This study found that 173 (42.2%) out of the total participants took herbal medicines and a significant link between female and herbal medicines usage was detected (p 0.001). More than one-half (56%) felt that herbal medicines might be used to improve health and treat diseases, while 45% believed that herbal medicines were safe. 153 of the participants (37.4%) believed that a combination of traditional or allopathic medication could be employed. The results also showed a significant association (p 0.05) between herbal medicine source knowledge and gender with women having higher information than men. Moreover, participants with chronic diseases take more herbal medication than people without illnesses (p 0.001). Surprisingly, most (n = 204; 49.9%) of the respondents used herbal remedies as their first choice when they fell unwell, whereas a significant number (n = 172; 42.1%), before using herbal medicine, had not seen doctors.
This is the first study regarding the knowledge, attitude, and practices on herbal medicines in the general population of Jeddah, the second largest city of Saudi Arabia. As everywhere else in the world, herbal medicines are used extensively in Saudi Arabia and the findings of our study would help to provide an insight into people’s behavior, attitude and knowledge and exhibit the level of understanding regarding herbal medicines particularly. Most of the previous research has been carried out on patients or specific population in Saudi Arabia, however, very little is documented about herbal medicines knowledge and attitudes among the general public. In the present study, utilization of herbal medicines among adults of Jeddah is found to be 42%. Several international studies have documented results of herbal medicines’ usage in general population. Findings of this study were also consistent with data obtained in other countries. Prevalence of use of herbal medicines was reported as 33.9% in Malaysian adults; in Czech adults as 56.6%; in American population as 57.3%; in Arabian population it was 77.6% [16,17,18,19].
A survey done among 1300 individuals documented that 1226 (94%) of the participants utilised herbal medicines for therapeutic purposes. The majority of them, 699 (57%), used herbal medicines on the basis of traditional beliefs or family recommendations 417 (34%). Young respondents < 35 years old who live in cities reveal that they know far more than their counterparts about the use of herbal medicines and the related hazards (p < 0.001). Despite the significant frequency of reported side effects, 702 (54%) utilise herbal medicines as their first line of therapy. However, the reasons for the use of herbal medicinal products are believed to be safer, more efficient and cheaper than mainstream medicinal products [20]. Furthermore, the tradition and culture in Saudi Arabia reinforce the use of herbal medicines. In addition, a recent study by Kennedy et al. stated that the majority of pregnant women use herbal medicine due to the perception of herbal medicines as safe therapy [21]. In fact, the accessibility and easiness of herbal medicines subsidize to the amplified use and many people have faith in that traditional recipes are not injurious and do not have side effects [21].
In this study, use of herbal medicines in general population is comparatively lower (42%) than some of the other studies in the world, e.g. in Kuwait (71%) or Nigeria (67%) [22, 23]. The second major finding was identification of the factors which influence the use of herbal medicine like gender, marital status, chronic conditions, medication use and general health perception. Gender differences may partly be explained by the disparity in health needs and social factors such as beliefs and attitudes. Our study finding is consistent with the findings of various other studies that women were more likely to use herbal medicines than men [16, 17, 24, 25]. This was similar in previous studies which could be related to many factors such as that women are more prone to exaggerate the efficacy of herbs and encourage each other to use them [22]. This study shows a notable relation between herbal medicines usage and joint diseases. This may be due to the fact that natural remedies are mostly for topical application like herbal oils and extracts etc. and help in avoiding systemic side effects of such remedies . One study in 2007 based on the survey of 1 year, concluded that almost 4 out of 10 American adults-use CAM i.e., 17.7% [26]. Another study in UK stated that the use of herbal medicines was 41.1% in 1 year [27]. Moreover, a cross-sectional study in UAE stated that 76% of respondents used herbal medicines, with 38% of them using a single herb [19]. Our study outcomes are supportive of the previous studies. One of the reason that people consume herbal medicines might be because of dissatisfaction with conventional medicine [28].
With respect to knowledge, the findings of our study indicated that most of the participants (80%) agreed that herbal medicines are made from plant sources, which gives a hint about how much people were aware when they were asked about herbal medicines in general. One third of participants (37%) acknowledged that herbal medicines could be taken with conventional or allopathic medicines, while in another study conducted in USA, the percentage was higher (55%) [26]. This is a bit alarming as many studies have reported adverse drug reactions when herbal medicines are taken concurrently with conventional medicines [29]. Another study stated that 64% of patients previously utilised herbs to manage diabetes; among them 27.0, 20.3, 15.2, and 10.8% used myrrh, black seeds, fenugreek and aloe respectively. 54.2% of respondents in this study did not experience any negative effects with herbs; 64.5% saw an improvement in blood sugar levels with herbs [30].
With respect to the association between demographics and knowledge regarding herbal medicines, some strong associations were found with respect to income, educational status, and gender. Respondents with higher income (> 5000 or 10,000 Saudi Arabia Riyals) were found to be significantly associated with the statement that “Herbal medicines can prevent all diseases”. However, majority of the participants (318 out of 409) fell under the category of low salary (< 5000 Saudi Arabia Riyals). Hence, this finding may not be a true representative of the general population and may need comparable number of participants in each category to ensure this outcome. A recent study conducted by University of Hail among general public in the Northern part of Saudi Arabia stated that the participants with higher income were significantly associated with more knowledge towards herbal medicines [20]. Regarding association with educational status, significant association with two statements of knowledge with an increase in educational status was found, that is statement 3 “Herbal medicines are preferred because of less side effects” and statement 7 “Overuse of herbal medicines can cause adverse effects”. This is in line with previous studies that higher education impacts on the knowledge of respondents [20]. Moreover, the impact of education on increasing awareness about adverse side effects due to overuse (statement 7 as mentioned above) is encouraging because overuse of anything including herbal medicines can be deleterious to health. With respect to gender, only statement 9 “Herbal medicines don’t need consultation with doctors” was found to be significantly associated with male gender who agreed with this statement. It is encouraging to see that although females are significantly associated with more use of herbal medicines (Table 2), they still think that herbal medicines need consultation with doctors. This creates a need to direct more awareness programs towards male population of the society.
In terms of attitude, results are slightly contradictory and confusing. Majority of the respondents looked optimistic about using herbal medicines than conventional medications that are prescribed by physicians. On the other hand, a minority of the people thought that herbal medicines are more effective than conventional medicines. These findings reflected that responses lacked clarity of information and supported the findings of previous studies that there is a lack of proper knowledge about herbal medicines among population [31, 32]. Moreover, with respect to attitude, 45% agreed that herbal medicines are safe which is slightly lower as compared to 61% in Kuwait population; it may be due to lower sample size in our study [22]. Approximately, more than half of the respondents in our study believed that herbal medicines can be used to improve and maintain health and treat illnesses which is similar to that in Kuwait, Canada and Australia [22, 33]. This could be explained by a general perception that these herbs are natural, hence will result in good effective outcomes for their health. With respect to association of demographics with attitude towards herbal medicines, only educational status and income of the respondents were found to be significant. Again, acquiring higher education is significantly associated with statement 1 “Herbal medicines can be used to help maintain and promote health” as compared to those with either no or less education. This may be due to the observation that literate people are more concerned towards maintaining their health as they are exposed to more sources of information, including books, newspapers, media etc. It is well documented that people with low literacy not only tend to delay treatment and diagnosis, but are also associated with increased mortality risk [34]. The same statement 1 is also significantly associated with increase in income. This may be due to the observation that people with less income are more focused to fulfil their basic daily necessities rather than spending much on promotion and maintenance of health. Furthermore, low income can further deteriorate this scenario by causing other hindrances like difficulty to access healthcare, lack of proper education etc. [35].
Regarding practices towards herbal medicines, results are quite interesting and convincing. Most strikingly, respondents (49.9%) agreed to use herbal medicines as a first choice when they get sick. This reflects the extent of practices towards herbal medicines by the general public in the second largest city of Saudi Arabia. Our findings are in line with the previous study which documented that more than half of the participants (54%) used herbal medicines as a first line therapy in Northern Saudi Arabia [20]. This may be because herbal medicines are generally considered safe and readily available. Another important finding is the use of herbal medicines without consultation of doctors by majority of the participants. Unsupervised use of herbal medicines can be dangerous in some circumstances where people are on conventional drugs, increasing the chances of drug-herb interaction and may lead to adverse events [36]. This calls upon the need for government authorities to conduct awareness campaigns in public regarding the proper use of herbal medicines, especially in case of concomitant use of conventional drugs. On the other hand, herbal medicine practitioners in Saudi Arabia should also be encouraged to incorporate scientific evidence-based practice (EBP), which seems to be quite low compared to herbal medicine practitioners in Western countries [37]. Similar recommendations were made by a study in Canada that both consumers and physicians should be kept updated about safety and efficacy of herbal products and also by registering herbal products as drugs [38]. A satisfying finding is the practice of around 43% of respondents towards looking at the expiry date of herbal medicines. In general, people believe that herbal medicines are safe and do not expire even after long time. However, this may result in lack of efficacy or sometimes side effects from degraded by-products within herbal medicines as with any other pharmaceutical products. Surprisingly, almost equal number of participants said yes and no to the statement, “I give herbal medicines to my children if they suffer from fever or pain” i.e. 33 and 33.7% respectively. Although, herbal medicines are supposed to be safe and effective in many diseases, still opting them for children in acute conditions, like fever, might not be a suitable choice, especially without proper supervision of a qualified doctor. Studies have documented safety as well as several side effects of herbal medicines in children [39, 40]. Hence, special care is required while using herbal medicines in children and awareness programs/lectures arranged by hospitals or government agencies might be a good option to overcome this issue. With respect to association of demographics with practices of herbal medicines, only educational status and gender of the respondents were found to be significant (p < 0.05). Acquiring education from primary till university level gradually impacted practice statement 6 i.e. “I take herbal medicines according to the instructions on the label”. These are encouraging results and signify the importance of education in the ethical practice of herbal medicines. Furthermore, proper labelling of herbal medicines products with substantial details about the constituents, usage and plausible side effects may help in decreasing the adverse events among general public while consuming herbal medicines [41]. In terms of gender impact on the practice statement no. 7 i.e. “I always look at the expiry date of herbal medicines before taking it”, female respondents practice it more than the males. Previous studies were not found to compare this result of the study, but this may be because females, in general, are more cautious about their appearance and expired products may cause adverse events like allergy on skin etc. However, females are found to be reluctant and rarely share the use as well as the side effects of herbal medicine with doctors. This calls for measures to decrease barriers in communication between female users and practitioners [42]. However, the practice of looking at the expiry date should be encouraged in both genders and commercials, as well awareness campaigns, can help in this regard.
Lastly, association of age was examined with knowledge, attitude and practice statements via ANOVA test and found significant associations only with two statements of knowledge i.e. “Herbal medicines are preferred because of few side effects” and “Overuse of herbal medicines can cause adverse effects”, and one statement of practice i.e. “I give herbal medicines to my children if they suffer from fever or pain”. Interestingly, increase in mean age was significantly associated with all three of the above statements indicating the impact of growing older on the knowledge and practice of herbal medicines. It is reported earlier that people with higher age are more inclined towards herbal medicines and hence their knowledge and practice toward herbal medicines also increases with the increasing age [43]. This may be due to the fact that people with higher age are consuming more medicines compared to younger age group to prevent diseases and maintain their health [44]. However, emphasis should be made to increase awareness regarding polypharmacy and drug-herb interaction, particularly in elderly, to avoid any detrimental events. It is highly recommended that the elderly population should be educated on the ethical practice of herbal medicines regarding its usage in children, particularly emphasizing on the need to consult with qualified traditional or allopathic doctors. Use of herbal medicine among Saudi population is a common practice and is related with female gender, adult population, and low level of education [45], which is also evident from the findings of this study. A recent study by Alghethmi et al. explored the specific role of gender in the use of herbal medicnes and found female gender to be more aware about herbal medicines and this knowledge increases with age [46]. Herbal medicines have been used and are still widely used in Saudi Arabia and other countries (Uganda) in treating and preventing diseases as well as during pregnancy [1, 21, 47]. This is mainly because users believe that herbal medicines are safe and without side effects. However, plants and herbal medicines are extremely complex material which are not devoid of adverse effects. In addition, there is lack of protocols and suitable methods of evaluating the products which is another barrier in the scientific validation of the effectiveness as well as adverse effects of these medicines. Herbal medicinal products need to be regulated by drug regulatory authorities similar to synthetic drugs to enhance quality, safety, and efficacy [48].
