Attitudes towards complementary alternative medicine among Malaysian adults

Article history: Received on: 01/03/2017 Accepted on: 08/05/2017 Available online: 30/06/2017 Complementary and alternative medicine (CAM) has become more popular in recent years. Psychosocial factors such as attitude towards CAM has been suggested as a predictor of CAM use in certain populations. This study investigated the association between attitude and CAM use among the local population. The questionnaire-based survey was performed prospectively among adults aged ≥18 years, with informed consent. Results demonstrated that a high number of respondents admitted to CAM use (n=297/417, 71.2%) compared with those that did not use CAM (n=117/417, 28.1%). The use of herbal products was the most popular CAM (n=227, 54.44%). The main reason for CAM use was recommendation from friends and family (n-217, 52%). The main reason for not using CAM was due to satisfaction with conventional medicines (n=106, 25.4%). Attitude scores demonstrated that respondents felt positive towards the need for pharmacists to equip themselves with sufficient CAM knowledge (3.04±0.032, maximum; 4). There was a positive correlation between the number of CAM used and total attitude score (ρ=0.102, p=0.036). In conclusion, personal attitude influenced their likelihood of using CAM among the local population. The need for appropriate advice on CAM use is reflected in the need for pharmacists’ community support.


INTRODUCTION
Complementary and alternative medicine (CAM) is a diverse group of traditional practices comprised mainly of herbal and dietary supplement, acupuncture or Ayurveda, energy therapies, body-based and mind body-based therapies.The National Policy of Traditional and Complementary Medicine Malaysia (MOH, 2007) has previously stated that traditional and complementary medicines should co-exist with modern medicines and contribute towards enhancing and improving the quality of life of Malaysians.This comes in view of the popular use of CAM among the local population.In Malaysia, CAM has been used widely among cancer (Farooqui et al., 2016), .asthmatic (Alshagga et al., 2011), hypertensive (Mahfudz and Chan, 2005) and diabetic (Ching et al., 2013) patients.Siti and colleagues reported that 69% of Malaysians used CAM in their lifetime (2009).Biological based therapies which include the use of herbs and animal parts, vitamins and supplements, diet based therapy and application of beauty or hygiene products are the most frequently used CAM in Malaysia.Studies in neighboring countries support the prevalent use of CAM where in Singapore 45% of the population use CAM (WHO, 1998), 30% in Thailand (WHO, 1999) and 40% in Indonesia (Ritiasa, 2000).
The use of CAM may be triggered by various factors (Hassan et al., 2010) for example; discontent with conventional medicine, the need for ideological congruence, and the need for personal control (Hasan et al., 2010).Other reasons for seeking CAM treatments are chronic illness which are not responding well to conventional medical treatment (e.g., back pain, arthritis) and feeling a greater sense of control over personal health when using CAM (McFadden et al., 2010).Demographic, cultural factors and the perception that CAM is more effective than conventional drugs are also among reasons for CAM usage (Carlson and Krahn, 2006).However, one problem with general characterizations of why people use CAM is that such representations overlook different motivations for initiating CAM and sustaining CAM use over time.
It is also essential to consider psychosocial factors towards CAM when assessing why it is chosen as a treatment.Psychosocial factors such as attitudes, beliefs and motivations have been recently identified as a possible predictor of medication behavior (McFadden et al., 2010).The decision to seek CAM treatment may be also due to the attitude towards health in general.A belief in being able to affect personal health, rather than attributing health to others (e.g., doctors, family) or chance, may influence the way a person actively contributes to their own health (McFadden et al., 2010).It is important to have a basic understanding of CAM before using it and that patients may disregard or even avoid doctors and healthcare professionals who do not understand their health beliefs and attitudes (Koh et al., 2003).
CAM are usually more expensive than conventional medicines and yet the public are willing to pay for it.This raises questions on psychosocial factors underlying their decisions to seek therapies from CAM.Currently, very little information is available on the general use of CAM and reasons for their popularity in the local setting.We hypothesize that the use of CAM is associated to their attitude towards CAM.Thus, this study was performed to account the attitudes of Malaysian adults towards the use of CAM and to further explore reasons that affect the decision to seek alternative therapies.

Study design
This was a prospective cross-sectional study performed among the public in Malaysia.The study was performed from July to November 2016 using a questionnaire.The respondents were adults>18 years of age, where verbal informed consent was obtained before the interview.Convenient sampling was employed and during the study we approached a total of 417 individuals, slightly higher than the calculated 384 individuals recommended.The sample size was calculated based on Krejcie and Morgan (1970).A slightly higher sample of 417 individuals was collected to account for the possibility of incomplete questionnaires.Ethical approval was obtained from the University Kebangsaan Malaysia hospital research and ethics committee (NF-RES-2016-19).

Questionnaire
The questionnaire consisted of three sections.The first section contained demographic information such as age, gender and ethnicity.Information on whether a family member was working in a health-related field, long-term illness, taking prescribed medicines and perception of general health were also collected.The second section was based on the use of CAM.Data on types of CAM were collected and categorized based on six types (Ching et al., 2013): herbal products, alternative medical system, energy, manipulative and body based systems, mind-body interventions and others.Reasons for using or not using CAM were identified based on previous studies (Koh et al., 2003).The options for reasons for using CAM were: recommended by friends or family, recommended by medical practitioner or pharmacist, dissatisfaction with conventional medicine, to treat health problems, for maintenance of general health, holistic orientation toward health, to relieve stress, natural and therefore safer, greater control over healthcare decisions and not applicable.The options for reasons for not using CAM were: lack of evidence of effectiveness, satisfied with conventional medicines, more expensive than conventional medicine, longer time to see effect and others.The third section was based on attitudes towards CAM (Yom and Lee, 2008).This was based on twelve statements related to attitude towards CAM usage.The statements were ranked on a four-point Likert scale from 1: strongly disagree to 4: strongly agree.The total maximum score was 48.A higher score indicated a more positive attitude towards CAM usage.

Statistical analyses
Analysis was performed using the statistical package SPSS version 22.0 (IBM; Armonk, NY) (Ngadimon et al., 2015).Descriptive statistics, such as mean, standard deviation (SD) and frequency were used to analyze continuous and categorical data, such as respondents' demographics and their attitude level.A Ttest or ANOVA was used to compare means between two or more groups, respectively.A Chi-squared test was used to determine association between categorical data.A significance level of p < 0.05 was considered statistically significant.

Demographic data
A total of 417 respondents were enrolled in this study.Majority of the respondents were Malay (n=311, 74.6%) followed by Chinese (n=63, 15.1%),), Indian (n=25, 6.0%) and others (n=18, 4.3%).The oldest respondent in this study was 66 years old while the youngest respondent was 18 years old.The mean age of the respondents was 22.06 ± 6.0 years.A small number of respondents admitted to having long termchronic illnesses such as asthma and diabetes (n=39, 9.4%), with a few taking prescribed medications (n=87, 20.9%).Respondents perceived health was found to be 'excellent' in 15.1% (n=63), 'very good' in 34.5% (n=144), 'good' in 43.6% (n=182) and 'fair' in 6.7% (n=28).No respondents perceived their health to be poor.

Use of CAM
The number of respondents admitting to CAM use was found to be higher (n=297, 71.2%) compared to those who did not use CAM (n=117, 28.1%).The use of herbal products was identified most popular among the respondents (n=227, 54.44%) (Table 1).Other types of herbal CAM used were honey, Habatus sauda, olive oil, herbal supplement, sea cucumber, gingko, curcumin, papaya leaf and lingzhi mushroom.On the other hand, other CAM used among the respondents was noted as Islamic medicine.Reasons for using or not using CAM are shown in Table 2. Respondents were allowed to choose more than one option where necessary.

Attitude towards CAM
The results about attitude towards CAM are presented in Table 3.A higher score indicated positive attitude towards CAM.The highest mean score was observed for statements 'Pharmacist should be able to advise their patients about commonly used CAM methods' (3.04 ± 0.032, maximum score; 4).
The lowest mean score was observed for the statement 'CAM should only be used as a last resort when conventional medicine did not work' (1.42 ± SD 0.727).
Further analysis demonstrated that there was a positive correlation between the number of CAM use and total attitude score (ρ=0.102,p=0.036).Respondents that were taking CAM were also found to have a higher attitude score (t=-2.170,df=415, p=0.031) than those that were not taking CAM.

DISCUSSION
There has been an increase in the use of CAM around the world to treat chronic, recurrent, or serious illness (Yeh et al., 2002;Li and Leung, 2014).The desire among human beings to explore beyond the realms of modern conventional medical treatment is frequently observed.Similarly, Malaysia has a strong tradition of CAM usage (Azizand Tey, 2009), as supported by the findings of this study.All ethnics in Malaysia were found to use CAM, similar to previous work (Siti et al., 2009).Despite the majority admitting to having good health, the use of CAM is still relatively high, demonstrating that perceived health does not determine the need for use of CAM among the local population.This is in contrast to previous findings that demonstrates CAM utilization was higher for people with poor health, chronic conditions, and low functional status (Ong et al., 2002).
The reason for CAM use may vary among different populations.
Interestingly, dissatisfaction with modern conventional medicine was not necessarily the reason people turned to CAM (Koh et al., 2003).Although the majority of the study population was found to use CAM, those who were taking prescribed medication were also among CAM users.From a previous study among pharmacists, the main reason for CAM use was to maintain general health and promote well-being (Koh et al., 2003).However, in this current work, we found that recommendations of friends and family were the main reasons of CAM use.It was also demonstrated that belief played a major role in its use, as respondents believed that CAM was natural and safer, similar to previous findings (Firenzuoli and Gori, 2007).Among the various CAM used, herbal medicine was most the common choice (Firenzuoli and Gori, 2007), which was representative of the current population.While they recognized its benefits, unfortunately not many were aware that CAM is not without its risks (Wong et al., 2012).In the current study, it was demonstrated that CAM users were more likely to have a positive attitude towards it.Users of CAM are known to indicate more positive attribute towards CAM in treating their illness (Carlsonand Krahn, 2006).Thus, personal attributes and opinions also influence their likelihood of using herbal medicines.These findings are important as positive personal attributes towards herbal medicines may help healthcare providers identify patients at increased risk of CAM usage.These patients would be strong candidates for receiving guidance on safe use of herbal or alternative medicines (Azizand Tey, 2009).
It was revealed during the results analyses that respondents agreed with many of the fundamental tenets of CAM, such as 'pharmacist should be able to advise their patients about commonly used CAM methods'.The need for pharmacists to be actively involved in CAM use and providing guidance is seemingly appropriate.Unfortunately, it has been demonstrated that many pharmacists are still ill-equipped with CAM knowledge (Chen et al., 2016).With the increase in CAM usage among the population, the need for ensuring adequate counseling on its use is highly recommended.The use of CAM among higher-risk patients such as elderly and organ failure patients poses a potential safety concern that could be mitigated by appropriate counseling.Instruments using psychometric properties in order to assess pharmacists' counseling behavior on herbal and dietary supplement products have been recently developed (Lin et al., 2010).The instrument can be used as a tool for quality assurance and training assessment to ensure that a standard level of patient counseling on herbal and dietary supplements is being provided.
Our findings confirm the high prevalence of CAM usage by Malaysian adults was significantly associated with a positive attitude towards CAM.However, with all questionnaire-based studies, the findings of this study were limited tothe feedback of respondents to survey questions.Therefore, generalization of the results should be done with caution.To that end, identifying attitudes towards CAM may help health care providers identify patients in need of additional guidance on their safe use.

CONCLUSION
Respondents' personal attitudes influence their likelihood of using CAM.Those with a positive attitude towards CAM were more likely to use CAM among the local population.These findings are important because knowledge of the predictors of CAM usage may help healthcare providers to identify patients at increased risk of CAM use.These patients would be candidates for receiving guidance on safe use of CAM.
Financial support and sponsorship: Nil.

Table 1 :
Types of CAM used among the study population.

Table 2 :
Reasons for using/ not using CAM among the study population.

Table 3 :
Attitude score of respondents towards CAM use (n=417).