Prevalence of Traditional Herbs and Supplements Use Among Hypertensive Patients in Om Elamad Health Center

Hypertension has become a health concern worldwide in the recent two decades since it has become the leading risk factor in terms of disease burden globally.1 According to the latest World Health Organization, data published in May 2014 Hypertension Deaths in Jordan reached 1,117 or 4.85% of total deaths.2 Control of blood pressure is suboptimal and only about 40% of patients suffering from hypertension manage to reach the target blood pressure level of 120/80mm Hg and below.


INTRODUCTION
Hypertension has become a health concern worldwide in the recent two decades since it has become the leading risk factor in terms of disease burden globally. 1 According to the latest World Health Organization, data published in May 2014 Hypertension Deaths in Jordan reached 1,117 or 4.85% of total deaths. 2 Control of blood pressure is suboptimal and only about 40% of patients suffering from hypertension manage to reach the target blood pressure level of 120/80mm Hg and below.
Hypertension defined as diastolic BP above 80mm Hg or systolic BP above 120mm Hg. 3 Treatment normally involve the use of antihypertensive medications, however, almost half of people diagnosed with hypertension do not seek right medication to control it. Lowering BP is important measure in preventing health complications of hypertension like cardiovascular conditions. Lowering BP to below 120mmHg in the case of systolic BP reduces the likelihood of death and development of cardiovascular conditions.
Prevalence of supplements and traditional herbs in treatment of hypertension is high in both developed and developing countries alike. About 65% to 80% of global adult population have used supplements and traditional herbs as a primary health intervention at some point in their lives. [4][5][6][7][8][9][10][11][12][13][14][15][16][17] According to the WHO report in 2008, 75% of the world's populations are using herbs for the management of basic healthcare needs, with over 60 billion American dollars invested in the trade market of herbal medicines. 2 In Jordan, use of herbal medicine is reported to be high, hence investigating the use and safety of herbal medicine has become a national priority. 6 Limited information exist on extent of usage among patients in Jordan particular in Om elamad area despite the potential side effects associated with nonconventional medications.
However, there is no study that has been published about prevalence of supplements and traditional herbs usage among hypertensive patients attending Om Elamad health centre and surrounding regions hence this study will close this gap in literature. The aim of this study is to determine prevalence and utilization of supplements and traditional herbs among patients with hypertension attending Om elamad health centre, to evaluate the control of blood pressure (systolic and diastolic) in hypertensive patients that take both herbal medicines and conventional medicines and patients taking conventional medicines alone,to assess the safety and side effects associated with utilization of supplements and traditional herbs among hypertensive patients and to determine the socioeconomic and demographic characteristics of hypertensive patients attending Om elamad health center.

SUBJECTS AND METHODS
A total of 200 Hypertensive patients in Om elamad health Centre, in the period from October,2018-June,2019. All of whom diagnosed with hypertension for at least 1 year, both genders, and not too ill to communicate with the researcher.
The hypertensive patients was divided into four groups • Group 1: patients taking drug only.
• Group 3: patients taking drug and herbs and supplements.
• Group 4: patients taking drug and herbs.

Study tool
A pretested and validated questionnaire used for data collection.
The questionnaire is attached at the appendix page no.19

Method
Cross sectional study design was adopted by the study in order to examine the prevalence of utilization of supplements and traditional herbs by hypertensive patients in Jordan. Each of the samples studied provided comprehensive and cross-sectional information regarding their behaviour of using medications for management and treatment of hypertension. Research approach used in this study was mainly quantitative approach since the data was gathered using quantitative methods.

Sampling
Sample targeted in this study included patients attending Om elamad health centre in Jordan. The requirement was that the patient must be an adult and have been confirmed to have hypertension.
Purposive and convenience sampling was used to select Om elamad health centre in Jordan. Om elamad health centre was selected because this health centre provides conventional treatment to hypertensive patients, moreover, people in the region tend to rely on supplement and traditional herbs. A total of 200 hypertensive patients were studied from Om elamad health centre after giving consent to participate out of which 208 questionnaires were found to be complete and answered consistently.

Inclusion criteria
Diagnosed hypertensive patients on conventional medication, managed at om elamad health center outpatient for at least 6 months, should be 16 years and above, and willing to participate in the study.

Data collection & statistical analysis
Data collection methods involved two main approaches including administration of questionnaires and interview technique which enabled the study to obtain primary data. In addition, questionnaire data can be analysed easily when coded with the aid of software SPSS version 21. The questionnaire used in this study had three parts namely: Part A on individual patient characteristics including sociodemographic factors and patient history; Part B included questions that assessed efficacy of supplements and traditional herbs; and Part C contained observation checklist where readings on BP were taken and recoded against a given date .

Ethics
Consent was considered from the participants. Information obtained was kept confidential and the study subjects were kept anonymous

Characteristics of the study sample
The characteristics of study sample indicate that the percentage of male (52.4%) representation is higher than that of female (47.6%) representation. In terms of age, the highest percentage of the sample was aged 55-65 (33.2%), 65% (27.9%) and the lowest age group (26-35) which amounted to (2.4%).
In terms of educational level, we find that the highest proportion of the sample of the secondary education by (41.3%), and in the second degree was the proportion of students with a bachelor's degree (22.1%), then came the proportion of non-educated (21.6%).
The results of the marital status indicate that the majority of the sample is married (97.1%). The economic indicators indicate that the economic level of the sample is low by (59.1%) of them are not working and (59.1%) are less than 500 JD per month.
It is also noted that the highest percentage of the respondents are practicing sports (68.7%), while the percentage of non-practicing sports (31.3%).
The data of the tables (2, 3) indicate that the average weights of the study subjects reached (76.59) kg and standard deviation (12.09) kg, while the average length (163.69) cm and standard deviation (7.70) cm. In terms of body mass index, it came with an average of (28.03) and a standard deviation (4.35). The results of the body mass also indicate that (34.6%) of the study subjects are obese, 37.5% are overweight and only (27.9%) have normal weight.
Table (4) shows the health conditions of the study subjects. It is noted that the hypertensive patient which suffer from diabetes is (90.4%), (53.8%) of kidney problems, While the percentage decreases to (4.3%) with cardiovascular disease, and (2.9%) with heart problems.
Table (5) shows that (61.5%) of the subjects have a family history of hypertension. Only (38.5%) have no family history with hypertension.
Table (6) shows the smoking status of the study sample. The percentage of smokers is (43.3%). The percentage of passive smokers (38.5%). In terms of the number of smoked cigarettes per day, the highest rate of smoking is between 20-29 cigarettes (42.2%). In the second category, the percentage of smokers who smoked between 10-19 cigarettes per day was (26.7%). Table (7) shows the lifestyle and changes in the diet of the study subjects. It is noted that (51.4%) of the individuals work on reducing the salt. The percentage of those working on weight reduction is (40.4%). While the proportion of exercise regularly (32.7%).
The data in Table (8) show that the highest percentage of study subjects received drugs have high blood pressure (79.8%). It is also noted that the most drugs taken by the patients was Bisoprolol fumarate by (34.3%). Then in the second class came Atenolol by (15.1%).          hibiscus sabdariffa with (26.4%). In the third class came cinnamon with (24.0%). At fourth class came flaxseed by (5.3%).
It is clear from the data in Table (11) that the majority of the sample takes herbal medicine daily and by (22.1%). Then came the proportion of those who take it sometimes (15.9%), but the proportion of those who take it Often (13.5%). It is noted from the data in Table (14) that the highest proportion of the study members take herbal tea as a treatment (48.1%). But only (3.4%) of the subjects did not take herbal tea as a treatment.  Table (17) shows that the proportion of people receiving dietary supplements for hypertension is only (10.1%). But highest percentage (40.4%) does not take supplements as a treatment for high blood pressure.
The data in Table ( 18), show that the highest percentage of study subjects ate omega-3 fatty acids with (5.8%), followed by cod liver oil (1.0%). The data also show that (3.4%) take other supplements.
Table (19), shows that individuals who take food supplements often (7.7%), and in the second class they sometimes eat (2.4%).   1. There was a significant difference (P-value=0.0001) between Mean systolic blood pressure SPB of patients taking only antihypertensive drug (Group 1) and Mean SPB of patients taking only herbs &\or supplement (Group 2).That means that the drugs were more potent than the herbs &\or supplement.
2. There was a significant difference(P-value=0.0290) between Mean SPB of (Group 1) and Mean SPB of patients taking drug and herbs (Group 4).That means that the drugs were more potent ,and the herbs have no effect on the SBP.
3. There was a significant difference (P-value=0.0050) between Mean SPB of (Group 1) and Mean SPB of patients taking drug and herbs and supplements (Group 3).That means that the combination of drugs and hers and supplement were more potent than taking the drug only. 1. There was a significant difference (P-value=0.0001) between Mean diastolic blood pressure DPB of (Group 1) and Mean DPB (Group 2).That means that the drugs is more potent than the herbs &\or supplement.
2. There was a significant difference (P-value=0.0001) between DPB Mean (75.25) of (Group 1) and DPB Mean (67.60) of (Group 4).That means that the combination of drugs and herbs were more potent than taking the drug only.
3. There was a significant difference (P-value=0.0001) between DPB Mean(75.25) of (Group 1) and DPB Mean (68.58) of (Group 3).That means that the combination of drugs and herbs and supplement were more potent than taking the drug only.
From                noted that the most common symptoms of the side effects experienced were nausea, headache, and dizziness, skin rash, bleeding disorder, gastrointestinal symptoms, and anorexia. The study reported that gastrointestinal symptoms were the most common side effects that the sample patients experienced when using medicinal herbs with 15.4% while a headache was second with 10.1% as shown in table 16. There was a significant difference (P-value=0.0001) regarding the patients who took only antihypertensive drugs and the mean of the SPB of the patients who took only herbs or the supplements thus indicating that the drugs seemed more potent than the herbs in conjunction with the supplements. There was a significant effect (P-value=0.0001) between DPB Mean (75.25) of (Group 1) and DPB Mean (67.60) of (Group 4) thus indicating that the combination of drugs and herbs was more potent than taking the drug only, as shown in table 22.

DISCUSSION
The study was instrumental in identifying the prevalence of medicinal use (51.4%) among hypertensive patients in Jordan. The prevalence of the use of medicinal herbs for the treatment of hypertension in Iraq was reported to be (65.5%) while that of Saudi Arabia has been reported to be 63.8 %. 5 The high prevalence of the usage of medicinal herbs has been attributed to the Islamic culture and beliefs regarding the consumption of herbs as treatment for various health conditions. Some previous evidence in the Middle East has reported some high rate of medicinal herbs use in hypertensive patients. Other studies conducted in developed nations have also shown some substantive increase in the application of medicinal herbs among the different hypertensive patients. 5 In the study conducted, the use of medicinal herbs was related to the marital status, educational level and the hypertension duration.
On the other hand, the usage was not associated with the age, gender and the comorbidity presence. There has existed some inadequate and conflicting information regarding the alternative medicines for hypertension that can be accessed by various patients.
A study undertaken in Tanzania reported that the patients from poor socioeconomic backgrounds, those with poor or inadequate knowledge concerning hypertension had some high prevalence of using medicinal herbs for their treatment. 18 Additionally, the studies conducted in China and Iraq confirmed the association of marital status, educational level, and socioeconomic level as some of the critical factors that influence the use and intake of medicinal herbs for treatment by hypertensive patients .6 Some other studies have also indicated that use of medicinal herbs for hypertension was not dependent on the socioeconomic and demographic factors as determined in our study. The given variation in the findings may be attributed to various cultural differences, variations in beliefs and norms of the communities that took part in the different studies. From the given variations, it may be deduced that the impact of the socioeconomic and demographic factors may be dependent on the community or country of study. The study also identified various factors such as body weight, medical conditions, and family history, smoking status and diet and lifestyle changes as the main risk factors for hypertension. 10,11 The study investigated the prevalence of the use of medicinal herbs and other drugs or supplements in the treatment of hypertension, from The use of supplements and other types of treatment for hypertension had some lower percentages as compared to the use of medicinal herbs. This may be attributed to the fact that western or scientific practices still being uncommon among Arabic culture and beliefs. It can be concluded from the study that the characteristics of the patients such as the education level, marital status and the socioeconomic factors were the influential factors for most patients in choosing the use of medicinal herbs. 9 However, it may not be easier to have a conclusive theory to describe the choice of the medicinal herbs as compared to other forms of treatment due to various contradictory findings of different studies in different communities and countries.
There still exists inadequate or minimal reasons behind why patients in Jordan and other cultures have the preference for medicinal herbs in the treatment of the different hypertension diseases. The patients that participated in this study used medicinal herbs in supporting the standard treatment, protection of their health, adherence to the Arabic culture and the obtaining of good treatment at some low cost. 10 The highlighted reasons were in tandem with those of the previous studies that were conducted on the same topic. The usage of the medicinal herbs for hypertensive treatment in this study was mainly supported by advice and information gathered from the internet, family or relatives, CAM users, friends or colleagues, books or magazines and the doctor or qualified pharmacists as shown in table 21. The influence of family or relatives was the highest with 40.9%. On the other hand, the influence of Cam user was the second with 17.8% while the internet was the third with 17.3 %. It is worth noting that the CAM users also did not seek proper and professional advice from the doctors since they mostly relied on the family or relatives and the internet on making their decisions whether to use supplements or not 23. The mean expenditure per annum for the sample patients included in the study was 20.95 dinars. However, there is scanty information regarding the total global expenditure on the use of CAM.
The study included patient perceptions concerning the side effects of the various forms of hypertension treatment. The most common symptoms of side effects were nausea, headache, and dizziness, skin rash, bleeding disorder, gastrointestinal symptoms and anorexia. Despite the scanty side effects of the use of medicinal herbs, the study reported that gastrointestinal symptoms were the most common side effects that the sample patients experienced as shown in table 16. 11-13 The experience of a headache as the side effect was the second most common among the patients who used herbal medicine.
From table 28, 29 it can be deduced that the use of drugs, herbs and the supplements was more potent than taking drugs only for the treatment of hypertension as shown by the existence of the significance difference (p value =0.0050). The more effective of the use of the drugs, herbs and other supplements can be attributed to the lesser side effects of the medicinal herbs as compared to the contemporary drugs. Supplements also play a pivotal role in increasing the effectiveness since supplements such as omega-3 fatty acids and magnesium have proven to be important in reducing depression and hypertension. 14,15 This more potency of the use of drugs, herbs and supplements can also be attributed to the existence of the significance effect on the SBP and DBP as shown in table 27. The study also highlighted the use of various supplements in the treatment of hypertension. Magnesium, cod liver oil, calcium, folic acid and omega -3 fatty acids were the main supplements that were used. The debate on the effectiveness of the medicinal herbs in the treatment of hypertension is still open since there is still more evidence needed in conclusively supporting the research.

CONCLUSION
From the study, it can be deduced that the use of herbal medicines and supplements as well as antihypertensive drugs was prevalent among hypertensive patients in Jordan. Over half of the patients involved in this study were taking medicinal herbs to treat their blood pressure diseases. Adults from low socioeconomic status, those with misunderstandings about hypertension, and those without high educational level were more likely to take herbs.
In a worrying trend, however, only 8.7% of the patients involved in this study know whether the herbs they were using was safe for their condition. The data obtained during the study shows that both herbal medicine and supplements do not affect the blood pressure while antihypertensive drugs are effective for hypertension patients.
In conclusion, it found that the use of the medication in controlling pressure in patients with high blood pressure is essential that does not accept change or switch, and the use of herbs and supplements is only as a complementary treatment.
It can also be deduced that a combined usage of herbal medicine and supplements with antihypertensive drugs was far more potent than using antihypertensive drugs only. It is recommended that a thorough sensitization campaign should be carried out to reduce the number of patients resorting to taking herbal medicines without any knowledge on whether the herbs are helping their conditions or not.

CONFLICTS OF INTEREST
There are no conflicts of interest.