Abstract
Abstract
Objectives:
The aim of this research was to identify patient preferences, concerns, and causes of noncompliance in the use of herbal medicine.
Materials and Methods:
Setting: This study involved patients from a community acupuncture clinic in Brooklyn, NY. Outcome Measures: A cross-sectional questionnaire was used to elicit responses on use of herbal medicines.
Results:
Eighty participants completed a survey on herbal medicine. Eighty-one percent (n = 65; confidence interval [CI]: 73%–90%) reported current or past use of herbal medicine; 19% (n = 15; CI: 10%–27%) had never taken herbs. Participants received recommendations on herbal selection from a variety of sources. Of the participants who had used herbal medicine, 63% (n = 32; CI: 49%–76%) preferred capsules or pills, 29% (n = 15; CI: 17%–42%) preferred tinctures, 10% (n = 5; CI: 2%–18%) preferred raw herbs, and 8% (n = 4; CI: 0%–15%) preferred powders. Forgetfulness and time constraints were major contributors to noncompliance. Participants with and without previous experience were concerned about cost, efficacy, quality, side-effects, taste, and product availability. One hundred percent (n = 15) of participants who had never used herbs responded that they would be more likely to consider it if they had more knowledge of the subject.
Conclusions:
Participants favored capsules/pills and tinctures due to ease of administration, taste, and time constraints. Patients might have broad concerns about using herbal medicine; therefore, practitioners should consider opening this discussion. Portable pillboxes or smartphone reminders could be utilized to improve compliance. Patients may be more likely to use herbs if a stock of commonly used formulas is maintained for immediate purchase.
Introduction
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A recent issue of the Centers for Disease Control and Prevention (CDC)'s National Health Statistics Reports lists “nonvitamin, nonmineral dietary supplements” as the most popular form of CAM in use during measured years (2002, 2007, and 2012), at just under 20% of the U.S. population using this modality. 1 The role of demographic factors—ethnicity, socioeconomics, presence of a particular disease—in the decision to use herbal medicine has also been considered. A survey of Hispanic patients at the University of California Irvine's community health center found herbal medicine to be one of the most common CAM modalities in use. Participants also reported that they would like to receive guidance from the health center on appropriate herb usage. 2 In a survey of low-income patients at a rural family practice in California, 56% of participants reported using herbs and supplements. The clinic's healthcare providers were also surveyed: 69% of practitioners had not received education in herbal medicine, yet 71% said their patients ask them questions about herbs at least biweekly. 3 Among patients receiving antiretroviral therapy at two human immunodeficiency virus clinics, 34% of respondents reported concurrent use of herbal medicine. 4
Many licensed acupuncturists gain significant experience in herbal medicine as part of their training and recommend these products to patients. Despite widespread use of botanical medicine, a systematic review of the literature identified few studies on practical aspects of herbal administration, such as adherence, preferred preparation type, and patient concerns. It would be advantageous for practitioners who frequently recommend herbal products to know what influences patients' choices and compliancy, in addition to what prevents patients who could benefit from herbal therapy from considering the modality.
The Brooklyn Acupuncture Project (BAP) is a sliding-scale, community acupuncture clinic located in a diverse neighborhood in Brooklyn, NY. Nine licensed acupuncturists currently practice at BAP, most of whom recommend herbal products to their patients when appropriate. Commonly used Chinese herbal formulas are available for purchase in the office; unique and custom formulas are prescribed via a home delivery service. BAP's clinical structure and large patient base provided an ideal setting to survey patient opinions on herbal medicine. As patrons of a CAM clinic, these patients were more likely to have experience with herbal medicine than the general population; this demographic factor would be advantageous in an inquiry of herbal medicine preferences and limitations around its use. The goal of this study was to identify factors that might be limiting the use of herbal medicine; resulting feedback could influence changes in clinical procedures.
Materials and Methods
Participants and Interventions
For the 2-month period of July 13, 2015 to September 14, 2015, all patients with an appointment at the Brooklyn Acupuncture Project were given the option to complete an anonymous survey on herbal medicine. Inclusion required each participant to be 18 years of age or older and fluent in English. Family members or others accompanying patients to appointments, who had never themselves been treated at the clinic, were excluded.
A cross-sectional questionnaire was approved by New York University Lutheran Medical Center's institutional review board. Survey submissions were anonymous and did not require follow-up; there were neither incentives nor participatory compensation. Questions were divided into relevant sections based on respondents' prior use of herbal medicine, allowing patients who had never taken herbs to participate. Herbal medicine was defined as “plant-based medicinals, aside from vitamins or supplements.” Questions included: prior use of herbal medicine; recommendation source for herbal products; preparation preferences; concerns; frequency and causes of noncompliance; and factors that might influence the decision to use herbs.
Data Analysis
Data were analyzed using Microsoft Excel, version 14.0.0. Survey responses were tallied and reported as frequencies; 95% confidence intervals (CIs) were computed using the Normal Approximation Method.
Results
Surveys were collected from a total of 80 participants. The mean age of respondents was 42 years, with a range of 23–70 years. Eighty-three percent (n = 66) of respondents were female and 16% (n = 13) were male. Eighty-one percent (n = 65; CI: 73%–90%) of participants reported current or past use of herbal medicine; 19% (n = 15; CI: 10%–27%) had never taken herbs.
Recommendation Source(s)
Table 1 provides a summary of the recommendation source(s) of participants' herbal selections; respondents were instructed to indicate all applicable sources. Of the 65 participants who had used herbal medicine, 86% (n = 56; CI: 78%–95%) received recommendations from their herbalists or acupuncturists, 18% (n = 12; CI: 9%–28%) were advised by other types of medical providers, 34% (n = 22; CI: 22%–45%) made selections based on personal research or the Internet, and 15% (n = 10; CI: 7%–24%) received advice from friends.
Total of 65 respondents.
CI, confidence interval.
Preparation Types and Preferences
Table 2 outlines familiarity with preparation types and participant preferences; for the familiarity section, respondents were instructed to indicate all types of herbal preparations they had used in the past. Of the 65 participants who had used herbal medicine, 92% (n = 60; CI: 86%–99%) had taken capsules or pills, 62% (n = 40; CI: 50%–73%) had prepared raw herbs, 48% (n = 31; CI: 36%–60%) had taken tinctures, and 43% (n = 28; CI: 31%–55%) had used powdered herbs. Participants were also asked to indicate their preferred preparation types; some respondents selected two types, though only 51 participants responded to this question. Sixty-three percent (n = 32; CI: 49%–76%) preferred capsules or pills, 10% (n = 5; CI: 2%–18%) preferred raw herbs, 29% (n = 15; CI: 17%–42%) preferred tinctures, and 8% (n = 4; CI: 0%–15%) preferred powders.
Total of 65 respondents
Total of 51 respondents (5 respondents selected two types).
CI, confidence interval.
The survey included a write-in section for participants to explain what influenced their preferred preparation types. Capsules and pills were favored due to ease, speed of administration, and decreased taste. Some patients who preferred tinctures and raw herbs perceived these preparations to be more potent or concentrated. Powders were described as being “easy” by 3 of the 4 respondents who preferred powders.
Compliance
Of the 65 participants who had used herbal medicine, 48% (n = 31; CI: 36%–60%) reported forgetting or skipping 1 or more doses, multiple days per week. Table 3 summarizes common factors causing patients to miss a dose of their herbs. Thirty-eight participants responded to this question, with instructions to select all applicable causes. Seventy-six percent (n = 29; CI: 63%–90%) reported missing 1 or more doses due to forgetfulness. Time constraints were another factor in skipped doses, with 21% (n = 8; CI: 8%–34%) reporting that these respondents did not always have enough time to take their herbs.
Total of 38 respondents
CI, confidence interval.
Concerns and Prohibiting Factors
Table 4 summarizes participants' concerns regarding herbal medicine. Of the 65 participants who had used herbal medicine, 63% (n = 41; CI: 51%–75%) were concerned with cost, 49% (n = 32; CI: 37%–61%) with efficacy of the products, 38% (n = 25; CI: 27%–50%) with quality of the herbs, 37% (n = 24; CI: 25%–49%) with side-effects, and 29% (n = 19; CI: 18%–40%) with taste. Participants without previous experience using herbs were also asked about these concerns, though the sample size was too small to perform valuable calculations. Of the 15 participants with no prior herb use, 5 were concerned with cost, 3 with efficacy, 3 with quality of the products, 2 with side-effects, and 2 with potential interactions with medications. One hundred percent (n = 15) of the 15 participants who had never used herbs reported that the participants would be more likely to use herbs if the participants had more knowledge of the modality.
Total of 65 respondents
CI, confidence interval.
Product Availability
All participants were asked if they would be more likely to consider an herbal formula if it were available for purchase at the time of their appointment. Sixty-eight percent (n = 44; CI: 56%–79%) of the 65 participants with experience using herbs and 73% (n = 11; CI: 51%–96%) of the 15 participants without experience indicated they would be more likely to use the products.
Discussion
A majority of participants had previous experience using herbal medicine. Eighty-six percent of those who had previously used herbs received the recommendations from acupuncturists or herbalists, an expected result given that the survey site offers such services. Herbal recommendations from other medical providers, friends, or personal research were also prevalent. When employing Traditional Chinese Medicine diagnostics, herbal recommendations are based not only on presenting symptom(s), but also on a patient's underlying physical constitution. Through this approach, 2 people with headaches should be given contrasting herbal formulas if the fundamental diagnostic causes of their conditions vary. Patients receiving herbal advice from friends, the internet, or practitioners unaware of these diagnostic subtleties might be using products that are not ideal for the patients' conditions. It might be beneficial for practitioners to review the products patients are taking to be sure the products are compatible with the patients' individual conditions, especially if the products were not recommended by trained herbalists.
Participants had used multiple herbal preparation types. Capsules and pills were the predominant preference (63% favored), as many respondents considered these forms to be the easiest options. Tinctures were favored by 29% and were also considered easy to use. Raw preparations and powders have the advantage of being customizable, though both were favored least at 10% and 8% respectively. Raw preparations require simmering whole herbs and consuming cups of the resulting tea multiple times daily. Similarly, powders are dried concentrated teas to be reconstituted in water. Common limitations regarding the latter two preparations were taste and time constraints. One survey response stated “the boiled tea type tasted so bad I couldn't even finish it” and another stated that “teas can be unpleasant to drink.” One participant wrote: “I'm better at remembering to take a pill rather than mix a powder. Raw is interesting, though (I'd) prefer not to cook for many days.” Alternately, 2 participants who preferred capsules or pills wrote that choosing the type that is most efficacious is just as important as ease of use. Survey results suggest that realistic factors regarding use should be considered by both the practitioner and patient before deciding on a preparation type.
Noncompliance was common among respondents, with 48% reporting one or more forgotten or skipped doses, multiple days per week. The most common cause was forgetfulness, with 76% of participants reporting that they forget to take their herbs. Issues of compliance may also relate to preparation type, as 21% of participants missed a dose due to time constraints; further analysis would be required to see if there is a significant correlation. A study of pharmaceutical compliance in patients recently discharged from a hospital found that participants commonly veered from their regimens; complexity of prescription protocols affected adherence negatively. 5 Another study found a smartphone reminder system to be a successful tool for increasing medication compliance. In addition to evaluating the reminders, researchers found that a pocket-sized container for carrying medications outside the home was essential to maintaining compliance. 6 A simplified version of this smartphone reminder system may improve herbal compliance. While it would not be compatible with raw herbs, powders, or tinctures, a pill box could be offered when patients purchase herbal capsules and pills. These accessories could increase compliance, particularly in patients who report forgetfulness or time constraints as causes of nonadherence.
A considerable proportion of participants who had used herbs indicated concerns about the following factors: cost; efficacy; quality; side-effects, and taste. Sixty-three percent reported cost to be an issue, though the population might have been be biased as it was drawn from patients at a clinic designed to provide affordable services. Twenty-nine percent of participants were concerned about taste of the products, which is addressed by the aforementioned considerations of preparation type. Expanding dialogues with patients could address the remaining concerns of efficacy, quality, and side-effects. Practitioners could mention these factors briefly when discussing herbal recommendations to address potential concerns, using the patients' responses to shape the conversations. Practitioners in a community clinic might be more likely to streamline this dialogue due to time constraints. Scheduling separate appointments for herbal consultations—particularly for first-time herb users or patients with complex concerns—could provide additional time for conversations. Clinics could also design a brochure outlining these issues.
Although the sample size of patients who had never taken herbs was small, their reported concerns might be valuable in practice. Three respondents with no herbal experience were concerned about product quality, so a simple brochure or conversation about sourcing and chemical analysis might be useful to this population. One hundred percent of the participants without herbal experience said they would be more likely to use herbs if these respondents knew more about the modality, reinforcing the above implementations.
A majority of respondents—both with and without experience of using herbal medicine—reported an increased likelihood of considering products if it were available for purchase at the time of their appointments. While BAP now offers an expanded selection of commonly used formulas, the pharmacy was limited at the time of the survey. Results of this study suggest expansion was a beneficial decision, which should be considered by other practitioners and clinics with high-volumes and spaces for storage.
The strength of this study came from its unique population of participants having previous experience with herbal medicine. The questionnaire was designed to be completed in <5 minutes, minimizing time commitment and increasing response rate. Any missing data appeared to be omitted intentionally, as all submitted surveys were completed through to the final question. The study was limited by its concision, as it did not allow for comparisons to be made among demographics. Given that respondents were drawn from a unique clinical setting, generalizations and recommendations might only be directly applicable to centers with similar structures. Participation in the study was voluntary, so a response bias was likely due to self-selection and interest in the subject. While the study was only available in English, it was not a significant limitation as the majority of patients at BAP are fluent in this language. Future studies could explore feasibility and effectiveness of using simple smartphone reminders or pocket-sized pill carriers to improve herbal compliance. Effects of placing a brochure in the waiting area could be evaluated for success in reducing concerns about herbal medicine. Lastly, a study could be performed to assess compliance rates in patients using capsules/pills and tinctures compared to raw or powdered preparations.
Conclusions
Herbal recommendations are received from a variety of sources; therefore, trained practitioners should assess patients' herbal formulas to ensure that appropriate selections were made. Participants were familiar with multiple preparation types, though survey trends indicated that capsules/pills and tinctures were preferred over raw or powdered herbs. Ease of administration, taste, and time constraints influenced the preparations favored by patients. Respondents with and without experience using herbal medicine indicated concerns such as cost, efficacy, quality, side-effects, taste, and product availability. Every participant who had never used herbs would be more likely to consider the modality with more knowledge of the subject. Survey findings could influence clinical procedures to accommodate concerns and increase accessibility.
Footnotes
Author Disclosure Statement
No competing financial interests exist.