– الوطنية النجاح جامعة نابلس

التمريض كلية

Faculty of Medicine and Health Sciences

Department of Nursing

Perception of Patient with Hypertension about

Complementary/Herbal Therapy

Students Name:

Mohammad Abu Serrieh

Kareem Attili

Hosney Ismael

Omar Shehadah

Supervisor: Dr. Mariam Al- Tell

2014 – 2015

INTRODUCTIONHypertension is one of the non-communicable disease (NCD’s) that

still considered a major health problem at global level. It can damage the

heart, blood vessels, kidneys, and other parts of the body it also may lead to

coronary heart disease, heart failure, stroke, and kidney failure. Fortunately ,

It is managed with lifestyle changes including eating a healthful diet, being

more physically active, maintaining a desirable body weight, not smoking,

and learning how to manage stress, and when necessary medication,

(NCCAM,2010),( Madhur, 2014) ,(AHA, 2014).

According to the MOH (2012), that 45.3% of Palestinian people age

of 25-65 years have hypertension and those who are in treatment were

39.5% and 25.5% of those who have hypertension are not on treatment.

From these statistics, hypertension is considered a major health problem

among Palestinian.

The use of Complementary and Alternative Medicine (CAM) to treat

hypertension is appeared to be increasing nationally.

Complementary and Alternative Medicine(CAM) according to

NCCAM(2012) was define as (a group of diverse medical and health care

systems, practices, and products that are not presently considered to be part

of conventional medicine). Complementary medicine is referred to those

methods which can be used together or to ‘complement’ conventional

medicine an example of a complementary therapy is using aromatherapy to

help lessen a patient’s discomfort following surgery. Alternative medicine is

referred to medical systems used to replace conventional medicine, as

using a special diet to treat cancer instead of undergoing surgery, radiation,

or chemotherapy that has been recommended by a conventional doctor.

BACKGROUND2.1 Definition of hypertension

Defining high blood pressure as indicated by Giles, et al, (2009) is

extremely difficult and arbitrary, Based on recommendations of the JNC 7,

the classification of BP (in mm Hg) for adults aged 18 years or older is as

follows: Normal: systolic lower than 120 mm Hg, diastolic lower than 80

mm Hg, Pre-hypertension: systolic 120-139 mm Hg, diastolic 80-89 mm Hg,

Stage 1: systolic 140-159 mm Hg, diastolic 90-99 mm Hg, Stage 2: systolic

160 mm Hg or greater, diastolic 100 mm Hg or greater. According to the

American Heart Association (AHA, 2014), Hypertension was defined as a

systolic blood pressure (SBP) of 140 mm Hg or more or a diastolic blood

pressure (DBP) of 90 mm Hg or more.

In the other hand WHO, (2013) defined it as “a condition in which

the blood vessels have continuous increase pressure. “The Normal adult

blood pressure is defined as a blood pressure of 120 mm Hg when the heart

beats (systolic) and a blood pressure of 80 mm Hg when the heart relaxes

(diastolic).” And so hypertension is considered when systolic blood pressure

is equal to or above 140 mm Hg and/or a diastolic blood pressure equal to or

above 90 mm Hg the blood pressure is considered to be raised or high. In

addition Giles,et al, (2009),defined hypertension as the presence of a chronic

elevation of systemic arterial pressure above a certain threshold value.

However, increasing evidence indicates that the cardiovascular (CV) risk

associated with elevation of blood pressure (BP) above approximately 115 ⁄

75 mm Hg increases in a log-linear fashion.

2.2 EpidemiologyAccording to WHO, (2013) Globally mortality of cardio vascular

disease is 17 million per year nearly one third of total, hypertension causes

9.4 million death a year. Kearney, et al.,(2005)in their study which aimed

to "pool data from different regions of the world to estimate the overall

prevalence and absolute burden of hypertension in 2000, and to estimate the

global burden in 2025" , found that hypertension in adult in 2000 was 972

million, and 333 million of them were estimated to be in economically

developed countries and 639 million in economically developing countries.

The study also predicted that by 2025 there will be an increased in the rate

of people with hypertension by about 60% to a total of 1.56 billion as the

proportion of elderly people will increase significantly.

Another study by Ikeda ,et al, (2014), aimed to provide comparable,

comprehensive and consistent evidence on the management of hypertension

internationally by analyzing data from health surveys, found that the

prevalence of hypertension in individuals aged between 35-49 years were

around : Egypt 12%, Jordan 13%, Iran 16%, Turkey 25%, USA 17%, Japan

13%, Germany 25.5 %, England 15%, Russian 28%. And prevalence of

hypertension between aged 35 to 84 years around Jordan 36.5%, Turkey

41%, USA 34.5%, Japan 31.8%, Germany 44.8%, and England 31%.

2.3 ClassificationAs indicated by Madhur, 2014; the American Society of Hypertension

classified hypertension for three stages. Stage one often characterized by

early sign of structural or functional of the heart and small arteries, and

Blood Pressure levels reach up to 115/75, it also can be elevated by

environmental stressor. Stage two, blood pressure ≥ of 140/70 , with much

higher elevations induced by physiologic or psychological stressors and

Stage three usually have sustained resting BP levels 140⁄90 mm Hg, and

marked elevations to levels >160⁄100 mm Hg are common. And according

to JNC 7 it is classified as following Pre-hypertension: systolic 120-139

mm Hg, diastolic 80-89 mm Hg, Stage 1: systolic 140-159 mm Hg, diastolic

90-99 mm Hg, Stage 2: systolic 160 mm Hg or greater, diastolic 100 mm Hg

or greater. (Madhur, 2014)

2.4 Risk FactorsIn 90% of all cases the reason for hypertension remains unclear, but

there some of risk factors as first Genetic predisposition example

hypertension heart disease type 2 diabetes, second Environmental factors:

age, hormone state, third Lifestyle – influential risk factors smoking heavy

such as drinking being overweight sodium and calorie-rich diet lack of

physical activity stress (Beevers, G., et al,2001). Tabassum and Ahmad,

(2011) sorted the cause of hypertension for two categories according to the

types of it .Essential hypertension, its affecting 90-95% of hypertension

patients and it have not direct cause but have many factors affecting it such

as sedentary lifestyle, stress, visceral obesity, potassium deficiency

(hypokalemia), obesity, salt (sodium) sensitivity, alcohol intake, and vitamin

D deficiency that increase the risk of developing HTN. Risk also increases

with aging, some inherited genetic mutations and having a family history of

HTN. Secondary hypertension, it has direct cause and it treated the

underlying cause such as the hormone-regulating endocrine system, that

regulate blood plasma volume and heart function, Cushing's syndrome,

which is a condition where the adrenal glands overproduce the hormone

cortisol, hyperthyroidism, hypothyroidism, and adrenal gland cancer,

kidney disease, obesity/metabolic disorder, pre-eclampsia during

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pregnancy, the congenital defect known as coarctation of the aorta, and

certain prescription and illegal drugs.

2.5 Signs and symptoms (silent killer)The main signs and symptoms, hypertension may causes in some cases

are headache, shortness of breath, dizziness, chest pain, palpitations of the

heart and nose bleeds., most people with hypertension have no symptoms,

(WHO, 2013),( Madhur, 2014).

2.6 Pharmacology therapy of hypertension

The general recommendation established by JNC-7 is to initiate a

thiazide-type diuretic initially for stage 1 hypertensive without compelling

indications for other therapies. Drugs such as angiotensin converting enzyme

(ACE) inhibitors, calcium channel blockers (CCBs), angiotensin receptor

blockers (ARBs), beta-blockers, and diuretics are all considered acceptable

alternative therapies in patients with hypertension. The available

antihypertensive agents are generally equally effective in lowering blood

pressure however; there may be interpatient variability that can affect the

way a patient will respond to one treatment over another (Madhur, 2014).

2.7 Problem StatementPatient with hypertension are not adherent to the hypertension drug

and use herbal therapy without knowing the effectiveness of these therapy

and the impact of management.

2.8 Significant of the problemAccording to the MOH (2012), which 45.3% of Palestinian people

ages of 25-65 years have hypertension and those who are in treatment were

39.5% and 25.5% of those who have hypertension are not on treatment.

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From these statistics, hypertension is considered a major health problem

among Palestinian. This study aimed to find out the perception of

hypertension patient regarding the use of herbal therapy its uses for

hypertension. The result will help in developing awareness program

regarding the usage of herbal therapy.

2.9 Aim and ObjectivesThis study aimed to find out the perception and uses about different

complementary /herbal therapy for hypertension

The objectives of this study include:

1-To find out the perception about the use of the herbal therapy.2-To find the most common herbal types that use for hypertension 3- To find how the patient use these herbals therapy4- To find out source of patient information about herbal therapy

2.10 The Question of the Study1- What is the perception of patient with hypertension about

complementary/herbal therapy?

2- What is the most common herbal type that use for hypertension in

Nablus?

3- How do the patient with hypertension use of herbal

therapy? 4- What is their source of information about herbal

usage?

5- Are there any differences between participation who use herbal

therapy and those who not use regarding their socio-demographic

data (age, sex, educational level, economical status)?

6- Is there any difference between the types of herbal therapy in relation

to its effect on blood pressure (general effect, effect on blood

pressure reading)?

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7- Is there any difference between the duration of use herbal therapy in

relation to its effect on blood pressure (general effect, effect on blood

pressure reading)?

8- Is there any difference between the frequency of use herbal therapy

in relation to its effect on blood pressure (general effect, effect on

blood pressure reading)?

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LITERATURE REVIEW3.1 Management of hypertension

In addition to medication therapy as recommended by (WHO,

2013),(AHA, 2014),(WebMD,2014) there are five steps to minimize blood

pressure; first healthy diet as reducing salt intake to less than 5 g of salt per

day (just under a teaspoon), eating five servings of fruit and vegetables a

day, reducing saturated and total fat intake. Second; avoiding harmful use of

alcohol i.e. limit intake to no more than one standard drink a day. Third;,

Physical activity as regular physical activity and promotion of physical

activity for children and young people (at least 30 minutes a day),

maintaining a normal weight: every 5 kg of excess weight lost can reduce

systolic blood pressure by 2 to 10 points. Fourth stopping tobacco use and

exposure to tobacco products and fifth managing stress in healthy way such

as through meditation, appropriate physical exercise, and positive social

contact.

One of the simplest and most effective ways to lower blood pressure

is to eat a healthy diet, such as the DASH diet. Eating more fruits,

vegetables, and low-fat dairy foods, cutting back on foods that are high in

saturated fat, cholesterol, and total fat, eating more whole grain products,

fish, poultry, and nuts, eating less red meat and sweets and eating foods that

are rich in magnesium, potassium, and calcium, all of these are lower blood

pressure.

A solid body of evidence shows that men and women of all age groups

who are physically active have a decreased risk of developing high blood

pressure. Findings from multiple studies indicate that exercise can lower

blood pressure as much as some drugs can. People with mild and moderately

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elevated blood pressure who exercise 30 to 60 minutes three to four days per

week (walking, jogging, cycling, or a combination) may be able to

significantly decrease their blood pressure readings.

Blood pressure increases when a person is under emotional stress and

tension, but whether or not psychological interventions aimed at stress

reduction can decrease blood pressure in patients with hypertension is not

clear. Nevertheless, recent studies suggest that ancient relaxation methods

that include controlled breathing and gentle physical activity, such as yoga,

Qigong, and Tai Chi, are beneficial. The results of a recent small study

suggest that a daily practice of slow breathing (15 minutes a day for 8

weeks) brought about a substantial reduction in blood pressure

(WebMD,2014).

Dotinga (2014), reported that alternative treatments like

transcendental meditation, biofeedback and guided breathing appear to

reduce high blood pressure in some people, a new report suggests. But only

one method that does not involve medication (aerobic exercise) is both

proven to have a major impact and highly recommended. The report, by the

American Heart Association, also says research doesn't support a reduction

in high blood pressure from other relaxation and meditation

techniques, yoga or acupuncture. However, the quality of research into these

strategies is limited, the report adds, suggesting that there's still hope they

have an effect.

Goodman,(2014), reported that vegetarian diet may help people shave

points off their blood pressure, a large study from Japan suggests. The

research, a review of 39 studies that included almost 22,000 people, found

vegetarians had blood pressure that was significantly lower than those who

ate meat. On average, reductions seen across the studies were 5 to 7

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millimeters of mercury (mm/Hg) for systolic blood pressure and 2 to 5

mm/Hg for diastolic blood pressure.

Several studies show that fiber intake among vegetarian significantly

greater than among non-vegetarians as result of their intake of fruits,

vegetables, legumes, nuts, and whole-grain breads and cereals. Dietary fiber

reduces energy density and influences satiety and body weight and thus may

have an effect on BP mediated by its effect on weight observational studies

has shown an inverse association between the consumption of dietary fiber

and both BP and risk of hypertension. Fruit and vegetable intake was

responsible for about one-half the BP reduction of the Dietary Approaches to

Stop Hypertension (DASH) diet. Because vegetarian diets are generally high

in fruits and vegetables and are associated with BP-lowering effects (Susan,

et al ., 2005).

Susan et al., (2005) indicated in their observational studies that there

was an inverse relationship between potassium intake and BP in free-living

populations. Results of two meta-analyses of 52 randomized, clinical trials

indicated that potassium intake significantly lowered systolic blood pressure

(SBP) and diastolic blood pressure (DBP) in hypertensive and normotensive

individuals and they reported that magnesium intake from a variety of plant

foods was independently associated with a lower risk of hypertension. Data

from the Honolulu Heart Study showed that a low magnesium intake was the

dietary factor most strongly associated with high BP .

3.2 Complementary and Alternative MedicineThe use of Complementary and Alternative Medicine (CAM) to treat

hypertension is appeared to be increasing nationally.

Complementary and Alternative Medicine(CAM) according to

NCCAM(2012) was define as (a group of diverse medical and health care

17

systems, practices, and products that are not presently considered to be part

of conventional medicine). Complementary medicine is referred to those

methods which can be used together or to ‘complement’ conventional

medicine an example of a complementary therapy is using aromatherapy to

help lessen a patient’s discomfort following surgery. Alternative medicine is

referred to medical systems used to replace conventional medicine, as

using a special diet to treat cancer instead of undergoing surgery, radiation,

or chemotherapy that has been recommended by a conventional doctor.

3.3 Types of Complementary and Alternative MedicineThe CAM therapies have been classified by NCCAM 2012 into five

categories; alternative medical systems, mind-body interventions,

biologically based therapies, manipulative and body-based methods and

energy therapies .

First, Alternative Medical Systems: which built upon complete systems of

theory and practice, an example of these systems is the traditional Chinese

medicine and Ayurveda.

Second, Mind-Body Medicine: that uses a variety of techniques designed

to enhance the mind’s capacity to affect bodily function and symptoms, as

meditation, prayer, mental healing, and therapies that use creative outlets

such as art, music, or dance.

Third, Biologically Based Therapies ; use substances found in nature, such

as herbs, foods, and vitamins.

Fourth, Manipulative And Body-Based Methods ; which are based on

manipulation and/or movement of one or more parts of the body. Some

examples include chiropractic or osteopathic manipulation and massage.

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Fifth, Energy Therapies: that involve the use of energy

fields.(NCCAM,2012),(National Cancer Institute,2013)

3.4 Definition of herbal therapyOne of the most types of CAM use is herbal medicine. Herbal

medicine also called botanical medicine or phytomedicine refers to using a

plant's seeds, berries, roots, leaves, bark, or flowers for medicinal purposes.

Herbalism has a long tradition of use outside of conventional medicine. It is

becoming more mainstream as improvements in analysis and quality control

along with advances in clinical research show the value of herbal medicine

in the treating and preventing disease. (University of Maryland,2011).

3.5 History of herbal therapy usePlants had been used for medicinal purposes long before recorded

history. Ancient Chinese and Egyptian papyrus writings describe medicinal

uses for plants as early as 3,000 BC. Indigenous cultures (such as African

and Native American) used herbs in their healing rituals, while others

developed traditional medical systems (such as Ayurveda and Traditional

Chinese Medicine) in which herbal therapies were used (University of

Maryland,2011).

In the early 19th century, when chemical analysis first became

available, scientists began to extract and modify the active ingredients from

plants. Later, chemists began making their own version of plant compounds

and, over time, the use of herbal medicines declined in favor of drugs.

Almost one fourth of pharmaceutical drugs are derived from botanicals

(University of Maryland,2011).

Researchers found that people in different parts of the world tended to

use the same or similar plants for the same purposes.

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3.6 Causes of Use CAMPeople use complementary or alternative therapies for many causes.

First one is to help them feel better; people often use complementary

therapies to help them feel better and cope with having problem and

treatment. Second one to reduce symptoms or side effects, there is

increasing evidence that certain complementary therapies can help to control

some of the symptoms and side effects and problem of treatments. Third

use is feeling more in control, when you are having conventional problem

treatment, it may sometimes feel as though your doctor makes many of the

decisions about your treatment. It can begin to feel like you don't have much

control over what happens to you. Fourth one; to have comfort from touch,

talk and time that a complementary therapist usually offers. Fifth use: for

staying positive, having a positive outlook is an important part of coping

with problem for most people. Having hope a to cure even when the problem

is so difficult..is very important in curing. Sixth one ; boosting immune

system, some people believe that certain complementary therapies can boost

their immune system and help fight their problem. There is evidence that

feeling good and reducing stress boosts the immune system but we don't

know if this can help the body to control problem. Last one; looking for a

cure ,some people may believe that specific alternative therapies may help

control or cure their problem if they are used instead of conventional

problem treatment. (CANCER RESEARCH UK, 2014)

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3.7 Uses of herbal among medical conditionRecently, the World Health Organization estimated that 80% of

people worldwide rely on herbal medicines for some part of their primary

health care. In Germany, about 600 - 700 plant based medicines are

available and are prescribed by some 70% of German physicians. In the past

20 years in the United States, public dissatisfaction with the cost of

prescription medications, combined with an interest in returning to natural or

organic remedies, has led to an increase in herbal medicine use.

Herbal medicine have widely use to decrease or treat many problem.

Herbal medicine can be very useful for treating many different illnesses

from minor scrapes and burns to serious diseases. Herbal medicines are

mostly used for persistent illnesses such as migraines, arthritis, depression

and PMS. Herbal remedies are easy to take, and many herbs can be grown at

home, so they are often more convenient for minor conditions. It is

important to note that herbal remedies cannot replace conventional

treatments in many cases, and that not all herbs are safe for human ingestion.

. (University of new Hampshire, 2014)

Regard the complementary therapy and its uses in hypertension,

Amira and Okubadejo (2007) conducted a study in Nigeria among 225

patient to find out "the frequency and pattern of use of complementary and

alternative medicine (CAM) in patients with essential hypertension attending

a tertiary hypertension clinic ". They found that 39.1% of the participants

were use the CAM and the most type of the CAM was the herbal therapy .

Another study by Shafiq, et al, (2003) conducted in India among 521

participants to find out "the prevalence and pattern of use of complementary

and alternative medicine (CAM) in patients with essential hypertension".

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The results indicated that 63.9% were using CAM and 14.4% of them were

use the herbal therapy.

In their study Su, CX., et al,(2014), which conducted in china aimed

to "assess the effectiveness and safety of Chinese herbal medicine for the

treatment of cancer-related fatigue". They found that Chinese herbal

medicine used alone or in combination with chemotherapy or supportive

care showed significant relief in cancer-related fatigue compared to placebo,

chemotherapy or supportive care based on single trials.

Chinese herbal medicine plus chemotherapy or supportive care was

superior to chemotherapy or supportive care in improving quality of life.

Data from one trial demonstrated Chinese herbal medicine exerted a greater

beneficial effect on relieving anxiety but no difference in alleviating

depression (Su, CX., et al, 2014)

Another study by Al-Rowais NA, (2002) conducted in Kingdom of

Saudi Arabia, to find the use of herbs for diabetic patients and which herbs

are used, they found that 296 diabetic patients out of 300 were interviewed

giving a response rate of 98.6%. 51 subjects (17.4%) reported using some

form of herbs. The commonest herbs used were myrrh, black seed, helteet,

fenugreek and aloes.

Study by Klepser, et al,(2000) aimed to evaluate "demographics and

beliefs regarding safety and efficacy of herbal therapy among individuals in

Iowa and assessed the willingness to discuss the use of these products with

health care providers ", they distribute 1300 surveys in two random sample:

patients attending eight clinics, and residents of the state. Data categorized

as herbal users and non users. 41.6% of respondents reporting herb use and

both groups believed that health care providers should be aware of use and

would provide this information.

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Some of studies indicate in men, soy product intake was inversely

significantly correlated with diastolic blood pressure. There were no

significant correlations between soy product intake and diastolic blood

pressure in women (Nagata, et al ., 2003).

There are a lot of herbal medicine, the most common used are garlic,

ginger, chamomile and another types.

Echinacea often used in tinctures or powders to reduce symptoms of

the common cold and flu. It is also used for infections, particularly those of

the kidney.

Gingko most commonly used to improve memory. Gingko improves

circulation, particularly to the brain, though it is also used to regulate

irregular heartbeats and to reduce symptoms of dementia. It is usually taken

as a tincture or an infusion.

Ginseng used to boost the immune system and decrease fatigue. It is

also used for lungs conditions such as coughs, and to reduce blood pressure.

The root is taken as a powder, tincture, or decoction.

St. John's Wort used as an anti-depressant, for anxiety, irritability

and exhaustion. It can also be used topically for burns and inflammations.

St. John’s Wort is usually taken as an infusion, tincture or cream.

Lavender popular as aromatic oil, and can be used to treat a wide variety of

ailments from exhaustion to headaches, and indigestion to depression. It is

commonly taken as an infusion, tincture, mouthwash, cream, lotion, massage

oil, chest rub, hair rinse or oil.

Chamomile a popular herb used for indigestion, stress relief, anxiety,

and insomnia. It is also used for asthma and bronchitis. It can be taken as an

infusion, tincture, ointment, inhalation or mouthwash. (University of new

Hampshire, 2014)

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3.8 Herbal uses for hypertensionIn Palestinian society there are some herbs used for reducing high

blood pressure such as garlic, ginger, rosemary, lupine and hibiscus.

Garlic is used to reduce cholesterol levels and blood pressure, as well

as for treating infections. It can be taken fresh, as a powder, as oil or as a

juice. Garlic is the edible bulb from a plant in the lily family. It has been

used as both a medicine and a spice for thousands of years. Garlic’s most

common folk or traditional uses as a dietary supplement are for high

cholesterol, heart disease, and high blood pressure. Other folk or traditional

uses include prevention of certain types of cancer, including stomach and

colon cancers. Garlic cloves can be eaten raw or cooked. They may also be

dried or powdered and used in tablets and capsules. Raw garlic cloves can be

used to make oils and liquid extracts.

Alicajic,(2009) conducted the study to assess " the efficiency of garlic

in the treatment of mild and moderate arterial hypertension". The sample

was consisting of thirty patients with mild and moderate hypertension, age

41–64 years, 17 men and 13 women had taken three cloves, about 10 grams

of garlic daily, during one month period. Patients did not take any other

antihypertensive medications. They found that 22 patients of the sample

(73.34%) were reduction of the average systolic blood pressure for 9.52%,

and the average diastolic for 10.42%.

Another study by Clement, et al ,(2007) conducted to know the "perception

of efficacy and assessed the perceived efficacy of herbal remedies by users

accessing primary health facilities throughout Trinidad". In this study 265

herbal users entered and the garlic was the most popular herb (in 48.3% of

the sample), It was used in 20% of hypertension patients. But the study of

Capraz, Dilek and Akpolat,(2007) conducted among 7703 hypertension

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patients to find out "the frequency of garlic usage in hypertensive population

and to evaluate acute effect of garlic and garlic tablets on blood pressure in

patients with hypertension". They found that 53.3% of patients were using

garlic and there are no significant effect on blood pressure was observed in

any of the three groups (placebo, garlic or garlic tablets).

Hibiscus (Hibiscus sabdariffa) has been used to treat high blood

pressure in both African and Asian traditional medicine. In 1996, researchers

in Nigeria confirmed this age-old wisdom by showing that hibiscus flowers

reduced blood pressure in laboratory animals. Soon after, researchers in Iran

showed the same benefit in people. After measuring the blood pressure of 54

hypertensive adults, the researchers gave them 10 ounces of either black tea

or hibiscus tea for 12 days. Average blood pressure decreased slightly in the

black tea group, but decreased a significant 10 percent in the hibiscus group.

In another study, scientists in Mexico gave 75 hypertensive adults either

captopril (Capoten; 25 milligrams twice a day) or hibiscus tea (brewed from

10 grams of crushed dried flowers — about 5 teaspoons per 1 to 2 cups

water — once a day). After four weeks, the herb had worked as well as the

drug, with both groups showing an 11 percent drop in blood pressure. In

another study, the same researchers gave 193 people either lisinopril,

(Zestril, Prinivil; 10 milligrams per day) or hibiscus (250 milligrams in the

form of a capsule). After four weeks, the herb had worked almost as well as

the drug: Blood pressure decreased 15 percent among those on the drug, and

12 percent among those taking hibiscus (Castleman,M.,2011). But another

study by Wahabi, et al,(2010) conducted in Kingdom of Saudi Arabia to "

examine the evidence of effectiveness and safety of hibiscus in the treatment

of hypertension". Two studies compared Hibiscus sabdariffa to black tea,

one study compared it with captopril and one with lisinopril. They found that

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Hibiscus reduce blood pressure greater than tea but less than the ACE-

inhibitors.

Rosemary is used for digestion problems, including heartburn,

intestinal gas (flatulence), liver and gallbladder complaints, and loss of

appetite. It is also used for gout, cough, headache, high blood pressure, and

reducing age-related memory loss. Some women use rosemary for

increasing menstrual flow and causing abortions. Rosemary is used topically

(applied to the skin) for preventing and treating baldness; and treating

circulation problems, toothache, a skin condition called eczema, and joint

or muscle pain such as myalgia, sciatica, and intercostals

neuralgia. (webmd,2014). In addition Rosemary may also have effects

similar to diuretics in reducing blood pressure. According to a study

published in the August 2000 issue of "Journal of Ethnopharmacology,"

rosemary has diuretic properties. This study was conducted in animal

subjects, using a daily dose of 10 ml/kg of 8 or 16 percent rosemary extract

in distilled water. At these doses, rosemary extract was found to have

diuretic properties by eliminating water and electrolytes from the body.

(venta,2011)

Ginger is commonly used to reduce nausea and to reduce symptoms of

colds and chills through sweating and to boost circulation. It can be taken

fresh, dried, or as oil. It is a spice commonly used in Asian and Indian

cuisine. The thick roots of this herb have a spicy taste and a pungent aroma

that add characteristic flavor to curries, Asian soups and stir fry dishes.

Ginger may also offer health benefits as well, according to Castleman

(2012). Moreover, the chemical compounds in this herb may help reduce

hypertension, or high blood pressure. The chemical compounds in ginger

may help lower overall blood cholesterol, as well as low density

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lipoproteins, which are components of cholesterol that can contribute to

heart disease, according to Castleman. Cholesterol and low density

lipoproteins can contribute to sticky plaque along the walls of your arteries

and blood vessels. This creates blockages that can contribute to high blood

pressure by restricting the inner diameter of blood vessels and arteries.

Plaque may also reduce the elasticity of arteries, further contributing to high

blood pressure. It also can decrease blood clotting and may interact with

anticoagulants such as warfarin. (University of Maryland Medical Center,

2011).

According to Medline Plus (2014), ginger might also lower blood

pressure in a way similar to calcium blockers, so taking them together may

cause your blood pressure to drop to dangerously low levels or lead to an

irregular heartbeat.

Regard use of lemon juice, Adibelli,Z.,et al ,(2009) conducted the

study in northern turkey to find out " the frequency of lemon juice usage

among the hypertensive patients". They found one hundred fifty six (72.5%)

of hypertensive patients were using alternative therapy and the most

common alternative therapy use was the lemon juice. Another study by Bell

stows,(2011) conducted to find out “the effect of pomegranate juice

consumption on blood pressure and cardiovascular health”. They found that

Pomegranate juice consumption inhibits serum angiotensin converting

enzyme activity and reduces systolic blood pressure and recommended that

further clinical study are needed.

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3.9 Methods used for preparation of herbs for using

Herbal therapy is easy to prepare. It has many ways to be ready for

use such as boiling, soaking in water, infusion and eating. Some like

decoctions are made by boiling barks, roots and berries to extract the active

ingredients. The liquid is strained and can be taken either hot or cold.

Tinctures are made by soaking herbs in water and alcohol to extract and

preserve the active ingredients. The liquid is then stored in small bottles and

taken with water. Infusions are made like teas. Boiling water is poured over

the herb and is left to sit for about 10 minutes, creating a liquid to be taken

as a hot drink or medicine. Infused Oils are made with chopped herbs and

oil. The mixture is either placed in a bowl over boiling water, or left to

infuse in the sunlight. Creams are made from herbs and either oil or fat. The

mixture simmers for about three hours before it is strained and set in dark

bottles. Ointments are also made from herbs combined with either oil or fat.

The ointment is then heated quickly over boiling water before it is strained

and set. (University of new Hampshire, 2014).

Theoretical frameworkThe culture: is the way people live. beliefs and values shared by two

or more individuals that shape their behavior”. Culture affects everything we think and do, from how we treat our elders, to who we allow to be a healer, to what we do when our children do not feel well.Health: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.How culture believe effect to health ?In culture effect to how think the cause of disease and illness and how to cure from it and effect it to how person perceive information and how use it and his attitude,, Cultural understanding play a major role in patient compliance.

28

In Christian Scientists for example :Believe the illness it’s just come from God and its Cleansing of sins and believe that healing does not come from within the body or from a person’s mind, but from God’s Mind, which is used as one of the seven synonyms for God. Many of Christian do not believe in any medical interventions Some of them are opposed to all medications.The church is against abortion except in the case of incest or rape, if the health of the mother is in serious jeopardy, or the baby is not expected to survive beyond birth. Members may take medicines that contain alcohol or caffeine as long as they are not using the medicines just for those ingredients and do not become addicted to them. Birth control is acceptable according to the individual.

In Muslim for example :Muslims believe that their bodies are given to them as a trust by God to use appropriately for the attainment of salvation. The consumption of alcohol or any intoxicant is forbidden. Smoking or using any other substance that is harmful to the body is also highly discouraged. e. Muslims believe that for every illness (except aging and death) there is a cure, though it may not be known medically. Health care workers are considered God’s agents of healing, whereas final healing comes from God alone. While in the hospital, many Muslims may still wish to perform their five daily prayers and reading the God book . Muslims do not believe in abortion unless the mother’s. Blood transfusions are acceptable.In Amish for example :

The Amish who are excluded from social security and health insurance coverage; they have different perceptions of health and illness; they do not practice birth control; they often lack the preventive practices of immunizations and prenatal care; and they may use a variety of traditional and nontraditional health care providers Only by understanding the religiocultural belief system of this minority religious sect can nurse practitioners effectively meet the health care needs of their Amish patients.

29

4.1 Study Design

METHODOLOGY

Mix approach: quantitative and qualitative approach was used to conduct

this study.

Quantitative approach: Cross sectional, descriptive design was used to

gather information on a hypertensive patients’ population to achieve the aim

of the study that was about Perception of these patients about

complementary/herbal therapy. And for Qualitative approach

phenomenological, descriptive design was used.

4.2 Setting

The study was conducted in the primary health care at Nablus city in

Al-Makhfia and Al- Wosta clinics.

Both clinics are PHC and provided the essential services including;

immunization, antenatal care, post natal care, baby well care and general

clinics as hypertension and diabetic care.

4.3 PopulationsPatients with hypertension who were between 35-60 years old in a

primary health care in Nablus city.

The number of population was estimated by the director about 3000

patients with diabetic and 2000 of them have hypertension. It was difficult

to determine the total number of population; the sample size was estimated

to be 120 participants.

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4.4 Sample and sampling

Sample size:

For quantitative design, 120 participants were included in the study

based on the inclusion and exclusion criteria.

For qualitative design, 8 hypertensive patients were selected.

This study applied a method of convenience sampling method to

select the participants because it is easy to reach and cost of collecting

information and time for collecting information can be reduced. Each

participant was chosen in a nonrandom manner so some members of the

population have no chance of being included. The main obstacle in finishing

this study was time. Thus, this method was chosen because this method is a

quick and relatively cost-effective method of gathering data.

4.5 Inclusion and exclusion criteria The sample which was selected was chosen in basic of inclusion

criteria:

1) Patients with hypertension.

2) Age between 35-60 years old.

3) Both gender (male and female).

4) In the primary health care at Nablus.

Exclusion criteria for selecting the sample which is the:

1) Any patient which doesn’t apply condition that we have mentioned.

2) Unwillingness patient who refused to cooperate when being approached to participate in this study.

31

4.6 Data Collection ToolsFor quantitative design: one tool was used to collect the data; it was

the face to face questionnaire. The questionnaire was developed ,based on

literature review , in addition to supervisor opinion, it consist of three parts.

(Annex 1):

First part: Demographic data for the patient, consisted of nine

questions included of age, occupation, gender, marital status, …. Etc.

Second part: Data about hypertension, consisted of five questions included

of the time of diagnose, types of medication use for hypertension and the

frequency at the day, last blood pressure reading, times of visiting doctor in

month.

Third part: Data about herbal usage, consisted of sixteen questions included

of use of herbs for any problem , types and how to use this herbs, use of

herbs for hypertension, types and how and frequency for use, the effect of

use, cause of use, source of information to use, if doctor know about use.

A method of face-to-face asking question based on question on

questionnaires is used to get information from all respondents and to

facilitate respondents to answer questions. Every respondent was take 5-10

minutes to answer the questionnaire.

For qualitative approach : face to face interview was used . The

interview was conducted in the primary health care. Each interview began

with a demographic data such as the respondent's age, marital status,

economical status, history of hypertension and medication used. The aim of

the study and the consent form were explained to the participants. Semi-

structured questions included Six open ended questions (Annex 2) have been

used to discuss the perception of these patients about the use of herbal

32

therapy for hypertension and this interview taken no longer than 30-45

minutes.

4.7 Validity and Reliability of the studyAfter the study tool was developed, it was reviewed by 4 expert doctor in

the college and to ascertain and test the content validity of the tool it was

tested twice:

Pilot was accomplished after developing of questionnaire on 10% of

the sample aiming to ensure patient understanding of the

questionnaire, time needed for fulfilling it, and as result of piloting no

correction was made .

Cronbach's alpha test: was done to measure the internal consistency

and reliability of the tool which was 0.768.

4.8 Administrative workApproval letter was attained from Ministry Of Health for primary

health care in Nablus after request letter has been sent by A Najah National

University to conduct the study.(Annex 3)

4.9 Field workAfter having the acceptance from the Ministry Of Health for primary

health care in Nablus that were included in the study and the questionnaire

and consent form were developed, the study was conducted in Al Makhfia

Clinic at 1-2/ 10/2014 and in Al Wosta Clinic at 14/10/2014.

At each clinic ,principle of clinic was met to explain aim of the study,

then patients were taken and the aim of the study, ethical issues and consent

form have been explained to them. Every patients accept to cooperate, have

the inclusion criteria and sign on consent form to be participant in this study

33

,question on the questionnaire have been asked to the participant face to face

for 5 minutes.

4.10 Ethical considerationApproval from the IRB committee at An-Najah National University

was obtained before starting data collection.(Annex 4)

Written signed consent form indicated patient agreement to participate

in the study was obtained after study objectives and aims were explained to

patient before answered the questionnaire and fulfilling it.(Annex 5)

4.11 AnalysisFor qualitative design thematic approach was used. For quantitative design

Statistical analysis was done using the Statistical package for Social

Sciences (SPSS) version 20. Frequency, percentage, and mean and cross

tabulation were generated and Chi-square was used to compare proportions.

The p-value of 0.05 was used to determine the level of statistical

significance.

34

Result5.1 Table 1: distribution of percentage of participant regards their socio-demographic data

Variables NO. %Age35-40 10 8.341-45 7 5.846-50 13 10.851-55 22 18.356-60 68 56.7Total 120 100.0SexMale 45 37.5Female 75 62.5Total 120 100.0Marital statusSingle 4 3.3Married 92 76.7Divorced 3 2.5Widowed 21 17.5Total 120 100.0Educational levelIlliterate 8 6.7Primary education 59 49.2Secondary education 33 27.5College education 20 16.7Total 120 100.0Economical status

<1000 26 21.71000- 2000 70 58.3>2000 24 20.0Total 120 100.0Place of residencyVillage 31 25.8City 83 69.2Camp 6 5.0Total 120 100.0Have any chronic diseasesNo 0 0Yes 120 100.0Total 120 100.0Family history (chorionic diseaseNo 42 35Yes 78 65Total 120 100

35

Table (1) shows socio- demographic data for participant, it showed that 56.7% of participant where among the age group of (56-60, and 62.5% where female. Regarding educational status 49.2% finished the preparatory stage, and 69.2% where living in the city, all of them have any chronic disease, and 65% of them having family history of any chronic disease.

5.2 Table (2): Distribution of percentage of participants regards their history of hypertension.

Diagnosis time No. %≤ one year 4 3.3

1-3 years 25 20.83-5 years 28 23.3≤ 5 years 63 52.5Total 120 100.0

Medication(Pharmacological Therapy)Anapril 53 44.2Amacor 42 35.0Cortinol 10 8.3Exforage 3 2.5Other medication 12 10.0Total 120 100.0

Frequency of medicationOnce/Day 79 65.8Twice/day 38 31.73times/day 2 1.7Other 1 .8Total 120 100.0

Follow up with doctorOne/month 99 82.5Twice /month 2 1.7Three times/day 4 3.3Others 15 12.5Total 120 100.0

Blood pressure reading No MeanSystolic 120 145.68Diastolic 120 81.70Valid N (listwise) 120

Table (2) shows that history of hypertension among participant; it indicated that 52.5% of them having hypertension since more than 5 years, and 44.2% are on Anapril , and 65.8% of them having their medication once per day. 82.5% of them do their follow-up visits onetime per month, regarding their blood pressure readings the mean of systolic reading was 145.68 and the diastolic was 81.7.

36

5.3 Table (3. 1): distribution of participant percentage regards their general use of herbal.

herbal use in treatment for any health condition

No. %

Used 15 12.5Not used 105 87.5Total 120 100.0Herbal uses methodGrinding 1 .8Boiling 104 86.7Total 105 87.5

Not use herbal 15 12.5Herbal use for hypertension

Used 52 43.3Not used 68 56.7Total 120 100.0

Table 3.1 showed that 87% of participant reported that they use herbal on their treatment of health condition and 86.7% of them using boiling method for preparing it . It also showed that 56.7% of participants using herbal for hypertension

5.4 Table (3.2): distribution of participant percentage regards the herbal uses in hypertension.

Type of used herbalGarlic 27 39.7Hibiscus 16 23.5

Rosemary 11 16.2Ginger 5 7.4Lupin 6 8.8Others 3 4.4Total 68 100.0

Herbal uses methodEat 30 44.1Grinding 3 4.4Boiling 32 47.1Others 3 4.4Total 68 100.0

Length of using herbal<1 month 2 2.91 month-1year 9 13.21year-3year 30 44.13year-5year 27 39.7Total 68 100.0

Regular use of herbalNo 17 25.0Yes 51 75.0Total 68 100.0

Frequency of useDaily 22 32.41\week 7 10.32-4\week 14 20.6

37

2\month 10 14.7Others 15 22.1Total 68 100.0

Use medication behind herbsYes 68 100.0Have an effect on hypertension

Don’t know 15 22.1No 9 13.2Yes 44 64.7Total 68 100.0

Effect in generalFeeling of comfort 48 70.6Not feeling of hypertension signs 20 29.4Total 68 100.0

Effect on blood pressure readingDon’t know 9 13.2

Not follow up regularly 30 44.1There was a decrease 28 41.2Nothing change 1 1.5Total 68 100.0

Cause of using herbalDrugs side effect 21 30.9Lack of control of blood pressure 42 61.8Others 5 7.4Total 68 100.0

Source of information about using herbalRelative and family 41 60.3Doctor prescription 6 8.8

Pharmacist 1 1.5Propaganda 19 27.9Others 1 1.5Total 68 100.0

Doctor informed about using herbalNo 52 76.5Yes 16 23.5

Table 3.2: showed the using of herbal among hypertension patients; it showed that 39.7% of participants reported of using garlic and 23.5% of them are using hibiscus. 47.1% of them reported preparing the herbal using boiling method. 44.1% using herbal since one - three years and 75% using it regularly and 32% of them reported that using it daily in addition all of them using their medication behind the using of herbal therapy. Regarding the herbal effects on hypertension 70.6% of them feeling better and 29.4% reported that it reduces the sign and symptom of hypertension and about the effect on their blood pressure reading 44.1% reported that they did not monitoring it and 41.2% reported that there was decrease. According to the reasons behind using herbal; 61.8% of participants were using herbal therapy related to un control blood pressure and 30.9% using it due the side effect of medication.60.3% reported that they have information about using herbal therapy from their relative and family and 27.9% from the media and 76.5% reported that they did not informed their doctor about using herbal therapy.

38

Hypothesis results/ objectives and research question5.5 Table 4: distribution of participant percentage regards who were used and who were

not use regarding their demographic data .Use herbal therapy for hypertension

Age Total Sig.35-40 41-45 46-50 51-55 56-60

No N. 4 2 6 7 33 52

0.373

% 7.7% 3.8% 11.5% 13.5% 63.5% 100.0%

Yes N. 6 5 7 15 35 68% 8.8% 7.4% 10.3% 22.1% 51.5% 100.0%

Total N. 10 7 13 22 68 120% 8.3% 5.8% 10.8% 18.3% 56.7% 100.0%

Sex

0.037

Male Female

No N. 25 27 52% 48.1% 51.9% 100.0%

Yes N. 20 48 68% 29.4% 70.6% 100.0%

Total N. 45 75 120% 37.5% 62.5% 100.0%

Educational level

0.406

Illiterate primary Secondary college

No N. 3 24 15 10 52% 5.8% 46.2% 28.8% 19.2% 100.0%

Yes N. 5 35 18 10 68% 7.4% 51.5% 26.5% 14.7% 100.0%

Total N. 8 59 33 20 120% 6.7% 49.2% 27.5% 16.7% 100.0%

Economical status

0.544

<1000 1000-2000 >2000

No N. 15 25 12 52% 28.8% 48.1% 23.1% 100.0%

Yes N. 11 45 12 68% 16.2% 66.2% 17.6% 100.0%

Total N. 26 70 24 120% 21.7% 58.3% 20.0% 100.0%

Diagnostic time before

0.413

< 1 year 1-3years 3-5 years ≥ 5 years

No N. 0 11 13 28 52% 0.0% 21.2% 25.0% 53.8% 100.0%

Yes N. 4 14 15 35 68% 5.9% 20.6% 22.1% 51.5% 100.0%

Total N. 25 28 63 120% 20.8% 23.3% 52.5% 100.0%

Table (4) show the differences between participants who used herbal therapy and participants who didn’t according to their demographic data .The percentage of participants who were used herbal therapy reached up to 51.5% among the age group of 56-60 years with no significant differences between the groups. And 70.6% of them were female, 51.5% have primary level of education. 66.2% have level of income of 1000-2000 NIS/ month. 51.5% had a diagnose of hypertension before more than 5 years. Among those who were not used herbal therapy 63.5% were within the age group of 56- 60 years and 51.9% of them were female. 46.2%were with initial education level and

39

48.1% were with economical status between 1000-2000 NC in every month and 53.8% had a diagnose of hypertension before more than 5 years. The table also indicated that there was no significant differences between who used the herbs or not n relation to their age , economic status, or education level, (p.value < 0.05), it was only significant in relation to gender.

5.6 Table 5: distribution of participant percentage regards relation between type of used herbal and its effect.Type of herbal effect of herbal use Total Sig.

Feeling of comfort Not feeling of hypertension signs

Garlic N. 21 6 27

0.473

% 43.8% 30.0% 39.7%Hibiscus N. 9 7 16

% 18.8% 35.0% 23.5%Rosemary N. 5 6 11

% 10.4% 30.0% 16.2%Ginger N. 5 0 5

% 10.4% 0.0% 7.4%Lupine N. 5 1 6

% 10.4% 5.0% 8.8%Others N. 3 0 3

% 6.3% 0.0% 4.4%Total N. 48 20 68

% 100.0% 100.0% 100.0%Type of herbal Effect on Blood Pressure Reading Total

0.037

Don’t know

Not follow up regularly

There was a decrease

Nothing change

GarlicN. 2 11 14 0 27% 22.2% 36.7% 50.0% 0.0% 39.7%

Hibiscus N. 1 7 7 1 16% 11.1% 23.3% 25.0% 100.0% 23.5%

Rosemary N. 3 3 5 0 11% 33.3% 10.0% 17.9% 0.0% 16.2%

Ginger N. 2 3 0 0 5% 22.2% 10.0% 0.0% 0.0% 7.4%

Lupine N. 0 5 1 0 6% 0.0% 16.7% 3.6% 0.0% 8.8%

Others N. 1 1 1 0 3% 11.1% 3.3% 3.6% 0.0% 4.4%

TotalN. 9 30 28 1 68% 100.0% 100.0% 100.0% 100.0% 100.0%

Table (5) indicated that the reasons behind participants usage of herbal was “feeling of comfort, as (70.6 %) of them reported it. It also showed that garlic ranked one in its related effect as (43.8%) of them reported (it) that they have feeling of comfort.29.4% reported that they feel releasing their sign and symptom of hypertension. It also showed that Hibiscus ranked one in its related effect as (35%) of them reported (it) that they have releasing their sign and symptom of hypertension.

40

It indicated that garlic and Hibiscus were ranked number one in their reported effect with no significant differences between the related effect and the type of used herbs.

Regarding the effect of using herbs on blood pressure reading, 41.2% of participants reported that there was decrease on their blood pressure reading. it also showed that 50%,25%,17.9% those from who use garlic, hibiscus, rosemary respectively with significant differences between types used in relation to the effect of it .

5.7 Table 6: distribution of participant percentage regards relation between the Length of using herbal and its relating effect.

Length of using herbal effect of herbal use Total

0.187

Feeling of comfort Not feeling of hypertension signs

<1 month N. 2 0 2% 4.2% 0.0% 2.9%

1 month-1year N. 8 1 9% 16.7% 5.0% 13.2%

1year-3year N. 20 10 30% 41.7% 50.0% 44.1%

3year-5year N. 18 9 27% 37.5% 45.0% 39.7%

Total N. 48 20 68% 100.0% 100.0% 100.0%

Length of using herbal Effect on blood pressure reading Total

0.47

Don’t know

Not follow up regularly

There was a decrease

Nothing change

<1 month N. 0 0 2 0 2% 0.0% 0.0% 7.1% 0.0% 2.9%

1 month-1year N. 1 7 1 0 9% 11.1% 23.3% 3.6% 0.0% 13.2%

1year-3year N. 3 11 15 1 30% 33.3% 36.7% 53.6% 100.0% 44.1%

3year-5year N. 5 12 10 0 27% 55.6% 40.0% 35.7% 0.0% 39.7%

Total N. 9 30 28 1 68% 100.0% 100.0% 100.0% 100.0% 100.0%

Table(6) 41.7% of those who feeling comfort and 50% of those feeling release sign and symptom of hypertension and 53.6% of those who had decrease on their blood pressure reading were used herbal since 1-3 years . It also 37.5% of those who feeling comfort and 45% of those feeling release sign and symptom of hypertension and 35.7% of those who had decrease on their blood pressure reading were used herbal since 3-5 years

It also showed that there was no significant differences between the effect of herbs in relation to the duration/length of using it as p.value < 0 .05

41

5.8 Table 7: distribution of participant percentage regards relation between the frequency of using herbal and its relating effect.Frequency of use effect of herbal use Total

0.417

Feeling of comfort Not feeling of hypertension signs

Daily N. 16 6 22% 33.3% 30.0% 32.4%

1\week N. 5 2 7% 10.4% 10.0% 10.3%

2-4\week N. 6 8 14% 12.5% 40.0% 20.6%

2\month N. 8 2 10% 16.7% 10.0% 14.7%

Others N. 13 2 15% 27.1% 10.0% 22.1%

Total N. 48 20 68% 100.0% 100.0% 100.0%

Frequency of use Effect on blood pressure reading Total

0.089

Don’t know

Not follow up regularly

There was a decrease

Nothing change

Daily N. 3 9 9 1 22% 33.3% 30.0% 32.1% 100.0% 32.4%

1\week N. 1 2 4 0 7% 11.1% 6.7% 14.3% 0.0% 10.3%

2-4\week N. 0 5 9 0 14% 0.0% 16.7% 32.1% 0.0% 20.6%

2\month N. 1 6 3 0 10% 11.1% 20.0% 10.7% 0.0% 14.7%

Others N. 4 8 3 0 15% 44.4% 26.7% 10.7% 0.0% 22.1%

Total N. 9 30 28 1 68% 100.0% 100.0% 100.0% 100.0% 100.0%

Table 7: 33.3% of those who feeling comfort and 30% of those feeling release sign and symptom of hypertension and 32.1% of those who had decrease on their blood pressure reading were used herbal were used daily . It also showed 12.5% of those who feeling comfort and 40% of those feeling release sign and symptom of hypertension and 32.1% of those who had decrease on their blood pressure reading were used herbal 2-4 time per week. It also showed that there was no significant differences between the effect of using herbs and the frequency of use it.

42

DiscussionThis chapter discussed the result of the study in relation to other

studies finding.

Table one showed that two third(62.5%) of the participant were

female ,and they were more than half in age group 56-60, and about half of

them finished primary education level (49.2%). these result was the same to(

Amira and Okubadejo,2007)and(Hu,H.,et al,2013) there were 40% male

and 60% female with mean age 55.1 years.

Regard the history of disease according the participants table (2) about

half of them (52.5%) has been diagnosed by hypertension since more than 5

years and near two third (65.8%) were follow up the doctor once per month.

According to use of herbal in any medical condition table (3.1) the

most of participants (87%)reported the use of herbal for many medical

problem and the most of them (86.7%) were used herbal by boiling. These

result were in the line with study results by (PE,O.,BE,O.,2010) as they

found 63% of participants were used herbal .

Regarding the use of herbal therapy among hypertension patients

(table 3.2) indicated that more than one third (39.7%) of them were used

garlic and nearly half of them (47.1%) were used the boiling method for

herbal therapy. These findings were supported by ( Amira and

Okubadejo,2007) that the garlic is the most herbal type used for

hypertension as 69.3% of participant reported it. While

(PE,O.,BE,O.,2010) found that garlic use was 21% .

In addition the table (3.2,5) highlighted that about two third (70.6%)

of them were feeling better when they used the herbal and about one third

(29.4%) reported that they have feeling of relieving the sign and symptom of

43

hypertension, as (CANCER RESEARCH UK, 2014) people often use

complementary therapies to help them feel better and cope with having

problem and treatment.

In relation to the reasons behind uses of herbs , less than two third

(61.8%) were using herbal due to their un controlled blood pressure and

one third or less of them (30.9%) were used herbal because of side effect of

medication. These results were the same as ( Amira and Okubadejo,2007)

who found that there were many reason for used herbal and some of these

are failure of modern medicine to cure the underlying problem, CAM is

cheaper and related cultural beliefs of the people.

Regard resources of the participants information about using the

herbal for hypertension table (3.2) showed that less two third (60.3%)

having it information from their relatives and family . These findings were

supported by (PE,O.,BE,O.,2010) who found that that Family/relatives,

doctors, and patients themselves were the three main sources of information

about CAM.

According to informing the physician about using of herbs, about

three fourth of participants (76.5%) were used herbal without informing

their doctors. These findings were opposite with results by (DM,E., et

al,2001) who found that 70% of participants saw their doctor before visited

the CAM provider and 15% visited the CAM provider before saw their

doctor.

In relation to differences between who used herbs and who did not

table (4) showed that there was no significant differences between who used

herbs or not in relation to their demographic data, and indicated that those

who were used herbal therapy reached up to half (51.5%) among the age

group of 56-60 years . And less than three fourth(70.6%)of them were

44

female, and half of them(51.5% ) have primary level of education. Two

45

third (66.2%) of them have level of income of 1000-2000 NIS/ month , and

half of them (51.5%) had a diagnose of hypertension before more than 5

years. These results were the same as ( Amira and Okubadejo,2007) found

that there was “no difference in the clinical characteristics, socio-economic

status, and blood pressure control of CAM users and non-users” . in addition

(Hu,H.,et al,2013) found that “CAM users did not differ statistically from

non-CAM users by age, marital status, health status, duration of

hypertension, income, or education”. But (Udo,I.,et al,2014) found that

“Respondents within the age of 40-49 years constituted the highest number

(33.3%)} of CAM users. The number of respondents from the low level

income bracket and those of the middle income bracket who used CAM

remedies were almost the same”.

Qualitative approach:

Face to face interview was used to find out the experience of herbal

usage among hypertension patients ; in term of the prevalence of use,

duration and frequency of use, type and method of herbal used, effect of

herbs on their health, and their source of information and related advices.

As a result and on regard to the prevalence of herbal usage;All patient reported usage of herbs for different health condition, in

addition they are using different type of herbal a onetime “use garlic,

ganger” “hibiscus, ginger, garlic” and some of them stopped specific types

as ganger.

According to the duration and length of usage, some reported the use

from one to two years others said that patient 5 used it since less than one

year " منتظم من 9 شهور "

46

About the dose, frequency of the use; some reported using daily based

on the type of the herbs, patient 1,3,7,8 use the garlic before eating anything

daily in the morning “ سن تومة على الريق ” in addition , patients 7,8 used

hibiscus nearly one cup daily “ كاسة متوسطة “. patient 3,5. Reported the use

of rosemary daily every morning “ فنجان الصبح “patient 6 while all of them

reported that they take it regularly “ الكركديه والزنجبيل منتظم يوم يوم بشرب" يوم اه "

يوم ال مرتين في اليوم ال اه" patient 2,5.

In addition half of them reported they have it one per day in the

morning before breakfast. As ate or one spoon. Patient 1,3,7,8.

Different method was reported to be used for preparing the herbs

based on the type of herbs such as eaten and some use the boiling for

preparing ,other used soaking and then boiling for preparing.

Source of information

Regard the participant information resource about the herbs and its

related uses 6 of the participants have the information from their relative

and neighbor since they reported that they rely on relatives experiences on

7. patient اه9تبرج اانه ليتالق يتخا ام دبع ةالتوم تمدخاست اان"herbs. of use the

Experience of relatives, family and neighbors was the most common

source of information, as participants reported that they based on others

experience in using it, and if it was used successfully and how it was used,,,

and if it was used by different people or not …..” من جارتنا ام محمود انه

مفيد وجوزها استعملو وشاف انه منيح اقتنعت بكالمها وصرت استعملو ولما سمعت ”

patient 4 . while

others reported that the experience of relative is not

sufficient والجيران قد ال يكون لهم خبرة patient 5" ومضار هذه االعشاب

كافية بفوائد

براقلاا"

Media also was another source of information,, as some reported that

47

they hear about it from TV, Or read about it on the net ” ادخل على النت

للبحث عنهم وكنت ” patient 6.

Effect of herbs:

Regarding to participant sample most of them said that the blood

pressure decrease when they used herbs according to follow up measure

every month ,two of them said when take some types of herbal therapy

feeling of comfort and the absence of high blood pressure symptoms as

patient 5 headache " " بحس اني مرتاحة وال كانو عندي ضغط ,one of the participant

admit she don’t know what is the effects of using herbs to decrease high

blood pressure.

Use of medication:

According to data collected the half and one of the sample agree about

taking of herbal therapy must be taken as compliment with hypertension

medication "" الزم نستخدم الدواء وبشكل منتظم, ما نعتمد بس على األعشاب .Furthermore

two of them try to decrease the medication frequency and take just patient 4

herbs to decrease high blood pressure one of the two stop taking drug and

just continue to use herbal therapy, one participant decide to take herbs just

without using any anti hypertension medication.

Informing physicians about herbal uses:

By reference of information the most participant said that its not

important to tell the doctor about using herbal therapy some of them said

patient 6 أنا9 ما قلت للدكتور وال غيره ألنو حسيت انو مش رح يشجعني على اني اخد أي عشبة"

بجنب الدواء" on the other hand the rest of the sample said they should telling

the doctor about using herbal therapy because of the believe that doctor

know more about treating high blood pressure

منا عن طرق patient 4

ةوهم مصصهخت داه ةرتاكدلا"رأخب

Conclusion

The study concluded that Herbal is commonly used among

hypertensive’s patients, different herbal were found to be used and tried the

most common type used were Garlic and Hibiscus. The main source of

information about herbal was from relatives and family, in addition they

were using it without informing the doctor.

There were no significant differences among those who used herbs or

not in relation to their demographic data.

There were no significant differences among the type of herbs and its

related effect

LimitationThis study has many limitations include:-

1. Unavailability of statistical information about the real number of

hypertensive population

2. The permission from ministry of health to do this study has came late, so

we have wasted a lot of time waiting the permission.

3. Time: to fill our questioners because the participants have low

educational background as most of them has the completed primary level of

educations .

4. Due to clinical policy the most of participants didn’t have enough time to

fill the questioners.

5. Female sample was larger than male.

6. Small sample size.

7. Participants not have enough time to do long interview.

Recommendation

1. CAMs may be used by clients for a variety of conditions including

hypertension. Healthcare providers must be aware of the use, efficacy,

adverse affects, and scientific evidence concerning CAM in order to

provide safe and effective practice as well as appropriate and accurate

information to their clients.

2. Each clinical area include special for health education include herbal

medicine.

3. Add to each doctor to his certificate degree, certificate about herbal

medicine.

4. Organize special group for continuous education in each clinical area

about herbal therapy.

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