Doctors’ attitudes towards the use of herbal medicine in Lagos, Nigeria

JOURNAL OF HERBAL MEDICINE

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Doctors’ attitudes towards the use of herbal medicine in Lagos, Nigeria O. Awodele a b c

a,* ,

E.O. Agbaje a, O.O. Abiola a, D.F. Awodele b, D.C Dolapo

c

Department of Pharmacology, College of Medicine, University of Lagos, PMB, 12003 Idi-Araba, Lagos, Nigeria Department of Nursing, College of Medicine, University of Lagos, PMB, 12003 Idi-Araba, Lagos, Nigeria Department of Community Health, College of Medicine, University of Lagos, PMB, 12003 Idi-Araba, Lagos, Nigeria

A R T I C L E I N F O

A B S T R A C T

Article history:

This paper is the second of a two part study looking at the integration of herbal medicine

Received 2 October 2011

into the Nigerian Healthcare System. This study continues by establishing doctors’ atti-

Accepted 27 January 2012

tudes towards the use of herbal medicine in Lagos and elucidating the possible factors that

Available online 19 March 2012

may limit their interest in the use of herbal medicine. A descriptive survey was carried out using a WHO standardized questionnaire to obtain the opinion of 300 resident doctors in

Keywords:

various specialties at Lagos University Teaching Hospital. The results showed that 60.0%

Doctors

(n = 181) of the respondents were disposed towards the use of herbal medicine, 40.7%

Herbal medicine

(n = 122) said however that they would discourage their patients from using it. The results

Nigeria

further showed that 62.0% (n = 186) of the respondents felt herbal medicine had a positive

Healthcare System

role in patients care; should be recognized by the government 28% (n-84) and that it is gen-

Herbal medicine research

erally safe for consumption by patients 60.3% (n = 181). Although 41.0% (n = 123) of the

Herbal medicine safety

respondents thought herbal medicine was effective in treating chronic diseases, none of the respondents thought herbal medicine alone could completely treat a patient. None of the respondents thought the level of research into herbal medicine was adequate and the level of education for herbal medicine practitioners was thought in the main to be inadequate. Extensive research into the ethnomedicinal preparations in common use to ensure patient safety and minimize risk and an improvement of educational standards in the training of herbal medicine practitioners may be needed before total integration into the Healthcare System can be contemplated. Ó 2012 Published by Elsevier GmbH.

1.

Introduction

This paper continues to look at the integration of traditional herbal medicine into the Nigerian Healthcare System. The previous paper Awodele et al. (2011) considered the views of Traditional Medicine practitioners, the focus of this paper is on the attitudes of orthodox medical doctors to the possible use of traditional herbal medicine in primary healthcare. The use of herbal medicine has been reported to be on the increase in many developing and industrialized countries * Corresponding author. Tel.: +234 8023624044. E-mail address: [email protected] (O. Awodele). 2210-8033/$ - see front matter Ó 2012 Published by Elsevier GmbH. doi:10.1016/j.hermed.2012.02.002

(Furnharm, 1996; Ernst and White, 2000). It is known that between 65% and 80% of the world’s population use herbal medicine as their primary form of healthcare (Eisenberg et al., 1998; WHO, 2007). The WHO directive encourages developing countries to supplement their health programmes with traditional herbal preparations provided they are proven to be non-toxic (WHO, 1985). Some of the commonly used Nigerian medicinal plants, Morinda lucida [Oruwo (root)], Azadirachta indica [Dongoyaro (leaf)] and Alstonia boonei [Ahun (bark)] have been demonstrated to possess analgesic, anti-inflammatory

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and antipyretic properties (Olajide et al., 2000). Thus, the use of herbal medicines has been documented to play significant roles in the management of both minor and major illnesses (Eisenberg et al., 1993; Barnes, 2003; Gardiner et al., 2007). In recent years a significant worldwide increase has been reported in the general use of complementary and alternative medicine (CAM) (Tindle et al., 2005; Crawford et al., 2006; Joos et al., 2008; Hori et al., 2008). Studies on the attitudes of Western doctors to complementary medicine have been carried out in European and North American countries (Berman et al., 1995; Eisenberg et al., 1998; Astin et al., 1998; Berman et al., 1998; Crock et al., 1999) and it has been shown that complementary medicine has become more important in terms of dissatisfaction with modern Western medicine (conventional medicine) or with medical economics (Eisenberg et al., 1998). A study on the attitude of doctors to traditional herbal medicine conducted in Africa (Ghana) showed that 75% of the population of Ghana depended on traditional herbal medicine for their healthcare (Tabi et al., 2006; Abel and Busia, 2005). Comparatively, Western pharmaceutical medicine is more successful in developed countries than in the underdeveloped African countries and a host of factors account for this. Amongst such factors are the high cost of pharmaceutical medicines, hospitals and medical facilities which are not accessible to many, and overcrowding of patients in clinics and hospitals. Use of CAM has therefore become more popular in these areas. The term CAM generally refers to practices that are not integral parts of conventional or orthodox medicine and are consequently not taught as part of the archetypal medical education curriculum (Eisenberg et al., 1998). The National Institute of Health (NIH) classifies CAM into five major categories: alternative medical systems (e.g. traditional oriented medicine, acupuncture, Ayurveda, naturopathy, homeopathy, Native American healing, and Tibetan medicine), mind–body interventions (meditation, hypnosis, dance, art and music therapy, spiritual healing, and prayer), biological-based therapies (herbal medicine and dietary supplements, special diets, and orthomolecular medicine), manipulative and body-based methods (chiropractic, massage, the Feldenkrais method, other ‘‘body work’’ systems and aspects of osteopathic medicine such as craniosacral work), and energy therapies (reiki, therapeutic touch and other methods affecting the ‘‘bioelectric field’’ of the body) (Hughes et al., 2005). It has earlier been projected that integrative medicine, which is defined as the blending of conventional and herbal/ natural/complementary medicines and/or therapies, with the aim of using the most appropriate of either or both modalities to care for the patient holistically (Sali and Vitetta, 2007) would make healthcare much more effective. Towards attaining this goal, one of the governmental arms in Nigeria, The National Agency for Food, Drugs, Administration and Control (NAFDAC) has started documenting ethnomedicinal preparations (herbal medicine) on the market in Nigeria, which can be purchased in bulk in crude form or in dosage forms such as capsules, tablets, concentrated extracts, teas, tinctures and decoctions. In addition, traditional medicine practitioners are employing a series of strategies to ensure integration and co-recognition of their practice in the National Healthcare Scheme. One of these strategies is the recent trend for

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traditional medicine practitioners to approach research institutes and Universities to help them establish the safety and efficacy of their herbal medicine preparations. It is noteworthy that many studies have already been conducted in this environment to assess the disposition of traditional medicine practitioners towards integrative medicine (Tilburt and Kaptchuk, 2008). It therefore becomes imperative to explore the attitude of orthodox doctors towards traditional/herbal medicine and its possible integration into the National Healthcare System. This study aimed to assess the attitudes of resident doctors in Lagos University Teaching Hospital (LUTH) in Nigeria towards the use of herbal medicine, with a view of contribution to the policy formulation and possible future integration of traditional herbal medicine practice into the National Healthcare Scheme.

2.

Methodology

2.1.

Description of the study area

LUTH is one of the largest teaching hospitals in Nigeria. It is located in Lagos State, which is a state in South-Western Nigeria. Lagos is one of Nigeria’s most populated states, the chief port and principal economic centre. The teaching hospital has 761 bed spaces and records over 9000 (10,000) patient attendances in a month. There are about 520 resident doctors working in LUTH in seven major Departments (Anaesthesia, Medicine, Obstetrics & Gynaecology, Paediatrics, Pathology, Psychiatry and Surgery).

2.2.

Study population

The study population included 300 out of a total of 520 resident doctors working in LUTH who consented to participate in the study.

2.3.

Study design

This study is a descriptive cross-sectional survey of the attitudes of doctors’ working in LUTH to the use of herbal medicine and its integration into the NHCS.

2.4.

Data collection

Data was collected using a standard closed-ended structured questionnaire originated by the authors following the WHO’s recommendations for healthcare questionnaire design (McColl and Thomas, 2000) with three (3) sections on sociodemography, the awareness and use of herbal medicine and perceptions about herbal medicine (Appendix A). The subjects were mainly not required to write but just to tick the appropriate boxes which were provided for each option given. Names were not used for identification but coding numbers were used instead.

2.5.

Data analysis

The 300 questionnaires obtained from the study were analyzed using the EPI-INFO 2002 software programme. The data

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was presented in frequency distribution tables with percentages and Chi square analysis was used to test the significance at p < 0.05.

3.

Results

The results obtained showed that out of the 300 resident doctors who participated in this study, the highest age frequency 29.3% (n = 88) was between 15 and 25 years of age and the lowest 18.7% (n = 56) were between 36 and 45 years. The results further showed 58.7% (n = 176) of the respondents to be male and 41.3% (n = 124) were female. Most of the respondents 22.0% (n = 66) were from the Obstetrics and Gynaecology department, 14.3% (n = 43) were in General Medicine and the lowest percentage 7.0% (n = 21) were in Anaesthesia. The data obtained showed that 39.3% (n = 118) of the respondents had practised for a period of between one and two years, while 18.0% (n = 54.0) had practised for more than six years (Table 1). The results in Table 2 show the awareness and use of herbal medicine by the respondents. A high percentage (95.0%, n = 285) of the respondents were aware of the possible hazards associated with the use of herbal medicine. Most of the respondents 96% (n = 288) had read materials on herbal medicine, 97.7% (n = 293) knowing the names of some of the herbal medicines used and some 96.7% (n = 290) were aware of some of the herbal medicines listed for use by NAFDAC. Only 20.7% (n = 62) of the respondents however had ever used herbal medicine.

Table 1 – Socio-demographic data of respondents (doctors working in LUTH). Respondent profile

Frequency of responses

Percentage

Age (year) 15–25 26–35 36–45 46–55 Total

88 79 56 77 300

29.3 26.3 18.7 25.7 100

Sex Male Female Total

176 124 300

58.7 41.3 100

Medical specialty Anaesthesia Medicine Obstetrics & gynaecology Paediatrics Pathology Psychiatry Surgery Others Total

21 43 66 22 27 42 54 25 300

7.0 14.3 22.0 7.3 9.0 14.0 18.0 8.3 100

Duration of medical practice (in years) 1–2 118 3–4 112 5–6 16 >6 54 Total 300

39.3 37.3 5.3 18.0 100

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The results in Table 3 show the respondents’ perceptions of herbal medicine. The majority of respondents (97.3% n = 292) believe that traditional herbal medicine practitioners should be given a chance to practise. Although 41.0% (n = 123) of the respondents thought that herbal medicine may be effective in treating chronic diseases, none of the respondents thought that herbal medicine alone could completely treat a patient. The results further showed that 60.3% (n = 181) of the respondents were kindly disposed towards the use of herbal medicine, 40.7% (n = 122) adding however that they would discourage their patients from using it. 62.0% (n = 186) of the respondents opined that herbal medicine had a positive role to play in patient care, 28.0% (n = 84) said that herbal medicine should be recognized by the government and 60.3% (n = 181) believed that herbal medicine is safe for patient consumption. The research further revealed that very few 3.0% (n = 9) of the respondents were satisfied with the educational level of herbal medicine practitioners and that none thought the level of research was adequate. Only one respondent (0.3%) thought that the practitioners were happy to supply the source of their medicines and only very few 9.7% (n = 29) had any confidence in the dosages used. Table 4 shows the significant (p 6 0.05) associations between age, sex, speciality, and duration of practice of respondents and their willingness to recommend herbal medicine to patients. There were also significant associations (p 6 0.05) between respondents who had read materials on herbal medicine and those who had used herbal medicine and their willingness to recommend herbal medicine to patients (Table 5). There were however no significant (p P 0.05) associations between the awareness of possible hazards associated with herbal medicine, knowing the names of some of the herbal medicines used and being aware of some of the herbal medicine listed by NAFDAC and the respondents’ willingness to recommend it to patients.

4.

Discussion

Despite the increasing use of herbal medicine in many developing and industrialized countries (Furnharm, 1996; Ernst and White, 2000) and the reported dependence of between 65% and 80% of the world’s population on herbal medicines as their primary form of healthcare (Eisenberg et al., 1998; WHO, 2007), it cannot be fully integrated into the National Healthcare Scheme in Nigeria, if the orthodox medical doctors are not well disposed towards its use. Studies conducted among the Nigerian population have shown widespread use of traditional herbal medicine amongst hypertensive patients (Amira and Okubadejo, 2007; Osamor and Owumi, 2010) and pregnant women (Fakeye et al., 2009). The increasing use of these preparations could be as a result of the beliefs of patients in their efficacy, as well as the accessibility and affordability of the herbal medicaments. There is need however for appropriate regulation and standardization of herbal medicine use. The results obtained from the present study regarding orthodox medical doctors’ attitudes towards herbal medicine use showed that almost all the doctors that participated in the study were aware of the possible hazards associated with herbal medicine, and have had access to literature on this subject. The study also showed that they possess a good

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Table 2 – Awareness and use of herbal medicine by respondents (doctors working in LUTH). Respondents answers to questions on the use of herbal medicine

Frequency (n = 300)

Percentage

Aware of any risks associated with the use of herbal medicine Yes No Total

285 15 300

95.0 5.0 100

Had read materials on herbal medicine Yes No Total

288 12 300

96.0 4.0 100

Know the names of some of the herbal medicines used by practitioners Yes No Total

293 7 300

97.7 2.3 100

Aware of some of the herbal medicines listed for use by NAFDAC Yes No Total

290 10 300

96.7 3.0 100

Had ever used/recommended herbal medicine Yes No Total

62 238 300

20.7 79.3 100

Table 3 – Perception of respondents (doctors working in LUTH) about herbal medicine. Respondents answers to questions regarding their perception of herbal medicine

Frequency Percentage (n = 300)

Think that herbal medicine practitioners should be given the chance to practise Consider that herbal medicine may be effective in treating chronic diseases Are favourably disposed towards the use of herbal medicine Would discourage patients from taking herbal medicine Think that the dosages used by practitioners are adequate to treat disease Consider that herbal medicine alone can completely treat a patient Believe that herbal medicines should all be standardized Think that herbal medicine should be recognized by the government Deem herbal medicines safe for consumption by patients Think that herbal medicines have a positive role to play in patient care Are satisfied with the educational level of traditional herbal medicine practitioners Regard the level of research on herbal medicine to be adequate Consider that the herbal medicine practitioners were willing to reveal the source of their medicines

292 123 181 122 29 0 5 84 181 186 9 0 1

knowledge of a host of herbal remedies as well as the herbal medicines listed for use by NAFDAC. It could therefore be inferred that the respondents are very familiar with herbal medicine. However, despite their supposedly good knowledge about herbal medicine, most of them 79.3% (n = 238) had never personally prescribed herbal remedies, perhaps due to lack of information regarding standard dosages and a comprehensive safety profile of these preparations. The latter could possibly explain why only 28% (n = 84) of the respondents indicated that herbal medicine should be formally recognized. While some of the respondents (40.7% (n = 122) were skeptical about herbal medicine and would always discourage their patients from taking the preparations, a large percentage 97.3% (n = 292) opined that herbal medicine practitioners should be given a chance to practise. The present study has shown that integrative medicine is still far from being a reality in this part of the world.

97.3 41.0 60.3 40.7 9.7 0 1.7 28.0 60.3 62.0 3.0 0 0.3

However, since enthusiasm for CAM including herbal medicine amongst patients continues to increase, patients will require appropriate information about CAM from healthcare providers and it therefore behoves the Western doctors to have enhanced awareness, if not detailed knowledge of herbal medicine, in order to provide a full range of care to their patients. To improve the knowledge of orthodox medical doctors on herbal medicine, Owen et al. (2001) suggested the inclusion of CAM in the university undergraduate medical curriculum, which is believed to be more fruitful than at post-qualifying level (Zollman and Vickers, 1999). Furthermore, most of the respondents 97% (n = 291) expressed their dissatisfaction about the level of education of herbal medicine practitioners and the limited level of research into their herbal remedies. The relative paucity of research on CAM to date is due historically to lack of research funding. Vickers (2000) has suggested that an increased

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Table 4 – Associations between age, sex and work history of respondents (doctors working in LUTH) and their willingness to recommend herbal medicine to patients. Participants profile

Age (year) 15–25 26–35 36–45 46–55 Sex Male Female Medical Specialty Anaesthesia Medicine Obstetrics & gynaecology Paediatrics Pathology Psychiatry Surgery Others Duration of practice (year) 1–2 3–4 5–6 >6

Willing to recommend (%)

v2

df

p

Fisher’s exact p

Yes n = 227

No n = 73

80 54 19 74

8 (9.1) 25 (31.6) 37 (66.1) 3 (3.9)

88 79 56 77

83.85

3

0.00*

121 (68.8) 106 (85.5)

55 (31.3) 18 (14.5)

176 124

10.17

1

0.00*

17 26 57 12 23 36 39 17

4 (19.0) 17 (39.5) 9 (13.6) 10 (45.5) 4 (14.8) 6 (14.3) 15 (27.8) 8 (32.0)

21 43 66 22 27 42 54 25

19.93

7

0.01*

9 (7.6) 16 (14.3) 5 (31.3) 43 (79.6)

118 112 16 54

0.00*

68 (23.4) 5 (55.6)

290 9

0.04*

42 (26.6) 31 (21.8)

158 142

(90.9) (68.4) (33.9) (96.1)

(81.0) (60.5) (86.4) (54.5) (85.2) (85.7) (72.2) (68.0)

109 (92.4) 96 (85.7) 11 (68.8) 11 (20.4)

Enjoy doing their job Yes 223 (76.6) No 4 (44.4) Have ever worked in private hospital Yes 116 (73.4) No 111 (78.2)

Total n = 300

0.68

1

0.41

* p 6 0.05.

Table 5 – Associations between awareness and the use of herbal medicine by respondents (doctors working in LUTH) and their willingness to recommend it to patients. Participants knowledge of herbal medicine

Willing to recommend (%) Yes n = 227

Fisher’s exact p

No n = 73

Total n = 300

Aware of any risks associated with taking herbal medicine Yes 216 (75.8) No 11 (73.3)

69 (24.2) 4 (26.7)

285 15

0.52

Had read materials on herbal medicine Yes No

73 (24.9) 0 (0)

288 12

0.03

Knew the names of some of the herbal medicines used by practitioners Yes 220 (75.1) No 7 (100)

73 (24.9) 0 (0)

298 7

0.14

Aware of some of the herbal medicines listed for use by NAFDAC Yes 220 (75.9) No 7 (70.0)

70 (24.1) 3 (30.0)

290 10

0.46

Had ever used herbal medicine Yes No

39 (62.9) 34 (14.3)

62 238

0.00*

215 (75.1) 12 (100)

23 (37.1) 204 (85.7)

volume of good quality CAM research is being conducted worldwide, reflecting a growing awareness of its importance

amongst researchers, yet it is worth noting that research funding for CAM still lags significantly behind that of

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conventional medicine. Funding of research into herbal preparations to establish their efficacy and safety could aid in the enlightenment of orthodox doctors.

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(8) Have you ever worked in a private hospital? Yes [ ] No [ ]

A.2.

5.

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Awareness and use of herbal medicine

Conclusion

The study has qualitatively explored the range of perspectives on herbal medicine among resident doctors in LUTH. While a good knowledge of the commonly used herbal preparations was recorded by the informants, skepticism about the value of herbal medicine was prominent, since about 40% indicated that they would discourage patients from taking herbal medicine and only 28% opined that it should be recognized by the government, with all participants indicating that research on herbal medicine is not good enough. Such negative attitudes towards herbal medicine would possibly hamper doctor– patient communication and prevent patients’ disclosure of herbal medicine use, which could be deleterious in some situations, especially where the patients were using both forms of medicine together. It is therefore important that the theoretical knowledge/experience of doctors about herbal medicine be translated to professional experience, which has been found to play a key role in shaping doctors’ perspectives. It is also imperative that governments increase budgetary allocations to the Universities and research institutes so as to be involved in extensive research on herbal preparations.

6.

Conflict of interest

There is no conflict of interest in the research.

Appendix A. Questionnaire Doctors’ attitudes towards the use of Herbal Medicine in Lagos, Nigeria

A.1.

Bio data

(1) Sex a) Male [ ] b) Female [ ] (2) Age (yrs): a) 15–25 [ ] b) 26–35[ ] c) 36–45 [ ] d) 46–55 e) 55 and above (3) Educational Qualification: a) MBBS [ ] b) M.Sc [ ] c) State other qualifications. (4) Marital Status: a) Married [ ] b) Single [ ] c) Divorce [ ] (5) 5.Duration of Practice a) 1–2 years [ ] b) 3–4 years [ ] c) 5–6 years [ ] d) 6 and above (6) Area of specialization: a) Anaesthesia [ ] b) Medicine [ ] c) Obstetrics and Gynaecology [ ] d) Paediatrics e) Pathology [ ] f) Psychiatry [ ] g) Surgery [ ] h) Others [ ] (7) Do you enjoy doing your job? Yes [ ] No [ ]

(9) Are you aware of any hazard associated with use of herbal medicine? a) Yes [ ] b) No [ ] (10) Have you read any materials on herbal medicine? a) Yes [ ] b) No [ ] (11) Do you know some of the medicine used as herbal medicine? a) Yes [ ] b) No [ ] (12) Do you know some of the herbal medicines listed for use by NAFDAC? a) Yes [ ] b) No [ ] (13) Have you ever used herbal medicine? a) Yes [ ] b) No [ ]

A.3.

Perception about herbal medicine

(14) Do you think herbal medicine practitioners should be given chance to operate? a) Yes [ ] b) No [ ] (15) Is herbal medicine effective in treating chronic diseases? a) Yes [ ] b) No [ ] (16) Are you favourably disposed towards the use of herbal medicine? a) Yes [ ] b) No [ ] (17) Can you discourage your patients from taking herbal medicine? a) Yes [ ] b) No [ ] (18) Do you think herbal medicine has required dosage to treat disease? a) Yes [ ] b) No [ ] (19) Do you think herbal medicine can completely treat a patient? a) Yes [ ] b) No [ ] (20) Do you think there is need for standardizing herbal medicine? a) Yes [ ] b) No [ ] (21) Should herbal medicine be recognized by Government? a) Yes [ ] b) No [ ] (22) Is herbal medicine safe for consumption? a) Yes [ ] b) No [ ] (23) Do you think herbal medicines have a positive role in patient care and health system? a) Yes [ ] b) No [ ] (24) Are you satisfied with the level of education of herbal (traditional) medicine practitioners? (a) Yes [ ] (b) No [ ] (25) Do you think the level of research on herbal medicine is good enough? (a) Yes [ ] (b) No [ ] (26) Do you think herbal medicine practitioners make public the sources of their medicaments? (a) Yes [ ] (b) No [ ]

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Deborah Funmilola Awodele (09.01.1979 to 01.01.2012)

Deborah Funmilola Awodele attended Trinity Nursery and Primary Ilorin, Kwara State from 1982 to 1989 followed by secondary school education at the University Secondary School Ilorin, Kwara State from 1990 to 1995. She obtained her Registered Nurse (RN) and Registered Midwife (RM) from the School of Nursing, University College Hospital, Ibadan (1997–2000) and School of Midwifery, University of Ilorin Teaching Hospital, Ilorin (2001– 2002), respectively. Funmilola proceeded to University of Ibadan (2002–2006) where she obtained her Bachelor of Nursing Science Degree and was awarded Juli-Rose best graduate student in research. Along with her Bachelor degree in Nursing, she also obtained a Higher National Diploma in Public Health Nursing from the same University. She had recently completed her postgraduate Diploma in Education from the University of Lagos and was pursuing her M. Sc in Nursing in Maternal and Child Health at the University of Ibadan.

Funmilola undertook her NYSC Programme at the Federal Medical Centre Owo, Ondo State (Sept 2006–Aug 2007). She worked as a clinical instructor from January 2008 to April 2011 at the School of Midwifery, Lagos University Teaching Hospital, Idi – Araba, Lagos, Nigeria and later transferred her service to the Department of Nursing, College of Medicine, University of Lagos from May 2011 till her death.

Funmilola was a member of several organizations such as the University of Ibadan Alumni Association (UIAA), Ibadan Medical College Alumni Association (IMCAA), National Association of Nurses and the Midwives of Nigeria (GNAN). She was the Committee Chairman Caretaker of the Nigeria Universities Nursing Students Association, University of Ibadan chapter (2005). She will be remembered by her loving Husband, supportive family and colleagues