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Prevalence of Complementary and Alternative Medicine Use in Patients with Hematological Malignancies in Marrakech, Morocco
J Acupunct Meridian Stud 2013;6(2):67e68
Available online at www.sciencedirect.com
Journal of Acupuncture and Meridian Studies journal homepage: www.jams-kpi.com
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LETTER TO THE EDITOR
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Prevalence of Complementary and Alternative Medicine Use in Patients with Hematological Malignancies in Marrakech, Morocco Complementary and alternative medicine (CAM) comprises a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. CAM has been found to improve the patient’s quality of life, the patient’s satisfaction and the physicianepatient relationship [1].The use of CAM has gained enormous popularity among the general public, and numerous surveys have reported particularly high prevalence of its use among cancer patients [2]. This is especially true among African and Arabic countries. However, no study on the use of CAM in Moroccan hematologic malignancy (HM) patients has been published previously. Thus, we performed a study to assess the prevalence and the pattern of use of CAM as well as the reasons for using CAM. This study included patients treated at the Hematology Department in Marrakech from December 2011 to January 2012. Patients were included if they met the following inclusion criteria: they were adult patients of either gender with a diagnosis of HM; they were able to understand the questions; they were free from any condition that would make completing the questionnaire inappropriate or overburdening; and they were willing to participate in the study. The questionnaire was anonymous and was administered by the same person. The questionnaire was based on data found in the literature, and was modified for the purposes of the study. The data were analyzed using SPSS software version 16.0. Two hundred patients were invited to participate in the study. Of 184 patients (92%) interviewed, 120 (65%) were female and 64 (35%) were male, and their mean age was 43 years (range, 23e69; standard deviation, 13). CAM had been used by 126 patients (68%) at some time during their current cancer illness: 78 (62%) female and 48 (38%) male. The 126 CAM users included 71 cases of non-Hodgkin’s Copyright ª 2013, International Pharmacopuncture Institute pISSN 2005-2901 eISSN 2093-8152 http://dx.doi.org/10.1016/j.jams.2012.12.007
lymphoma, 27 of Hodgkin’s disease, 13 of multiple myeloma, 11 of acute myeloid leukemia, and 4 of acute lymphoid leukemia. The treatment used for HM was chemotherapy for all patients. Treatment was ongoing for 90% of the cases. Seventy patients (56%) were illiterate, 30 (24%) had studied in Coranic School, 20 (16%) had completed high (secondary) school and six (4%) had college or university education. Regarding the professional categories, the group consisted of 57% housewives, 27% farmers, 12% manual workers and 4% professionals (business, health, or education). Most (79%) were married and earning less than 2000 Moroccan dirhams monthly (approximately 200 Euro), and 103 patients (83%) had insurance coverage. The majority of patients (63%) had used CAM for <1 year. Regarding the 126 users of CAM, 83 (65%) used CAM techniques and 91 (72%) used CAM substances. The substances most commonly used were plants (50 cases, 39%), pure honey (41 cases, 32%) and water of ZamZam (holy water from Mecca; 4 cases, 3%). The most reported plants used were Nigella and Aristolochia longa (30%). Concerning techniques, religious practices (58%), recourse to traditional healers (9%), and special diets (4%) were most commonly used. Monthly expenditure on CAM products varied highly. Patients spent an average of 350 dirhams (35 Euros)/month on CAM (range, 20e2000 dirhams). Most patients (89%) spent <1000 dirhams (100 Euros) a month on CAM, and 9% were spending >1000 dirhams. A minority of patients (2%) was unable to give an estimated cost of the CAM products as they had been given by family members or friends. Friends and others cancer patients were found to be the main sources of information regarding CAM therapies (62%), followed by recommendations from family members or relatives (17%). Other sources were media influence (15%)
68 and the internet (5%). Only 1% of patients had obtained information on CAM from a doctor. The main reasons cited for CAM usage were to improve physical well-being or increase quality of life (51%) and to boost the body’s immune system (32%). Other reasons were to relieve cancer symptoms (13%) and to treat or cure the disease (4%). Ninety-eight (78%) users saw no benefit, but 28 (22%) could describe some specific benefits. Five patients (4%) reported transient side-effects from the CAM therapy related to ingesting herbs. These side effects included nausea, headaches, and diarrhea. Approximately 95% of the patients using CAM did not discuss the use of CAM with their doctors. The most common reason cited was that the hematologists might have discouraged CAM use (87%). To the best of our knowledge, this is the first study of the use of CAM therapies to treat hematological malignancies in patients from Morocco. In view of the considerably high prevalence of CAM use among our patients, the issues related to CAM usage in hematological malignancies can no longer be avoided or simply ignored. Morocco is a country of 30 million inhabitants. The per capita income is $1200, and the minimum wage $180. The annual per capita medical expenditure is $50. Morocco faces problems typical of developing countries. In all, 19% of the population is below the poverty line, and up to 50% is illiterate. Only 15% of the population is covered by health care insurance. HM is emerging as a major public health problem in Morocco, with approximately 2000 new HM cases reported each year. In this study, the prevalence of CAM use among our patients was found to be 68%, higher than the average prevalence reported in other adult studies. The only study found in the literature examining CAM use in hematological cancer comes from India, suggesting that 56.6% used some form of CAM [3]. Molassiotis et al found a prevalence of 26.5% in a descriptive cross-sectional survey in Europe [4]. Several studies showed women to be more likely to use CAM than men. Also, higher income, higher level of education, and higher socioeconomic status have been linked to higher prevalence of CAM use [5]. The most commonly used form of CAM in Marrakech is herbal preparations, followed by faith healing/prayer-house healing. With the occurrence of a difficult event causing anxiety, such as a HM, Moslem patients, even those that are nonpracticing, will resort to religion. Indeed, the patient thinks that religion will help him or her to accept the disease and, perhaps, to cure it. The attempt to analyze and understand this passion of spirituality returns also to the sociocultural, familial, and religious context of Moroccan patients on whom modern medicine has little influence. Many studies have shown that CAM users expected the CAM to improve their quality of life, augment their immune systems, relieve their symptoms, cure their illnesses, or give them feelings of hope [3,4]. Some of our patients (95%) who used CAM did not tell their doctors about it. The fact that these patients will not disclose their use of CAM unless asked makes it necessary for every oncologist to routinely ask his/her cancer patients
Letter to the Editor whether they use CAM, the patterns of CAM they use, and the reasons they use CAM. Therefore, patients should be encouraged to discuss their CAM use openly with doctors. Doctors should also contribute by playing an active role in eliciting information about CAM usage from the patients. If the patientephysician relationship is to be optimized and the propensity to improved treatments is to be avoided, accurate and adequate communication is necessary. We recognize that our study suffers from several shortcomings. It was a single-institutional hospital-based interviewer-administered study; therefore, our patient population may not be a true reflection of the HM population in Morocco. Also, our questionnaire was developed after a review of existing studies, most of which were from industrialized Western countries, even though we had attempted to make it relevant to our local environment by incorporating local CAM and local ideas on CAM. Not only the scientific, but also the economic aspects of CAM usage should be studied further in order to ensure proper distribution of medical resources. Further research is needed in ascertaining the use of CAM for the treatment of hematological cancers in individual countries.
References 1. Cassileth BR, Deng G. Complementary and alternative therapies for cancer. Oncologist 2004;9:80e9. 2. Hyodo I, Amano N, Eguchi K, Narabayashi M, Imanishi J, Hirai M, et al. Nationwide survey on complementary and alternative medicine in cancer patients in Japan. J Clin Oncol 2005;23: 2645e54. 3. Gupta M, Shafiq N, Kumari S, Pandhi P. Patterns and perceptions of complementary and alternative medicine (CAM) among leukaemia patients visiting haematology clinic of a north Indian tertiary care hospital. Pharmacoepidemiol Drug Saf 2002;11: 671e6. 4. Molassiotis A, Fernandez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, et al. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol 2005;16: 655e63. 5. Verhoef MJ, Balneaves LG, Boon HS, Vroegindewey A. Reasons for and characteristics associated with complementary and alternative medicine use among adult cancer patients: a systematic review. Integr Cancer Ther 2005;4:274e86.
Illias Tazi* Hatim Nafil Mohamed Sifesalam Mohamed Bouchtia Lahoucine Mahmal Hematology Department, CHU Mohamed VI, Cadi Ayyad University, Marrakech, Morocco *Corresponding author. Hematology Department, CHU Mohamed VI, Cadi Ayyad University, Marrakech, Morocco. E-mail: [email protected] (I. Tazi) 1 October 2012
Available online at www.sciencedirect.com
Journal of Acupuncture and Meridian Studies journal homepage: www.jams-kpi.com
-
LETTER TO THE EDITOR
-
Prevalence of Complementary and Alternative Medicine Use in Patients with Hematological Malignancies in Marrakech, Morocco Complementary and alternative medicine (CAM) comprises a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. CAM has been found to improve the patient’s quality of life, the patient’s satisfaction and the physicianepatient relationship [1].The use of CAM has gained enormous popularity among the general public, and numerous surveys have reported particularly high prevalence of its use among cancer patients [2]. This is especially true among African and Arabic countries. However, no study on the use of CAM in Moroccan hematologic malignancy (HM) patients has been published previously. Thus, we performed a study to assess the prevalence and the pattern of use of CAM as well as the reasons for using CAM. This study included patients treated at the Hematology Department in Marrakech from December 2011 to January 2012. Patients were included if they met the following inclusion criteria: they were adult patients of either gender with a diagnosis of HM; they were able to understand the questions; they were free from any condition that would make completing the questionnaire inappropriate or overburdening; and they were willing to participate in the study. The questionnaire was anonymous and was administered by the same person. The questionnaire was based on data found in the literature, and was modified for the purposes of the study. The data were analyzed using SPSS software version 16.0. Two hundred patients were invited to participate in the study. Of 184 patients (92%) interviewed, 120 (65%) were female and 64 (35%) were male, and their mean age was 43 years (range, 23e69; standard deviation, 13). CAM had been used by 126 patients (68%) at some time during their current cancer illness: 78 (62%) female and 48 (38%) male. The 126 CAM users included 71 cases of non-Hodgkin’s Copyright ª 2013, International Pharmacopuncture Institute pISSN 2005-2901 eISSN 2093-8152 http://dx.doi.org/10.1016/j.jams.2012.12.007
lymphoma, 27 of Hodgkin’s disease, 13 of multiple myeloma, 11 of acute myeloid leukemia, and 4 of acute lymphoid leukemia. The treatment used for HM was chemotherapy for all patients. Treatment was ongoing for 90% of the cases. Seventy patients (56%) were illiterate, 30 (24%) had studied in Coranic School, 20 (16%) had completed high (secondary) school and six (4%) had college or university education. Regarding the professional categories, the group consisted of 57% housewives, 27% farmers, 12% manual workers and 4% professionals (business, health, or education). Most (79%) were married and earning less than 2000 Moroccan dirhams monthly (approximately 200 Euro), and 103 patients (83%) had insurance coverage. The majority of patients (63%) had used CAM for <1 year. Regarding the 126 users of CAM, 83 (65%) used CAM techniques and 91 (72%) used CAM substances. The substances most commonly used were plants (50 cases, 39%), pure honey (41 cases, 32%) and water of ZamZam (holy water from Mecca; 4 cases, 3%). The most reported plants used were Nigella and Aristolochia longa (30%). Concerning techniques, religious practices (58%), recourse to traditional healers (9%), and special diets (4%) were most commonly used. Monthly expenditure on CAM products varied highly. Patients spent an average of 350 dirhams (35 Euros)/month on CAM (range, 20e2000 dirhams). Most patients (89%) spent <1000 dirhams (100 Euros) a month on CAM, and 9% were spending >1000 dirhams. A minority of patients (2%) was unable to give an estimated cost of the CAM products as they had been given by family members or friends. Friends and others cancer patients were found to be the main sources of information regarding CAM therapies (62%), followed by recommendations from family members or relatives (17%). Other sources were media influence (15%)
68 and the internet (5%). Only 1% of patients had obtained information on CAM from a doctor. The main reasons cited for CAM usage were to improve physical well-being or increase quality of life (51%) and to boost the body’s immune system (32%). Other reasons were to relieve cancer symptoms (13%) and to treat or cure the disease (4%). Ninety-eight (78%) users saw no benefit, but 28 (22%) could describe some specific benefits. Five patients (4%) reported transient side-effects from the CAM therapy related to ingesting herbs. These side effects included nausea, headaches, and diarrhea. Approximately 95% of the patients using CAM did not discuss the use of CAM with their doctors. The most common reason cited was that the hematologists might have discouraged CAM use (87%). To the best of our knowledge, this is the first study of the use of CAM therapies to treat hematological malignancies in patients from Morocco. In view of the considerably high prevalence of CAM use among our patients, the issues related to CAM usage in hematological malignancies can no longer be avoided or simply ignored. Morocco is a country of 30 million inhabitants. The per capita income is $1200, and the minimum wage $180. The annual per capita medical expenditure is $50. Morocco faces problems typical of developing countries. In all, 19% of the population is below the poverty line, and up to 50% is illiterate. Only 15% of the population is covered by health care insurance. HM is emerging as a major public health problem in Morocco, with approximately 2000 new HM cases reported each year. In this study, the prevalence of CAM use among our patients was found to be 68%, higher than the average prevalence reported in other adult studies. The only study found in the literature examining CAM use in hematological cancer comes from India, suggesting that 56.6% used some form of CAM [3]. Molassiotis et al found a prevalence of 26.5% in a descriptive cross-sectional survey in Europe [4]. Several studies showed women to be more likely to use CAM than men. Also, higher income, higher level of education, and higher socioeconomic status have been linked to higher prevalence of CAM use [5]. The most commonly used form of CAM in Marrakech is herbal preparations, followed by faith healing/prayer-house healing. With the occurrence of a difficult event causing anxiety, such as a HM, Moslem patients, even those that are nonpracticing, will resort to religion. Indeed, the patient thinks that religion will help him or her to accept the disease and, perhaps, to cure it. The attempt to analyze and understand this passion of spirituality returns also to the sociocultural, familial, and religious context of Moroccan patients on whom modern medicine has little influence. Many studies have shown that CAM users expected the CAM to improve their quality of life, augment their immune systems, relieve their symptoms, cure their illnesses, or give them feelings of hope [3,4]. Some of our patients (95%) who used CAM did not tell their doctors about it. The fact that these patients will not disclose their use of CAM unless asked makes it necessary for every oncologist to routinely ask his/her cancer patients
Letter to the Editor whether they use CAM, the patterns of CAM they use, and the reasons they use CAM. Therefore, patients should be encouraged to discuss their CAM use openly with doctors. Doctors should also contribute by playing an active role in eliciting information about CAM usage from the patients. If the patientephysician relationship is to be optimized and the propensity to improved treatments is to be avoided, accurate and adequate communication is necessary. We recognize that our study suffers from several shortcomings. It was a single-institutional hospital-based interviewer-administered study; therefore, our patient population may not be a true reflection of the HM population in Morocco. Also, our questionnaire was developed after a review of existing studies, most of which were from industrialized Western countries, even though we had attempted to make it relevant to our local environment by incorporating local CAM and local ideas on CAM. Not only the scientific, but also the economic aspects of CAM usage should be studied further in order to ensure proper distribution of medical resources. Further research is needed in ascertaining the use of CAM for the treatment of hematological cancers in individual countries.
References 1. Cassileth BR, Deng G. Complementary and alternative therapies for cancer. Oncologist 2004;9:80e9. 2. Hyodo I, Amano N, Eguchi K, Narabayashi M, Imanishi J, Hirai M, et al. Nationwide survey on complementary and alternative medicine in cancer patients in Japan. J Clin Oncol 2005;23: 2645e54. 3. Gupta M, Shafiq N, Kumari S, Pandhi P. Patterns and perceptions of complementary and alternative medicine (CAM) among leukaemia patients visiting haematology clinic of a north Indian tertiary care hospital. Pharmacoepidemiol Drug Saf 2002;11: 671e6. 4. Molassiotis A, Fernandez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, et al. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol 2005;16: 655e63. 5. Verhoef MJ, Balneaves LG, Boon HS, Vroegindewey A. Reasons for and characteristics associated with complementary and alternative medicine use among adult cancer patients: a systematic review. Integr Cancer Ther 2005;4:274e86.
Illias Tazi* Hatim Nafil Mohamed Sifesalam Mohamed Bouchtia Lahoucine Mahmal Hematology Department, CHU Mohamed VI, Cadi Ayyad University, Marrakech, Morocco *Corresponding author. Hematology Department, CHU Mohamed VI, Cadi Ayyad University, Marrakech, Morocco. E-mail: [email protected] (I. Tazi) 1 October 2012