Original-Article-II

75
Use of and satisfaction with complementary and alternative
medicine in four chronic diseases: A cross-sectional study
from India
M.S. BHALERAO, P.M. BOLSHETE, B.D. SWAR, T.A. BANGERA, V.R. KOLHE, M.J. TAMBE,
M.P. WADE, S.D. BHOWATE, U.B. SONJE, N.J. GOGTAY, U.M. THATTE
ABSTRACT
Background. We assessed the extent of use of
complementary and alternative medicine (CAM) by patients
with four chronic diseases—epilepsy, HIV, rheumatoid arthritis
(RA) and diabetes mellitus (DM)—at a tertiary care, teaching
hospital of allopathic medicine in India. We also assessed
patients’ satisfaction with CAM.
Methods. Adults attending the outpatient clinics for
epilepsy, HIV, RA and DM who took CAM were recruited
over a period of 16 weeks. After obtaining written informed
consent, they were administered the ‘Treatment Satisfaction
Questionnaire for Medication’ (TSQM)TM
to assess satisfaction
in domains such as effectiveness, no side-effect, convenience
and global satisfaction.
Results. Of the 4664 patients screened, 1619 (34.7%)
were using CAM and 650 (40%) of them consented to
participate. The extent of use of CAM was 63% in patients
with DM, 42.7% in RA, 26.2% in HIV and 7.7% in epilepsy.
Ayurveda 57.1% (95% CI 53.27–60.89) was the most
frequently used CAM. Satisfaction in terms of effectiveness
and global satisfaction was highest among patients with HIV
(69.4% and 69.2%, respectively) and least among those who
had RA (56.6% and 54.1%, respectively). High scores were
reported to ‘no side-effect’ domain in all the four diseases. The
proportion of physicians who were aware about their patients’
using CAM was 100% in patients with RA, 95% in HIV, 74%
in epilepsy and 29% in DM.
Conclusion. A large proportion of patients with four
chronic diseases reporting to a hospital of allopathic medicine
in India were also using CAM and were satisfied with its use.
GiventhepotentialinteractionofCAMwithallopathicmedicines,
a history of use of CAM should be elicited in clinical practice.
Natl Med J India 2013;26:75–8
© The National Medical Journal of India 2013
INTRODUCTION
It has been estimated that two-thirds of the world’s population
seekshealthcarefromsourcesotherthanthoseprovidingtreatment
with the allopathic system of medicine. While some patients self-
medicate, most seek care from learned practitioners of traditional,
indigenous systems of medicine, viz. Ayurveda,1
which is a
popular traditional system of healthcare in India. Complementary
and alternative medicine (CAM) is a broad domain of healing
resources that encompasses all healthcare systems, modalities,
and practices and their accompanying theories and beliefs, other
than those intrinsic to the politically dominant healthcare system
of a particular society or culture in a given historical period. CAM
includes all such practices and ideas self-defined by their users as
preventingortreatingillnessorpromotinghealthandwell-being.2
The use of CAM for prevention and treatment of diseases is
prevalent in patients with some diseases particularly those
considered to be chronic and incurable such as breast cancer,3
arthritis,4
asthma,5
diabetes,5
migraine,5
epilepsy5
and HIV
infection.6–9
It has been reported that patients opt for CAM because they are
dissatisfied with allopathic healthcare as it is perceived to be
ineffective, have side-effects, is impersonal or too expensive.10,11
However,ithasbeensuggestedthatdisenchantmentwithallopathic
medicine is not necessarily the only reason why patients turn to
CAM.12
This observation is supported by an American study that
reported ‘users of alternative healthcare are no more dissatisfied
with or distrustful of conventional western care than non-users’.9
Patients may also find CAM attractive because it is in consonance
with their personal values as well as religious and health
philosophies.9–13
It has been suggested that CAM offers such
patients a consultation model that is more appropriate and
egalitarian for their illness.14,15
The general attributes of CAM do
not always lead to increased patient satisfaction. Complementary
medicines have some features that can cause problems or have
deleterious effects.16
The safe and appropriate use of CAM is also a source of
concern,especiallywhenusedconcomitantlywithothermedicines.
Treating physicians are often unaware of the use of CAM by their
patients. One study reported that only 38.5% of patients discussed
alternative therapies with their physician.17
These treatments
sometimes have a negative impact including side-effects,
unchecked progression of an underlying illness and unnecessary
expense.18
These side-effects and interactions affect patients with
regard to their adherence to treatment and quality of life, thus
impactingtheeffectivenessofallopathicmedicines.Whileresearch
has been done examining the use of CAM in patients with specific
Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai 400012,
Maharashtra, India
M.S. BHALERAO, P.M. BOLSHETE, B.D. SWAR, T.A. BANGERA,
V.R. KOLHE, M.J. TAMBE, M.P. WADE, S.D. BHOWATE,
U.B. SONJE, N.J. GOGTAY, U.M. THATTE
Department of Clinical Pharmacology
Correspondence to U.M. THATTE, Department of Clinical
Pharmacology, 1st Floor, New M.S. Building, Seth G.S. Medical
College and K.E.M. Hospital, Parel, Mumbai 400012, Maharashtra,
India; urmilathatte@kem.edu, urmilathatte@gmail.com
THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 26, NO. 2, 2013

76 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 26, NO. 2, 2013
diseases and for those with one or more chronic conditions, little
attention has been paid to how use of CAM differs by the type of
chronic disease. Very few studies have compared the use of CAM
among individuals with different types of chronic disease. We
assessed the extent of use of CAM and satisfaction with its use in
four chronic diseases—epilepsy, HIV, rheumatoid arthritis (RA)
and diabetes mellitus (DM).
METHODS
Across-sectional,observationalstudyapprovedbyourinstitutional
reviewboardwasconductedatourtertiarycare,teaching(allopathic
medicine) hospital in Mumbai, Maharashtra, India, over a period
of 16 weeks from March 2010 to June 2010. It was calculated that
a minimum of 800 patients (estimating a 15% drop-out rate with
an allowable error of 20%) would be required to estimate an
approximate 12% use of CAM in four chronic diseases. During
the period of 16 weeks, we could enrol 650 patients for the
assessment of satisfaction of use of CAM.
Patientsofeithergender,over18yearsofageandattendingthe
outpatient clinic of the disease under study (epilepsy, HIV, RA
and DM) were asked if they took CAM. If the reply was in the
affirmative, they were invited to take part in an interview where
they were required to answer a structured questionnaire.
Demographicdata,detailsofuseofCAMandallopathicmedicines
with a short medical history were recorded. All patients who
attended the outpatient constituted the denominator. Physician
awareness was calculated by the number of patients who had been
recommended CAM by the physician and/or patient disclosure to
the physician regarding the use of CAM.
After obtaining consent, the participants were administered
the ‘Treatment Satisfaction Questionnaire for Medication’
(TSQM)TM
version 1.4 (details available at www.quintiles.com/
clinical-services/tsqm/; last accessed 14 March 2012) to assess
the patients’ satisfaction through four domains, such as
effectiveness,noside-effect,convenienceandglobalsatisfaction.
AlthoughtheoriginalquestionnairewasinEnglish,itwasavailable
as a translated and validated version in Hindi and Marathi
languages. Participants were interviewed in the language they
weremostfamiliarwith(Hindi,MarathiorEnglish).Patientswith
a psychological disorder were excluded.
The TSQM version 1.4 is a 14-item/questions validated19,20
instrument consisting of four domains as effectiveness (questions
1–3), no side-effects (questions 4–8), convenience (questions 9–
11)andglobalsatisfaction(questions12–14).Thesequestionsare
scaled on a seven-point bipolar scale from ‘extremely satisfied’ to
‘extremelydissatisfied’exceptquestion4whichhasadichotomous
response. The domain score was computed by adding the score of
questions representing the specific domain called as composite
score.Thelowestpossiblescorewassubtractedfromthiscomposite
score and divided by the greatest possible score minus the lowest
possible score. This provided a transformed score between 0 and
1 that was multiplied by 100, for example
[Sum of score (Question 1+Question 2+Question 3)–
Lowest possible score] % 100
(Highest possible score–Lowest possible score)
The domain scores range from 0 to 100 with higher scores
representing higher satisfaction on that domain. 95% confidence
intervals (mean±1.96 SEM) were determined and a p value <0.05
was considered statistically significant. The difference in the
satisfaction of four chronic diseases was assessed for normality
using the Kruskal–Wallis test and the analysis of variance was
used. The outcome measures included patient’s satisfaction,
extent of use of CAM and physician’s awareness about the use of
CAM by their patient.
RESULTS
Atotalof4664patientswerescreenedfromtheepilepsy,HIV,RA
and DM outpatient clinics (Table I). Of these, 1619 (34.7%, 95%
CI 33.34–36.06) reported the use of CAM. However, 969 of them
(59.9%) declined consent to participate and thus we were able to
recruit a total of 650 patients for the study. The highest proportion
of consent refusals were from the DM outpatient (965/1844;
52.3%)followedbytheHIVoutpatient(4/397;1%).Morewomen
used CAM in the RA (4.5 women to 1 man) and HIV groups (1.7
women to 1 man).
Use of CAM
The overall use of CAM in the four chronic diseases was 34.7%
(1619/4664, 95% CI 33.34–36.06). The use among patients with
DM was 63.2% (95% CI 60.99–65.37), while in patients with RA
it was 42.7% (95% CI 38.25–47.21), in HIV it was 26.2% (95%
CI 17.74–34.65) and in epilepsy it was 7.7% (95% CI 6.5–8.84).
We found that Ayurveda was used by more than half the patients
(57.1% [95% CI 53.27–60.89]) and was the most frequently used
CAM (Table II) irrespective of whether the patient had HIV 97%
(97/100), RA 72% (144/200) or epilepsy 46% (82/150). Patients
with DM, however, used home remedies most frequently (44%
[88/200]). The use of two or more CAMs was reported in RA
(27%), DM (9%), epilepsy (8%) and HIV (2%).
Patients’ satisfaction with the use of CAM
Patients with HIV reported the highest satisfaction in domains of
effectiveness, global satisfaction and convenience while those
with RA had the least satisfaction in these domains. High scores
were reported for the ‘no side-effect’ domain in all the four
diseases indicating satisfaction with CAM. The difference in
effectiveness and convenience domains for RA was significantly
(p<0.001) different when compared to HIV, epilepsy and DM
(Table III).
Physicians’ awareness of CAM treatment by patients
The proportion of physicians aware about their patients using
CAM was 100% among patients with RA, 95% among those with
TABLE I. Demographic data
Characteristic Disease
Epilepsy HIV Rheumatoid arthritis Diabetes mellitus
(n=150) (n=100) (n=200) (n=200)
Mean (SD) age (years) 29.6 (10.99) 37.9 (9.06) 42.0 (13.14) 46.4 (13.26)
Men (%) 60.7 37.0 18.0 62.0
Men:Women ratio 1.5:1 1:1.7 1:4.5 1.6:1
Median (range) duration of disease (years) 4 (0.1–45) 2.5 (0.5–11) 4 (0.2–30) 5 (0.2–30)

77
HIV, 74% among those with epilepsy and 29% among those with
DM.
DISCUSSION
We assessed the extent of use of CAM and patients’ satisfaction
with CAM among patients with four chronic diseases—epilepsy,
HIV, RA and DM in a tertiary care teaching (modern medicine)
hospital in India. We found that women were using CAM more
than men for RA (82%) and HIV (63%), which is consistent with
other studies.5
The rates of use of CAM reported previously vary
widely (6%–84%).21–28
We found 34.7% of patients attending
various outpatient clinics in our hospital were using CAM. This
is higher than the 12.4% reported in the Canadian Community
Health Survey (CCHS)5
of four chronic diseases—Asthma, DM,
migraine and epilepsy. We found the highest use of CAM in
patientswithDM(63%)whichissimilartothatreportedpreviously
(67.7%).29
Among patients reporting to the epilepsy clinic, 7.6%
reported that they used CAM, which is lower than the 32%
reported in an Indian study.30
Our patients with HIV reported a
higher use of CAM (26%) compared to the previous report from
the HIV Cost and Services Utilization Study (HCSUS) which
suggested that CAM was used by 16% of HIV-infected patients.31
Among patients with RA, 42.7% reported using CAM, which lies
within the wide range (28%–90%)32
reported by previous studies
in a variety of conditions including breast cancer.
Of the 650 patients who gave a history of using CAM and who
consented to participate in the study, Ayurveda was found to be
themostcommonlyusedCAM(57.1%),especiallyamongpatients
with HIV (97%). However, among patients with DM, home
remedies were used more commonly (44%). The CCHS reported
massage therapy (62.9%), acupuncture (18.3%), homoeopathy
(18.2%),chiropracticcare(11.3%),herbalists(5.2%),reflexology
(2.4%) and spiritual healing (1.0%) as the commonly used CAM
therapies.5
The difference in the types of CAM used may be
related to availability, dominance and classification of CAM in
various regions.2
We evaluated patients’ satisfaction with CAM in four
domains—effectiveness, no side-effects, convenience and global
satisfaction. The domain scores ranged from 0 to 100 with higher
scores representing greater satisfaction. We found that patients
reported highest satisfaction in the domains of effectiveness,
global satisfaction and convenience in the HIV group and least
satisfaction in the RA group and this was significantly different
compared with HIV, epilepsy and DM (p<0.001). High scores
were reported in the ‘no side-effect’ domain in all the four
diseases indicating satisfaction with CAM. The least satisfaction
in RA may be due to factors such as severity, persistence of
disabling symptoms such as pain33
and swelling after the use of
CAM. There are no reports on the extent of satisfaction using this
scale although some studies have shown that a majority of CAM
users found their CAM treatment to be effective.34
Our findings
indicate that patients suffering from HIV, DM and epilepsy
reported CAM as effective, convenient and safe to use.
Interestingly, a large proportion (59.9%) of patients who used
CAM declined consent to participate in our study. One of the
reasons they cited was they did not wish the treating physician to
become aware of the fact that they used CAM. This is disturbing as
druginteractionsbetweenCAMtherapiesandallopathicmedicines
can have serious adverse effects, and physicians who are treating a
patient should be aware of the use of CAM. It was reassuring that
BHALERAO et al. : COMPLEMENTARY AND ALTERNATIVE MEDICINE IN CHRONIC DISEASES
TABLE II. Proportion (%) of use of different types of complementary and alternative systems of medicine (CAM)*
CAM Epilepsy HIV Rheumatoid arthritis Diabetes mellitus
(n=150) (n=100) (n=200) (n=200)
Overall use (95% CI) 7.7 (6.5–8.84) 26.2 (17.74–34.65) 42.7(38.25–47.21) 63.2(60.99–65.37)
Ayurveda 46 97 72 14
Homeopathy 22 1 25 1.5
Unani 1 1 1 0
Yoga 22 1 9 35
Home remedies 0 0 2 44
Diet 0 0 0 13
Acupuncture 0 0 0.5 0
Sidhha 0 0 0.5 0
Massage 0 0 17 0
Herbals 0 1 0.5 0
Panchakarma 12 0 0 0
* Types of CAM add up to more than 100% due to use of more than one CAM by some patients
TABLE III. Patients’ satisfaction with the use of CAM (mean scores and 95% confidence intervals)
Domain (mean score) Epilepsy HIV Rheumatoid arthritis Diabetes mellitus Statistical significance*
(n=150) (n=100) (n=200) (n=200)
Effectiveness 69.43 63.59 56.61 66.11 RA v. HIV, DM and epilepsy: p<0.001;
(66.22–72.65) (61.29–65.87) (54.05–59.17) (64.54–59.17) HIV v. epilepsy v. DM: ns
No side-effect 98.96 99.75 97.68 99.12 ns
(97.66–100.26) (99.26–100.24) (96.11–99.26) (98.26–99.98)
Convenience 70.43 66.55 65.27 69.08 RA vs. HIV, DM and epilepsy: p<0.001;
(68.02–72.86) (65.08–68.10) (63.88–66.66) (67.62–70.54) HIV v. epilepsy v. DM: ns
Global satisfaction 69.24 63.19 54.13 67.53 RA v. HIV, DM and epilepsy: p<0.001;
(65.73–72.74) (60.68–65.66) (51.33–56.94) (65.48–69.59) Epilepsy v. DM: p<0.01; HIV v. epilepsy:
p<0.05; HIV v. DM: ns
*Kruskal–Wallis test or analysis of variance Values in parentheses are 95% confidence intervals ns not significant RA rheumatoid arthritis DM diabetes mellitus

78 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 26, NO. 2, 2013
amongthepatientswhoconsentedtoparticipateinthestudy,alarge
proportion (100% in RA, 95% in HIV and 74% in epilepsy) did
inform their physician about using CAM. Interestingly, only 29%
of patients with DM informed their physician about their use of
CAM. This may be because a larger proportion of them used home
remedies and may not have considered these as CAM. Our study
suggests that physicians treating chronic diseases must elicit a
history of use of CAM as patients may not always inform their
physicians. This could lead to drug interactions.18
Other studies
have reported that only 38.5%17
of patients discussed their CAM
therapies with their treating physicians and 70%5,31
to 84%35
physicians did not ask patients about their use of CAM. This may
bebecausephysiciansareuncomfortablediscussingCAMtherapies
with their patients as they usually have little formal knowledge or
personal experience about these therapies.
A potential limitation of our study is its cross-sectional nature,
which limits causal inferences. In addition, we were dependent on
patient reports and were unable to validate the use of CAM.
In conclusion, we found a high prevalence of use of CAM
among patients with chronic diseases. Patients are more likely to
disclose the use of CAM if they are specifically asked. Patients
with DM, HIV and epilepsy who used CAM believed it was safe,
effective and convenient with a high satisfaction score. Given the
potential interaction of CAM with allopathic medicines, a history
of use of CAM must be elicited at least among patients with
chronic ailments. Studies on the actual effectiveness of CAM
interventionsmayhelpboththephysiciansandpatientsinchoosing
an appropriate therapy for management of these chronic diseases.
Conflict of interest. None declared
Contributions. UMT and NJG made substantial contributions to
conception and design, acquisition, analysis and interpretation of
data; were involved in drafting the manuscript and revising it
critically for important intellectual content; and gave approval to
the final version to be published. MSB, PMB and BDS made sub-
stantialcontributionstoconceptionanddesign,acquisition,analysis
and interpretation of data; were involved in drafting the manuscript
and revising it critically for important intellectual content. TAB,
VRK, MJT, SDB, MPW and UBS made substantial contributions
to acquisition of data, or analysis and interpretation of data.
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