Awareness, knowledge, attitude, perception, and utilization of complementary and alternative medicines (CAMs) in the common population of Dammam, Saudi Arabia.

Background: Complementary and alternative medicine (CAM)/natural products/herbs are frequently used for therapeutic purposes as a homemade remedy in Saudi Arabia. The use of CAMs is rising globally. However, special attention or precaution should be paid when using CAMs along with other drugs. Objective: The current study aims to examine the perception, attitude, knowledge, and awareness of the general population about CAMs and their utilization. Material and
Methods: A cross-sectional study was conducted in March 2020 in the Dammam region of Saudi Arabia. The study included both the gender participants of the general population of Dammam, Saudi Arabia. The questionnaire contains the following sections including socio-demographic data, knowledge, attitude, and behavior of participants related to CAMs, and the prevalence of CAMs utilization in Dammam.
Results: Participants were closely sex-matched (male: 50.93% and female: 49.07%), consisting of 97.1% Saudis and only 2.9% expats. The response rate was 67%; out of 559 participants, only 375 participants completed the questionnaire. Approximately 53% of participants had some knowledge of CAMs. Mass media (media/web/internet, advertisement, and television (TV), academic education, and family friends/relative represented the main source of the CAMs information (50%, 8.8%, and 15.2%, respectively). Among 77.3% of the participants, one of their family members has used some form of CAMs earlier. 90% of the participants or their family members using CAMs reported that olive oil (95.7%), green tea (89.1%), thyme (85.3%), cinnamon bark (84.8%), star anise (84.5%), and black seeds (78.4%) were the most used CAMs. Participants used CAMs for cold (28.3%), cough (14%), constipation (11.97%), ease of menstruation (10.8%), diarrhea (9.87%), and fever (8.62%). Approximately 75% of participants did not observe any side effects. Only 1% of participants reported that the CAMs are not useful therapeutically whereas the majority of the participants reported them as very useful (32.7%), useful (45.5%), and good (20.7%).
Conclusion: Current study demonstrates that there is a positive attitude and perception toward CAMs. It is influenced by their traditional use as well. However, a community awareness program is essential for the adverse effects of CAMs. Copyright:

INTRODUCTION

Herbal medicine is the ancient system of treatment for various ailments. It is still being the most extensively used system of medicine around the world. Several people rely on herbal medications for the management of minor ailments. The popularity of herbal medications depends on their availability in the geographic area and the knowledge of the community about their usage. Herbs are an integral part of treatment in complementary and alternative medicine (CAM). CAM has gained acceptance globally and in industrialized countries over the last few decades. CAM refers to a wide variety of treatment modalities including herbal preparations, massage therapy, aromatherapy, foot reflexology, etc. Predominantly, these methods are based on several theories which are entirely different from the conventional method of treatment.[1] The types of medications used in CAM differ markedly across the globe. The Saudi Arabian population demonstrated increasing interest in the practice of alternative medicine. Tibbu Nawami is a traditional method of alternative treatment, which was popular in Saudi Arabia in ancient times. The majority of the population especially in Riyadh depended on prophetic medicine for various ailments.[2] However, alternative treatment, including herbal medicine, is indeed not a recent practice and has historically been used in the management of various diseases for centuries and has commonly been known as traditional folk healing.[3]

There is a growing literature on the various aspects of usage, awareness, and effectiveness of herbal medicine. Herbal medicines are prepared exclusively from plants. A herb is a plant with leaves, seeds, or flowers that is commonly used to enhance flavors in the food, used as a healing agent, or for their fragrance. Numerous cultures internationally have their own herbal medicines, which have been used by them for many centuries. Different varieties of plants were used by different populations and what they had in common is the medicinal properties of herbs. The parts of the plants they used, and the technique of preparations depended on their treatment approaches and the philosophy they believed in. One of the reasons for the growing popularity of herbal medicine is that they are believed to have fewer side effects than conventional medicine. But in fact, herbal medicines are not always free from impurities, and they may contain additives that may not be found on their labels. They may also lead to severe allergic reactions, may show incompatibility with conventional medicine, and can lead to drug toxicity if consumed in inappropriate doses. The World Health Organization (WHO) estimates that most of the populations in Asian-African countries rely on herbal medicines for minor ailments. As the herbs are grown around the home, the accessibility is high and thereby play an integral role in home remedies. Anyhow, the growing interest in herbal medications by the global population indicates that there is a dire need to study the effectiveness and practices of CAM, especially that of herbal preparations.[4]

A study conducted by Ahmed et al.[5] in Taif city, Saudi Arabia estimated that 58% of parents who were the respondents used herbal remedies for the treatment of various disease conditions in the four months period before responding to the questionnaire and 70.3% of them did the same some time in the past years. Mathew et al.[6] reported that most of the users of CAM were not aware of its scientific evidence though some of them felt that it is based on science. The effectiveness of the CAM in the treatment of minor illnesses and minimal reported complications as identified in previous experiences made them practice it more frequently. It has also been reported that one-third of the users of modern medicine also seek CAM even without their physician's advice.

CAM has been widely used to alleviate the side effects of chemotherapy by many cancer patients. In Israel, it is found to be used as adjunctive therapy with conventional treatment by cancer patients as they believed that it strengthens the immune system and helps to relieve pain and stress. For most of the patients, either friends or family recommended it but a majority of them did not inform their treating doctors about their use of CAMs, though they claimed that it was beneficial. Therefore, it is important to improve the knowledge of physicians about CAMs to educate the patients about the risks and benefits associated.[7]

Most of the alternative health care systems gained acceptance worldwide because the users perceive them as more congruent with their personal beliefs and philosophy of health and life. Another attractive factor towards CAMs is the holistic approach it offers considering the mind, body, and spirit in treating health-related conditions. It also helps the patients to achieve better self-control.[8] Singh et al.[9] reported in their study that the majority of the participants benefited from CAMs as evidenced by the improvement of their symptoms and some of them believed that CAMs are a safe and natural method of medical care. On the contrary, CAMs usage in Iranian patients with multiple sclerosis revealed that there is an exacerbation of symptoms (18%) and the onset of symptoms from the time of diagnosis was prolonged.[10] The present investigation aims to analyze the awareness, knowledge, attitude, perception, and utilization of CAMs among the general population of Dammam, Saudi Arabia.

MATERIAL AND METHODS

This cross-sectional study was conducted in March 2020 in the Dammam region of Saudi Arabia. The study included both the gender participants of the general population of Dammam, Saudi Arabia. A questionnaire was distributed to 1016 people out of which 559 started to respond but were not completed, only 375 responded completely, and the remaining uncompleted responses were removed from the study. The present study was approved by MACHS (SR/RP/35) Dammam, KSA. The present study was approved by MACHS (SR/ RP/35) Dammam, KSA. This study approved by MACHS Scientific research unit on 06/05/2020.

Data were collected using a self-administered questionnaire that was developed after an extensive literature review from related studies. The questionnaire was written in English and Arabic language and contained 38 questions including socio-demographic data, knowledge, attitude, and behavior of participants related to CAMs, and the prevalence of CAMs utilization in Dammam. Questionnaires were distributed randomly to the common population, after taking informed consent from participants, and the time required to respond to the questionnaire was only 10–15 min.

Statistical analysis

Data were analyzed using the Statistical Package for the Social Science version 21 (SPSS, Inc., Chicago, IL, USA). The P value was calculated using the Chi-square test and <0.05 was considered as significant.

RESULTS

Out of 559 responses, only 375 respondents completed the questionnaire, so the response rate was 67% and the remaining were considered invalid.

Demographic profile

Demographic characteristics of the current investigation are shown in Table 1. 50.93% of the participants were males whereas 49.07% were females. A majority (32.26%) of them belonged to the age group of 25–34 years and 29.86% of them belonged to the age group of 18–24 years. Only 7.2% were above 55 years. 66.93% of the participants were married, 1.6% were divorced, and the remaining group was single. Regarding their nationality, 97.06% were Saudis and 2.93% were non-Saudis. About 84% are urban residents whereas rural residents constituted 16%. About 43.2% of the participants were having a job while 3.73% were running a business. Students constituted 29.06% whereas housewives and not working participants accounted for 12% each. Only 4% of the participants had postgraduate education, and a majority (56.53%) of them were having a university education. 35.46% were having secondary, 3.73% preparatory, and 0.26% were having primary education, respectively. There were no illiterate participants.

Table 1

Demographic characteristics of participants (n=375)

Characteristics	Response (n)	Percentage %	P (X2 test)
Gender			<0.01
Male	191	50.93%
Female	184	49.07%
Age (years)			<0.01
18-24	112	29.86%
25-34	121	32.26%
35-44	66	17.60%
45-54	49	13.06%
>55	27	7.20%
Marital status			<0.01
Single	118	31.47%
Married	251	66.93%
Divorced	6	1.60%
Nationality			<0.01
Saudi	364	97.06%
Non-Saudi	11	2.93%
Residence			<0.01
Urban	315	84%
Rural	60	16%
Occupation			<0.01
Working	162	43.20%
Not working	45	12.0%
Business	14	3.73%
Housewife	45	12.0%
Students	109	29.06%
Education			<0.01
Postgraduate	15	4.0%
University	212	56.53%
Secondary	133	35.46%
Preparatory	14	3.73%
Primary	1	0.26%
Illiterate	0	0.0%

P<0.05 considered as significant P value

Knowledge and utilization of CAMs

Approximately 53.33% of the participants reported that they know about CAMs whereas 46.66% of the respondents did not have any knowledge. Reportedly, 68.26% of them use them in their daily life whereas 31.73% declined any use of CAMs. 77.33% of the respondents revealed that their family/relatives used them; on the other hand, 22.66% reported that it was not used by their family/relatives. Several CAMs were used by the participants. 95.73% of the participants used olive oil as an alternative medicine. Other commonly used CAMs among the participants are illustrated in Table 2.

Table 2

Knowledge and utilization of CAMs (n=375)

Characteristics	Response (n)	Percentage %	P
Do you have knowledge of CAMs			>0.05
Yes	200	53.33%
No	175	46.66%
Do you use CAMs			<0.01
Yes	256	68.26%
No	119	31.73%
CAMs used by your family/relatives			<0.01
Yes	290	77.33%
No	85	22.66%
Use of CAMs by you and your family/relatives			<0.01
Yes	338	90.13%
No	37	9.86%
CAMs Used
Garlic			<0.01
Yes	260	69.33%
No	115	30.66%
Cinnamon			<0.01
Yes	318	84.8%
No	57	15.2%
Cumin			<0.01
Yes	271	72.66%
No	104	27.73%
Black seed			<0.01
Yes	294	78.4%
No	81	21.6%
Star Anise			<0.01
Yes	317	84.5%
No	58	15.46%
Fenugreek			<0.01
Yes	235	62.66%
No	140	37.73%
Cardamom			<0.01
Yes	269	71.73%
No	106	28.26%
Clove			<0.01
Yes	259	69.06%
No	116	30.93%
Aloe			<0.01
Yes	172	45.86%
No	203	54.13%
Turmeric			<0.01
Yes	283	75.46%
No	92	24.53%
Flaxseed			<0.01
Yes	223	59.46%
No	152	40.53%
Senna			<0.01
Yes	75	20.0%
No	300	80.0%
Green Tea			<0.01
Yes	334	89.06%
No	41	10.93%
Mint			<0.01
Yes	269	71.73%
No	106	28.26%
Nutmeg			<0.01
Yes	290	77.33%
No	85	22.66%
Myrrh			<0.01
Yes	216	57.6%
No	159	42.4%
Thyme			<0.01
Yes	320	85.33%
No	55	14.66%
Olive oil			<0.01
Yes	359	95.73%
No	16	4.26%

P<0.05 considered as significant P value

Herbal drugs instruction

A majority (40%) of the respondents reported that media/web/internet is the main source of their information regarding CAMs. 15.2% stated that they received information about CAMs from family, friends, and relatives. The remaining of them got their knowledge from different sources such as educational academics (8.80%), TV (2.40%), advertisements (2.40%), and newspapers (0.26%), respectively. 5.33% of them considered other sources. Out of all, 25.6% had more than two sources [Figure 2].

Figure 2

I use CAMs therapy for my health

Source of information about CAMs

Regarding the frequency of use of CAMs, 57.86% of the participants reported that they use it as and when required, though 18.40% said they use it every day. 10.93% of the respondents use it twice a week, 7.73% of them use it once a week, 2.93% once every 2 weeks, and 2.13% use them once a month.

Knowledge about traditional/medicinal uses of CAMs for colds was higher (28.37%) compared to other ailments such as cough (14.06%), constipation (11.97%), menstruation and menstrual pain (10.88%), diarrhea (9.87%), fever (8.62%), digestive problems (8.37%), diabetes (4.69%), and wounds (3.18%). A vast majority (74.66%) of the participants did not experience any side effects while treating their ailment with CAMs whereas 25.33% of them reported some side effects [Table 3].

Table 3

Herbal drugs instruction (n=375)

Characteristics	Response (n)	Percentage %	P
What is your source of information about CAMs			<0.01
Educational academics	33	8.80%
TV	9	2.40%
Media/web/internet	150	40.0%
Newspaper	1	0.26%
Family, friends, and relatives	57	15.20%
Advertisement	9	2.40%
Other	20	5.33%
More than two source	96	25.6%
Frequency of use			<0.01
Everyday	69	18.40%
Once a week	29	7.73%
Twice a week	41	10.93%
Once every 2 weeks	11	2.93%
Once a month	8	2.13%
As needed	217	57.86%
Knowledge about traditional/medicinal uses of CAMs (n=1195)			<0.01
Cold	339	28.37%
Cough	168	14.06%
Fever	103	8.62%
Constipation	143	11.97%
Wounds	38	3.18%
Diarrhea	118	9.87%
Ease of menstruation and menstrual pain	130	10.88%
Diabetes	56	4.69%
Digestive	100	8.37%
Observe any side effects			<0.01
Yes	95	25.33%
No	280	74.66%

P<0.05 considered as significant P value

Attitude and perception of participants regarding CAMs

While assessing the attitude and perception of the participants regarding CAMs, it was found that 27.52% strongly agreed that they are using CAMs for their health. 44.96% of them agreed whereas 22.89% were neutral about the statement. 4.09% disagreed that it is healthy to use CAMs whereas 0.54% strongly disagreed [Figure 2]. 43.59% of the participants either agreed or strongly agreed that they use CAMs as they are more effective than conventional therapy. 43.32% were neutral, 11% disagreed, and 2% strongly disagreed that CAMs are more effective than conventional therapy [Figure 3]. A majority (66.76%) of them used CAMs as they were recommended by the family, 24.80% were neutral about this statement, and 8.45% disagreed with this statement. Interestingly 67.85% of the respondents reported that the use of CAMs was recommended by their treating doctor although 11.72% did not receive any recommendation from doctors. 32.70% of the participants reported a very useful therapeutic outcome of CAMs therapy and 45.50% reported it as useful. 20.71% of them stated that the therapeutic outcome is good, though a minority of them (1.09%) reported that it was not useful.

Figure 3

I use CAMs therapy, as they are more effective than conventional therapy

DISCUSSION

Saudi Arabia is a country with historical background that has a rich cultural heritage and traditional values. The traditional use of CAM in the KSA represents a strong interconnection among familiar remedies, health, diet, and traditional healing practices characterized by a specific culture. This study was planned and conducted to evaluate the awareness, knowledge, attitude, perception, and utilization of CAMs among people of the Dammam region, Saudi Arabia. The respondents were Saudi nationals living in cities. It is observed that the majority are working and some of them are students. 60% of them have completed university education. Male and female have equally responded. Though 68.26% of the respondents use herbal medicine in their daily life, 53.3% know about CAMs. While 31% have declined the use of CAMs. But almost half of the respondents do not know about CAMs. This reveals that knowledge does not influence the use of CAMs.

Herbal medications are an integral part of the daily lives of the people in Saudi Arabia. There are various herbs used for different ailments. Different herbs were used for many ailments. Ahmad et al.[11] reported that green tea, ginger, and flaxseed were the most frequently used herbal drugs for obesity treatment by the general population in Dammam. From this study, it is observed that olive oil is very commonly used by the participants. Other frequently practiced CAMs are green tea, star anise, thyme, cinnamon, turmeric, and nutmeg. This may be related to habits and beliefs among the Saudi population and religious background. Whereas in the study done by Abdulaziz et al., myrrh and ginger were very commonly used.[12] Herbal medications are used as a remedy for minor ailments rather than major diseases, to avoid going to the hospital and taking medications. Among the participants, it was used mainly for the common cold and cough. The other less use of CAM was found for constipation, during the menstruation, and least used for wounds. When inquired about the side effects, most of them did not experience any side effects although side effects were experienced by 25%.

When compared with the conventional therapies, it was believed that CAM and conventional methods were equally effective in 80% of the respondents. Others were not convinced with the treatment with CAMs. Family, as well as the treating doctors, have recommended the use of herbal medicines. From this study, it is revealed that the majority of them have a positive attitude toward the use of CAMs. The results of the current investigation are supported by Ahmad et al.[13] who reported that 70% of diabetic people claimed beneficial effects of herbal products/herbal medicine.

Media is found to be the main source of information among the participants followed by friends and relatives. This contradicts the study done by Ahmed et al.[14] in which family and friends were the main sources of information. This shows the influence of media on communicating information among the population. Television and advertisements were the least used for dispensing information.

CONCLUSION

This study showed the positive attitude and perception of CAMs in the Dammam region. The utilization of CAMs has risen among the Saudi population. The main source of information/knowledge about CAMs is media/social media and advertisement. However, so many studies have suggested beneficial effects of CAMs/herbal medicine, but adverse effects are also reported. Therefore, it is recommended that the Saudi Food and Drug Authority (FDA) should consider the standardization and quality control of herbal drugs.

Limitations

The current study's limitation is that it is a self-reported evaluation. The self-reported evaluation is linked with validity issues because respondents may overstate their responses. The sample was taken only in the Dammam region, so the results cannot be generalized to another region.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.