Use of alternative medicine for hypertension in Buikwe and Mukono districts of Uganda: a cross sectional study

Background Use of alternative medicine for chronic diseases such as hypertension is common in low as well as high income countries. This study estimated the proportion of people who were aware of their hypertension that use alternative medicine and identified factors predicting the use of alternative medicine. Methods In a community based cross sectional survey among people ≥ 15 years in Buikwe and Mukono districts of Uganda 258 people aware of their hypertension were questioned about use of alternative medicine for hypertension, advice about uptake of life style intervention for hypertension control such as reduction of salt intake and about their attitude towards use of alternative medicine. Proportions of people who used alternative medicine and adopt life style interventions and their 95% confidence intervals (CI) were calculated. Predictors of using alternative medicine were identified using logistic binary regression analysis. Results More than a half 144 (56.2%) had ever used alternative medicine whereas more than one in four 74 (28.6%) were currently using alternative medicine alone or in combination with modern medicine (50%). People who were using alternative medicine alone (29.7% CI 17.5-45.9) were less likely to have received advice on reduction of salt intake compared to those using modern medicine alone or in combination with traditional medicine (56.6%, CI 47.7-65.0). The only independent predictor for using alternative medicine was agreeing that alternative medicine is effective for treatment of hypertension (adjusted odds ratio [AOR] 2.6; 95% CI 1.40-4.82). Conclusion The use of alternative medicine was common among patients with hypertension and usage was underpinned by the belief that alternative medicine is effective. As patients with hypertension use alternative medicine and modern medicine concurrently, there is need for open communication between health workers and patients regarding use of alternative medicine.

workers do not take cognizant of the fact that some patients use alternative medicine [1,[18][19][20][21]. As a result policy and practice regarding use of alternative medicine remain blurred [22,23]. Use of alternative medicine is common in the management of hypertension which is one of the most common non-communicable diseases worldwide affecting up to 20% of the world's adult population [24]. Hypertension is prevalent in many developing countries [24][25][26][27][28] and is the main driver of the cardio vascular disease (CVD) epidemic in Africa where it is a major, independent risk factor for heart failure, stroke and kidney failure [26]. Treatment and control remain sub-optimal; moreover, the health care system is constrained in most of the sub Saharan African countries [25,26]. The use of alternative medicine is increasingly being documented and studied and usage varies between countries with 80% usage reported in Morocco, 48.5% in the Australia, and 40% in the United States [29,30]. The reasons why patients choose to use alternative medicine in the management of hypertension are not fully understood [31].
This study aimed to understand the use of alternative medicine among patients aware that they have hypertension with a view of suggesting measures for improved care. Specifically it estimated the proportion of patients with hypertension that use alternative medicine and analyzed the determinants for use of alternative medicine.

Design
A community cross-sectional survey was carried out in 2012 in Buikwe and Mukono districts of Uganda. The survey that has been described elsewhere [25] measured blood pressure of all people 15 years and above during home visits. In addition people who were aware that they were hypertensive before the survey answered questions regarding treatment and care for their hypertension. Participants were classified as hypertensive aware if they reported that they had previously been informed by a health professional that they had hypertension.

Setting
Buikwe was carved out of Mukono district in 2009. These two districts lie between the two biggest urban areas of Jinja and Kampala (the capital city). Together the two districts have a population of over 1,000,000 people (projected from the 2002 national census at annual growth rate of 4%). About 80% of the populations are rural dwellers whose main occupation is agriculture. Health services in the two districts are provided by six hospitals, 60 health centres and many private clinics. The major causes of morbidity and mortality are communicable diseases such as malaria, respiratory infections, diarrhoea, HIV/AIDS and tuberculosis. However, non-communicable diseases (NCD) are emerging with hypertension being the commonest reported NCD [32]. Most of the health units are able to diagnose hypertension but drugs for treatment of hypertension are available at the six hospitals and at ten of the health centres which occasionally report drug stock out.

Sample size
We aimed at interviewing at least 250 respondents aware of their hypertension. This sample size was large enough at 95% confidence interval and a power of 80% with a detectable relative risk of 2 provided that the determinants of using alternative medicine within the study population are not uncommon (less than 20%) or very common (greater than 80%). The sample size assumed that at least a quarter of the respondents use alternative medicine. The sample size was determined using statcal of EPIINFO version 6 (www.cdc.gov/epiinfo CDC, Georgia) for cross-sectional studies.

Data collection and measures
A modified questionnaire [11] for health care seeking behaviour was administered to the respondents who reported that they were aware of being hypertensive. Data was collected on treatment and care for hypertension such as type of treatment (modern and or alternative), type of alternative treatment (herbal or otherwise), and life style interventions for hypertension such as advice on salt intake, physical activity, drinking alcohol and on smoking. Among the socio-demographic variables, data was collected on sex, age, place of residence, level of education, marital status and time since diagnosis of hypertension. Furthermore, data was collected on psycho-social factors such as attitude towards alternative medicine, traditional healers, on self treatment and on government health units.

Analysis
Analysis was done at three levels, univariate, bivariate and multivariable. At univariate level proportion of patients and their 95% confidence intervals (CI) were computed for those that use alternative medicine alone or in combination with modern medicine those that use modern medicine alone and those that neither use modern nor alternative medicine. The proportion of patients that had been advised on life style interventions for hypertension such as reduced salt intake, increased physical activity, reduction or stopping of alcohol consumption and on cessation of smoking were also computed. At bivariate level, social-demographic and psycho-social variables were subjected to a comparison of proportions among users and non users of alternative medicine. For this analysis users of alternative medicine were those using alternative medicine alone or in combination with modern medicine. Non users of traditional medicine were those using modern medicine alone and those that neither use modern nor alternative medicine. At bivariate analysis crude odds ratios (COR) and 95% CI were used as tests of association and significance respectively. All variables that were significant on bivariate analysis (P < 0.05) were entered in a multivariable binary logistic regression model to identify independent predictors of using alternative medicine. Adjusted odds ratios (AOR) and 95% CI were calculated for variables that remained significant after controlling for one another.

Ethics
The study was approved by Makerere University School of Public Health institutional review board and the Uganda National Council of Science of Technology. Written informed consent was obtained from adult participants. For participants below the age of 18, assent and written informed consent were obtained from minors and their parents/guardians respectively. Patients with uncontrolled hypertension and not on modern treatment were referred to health units.

Results
Of the 281 patients that were aware of their hypertension 23 (8%) were excluded from further analysis because of missing data. For the remaining 258, 40 (15.5%) were men, 74 (28.7%) were urban dwellers, 189 (73.3%) either had no formal education or had finished primary school, 133 (51.6%) were married, and 167 (57.2%) were less than 55 years of age. Of the sample, 103 (40%) had their hypertension diagnosed within the previous one year, 90 (35%) had their hypertension diagnosed between the last one and four years whereas 65(25%) had their hypertension diagnosed within the past 5 years.

Treatment for hypertension and use of alternative medicine
As shown in Table 1, 237 (91.8%) had ever used modern medicine and 122 (47.2%) were currently using modern medicine. More than a half 144 (56.2%) had ever used alternative medicine whereas more than one in four 74 (28.6%) were currently using alternative medicine. Of the people currently using alternative medicines, half were only using the remedies for treatment of hypertension. The type of alternative medicine used was almost exclusively herbal remedies reported by 73/74 (99%). A big number of people with hypertension 99 (38.4%) were neither receiving modern nor alternative medicine.

Life style interventions
Overall 61 (23.6%, CI 18.7-29.1) were advised to increase physical activity, 116 (45.0%, CI 40.1-51.0) were advised to reduce salt intake, 58 (22.5%, CI 17.7-27.8) were advised to reduce or stop use of alcohol and 34 (13.2%, CI 9.4-17.8) were advised to stop smoking. As can be seen in Table 2, use of alternative medicine alone was associated with lower likelihood of being advised to adopt life style interventions particularly for increased physical activity and for reduced salt intake.

Factors influencing use of alternative medicine
In Table 3 all the socio-demographic variables tested such as year of diagnosis for the hypertension, age of patient, sex, place of residence, level of education and marital status did not influence use of alternative medicine for hypertension (P > 0.05).
Among the psycho-social variables; agreeing that alternative medicine is effective for treatment of hypertension, that traditional healers provide quality treatment for hypertension, are convenient, kind and keep patients secrets, and saying that self treatment for hypertension is good were associated with a higher likelihood of using  alternative medicine (P < 0.05). On the other hand, saying that government health units provide quality treatment for hypertension, that free treatment for hypertension is good and that traditional healers delay patients were not associated with use of alternative medicine (P > 0.05) [ Table 4]. On multivariable binary logistic regression analysis the only independent predictor for using alternative medicine was agreeing that alternative medicine is effective for hypertension (adjusted odds ratio [AOR] 2.6; 95% CI 1.40-4.82).

Discussion
The use of alternative medicine for hypertension was very high. More than a half of the people aware of their hypertension had ever used alternative medicine whereas more than a quarter were currently using alternative medicine alone or in combination with modern medicine. Among the people with hypertension who use alternative medicine 50% were using it alone without modern medicine. The only independent predictor of using alternative medicine identified in this study was the belief that alternative medicine is effective for the treatment of hypertension. Thus the results of this study complement findings in this setting [11,33] and elsewhere [7][8][9][10][11][12][13][14][15][16] that use of alternative medicine is  ubiquitous and that its use is underpinned by the common belief that alternative remedies are effective against a number of illness [7,11,12,17,20]. Meanwhile, these results also show that use of modern medicine was nearly universal (92%) and alternative medicine was not used alone but as an adjunct to modern medicine except for only 4% of the subjects who reported using alternative medicine alone. The fact that so few use alternative medicine alone, while a significant proportion use a combination, alternative medicine "on its own" could be perceived as insufficient in the control hypertension among combined users of modern and alternative medicines.
In the current study, psycho-social variables rather than social-demographic variables were the predictors for use of alternative medicine. These data are supported by research from applied social psychology and health education, where attitudinal, social influence and selfefficacy beliefs of this nature are very important in influencing health-related behavior [34,35]. According to social-psychological models, these beliefs are also important in behavior change because they could be targeted for modification using health education/promotion or other appropriate methods [36].
The high rate for concurrent use of alternative and modern medicine found in this study and common elsewhere [7][8][9][10] is a cause for concern. Alternative medications may interact with modern medicine causing adverse events [37][38][39]. Therefore, there is need for health workers to be aware that patients with hypertension use alternative medicine. Because patients do not necessarily volunteer this information [1], health workers should specifically question patients under their care regarding use of alternative medicine. Patients should also be encouraged to volunteer this information to attending clinicians. There is also need to document common herbal remedies used for treatment of hypertension with their possible effects [20] and avail this information to health workers. Collaboration between providers of modern medicine and of alternative medicine as has been reported elsewhere [33] may be a good entry point for this form of documentation.
In the present study patients receiving alternative medicine were less likely to receive life style interventions. Reasons for this observation could be due to selection bias with users of alternative medicines not being comparable to users of modern medicine. Second, it is possible that users of alternative medicine are less likely to consult providers that advise on life style interventions. Third is the possibility that alternative remedies themselves are taken as substitutes for life style interventions by patients as well as traditional healers [33].
This study was aimed at estimating patients with hypertension who use alternative medicine. The strengths of the research design were that patients with hypertension were derived from a community survey rather than health units and the study used a tested protocol that was based on a theoretical methodology [11] for analyzing possible reasons for use of alternative medicine. However, this study had some limitations. First, the psychosocial variables were measured after the behavior (i.e. use of alternative medicine) had occurred. This could have changed their beliefs, particularly the attitudinal ones, depending on the quality of service and the way they were attended to at the places where they received medicines. Second, the cross-sectional nature means that it was difficult to establish cause and effect. For example, it is difficult to conclude whether the belief that alternative medicine is effective against hypertension came before or after using it. Nevertheless, this study provides useful information about use of alternative medicine that may be of practical importance.

Conclusion
The use of alternative medicine was common among patients aware of their hypertension and usage was underpinned by the belief that alternative medicine is effective. Because patients with hypertension use alternative medicine and modern medicine concurrently, open communication regarding use of alternative medicine is necessary between health workers and patients.