Abstract
Objectives
To determine how the Thai elderly perceived the benefits of herbal medicine consumption and to study related variables influencing their perception.
Design
A cross-sectional study was used. Participants/Settings: 419 participants were chosen by systematic stratified sampling; people between 60–96 years of age (mean age 70.2 years); 68.3 % female, and 31.7% male of Chonburi Province (Thailand).
Measurements
To determine the elderly perception about the benefits of herbal medicine consumption, a scale from one to four based upon 12 simply worded item check lists was used among the others. The questionnaires were conducted in June to August 2008 in 3 different regions (urban, suburban and rural areas).
Results
97.4% having used herbal medicines in many ways. Most of the elderly used the local herbals together with conventional medicines. They believed that herbals could reduce expenses (51%), cure diseases (41.9%), relieve symptoms (35.4%), and provide good health (33.6%). A 16.7% of the elderly had the strongest opinion regarding the use of herbal medicines as substitutes for conventional medicines. They also strongly agreed on using them as nutrients (39.8%). The study found significant correlation among levels of education, stress levels, happiness levels, and perception of benefits of herbal medicine consumption.
Conclusions
This study indicated that levels of education, happiness, and stress could influence the perception of herbal medicine consumption. Knowing how people perceive herbal medicine, its use, and local culture can help practicing health professionals, among other things, to avoid side effects from prescriptions and so maintain or promote the elderly health status.
Key words: Herbal medicine consumption, thai elderly, health promotion
Introduction
Presently, Thailand is one of the developing countries facing the largest increase of the aging population, being 8.7% per year in 2000s, further increasing by 10.8%, 15.2%, 29.6%, respectively, in 2010s, 2020s, and 2050s (1). Consequently, Thailand is rapidly becoming an aging society within the next two decades and there is little time to properly design health promotion and prevention strategies. To avoid the expected “explosion” of the health budget, Thai governments have adopted a policy, which is in accordance with the guidelines of the World Health Organization (2), to provide financial support for Thai traditional medicine as an effective and cheaper way to promote good health of the population.
The fact that herbal medicines have always been popular as traditional household medications, a long tradition of preparing and using herbs both as food and as medicine is still being practiced in the Thai society. These skills are taught, from generation to generation, by older and knowledgeable people as well as by formally trained folk doctors and Buddhist monks. Some ready prepared herbals are sold in the markets as well as in the traditional Thai medicine pharmacy. The most popular commercial herbal preparations used among the Thai are adaptogens. These natural substances are believed to help the body to adapt to stress, support and/or restore normal metabolic functions and balance (3). Medicinal herbs are important for healthcare because they already have reputations among the elderly. Taking these into account, we have designed a study to determine how the Thai elderly perceived the benefits of herbal medicine consumption as well as to investigate related variables influencing their perception.
Materials and Methods
A cross-sectional study was used in this investigation. Random inquiries were made from 419 participants chosen in Chonburi Province (Eastern Thailand), from three geographical areas (rural: n =106, 25.3%; suburban: n =120, 28.6%; and urban areas: n =193, 46.1 %). Chonburi municipalities have provided detailed information about the elderly.
The research instruments consisted of an inquiry which includes, among other things, questions on demographic data and their experiences in herbal medicine consumption. To understand the perception in the benefits of herbal medicine consumption, a scale from 1 to 4 based on 12 simply worded check list items was used: 1- slight agreement/disagreement and 4- strong agreement. The Thai Happiness Indicators: THI-15 (4) and Suanprung Stress Test-20: SPST-20 (5) of the Thai Ministry of Public Health were also used in this study. The THI-15 contained 15 simply worded check list items (12 positive and 3 negative items), each eliciting the participants' answers using the Likert's Rating Scale score from 0 (never) to 3 (always), whereas SPST-20 contained 20 simply worded check list items, each question eliciting the participants' answers on that rating scale score from 1 (slight stress) to 5 (high stress), and 0 (no check mark).
Data collection was performed from June to August 2008. 419 subjects aged 60 years or above were enrolled from the municipalities. The elderly were chosen by systematic stratified sampling. The research questionnaires were distributed to the participants and were collected after completion. To characterize the population, a descriptive analysis was performed. The frequency of responses was compared with the Pearson chi-squared test. The non-parametric Kruskal-Wallis test was used when comparing the mean among the grouping variables. All reported P-values of less than 0.05 were considered significant. All analyses were conducted using SPSS Windows version 15.0.
The study was conducted after receiving an approval from the Burapha University Review Board. Permission was also requested from the participants and information was clearly explained prior to the interview regarding the aims, the procedures of the study, and the participants' rights.
Results
The mean age of the participants was 70.2 years, ranging from 60 to 96 years (68.3% female). Most were Buddhist (99.3 %) and majorities were married (54.7%). 72.6% of the participants had primary school education (Table 1) and 51% were identified as having sufficient income. Most (97.4%) had experiences with herbal medicine consumption. Adaptogens were found to be popular among the participants (43.9%). They learnt about herbal medicine mainly from verbal transmission (54.9%) but mass-media also had an influence on them (Table 2).
Table 1.
Characteristics of Participants- Thai Community Elderly
| Characteristics | No. (%) of Elderly | |||
|---|---|---|---|---|
| Total (N = 419) | Urban (n = 193) | Suburban (n = 120) | Rural (n = 106) | |
| Age (years) Mean in years = 70.2 | ||||
| 60 – 69 | 215 (51.3) | 108 (25.7) | 54 (12.9) | 53 (12.6) |
| 70 – 79 | 153 (36.5) | 68 (16.2) | 49 (11.7) | 36 (8.6) |
| = 80 | 51 (12.2) | 17 (4.1) | 17 (4.1) | 17 (4.1) |
| Gender | ||||
| Male | 133 (31.7) | 50 (11.9) | 33 (7.9) | 50 (11.9) |
| Female | 286 (68.3) | 143 (34.1) | 87 (20.8) | 56 (13.4) |
| Marital status | ||||
| Single | 26 (6.2) | 13 (3.1) | 11 (2.6) | 2 (.5) |
| Married | 229 (54.7) | 99 (23.6) | 61 (14.6) | 69 (16.5) |
| Separated / Divorced | 16 (3.8) | 7 (1.7) | 1 (.2) | 8 (1.9) |
| Widowed | 148 (35.3) | 74 (17.7) | 47 (11.2) | 27 (6.4) |
| Education | ||||
| No formal education | 47 (11.2) | 8 (1.9) | 19 (4.5) | 20 (4.8) |
| Primary school | 304 (72.6) | 159 (37.9) | 71 (16.9) | 4 (17.7) |
| More than primary school | 57 (13.6) | 26 (6.2) | 28 (6.7) | 3 (.7) |
| No information available | 11 (2.6) | - | 2 (.5) | 9 (2.2) |
| Income perception | ||||
| Sufficient | 214 (51) | 118 (28.1) | 48 (11.5) | 48 (11.5) |
| Insufficient | 205 (49) | 75 (17.9) | 72 (17.2) | 58 (13.8) |
| Health status perception | ||||
| Healthy | 85 (20.29) | 27 (6.4) | 33 (7.9) | 25 (6) |
| Less healthy | 130 (31.02) | 70 (16.7) | 26 (6.2) | 34 (8.1) |
| Unhealthy | 204 (48.69) | 96 (22.9) | 61 (14.6) | 47 (11.2) |
Table 2.
The frequencies sources of information and type of herbal preparing regarding herbal medicine use
| Response rate*(N = 419) | ||
|---|---|---|
| n | % | |
| Sources of information | ||
| Verbal discussions | 230 | 54.89 |
| Radio | 99 | 23.63 |
| Television | 131 | 31.26 |
| Magazines/Newspapers and official | 93 | 22.20 |
| announcements | ||
| Outdoor posters/Billboard advertisements | 53 | 12.65 |
| Others (i.e. dreams, superstition, folk | 41 | 9.79 |
| doctor) | ||
| Types of herbal preparation | ||
| Fresh herbs | 137 | 32.70 |
| Herbal teas/Infusions | 91 | 21.72 |
| Fluid extracts (herbal hotpots) | 98 | 23.39 |
| Adaptogens | 184 | 43.91 |
Multiple responses
The high percentage of “strong agreement (level 4)” on benefits of herbal medicine consumption were (i) to cure diseases (41.9%), (ii) to provide nourishment (39.8%) and food flavoring (28.6 %), (iii) to relieve symptoms including pain (35.4%), and (iv) to maintain good general health (33.6%). Only 16.7 % of the elderly had “strong agreement (level 4)” for the use of herbal medicines as substitutes for conventional medicines. 54.6 % agreed on using both conventional and herbal medicines without any serious concerns. The majority (51%) believed that the herbal medicine consumption could reduce family expenses as well as national health budget (Table 3).
Table 3.
Distribution of percentage in agreement levels on benefits of herbal medicine consumption (n = 419)
| No. | Items | Levels of agreement | |||
|---|---|---|---|---|---|
| 4a(%) | 3b(%) | 2c(%) | 1d(%) | ||
| 1. | Provide nourishment. | 39.8 | 28.9 | 27.2 | 4.1 |
| 2. | Cure diseases. | 41.9 | 29.4 | 26.0 | 2.7 |
| 3. | Relieve symptoms including pain. | 35.4 | 29.6 | 29.9 | 5.1 |
| 4. | Provide good health maintenance. | 33.6 | 30.2 | 28.7 | 7.5 |
| 5. | Use as food and food flavorings. | 28.6 | 26.6 | 30.8 | 14 |
| 6. | Cheaper than conventional medicine. | 27.3 | 25.8 | 31.4 | 15.4 |
| 7. | More convenient to use herbal medicines than the others. | 22.5 | 27.3 | 36.2 | 14.0 |
| 8. | Available in the community. | 25.6 | 29.7 | 33.3 | 11.4 |
| 9. | Use along with conventional medicine without any concerns. | 26.8 | 27.8 | 34.5 | 10.8 |
| 10. | Use to tail off conventional medicine. | 16.7 | 26.6 | 31.6 | 25.1 |
| 11. | Reduce family medical expenses and the country health budget. | 23.7 | 27.3 | 31.2 | 17.9 |
| 12. | Herbal medicines are useful and they comprise valuable Thai folk medicines. | 49.4 | 28.2 | 16.9 | 5.5 |
4 = Strong agreement.
3 = High agreement.
2 = Low agreement.
1 = Slight agreement/disagreement
Regarding the education levels, the study revealed that the higher the education level was the higher benefits perception of herbal medicine (p < 0.001). Also, the benefits perception is higher (p = 0.006) among the elderly who had sufficient income (Table 4).
Table 4.
The scores of perception of benefits of herbal medicine consumption among groups: education levels; income perception; happiness levels; and stress levels
| Groups | median | mean (SD) | n | P-value |
|---|---|---|---|---|
| Education levels (?2 (2, n = 402) = 15.350) | < 0.001 | |||
| No formal education | 28.00 | 28.68 (8.83) | 47 | |
| Primary school | 34.00 | 34.00 (8.60) | 299 | |
| More than primary school | 36.00 | 34.45 (8.35) | 56 | |
| Income perception (?2 (1, n = 413) = 7.691) | 0.006 | |||
| Sufficient income | 35.00 | 34.64 (8.56) | 211 | |
| Insufficient income | 32.00 | 32.25 (8.68) | 202 | |
| Happiness levels (?2 (2, n = 412) = 29.495) | < 0.001 | |||
| Poor (happiness scores = 26; lower than | 36.00 | 35.68 (8.36) | 185 | |
| normal range of happiness) | ||||
| Fair (happiness scores = 27 – 32; equal | 34.00 | 33.78 (8.07) | 89 | |
| with normal range of happiness) | ||||
| Good (happiness scores 33-45; over than | 29.50 | 30.38 (8.62) | 138 | |
| normal range of happiness) | ||||
| Stress levels (?2 (3, n = 409) = 14.114) | 0.003 | |||
| Mild Stress (score = 0 – 23) | 36.00 | 35.21 (7.61) | 63 | |
| Moderate Stress (score = 24 – 45) | 33.00 | 33.81 (8.76) | 221 | |
| High Stress (score = 46 – 61) | 30.00 | 30.69 (8.44) | 87 | |
| Severe Stress (score = 62) | 37.50 | 35.45 (9.12) | 38 |
There are differences in the benefits perception among people with different stress (p = 0.003) and happiness levels (p < 0.001) (Table 4). The results also showed the differences among groups in happiness levels (c2 (2, N = 417) = 21.749, p < 0.001) and in stress levels (c2 (2, N = 413) = 11.037, p = 0.004) in different geographical areas. The urban elderly with higher education indicated higher scores for happiness than the elderly living in the other areas. The rural elderly indicated higher scores of stress than those from the other two areas.
Regarding the benefits perception of herbal medicine consumption, no significant correlations were verified with the number of family members, gender, marital status and health status.
Discussion
Herbal medicines are considered to be one type of the Complementary and Alternative Medicine (CAM) treatment affecting the physical, mental, emotional, energetic, and spiritual dimensions of the individual (6, 7, 8). In Thailand, it is encouraged to use herbal medicines to promote health (9). There are more people now consuming herbal medicines in parallel with conventional medicines than in the past decade and the results of this study have corroborated this trend. Generally, most herbs used in Thai traditional medicine are safe; however, some can interact with medications (10). DerMarderderosian and Briggs argued that herbal products often contain a wide variety of different compounds such as alkaloids, steroids, phenylpropanoids, among others, which, in increased dosages over long periods of time, potentially increase the risk of toxic effects like hepatotoxicity and carcinogenesis (11).
Nowadays, herbal medicines play an important role in encouraging people to remain healthy and/or to solve their health problems. In the U.S.A., the increased use of alternative or unconventional therapies, including herbal medicines has been frequently reported (12, 13, 14). DerMarderosian and Briggs reported that the herbal market in the U.S.A. had reached an unprecedented growth (11) and according to the study conducted in 2001 by Eisenberg et al. (15) the sales in the U.S.A. had increased nearly 20% annually. Likewise, the popularity of herbal medicines had increased substantially during the previous decade in Thailand (16), not only for their health and economic values but also because of the promotion and advertisement.
It is interesting to note that the elderly participants in this study enjoyed socializing together during the day time while they normally shared their life experiences including health situations and the use of herbal medicines. Mass-media, namely television and radio, were also found to influence their perception of herbal medicine benefits. As Thai herbal medicines have been officially and commercially encouraged to promote health and prevent illness in primary health care systems, some herbal products have already been incorporated into the National Essential Drug List (9). This study revealed that 42.7 % of the participants used both conventional and herbal medicines and 54.6 % agreed on using them together without any concern. Thailand has a long tradition of collecting and preparing herbs both as food and as medicine. In this study, there was a strong agreement of herbs used as medicine and supplements to treat and relieve symptoms and maintain good health. In Thai culture, people learn how to use herbal medicine from old books and from the records of older family members. It is noteworthy to mention that Buddhism has a strong influence in Thai traditional medicine since the essence of the Buddha's teaching is to convey people to seek liberation from illness and fear of death (17). Thus, Thai Buddhism represented not only religious beliefs, but also a means of finding ways of relieving and curing some symptoms and diseases (18, 19).
It is interesting to point out that, with no exception, women live longer than men in Thai society. Thus, in this study the majority of the participants (68.3%) were female and the oldest was 96 year old. Concerning marital status, we have found that the majority of the participants (54.7%) were married, 35.3 % were widowed and a low percentage (3.8 %) were divorced or separated. This reflects the Thai society in which people of this generation usually stay married for life. We have found also that although their offspring are the main caregivers for the elderly following the tradition of showing gratitude towards the parents (20), elderly couples continue to take care of each other. In this perspective, the household work is done by women to provide comfort as well as to procure food and medicine to their husbands. Contrary to many societies, in Thailand, elderly who do not live with their family are normally integrated in the community which provides them a warm social environment.
This study revealed that almost all of the participants have little education (primary schooling, 72.6 % and no formal education, 11.2%) and their educational background was found to be related to the perception of their health status. Thus, 51.2 % of the participants perceived themselves as not being healthy, referring to their chronic diseases. As people with little formal schooling usually work in low skilled and low paid jobs, chronic diseases are found to be common among the elderly who have had a hard life. Interestingly, these elderly believed that herbal medicines could help relieve their symptoms and they usually need individualized prescriptions. On the other hand, palliative treatment using herbal medicines can always be offered with decreased dependence on conventional medications (6). A previous study about the predictors of herbal medicines used in surgical patients in U.S.A. revealed that participants with a better perception of their own health status were more likely to use herbal medicines than those with a poor or average self-esteem and health (21); however, there is no significant correlation in this study. We have found that the higher the level of education, the stronger the perception supporting the benefits of herbal medicine is among the participants. More often than not, inflicted people and their families have to develop skills to manage stressors and the needs of physical care and lifestyle modifications accompanying the illness including psychosocial tasks (22). This study showed that the participants who had severe stress levels perceived more benefits from herbal medicines than the others. This was also found for the participants who had happiness scores lower than a normal range of happiness. Herbal medicines can be supplements which bring out the psychological well-being and better quality of life (23). We have also found, in this study, the differences among regions on education, happiness, and stress levels. The urban elderly were found to have higher scores on happiness. Interestingly, these results were found to be correlated with their higher formal education. On the other hand, the rural elderly showed higher scores on stress. It is evident that people living far from the public healthcare service have to take care of themselves and their families with whatever resources available to maintain their good health.
We found in this study that the majority of the elderly believed that herbal medicines could improve health, alone or together with conventional medicines, though, the majority thought herbal medicines would not provide a substitute for conventional medicines. In this study, the majority (77.6 %) believed in the efficacy of herbal medicines but normally would not discuss this subject with doctors (6). Thus, health professionals should realize that the elderly sometimes consume herbal medicines without an awareness of their side effects.
In summary, this study revealed that education, happiness and stress could influence the perception of herbal medicine consumption. Limitation to this perception can be culture, since one cannot generalize the findings from one region to another with a different culture. Local health care providers should be challenged to create multidisciplinary activities appropriate to Thai culture, living areas, sources of information, and personal abilities to use the proper traditional medicine resulting in increased quality of life (QOL) of the elderly. Self confidence and well-being are important for achieving better quality of life. As they grow up learning the benefits of herbal medicines, using them as food and/or as complements of conventional medicines, they will gain self-confidence to care for their own health.
Conclusions
Most of the elderly believe in the benefits of herbal medicine consumption and they use them not only as traditional medicines but also as nutritional supplements and food flavorings, in spite of their potential side effects. Health care professionals must update their knowledge of the combined effects of herbal medicines and conventional medicines on the elderly. It is important that doctors question their elderly patients and families on how they use herbal medicines and what benefits they believe.
Like in Thailand, Herbal medicines are becoming more and more popular in Western countries nowadays. However, these countries have a strong measure to avoid misuse and potential adverse effects of these herbs by establishing strict laws in handling these kinds of medicines, from the manufacturing and purification of the ingredients to the marketing strategies. This policy is facilitated by their juridicial conventions since issuing prescriptions should be accompanied by the observation of the patients by the physicians.
Acknowledgements: The authors wish to thank municipality authorities of the districts of Chonburi Province for their support and the elderly participants for their kindness and collaboration. C. Sumgnern thanks the Faculty of Nursing Science and the Office of International Relations of Burapha University for the scholarship and to Prof. John Bulger for revising the English language of this manuscript.
Author Disclosure Statement: There is no competing financial interests exist.
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