Roderick Salenga et al. /JAASP 1(2012) 16-24

RESEARCH PAPER

Prevalence, perceptions and predictors of complementary and alternative medicine use in selected communities in the Philippines

Vina R.A. Dahilig1 and Roderick L. Salenga1,* 1College of Pharmacy, University of the Philippines, Philippines.

Keywords Abstract complementary medicine alternative The study examines the use of complementary and medicine alternative medicine among residents of selected rural community rural and urban communities in the Philippines urban community using the CAM Healthcare Model. Interviews were conducted on 146 respondents in Batangas, Correspondence Caloocan and Paraňaque using a structured Roderick Layug Salenga questionnaire that applies the RAND Short Form R.Ph., M.P.H. (SF) 36 and the Brief Illness Perception College of Pharmacy Questionnaire as measures of self-perceived health University of the status. A higher prevalence was observed among Philippines Philippines the rural respondents (68.4%) as compared with E-mail: their urban counterparts (51.5%). Users in both [email protected]. rural and urban areas perceived CAM as beneficial. Significant predictors of use included the type of community, an annual income of less than USD 10,500, more than 10 years of residence in the community, self-perceived health status in the Energy/Fatigue, Emotional Well-being and Pain scales in the SF 36, presence of chronic illness, and consultations to traditional faith healer for health issues. Since only about 27% of the variability in the odds of using CAM can be explained by the model, further studies investigating other predictors of use are recommended.

Introduction Complementary and alternative Alternative Medicine (NIH-NCCAM) in medicine (CAM), as defined by the the United States, is a term for a National Institutes of Health- National group of diverse medical and health Center for Complementary and care systems, practices, and products

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Roderick Salenga et al. /JAASP 1(2012) 16-26 that are not generally considered to Materials and Method be a part of conventional medicine. It encompasses a broad type of practice, Across sectional design was used to including, but not limited to, evaluate CAM use among adults in the aromatherapy, yoga, homeopathy, rural municipality of Mataas na Kahoy, prayer, meditation, acupuncture and Batangas and two urban communities treatment with herbs, vitamins and in Barangay Baesa 160 Zone 14 food supplements. The increasing District II in Caloocan City and in growth of global CAM use has already Barangay Don Bosco, Paraňaque City. been well documented in literature. In The setting was based on the the national survey in the United definition of rurality and urbanity of a States, for example, CAM use community from Statistical Research increased from 33.8% in 1990 to and Training Center of the National 42.1% in 1997.1 Regional studies in Statistics Office in the Philippines. Australia suggested that Sample size was computed using approximately 50% of South PASS (Power Analysis and Sample Australians were CAM users with an Size Software) 2008 at a power of increase from 52.1% in 2000 and 80% and significance level of 0.05, 52.2% in 2004.2 Within the whole resulting in a sample size of at least African region, it was reported in 2001 146. Population allocation was used to that over 80% of the population used determine the number of samples African traditional medicine for needed for Mataas na Kahoy, primary healthcare needs.3 Most Caloocan and Paraňaque. From countries in the South East Asian Mataas na Kahoy and Paraňaque, 57 region, it is generally believed that samples were included for each and 70% to 80% of the population use from Caloocan, 32 households were CAM in the rural and semi urban areas selected. Simple random sampling where allopathic medicine is less was conducted to choose the available. Meanwhile, in the Western barangays in the rural community. Pacific region, it is acknowledged that Four out of the eleven barangays were CAM is practiced in many countries investigated. The barangays of Santol but is not regulated by most (population:1,684), Loob (population: governments. Similar data on the 988), Bubuyan (population:1,107) and widespread use and cultural Calingatan (population:2,386) were acceptance of CAM was found by the drawn. The starting point of every World Health Organization (WHO) on sampling was the barangay hall. the Eastern Mediterranean region Convenience sampling was conducted although the exact prevalence was not to select the respondents from the provided. households in the barangay. One adult representative from each National data on the prevalence of household drawn was requested for an CAM use particularly in the urban and interview. Respondents who were rural communities in the Philippines is included in the study are adults who lacking. As such, this study was are residents in the study areas for conducted to compare the prevalence more than a year, regardless of and perceptions on complementary whether they have used CAM or not and alternative medicine and identify and are physically and mentally able its predictors of use among adults in to participate in the survey. The the rural barangays in Batangas and survey instrument was administered in the urban communities in the cities to the respondents using a structured of Caloocan and Paraňaque and interview, composed of 3 parts, as Philippinses. follows: part 1 the respondent demographics; part 2 the evaluation

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of health status by using the RAND entered into a multivariate logistic Short Form (SF) 36-item Health regression model to assess their Survey Questionnaire and the 8-item relationship with CAM use in order to Brief Illness Perception Questionnaire obtain the predictors of use. The odds (BIPQ). The questions in the SF 36 are ratio (OR) and a 95% confidence scored in a scale of zero to 100 where interval (CI) for each variable were 100 represents highest level of determined. Variables not contributing functioning. Aggregate scores are substantially to the model were combined as total percentages of the systematically removed in a backward total points possible, and scores from stepwise regression process using the the items representing eight scales of likelihood ratio test as the criterion for health status were averaged to obtain removal. The Hosmer-Lemeshow χ2 the final scores in each dimension. In test was used to assess the goodness the BIPQ, 8 items were measured with of fit between the observed and a 0-10 scale where the highest score predicted number of outcomes for the of ten reflects a more threatening final model. view of the illness. These questionnaires were translated to Filipino and back-translated in English Results and Discussion to ensure content validity. Part 3 includes the study-specific questions Table 1 Socio-demographic characteristics of the respondents. particular to complementary and alternative medicine use. For quality Factors n % of data, the interviewers were trained Type of community and using the same prepared visual Urban 90 61.6 aids to further enhance Rural 56 38.4 comprehension of some questionnaire Age group concepts. The researches monitored 61 years and above 26 17.8 data collection and checked during 55 to 60 years 10 6.9 field interview. Six interviewers who 37 to 54 years 45 30.8 have had adequate background in 36 years and below 65 44.5 Sex public health were trained prior to the Male 88 39.7 conduct of the data collection. The Female 58 60.3 interview was conducted from Educational Attainment December 2011 to February 2012. At least college 104 71.2 The setting of the interview was of the High School 35 24.0 respondents’ own preference. Prior to At most elementary 7 4.8 the interview, informed consent was Employment Status reviewed and signed by the Employed 31 21.2 respondent. A copy was given to each Unemployed 115 78.8 Annual Income respondent. Data were verified and Less than USD 2,500 7 4.8 coded for analysis. Descriptive USD 2,500 to USD 10,500 78 53.4 statistics were used to describe the Greater than USD 10,500 61 41.8 prevalence and frequency of CAM use. Years in the barangay Association between health Greater than 10 years 91 62.3 perceptions and CAM use by type of 5 to 10 years 20 13.7 community was tested using Wald Less than 5 years 35 24.0 test. Comparison of existing prevalence and perceptions of CAM A total of 146 respondents were use between urban and rural included in the study. Table 1, More respondents were evaluated using than three-fifths of the respondents Fisher’s exact test. Candidate live in the urban areas. Three fourths variables were grouped and then of the respondents are aged 54 years

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or below. Majority of the respondents respondents claim that they are not are females (60.27%) and have at healthy. least college education (71.23%)

Almost four-fifths of the respondents are unemployed. Most of the Table 3 Association of socio-demographic respondents (62.33%) have resided in characteristics with complemen- their respective barangays for more tary and alternative medicine than 10 years already. use Factors OR p 95%CI

Type of community Table 2 Health perception and status of Urban 2.2 0.029 1.1, 4.4 the respondents (n=146) Rural 1.0

SF 36 Health Status Mean SD Age group Physical functioning 72.9 27.5 > 60 years 2.2 0.113 0.7, 3.5 Role limitations due to 55 to 60 years 1.5 0.586 0.4, 5.6 physical health 37.3 44.6 37 to 54 years 1.6 0.236 0.8, 5.7 Role limitations due to < 37 years 1.0 emotional problems 40.2 45.3

Energy/Fatigue 62.0 19.6 Sex Emotional well-being 72.0 19.6 Female 1.2 0.545 0.6, 2.4 Social functioning 72.1 24.3 Male 1.0

Pain 72.0 22.7 Educational Attainment General health 61.4 19.5 At least college 0.6 0.510 0.1, 3.1 Brief Illness Perception High School 0.5 0.410 0.1, 2.8 Questionnaire Score 3.6 2.2 At most 1.0 N % elementary Healthy? Employment Yes 35 24.0 EmployedStatus 1.0 0.984 0.4, 2.2 No 111 76.0 Unemployed 1.0 With acute illness(es)? Approximate annual Income Yes 43 29.5 < USD 2,500 1.1 0.924 0.2, 5.3 No 103 70.6 USD 2,500- 1.0 0.875 0.2, 4.9 With chronic illness(es)? >10,500 USD 10,500 1.0 Yes 81 55.5

No 65 44.5 Years in the barangay Who is consulted when ill? > 10 years 2.9 0.009 1.3, 6.5 Medical doctor 74 50.7 5 - 10 years 1.8 0.285 0.6, 5.6 Allied medical professionals 64 43.8 < 5 years 1.0 Traditional 8 5.5

About 30% of the respondents claim that they have acute illness(es). More Table 2 shows the health-related than half of the respondents (55.5%) characteristics of the respondents claim that they have chronic illness. measured by dichotomous questions About 94% of the respondents consult that inquire if they feel they are medical doctors and allied medical healthy, have acute illness(es) or professionals when they are sick. The chronic illness(es). Self-perceived prevalence of CAM use among health status was measured through respondents residing in rural areas is the SF 36 tool and the BIPQ. Among 68.4% (95% CI: 57.2%, 82.1%) the health perception components, the while the prevalence of CAM use respondents had the highest and among respondents residing in urban lowest mean scores for physical areas is 51.5% (95% CI: 40.6%, functioning (72.9 ± 27.5) and role 61.6%). limitations due to physical health(37.3 ± 44.6), respectively. The mean BIPQ The reasons for not using CAM differ, score is 3.6 with a standard deviation as follows: respondents from the rural of 2.2. More than three-fourths of the areas; no need (41.2%) no experience (23.5%) and no belief

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(23.5%), whereas those from the and use of holy oil (20.00%). About urban areas; no belief (26.7%), no 10% and 13% of the respondents experience (22.2%), preference for from the rural and urban areas, conventional medications (17.8%), no respectively, used CAM on a daily need (20.0%) and ineffectiveness basis for illness prevention, pain relief (8.9%). From the CAM users’ and treatment of cough and colds. The viewpoint, the reasons for choosing most common indication of CAM use CAM from the rural areas were was for pain relief in the rural inability to afford conventional (79.5%) and urban areas (58.7%). medications (33.33%), accessibility The associations between CAM use (20.5%) and family tradition (15.4%). and health status perception Also, CAM was used to fill in the void components were not statistically of conventional medications (5.13%), significant by Wald tests; as follows: and due to their intimate acquaintance physical functioning (PF) (p = 0.606), with the CAM product/practice (the role limitations due to physical health Filipino traditional concept of (RLPH) (p = 0.65), role limitations “hiyang”) (12.8%) and avoidance of due to emotional problems (RLEP) (p chemicals (5.1%). = 0.90), energy/fatigue (EF) (p = Respondents from the urban areas 0.72), emotional well-being (EW) (p = stated that they selected CAM because 0.59), social functioning (SF) of the following: avoidance of (p=0.96), pain (p = 0.23); and chemicals (34.8%), their intimate general health (GH) (p=0.15), as acquaintance with CAM shown in Table 4. However it should product/practice (26.09%), and be noted that the lower the scores in expensive conventional medications PF, RLPH, EF, SF, P or GH, the higher (21.74%). CAM products mostly used the odds of using CAM. Correspond- by the respondents in the rural areas ingly, the higher the scores in RLEP or are of herbal origin such as: horse EW, the higher the odds of using CAM. radish, or Moringa oleifera (35.9%), guava (30.8%), bitter gourd (28.2%), herbal supplements (23.1%) and sambong or Blumea balsamifera (20.5%). CAM products mostly used by the respondents in the urban areas are: horse radish, or Moringa oleifera (60.9%), alkaline water (45.7%), bitter gourd (43.5%), bayabas (39.1%) and herbal supplements (23.9%). The most common CAM methods used in the rural areas, included: (1) hilot or traditional Filipino massage (46.2%), use of holy oil (46.2%), consultations with an albularyo (traditional faith healers) (38.5%), tawas or an albularyo’s Figure 1 Proportion of respondents with traditional diagnostic ritual using and without chronic diseases interpretations of figures formed by and their experience and perceptions. candle wax drops on water (18.0%) and magnets (10.3%); whereas those in the urban areas included: hilot (53.3%), Chinese medicine (26.7%), tawas (24.4%), albularyo (22.22%)

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Table 4 Association of health-related factors, only the type of community characteristics with the use of and years in the barangay have complementary and alternative significant crude associations with medicine. CAM use (p < 0.05). Health-related OR p 95% CI Healthy? Among the health-related factors Characteristics Yes 0.8 0.589 0.4, 1.7 measured in this study, only the No 1.0 presence of acute and chronic With acute illness? illness(es) had statistically significant Yes 0.3 0.000 0.1, 0.5 crude associations with CAM use (p < No 1.0 0.001). The odds of using CAM among With chronic illness? respondents without acute illness is Yes 6.0 0.000 2.9, 12.3 four times higher than that of those No 1.0 with acute illness(es). The odds of Health Perception using CAM among respondents with SF 36 Scales chronic illness(es) is six times higher Components Physical 1.0 0.166 1.0, 1.0 than that of those without chronic illness. Using backward elimination Role limitations Functioning method, the significant predictors of due to 1.0, 1.0 1.0 0.490 CAM use include the type of physical health community, an annual income of less than USD 10,500, more than 10 years Role Limitations of residency in the barangay, low due to 1.0, 1.0 1.0 0.974 Energy/Fatigue (EF) score, high emotional problems Emotional Well-being (EW) score, low Energy/ Fatigue 1.0 0.177 1.0, 1.0 Pain score, good health status, Social 1.0 0.365 1.0, 1.0 presence of chronic illness(es), and when a person consults traditional Pain 1.0 0.666 1.0, 1.0 Functioning healers when sick. General Health 1.0 0.081 1.0, 1.0 Brief Illness 1.7 0.380 0.9, 1.2 The Hosmer-Lemeshow goodness-of- Perception Scale fit test shows that the model has good internal fit (p=0.3460). The final Score 2 About half (55.5%) of the model has a pseudo-R equal to respondents suffer from chronic 0.2699 which means that about 27% conditions such as hypertension of the variability in the odds of using (36.1%), arthritis (12.4%) and CAM can be explained by the model. diabetes mellitus (7.2%). They are The characteristics of the respondents currently taking antihypertensives are consistent with the common (31.1%), multivitamins (12.2%), pain demographics of the country although reliefs (9.5%) and oral hypoglycaemic some of the data in the study may not agents (9.5%). Respondents from the be generalizable to the whole rural and urban areas with positive population. Majority of the experiences with CAM, were 89.7% respondents lived in the urban areas, and 93.5%, respectively, and were among these, 75% aged 54 years and not significantly different (p = 0.698). below and females. When the Crude logistic regression to determine interview was conducted, the the association between a particular unemployed females were most likely factor and outcome of interest to be left in charge of the household. regardless the effects of the other The number of years of residence in factors showed that, despite the the barangay to determine the degree differences in socio-demographic of adaptation of the majority of the respondents of more than ten years

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probable suggest that the participant but they also realize that due to their most likely represents the culture in conditions, the quality of doing such his/her geographic location. activities becomes lower and the amount of time doing the same work Table 5 Significant predictors of takes longer. Mean BIPQ score of 3.56 complementary and alternative  2.17 indicates a nonthreatening medicine use. perspective of their conditions, Significant OR p 95% implying that the respondents may predictors CI tolerate illnesses. Type of Community Rural 5.5 0.01 0.05, CAM use of about 68.4% was found 0.64 among the residents in the rural Urban 1.0 Annual Income areas. This was expected because it 1.31, has better accessibility and is locally < USD 2,500 15.0 0.030 171.7 available.4-5 Also, women were more USD 2,500- 1.36, 15.1 0.027 10,500 166.7 readily to use CAM than men. Non- > USD 10,500 1.0 CAM users (41.2%) from the rural Years in the barangay areas stated that they were “healthy” > 10 years 3.0 0.043 1.03, 8.46 and 27.5% have no experience but 5 to 10 years 1.2 0.85 0.28, would try when necessary. In the 4.66 urban areas, most respondents did < 5 years 1.0 not believe and had no prior Health Perception Components 0.93, experience with CAM. It is noted that Energy/Fatigue 1.0 0.019 0.99 non CAM users in the rural areas were Emotional well- 1.03, 1.1 0.001 more receptive to CAM than the urban being 1.1 0.94, respondents. Pain 1.0 0.023 1.00 Healthy? Literature points that CAM users 0.98, Yes 3.9 0.05 choose alternative therapies to make 15.67 No 1.0 their health care more congruent with With chronic illness(es) their personal values, beliefs, and 3.15, Yes 8.4 >0.01 overall philosophic orientation toward 22.17 6 No 1.0 health and life. Such philosophical Who is consulted when ill? reason was said to result from Traditional 2.20, 18.4 0.007 personal values, disillusionment with healers 154.5 conventional therapies because of lack Allied medical 0.93, 2.7 0.069 professionals 7.68 of efficacy or of side effects, or a Medical doctors 1.0 desire to have better control over health care matters.6 However, this study does not fully support these. When the health-related characteris- Mainly, high costs of drugs prevent tics of the respondents were majority of the Filipinos to use evaluated, it was found that more conventional medicines, which is than 75% of the respondents do not supported by the rural respondents in believe that they are healthy. This this study who stated that they used self-perceived existence of a disease more affordable and accessible CAM. was consistent with the scores The rural residents have limited obtained in the SF 36. The obtained access to conventional health care highest mean score for PF of 72.9  services with stronger informal 27.5 and the lowest mean score community networks7, fewer obtained for RLPH of 37.3  44.6 could resources, widespread poverty as a mean that most of the interviewees consequence of lower income8, and believe that they are still capable of geographic isolation9. Almost 13% of doing moderate to vigorous activities the rural respondents raised the

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phenomenon of hiyang, a concept between CAM use and the various usually cited by Filipinos within the health perception components were context of medication-taking behaviour. not statistically significant, as what Most older respondents mentioned was reported previously in literature11. that they take herbal medicines Although the model indicating the because they feel hiyang, or that the predictors of use could only explain product is compatible with their body about 27% of the variability in the constitution. Only 5.1% of the rural odds of using CAM in the Philippines, respondents patronize CAM because it this is still considerably higher than has no chemicals. This is the major the reported variability in odds (4.9%) reason of CAM use in urban residents using the Andersen’s model in the (34.8%). Urban respondents have context of CAM use in a national more access to conventional survey in England12. medicines and as such, they compare conventional and alternative Conclusion medicines (ex. the concept of taking “natural” drugs as opposed to the The results of this study show a “chemical” drugs). Another reason higher prevalence of CAM use in the common to both urban and rural rural setting (68.4%) than in the respondents is that “CAM is a tradition urban areas (51.1%). CAM methods in the family”, a point that suggests and modalities used in both types of that CAM use is also influenced to communities do not differ some extent by culture and faith as significantly. Most of the respondents opposed to conventional treatments only use CAM when needed and these where medication taking is based are used in the treatment of acute largely on science. Other reasons cited rather than chronic conditions even if by the respondents are that they use most of the respondents have chronic CAM to avoid side effects of illness(es). The most common reason conventional treatment, because a why people turn to CAM is that they friend had recommended it, or cannot afford the costs of because regular treatments had failed conventional medicine. By itself, this to provide a cure. should raise the idea that some patients may have used CAM in place CAM is used by both groups of of the conventional treatments respondents when necessary for the prescribed by their doctor and thus, same indications: pain relief (rural > there is a risk for noncompliance. urban), illness prevention (urban > Although most of the respondents rural) and treatment of coughs and consult their primary physicians for colds (rural > urban). Pain which their health concerns, they are more affects general health, psychological frequently in touch with their relatives health and economic well being, one and friends who are their most of the strong predictors of CAM usage, common sources of information could diminish fears and bring hope regarding complementary and 10 with natural approaches to relief. alternative medicine. Individuals with The association between health low scores in the RAND Short Form perception and CAM use in the urban (SF) 36 scales of physical functioning, and rural areas was not statistically role limitations due to physical health, significant. It has been seen in this energy/fatigue, social functioning, study that individuals with poor self- pain or general health but have high perceived health status due to scores in the scale role limitations due physical constraints but with better to emotional health and emotional emotional status are more likely to well-being have higher odds of using use CAM. However, the associations CAM. Low scores in the brief illness

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perception questionnaire also increase national study. J Am Med Assoc. the likelihood of CAM usage. Both 1998;279:1548-1553. respondents in urban and rural 7. Adams J, Sibbritt D, Lui C. The communities perceive CAM to be urban-rural divide in complementary beneficial in the management of their and alternative medicine use: a health. Significant predictors of CAM longitudinal study of 10,638 use include residence in a rural women. BMC Complem Altern M. 2011;11(2):1-2. location, an annual income of less than USD 10,500, more than 10 years 8. Cuellar N, Aycock T, Cahill B, Ford of residence in the barangay, J. Complementary and alternative energy/fatigue score, emotional well- medicine (CAM) use by African American (AA) and Caucasian being score, pain score, overall health American (CA) older adults in a rural status, presence of chronic illness and setting: a descriptive, comparative if the person consults traditional study. BMC Complem Altern M. healers when sick. The model 2003;3(8):5-6. proposed by this study can only 9. Cuellar N, Butts JB. Caregiver explain about 27% of the variability in distress: what nurses in rural the odds of using CAM. As such, settings can do to help. Nursing future studies are warranted to Forum 1999;34:24-30. supplement the gaps in literature and 10.Foulad-bakhsh J, Stommel further assess the factors that M. Comparative analysis of CAM use influence CAM use. in the U.S. cancer and noncancer populations. J Complementary References Integrative Medicine. 2008; 5(1):19- 1. Eisenberg DM, Davis RB, Ettner SL, 20. Appel S, Wilkey S, Van Rompay, et 11. Palinkas LA, Kabongo ML. The use of al. Trends in alternative medicine use complementary and alternative in the United States, 1990-1997. medicine by primary care patients. A Results of a follow-up national SURFNET study. J Fam Practice. survey. J Am Med Assoc. 2000, 49:1121-1130. 1998;280:1569-1570. 12. Hildreth K, Elman C. Alternative 2. MacLennan AH, Myers S, Taylor AW. worldviews and the utilization of The continuing use of complementary conventional and complementary and alternative medicine in South medicine. Sociol Inq. 2007;77(1): Australia: costs and beliefs in 2004. 76-103. Med J Australia. 2006;184(1):27-31. 3. World Health Organization. Fact sheet no. 271. Geneva: WHO; 2002. 4. Nunes B, Esteves MJS. Therapeutic itineraries in rural and urban areas: a Portuguese study. Rural and Remote Health 6 (online) 2006;394;2- 5. Available from: http://rrh.deakin. edu.au. Accessed July 8, 2009. 5. Moga MM, Mowery B, Geib R. Patients are more likely to use complementary medicine if it is locally available. Rural and Remote Health 8 (online) 2008:1028. Available from: http://www.rrh. org.au. Accessed July 8, 2009. 6. Astin JA. Why patients use alternative medicine: results of a

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