Factors associated with herbal usage among hypertensive and diabetic patients in Yogyakarta, Indonesia: A cross-sectional study

Abstract

Herbal or traditional medicine (TM) is widely used among chronic disease patients. The Indonesian government actively supports the development and integration of herbal remedies, including phytopharmaceuticals, into the national healthcare system. The support is grounded on Law Number 17 of 2023, which delineates the role of natural medicines. The purpose of the study is to describe the use of TM and the factors associated with TM use among hypertensive and diabetic patients in Yogyakarta City, Indonesia. This study is a cross-sectional design. The respondents were patients with hypertension or diabetes mellitus, and comorbidities were excluded. They were selected conveniently when they attended the Primary Health Centre (PHC) in Yogyakarta, Indonesia. Data were gathered between July and August 2024 using a pretested questionnaire. The measured variables included TM use and the following variables: gender, age, education level, income level, TM knowledge, source of TM information, family support, neighborhood support, friends and other social support networks, and medication adherence. Data were analysed using descriptive, bivariate Chi-square, and multivariate logistic regression. Ninety-nine hypertensive and 100 diabetic patients resulted in 199 study participants. All participants used prescription medicines, and 51% (n = 199) reported using TM. The use of TM was 47% and 56% in hypertensive and diabetic patients, respectively. The most commonly used TMs were cucumber (36%) and garlic (18%) for hypertensive patients, while bitter melon (28%) and ginger (10%) were for diabetic patients. Several main reasons for TM use were feeling healthier (59%), hereditary from the family (13%), cheap (6%), easy to obtain (6%), easy to make by themselves (6%), minimal side effects (6%), and taste good (6%). As many as 68% and 61% hypertensive people had good adherence among TM and non-TM users, respectively. In diabetic individuals, 50% and 54% have good adherence for TM and non-TM users, respectively. The study indicated there was no significant association between various factors and the use of TM in hypertensive and diabetic patients. Gender, age, education level, income level, adherence to prescription medication, and support from family and friends were not significantly associated with the use of TM. For hypertensive patients, peer support and TM information sources show significant bivariate relationships with TM use, while for diabetic patients, personal knowledge and information sources are key factors. Multivariate analysis reveals no independent predictors for TM use in diabetes, but the TM information source emerges as the sole dominant predictor in hypertension (OR: 5.67, p = 0.018). The findings highlight the critical importance of information channels in facilitating the adoption of TM among hypertensive patients, with exposure significantly increasing the likelihood of usage. The absence of independent predictors in diabetes after adjustment indicates that various factors, such as knowledge and support, may interact in complex ways, thereby diminishing the impact of individual factors. Healthcare providers must prioritize verifying the quality of TM information through reliable channels to reduce risks.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-31978-z.

Introduction

In Southeast Asia, traditional medicine (TM), which encompasses herbal medicine, is frequently used for chronic ailments, such as hypertension and diabetes mellitus ^1,2. A study in Thailand found that 13.0% of urban hypertensive patients and 17.5% of rural hypertensive patients utilized herbals ³. Research in Malaysia indicated that 21% of 1,000 respondents with diabetes mellitus utilized herbals ⁴. A study in Indonesia indicated that 22% of 190 respondents with type 2 diabetes mellitus utilized herbals ². Meanwhile, another study among hypertensive patients in rural areas in Indonesia found that 68.5% of 384 patients used herbal medicines, either alone or in conjunction with prescription medicines ⁵. In Indonesia, herbal medicines have received formal recognition and integration into the Indonesian national health system, as authorized by Law Number 17 of 2023 and Government Regulation Number 28 of 2024. The Indonesian Ministry of Health has established a formulary, approved in 2022, which functions as a reference guideline for systematic use of phytopharmaceuticals in healthcare facilities ⁶.

A study conducted on hypertensive patients in rural areas of Yogyakarta, Indonesia, found that administration of herbal supplements containing BCSO (black cumin seed oil) for 20 days reduced blood sugar levels, HbA1c levels, and urea levels (p < 0.05) compared to the control group ⁷. A systematic review with meta-analysis on the effects of fenugreek in diabetic patients provided scientific evidence of its reduction in fasting blood glucose levels (MD: 3.70, 95% CI − 27.02, 19.62; p = 0.76), postprandial blood glucose (MD: − 10.61, 95% CI − 68.48, 47.26; p = 0.72), and HbA1c (MD: − 0.88, 95% CI − 1.49, − 0.27; p = 0.00) ⁸. A comprehensive review included three Indonesian and one Philippine studies that assessed turmeric (Curcuma longa), garlic (Allium sativum L.), bitter melon (Momordica charantia), and rosella flower (Hibiscus sabdariffa) for Southeast Asian diabetic patients, found that the bitter melon was the only one without a substantial blood glucose change ⁹. Another study investigating the effects of sour tea (Hibiscus sabdariffa) administered to stage one hypertensive patients each morning for 40 days found a significant mean reduction in systolic and diastolic blood pressure in the treatment group (P = 0.004 and P < 0.001, respectively) ¹⁰. A systematic review with meta-analysis conducted in Nigerian journals concluded that the use of Hibiscus sabdariffa was the most frequently reported plant for treating hypertension and improving the clinical outcome of hypertensive patients ¹¹.

Many patients turn to traditional medicine due to beliefs about its safety and effectiveness, which are often influenced by cultural practices and the high costs associated with conventional treatments ^5,12. Cultural beliefs are crucial in shaping patients’ attitudes toward treatment options ^13,14. In many communities worldwide, traditional remedies are often viewed as more natural and less harmful than synthetic medicines ^1,4,15. Many others may prefer traditional remedies due to a lack of understanding about their conventional treatments ⁵. These preferences can lead patients to prioritize herbal treatments over-prescribed medications, especially when they perceive these alternatives as more accessible or affordable ^5,14.

The financial burden experienced by individuals with hypertension and diabetes is another considerable issue, especially in low- and middle-income nations ^16–18. In Indonesia, the average yearly direct medical expenditure for diabetic patients was US$708 ± US$1,247 per person ¹⁷. The economic burden is intensified by insufficient health insurance coverage. Sometimes, patients are compelled to personally cover the costs of therapies, resulting in financial hardship ^19,20. Approximately 42.9% of respondents in Ghana reported paying for their healthcare out-of-pocket ²¹. In India, the average out-of-pocket expenditure for outpatient visits amounted to 3,518.30 (Indian Rupees) during three months for patients with these diseases¹⁶. In response to rising healthcare costs, many individuals opt for traditional medicines as alternatives or supplements to conventional therapies⁵. The trend is especially evident in areas where access to conventional medicines is restricted or excessively expensive^5,12. Traditional medicines frequently offer a more economical alternative for alleviating symptoms related to hypertension and diabetes^4,14. Nevertheless, whereas traditional medicines may yield financial savings, the pharmacological properties of herbals may interact with antihypertensive medications, potentially resulting in adverse effects²². Meanwhile, the use of traditional medicine in patients with chronic diseases is influenced by many factors, including education level, economic level, age, gender, duration of disease, and low medication adherence^12,23.

Many studies have shown that using traditional medicine may reduce adherence to conventional medicines. Many patients who use herbals along with standard treatment are likely to have poor adherence to their prescription medication^22,24,25. Herbals can lead to sub-therapeutic dosing of prescribed medicines or outright non-adherence, as patients may believe that herbals are sufficient for managing their health conditions^12,23. A study focusing on hypertensive patients indicated that those who used herbal medicines tended to have lower adherence to their prescribed medications¹². Dependence on herbal medicines may postpone obtaining suitable medical treatment, thereby exacerbating health effects²². While more studies suggest that using traditional medicines may decrease adherence to conventional medicines, a few studies indicate the opposite. A study in Tanzania reported that herbal use was not associated with adherence to prescription medication in hypertensive patients²⁶. Factors, including demographics, knowledge, beliefs, dosage regimen, chronic conditions, symptoms, access to medicines, and socioeconomic status, influence medication adherence^27,28. Furthermore, the relationship between patients’ views on traditional medicine and their adherence to conventional treatment is complex^26,27,29. Although numerous patients perceive traditional medicine as advantageous and safer options^14,26,30, improper usage may diminish adherence to prescribed medicines^12,27,29. This reported study aims to describe TM profilesand TM use factors among hypertensive and diabetic patients in Yogyakarta, Indonesia.

Methods

Study setting and the research ethics

The study applied a cross-sectional design conducted in Yogyakarta, Indonesia. Indonesia is a vast country with thousands of islands, divided into 38 provinces, and Yogyakarta Province is one of them. Yogyakarta Province ranks second in terms of diabetes prevalence in Indonesia, after the country’s capital city, Jakarta. Moreover, Yogyakarta Province ranks third for hypertension cases, after South Kalimantan and West Java³¹. Therefore, these data form the basis for selecting Yogyakarta as a study location that will facilitate fulfilling the required number of participants.

The study protocol has been approved by the Health Research Ethics Committee of the Faculty of Medicine and Health Sciences in UMY Yogyakarta, Indonesia, with the Ethical Clearance Letter Number 271/EC-KEPK FKIK UMY/VIII/2024. The committee had assessed the study protocol in accordance with the Declaration of Helsinki.

Informed consent was obtained from all the study participants. The authority in the Health Department of Yogyakarta has released permission to conduct the study.

The number of participants and recruitment of the participants

To calculate the minimum number of samples, the Lameshow formula was used, with a margin of error of 10%, a population proportion of 50%, and a Zα value of 1.96 (95% confidence level); the minimum number of samples calculated was 96. The Lameshow formula used is as follows:

$$n=\frac{Z{\alpha }^2\times P(1-P)}{d^2}$$ 1

Based on the minimum sample calculation, the number of participants in the hypertension and diabetes mellitus groups was determined to be at least 96 patients, respectively.

The selection of the PHCs applied a convenience approach. A personal approach was applied at 12 of the 18 PHCs in Yogyakarta City, selected for their proximity and ease of access for moving from one location to another. Out of the 12, seven PHCs provided consent. Thus, patients were recruited from these seven PHCs. The inclusion criteria were hypertensive or diabetic patients who voluntarily agreed to participate in the study. The exclusion criteria were those under 18 years or over 80 years. Hypertension as a comorbidity of diabetes and vice versa was excluded. All individuals diagnosed with diabetes were included, regardless of their type. All individuals with hypertension were included, regardless of their stage. By utilizing the diagnoses provided by the respondents’ physicians and the prescriptions acquired for diabetic or hypertension medications, it was confirmed that the subjects were recruited with a diagnosis of one of these conditions. The diagnosis was confirmed by reviewing the patient’s medical records, facilitated by the nurse on duty, and also by asking the patient directly.

The sampling technique applied was a non-random, convenience method. A non-random sampling technique was used in this study due to the absence of a clear sampling frame of hypertensive and diabetic patients in the study location. First, the research team contacted pharmacists at the targeted PHCs. The pharmacist was asked to recruit patients with either hypertension or diabetes who attended PHCs. Then, the pharmacist asked for the patient’s willingness to participate in this study. If the patient was willing, the pharmacist connected the patient to the research team. After that, the research team contacted the patients who had agreed to participate, provided brief information about this study, and asked them to sign an informed consent form voluntarily. Furthermore, the participant and the research team met at a time and place mutually agreed upon for data collection at the PHC or the patient’s home.

Variables, instrument, and data collection

The TM use patterns included TM type, name of TM, duration of use, place of obtaining, and reason for use. The dependent variable was herbal usage, which refers to a dichotomous response, with options of “yes” or “no”. The independent variables involved age, gender, level of education, monthly income, family support, social support network, community support, and medication adherence^5,12,32.

The age variable is divided into two categories: < 60 years and ≥ 60 years. Gender includes men and women. Education level consists of the categories: No formal education, Elementary school, Junior high school, Senior high school, and University. Income level is divided into two categories: below 2.5 million rupiah and above. The 2.5 million rupiah cut-off is based on the regional minimum wage for workers in the study location area. The knowledge variable encompasses respondents’ understanding of traditional medicine that is commonly used for diabetes and hypertension, respectively. Sources of information about TM refer to the original from which respondents obtained information about TM, which are categorized into two: within the primary family members and outside the family, such as playmates, coworkers, health workers, and social media. Support from family and social environment refers to the extent to which patients receive support from their family and social environment. Medication adherence refers to a patient’s compliance with using prescription medicines as instructed.

Data on the patterns and factors of TM usage were gathered through several referred questions developed by the research team based on the operational definitions of the variables mentioned earlier. Questions about usage patterns and reasons were multiple-choice and short-open-ended (direct) questions. Knowledge questions used "yes–no-don’t know" responses. Questions about support from family and social environment were measured on a scale ranging from "not at all" to "very often." The content validity of the questionnaire was established through professional judgment by two pharmacists. This questionnaire was tested for reliability using a Cronbach’s Alpha approach, resulting in a value of 0.765. With a cut-off of 0.60, the questionnaire is reliable³³. Data on adherence to medication were collected using the Medication Adherence Rating Scale (MARS) questionnaire, which involved five questionnaire items³⁴. The validation of the MARS questionnaire referred to some previous studies conducted in Indonesia, because the characteristics of respondents in the earlier studies were similar to those of respondents in the survey currently reported³⁵. The questionnaire was given to the participants to be self-administered. The five questions of the MARS questionnaire used in this study are as follows: 1) I forget to take my medicines; 2) I alter the dose of my medicines; 3) I stop taking my medicines for a while; 4) I decide to skip one of my dosages; 5) I take less medicine than instructed. The response forms are as follows: 1) Always; 2) Often; 3) Sometimes; 4) Rarely; 5) Never.

Data analyses

Descriptive analysis was conducted to describe the distribution of TM users based on respondent characteristics, TM use profiles, types of TM used, and reasons for using TM. Chi-square analysis was conducted to explore the association between the TM use and the variables of gender, age, education level, income level, TM knowledge, source of TM information, family support, neighborhood support, friends and other social support networks, and medication adherence. The analysis was continued with logistic regression, with TM use as the dependent variable and the other previously mentioned variables as independent variables.

Results

The number of hypertensive patients was 99, while the number of diabetic patients was 100. All respondents in this study used prescription medicines (199), while those who used TM were 51% (102). The hypertensive patients who used TM were 46% (46), and the diabetic patients who did so were 56% (56). Most respondents were female, with percentages of 71% for hypertensive patients and 61% for diabetes patients. The average age for hypertensive patients was 60 years, and for diabetic patients was 58 years old. The highest level of education of the respondents was senior high school, with as many as 39% for hypertensive patients and 37% for diabetic patients. Details of the respondents’ socio-demographic characteristics are presented in Table 1.

Table 1.

Distribution of Herbal Use According to Respondents’ Characteristics.

Variables	Hypertensive patient n = 99		Diabetic patient n = 100
	With traditional medicine (n = 46)	Without traditional medicine (n = 53)	With traditional medicine (n = 56)	Without traditional medicine (n = 44)
	Frequency (percentage)	Frequency (percentage)	Frequency (percentage)	Frequency (percentage)
Gender:
Female	36 (51%)	34 (49%)	37 (61%)	24 (39%)
Male	10 (34%)	19 (66%)	19 (49%)	20 (51%)
Age:
< 60 years	42%	40%	57%	52%
≥ 60 years	58%	60%	43%	48%
Highest education level:
No formal education	1 (33%)	2 (67%)	1 (100%)	0 (0%)
Elementary school	11 (73%)	4 (27%)	10 (48%)	11 (52%)
Junior high school	13 (50%)	13 (50%)	13 (57%)	10 (43%)
Senior high school	14 (36%)	24 (64%)	19 (51%)	18 (49%)
University	7 (44%)	9 (56%)	13 (72%)	5 (28%)
Family income per-month (IDR: Indonesian Rupiah in million):
< 2.5	66%	62%	60%	64%
≥ 2.5	33%	38%	40%	36%
Adherence to medication:
Good adherence	68%	61%	50%	54%
Low adherence	32%	39%	50%	46%

Profiles of TM use

The TM use profiles among hypertensive and diabetic patients in this study are described in Table 2. The findings show that most of them used raw homemade herbal products, at rates of 96% and 93%, in hypertensive and diabetic patients, respectively. Most of the respondents in this study had used herbals for more than a year, at percentage of 59% and 66%, in hypertensive and diabetic patients, respectively. Most herbals were obtained from traditional markets or kiosks, at rates of 70% and 66%, in hypertensive and diabetic patients, respectively. Most respondents received information about the herbals from the internet and their social networks, at rates of 78% and 70%, respectively among hypertensive and diabetic patients.

Table 2.

Profiles of TM use among hypertensive and diabetic patients in Yogyakarta, Indonesia.

Profiles of TM use	Hypertensive patients (n = 46)	Diabetic patients (n = 56)
Types of TM
Raw herbal homemade product	44 (96%)	52 (93%)
Manufactured herbal product	2 (4%)	4 (7%)
Duration of having TM
Less than 1 year	19 (41%)	19 (34%)
More than 1 year	27 (59%)	37 (66%)
Place to obtain TM
Traditional market/kiosk	32 (70%)	37 (66%)
Own garden/backyard	11 (24%)	12 (21%)
Pharmacy	2 (4%)	4 (7%)
Online shop	1 (2%)	2 (4%)
Friend/relative	0 (0%)	1 (2%)
Source of TM information
Family members and relatives	10 (22%)	17 (30%)
Internet, social network, others	36 (78%)	39 (70%)

Names of herbals

The most commonly used herbal remedies among diabetic patients in this study are bitter melon (28%) and ginger (10%). The most popular herbal remedies used by the hypertensive patients in this study are cucumber (36%) and garlic (18%). The types of herbal remedies used by the study’s participants are listed in Table 3.

Table 3.

The herbal varieties used by individuals with hypertension and diabetes in this study.

Herbals used by hypertensive patients*	Percentage	Herbals used by diabetic patients*	Percentage
Cucumber	36%	Bitter melon	28%
Garlic	18%	Ginger	10%
Celery	11%	Cinnamon	7%
Bay leaf	9%	Moringa leaf	7%
Grass jelly leaves	5%	Lemongrass	7%
Bitter melon	2%	Insulin leaf	5%
Honey	2%	Cosmos caudatus	3%
Ginger	2%	Mangosteen peel	3%
Starfruit	2%	Chinese betel leaf	2%
Chayote	2%	Starfruit	2%
Chinese cabbage	2%	Tinospora cordifolia	2%
Watermelon	2%	Soursop leaf	2%
Moringa leaf	2%	Andrographis paniculata Herba	2%
Lemongrass	2%	Coriander	2%
Pear	2%	Pandan leaf	2%
Betel leaf	2%	Carrot	2%
Melon	2%	Green apple	2%
Citrus	2%	Betel leaf	2%
Aloe vera	2%	Vernonia amygdalina	2%
Avocado	2%	Papaya leaf	2%
Butterfly pea	2%	Gingseng leaf	2%
Gynura procumbens	2%	Turmeric	2%
Apel vinegar	2%	Bay leaf	2%
Noni fruit	2%	“Habatussauda”	2%
Soursop leaf	2%	Piper retrofractum Vahl	< 2%
Vinca	2%		< 2%
Coriander	2%
Fish oil	2%
Cosmos caudatus	2%
“Habatussauda”	< 2%

* Respondents were allowed to choose more than one type of herbals.

Reasons for using TM

Table 4 describes why respondents used TM despite also receiving prescription medicines from their doctors. There are various reasons for using herbals among the study participants. The main reason is that using traditional medicine makes the respondents feel healthier. Some common reasons include family culture and beliefs, lower cost compared to prescribed medicines, and accessibility. The unique reason is the taste of the herbals. Another common reason is the perception of minimal side effects compared to prescription medicines.

Table 4.

Reasons for using traditional medicines among hypertensive and diabetic patients.

Reasons for using traditional/herbal medicines*	Percentage
Feeling healthier after using herbals	59%
Hereditary from the family	13%
Cheap	6%
Easy to obtain	6%
Easy to make by themselves	6%
Minimal side effects compared to prescription medicines	6%
Taste good	6%
The benefits are proven	1%
Tired of taking prescription medicines	1%
For a break from prescription medicines	1%
Often forget to take prescription medicines	1%
Information from social media, websites	1%
Lazy to queue at the health center to get the prescriptions	1%

* Respondents were allowed to choose more than one response.

Factors associated with TM use (bivariate and multivariate tests)

Results in Table 5 indicate a significant association between knowledge level and the use of traditional medicine among individuals with diabetes (p < 0.001) as tested by the chi-square test. In contrast, no such relationship was observed in those with hypertension. Individuals with diabetes who possess a higher level of knowledge tend to use traditional medicine more frequently compared to those with lower knowledge levels. The chi-square test results indicated a significant difference in the information sources utilized by hypertensive individuals who used traditional medicine (p < 0.001). Most information was sourced from the internet and social networks (78%), while a minority was obtained from family members and relatives (22%). A significant difference was also observed among individuals with diabetes (p < 0.001), with 70% sourcing information from the internet and social networks, while 30% relied on family members and relatives. Significant differences in social support from friends and other networks were seen between users and non-users of traditional medicine among individuals with diabetes. However, they were not significant among individuals with hypertension. Individuals with diabetes receiving substantial support from friends and social networks exhibited a higher proportion of traditional medicine utilization (64%) compared to those with little support (36%). The other factors, i.e., gender, age, education level, income level, family member support, neighbourhood support, and medication adherence, are not significantly associated with TM use in patients with hypertension and diabetes.

Table 5.

Factors associated with traditional medicine use among hypertension and diabetes patients in Yogyakarta, Indonesia (Chi-square test).

Variables	Hypertension (p-value)	Diabetes (p-value)
Source of TM information	0.001*	0.001*
Knowledge	0.569	0.001*
Friends and other social support networks	0.047*	0.089
Family members support	0.151	0.489
Neighborhood support	0.119	0.344
Gender	0.188	0.334
Age	0.418	0.520
Education level	0.118	0.394
Income level	0.722	1.000
Medication adherence	0.418	0.350

*Significant at p-value ≤ 0.05.

The bivariate chi-square test results, as presented in Table 5, provide a general overview of the variables associated with TM use. The analysis was then continued with multivariate binary logistic regression. The multivariate binary logistic regression test results showed that in diabetes mellitus, there were no significant predictors (p > 0.05). In hypertension, there was one significant predictor: the source of TM information (OR: 5.67; p = 0.018). These results indicate that individuals with hypertension who received information about TM were 5.67 times more likely to use TM than those who did not.

Discussion

The study revealed the main reasons why hypertensive and diabetic patients in this study use TM, such as feeling healthier, family inheritance, being cheap, and easy to obtain. The study showed no significant association between several factors and TM use in both hypertensive and diabetic patients. Several factors that were not significantly associated with TM use were gender, age, education level, income level, adherence to taking prescription medicines, family member support, and friend support. The source of TM information was significantly associated with TM use among hypertensive and diabetic patients. The other significant associations were support from friends and other social support networks for hypertensive patients and TM knowledge for diabetic patients. When adjusted for multiple factors in multivariate logistic regression, no significant predictors for TM use were found in diabetes patients, suggesting that the observed bivariate associations mentioned earlier may be interrelated or confounded. In contrast, among hypertension patients, the source of TM information remains a strong independent predictor, making those informed via TM sources 5.67 times more likely to use TM.

It is known that hypertension and diabetes have a relatively significant economic burden, especially in terms of treatment and care^16,17. Therefore, alternative medicine is widely chosen to accompany or replace prescription medicines^5,30. A study in Indonesia revealed that patients with chronic diseases frequently utilize traditional medicines as a supplementary treatment option¹². Reasons for individuals include concerns about the side effects of prescription medicines on long-term use and the potential benefits of improving overall health  ^1,4. Traditional medicine that is easy to get and prepare also supports chronic disease patients in choosing herbals⁵. The use of traditional medicines among people with chronic diseases, including hypertension and diabetes, seems to get positive responses, such as a study on people living with diabetes in Malaysia, which stated that there was a positive attitude and relatively high modality in terms of using herbals⁴.

Many herbals can be used as everyday food. Even if they have to buy them, the prices are very affordable. Vegetables, fruits, and various herbs are well produced on agricultural land in tropical countries⁵. For example, bitter melon, which is believed to be efficacious in maintaining blood sugar levels, can be quickly cooked into various recipes as an everyday food; likewise, cucumber, garlic, and celery are known to help control blood pressure^5,14,30. In tropical countries, these herbals are readily available in markets and stalls near homes; many people also cultivate them around their homes^5,36. Uniquely, each region or country often has herbal plants that are believed and used for generations to treat certain diseases, which are not used elsewhere. In the case of diabetes, in Ethiopia, the hare lettuce plant (Sonchus luxurians) is prominent³⁰, but it is uncommon in Indonesia, for example. However, it should be noted that most traditional medicines lack scientific information regarding dosage, interactions with other substances, and potential side effects^37,38. The risks of using traditional medicine have also been reported³⁹. Therefore, the Indonesian government has established regulations for herbal medicinal products, including standardized herbal medicines and phytopharmaceuticals, to provide natural medicinal preparations that have undergone pre-clinical and clinical trials to be included in the national health system⁶.

The source of TM information was significantly associated with TM use in hypertensive and diabetic patients in this study through a bivariate analysis. When adjusted for multiple factors, the only independent predictor is the source of TM information in hypertensive patients only. This highlights the significant influence of information channels on shaping TM use behavior in individuals with hypertension. The results suggest that where patients obtain TM information (e.g., media, community sources) impacts their decisions. The results emphasise the necessity for reliable information sources. TM use sometimes focuses on commonly recognized remedies (e.g., celery and garlic for blood pressure reduction) transmitted through social interaction⁴⁰. The use of TM is substantially promoted by social networks, which include relatives and acquaintances³². Information source exposure can be a potent driver in health behaviors, especially in hypertension.

Uniquely, through bivariate analysis, this study identified disease-specific drivers, i.e., TM use in diabetic patients is driven by knowledge, and in hypertensive patients is socially driven—friends/network influence decisions more than personal knowledge. Understanding traditional medicine is essential for diabetes patients, as medicinal plants have a significant historical role in reducing blood glucose levels. Furthermore, elevated incidences of adverse effects from prescription medications stimulate the pursuit of safer TM alternatives. In hypertension, patients report fewer side effects and have greater confidence in the efficacy of traditional medications, which reduces the impulse to seek knowledge³². This phenomenon may also arise from the unnoticed symptoms in hypertensive patients, hence its designation as a silent killer. The condition differs from diabetes, in which individuals exhibit more noticeable symptoms during episodes of hyperglycaemia or hypoglycaemia. Hypertensive patients are more inclined to explore herbal therapies advised within their social networks, while the symptoms and effects remain opaque until they assess their blood pressure with a sphygmomanometer. TM use for hypertension is socially motivated, perhaps because community recommendations are sufficient. Even social support influences the prevalence of hypertension⁴¹. Conversely, individuals with diabetes typically practice greater caution in selecting alternative treatments and demonstrate increased vigilance in acquiring sufficient information and expertise prior to their utilization due to the evident self-recognized symptoms. This gap highlights the need for health education tailored to specific conditions, such as building knowledge for individuals living with diabetes and social networks for hypertension patients, to help them access accurate information about the selection and use of traditional medicines. This also highlights the urgency of transparent communication with healthcare providers regarding the use of herbal and conventional therapies by patients.

Low medication adherence rates in patients with chronic illnesses have been widely reported. For example, the hypertensive patients with good adherence levels in Yogyakarta and East Java, Indonesia, are 26% and 16%, respectively^42,43. Many studies have linked herbal use to low adherence to prescription medication ^27–29. However, this reported study found the opposite: there was no difference in prescription medicine adherence between TM users and non-users in hypertension and diabetes patients. The results indicate that traditional medicine does not have a negative or positive impact on adherence to prescribed medication. In this study population, TM is used in addition to, not instead of, prescribed drugs. Patients may incorporate TM into their overall care while continuing to receive their medical care. Likewise, a study in Ethiopia yielded similar findings²⁶. The outcome questions using TM as an adjunct to medical therapy⁴⁴. Furthermore, it suggests that monitoring medication adherence should be treated as an independent matter, free from prejudice towards TM users.

Overall, findings of the study suggest that interventions aiming to optimize hypertension and diabetes management should consider the cultural, informational, and social context that encourages TM use, while not assuming that TM usage undermines medication adherence. Targeted education on TM and prescription medicine safety, as well as ongoing dialogue between health professionals and patients about TM, may help maximize safe and effective disease management.

Study limitations

This study has several key limitations to consider when interpreting its findings. The limited sample size, non-random selection of participants, and non-random choice of PHCs for patient recruitment render generalization to the wider community in Yogyakarta, Indonesia, implausible. Secondly, the data were collected via a self-report questionnaire, which may compromise data accuracy and be influenced by social desirability bias.

Conclusion

Since the source of TM information is associated with TM use in hypertensive and diabetic patients, healthcare providers should ensure that accurate, evidence-based TM information is available and clearly communicated to patients. Given the importance of social support in TM use, particularly among hypertension patients, community-based treatments, including peer educators or support groups, may be useful in promoting safe TM practices. For diabetes patients, increasing understanding about TM through tailored education initiatives is critical for enabling safe and effective use. The evidence showing that TM use does not impair adherence to prescribed medications shows that it can be used as a supplemental approach without jeopardizing conventional treatments. Based on the findings of this study, further investigation is advised to assess the efficacy and safety of traditional medicine in individuals with hypertension and diabetes. Alleviating the detrimental impacts of traditional medicine is imperative and urgent.

Author contributions

Conceptualization: AW. Methodology: AW. Software: AW. Validation: AW. Formal analysis: IH, ETW. Investigation: AW, IH, ETW. Resources: ETW. Data curation: AW. Writing – Original Draft: AW. Writing – Review & Editing: AW, IH, ETW. Visualization:IH. Supervision:AW. Project administration:ETW. Funding acquisition: AW.

Funding

This research was supported by DRTPM of the Indonesia Ministry of Higher Education Research and Technology year of 2024. with the grant number of No.107/E5/PG.02.00.PL/2024.

Data availability

The data that support the findings of this study will be shared on reasonable request to the corresponding author.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval

This research was reviewed and approved by the institutional review board of the Faculty of Medical and Health Sciences Universitas Muhammadiyah Yogyakarta Indonesia (registration number 271/EC-KEPK FKIK UMY/VIII/2024). Informed consent was obtained from all participants.

Consent to participate

The research team contacted the participants who had agreed to participate, provided a brief information about the study, and asked them to sign an informed consent form voluntarily.