- Email: [email protected]
Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia
+Model EUJIM-380; No. of Pages 6
ARTICLE IN PRESS Available online at www.sciencedirect.com
ScienceDirect European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6
Original article
Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia Saranyaa Silvanathan, Bin Seng Low ∗ School of Medicine, Taylor’s University, 47500 Subang Jaya, Selangor, Malaysia Received 8 October 2014; received in revised form 9 December 2014; accepted 11 December 2014
Abstract Introduction: Traditional and complementary medicine (T&CM) has always been an important part of healthcare. However, many people underestimate the benefits and also the risks of taking T&CM. Therefore, the aim of the present study was to analyse the public awareness of the efficacy and safety of T&CM compared to the conventional Western treatments in Malaysia. Methods: A cross-sectional study was carried out with university staff and students residing in Selangor and Kuala Lumpur, Malaysia on their perceptions and awareness of T&CM using an online self-administered questionnaire. Results: Most respondents (85%, n = 200) preferred T&CM over the conventional Western treatments and had the impression that T&CM was safe. Herbal medicine (28%) was the most preferred form of T&CM to treat cough and cold as well as backache. About 51% of the respondents were unaware of the possible side effects of the T&CM but did not recognise the possibility of using counterfeits, men being more aware than women and 77% were more likely to inform clinician about their T&CM consumption. Respondents who were aware of T&CM counterfeits and herb–drug interactions reported experiencing significantly improvement but not those were aware of side effects. Only those aware of T&CM counterfeit would like to inform medical practitioners about their T&CM consumption. Conclusion: The prevalence of T&CM was high but experiencing improvement through its use may attribute to different levels of awareness. Campaigns to educate public on T&CM are pertinent since the public awareness on the T&CM side effects still lacking. © 2014 Elsevier GmbH. All rights reserved. Keywords: Traditional; Complementary; Awareness; Safety; Knowledge; Malaysia
Introduction Traditional and complementary medicine (T&CM) has emerged again as an important part of modern healthcare despite being practiced before the advent of conventional Western treatments. According to the World Health Organization (WHO), 80% of the population in Africa, Asia and Latin America use T&CM every year [1]. Almost half of the population from developed countries including United States, Australia, France and Canada use T&CM on a regular basis [2]. A study in Malaysia reported that the popularity of T&CM use among the elderly was associated with its lower cost, lower rate of side effects and better
∗
Corresponding author. Tel.: +60 3 5629 5176; fax: +60 3 5629 5455. E-mail addresses: [email protected], [email protected] (B.S. Low).
accessibility compared to conventional Western medicines [3]. In Ghana, the expense of western medical treatments for malaria costs USD$1.60 per treatment, compared with USD$0.35 per treatment for herbal medicines and USD$0.10 per treatment or almost free for home-grown herbs [4]. About two-thirds of all marketed drugs discovered in the past quarter-century have been derived from natural products such as artemisinin from Artemisia annua, a potent antimalarial herb found in East Asia [5]. Malaysia is a rapid developing country with a population approaching 28 million [6]. Recent studies reported that the prevalence of the use of T&CM in Malaysia was relatively high [7,8] especially for middle-aged adults who use them to enhance their well-being including sexual libido [9]. Studies have also shown that patients suffering with chronic diseases [8] and cancer [10] also prefer T&CM as their alternative source of treatment. As T&CM emerges as an alternative for both acute
http://dx.doi.org/10.1016/j.eujim.2014.12.003 1876-3820/© 2014 Elsevier GmbH. All rights reserved.
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
+Model EUJIM-380; No. of Pages 6 xxx.e2
ARTICLE IN PRESS S. Silvanathan, B.S. Low / European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6
and chronic treatment, there have been numerous cases of adulteration of T&CM with various substances such as; sildenafil, tadalafil, vardenafil and their structurally modified analogues [11]. Despite evidence of the high prevalence of T&CM use in Malaysia, no study has been carried out to scrutinise the level of public awareness in terms of safety towards counterfeit preparations, herb–drug interactions and side effects of T&CM. The aim of present study was to investigate the level of public awareness towards the efficacy and safety of T&CM and any demographic differences in perceived improvement and the awareness of T&CM side effects following the T&CM use. The source and knowledge of T&CM were also evaluated.
Methodology Study design and sample A cross-sectional study of population residing in Selangor and Kuala Lumpur, Malaysia was conducted using self-administered questionnaire. The study was piloted from 18th January to 7th February 2014 as a part of medical school’s undergraduate research project. Staff and students from the institution (all living in Selangor and Kuala Lumpur) were randomly selected from the database to participate in this study. By using an online sample calculator (http://www.raosoft.com/samplesize.html) (Raosoft® Inc., Seattle, WA) [9], sample size of 195 participants based on 7% margin of error with 95% confidence interval was estimated. Allowing for a 5% dropout, 211 participants were recruited into the study. From the university database, email addresses were retrieved and invitation emails sent with a hyperlink to the questionnaire. Participants were assured of the confidentiality of their personal and demographic data, which was stated on the front page of the questionnaire. Participation agreement was only considered upon the completion and submission of the online questionnaire. The study was approved by the ethical review.
Table 1 Demographic characteristics of the respondents. Parameters
Number
(%)
Gender Male Female
93 107
(46.5) (53.5)
22 90 31 33 20 4
(11.0) (45.0) (15.5) (16.5) (10.0) (2.0)
2 10 35 153
(1.0) (5.0) (17.5) (76.5)
78 68 44 10
(39.0) (34.0) (22.0) (5.0)
Age Below 20 20–30 31–40 41–50 51–60 Over 61 Education level No proper schooling Primary school Secondary school Tertiary school Monthly household income Below 5000 5000–10,000 10,001–50,000 Above 50,000
All data indicate the true number of the respondents (n = 200). Value in parenthesis indicates percentage of the number over the total number of respondents.
quantitative data, apart for one question on the rating towards knowledge of T&CM (Supplementary document 1). Data analysis All data from the respondents were subsequently analysed using Statistical Package for the Social Sciences (SPSS® ) version 20 (IBM SPSS New York, USA). Descriptive statistics including frequencies and percentages were calculated. Bivariate analysis using the Chi-square test was performed to determine the significance of the association between the demographics and other variables related to the awareness of three major concerns about T&CM. A p value less than 0.05 was considered significant.
Survey instrument
Results
Data was collected using a self-reported structured questionnaire which was constructed in the English language, prepared by Google® Docs online. A pre pilot study comprising of 8–10 participants, was conducted before the main assessment in order to evaluate the content validity and language simplicity of the questionnaire. It was sent to participants with hyperlink via email allowing one day to reply. Subsequently, modification of the final questionnaire was made based on the feedback from participants’ comments. Data from the pilot study was not included in the final assessment. The final questionnaire consisted of a total of 23 questions, 4 items related to the respondent’s demographic data and 19 related to the respondents’ perceptions, the use and awareness towards counterfeit preparations, herb–drug interactions and side effects of traditional and complementary medicine (T&CM). All questions were closed in order to obtain
Of the 211 participants invited to participate, 200 questionnaire responses were returned giving a response rate of 94.8%. The gender distribution was fairly equal with slightly more females than males responding and the majority aged between 20 and 30 years old (Table 1). The majority of the respondents had received higher education level qualifications and had medium to low household income (below RM 10,000 per month) (Table 1). Traditional and complementary medicine (T&CM) was perceived as either more natural, more effective, lower cost and/or respondents were prejudiced against Western medicines. These reasons made up two thirds of responses (62.8%) and were the major reasons given to explain the respondents’ inclination towards the use of T&CM (Table 2). The majority of respondents preferred T&CM than conventional Western treatment. A high proportion of respondents (66.0%) had only used
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
+Model
ARTICLE IN PRESS
EUJIM-380; No. of Pages 6
S. Silvanathan, B.S. Low / European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6
xxx.e3
Table 2 Reasons given by the respondents on the use of traditional and complementary medicine (T&CM). Reasons
Frequency %
I prefer natural therapy T&CM is effective The cost is cheaper I do not prefer T&CM over western medicine Western medicine produce side effects T&CM is recommended by doctor, family and friends Western medication does not help and it is toxic I have consumed too many Western medications It is easy to communicate with T&CM practitioners
84 53 48 35 34 31 28 27 10
(24.0) (15.1) (13.7) (10.0) (9.7) (8.9) (8.0) (7.7) (2.9)
All data indicate the frequency from the respondents. Value in parenthesis indicates percentage of the frequency per reason over the total frequency given by respondents. Respondents were allowed to select more than one option.
T&CM occasionally for health purposes (Table 3). Only 6.0% of the respondents used T&CM for all the health problems they currently experienced and this was mainly acknowledged as being supplements (54.7%). More than 75.0% respondents perceived improvements after taking T&CM (Table 3). This study showed that the most common types of T&CM used were herbal medicine (28.4%) followed by oil (22.9%) and massage (15.4%) (Fig. 1) to treat a variety of illnesses including coughs, colds, backache, general pain management and headache (Table 4). The majority of the respondents obtained their T&CM from the shops (48.8%) as well as from family members (32.2%) (Fig. 2) as more than half (58.0%) of the respondents revealed that their family members also used T&CM (Table 3). Table 3 Perceptions of the respondents towards traditional and complementary medicine (T&CM). Parameters
Number
(%)
Preference of T&CM over Western medicine All the time Sometimes Never
16 154 30
(8.0) (77.0) (15.0)
Use of T&CM for health purpose in past one year All health problems Occasionally Never
12 132 56
(6.0) (66.0) (28.0)
Role of T&CMa As a supplement Long term maintenance Substitute for Western medicine When required
117 49 44 4
(54.7) (22.9) (20.6) (1.9)
152 48
(76.0) (24.0)
116 84
(58.0) (42.0)
Improvement after taking T&CM Yes No Family member taking Yes No
T&CM
All data indicate the true number of the respondents (n = 200) except a Respondents may select more than one option indicated the frequency. Value in parenthesis indicates percentage of the number over the total number or frequency of respondents.
Fig. 1. Percentage of the respondents’ preferences towards the different types of traditional and complementary medicine (T&CM). Powder indicated the ground preparation including the aerial parts, stem, root and animal parts which could apply directly whilst the herbal medicine indicated the herbal remedies which can be prepared following infusion, decoction, tincture and maceration methods.
Despite the highly preference for use of T&CM from the respondents, the median rate of knowledge on T&CM from total 200 respondents was 5.04 (1 being the lowest and 10 being the highest in rating of knowledge) (Fig. 3). Knowledge about Table 4 Heath conditions and illnesses that respondents preferred to be treated with traditional and complementary medicine (T&CM). Health Problems
Frequency
%
Cough and cold Backache General pain management Headache Asthma Diarrhoea Fever Detoxification Skin disorder Digestive tract problem Diabetes Food poisoning Sleep disorder Nausea/vomiting, diarrhoea Menstrual problems Wound/oedema Arthritis Hypertension Cardiovascular problems Neurological disorder Urological disorder Hyperlipidemia Kidney/Gall stones Infertility Psychological disorder Aphrodisiac Dermatitis Ear wax Strengthen the immune system
67 55 47 45 38 37 37 35 35 28 27 25 25 24 21 20 18 14 9 9 9 7 7 6 3 2 1 1 1
10.3 8.4 7.2 6.9 5.8 5.7 5.7 5.4 5.4 4.3 4.1 3.8 3.8 3.7 3.2 3.1 2.8 2.1 1.4 1.4 1.4 1.1 1.1 0.9 0.5 0.3 0.2 0.2 0.2
Respondents may select more than one option indicated the frequency. The percentage indicates the number over the total number or frequency of respondents. Respondents were allowed to select more than one option.
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
+Model EUJIM-380; No. of Pages 6 xxx.e4
ARTICLE IN PRESS S. Silvanathan, B.S. Low / European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6 Table 5 Awareness from the respondents towards the side effects of traditional and complementary medicine (T&CM), the issue of counterfeit and the interaction with Western medicine.
Fig. 2. Respondents methods of accessing traditional and complementary medicine (T&CM).
Fig. 3. The knowledge on traditional and complementary medicine (T&CM) rated by the total 200 respondents (with 1 being the lowest and 10 being the highest in rating of knowledge).
T&CM was generally obtained from family members (29.4%), online websites (21.3%) and/or recommended by peers (22.5%) (Fig. 4) suggesting there were inadequacies in their knowledge. Approximately half (50.5%) of the respondents were unaware of the possible side effects and herb–drug interactions of T&CM (except from knowledge of counterfeit and adulteration issues) and more than 75.0% of all respondents were keen to inform their medical practitioner about their T&CM consumption (Table 5). As very few respondents (9.0%) had experienced side effects after consuming T&CM, it was generally thought that T&CM was seldom harmful (51.0%) (Table 5). Bivariate
Parameters
Number
%
Aware of counterfeit Yes No
115 85
(57.5) (42.5)
Aware of herb–drug interaction Yes No
99 101
(49.5) (50.5)
Concurrently use of Western medicine and T&CM Yes No
122 78
(61.0) (39.0)
Willing to inform doctor about the use of T&CM Yes No
154 46
(77.0) (23.0)
Aware of T&CM side effects Yes No
99 101
(49.5) (50.5)
Experience of side effects after consuming T&CM Yes No
18 182
(9.0) (91.0)
Opinion on T&CM harmfulness Frequently Occasionally Seldom No opinion
4 34 102 60
(2.0) (17.0) (51.0) (30.0)
All data indicate the true number of the respondents (n = 200). Value in parenthesis indicates percentage of the number over the total number of respondents.
analysis showed that male respondents were significantly more aware of counterfeit T&CM preparations, (p = 0.031) than female respondents (Table 6). Respondents who were aware of the counterfeits and herb–drug interactions felt significant improvement after taking T&CM (p = 0.001 and 0.025, respectively). Respondents who aware of the counterfeit were more likely to inform their doctors (p = 0.011). Respondents still concomitantly consumed T&CM with Western medicine regardless of whether they were aware of the potential of T&CM counterfeits, herb–drug interactions or side effects (Table 6). Discussion
Fig. 4. Respondents methods of gaining knowledge and safety awareness of traditional and complementary medicine (T&CM).
Of the two hundred respondents, the percentage of females respondents was higher than males. This was slightly higher (by 5%) than the gender demography in Malaysia [6]. This was probably due to the higher percentage of female staff and students who were currently working and studying in the institution and who agreed to participate in the present study. Data suggested that household income did not influence the preference of the respondents towards the traditional and complementary medicine T&CM (data not shown). In other words, T&CM preference not only limited to respondents with lower household income but also favour for those with higher household incomes. Among various types of T&CM, herbal medicines were the most commonly used in agreement with an earlier study [12] and
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
+Model
ARTICLE IN PRESS
EUJIM-380; No. of Pages 6
S. Silvanathan, B.S. Low / European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6
xxx.e5
Table 6 Bivariate analysis of the respondents’ demography and awareness towards three major concerns of traditional and complementary medicine (T&CM). Variables
Gender F/M Experience AE N/Y Inform doctor Consume T&CM with Western medicine Feeling some improvement
Aware of counterfeit
Aware of herb–drug interaction
Aware of side effect
p Value
OR
95% CI
p Value
OR
95% CI
p Value
OR
95% CI
0.031a
1.871 0.503 2.352 1.445 4.810
1.056–3.313 0.193–1.311 1.202–4.603 0.813–2.570 2.370–9.759
0.784 0.845 0.052 0.156 0.025a
1.081 0.910 1.943 0.661 2.136
0.620–1.884 0.353–2.345 0.987–3.824 0.373–1.172 1.091–4.183
0.992 0.083 0.552 0.973 0.056
0.997 2.393 1.222 1.010 1.901
0.572–1.738 0.871–6.573 0.631–2.365 0.571–1.785 0.977–3.699
0.154 0.011a 0.209 0.001a
OR: odds ratio; CI: confidence interval. a p Value is statistically significant.
most of the respondents agreed on T&CM lower costs and/or lower toxic effects compared with Western medicines. The high percentage of respondents who reported improvement after consuming T&CM indicated the perceived efficacy of T&CM which may be a potential issue for concern in Malaysia as well as in developed countries [13]. Despite the fact that various information regarding T&CM could be obtained from family member and websites, as reported earlier [14], the knowledge on T&CM among Malaysians was not promising. Indeed, higher educational levels had no enhancement effect on the awareness among respondents as the bivariate analysis showed that different educational levels did not increase the safety awareness among respondents on T&CM (data not shown). In fact, people in rural areas who may not be welleducated, may be proficient in T&CM practices as this is their primary source of healthcare [15,16]. Interestingly, more than half of the respondents were particularly aware of T&CM counterfeits and adulteration in the market with male respondents being more aware of the T&CM counterfeits and adulteration issues compared to female respondents. This may probably be due to males who are concerned about erectile dysfunction and as an earlier report revealed that middle-age adults were more preferring alternative medicines to enhance their libido [9]. This probably may explain why more respondents were likely to inform their medical practitioners about their T&CM consumption during consultation. The willingness of the respondents to inform doctor about their T&CM consumption, contradicts a study carried out in a US population which suggested that most participants were reluctant to tell their medical doctor about the concomitant use of T&CM [17]. Public may not be aware of the T&CM side effects as the knowledge on T&CM toxicity remains scanty or there is lack of proper reference resources [18,19]. Therefore, public may perceive that T&CM has lower rate of side effects than that of conventional Western treatments so many consumers may turn to T&CM products [20]. As a result, they may therefore be routinely co-administered with Western medicine which they may think it is safe without knowing the medical consequences of herb–drug interactions. Indeed, T&CM may not induce the toxic effect or the dose may be far too low compared to Western medicine, yet report have showed that natural products used in T&CM may potentially affect the absorption, metabolism and elimination process of drugs [21]. Moreover, present study showed the perception about improvement was only significant for those who were aware of counterfeits and herb–drug
interactions but not for those aware of T&CM side effect. It may however indicate that, the feeling of improvement could be results of a possible placebo effect. A separate study would be needed to test this hypothesis. More studies to explore toxicity effects and herb–drug interactions of T&CM are urgently required in case patient safety is compromised [22]. In many developing countries, T&CM is the primary source of healthcare at the community level and conventional healthcare is vastly limited [1]. As T&CM has been said to recognise the need to focus on quality of life when a cure is not possible [5], this could be the reason why individuals perceive that T&CM has better potential for treating disease. Besides, the rising of cost for conventional Western medicine in some developed countries may have contributed to the increase for the use of alternatives including T&CM for treatment [23]. Perhaps, it may not surprising to see that the popularity of T&CM is growing exponentially as this study also showed that respondents will still taking T&CM regardless of whether they know that there may be potentially harmful effects associated with T&CM. T&CM is also popular in United Kingdom among adults who using a range of therapies for their children [24]. Hence, many countries including Malaysia have now recognised the need to develop a cohesive and integrative regulatory approach to access T&CM in a safe, evidence-based environment and increase public awareness [22,25]. Beside the governance, healthcare practitioner may also need to appreciate the role of T&CM as part of clinical care [24,26]. To the best of our knowledge, it is the first time that the awareness regarding to the safety of the T&CM has been assessed, analysed and reported. However, the findings from the present study should be interpreted with caution. First, the sample of two hundred respondents is limited as it reflects only a selected population in a specific area and data cannot be generalised to the whole country. Additionally, participants were limited to the staffs and students who live in a specific area within the university campus. Second, the majority of our respondents were tertiary educated and were young (20–30 years old). Tertiary education level comprised undergraduates and postgraduates and the recruitment was limited to an urban area and did not extend to a rural area. Besides, it could be also argued that this age group may not necessarily take T&CM at their age so their perceptions may not have been based on their own experience, although, the use of T&CM in Malaysia is generally prevalent for the whole population across various age groups [7]. Family members and peers are always the major influence for the
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
+Model
ARTICLE IN PRESS
EUJIM-380; No. of Pages 6 xxx.e6
S. Silvanathan, B.S. Low / European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6
younger age group to take T&CM not only for treatment, but mostly for supplementary and adjuvant therapy. Third, the concept of herbal medicines is this context is difficult to define. Depending on the regulation of herbal medicines in different countries, a particular herbal product may be classified as a dietary supplement in one country and may differ to another. In this study, we have defined herbal medicines as herbal remedies which contain either raw or processed ingredients from one or more plants or parts used by which can be prepared following infusion, decoction, tincture and maceration methods for therapeutic or other health benefits. Powder indicates the ground preparation including the aerial parts, stem, root and animal parts which could apply directly without preparation methods as mentioned. Our definition of herbal medicines does not include products that are supplemented with vitamins and minerals. These explanations were included for participants in the invitation email. Fourth, apart from age, education levels and locality, ethnic background, religion and other cultural differences were not assessed. Also the validity of the study questionnaire was not assessed.
[4]
[5] [6]
[7] [8]
[9]
[10]
[11]
Conclusion [12]
In conclusion, public preference for T&CM is high but there was lack of awareness on the side effects and understanding and knowledge of T&CM. The willingness of the respondents to inform their medical practitioner regarding the use of T&CM was impressive. Since the prevalence of T&CM is high, healthcare professionals need to improve their knowledge on T&CM and their ability to manage the possible of any adverse events. Public education on the safety of T&CM is highly recommended. Conflict of interest statement
[13]
[14]
[15]
[16] [17]
The authors have no conflict of interests. Acknowledgements Author wish to thank Ms Uta Dietrich, who coordinated the medical students’ research study and all participants, who had participated in the present study. No funding was granted for this study. Appendix A. Supplementary data
[18] [19]
[20]
[21] [22]
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j. eujim.2014.12.003.
[23] [24]
References [1] World Health Organization. WHO traditional medicine strategy 2002–2005. Geneva: World Health Organization; 2002. p. 11–2. [2] Bodeker G, Kronenberg F. A public health agenda for traditional, complementary, and alternative medicine. Am J Pub Health 2002;92(10):1582–91. [3] Mitha S, Nagarajan V, Babar MG, Siddiqui MJA, Jamshed SQ. Reasons of using complementary and alternative medicines (CAM) among elderly
[25]
[26]
Malaysians of Kuala Lumpur and Selangor states: an exploratory study. J Young Pharm 2013;5:50–3. Ahorlu CK, Dunyo SK, Afari EA, Koram KA, Nkrumah FK. Malariarelated beliefs and behaviour in Southern Ghana: implications for treatment, prevention and control. Trop Med Int Health 1997;2(5): 488–99. Newman DJ, Cragg G. Natural products as sources of new drugs over the 30 years from 1981 to 2010. J Nat Prod 2012;75(3):311–35. Taburan Penduduk dan Ciri-ciri Asas Demografi. Jabatan Perangkaan Malaysia; 2010. Available from URL http://www.statistics.gov.my/portal/ download Population/files/census2010/Taburan Penduduk dan Ciriciri Asas Demografi.pdf (assessed February 2014). Aziz Z, Tey NP. Herbal medicines: prevalence and predictors of use among Malaysian adults. Complement Ther Med 2014;22:49–56. Hasan SS, Ahmed SI, Bukhari NI, Cheah WLW. Use of complementary and alternative medicine among patients with chronic diseases at outpatient clinics. Complement Ther Clin Prac 2009;15:152–7. Hassali MA, Saleem F, Shafie AA, et al. Assessment of general public perceptions toward traditional medicines used for aphrodisiac purpose in state of Penang, Malaysia. Complementary Ther Clin Prac 2012;18: 257–60. Farooqui M, Hassali MA, Shatar AKA, Shafie AA, Tan BS, Farooqui MA. Complementary and alternative medicine (CAM) use by Malaysian oncology patients. Complementary Ther Clin Prac 2012;18:114–20. Sahoo N, Manchikanti P, Dey S. Herbal drugs: standards and regulation. Fitoterapia 2010;81:462–71. Siti ZM, Tahir A, Ida Farah A, et al. Use of traditional and complementary medicine in Malaysia: a baseline study. Complement Ther Med 2009;17(5):292–9. Su D, Li L. Trends in the use of complementary and alternative medicine in the United States: 2002–2007. J Health Care Poor Underserved 2011;22(1):296–310. Bauer BA. Herbal medicine, the good, the bad, and the ugly. In: SoCRA source; 2003. Available from http://www.mrshumansays.com/uploads/ 1/2/6/8/12688070/herbal medicine the good the bad and the ugly.pdf; assessed February 2014. Winfred del Mundo FB, Shepherd WC, Marose TD. Use of alternative medicine by patients in a rural family practice clinic. Fam Med 2002;34(3):206–12. Ariff KM, Beng KS. Cultural health beliefs in a rural family practice: a Malaysia perspective. Aust J Rural Health 2006;14:2–8. Ehrlich SD. Herbal medicine. University of Maryland Medical Centre; 2013. Available from https://umm.edu/health/medical/altmed/ treatment/herbal-medicine; assessed January 2014. Ernst E. Harmless herbs? A review of the recent literature. Am J Med 1998;104(2):170–8. Babar MG, Syed SH, Naing CM, Hamzah NH. Perceptions and self-use of complementary and alternative medicine (CAM) among Malaysian dental students. Eur J Integr Med 2012;4:e63–9. Roberti di Sarsina P. The social demand for a medicine focused on the person: the contribution of CAM to healthcare and health genesis. Evid Based Complement Alternat Med 2007;4(S1):45–51. Bailey DG, Dresser GK. Natural products and adverse drug interactions. CMAJ 2004;170(10):1531–2. White A, Boon H, Alraek T, Lewith G, Liu J-P, Norheim A-J, et al. Reducing the risk of complementary and alternative medicine (CAM): challenges and priorities. Eur J Integr Med 2014;6:404–8. Pagán JA, Pauly MV. Access to conventional medical care and the use of complementary and alternative medicine. Health Aff 2005;24(1):255–62. Robinson N, Blair M, Lorenc A, Gully N, Fox P, Mitchell K. Complementary medicine use in multi-ethnic paediatric outpatients. Complementary Ther Clin Prac 2008;14:17–24. Wardle J, Weir M, Marshall B, Archer E. Regulatory and legislative protections for consumers in complementary medicine: lessons from Australian policy and legal developments. Eur J Integr Med 2014;6:423–33. Lorenc A, Blair M, Robinson N. Parents’ and practitioners’ differing perspectives on traditional and complementary health approaches (TCAs) for children. Eur J Integr Med 2010;2:9–14.
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
ARTICLE IN PRESS Available online at www.sciencedirect.com
ScienceDirect European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6
Original article
Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia Saranyaa Silvanathan, Bin Seng Low ∗ School of Medicine, Taylor’s University, 47500 Subang Jaya, Selangor, Malaysia Received 8 October 2014; received in revised form 9 December 2014; accepted 11 December 2014
Abstract Introduction: Traditional and complementary medicine (T&CM) has always been an important part of healthcare. However, many people underestimate the benefits and also the risks of taking T&CM. Therefore, the aim of the present study was to analyse the public awareness of the efficacy and safety of T&CM compared to the conventional Western treatments in Malaysia. Methods: A cross-sectional study was carried out with university staff and students residing in Selangor and Kuala Lumpur, Malaysia on their perceptions and awareness of T&CM using an online self-administered questionnaire. Results: Most respondents (85%, n = 200) preferred T&CM over the conventional Western treatments and had the impression that T&CM was safe. Herbal medicine (28%) was the most preferred form of T&CM to treat cough and cold as well as backache. About 51% of the respondents were unaware of the possible side effects of the T&CM but did not recognise the possibility of using counterfeits, men being more aware than women and 77% were more likely to inform clinician about their T&CM consumption. Respondents who were aware of T&CM counterfeits and herb–drug interactions reported experiencing significantly improvement but not those were aware of side effects. Only those aware of T&CM counterfeit would like to inform medical practitioners about their T&CM consumption. Conclusion: The prevalence of T&CM was high but experiencing improvement through its use may attribute to different levels of awareness. Campaigns to educate public on T&CM are pertinent since the public awareness on the T&CM side effects still lacking. © 2014 Elsevier GmbH. All rights reserved. Keywords: Traditional; Complementary; Awareness; Safety; Knowledge; Malaysia
Introduction Traditional and complementary medicine (T&CM) has emerged again as an important part of modern healthcare despite being practiced before the advent of conventional Western treatments. According to the World Health Organization (WHO), 80% of the population in Africa, Asia and Latin America use T&CM every year [1]. Almost half of the population from developed countries including United States, Australia, France and Canada use T&CM on a regular basis [2]. A study in Malaysia reported that the popularity of T&CM use among the elderly was associated with its lower cost, lower rate of side effects and better
∗
Corresponding author. Tel.: +60 3 5629 5176; fax: +60 3 5629 5455. E-mail addresses: [email protected], [email protected] (B.S. Low).
accessibility compared to conventional Western medicines [3]. In Ghana, the expense of western medical treatments for malaria costs USD$1.60 per treatment, compared with USD$0.35 per treatment for herbal medicines and USD$0.10 per treatment or almost free for home-grown herbs [4]. About two-thirds of all marketed drugs discovered in the past quarter-century have been derived from natural products such as artemisinin from Artemisia annua, a potent antimalarial herb found in East Asia [5]. Malaysia is a rapid developing country with a population approaching 28 million [6]. Recent studies reported that the prevalence of the use of T&CM in Malaysia was relatively high [7,8] especially for middle-aged adults who use them to enhance their well-being including sexual libido [9]. Studies have also shown that patients suffering with chronic diseases [8] and cancer [10] also prefer T&CM as their alternative source of treatment. As T&CM emerges as an alternative for both acute
http://dx.doi.org/10.1016/j.eujim.2014.12.003 1876-3820/© 2014 Elsevier GmbH. All rights reserved.
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
+Model EUJIM-380; No. of Pages 6 xxx.e2
ARTICLE IN PRESS S. Silvanathan, B.S. Low / European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6
and chronic treatment, there have been numerous cases of adulteration of T&CM with various substances such as; sildenafil, tadalafil, vardenafil and their structurally modified analogues [11]. Despite evidence of the high prevalence of T&CM use in Malaysia, no study has been carried out to scrutinise the level of public awareness in terms of safety towards counterfeit preparations, herb–drug interactions and side effects of T&CM. The aim of present study was to investigate the level of public awareness towards the efficacy and safety of T&CM and any demographic differences in perceived improvement and the awareness of T&CM side effects following the T&CM use. The source and knowledge of T&CM were also evaluated.
Methodology Study design and sample A cross-sectional study of population residing in Selangor and Kuala Lumpur, Malaysia was conducted using self-administered questionnaire. The study was piloted from 18th January to 7th February 2014 as a part of medical school’s undergraduate research project. Staff and students from the institution (all living in Selangor and Kuala Lumpur) were randomly selected from the database to participate in this study. By using an online sample calculator (http://www.raosoft.com/samplesize.html) (Raosoft® Inc., Seattle, WA) [9], sample size of 195 participants based on 7% margin of error with 95% confidence interval was estimated. Allowing for a 5% dropout, 211 participants were recruited into the study. From the university database, email addresses were retrieved and invitation emails sent with a hyperlink to the questionnaire. Participants were assured of the confidentiality of their personal and demographic data, which was stated on the front page of the questionnaire. Participation agreement was only considered upon the completion and submission of the online questionnaire. The study was approved by the ethical review.
Table 1 Demographic characteristics of the respondents. Parameters
Number
(%)
Gender Male Female
93 107
(46.5) (53.5)
22 90 31 33 20 4
(11.0) (45.0) (15.5) (16.5) (10.0) (2.0)
2 10 35 153
(1.0) (5.0) (17.5) (76.5)
78 68 44 10
(39.0) (34.0) (22.0) (5.0)
Age Below 20 20–30 31–40 41–50 51–60 Over 61 Education level No proper schooling Primary school Secondary school Tertiary school Monthly household income Below 5000 5000–10,000 10,001–50,000 Above 50,000
All data indicate the true number of the respondents (n = 200). Value in parenthesis indicates percentage of the number over the total number of respondents.
quantitative data, apart for one question on the rating towards knowledge of T&CM (Supplementary document 1). Data analysis All data from the respondents were subsequently analysed using Statistical Package for the Social Sciences (SPSS® ) version 20 (IBM SPSS New York, USA). Descriptive statistics including frequencies and percentages were calculated. Bivariate analysis using the Chi-square test was performed to determine the significance of the association between the demographics and other variables related to the awareness of three major concerns about T&CM. A p value less than 0.05 was considered significant.
Survey instrument
Results
Data was collected using a self-reported structured questionnaire which was constructed in the English language, prepared by Google® Docs online. A pre pilot study comprising of 8–10 participants, was conducted before the main assessment in order to evaluate the content validity and language simplicity of the questionnaire. It was sent to participants with hyperlink via email allowing one day to reply. Subsequently, modification of the final questionnaire was made based on the feedback from participants’ comments. Data from the pilot study was not included in the final assessment. The final questionnaire consisted of a total of 23 questions, 4 items related to the respondent’s demographic data and 19 related to the respondents’ perceptions, the use and awareness towards counterfeit preparations, herb–drug interactions and side effects of traditional and complementary medicine (T&CM). All questions were closed in order to obtain
Of the 211 participants invited to participate, 200 questionnaire responses were returned giving a response rate of 94.8%. The gender distribution was fairly equal with slightly more females than males responding and the majority aged between 20 and 30 years old (Table 1). The majority of the respondents had received higher education level qualifications and had medium to low household income (below RM 10,000 per month) (Table 1). Traditional and complementary medicine (T&CM) was perceived as either more natural, more effective, lower cost and/or respondents were prejudiced against Western medicines. These reasons made up two thirds of responses (62.8%) and were the major reasons given to explain the respondents’ inclination towards the use of T&CM (Table 2). The majority of respondents preferred T&CM than conventional Western treatment. A high proportion of respondents (66.0%) had only used
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
+Model
ARTICLE IN PRESS
EUJIM-380; No. of Pages 6
S. Silvanathan, B.S. Low / European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6
xxx.e3
Table 2 Reasons given by the respondents on the use of traditional and complementary medicine (T&CM). Reasons
Frequency %
I prefer natural therapy T&CM is effective The cost is cheaper I do not prefer T&CM over western medicine Western medicine produce side effects T&CM is recommended by doctor, family and friends Western medication does not help and it is toxic I have consumed too many Western medications It is easy to communicate with T&CM practitioners
84 53 48 35 34 31 28 27 10
(24.0) (15.1) (13.7) (10.0) (9.7) (8.9) (8.0) (7.7) (2.9)
All data indicate the frequency from the respondents. Value in parenthesis indicates percentage of the frequency per reason over the total frequency given by respondents. Respondents were allowed to select more than one option.
T&CM occasionally for health purposes (Table 3). Only 6.0% of the respondents used T&CM for all the health problems they currently experienced and this was mainly acknowledged as being supplements (54.7%). More than 75.0% respondents perceived improvements after taking T&CM (Table 3). This study showed that the most common types of T&CM used were herbal medicine (28.4%) followed by oil (22.9%) and massage (15.4%) (Fig. 1) to treat a variety of illnesses including coughs, colds, backache, general pain management and headache (Table 4). The majority of the respondents obtained their T&CM from the shops (48.8%) as well as from family members (32.2%) (Fig. 2) as more than half (58.0%) of the respondents revealed that their family members also used T&CM (Table 3). Table 3 Perceptions of the respondents towards traditional and complementary medicine (T&CM). Parameters
Number
(%)
Preference of T&CM over Western medicine All the time Sometimes Never
16 154 30
(8.0) (77.0) (15.0)
Use of T&CM for health purpose in past one year All health problems Occasionally Never
12 132 56
(6.0) (66.0) (28.0)
Role of T&CMa As a supplement Long term maintenance Substitute for Western medicine When required
117 49 44 4
(54.7) (22.9) (20.6) (1.9)
152 48
(76.0) (24.0)
116 84
(58.0) (42.0)
Improvement after taking T&CM Yes No Family member taking Yes No
T&CM
All data indicate the true number of the respondents (n = 200) except a Respondents may select more than one option indicated the frequency. Value in parenthesis indicates percentage of the number over the total number or frequency of respondents.
Fig. 1. Percentage of the respondents’ preferences towards the different types of traditional and complementary medicine (T&CM). Powder indicated the ground preparation including the aerial parts, stem, root and animal parts which could apply directly whilst the herbal medicine indicated the herbal remedies which can be prepared following infusion, decoction, tincture and maceration methods.
Despite the highly preference for use of T&CM from the respondents, the median rate of knowledge on T&CM from total 200 respondents was 5.04 (1 being the lowest and 10 being the highest in rating of knowledge) (Fig. 3). Knowledge about Table 4 Heath conditions and illnesses that respondents preferred to be treated with traditional and complementary medicine (T&CM). Health Problems
Frequency
%
Cough and cold Backache General pain management Headache Asthma Diarrhoea Fever Detoxification Skin disorder Digestive tract problem Diabetes Food poisoning Sleep disorder Nausea/vomiting, diarrhoea Menstrual problems Wound/oedema Arthritis Hypertension Cardiovascular problems Neurological disorder Urological disorder Hyperlipidemia Kidney/Gall stones Infertility Psychological disorder Aphrodisiac Dermatitis Ear wax Strengthen the immune system
67 55 47 45 38 37 37 35 35 28 27 25 25 24 21 20 18 14 9 9 9 7 7 6 3 2 1 1 1
10.3 8.4 7.2 6.9 5.8 5.7 5.7 5.4 5.4 4.3 4.1 3.8 3.8 3.7 3.2 3.1 2.8 2.1 1.4 1.4 1.4 1.1 1.1 0.9 0.5 0.3 0.2 0.2 0.2
Respondents may select more than one option indicated the frequency. The percentage indicates the number over the total number or frequency of respondents. Respondents were allowed to select more than one option.
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
+Model EUJIM-380; No. of Pages 6 xxx.e4
ARTICLE IN PRESS S. Silvanathan, B.S. Low / European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6 Table 5 Awareness from the respondents towards the side effects of traditional and complementary medicine (T&CM), the issue of counterfeit and the interaction with Western medicine.
Fig. 2. Respondents methods of accessing traditional and complementary medicine (T&CM).
Fig. 3. The knowledge on traditional and complementary medicine (T&CM) rated by the total 200 respondents (with 1 being the lowest and 10 being the highest in rating of knowledge).
T&CM was generally obtained from family members (29.4%), online websites (21.3%) and/or recommended by peers (22.5%) (Fig. 4) suggesting there were inadequacies in their knowledge. Approximately half (50.5%) of the respondents were unaware of the possible side effects and herb–drug interactions of T&CM (except from knowledge of counterfeit and adulteration issues) and more than 75.0% of all respondents were keen to inform their medical practitioner about their T&CM consumption (Table 5). As very few respondents (9.0%) had experienced side effects after consuming T&CM, it was generally thought that T&CM was seldom harmful (51.0%) (Table 5). Bivariate
Parameters
Number
%
Aware of counterfeit Yes No
115 85
(57.5) (42.5)
Aware of herb–drug interaction Yes No
99 101
(49.5) (50.5)
Concurrently use of Western medicine and T&CM Yes No
122 78
(61.0) (39.0)
Willing to inform doctor about the use of T&CM Yes No
154 46
(77.0) (23.0)
Aware of T&CM side effects Yes No
99 101
(49.5) (50.5)
Experience of side effects after consuming T&CM Yes No
18 182
(9.0) (91.0)
Opinion on T&CM harmfulness Frequently Occasionally Seldom No opinion
4 34 102 60
(2.0) (17.0) (51.0) (30.0)
All data indicate the true number of the respondents (n = 200). Value in parenthesis indicates percentage of the number over the total number of respondents.
analysis showed that male respondents were significantly more aware of counterfeit T&CM preparations, (p = 0.031) than female respondents (Table 6). Respondents who were aware of the counterfeits and herb–drug interactions felt significant improvement after taking T&CM (p = 0.001 and 0.025, respectively). Respondents who aware of the counterfeit were more likely to inform their doctors (p = 0.011). Respondents still concomitantly consumed T&CM with Western medicine regardless of whether they were aware of the potential of T&CM counterfeits, herb–drug interactions or side effects (Table 6). Discussion
Fig. 4. Respondents methods of gaining knowledge and safety awareness of traditional and complementary medicine (T&CM).
Of the two hundred respondents, the percentage of females respondents was higher than males. This was slightly higher (by 5%) than the gender demography in Malaysia [6]. This was probably due to the higher percentage of female staff and students who were currently working and studying in the institution and who agreed to participate in the present study. Data suggested that household income did not influence the preference of the respondents towards the traditional and complementary medicine T&CM (data not shown). In other words, T&CM preference not only limited to respondents with lower household income but also favour for those with higher household incomes. Among various types of T&CM, herbal medicines were the most commonly used in agreement with an earlier study [12] and
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
+Model
ARTICLE IN PRESS
EUJIM-380; No. of Pages 6
S. Silvanathan, B.S. Low / European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6
xxx.e5
Table 6 Bivariate analysis of the respondents’ demography and awareness towards three major concerns of traditional and complementary medicine (T&CM). Variables
Gender F/M Experience AE N/Y Inform doctor Consume T&CM with Western medicine Feeling some improvement
Aware of counterfeit
Aware of herb–drug interaction
Aware of side effect
p Value
OR
95% CI
p Value
OR
95% CI
p Value
OR
95% CI
0.031a
1.871 0.503 2.352 1.445 4.810
1.056–3.313 0.193–1.311 1.202–4.603 0.813–2.570 2.370–9.759
0.784 0.845 0.052 0.156 0.025a
1.081 0.910 1.943 0.661 2.136
0.620–1.884 0.353–2.345 0.987–3.824 0.373–1.172 1.091–4.183
0.992 0.083 0.552 0.973 0.056
0.997 2.393 1.222 1.010 1.901
0.572–1.738 0.871–6.573 0.631–2.365 0.571–1.785 0.977–3.699
0.154 0.011a 0.209 0.001a
OR: odds ratio; CI: confidence interval. a p Value is statistically significant.
most of the respondents agreed on T&CM lower costs and/or lower toxic effects compared with Western medicines. The high percentage of respondents who reported improvement after consuming T&CM indicated the perceived efficacy of T&CM which may be a potential issue for concern in Malaysia as well as in developed countries [13]. Despite the fact that various information regarding T&CM could be obtained from family member and websites, as reported earlier [14], the knowledge on T&CM among Malaysians was not promising. Indeed, higher educational levels had no enhancement effect on the awareness among respondents as the bivariate analysis showed that different educational levels did not increase the safety awareness among respondents on T&CM (data not shown). In fact, people in rural areas who may not be welleducated, may be proficient in T&CM practices as this is their primary source of healthcare [15,16]. Interestingly, more than half of the respondents were particularly aware of T&CM counterfeits and adulteration in the market with male respondents being more aware of the T&CM counterfeits and adulteration issues compared to female respondents. This may probably be due to males who are concerned about erectile dysfunction and as an earlier report revealed that middle-age adults were more preferring alternative medicines to enhance their libido [9]. This probably may explain why more respondents were likely to inform their medical practitioners about their T&CM consumption during consultation. The willingness of the respondents to inform doctor about their T&CM consumption, contradicts a study carried out in a US population which suggested that most participants were reluctant to tell their medical doctor about the concomitant use of T&CM [17]. Public may not be aware of the T&CM side effects as the knowledge on T&CM toxicity remains scanty or there is lack of proper reference resources [18,19]. Therefore, public may perceive that T&CM has lower rate of side effects than that of conventional Western treatments so many consumers may turn to T&CM products [20]. As a result, they may therefore be routinely co-administered with Western medicine which they may think it is safe without knowing the medical consequences of herb–drug interactions. Indeed, T&CM may not induce the toxic effect or the dose may be far too low compared to Western medicine, yet report have showed that natural products used in T&CM may potentially affect the absorption, metabolism and elimination process of drugs [21]. Moreover, present study showed the perception about improvement was only significant for those who were aware of counterfeits and herb–drug
interactions but not for those aware of T&CM side effect. It may however indicate that, the feeling of improvement could be results of a possible placebo effect. A separate study would be needed to test this hypothesis. More studies to explore toxicity effects and herb–drug interactions of T&CM are urgently required in case patient safety is compromised [22]. In many developing countries, T&CM is the primary source of healthcare at the community level and conventional healthcare is vastly limited [1]. As T&CM has been said to recognise the need to focus on quality of life when a cure is not possible [5], this could be the reason why individuals perceive that T&CM has better potential for treating disease. Besides, the rising of cost for conventional Western medicine in some developed countries may have contributed to the increase for the use of alternatives including T&CM for treatment [23]. Perhaps, it may not surprising to see that the popularity of T&CM is growing exponentially as this study also showed that respondents will still taking T&CM regardless of whether they know that there may be potentially harmful effects associated with T&CM. T&CM is also popular in United Kingdom among adults who using a range of therapies for their children [24]. Hence, many countries including Malaysia have now recognised the need to develop a cohesive and integrative regulatory approach to access T&CM in a safe, evidence-based environment and increase public awareness [22,25]. Beside the governance, healthcare practitioner may also need to appreciate the role of T&CM as part of clinical care [24,26]. To the best of our knowledge, it is the first time that the awareness regarding to the safety of the T&CM has been assessed, analysed and reported. However, the findings from the present study should be interpreted with caution. First, the sample of two hundred respondents is limited as it reflects only a selected population in a specific area and data cannot be generalised to the whole country. Additionally, participants were limited to the staffs and students who live in a specific area within the university campus. Second, the majority of our respondents were tertiary educated and were young (20–30 years old). Tertiary education level comprised undergraduates and postgraduates and the recruitment was limited to an urban area and did not extend to a rural area. Besides, it could be also argued that this age group may not necessarily take T&CM at their age so their perceptions may not have been based on their own experience, although, the use of T&CM in Malaysia is generally prevalent for the whole population across various age groups [7]. Family members and peers are always the major influence for the
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003
+Model
ARTICLE IN PRESS
EUJIM-380; No. of Pages 6 xxx.e6
S. Silvanathan, B.S. Low / European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e6
younger age group to take T&CM not only for treatment, but mostly for supplementary and adjuvant therapy. Third, the concept of herbal medicines is this context is difficult to define. Depending on the regulation of herbal medicines in different countries, a particular herbal product may be classified as a dietary supplement in one country and may differ to another. In this study, we have defined herbal medicines as herbal remedies which contain either raw or processed ingredients from one or more plants or parts used by which can be prepared following infusion, decoction, tincture and maceration methods for therapeutic or other health benefits. Powder indicates the ground preparation including the aerial parts, stem, root and animal parts which could apply directly without preparation methods as mentioned. Our definition of herbal medicines does not include products that are supplemented with vitamins and minerals. These explanations were included for participants in the invitation email. Fourth, apart from age, education levels and locality, ethnic background, religion and other cultural differences were not assessed. Also the validity of the study questionnaire was not assessed.
[4]
[5] [6]
[7] [8]
[9]
[10]
[11]
Conclusion [12]
In conclusion, public preference for T&CM is high but there was lack of awareness on the side effects and understanding and knowledge of T&CM. The willingness of the respondents to inform their medical practitioner regarding the use of T&CM was impressive. Since the prevalence of T&CM is high, healthcare professionals need to improve their knowledge on T&CM and their ability to manage the possible of any adverse events. Public education on the safety of T&CM is highly recommended. Conflict of interest statement
[13]
[14]
[15]
[16] [17]
The authors have no conflict of interests. Acknowledgements Author wish to thank Ms Uta Dietrich, who coordinated the medical students’ research study and all participants, who had participated in the present study. No funding was granted for this study. Appendix A. Supplementary data
[18] [19]
[20]
[21] [22]
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j. eujim.2014.12.003.
[23] [24]
References [1] World Health Organization. WHO traditional medicine strategy 2002–2005. Geneva: World Health Organization; 2002. p. 11–2. [2] Bodeker G, Kronenberg F. A public health agenda for traditional, complementary, and alternative medicine. Am J Pub Health 2002;92(10):1582–91. [3] Mitha S, Nagarajan V, Babar MG, Siddiqui MJA, Jamshed SQ. Reasons of using complementary and alternative medicines (CAM) among elderly
[25]
[26]
Malaysians of Kuala Lumpur and Selangor states: an exploratory study. J Young Pharm 2013;5:50–3. Ahorlu CK, Dunyo SK, Afari EA, Koram KA, Nkrumah FK. Malariarelated beliefs and behaviour in Southern Ghana: implications for treatment, prevention and control. Trop Med Int Health 1997;2(5): 488–99. Newman DJ, Cragg G. Natural products as sources of new drugs over the 30 years from 1981 to 2010. J Nat Prod 2012;75(3):311–35. Taburan Penduduk dan Ciri-ciri Asas Demografi. Jabatan Perangkaan Malaysia; 2010. Available from URL http://www.statistics.gov.my/portal/ download Population/files/census2010/Taburan Penduduk dan Ciriciri Asas Demografi.pdf (assessed February 2014). Aziz Z, Tey NP. Herbal medicines: prevalence and predictors of use among Malaysian adults. Complement Ther Med 2014;22:49–56. Hasan SS, Ahmed SI, Bukhari NI, Cheah WLW. Use of complementary and alternative medicine among patients with chronic diseases at outpatient clinics. Complement Ther Clin Prac 2009;15:152–7. Hassali MA, Saleem F, Shafie AA, et al. Assessment of general public perceptions toward traditional medicines used for aphrodisiac purpose in state of Penang, Malaysia. Complementary Ther Clin Prac 2012;18: 257–60. Farooqui M, Hassali MA, Shatar AKA, Shafie AA, Tan BS, Farooqui MA. Complementary and alternative medicine (CAM) use by Malaysian oncology patients. Complementary Ther Clin Prac 2012;18:114–20. Sahoo N, Manchikanti P, Dey S. Herbal drugs: standards and regulation. Fitoterapia 2010;81:462–71. Siti ZM, Tahir A, Ida Farah A, et al. Use of traditional and complementary medicine in Malaysia: a baseline study. Complement Ther Med 2009;17(5):292–9. Su D, Li L. Trends in the use of complementary and alternative medicine in the United States: 2002–2007. J Health Care Poor Underserved 2011;22(1):296–310. Bauer BA. Herbal medicine, the good, the bad, and the ugly. In: SoCRA source; 2003. Available from http://www.mrshumansays.com/uploads/ 1/2/6/8/12688070/herbal medicine the good the bad and the ugly.pdf; assessed February 2014. Winfred del Mundo FB, Shepherd WC, Marose TD. Use of alternative medicine by patients in a rural family practice clinic. Fam Med 2002;34(3):206–12. Ariff KM, Beng KS. Cultural health beliefs in a rural family practice: a Malaysia perspective. Aust J Rural Health 2006;14:2–8. Ehrlich SD. Herbal medicine. University of Maryland Medical Centre; 2013. Available from https://umm.edu/health/medical/altmed/ treatment/herbal-medicine; assessed January 2014. Ernst E. Harmless herbs? A review of the recent literature. Am J Med 1998;104(2):170–8. Babar MG, Syed SH, Naing CM, Hamzah NH. Perceptions and self-use of complementary and alternative medicine (CAM) among Malaysian dental students. Eur J Integr Med 2012;4:e63–9. Roberti di Sarsina P. The social demand for a medicine focused on the person: the contribution of CAM to healthcare and health genesis. Evid Based Complement Alternat Med 2007;4(S1):45–51. Bailey DG, Dresser GK. Natural products and adverse drug interactions. CMAJ 2004;170(10):1531–2. White A, Boon H, Alraek T, Lewith G, Liu J-P, Norheim A-J, et al. Reducing the risk of complementary and alternative medicine (CAM): challenges and priorities. Eur J Integr Med 2014;6:404–8. Pagán JA, Pauly MV. Access to conventional medical care and the use of complementary and alternative medicine. Health Aff 2005;24(1):255–62. Robinson N, Blair M, Lorenc A, Gully N, Fox P, Mitchell K. Complementary medicine use in multi-ethnic paediatric outpatients. Complementary Ther Clin Prac 2008;14:17–24. Wardle J, Weir M, Marshall B, Archer E. Regulatory and legislative protections for consumers in complementary medicine: lessons from Australian policy and legal developments. Eur J Integr Med 2014;6:423–33. Lorenc A, Blair M, Robinson N. Parents’ and practitioners’ differing perspectives on traditional and complementary health approaches (TCAs) for children. Eur J Integr Med 2010;2:9–14.
Please cite this article in press as: Silvanathan S, Low BS. Current public awareness on the safety of traditional and complementary medicines (T&CM) in Malaysia. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.12.003