The Use of Herbal Medicine by Older Mexican Americans

Transcription

1 Journal of Gerontology: MEDICAL SCIENCES 2001, Vol. 56A, No. 11, M714 M718 Copyright 2001 by The Gerontological Society of America The Use of Herbal Medicine by Older Mexican Americans Jose A. Loera, 1,2 Sandra A. Black, 1,2 Kyriakos S. Markides, 2,3 David V. Espino, 4 and James S. Goodwin 1,2 1 Department of Internal Medicine, 2 Sealy Center on Aging, and 3 Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas. 4 Department of Family Medicine, University of Texas Health Service Center at San Antonio. Background. Little is known about use of herbal medicines by older Mexican Americans. The objective of this study was to determine the characteristics among older Mexican Americans that correlate with use of herbal medicines. Methods. We administered a cross-sectional regional sample survey, the Hispanic Established Populations for the Epidemiologic Study of the Elderly of Mexican Americans, by in-home interviews of noninstitutionalized older Mexican Americans age 65 and over living in Texas, New Mexico, Colorado, Arizona, and California. Results. The use of herbal medicine in the 2 weeks prior to the interview was reported by 9.8% of the sample. Chamomile and mint were the two most commonly used herbs. Users of herbal medicines were more likely to be women, born in Mexico, over age 75, living alone, and experiencing some financial strain. Having arthritis, urinary incontinence, asthma, and hip fracture were also associated with an elevated use of herbal medicines, whereas heart attacks were not. We found that herbal medicine use was substantially higher among individuals reporting any disability in activities of daily living, poor self-reported health, and depressive symptoms. Herbal medicine use was associated with the use of over-the-counter medications but not with prescription medications. Herbal medicine use was particularly high among respondents who had over 24 physician visits during the year prior to interview. Conclusions. Herbal medication use is common among older Mexican Americans, particularly among those with chronic medical conditions, those who experience financial strain, and those who are very frequent users of formal health care services. D URING the past decade, the adult U.S. population has shown an increasing interest in the use of complementary or alternative medicine. The number of people stating that they have used alternative medicine increased from 33.8% in 1990 to 42.1% in 1997 (1). Many adults use alternative treatments in conjunction with allopathic medicines, especially when treating certain chronic conditions such as arthritis (2 4). The rising popularity of alternative therapies could represent an attempt to lower health care expenses by substituting less expensive alternative medicines for prescription medicines (5), in addition to dissatisfaction with allopathic therapies (3). Concerns have been raised about the quality and safety of complementary alternative medicine products, particularly because many herbal medicines, homeopathic remedies, vitamins, and nutritional supplements can be purchased directly from health food stores, mail- and internet-order catalogs, and mainstream food markets and pharmacies without the proper information on interaction with prescription and over-the-counter (OTC) medications (6 8). Herbal medicine use has traditionally been associated with ethnic populations, particularly among elders (9 11). Recent trends have shown an increasing use of herbal medications by various ethnic groups (7,10). Little is known, however, about the frequency and patterns of the use of herbal medicines by older Mexican Americans. The purpose of this study was to provide more information about patterns and correlates of use of herbal medicines by older Mexican Americans. METHODS Data are from the Hispanic Established Populations for the Epidemiologic Study of the Elderly (Hispanic-EPESE), one of a series of population-based panel surveys conducted in various parts of the United States that were designed to examine the health status of community-dwelling elderly persons (12). The baseline wave of the Hispanic-EPESE was conducted during 1993 and 1994 in the five southwestern states of Texas, Colorado, New Mexico, Arizona, and California. Area probability sampling resulted in a sample of 3050 Mexican Americans aged 65 and over, representing a response rate of 83%. The sample is representative of almost 500,000 Mexican-American elderly persons residing in the southwestern United States. A more complete description of the survey methods can be found in Markides and colleagues (13). Respondents were administered inhome, face-to-face interviews conducted in Spanish or English that included items pertaining to sociodemographic characteristics and health-related measures. Although interviews were conducted for a total of 3050 Mexican-American subjects, the analyses presented here reflect the reports M714

2 HERBAL MEDICINES M715 of 2734 respondents for whom complete data regarding use of herbal medicine were available. Measures Respondents were asked if they had taken or used any folk medicine, herbs, or herbal remedy during the 2 weeks prior to the baseline interview. Individuals who responded in the affirmative were then asked to show interviewers the container of the herbal remedy. The interviewers collected the following information from the container label: dosage, route of administration, and frequency of usage. Respondents were also asked similar questions pertaining to their use of prescription and OTC medications during the 2 weeks prior to interview. Sociodemographic measures included the respondents age, gender, years of education, current marital status, living arrangements (number of persons residing in the household), if they had been born in the United States or in Mexico, and if they had any type of health-insurance coverage. Respondents were also asked how often they did not have enough money to afford the kind of food and the kind of medical care they needed, with responses including never, once in a while, fairly often, and very often. Those respondents who reported not having enough money fairly often or very often were categorized as having financial strain. We originally intended to include a measure of household income but found that it was very highly correlated with education and financial strain. Health-related measures included a number of self-reported, physician-diagnosed medical conditions including cardiac problems, diabetes, stroke, hypertension, cancer, arthritis, hip fracture, urinary and bowel incontinence, and asthma. Self-reported disabilities in bathing, dressing, grooming, eating, transferring from bed to chair, using a toilet, and walking were measured with a modified version of the Katz Activities of Daily Living (ADL) scale (14). Respondents were also asked if they had needed to cut down on their activities during the 3 months prior to the interview, how they rated their health (excellent, good, fair, or poor), and how satisfied they were with life. Psychological distress was measured with the Center for Epidemiologic Studies Depression Scale (CES-D) (15). Responses to the CES-D were scored on a four-point scale, with potential total scores ranging from 0 to 60. The standard cut point of 16 or greater was used to distinguish symptomatology in the clinical range (16). Respondents were asked how many times they had seen a physician during the year prior to interview and were categorized as very-high-frequency users of formal health care services if they reported 24 or more visits. Analyses The rates of herbal medicine use were assessed for the sample as a whole and by sociodemographic and healthrelated measures. Differences in the rates across independent variables were assessed using the chi-square statistic. Logistic regression was then employed to model the use of herbal medicine, first with sociodemographic characteristics and then for each of the health-related measures, controlling for the influence of the sociodemographics. All analyses incorporated weighted data that were adjusted for design effects to produce results that were representative of the older Mexican-American population in the five-state region. Analyses were conducted using SAS (17), and confidence intervals were computed using SUDAAN (18). RESULTS Table 1 presents the weighted prevalence of use of herbal medicines in the 2 weeks prior to the interview as well as the prevalence of use by various sociodemographic characteristics. Overall, 9.8% of the sample reported having used herbal medicine in the 2 weeks prior to the interview; however, rates varied substantially by sociodemographic characteristics. Women were more likely to report the use of herbal medicine than men, and individuals aged 75 and older were more likely to use herbal medicine than younger individuals. Those with 12 years or more of education were less likely to use herbal medicine than individuals with fewer years of education. Rates were also substantially higher among individuals who were not currently married, who lived alone, or who were immigrants. Older adults who reported financial strain were more likely to report herbal medicine use; however, no significant differences were apparent for insurance coverage. A total of 160 different types of herbal products were reported as being used by 268 respondents. Table 2 shows the ten most frequently reported herbs, along with the Spanish name, botanical name, and reported properties and uses. Chamomile and mint were the most frequently consumed herbal preparations, both in the form of teas. Table 1. Weighted Prevalence Rates of Folk or Herbal Remedy Use Among Older Mexican Americans, by Sociodemographic Characteristics Characteristic n Weighted % Use of Any Folk Remedy (n 268) Overall Gender Men Women ** Age Group y y ** Education 5 y y y * Current Marital Status Married Not married ** Living Arrangements Lives alone Lives with others ** Born in the United States No Yes ** Insurance Coverage Yes No No Financial Strain Any Financial Strain ** *p.05; **p.001; chi-square analyses.

3 M716 LOERA ET AL. Table 2. Herbal Medicines Most Frequently Used by Mexican-American Elderly Persons English Name Spanish Name Botanical Name Reported Properties and Uses Frequency (%) Formulation Chamomile Manzanilla Matricaria chamomila Anti-inflammatory, antispasmodic, indigestion, insomnia 24.3 Tea Spearmint Yerba Buena Mentha spicata Analgesic, antispasmodic, diarrhea, respiratory disease 13.1 Tea Aloe Vera Sávila Aloe barbadensis Emollient, antibacterial, laxative, skin irritations, heartburn 3.4 Tea or gel Chaya Chaya Cnidoscolus chayamansa Help digestion, antitussive, decongestant, improve memory 2.2 Tea Orange leaf Naranjo Citrus aurantium Appetite stimulant, insomnia, anti-inflammatory 2.2 Tea Oregano Orégano Lippia dulcis Stomachache, colic, asthma, bronchitis, expectorant, anti-inflammatory 2.2 Tea Garlic Ajo Allium sativum Ear infection, toothache, upper respiratory infection 1.9 Tea Ginseng Jengibre Zingiber officinale Antinausea, colic, dyspepsia, antiflatulent 1.9 Tea Cinnamon Canela Cinnamonium zeylanicum Antispasmodic, fever, vomiting, diarrhea 1.5 Tea Wormwood Estafiate Artemisia mexicana Diuretic, expectorant, cough, arthritis, antiseptic, antiparasitic 1.5 Tea Table 3 shows the prevalence of herbal medicine use by health-related measures. The use of herbal medication was elevated among individuals reporting hypertension, cancer, arthritis, hip fracture, urinary and bowel incontinence, and asthma. No association was found with diabetes or stroke, whereas individuals reporting myocardial infarction were less likely to report using herbal medicine. Rates were higher among those reporting any ADL disability and among those who had to cut down on activities during the 3 months prior to the interview. The rates of herbal medicine use were higher among those with poor or fair self-related health, those with poor life satisfaction, and those with high levels of depressive symptoms. Herbal medicine use was associated with the use of OTC medications but not with the use of prescription medications. Those respondents who reported 24 or more physician visits during the year prior to the interview were particularly likely to report herbal medicine use. Table 3. Weighted Prevalence Rates of Folk or Herbal Remedy Use, by Health-Related Characteristics Characteristic n Weighted % Percentage Using Any Folk Remedy Total sample Medical conditions Myocardial infarction * Diabetes Stroke Hypertension * Cancer * Arthritis ** Hip fracture ** Urinary incontinence ** Bowel incontinence ** Asthma ** Any ADL disability ** Reduction in activity ** Fair to poor self-rated health ** Poor global life satisfaction ** Depressive case ** Use of OTC medication ** Use of prescription medicine physician visits in the past year ** Note: ADL activities of daily living; OTC over the counter. *p.01; **p.0001; chi-square analyses. Defined as a score of 16 or more on the Center for Epidemiologic Studies Depression Scale. Table 4 presents the results of a series of multiple logistic regressions that modeled the use of herbal medicine in this population. The first analysis included only the sociodemographic characteristics as independent variables. As can be seen in the table, female gender, being age 75 and older, living alone, being an immigrant, and reporting financial strain remained significant predictors of herbal medicine usage even when controlling for other sociodemographic factors. Table 4 also shows the results of individual logistic regressions modeling herbal medicine use on each of the health-related measures, controlling for the influence of the sociodemographic variables. All variables shown in Table 3 were analyzed, but only those that remained significant predictors are shown in Table 4. Arthritis, hip fracture, urinary Table 4. Results of Multiple Logistic Regression Predicting the Use of Folk or Herbal Remedies in Older Mexican Americans Variable Odds Ratio 95% Confidence Interval Sociodemographic characteristic Gender (female vs male) Age 75 and older (vs 65 74) Education 5 y (vs 12 y) y Married Live alone Immigrant No insurance coverage Financial strain Health-related measure* Chronic conditions Myocardial infarction Arthritis Hip fracture Urinary incontinence Asthma Any ADL disability Fair/poor self-rated health Depressive case Use of OTC medicine physician visits in the past year Note: ADL activities of daily living; OTC over the counter. *All models control for sociodemographic characteristics. Defined as a score of 16 or more on the Center for Epidemiologic Studies Depression Scale.

4 HERBAL MEDICINES M717 incontinence, and asthma remained predictive of a higher use of herbal medicine, and myocardial infarction remained predictive of a lower use. ADL disability, high levels of depressive symptoms, and the use of OTC medications also remained predictive of herbal medicine use, as did having 24 or more physician visits in the year prior to interview. DISCUSSION We found that 9.8% of older Mexican Americans reported using herbal medicines in the 2 weeks prior to the interview. Users of herbal medicines were more likely to be women, born in Mexico, over age 75, living alone, and experiencing some financial strain. Individuals with one of several chronic conditions, dependent in ADL, or with low self-rated health were more likely to take herbal medicines, as were those who experienced depressive symptoms and those with very frequent physician visits. This picture of the typical herbal medicine user among older Mexican Americans is in contrast to the user in the non-hispanic white population, which is more likely to be young and well educated and with substantial financial resources (2,3,7). This study should be interpreted with an understanding of the limitations in its methodology. First, our estimates of herbal medicine use represent a point prevalence: the percentage of individuals who used herbal medications in the 2 weeks prior to the interview. This method would underestimate those who used herbal medications on an as-needed basis for medical conditions such as an upper respiratory infection or upset stomach. Because the methodology selected for chronic users of herbal medications, it is not unexpected that herbal use correlated with the presence of several chronic medical conditions. Second, although we found associations between the use of herbal medicines and certain medical conditions, we did not ask the subjects for the specific reasons why they were taking a particular herbal medicine. Finally, we did not determine how the subjects came to be using a particular herbal medication; for example, whether it was prescribed by a practitioner or recommended by a family member or friend. This study has several strengths, the most important of which is the sampling design, which allows us to make valid estimates of herbal medication use for the entire older Mexican-American population in the five southwestern states. In addition, the longitudinal design of the study should allow for the examination of changes in the pattern of herbal medication use over time. A possible explanation for the pattern of herbal medicine use associated with certain chronic diseases is the four conditions associated with increased herbal medicine use; three (arthritis, urinary incontinence, and asthma) are highly bothersome chronic conditions for which less than optimal treatments exist. In contrast, subjects who had experienced heart attacks were significantly less likely to use herbal medications. Heart attack is an acute life-threatening condition requiring hospitalization and normally leads to lifestyle changes and close medical supervision of blood pressure and serum lipid levels. Herbal medicine users were more likely to be immigrants, which is also consistent with previous reports (19). Literature on Hispanics access to health care has proposed that recent Mexican-American immigrants rely more on herbal medicines than on allopathic medicine because of limited access to medical care. Hispanic families are 2.5 times as likely to live below the poverty level (10,11). The Council on Scientific Affairs also noted that poverty and lack of health insurance affected Hispanics choice between allopathic therapies and herbal medicine (11). Although we did not find an association of herbal medicine use with access to medical care as measured by insurance coverage, we did find that those respondents who reported a very high frequency of visits made to allopathic physicians were two to three times as likely to use herbal medicines as those with less frequent visits. Similar findings were reported by Druss and Rosenheck (20), who, using data from the Medical Expenditure Panel Survey, found that among adults aged 18 and older, those in the highest quartile of number of physician visits were more than twice as likely to report the use of unconventional treatments. Our findings are very much in keeping with previous studies, noting similar ailments or chronic medical conditions associated with a higher use of herbal medicine. We found that a majority of health-related measures were associated with elevated rates of herbal medicine and that rates were substantially higher among individuals reporting depressive symptoms. Among the most common problems identified by previous investigators to be associated with herbal medicine use among a variety of ethnicities were back pain, anxiety, arthritis (21), depression, and digestive conditions (4,21). Concerns have been raised regarding the quality and safety of herbal medicine products, although both chamomile and mint are seldom associated with adverse effects in the adult population (22 24). Chamomile and mint were the two most commonly used herbs in our study; both herbs appear to have a wide acceptance across cultural and geographic boundaries (25,26). In fact, the ten herbal products listed in Table 2 are similar to the folk remedies reportedly used by the West Virginia population (22). In summary, herbal medications are relatively common among older Mexican Americans with chronic medical conditions, particularly among those with limited financial resources. This profile contrasts sharply with the typical herbal medicine user found in mainstream society: the young and well educated, with substantial financial resources. Acknowledgments This study was supported by grants from the National Institute on Aging (AG10939) and the National Institute of Diabetes, Digestive, and Kidney Diseases (DK51261). Address correspondence to Dr. Jose Loera, University of Texas Medical Branch, 301 University Blvd., Galveston, Texas jloera@ utmb.edu References 1. Eisenberg D, Roger D, Ettner S, et al. Trends in alternative medicine use in the United States JAMA. 1998;280: Eisenberg D, Kessler R, Foster C, Norlock F, Calkins D, Delbanco T. Unconventional medicine in the United States. New Engl J Med. 1993; 328: Astin J. Why patients use alternative medicine. JAMA. 1998;279:

5 M718 LOERA ET AL. 4. Becker G, Beyene Y, Newsom EM, Rodgers DV. Knowledge and care of chronic illnesses in three ethnic minority groups. Fam Med. 1998; 30: Adams WR. Economic factors influencing the use of folk remedies. Texas Med. 1986;82: Ness J, Sherman FT, Pan CX. Alternative medicine: what the data say about common herbal therapies. Geriatrics. 1999;54: Health Care Financing Administration, Office of National Cost Estimates. National health expenditures Health Care Financing Rev. 1990;11: Crone CC, Wise TN. Use of herbal medicines among consultation-liaison populations. Psychosomatics. 1998;39: Hufford D. Cultural and social perspectives on AM: background & assumption. Alternative Therapies. 1995;1: Andersen R, Lewis S, Giachello A, Aday L, Chiu G. Access to medical care among the Hispanic population of the southwestern United States. J Health Soc Behav. 1981;22: The Council on Scientific Affairs. Hispanic health in the US. JAMA. 1991;265: Cornoni-Huntley J, Blazer DG, Lafferty ME, Everett DF, Brock DB, Farmer ME, eds. Established Populations for Epidemiologic Studies of the Elderly. Vol. II. Washington, DC: National Institute on Aging Markides KS, Stroup-Benham CA, Goodwin JS, Perkowski LC, Lichtenstein M, Ray LA. The effects of medical conditions on physical functioning in Mexican American elderly. Ann Epidemiol. 1996;6: Branch L, Katz S, Kniepmann K, Papsidero J. A prospective study of functional status among community elders. Am J Public Health. 1984; 74: Radloff LS. The CES-D Scale: a self reported depression scale for research in the general population. J Appl Psychol Meas. 1977;1: Boyd JH, Weissman M, Thompson W, Myers JK. Screening for depression in a community sample. Arch Gen Psychiatry. 1982;39: SAS Institute. SAS Systems for Microsoft Windows, Release Cary, NC: SAS Institute Inc; Shah BV, Barnwell BG, Hunt PN, LaVange LM. SUDAAN User s Manual, Release Research Triangle Park, NC: Research Triangle Institute; Trotter RT. Remedios caseros: Mexican American home remedies and community health problems. Soc Sci Med. 1981;15B: Druss BG, Rosenheck RA. Association between use of unconventional therapies and conventional medical services. JAMA. 1999;282: Bliddal H. A randomized, placebo-controlled, cross-over study of ginger extracts and ibuprofen in osteoarthritis. Osteoarthritis Cartilage. 2000;8: Cheryl C, Baisden D. Ancillary use of folk medicine by patients in primary care clinics in southwestern West Virginia. South Med J. 1986; 79: Ernst E. Harmless herbs? A review of the literature. Am J Med. 1998; 104: Gray MA. Herbs: multicultural folk medicines. Orthop Nurs. 1996;15: Ripley GD. Mexican-American folk remedies: their place in health care. Texas Med. 1986;82: Boyd EL, Taylor SD, Shimp LA, Semler CR. An assessment of home remedy use by African Americans. J Natl Med Assoc. 2000;92(7): Received September 11, 2000 Accepted November 15, 2000 Decision Editor: John E. Morley, MB, BCh