important issue because it showed relation with gender and age of P value 0.000, area (0.001), education (0.030), and salary (0.041). The frequency of use is associated with age groups and area significantly. Regarding the question on the effectiveness of traditional recipe, gender and age are the only factors associated with P values of 0.031 and 0.018, respectively. Also, the type of recipe used is associated with gender of P value 0.00, area (0.008), and salary (0.005). The last question is the use of traditional recipe on children and is associated with age, area, occupation, and salary [Figure 3].

Figure 3

The attitude percentages of using traditional recipes and manufactured medicines

Regression analyses

Table 9 shows the results of binary logistic regression models for the question about interest of a participant in traditional therapy. By controlling all basic characteristic predictors, participants who are more than 40 years old tend to report twice as much interest in traditional recipe compared with the other age groups. High school degree participants show three times more use of traditional recipe compared with the reference which is the university with P value of 0.002. Also, working in administrative job is considered a protective factor from using herbal medicine with almost 60% less than the reference factor which is not working participants.

Discussion

This study about exploring the knowledge, attitude, and practice of using traditional medicines among Saudi population is presumed to be the first to be conducted in the field. In this cross-sectional descriptive study, 1,067 adults were randomly sampled and 809 participated. Although 85% participants were female, herbal medicines are mostly used by female than male. This may be attributed to female characteristics such as pregnancy.[89] A recent study by Kennedy et al.[10] also showed that the majority of pregnant women use herbal medicine. In addition, the tradition and culture in Saudi Arabia encourage the use of herbal medicines. Also, the availability and simplicity of herbal medicines contribute to the increased use and many people believe that traditional recipes are not harmful and do not have side effects.

The study showed that the majority of participants who use traditional medicines were recommended by friends and neighbors. This finding can be attributed to the Islamic culture and conservative nature of the Saudi Arabian community, in which people are slow in accepting western ideas.[11] Saudi Arabians still prefer to consult their relatives, neighbors, elders, and religious leaders. The influence of Saudi Arabian setting must have influenced the outcomes regarding trusting source of information, reasons for using traditional therapy, safety of herbal medicine, and correct prescription of the medicine, among other issues that were surveyed. For instance, 76% of the respondents said they did not trust published information on commercial channels, 57.5% stated that they used traditional therapy based on inherited beliefs, 40.8% were confident about the safety of herbal medicines, and 61.7% stated that correct prescription of medicines was obtained from inherited believes. In addition, most of the participants were interested to traditional recipes. Participants who were older than 40 years of age have twice much interest in traditional recipe than those 40 years of age or younger. This is contributed to inherited description of herbal medicines and their lack of trust on information from commercial channels.

The use of traditional recipes is found to be three times more among participants with high school degrees compared with those holding university degrees with P value of 0.002. Through the finding, it can be hypothesized that though Saudi Arabians still use traditional recipes, those with advanced education are more willing to use modern medications. Additionally, people who hold administrative positions and have better salaries are much interested in using modern medicines than traditional recipes. According to Williams,[12] people with advanced education are more exposed, and therefore are ready to accept new ideas.

The usages were as needed for therapeutic reason with successful effectiveness of about 6 of each 10 participants. However, the finding should not lead to a conclusion that recommends traditional recipes based on therapeutic value. Randomized clinical studies involving the effectiveness of herbal and modern medicines in Saudi Arabia need to be conducted to ascertain the efficacy of the products. Randomized controlled trials are the most rigorous approach of determining whether cause-and-effect relation exists between the outcome and treatment, thus providing highest grade of evidence.[13]

Herbal medicines have been used and are still widely used in Saudi Arabia in treating and preventing diseases. Users believe that herbal medicines are safe and without side effect.[13] However, plants and herbal medicines are extremely complex material. In addition, there is lack of protocols and suitable methods of evaluating the products. Herbal medicinal products need to be regulated to enhance quality, safety, and efficacy.[7]

Conclusion

The use of herbal medicine among Saudi population is a common practice and is associated with female gender, adult population, and low level of education. Saudi people mainly depend on friends and neighbors as a source of information and do not trust commercial channels about traditional recipes. The increased use of herbal medicine in the country is mainly facilitated by the positive attitudes and perceptions which the people have about the recipes. The conservative nature of the Saudi Arabian society also contributes to the prevalence of using herbal medicine in the country. However, most studies have indicated that despite the effectiveness of herbal medicines in treating diseases, the products have potential health risks. Therefore, it is recommendable that the regulatory agencies should consider standardization, stability, and quality control for herbal products. The study's limitation is that it is a self-reported assessment. The self-reported assessments are associated with validity issues because the participants may exaggerate their answers. Though the sample was taken from different parts of Saudi Arabia, a majority of the participants (almost 70%) were from the central region, which may limit generalizability of the findings. Future studies need to focus on approaches that may enhance standardization and quality control of herbal medicines in Saudi Arabia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 6

Sociodemographic data and attitude relations

Table 7

Sociodemographic data and practice relation

Table 8

Regression analysis between Question 1 (are you interested in the traditional recipes?) and demographic data