|Year : 2017 | Volume
| Issue : 2 | Page : 51-63
Awareness, perception, attitude, and knowledge regarding complementary and alternative medicines (cams) among the pharmacy and medical students of a public university in Saudi Arabia
Rizwan Ahmad1, Atta A Naqvi2, Niyaz Ahmad3, Mohamed Baraka4, Mohammad Mastour5, Saleh Al Sharedah5, Shatha Al Ghamdi5, Ghada Al Rabae5, Mastour S Al Ghamdi6
1 Natural Products and Alternative Medicines, College of Clinical Pharmacy, Saudi Arabia
2 Department of Pharmacy Practice, College of Clinical Pharmacy, Saudi Arabia
3 Department of Pharmaceutics, College of Clinical Pharmacy, Saudi Arabia
4 Department of Pharmacy Practice, College of Clinical Pharmacy, Saudi Arabia; Department of Clinical Pharmacy, Al Azhar University Cairo, Egypt
5 College of Medicine, Saudi Arabia
6 Department of Pharmacology, College of Clinical Pharmacy, University of Dammam, Saudi Arabia
|Date of Web Publication||17-Apr-2017|
Natural Products and Alternative Medicines, College of Clinical Pharmacy, University of Dammam, Dammam, Saudi Arabia
Source of Support: None, Conflict of Interest: None
Introduction: The use of natural products, that is, herbs for clinical and domestic purposes, is quite common in Saudi Arabia. Studies have reported an increasing use of complementary and alternative medicines (CAMs). This study aims to investigate the perception, attitude, and knowledge of the students regarding CAMs and their use. Materials and Methods: A quantitative, cross-sectional study targeting the students of the pharmacy and medical colleges at the University of Dammam, Saudi Arabia was conducted for a 6-month duration. It employed a survey questionnaire termed as CAMs inventory. Results: The majority of the respondents were females (N = 180, 60.8%), and a major segment (N = 170, 57.4%) belonged to the age group between 21 and 23 years. Nearly half of the students (N = 121, 40.9%) strongly agreed on the need for integration of CAMs-related courses in medical and allied health education, and a similar proportion (N = 129, 43.6%) of the target population acknowledged using CAMs, based on family recommendations (N = 134, 45.3%). Half of the students (N = 142, 48%) had no knowledge about CAMs. Some of the CAMs were more prevalent in males and vice versa (P value <0.05). Conclusion: A positive perception and attitude toward CAMs was observed. It is influenced by their traditional use and partly by the recent induction of CAMs-related education in pharmacy. The majority of the students agreed on integrating CAMs-related courses in their curriculum. It was also observed that the knowledge regarding the subject was inadequate. Lastly, gender has the potential to influence the use of particular CAMs.
Keywords: Attitude, awareness, CAMs, complementary and alternative medicines, knowledge, medical students, perception, pharmacy students, Saudi Arabia
|How to cite this article:|
Ahmad R, Naqvi AA, Ahmad N, Baraka M, Mastour M, Al Sharedah S, Al Ghamdi S, Al Rabae G, Al Ghamdi MS. Awareness, perception, attitude, and knowledge regarding complementary and alternative medicines (cams) among the pharmacy and medical students of a public university in Saudi Arabia. Arch Pharma Pract 2017;8:51-63
|How to cite this URL:|
Ahmad R, Naqvi AA, Ahmad N, Baraka M, Mastour M, Al Sharedah S, Al Ghamdi S, Al Rabae G, Al Ghamdi MS. Awareness, perception, attitude, and knowledge regarding complementary and alternative medicines (cams) among the pharmacy and medical students of a public university in Saudi Arabia. Arch Pharma Pract [serial online] 2017 [cited 2019 Mar 19];8:51-63. Available from: http://www.archivepp.com/text.asp?2017/8/2/51/204639
| Introduction|| |
Complementary and alternative medicines (CAMs) may be defined as any alternative treatment other than conventional system of treatment. This includes the use of herbal and natural products, traditional medicines, and treatment strategies such as the use of plants and herbs, aromatherapy, acupuncture, and chiropractic. Studies report that in the recent years, there has been an increase in the use of the CAMs worldwide.  In USA, around 42% of the population use CAMs for their medical problems. This figure was even higher in the European countries and Australia, because 50% of the population use CAMs. 
In Saudi Arabia, CAMs use has been prevailing since a long time. The use of traditional Arabic and Islamic plants was very common in this region and has an association with the religious and cultural background.  This has drawn its roots from Tibbi Nabawi or Prophetic medicine, which is basically the teachings of Prophet Muhammad (P.B.U.H.) regarding natural products and their use. Hence, this practice (sunnah) is predominantly followed in the region. 
In the context of Saudi Arabia, this use of CAMs present an increasing demand and need to include courses related to the knowledge of CAMs in the curriculum of health-related programs that may differ among countries.  The present study derives its rationality from the fact that CAMs are now widely used in the Arab world, but there is very limited information on the topic. 
In Saudi Arabia, there is a tendency to use the Arabic and Islamic plants and herbs as home-based remedies for different ailments or simply as prophylactic treatment. Therefore, we would like to know whether the modern education in medical and health sciences in Saudi Arabia has fortified this concept of using CAMs among the students of medical and health sciences or not. The study is aimed at investigating the level of knowledge, personal experience, and perceptions toward CAMs among the medical and health sciences students (future doctors) at the University of Dammam.
| Materials and Methods|| |
A cross-sectional study was conducted among the students of the pharmacy and medical colleges at the University of Dammam, Saudi Arabia for 6 months with especially formulated survey questionnaire known as CAMs inventory.
Purpose and rationality
The study derives its rationality from the fact that CAMs are now actively used in the modern world. In addition, in the region of Saudi Arabia, there is a tendency to use the Arabic and Islamic plants and herbs as home-based remedies for different ailments. There is a need for knowing whether the modern education in medical and health sciences has fortified this concept of using CAMs among the minds of the students or not.
Study duration and venue
The duration of the study was 6 months. The study took place in the pharmacy and medical colleges affiliated with the University of Dammam, Saudi Arabia.
The target population of the study was the students of the pharmacy and medical colleges affiliated with the University of Dammam, Saudi Arabia who were studying in the 2 nd to the 6 th year of professional education.
The study included the students currently enrolled in the pharmacy and medical colleges affiliated with the University of Dammam, Saudi Arabia. The students from other faculties as well as the students who were dropped from the program were excluded. All incomplete and incorrectly filled responses along with nonconsenting participants were excluded from the study.
The study employed convenient sampling to gather as much responses as possible, and the data of the students were collected in their free (off peak) time.
Estimated sample size
An estimated sample size was calculated by keeping the response rate to 50%, alpha error (α) at 5%, and confidence level at 95%, and the size was found to be 369.
The research instrument consisted of survey questionnaire with 38 multiple choice type questions. The questionnaire was divided into four sections; the first part dealt with the demographic information of the respondents, the second section was concerned with the personal experiences of the respondents with CAMs, the third section dealt with the attitudes and perception of the students toward CAMs, and the fourth section tested the student knowledge about CAMs. The question related to the attitudes and perceptions employed Likert Scale format options for answer.
The questionnaire was validated by four academic professionals who were pharmacists with expertise in herbs (CAMs) and specialization in Pharmacy Practice. The first phase of the validation consisted of fortification of the questions with Arabic names of the CAMs to promote better understanding of the questions for the respondents. The second phase involved addition of more questions regarding the knowledge about CAMs used at homes. Finally, the questionnaire was subjected to thorough editing and was checked for spelling and grammatical errors.
Sampling adequacy and reliability
The sampling adequacy of CAMs inventory was measured by Kaiser-Meyer-Olkin measure of sampling adequacy, which reported the value of 0.397 and Bartlett's test of sphericity, which reported significant P value of <0.0001. The reliability analysis reported a Cronbach's alpha value of 0.82, that is, good reliability for N = 63 items.
Piloting of the questionnaire
The questionnaire was piloted on four pharmacy students, and it was validated. It took 21 min to fill in the responses correctly. The students did not find it difficult to comprehend. After piloting, it was found to be validated and was approved for data collection.
Data coding and analysis
The data obtained from the students were coded into categorical variables. The demographic data were expressed as numbers (N) and percentages (%). The data about the knowledge and personal experiences were expressed as numbers and percentages. The data relating to the attitudes and perceptions regarding CAMs were expressed as mean (X) and standard deviation. Regarding inferential statistics, the data were subjected to Chi-square test for independence and test for association. Cross-tabulation was also employed to check for associations between demographics of the respondents and their knowledge, attitudes, and perceptions regarding CAMs. Correlation using Spearman's rho (R) was applied to find the correlation between the variables. Statistical Package for the Social Sciences version 22 software (SPSS Inc., IBM Corporation, 1 New Orchard Road Armonk, New York 10504-1722, United States. 914-499-1900) was employed to analyze the data. Statistical significance was set at P values <0.05.
The respondents were handed a written informed consent form, and upon consenting, they were given CAMs inventory. The participation of the respondents was anonymous and voluntary. No incentive was given to the respondents upon filling the questionnaire.
The study was submitted for ethical approval and was granted exemption from review.
| Results|| |
The majority of the respondents were females (N = 180, 60.8%), and a significant segment (N = 170, 57.4%) belonged to the age group between 21 and 23 years. The survey incorporated the students from the College of Clinical Pharmacy (N = 170, 57.4%) and the College of Medicine (N = 126, 42.6%). The breakdown of data based on years of study revealed an equal proportion of the students involved in the study, with the students of the 2 nd professional year making up a quarter of the target segment (N = 75, 25.3%) and the students of the 4 th year forming a 10 th proportion (N = 32, 10.8%). Nearly a third proportion (N = 95, 32.1%) reported family, friends, and ancestral background as their source of information regarding CAMs. The data are represented in [Table 1].
Use of CAMs
The data regarding the use of natural products as CAMs revealed that the majority of the students highlighted the use of cascara (N = 199, 67.2%) personally and in the family (N = 221, 74.7%) as well. Similar results were obtained for cardamom, ginger, anise, garlic, and nigella; however, the use of aloe, clove, fennel, fenugreek, castor oil, and chamomile was prevalent in the family of the students, whereas declined by the students in their personal use. The use of mustard was neither prevalent in the family (N = 97, 32.8%) nor among the students (N = 68, 23%). A detailed summary is tabulated in [Table 2].
|Table 2: Summary of use of CAMs by respondents and their family/relatives|
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Perceptions toward CAMs use
The students were also evaluated regarding their perception toward CAMs use. Nearly half of the students (N = 121, 40.9%) strongly agreed on the need for integration of CAMs-related courses in the medical and allied health education. A similar number of students (N = 120, 40.5%) strongly agreed to the idea of consulting healthcare professionals, that is, practitioners and pharmacists prior to using CAMs, and the students believed that pharmacists should counsel patients on its usage (N = 115, 38.9%). Besides, a major segment believed the lack of evidence-based studies as a barrier toward proper CAMs usage (N = 114, 38.5%) as well as a majority (N = 130, 43.9%) remained neutral in responding to legalities being a barrier to CAMs usage. However, a third proportion (N = 102, 34.5%) were not confident of CAMs being appropriate for use in disease state management, and they remained neutral to the notion of CAMs use being a health risk for the public (N = 108, 36.5%) followed by similar numbers (N = 100, 33.8%) regarding the perception that CAMs have fewer side effects. The summary of the perceptions is presented in [Table 5].
Attitude toward CAMs and their use
The students' attitudes toward CAMs use were also investigated. In response to the question of personal use of CAMs for one's own health, nearly half (N = 129, 43.6%) of the target segment acknowledged using CAMs, whereas the majority of the students (N = 134, 45.3%) agreed that their usage of CAMs was based on family recommendation. However, similar figures (N = 110, 37.2%) for being neutral were obtained when asked about its use based on the health practitioners' recommendation. When they were asked if they used CAMs therapy as they were more effective when compared to conventional medicines, a fourth proportion (N = 118, 39.9%) remained neutral. The details of the respondents' attitude toward CAMs use are presented in [Table 6]. The correlation of demographics and attitudes are given in [Table 7].
Knowledge regarding CAMs and its use
The knowledge of the respondents regarding CAMs use was assessed by 10 points scoring item. The students were asked five questions graded with points, that is, 2 points and 0 points for correct and wrong answers, respectively. On the basis of the aforementioned grading system, the results observed were: the students with excellent knowledge (N = 0, 0%), no knowledge (N = 142, 48%), and low knowledge (N = 129, 43.6%). The results are tabulated in [Table 8].
Associations of gender with different types of CAMs use
The use of CAMs for personal and family use was cross-tabulated with gender, which revealed significant findings. The use of aloe and clove was more prevalent in the family, particularly in the male respondents (N = 50 aloe, N = 68 clove for observed) as compared to the expected count (i.e., N = 47 aloe, N = 63.1 clove); however, it was not significant in both instances (i.e., P values >0.05). Furthermore, the use of cardamom and fennel was prevalent in the family with male observed count (N = 76 cardamom, N = 44 fennel) more than expected (i.e., N = 70.1 cardamom, N = 41.5 fennel) but was not observed to be statistically significant with P values >0.05; however, the personal use of cardamom by the students was significant (P value <0.01). The use of cardamom by the male gender was higher than the expected count (N = 78 observed, N = 62.7 expected). The use of cascara was prevalent and significant for family (<0.01) and personal use (<0.05). The tendency toward the use of cascara by females was found more than expected count in both instances (i.e., N = 128 observed, N = 121 expected) and use in the family (i.e., N = 148 observed, N = 134 expected). The use of ginger was prevalent in both personal and family; however, a statistical significance was observed in personal use (<0.01) in males with observed count more than expected (i.e., N = 100 observed, N = 89.4 expected) for personal use. Family use of anise was significant (i.e., P values < 0.05) and females observed in more numbers, (N = 154 observed, N = 142.3 expected). The personal use of garlic and fenugreek was also statistically significant, that is, P values < 0.01 and males were observed using it to in more numbers than expected (i.e., N = 79 observed, N = 66.6 expected) for garlic and (N = 53 observed, N = 41.5 expected) for fenugreek. The use of chamomile was significant in the family, that is, P values <0.05 and females using it were observed (N = 90) more than expected (N = 77.8). The use of nigella was significant in case of personal use (<0.05), and males were observed to use it more than the expected count (N = 83 observed, N = 74.9 expected). The summary of cross-tabulated data is presented in [Table 9].
In addition to this, the affiliation of the students was also tabulated with their personal use of CAMs. The use of aloe, anise, mustard, and chamomile was not statistically significant (>0.05), because they were observed to be used by the students of both colleges. However, the use of clove appeared significant (<0.05), with the students of the College of Clinical Pharmacy using it more than expected (i.e., N = 93 observed, N = 77 expected). In the same way, the use of cascara was more prevalent among the students of the pharmacy colleges, because 138 students appeared using it out of 114.3 expected, with statistical significance of <0.01. Similarly, significant results (<0.01) were obtained for cardamom, fennel, ginger, fenugreek, castor oil, garlic, and nigella, because the students of the College of Clinical Pharmacy were observed to be using it in more numbers than expected. The results of cross-tabulation between the student affiliation and the use of CAMs are presented in [Table 10].
|Table 10: Use of CAMs by students of college of medicine and clinical pharmacy|
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Furthermore, the year of study of the students was also cross-tabulated with their use of CAMs. The results revealed no significant P values (>0.05) for aloe, anise, mustard, and chamomile. However, the use of clove and fennel appeared significant (<0.01), with the students of the 3 rd and 4 th professional year using it more than expected. The use of cascara, cardamom, and ginger was also significant (<0.01), and the students of the 2 nd , 3 rd , and 4 th professional year reported using it in more numbers than expected. Similar results were observed for the use of mustard, garlic, nigella, and castor oil, but with P value <0.05. The students of the 2 nd and 3 rd professional year of study appeared using fenugreek more than expected, with statistical significance of P value <0.05. The details of cross-tabulation are presented in [Table 11]. The significant observed-to-expected counts are highlighted as black color.
|Table 11: Use of CAMs by breakdown of professional year in college of clinical pharmacy|
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| Discussion|| |
The use of CAMs has been increasing recently; however, the knowledge and perception regarding CAMs use among the students of the medical and pharmacy colleges from the University of Dammam, Saudi Arabia have not been documented lately. This study was conducted to assess the awareness, perception, and knowledge level of the students regarding CAMs. The respondents were females for most part followed by a fourth proportion of male students, and the majority of the students belonged to the age group between 21 and 23 years. It is quite pertinent to mention here that the gender distribution and age group are characteristic hallmarks of the academia in this region. It represents true enrollment of the students (gender-wise) in this country. The studies conducted in the medical and pharmacy colleges in this region and South Asia revealed similar findings. ,,, The study was conducted among the students of the College of Medicine and the College of Clinical Pharmacy and incorporated almost a similar number of the pharmacy and medical students. Authors tried to incorporate all students in equal numbers by breakdown of year of study; however, because of less enrollment, the students of the 4 th professional year were less in numbers. The students of the 2 nd professional year accounted for a quarter proportion followed by similar numbers for the 3 rd , 5 th , and 6 th professional year.
Regarding their source of information, a third proportion of the respondents banked upon their family and friends concerning the use of CAMs followed by formal education and courses. Significant reason for this dependence on family regarding knowledge of CAMs is due to the fact that Arabic and Islamic plants are being used as folkloric in this region.  Moreover, it does not solely depend upon the education, because this legacy is transferred through generations. The recent induction of CAMs-related courses being taught in the higher study institutes, particularly in pharmacy curriculum of Saudi Arabia, also contributes as a valuable factor. 
Furthermore, regarding the use of natural products as CAMs, a huge proportion of the students reported using cascara personally and by their family members. According to the literature, there are scant research studies that can highlight the purpose of its use among the Saudi population, and this needs to be further investigated. However, the use of aloe, clove, fennel, fenugreek, castor oil, and chamomile was prevalent in the family of the students, but the students declined them in their personal use. Cross-tabulation revealed that aloe, clove, cardamom, fennel, garlic, fenugreek, and nigella use was prevalent among the males. On the other hand, the use of cascara, anise, and chamomile was prevalent among the females. Furthermore, a significant positive correlation was reported among personal use of CAMs with higher coefficient (R) values for cardamom. Additionally, the family use of CAMs appeared highly correlated with personal uses. This notion of use in the family can be attributed to the fact that most of these natural products are used traditionally as food condiment, flavoring agents, and beverages in addition to its conventional uses. With regard to their affiliation, the pharmacy students were observed using CAMs more than the medical students. The declined use by the students might have been caused by either dissatisfaction or lack of CAMs specialized educational practices, which have the potential to dissuade them from using it.  Considering the professional year of study of the students (i.e., year-dependent), increased use of CAMs was observed from the 2 nd year to the 4 th year. A strong justification for this concept is the fact that CAMs-related courses are taught during the 2 nd to 3 rd year in pharmacy curriculum. Hence, the education could have influenced their use.
Regarding perceptions about the use of CAMs, almost half of the students strongly agreed upon the integration of CAMs-related courses in medical and allied health education. This perception may have been driven from the affiliation of the students, that is, the colleges of pharmacy had courses of CAMs integrated in their pharmacy curriculum; hence, the pharmacy students were aware of the importance of CAMs in practice, and this has been reflected as high CAMs use. On the contrary, the students of the colleges of medicine do not have such provision; however, the association of affiliation with perception was not significant (>0.05), and the students of the colleges of medicine had a positive perception, with observed count being the same as expected count, that is, N = 97 (observed), N = 98 (expected). This positive perception about adding CAMs-related courses in the medical curriculum was also reported by a study conducted in a different university of Saudi Arabia.  In addition to this, studies conducted in other regions reported that the students appeared confused about the additional contents and information that might add to their already heavy course load in the curriculum and, hence, tend to have a negative perception about addition of courses.  A third proportion perceived lack of scientific evidences as a barrier toward the use of CAMs. This finding has been reported by a number of previous studies in the region as well as the country. , A third proportion was not confident of CAMs being appropriate to use in the disease state management. This perception can be a result of the low knowledge of the respondents. Natural products have a history of being used as an adjunct therapy for disease state management. Additionally, recent literature reports the use of CAMs in highly sophisticated and complicated diseases such as cancers.  Furthermore, a third segment remained neutral to the notion of CAMs use being a health risk for the public, followed by similar numbers regarding the perception that CAMs have fewer side effects. One of the major issues of CAMs is the lack of toxicological and safety studies available as well as anecdotal studies documenting interactions with conventional medicines, which impart low confidence to the user. Moreover, some of the natural products have been banned in some countries due to their toxic/adverse effects. ,
Nearly half of the students remained neutral, and a third segment agreed with the perception of legalities being a barrier to the use of CAMs. In this context, it is pertinent to mention that the use of natural products differs geographically, culturally, and traditionally.  In addition, the active ingredient and potency of the plants vary, which needs proper sophisticated quality control methods and approval of the regulatory agencies. , A fourth proportion of the target segment agreed with the perception of a pharmacist being a patient counselor on CAMs use. Studies emphasize the importance of a pharmacist in such situations, because a pharmacist is in the best position to educate patients on the safe use of such products. 
The students were also asked questions related to their attitudes toward CAMs use. Almost half of the target segment acknowledged using CAMs, and a similar fraction agreed that their usage of CAMs is based on family recommendation. The variable of colleges had a significant negative correlation with the attitudes such as the use of CAMs for one's health (−0.256), being effective (−0.225), and the use of CAMs based on family recommendation (−0.147). This highlights that the domain of the study also influences the attitudes. A significant positive correlation was reported between using CAMs for health and; CAMs being effective (0.361), CAMs use based on family recommendation (0.350). This notion of using CAMs based on family recommendation can be attributed to the fact that natural products have traditional use in the Arab world; hence, this legacy is transferred through generations.
The questionnaire also tested the knowledge of the respondents regarding CAMs on 10 point scoring items. Almost half of the students had no knowledge about CAMs followed by slightly greater than a fourth segment having low knowledge. Very few respondents had adequate knowledge. No student had excellent knowledge. In congruence to the studies conducted in different parts of the country and the region, the knowledge is not adequate, and there is a growing need to incorporate CAMs in the education curriculum; hence, our findings confirm the phenomenon.
The study revealed that the use of natural products is influenced by gender, because some of the CAMs were more prevalent in males and vice versa; however, further investigation is needed to find out their intended purpose.
| Conclusion|| |
The use of CAMs has increased among the Saudi students. It is partly influenced by their traditional use and somewhat by the recent induction of CAMs-related education in pharmacy. There is a positive perception and attitude toward CAMs use, and the students of the medical background also call for including CAMs-related courses in their curriculum. However, the knowledge regarding the subject is inadequate. Lastly, gender has the potential to influence the use of particular CAMs. Further study to document the intended purpose of the use of different CAMs among males and females is recommended to develop in-depth understanding of its correlation with gender.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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