PATIENT REPORTING OF HERBAL REMEDY USE:

A COMMUNICATION PROBLEM IN PRIMARY CARE

By
Carol Christine Flanders, RN, BSN

Submitted in Partial Fulfillment of the Requirements for
the Master of Science in Nursing Degree

Edinboro University of Pennsylvania

Approved by:
/I

Judith Schilling, CRNP, PhD
Committee Chairperson

'Date^

"7'^9 -to
Jan ^3ejgel, PhD, RN
Committee Member

Date

Abstract

Patient Reporting of Herbal Remedy Use: A Communication Problem in Primary Care
There has been a large increase over the last 10 years in the use of herbal remedies by the

general population of the United States (Greenwald, 1998). The FDA does not regulate herbal

remedies as drugs but as nutritional supplements (Glisson, Crawford, & Street, 1999). Up to 75%
of patients are self-medicating with herbal remedies without consulting primary care physicians

and practitioners (Glisson et al., 1999). There is a potential for drug-drug interactions, side
effects from inappropriate dosing, and delay in the treatment of serious medical conditions with

self-medication with herbal remedies (Barnes, Mills, Abbott, Willoughby, & Ernst, 1998)
Understanding the reason for the nondisclosure of herbal remedy use is critical to the

improvement of physician-patient communication and patient care and safety (Glisson et al.)).
A self-administered survey was conducted in a large rural primary care facility to further

define demographics of herbal remedy users, to assess why they choose to utilize herbal
remedies, and to assess the patient-provider communication barriers concerning herbal remedy
use. The survey had an 86.5% return rate and showed that in this population sample of 865

subjects, 49% had used herbal remedies at some time. The herbal remedy users were more likely
to be 36 to 45 years of age (%2=7.2, p=0.01), have about the same household income as nonusers,
2

be married, have some college or vocational education (% =13.4, p=0.001) or bachelor degree
(X2=9.8, p=0.01), and, like nonusers, rate their overall health as "good" on the day of the survey.

In summary, the percent of herbal remedy users in primary care practices is much higher
than the previous studies have shown. Fifty-seven percent of all subjects had not offered or asked

information about herbal remedies from their providers and staff. Ninety-five percent of

i

Abstract

Patient Reporting of Herbal Remedy Use: A Communication Problem in Primary Care
There has been a large increase over the last 10 years in the use of herbal remedies by the

general population of the United States (Greenwald, 1998). The FDA does not regulate herbal
remedies as drugs but as nutritional supplements (Glisson, Crawford, & Street, 1999). Up to 75%

of patients are self-medicating with herbal remedies without consulting primary care physicians
and practitioners (Glisson et al., 1999). There is a potential for drug-drug interactions, side

effects from inappropriate dosing, and delay in the treatment of serious medical conditions with

self-medication with herbal remedies (Barnes, Mills, Abbott, Willoughby, & Ernst, 1998)
Understanding the reason for the nondisclosure of herbal remedy use is critical to the

improvement of physician-patient communication and patient care and safety (Glisson et al.)).
A self-administered survey was conducted in a large rural primary care facility to further
define demographics of herbal remedy users, to assess why they choose to utilize herbal

remedies, and to assess the patient-provider communication barriers concerning herbal remedy
use. The survey had an 86.5% return rate and showed that in this population sample of 865

subjects, 49% had used herbal remedies at some time. The herbal remedy users were more likely
to be 36 to 45 years of age (%2=7.2, p=0.01), have about the same household income as nonusers,
2

be married, have some college or vocational education (% =13.4, p=0.001) or bachelor degree

0,2=9.85 p=0.01), and, like nonusers, rate their overall health as "good" on the day of the survey.
In summary, the percent of herbal remedy users in primary care practices is much higher

than the previous studies have shown. Fifty-seven percent of all subjects had not offered or asked

information about herbal remedies from their providers and staff. Ninety-five percent of

ii

respondents had not been asked about them by the staff. Communication barriers may be causing

a situation where herbal remedy users might have drug/herbal remedy interactions that would
affect their medical care. Suggestions are offered for better provider/patient communication as
well as future research.

iii

Acknowledgments

I would like to express my sincere appreciation to all those people who helped me

complete this research project. To Dr. Judith Schilling, thank you for being the chairperson of
this committee and for interrupting my tunnel vision to allow me to see the whole picture. To Dr.

Alice Conway, thank you for your objective views of the research and your knowledge of herbal

remedies. To Dr. Janet Geisel, thank your for your day-to-day input, encouragement, and

understanding of the research process. To Dr. Buckwaiter, thank you for your statistical expertise
and interest in the subject of herbal remedies. Thank you to the Westfield Family Physicians

organization for their cooperation and support of this research. Dr. Don Brautigam's enthusiasm
and the tireless efforts of the staff helped this project to be meaningful not just for their offices
but for providers and patients in other rural areas. This study received partial support from Nu
Theta Chapter, Sigma Theta Tau on April 1, 2000.

iv

Table of Contents

Content

Page

Abstract

i

Acknowledgements

List of Tables
List of Figures
Chapter 1: Introduction
Background of the Problem

ni

viii
ix

1
1

Communication

2

Natural is Better

3

Statement of the Problem

4

Theoretical Framework

.4

Statement of the Purpose

7

Assumptions

7

Limitations

8

Definition of Terms

8

Summary

9

Chapter 2: Review of the Literature.

History.

11
11

Ayurveda

11

Traditional Chinese Medicine

12

Naturopathy.

12

Homeopathy

13

V

Content
Complementary and Alternative Medicine

Page
13

Regulation of Herbal Remedies

15

Nutritional Supplements

15

Manufacturing

16

Research

18

Prescriptive Authority

18

Self-Care and Self-Medication

19

The Risk of Herbal Remedy Use

20

Demographics of Herbal Remedy Users

21

Provider-Patient Communication,

24

Summary

26

Chapter 3: Methodology

28

Research Questions

28

Research Design,

28

Sample, Setting, and Procedure

29

Instrumentation

29

Protection of Human Rights

30

Pilot Study,

30

Data Analysis

31

Summary

32

Chapter 4: Findings
Sample,

33
33

vi

Content

Page

Results

33

Herbal Remedy Users

34

Demographics

34

Overall Health

39

Herbal Remedy Use

40

Risk/Benefit Knowledge

42

Adverse Reactions

.48

Herbal Remedy Knowledge

50

Communication

51

Summary

55

Chapter 5: Discussion

Herbal Remedy Users

57

58

Demographics

58

Herbal Remedy Use

60

Risk/Benefit Knowledge

61

Knowledge

63

Communication

62

Conclusions

64

Limitations of the Study

64

Recommendations for Further Study

65

Summary

65

vii

Content

Page

References

67

Appendix A: Side Effect Profiles of Common Herbal Remedies

73

Potentially Toxic Herbs

Appendix B: Patient/Provider Communication Strategies

Communication Strategies for the Patient

75
78
80

Appendix C: Herbal Remedy Survey

81

Appendix D: Raw Data Tables

86

viii

List of Tables

Table

Page

1: Gender: Percentage of Total Sample (N=865), User and Nonuser Status

34

2: Age Comparison of Herbal Remedy Users and Nonusers

35

3: Income Comparison of Herbal Remedy Users and Nonusers

36

4: Marital Status Comparison of Herbal Remedy Users and Nonusers

37

5: Highest Education Level Comparison of Herbal Remedy Users and Nonusers

38

6: Herbal Remedy Use Comparison Of Users and Nonusers

42

7: Who Recommended Herbal Remedies Comparison of Users and Nonusers

.44

8: Who Could Recommend Herbal Remedies, Comparison of Users and Nonusers

46

9: Are Herbal Remedies More Natural, Comparison of Users and Nonusers

.47

10: Comparison of Herbal Remedy Users and Nonusers Interpretation of the word “Natural”

48

11: Comparison of herbal Remedy Users and Nonusers, Reasons for Using Herbal Remedies

50

12: Communication: Updating Medications List Comparison of Herbal Remedy Users and

Nonusers

52

13: Communication: Staff Asking About Herbal Remedies Comparison of Users and Nonusers.... 5 3
14: Communication: Volunteering of Herbal Remedy Use Comparison of Users and Nonusers

54

15: Communication: Ask Information from MD/NP Comparison of Users and Nonusers

56

ix

List of Figures

Figure
1.

Revised Health Promotion Model

2.

Spearman Rank Order Correlation Scattergram: Overall Health

Page
5

40

1

Chapter 1

Introduction
This chapter provides a brief overview of the use of herbal remedies by the

general population of the United States. This study utilized a survey to determine the
demographics of herbal remedy users in a primary care setting, their perceived risk and

benefits of herbal remedies, and what barriers they perceived to communication with their

clinicians about their use of the herbal remedies. The Health Promotion Model by Nola J.
Pender, PhD, RN, FAAN (1996) was the theoretical framework for this study.
Assumptions, limitations, and definition of the terms utilized in the survey are also

included.
Background of the Problem

It has been estimated that up to one in three patients have used some form of

unconventional therapy within the past year, including megavitamins and herbal remedies
(Hadley & Petry, 1999; Glisson, Crawford, & Street, 1999; O’Koon, 1999;
Greenwald, 1998). This commercial boom comes years after the common use of herbal

remedies in the rest of the world (Greenwald, 1998; Berg, Amelia, Gagan, & McArthur,

1998). The Federal Drug Administration does not regulate herbal remedies as
medications. They are nutritional supplements that do not have to go through the rigorous

testing and proof of efficacy that prescription drugs are required to pass (Glisson et al.,

1999). Patients are not asking their primary care providers’ advice about the herbal
remedies. Many patients may not tell their provider that they take herbs and other
nutritional supplements. One estimate is that up to 75% of patients did not notify their

primary caregiver about their use of alternative medicine (Glisson et al.), while an

2

estimated 15 million adults in 1997 took prescription medications concurrently with
herbal remedies and/or high-dose vitamins (Eisenberg et al., 1998). Another interesting
finding is from a recent British study of patients experiencing a serious adverse drug

reaction to an herbal or other over-the-counter remedy (Barnes, Mills, Abbot,
Willoughby, & Ernst, 1998). Over 42% would not consult their physician about the

adverse reaction. Of the 26% who would call their physician with a severe adverse

reaction, none said they would if it was an herbal remedy rather than an over-the-counter

medicine had caused the problem (Barnes, et al., 1998).
More than 60 million people in the United States use alternative medicines

(Fetrow & Avila, 1999). Herbal remedies are being used with increasing frequency by

patients who seek treatment with largely unresearched therapies. This has become a daily

problem in primary care practices everywhere (Fetrow & Avila., 1999). The focus of
further research could be best guided by a general fact finding survey in these busy

primary care practices.

Communication. Fetrow & Avila (1999) wrote about the rights of patients to
information from their health care providers about herbal remedies just as they have the

right to information about prescription medications. Patients need to know drug-drug
interactions, side effect profiles, dosing, and duration of treatment. This all needs to be

done in a nonjudgmental manner to promote communication (Wisneski, 1999a).
Traditional (allopathic) medicine has often taken a paternalistic role in health care, while

the alternative or integrative approaches have tended to work in partnership with patients
(Berg, Amelia, Gagan, & McArthur, 1998).

3

Most allopathic approaches tend to be aggressive or invasive, while integrative

therapies generally take a gentler or slower approach. Moreover, most integrative
therapies focus on optimizing and fortifying health while ameliorating

symptomatology. In a review of integrative therapies, Chung described the
’softness’ of integrative therapies that use soothing words, such as “to
restore balance,’ ‘to tonify,’ and ‘to enhance,’ while allopathic approaches

use harsher words like ‘painkillers’ ‘antibiotic’, and ‘anti-inflammatory.’
(Berg et al., 1998, p. 542)

Natural is Better. Patients who self-medicate with herbs for preventive and

therapeutic purposes may assume that these products are safe because they are "natural,”
but some products cause adverse effects or have the potential to interact with prescription

medications (Berg, Amelia, Gagan, & McArthur, 1998; Greenwald, 1998). Physicians
and practitioners need to educate themselves and their patients about the efficacy and
adverse interactions of herbal agents and especially the limitations of our present

knowledge about them (Zink & Chaffin, 1998). Lay literature, whether written, on radio
and TV, or on the Internet, freely endorses the use of herbal medicines (Greenwald,
1998). Anecdotal accounts of so-called cures promote the use of the plants. Fetrow &
Avila (1999) documented that occasionally these stories of success with herbs have taken
on almost mythical or supernatural proportions. To avoid drug-herb interactions or

exacerbation of an existing medical condition, nurse practitioners and all providers need
to be available to their patients to help in the decision making process concerning self-

medication with herbal remedies.

4

Statement of the Problem

Natural herbal remedies are a large part of the national movement to the use of

complementary and alternative medicine (Fetrow & Avila, 1999). More than 60 million
people in the United States report using alternative medicines (Fetrow & Avila, 1999). Of
these, three out of four patients did not notify their primary care provider about their use

of alternative medicine (Glisson, Crawford, & Street, 1999). Understanding the reason for
nondisclosure is critical to the improvement of provider-patient communication and

patient care (Glisson et al., 1999).
Primary care practices, whether rural or urban, need to become more educated in
phytomedicine and other alternative therapies (Fetrow & Avilla, 1999). Barriers to

communication between providers and patients need to be addressed to reverse the 75%
who do not reveal their alternative therapies during acute or routine primary care visits

(Glisson, Crawford, & Street, 1999). Talking with patients about their use of alternative
therapies is not significantly different "from exploring patients' use of alcohol or drugs,

exposure to abuse, or preferences for cardiopulmonary resuscitation. Each is critically

important to maintaining health and, respecting patient values, each takes time.” (Hadley
& Petry, 1999, p. 122)

Theoretical Framework
Barriers that prevent patients’ communication of self-medication to primary care

providers need to be assessed (Glisson, Crawford, & Street, 1999). Herbal remedies

highly advertised by the media, and on display in grocery stores and pharmacies, are
being self prescribed by patients (Hadly & Petry, 1999; Glisson et al., 1999). Serious
drug-drug interactions with prescription medications, and side effects from mega-dosing

5

of herbal remedies, are becoming an every day problem in primary care practices

(Barnes, Mills, Abbot, Willoughby, & Ernst, 1998).
The Revised Health Promotion Model (HPM) by Nola Pender, PhD, RN, FAAN

(Figure I) assesses the cues to action and the barriers to action for health promoting

behaviors (Pender, 1996). This is a wellness-oriented model rather than a disease

oriented model such as Becker’s Health Belief Model (1974).

BEHAVIOR SPECIFIC COGNITIONS

INDIVIDUAL
CHARACTERISTICS
AND EXPERIENCES

BEHAVIORAL
OUTCOME

PERCEIVED
BENEFITS
OF ACTION

PRIOR

PERCEIVED
BARRIERS

RELATED

BEHAVIOR

IMMEDIATE
COMPETING

TO ACTION

DEMANDSAND

PREFERENCES

PERCEIVED
SELF-SUFFICIENCY

PERSONAL
FACTORS

BIOLOGICAL

►

ACTIVITY-RELATED
AFFECT

PSYCHOLOGICAL
SOCIOCULTURAL

INTERPERSONAL
INFLUENCES;

FAMILY, PEERS,
PROVIDERS

u

V
COMMITMENT
TO A PLAN

HEALTH

OF ACTION

PROMOTING
BEHAVIOR

>
SITUATIONAL
INFLUENCES

4

I

Figure 1. Revised Health Promotion Model: Balance of perceived benefits and barriers to

health promotion resulting in behavioral outcomes of health promoting behavior (Pender,

1996, p. 160-161).

One of the incentives to action might be to prevent illness or injury by taking an
herbal remedy. Pender proposes another incentive to action, the desire for enhanced well

6

being. Herbal products to boost the immune system, for example, could be used to attain

this goal (Fetrow & Avila, 1999). The HPM is based on social cognitive theory in which

cognition, affect, actions, and environmental events all interact in determining health

promoting behaviors (Polit & Hungler, 1999).
There are two phases in Pender’s HPM, a decision making phase and an action
phase. Pender cites seven factors in the decision making phase that directly affect

participation in health promoting behaviors: (a) the importance of health, (b) perceived
self-sufficiency, (c) definition of health, (d) perceived health status, (e) perceived benefits

of health promoting behavior, and (f) perceived barriers.

There are also five modifying factors that indirectly influence patterns of health
behavior: (a) demographic characteristics, (b) biologic characteristics, (c) interpersonal
influences, (d) situational factors, and (e) behavioral factors (Pender, 1996). Patients
move back and forth between the decision and action phases.

Patients who decide to take an herbal over-the-counter remedy have consciously

or unconsciously gone through the processes described in the HPM (Pender, 1996).
Patients seem to have a barrier to discussing self-medication with their primary care
physician (Glisson, Crawford, & Street, 1999). Patients taking herbal remedies may not

sense any harm or adverse consequences in taking these products (Greenwald, 1998), and
so do not seek the advice or approval of these products (Barnes, Mills, Abbot,
Willoughby, & Ernst, 1999). They may fear disapproval by the physician for the use of an
unknown treatment or because the physician’s health care directives were not exclusively

followed (Belson, 1999).

7

The HPM by Pender (1996) provided a framework to help define the problem of

patient self-medication versus the traditional allopathic medications. The model helped to
focus research on the barriers to communication and the knowledge gaps that are

producing the patients’ self-medication without disclosure or the knowledge of risks
(Glisson, Crawford, & Street, 1999).
Statement of the Purpose
The purpose of this research was to understand who is taking herbal remedies and

why. The users' perceived risk and benefits of herbal remedy use needs to be understood.

Barriers to patient communication and consultation about herbal remedy use and efficacy
with primary care providers need to be uncovered.
Assumptions

For the purpose of this study, the following assumptions were made:
1. Patients are motivated to learn.
2. Patients would ask for help in deciding whether to add herbal remedies to their

medications if they perceived no barrier to communication with their provider.
3. The current model of medicine is changing to one of partnering in health care

rather than a paternalistic directing of health care.

4. Nurse practitioners’ educational focus on health promotion and
communication make them ideal providers to lead the integration of complementary
therapies such as herbal remedies that have been proven safe and effective.
5. The research subjects could read English and comprehend the survey.

8

Limitations
The limitations of the study were identified as follows:
1. The research subjects were comprised of a convenience sample in a large

primary care practice in western New York, which has three locations and approximately
4,500 patient visits per month. Survey results, therefore, may not apply to other primary
care populations.

2. The survey instrument was researcher-developed.

Definition of Terms
1. Complementary or alternative medicines (CAM) are self-initiated treatments,

as well as approaches and techniques, that were not traditionally taught in medical or

nursing schools, and that were not prescribed by clinicians trained in the Western Medical
Tradition (Berg, Amelia, Gagan, and McArthur, 1998). These include traditional Chinese

medicine, acupuncture, homeopathy, massage therapy, therapeutic touch, guided imagery,

and herbal remedies to name a few.

2. Herbal remedies are plant-based remedies that are outside of the traditional

biomedical paradigm and that are designated nutritional supplements by the FDA (Fetrow
& Avilla, 1999).
3. Phytomedicine is the practice of using plants or plant parts to achieve a

therapeutic improvement (Fetrow & Avila, 1999).
4. Allopathic medicine is traditional Western-based medicine as we know it in
the United States (Integrative Medicine Primer [IMP], 1999).

5. Self-medication is the practice of patients who decide without the advice or
counsel of their health care provider to take an over-the-counter (OTC) medication. This

9

can be for an acute or chronic physical complaint. It can also be to prevent an illness or

disease. Patients can use one that is a FDA approved OTC medication or a nutritional
supplement such as an herbal remedy (IMP, 1999).
6. Adverse event refers to any unintended physical problem caused by a

medication that requires medical attention. An example would be an anaphylactic
reaction to penicillin or to an herbal remedy such as feverfew (IMP).
7. Side effect refers to a physical problem caused by the use of a medication that

is not serious enough to stop the medication or to seek professional help. An example
would be diarrhea with the administration of erythromycin or a photosensitivity reaction

to St. John’s Wort (IMP).

8. Drug-drug interaction refers to either the enhancement of a drug’s action in the
body or the decreased efficacy of a drug when taken with another prescription or OTC

medication. An example is the enhanced anticoagulation effect of coumadin when taken

with the herbal remedy gingko biloba (IMP).
Summary
The problem of the increased use of herbal remedies without the knowledge or

advice of primary care providers was discussed (Glisson, Crawford, & Street, 1999). The

use of herbal remedies by the public without fear of adverse effects or a proof of benefit

is a concern that needs to be assessed (Greenwald, 1998). The need for communication
and trust between health providers and patients in the context of the use of herbal

supplements also needs to be assessed (Fetrow & Avilla, 1999). The Revised Health
Promotion Model, designed by Pender (1996), is the theoretical framework for the study

10

and was utilized in the design of the survey as well as to interpret the results. The
assumptions, terminology, and limitations of the study were presented.

11

Chapter 2
Review of the Literature

This chapter provides a brief history of herbal remedies as a part of alternative and
complementary therapies. A review of the literature on herbal remedy usage in the United

States, the regulations governing herbal remedies, and risk of adverse reactions are

presented. Current demographic studies on herbal remedy users are discussed. Patient­
physician communication literature is reviewed for barriers to communication as they

might relate to self-prescribed over-the-counter herbal remedies.
History
The interplay of plants and human health has been documented for thousands of

years. Herbs are integral to Ayurvedic medicine which dates back over 5000 years, and to

Traditional Chinese Medicine (TCM) which dates back 4000 years or more (Hadley &
Petry, 1999). According to the World Health Organization, approximately 75% of the

global population currently depend on botanical medicines for their basic health care
(Barrett, Kiefer, & Rabago, 1999).
Ayurveda. Traditional Indian medicine or Ayurveda emphasizes the relationship

between the inner life of an individual and the external world (Integrative Medicine
Primer [IMP], 1999; Berg, Amelia, Gagan, & McArthur, 1998). Herbal remedies are

prescribed according to their effects on vayus (organ centers) and are often mixed with
warm milk, clarified butter (ghee), or used as a nasal rinse (nasyes) (IMP, 1999). The
most common remedies are triphala to help with elimination and trikata to increase

digestive force and aid in nutritive absorption (IMP). Ayurvedic medicine and its
practitioners are not licensed in the U.S. (IMP).

12

Traditional Chinese Medicine (TCM). TCM is a broad range of therapies, that

includes acupuncture as well as herbal remedies (Berg, Amelia, Gagan, & McArthur,

1998; IMP, 1999). The effect of the herbs is the result of the herb's specific qualities or
energetics (IMP, 1999). Herbs are categorized by flavors: sour, pungent, sweet, bitter, and

salty. The flavor determines the value of the herb for a specific diagnosis (IMP; Fetrow &
Avila, 1999). As a modem pharmacotherapy, the TCM herbal remedy has a very specific

formula which considers the targeted disorder, how each ingredient interacts with others,
as well as how the addition of certain substances can reduce or cause side effects (IMP).

Unlike traditional pharmacotherapy, TCM remedies are compounded for each individual
(Fetrow & Avila, 1999). The U.S. government recognizes and regulates only acupuncture
as a therapy, and practitioners of TCM are not licensed (IMP). Their TCM herbal
remedies are considered nutritional supplements.

Naturopathy. Based on vis medicatrix naturae or the healing power of nature,
naturopathy originated in Germany (IMP, 1999). Benedict Lust started the first school of

naturopathy in the U.S. in 1902. Naturopathy uses the standard medical physical
assessment and testing but also uses elimination diets and nutritional botanical

supplements to help in diagnosis (IMP). Naturopathy is now practiced in Europe and
parts of India and Asia, as well as in 11 states in the U.S. (IMP). The national College of

Naturopathic Medicine was recently the recipient of a National Institute for Health (NIH)
grant for a long-term study of natural therapies for the treatment of AIDS (National

Center for Complementary and Alternative Medicine, 1999). It also operates the first
American Alternative Medicine Clinic in Washington DC for the National Center of

13

Complementary and Alternative Medicine (NCCAM), first funded in 1996 as part of the

NIH (IMP; NCCAM).
Homeopathy. Samuel Hahneman, a German physician in the late 18th century,

developed the 'like cures like’ theory which became the basis for Homeopathy (IMP,
1999). He proposed that the symptoms of an illness are a sign that the body's defense

system is trying to ward off infection or adapt to stress. The remedies act as a catalyst that
aids the body's inherent healing mechanism (IMP). Hahneman wrote extensively about
the mental and emotional component of any physical disease. Homeopathic remedies are

infinitesimal doses of an herb, mineral, or animal product where the more extreme the

dilution, the higher the potency (Fetrow & Avila, 1999; IMP). Each individual has a set
of chronic tendencies which form a constellation referred to as their constitutional type.

Homeopathy refers to the practice of looking for a single remedy that can alleviate or
lessen these global tendencies (IMP). Two states license physicians to practice

homeopathy and homeopathic physician assistants are licensed in most states (IMP).
Homeopathy is currently the most well researched blend of both allopathic and

complementary medicine (IMP).
Complementary and Alternative Medicine (CAM)

In contrast to traditional Western allopathic medicine, CAM remedies do not
suppress symptoms, eradicate harmful organisms, or eliminate disease (IMP, 1999).

CAM herbal remedies try to correct deficiencies in the body's homeostatic balance (IMP).
"Symptoms are viewed as an integral pail of the body's attempt to heal itself by boosting

its own defenses to combat illness" (IMP, p. 8).

14

Herbal remedies are increasing in popularity because: (a) they are a continuation
of the 'green is natural' movement of the 1960s which was partly a reaction against the

products and pollution of an aggressively industrialized society, (b) Western medicine is

viewed as too expensive and often ineffective, (c) prescription and over-the-counter
(OTC) medicines are believed to have many side effects compared with natural products

which are perceived as having low or no side effects (Lee, Tyler, & Weart, 1999).
Greenwald (1998) added that the main reason for the rise in CAM use is "the fears of 80
million aging baby boomers who are eager to seize control of their medical destinies"

(p. 61). There is a perceived coldness and remoteness of conventional medicine. The

tangled red tape of managed care makes readily available herbs and other supplements
particularly appealing (Greenwald). The public does not consider herbal remedies to be
drugs, a misconception that is perpetrated by nutritional manufacturers and marketers

(Glisson, Crawford, & Street, 1999).
An herbal remedy timeline, more directly connected to current Western
pharmacotherapy, first identified the age of herbal medicines, then the age of antibiotics,

leaving us now in the post antibiotic era (Alschuler, Benjamin, & Duke, 1997). There is
now a proliferation of resistant microbes and attenuated antimicrobial efficacy that are
causing drug researchers and herbalists, along with many patients, to look back to the

older medications (Alschuler et al., 1997). Botanicals are the source for many of our

contemporary synthetic medications such as digitalis. Many authorities in drug
development see the botanical world, and the rain forests in particular, as the best

remaining source of new drugs once those currently available are exhausted
(Alschuler et al.).

15

The use of botanicals or herbal remedies is in the process of changing from an

eclectic, intuitive science to the practice of rational phytotherapy through research

(Hadley & Petry, 1999; IMP, 1999). Herbal remedies are designated as dietary or
nutritional supplements by the United States federal government

(Fetrow & Avila, 1999).
Regulation of Herbal Remedies. Herbal remedies are not regulated under drug

laws by the Federal Drug Administration (FDA); safety and effectiveness do not have to
be demonstrated before these products are marketed (Zink & Chaffin, 1998). Herbal
remedies fall through governmental cracks, permitting herbal supplement marketers to

promote various health benefits for their products (Rose, 1999). John Renner, MD, head
of the National Council for Reliable Health Information, wrote that it is not the herbs that
are necessarily dangerous but the hype of the marketing (Rose). Renner felt that people
use these products before sufficient research, and do not realize that they are the guinea
pigs. If a product states that it promotes a healthy heart, it is not subject to federal

regulation (Rose; Zink & Chaffin, 1998). If it stated that it helps to reduce the risk of

heart disease, the herbal remedy would need to be backed up by scientific studies and be
subject to FDA review (Rose; Zink & Chaffin; Alschuler, Benjamin & Duke, 1997). Zink
& Chaffin added that, in addition to no FDA regulations of effectiveness, there are no

legal standards applied to herbal harvesting, processing, or packaging. The possibility of

poor quality, adulteration, contamination, and varying strengths must be kept in mind
when evaluating herbal remedies (Zink & Chaffin).

Nutritional Supplements. The FDA has designated all herbal remedies including
homeopathic remedies as nutritional supplements via the Dietary Supplements Health &

16

Education Act of 1994 (Fetrow & Avila, 1999; IMP, 1999). Manufacturers can make

claims concerning the structure-function and possible effects of their products but no
claims of cure, or use of medical terminology or disease name (Fetrow & Avila, 1999;
IMP). In Europe the regulating of herbal remedies is done through Germany's

Commission E who, in 1978, issued 200 monographs about the most often used herbal

remedies (Alschula, Benjamin, & Duke, 1997; D'Epiro & Benjamin, 1999; NIEHS

NewsrEnvironmental Health Prospectives, 1998; Fetrow & Avila.; Zink et al., 1998).

While very comprehensive, these monographs are less rigorous than FDA approval of
medications (Fetrow et al.). The Commission E Monographs require "reasonable

certainty" of efficacy compared with the FDA's regulation of "absolute certainty" of
efficacy (Alschula et al., 1997). Manufacturers of herbal remedies in the U.S. have

difficulty justifying the approximately $350 million generally required to bring a new

drug onto the market when it can not then be patented because it is of plant origin
(Alschula et al.).

Glisson, Crawford, and Street (1999) discussed the labeling of herbal remedies,
which must state that the product is not evaluated by the FDA and "is not intended to

treat, diagnose, prevent or cure a disease" (p. 46). Unfortunately, literature with claims of
efficacy is often legally displayed right next to the product (Glisson et al., 1999).

Manufacturing. Manufacturers are also not required to report injury or illness
claims to the FDA (Glisson, Crawford, & Street, 1999). Adverse effect claims, however,
can be voluntarily reported to the FDA department MEDWATCH (1-800-332-1088).

This may lead to proof that a given product is unsafe and its removal from the market
(Glisson et al., 1999). A joint FDA and nutritional supplement manufacturer effort is

17

being developed to track adverse effects in post marketing surveillance because
physicians and researchers are in search of a rational, evidence-based way to safely
integrate CAM with primary care (Klinger, 1998). Benjamin Klinger, MD called for an

even greater role of the FDA, National Institute of Health, and the herbal supplement
industry in collecting data on outcomes of herbal medicine use, both adverse and

beneficial. Some manufacturers make products with little or no active ingredients or use
parts of the plant that do not contain the active ingredient (Glisson et al.). Products may
also contain a plant that is only similar to the one on the label, or be contaminated with

heavy metals, prescription medicine drugs such as digitalis, or toxic chemicals
(Glisson et al.). Concern about the purity, dilution, and manufacturing of herbal remedies
has been voluntarily addressed by the Council for Responsible Nutrition (Glisson et al.;

O'Koon, 1999). This trade association for dietary supplement manufacturers monitors and
accredits manufacturers of herbal remedies by applying the "good manufacturing

practices" utilized by the FDA (Borins, 1998; O'Koon; Zink & Chaffin, 1998). Voluntary
accreditation involves the monitoring of: (a) variations in the source (plant) and the part

of the plant used, (b) the listing of additives and, (c) cleanliness of manufacturing
(O'Koon). The word “standardized” used on an herbal remedy label means that one

manufacturer's batch of a product will be the same as the next (O'Koon).
New labels for nutritional supplements, including herbal remedies, have been

mandated by the federal government and must be user friendly and formatted like food
labels, including: (a) serving size, (b) list of ingredients, (c) percentage of the
recommended daily intake (RDI), (d) parts of the plant used, (e) labeled as high potency

18

or antioxidant if criteria are met, and (f) printed in a type size mandated for ease of
reading by the general public ( MedWatch News, 1997; O’Koon, 1999).
Research. Because there is a gap in the research of U.S. herbal remedies and other

CAMs, the NIH National Center for Complementary and Alternative Medicine
(NCCAM) has chosen 10 different research centers to provide comprehensive research on
CAM (Lee, Tyler, & Weart, 1999). Health and Human Services secretary Donna Shalala

announced a new council on August 30°’, 1999 that provides advice to the NCCAM in

order to focus the research of the 10 sites on usable alternative therapies (Lee et al.,
1999). The council is made up of 50% practitioners of CAM, 25% physicians, and 25%

consumer representatives (Lee, et al.). As an example, the FDA originally banned all

nonprescription medications for benign prostatic hypertrophy (BPH) in 1990 (Alschuler,
Benjamin, & Duke, 1997). FDA action was based on a lack of evidence of efficacy and

concern that patients would fail to seek medical attention for the serious life threatening

complications of BPH (Alschuler et al., 1997). Now, including research on Saw Palmetto,
there are more than 12 independent research studies of CAM herbal remedies under
review by the FDA (Alschuler; D'Epiro & Benjamin, 1999). Less that a decade after

being banned, Saw Palmetto is expected to be the first herbal product to be licensed as an
herb with a specific indication (D'Epiro et al., 1999).

Prescriptive Authority. Another aspect of the regulation of herbal remedies
concerns whom may prescribe or recommend the remedies. The practitioners of CAM

who may be licensed in some, not all, states are acupuncturists, chiropractors, and

naturopaths (IMP, 1999). Their licenses are limited and cannot be considered the practice
of medicine: "the diagnosis, treatment, prevention, cure and mitigation of disease"

19

(IMP, 1999, p. 25). Their scope of practice is limited by the same guidelines as are used

to label herbal remedies: no diagnosis or treatment of a medical disease (IMP, 1999). It is
common for lay practitioners recommending herbal remedies to state that they are not
practicing medicine, and that the remedies are not prescription drugs, and that the

remedies are available in any health food store (IMP).

Self-Care and Self-Medication

Awareness of self-care has increased in recent years from the use of daily-living
help books to books on medical self-care (Sorofman, 1992). The notion of self-health

care is the oldest form of medicine. Information is obtained through a wide variety of
promotional activities about symptoms and treatment options. Lay self-care information

sources include: (a) traditional health industry advertising, (b) lay-initiated self-care/selfhelp information, and (c) manufacturer's direct-to-the-consumer-activities such as

'medical breakthrough' news releases (Sorofman). Talk shows, news shows, and
newspapers often do medical breakthrough releases on Wednesdays, quoting from The
Journal of the American Medical Association and The New England Journal of Medicine

(Sorofman). The 35 to 54 year age group is leading the boom in self-medication with
"neutraceuticals," vitamins, minerals, and designer prescription drugs (Krantz & Bjerkler,
1994). Once the average American turns 65, the proportion of medications used becomes

predominantly by prescription and less OTC (Feinberg, 1997). The National Drug

Manufacturing Association (NDMA) found by survey that 70% of all OTC drug
consumers never consulted a health care professional before choosing a product

(Feinberg). The people who self-medicate because of the high cost and side-effect profile
of prescription drugs, and who mistrust the HMOs, are self-medicating to help prevent

20

illness, rather than to treat acute symptoms (Krantz & Bjerklie, 1997). The trend toward
self-medication has the benefit of increasing the empowerment of patients while being

counterbalanced by the risk of uninformed choices as to the type and amount of the
remedy (Blenkinsopp & Bradley, 1999).
The Risk of Herbal Remedy Use

Patients who self-medicate with herbs for preventive and therapeutic purposes

may assume that these products are safe because they are natural. Some products,
however, cause adverse effects or have the potential to interact with prescription
medications (Zink & Chaffin, 1998) (Appendix A). Historically, herbs and drugs have

been two very different treatment modalities which have rarely, if ever, been used

together (Chen, 1999). Now, patients may be taking multiple drugs from multiple

providers concurrently with herbs and vitamins (Chen). There are very few studies
published in English to document the safety and effectiveness of combining herbs with
prescription drugs (Chen).

Drug-drug interactions rest on the possibility that one substance may alter the

bioavailability or the clinical effectiveness of another substance when they are given

together (Chen, 1999). Herb-herb interactions are noted in Traditional Chinese Medicine
in the 18 Incompatibilities or in the 19 Counteractions (Chen). Herb-drug interactions

have the highest risk of clinically significant interactions with preparations that have
sympathomimetic, cardiovascular, diuretic, or antidiabetic effects (Chen). Appendix A

documents side-effect profiles and toxicity of common herbal remedies.

Herbal use during pregnancy is not recommended because of possible teratogenic
effects; herbal remedies have not been subjected to clinical research concerning efficacy

21

or safety during pregnancy (Chen, 1999). Along with the NCCAM division of the NIH,
the Society for Women’s Health Research supports initiatives for increased research of

herbal products and clinical trials that evaluate the safety and efficacy of herbal remedies

(Greenberger, 1998; HHS News, 1999; NCCAM, 1999).
Demographics of Herbal Remedy Users

An informal observational study by Grevier (1998) of her own patient population

correlated the number of prescription and OTC drugs taken with the patient’s state of
health. Sicker patients tended to take fewer total medications, with the number of

unconventional remedies decreasing as the number of medical conditions increased
(Grevier).

In 1999, Astin identified who utilized CAM, with a random mail survey. A 69%
return, equaling 1035 surveys, showed CAM users to be: (a) more educated; (b) in poorer

health status; (c) to have a holistic orientation to health; (d) to be feminists; (e) to be
interested in spirituality and personal growth; (f) and to be those whose common health

problems were anxiety, back problems, chronic pain, or urinary tract problems. All but
4.4% relied on both CAM plus conventional primary care. Dissatisfaction with
conventional medicine was not a predictor of CAM use (Astin). Zeil (1999) characterized
a CAM user as a white, educated woman aged 25 years and up with a family income of

$50,000 or more.

Trends in alternative medicine in the U.S. were tracked with a before and after
comparison telephone survey in 1990 and 1997 (Eisenberg et al., 1998). Of 1500 subjects
in 1990, 33.8% used CAM and of 2000+ subjects in 1997, 42.1% used CAM. Therapies

increasing the most were herbal remedies, message therapy, and mega-vitamin use. CAM

22

therapy was used most frequently by those with chronic conditions, back problems,

anxiety, depression, and headache (Eisenberg et al.). Of those surveyed, the lack of
disclosure of herbal use to their physicians was 39.8% in 1990 and only down to 38.5%
in 1997. The number of patients using both prescription and herbal products remained
steady at 18.4% (Eisenberg). Critics of Eisenberg’s research charge that he inflated the

consumption numbers by including relaxation techniques, meditation, commercial weight

loss programs, and self-help groups in his definition of CAM (Weber, 1998).
Sibbald's Canadian study (1999) showed that among the users of natural products,
30% got information about herbal remedies from family and friends; 18% from health
care books; and 7% from other health professionals, printed articles, and product

information. Herbal users were more likely to use conventional OTC and also

prescription medications when compared with the general population (Sibbald, 1999).

Users who cited physicians as their source of information about herbal remedies rose
from 3% in 1996 to 11% in 1998.

Herbal remedy users are well educated and embrace alternative modalities that are
more congruent with their beliefs and philosophical orientations toward health and life

(Weber, 1998). In Weber’s survey, only one-half of the 18% of patients who had gone to
alternative practitioners come away satisfied, although 82% acknowledged some

improvement in their condition (Weber).
A study by the Medical Expenditure Panel Survey (MEPS) of 16,000 U.S. adults

reported a lower use of unconventional therapies, including herbal remedies, than the
study by Eisenberg (Druss & Rosenhek, 1999). Of the 65% of the group surveyed by

MEPS in 1996 who made visits to both conventional and CAM providers, 1.8% used

23

only unconventional services, 59.5% used conventional care only, and 32.2% used

neither. This study, along with others, showed that unconventional care is not being used
as a substitute for conventional medical care (Druss & Rosenhek, 1999). While this study

answered the question of concomitant use of traditional and CAM therapies, critics felt

that the definition of CAM therapies used deflated the number of CAM users (Weber,

1998). A positive critique is that, unlike the study of Eisenberg et al., this one was not
telephone based, and not dependent on fluency in English, so included a broader
economic base of subjects (Wisneski, 1999b).

A large survey by Consumer Reports (May, 2000) of 46,806 readers yielded
results that show a 35% use of alternative therapies. Alternative therapies were classified
as megavitamins, nutritional supplements, deep tissue message, chiropractic,

accupressure, and mind-body therapies (Mainstreaming, 2000). Their sample was 70%
male, with a higher educational level and income than the national norm. This selective

sample is interesting in its size, but may not reflect herbal remedy or CAM usage in the

general population. Fifty percent tried new remedies on their own, with 25% trying them
at the recommendation of either a nurse or a physician. Of the new remedies, 50% were

herbal remedies. Fifty-eight percent reported conditions such as respiratory infections,

prostate enlargement, insomnia, head aches, depression, and back pain that were treated

conventionally. Twenty-five percent of these problems were treated with both CAM and

traditional therapies, and 9% were alternative therapies only. Those who turned to
alternative therapies did so for conditions that had not yielded to traditional treatment.

Four percent of users of CAM reported side-effects, but not sufficient to worsen their
condition (Mainstreaming).

24

Provider-Patient Communication
The study by Eisenberg et al. (1998) showed a 380% increase in the use of herbal

remedies between 1990 and 1997, yet the majority of patients did not tell their physicians
about using herbs. "We are now obliged as the standard of care to ask about herbs,
vitamins, and other OTC products.. ..and open ourselves up to potential medical liability

if we have no record of having asked" (D'Epiro & Benjamin, 1999, p. 30).
The three biggest obstacles to a good provider-patient relationship are: (a) fear

that a symptom means the worst disease, (b) embarrassment concerning use of
nontraditional therapies or that undisclosed drug or alcohol problems will be treated as a

moral rather than a medical problem, and (c) forgetfulness under stress leading to failure
to mention key facts to the doctor (Belson, 1999).

In the Consumer Report survey, 60% of the CAM users reported their use of
alternative therapies to the provider. This is higher than reported in all other studies.

Fifty-five percent of the providers showed approval, 40% showed neutrality, and 5%
disapproved of the CAM therapy (Mainstreaming, 2000).

A 1996 patient satisfaction survey by the Kaiser Family Foundation and the
Prevention Survey Research Association found that, for 84% of adults, the main issue in
choice of a physician was how well the physician communicated with patients and

showed a caring attitude (Weber, 1999). The patients assumed that their physician would
have technical competence (Weber). Provider-patient relations may be viewed on a
continuum between the extremes of the paternalistic model where the provider decides

and the patient complies, and the informative model where the provider provides
information and the patient decides (Benbassat & Pipel, 1998). Published evidence shows

25

that patients who ask questions, elicit treatment options, and express their preferences
have better health outcomes than those who do not (Benbassat et al., 1998).

Health care providers should ask patients if they are considering or are already

using other therapies, avoiding the use of the word ‘alternative’ because it is not an
alternative treatment to the patient (Kent, 1999). In An Integrative Medical Primer
(1999), it was suggested that an integrative approach is best between provider and patient

but that a patient’s wishes should not override a physician's professional judgment.

Physicians and patients should dare to disagree, especially about therapies for which
scientific support is anecdotal, equivocal, or preliminary. "Often the most sensitive

barometer of a relationship is the ability to resolve disagreements" (IMP, 1999, p. 5).

Seligson (1996) wrote of an altruistic reason for patients to "come out of the
closet.” Even conservative providers can learn from patients’ accounts of herbal drug use.

While awaiting specific research results on herbal remedies, patient information gives a
picture of what herbal remedies can and cannot do (Seligson). To illustrate the barriers to
communication, a study by Adler & Fosket (1999) of women with breast cancer found

that discussion of CAM therapies including herbal remedies was less well integrated into

the traditional medical encounter (54%) than is biomedical treatment with an alternative

practitioner (94%).
Clinicians should be concerned about nondisclosure of herbal remedy use and

about global patient-physician communication because of a recent decrease in the

continuity of doctor-patient relationships, and an increase in the use of acute episodic
health care (Korsch, 1994). More malpractice litigation results from communication

breakdown than from technical errors alone. Patient satisfaction reflects interpersonal,

26

lather than the instrumental (technical), aspect of the communication process (Korsch).
(For a list of patient-physician communication strategies see Appendix B.)

Lowe & Kerridge (1997) wrote that physicians have an ethical obligation to
provide health care that does not differ depending on the form of treatment being offered,

whether traditional or CAM. For the patient, this includes receiving information for
decision making, and being informed about the risks and benefits of any proposed

treatment (Lowe & Kerridge). Doctors are often seen as keeping their thoughts about
alternative therapies separate from their understanding of the body, and neglecting

opportunities for insight into disease or for refuting suspected ideologies (Lowe &
Kerridge). Continuing the patient-physician relationship while monitoring the patient’s
progress with an herbal product provides a mutual learning opportunity (Zink & Chaffin,

1998).

Allopathic providers today, despite their vast armory of medications,
devices, and surgical techniques have lost some of the art of the oldtime MD.. .and must regain charisma and humility, the sincere hand­
shake, the ability to listen and the willingness to share the inner thoughts

and concerns of their patients. (Zeil, 1997, p. 88)
Summary

This literature review has presented a history of herbal remedy use as a part of

complementary and alternative medicine therapies. Herbal remedy usage in the U.S. is
profiled as well as the regulations governing the manufacture and marketing of herbal
remedies, and the licensing of providers. The tracking of potentially serious drug-herbal

remedy reactions was discussed. Review of the demographic studies relating to herbal

27

remedy users was presented along with critiques of the studies. Physician-patient

communication literature was reviewed to obtain a picture of the barriers to reporting
patient herbal remedy use in the primary care setting.

28

Chapter 3
Methodology

This chapter concerns the methodology utilized in this study to describe the

population of herbal remedy users seen in a primary care setting. After obtaining
demographic information, a self-administered survey addressed patients' perceptions of

the risks and benefits of herbal remedies. The survey also described the barriers to
communication and mutual learning between provider and patient relating to herbal
remedies. Protection of human rights for those completing the survey is addressed. Pilot

study modifications to the researcher-designed survey are outlined. A summary of the
goals of the study is provided.
Research Questions
The research questions were as follows:

1) Who is using herbal remedies and why?

2) What are the patients' perceived risks and benefits of herbal remedies?
3) Are there patient/provider communication difficulties concerning the use of

herbal remedies?

Research Design

This quantitative study utilized a descriptive survey research design. Findings of
this study may help to pinpoint those patients at most risk for herbal remedy and

prescription drug interactions. This research augments information from other recent

descriptive studies.

29

Sample, Setting, and Procedure

The targeted sample included all English speaking patients over the age of 18 who

were seen in the three rural locations of a primary care facility in Chautauqua County,
NY, duiing the month of January, 2000. The survey was administered in this family

practice setting of approximately 4500 patient visits per month. The study population

included those patients who were seen for well-visits, acute same-day visits, allergy and

vaccination visits, obstetrical-gynecologic visits, and post-hospitalization visits. It also
included the parents of children brought in for their visits. Subjects were given the survey
as they registered at the main desk, and returned it when they were called into the
examination room by the nurse. The receptionists gathered the completed anonymous
surveys and locked them into a safe until collected by the researcher.

Instrumentation

A researcher-designed survey was utilized as the research tool. It was a

self-administered questionnaire (Appendix C). The survey consisted of a cover letter
explaining the purpose of the study, and instructions for the completion of the survey.
Following a reference list of the most commonly used over-the-counter herbal products,

there were 22 dichotomous and multiple-choice questions. The first five consisted of
demographic questions. Age, gender, household income, marital status and educational

level were included along with a multiple choice question on perceived overall health
status at the time of the current visit. Later there was a visual analogue scale on overall
health status for comparison with the multiple-choice question asked at the start of the
survey. The next five multiple-choice questions dealt with the use of herbal remedies: if

30

"ever used,” currently using daily,” or "as needed,” whether the subjects have ever

bought an herbal remedy; if one has ever been recommended and, if so, by whom.
The next three multiple-choice questions concerned discussion, during the

subject's last primary care visit, of any herbal remedy use. If discussed, subjects were
asked to indicate whether the interaction was staff-initiated or patient-initiated. Adverse
reactions to herbal remedy products and whether they were reported to the primary care

office were covered in the next two multiple-choice questions. Respondents who were not
herbal remedy users were asked whom they would be willing to trust for advice, with an
open fill-in option. The last four questions dealt with the relative risks perceived in herbal

remedy use: (a) by comparing them with prescription medications, (b) by asking what

subjects perceived the word natural to mean on a label, (c) by asking what they hoped to
achieve with the remedy, and (d) asking if they ever had actively sought herbal remedy

information from a primary care provider.
Protection of Human Rights
An introduction on the face sheet of the survey explained the purpose of the study.

Potential participants were informed that their care would in no way be affected by their
participation or nonparticipation in the study. The completion and return of the survey to
the researcher constituted informed consent. All data remained anonymous. No names or

numbers were required on the surveys. Only over-all grouped data were reported. The
surveys remained in a locked file.
Pilot Study
The survey was pilot tested in a primary care employee in-service meeting in

Chautauqua County, NY. The population included physicians, nurse practitioners,

31

registered nurses, office management, and staff. There were 35 surveys given and 35
completed and returned. The survey took an average of 8 to 10 minutes to complete. As a

lesult of the analysis, three questions were reworded to elicit more definitive answers.

Question 7 was changed to include a response for those who take herbal remedies on an

intermittent basis along with those who take them daily to expanded the definition of an
herbal remedy user. This eliminated the necessity of skipping questions if herbal

remedies were not currently being taken. All questions were worded to include the
response "not taking any herbal remedies" as an option. Question 11 was split into two

separate questions to determine more clearly who initiated the communication about
herbal remedies, the staff or the patient. Question 15 was moved to the end of the survey

for better flow of information, and a question was added to ask directly if subjects had
ever initiated conversation with their primary care provider about herbal remedies.

Data Analysis

The survey data were analyzed using descriptive statistics. The responses on the

dichotomous and multiple-choice questions were reduced and summarized as frequency
distributions. The inferential Chi-square Rank Order Correlation statistic was used to

determine if the subgroups of users and nonusers were statistically different from the total
sample.

As noted the survey included two questions to assess the perceived overall health
status of the respondent, one a Likert multiple-choice and the other a visual analogue

scale. This

analogue scale was divided for analysis into five sections reflecting the five

Likert responses. The reliability and internal consistency of this repeated measure

attribute was assessed using the Spearman Rank Order Correlation Coefficient. The

32

Likert question was placed before all of the herbal remedy questions, but the visual
analogue was positioned after most of the questions about the patient’s self-initiated

health care to assess internal reliability of the survey..
There were five questions that offered the option of an open-ended response. A

content analysis of these responses was reported separately from the other survey
responses. All statistics were calculated using StatView software by Abacus.

Summary

A goal of this study was to determine if self-medication with herbal remedies is
common in those patients utilizing primary care facilities. The study also sought to gain

some insight into the perceived risks and benefits that patients consider when using
herbal remedies. The final goal was to determine if banders to communication between

providers and patients existed in relation to self-medication with herbal remedies. The
research design and pilot study modifications of the survey have been described. Human

rights provisions and projected data analysis strategies have also been discussed. In a
population that is most likely to be taking herbal remedies and prescription medications

concomitantly, tactics could be developed and utilized by nurse practitioners in primary
care practices to open the lines of education and communication.

33

Chapter 4

Findings
This chapter presents the results from a researcher-developed survey
(Appendix C) concerning herbal remedy use by patients in a rural primary care practice

located in western New York State. The results were analyzed using descriptive statistics.
Statistical significance was calculated using the Chi-square test of differences between

groups and the Spearman Rank Order Correlation Coefficient. Results were reported in

aggre£ate and according to the total group of subjects, male and female subsets of the

subjects, female and male users of herbal remedies, and users and nonusers of herbal

remedies. Additional data is displayed in full in Appendix D.

Sample
The surveys were given to all patients 18 years or older registering for a visit at
the primary care practice in three New York locations during January 2000. The surveys

were filled out prior to the patients being taken into an examination room, and took

between 5 and 10 minutes to complete. Of the 1000 surveys that were dispensed, 865
surveys were returned to the researcher, for a return rate of 86.5%. All of the returned
surveys were complete and used in the analysis.
Results
The results are presented in number and percentage of the total subject population

and for the above-mentioned subgroups. Percentages were calculated to two decimal
points and rounded to the nearest whole percentage. Questions with no response by the

subject are included in the tables. The Chi-square statistic was calculated with a 95%

confidence level and one degree of freedom.

34

Herbal Remedy Users
To answer the first research question, who is using herbal remedies, the survey
results weie analyzed for demographic characteristics. The subjects’ perception of their
overall health and the reason they used herbal remedies was analyzed.

Demographics. In the total sample (N=865), females comprised 68% (Table 1).

Fifty percent (n-296) of the female subgroup were users of herbal remedies at some time,
but 175 were not currently using the remedies. Of the 274 male research subjects, 60 were

current users, but 126 of the male subgroup (46%) had been users of herbal remedies at
some time.

Table 1
Gender: Percentage of Total Sample (N=865), User and Nonuser Status

Groups

n

%

Females

591

68

Males

274

32

Female Users

296

34

Male Users

126

14

Notes. User indicates a subject who has ever used herbal remedies. Nonusers
are subjects who have never used herbal remedies.
Age comparison of users and nonusers of herbal remedies showed that 60% of

those 36 to 45 years were herbal remedy users (XM.2, p=0.01). Fifty-eight percent of

35

those 25 to 35 years of age were nonusers. Nonusers had more subjects in the >65 age
bracket, 62% versus users with 48% (%2=5.2, p=0.05).

Table 2

Age Comparison of Herbal Remedy Users and Nonusers

Age Groups

Total

Users

Nonusers

n

(%)

n

(%)

n

(%)

<25

134

(15)

60

(45)

74

(55)

25-35

188

(22)

78

(42)

109

(58)*

36-45

178

(21)

107

(60)

71

(40)*

46-55

156

(18)

85

(54)

39

(46)

>65

124

(14)

46

(48)

78

(62)*

Total

865

422

442

Notes. Percentages of the total sample are within the group. User and nonusers

percentages calculated within age categories. User indicates a subject who has
ever used herbal remedies. Nonusers are subjects who have never used herbal

remedies. *Chi-square comparisons of user and nonuser calculated at

oc

0.05 level of significance with df=l.

Income levels showed more similarities than differences across the subgroups
(Table 3). Males had a higher percentage in the $50,000+ income (30%) when

36
compared with 21% of the total sample and with only 17% of females (n=100). There
weie moie (61 /o) nonusers in the $10,000-14,999 income category than users (%2=4.8,
p 0.05). One percent (n—8) of the total subjects did not choose to answer this question.

Table 3
Income Comparison of Herbal Remedy Users and Nonusers

Income

Total

Users

Nonusers

n

(%)

n

(%)

n

(%)

104

(12)

42

(40)

62

(60)

10-14,999

86

(10)

34

(49)

52

(61)*

15-24,999

179

(21)

83

(47)

96

(53)

25-49,999

302

(35)

155

(51)

146

(49)

>50,000

185

(21)

103

(56)

82

(44)

No Ans.

8

(1)

4

(50)

4

(50)

$

5-9,999

Total

865

422

442

Notes. Percentages of the total sample are within the group. User and nonuser

percentages calculated within income categories. User indicates a subject who has

ever used herbal remedies. Nonusers are subjects who have never used herbal
remedies. -Chi-square comparisons of user and nonuser calculated at

oc= 0.05 level of significance with df~l.

37

Comparison of marital status between herbal users and nonusers showed more

similaiities than differences (Table 4). Sixty-six percent of the total sample indicated that

they were currently married. Females who were married comprised 62% of this subgroup

conti asted with 75% of males. Users and nonusers of herbal remedies showed equality in
the married category (50%). By number, slightly more nonusers were separated or living

with someone than those who used herbal remedies.

Table 4
Marital Status Comparison of Herbal Remedy Users and Nonusers
Users

Total

Status

Nonusers

n

(%)

n

(%)

n

(%)

Single

143

(17)

71

(50)

72

(50)

Mamed

572

(66)

284

(50)

287

(50)

Separated

22

(3)

8

(33)

14

(67)

Divorced

54

(6)

28

(52)

26

(48)

Widowed

38

(4)

14

(37)

24

(63)

Living with

37

(4)

17

(46)

20

(54)

Total

865

422

442

Notes. Percentages of the total sample are within group. User and nonuser

percentages calculated within marital status categories. User indicates a subject
who has ever used herbal remedies. Nonusers are subjects who have never used

herbal remedies. There were no significant Chi-square comparisons of user and

nonuser calculated at oc

0.05 level of significance with df=l.

38

At first glance, educational levels across the subgroups appeared to be
comparable, but if information was combined within subgroups, a trend for higher

education levels in herbal remedy users appeared (Table 5). Sixty percent of users of
herbal remedies had some college or vocational training or higher, contrasted with 40%

of nonusers (%2=13.4, p=0.001).

Table 5
Highest Education Level Comparison of Herbal Remedy Users and
Nonusers

Education

User

Total

Nonusers

n

(%)

n

(%)

n

(%)

359

(42)

126

(35)

233

(65)

College/V.

34

(39)

199

(60)

132

(40)*

Bachelors

111

(13)

72

(65)

39

(35)*

> Masters

53

(6)

25

(47)

39

(53)

< H.S.

Total

865

422

442

Notes. H.S. indicates High School. Percentages of the total sample are within

group. User and nonuser percentages calculated within highest education group.

User indicates a subject who has

ever used herbal remedies. Nonusers are subjects

who have never used herbal remedies. •Chi-square comparison of user and nonuser

calculated at oc = 0.05 level of significance with df-1.

39

Comparison at the bachelor degree level showed that users comprised 65% of the

total subjects with bachelor degrees (%2=9.8, p=0.01). The difference between users and

nonusers was not significant at the master degree level of education.

Overall Health. The subjects' overall health on the day they took the survey was
measured with a Likert multiple-choice question and with a visual analog scale. Within
the herbal remedy user subgroups, female users chose ’’fair” to "poor” on the multiple­

choice question 19% of the time while male users chose the same categories 14% of the
time. Male users chose "good” to "excellent” 86% of the time contrasted with female

users with 81%. Nonusers of herbal remedies (n=78) comprised 54% of the total subjects
(n=144) who ranked their health as "fair" on the day they filled out the survey. The nonusers comprised 65% of all subjects who considered their health "poor."

The visual analog health scale was interpreted as a measurement in inches as well
as expressed in a percentage of the 6 inch line. The mean measurement in inches for all

groups was rounded to two decimal places. Percentages of the total weie rounded to the

nearest whole integer (Appendix D, Table 7).
The visual health analog (key: 0 equals death and 100 represents perfect health)

measured overall health a second time. The mean percentage of the 6 inch analog

line for all subjects was 72.5% (4.36 inches). Comparison of the two overall health
questions was tested for correlation using Spearman Rank Order Correlation Coefficient.
A moderate correlation was shown (^=0.73), with all subjects ranking their overall health

one category higher (" very good") on
choice question ("good") (Figure 2).

the visual analog scale than on the Likert multiple

40

7

61
51
w

ID

>s;

• Multiple Choice
Visual Analog

3-

21
11
0

Observations

Figure 2. Spearman Rank Order Correlation Scattergram showing the comparison of
overall health multiple choice ranking (black) and visual analog overall health ranking

(red) of the total sample (n=865). Key: 4=”good” and 5= "very good" on Likert scale.
Herbal Remedy Use. Of the total subjects, 27% were currently using herbal
remedies (Table 6). Of more significance, because herbal remedies are not all used on a

daily basis, 49% of the total subjects indicated that they had at some time used herbal
remedies.
Female users (n=172) comprised 73% of those subjects who currently use herbal
remedies with male users comprising 25%. This is mirrored in the female group who had
ever used herbal remedies, which made up 70% of the total users.

41

Subjects who had ever bought herbal remedies were fewer than subjects who had
evei used the remedies. Female users of herbal remedies represented 70% and males

represented 27% of those who had ever bought herbal remedies.

Eighty-seven percent of the subjects who had had herbal remedies recommended
to them were herbal remedy users. Only 10% of nonusers reported herbal remedies
recommended.

Question 11 offered a choice of answers concerning who recommended herbal
remedies to the subjects. Among herbal remedy users 94% took advice from family
members (n=179), contrasted with 6% of the nonusers (x2=127, p=0.001). Eighty-nine

percent of users had herbal remedies recommended by a nutritionist or herbalist (%2=32.4,
p=0.001). Fifty-five percent of herbal remedy users indicated that they took

recommendation from magazines, pamphlets, books and TV shows contrasted with 45%
(n=6) for nonusers (%2=97.4, p=0.001). Eighty-four percent of users utilized doctor/nurse

practitioner as a source for recommending herbal remedies (% 25.8, p 0.001).
Pharmacists were generally ranked lowest among users compared with nonusers

(%2=10.8, p=0.01). The alternatives for Question 11 included the following: friend (n=62),

coworker (n=7), chiropractor (n=6), teacher/educator (n=3), and midwife (n=3). Another
16 answers ranged from naturopath to counselor to yoga instructor, each with one entry,

42

Table 6

Herbal_Remedy Use Comparison of Users and Nonusers

Groups

Currently Use

Ever Used

Ever Bought

Recommended

n

(%)

n

(%)

n

(%)

n

(%)

Total

235

(27)

422

(49)

377

(44)

354

(41)

Users

231

(55)

422 (100)

365

(87)

308

(73)

0

(0)

11

(3)

45

(10)

Nonusers

0

(0)

Notes. Percentages are calculated within groups. Percentages will not total 100% due to
multiple questions within each group. User indicates a subject who has ever used herbal

remedies. Nonusers are subjects who have never used herbal remedies.
Risk/Benefit Knowledge
How patients perceived their personal risks and benefits of using herbal remedies
was related to their knowledge of those remedies. Adverse reactions were reviewed as
well as knowledge of why herbal remedies were taken and what the word natural really
means.

Adverse Reactions. Questions 16 and 17 addressed whether the subjects had ever

had a reaction to over-the-counter herbal remedies, and, if so, whom they had consulted,
Of the total subjects, only 3% (n 27)

stated that they had had an adverse reaction to an

,
was defined in Question 16 as either the condition
herbal remedy. An adverse reaction was detinea v

43

getting much worse or having a rash, nausea, or trouble breathing. Female users (n=296)

reported 21 adverse reactions contrasted with 6 for male users of herbal remedies
(Appendix D).

Question 17 addressed whether or not the subjects with an adverse reaction to an
herbal remedy had called their doctor or nurse practitioner. Of the total subjects, 10 out of
the 27 had had adverse reactions and called their provider (37%). Only one subject went

to the emergency room. Eighty-five percent of herbal remedy users indicated that they

had had no adverse reaction to herbal remedies. Nineteen percent (n=164) did not answer
Question 17 (Appendix D).

Herbal Remedy Knowledge. Questions 18, 19, 20, and 21 dealt with the subjects'
knowledge and beliefs about herbal remedies. Of those who chose the pharmacist as a

reference they would use for herbal remedy use, 60% were users (%2-6.6, p-0.05)

(Table 8). Sixty-one percent of nonusers indicated that they would accept information
about herbal remedy use from a doctor or nurse practitioner in this rural primary care
patient population &M3.4, p=0.001). This contrasts with Table 7, "who recommended

herbal remedies to you,” where nonusers had a doctor or nurse practitioner recommend
herbal remedies only 16% of the time. Seventy--one percent of those who utilized
magazines and pamphlets were

herbal remedy users (%2=9.4. p=0.01). Users were also

67% of those who would take advice from

an herbalist (%2-11.2, p-0.001).

44

Table 7

WhoRecommended_He±alRemedies Comparison of Herbal Remedy Users and

Nonusers

Categories

Total

Users

Nonusers

n

(%)

n

199

(23)

179

(90)

20

(10)*

46

(5)

41

(89)

5

(U)*

120

(14)

114

(95)

6

(5)*

Pharmacist

21

(2)

18

(86)

3

(14)*

MD/NP

57

(47)

47

(84)

9

(16)*

Other

111

(13)

88

(79)

23

(21)

None recommended

248

(29)

52

(23)

183

(77)

Family Member

Nutritionist/Herbalist

Magazine/Pamphlet/Book

(%)

n

(%)

Notes. Percentages of the total sample are within group. Percentages will not equal 100%
due to multiple choices per subject. User and nonuser percentages calculated within the
categories. User indicates a subject who has ever used herbal remedies. Nonusers are
subjects who have never used herbal remedies. *Chi-square comparisons of user and

nonuser calculated at a

0.05 level of significance with df=l.

45

Question 18 (Table 8) also included

an open-ended option. Responses included:

friend (n=9), family (n=6), would never take (n=3), and with own research (n=3).
Eighteen othei responses of who could recommend herbal remedies ranged from

chiropractor to boyfriend to witch, all with one response each.

Of the total subjects, 65% believed that herbal remedies were more natural than

prescribed medications (Table 9). Only 4% of the total were unsure of the answer. Fifty­

eight percent of those who felt herbal remedies were more natural were users (%2=7.5,
p-0.01). Sixty-eight percent of the subjects who thought they were not more natural than
prescription medications were nonusers (%2=34.7, p=0.001).

Of the total subject population, 54% indicated that natural means "no chemicals"
when applied to over-the-counter herbal remedies (Table 10). Fifty-five percent of both

users and nonusers indicated that a "natural" product means that it contains no chemicals.
Users were 57% of those who chose "made from plants only" as natural (%2= 5.4,

p=0.05). Fifty-two percent of nonusers thought herbal remedies were safe (%-- 4.6,
p=0.05) Forty subjects wrote in that "natural" meant the following: derived from nature

(n=6), not man-made (n=5), non-synthetic (n=3), and not controlled (n=2). Nineteen other
entries by one subject each included: unprocessed, not standardized, not under FDA
regulation, and less expensive. Two subjects addressed deceptive advertising: make you

think it is "better for you,

"and it's "a marketing ploy."

46

Table 8
Who Could Recommend Herbal Remedies Comparison of Herbal Remedy Users and

Nonusers

Answers

Total

Users

Nonusers

n

(%)

n

(%)

n

Magazine/pamphlet

52

(6)

37

(71)

15

TV/Advertisement

19

(2)

10

(53)

9

Herbalist

92

(11)

62

(67)

30

(33)*

Pharmacist

165

(19)

99

(60)

30

(33)*

MD/NP

572

(66)

99

(60)

66

(40)*

51

(6)

29

(57)

22

(43)

I already take

136

(16)

132

(98)

3

(2)

No answer

142

(16)

73

(51)

69

(49)

Other

(%)

(29)*
(47)

Notes. Percentages of the total sample are within group. User and nonuser

percentages calculated within categories. User indicates a subject who has ever

used herbal remedies. Nonusers are subjects who have never used herbal
remedies. *Chi-square comparisons of user and nonuser calculated at

a 0.05 level of significance with df-1.

47

Table 9
Are Herbal Remedies More Natural Comparison of Herbal Remedy Users

and Nonusers

Answers

Total

Users

Nonusers

n

(%)

n

(%)

n

Yes

565

(65)

328

(58)

236

(42)*

No

271

(31)

87

(32)

184

(68)*

29

(4)

7

(23)

23

Unsure

Total

865

422

(%)

(77)

442

Notes. Percentages of the total sample are within group. User and nonuser
percentages calculated within answer categories. User indicates a subject
who has ever used herbal remedies. Nonusers are subjects who have never
used herbal remedies.*Chi-square comparisons of user and nonuser

calculated at Ot = 0.05 level of significance with df-1

48

Table 10
Comparison of Herbal Remedy Users and Nonusers Interpretation of the
Word “Natural.”

Choices

Total

Users

Nonusers

n

(%)

n

(%)

n

(%)

Pure

223

(26)

98

(44)

124

(56)

Better for you

251

(29)

132

(53)

118

(47)

Safe

181

(21)

87

(48)

94

(52)*

Plants only

312

(36)

176

(57)

135

(43)*

No chemicals

469

(54)

31

(51)

29

(49)

None

62

(7)

24

(39)

38

(61)

Other

40

(5)

23

(58)

17

(42)

Notes. Percentages of the total sample are within group. Percentages will not
total 100% due to multiple choices per subject. User and nonuser

percentages calculated within answer categories. User indicates a subject
who has ever used herbal remedies. Nonusers are subjects who have never
used herbal remedies. *Chi-square comparisons of user and nonuser
calculated at a = 0.05 level of significance with dM.

49

Of the total subjects, 36 /o indicated the choice "to feel better" and 28% indicated

"to enhance the immune system" for what they hoped to accomplish with herbal remedies
(Table 11). Only 5 /o of the total indicated that they hoped to have herbal remedies "cure a

sudden illness. Eighty-seven percent of herbal remedy users indicated "to feel better" for

their reason to use herbal remedies (x,2-40.2, p=0.001). Eighty-nine percent of users

indicated "to enhance the immune system" (x2=l44.2, p=0.001). Eighty-four percent of
those who chose "to cure a sudden illness" (n=44) were users (x2=20.4, p=0.001). Ninety-

two percent of those who hoped "to prevent an illness" with herbal remedies were users
(X2= 166.1, p=0.001).

An open-ended option was included in question 21, and responses written in

concerning what the subjects hoped herbal remedies would do for them were as follows,
to increase energy (n=12), for weight control (n=9), for arthritis (n—6), for memory

improvement (n=5), to relieve cold symptoms/relieve sinus problems (n=3), to help with

PMS symptoms (n=2), and to clean/help the system (n=2). Thirteen other responses of

one entry each included benign prostatic hypertrophy, allergies, thyroid, and acne.

50

Table 11
Comparison of Herbal Remedy Users and Nonusers, Reasons for Using

Herbal Remedies

Choices

Total

Users

Nonusers

n

(%)

n

(%)

n

(%)

44

(5)

37

(84)

7

(16)*

To feel better

313

(36)

272

(87)

40

(13)*

Immune system

240

(28)

213

(89)

27

(11)*

Prevent illness

164

(19)

151

(92)

13

(8)*

53

(6)

49

(93)

4

(2)

351

(41)

17

(5)

39

(95)

Cure sudden illness

Other

Never taken HR

iple are within group. Percentages will not
Notes. Percentages of the total sam]
total 100% due to multiple choices per subject. User and nonuser
percentages calculated within answer categones. User indicates a subject

who has ever used herbal remedies. Nonusers are subjects who have never used

prisons of user and nonuser calculated at
herbal remedies. *Chi-square comparisons

a = 0.05 level of significance with df“l •

51

Communication

The following questions, 12, 13,14, and 22, related to the issue of

communication between patients and providers in a primary care setting. The options
were always given on the communication questions for the subject to differentiate

between not taking herbal remedies” (currently) and "never having taken" them.
Of the subjects who had ever used herbal remedies, 55% had not updated their

medication lists to include herbal remedies at their last primary care visit (%2=5.8, p=0.05)

(Table 12). Ninety-four percent of those who did update their medications list with over
the counter medication were herbal users, which upholds the internal validity of the

survey (%2=41.6, p=0.001).
Ninety-five percent of the total and 100% of nonusers were not asked by any staff

members at their last primary care visit if they took over-the-counter herbal remedies
(Table 13). There were no significant differences between users and nonusers. Providers

and staff were no more likely to ask women
remedy use.

than men about over-the-counter herbal

52

Table 12

Communication: UpdatinaMedication List Comparison of Herbal Remedy
Users and Nonusers

Answer

Total

Users

Nonusers

n

(%)

n

(%)

n

(%)

Yes

53

(6)

50

(94)

3

(6)*

No

486

(57)

269

(55)

216

(45)*

Not Taking

194

(22)

77

(45)

93

(55)

(15)

1

(1)

130

(99)

Never Taken

132

Notes. Percentages of the total sample are within group. User and nonuser
percentages calculated within answer categories. User indicates a subject who

has ever used herbal remedies. Nonusers are subjects who have never used
herbal remedies. There were no significant Chi-square comparisons of user and
nonuser calculated at Ct - 0.05 level of significance with d

53

Table 13

Communication: Staff Asking About Herbal Remedies Comparison of
Users and Nonusers

Answers

Total
n

(%)

Yes

46

(5)

No

819

(95)

Total

865

Users
n

Nonusers

(%)

n

(%)

36 (100)

0

(0)

(47)

442

(53)

386
422

442

Notes. Percentages of the total sample are within group. User and nonuser
percentages calculated within answer categories. User indicates a subject who

has ever used herbal remedies. Nonusers are subjects who have never used

herbal remedies. There were no significant Chi-square comparisons of user and
nonuser calculated at a

0.05 level of significance with df-l.

Question 14 mirrored question 12, but was more specific for herbal remedies only,

excluding other over-the-counter medications (Table 14). Fifty-nine percent of herbal
remedy users did not volunteer this information to the primary care staff (X2=14.4,
p=0.001). Female users were les. likely (61%) than male users (70%) .0 keep herbal

remedy use from their provider and/or staff members.

54

Table 14

Communication: Volunteering of Herbal Remedy Use Comparison of
Users and Nonusers

Answer

Total

Users

Nonusers

n

(%)

n

(%)

57 (100)

0

(0)

n

(%)

Yes

58

(7)

No

453

(52)

267

(59)

186

Not Taking

184

(21)

95

(51)

92

(49)

70

(20)

35

(18)

164

(82)

Never Taken
Total

865

422

(41)*

442

Notes. Percentages of the total sample are within group. User and nonuser
percentages calculated within answer categories. User indicates a subject

who has ever used herbal remedies. Nonusers are subjects who have not

used herbal remedies. *Chi-square comparisons of user and nonuser
calculated at a = 0.05 level of significance with df=l.

Question 22 sought to detenttine whether th. subjects had ever asked their
providers for inflation about herbat .en.ed.es and the., use (Tab,. 15). Eighty percent

of the total subjects answered that they had not asked their prov.de,. Seven.y-f.ve percent
of the nonusers said no, as did 75 /o of the u

55

Only 5 /o (n 40) of the total thought that the provider was not interested, and 2%

(n=15) were unsure how to ask the provider about herbal remedies. Nonusers comprised
56 /o of those who did not ask information from the providers contrasted with 44% of the
herbal remedy users (%M 1.4, p=0.001). Herbal remedy users were 90% of those who

asked information from their MD/NP (x2=57.6, p=0.001).
The open-ended other” option (Table 15) provided additional reasons why
subjects had not asked their doctor or nurse practitioner about herbal remedies. Responses

included: he doesn't take them (herbal remedies) seriously (n=l), my former MD wouldn't
talk about it (n=l), I did, but wouldn't do it again! (n=l), and they don't know about

herbal remedies (n=l). Three additional subjects circled "other" but did not write in any
reason for not asking for advice about herbal remedies.

Summary

The results from a researcher developed questionnaire (Appendix C) concerning
herbal remedy use by patients in a rural primary care practice located in western New

York State were presented in text, graph, and table form. Results were presented as the
total sample (N=865), users (n:

422), and nonusers of herbal remedies (n=422). Results

were grouped according ro the research questions. All significant differences between

users and nonusers were valtdated wrth Chi-Square stalrstics at the alpha = 0.05 level of

significance and with one degree of fieedom. The Speacan Rank Order Correlation

Coefficient was used to validate the two tneasures of overal! health. Addition.! data is

presented in full in Appendix D.

56

Table 15
Communication: Ask Information from MD/NP Comparison of Users
and Nonusers

Answers

Total

Users

Nonusers

n

(%)

n

(%)

n

(%)

Yes

91

(11)

81

(90)

9

(10)*

No

695

(80)

303

(44)

392

(56)*

Not Interested

40

(17)

23

(58)

17

(42)

Not sure how

15

(2)

6

(40)

9

(60)

Other

6

(1)

2

(33)

4

(67)

No Answer

7

(1)

3

(43)

4

(57)

Total

865

422

442

Notes. Percentages of the total sample are within group. User and nonuser

percentages calculated within answer categories. User indicates a subject

who has ever used herbal remedies. Nonusers are subjects who have never used

herbal remed.es. •Chi-square comparisons of user and nonuser calculated a.

a = 0.05 level of significance with df"l.

57

Chapter 5
Discussion

This chapter provides a summary of the study to define demographics of herbal
remedy users who are currently followed in primary care. The research question
determining who is using herbal remedies and if herbal remedy use is frequent in primary

caie patients is discussed. Also reviewed are the users' beliefs about the risks or benefits
of herbal remedy use. Provider/patient communication difficulties concerning herbal

remedy use in the users and nonusers is reviewed. Limitations of the study, and
conclusions are presented. Recommendations for further research based on this study are
included in this chapter.

The literature review of herbal remedy use showed that information about herbal

remedy users was predominantly obtained from the general public, rather than an actual

patient population. The potential for herbal remedy/prescription drug interactions and
worsening of existing diseases through inappropriate dosing of herbal remedies made it

important to do a

fact-finding study within the population of primary care practice

patients. This study was conducted in a large rural primary care practice in New York
State. A researcher-developed survey was adnruuatered to dibit: (a) the demographies of

herbal remedy users along with their perception of overaU hcaith status and their amount

of herbal remedy use. (b) uncover the subjects' herb.! remedy beltefs and pledge and
incidence of adverse reactions to herbal reme

barriers between provider and patient.

and (c) to find any communication

58

Herbal Remedy Users
To answer the first research question about whom is using herbal remedies the
demographic information obtained from the surveys is discussed. Demographics, overall

health, who uses, has bought, or has had herbal remedies recommended to them is
compared with the literature search surveys.

Demographics. Of the total subjects, all patients in a large rural New York

primary care practice, 68% of the respondents were female and 32% male (Table 1). Fifty
percent of females and 46% of males had used herbal remedies at some time

(Table 8). However, the literature search showed that herbal remedy users comprised onethird of those surveyed (Arnold, 1999; Groman, 1998; Hadley & Petry, 1999; Glisson

Crawford & Street, 1999; O’Koon, 1999). Sixty percent of 36 to 45 year olds were users
of herbal remedies (%2=7.2, p=0.01), with 58% of those from 25 to 35 years of age

nonusers (%2=5.2, p=0.05) (Table 2). Forty-five percent of all users of herbal remedies

were between 36 to 55 years of age compared with non-users at 32%. Krantz & Bjerkler

(1994) wrote that the 35 to 54 age group is leading the boom in self-medication with
"neutraceuticals", vitamins, minerals, and designer prescription drugs. This study, 6 years
later, concurs with his statement.

Zeil (1999) characterized herbal remedy users as female, age25 and up, with a

family income of $50,000 or mom. Demons from this survey showed that 60% of
$25,000 to >50,000 compared to 51% of nonusers
herbal remedy users' income was
/ mho «10 000 to 14,999 category (x2=4.8, p=0.05). This
(Table 3). Nonusers were 61 /o of the $1 ,

59

agrees with the literature review of herba! remedy users earning more income, hut not at
the >$50,000 level.
Astin (1999) characterized herbal remedy users as more highly educated, in

poorer health, feminist, and to have a holistic outlook on health. All subjects (66%) and
all subgroups tended to married, including 67% of users and 65% of nonusers (Table 4).
Educational levels (Table 5) showed herbal remedy users to be more educated, with 60%

of users having completed some college/vocational education or higher compared with

40% of non-users (x2=13.4, p=0.001). Users comprised 65% of those with bachelor

degrees (%2=9.8, p=0.01). Nonusers were 53% of those with master or higher degrees but
65% of those with high school or less.

Overall health on the day of the survey was measured using both a multiplechoice Likert question as well as on a visual analog health scale. Forty-two percent of the
total subjects chose the "good" category of overall health (Table 6). The visual analog

health scale showed the same total population scoring 72% (Table 7), analogous to "very-

good" (60-80%) or the next to highest of the five choices in the multiple-choice question.
Users were the same as nonusers in the "good.” "very good,” and "excefient" choices on
the multiple-choice question, but nonusers were 65% of subjects who ranked their heahh

as "'poor.” This study contrasts with previous surveys

with the overall health of users and

nonusers generally the same (good to very good).

Comparison of ,Ms survey with others cited in the

review, shows near),

50% of the subjects users of herbal remedies. This research is consistent with earlier

60

showing that herbal remedy users are often fema|e (73%)

educated, and with a somewhat higher income level than uonusers.
HsMReme^, Herbal remedy use,

thls study, was defined as -cumnt|y

using" or "have ever used" herbs! remedies. Research focused in the Iherature often

combined herbal remedy use with the use of other complementary and alternative
medicine (CAM) (Astin, 1999; Eisenberg et al., 1998). Druss and Rosenhek (1999)

showed that 65% of those they surveyed were using both CAM and conventional primary

care services, indicating that conventional care is not being replaced by alternative
therapies, but is being used concurrently. This researcher survey in a primary care

practice showed that 50% of females and 46% of males used herbal remedies
concurrently with their other traditional primary care therapies. This is contrasted with
the Consumer Reports' survey obtained around the same time as this research. Twenty-

five percent of their sample used CAM concurrently with traditional care
(Mainstreaming, 2000). The concurrent use of herbal remedies and conventional
medicine increases the chances for herb/prescription drug interactions (Appendix A).

Of the 422 users of herbal remedies in this study. 87% bought the herbs

themselves, and 73% had had the remedy recommended to them by someone (Tab!e 8).
Sibbald's Canadian study (1999) found that 30% of subjects got tnformalton about herba!
remedies from friends/fmnily. In Uns cement study, 23% of the total sarmple got their

recommendations from family G* 9). Twenty-^ percent of those surveyed by
■ „ 7000) had their CAM therapy recommended to them
Consumer Reports (Mainstreaming,
)

61

taken the recommendation from a MD/NP Thio u-rr
lhis difference points out the communication
gap between patiems/providers. Sibbald (1999) a|s0

got their herbal remedy information ftom the aggregate

articles, and product information. Sibbald (1999) also wrote that users who cited
physicians as their source of information rose from 3% in 1996 to 11% in 1998. Eleven

percent of herbal remedy users in this current study also cited MD/NP as the source of

their recommendation for herbal remedy use and were 84% of those who chose that
category ((Table 9).
Risk/Benefit Knowledge
The perceived risks and benefits of herbal remedies are discussed for users,
nonusers, and the total subjects of the survey. Comparisons are made with the literature

reviewed.
Knowledge. Herbal remedy knowledge is increasing through controlled

randomized studies. Knowledge is also enhanced by a newly released PDR (Physician
Desk Reference) of herbal remedies, and by seminars or other source materials for

providers. The National Institute of Health National Center for Complementary &

Alternative Medicine continues to sponsor research.
Th. Revised Health Pmmonon Medel (Pender, 1996) addled patient

knowledge mrd behefs. The nse of herb.) temed.es depended on the herbal remedy users'

, „f ,be U S popnlation and, in particular, those in pnm^y
growing among all segments oi the u.o. f f
i mdv as a whole, felt that herbal remedies were
care practices. The subjects in this rura s
Rations (65%) (T*H). and that ^ey —no
more natural than prescription

62

chemicals (54%) (Table 12). Users toot ,Krbs p
them immune system (51%) (Table 13). Only 5%

that herbal remedies wouid cure a sudden ihness. The herbs! remedy users reported 27
adverse reactions to herbal remedies, but only 8 reported to their provider. Eighty-five

percent of users reported no adverse reactions to herbal remedies.
The subjects did not perceive taking herbal remedies as a significant risk to their

health, and so did not seek qualified advice. They did not feel that herbal remedies were a
medication and did not report their use to providers and staff at the primary care office.

Communication. Communication between patients and providers was assessed by
asking questions about whether they (a) updated their medication list at their last primary
care visit, (b) were asked by the staff if they took OTC herbal remedies, and (c) directly
ask their provider about herbal remedies. Sixty-four percent of herbal remedy users did

not volunteer information about their herbal remedy use. Eisenberg et al. (1998) also

found that the majority of patients did not tell their physicians about using herbs. Of
additional significance in this study is that 95% of all subjects indicated that they were

not asked by medical office staff about herbal remedy use (Table 15). This question had
not been addressed in earlier studies. To illustrate communication barriers, combine the
finding that 96% of patients were not ashed about herb use with the fact that 65% of these

ash information on herba! remedies fiom their P-iders. These figures vaiidate concerns

that: (a) herbal remedy users are relying on family n

not their providers, for

information and recotnmendations about herba! remedy use and cense,uenfiy nay no.

more than anecdotal information,, - (fi)tha. staffmembers are not
base their choices on

63

consistently asking patients if they take OTC herbal remedies. This barrier to

communication is the most powerfu! and possibly the eaaieu, to remedy by teaming staff

members to always ask tn a nonjddgmentat f*, about all 0TC
including herbal remedies (Appendix B). All subjects were reluctant to ask their MD/NP

about herbal remedies. Forty respondents thought their provider was not interested.

Herbal remedy users are subjects who are the most vulnerable for herbal

remedy/prescription drug interactions. Korsch (1994) wrote that more malpractice
litigation results from communication breakdown than from technical errors alone.

Communication lines need to be opened in order for providers and patients to

share information about herbal remedy use, its benefits and risks, and side-effect profiles.
For patients, the newer randomized herbal remedy studies could form the basis for

education and information dissemination from the provider. For providers, discussion

with patients gives an anecdotal picture of what herbal remedies can and cannot do

(Seligson, 1996). These patient experiences might help the provider give better informed
care until more definitive evidence-based information is available in the literature.
Continuing and promoting the patient/provider relationship through open

communication while monitoring the patients' progress whh » herba! product provides a
mutual learning opportuntly (Zink & Chaffin, 1998). Comments horn this study's primtuy

at almost every encounter since the survey was conducted.

herbal remedy use
Communication barriers have been changed in this pra

64

Conclusions

Overall, the survey results from this

study met the goal of describing herbal

remedy users in a rural setting of New York State who also utilize primary care. The

study also met its goal of confirming the demographics of herbal remedy users in the year

2000 for comparison with previous studies. This study addressed herbal remedy users
rather than combining herbal remedy use with other CAM (complementary and

alternative medicines) therapies. This gave a clearer picture of herbal remedy users' (a)
usage, (b) adverse reaction profile and the subjects' knowledge and perceived risk/benefit

view of herbal remedies, and (c) communication with providers concerning herbal

remedies.
Herbal remedy use is more prevalent than previously reported. Although the

knowledge base of providers may be growing, patients are not consulting providers for
information and guidance in the use of herbal remedies. Herbal remedy information is
often obtained from friends, family, and herbal manufacturers' advertising. The

nonreporting of herb use is making it inoreasingiy difficult for providers io practice good

preventive health care.
Limitations of the Study

While this sample size was

large, the results can be applied only to primary care

archer-developed survey demonstrated
patients in a rural eastern location. The rese<
in different words, for the same
internal validity with several questions asking,
id reliability.
• r
■ n rther testing for both validity an
information, but requires further te

65

Recommendations for Further Study
Communication is the key to demystiiying herba,
providers. Without communion, no decision can be made either about herbal remed,

concurrent use with prescription medications or their substitution for conventional
evidence-based treatments. Without this knowledge, providers will not have the
information needed to safely choose the best course for their patients' health care.

This survey needs to be tested on other populations and in different locations to

further evaluate its validity and refine its effectiveness as a tool to elicit patient/provider
communication barriers and the herbal remedy knowledge of the subjects. In future
studies, the refinement of information would be furthered by surveying in urban primary
care practices, specialty practices, and primary care practices in other geographic

locations. Future surveys should include questions asking how many prescriptions the
subjects are taking at the time of the survey. Questions should be added to delineate the
disease processes of the subjects. These questions would help to estimate the risk of
concurrent herbal remedy use with prescription medications and chrome disease
processes such as diabetes, hypertension, renal 01 hepatic dise

Summary
Increased herba! remedy use by patients

conventional prescription

immunication problem for providers of primary
medication and therapies presents a co
acknowledges the needs of patients who
care. The most effective communication style
• nn making (Belzer, 1999) (Appendix B).
want to participate in their care and in ecisi

66

For the patient, telling providers about herbal remedy use and alternative therapies, and
making sure they become a part of the medical record could safeguard their health

(Seligson, 1996).

Maybe the two worlds of medicine, conventional with
complementary/altemative medicine, will become closer together and benefit the health

of the patients they both serve. Nurse practitioners could play a major role in the
nonjudgmental communication of current herbal remedy knowledge, safety, and efficacy

with their patients. Communication is the key for all patients and providers.

67

References

Adler, S. R., & Fosket, J. R. (1999). Disclosing complementary and alternative
medicine use in the medical encounter: A qualitative study in women with breast cancer.

Journal of Family Practice, 48(6), 453-458.
Alschuler, L., Benjamin, S. A., & Duke, J. A. (1997). Herbal medicine: What
works and what is safe. Patient Care, 31(21), 48-52, 55-56, 61-62, 64, 66-68.
American Council on Science and Health (1999, Aug. 23). Study shows that

alternative medicine is ‘complementary’. [On line]. Available: http://www.acsh.org./.
Angell, M., & Kassirer, J. P. (1998). Alternative medicine: The risks of untested
and unregulated remedies. The New England Journal of Medicine, 339(12), 839-841.
Arnold, K. (1999). Alternative medicines gain popularity: Merits closer scrutiny.

Journal of the National Cancer Institute, 9( 13), 1104-1106.
Astin, J. A. (1998). Why patients use alternative medicine: Results of a national
study. Journal of the American Medical Association, 279(19), 1548-1553.

Barnes, J., Mills, S. Y., Abbott. N. C., Willoughby, M., & Ernst, E. (1999).

Different standard for reporting ADRs to herbal remedies and conventional OTC
medicines: Face to face interviews with 515 users of herbal remedies. British Journal of
Clinical Pharmacology, 45(5), 496-500.
Barrett, B., Kiefer, D., & Rabago, D. (1999). Assessing the risks and benefits of

herbal medicines: An overview of scientific evidence. Alternative Therapies, 5(4), 40-49.
Becker, M., (1974). The health belief model and personal health behaviors.
Thofofacce, N J: Charles B. Black.

68

Belson, A. (1999). The 5 biggest myths about doctors. Woman’s Day, 62( 12),

64-66.
Belzer, E. (1999). Improving patient communication in no time. Family Practice
Management, 6(5), 23-29.

Benbassat, J., &.Pipel, D. (1998). Patients’ preferences for participation in clinical

decision making: A review of published studies. Behavioral Medicine, 24(2),
81-90.
Berg, J. A., Amelia, E, Gagan, M. J, & McArthur, D. B. (1998). Integrative
therapies in primary care practice. Journal of the American Academy of Nurse
Practitioners, 10(12), 541-546.

Blenkinsopp, A., & Bradley, C. (1999). Patients, society, and the increase in self-

medication. British Medical Journal, 312(31), 639-633.
Blumenthal, M., Busoe, W. R., & Goldberg, A. (1998). The complete German
Commission E monographs: Therapeutic guide to herbal medicine. Austin, TX: The
American Botanical Council.

Borins, M. (1998). The dangers of using herbs: What your patients need to know.
Postgraduate Medicine, 104, 91-95, 99.

Cecil D. W. & Killeen, I. (1997). Control, compliance, and satisfaction in the

family practice encounter. Family Medicine, 29(9), 653-657.

Chen, J. (1999). Recognition and prevention of herb-drug interaction. [On line].

Available: http://www.acupuncture.com/Herbology/drug.htin..

D’Epiro, N. W., & Benjamin, S. A. (1999, Apr. 15). Herbal update: Saw palmetto
and the prostate. Patient Care, 33(5), 29-30, 32, 35.

69

Druss, B. G., & Rosenhek, R. A. (1999). Association between use of

unconventional therapies and conventional medical services. Journal or the American
Medical Association, 282 (7), 651-656.
Eisenberg, D. M., Davis, R. B., Ettner, S. L., Appel, S., Wilkey, S., Von Rompay,

M., & Kessler, T. C. (1998). Trends in alternative medicine use in the United States,

1990-97: Results of a follow-up national survey. Journal of the American Medical

Association, 280(18), 1569-1575.

Feinberg, M. (1997, Jan.). Self-medication in the elderly. Advance for Nurse
Practitioners, 17-18, 21.
Fetrow, C. W., & Avila, J. R. (1999). Professional’s handbook of complimentary

& alternative medicines. Springhouse, PA: Springhouse Corporation.
Glisson, J., Crawford, R., & Street, S. (1999). Review, critiques, and guidelines

for the use of herbs and homeopathy. The Nurse Practitioner, 24(4), 44-46, 53, 60, 65-67.
Greenberger, P. (1998, Sept. 23). Opening remarks to the society for women’s
health research. [On line]. Available: http://www.women’s-health.org/rempg.herb.html .

Greenwald, J. (1998, November 23). Herbal healing. Time, 58-69.

Grevier, M. (1998). The cure is in the bag: Is there a correlation between the

number of unconventional remedies ingested and overall health status? Canadian Medical
Association Journal, 159(12), 1498.
Gorman, C. (1998, Nov.23). Is it good medicine? Time, 69.

Hadly, S. K., & Petry, J. J. (1999, June 15). Medicinal herbs: A primer for
primary care. Hospital Practice, 105-106, 109-112, 115-116, 121-123.

70

HHS News (1999, Aug. 30th). HSS secretary appoints members to new advisory

council on complementary and alternative medicines. [On line]. Available:
http://www.hhs.gov.

An integrative medicine primer: An introduction to the theory and practice of the

most widely used complementary and alternative therapies (IMP) (1999). Newton, MA:

The Integrative Medicine Consult.
Kent, H. (1999). It's not alternative (medicine) to the patient. Canadian Medical
Association Journal 160(5), 627-628.
Klinger, B. (1998, Oct. 15). Herbal medicines and the family physician. American

Family Physician, 1064.

Korsch, B. M. (1994). Patient-physician communication: More research needed.
Clinical Pediatrics, 33(4), 202-203.
Krantz, M., & Bjerklie, D. (1997, Sept. 8). The self-medication generation.

Time, 72.

Lee, R., Tyler, V. E., & Weart, W. (1999, Sept. 15). Herbal medicines you can
recommend with confidence. Patient Care, 34(17), 75-78, 80, 82, 85-86, 89-90, 92-94.

Lowe, M., & Kerridge, J. (1997). Alternative ethics: Challenge of complementary
medicine. Student British Medical Journal, 5, 146-150.
The mainstreaming of alternative medicine. (2000, May). Consumer Reports,

17-25.
MedWatch News-FDA Talk Paper (1997, Sept. 23). [On line]. Available:

http://pharminfo.com/medwatcli/mwrpt26.html

71

Meryn, S. (1998). Improving communication skills: To carry coals to
Medical Teacher. 20(4), 331-337.

National Center for Complementary & Alternative Medicine (1999). Considering

alternative therapies. [On line]. Available:
http://nccam.nih.gov/nccam/what-is-cam/ consider, shtml.

NIEHS News-Herbal News (1998, Dec. 12). Environmental health prospectives.

[On line]. Available: http://ehpnet.niehs.nih.gov/docs/1998/106-12/niehsnews.html .
O’Koon, M. (1999, March-April). Shopping for a “cure”. Arthritis Today, 20-35.
Pender, N. J. (1996). Health promotion in nursing practice (3d ed.). Stamford,
CA: Appleton & Lange.

Polet, D. F., & Hungler, B. P. (1999). Nursing research: Principles and methods

(6th ed.). Philadelphia: Lippincott.
Rose, E. O. (1999, July 30th). An herb by any other name. American Council on

Science and Health. [On Line]. Available: http://www.asch.org.
Seligson, S. V. (1996). Melding medicines. Health, 12(4), 64-66.

Sibbald, B. (1999). New federal office will spend millions to regulate herbal

remedies, vitamins. Canadian Medical Association Journal, 160(9), 1355-1358.
Sorofman, B. (1992). Drug promotion in self-care and self-medication. Journal of

Drug Issues, 22(2), 377-389.
The mainstreaming of alternative medicine. (2000, May). Consumer Reports,

17-25.

72

Walker, M. (1999, Sept.). What do patients really want? Hypocrites, 34-39.

Weber, D. D.(1998). Considering the alternatives. Physician Executive, 24(6),
6-15.

Wisneski, L.A. (1999a, Aug. 1). The integrative medicine consult: The essential
guide to integrative conventional and complementary medicine,!(12), 107-114.

Wisneski, L. A. (1999b, Oct. 9). The integrative medicine consult: The essential

guide to integrative conventional and complementary medicine, 1(16), 147-154.

Ziel, H. K. (1999). Complementary alternative medicine: Boon or boondoggle?
Skeptic, 7(1), 86-90.

Zink, T., & Chaffin, J. (1998). Herbal ‘health’ products: What family physicians
need to know. American Family Physician, 58(5), 1133-1140.

73

Appendix A
Side Effect Profiles of Common Herbal Remedies

(Borins, 1998)
Common Name

Potential Side Effects

Aconite

Dangerous arrhythmias, cardiovascular
collapse.

Aloe

GI catharsis, diarrhea when ingested,

nephritis, abdominal pain, dermatitis

when used topically.
Buckthorn bark

Catharsis, diarrhea.

Calamus

Beta asarone found in some calamus

species may be carcinogenic.

Chamomile

Allergies, anaphylaxis (especially in
persons sensitive to Compositae

family), contact dermatitis.

Chaparral

Hepatitis.

Comfrey

Liver damage.

Devil’s claw

Abortion

Dong quai

Abortion, affects estrogen levels.

Garlic

Dermatitis, vomiting, diarrhea,
anorexia, flatulence, antiplatelet.

74

Common Name

Potential Side Effects

Germander

Hepatitis

Ginsing

Hypertension, diarrhea, nervousness,
depression, amenorrhea, insomnia,

skin rashes.

Jimsonweed

Dry mouth, blurred vision, sedation,
tachycardia.

Licorice

Hypokalemia, hypertension, sodium

and water retention.
Mistletoe

Gastroenteritis, cardiac effects.

Ragwort

Hepatitis.

Sassafras

potential carcinogenic effects,
nosebleeds.

Seim a

Diarrhea, abdominal pain.

Wormwood

Hallucinations.

75

Potentially Toxic Herbs (Lee, Tyler, & Weart, 1999)
Common Name

Potential Toxicity

Blue Cohosh

This herb may induce labor.

Borage

Traditionally used for coughs and
illnesses of the throat, it has liver

toxicity and may contain ingredients
that are hepatocarcingenic.
Calamus

Used as a tea to treat dyspepsia,

gastritis, and ulcers, it should not be
used chronically as long-time use
has been associated with malignant

tumors in rats.
Chaparral

Once popular as an underground
anticancer dmg, it has never been
proven effective. It has liver toxicity.

Colt's foot

Used to reduce throat irritations and
coughing, it may have carcinogenic

potential and liver toxicity.

76
Common Name

Potential Toxicity

Comfrey

Used for many years for external

wound healing. It was used starting in
the 1970s internally in the US. It contains

very toxic pyrrolizidine alkaloids, which
have caused liver cancer in small animals

and veno-occlusive disease in humans. The

herb remains on the US market.
Ephedra

This CNS and sympathomimetic

stimulant has been used as a general

stimulant, treatment for asthma, and
for weight loss. If used for more than

one week, it requires medical supervision.
In extremely high dosages, it can lead to
asphyxiation and heart failure
Germander

Although this herb has been used to help

digestion and treat gall bladder disease,

it has strong liver toxicity.
Licorice

Used for gastric and duodenal ulcers, this
herb has liver toxicity, if used in large doses

over extended periods of use.

77

Common Name

Potential Toxicity

Poke root

This herb has been used as an emetic and as

a treatment for rheumatic disorders, but it is
poisonous, containting toxic lectins and

mucous-membrane irritating eaponins.

Sassafras

This herb has been used to treat urinary tract

disorders, but the FDA has banned the food
or drug use of both the herb itself and

safrole, a constituent in the oil in sassafras,

because they have caused cancer of the liver

in small animals. Because the ban has not
been enforced, sassafras tea remains on the
market.

Wormwood

This is the key ingredient in the alcoholic
beverage absinthe, which is ilegal in the US
because it contains a toxic combination of

thijone and isothijone.

78

Appendix B
Patient-Provider Communication Strategies
Provider Speedbar (Belzer, 1999)

1. Physicians have less time today to build rapport with patients and must refine their

communication skills to maximize their time.

2. Patients who have a strong relationship with their provider are more likely to be
compliant with their health care.

3. Busy providers should remember the pleasantries such as calling patients by their
name and shaking hands; doing so builds good relationships.
4. Communicating with a dual purpose helps you obtain crucial information about a

patient's health even during informal conversation.
5. To obtain more information from patients in less time, don't interrupt them.

6. Using a structured patient interview, such as the BATHE technique, will help you
maximize your time with the patient.

7. Try to build patient trust. Patients who trust their physicians cut to the heart of what's
bothering them more quickly.
8. The most effective communication style acknowledges the needs of patients who

want to participate in their care and in decision making.
9. Patient satisfaction depends on the provider's ability to manage patient expectations

about what can be accomplished in one visit.

aterial into the office visit helps you provide more
10. Integrating patient education m;
information without investing more time.

79

11. Time-saving tips include delegating patient education to staff members and

maintaining a patient education library.

12. A workplace designed for convenience and efficiency will enable you to spend more
time with patients.

13. A welcome letter for new patients lets you ease their transition to a new practice and

share your philosophy of health care.
14. The letter might invite patients to take responsibility for their health and explain the

type of provider-patient relationship you hope to build.
15. To meet patient expectations for more information, use e-mail to keep in touch and

answer patients' questions; it can be a time saver.
16. You can use your computer as a patient information tool and tell patients about

helpful web sites.
17. A good patient-staff relationship can build patient satisfaction. Staff should attend

training sessions on patient communication.

18. Call patients with lab results as soon as they are in, and create a system to remind the

staff to call for results that are overdue.
19. Patients today evaluate physicians based on how they interact with patients, not solely

on their clinical skills.
20. To increase patient retention, evaluate your interaction style and understand how it

affects patient satisfaction.

80

Strategies for the Patient (Seligson, 1996)
1. Listen first, don t assume your provider can’t help. Your health care provider can rule

out underlying problems, A diagnosis does not necessarily wed you to mainstream

therapy.

2. Tell your story: try to reach a mutual goal about your health problem. Bring up
alternative treatments and if derided, ask why. If no specific contraindications, ask

that your alternative treatment be added to your chart, as a good provider always
wants to know what his patient is doing. Mention your herbal remedies when asked

about medications currently being taken.

3. Strategize together: agree on a time to reassess. Ask your provider for symptoms that
should be reported to him for medical attention.
4. Get it in writing: ask your provider to note your alternative therapies in your chart. If

a problem arises, every possible clue should be documented.

5. Set a revisit: to reassess the therapies in 4-8 weeks with your provider.
6. Make introductions: if your provider is open-minded, have your alternative therapist

contact him. They are actually practicing in parallel. They will then both be better
equipped to meet your health needs.

7. Even if all you do is tell your provider about your nontraditional therapies, get them
written into your chart, and let your provider know how they are working, you'll have

safeguarded your health and perhaps brought the two worlds of medicine a little
closer together.

81

EDINBORO UNIVERSITY
o~f
pen nITVTVaYTTT
Department of Nursing
Edinboro, PA 16444
(814) 732-2900

Appendix C

I would like to introduce myself. My name is Chris Flanders, RN, FNPs.
This survey is part of a research project that I am doing for an
advanced nursing degree at Edinboro University of Pennsylvania. It will
provide information about herbal remedies and who is using them and what
questions they may have about these remedies and their current medications .

This survey should take about 5-10 minutes for you to complete.
Please do not place your name on the survey.
Your answers will be strictly anonymous.
All information will be reported as group information.
Your care here will in no way be affected whether or not you wish to
participate in the survey.
**********************************

For your information, the results of this survey will be posted at the
reception desk in March of 2000.
If you have any questions,

S0™”8’CRM>’PhD

Thank you very much for your participation.

82

Echinacea
St. John’s Wort
Fish Oils/Cartilage
Melatonin
Yohimbine
Kava Kava

Ginkgo Biloba
Garlic
Glucosamine
Valerian
Ephedra
Milk Thistle

Probiotics
DHEA
Ginseng
Feverfew
Ginger
Aloe Vera

Black Cohosh
Dong Quai
Sassafras
Saw Palmetto
Chamomile
Goldenseal Root

Please answer all the questions to the best of your ability and return the survey to the
receptionist or the nurse.

1. What is your gender? (Please circle one answer)
1. Male
2. Female
2. What is your present age? (Please circle one answer)
1. Under 25 years
2. 26-35 years
3. 36-45 years
4. 46-55 years
5. 56-65 years
6. Over 65 years

3. Which of the following categories best describes your yearly total household income?
(Please circle one answer)
1. $5000-9,999
2. $10,000-14,999
3. $15,000-24,999
4. $25,000-49,999
5. $50,000 or more

4. What is your marital status? (Please circle one answer)
1. Single
2. Married
3. Separated
4. Divorced
5. Widowed
6. Living with someone

83

5. What is the highest level of education that you have completed? (Please circle one
answer)
v
1. High School or less
2. Some College/Business School or Vocational Training
3. Bachelor’s Degree
4. Masters or above
6. How would you describe your overall health today? (Please circle one answer)
1. Excellent
""~
2. Very Good
3. Good
4. Fair
5. Poor
7. Do you currently take any form of herbal remedy either daily or as needed? (Please
circle one answer) (For help see the partial listing of herbal remedies at the top of this
survey)
1. Yes
2. No

8. Have you ever taken an herbal remedy, even for a short time? (Please circle one
answer)
1. Yes
2. No
9. Have you ever bought an herbal remedy for yourself? (Please circle one answer)
1. Yes
2. No

10. Has an herbal remedy ever been recommended to you? (Please circle one answer)
1. Yes
2. No
11. If so, who recommended it to you? (Circle all answers that apply)
1. Family Member
2 Nutritionist or Herbalist
3. A Magazine, Pamphlet, Book or TV Program
4. Pharmacist
5 Your Doctor or Nurse Practitioner

6. Other
—------------------6. None recommended.

84

.
your as visit, did you update your medication list by adding any herbal remedies
that you are currently taking? (Please circle one answer)
1. Yes
2. No
3. Not taking any herbal remedies.
4. Have never have taken herbal remedies
13. ,At your last visit, did the staff ask you if you took any herbal remedies?
(Please circle one answer)
1. Yes
2. No

14. At your last visit did you volunteer information about your herbal remedies to the
staff? (Please circle one answer)
1. Yes
2. No
3. Not taking any herbal remedies.
4. Never taken herbal remedies.

15. On the line below, please place a single pen mark to show where you think your
overall health score is today on a scale of 0 = death on the left to 100 = perfect health on
the right. (If you feel as if your health is great today, place the mark closer to 100, or if
your over-all health is horrible today, place your mark closer to the 0)
{
0
death

50

__________ }
100
perfect health

16. Have you ever had an adverse reaction to an herbal remedy? (Either your condition
got much worse or you had a rash, nausea, or trouble breathing) (Circle one answer)
1. Yes
2. No
3. Do not take herbal remedies.
4. Have never taken herbal remedies.
17. If you had an adverse reaction to an herbal remedy, did you call your doctor’s office?
(Please circle one answer)
1. Yes
2. No
3. Went to the emergency room.
4 Do not take herbal remedies, so no adverse reaction.

85

18.1If you have never taken any herbal remedies, would you be willing to try one with the
advice
--- of:
cf: (Circle all that apply)
1. A magazine or a pamphlet at the health food store
2. A TV program or advertisement
3. Advice of an herbalist
4. Advice of a pharmacist
5. Advice of your doctor
6. Other
7. I already take herbal remedies.
19. Do you think that herbal remedies are more natural than medications prescribed for
you by your doctor? (Please circle one answer)
1. Yes
2. No

20. What does the word natural on an over-the-counter herbal remedy mean to you?
(Please circle all answers that apply)
1. Pure
2. Better for your body
3. Safe
4. Made from plants only
5. No chemicals
6. Effective
7. None of the above
8. Other

21. If you have ever used herbal remedies, what were you hoping to do?
(Circle all answers that apply)
1. To cure a sudden illness
2. To make you feel better
3. To enhance your immune system.
4. To prevent and illness
5. Other:
__________________________
6. Never taken an herbal remedy
22. Have you ever asked for advice from your doctor or nurse practitioner about taking
an herbal remedy? (Please circle one answer)
1. Yes
2. No
3. Did not think that they would be interested
4 Not sure how to ask them about herbal remedies
5. Other
_
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