epidemiology of herbal drugs use in addis ababa, ethiopia

pharmacoepidemiology and drug safety 2002; 11: 587–591Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pds.729

ORIGINAL REPORT

Epidemiology of herbal drugs use in Addis Ababa, Ethiopia

Teferi Gedif* and Heinz-Jurgen Hahn

Institute of Pharmacoepidemiology, Faculty of Pharmacy, Martin-Luther University Halle-Wittenberg, Halle, Germany

SUMMARY

Objective To study the utilization patterns of herbal drug use in urban Ethiopia.Methods A cross-sectional community-based survey was conducted in Addis Ababa, capital city of Ethiopia, using a pre-tested semi-structured questionnaire. The questionnaire was administered to 600 heads of households, largely mothers,selected using a multi-stage systematic random sampling technique, where the final sampling units were households.Results The prevalence of herbal drugs use was found to be 37%. The main reasons given for choosing herbal medicine asthe first line medication option were: dissatisfaction with the services of modern health institutions due to their time con-suming nature, cost considerations and perceived efficacy.Conclusion This study showed that in spite of the geographic accessibility of modern health institutions in urban areas, theuse of traditional medicine, particularly herbal drugs, remains a major form of health care option. Hence health plannersshould give appropriate consideration to this sector. Copyright # 2002 John Wiley & Sons, Ltd.

key words— utilization pattern; herbal drugs; prevalence; Addis Ababa

INTRODUCTION

Modern health services cater for less than half of theEthiopian population. The majority of people in ruralareas have no access to any type of modern healthcare.1 Hence, traditional medicine (TM) may be theonly available source of health care within a reason-able distance. Even in big cities such as Addis Ababawhere both government and private run modern healthinstitutions of the country are concentrated,2 tradi-tional healers are flourishing. Investigation of theunderlying factors for the increasing tendency ofurban dwellers to use TM, is important for appropriatehealth care planning.

SUBJECTS AND METHODS

Description of the study area

Addis Ababa is the largest city in Ethiopia and itscapital. The city occupies an area of 324 km2 withan altitude ranging from 2200 to 3000 m above sealevel. The estimated population size of Addis Ababais nearly 3 million.2 As in other metropolitan cities,the advantages of urbanization bring many peoplefrom other parts of the country to Addis Ababa, result-ing in ethnic diversity. There are 18 hospitals, 251clinics and 18 health centres. The major teachingand central referral hospitals in the country are alsofound in Addis Ababa.3 As in other parts of the coun-try communicable diseases are public health threats.The prevalence of non-communicable diseases suchas malnutrition, cardiovascular diseases, mentaldisorder, etc. is also on the increase.

Sampling and data collection

The sample size of this survey was calculated usinga modified Kirkwood formula for cross-sectionalsurveys as follows.4 N (sample size)¼ (Z�) 2� p(100� p)/d2, where p is a rough approximation of

Received 31 January 2002Revised 25 March 2002

Copyright # 2002 John Wiley & Sons, Ltd. Accepted 15 April 2002

* Correspondence to: Teferi Gedif, Institute of Pharmacoepidemiol-ogy, Faculty of Pharmacy, Martin-Luther University Halle-Witten-berg, W-Langenbeck Strasse 4, D-06120, Halle, Germany.E-mail: [email protected]

Contract/grant sponsor: Katholischer Akademischer Auslander-Dienst (KAAD).

the proportion and d is the absolute sampling errorthat can be tolerated. Since no up to date and reliableinformation was available on the prevalence of herbalmedicine use in the area, conservative assumptionsof 50% prevalence, 95% certainty, and expectedsampling error of 4% were used in the calculation.Accordingly, the sample size requirement was esti-mated to be 600 households. The 600 households werethen selected using a multi-stage systematic randomsampling technique. Information on demographiccharacteristics, history of illness in the family in the4 weeks preceding the interview date, action(s) taken,herbal drugs people hoard in their house and reasonsfor the choice of herbal medicine as the first line ofaction were collected using a semi-structured ques-tionnaire. The questionaire was first prepared inEnglish and translated into the official language; itwas also translated back by a second person andpre-tested on 50 households with the aim of practi-cally evaluating the questionnaire. Selected final yearpharmacy students in Addis Ababa University weregiven vigorous training for 2 days on the data collec-tion instrument. The questionnaire was administeredto mothers. When a mother was absent in a household,a person who assumed the role of caretaker in thefamily would be interviewed. Before the initiationof the interview, oral consent was obtained from eachrespondent who participated in the study. During datacollection, the quality of the data was monitored byspot checking the interviewers. In addition the princi-pal investigator checked each questionnaire daily.Any incomplete forms and misunderstandings duringdata collection were corrected.

Data entry and analysis

The quantitative data collected was entered andanalysed using EPI-info 6.0 statistical software.

RESULTS

Perceived illness

Two hundred and fifty-four persons (8.0%) reportedepisodes of illness in the 4-week recall period.Respiratory problems including cough/cold andasthma, headache, dyspepsia, fever, tonsillitis, parasi-tosis and skin problems were the most frequentlyreported health problems.

Action taken

Table 1 shows the kind of action taken by those report-ing illness in the 4 weeks preceding the interview date.

A fairly large proportion (94.9%) of those whoreported illness took action against their illness; ofwhich about 59.8% took modern medicine, 39.0%used herbal medicine and the rest (1.2%) consultedspiritual healers or used Holy water. Relatively morefemales than males resorted to the use of herbal med-icine and other actions such as consulting spiritualhealers or taking Holy water. Education tends toreduce non-action and enhances the use of herbalmedicine. Marital status appears to have some influ-ence on the action taken against illness. In this regard,unmarried respondents tended to use herbal medicinemore than those who were married. Also, there wasmore of a tendency to take no action among unmarriedrespondents.

Reasons for choosing herbal medicineas the treatment option

As shown in Table 2, when respondents were askedfor their reasons for choosing herbal medicine as thefirst line of defence against their illness, 43% said theillness was minor and did not warrant a visit to amodern health care unit as they are time consuming,31.9% said that modern medicine was too expensiveand 19.1% used herbal medicine because of itsperceived efficacy. The rest (6.4%) claimed that easyaccess was the reason for choosing herbal medicine asthe first line of defence.

Self-care with herbal drugs

Of a total of 254 persons who reported an illness,35.4% practised self-care with herbal drugs. Rela-tively females practised self-care with herbs morethan males (Table 3).

Hoarding of herbal drugs

Hoarding of herbal drugs was reported in 68 (11.3%)of the households studied. The most commonly storedherbs were Zingiber oficinale (Zingible), Tavarneraabyssinica (dingetegna), Lipidium sativum (feto),Ocium lamifolium (damakesse), and Ruta chalpensis(tena-adam). The storage places and shelf-life ofherbs varied from household to household. Somestored them in plastic containers or bags, while otherskept them in wooden boxes or wrapped them in cloth.Regarding the duration of storage, it varied from1 month to indefinitely in 51.5 and 11.8% of thehouseholds respectively.

588 t. gedif and h.-j. hahn

Copyright # 2002 John Wiley & Sons, Ltd. Pharmacoepidemiology and Drug Safety, 2002; 11: 587–591

DISCUSSION

Because of the general incomparability of surveyresults (due to differences in the recall periods,seasons when one studies are conducted or generalstudy design), it was difficult to make a comparativeanalysis of the prevalence of perceived illness in ourstudy with the results of other morbidity surveys con-ducted in Ethiopia. It was, however, evident that themorbidity pattern documented in the present study issimilar to the patterns observed in previous studies.5,6

In most developing countries, including Ethiopia,women’s access to modern health services is nega-tively affected by their poor social status (lack of

Table 1. Action taken against illnesses by background factors during a recall period of 4 weeks, Addis Ababa, 2000 (N¼ 254)

Background Number Action for illness (%)factors reporting ——————————————————————————

illness Modern medicine Herbal medicine Others No action

SexMale 81 60.5 33.3 — 6.2Female 173 54.9 38.8 1.7 4.6

Age (years)0–14 50 54.0 44.0 — 2.015–54 165 61.2 37.0 1.8 6.1>54 39 66.7 28.2 — 5.1

EthnicityAmhara 180 58.9 36.1 0.6 4.4Oromo 38 50.0 39.5 — 10.5Gurage 16 62.5 25.0 6.3 6.3Others 20 45.0 50.0 5.0 —

ReligionOrthodox 231 56.7 37.7 1.3 4.3Muslim 11 36.4 54.5 — 18.1Others 12 75.0 16.7 — 8.3

Marital status*Married 73 61.6 31.5 4.1 2.7Others 130 54.6 37.7 — 7.7

Educationy

Illiterate 28 71.4 21.5 — 7.1Literate 208 53.4 39.9 1.4 5.3

Household size (no. of persons)1–4 110 52.7 39.1 0.9 7.35þ 144 59.7 35.4 1.4 3.5

* Excludes those too young to be married.yExcludes those too young to be literate.

Table 2. Reasons given for selecting herbal medicine as healthcare option in Addis Ababa, 2000 (N¼ 94)

Reasons Percentage

Time consuming nature of MHCU* 42.6Less costly 31.9Perceived efficacy 19.1Ease of access 6.4

*Modern health care units.

Table 3. Self-care with herbal drugs in Addis Ababa, 2000(N¼ 254)

Category Number Self-care with herbsreporting illness (%)

SexMale 81 33.3Female 173 36.4

Age (years)0–14 50 44.015–54 165 34.555þ 39 28.2

ReligionOrthodox 231 35.9Muslim 11 45.6Others 12 16.7

Marital status*Married 73 28.8Others 130 36.2

Educationy

Illiterate 28 21.4Literate 208 38.0

Household size (no. of persons)1–4 110 36.45þ 144 34.7

*Excludes those too young to be married.yExcludes those too young to be literate.

epidemiology of herbal drugs use 589


access to family money and restricted mobility) andpoor organization of health services, particularly alack of cultural sensitivity.7–9 As a result it appearsthat the majority of females resort to traditionalmedicine or self-care. Our study also demonstratedthat females tended to use herbal medicine and con-sulted spiritual healers more frequently than males.

There are multiple reasons why people turn toherbal medicine. The most common reasons citedare, psychological comfort from having taken someaction, cultural acceptability, perceived efficacy andinaccessibility of modern health services in terms ofgeography, cost, or time.10,11 In accord with thesearguments, our study revealed that because of dissatis-faction with the services of modern health care unitsowning to their time consuming nature, people pre-ferred to use herbal drugs unless the illness was serious.Cost and perceived efficacy were also reported to beimportant reasons for using herbal medicine as the firstline of action. A similar study carried out in Tanzaniaidentified cost and perceived efficacy as importantfactors influencing the choice of health care.12

This study documented that the overall use of her-bal medicine was found to be 37%. A telephonesurvey conducted in 1999 among 1204 randomlyselected British adults revealed that 34% of respon-dents had used herbal medicine within the last year.13

Another study conducted among Yemenite immi-grants in Israel found that 11.5% of those whoreported an illness reported the use of herbal reme-dies.14 The variability of the estimates on the preva-lence of herbal medicine use, according to Winslowand Kroll,11 is due to discrepant definitions of herbsand discrepancies in the reported duration of use.Generally the use of herbal medicine is high and about80% of the world’s population, particularly in devel-oping countries, relies on traditional medicine fortheir health care needs.15

In this study it was also noted that most people(35.4%) in Addis Ababa used herbal drugs for self-care. In a previous study carried out in 1984, Kitawdocumented a 29% prevalence of herbal drugs usein self-care.5 This difference, may be partially attribu-table to the discrepancy between the two studies inspecifying the duration of use (i.e. four weeks versustwo weeks) and may indicate the increasing trend inthe use of herbal drugs as an alternative health careoption in the community. The increasing cost of thehealth services in general and pharmaceuticals in par-ticular could lead more peoples to resort to herbalmedicine. For example, a study carried out in Abidjan,Cote d’Ivore, indicated that 14 to 17% of urban house-holds changed from modern to traditional medicine

when the franc was devalued.16 The emergence of dis-eases in which modern medicine has failed to providea complete solution could be another reason for theincreasing popularity of herbal medicine. Zollmanand Vickers argued that relief from chronic disorderswhich did not respond adequately to conventionalmedicine could be a common reason for the use ofalternative or complementary therapies.17

This study also showed that a fairly significant per-centage of the households were found to be hoardingherbal drugs. It was also found that the duration of sto-rage varied from household to household. In approxi-mately 10% of households herbal drugs were reportedto be stored for unlimited periods. This may result ineither loss of potency or may pose a health hazard asthe concentration of the constituents of some plantmaterials may rise to toxic levels during the degrada-tion process which may take place when these drugsare stored for long periods.

This study is not without of the weaknesses of gen-eral survey results as described by Kroeger whoreports that the recall of illness events and the corre-sponding action taken decline even during the firstweek.18 In addition, since the interviewers were mod-ern health professionals, some of the respondents maywell have refrained from reporting the use of herbalmedicine for their illnesses, a form of social desirabil-ity bias. The overall effect of these weaknesses wouldbe therefore, an underestimation of the prevalence ofherbal medicine use. But from this study one cansafely conclude that the Addis Ababa community,which can be said to have relatively better access tomodern health facilities than most other communitiesin Ethiopia, commonly uses herbal drugs.

ACKNOWLEDGEMENTS

Financial assistance from Katholischer AkademischerAuslander-Dienst (KAAD) is gratefully acknowledged.We extend our deepest appreciation to Professor DrR. Neubert for his complete support in making thisstudy a reality. The Ethiopian Science and TechnologyCommission is acknowledged for facilitating the fieldwork. Special thanks go to the enumerators who skil-fully collected the data. And finally, we are grateful tointerviewees who were willing to openly share theirexperiences.

REFERENCES

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Research Consolidating in Ethiopia, Teklai Y (ed.). EthiopianScience and Technology Commission: Addis Ababa, 1998.

3. Ministry of Health. Health and Health Related Indicators.Semayata Press: Addis Ababa, 1998.

4. Kirkwood B. Essentials of Medical Statistics. BlackwellScientific Publications: Oxford, UK, 1988.

5. Kitaw Y. Self care: a study of three communities in Ethiopia.Ethiopian J Health Dev 1987; 2: 1–75.

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12. Satima F, McBride SR, Leppard B. Prevalence of skin diseasesin rural Tanzania and factors influencing the choice of healthcare, modern or traditional. Arch Dermatol 1998; 134:1363–1366.

13. Ernst E, White A. The BBC survey of complementarymedicine use in the UK. Comp Ther Med 2000; 8: 32–36.

14. Nakar S, Vinker S, Kitai E, Wertman E, WeingartenM. Folk, traditional and conventional medicine among elderlyYemenite immigrants in Israel. Isr Med Assoc J 2001; 3: 928–931.

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16. ADB/UNICEF. Les strategies d’adaptation sociales despopulations pulnerables d’Abidjan face a la devaluation et ases effects. African Develop Bank 1995; 87: 34–36.

17. Zollman C, Vickers A. ABC of complementary medicine:users and practitioners of complementary medicine. Br Med J1999; 319: 836–838.

18. Kroeger A. Health interview surveys in developing countries:a review of methods and results. Int J Epidemiol 1983; 12:465–478

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epidemiology of herbal drugs use in addis ababa, ethiopia

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