Study of Usage Rate for Various Complementary and Alternative Medicine among People Visited Non-Conventional Medical Centers in Shiraz, Iran, in 2016

Introduction: The present research was aimed at studying the usage rate for the complementary and alternative medicine, at identifying its low-consumption and high-consumption methods, and at analyzing the relationship between demographic variables and the usage rate of this medicine among the people who visited the non-conventional medical centers in Shiraz, Iran. Methods: This research is an analytical-cross-sectional study in which 800 people have been visited 6 non-conventional medical centers in July 2016; having gained their satisfaction, they were studied by method of complete enumeration. The data were collected using a researchermade questionnaire and analyzed through SPSS. Result: In this study, 68% of visitors used the complementary and alternative medicine in medium rate. The high-consumption kind includes the Natural products, the Movement-based approaches and the Traditional treatments. The low-consumption kind includes the Energy-based treatments and whole medical system. The demographic variables such as age, gender, ethnicity, education, birth place and occupation were in relation with the usage rate of complementary and alternative medicine. Conclusion: The healthy people have tended to use the complementary and alternative medicine as a part of their healthy lifestyle. The high-consumption strands had origin in the culture and tradition of a society and they are easily available. The low-consumption strands include the methods that the people were less familiar with them; these strands have limited accessibility and the higher costs.


Introduction
In the new era, every community faces an increase in using the alternative methods of heath care being located outside of official medical system or having overlapped to it 1 .The traditional medicine is a series of knowledge, skills and theories-based performance, beliefs and native experience of various cultures which have been utilized to maintain, prevent, diagnose, improve and/or treat physical and psychological illnesses 2 .The complementary and alternative medicines are defined under the title of a various series of medical methods, performances and products as well as the hygiene cares that is not necessarily considered as a part of conventional medicine 2,3 .Each two terms of the complementary medicine and the alternative medicine has distinctive definition; the complementary medicine is the nonmainstream practice of therapies being applied along medicine whereas the alternative medicine is that cluster of the non-mainstream practice of therapies being used instead of conventional medicine 3 .According to the definitions and the various categories, the kinds of traditional, complementary and alternative medicines are taken into various clusters, some as follows: -Natural materials such as herbs, diet therapy, vitamins, dietary supplements, minerals and aromatherapy.-Mind-body therapies such as Yoga, Tai-Chi, meditation, relaxation, hypnotism, and acupuncture.-Handy and physical therapies such as chiropractic, reflexology and massage.
-Energy-based therapies such as energy therapy, magnetic therapy and Reiki.-Traditional therapies such as phlebotomy, leech therapy, bloodletting and cupping.-Full-therapy systems such as homoeopathy.
-Physical and movement methods such as sport therapyand hydrotherapy.In addition, there are other kinds of complementary therapies such as various Chinese traditional medicine, Indian medicine, nature therapy,spiritual therapies and so forth [3][4][5][6] .Using the traditional, complementary and alternative medicines has been developed throughout the world and being applied in all communities such as the developed nations or the developing ones [7][8][9] .Many studies have shown the increasing tendency toward using the complementary and alternative medicines among the general public such as the healthy people and ill people 10 .According to a WHO report, more than 100 million Europeans use the traditional, complementary and alternative medicines.In addition, many users of complementary and alternative medicines live in Asia, Africa, Australia and North America 11 .In Europe, the common rate of using complementary and alternative medicines is between % 0.3 and % 86 and the maximum therapies include the herbs, acupuncture, homoeopathy, dietary supplements and the handy methods such as massage and reflexology 12 .In the United States, the use of the complementary and alternative medicines was increased among adults significantly in the 1990s and continued with as approximate stable rate (%36 -%38) and reached to % 40 by 2007 8,13 .In Canada, % 38 of people use herbal products and % 89 of manufacturers sell herbs 9 .The use of the complementary and alternative medicines has been between % 34 and % 49 in the Scandinavian countries 14 .In South Korea, % 74.8 of people have been used at least one of the complementary or alternative medicines 15 .Based on another study in South Korea, the most popular methods of the complementary medicine include sport therapy, vitamins and minerals 16 .A study in Czech showed that % 76 of people, in the past one month of this research, used at least one of the complementary or alternative medicines which respectively include vitamins and minerals, herbal therapies, massage, relaxation techniques and food supplements 6 .The traditional and complementary medicines are used in a widespread spectrum by people in Iran among which the herbals are the most popular ones 17 .
In a research carried out in Isfahan, the widespread use of the complementary and the alternative medicines has been reported % 62.5 5 .Findings of a research in Tehran showed that half of Tehran's population has used at least one of the complementary or traditional medicines in the past one year among which the herbs, herbal medicines and pray therapy were the most popular ones whereas the hypnotism, acupuncture, yoga, meditation, energy therapy were the least popular ones 18 .In addition, the results of a research on 4123 Tehran population showed that % 42.2 have used at least one of the methods of complementary medicine; then, omitting the method of herbal medicine, it was distinguished that the use of other methods of complementary medicine was reaching % 9.6 17 .Furthermore, studying in the field of using the complementary and alternative medicines among the special groups, a research on pregnant women in Mashhad showed that % 83.7 of them have made use of the complementary and alternative medicines during pregnancy; from top to down,usingthe herbal medicines, diet changes, body-based performances and the spiritual methods were noticed among the pregnant women 19 .Findings of another research on the Multiple Sclerosis (MS) patients in Isfahan showed that % 85 of these patients used at least one of the traditional and complementary medicines during illness and the most popular methods were taking vitamins, doing sport and taking herbal medicines 20 .Findings of another research on the pregnant women in Mazandaran Province revealed that % 45 of mothers were familiarized, at least, with one of the traditional and complementary medicines among which the herbal therapy, pray therapy, hydrotherapy and phlebotomy were the most applied methods 21 .The results of another research on diabetic patients in Sari city showed that % 36 of these patients used at least one of the traditional and complementary medicines among which the herbs, phlebotomy, acupuncture, bloodletting and massage were respectively used most 22 .In addition, another study showed that % 85.7 of 2 nd -type diabetic patients in Isfahan were using, at least, one of the complementary medicines among which the natural medicines, physical and movement methods were taken most whereas the energy-based therapies and full-therapy systems were used least 5 .Generally, the internal and external studies represent the increasing tendency towards the widespread use of traditional, complementary and alternative medicines both for the general public including healthy people and for the special groups including different diseases.This signifies the importance of carrying out widespread studies in this area.Since most of the internal researches have studied the use of traditional, complementary and alternative medicines among special groups such as patients afflicted by diabetics, cancer, MS, pregnant women etc., and meanwhile all the people using the traditional, complementary and alternative medicines are not necessarily patients 18 , the present research aims at studying the use of various types of traditional, complementary and alternative medicines among healthy people and patients in Shiraz without focusing on special groups.By considering Shiraz as the south medical polar of Iran where it has optimum medical services in terms of quantity and quality, studying the use of non-mainstream therapies such as traditional, complementary and alternative medicines and measuring the conventional, mostused and least-used kinds sound important.Since a few researches have been carried out in this case in Shiraz, therefore, the significance and necessity of this study is distinguished.Thus, the present study attempts to investigate the use for traditional, complementary and alternative medicines in Shiraz and determines the conventional, most-used and least-used ones.Furthermore, the relationship between age, gender, ethnicity, education, birthplace, type of occupation in addition to the use of traditional, complementary and alternative medicines were studied in order to determine what feature is related to the use of various types of traditional, complementary and alternative medicines.

Materials and Methods
The present research is an analytical and crosssectional research.The research community includes all the visitors to 6 centers of delivering type of nonconventional medicine (including Iranian traditional medicine and the complementary and alternative medicines) in Shiraz.First, 6 centers of delivering various types of non-conventional medicine in different areas of Shiraz (north, south, east, west and center) were selected.Their selection was based on diversity in demanding the complementary medicine and Iranian traditional medicine, on coverage of the intended urban area and finally on their popularity and mostly-visited features.After selecting these centers, the experienced and trained questioners visited these centers for 30 days (June 2016), from Saturday to Wednesday, in the mornings and the evenings.All visitors were investigated based on census.The criteria for entering the research were to agree with the collaboration in research, having used at least one of the traditional, complementary and alternative medicine in the past year, be above 15 years old and being able to speak (and read) Persian.The criterion for exit was determined if they do not have tendency in collaborating in the research.It is worth mentioning that the satisfaction was the most important criterion for people to be interviewed (questioned).The sampling method was based on census.After the intended 30 days, 834 questionnaires were collected.34 questionnaires were taken out from the process because they were included incomplete information.Finally, 800 complete questionnaires were entered the final analysis.The researcher-made questionnaire consists of two parts.The first part includes the fundamental information received from the visitors such as age, gender, education, ethnicity, birthplace and their occupation.The second part questioned the use of different types of traditional and complementary medicines in terms of Likert's five-scale from very little (1) to very large (5).After extracting the different methods of complementary and alternative medicines from website of National Center for Complementary and Integrative Health, and meanwhile using the previous internal studies and ideas of theoreticians of this domain, those parts of the traditional, complementary and alternative medicines that were more common ad conventional in Shiraz and the people were familiar with them and delivered by non-conventional medical centers were selected and questioned in the forms of 14 therapeutic methods.The second part questioned the reason for the visitors' last use of traditional, complementary and alternative medicines.In the end, the visitors were questioned whether the doctor (family doctor and specialist doctor) was informed about their use of non-conventional medicine or not; if s/he was inform, how does s/he evaluate their use as good?Since completing the questionnaire, the necessity of having information on the definitions and the intended therapeutic methods for the respondents was felt.Therefore, definitions of and examples for conventional medicine, traditional medicine, complementary medicine and the alternative medicine were written in the top of questionnaire.In addition, some respondents were eager to present more information and on the other hand some respondents were not able to complete the questionnaire because of illness, illiteracy, therefore they answered orally to the questions and the interviewers recorded them.In this study, after receiving the questioning certificate from the relevant committee at Shiraz University, the interviewers referred to the given centers.After explicating the aims and process and achieving the satisfaction from the officials as well as receiving their conscious satisfaction, they started questioning.There would not be any insistence if a visitor was not eager to take part in.Only didthe people interview who had really a strong desire to participate and who had satisfaction.To analyze the data, SPSS Ver.22 was used.To determine the relationship between the variables, depending on the measurement level of variable, the independentsample T-test, variance analysis and Pearson correlation coefficient were helpful.

Ethical Clearance:
This study was approved by Department of Sociology, Shiraz University, Shiraz, Iran.

Findings
In the present study, the analyzed samples were in age range of 15-73 with average age of 36.3±11.8.461 women (% 57.60 and 339 men (% 42.4) were included.Meanwhile, 346 people (% 43.3) were sick whereas 454 people (% 56.8) were healthy.In addition, most of the visitors to these centers, 424 people (% 53) have stated their reason for the final use of various types of traditional, complementary and alternative medicines as to promote their general health.Meanwhile, % 55.8 of visitors reported that their doctor (family doctor or specialist) knows about their use of various types of traditional, complementary and alternative medicines.Among this, % 73.3 stated that their doctors evaluated these medicines as useful.Table 1 consists of frequency of fundamental variables and health condition of visitors.The results of independent T-test showed that there is a significant difference between use of traditional, complementary and alternative medicines for two groups ofmen and women.Men have made use of traditional, complementary and alternative medicines more than women (p=0.017,T=2.38).In addition, there is a significant difference between Persian ethnicity and non-Persian ethnicity to use traditional, complementary and alternative medicines more.Non-Persian people (other than Fars ethnicity including Lor, Turk, Baluch, Arab and etc.) mostly tended to use traditional, complementary and alternative medicines more than Persian people (p=0.04,T=2.003).Based on the T-test result, there is a significant difference in using traditional, complementary and alternative medicines between those whose doctors were well aware of such an application and those whose doctors were not au courant; the people whose doctors were knowledgeable about it, used the traditional, complementary and alternative medicines much more (p=0.04,T=2.92).The results of variance analysis showed that there is a significant difference between the people's occupation and their use of the traditional, complementary and alternative medicines; that is, the educating people(students) have used a higher rate of traditional, complementary and alternative medicines (p=0.006,F=3.27).In addition, the resultsrepresented that there is a significant relationship between the average score of using traditional, complementary and alternative medicines and the birthplace of people (p=0.012,F=4.45).The people who were born in citieswould greatly use the traditional, complementary and alternative medicines.The results of Pearson correlational coefficient showed that there is a significant relationship between the education and the use of traditional, complementary and alternative medicines; that is, the more the level of education, the more the use of traditional, complementary and alternative medicines (p=0.025,r=0.079).The results of Pearson correlational coefficient showed that there is a significant relationship between the age and the use of traditional, complementary and alternative medicines; that is, the less the age of people, the less the use of traditional, complementary and alternative medicines (p=0.003,r=-0.1).The averages for use of various types of traditional, complementary and alternative medicines are mentioned, as follows, for the centers presenting various types of non-conventional medicine in 2016, Summer (top average is 5): herbal medicines (3), herbs (3.2), dietary supplements, vitamins and minerals (2.6), food diet (20.5), phlebotomy (2.13), hydrotherapy (2.1), massage (1.8), cupping (1.7), leech therapy (1.52), yoga and meditation (1.51), acupuncture (1.3), energy therapy (1.2), homeopathy (1.1), and chiropractic (1.09).In order to better and more comprehensively present the results in the domain of use of various types of traditional, complementary and alternative medicines, these 14 examples of traditional, complementary and alternative medicines categorized based on the clustering in Introduction.Finally, Table 3 consists of the use of each various types of traditional, complementary and alternative medicines in categorized and comprehensive form.According to the scores (responses score ranging from 1 to 5) received on the use of various types of traditional, complementary and alternative medicines (14 items),which is theoretically between 14 and 70, the obtainedaverage was27±8.35.Totally, % 17.1 of people studied (137 people) have used various types of traditional, complementary and alternative medicines at low level, % 68 (543 people) in a medium range, and % 15 of people (120 people) in a maximum range.

Discussion
The present research carried out to study the use of traditional, complementary and alternative medicines among the visitors of non-conventional centers in Shiraz.These people had background in using the traditional, complementary and alternative medicines.The results revealed that a striking part of these people (% 68) used various types of these medicines.Among the various methods of traditional, complementary and alternative medicines, the natural materials (including herbals, herb medicines, dietary supplements, vitamins and minerals, and food diet), the physical and movement methods (such as hydrotherapy), and the traditional therapies (including phlebotomy, leech therapy and cupping) have been mostly used.Selke-Krulichova have reported the most frequency of using complementary and alternative medicines such as natural materials and especially the herbal medicines.These studies confirm the findings of this research 5,6,16,18,19,20,21,23,24 .In addition, Tehrani Bani-Hahemi et al., Mahmoodian et al., Abdollahi et al., Yusefpoor et al., show the high consumption of traditional therapies in Iran and their popularity especially phlebotomy 18,21,22,24 .Furthermore, the findings of Abdollahi et al., Mahmoodian and Hosseini introduced hydrotherapy as the mostly methods applied 20,21 .Consuming the natural materials (especially herbs) and the traditional therapies has its origin in the Iranian culture.After introducing other methods of complementary and alternative medicines to Iran, these methods still remain popular.In addition, the positive effects of using natural materials, herbs and traditional therapies have been proved for curing and promoting the health for many years.The effects also attracted the general satisfaction and trust and in addition the side effects and dangers of natural materials are very little and because of this the natural materials are very popular from the past to the present 5,23 .In relation to the more use of physical and movement methods such as hydrotherapy in contrast to other methods, it seems that hydrotherapy, in addition to being located in the complementary medicine, is known as a kind of sport.It is easily accessible to people by means of sport complexes and pools.It is also cheaper than other methods so that it is mostly used.In this study, the least usewas seen in the group of energy-based therapies (such as energy therapy) and full-therapy systems (such as homeopathy).Energy therapy and homeopathy were also seen in the studies of Mahmoodian and Hosseini, Anbari and Ghanadi, Yamashita and Sujoshita 20,23 .The little frequency for these methods can be because of the unawareness of general public of the effects and also expensive costs of using these methods 5 .Furthermore, Sadighi et al. states that the users of homeopathy and energy therapy have visited a doctor 17 .It sounds that less accessibility of people to these therapies and the necessity of visiting a doctor will be the reason for less use of these methods.The findings of this research showed that half of the visitors to non-conventional centers have had full health and more than half of these people mentioned their reasons for the final use of various types of traditional, complementary and alternative medicines as to promote their general health.The findings also show that the use of traditional, complementary and alternative medicines is not common only among patients; other full-healthy people also have had tendency toward use of these therapies as a part of their healthy lifestyle.In fact, illness and need to cure are not the only factors leading people to use traditional, complementary and alternative medicines.People may seek the complementary and alternative medicines for some other reasons.Certain people are dissatisfied with the performance of medical systems such as long-time turns, being played among a group of specialists, and financial limitations.Being worried about the destructive effects of medicines and force to surgery are other important reasons.Asymmetrical power relations between the doctors and the patients are also among the main reasons that people prefer using the complementary and alternative medicines.In fact, people feel that the potential role of patients does not allow them in the current medical system to be efficiently concerned in their treatment and some others also believe that the psychological dimensions of health and illness are not taken into consideration in the current medical system 1 .In the relationship between background factors with the use of traditional, complementary and alternative medicines, the results showed that there is a significant difference between the use of traditional, complementary and alternative medicines between men and women groups; however, the findings of this research show that the number of women visitors were more than that of the men visitors to the centers under study in aperiod of one month.The results of statistical analysis showed that men used more of the traditional, complementary and alternative medicines.The significance of relationship between the gender and the use of traditional, complementary and alternative medicines is in tune with Heidarifar et al. 25 .But on the other hand, the result of more used of traditional, complementary and alternative medicines by men are not in harmony with Mahmoodian and Hosseini, Schwarz in Germany, Honda in USA, Moradi Lake et al. because these studies showed that the women have used traditional, complementary and alternative medicines much more than men 20,[26][27][28] .According to Anthony Giddens, the reason is that women go for drugs and therapy and report their illness more than men and, meanwhile, "the ratio of becoming ill is less for men but the diseases that men are afflicted by, threaten their lives more than women diseases" 1 .It seems that the diseases for men are more serious and harder and consequently the use of traditional, complementary and alternative medicines was followedmore.Therefore, men make use of medicines much more although women visit doctors more frequently.Meanwhile, some of the traditional and complementary medicines such as phlebotomy, cupping, bloodletting and leech therapy are more compatible with the men's nature.The results also showed that the use of traditional, complementary and alternative medicines is highly observed among the youth, the high educated people, the employees and capital-born people.It sounds that more relationship of these people with the information sources such as the mass media, the Internet, and more interaction with the virtual and real social networks has made them receive more information in the case of traditional, complementary and alternative medicines and their curers.Having received the various opinions in the area of effectiveness of this medicine are of the reasons for using the more traditional, complementary and alternative medicines.Meanwhile the studies have shown that the real social networks (such as encouragement of family, friends and the peers) are known as the important factor in decision-making to use traditional, complementary and alternative medicines 8 .Furthermore, not only is there widespread notices and advertising in relation to the traditional, complementary and alternative medicines, but also having more facility and accessibility to the providers (centers) in these areas can cause more use of traditional, complementary and alternative medicines for capital-born people.The results of Prasad in the United States about the individual features of users on mind-body methods show that the frequency of using these methods are relevant for people under 40 years old and higher level of education.In addition, Opheim et al., Sluijs et al., Gholi et al., and Yasuhiro and Hiroki and others resulted that there is a relationship between education, occupation and the use of traditional, complementary and alternative medicines 23,[29][30][31][32][33] .Aravapalli et al. showed that there has been a significant relationship between the living place and the age with the use of traditional, complementary and alternative medicines.Mahmoodian and Hosseini also found out that there was a relationship between the age and use of traditional, and complementary medicines but on the other hand this relationship was not accomplished with the education which may be because of studying only the MS patients 20,34 .It is worth noting that Moradi Lake et al. showed that there was not a significant relationship between age, education, occupation, dominant living place (city or the country) and ethnicity with the use of herbal medicines or herbs 28 .Since Moradi Lake et al. have studied the use of herbal medicines or herbs only among Tehranian citizens, it is different from the current research in terms of features for samples studied, the socio-cultural context, and omitting other methods of traditional, complementary and alternative medicines.So, it seems that the results are different because of these reasons.In addition, more frequent use of the traditional, complementary and alternative medicines by non-Persian groups (Like Lurds, Kurds, Turks, Arabs and Baloch people) is another finding.It seems that maintaining a strong network of social relations, notices and encouragement to use traditional, complementary and alternative medicines became popular among the various ethnic groups and finally it caused more frequent use of the traditional, complementary and alternative medicines.The results also revealed that patients who inform their doctor about the use of the traditional, complementary and alternative medicines, apply these therapies more often.Here, trusting the traditional, complementary and alternative medicines can be pointed out.It seems when a doctor is informed about the use of the traditional, complementary and alternative medicines, this issue can follow the trust,encouragement and willingness of a person to use more the traditional, complementary and alternative medicines.Moreover, impossibility of generalizing the results to the whole population of Shiraz can be the limitation of this study.

Conclusion
The present study showed that the traditional, complementary and alternative medicines are used among Shiraz population in a mediocre level.Their most-used branches include those methods that have origin in culture and tradition of the community, that have easy accessibility to those centers, and that have framed trust and less danger by passing time and people's awareness of these methods.On the other hand, the least-used include those methods that people were less familiar with them, with limited access and the high costs.Meanwhile, since the traditional, complementary and alternative medicines are mostly used among the young people, highly educated or educating people, capital-born people and people with non-Persian nationality (Like Lurds, Kurds, Turks, Arabs and Baloch people), it seems that the common bases of these groups have been accessibility to facilities, various health information and more interactions with the virtual and real social networks so that the awareness of and information about the traditional, complementary and alternative medicines are increasing and finally they have been greatly used.Since we live in an era that bulk of information we receive daily and these information are oriented towards our decision in the realm of health care and converted us into health users, i.e. those who have active position in their health and welfare 1 , therefore, by increasing the information and awareness of the traditional, complementary and alternative medicines especially of their less-common methods, we can raise more awareness in the people and attract trust of medical community and of public opinion with different ages, classes, nationalities and levels of education, occupation and etc. to these therapy methods.By increasing the number of valid centers providing types of traditional, complementary and alternative medicines and making the accessible to people, we can cut the hands of profiteers and non-professional people of these therapy methods and finally cause more attraction of people towards traditional, complementary and alternative medicines.