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Journal of the Association of Arab Universities for Basic and Applied Sciences (2016) xxx, xxxxxx

University of Bahrain
Journal of the Association of Arab Universities for
Basic and Applied Sciences
www.elsevier.com/locate/jaaubas
www.sciencedirect.com

ORIGINAL ARTICLE

Knowledge, attitude, and utilization of herbal


medicines by physicians in the Kingdom of Bahrain:
A cross-sectional study
Mahmood Hilal a, Sawsan Hilal b,*

a
College of Medicine, AMA International University, Bahrain
b
Department of Mathematics, College of Science, University of Bahrain, Bahrain

Received 15 February 2015; revised 16 September 2016; accepted 12 November 2016

KEYWORDS Abstract Herbal medicines are widely accepted as a primary source of healthcare due to their nat-
Attitude; ural origin. However, this widespread popularity is counterbalanced with the lack of relevant
Herbal medicines; research. The need to account for this deficiency motivated the present study which aims at (1)
Kingdom of Bahrain; assessing physicians knowledge and attitude toward herbal medicines, (2) determining to what
Knowledge; extent herbal medicines are utilized by physicians in the Kingdom of Bahrain, and (3) highlighting
Physicians; the main factors that may facilitate or hinder the utilization of herbal medicines. A cross-sectional
Utilization study was conducted to cover 96 physicians conveniently sampled from different departments
among one public and two private hospitals. The main tool that was used to gather the required
data was a self-administered questionnaire that has been specifically developed by the researchers
to address the study objectives. The collected data were processed by the statistical package for
social sciences SPSS (version 18). The study found that 64.6% of the participated physicians have
generally basic knowledge on herbal medicines, and half of them acquired their knowledge from
experience. Moreover, the results showed a tendency by physicians to use herbal medicines person-
ally more frequently than prescribing them to the patients. Interestingly, the majority (91.7%) of the
participants showed a desire to enhance their knowledge with regard to herbal medicines. They
ascertained that the rational use of herbal medicines is hindered by poor quality control (65.6%)
and limited information on their adverse events (62.5%). The physicians claimed that the availabil-
ity of sufficient knowledge (68.8%) beside the low cost (66.7%) are major facilitating factors toward
utilizing herbal medicines.
2016 University of Bahrain. Publishing services by Elsevier B.V. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Complementary and alternative medicine (CAM) is widely


* Corresponding author. used worldwide. According to WHO guidelines (2004) and
E-mail address: shilal@uob.edu.bh (S. Hilal). NIH (2010) then CAM is defined as a group of diverse medical
Peer review under responsibility of University of Bahrain.
http://dx.doi.org/10.1016/j.jaubas.2016.11.001
1815-3852 2016 University of Bahrain. Publishing services by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Hilal, M., Hilal, S. Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: A cross-
sectional study. Journal of the Association of Arab Universities for Basic and Applied Sciences (2016), http://dx.doi.org/10.1016/j.jaubas.2016.11.001
2 M. Hilal, S. Hilal

and healthcare systems, practices, and products that are not est here lies in the Kingdom of Bahrain, which is known to be a
currently considered to be part of conventional medicine. This pioneer among the Arabian Gulf countries regarding health-
popularity of CAM is basically derived from the wishes for care. According to WHO report (2005), Bahrain regulates her-
non-pharmacological treatment. One important example of bal medicines using the same, or partly the same, legal
CAM is herbal medicines which constitute the focus of this framework as is used for conventional pharmaceuticals. More-
study, and defined as medicines originate from plant-based over, herbal medicines are sold in pharmacies as over-the-
ingredients which are produced by extraction, fractionation, counter medicines and in special outlets in the Kingdom of
purification, concentration, steeping, heating or any other Bahrain. A few studies have been conducted in Bahrain con-
physical or biological processes with no chemically defined cerning CAM in general (Khalaf and Whitford, 2010) and her-
substances. Herbal medicines have been used since the begin- bal medicines in specific (Al-Khuzai et al., 2010). However, the
ning of human history. There are four basic systems known intention of these studies was not the physicians. To the best of
for herbal medicines: Traditional Chinese, Traditional Indian our knowledge, there is no previous study conducted in the
(Ayurvedic), Western, and Traditional Arab. Then it comes Kingdom of Bahrain to assess physicians knowledge and atti-
as no surprise that herbal medicines play an increasingly tude toward herbal medicines as well as the extent of their
important role in healthcare and their use at the hope of tack- utilization.
ling diseases is widespread (Adhiah et al., 2013; Amin and
Mousa, 2007; Gratus et al., 2009). Indeed, several studies
found that herbal medicines are the most commonly used 2. Methods
CAM among pharmacy/medical students (Awad et al., 2012;
Freymann et al., 2006; James and Bah, 2014). A cross-sectional study was conducted to assess physicians
WHO guidelines (2004) on safety monitoring of herbal knowledge and attitude toward herbal medicines. The study
medicines in pharmacovigilance systems stated that there is a determined to what extent herbal medicines are utilized by
widespread misconception that natural remedies are harmless physicians in the Kingdom of Bahrain with respect to the cat-
and carry no risk. This common belief was confirmed by sev- egory of utilization (prescription or personal-use) and purpose
eral studies (Ernst, 1998; Saad et al., 2005) which ascertained of utilization (complementary or alternative). It also high-
that one main reason behind the interest in herbal medicines lighted the main facilitating factors that might encourage
is the notion that all herbal products due to their natural origin physicians to utilize herbal medicines, and the main hindering
are safe and effective. As a consequence of this belief, side factors that might preclude the rational use of herbal medicines
effects (unintended effect of a drug related to its pharmacolog- from physicians perspective.
ical properties) of herbal medicines and adverse events According to the Central Informatics Organization, Bah-
(unwanted medical occurrence that may present during treat- rain has 27 health centers, 3 public hospitals and 16 private
ment with a drug) that may arise from their consumption are hospitals in 2013. All physicians working in the healthcare sys-
often overlooked (Bent, 2008; De Smet, 2002). There is also tem of the Kingdom of Bahrain represented by the health cen-
the possibility of interaction between herbal medicines and ters and general hospitals (excluding specialized hospitals such
the conventional medicines which might cause serious health as maternity and psychiatric hospitals) were eligible to partic-
problems (Neustadt, 2006). On the other hand, patients have ipate in the study. A convenience sampling method was imple-
very limited reliable resources concerning the use of herbal mented on which the inclusion of both public and private
medicines and the most common sources of advice on herbal hospitals was taken into account at the attempt to gain a gen-
medicines are friends and relatives (Gratus et al., 2009; eral understanding about the research topic of interest. More
Suleiman, 2014). specifically, the Salmaniya Medical Complex was included as
As far as the herbal medicines are concerned, then physi- the largest public hospital. The complex dates back to the
cians are not in a better situation than patients since physicians 1950s and has around 900 beds. As for the private hospitals,
themselves lack the relevant knowledge and hence they are the American Mission Hospital was included since it is the old-
unable to give informed advice to their patients (Ameade est hospital in the Kingdom of Bahrain (dates back to 1902)
et al., 2015; Xu and Levine, 2008). Indeed, Suleiman (2014) and it is also the longest-standing hospital in the Arabian Gulf.
and Vickers et al. (2006) found that the majority of patients Moreover, the International Hospital of Bahrain was consid-
are not disclosing the use of herbal medicines to their physi- ered in the study as one of the major private hospitals. It is
cians. This lack of communication between patients and physi- worth mentioning that, according to the Health Statistics
cians is a serious problem that supports the need for healthcare 20132014 published by the Health Information Directorate
professionals to be aware of herbal medicines use alongside Ministry of Health, the selected private hospitals are among
conventional medicines. The same assertion was confirmed the largest private hospitals in the Kingdom of Bahrain in
by several studies (Awodele et al., 2012; Clement et al., 2005; terms of the medical and allied health manpower. Once the
Ghia and Jha, 2012) which reported that the gap between hospitals have been specified, a number of physicians were
acceptance of herbal medicines and the poor knowledge that conveniently selected from different departments within each
healthcare professionals have about these remedies reflects of the three hospitals to participate in the study. We note that
the need for educational intervention. the study design detailed above was mainly adopted from
The aforementioned problems raise the need for further Suleiman (2014).
research to provide adequate information concerning the use The researchers developed a self-administered question-
of herbal medicines toward integrating them into the health- naire that was specifically designed to address the study objec-
care system. Despite the fact that the Arabian Gulf region tives after reviewing the relevant literature (Ameade et al.,
has a long tradition of herbal therapies (Amin and Mousa, 2015; Awodele et al., 2012; Clement et al., 2005; Gaul et al.,
2007), the number of relevant studies is very limited. The inter- 2011; Hasan et al., 2011; James and Bah, 2014; Xu and

Please cite this article in press as: Hilal, M., Hilal, S. Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: A cross-
sectional study. Journal of the Association of Arab Universities for Basic and Applied Sciences (2016), http://dx.doi.org/10.1016/j.jaubas.2016.11.001
Knowledge, attitude, and utilization of herbal medicines 3

Fig. 1 A graphical representation for the four sections of the developed questionnaire.

Levine, 2008). The developed questionnaire has four sections. were distributed to the physicians from the available depart-
Section 1 concerns with the physicians profile including gen- ments and collected back (after three weeks) by the administra-
der, qualification, position, experience, and the department tors in order to be returned to the researchers.
in which the physician works. With regard to the physicians The collected data were processed by the statistical package
knowledge on herbal medicines, then Section 2 covers ques- for social sciences SPSS (version 18). More concretely, the data
tions about knowledge level, source, and enhancement. Sec- have been analyzed using both descriptive and inferential
tion 3 consists of 5-point likert scale questions that evaluate statistics (non-parametric tests: chi-square test for association,
physicians utilization of herbal medicines in terms of prescrip- KruskalWallis test and MannWhitney test for differences).
tion, personal-use, complementary-usage, and alternative-
usage. The point descriptors are never, rarely, sometimes,
often and always. Section 4 consists of yesno questions that 3. Results
explore the facilitating and hindering factors of herbal medici-
nes utilization. A graphical representation for the four sections 3.1. Physicians profile
of the developed questionnaire are presented in Fig. 1.
The developed questionnaire was initially piloted among Out of the 150 distributed copies of the questionnaire, 100
sixteen physicians from two health centers (Jidhafs Health were returned back to represent a response rate of 66.7%.
Center and Al-Naim Health Center). We elected to conduct However, four of the returned copies were invalid due to a
the pilot study in health centers instead of hospitals for sim- noticeable number of non-answered questions to left with a
plicity in distributing and collecting the questionnaire. The net total of 96 participants that constituted the study sample
received feedback was incorporated into the revised version as shown in Table 1.
of the questionnaire to ensure its validity before embarking Some demographic information of the participated physi-
on the fieldwork. The corresponding Cronbach-alpha coeffi- cians is summarized in Fig. 2. Nearly 51% of the participated
cient was 0.779 and hence the reliability of the questionnaire physicians were males. With regard to the five major depart-
was established. Then a total of 150 copies of the revised ver- ments, the majority of the participants were from the out-
sion of the questionnaire were distributed among the three patient and OB/GYN with 26.0% and 17.7% respectively.
selected hospitals. Each copy of the questionnaire was accom- Only 5.2% of the participants were from the internal medicine
panied with a cover page stating the purpose of the study and department, while 8.3% of the participants were from each of
giving clear instructions to the respondents. Moreover, volun- the surgery and pediatrics departments. The rest of the partic-
tary participation and confidentiality were assured. The ques- ipants (33.3%) distributed among other departments (not
tionnaires were handled personally to the administrators in specified). About 37.5% of the participants have a bachelor
the selected hospitals who signed a letter confirming their con- degree and 41.7% of them have a master degree, while those
sent to take a role in the study. Afterward, the questionnaires holding a PhD degree constitute 19.8% of the study sample.

Please cite this article in press as: Hilal, M., Hilal, S. Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: A cross-
sectional study. Journal of the Association of Arab Universities for Basic and Applied Sciences (2016), http://dx.doi.org/10.1016/j.jaubas.2016.11.001
4 M. Hilal, S. Hilal

47.9% whose experience exceeds ten years. The majority of


Table 1 The study sample.
the participants were specialists (44.8%) and the rest of them
Name of hospital No. of participants were either residents (26.0%) or consultants (28.1%).
Salmaniya Medical Complex (Public) 33
American Mission Hospital (Private) 12 3.2. Knowledge on herbal medicines
International Hospital of Bahrain (Private) 51
Total 96 Table 2 summarizes physicians responses regarding knowl-
edge on herbal medicines. It reveals that the level of knowledge
on herbal medicines is considered to be basic for the majority
There were only 15.6% of the participants having less than five (64.6%) of the participated physicians. In contrast, there were
years of experience in the medical field, while about 36.5% of only two out of 96 participants (2.1%) having an advanced
the participants experiencing five-to-ten years and about level of knowledge on herbal medicines. The experience was

Fig. 2 The profile of the participated physicians (X means missing data due to non-answered questions). As per the position of the
participants: the resident is a physician who spends a number of training years in a certain medical department after graduation; the
specialist is a board certified physician who has successfully completed the residency period in the intended medical specialty and passed a
comprehensive test given by a recognized medical organization; the consultant is a physician who has an additional training in his/her
medical specialty and hold a fellowship from a recognized medical agency.

Please cite this article in press as: Hilal, M., Hilal, S. Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: A cross-
sectional study. Journal of the Association of Arab Universities for Basic and Applied Sciences (2016), http://dx.doi.org/10.1016/j.jaubas.2016.11.001
Knowledge, attitude, and utilization of herbal medicines 5

Table 2 Summary of physicians responses regarding knowledge on herbal medicines.


Physicians profile Knowledge on Herbal Medicines
Level Source Enhance.
Basic Moderate Advanced Experience Study Others No Yes
Gender
Male 27 21 1 25 16 8 6 43
Female 35 11 1 23 11 13 2 45
Total 62 32 2 48 27 21 8 88

Qualification
Bachelor 24 12 0 18 10 8 2 34
Master 26 14 0 24 10 6 4 36
Doctorate 11 6 2 5 7 7 2 17
Total 61 32 2 47 27 21 8 87

Department
Out-Patient 18 7 0 18 4 3 2 23
OB/GYN 11 5 1 7 4 6 2 15
Surgery 4 4 0 0 6 2 1 7
Pediatrics 6 2 0 6 1 1 0 8
Internal Medicine 2 2 1 2 2 1 0 5
Others 21 11 0 14 10 8 3 29
Total 62 31 2 47 27 21 8 87

Position
Resident 20 5 0 8 7 10 1 24
Specialist 30 13 0 29 5 9 4 39
Consultant 11 14 2 10 15 2 3 24
Total 61 32 2 47 27 21 8 87

Experience
< 5 years 11 4 0 4 5 6 0 15
5; 10 20 15 0 18 10 7 2 33
> 10 31 13 2 26 12 8 6 40
Total 62 32 2 48 27 21 8 88

found to be the main source of knowledge on herbal medicines Table 3 Results of chi-square test for association.
among three options provided in the questionnaire by half of
Knowledge Source
the participants, followed by the academic study (28.1%)
and other resources such as the internet (21.9%). Interestingly, Experience Academic study Others
91.7% of the participated physicians showed a desire to Position
enhance their knowledge regarding herbal medicines compared Resident 08 (17.0%) 07 (25.9%) 10 (47.6%)
to only 8.3% who did not want to do so. Furthermore, Table 3 Specialist 29 (61.7%) 05 (18.5%) 09 (42.9%)
reports a significant association (using chi-square test) between Consultant 10 (21.3%) 15 (55.6%) 02 (09.5%)
physicians position and the source of knowledge on herbal Total 47 27 21
medicines. It was found that 61.7% of the physicians in the
v 22:743 with p-value < 0.001.
2
study who acquired their knowledge from experience were spe-
cialists, while 55.6% of those having academic-based knowl-
edge were consultants. ipants often or always use herbal medicines, while the
majority of the participants ranked their utilization of herbal
3.3. Utilization of herbal medicines medicines as either rarely or sometimes. Furthermore,
the presented results seem to indicate that the participated
The results obtained regarding the utilization of herbal medici- physicians tend to use herbal medicines personally more than
nes by the physicians in the study are presented in Table 4. The prescribing them to their patients. Interestingly, the results
overall conclusion that emerged from the corresponding regarding the complementary-usage and the alternative-usage
results is that physicians utilization of herbal medicines was of herbal medicines are comparable in the sense that almost
found to be limited. More specifically, about 18.833.3% of the same percentage of the participants ranked their utilization
the participated physicians never used herbal medicines and of herbal medicines to complement or to replace conventional
that a small percentage (does not exceed 11.5%) of the partic- medicines as never, rarely or sometimes.

Please cite this article in press as: Hilal, M., Hilal, S. Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: A cross-
sectional study. Journal of the Association of Arab Universities for Basic and Applied Sciences (2016), http://dx.doi.org/10.1016/j.jaubas.2016.11.001
6 M. Hilal, S. Hilal

Table 4 Summary of physicians responses regarding utilization of herbal medicines.


Utilization of Herbal Medicines
Rank Prescription Personal-use Complementary Alternative
Never 32 18 32 25
Rarely 33 28 24 32
Sometimes 26 39 30 27
Often 2 3 5 6
Always 3 8 4 4
Total 96 96 95 94

3.4. Facilitating and hindering factors 3.5. Testing for differences among participants

As far as the facilitating factors are concerned, Fig. 3 shows The interest here lies in testing for statistically significant dif-
that the majority of the participants considered sufficient ferences among the participated physicians with respect to
knowledge on herbal medicines (68.8%) as well as the low cost their utilization of herbal medicines (prescription, personal-
of herbal medicines (66.7%) as major factors that encourage use, complementary, alternative). The overall comparisons
physicians toward utilizing these remedies. Moreover, deficits were performed using the KruskalWallis test and the corre-
and unfulfilled goals of conventional medicines as well as side sponding results are summarized in Table 5. The bivariate
effects and adverse events of conventional medicines were con- comparisons were performed using the MannWhitney test
sidered to be as facilitating factors by 61.5% of the partici- and the corresponding results are summarized in Table 6.
pated physicians. The personal-use of herbal medicines was found to be sig-
With regard to the hindering factors, Fig. 4 shows that nificantly more by female-physicians than male-physicians.
about two third of the participated physicians asserted that In contrast, no significant differences were found among physi-
the most important factor is the poor quality control (lack of cians from the five major departments (those fall under the title
safety and efficacy monitoring) of herbal medicines. Moreover, Others were excluded from the analysis). The same conclu-
physicians claimed that the other hindering factors are the lim- sion can be drawn when looking at the qualification or the
ited information on the adverse events of herbal medicines experience in the medical field. Similarly, utilizing herbal
(62.5% of the participants) and the absence of formal regula- medicines did not significantly differ between physicians with
tion such as standardized terms, definitions, classification of basic knowledge and those having moderate knowledge. We
herbal medicines (61.5% of the participants). The least note that the only two physicians enjoying an advanced level
important hindering factors (according to 55.2% of the of knowledge on herbal medicines were excluded from these
participants) were found to be the lack of effective communi- comparisons. On the other hand, when prescription for herbal
cation with health authorities regarding herbal medicines and medicines was concerned, then specialists generally used herbal
the fear of formal liability with regard to utilizing herbal medicines more than other physicians in the study sample and
medicines. this realization was found to be statistically significant.
NO YES

37
A 59

36
B 60
HINDERING FACTORS

43
C 53

33
D 63

43
E 53

40
F 56

Fig. 4 The hindering factors from the perspective of the


participated physicians. These factors are represented by the
letters on the vertical axis as follows. A: Absence of formal
Fig. 3 The facilitating factors from the perspective of the regulation on herbal medicines, B: Limited information on adverse
participated physicians. These factors are represented by the events of herbal medicines, C: Not effective communication with
letters on the vertical axis as follows. A: Low cost of herbal health authorities regarding herbal medicines, D: Poor quality
medicines, B: Sufficient knowledge on herbal medicines, C: control of herbal medicines, E: Fear of professional liability with
Deficits and unfulfilled goals of conventional medicines, D: Side regard to utilizing herbal medicines, F: Lack of availability of
effects and adverse events of conventional medicines. herbal medicines.

Please cite this article in press as: Hilal, M., Hilal, S. Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: A cross-
sectional study. Journal of the Association of Arab Universities for Basic and Applied Sciences (2016), http://dx.doi.org/10.1016/j.jaubas.2016.11.001
Knowledge, attitude, and utilization of herbal medicines 7

Furthermore, it seems to be that physicians with knowledge on medicines was considered with female physicians recording
herbal medicines sourced from experience prescribed herbal higher percentage of utilization than male counterparts. This
medicines to their patients significantly more than those who comes in line with the results of the study conducted by
acquired their knowledge from other sources (apart from Risberg et al. (1999).
academic-source). Interestingly, when comparing specialists It was found that physicians position and knowledge on
with consultants with respect to the complementary-usage of herbal medicines are significantly associated. Specifically, spe-
herbal medicines then the former physicians used these reme- cialists constituted the majority of the participants who have
dies significantly more than the latter physicians. experience-based knowledge on herbal medicines, while con-
sultants constituted the majority of the participants who have
academic-based knowledge on herbal medicines. Furthermore,
4. Discussion
the study reported comparable results with regard to utilizing
herbal medicines as complementary or alternative to the con-
The results revealed that the physicians who took place in the ventional medicines. This skeptical perception by physicians
study have basic knowledge on herbal medicines. In light of is possibly due to the limited information available on herbal
this realization, it might be argued that patients will not be medicines. It is likely that physicians who used herbal medici-
provided with the necessary advice and guidance regarding nes along with the conventional ones had doubt on their effec-
herbal medicines. Nevertheless, the participated physicians tiveness. It is worth mentioning that Awodele et al. (2012)
showed positive attitude toward herbal medicines that was found that none of the 300 doctors in their study thought that
demonstrated by the overwhelming tendency to enhance their herbal medicines alone could completely treat a patient. It is
knowledge. This seems to represent a strong desire by physi- also interesting to note that PhD-holders and those having
cians to be better equipped to serve their patients. Our findings more than 10 years experience in the medical field believed that
are consistent with those reported by other studies such as herbal medicines should not be used to replace the conven-
Awodele et al. (2012) for resident doctors in Nigeria, tional ones unless the efficacy of the former medicines has been
Clement et al. (2005) for physicians in Trinidad, and Ghia proved by well-known accredited scientific research centers
and Jha (2012) for healthcare professionals in India. More- such as FDA in USA. This note was taken from the comments
over, physicians desire to enhance their knowledge on herbal provided by the participated physicians (not reported). On the
medicines supports the need for incorporating herbal medici- other hand, physicians who used herbal medicines instead of
nes into the undergraduate curricula of medicine. A similar the conventional ones probably tried to avoid unexpected con-
conclusion was drawn by Ghia and Jha (2012) for herbal sequences caused by possible risk of interaction between the
medicines, and by Hasan et al. (2011) as well as James and two types of medicines. This risk was addressed in detail by
Bah (2014) for CAM. Neustadt (2006). In general, our findings regarding the com-
It was expected that physicians poor knowledge on herbal plementary or alternative usage of herbal medicines emphasize
medicines would have an impact on their utilization of these the need for constructing a reliable database about herbal
remedies. Indeed, the utilization of herbal medicines by the medicines, a point that was also highlighted by Suleiman
participated physicians was found to be limited, and that expe- (2014).
rience was the main source consulted regarding herbal medi- In agreement with Xu and Levine (2008), the participants
cines. This comes as no surprise since practical experience believed that being equipped with the necessary knowledge is
itself proves to be a useful source of knowledge given that the main factor that would encourage physicians to use herbal
the majority of the participants had no formal training on her- medicines rationally. On the other hand, poor quality control
bal medicines during their academic study. Furthermore, when of herbal medicines with respect to their safety and efficacy
comparing the personal-use with the prescription of herbal was considered by the majority of the participants as the main
medicines then a tendency to the former category of utilization hindering factor. Therefore, the National Health Regulatory
was realized. A possible explanation for this tendency might be Authority in the Kingdom of Bahrain has an essential role
the poor knowledge that the physicians have on herbal medici- to take with this regard.
nes which makes experience, in spite of its importance, not an A valuable contribution of the study is enhancing aware-
authorized source of information on which physicians can ness about herbal medicines by providing primary information
refer to in order to be confident when prescribing such reme- on the knowledge, attitude and utilization of herbal medicines
dies to their patients. Interestingly, a significant difference by physicians in the Kingdom of Bahrain. However, there are
was found between genders when personal-use of herbal issues pertaining to the study design that may limit its general-

Table 5 Results of the overall comparisons using KruskalWallis test (p-value).


Characteristic Utilization of Herbal Medicines
Prescription Personal-use Complementary Alternative
Qualification 0.050 (0.975) 1.577 (0.455) 0.066 (0.967) 4.169 (0.124)
Department 3.728 (0.444) 3.558 (0.469) 0.939 (0.919) 1.372 (0.849)
Position 9.873 (0.007)* 0.702 (0.704) 6.231 (0.044)* 5.009 (0.082)
Experience 1.193 (0.551) 2.675 (0.262) 3.118 (0.210) 6.367 (0.041)*
Knowledge Source 9.059 (0.011)* 3.041 (0.219) 3.636 (0.162) 0.979 (0.613)
The significance level is 5%.

Please cite this article in press as: Hilal, M., Hilal, S. Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: A cross-
sectional study. Journal of the Association of Arab Universities for Basic and Applied Sciences (2016), http://dx.doi.org/10.1016/j.jaubas.2016.11.001
8 M. Hilal, S. Hilal

Table 6 Selected results of the bivariate comparisons using MannWhitney test.


Characteristic Utilization of Herbal Medicines
Prescription Personal-use Complementary Alternative
Gender
Male 47.09 43.13 48.26 48.00
Female 49.97 54.10 47.73 46.98
Test (p-value) 1082.5 (0.595) 888.5 (0.042)* 1114.5 (0.922) 1080.0 (0.850)
Position
Resident 26.24 32.00 31.28 30.00
Specialist 39.30 35.95 35.62 35.63
Test (p-value) 331.0 (0.006)* 475.0 (0.405) 457.0 (0.353) 425.0 (0.227)
Resident 26.24 25.46 29.32 28.62
Consultant 26.74 27.46 23.89 24.54
Test (p-value) 331.0 (0.896) 311.5 (0.613) 267.0 (0.173) 284.5 (0.303)
Specialist 39.95 36.02 39.63 38.51
Consultant 28.41 34.67 27.80 28.41
Test (p-value) 389.0 (0.015)* 558.0 (0.775) 372.5 (0.012)* 389.0 (0.032)
Experience
<5 22.27 25.13 21.10 27.33
5; 10 26.89 25.66 26.72 23.97
Test (p-value) 214.0 (0.278) 257.0 (0.902) 196.5 (0.182) 220.0 (0.429)
<5 28.53 35.20 30.37 39.00
>10 31.80 29.63 31.21 27.67
Test (p-value) 308.0 (0.514) 282.0 (0.265) 335.5 (0.867) 210.0 (0.022)
5; 10 42.71 45.24 45.15 45.12
>10 39.70 37.77 37.07 36.13
Test (p-value) 745.0 (0.547) 656.5 (0.136) 624.0 (0.108) 591.0 (0.071)
Knowledge Level
Basic 47.30 45.98 45.52 44.29
Moderate 47.89 50.44 49.81 50.85
Test (p-value) 979.5 (0.916) 898.0 (0.429) 886.0 (0.447) 810.5 (0.244)
Knowledge Source
Experience 41.73 37.61 39.40 38.29
Academic Study 31.37 38.69 34.19 34.80
Test (p-value) 469.0 (0.038) 629.5 (0.829) 545.0 (0.295) 561.5 (0.478)
Experience 39.23 37.30 37.44 35.34
Others 25.33 29.74 27.93 31.07
Test (p-value) 301.0 (0.005)* 393.5 (0.132) 355.5 (0.054) 421.5 (0.387)
Academic study 25.24 27.26 25.44 25.04
Others 23.55 20.95 23.29 23.81
Test (p-value) 263.5 (0.654) 209.0 (0.098) 258.0 (0.575) 269.0 (0.752)
The figures given in bold are the mean ranks for the comparing groups.
The significance level is 5% for malefemale and basic-moderate comparisons.
The significance level is 5%=3  1:7% (using Bonfferoni correction) for other comparisons.

ization including the small sample size and the implemented and utilization of herbal medicines. The environment and the
sampling method. In particular, no permission was given by cultural background are two important examples of such fac-
the administration of the selected hospitals to distribute and tors. In addition, it would be interesting to investigate which
collect the questionnaires under the researchers control and diseases that herbal medicines are commonly used for.
hence the process has been managed by the administrative staff
at those hospitals. For this reason, the convenience sampling 5. Conclusion
method was found to be the most appropriate method to be
implemented. Another issue that is worth mentioning is the rel- This study revealed that the participated physicians have gen-
atively high percentage of PhD holders in the study sample erally basic knowledge on herbal medicines and that the main
which is probably reflected by the fact that the majority of source of this knowledge was the experience. However, almost
the participants were working in well-known private hospitals all the participants showed a desire to enhance their knowledge
that usually employ highly-qualified physicians. Therefore, about herbal medicines. It was found that the utilization of
future research should take these issues into consideration. herbal medicines by the participated physicians was limited
Moreover, the present study can be improved by several con- and mainly for personal-use. The low cost of herbal medicines
siderations. One direction of improvement is considering other and the availability of sufficient knowledge on these remedies
factors that might influence physicians knowledge, attitude were the two major facilitating factors that encourage physi-

Please cite this article in press as: Hilal, M., Hilal, S. Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: A cross-
sectional study. Journal of the Association of Arab Universities for Basic and Applied Sciences (2016), http://dx.doi.org/10.1016/j.jaubas.2016.11.001
Knowledge, attitude, and utilization of herbal medicines 9

cians toward utilizing herbal medicines. On the other hand, Bent, S., 2008. Herbal medicine in the United States: review of efficacy,
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bal medicines in an effort to promote an integrated healthcare Knowledge and use of complementary and alternative medicine
system in the Kingdom of Bahrain. among British undergraduate pharmacy students. Pharm. World
Sci. 28, 1318.
Gaul, C., Schmidt, T., Eismann, R., Zierz, S., 2011. Attitudes towards
Ethical approval complementary and alternative medicine in chronic pain syn-
dromes: a questionnaire-based comparison between primary head-
The original work on which the present study is based is the ache and lower back pain. BMC Complement. Altern. Med. 11.
graduation project of the first author. The relevant ethical Ghia, C.J., Jha, R.K., 2012. Influence of knowledge on attitude and
approval was obtained from the School of Medicine at the practice of health care professionals regarding use of herbal
medicines in a tertiary care teaching hospital: a cross-sectional
AMA International University, BAHRAIN.
survey. Int. J. Res. Pharmaceut. Biomed. Sci 3, 12151219.
Gratus, C., Wilson, S., Greenfield, S.M., Damery, S.L., Warmington,
Authors contribution S.A., Grieve, R., Steven, N.M., Routledge, P., 2009. The use of
herbal medicines by people with cancer: a qualitative study. BMC
MH (physician) conceived the idea for the study, took part in Complement. Altern. Med. 9.
the design, acquisition of data, interpretation and analysis of Hasan, S.S., Yong, C.S., Baber, M.G., Hameed, A., Baig, M.R., Iqbal,
S.M., Kairuz, T., 2011. Understanding, perceptions and self-use of
data. SH (statistician) was mainly involved in the preparation
complementary and alternative medicine (CAM) among Malaysian
of the study questionnaire and the relevant statistical analysis
pharmacy students. BMC Complement. Altern. Med. 11.
of the collected data. Both authors involved in the writing of James, P.B., Bah, A.J., 2014. Awareness use attitude and perceived
the manuscript; they read and approved its final version. need for complementary and alternative medicine (CAM) educa-
tion among undergraduate pharmacy students in Sierra Leone: a
Conflicts of interest descriptive cross-sectional survey. BMC Complement Altern Med
14.
Khalaf, A.J., Whitford, D.L., 2010. The use of complementary and
The authors declare no personal or financial interests that alternative medicine by patients with diabetes mellitus in Bahrain: a
could inappropriately influence the study. cross-sectional study. BMC Complement. Altern. Med. 10.
National Institutes of Health (NIH), National Center for Comple-
Acknowledgements mentary and Alternative Medicine (NCCAM), 2010. What is
complementary and alternative medicine (CAM)? [Online; accessed
We are grateful to the administrators and physicians who took April 2014]. URL: http://nccam.nih.gov/health/whatiscam/
interest in the research and we would like to thank them for the Neustadt, J., 2006. Herb-drug interactions: what clinicians need to
time they have devoted to participate in this study. know? J. Integr. Med. 5, 1626.
Risberg, T., Kolstad, A., Johansen, A., Vingerhagen, K., 1999.
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Please cite this article in press as: Hilal, M., Hilal, S. Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: A cross-
sectional study. Journal of the Association of Arab Universities for Basic and Applied Sciences (2016), http://dx.doi.org/10.1016/j.jaubas.2016.11.001

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