original research article

Hamdan Medical Journal 2015; 8:137–144 (http://dx.doi.org/10.7707/hmj.371)

ORIGINAL RESEARCH ARTICLE Factors influencing the use of complementary and alternative medicine for musculoskeletal disorders in the United Arab Emirates Sharfaa Ahmed, Faryal Shaikh, Salihu M Lawal, Fredrick Ogugua, Khaleifah Al-Hafeiti, Saif Saeed Al-Hafri and Rizwana B Shaikh Department of Community Medicine, Gulf Medical University, Ajman, United Arab Emirates

Abstract The objective was to estimate the prevalence of and reasons for using complementary and alternative medicine (CAM) for various musculoskeletal conditions and to determine the most common musculoskeletal problems for which CAM is used. A cross-sectional study was conducted using 305 subjects, which included the doctors and staff members of Gulf Medical University and Gulf Medical Hospital, 20 years of age and over. Data were analysed using the SPSS program. Of the subjects documented, 51.1% admitted that they used alternative medicine, of which 30.1% used it alongside conventional medicine. Most subjects interviewed used Ayurveda (34%) and the most common use of CAM was to relieve general aches and pains (46.8%). A total of 30.2% of CAM users stated that ‘conventional medicine was not effective’, 23% of them felt that CAM ‘relieves stress’ and 22.6% felt that it could reduce the severity of the condition. Painkillers were the most common conventional medicine used alongside alternative medicine (48.2%). No significant difference was found between the effectiveness of CAM alone and CAM with conventional medicine. More than half the participants were making increasing use of CAM. Hospitals can provide CAM alongside conventional medicine in the UAE.

Introduction The use of natural substances has carried on from past generations up to the present day, and some of these alternative practices have influenced current conventional medicine. Complementary and alternative medicine (CAM), as defined by the National Centre for Complementary and Alternative Medicine (NCCAM), is a group of diverse medical and health care systems, practices Correspondence: Sharfaa Ahmed, Department of Community Medicine, Gulf Medical University, Ajman, United Arab Emirates. Email: [email protected]

and products that are not presently considered to be part of conventional medicine. It is based on the belief that a medical care provider has to treat the whole person – body, mind and spirit.1 On the contrary, conventional medicine refers to the use of physical interventions or pharmacologically active agents that have been proven effective through scientific research.2 The non-medical therapies are classified into five categories by NCCAM: (1) alternative medical systems, (2) biologically based therapies, (3) mind–body interventions, (4) manipulative and body-based methods, and (5) energy therapies.3 In this method of health care alternative physicians guide their patients to facilitate healing and total well-being. Recent studies show that in any given year at least one type of CAM is used by 69% of Americans.4 Other studies have shown that up to 60% of French, German and British people use homeopathic or herbal products.5 A survey conducted in 2006 in Dubai showed that 28% of the population had used more than one form of alternative medicine in the last 12 months, and about 48% of the population had used an alternative therapy at least once in their lifetime.6 Complementary and alternative medicines are most frequently used for musculoskeletal problems, including neck, back and joint pain, according to US studies.7 For certain conditions, CAM has been used in conjunction with conventional medicine.

© 2015 The Author(s) Journal Compilation © 2015 Sheikh Hamdan Bin Rashid Al Maktoum Award for Medical Sciences

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ORIGINAL RESEARCH ARTICLE

Various studies have been conducted worldwide to assess the use of alternative medicine. This study was conducted to evaluate the use of alternative medicine, with and without conventional medicine, among the population of the United Arab Emirates (UAE), specifically those with musculoskeletal problems, and also to determine the factors that influence individuals to choose CAM as a therapy.

Materials and methods The study is a cross-sectional survey. A total of 305 subjects participated in the study. All individuals above 20 years of age residing in the UAE were eligible for inclusion in the study. Individuals below 20 years of age were excluded. A convenience sampling strategy was used. Based on the statistics given by the Eastern Mediterranean Health Journal in 2000, 73% of the study subjects documented that they used alternative medicine, including mainly herbal medicine, as well as other types.8 Thus, the sample size was calculated using the formula: n=z2 pq/C2 , which results in a sample size of 303 individuals.

A pilot study was carried out using 10 people meeting the inclusion criteria and feedback was taken from them in order to improve the structure of the questions in the questionnaire. Data were collected after getting approval from the Ethics Committee, Gulf Medical University. Written consent was taken from the institutions and organizations concerned and the individuals before they were interviewed. Collected data were entered into Microsoft Excel (Microsoft, Washington, DC, USA) and analysed using Statistical Product and Service Solutions (SPSS) version 19 (IBM Corporation, New York, NY, USA). Data were presented as percentages, tables and graphs. A chi-squared test was carried out to verify association.

Results

[Where: z=z value (normal standard variate)=1.96 for 95% confidence level; p=expected proportion in population based on previous studies or pilot studies; q=1 – p; C=confidence interval (absolute error or precision)=expressed as a decimal.] The survey was conducted in Ajman, UAE. The study was conducted from January to December 2012. The tool for data collection was a questionnaire, which was drawn up after an extensive review of the literature.

The mean age of the 305 participants was 32.2 (standard deviation ±1.4) years. Table 1 shows the sociodemographic profile of the 305 study subjects used for this study. As presented, approximately half of the population were male (56%) and the other half were female (44%). The majority of the population surveyed were Indian (69%). With regard to education, most subjects had a Bachelor’s degree (30%), but this was closely followed by subjects with a Master’s degree (27%). Most of the participants (60%) were married. The frequency and percentage of CAM users in the population surveyed is illustrated in Figure 1.

Data required for this research were collected by means of an interviewer questionnaire of university and hospital staff members residing in the UAE. A total of 305 questionnaires were completed. The questionnaire included both open-ended and closed questions. Questions regarding factors influencing the choice to use CAM

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as a therapy were also asked. In addition, a final question was asked to determine whether people would prefer to have alternative therapies available alongside allopathic practices in hospitals, so as to suggest a possible change in health care policies.

Table 2 shows the frequency and percentage of CAM users who also used allopathic medicine. As presented, the number of people using solely alternative medicine was 70%, while the number of people using both allopathic medicine and alternative medicine was 30%.




TABLE 1 Demographic profile

Demographics Gender

Male Female Indian Pakistani Filipino Bangladeshi Others High school diploma College diploma Bachelor’s degree Master’s degree Doctorate (PhD) Single Married Widowed Divorced

Nationality

Education level

Marital status

Frequency

Percentage of people

170 135 209 16 37 6 35 36 73 92 84 20 115 183 5 2

55.7 44.3 68.8 5.3 12.2 2 11.5 11.8 23.9 30.2 27.5 6.6 37.7 60.0 1.6 0.7

200

156 (51.1%)

149 (48.9%)

People who use CAM

People who have never used CAM

Frequency

150 100 50 0

FIGURE 1 Prevalence of CAM use (n=305).

TABLE 2 CAM use with and without conventional medicine

People using CAM only People using CAM with conventional medicine TOTAL

Frequency

Percentage

109 47

69.9 30.1

156

100


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Table 3 shows the frequency and percentages of conditions for which CAM was used. It shows that most people using alternative medicine use it for general aches and pains, and that this condition was acute (less than 3 months’ duration).

The frequency and percentages of people using the different types of CAM are shown in Figure 2. The most commonly used form of alternative medicine was Ayurveda (34%), followed by homeopathic medicine (17%) and yoga (12.3%).

TABLE 3 Conditions for which CAM is used and the duration of illness (whether acute or chronic)

Conditions for which CAM is used

Nil (%)

Acute (%)

Chronic (%)

General aches and pains (back, upper limb, lower limb, neck, hip, joint) Muscle weakness Muscle stiffness Muscle cramps Swelling Osteoporosis Fractures Rheumatoid arthritis Osteoarthritis Repetitive strain injuries Ligament tears Frozen shoulder Dislocation of shoulder Dislocation of hip Osteomyelitis Myositis Tendonitis Prolapsed disc Other

67 (42.9) 140 (89.7) 131 (84) 117 (75) 146 (93.6) 152 (98.1) 149 (95.5) 151 (96.8) 153 (97.4) 149 (95.5) 151 (96.8) 150 (96.2) 153 (97.4) 155 (99.4) 155 (99.4) 154 (98.7) 152 (97.4) 144 (92.3) 149 (95.5)

73 (46.8) 12 (7.7) 18 (11.5) 32 (20.5) 7 (4.5) 1 (0.6) 6 (3.8) 4 (2.6) 3 (1.9) 5 (3.2) 5 (3.2) 3 (1.9) 2 (1.3) 1 (0.6) 1 (0.6) 2 (1.3) 3 (1.9) 7 (4.5) 5 (3.2)

16 (10.3) 4 (2.6) 7 (4.5) 7 (4.5) 3 (1.9) 2 (1.3) 1 (0.6) 1 (0.6) 1 (0.6) 2 (1.3) 0 (0) 3 (1.9) 1 (0.6) 0 (0) 0 (0) 0 (0) 1 (0.6) 5 (3.2) 2 (1.3)

FIGURE 2 Different types of CAMs used by the participants (multiple responses, n=228).

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Table 4 shows the various reasons why people chose to use CAM. Most people found conventional medicine to be ineffective (30%). About 20.5% of people said they found CAM relaxing. The benefits of using alternative medicine are shown in Figure 3. The majority of the people using CAM (22.6%) believed it reduced the severity of their condition and 20.5% felt that they experienced fewer side effects than with conventional medicine. Furthermore, 23% used it because they believed it relieved stress, whereas 16.3% believed that it had a long-term effect. About 10.5% believed that it reduced recurrent episodes, while 4.6% thought it helped with other medical conditions. Table 5 shows the different sources of knowledge about alternative medicine. The most common TABLE 4 Reasons for using CAM

a

Reason

Frequency

Percentage

Conventional medicine was not effective It is relaxing Heard about other benefits Wanted to give it a try More economical Fewer side effects Other TOTAL

65 44 29 24 20 17 16 215a

30.2 20.5 13.5 11.2 9.3 7.9 7.4 100.0

Multiple responses, n=215.

TABLE 5 The different sources of knowledge of alternative medicine

Source of knowledge

Frequency

Percentage

Family Friends Doctor Internet Magazines Newspapers Other TOTAL

97 49 22 13 12 9 3 205a

47.3 23.9 10.7 6.3 5.9 4.4 1.5 100.0

a

Multiple responses, n=205.

source was family (47%), followed by friends (24%) and doctors (10.7%). Figure 4 shows the reasons for stopping the use of alternative medicine. As displayed, the major reason people stopped using CAM is because they completed treatment (45%). Unavailability is the second most frequent reason for the cessation of CAM usage (19%). Furthermore, 13.4% stopped usage because they felt they did not need it any more, whereas 2.4% stopped use of CAM because it caused them other problems. Figure 5 illustrates the number of people who prefer having alternative and conventional treatments in the same hospital. Of the people who used CAM (51.1%), 72% responded positively.

FIGURE 3 Perceived benefits of using alternative medicine (multiple responses, n=239).


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FIGURE 4 Reasons for stopping the use of alternative medicine (multiple responses, n=82).

FIGURE 5 People who prefer having alternative and conventional treatments in the same hospital (n=56).

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Discussion Using a sample size of 305, it was found that approximately 51.1% of the population surveyed used alternative medicine (Figure 1). These results are very similar to previous research conducted in the UAE. Approximately 73% of the population surveyed in the previous study used alternative medicine. This indicates that the use of alternative medicine is widespread in the UAE and the majority of people who reside in the UAE currently use or have used some form of alternative therapy.8 In addition, previous studies have shown that age, gender and level of education are predictors of the use of alternative medicine.9 However, no significant association was found when the demographics (Table 1) were compared with the usage of alternative medicine. Thus, it can be concluded that the age of the person, their gender, their education level and their marital status are not related to their choice of using alternative medicine. The majority of the participants in this study were Indians. The results indicated that the most common conditions for which alternative medicine is used are general aches and pains, including back, neck and joint pain. These findings are consistent with another study, conducted in the USA, which found that alternative medicine was mostly used to treat back pain or back problems, head or chest colds, neck pain or neck problems, joint pain or stiffness and anxiety or depression.10 Our study indicated that, among the various alternative therapies available, most of the participants claimed that they used Ayurveda (Table 4). This was followed by homeopathic medicine, other cultural remedies and yoga. Studies conducted in the USA showed that natural products, breathing exercises, yoga and massage were among the most commonly used forms of alternative therapies.10 In addition, a study conducted in South Africa documented similar results, with herbal medicines, yoga and homeopathy being those most commonly used.9 This difference may be because the subjects surveyed in this project consisted primarily of Indians (69% of the population surveyed) and Ayurveda is recognized as a legitimate medical system in that country.

Furthermore, about two-thirds of the population of India (70%) primarily use Ayurveda for their health care needs.11 An important question that needed to be answered was, ‘What are the most important factors influencing the use of alternative medicine’. Approximately 30% of the participants said that they used alternative medicine because they found that the conventional treatment was not effective. This result is consistent with a study conducted in the USA which documented that about 20% of individuals used alternative medicine because they believed conventional treatments would not work or because conventional medical treatments were too expensive.10 When the participants were asked about what they felt were the benefits of alternative medicine, the two most frequently chosen responses were ‘relieves stress’ and ‘reduces severity of the condition’. This was expected, as alternative medicine is known to significantly diminish pain.9 Another popular choice was ‘experience fewer side effects’, which was stated in a previous study, in which the statement that CAM is used to eliminate all side effects caused by conventional therapy was also mentioned.7 Participants were also asked if they used alternative medicine in combination with conventional treatment. It was found that all of the individuals receiving osteopathy used it alongside conventional medicine. This could be because osteopathy is an alternative practice carried out by osteopathic physicians who are licensed doctors of osteopathic medicine with additional training in osteopathic manipulative medicine; thus, they prescribe conventional medications as well.12 In addition, about 50% of people using naturopathic and Chinese medicine also used conventional treatment, the most common of which were ‘painkillers’ (48.2%). The reason for this could be that they are easily accessible and normally used for any sort of pain alleviation. Users were asked to rate on a scale from 1 to 10, the mean being 7, how effective they considered their alternative therapy to be. This was compared with the mean effectiveness of alternative therapy used alongside conventional medicine, which was also 7. A paired t-test was carried out to compare the means and showed no difference between these


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two groups. It was concluded that alternative medicine used alone was just as effective as it was when used alongside conventional medicine. The lack of difference between the means could be explained by the fact that the majority of the individuals surveyed stated that they used only alternative medicine. A larger sample size of individuals using both types of medicine might have given a more accurate result.

References 1

2

3

Frequency of use per month or per week was not determined, hence we could not differentiate between regular and occasional users of CAM. As data were collected from only two centres by convenience sampling and three-quarters of the population were Indians, the results of the study cannot be generalized.

4

5

Conclusion More than half of the participants used CAM, two-thirds of whom used CAM alone without conventional medicine. The most common musculoskeletal disorder for which alternative therapies were used was general aches and pains, which included back pain, neck pain and joint pain (46.8%). The most common form of alternative medicine used was Ayurveda followed by homeopathy.

6

7

Family and friends had a major influence on the choice of alternative therapy that was used. CAM therapy alone was perceived as being equally effective as CAM in combination with conventional medicine. Three-quarters of those using alternative medicine said that they would prefer to have CAM therapies available in the same hospital as conventional medicine. As alternative medicine is now practised in many countries worldwide, these changes, if considered, may benefit the population. We recommend that hospital policy makers offer alternative therapies in the same hospital as conventional medicine.

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Acknowledgements We would like to express our gratitude to all the study participants, i.e. the doctors and staff of Gulf Medical University and Gulf Medical Hospital. Without them this project would not have been possible.

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