The socio-demographic details of the comprehensive PURE THM study population as well as a breakdown of these details by THM use, have been reported elsewhere [26]. The present study explores the health-seeking behaviour, healthcare practices and prevalence of THM use among elderly women with self-reported NCDs, who participated in the South African leg of the PURE study. About three-quarters of the study sample reported having an NCD, with more than half of them self-reporting two or more NCDs.
NCDs have been considered to be poorly managed in South Africa as a result of infrequent access to such healthcare [28]. This is despite the fact that healthcare was rated by participants in the reported study as accessible and affordable, indicating the need for more research aimed at addressing barriers to healthcare utilization [28]. With regard to their health-seeking behaviours, most of the participants in the present study visit public clinics (the community health centres, CHCs), and very few of them utilized the district public hospitals or general hospitals. This is probably because of the fact that the first port of call for patients presenting to the public healthcare sector in South Africa is the local CHC. Generally, patients who utilize the public healthcare system may not present at the district public hospital without referral from the CHC.
Co-morbidities have been found to be a common phenomenon among the elderly [12, 29]. The prevalence of co-morbidities was higher (54 %) in the present study compared to those previously reported for South Africa by Phaswana-Mafuya et al., [4] (22.5 %) and Ibanez-Gonzales and Norris, [28] (19.9 %). This variation in the reported prevalence of NCDs might be attributable to the number of diseases investigated in both previous studies; generally, the higher the number of diseases, the higher the prevalence of co-morbidity [30]. However, studies conducted in other parts of the world such as the United States (65 %) [31] and Bangladesh (53.8 %) [30], reported a prevalence of co-morbidity similar to that of the present study. This present study indicates that participants with co-morbidities were less likely to use THM than those without co-morbidities. This is in contrast to a study conducted in the United States which aimed to examine the association between the type of multimorbidity and complementary and alternative medicine CAM use among adults with multimorbidity [32].
Older women, particularly those within the ages 50 and 64 years, as well as those living in rural areas or non-urban environments are also known to be major users of CAM [33, 34]. In the present study, about a third of the respondents with NCDs used THM. Among older women who had NCDs and used THM, a large fraction reported having hypertension, a finding supported by several other studies [35–37]. Several factors influence THM use among older women. According to McLaughlin et al., [34] personal beliefs and social networks are influences to CAM use. The present study showed that THM use was associated with family history and positive recommendations from other individuals. Interestingly, cultural beliefs were not a very popular reason for THM use among the study participants. The reason for this might be because most of the participants in this study were born in Langa, an urban area. For them, the term ‘cultural beliefs’ may be something associated with a rural lifestyle, with which they have never identified.
The present study also documents that THMs are used extensively to treat health conditions, which differed from other studies where CAM/THM were used more for health maintenance [34, 37, 38]. Symptoms such as heart palpitation, headaches, severe tiredness, and dental problems all had a positive association with THM use (Table 4). According to Alwhaibi et al., [32] the presence of a physical illness with a chronic condition was associated with CAM use in their study. The positive association reported in the present study may perhaps also be by reason of the participant’s view of these symptoms as merely self-limiting, without the need for specialised care. Hence, their preference to self-medicate rather than consult a healthcare practitioner. Medical professionals’ awareness of older women’s habits to treat specific symptoms with THM, will help them in prescribing efficacious medicines to alleviate these symptoms. This will simultaneously reduce adverse effects or drug-herb interactions which may be caused by THM use alone or in combination with CM.
While THMs were used frequently and in combination with CM, most of the respondents did not disclose their use of THM to their healthcare practitioners. This is despite the fact that health information is received by participants mostly from conventional healthcare practitioners. Such non-disclosure of THM use is not peculiar to this study, and has been reported in other studies [37, 39, 40]. However, this is in contrast to findings from studies conducted in Australia [27] and the United States [20], where older women disclosed CAM use to their healthcare providers. Reasons for non-disclosure of THM use are quite diverse and range from fear of discrimination by healthcare workers to lack of required treatments at clinics and hospitals [39, 41].
The present study showed that older women with anxiety are five times more likely to practice medical pluralism. This is supported by findings from another study conducted among patients attending four primary care facilities in the United States, where adults with anxiety and chronic conditions are known to use CAM more than those who do not report anxiety [42]. The high prevalence of THM use among patients with anxiety has been attributed to the holistic nature of the treatment and to patients’ dissatisfaction with CM used for the treatment of this disorder. For instance, some classes of anti-anxiety drugs may worsen anxiety symptoms or result in undesirable side effects, making patients to feel more anxious about their apparent lack of control over their life [43]. In an effort to address these symptoms or side effects, such patients may attempt to regain the desired control by the use of THM, a move which increases the prevalence of THM use among this sub-population [44].
Older women with allergies were also 20 times more likely to use THM in conjunction with CM. This estimate should, however, be interpreted with caution, as the confidence interval is very wide. Common allergies may in some cases be viewed by individuals as ‘harmless’ and merely self-limiting, a condition which participants may then have tried to control through the use of THM as opposed to CM. This particularly may be the case, given the view that complementary treatment measures (such as THM use) are seen to be holistic, i.e., treating the whole person as opposed to only treating symptoms of an ailment [44].
There are several study limitations that should be addressed. First, the use of a small sample of people in a peri-urban disadvantaged community from Cape Town, South Africa, which is primarily composed of one ethnic group. This is because the participants were a sub-set from a larger study. Therefore, the results cannot be generalizable to other contexts within South Africa, let alone other countries. Second, the study utilized self-reported measures of NCDs which were not cross-checked with any medical records or doctor’s diagnoses. Therefore, the chance is that the study could have suffered from misclassification. Since it was not the study objective to report true prevalence of these conditions, these limitations will probably have little effect on result interpretation. In the South African setting, such information is of utmost importance, especially when viewed against the background of older women’s major roles at family and community levels.
Conclusion and recommendation
Most of the older women in this study self-reported having an NCD, with over half of them having co-morbidities. In terms of health-seeking behaviour, most of the participants utilized state-owned public health facilities. No statistically significant difference in THM use was observed between those with co-morbidities and those without. THM was used mainly to treat a health condition. A few of the older black women with NCDs used THM, with many of them also practicing medical pluralism. Those with anxiety and allergies were also more likely to practise medical pluralism.
Learning how to care for and treat older black South African women, especially those with multiple NCDs, is very important in the public health discourse. This is because of their social and economic relevance within their communities. Awareness around older women with multiple NCDs/co-morbidities and their use of alternative treatment modalities, especially within African cultural paradigm is important. Therefore, healthcare workers should be more observant of medical pluralism, and educate patients on the importance of disclosure of their THM use. Furthermore, healthcare workers should be educated about the importance of questioning older women about THM use during consultations. Enabling conditions to improve the communication gap between older women with NCDs and the health caregivers are also required. This would create awareness and room for education on the potential benefits cum downfalls of possible drug interactions which may arise from medical pluralism, and which may ultimately influence patient therapy.
This study is just the beginning of efforts to understand the health-seeking behaviours among older black South African women. Future studies should also investigate THM use in other contexts.
