Traditional medicines (TMs) cover a heterogeneous spectrum of ancient to new-age approaches to prevent or treat disease. They include the use of herbal medicines (HMs), spiritual healing, and practices such as bone setting [
DM is one of the largest global health emergencies of the 21st century. In 2015, 14.2 million people were estimated to be living with DM in Africa, and this is projected to 34.2 million by 2040 [
Until recently, however, herb-drug interaction was often unsuspected by healthcare providers. Most trained physicians lack adequate knowledge on HM and its potential for drug interactions [
Ethiopia is not an exception to this worldwide phenomenon as HM is still the main source of healthcare for many millions of people [
The study was conducted in Addis Ababa, the capital city of Ethiopia. Addis Ababa is divided administratively into 10 subcities and has a total population of 3.43 million [
A health facility-based prospective cross-sectional study design was carried out to determine the prevalence of concomitant use of herbal and conventional medicines among patients with DM. Data were collected between April and August, 2016.
The source population for the quantitative data constituted all patients with diabetes attending treatment in outpatient clinics of public hospitals in Addis Ababa City Administration (AACA). Patients with diabetes from four public hospitals in Addis Ababa, two hospitals from AACA (Yekatit 12 Hospital Medical College and Zewditu hospital) and two hospitals from Federal (St. Paul’s Hospital Millennium Medical College (SPHMMC) and Tikur Anbessa Specialized Hospital) were the study population. On the contrary, all prescribers working in the diabetic clinics were considered as the source population for the qualitative data.
Patients aged ≥18 years and taking antidiabetic medicines were eligible for the survey. Patients with DM who were physically or mentally not capable for the interview and those who were health professionals were excluded from the study. For the qualitative interview, prescribers who were working in diabetic clinics and had no previous diagnosis of DM were recruited.
The sample size was determined using the single population proportion formula [
Based on ownership, hospitals were stratified into those administered by AACA and Federal Government. Then, from each stratum, two hospitals, Zewditu Memorial Hospital (ZMH) and Yekatit 12 Hospital Medical College, from AACA and Tikur Anbessa Specialized Hospital (TASH) and St. Paul’s Hospital Millennium Medical College (SPHMMC) from federal hospitals were selected using simple random sampling technique. The sample size was proportionately allocated considering total patients with diabetes of each hospital of which 336 were from TASH, 206 from SPHMC, 132 from ZMH, and 171 from Yekatit 12 Hospital Medical College. Recruitment of the respondents was achieved through the consecutive sampling approach.
For the qualitative data, selection of participants was based on the purposive sampling method. Key informants were recruited on the basis of their professional role and work experience in the diagnosis and treatment of diabetes mellitus. Selection of participants was continued until theoretical saturation was achieved.
For the concomitant use of herbal and conventional medicine assessment, a total of 45-item questionnaire was adopted from the previous literature (supplementary 1) [
On the contrary, a semistructured open-ended interview guide with flexible probing techniques was employed to explore prescriber’s experience of history taking about herbal medicine use during examination of patients with DM.
Two trained pharmacists were recruited as data collectors for each hospital. As part of the training, data collectors conducted pretesting of the instrument in Ras Desta Damtew Memorial Hospital under the supervision of the principal investigator, and modifications were done accordingly. All key informant interviews were administered by the principal investigator, who was trained on qualitative research methods. All interviews were recorded, and notes were also taken during interviews to expand later. The interviews were done in Amharic (a local language), and any ambiguities raised from the interviewees were cleared at the time of the interview. Questionnaires prepared in English were translated into Amharic and backtranslated into English to ensure consistency.
After the data collection, the principal investigator coded each question, and data entry was made using Epi Info version 3.5.4 and transferred to SPSS version 20 for analysis. Descriptive statistics were used to summarize the data.
The qualitative data were analyzed using content analysis. It involved intensive reading and rereading through the data, and content analysis had been conducted manually, focusing on similarities and differences of perspectives between different informants.
Ethical approval was obtained from the Ethics Review Committee of the School of Pharmacy, Addis Ababa University, and AACAHB Ethics Review Board. The study was conducted after obtaining permission from the respective hospitals. Participants of the study were also asked for verbal consent before participating in the study. Participants were assured about confidentiality of the information obtained in the course of the study, and there was no use of personal identifiers.
From 845 respondents, 791 completed the interview, making up a response rate of 93.6%. Males and females accounted almost similar proportion of sample size of 402 (50.8%) and 389 (49.2%), respectively. The age of the respondents ranged from 18 to 83 with the mean age of 49.07 ± 14.76 years. Among the respondents, one-third of them were housewives, and two-thirds of respondents had attended at least elementary school. A majority (667 (84.3%)) of the respondents were reported as residents of Addis Ababa (Table
Demographic characteristics of respondents in selected public hospitals of Addis Ababa, Ethiopia, 2016 (
Variable | Frequency | Percent |
---|---|---|
Gender | ||
Male | 402 | 50.8 |
Female | 389 | 49.2 |
Age | ||
18–40 | 290 | 36.7 |
41–64 | 368 | 46.5 |
>64 | 133 | 16.8 |
Marital status | ||
Single | 159 | 20.1 |
Married | 526 | 66.5 |
Divorced | 43 | 5.4 |
Widowed | 63 | 8.0 |
Residency | ||
Addis Ababa | 667 | 84.3 |
Oromia | 111 | 14.1 |
Others | 13 | 1.6 |
Religion | ||
Orthodox Christian | 590 | 74.6 |
Muslim | 97 | 12.3 |
Protestant Christian | 89 | 11.2 |
Others | 15 | 1.9 |
Educational level | ||
Unable to read and write | 187 | 23.7 |
Nonformal education | 80 | 10.1 |
Elementary school | 166 | 21.0 |
High school | 190 | 24.0 |
TVET college and above | 168 | 21.2 |
Occupation | ||
House wife | 231 | 29.2 |
Government employee | 146 | 18.5 |
Merchant | 70 | 8.8 |
Daily laborer | 80 | 10.1 |
Student | 45 | 5.7 |
Jobless | 75 | 9.5 |
Others | 144 | 18.2 |
At the time of the study, 210 (26.5%) of patients were on insulin injection, 499 (63.1%) on oral hypoglycemic medicines, and 82 (10.4%) on both. A sizeable number of the patients (333 (42.1%)) were diagnosed as diabetic before 5 to 10 years. More than half (58%) of them had other comorbid conditions, of which 313 (39.5%) of patients had hypertension (Table
Clinical conditions of patients with diabetes mellitus in selected public hospitals of Addis Ababa, Ethiopia, 2016 (
Variable | Frequency | Percent |
---|---|---|
Current treatment | ||
Insulin | 210 | 26.5 |
Oral hypoglycemic | 499 | 63.1 |
Both | 82 | 10.4 |
Comorbidity type | ||
Hypertension | 313 | 39.6 |
Asthma | 49 | 6.2 |
Kidney disease | 65 | 8.2 |
Heart problem | 53 | 6.7 |
Eye disease | 47 | 5.9 |
Others | 126 | 15.9 |
None | 332 | 42.0 |
Years of pre-existing diabetes diseases | ||
<5 | 174 | 22.0 |
5–10 | 333 | 42.1 |
>10 | 284 | 35.9 |
More than half (409 (51.7%)) of the respondents revealed their use of TM at least once in their life time, and 357 (45.1%) used TM in the last six months. Of these, the majority (218 (61.1%)) of them was used to treat only diabetes mellitus. From the total TM users within the last six months, 288 (80.7%) used HMs.
Patients with diabetes mentioned various reasons for using TM. The most common one was patient’s belief that TM is more potent than conventional antidiabetic medicines which was mentioned by 240 (58.7%) of the respondents. A sizable number of respondents (96 (23.5%)) also believed conventional medicine is expensive and reported to use TM (Table
Traditional medicine use practices of patients with diabetes in selected public hospitals of Addis Ababa, Ethiopia, 2016 (
Variable | Frequency | Percent |
---|---|---|
Ever use of TM | ||
Yes | 409 | 51.7 |
No | 382 | 48.3 |
TM use in the last six months | ||
Yes | 357 | 87.3 |
No | 52 | 12.7 |
Disease to be treated using TM | ||
Diabetes mellitus | 218 | 61.1 |
Diseases other than DM | 25 | 7.0 |
Both | 114 | 31.9 |
Time for TM use | ||
Before starting antidiabetic drugs | 101 | 30.4 |
After starting antidiabetic drugs | 231 | 69.6 |
Type of TM | ||
Herb/herb product | 288 | 80.7 |
Holy water | 69 | 19.3 |
Perceived reasons to use TM | ||
TM is more potent and curable | 240 | 58.7 |
High cost of the conventional drugs | 96 | 23.5 |
Toxicity/side effect of the conventional drugs | 33 | 8.1 |
Inaccessibility to the modern health facilities | 29 | 7.1 |
Others | 11 | 2.7 |
The majority (260 (90.3%)) of patients remembers the name of the herbal medicine they used, and 211 (73.3) of them reported using the leaf of the herb. Market 217 (75.3%), garden 49 (17%), and traditional healers 31 (10.8%) were the major sources for obtaining herbal medicine. From the total herbal medicines, 111 (38.5%) respondents used herbal medicine once, and 40 (13.9%) respondents used for more than 30 days (Table
Source, duration, and part of the herb used by respondents in selected public hospitals of Addis Ababa, Ethiopia, 2016 (
Variable | Frequency | Percent |
---|---|---|
Remember the name | ||
Yes | 260 | 90.3 |
No | 28 | 9.7 |
Part of the herb used | ||
Leaf | 211 | 73.3 |
Seed | 37 | 12.8 |
Oil | 19 | 6.3 |
Root | 5 | 1.7 |
Stem | 4 | 1.4 |
Others | 65 | 22.6 |
Source of the herb | ||
Traditional healer | 31 | 10.8 |
Market | 217 | 75.3 |
Garden | 49 | 17 |
Others | 24 | 8.3 |
Duration of use | ||
Used once | 111 | 38.5 |
2–7 days | 57 | 19.8 |
8–30 days | 80 | 27.8 |
More than 30 days | 40 | 13.9 |
Commonly used herbal medicines by patients with diabetes in selected public hospitals of Addis Ababa, Ethiopia, 2016 (
Local name | Common name | Scientific name | Part used | Frequency | Percent | Formulation |
---|---|---|---|---|---|---|
Shiferaw | Moringa | Leaf | 144 | 50 | Dried leaves of Moringa are crushed and taken as tea on daily basis. | |
Tosign | Thyme | Leaf | 50 | 17.4 | Tea of dried, crushed leaves is taken daily. | |
Abish | Fenugreek | Seed | 21 | 7.3 | Dried seeds are powdered. The powder is mixed with water and taken in the morning with an empty stomach. | |
Tikurazimud | Black seed | Oil | 19 | 6.6 | Oil obtained from squeezed seeds of the dried black seed is taken after food at any time. | |
Nech Shinkurit | Garlic | Knob/clove | 16 | 5.6 | Fresh knob or clove of garlic cooked with food. | |
Teliba | Linseed | Seed | 9 | 3.1 | Dried seeds of Linseed are powdered. The powder of linseed seed is mixed with water and taken with food. | |
Zingible | Ginger | Rhizome | 9 | 3.1 | The dried and crushed rhizomes of ginger are cooked with food. | |
Damakese | Damakese | Leaf | 9 | 3.1 | Fumigation of the fresh leaf. | |
Senafich | Mustard | Seed | 7 | 2.4 | Dried seeds are powdered. The powder is then mixed with water and taken with food. | |
Tena'dam | Rue | Leaf | 5 | 1.7 | Fresh leaves are soaked in tea for some time and drunk. | |
Arenguade Shay kitel | Green tea | Leaf | 3 | 1 | The dried leaves of green tea are soaked in hot water for some time and drunk as tea. | |
Others | 28 | 9.7 |
Of 288 herbal medicine users, 263 (91.3%) respondents tried to get more information about the HM related to its effectiveness and toxicity they used (Table
Source of information for decision on herbal medicine use of diabetic patients interviewed in selected public hospitals of Addis Ababa, Ethiopia, 2016 (
Variable | Frequency | Percent |
---|---|---|
Sought for more information | ||
Yes | 263 | 91.3 |
No | 25 | 8.7 |
Recommendation obtained from | ||
Community | 164 | 62.4 |
Prescriber | 24 | 9.1 |
Herbalist | 28 | 10.6 |
Pharmacist | 3 | 1.1 |
Others | 44 | 16.7 |
Patients who informed the doctor | ||
Yes | 103 | 35.8 |
No | 185 | 64.2 |
Reason not to inform the healthcare provider | ||
Afraid of the doctor | 74 | 25.8 |
There is no problem | 72 | 25.0 |
The prescriber did not ask | 14 | 4.9 |
Considered as food | 25 | 8.7 |
Has information about drug-herb interaction | ||
Yes | 44 | 15.3 |
No | 244 | 84.7 |
Prescribers’ advice | ||
Discontinue | 28 | 27.2 |
Continue | 74 | 71.8 |
Neither continue nor discontinue | 1 | 1.0 |
From 288 respondents, 40 (13.9%) of them had encountered side effects from HM use. Among these, constipation, vomiting, and headache were the most frequently reported side effects as mentioned by 14 (24.6%), 8 (20%), and 8 (20%) of the participants. Of those who had side effects, 24 (60%) discontinued herbal medicine use by themselves, and 10 (25%) consulted health professionals to avert the side effects (Table
Herbal medicines’ effectiveness perception and the method of side effect aversion of respondents in selected public hospitals of Addis Ababa, Ethiopia, 2016 (
Variable | Frequency | Percent |
---|---|---|
Effectiveness perception | ||
Yes | 199 | 69.1 |
No | 89 | 30.9 |
Side-effect experience | ||
Yes | 40 | 13.9 |
No | 248 | 86.1 |
Type of side effects | ||
GI problem | 5 | 12.5 |
Vomiting | 8 | 20.0 |
Headache | 8 | 20.0 |
Diarrhea | 5 | 12.5 |
Tiredness | 5 | 12.5 |
Constipation | 14 | 35.0 |
Abdominal pain | 5 | 12.5 |
Others | 8 | 20.0 |
Actions to avert side effect | ||
Consulted the health professional | 10 | 25.0 |
Discontinued using herbal medicine | 24 | 60.0 |
Consulted the herbalist | 3 | 7.5 |
No action | 3 | 7.5 |
A total of 8 physicians (4 general practitioners and 4 consultants) were interviewed. Five of them were males, and their mean age was 44.2 (ranged from 29 to 54 years). Participants’ work experience in diabetic clinics was from 2 to 12 years.
Three major themes were defined in qualitative data analysis: prescriber’s perceived knowledge about herb-drug interactions, herbal medicine history taking practice, and commonly used herbal medicines.
The majority ( “If I ask the patient whether he/she has been using herbal medicine and found that he/she was using any herb, I wouldn’t take any decision towards using herb because I don’t have any knowledge about a specific herb and the conventional anti-diabetic drug interactions.”
All ( “Usually, I don’t check patients’ history of herbal medicine use practice. I haven’t learnt it at school and I don’t have experience on how to handle it. But even if I want to do it, there are a lot of patients waiting for service so that I don’t have time to ask my clients about their herbal medicine use practice but occasionally when I suspect signs of liver toxicity, I would ask whether they took herbal medicine or not. But, I would not record it on the patients’ chart.”
Most of the key informants (
One general practitioner also explained that there were patients who told him as they were using herbal medicines for the treatment of diabetes mellitus. He expressed his experience as follows: “There were plants used by patients with diabetes that I didn’t remember the name and type of the herbs since I did nothing with that. I only advised them to discontinue using herbal medicine.”
This study has been carried out with the purpose of determining the prevalence of herbal medicine use and identifying the commonly used herbs by patients with DM. The study estimated that, from total patients with DM, 288 (36.4%) took herbal medicine which was higher than a study in black South African communities, where 28 (21%) used HM to treat hypertension [
In this survey, 231 (69.6%) of the respondents used HMs along with prescribed therapy for the last six months which was higher than in South Sudan (58%) [
Even though the quantitative study indicated high proportion of patients with diabetes used HMs concomitantly with conventional antidiabetic medicines, finding on exploration of HM history taking practice of prescribers during physical examination of patients with diabetes showed low. The contradictory results from the quantitative and qualitative data could be due to prescriber’s low knowledge on herb-drug interaction and work load.
A majority of patients with DM (240 (58.7%)) in this study used HM since they believed that TM was more potent and affordable than conventional antidiabetic medicine which was the major reason to use HM. Similarly, studies in North Sudan [
This study also revealed that 69.1% of the HM users perceived herbal medicines they used were effective. Qualitative data also indicated patients with diabetes were benefited from
This study also revealed that 40 (13.9%) of HM users reported they experienced side effects. This might be due to an additive and/or synergetic effect of the concomitant use of these herbs with conventional antidiabetic medicines. Like hypoglycemic effect, experimental studies on
This study revealed that the very common method of remedy preparation was in dried and crushed form which was taken by mixing with water. However, another study in Ethiopia indicated more than half of the HMs were used in fresh form [
This study found that market and community were the major sources and sources of information for the HMs, respectively. The societies’ belief on antidiabetic effect of HMs might affect adherence to the conventional medicine. This survey also indicated that a small proportion of respondents obtained information about the HMs from healthcare providers. This result was supported from Ubon Ratchathani province, Thailand [
According to the findings of this study, herbal medicines are used concomitantly with conventional antidiabetic medicines for the treatment and management of DM by patients attending treatment in four selected hospitals of Addis Ababa. More than eighty percent of patients with diabetes used HMs, and 231 (69.6%) of them used HMs concomitantly with conventional antidiabetic medicines. Combined use of HMs and conventional antidiabetic medicines could potentially lead to serious toxic effects due to herb-drug interactions.
The data used to support the findings of this study are included within the article.
The authors declare that they have no conflicts of interest.
SG contributed to the conceptualization of the study, supervised the data collection and analysis processes, and wrote the first draft of the manuscript. MY contributed to the write-up of the manuscript. GB and ZT cosupervised the analysis processes and played a key role in the write-up and submission of the manuscript. TG led the statistical analysis carried out in this study and contributed to the write-up.
This study was supported by Addis Ababa Regional Health Bureau and Addis Ababa University.