Complementary and Alternative Medicine (CAM) is a growing area of Primary care among professionals in both developing and developed countries of the world [1]. Patronage of CAM is predicated on socio-cultural and spiritual issues as well as the nature and severity of the ailments.

The United States National Centre for Complementary and Alternative Medicine (NCCAM) defines CAM as a group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine [2].

CAM remedies are classified into five areas namely: biologicalbased therapies and include herbs, vitamins, dietary supplements, health foods and aromatherapy; whole medical systems which include homeopathic medicine, naturopathic medicine, chiropractic, traditional Chinese medicine; mind-body interventions which include meditation, prayer, mental healing, art, dance, music therapy; manipulative and body-based methods like: massage, chiropractic or osteopathic manipulation. It also covers energy therapies including therapeutic touch and electromagnetic fields.

Although social and cultural issues as well as the nature and severity of diseases constitute some reasons for CAM use [3], it is difficult to completely unravel what accounts for the vast level of patronage of unorthodox health products and measures employed as CAM [4].

CAM use has often been seen as popular because of the seeming harmlessness since most of CAM is considered to be natural. On the other hand, they are detested for their lack of standardization of the dosage regimen, unwanted side effects that arise from the varied nature of combined elements, injuries resulting from mechanical procedure of treatment and increased diagnostic and treatment failures that follow poor training of most providers [5]. Notwithstanding all the above, it must be stressed that CAM has a major persuasive appeal to many people.

In developing countries, however, reports on the prevalence of CAM use are variable and are at best estimates because of the paucity of published literature on the subject.

In Nigeria, there are reports from different parts of the country on the use of CAM by various patient groups. The reported prevalence of CAM use among cancer patients in Enugu, South-East Nigeria was 65% [6]. The various forms of CAM used included: herbs, faith/prayer healing, aloe vera, forever living products, medicinal tea and black stone [6].

Among hypertensive patients seen in an urban tertiary care centre in Lagos, South-West Nigeria, 39.1% reportedly used CAM. Herbal products were the most commonly used CAM type [7]. In yet another report from Lagos, CAM use prevalence of 46% was recorded among patients with diabetes mellitus treated in a tertiary health care delivery facility [8].

There is, however, no population or institutional-based reports on the use of CAM in Uyo, South-South Nigeria.

The present study aimed to describe the extent of CAM use among adult patients who reported for treatment at the Family Medicine Clinic of University of Uyo Teaching Hospital and had used CAM during the 12 months period prior to their presentation in the Clinic.

Findings from this study should sensitize health care providers to be inquisitive regarding non-orthodox forms of treatment that their patients might be taking while in their care with a view to seeking to understand their beliefs and rationale for taking such alternative therapies in order to be able to plan care appropriately. This is especially important since CAM remedies are believed to be cheaper and as such more affordable by many people, majority of whom are poor who cannot afford the ever increasing cost of orthodox medical care.

Location of the study

This study was carried out at the Family Medicine outpatient clinic of the University of Uyo Teaching Hospital (UUTH). The UUTH is located in the outskirts of Uyo, the capital of Akwa Ibom State of Nigeria. Nigeria is divided into six geo-political zones as follows: North-East, North-West, North-Central, South-East, South-West and South-South. Uyo, the Akwa Ibom state capital is located in the southsouth geo-political zone, which is often referred to as the Niger Delta Region of Nigeria.

The Hospital is the only tertiary and referral health institution in the State and its environs and serves a population of about 3.9 million people [9].

Subjects

A total of 574 consenting adult male and female subjects aged from 18 to 69 years attending the Family Medicine Clinic participated in this study.

Sample size for this study was calculated using n=z²pq/d² [10], where ‘n’ is the desired sample size, ‘z’ represents standard normal deviation set at 95% confidence level which corresponds to 1.96. ‘p’ is the prevalence of CAM use quoted in this study [6], ‘d’ is precision which at 95% confidence interval is 5%. The calculated sample size was 349. Two thousand four hundred (2400) respondents were sampled during the study period.

They were recruited using a systematic sampling method with a sampling interval of six. Numbers ranging from one to six were assigned to the first six subjects who met the inclusion criteria. The first respondent was chosen by simple balloting, at which one of the numbers from a basket containing the assigned numbers was selected. Subsequently, every 6th subject was recruited into the study.

Ethical approval for the study was obtained from the UUTH Health Research and Ethical Committee. A pre-test of the research proforma was performed to determine its applicability, experience and logistic problems.

Methods

This study was conducted from October 2011 to March 2012. Five Hundred and seventy-four respondents aged between 18 and 69 years were recruited after obtaining informed consent from them. A structured and pre-tested questionnaire was used to obtain information about Socio-demographic profile of the respondents.

The level of income of respondents was determined using the Nigerian National Minimum wage act approved by the Nigerian National Assembly [11]. According to the act, low level income earners range from salary grade levels 01 to 07 with a maximum basic monthly income of sixty thousand naira (one US dollar≡₦160.00 approx. currently), middle level income earners range from salary grade level 08-15, with a maximum basic monthly income of one hundred and sixty-five thousand naira, while high level income earners range from salary grade level 16 to 17 with a maximum basic monthly income of two hundred and ninety-five thousand naira. The questionnaire also elicited information about forms of complementary and alternative medicine (CAM) used by the respondents and possible reasons for CAM patronage. Clinical conditions of respondents were diagnosed using standard guidelines. Hypertension was diagnosed based on the joint National Committee on prevention, detection, evaluation and treatment of high blood pressure criteria which uses an average of >140/90 mmhg after two readings [12].

Diabetes mellitus was diagnosed based on the 2011 revised criteria by the expert committee on the diagnosis and classification of diabetes mellitus which recommends the diagnosis of diabetes based on two fasting plasma glucose (2FPG) levels of 126 mg/dl (7.0 mmol/l) or higher or 2-hours post-prandial glucose (2 hppg) reading of 200 mg/ dl (11.1 mmol/l) after a glucose load of 75 g or higher or two casual glucose readings of 200 mg/dl (11.1 mmol/l) or higher or glycosylated haemoglobin of >6.4% [13].

Osteoarthritis was diagnosed based on the American College of Family Physician diagnostic criteria of joint pain and stiffness of insidious onset occurring in a middle-aged or elderly person involving the knee, hip, hand or spine [14].

Data analysis

Statistical analysis was done using the Statistical package for Social Sciences (SPSS) version 17. Distribution and cross tabulation were generated and Chi-square was used to compare proportions. The p-value of 0.05 was used to determine the level of statistical significance.

Of the 574 subjects recruited into the study, 37.1% (n=213) were males while 62.9% (n=361) were females.

Table 1 shows the Socio-demographic characteristics of the respondents. A total of 19.5% (n=112) male respondents used CAM remedies while the number of female respondents that used CAM remedies was 44.3% (n=254).

Table 1: Socio-demographic characteristics of respondents using or not using complementary and alternative therapies.

Respondents within the age brackets of 40-49 years constituted the highest number {191 (33.3%)} of CAM users in this study.

The number of respondents from the low level income bracket and those of the middle income bracket who used CAM remedies were almost the same: 29.6% (n=170) and 30.1% (n=173), respectively.

A total of 3.3% (n=19) respondents did not have any formal education; of this, 1.2% (n=7) used CAM remedies, while 2.1% (n=12) did not. This gave an intra-group proportion of 36.8% for users of CAM among the uneducated in this study.

Table 2 shows the breakdown of CAM products used by the respondents. Herbal drugs were the most commonly used CAM products patronized by respondents in this study and accounted for 61.7% (n=226) of CAM remedies used.

Table 2: Breakdown of cam products used by respondents*.

Aloe Vera was the next commonly used biological-based CAM remedy, accounting for 4.4% (n=17) of CAM remedies used. Honey was used by 1.8% (n=7) of the subjects.

Faith and prayer healing was used up to 3.4% of the time (n=13) by the respondents.

Among the Alternative systems-based CAM products, homeopathy was the more frequently used remedy, accounting for 7.6% (n=29) of preferred methods.

Massage was the preferred CAM remedy by respondents who used physical therapy and body manipulation. This therapy accounted for 3.1% (n=12) of preferred techniques.

Crude oil was another CAM remedy used by respondents who cited other CAM product class as their preferred choice accounting for 3.9% (n=4); while python fat and animal extracts accounted for 1.0% (n=4) of preferred CAM choices respectively.

Table 3 shows the reasons given by CAM product users.

Table 3: Reasons for using cam remedies*.

The major reason given for CAM use was health promotion and disease prevention (53.3%) Some respondents preferred CAM because it agrees with their beliefs and faith (8.2%); some chose CAM because orthodox medicine had side effects (6.7%); while some preferred CAM because of its fast onset of action (4.9%).

Table 4 shows the clinical characteristics of respondents who participated in the study as they were evaluated at the Family Medicine outpatient Clinic.

Table 4: Clinical characteristics of respondents using or not using complementary and alternative therapies.

A total of 18.5% (n=106) respondents who used CAM products were diagnosed with hypertension while 8.0% (n=46) respondents who were hypertensive did not use CAM. A total of 19.5% (n=112) respondents who were diagnosed with osteoarthritis (OA) used CAM remedies, while 5.7% (n=33) respondents did not use CAM remedies.

Out of a total of 25.8% (n=148) respondents whose ailments were not classified, 8.7% (n=50) used CAM remedies.

One hundred and two respondents (17.8%) who were on antihypertensive medication also used CAM remedies, while 52 (9.1%) did not use CAM. Eighty-six respondents (15.0%) who were both on antihypertensive and anti-diabetic therapy used CAM remedies while 46 (8.0%) did not use CAM. Eighty two (n=82) respondents (14.3%) on steroids used CAM remedies, while 69 (12.0%) did not use CAM.

The frequency of CAM use in this study was 19.5% for male and 44.3% for female respondents.

Different workers in various parts of Nigeria have reported differing frequency of CAM use among many patient groups ranging from 65% among cancer patients [6], 39.1% among hypertensives [7] and 46% among patients with diabetes mellitus [8]. The result of this study, adds to that position. The possible reason may be that laws that regulate the sales, advertisement and distribution of Complementary and Alternative therapy in Nigeria are not stringent while access to these modalities of care is largely unrestricted [15,16].

Moreover, practitioners of Complementary and Alternative medicine offer unlimited range of therapeutic claims which are powerfully tempting for consumers who perceive CAM therapies to be better and safer than Orthodox Medicare.

It is therefore necessary that physicians ascertain if their patients are taking CAM therapies, and those who do, must be properly counselled in terms of their illness, beliefs and rationale for patronizing such alternative therapies [16,17].

Another significant finding of this study is that CAM therapy was more prevalent among respondents between 40 and 49 years of age (p=0.000). The reason for increased popularity of CAM among people in the middle age bracket is not very clear, but may be related to their health seeking behaviour. Further study in this regard is hereby advocated.

Married respondents constituted the largest proportion of CAM users in this study (p=0.000). This finding is similar to a communitybased report among adult respondents presented by Onyiapat, Okoronkwo and Ogbonnaya working together in Enugu, South East Nigeria [17]. The persuasive appeal of alternative therapies to married people may be related to beliefs regarding the nature and meaning of health and illness [17].

Low Level and middle level income earners patronized CAM therapy more than high income earners in this study (p=0.000). Again, this finding bears agreement with the report from Enugu [17]. It could be argued that the high level of patronage of CAM by respondents in these income brackets is due to the seeming low cost of CAM compared to orthodox medical care.

The very low intra-group percentage of users {36.8% (n=7)} of CAM among those with no education in this study is difficult to explain since poverty and low education usually present together. In this study, herbs were the most frequently patronized CAM therapy, Amira and Okubadejo [7], also reported high prevalence of herbs use among hypertensive patients attending an urban tertiary health institution in Lagos, South-West Nigeria.

It is known that between 65 and 80% of the World’s population use herbal medicines as their primary form of health care [17]. In Nigeria, indigenous medicinal plants form an important component of the natural wealth of the people [18]. The popularity of herbs among Nigerians is related to its low cost and easy availability, the naturalness of its source as well as the beliefs in the supernatural causes of diseases among the people.

Despite the fact that herbal medicine use is increasing, most herbal remedies have not undergone careful scientific assessment and standardization. It is equally true that some of these CAM products have the potential to cause serious toxic effects because of interactions with other orthodox or non-orthodox drugs that may be taken concurrently [19].

Thus, health care providers should be familiar with the most common herbal medicines, especially their potential for adverse effects and drug interactions to be able to counsel patients appropriately. Orthodox health care providers need to be more willing to discuss the use of CAM with their patients [20].

Most of the respondents used CAM therapies to promote and maintain health because of the natural source of some components. These findings agree with reports from other studies which showed the increasing popularity of CAM especially herbs in the treatment of most health conditions because of their perceived natural source of origin, with less potential to cause side effects [7,16,18,21].

Most respondents with various medical conditions such as hypertension, diabetes mellitus, osteoarthritis and other clinical conditions reportedly used CAM therapies in this study.

This is in agreement with reports by other workers in different parts of Africa including Nigeria [6-8].

The popularity of CAM among respondents may not be unconnected with the belief that CAM remedies are cheaper than orthodox medicine and are thus easily affordable by majority of the respondents who were mostly low income earners. Other attractions to alternative therapies may be related to the power of the underlying philosophies inherent in CAM, such as closeness to nature, spirituality and the fact that these remedies often go along with the cultural belief of the people [22].

Findings from this study also show that respondents who were on treatment with other forms of medications also used CAM therapies [6-8]. This is particularly dangerous because of the potential danger that could arise from the combination of orthodox and CAM therapies [5]. Consequently, health care providers should be familiar with the most common CAM therapies especially their potential for adverse effects and major drug-to-drug interactions.

In Conclusion, findings from this study show that the use of CAM therapies is common among respondents seen in the Family Medicine Clinic of University of Uyo Teaching Hospital.

This underlines the need for physicians to be more pains-taking in interviewing patients regarding their current use of CAM before commencing orthodox treatment. Such efforts would avert drug-drug interaction in the midst of patients who harbour varying beliefs on approaches to treatment and create room for proper counselling on the need for caution regarding the use of CAM products.