Complementary and alternative medicine use by Bangladeshi adult patients with diabetes and hypertension: A multicenter study

Introduction

Non-communicable diseases (NCDs), namely hypertension and diabetes, have emerged as a global pandemic in the form of higher morbidity and mortality rate in the last few years (Terzic & Waldman, 2011; Mendis et al., 2014). The World Health Organization (WHO) predicts NCDs will rise globally in the next decade. About 74% of all deaths worldwide are attributed to NCDs, which kill 41 million people annually.

The prevalence of NCDs is significantly higher in developing nations (Terzic & Waldman, 2011). Notably, the number of fatalities from NCDs has already surpassed the total number of deaths from communicable, maternal, perinatal, and nutritional diseases on every continent except Africa (Wang & Wang, 2020). Hypertension is the reason for half of coronary heart disease and around two-thirds of the burden of cerebrovascular disease globally (Benjamin et al., 2019; Stanaway et al., 2018) and also enhances the risk of stroke, kidney failure, disability, and premature death (Rapsomaniki et al., 2014; Wei et al., 2017).

In Bangladesh, hypertension is the major preventable cause of a wide range of health issues and the resulting financial strain (Chowdhury et al., 2022; Hossain et al., 2022a). Approximately 68% of fatalities in Bangladesh are attributable to NCDs, and hypertension is responsible for 15–20% (El-Saharty et al., 2013). There is a wide range of variation in the prevalence of hypertension reported by several studies ranging from 11 to 44% in Bangladesh (Hossain et al., 2022b; Khanam et al., 2015). It’s estimated that the number of people living with diabetes worldwide is expected to climb to 783 million by 2045 (Saeedi et al., 2019). According to the International Diabetes Federation’s (IDF) latest report, 90 million people are living with diabetes in South East Asia. The report highlighted that diabetes is expected to reach 113 million adults by 2030 and 151 million by 2045 in South East Asian countries. The latest IDF report also showed that over 3 in 4 adults with diabetes live in low- and middle-income countries like Bangladesh. The IDF also reported that 13.1 million cases of diabetes were diagnosed in 2021 and will increase to 22.3 million cases by 2045 in Bangladesh. Because there are only a handful of studies related to the prevalence of hypertension and diabetes in Bangladesh, the findings are not consistent yet. Although, there is a dearth of research that properly combines systematic reviews and meta-analyses to compile the current collection of knowledge on the incidence of hypertension.

In the current health system, Bangladesh lacks a population-based surveillance system to monitor the prevalence and inadequate treatment and control mechanisms for hypertension and diabetes (Chowdhury et al., 2018). Despite the progress of modern medicine, complementary and alternative medicine (CAM) such as homeopathic medicine, Ayurveda, Unani, acupuncture, acupressure, yoga and other CAM therapies have traditionally been accepted as necessary treatments and found to be more prevalent among Asians (Calcagni et al., 2019; Peltzer & Pengpid, 2015), including Bangladeshi (Shahjalal et al., 2022a). A study suggested that CAM may help to promote an integrative, participatory model of diabetes care (DiNardo et al., 2012). Several studies showed that 2 to 36 million diabetic patients used CAM in the USA (Dham et al., 2006; Egede et al., 2002; Eisenberg et al., 1998). A large number of studies showed that 39.3% of diabetic patients used CAM in the UAE (Radwan et al., 2020), 36.7% of diabetic patients used CAM in Turkey (Yıldırım & Marakoğlu, 2018), 46.3% in Australia (Manya et al., 2012), 53.5% in Pakistan (Jawed et al., 2019), and 67.7% in India (Kumar et al., 2006). A systemic review reported that the prevalence of CAM use for diabetes ranged from 17 to 72.8% (Chang et al., 2007).

In the USA, CAM used for hypertension was higher among those without diagnosed hypertension than those with diagnosed hypertension, and only 7.8% of CAM users reported using CAM to treat hypertension (Bell et al., 2006). About 29% of hypertensive patients use CAM in Nigeria (Osamor & Owumi, 2010), 63.5% in Germany (Jeschke et al., 2009), and 63.9% in India (Shafiq et al., 2003).

Sustainable Development Goal (SDG) 3 has set target 3.4 of reducing premature mortality from NCDs through prevention and treatment, and target 3.8 of achieving universal health coverage through the access to quality essential health-care services and safe, effective, quality and affordable essential medicines and vaccines for all. In that case, CAM can play a significant role in achieving these two targets because in recent studies of Bangladesh, 33% of patients utilized CAM exclusively for treatment purposes (Shahjalal et al., 2022b) while 32.8% NCD patients used CAM for the treatment of chronic illness (Shahjalal et al., 2022a). The abovementioned findings of Bangladesh-based studies indicated that even though conventional medicine has come a long way, the number of people using CAM keeps growing across the country.

Despite the widespread acceptance of CAM alongside conventional treatment, there is still a lack of data on the prevalence, utilization, and associated factors of using CAM for chronic illness among NCD patients in Bangladesh, as the studies conducted in Bangladesh did not address the current situation of CAM usage for diabetes and hypertension exclusively. As one of the studies conducted in three tertiary care hospitals in Dhaka explored the CAM usage among the chronic illness patients only (Shahjalal et al., 2022a); another study was conducted on CAM usage for diabetes patients but only in a specific region. These studies did not explore the nationwide perspective of CAM usage for diabetes and hypertension only, although despite the widespread acceptance of CAM alongside modern treatment, there is still a lack of data on the prevalence, utilization, and associated factors of using CAM among diabetes and hypertension patients in Bangladesh. For that reason, this study aimed to assess the prevalence of using CAM for diabetes and hypertension, along with exploring the factors associated with both CAM usage.

Methods

Participants

The data collection was done by the research team. Patients who sought treatment at the study health facilities during the data collection window were eligible to participate. Every eligible patient was selected using a purposive sampling technique at the health care centre. Upon screening the inclusion criteria and obtaining informed consent from all eligible patients, a face-to-face interview was conducted in the outpatient department of the survey health facilities using a structured questionnaire. A pilot survey was conducted among 24 patients. It was intended to investigate the capacity to comprehend the relevant techniques and trouble-some situations while interviewing. Following piloting, we made the necessary corrections in the questionnaire. In order to avoid repatriation and potential skewing of the results, we used the patients’ IDs to ensure they did not repeat the questionnaire. The required minimum sample size was 288 at 90% power, 95% CI of 0.05 to 1.96, with 29 % of a patient used CAM for NCDs in Bangladesh (Shahjalal et al., 2022a), and the margin of error was 5%. Finally, we collected 400 samples (response rate was 94%), including 200 diabetes and 200 hypertensive patients from the outpatient departments between March and May 2021. The process of data collection, identification and inclusion flow diagram is presented in Figure 1. A detailed description of the study variables has been discussed in Supplementary File 1 (Hasan et al., 2023).

Figure 1. Flow diagram of survey procedures.

Results

CAM utilisation

In total, 29% (n=116) of patients utilised CAM for hypertension and diabetes, where 20.5% (n=41) of hypertension and 37.5% (n=75) of diabetes patients used CAM (Table 2). Among CAM users, we found three types of CAM that the patients use for the treatment purpose of diabetes and hypertension. Homeopathic medicine, ayurvedic medicine and Unani medicine were the most common CAM modalities (Figure 2). About 50.86% (n=68) used homeopathic medicine, while 31.80% (n=37) used Ayurvedic medicine and 15.51% (n=18) of patients used Unani medicine to treat diabetes and hypertension.

Table 2. Relationship between the sociodemographic and clinical characteristics with the CAM use.

Participants’ Characteristics	CAM user		Odds ratio	95 % CI		P-value
	Yes (n=116, 29.0%)	No (n=284, 71.0%)		Lower	Upper
Age, years
<35 years (Young adult)	20 (15.0)	113 (85.0)	1
35-59 years (Adult)	65 (31.1)	144 (68.9)	1.779	0.830	3.814	0.139
>59 years (Older aged)	31 (53.4)	27 (46.6)	7.527	3.224	17.574	<0.001
Gender
Male	46 (27.1)	124 (72.9)	0.848	0.546	1.316	0.462
Female	70 (30.4)	160 (69.6)	1
Religion
Muslim	105 (30.3)	242 (69.7)	1.657	0.821	3.344	0.159
Other religions	11 (20.8)	42 (79.2)	1
Education
No education	20 (37.0)	34 (63.0)	1.495	0.784	2.851	0.222
Primary	31 (30.1)	72 (69.9)	1.094	0.639	1.873	0.742
Secondary	17 (23.3)	56 (76.7)	0.772	0.408	1.459	0.425
Tertiary	48 (28.2)	122 (71.8)	1
Marital status
Never married	2 (25.0)	6 (75.0)	0.813	0.162	4.087	0.801
Married	114 (29.1)	278 (70.9)	1
Type of family
Nuclear (≤4 members)	35 (14.8)	201 (85.2)	0.178	0.111	0.286	<0.001
Extended (>4 members)	81 (49.4)	83 (50.6)	1
Current employment status
Employed	28 (18.8)	121 (81.2)	0.429	0.264	0.697	<0.001
Unemployed	88 (35.1)	163 (64.9)	1
Monthly income
≤10 BDT	6 (14.6)	35 (85.4)	0.339	0.134	0.862	0.023
11 to 30 BDT	61 (28.6)	152 (71.4)	0.794	0.504	1.251	0.321
31 to 50 BDT	49 (33.6)	97 (66.4)	1
Current smoking history
Smokers	24 (33.3)	48 (66.7)	1.283	0.743	2.214	0.372
Non-smokers	92 (28.0)	236 (72.0)	1
Clinical characteristics
Type of disease
Hypertension	41 (20.5)	159 (79.5)	0.430	0.275	0.672	<0.001
Diabetes	75 (37.5)	125 (62.5)	1

Figure 2. Types of CAM used.

Discussion

This study investigated the prevalence of using CAM for diabetes and hypertension among Bangladeshi adults, and the factors associated with CAM use. In this study, a majority of the diabetes patients used CAM rather than hypertension patients. Among older aged patients, CAM usage had the highest preferences in Bangladesh. This result is concurrent with the previously reported findings among NCD patients (61.7%) (Shahjalal et al., 2022a) in Bangladesh. A study undertaken in India revealed that 63% of diabetic patients utilize CAM (Bhalerao et al., 2013). Another investigation carried out in Sydney determined that 28% of diabetic patients utilized CAM (Manya et al., 2012). On the other hand, the patients with chronic illness had a lower percentage of CAM use in Singapore (22.7%) and South Africa (27.2%) (Hughes et al., 2015; Lee et al., 2004). The findings of these studies suggested that CAM usage is shared among diabetic and hypertension patients globally.

The female patients of this study were more likely to use CAM than the male ones. In India, 30% of male patients of age 51-60 years old used CAM, whereas 57% female participants used CAM for treatment (Roy et al., 2015). On the other hand, other studies reported that younger adults had a higher prevalence of using CAM, and that women mostly used CAM. A previous Bangladeshi study revealed that 60.6% of patients of age 26 to 45 years old used CAM, which was the highest figure of all age groups, and 39.8% of female participants used CAM for treatment (Shahjalal et al., 2022b). Another study revealed that 15.6% of patients aged between 20-39 years old and 40-59 years old used CAM to treat chronic illness, whereas 16.7% of female patients used CAM (Shahjalal et al., 2022a). In Pakistan, 63% of patients of age less than 45 years old and 71% of female patients used CAM for diabetes treatment (Jawed et al., 2019).

According to the findings of this study, socio-demographic characteristics such as educational status, employment status and smoking behaviour were significantly related to CAM use among the diabetes and hypertension patients in Bangladesh, which reflects the similar findings of earlier studies from Malaysia, Nepal and Pakistan (Hasan et al., 2009; Kadayat et al., 2012; Shaikh & Hatcher, 2005). These findings indicated that patients with no formal education, unemployed patients and patients with smoking habits were more likely to use CAM for treating diabetes and hypertension. These findings support the findings of previous studies of Bangladesh and Pakistan, where 17.5% of patients who had schooling less than five years of and diabetic patients with less than ten years of education, respectively, used CAM for chronic illness treatment purpose (Jawed et al., 2019; Shahjalal et al., 2022a). This study revealed that married patients and members of joint families are more likely users of CAM than single ones. In a previous study in Bangladesh, 27.7% of married patients utilized CAM for chronic illness treatment (Shahjalal et al., 2022a).

Our results depicted that older aged patients use higher amounts of CAM to treat diabetes and hypertension. This result supports the findings of other studies in South-East Asian countries like India, Malaysia, and China (Hasan et al., 2009; Hughes et al., 2015; Xin et al., 2020). The main reason could be the tendency of seeking traditional medical aid for severe complications. Considering the growing popularity among NCD patients, especially diabetes and hypertension patients, the government should promote CAM along with conventional or modern medicine. This will help to lessen the pressure on the existing healthcare system and will ensure proper treatment for the patients.

Homeopathic medicine was the most used type of CAM by hypertension and diabetic patients in this study. A previous study in Bangladesh reported that 52.2% of patients used homeopathy treatment for treating chronic illnesses (Shahjalal et al., 2022a). 36% of patients in India used Ayurveda, followed by homeopathy for their treatment purpose (27%) (Roy et al., 2015).

External and internal influences were prominent among the patients for utilizing CAM. Media influence and fewer side effects were the most influential factors among the patients. Along with these, media influence, better performance from CAM, and poor results from modern medicine were also common influential factors in using CAM. The study in Bangladesh reported that 55.5% of patients used CAM because of its less adverse effects and 41.6% of patients utilised it for its effective disease management (Shahjalal et al., 2022b). In India, patients used CAM because of its effectiveness (50%), advice from family (43%), and on-time usage on illness (51%) (Roy et al., 2015). Another study in India reported that the effectiveness (70.4%), own will (38.5%) and immediate usage of CAM (65.7%) were significant factors in using CAM among elderly patients (Sharma et al., 2017).

This research has several positive aspects. First, we gathered data by physicians from the surveyed health care centers. By involving physicians as the data collectors from the study hospitals, we reduced possible information bias. Secondly, we collected data from two specialised health care centres that provide only hypertension and diabetes services. There are also some limitations to the study. The study was cross-sectional, and it isn’t easy to determine causality. Further, using cardinal-based items may reduce the response validity of the variables studied.

Conclusion

Though patients with hypertension and diabetes use a high percentage of modern medicine, CAM is also widely used in Bangladeshi adults. Our results show a relationship between CAM usage and age, gender, employment history, economic status and family size. Homeopathy, Ayurvedic medicine and Unani medicine were the most common CAM practices in Bangladeshi adults with hypertension and diabetes. Most CAM users were influenced by the media, family members and friends. CAM use was most common for perceived effectiveness, fewer side effects, and low cost. The findings suggest future directions for research and have practical implications for diabetes and hypertension.