Knowledge, attitude, and practice of Iranian adults toward Persian Medicine: a national survey

Background Previous researches conducted in both developed and developing countries have demonstrated a rising trend in the utilization of complementary and alternative medicine. The World Health Organization has underscored the importance of studying the prevalence and determinants of such alternative practices. This study delves into the knowledge, attitudes, and practices of Iranian adults towards Persian medicine, a distinct form of complementary and alternative medicine, through a national survey for the first time. Methods A total of 2882 Iranian adults (aged ≥ 15 years) were randomly chosen from all regions. Data were gathered through structured door-to-door interviews using a survey questionnaire, wherein cases were selected randomly based on postal codes, and interviewers completed the forms at the participants’ residences. Results Approximately 46% of the subjects exhibited familiarity with Persian Medicine. The study revealed that the primary sources of knowledge about Persian Medicine were family, relatives, and friends, with only 2.9% indicating medical staff as their source of information. Furthermore, the study indicated that 21% of participants expressed a strong interest in using Persian Medicine, while 30.3% did not. When comparing Persian medicine to modern medicine, respondents indicated that Persian medicine is more cost-effective and has fewer side effects, yet modern medicine is more widely used globally; although, the majority responded “I don’t know” to other questions. The results also demonstrated that approximately 37% of the participants had a history of Persian Medicine utilization in their lifetime. Conclusion This study revealed that Iranian adults have low reliable knowledge (from medical staff, Persian medicine books and other publications) and limited familiarity with Persian medicine, with about one third of the participants expressing disinterest (attitude) and over half of them having not utilized this form of medicine (practice).


Introduction
Complementary and alternative medicine (CAM) encompasses diverse medical approaches beyond conventional medicine.Complementary medicine refers to non-mainstream practices used alongside conventional medicine, while alternative medicine refers to non-mainstream practices used in place of conventional medicine [1].The World Health Organization (WHO) underscores the importance of studying the prevalence and determinants of CAM use [2].Previous studies have indicated that CAM utilization ranges from 9.8 to 76% in highincome countries [3].The escalating incidence of chronic diseases has led to increased CAM use in recent years [4].Prior researches have shown a growing trend in the adoption of complementary medicine in both developed and developing countries [5][6][7].
It is estimated that approximately 33% of people use traditional medicine products to address common issues such as back pain, anxiety, and depression [7].Roughly 40% of the general population in the United States of America (USA) engages with some form of alternative medicine [8].Findings from a telephone survey in the United Kingdom (UK) regarding CAM usage showed a one-year prevalence of 20% [9].Data indicates that the majority of CAM usage is in many developing countries.For instance, in Colombia, Chile, and various African countries, 42%, 48%, and over 80% of the population reported using CAM [10].
In Iran, there exists a rich traditional medicine known as Persian Medicine (PM) with a history of more than 3000 years for treating medical conditions [11].In recent centuries, traditional medicine in Iran encountered legal challenges.However, it never completely disappeared from the lives of the people and remained an integral part of the culture, despite significant pressure from modern medicine [12].Presently, numerous medications and procedures of PM are being researched [13][14][15][16][17].However, there is no accurate estimation of traditional and PM utilization in Iran.For this reason, the current study aims to evaluate Iranian adults' knowledge, attitudes, and practices concerning PM as a type of CAM in the first step.

Study Design & Sampling
This cross-sectional study was carried out in Iran in 2016, using a representative sample of adults aged 15 years or older.Based on the Ministry of Health classification, Iran is divided into 5 regions.Tehran city encompasses approximately 20% of Iran's population itself, thus, we considered 3 regions from central region which Tehran city is located in it.Hence, we aimed to cover 7 regions for sampling.For determining the sample size, we considered a 95% confidence interval and 5% absolute error.Utilizing Cochrane's formula, the sample size for each region was calculated as 384 persons, resulting in a total of 2688 participants nationwide.Additionally, we allowed for an 8% dropout rate based on our pilot study.Eventually, a total of 2902 participants were selected for the study.Participants from each region were chosen through simple random sampling based on household postal codes.
Data collection included structured door-to-door interviews.In door-to-door interviews, investigators went selected postal code and completed the questionnaire with a household's member who was 15 years or older.We utilized a questionnaire composed of 68 questions in 4 main sections: (1) demographic characteristics (2), knowledge of PM (3), attitude toward PM, and (4) practice regarding PM.
The primary questionnaire was developed by 10 faculty members specializing in PM.This questionnaire underwent review in three expert panels to establish and confirm its validity.Furthermore, the survey questionnaire was tested by 30 individuals similar to the study participants, and its reliability was confirmed through a test-retest method.During the pilot study, input data was employed to refine the questionnaire, and questions that most participants found challenging to comprehend or respond to were removed.
Ten interviewers, each holding at least a Bachelor of Science in the medical fields, conducted the interviews after receiving 5 h of training from the research team and passing an exam in role-playing.

Variables
The study's outcomes focused on knowledge, attitude, and practice toward Persian Medicine.Demographic variables included gender, marital status, nationality, residency, and age.

Ethical approval
At the time of study design and approval, there was no requirement to obtain an ethics approval ID for such studies, according to the regulations of the Ethics Committee of Tehran University of Medical Sciences.To ensure the validity of participant responses, strict confidentiality was assured, and participants' anonymity was preserved through the use of anonymous questionnaires.Participants were also made aware of the voluntary nature of their participation and their right to refuse or skip any questions.Consequently, there were minimal instances of missing data noted in the tables, and 20 participants refused to participate in the study.

Statistical analysis
We depicted qualitative and quantitative variables using frequency (percent) and mean ± standard deviation (SD).Single-factor and multi-factor analysis of variance were employed to ascertain the factors associated with participants' knowledge, attitude, and practice.Significant variables identified in the single-factor model were included in the multi-factor model.The Chi-Square test was used to examine differences between groups.All analyses were conducted using SPSS-16 for Windows [SPSS, Chicago, IL, USA] and a p-value of ≤ 0.05 was deemed statistically significant.
Close to 46% (N = 1333) of participants were familiar with Persian Medicine (PM), with the most common source of their knowledge being family, relatives, and friends.Only 2.9% reported that medical staff were their source of knowledge.Table 2 presents the distribution of participants' knowledge about PM.
The knowledge score regarding PM was associated with gender, residency, and age.Table 3 illustrates the association between demographic characteristics and familiarity with PM.
Table 4 indicates participants' general attitudes toward PM.
The demographic characteristics and the tendency to use PM among the total sample are shown in Table 5.According to this table, there is a statistical association between residency and age groups with this tendency.
Table 6 showcases the participants' attitudes regarding the comparison of traditional medicine and modern medicine.They stated that traditional medicine has a lower cost and fewer side effects, and modern medicine is more widely used in the world.However, the majority of responses to other questions were "I don't know." The practice of PM is illustrated in Table 7.We asked about PM use.The results showed that about 36.9% of the participants have a history of using PM in their lifetime.The next question was a reflection of whether their practitioner had inquired about PM use.If PM users had not informed their practitioner, the reason for this was explored.The final question in this section related to the participants' first choice when they are sick.
Table 8 describes the relationship between demographic characteristics and PM use among participants.According to this table, PM utilization was significantly associated with gender and age groups.

Discussion
The current study assessed the knowledge, attitudes, and practices of Iranian adults towards Persian Medicine (PM).Our findings revealed that less than half of Iranian adults were familiar with PM, with only 2% demonstrating high knowledge of it.This figure contrasts with previous studies, which reported a 45 to 80% range of good knowledge about traditional medicine in other countries.Therefore, we can conclude that the adult population in Iran lacks adequate knowledge toward PM.We discovered that the primary sources of knowledge about PM were family, relatives, and friends, while only 2.9% cited medical staff as their source of information.Comparatively, Molavi Vardanjani et al. found that 44.43% of pregnant women in Shiraz (south of Iran) were recommended to use complementary and alternative medicine (CAM) by relevant individuals [18].Moeini et al. found that 63% of the population in Babol (located in northern Iran) chose complementary and alternative medicine (CAM) based on recommendations from family and relatives [19].Al Akeel et al. mentioned that friends and the web played a significant role, with 48% and 23.5% respectively, as sources of knowledge for CAM in Saudi Arabia, while only 6% of participants obtained CAM information from practitioners [20].
Our study highlighted that approximately 18% of participants who were familiar with PM believed it could have potential side effects.For instance, Wassie et al. reported that about 11% of Merawi residents believed that traditional medicine had adverse effects [21].This implies that despite a level of knowledge about PM, there is some skepticism toward this form of medicine among the Iranian population.
Furthermore, our findings revealed that Iranian adults believed traditional medicine to be more cost-effective and to have fewer side effects compared to modern medicine.On the other hand, they viewed modern medicine as more hygienic, having greater global usage, and providing quicker response to treatment compared to traditional medicine.Similarly.Moeini et al. elucidated that the primary reasons for utilizing complementary and alternative medicine (CAM) in the northern Iranian city of Babol are the perceived lower complication rates and the effectiveness of these methods [19].Wassie et al.  found that 26% of participants believed traditional medicines were more effective and safer than modern health services [21].Singh et al. showed that 23.4% of the Indian population in South Africa perceived CAM as natural as and safer than medical care, with 15.6% choosing CAM due to the undesired adverse effects of modern medicine [22].
Our study also demonstrated that 37% of participants had a history of using PM in their lifetime.Comparatively, Moeini et al. reported that 71.46% of participants in Bobol (north of Iran) had used CAM in their lives [19].The utilization of CAM in the USA increased from 28.9% in 1999 to 38.3% in 2007 [3].
These comparisons suggest a lower prevalence of CAM use among the Iranian population in comparison to other countries.Despite previous studies concluding an increasing interest in CAM among the Iranian population [1,11], our results indicate a relatively low percentage of CAM usage among Iranian adults.
We observed a statistically significant association between gender and age groups with PM use.Generally, females and individuals under 45 years old demonstrated the highest usage of PM.This aligns with the findings of several studies by Dehghan et [19,20,30,31], a statistically significant relationship between gender and CAM use was also revealed, similar to our study.In summary, our results suggest that Iranian adults possess low knowledge, relatively negative attitudes, and a low practice rate towards PM.

Strengths
The present study boasted a large sample size and an exact sampling scheme, both of which heightened the generalizability of the findings.Finally, the availability of CAM services and providers is a critical consideration for analyzing the study's results.
Our study did not compare the results with the current map of CAM services in Iran due to the absence of such a map.Nonetheless, the existence of an educational environment where clinicians are trained and a highly educated staff is crucial for the availability of CAM therapies, which in turn is an undeniable factor when filling out the questionnaires.

3 .
Inherent limitations related to the recall of PM utilization experiences.

Table 1
Demographic characteristics of participants

Table 2
Distribution of knowledge of the participants toward PM in a sample of the Iranian population * A high mean indicates a preference for using as the primary choice of treatment, while a medium mean suggests using it as complementary medicine alongside modern practices.A low mean indicates infrequent usage, and 'no interest' signifies no intention to use

Table 3
Demographic characteristics and Familiarity with Persian Medicine in a sample of the Iranian population A high mean indicates a strong inclination to use Persian Medicine as the primary treatment choice, while a medium mean suggests familiarity with using it as a complementary medicine alongside modern medical practices.A low mean reflects minimal familiarity or unwillingness to use Persian Medicine *

Table 4
Distribution of attitude of the participants toward PM in a sample of the Iranian population

you want use the PM what is the reason
al., Moeini et al., Von Conrady et al. and Al Akeel et al.In studies conducted in Kerman and Babol, southern and northern Iran, as well as in Australia and Saudi Arabia

Table 5
Demographic characteristics and tendency to use PM in a sample of the Iranian population A high mean indicates a tendency to use as the primary choice of treatment, while a medium mean suggests a tendency to use it as complementary medicine alongside modern practices.A low mean implies a rare tendency to use, and 'no interest' signifies no inclination to use. *

Table 6
Persian medicine and modern medicine comparisons based on participants' attitudes

Table 7
Distribution of participants' practice toward PM in a sample of the Iranian population

Table 8
Demographic characteristics and use of PM in a sample of the Iranian population