Knowledge , use of complementary alternative medicine and health-related quality of life among cardiovascular disease patients

The use of complementary and alternative medicine (CAM) has become more prevalent among chronic disease patients. Moreover, health-related quality of life (HRQoL) related to cardiovascular disease (CVD) is a vital assessment for health intervention and treatment outcome. Hence, this study attempted to determine the knowledge and use of CAM among CVD patients and their HRQoL. A cross-sectional study was conducted among ninety CVD patients at the cardiology specialist clinic in Hospital Sultanah Bahiyah, Kedah using a purposive and convenience sampling method. A self-administered questionnaire was used to collect their clinical characteristics, knowledge of CAM and pattern usage, while Minnesota Living with Heart Failure Questionnaire was used to determine HRQoL. The data was analysed using multiple response analysis, Mann-Whitney and Chi-Square tests. The knowledge level among respondents was fair with a median score of 53.33%. Furthermore, 63.3% respondents use CAM, while potential improvement in condition (71.9%) and fear of side effects (66.7%) were the most cited reasons for CAM use and non -CAM use, respectively. The most common type of CAM reported was biological-based therapies (91.2%). The main purpose of using CAM was to maintain general health and improve well-being (82.5%). Majority were satisfied with CAM effectiveness (78.9%) and claimed that they did not experience any side effect from CAM use (96.5%). Family and friends (70.2%) were the main sources of CAM recommendation, while 56.1% did not disclose the use of CAM to their doctor. The HRQoL score (median 18) among CVD respondents were deemed to be good. However, no significant difference in HRQoL between CAM users and non-users was noted. In addition, no significant association was found between knowledge level and CAM usage, while only gender and marital status was significantly associated (p<0.05) with CAM use. The use of CAM among CVD patients was not significantly influenced by their knowledge of CAM and did not show any significant improvement in HRQoL although more than half were CAM users.


Introduction
Cardiovascular disease (CVD) is the leading cause of mortality worldwide and in Malaysia.The total deaths in Malaysia caused by CVD reached 36% in 2012 (World Health Organization [WHO], 2014; Ang and Chan, 2016).Coronary artery disease (CAD) is the most common form and was found as the major burden of disease in Malaysia (Ang and Chan, 2016).Meanwhile, the National Cardiovascular Disease Database (NCVD) reports that more than 95% patients have at least one CVD risk factor, such as hypertension, diabetes mellitus, dyslipidaemia, smoking, obesity and family history (Ahmad and Sim, 2013).
Although many conventional medications are available for treating CVD, the trend of complementary and alternative medicine (CAM) use in recent decades has become more common among patients.For instance, research has documented that CAM use in Asian patients is prevalent, especially among those associated with chronic disease (Lee et al., 2004).In addition, a review by Grant et al. (2012) showed that the worldwide prevalence of CAM use among cardiac patients ranged from 4% -61%.According to the National Center for Complementary and Integrative Health (NCCIH, 2007), CAM encompasses diverse medical and health care systems, practices and products that are not considered part of conventional medicine, which consist of biologically-based therapies, mind-body interventions, manipulative and body-based systems, alternative medical systems, and energy therapies.
The use of CAM has been increasing dramatically in both developed and developing countries (Qidwai et al., 2013).In Malaysia, the use of traditional and complementary medicine (TCM) among the population has become more prevalence (Siti et al., 2009).Moreover, a previous survey involving chronic disease patients in Malaysia reported that 63.9% were using CAM (Hasan et al., 2009).Previous studies also showed that biologically-based therapies were the most common form of CAM used among CVD patients, including herbal medicine, megavitamin, non-vitamin non-mineral, and so on (Chu et al., 2013;Bahall, 2015;Teo et al., 2016).Studies reported that 29-60% of general CAM users believed that this modality has remedial benefits and known to be safe, natural and fewer side effects than modern medications (Qidwai et al., 2013;Rabito and Kaye, 2013).
Apart from that, the use of CAM among heart disease patients was influenced by friends and family (Hasan et al., 2009;Ching et al., 2013;Bahall, 2015).As a result, patients' knowledge of CAM may not be well structured.In fact, it is essential to obtain adequate knowledge of CAM from qualified physicians or CAM practitioners prior to use a form of CAM.This is because CAM modalities may have a negative impact on the compliance with modern medicine.For example, there are potential drug interactions between CAM products with the concomitant prescribed medications which may lead to fatalities (Qidwai et al., 2013).Nonetheless, CVD patients often do not disclose or discuss CAM use with their physicians, with the cited reasons such as 'physicians will disapprove', 'it is not important to inform the doctor on the use of CAM', 'doctor would not understand', and 'lack of time during consultation' (Hasan et al., 2009;Teo et al., 2016).
With CVD remaining the leading cause of death worldwide, the health-related quality of life (HRQoL) of patients has become a major concern.The HRQoL outcome is an essential indicator of both diagnostic and therapeutic interventions, and the measure elements included physical, psychological, and social aspects of positive well-being as well as negative impacts of illness, treatment, and infirmity (Kawecka-Jaszcz et al., 2013).CVD usually leads to devastating consequences, resulting in impaired HRQoL (Wang et al., 2014).To date, no research has been done on the knowledge of CAM and the HRQoL among CVD patients in Malaysia.Hence, this study is aimed to determine the knowledge and pattern of CAM use among CVD patients and their HRQoL.

Research design
A cross-sectional study was conducted in Kedah, Malaysia between July and September 2017.In the present study, a total of ninety patients associated with CVD, whether CAM users or non-users, participated.The cardiology specialist clinic of Hospital Sultanah Bahiyah (HSB) was chosen as the sampling location because the clinic is referred by most of the CVD patients in Kedah.According to the National Cardiovascular Disease -Acute Coronary Syndrome Registry (NCVD-ACS) 2011 -2013, the distribution of patients with acute coronary syndrome (ACS) at HSB was 4.7% (Ahmad and Sim, 2015).Thus, the sample size was calculated using the formula suggested by Charan and Biswas (2013) with a confidence level of 95% and a margin error of 5%.A total of ninety respondents were recruited, although only a minimum of seventy respondents was required in this study because there would be more CVD cases that were not included in the NCVD-ACS Registry as this only involved seventeen public hospitals, one university hospital and the National Heart Institute.The study was approved by the Institute for Health Behavioural Research (IHBR) and Medical Research and Ethics Committee (MREC) under the Ministry of Health Malaysia with registration number NMRR-17-1084-35979.Additionally, written consent forms were obtained from all the respondents prior to answering the questionnaire.

Research instrument
A self-administered questionnaire consisting of five sections (socio-demographics, clinical characteristics, knowledge of CAM, pattern of CAM use and HRQoL) was used as the research instrument in the present study.The items, number of questions, scales used, and references were summarized in Table 1.
Multiple choices (Yes, No, Not Sure) were provided for items of knowledge section, with four items worded negatively to avoid respondents answering in a consistent manner.The correct scores were summed up and categorized into poor (0 -50%), fair (51 -69%) and good (70 -100%) (Khan et al., 2014).The last section was adopted from the Minnesota Living with Heart Failure Questionnaire by Rector and Cohn (1984) which rate based on 6-point Likert scale (0 = no impairment to 5 = very much impairment).This questionnaire was used because it is short, easy to understand and administer, and has a high internal consistency reliability with Cronbach's alpha of 0.86 (Rector et al., 1987;Adebayo et al., 2017).Referencing the cut-off scores for overall FULL PAPER HRQoL suggested by Behlouli et al. (2009), a total score below 24 represents good HRQoL; a score between 24 and 45 represents moderate HRQoL; and a score above 45 represents poor HRQoL.Both English and Malay versions of the questionnaire were prepared for the respondents from different ethnicities to ease the comprehension of the questions.Content validity was achieved via a rational review from the professional reviewer of Institute for Health Behavioural Research, while internal consistency was used to determine the reliability.The Cronbach's alpha for HRQoL was 0.795, indicating good reliability.

Data analysis
The data was analysed using Statistical Package for Social Science (SPSS, Version 20.0).The descriptive test was used to present socio-demographic characteristics, level of CAM knowledge, prevalence of CAM use, CAM disclosure, perceived effectiveness, side effects and HRQoL in frequency (n) and percentage (%).Clinical characteristics and pattern of CAM use (reasons, types, purposes, recommendation sources, reason for nondisclosure) were reported in terms of frequency (n) and percentage of cases (%) due to multiple responses being given for those questions.Mann-Whitney U test was employed to compare HRQoL between CAM users and non-users.Association between categorical variables (level of CAM knowledge and CAM usage, sociodemographic profile and CAM usage) were determined by cross-tabulation (Chi-square test).The significant value was set at 0.05 for all statistical analyses.

Socio-demographics and clinical characteristics
The socio-demographic characteristics of the respondents are shown in Table 2.A majority of the CVD respondents were male (60%), Malay (66.7%), married (87.8%) and aged between 50-69 years (66.6%).For the educational level, 61.2% of respondents had achieved a SPM certificate or lower and only 26.6% had a STPM certificate or above.A majority (72.2%) were unemployed or retired.Almost 60% also reported a lower monthly household income (< RM3000).
In the present study, a majority (51.1%) reported two types of CVD.Coronary heart disease (CHD) (64.4%) was the most prevalent type of CVD, followed by hypertension (50%).Meanwhile, 86.7% of respondents reported with at least one type of CVD risk factor, in which hypercholesterolemia (64.4%), family history (33.3%) and diabetes mellitus (32.2%) were the three most common risk factors as shown in Table 3.In addition, more than half of the respondents (51.1%) were not sure of their types of CVD medication.

Level of knowledge of CAM
Based on Figure 1, a similar percentage of respondents (43.3%) were within a poor or fair range, and only 13.3% of respondents had good CAM knowledge.The overall result showed that the respondents had a fair knowledge of CAM since the median score was 53.33% (IQR=28.33).Most of the respondents could correctly provide the general definition of CAM (68.9%); types of Traditional Malay Medicine (68.9%); general benefits of Traditional Chinese Medicine (70%); benefits of garlic and massage therapy (62.2%); benefits of yoga (56.7%); advantages of Tai Chi (75.6%); and benefits of acupuncture (62.2%).In contrast, majority of respondents were not sure of the benefit of Chinese herbal medicine (62.2%); benefits of fish oil consumption (47.8%); benefits of ginseng (55.6%); benefits of ginkgo biloba (67.8%); and advantages of deep breathing exercise (51.1%).Furthermore, from questions about knowledge of the adverse effect of CAM, 51.1% of respondents answered correctly that there are potentially dangerous drug interactions between supplements and modern medication.However, 51.1% of respondents did not score well on the potential herb-drug interactions between herbal medicine and cardiovascular medications, as 11.1% answered wrongly and 40% were not sure.

Prevalence of CAM use and reasons
As illustrated in Figure 2, 63.3% of respondents were CAM users.Based on Table 4, the most commonly cited reasons for CAM use were "potential improvement in condition" (71.9%), "proven benefit in the condition being treated" (43.9%) and "fewer side effects than modern medicine" (40.4%).On the other hand, "afraid of FULL PAPER side effect" (66.7%) and "satisfied with current modern medicine" (60.6%) were the most common reasons claimed by non-CAM users.14) 30 (90.9) 3 (9.1)p = 0.740 1 cell (25%) have expected count < 5.The minimum expected count is 4.03.

As shown in
their current CVD problem (Table 6).Moreover, almost 80% of respondents were satisfied with the effectiveness of CAM, and 96.5% claimed that they did not experience any side effects from using CAM.
The findings in Table 7 also showed that friends and family (70.2%) were the major sources of the recommendation of using CAM among respondents, while more than half of respondents (56.1%) reported that they did not disclose CAM use to their doctor.The most common reason for not disclosing cited by the respondents was "doctors never ask" (81.2%).

Health-related quality of life among CVD patients
Based on Table 8, the score for overall HRQoL of the respondents was low, indicating that their HRQoL were good.Moreover, the score for both physical and emotional dimension was also considered low.No significant differences in HRQoL were found between CAM users and non-users (Table 9).

Association between knowledge level and CAM use and socio-demographic and CAM use
According to Table 10, there was no significant association between knowledge level and CAM usage among CVD respondents, which indicates that the use of CAM was not significantly influenced by respondents' level of knowledge of CAM.
Based on Table 11, gender (p=0.018) and marital status (p=0.016) were significantly associated with CAM use, while other socio-demographic characteristics were not significantly associated with CAM use.

Discussion
In the present study, the demographic data was in line with the annual report of National Cardiovascular Disease -Acute Coronary Syndrome Registry (NCVD-ACS) 2011-2013 and National Cardiovascular Disease -Percutaneous Coronary Intervention Registry (NCVD-PCI) 2010-2012, where majority of CVD patients were male, Malay and aged between 50-59 years (Ahmad and Sim, 2014;Ahmad and Sim, 2015).Thus, the outcome of the results can be inferred to the study population.Furthermore, the findings showed that coronary heart disease (CHD) was the most prevalent types of CVD, as supported by WHO (2017) and Malaysian National Burden of Diseases and Injury Study (Yusoff et al., 2013), whereby the CHD is the main cause of death in Malaysia as well as global.Next, strokes are the second leading cause of death from CVD according to WHO (2017) and the Malaysian National Burden of Disease and Injury Study (Yusoff et al., 2013), however, was the least in the study.This is because most stroke patients have difficulties in moving, speaking as well as writing, and were subsequently unable to participate in the study since they were required to complete the questionnaire on their own.Additionally, findings for CVD risk factors are also supported by the National Health and Morbidity Survey (NHMS, 2015), which reported that dyslipidaemia, hypertension and diabetes were the most common modifiable risk factors.Also, a majority were not sure of their types of CVD medication, which may cause them to be more susceptible to the consequences of herb-drug interaction if they were CAM users (Rabito and Kaye, 2013).
In Malaysia, no study on CAM knowledge among CVD patients has been reported.Nevertheless, one study did reveal that 89.8% of Malaysia women (with total respondents, n=460) had a low level of knowledge of herbal medicines (Law and Soon, 2013), which was consistent with the present study.In Malaysia, garlic consumption (Ching et al., 2013) and massage therapy (Othman and Farooqui, 2013) are commonly practiced as part of CAM, hence the percentage of positive responses on the benefit of garlic and massage therapy among respondents was high.On the other hand, a majority of respondents were not sure of the benefit of Chinese herbal medicine, perhaps due to the fact that other ethnicities might not be familiar with the function and benefits.In addition, respondents who reported a lack of knowledge of the potential herb-drug interactions may have a lack of discussion on CAM with their regular physician.For instance, the present findings reported that the main source of CAM knowledge was from family and friends, and most of the CAM users did not disclose CAM use to their doctor.As a consequence, they lack knowledge of the adverse effect of concurrent use of CAM with conventional medicine.
In the present study, the prevalence of CAM use was in line with studies by Chu et al. (2013), Siti et al. (2009) and Hasan et al. (2009).Additionally, a previous study done by Kew et al. (2015) in Pahang reported that the study population with CVD risk factors was more likely to use CAM as compared to general study population (31.7% versus 25.9%), although the prevalence of use of CAM among patients with CVD risk factors was lower compared with the present study.This may be due to the study not being conducted in a clinical setting, as it was a community-based study.According to Bahall and Edwards (2015), positive feedback of CAM is the main factor promoting CAM usage.Hence, it was believed that respondents may have obtained positive testimonies for a particular form of CAM, or even witnessed how CAM benefited someone who used it to treat a specific condition, which could explain why "potential improvement in condition" was cited by most of the FULL PAPER CAM users in the present study.In contrast, respondents who did not use CAM were afraid of side effects may be due to lack of knowledge of CAM which caused them afraid to try.In addition, the respondents also felt their current prescribed medications and medical treatment was sufficient to treat their condition; thus, any form of CAM became unnecessary to them.
The prevalent use of biological-based therapies among CVD patients, particularly herbal medicine, was comparable with previous studies by (Siti et al., 2009;Chu et al., 2013;Bahall, 2015).Moreover, Erku and Mekuria (2016) and Ching et al. (2013) reported that herbal products were used by the majority of hypertensive patients in Ethiopia and Malaysia, respectively.The trend of herbal remedies was dominant among the Malaysian population because the traditional healing practices, supported by vast natural resources available since ancient times, are still being practiced by most of the population of various ethnicities (Siti et al., 2009).Nonetheless, Farooqui et al. (2016) and Hasan et al. (2009) revealed that vitamin supplements were the most common CAM used among patients with cancer and chronic disease, respectively, to reduce the effects of chemotherapy and for health maintenance.Meanwhile, massage therapy was prominent among Malaysian stroke patients due to its effectiveness in decreasing blood pressure, pain, anxiety level and muscle tone, as well as increasing health-related quality of life (HRQoL) (Jouzi, 2009;Kadir et al., 2015;Lämås et al., 2016;Yang et al., 2017).
The typical purpose of CAM use in the present study was also comparable with Siti et al. (2009), namely for health maintenance.This may be because the majority believed the use of herbal medicine can promote vital life energy, which can maintain general health (Tabish, 2008).The vital energy is especially essential for those associated with chronic disease patients.Additionally, the findings of the present study are consistent with those of Teo et al. (2016); Bahall (2015); Chu et al. (2013) and Hu et al. (2013), as most of the study respondents were satisfied with the CAM efficacy and only fewer respondents experienced side effects (Bahall, 2015;Teo et al., 2016).Therefore, CAM therapies were deemed to be helpful for CVD and non-CVD condition, since most were satisfied with the effectiveness of CAM.One noteworthy point is that respondents were combining the use of CAM with currently prescribed medication, but not substituting their medications with CAM.This may imply that they were satisfied with current modern medications, yet also believed that the use of CAM can act as complementary medicine for their CVD condition, or as an alternative treatment for other non-CVD illness, as well as improve their general health.
In general, the overall HRQoL of the respondents was good, indicating that the impact of their heart condition on the quality of life was low.This finding was in accordance with study among cancer patients in Malaysia, whereby their HRQoL was considered as good (Loke et al., 2017), but in contrast with studies by Ko et al. (2015), Tan et al. (2014) and Xie et al. (2008).This may be because a majority of respondents in this study attended a cardiology specialist clinic for checking-up as well as consulting their own doctor.In addition, they were taking modern medication, and some told that they came to follow-up the treatment of their heart condition.Thus, it was believed that the HRQoL of respondents may have been improved before they were recruited in the present study, which resulted in good HRQoL.This was supported by a previous study by Azmi et al. (2015), in which the HRQoL of patients with ACS improved from the time of admission to follow-up at 12 months after discharge.Furthermore, findings have reported that the intervention of pharmaceutical care such as cardiac rehabilitation program can improve HRQoL of ACS patients (Anchah et al., 2017).
Apart from that, no significant difference of HRQoL found between CAM users and non-users, which indicates that CAM usage among respondents did not significantly improve their HRQoL.This finding is in line with previous studies by Loke et al. (2017) and Zick et al. (2005).However, Chu et al. (2013) reported a significant difference of HRQoL between CHD patients who use CAM and do not use CAM, whereby patients who use CAM showed better current health status.This is because, in China, traditional Chinese medicine is considered to be the main type of CAM, and can even be the major treatment method in certain rural area, thus have a significant effect on their HRQoL; this may explain the reason why patients who use CAM showed better current health status (Chu et al., 2013).
On the other hand, the lack of a significant association between knowledge level and CAM usage implies that the use of CAM was not significantly influenced by respondents' level of knowledge of CAM, which was consistent with the previous study conducted among people living with AIDS (Limsatchapanich et al., 2013).It was further reported that positive perceptions towards the use of CAM are believed to be one of the factors that drive them to use CAM.In contrast, the previous study by Nagashekhara et al. (2015) reported that patients' level of knowledge of CAM was negatively correlated with CAM usage.This finding may be explained in that most respondents were using CAM based on anecdotal rather than scientific evidence, as they believed what they had been told, especially from those who had the experience using CAM modalities FULL PAPER (Evans et al., 2007).For instance, a qualitative study by Farooqui et al. (2012) revealed that Malaysian cancer patients who were CAM users are the best evidence to prove the effectiveness of a type of CAM, as they believed they would also get the same effect as others experienced from using the CAM.
Except for gender and marital status, the present study showed no significant association between CAM use and socio-demographic characteristics, suggesting that gender and marital status are possible factors that predict that married male was more likely to use CAM.The present findings are in accordance with a previous study among hypertensive patients in African countries (Osamor and Owumi, 2010;Erku and Mekuria, 2016), but are contradictory to previous studies that reported women were more likely to use CAM in general, as well as people with multiple chronic diseases (Zhang et al., 2015;Alwhaibi and Sambamoorthi, 2016;Farooqui et al., 2016).One possible explanation may be because most women involved in the current study were housewives, which might have a disproportionate share of household work than men, and thus be less likely to use CAM because they have less exposure to CAM modalities (Bianchi et al., 2012).Moreover, Osamor and Owumi (2010) also supported that respondents who are married were more likely to use CAM because they were supported by their spouse in considering taking CAM as adjunct treatment.In addition, they can also discuss with their partner before deciding to take a form of CAM or may even be influenced by their family members who had been helped by CAM.For instance, Hasan et al. (2009) stated that patients often begin use CAM due to the direct influence of the family history of CAM use.

Conclusion
More than half of CVD patients in Kedah reported using CAM with biological-based therapies, particularly herbal medicines, as the most prevalent CAM modalities used.Although the level of knowledge of CAM among CVD respondents was fair, the majority were unsure about the benefits of certain CAM modalities and the potential herb-drug interaction.The existence of an interaction gap between patients and doctors in the discussion of CAM may place them at higher risk of adverse effects from the concurrent use of modern medicine and CAM.Additionally, the impact of heart failure on respondents' quality of life was low, indicating a good HRQoL.Also, the HRQoL was not significantly different between CAM users and non-CAM users.Furthermore, the use of CAM was not significantly influenced by the level of CAM knowledge, while only gender and marital status were significantly associated with CAM use.

Table 1 .
Summary of each section in questionnaire

Table 3 .
Clinical characteristics and current CVD medication used among respondents * Percentage are reported per cases.

Table 4 .
Reason of CAM use and non-use among respondents

Table 5 .
Types of CAM use among the respondents

Table 6 .
Purpose of using CAM among respondents and their perceived effectiveness

Table 8 .
HRQoL score among respondents

Table 9 .
Median score of HRQoL between CAM users and non-CAM users *p<0.05 indicate significance by Chi-Square test.