Prevalence, Pattern, and Predictors of Ever Use of Complementary and Alternative Medicine in Diabetes and Hypertension: A Cross-Sectional Study

Abstract

Introduction:

Noncommunicable diseases (NCDs) have emerged as a pandemic globally and the situation is worse for developing nations. The four major NCDs that are responsible for a major proportion of mortality across the globe are cardiovascular diseases, cancer, respiratory diseases, and diabetes. For a country with limited resources, an integrated approach toward the management of NCDs is of particular importance. Complementary and alternative medicines (CAMs) are those health-care and medical practices that are not currently an integral part of conventional medicine system. This study was undertaken to estimate the prevalence, pattern, and predictors of CAM use among patients with NCDs (diabetes, hypertension, or both).

Materials and Methods:

A health-facility-based cross-sectional study was conducted at different levels of government health-care facilities in Rishikesh, Uttarakhand. CAM categories included alternative medical systems, mind–body intervention, biologically based therapies, manipulative and body-based methods, and energy therapies. Additionally, jhaad phook/local healers were also included in our study.

Results:

The study showed that 41% of all the study participants were ever users of CAM. While most of the users were practicing more than one type of CAM, the most common type of CAM practiced was alternative medicine system (83.3%) followed by mind–body medicine (40.2%). Except religion and place of residence of the study participant, no other factor showed a significant association with ever usage of CAM.

Conclusion:

CAM use was popular among study participants as almost half of them were using/consuming it and alternative medicine system was the most common type of CAM practiced.

INTRODUCTION

In the past few years, noncommunicable diseases (NCDs) such as cardiovascular diseases (CVDs), diabetes, or cancer have emerged as a pandemic globally and the situation is worse in developing nations.[1] WHO states that NCDs alone account for 71% of deaths annually, out of which 77% of all NCDs deaths are from middle- and low-income countries. The four major NCDs that are major contributors of mortality across the globe are CVDs, cancer, respiratory diseases, and diabetes.[2] In India too, NCDs have become a major public health problem and account for 62% of the total burden of Disability adjusted life years (DALYs) and 53% of total deaths. They are also a major cause of catastrophic health expenditure for the public and is expected to worsen in the next two decades.[3] The major NCDs share four modifiable behavioral risk factors, that is, unhealthy diet, lack of physical activity, and use of tobacco or alcohol or both and four metabolic risk factors, that is, raised blood pressure, overweight/obesity, hyperglycemia, and hyperlipidemia.[2]

As per WHO, prevention and control of NCDs include interventions to reduce risk factor exposure at mass level, individual approaches to modify risk factors for high-risk individuals, and treatment of NCDs. Delivery of high impact essential health-care interventions at primary level can be an excellent economic investment as they can reduce the need for more expensive treatment.[4] For a country with inadequate health resources, an integrated approach toward management of NCDs is of particular importance. The available allopathic treatment modalities for such diseases go hand in hand with the indigenous or locally popular health-care options. These treatment modalities could be better understood by the help of the term complementary and alternative medicine (CAM).

CAM is defined by Ernst et al. as “diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a whole, by satisfying a demand not met by orthodox or by diversifying the conceptual framework.”[5] The US National Center for Complementary and Alternative Medicine defines CAM as those health-care and medical practices that are not currently an integral part of conventional medicine system.[6] The increasing popularity of CAM among patients with various diseases may be due to various social, cultural, and economic factors.

This study was undertaken to estimate the prevalence, pattern, and predictors of CAM among patients with NCDs (diabetes, hypertension, or both).

MATERIALS AND METHODS

Study design

A health-facility-based cross-sectional study was conducted at tertiary level, secondary level, and primary level of government health-care facilities in Rishikesh, Uttarakhand, India.

Study population

Patients (both men and women) visiting the OPDs of health facilities of Rishikesh, above the age of 18 with a confirmed diagnosis of one of the following NCDs, namely, diabetes and hypertension or both, were included.

Noncommunicable disease

For the purpose of this study, NCDs were only hypertension and/or diabetes.

Hypertensive participant

A confirmed diagnosis of hypertension, which was included in the patient’s prescription, was used to determine the hypertensive condition.

Diabetic participant

A confirmed diagnosis of diabetes as described in the patient’s prescription was used to determine the patient’s diabetic state.

Smoking status

• Past habits of smoking or alcohol were those which the participants did before the diagnosis of their disease.

• Present habits are those which the participants did even after the diagnosis of his/her disease.

Complementary and alternative medicine

To measure the use of CAM, the following questions were asked to the patient: “Do you currently use or have used in the recent past (less than or equal to 1 year) any method or substance other than those prescribed by your healthcare provider for management of hypertension/diabetes?” A CAM user was defined as a patient who responded as “YES” to the above question.

Pattern of CAM use was assessed by a positive response to the use of one or more of the CAM categories in line with the definition provided by the National Institute of Health (NIH).

NIH has classified CAM in five categories (2002)

1. Alternative medical systems (e.g., traditional oriental medicine, acupuncture, Ayurveda, and naturopathy).

2. Mind–body intervention (meditation, hypnosis, dance, art, music therapy, spiritual healing, and prayer).

3. Biologically based therapies (herbal medicine and dietary supplements, special diets, and orthomolecular medicine).

4. Manipulative and body-based methods (chiropractic, massage, etc.).

5. Energy therapies

All these five categories and one more category was included in our study consisting of jhaad phook/local healers considering the cultural diversity of the city.[7]

Conventional medicine

Medication that has been prescribed by a medical professional with at least an MBBS degree.

Ever users of CAM

Those who have utilized CAM at any stage since receiving a confirmed diagnosis of above-mentioned NCDs.

Never users of CAM

Anyone who has never used any of the above-defined CAM products or services.

Inclusion criteria

Patients who gave their consent to participate in the study and were over the age of 18.

Exclusion criteria

Patients who were unable to participate in the study because they were too ill.

Sample size

The sample size was calculated using the prevalence of CAM in diabetes in the Indian population as 55.0% and 42.2% in hypertensives, as per a study done by Nailwal D et al. in Uttarakhand, India.[8] Taking an absolute precision of 5%, and a confidence level of 95%, the final minimum sample size was 244 after adjusting for a finite population size.

Control of bias

Because the study was conducted during COVID-19, there were fewer patients than normal attending the OPD. Therefore, to determine the most accurate sample size and to combat this bias, records from the preceding two consecutive years were used. However, it was also taken into consideration that participants might have a tendency to provide false information during interviews out of a fear that doing so might prevent them from receiving care from the relevant health-care facility. To combat this, the principal investigator made sure to reassure each participant that their information would be kept private and gained their trust by meeting them in the OPD waiting area rather than the consultation room.

Data collection tool

The study’s methodology included the use of a predesigned, semistructured questionnaire. It was approved by professionals. Before beginning the main data collection, a pilot survey was first conducted with a small number of participants to test and improve study instruments.

Tool validation

Tool validation was done using Lawshe method.[9] Study tool was divided into 11 subparts. Each study question was given a number. A team of five experts was identified (none of them had any relation with the study, all of them were experts in the field of NCDs and public health and were recruited voluntarily). The tool was sent to them physically along with a response sheet to score the content individually. Responses were recorded and an Excel sheet was prepared to calculate the content validity ratio for each item. After which the content validity index of all the study tools was calculated and only validated items were used to collect data. Pilot testing of the tool was done before the main data collection on the general population (not in the health facilities).

Data analysis

Data analysis was done using IBM SPSS v. 25. Categorical data were reported as proportions and continuous or discrete data were reported as means/standard deviation or median/interquartile range. Comparison of proportions was done using Chi-square test or Fisher exact test as appropriate, while means were compared using independent t-test. A P value of < 0.05 was considered significant.

Ethical considerations

Permission to conduct the study was obtained from Institutional Ethics Committee. Written informed consent was obtained from all the study participants.

RESULTS

A total of 247 participants were recruited from different levels of health-care facilities. The proportion of recruitment at each level of health care was set after analyzing previously available records. The mean age of all participants was 55.7 years, 55.1% were male and 84.6% were Hindu by religion; 78.9% were having at least primary education; 47.8% were either retired or house maker or unemployed; 47.8% participants belonged to middle-class families. About 17.8% study participants were either smoking/chewing tobacco or drinking alcohol or both currently, whereas 25.1% were indulged in such activities in the past (before the diagnosis of their disease(s)).

The prevalence of ever users of CAM was reported to be 41%, with a higher proportion among those with both diabetes and hypertension (46%) as compared to those with diabetes only (35%) [Figure 1].

Figure 1.

Prevalence of ever use of CAM

The pattern of usage of CAM among various users showed that most of the study participants were using/had used more than one type of CAM modality. The most common type of CAM being practiced was an alternative medicine system (83.3%) which included Ayurveda, homeopathy, and Yoga, followed by mind–body medicine (40.2%) which included prayers and meditation. The use of supplements was particularly high among hypertensives (13.8%), whereas treatment from local healers was highest among diabetics (10.7%). In general, study participants with both diseases used all types of CAM more frequently than those with only one disease [Table 1].

Table 1.

CAM usage pattern among ever users of CAM

Type of CAM*	Diabetes only (n=28)		Hypertension (n=29)		Both (n=45)		Total (n=102)
	No.*	%	No.*	%	No.*	%	No.*	%
I. Alternative medical systems	18	64.3	26	89.7	41	91.1	85	83.3
• Ayurveda	11	39.3	13	44.8	23	51.1	47	46.1
• Homeopathy	2	7.1	7	24.1	11	24.4	20	19.6
• Yoga	10	35.7	10	34.5	14	31.1	34	33.3
II. Naturopathy	2	7.1	2	6.9	5	11.1	9	8.8
Natural herbal products	2	7.1	2	6.9	5	11.1	9	8.8
III. Mind–body medicine	6	21.4	12	41.4	23	51.1	41	40.2
• Meditation	0	0.0	2	6.9	1	2.2	3	2.9
• Prayers	6	21.4	12	41.4	23	51.1	41	40.2
IV. Manipulative/Body based	1	3.6	1	3.4	1	2.2	3	2.9
• Massage	1	3.6	1	3.4	1	2.2	3	2.9
V. Vitamin/Dietary supplements	1	3.6	4	13.8	1	2.2	6	5.9
• Multivitamins	1	3.6	4	13.8	1	2.2	6	5.9
VI. Jhaad phook/Local healers/Folk remedy	3	10.7	2	6.9	3	6.7	8	7.8

*Multiple responses. (note: in categories II, IV, and V, other subcategories were also included but no results were recorded in them so they were excluded from the table. Category II also included dietary and lifestyle changes, practitioner guided detoxification, psychotherapy, and counseling. Category IV included spinal therapy along with massage and category V included fish liver oil along with multivitamins)

Association of sociodemographic characteristics of study participants with ever use of CAM showed that only religion and place of residence were significantly associated with ever use of CAM. The proportion of ever users was higher among Hindus and in urban areas. The mean age of study participants who were ever users of CAM was almost the same as to that of never users. Most of them were of 45–60 years of age group. None of the other variables such as gender, caste, BMI, or type of family were found to be significantly associated with ever use of CAM [Table 2].

Table 2.

Sociodemographic predictors of ever users of CAM

Sociodemographic characteristics		Ever users (n=102)		Never users (n=145)		P
		No.	%	No.	%
Mean±SD		55.7 ± 11.6		55.7±5.75		0.99
Gender	Male	60	58.8	76	52.4	0.32
	Female	42	41.2	69	47.6
Religion	Hindu	94	92.2	115	79.3	0.01
	Other	8	7.8	30	20.7
Place of residence	Urban	69	67.6	67	46.2	0.01
	Rural	33	32.4	78	53.8
Caste	General	75	73.5	98	67.6	0.32
	Other	27	26.5	47	32.4
BMI	Underweight (>18.5)	1	1.0	3	2.1	0.59
	Normal (18.5–24.9)	39	38.2	64	44.1
	Overweight (25–29.9)	49	48.0	65	44.8
	Obese (>30)	13	12.7	13	9.0
Type of family	Nuclear	62	60.8	71	49.0	0.16
	Joint	19	18.6	39	26.9
	Extended	21	20.6	35	24.1

For comparison of means t-test was used whereas for comparing proportions Chi-square was used

Association of the personal habits of study participants consisting of substance abuse like drinking alcohol (occasionally or regular), smoking, or chewing tobacco with ever use of CAM was analyzed and it was observed [as shown in Table 3] that although there was a considerable decline in substance abuse among study participants after diagnosis of their disease(s) (past habits vs. present habits), we could not observe any association between substance abuse and ever use of CAM.

Table 3.

Personal habits with ever use of CAM among study participants

Personal habits*		Ever users (n=102)		Never users (n=145)		P
		No.	%	No.	%
Diet type	Vegetarian	67	65.7	81	55.9	0.06
	Mixed diet	32	31.4	49	33.8
	Nonvegetarian	3	2.9	15	10.3
Present habits	Yes	19	18.6	25	17.2	0.78
	No	83	81.4	120	82.8
Past habits	Yes	24	23.5	38	26.2	0.63
	No	78	76.5	107	73.8

Chi-square test was used for comparing proportions. *Multiple responses (many participants were using one or more than one type of substance)

Logistic regression analysis was used to analyze the relationship between ever use of CAM and predictor variables. It was observed that only two factors, namely, religion of the participant, that is, Hindu (OR 2.73 [95% CI 1.18–6.33]) and place of residence (OR 0.42 [95% CI 0.26–0.75]) were found to have a significant independent association with ever use of CAM as shown in Table 4, holding other predictor variables constant.

Table 4.

Logistic regression analysis to determine the correlates of ever use of CAM among study participants

Characteristics of ever user	B	Exp. (B)	95% CI Exp. B		P
			Upper	Lower
Religion	1.00	2.73	1.8	6.3	0.01
Hindu
Place of residence	−0.82	0.42	0.3	0.8	0.01
Urban

Variables used for logistic regression were gender, religion, caste, BMI, socioeconomic status, personal habits, and duration of disease

DISCUSSION

Prevalence of CAM use

In our study, it was observed that the prevalence of ever use of CAM among total study participants was 41.3%. The prevalence of CAM calculated as per disease type. It was found highest (46.4%) among participants with both the diseases and lowest (34.1%) among participants with diabetes only. The prevalence of ever use of CAM among participants with hypertension only was 42.6%.

As per a study in Taiwan, 32.5% of all adults reported the use of CAM in a national survey.[10] Another study (cross-sectional) conducted in Bangladesh reported that the prevalence of CAM usage among NCD patients visiting the tertiary care hospitals of Bangladesh was 32.8%.[11] Nalilwal D et al. mentions that the prevalence of CAM among patients with NCDs in Uttarakhand, India, was 49.8%.[8] Similarly, in a cross-sectional study, the prevalence of CAM usage among diabetic patients in Kerala was reported as 30%.[12] Another study in Uttarakhand, India, mentioned that the prevalence of ever user of CAM was 43.2%.[13]

These variations among the results may be due to different study area and study setting, which henceforth constitutes different type of people having different biosocial characteristics and attitudes and due to different facilities available near them.

CAM usage pattern among ever users

The most common form of CAM that was being used by our study participants was alternative medical system (83.3%), which constituted of Ayurveda (46.1%), Yoga (33.1%), and homeopathy (19.6%) followed by mind–body medicine system (40.2%). Mind–body medicine system in our study was a form of spiritual medicine belief comprising meditation (2.9%) and prayers (40.2%). A percentage of 7.8 of all CAM users were also following practices like jhaad phook/folk healers, while 47.4% of all study participants also reported the use of Indigenous herbal preparation, in one form or other to cure/control their condition.

Pattern of CAM usage in a study conducted among diabetics in Kerala, India, reported that most common form of CAM practice being used was Ayurveda (26.7%), homeopathy (3.2%), and Yoga (7.1%), while 63.2% were also using herbal medicine.[12] Another study also reported almost similar pattern of CAM usage, where 25.5% were using combination of Ayurveda and spiritual approach. While Ayurveda alone was adopted by 24.8% and 21.7% were using spiritual approach alone, homeopathy use was reported to be 13%. About 47.2% were also using jhaad phook/folk healers.[14] Conducted in Uttarakhand, India, a study mentioned that Ayurveda (44.4%) was the most common CAM modality being used followed by Herbal medicine (40.7%). Use of homeopathy was reported to be 20.4% and Yoga was used by 11.1%.[13] Similarly, another study reported that Ayurveda was the most common (46.6%) CAM modality being used followed by herbal medicine (14.4%),[15] whereas it was also reported in a study that the most common form of CAM is medicinal herbs (62.9%), followed by Ayurveda (29.8%), and nearly one-fifth practiced spiritual therapy/mind–body systems, and local/folk remedies, respectively.[8]

These wide variations in the pattern of CAM usage may be attributed to the fact that no common operational definition of CAM was adopted in the studies. Also, all the studies were having different study setting and different time periods which attributes to different types of people with different sociodemographic characteristics.

Predictors of CAM usage

It was observed in our study that the use of CAM was significantly associated with religion and place of residence of the study participants.

A study reported that there was a significant association between usage of CAM among NCD patients and higher educational attainment along with older age group people. They also described that CAM usage among the general population (without NCDs) was significantly associated with the gender of the participant (women), higher educational attainment, poor physical health (self-reported), and not being covered under any health insurance scheme.[16] Kristoffersen et al.[17] reported in their study that being female was associated with CAM use; also, participants with the younger age group were more likely to adopt CAM. A study conducted in Kerala reported that there was a significant association between the use of CAM and doing regular exercise for control of diabetes.[12] Kumari R et al. in their study reported that there was a significant association present between use of CAM and the absence of health insurance.[13] Dhankar M et al. in his study mentioned that there was a significant association between use of CAM and gender (female).[14]

A possible explanation regarding predictors of CAM use and different variables could be the fact that the study was done in different study settings. Regression analysis for predictor variables may provide us with the details of confounder factors and factors explicitly associated with the ever use and present use of CAM.

Moreover, it should be noted that this study was conducted among different levels of health-care facility which were selected on the basis of feasibility and the recruitment of patients was also done consecutively. The results of the study may have limited external validity because of nonrandom sampling. Qualitative research on various factors and attitudes related to the use of CAM may provide us more in-depth understanding about factors related to CAM use.

CONCLUSION

As it is clear from above results that almost half of the study participants were using one or more than one type of CAM modality and alternative medicine system which includes Ayurveda and homeopathy, yoga was the most common type of CAM modality being practiced. It was also seen that mind–body medicine, which includes prayers and meditation, was also being practiced by a large fraction of study participants.

Also surprisingly, it was observed that some participants were still relying on jhaad phook/local healers as a treatment option.

Moreover, use of CAM was seen as a popular option among many study participants, and it was observed that religion and place of residence played a significant role in the acceptance of CAM as participants who belonged to Hindu community were using CAM more often when compared with others; also the participants who hailed from urban background were using/consuming CAM in greater proportion when compared to their rural counterpart.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.