A Representative Survey of Knowledge,Use,Perceived Benefits,Barriers,and Risks of Select Herbal Drugs Among Female Students in Gorgan City (Northeast Iran)

Abstract

We conducted a representative survey among young women to determine knowledge, use, and perceptions on barriers, benefits, and risks related to selected herbal drugs (Crocus sativus, Borago officinalis, Citrus aurantium, Thymus vulgaris, Matricaria chamomilla, Lavandula angustifolia, Valeriana officinalis, Hypericum perforatum, and Panax ginseng) in Gorgan by using an internally validated questionnaire. There were 344 participants (mean age 16.3 years; 16.2% in science course). Saffron had most reported knowledge (n = 265, 77.0%) and ever use (n = 324, 94.1%). The average number of source of knowledge was 2.5; parents (n = 224, 65.1%) were the single most frequent source. Media (combined magazine, the Internet, TV, radio) was the source of knowledge for 283 (82.2%) participants. Actual use was “harmful” for the majority (n = 182, 52.9%; no idea n = 83, 24.1%). Parents and media provided knowledge on herbal drugs for most, supporting unsurprisingly high perceived knowledge but harmful actual experience. Programs to educate people are needed to not take herbal drugs lightly.

Herbal drugs are the ancient, prevalent, and popular method of treatment and/or prevention worldwide. ¹ These drugs particularly fulfil the primary care need of up to 80.0% of those living in developing countries, the Middle East being no exception. ¹ They have always gained public attention and acceptance since they are considered to be “natural” and devoid of possible side effects of modern medications, which is often not the case. ^2,3 Iran is a large, geographically diverse and a progressive Middle East country where at least 85.0% of the population is medically covered and receives up to 90.0% reimbursement of their medical cost. Iran has an established pharma market with 70 local manufacturers who fulfil ∼95% of the market needs. It is one of the few countries with formal herbal drug regulation since 1994 for developing herbal pharmaceuticals. It has huge natural abundance, ^4,5 with 8000 species of plants of which 2100 species are used in medicine. ⁶ Promoting herbal drugs is also a formal part of Iran’s National Drug Policy. Today, Iran has 150 registered and hundreds of unregistered herbal products. ^4,5 Interest in the herbal market in Iran can be understood from a 2014 National Herbal exhibition that was attended by 353 herbal companies (manufacturers, exporters, traders). ⁶ Since herbal drugs are considered “natural,” they are liable to be self-prescribed, self-managed, and be loosely handled, which may lead to undesirable consequences. ⁷ This is not unexpected since the use of herbal drugs in Iran is indiscriminate, self-prescription based, and follows family traditions. ⁸ We believe such aspects are more likely to be among young and women for a variety of reasons. Women are well recognized to have additional health care (access, quality) challenges than men, which may have an impact in societies such as Iran where there are strong family traditions and parental role in day-to-day decision making. ⁹ Moreover, access to media is wider among younger adults, which may influence people toward using herbal drugs on their own. A previous survey reported that this influence is present even though the details presented in the media about herbal drugs are inaccurate. ¹⁰ With these visions in mind, we conducted a representative population-based survey of select herbal drugs among young female high school students in Gorgan in order to determine their knowledge, sources of knowledge, actual herbal drug use experience, and determinants of perceived risk, benefits, and barriers of select herbal drugs.

Methods

Study Area and Population

The survey was conducted among young female high school students of Gorgan, the capital of Golestan Province. It is located at about 400 km from Tehran, the capital of Iran. Based on certain criteria (z = 1.96, P = .22, d = 0.45) plus 5% nonresponse rate, 329 participants were estimated to be required. ¹¹ According to the Directorate of Education of the Government of Gorgan, there are 65 818 students in the Golestan province and 14 641 students in Gorgan. Of which, 39.5% and 34.1% are female students in Golestan and Gorgan, respectively. Initially, schools were selected from a sampling frame that was made of all high schools of Gorgan (n = 48), a list of which was obtained from the State Education Department. Each school was considered a cluster, and from them a total of 33 clusters were selected by using population proportional to size. In each cluster, each individual unit (ie, students) was given a random number by using a class attendance sheet, and 10 students were randomly selected. Only female students were included because of cultural restrictions.

Questionnaire

In order to prepare a data collection questionnaire, initial literature was searched following which discussions were carried out to prepare a more refined version of the questionnaire. The questionnaire was internally consistent (Cronbach’s α = .88). The questionnaire was prepared having 5 sections: (a) sociodemographic details, (b) knowledge, (c) sources of knowledge, (d) actual herbal drug use experience, and (e) perceived risks, benefits, and barriers. The 9 selected herbal drugs were saffron (Crocus sativus), borage (Borago officinalis), citrus aurantium (Citrus aurantium), thyme (Thymus vulgaris), chamomile (Matricaria chamomilla), lavender (Lavandula angustifolia), valerians (Valeriana officinalis), hypericum (Hypericum perforatum), and ginseng (Panax ginseng).

Statistical Analysis

The results are presented as means for continuous variables and frequencies for nominal variables. Confidence intervals (CIs) were calculated at the 5% risk level. We also performed logistic regression in order to determine correlation of dependent with independent variables, particularly between (a) sources of knowledge particularly parents and the Internet (media) and reporting as being knowledgeable about herbal drugs, drug use experience as “harmful,” and ever use of herbal drugs; (b) actual drug use experience with duration of drug use; (c) duration of drug use with actual drug use experience; and (d) determinants of perceived risks, benefits, and barriers with actual drug use experience.

Ethical Statement

Ethics permission was obtained from the Institutional Ethics Committee of Gorgan University of Medical Sciences. Verbal informed consent was also obtained from patients prior to their eventual participation.

Results

A total of 344 participants were included in the survey. Age was normally distributed (P = .08), and the mean age of the sample therefore was 16.3 years (range = 14-19, 95% CI = 16.2-16.5). Most of them belonged to Turkman and Turc ethnic groups (n = 195, 56.6%), followed by Ghazagh (n = 54, 15.6%), Sistani (n = 49, 14.2%), and others (n = 20, 5.8%). Farsis were only 26 (7.5%) in total. Only 11 (3.1%) and 22 (6.3%) had either of their parents (father, mother, respectively) as illiterate, and only 4 fathers (1.1%) and 2 mothers (0.58%) were doctors. In the sample, 16.2% were in the science course and 83.8% were in the nonscience course.

Knowledge

Participants responded that they have good knowledge of herbal drugs, as follows: saffron (n = 265, 77.0%), citrus (n = 237, 68.9%), borage (n = 229, 66.5%), thyme (n = 216, 62.7%), chamomile (n = 175, 50.8%), hypericum (n = 101, 29.3%), lavender (n = 61, 17.7%), ginseng (n = 53, 15.4%), and valerians (n = 45, 13.0%).

Source of Knowledge

Mean number of sources of knowledge for each participant was 2.5 (95% CI = 1.9-3.0). The most frequently reported individual source of knowledge was parents (n = 224, 65.1%). Media (combined as magazine, the Internet, TV, radio) was the source of knowledge for 283 (82.2%) participants. Other more relevant sources were infrequent, that is, doctors (n = 108, 31.4%) and school health staff (n = 40, 11.6%). Other sources of knowledge reported were as follows: books (n = 83, 24.1%), friends (n = 103, 29.9%), and teachers (n = 46, 13.7%). Based on the regression results, there was a significant relationship between “source of knowledge” and “reporting as having good knowledge of herbal drugs,” as follows: friends (citrus P = .008, thyme P = .01), doctor (lavender P = .01), parents (thyme P = .05), magazine (ginseng P = .03), media (citrus P = .01), school health staff (saffron P = .001). The relationship of any “source of knowledge” with “drug use experience as harmful” was not significant (P > .05).

Ever Use of Drug, Purpose, Period

Drugs that were ever used by participants were the following: saffron (n = 324, 94.1%), borage (n = 269, 78.2%), valerians (n = 264, 76.7%), citrus (n = 192, 55.8%), lavender (n = 102, 29.6%), ginseng (n = 73, 21.2%), chamomile (n = 26, 7.5%), thyme (n = 22, 6.4%), and hypericum (n = 20, 5.8%). Ever use of herbal drugs statistically differed by different ethnic groups, particularly for citrus (P = .01), borage (P = .05), and chamomile (P = .01). The reasons for drug use were treatment (n = 130, 37.7%), prevention (n = 123, 35.7%), or both (n = 91, 26.6%). Drugs were used for less than 1 week by most (n = 216, 62.7%), for 1 week (n = 26, 7.5%), and between 1 week and 1 month (n = 10, 2.9%). Only 58 (16.8%) participants used any of these drugs for a relatively long period of time (at least 1 year). Based on actual drug use experience, herbal drugs were harmful (n = 182, 52.9%), effective (n = 57, 16.5%), had no effect (n = 83, 24.1%), and had no response (n = 22, 6.4%). Ever use of these drugs was individually found to be related to various sources of knowledge, that is, friends (citrus P = .008, borage P = .06, thyme P = .01), doctor (lavender P = .01), and parents (thyme P = .006). Actual drug use experience and duration of drug use were found to be significantly related (P = .001) and so was also the relationship of duration of drug use and actual drug use experience as “harmful,” P = .001.

Determinants (Risks, Benefits, Barriers)

Risks that were perceived by respondents were the following: interaction with regular drugs (n = 241, 70.0%), side effects (n = 188, 54.6%), insufficient information on these drugs (n = 178, 51.7%), insufficient knowledge of prescribers (n = 165, 48.0%), and addiction in the future (n = 134, 39.0%). The only risk that was relevant was the possibility of interaction with other drugs but only for borage (P = .04) and chamomile (P = .03).

Benefits that were perceived were the following: good efficacy (n = 261, 75.8%), infrequent side effects (n = 249, 72.3%), easy to use (n = 261, 75.8%), more effective than modern drugs (n = 242, 70.3%), inexpensive (n = 237, 68.8%), no fear of injections (n = 228, 66.2%), are suitable even in acute situations (n = 220, 63.9%), and no long waiting at the clinics (n = 217, 63.0%). Two benefits that significantly related with actual drug use experience (as above) were efficacy of herbal drugs more than modern drugs (P = .03) and herbal drugs suitable in acute situations (P = .001). Perceived benefits include less side effects (citrus P = .05, saffron P = .02), suitable in acute situations (valerian P = .02), no long waiting at clinics (chamomile P = .02), and strengthen immune system (thyme P = .03).

Barriers that were perceived by the respondents were the following: treatment requires a lot of time (n = 246, 71.5%), they are expensive (n = 191, 55.5%), some of these drugs are illegal and unnatural (n = 187, 54.3%), insufficient scientific evidence on their use (n = 183, 53.1%), drugs are not easy to access and obtain (n = 124, 36.0%), and lack of experts who may correctly prescribe these drugs (n = 121, 35.1%). Statistically significant barriers were the following: lack of good manufacturing practice (thyme P = .05), no scientific experts for guiding about herbal drugs (borage P = .05, ginseng P = .01), too expensive (hypericum P = .03), and difficult to use (saffron P = .04).

Discussion

We conducted a large representative survey to determine several aspects of knowledge, actual drug use, and popular perceptions about 9 select herbal drugs among young women high school students in Gorgan, Iran. Herbal drugs that we chose were considered as example herbal drugs since these are popular, known, and relevant in this Muslim society; some of these drugs are mentioned in the Holy Quran as well. These drugs were also deemed to be women-relevant such as thyme or saffron indicated for the relief of dysmenorrhea.

Only women participants were included because of cultural restrictions. Also, Gorgan was particularly suitable since climatic conditions in this region favor growth of various medicinal plants. Moreover, the population of Gorgan belongs to several ethnic groups such as Turc, Turkman, Baluch, Sistani, and Ghazagh. Also, a number of those from other provinces (particularly Semnan, Khorasan) live in Gorgan, making Gorgan representative of Iran’s ethnic structure. This came out significant since ever use of herbal drugs statistically differed by different ethnic groups (refer to the aforementioned results). Other studies do also show ethnic differences in the use of herbal drugs. ¹²

There was 100% response rate in our survey. More than 50% participants were non-Fars, particularly Turkmen and Turc. This was not unexpected, since in Iran, Turkmen and Turc are mainly concentrated in the provinces of Golestan and North Khorasan. Gorgan is the capital of Golestan. Only few participants had illiterate parents, an observation of importance since literacy (self or parents) proportionally affects prevalence, knowledge, and treatment-related parameters. ^{13 –15} This influence is irrespective of different herbal drugs addressed in different studies, ¹⁵ meaning parents’ literacy may have a generic influence on the usage of herbal drugs.

One drug that most participants reported that they are knowledgeable about was saffron, which was also the drug reported to be used by most. Saffron is a sacred plant, a part of Arab-Islamic healing, ¹⁶ and used for writing verses of the Holy Quran. ¹⁷ Thus, it might not be unexpected that in this Muslim population, most were aware of and were using saffron. Frequent use of saffron has been noted in other populations as well. ^18,19 Modern therapeutics recognizes its anticarcinogenic, antimutagenic, immunomodulating, and antioxidant-like properties ²⁰ and its women-centric benefits. ²¹ Saffron is indicated for use in dysmenorrhea, ²² which might be a very likely reason that this drug was highly used in this population with a very young mean age, that is, 16 years. Its correlation with school health staff as the only statistically significant source of knowledge (refer to the Results section) may further emphasize this possibility.

Besides saffron, there were other drugs, such as citrus aurantium, borage, thyme, that the participants were knowledgeable about. These drugs have different medicinal purposes and are known to be used in populations, ²³ including in Iran, ²⁴ where some of these are easily accessible. ²⁵ One of the most striking observations was about valerian, since only 13.0% reported that they have knowledge of this drug yet 77.0% reportedly used this drug. Valerian is mostly indicated for sleep disturbance and psychological stress, ²⁶ which is not unexpected in our student-only population. Since no correlation of valerian use was found with any source of knowledge (refer Results section), it is therefore likely that its use was probably self-indicated.

Parents were the most frequently reported individual source of knowledge, besides media (ie, combined magazine, the Internet, TV, radio). This is not unexpected where participants are both young as well as women, especially in a patriarchal society with respect for family involvement and parental inclusion. ⁹ This in fact indicates a healthy social relationship between parents and children wherein problems are discussed within the family. This might even be more likely since our participants were very young (mean age ∼16 years). Moreover, media does play a major role in influencing people to use herbal drugs, ²⁷ but information given on herbal drugs may not always be accurate. ¹⁰ Although we could not find any direct evidence of this since there was no significant relationship between media as a source of information and “harmful” drug use experience, it might be likely.

Several risks, barriers, and benefits were perceived by our population. Interaction with other drugs was the most frequent risk, particularly for borage and chamomile (refer to Results section). These drugs do interact with other modern drugs as common as nonsteroidal anti-inflammatory drugs. This might be related to quality as well since we noted that the drug use experience as harmful was only statistically significant for borage (P = .006). This may be related to the fact that in Iran borage is an unlicensed herbal drug with likely risks for the women users due to unprofessional referral for use, something what we observed as well wherein the statistical significant source of knowledge for borage was friends (refer to Results section). ²⁸ Most perceived benefit was herbal drugs more efficacious than modern drugs, which replicates that from other populations implying these aspects are generic in nature not specific to any population or drug type. ²⁹ With respect to barriers, several barriers were found to be statistically significant such as lack of good manufacturing practice, expensive, lack of scientific experts, and so on. This replicates results from other Iran surveys that many products in the market have ambiguous identification, are adulterated and contaminated, ³⁰ and not according to good manufacturing standards. ³¹

Overall, this was a humble attempt to understand the knowledge, drug use, and perception scenario among young women in Gorgan. Because of restrictions, only women were included inhibiting any possibility of gender-based evaluations. Our sample was taken from the whole school population of Gorgan and may therefore be not representative in strictest sense, although it is extremely rare in Iran that women may not attend any school (98.0% literacy in 2012 among young women, as among young men, aged 15-24 years).

Conclusions

Overall, this population seemed confident of herbal drugs and believes to be knowledgeable of herbal drugs just like other populations yet actual experience of most of them was reportedly “harmful.” Like elsewhere, parents and media are the significant mediators in disbursing herbal drug knowledge to young adults and children; therefore, it becomes essential to evaluate what knowledge and information they have and disburse to others. This is important since ever use of drug was significantly related to the source of knowledge. Saffron was the most popular drug for use. Actual drug use experience (and not perceived knowledge) decides duration for which the drug is to be actually used. Moreover, practice of using drugs, such as valerian in our case, despite limited knowledge may pose health hazards to the population. The determinant that decides risk is possibility of interaction with other drugs; and that of perceived benefits are possibility of fewer side effects, no long waiting at clinics; and that of perceived barriers are lack of good manufacturing practices and no scientific expertise. There should be programs aimed to educate people to not take herbal drugs lightly but consider them in the same manner as they consider modern drugs.