Praveen Partha, Ravi Shankar, Nagesh Shenoy

Running title: Complementary medicine use in Pokhara, western Nepal

Praveen Partha DNB

Department of Medicine

Manipal Teaching Hospital

Pokhara, Nepal.

Ravi P Shankar MD

Department of Pharmacology

Manipal College of Medical Sciences

Pokhara, Nepal.

Nagesh Shenoy MPharm

Department of Community Pharmacy

Manipal Teaching Hospital

Pokhara, Nepal.

Manipal College of Medical Sciences and Manipal Teaching Hospital

Pokhara, Nepal.

Dr. P.Ravi Shankar

Department of Pharmacology

Manipal College of Medical Sciences

P.O.Box 155

Deep Heights

Pokhara, Nepal.

Phone: 00977-61-21387, 23600.

Fax: 00977-61-22160.

E-mail: mcoms@mos.com.np, pathiyilravi@rediffmail.com

Purpose: An increasing number of patients the world over are increasingly preferring complementary and alternative medicines. In Nepal previous studies mainly based around Kathmandu valley have shown that more than 50 % of the population use complementary medicine. Studies in western Nepal and in the Pokhara valley are lacking. Hence the present study was undertaken to study the patterns of complementary medicine use in Pokhara city and the surrounding villages. Subjects and methods: 142 respondents were interviewed using a semi structured questionnaire by seventh semester medical students who were briefed by the authors before the study. The study was carried out in the month of August 2001. The pattern of use of complementary medicines in the year preceding the study was noted. Results: 62 % of the respondents had used some form of complementary medicine. Ayurveda was the most popular system. Abdominal pain was the commonest complaint and the commonest reason for preferring complementary medicine was faith in the practitioner. The lack of side effects with complementary medicine and the non-availability of doctor/health post were other commonly cited reasons. Conclusions: Complementary medicine remains very popular in and around Pokhara city. Greater integration of complementary medicine into the primary health care system should be attempted.

Key words: Alternative medicine; Health care surveys; Integrated organization and administration

More than 50 % of the population in Nepal use alternative medicines because of culture, lack of health facilities and the expensiveness of modern allopathic medicines. ¹

Complementary and alternative medicines are becoming increasingly popular with patients over the world. In the United States in 1997 over 40 % of the general population visited a CAM practitioner.² In the developed world patients who prefer complementary therapies are generally females, well educated, of a high socioeconomic class^3,4 and have a holistic orientation towards life.⁵

The common providers of complementary medicine in Nepal are: a) faith healers: 1) Dhami-Jhankri 2) Pandit-Lama-Gubhaju-Pujari (priestly people) and 3) Jyotishi (astrologer) and

b) Traditional medical providers: 1) Baidhya-Kabiraj 2) Jadi-Buti wala (herbalists).¹

Dhami-jhankris are faith healers who by rhythmic beating of a drum and other rituals put the patient in to a trance. Baidhyas and kabiraj are ayurvedic practitioners who use elixirs, massage and herbal preparations to cure illness.

In the developed world complementary therapies are judged to be more helpful for treating chronic conditions.⁶ In developing countries the situation is not so clear cut and information on complementary medicine practices is incomplete .

Hence the present study was carried out in the sub-metropolitan city of Pokhara and the surrounding villages to note the prevalence of use of alternative system medications and the factors governing their use.

The study was carried out on 142 respondents residing in the sub-metropolitan city of Pokhara, western Nepal and the surrounding villages during the month of August 2001. A semi-structured questionnaire was designed to elicit the type of complementary medication prescribed, the illness for which it was prescribed, the reason for prescribing the medicine and information about the practitioner. Seventh semester medical students who were briefed beforehand randomly interviewed the respondents and noted the details in the questionnaire. The name, address, age, sex and ethnic group of the respondent were noted. The distance from the nearest road head and from the nearest health post/ medical store was noted. The time taken for an average person to walk the particular distance was employed as the basis for comparison. The pattern of use of complementary medicines in the preceding year was studied. Differences in the proportion of respondents who had used complementary medicines was compared between urban and rural respondents, young respondents (less than 40 years) and older respondents (40 years and above) and between male and female respondents using the z test of proportions. A p value of < 0.05 was taken as statistically significant.

Complementary medicine incorporates several methods of treatment, all of which aim to promote the health and quality of life of the patient. In recent years, public interest and demand for complementary medicine services has increased in the developed world.^2,3,7 In addition to the reasons already discussed the longer appointment times given by the therapists and the in-depth discussion of their illness was particularly valued by patients.⁸

Seventy six respondents (53.5 %) were aged between 20 to 39 years. The percentage of respondents residing in an urban area was 52.8 % while the remainder resided in rural areas. Out of the total of 142 respondents, 117 were male. Thirty nine respondents (27.46 %) were farmers and 33 (23.2 %) were students. Eighteen respondents were employed in the army or were ex-servicemen. The commonest ethnic/caste group was Brahmins (38 %). The other common groups were Chettris 36 (25.3 %) and Gurungs 29 (20.4 %). The age and ethnic profile of the study population corresponds to the data in the District development profile⁹ and that in a previous study.¹⁰

The distance of the respondent’s houses from the nearest road head was studied. Seventy seven respondents (54.2 %) stayed within 10 minutes walking distance from a road head. A similar yard stick was used to measure the distance from the nearest health post/medical store. One hundred and two respondents (71.8 %) resided within 30 minutes walking distance from a health post/medical store.

Sixty nine respondents belonged to the lower socioeconomic strata while 73 respondents belonged to the middle strata. A monthly household income less than 3000 Nepalese rupees (40 US dollars) was taken as the dividing line between the lower and the middle strata.

Eighty eight respondents (62 %) had used some form of complementary medicine during the year preceding the study which is higher than the figures reported in the literature.^2,3,7. Some individuals had used more than one system of complementary medication. Ayurveda was the most popular used by 67 out of the total of 88 patients using complementary remedies. Different types of faith healing practices were used by 28 respondents. This included witch craft/sorcery which was used by 16 respondents. No significant difference was noted in the preference for complementary therapies between urban and rural respondents. Given the lower indices of human development in the rural areas ⁹ these results are difficult to explain. There was a greater preference for witch craft in the rural areas but it was not statistically significant.

A greater proportion of the respondents above the age of 40 years preferred complementary remedies compared to those below 40 years but the difference was not significant. This could be due to the increasing levels of education and exposure to western influences among the youth (Table 1).

The most popular system of complementary medicine was ayurveda and The baidya was the most frequently visited practitioner. In Nepal, the ayurvedic system is widespread and the medicines are provided both by trained practitioners and hereditary baidyas. The practitioners are often village elders and their advice is sought after. In a western study most practitioners did not favour Homeopathy and traditional oriental medicine as legitimate medical practice.¹¹ Faith healing and Shamanism were also frequently observed both among the urban and rural respondents. The shaman’s role as a psychotherapist centers around his ability to treat social conflict.¹² Illnesses caused by ‘social deprivations’ are treated most effectively by shamans in numerous situations. The academic qualifications and training of the baidya was not recalled by the majority (82 %) of the respondents.

Abdominal pain, fever and diarrhea were the commonest reasons for visit to a complementary practitioner. The other common reasons were fever and diarrhea (Table 3).This is in contrast to the situation in developed countries where complementary medicine is commonly used for chronic conditions and emotional problems^3,6 and where some patients with advanced cancer had also preferred CAM therapies.¹³

The commonest reason for using complementary medicines was belief in the practitioner. Tradition and cultural pressure were other common reasons. These reasons were similar to those cited in previous studies.^6,8 In our study the pressure of elders and family members was a key reason for preferring complementary remedies. Non availability of doctors and health posts was also cited as an important reason along with the popular perception that modern allopathic medicine was expensive. Thirteen respondents using these remedies stated that complementary medicine had no side effects. 59 out of the total of 88 respondents using complementary medicine had also used allopathic medicines during the past one year preceding the study. Information on the concurrent usage of these two systems of medicine was not collected.

Primary health care services have been identified as the basic need of a community as it alone can lead to improvement in health standards of the general population. In developed countries, general practitioners are experimenting with integrating complementary practitioners in to the health care team.¹⁴ In remote areas the complementary practitioners can be trained to provide medical care through the existing health net work to improve the acceptance of immunization and other modern health care practices among the rural masses. Their acceptability to the rural masses and high standing in the village community will be of help in achieving these objectives. Community health volunteers trained in both complementary and modern medicines can become a major force for change in the village community.¹⁵

Though a small study the data gives us a glimpse of the prevalence of complementary therapies in and around Pokhara sub-metropolitan city and the reasons for the preference for these therapies among the population. Further studies in this direction are needed and are being planned as study modules for students during their field study programs in community medicine.

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The following seventh semester medical students interviewed the respondents and collected the data: Subodh Kumar Regmi, Anuj Shrestha, Jiwan Kumar Thapa, Kirti Subash Joshi, Ashok Chaudhary, Somnath Chalise and Adarsha Siddhi Bajracharya. Their help is gratefully acknowledged. The help of Dr. Ritu Prasad Gartoulla, Medical Anthropologist, Institute of Medicine, Kathmandu , Nepal and of the management and staff of the Phulbari Resort, Pokhara for the use of their well-stocked library is also gratefully acknowledged. Written permission has been obtained from all those quoted in the acknowledgements.

Table 1: Use of different systems of medicine according to age of the respondents

* z value =3.27, p<0.05

+ a single person may be using more than one type of complementary medication

Table 2: Common illnesses for which complementary medicine was used

+ A single respondent may have used complementary medicine for more than one illness

Table 3: Reason for preferring complementary and alternative medication

* A single respondent may have given more than one reason for preferring complementary medicine