native Medicine (NCCAM) defines CAM as “a Alternative medicine is used instead of conventional medicine. and Alternative. Medicine. Herbal Medicine …
BMC Complementary and Alternative Medicine
Research article
BioMed Central
Open Access
Factors associated with herbal use among urban multiethnic primary care patients: a cross-sectional survey
Grace M Kuo1, Sarah T Hawley2, L Todd Weiss1, Rajesh Balkrishnan3 and Robert J Volk1
Address: 1Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA, 2Division of General Medicine, University of Michigan and Ann Arbor VA Center for Practice Management and Outcomes Research, Ann Arbor, Michigan, USA and 3University of Texas Health Science Center School of Public Health, Houston, Texas, USA Email: Grace M Kuo - gkuo@bcmtmcedu; Sarah T Hawley - sarahawl@medumichedu; L Todd Weiss - lweiss@bcmtmcedu; Rajesh Balkrishnan - RajeshBalkrishnan@uthtmcedu; Robert J Volk - bvolk@bcmtmcedu Corresponding author
Published: 02 December 2004 BMC Complementary and Alternative Medicine 2004, 4:18 doi:101186/1472-6882-4-18
Received: 20 March 2004 Accepted: 02 December
2004
This article is available from: http://wwwbiomedcentralcom/1472-6882/4/18 2004 Kuo et al; licensee BioMed Central Ltd This is an Open Access article distributed under the terms of the Creative Commons Attribution License http://creativecommonsorg/licenses/by/20, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited
Abstract
Background: The use of herbal supplements in the United States has become increasingly popular The prevalence of herbal use among primary care patients varies in previous studies; the pattern of herbal use among urban racially/ethnically diverse primary care patients has not been widely studied The primary objectives of this study were to describe the use of herbs by ethnically diverse primary care patients in a large metropolitan area and to examine factors associated with such use The secondary objective was to investigate perceptions about and patterns of herbal use Methods: Data for a
cross-sectional survey were collected at primary care practices affiliated with the Southern Primary-care Urban Research Network SPUR-Net in Houston, Texas, from September 2002 to March 2003 To participate in the study, patients had to be at least 18 years of age and visiting one of the SPUR-Net clinics for routine, nonacute care Survey questions were available in both English and Spanish Results: A total of 322 patients who had complete information on race/ethnicity were included in the analysis Overall, 36 of the surveyed patients n 322 indicated use of herbs, with wide variability among ethnic groups: 50 of Hispanics, 50 of Asians, 41 of Whites, and 22 of African-Americans Significant factors associated with an individuals herbal use were ethnicity other than African-American, having an immigrant family history, and reporting herbal use by other family members About 40 of survey respondents believed that taking prescription medications and herbal medicines together was more
effective than taking either alone One-third of herbal users reported using herbs on a daily basis More Whites 67 disclosed their herbal use to their health-care providers than did African-Americans 45, Hispanics 31, or Asians 31 Conclusions: Racial/ethnic differences in herbal use were apparent among this sample of urban multiethnic adult primary care patients Associated factors of herbal use were non-AfricanAmerican ethnicity, immigrant family history, and herbal use among family members Whereas Hispanics and Asians reported the highest rates of herbal use, they were the least likely to disclose their use to health-care professionals These findings are important for ensuring medication safety in primary care practices
Page 1 of 9
page number not for citation purposes
BMC Complementary and Alternative Medicine 2004, 4:18
http://wwwbiomedcentralcom/1472-6882/4/18
Background
The use of complementary and alternative medicine CAM in the United States gained greater popularity in the
1990s Two national telephone surveys of 1,539 and 2,005 adults, respectively, demonstrated an increasing trend in the use of CAM, including relaxation techniques, herbal medicine, massage, chiropractic, and acupuncture[1,2] Specifically, the use of these unconventional treatments rose from 338 in 1990 to 421 in 1997 These surveys found that use of herbal medicine within the past year increased from 25 in 1990 to 121 in 1997[2] CAM use was also found to be more frequent among females, persons 35 to 49 years of age, persons of ethnicities other than African-American, persons who were college educated, and persons whose annual income was greater than 50,000[2] In a separate study also conducted in the 1990s, the American Botanical Council estimated that one-third of the nations adults use herbal remedies[3] Efficacy studies of herbal supplements are on the rise, but most data published to date are preliminary and do not provide strong evidence for the clinical effectiveness of herbs
Nevertheless, about 15 million American adults 18 are thought to use prescription medications concurrently with herbal or vitamin products[4], and as many as 70 of persons who use herbal remedies do not discuss their use of such remedies with their physicians or pharmacists[1,5-7] By not communicating about herbal use, they may put themselves at increased risk for adverse drug-herb interactions[8] and make it extremely difficult for health-care professionals to monitor them for such interactions[9] Likewise, patients do not know what symptoms they should report to their health-care provider that indicate potential adverse effects of drug-herb interactions Consequently, unintentional medication errors could occur The prevalence of herbal use among racially/ethnically diverse primary care patients varies from study to study[2,3,5-7,10-12], ranging from 30[5,6] to 77[7] Since patients must interact with their primary care providers and pharmacists for illnesses to be diagnosed and quality
medical care to be provided, a better understanding of variations in herbal use patterns among primary care patients is needed To this end, we conducted a study with two objectives: 1 to describe the herbal use of ethnically diverse patients in a large metropolitan area and to examine factors associated with herbal use; and 2 to investigate perceptions about and patterns of herbal use among those patients
Methods
Setting and study population We implemented this cross-sectional study within the Southern Primary-care Urban Research Network SPURNet from September 2002 to March 2003 SPUR-Net is a practice-based research network in Houston, Texas, that consists of five constituent member organizations affiliated with a county health system, a managed care organization, or a private practice clinic SPUR-Net clinicians provide care to patients from diverse ethnic and socioeconomic backgrounds, with approximately one million patient visits per year A total of six primary care clinics were
included in this study that varied according to socioeconomic status SES of their patients as measured by income level and insurance type For the purposes of this study, we defined clinic SES according to the insurance status of the majority of patients; high SES means that most patients have insurance ie, private insurance and/ or Medicare, and low SES means most patients are indigent ie, county health-care coverage and/or Medicaid Human subject approvals were obtained from the Institutional Review Boards at all of the SPUR-Net constituent organizations Permission to conduct the study was also obtained from the medical directors and applicable patient advisory groups at each of the six participating clinics
To be eligible for participation in the study, patients had to be at least 18 years of age and to be visiting one of the participating clinics for routine, nonacute care A target of 50 surveys in each of the six clinics was collected from a convenience sample of patients The
decision regarding the number of patients to be surveyed was limited by our resources, including availability in funding and personnel A research assistant approached potential subjects in the clinic setting to determine their willingness to complete a 23-item questionnaire about herbal use in either English or Spanish Those patients who consented to participate were either given the survey to complete on their own or had the survey administered to them by the research assistant Research assistants were available onsite to answer any questions the patients had, helping to improve patients understanding of the terms used in the survey Recruitment methods were the same in all of the participating clinics The research assistants stopped recruiting patients when a minimum of 50 surveys was collected in each clinic
Survey instrument Survey questions were adopted and modified from previously developed and validated surveys on CAM use, including national telephone surveys conducted by
Eisenberg et al[1,2,13], a family practice survey by Elder et al[5], a research clinic survey by Johnson et al[3], and a national mail survey by Astin et al[14] We modified these
Page 2 of 9
page number not for citation purposes
BMC Complementary and Alternative Medicine 2004, 4:18
http://wwwbiomedcentralcom/1472-6882/4/18
questions for use among our multiethnic patient population; we also translated the survey questions into Spanish The survey instrument was pilot tested with 54 Englishspeaking subjects and 10 Spanish-speaking subjects before the study The survey was reviewed by several groups of patient representatives in the community health centers to ensure consistency in responses For example, some members of a patient advisory group representing a homeless clinic perceived herbal use to be marijuana use; for this reason, we decided not to include this patient population in our study The final survey instrument had three components First, all participating patients answered
questions regarding sociodemographic characteristics eg, gender, age, race, ethnicity, education, immigrant family history, herbal use by other family members, spoken language other than English, and clinic location Immigrant family history and spoken language were elicited with the following questions: Are your family members immigrants to the United States Y/N?, and Do you speak another language other than English? After completing the demographic questions, respondents answered a series of questions regarding their belief in herbal use and their herbal information sources The questions pertained to their personal use of herbs Y/N; their belief in the benefit of herbal remedies Y/N, the source of their herbal information physician, pharmacist, family, friends, etc; their preferred content of herbal information eg, effectiveness, side-effects, interactions with other medications, and their preferred methods for obtaining herbal information from physicians or pharmacists eg, handout,
World Wide Web site, consultation Patients who reported using herbal supplements answered additional questions related to their patterns of and reasons for herbal use In open-ended questions, the participating patients were asked about the herbs they specifically used and the health conditions for which they took the herbal products Related questions included frequency of herbal use daily, frequently-few times/month, occasionally– few times/year; duration of use 1 year, 12 years, 35 years, 5 years; expenditure on herbal products; reported concomitant use of prescription medications; disclosure of herbal use to physicians or pharmacists; and any experiences of adverse reactions from using herbs For the purposes of this study, we used the definition of dietary supplements stipulated in the 1994 Dietary Supplement and Health Education Act DSHEA to differentiate herbs from vitamins and minerals Herbal use was defined as having ever used herbal products or natural medicines for health
maintenance or treatment of health conditions To measure herbal use, we asked the following question: Do you use any of the following? Response options included: herbs/herbal products or nat-
ural medicine eg, echinacea, St Johns wort, ginseng, ginkgo biloba, soy supplements, folk medicine or home remedy, vitamins, minerals, or none Herbal use did not include the use of folk medicine, home remedies such as honey, vitamins, or minerals
Data analysis Data from the paper-based survey were entered into an ACCESS database and were imported into SAS 91 for Windows The study variables were summarized by using one-way frequencies to examine the sociodemographic characteristics of the study sample, the belief in and information source for herbal use, and the patterns of and reasons for herbal use among urban multiethnic primary care patients The frequencies of use of specific herbs were counted, and the health conditions for which herbs were used were further coded into three types–acute,
chronic, and health maintenance
Based on findings from previous studies, we used the following independent variables as reference variables for both the univariate and multivariate logistic regression analyses: male gender, age less than 30 years, AfricanAmerican ethnicity, less than a college education, no immigrant family history, no herbal use by other family members, and visiting a high SES clinic A Chi-square test of proportions was used to determine the association between herbal use and each of the independent variables related to demographic characteristics; a p value 005 was considered to be statistically significant In order to assess factors associated with herbal use, all hypothesized variables age, gender, race and ethnicity, education, immigrant family history, herbal use by other family members, and clinic clientele stratified by SES were included in both the univariate and the multivariate logistic regression analyses These independent variables were entered as
dichotomous variables in the model: gender male vs female, age 50 years, 50 years, ethnicity African-American vs other, including Whites and Hispanics, education less than college vs college and greater, immigrant family history yes vs no, herbal use by family members yes vs no, and clinic clientele high SES vs low SES Significant variables identified by backward elimination of the main effects from the multivariate analysis were further evaluated in two-way interactions Thus, the final model contained all of the significant main effects and the two-way interaction terms Odds ratios and 95 confidence intervals were calculated to determine the effects of the significant variables on herbal use Since the sample size for Asians was small, Asians were not included in the logistic regression analyses Furthermore, the language variable was excluded from the regression analyses because the survey question was not clearly answered by many patients; for example, 10 Spanish-language forms had
no language other than English
Page 3 of 9
page number not for citation purposes
BMC Complementary and Alternative Medicine 2004, 4:18
http://wwwbiomedcentralcom/1472-6882/4/18
Table 1: Descriptive Characteristics of the Study Sample n 322
Variables Totals Gender Male Female Age yrs 30 3049 50 Education High School High School College Immigrant Family History No Yes Herbal Use by Other Family Members No Yes Clinic Type High SES Clinic Low SES Clinic
White n 68211 20294 48706 13191 34500 21309 344 16235 49721 57864 9136 43632 25368 40588 28412
Hispanic n 98304 34347 64653 17173 34347 47480 52530 23235 23235 41418 57582 42429 56571 14143 84857
African American n 136422 37274 98726 27198 47346 62456 17126 54400 64474 101771 30229 95699 41301 52382 84618
Asian n 2062 7350 13650 4200 5250 11550 0 5250 15750 0 201000 1155 945 945 1155
indicated In addition, some answers were possibly indicative of an exclusive language other than English instead of the bilingual capability
of the respondent
Results
Description of sample Of the 327 patients who agreed to participate in the survey, only 322 completed the race/ethnicity information and were included in the analysis The characteristics of the study sample are summarized in Table 1 Two-thirds of the patients were female, and approximately half of all the patients had less than a college education More than a third 37 of the patients reported having an immigrant family history, and 50 patients 15 used the Spanish-language form to complete the survey Herbal use Overall, 36 of our study sample reported ever using herbs The proportions of herbal users varied across racial/ ethnic groups, with use being reported by 50 of Hispanics, 50 of Asians, 41 of Whites, and 22 of AfricanAmericans Herbal use by other family members was reported to be 41 57 among Hispanics, 45 among Asians, 37 among Whites, and 30 among AfricanAmericans Patients who reported using herbs indicated that they received information about those
herbs mainly from family members and relatives Nevertheless, most patients reported that they preferred receiving herbal information eg, on effectiveness, side-effects, and drug interactions through handouts or brochures from their
physicians or pharmacists, followed by having access to a consultation service or a Web site About 40 of all of the survey respondents, but especially Asians 55 and Whites 47, believed that taking prescription medications and herbal medicines together was more effective than taking either alone About 41 of Hispanic respondents believed that herbal medicines were superior to prescription medications, as compared to 12 of Whites These differences in beliefs about herbal use among the ethnic groups were found to be statistically significant p 005 Nearly half of the patients who reported using herbs 46, particularly Hispanics 63 and Asians 57, also reported taking prescription medications concomitantly with the herbs Table 2 Since our survey question was
designed to measure self-reported concomitant herbal use and prescription drug use, we cannot confirm whether or not those who reported taking both were actually using both
Factors associated with herbal use Variables demonstrating a significant univariate association p 005 with herbal use were ethnicities other than African-American, immigrant family history, and herbal use by other family members Table 3 In the multivariate logistic regression model, non-African-American race/ethnicity OR 242, 95 CI, 133440, immigrant family history OR 223, 95 CI, 120 414, and reported herbal use by other family members OR 798, 95 CI, 4481418 remained significant predictors of reported herbal use p 005 In addition,
Page 4 of 9
page number not for citation purposes
BMC Complementary and Alternative Medicine 2004, 4:18
http://wwwbiomedcentralcom/1472-6882/4/18
Table 2: Patterns of and Reasons for Herbal Use Among Urban Multiethnic Primary Care Patients n 322
Variables Herbal Use Daily Herbal
Use Herbal Use 3 Years Report Taking Herbs and Prescription Medications for the Same Health Problems Told Physicians/Pharmacists About Herbal Use Had a Bad Reaction Believed Both Prescription Medications and Herbal Medicines Are Better Than Either Alone Agree Disagree Neither Believed Herbal Medicines Are Superior to Prescription Medications Agree Disagree Neither Received Herbal Information multiple Family or relatives Magazines Television Internet Physician Pharmacist Preferred Herbal Information multiple Effectiveness Side-effects Interactions Preferred Method for Obtaining Herbal Information multiple Handout/Brochure Website Consultation Indicates only those patients who reported herbal use p 0008; p 00001
White n 28412 14483 12411
Hispanic n 49500 13228 45789
African American n 30221 13333 17459
Asian n 10500 4308 7538
10333 20667 274
36632 17309 120
17327 21447 3111
8571 4308 0
32471 14206 22324
28286 44449 26265
54406 48361 31233
11550 6300 315
8123 36554
21323 20294 24353 13191 12177 10147 229 53779 42618 46677 45662 25368 29427
40412 20206 37381 60612 19194 24245 771 882 220 72735 76776 67684 80816 11112 20204
31231 62463 41306 43316 38279 45331 966 1288 644 87640 82603 75552 84618 20147 47346
6300 8400 6300 10500 5250 0 420 2100 0 9450 12600 9450 11550 6300 5250
interactions between immigrant family history and herbal use by other family members were found to be significant terms in the model Table 3 With the race/ethnicity variable adjusted, having an immigrant family history was associated with a 19 times greater likelihood of herbal use among those whose family members also use herbs When the analyses were run with the Asian group included, the results did not change
Perceptions about and patterns of herbal use The reasons given by the study subjects for herbal use included faster resolution of symptoms 47, the desire to try alternative therapies 33, and preference for having their own methods to care for their health 20 Among
the herbal users, 32 reported taking herbs on a daily basis, and 60 reported using herbs for longer than three years Usage varied by race/ethnicity; for example,
48 of Whites reported taking herbs on a daily basis, and 79 of Hispanics reported using herbs for longer than three years Even though Hispanics and Asians used herbs more frequently, they were the least likely to disclose their herbal use to their physicians or pharmacists More Whites 67 told their health-care professionals about their herbal use than did the African-Americans 45, Hispanics 31, or Asians 31 The reasons given for nondisclosure generally fell into two main categories: 1 They the provider never asked, and 2 It wasnt important for them to know While few respondents 53 reported having experienced an adverse reaction to herbs, many of them 43 did not inform their physicians of it
Page 5 of 9
page number not for citation purposes
BMC Complementary and Alternative Medicine 2004,
4:18
http://wwwbiomedcentralcom/1472-6882/4/18
Table 3: Univariate Analysis of Factors Associated with Herbal Use Among Urban Multiethnic Primary Care Patients n 302
Variables
Tot al
Herbal Use n
X2 pvalue
Gender Male Female Age yrs 30 30 Race/Ethnicity African-American White Hispanic Education College College Immigrant Family History No Yes Herbal Use by Other Family Members No Yes Clinic Type High SES Clinic Low SES Clinic
91 210 106 196 136 166 165 136 199 96 180 122 106 196
32352 75357 34321 73372 30221 77464 57346 49360 56281 49510 31172 76623 35330 72367
09
Asians reported the highest rates of herbal use 50, and African Americans reported the lowest 22 Previous research conducted in the western United States found that the prevalence of herbal use among racially/ethnically diverse primary care patients varies[2,3,5-7,10-12], ranging from 30 among primary care patients residing in urban settings on the west coast of the United States[5,6] to 77 among primary care
patients residing in the largest United States–Mexico border city[7] As expected, factors associated with herbal use included race/ethnicity, having an immigrant family history, and herbal use by other family members In addition, we found interactions between having an immigrant family history and herbal use by other family members Previous studies did not examine such interactions and found age to be predictive of herbal use[2,6,7] Unlike other investigators, we did not find a significant relationship between age and herbal use Other investigators, however, did not account for interactions such as those addressed in our analysis One study n 113 found no significant differences in the use of CAM therapies that could be attributable to gender, educational level, age, race, or clinic attended[5] Another study n 542 found an association between the use of CAM therapies, high education level, and female gender[6] In addition, a recent study conducted in a large United States–Mexico
border city revealed that 77 of the residents surveyed n 547 use all modalities of CAM therapies and that such use was associated with a high education level[7] When the residents reported specifically using herbal and home remedies 59, however, herbal use was found to be associated with a low education level[7] We found that nearly half of herbal users 46 reported taking herbal medicines and prescription medications concomitantly More importantly, 43 of herbal users reported not disclosing their herbal use to their physicians or pharmacists Interestingly, Hispanics and Asians used herbs the most frequently but disclosed their herbal use to their physicians or pharmacists less often than did Whites and African Americans This lack of communication about herbal use is an area of concern because of the potential for medication errors and untoward reactions to herbdrug interactions Adverse drug-herb interactions pose a great danger for patients For example, ginkgo biloba, garlic, and
ginseng all may interact with Coumadin warfarin sodium and cause an increase in bleeding time[15,16] Echinacea, an immunostimulant, can counteract the action of the immunosuppressants eg, the corticosteroids prednisone, methotrexate, and cyclosporine used to treat immune disorders[17,18] The interaction between St Johns wort and cyclosporine–which is used to treat rheumatoid arthritis and psoriasis and to prevent the rejection of a transplanted organ–could result in
04
00001
08
00001
00001
05
The specific herbs used by the patients covered a wide spectrum and varied by ethnicity The herbs used most commonly by White patients were echinacea 321, St Johns wort 214, ginkgo biloba 143, and chamomile 143 Hispanic patients most often reported using chamomile 612, aloe vera 449, and garlic 204 African-American patients reported primarily using garlic 40, ginseng 30, and ginkgo biloba 10 The herbs used by Asian patients were garlic 50, ginkgo biloba 30, and ginger 30 Other herbs that
were reported by patients–albeit infrequently–included Yun Zhi, black cohosh, dong quai, guggle phosphate, bee pollen, cat claws, and a shot of whiskey The patients who reported using herbs used them for a wide range of health problems, such as boosting the immune system, improving memory, and treating insomnia, depression, or diabetes For conditions considered to be chronic, 44 of the White patients reported herbal use versus 32 of African-American patients For conditions considered to be acute, 71 of Hispanic patients used herbs versus 10 of Asians For health maintenance, 50 of Asian patients used herbs versus 16 of Hispanic patients
Discussion
Our data show that herbal use is common 36 among urban multiethnic primary care patients, but has a wide variability among racial/ethnic groups Hispanics and
Page 6 of 9
page number not for citation purposes
BMC Complementary and Alternative Medicine 2004, 4:18
http://wwwbiomedcentralcom/1472-6882/4/18
Table 4: Multiple Logistic
Regression Analysis of Factors Associated with Herbal Use Among Urban Multiethnic Primary Care Patients n 302
Variable Main Effects Gender Male Female Age yrs 30 30 Race/Ethnicity African-American White Hispanic Education College College Immigrant Family History No Yes Herbal Use by Other Family Member No Yes Clinic Type High SES Clinic Low SES Clinic Interactions Immigrant Family History Herbal Use by Other Family Members
OR
95 CI
100 112 100 137 100 242 100 111 100 223 100 798
060211
074255
handout or a brochure These findings suggest that future studies are warranted to develop and test educational materials to 1 deepen our understanding of racial/ethnic variation in herbal use among primary care patients; 2 educate health-care professionals about the variations in the use patterns and the rationales for use that may help to reduce medication errors and increase the quality and safety of medical care; and 3 educate patients regarding evidence-based herbal information
and encourage patients to communicate their herbal use to their physicians/pharmacists Our study results should be interpreted in the context of several limitations First, our estimates of herbal use frequency are imprecise because we used a convenience sample instead of identifying patients by randomized sampling Secondly, even though we adopted the DSHEA definition of herbs, some patients had difficulty understanding this definition Specifically, a small group of patients thought that herbs were equivalent to prescription medications such as digoxin and aspirin; the patients level of understanding of herbs was improved after the research assistants provided further explanation and clarification Third, we discovered that asking questions, such as What do you take when you run out of your medications?, was more effective in eliciting answers from the study subjects than when asking them, Do you use herbs, herbal products or natural medicine? For these reasons, we had research
assistants on-site to help facilitate the survey process Fourth, the patients surveyed reported their concomitant use of herbs with prescribed medications based on their perceptions and memories Last, we did not include measures of quality of life or questions about patient satisfaction with herbal use, which would be helpful in future studies, especially when comparing multiethnic and socioeconomically diverse patient groups
133440
058215
120414
448 1418
100 080
040160
1939
811 4638
p 005
decreased availability of cyclosporine and, consequently, to the worsening of arthritis or psoriasis or the rejection of a transplanted organ [19-23] St Johns wort may also interact with antidepressants, such as monoamine oxidase inhibitors eg, Nardil, Parnate and potentiate the effects of selective serotonin reuptake inhibitors eg, Paxil, Prozac, Zoloft[24] Moreover, drug-herb interactions might adversely affect the monitoring of certain drug therapies and might even cause
life-threatening complications For example, ginseng, hawthorn, licorice, kyushin, plantain, and uzara root have the potential to interfere with the monitoring of Lanoxin digoxin[25] In addition, kava has been associated with hepatitis[26] and has resulted in coma when used with Xanax alprazolam[27] As these detrimental effects have been realized, concern about the increased use of herbal supplements has grown[2,28-33] Two-thirds of the patients we surveyed reported wanting to receive information on herbal medicines from their physicians or pharmacists, preferably in the form of a
Conclusions
Despite these limitations, our findings confirm the increasing frequency of herbal use as reported in previous studies Our study also gives a unique perspective by focusing on factors associated with reported herbal use among an urban multiethnic primary care patient population In particular, we found that patients with immigrant family history–especially those with family members who use
herbs–are most likely to report herbal use Perhaps most disconcerting was our finding that while an increasing number of primary care patients report taking herbal medicines concomitantly with prescription medications, many of them do not disclose their herbal use to their physicians or pharmacists These findings suggest that primary care clinicians need to understand the extent and patterns of herbal use by their multiethnic patients and efforts to elicit information from patients about herbal use may be warranted Future studies are needed to
Page 7 of 9
page number not for citation purposes
BMC Complementary and Alternative Medicine 2004, 4:18
http://wwwbiomedcentralcom/1472-6882/4/18
develop effective interventions for primary care healthcare professionals and patients to improve medication safety by eliminating potential adverse herb-drug interactions and medication errors
8 9 10 11
Competing interests
The authors declare that they have no competing interests
Authors
contributions
GMK conceived of the study, designed the survey questionnaires, coordinated and managed the data-collection process, directed data analysis, and drafted the manuscript STH participated in drafting the manuscript and helped with data analysis LTW performed the statistical analysis and participated in drafting the manuscript RB helped with data analysis RJV reviewed the questionnaires and data analysis, and participated in drafting the manuscript All authors read and approved the final manuscript
12
13
14 15 16
Acknowledgments
This project was supported in part by grants P20 HS11187 from the Agency for Healthcare Research and Quality and grant D12 HP00042 from Bureau of Health Professions of the Health Resources and Services Administration, which provided infrastructure support for the Southern Primary-care Urban Research Network SPUR-Net The authors wish to acknowledge the following clinics for their participation in this study: Baylor Family Medicine, Casa de Amigos
Community Health Center CHC, Gulfgate CHC, Martin Luther King CHC, Peoples CHC, and Kelsey Seybold Clinic–Main Campus We appreciate the support from members of the SPUR-Net Executive Committee We thank the following individuals, Carlos Vallbona, MD, Thomas Gavagan, MD, MPH, and Anthony Greisinger, PhD, for helping us facilitate project approval processes at community health centers and the Kelsey Seybold Clinic We also thank the efforts of the following individuals from the Department of Family and Community Medicine at Baylor College of Medicine: research assistants Joanne Wei, Nancy Cheak, Jana Davis, and Armandina Garza for administering the surveys at the participating clinics; Cai Wu and Carol Mansyur for their computer information systems support; and Pamela Paradis Tice, ELSD for her editorial assistance 17 18 19 20
21 22 23 24 25 26 27 28 29 30 31
References
1 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL: Unconventional medicine in the United
States: prevalence, costs, and patterns of use N Engl J Med 1993, 328:246-252 Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC: Trends in alternative medicine use in the United States, 19901997: results of a follow-up national survey JAMA 1998, 280:1569-1575 Johnston BA: One-third of nations adults use herbal remedies Herbalgram 1997, 40:49 Smolinske SC: Dietary supplement-drug interactions J Am Med Womens Assoc 1999, 54:191-192 195 Elder NC, Gillcrist A, Minz R: Use of alternative health care by family practice patients Arch Fam Med 1997, 6:181-184 Palinkas LA, Kabongo ML: The use of complementary and alternative medicine by primary care patients A SURFNET study J Fam Pract 2000, 49:1121-1130 Rivera JO, Ortiz M, Lawson ME, Verma KM: Evaluation of the use of complementary and alternative medicine in the largest
2
3 4 5 6 7
United States-Mexico border city Pharmacotherapy 2002, 22:256-264 Sorensen JM: Herb-drug, food-drug, nutrient-drug, and drugdrug
interactions: mechanisms involved and their medical implications J Altern Complement Med 2002, 8:293-308 Bush M, Visser A: Complementary and alternative medicine: whose responsibility? Patient Educ Couns 2004, 53:1-3 Zeilmann CA, Dole EJ, Skipper BJ, McCabe M, Dog TL, Rhyne RL: Use of herbal medicine by elderly Hispanic and non-Hispanic white patients Pharmacotherapy 2003, 23:526-532 Dole EJ, Rhyne RL, Zeilmann CA, Skipper BJ, McCabe ML, Dog TL: The influence of ethnicity on use of herbal remedies in elderly Hispanics and non-Hispanic whites J Am Pharm Assoc Wash 2000, 40:359-365 Giveon SM, Liberman N, Klang S, Kahan E: Are people who use natural drugs aware of their potentially harmful side effects and reporting to family physician? Patient Educ Couns 2004, 53:5-11 Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S, Davis RB: Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey Ann
Intern Med 2001, 135:344-351 Astin JA: Why patients use alternative medicine: results of a national study JAMA 1998, 279:1548-1553 Miller LG: Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions Arch Intern Med 1998, 158:2200-2211 Norred CL, Brinker F: Potential coagulation effects of preoperative complementary and alternative medicines Altern Ther Health Med 2001, 7:58-67 Parnham MJ: Benefit-risk assessment of the squeezed sap of the purple coneflower Echinacea purpurea for long-term oral immunostimulation Phytomedicine 1996, 3:95-102 Wagner H, Suppner H, Schafer W, Zenk M: Immunologically active polysaccharides of Echinacea purpurea cell cultures Phytochemistry 1988, 27:119-126 Barone GW, Gurley BJ, Ketel BL, Abul-Ezz SR: Herbal supplements: a potential for drug interactions in transplant recipients Transplantation 2001, 71:239-241 Karliova M, Treichel U, Malago M, Frilling A, Gerken G, Broelsch CE: Interaction of Hypericum
perforatum St Johns wort with cyclosporin A metabolism in a patient after liver transplantation J Hepatol 2000, 33:853-855 Barone GW, Gurley BJ, Ketel BL, Lightfoot ML, Abul-Ezz SR: Drug interaction between St Johns wort and cyclosporine Ann Pharmacother 2000, 34:1013-1016 Breidenbach T, Hoffmann MW, Becker T, Schlitt H, Klempnauer J: Drug interaction of St Johns wort with cyclosporin Lancet 2000, 355:1912 Ruschitzka F, Meier PJ, Turina M, Luscher TF, Noll G: Acute heart transplant rejection due to Saint Johns wort Lancet 2000, 355:548-549 Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammer W, Melchart D: St Johns wort for depression: an overview and metaanalysis of randomized clinical trials BMJ 1996, 313:253-258 Blumenthal M: Industry alert: plantain adulterated with digitalis HerbalGram 1997, 40:28-29 Escher M, Desmeules J, Giostra E, Mentha G: Drug points: hepatitis associated with kava, a herbal remedy for anxiety BMJ 2001, 322:139 Almeida JC, Grimsley EW: Coma from the health
food store: interaction between kava and alprazolam Ann Intern Med 1996, 125:940-941 Eliason BC, Kruger J, Mark D, Rasmann DN: Dietary supplement users: demographics, product use, and medical system interaction J Am Board Fam Pract 1997, 10:265-271 Fugh-Berman A: Herbal medicinals: selected clinical considerations, focusing on known or potential drug-herb interactions [letter; comment] Arch Intern Med 1999, 159:1957-1958 Fugh-Berman A, Ernst E: Herb-drug interactions: review and assessment of report reliability Br J Clin Pharmacol 2001, 52:587-595 Neal R: Report by David M Eisenberg, MD, on complementary and alternative medicine in the United States: overview
Page 8 of 9
page number not for citation purposes
BMC Complementary and Alternative Medicine 2004, 4:18
http://wwwbiomedcentralcom/1472-6882/4/18
32
33
and patterns of use J Altern Complement Med 2001, 7Suppl 1:S19-S21 Kessler RC, Davis RB, Foster DF, Van Rompay MI, Walters EE, Wilkey SA, Kaptchuk TJ, Eisenberg DM:
Long-term trends in the use of complementary and alternative medical therapies in the United States Ann Intern Med 2001, 135:262-268 Ernst E: Harmless herbs? A review of the recent literature Am J Med 1998, 104:170-178
Pre-publication history
The pre-publication history for this paper can be accessed here: http://wwwbiomedcentralcom/1472-6882/4/18/prepub
Publish with Bio Med Central and every scientist can read your work free of charge
BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright
Submit your manuscript here:
http://wwwbiomedcentralcom/info/publishing_advasp
BioMedcentral
Page 9 of 9
page number not for citation
purposes
Source:hcvadvocate.org
