An-Najah National University



| |جامعة النجاح الوطنية – نابلس | |

| |كلية التمريض | |

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

INTRODUCTION

Hypertension 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.

BACKGROUND

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 Epidemiology

According 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%.

3 Classification

As 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)

4 Risk Factors

In 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

pregnancy, the congenital defect known as coarctation of the aorta, and certain prescription and illegal drugs.

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).

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).

7 Problem Statement

Patient 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.

8 Significant of the problem

According 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.

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.

9 Aim and Objectives

This 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 therapy

4- To find out source of patient information about herbal therapy

10 The Question of the Study

1- 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)?

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)?

LITERATURE REVIEW

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

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

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 .

2 Complementary and Alternative Medicine

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.

3 Types of Complementary and Alternative Medicine

The 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.

Fifth, Energy Therapies: that involve the use of energy fields.(NCCAM,2012),(National Cancer Institute,2013)

4 Definition of herbal therapy

One 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).

5 History of herbal therapy use

Plants 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.

6 Causes of Use CAM

People 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)

7 Uses of herbal among medical condition

Recently, 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".

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.

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)

8 Herbal uses for hypertension

In 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

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

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

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.

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 framework

The 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.

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.

10 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.

11 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.

12 Populations

Patients 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.

13 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.

14 Inclusion and exclusion criteria

1 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.

2 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.

15 Data Collection Tools

For 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

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

16 Validity and Reliability of the study

After 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.

17 Administrative work

Approval 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)

18 Field work

After 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

,question on the questionnaire have been asked to the participant face to face for 5 minutes.

19 Ethical consideration

Approval 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)

20 Analysis

For 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.

Result

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

|Variables |NO. |% |

|Age |

|35-40 |10 |8.3 |

|41-45 |7 |5.8 |

|46-50 |13 |10.8 |

|51-55 |22 |18.3 |

|56-60 |68 |56.7 |

|Total |120 |100.0 |

|Sex |

|Male |45 |37.5 |

|Female |75 |62.5 |

|Total |120 |100.0 |

|Marital status |

|Single |4 |3.3 |

|Married |92 |76.7 |

|Divorced |3 |2.5 |

|Widowed |21 |17.5 |

|Total |120 |100.0 |

|Educational level |

|Illiterate |8 |6.7 |

|Primary education |59 |49.2 |

|Secondary education |33 |27.5 |

|College education |20 |16.7 |

|Total |120 |100.0 |

|Economical status |

|2000 |24 |20.0 |

|Total |120 |100.0 |

|Place of residency |

|Village |31 |25.8 |

|City |83 |69.2 |

|Camp |6 |5.0 |

|Total |120 |100.0 |

|Have any chronic diseases |

|No |0 |0 |

|Yes |120 |100.0 |

|Total |120 |100.0 |

|Family history (chorionic disease |

|No |42 |35 |

|Yes |78 |65 |

|Total |120 |100 |

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.

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 |20.8 |

|3-5 years |28 |23.3 |

|≤ 5 years |63 |52.5 |

|Total |120 |100.0 |

|Medication(Pharmacological Therapy) |

|Anapril |53 |44.2 |

|Amacor |42 |35.0 |

|Cortinol |10 |8.3 |

|Exforage |3 |2.5 |

|Other medication |12 |10.0 |

|Total |120 |100.0 |

|Frequency of medication |

|Once/Day |79 |65.8 |

|Twice/day |38 |31.7 |

|3times/day |2 |1.7 |

|Other |1 |.8 |

|Total |120 |100.0 |

|Follow up with doctor |

|One/month |99 |82.5 |

|Twice /month |2 |1.7 |

|Three times/day |4 |3.3 |

|Others |15 |12.5 |

|Total |120 |100.0 |

|Blood pressure reading |No |Mean |

|Systolic |120 |145.68 |

|Diastolic |120 |81.70 |

|Valid 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.

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 |12.5 |

|Not used |105 |87.5 |

|Total |120 |100.0 |

|Herbal uses method |

|Grinding |1 |.8 |

|Boiling |104 |86.7 |

|Total |105 |87.5 |

|Not use herbal |15 |12.5 |

|Herbal use for hypertension |

|Used |52 |43.3 |

|Not used |68 |56.7 |

|Total |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

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

|Type of used herbal |

|Garlic |27 |39.7 |

|Hibiscus |16 |23.5 |

|Rosemary |11 |16.2 |

|Ginger |5 |7.4 |

|Lupin |6 |8.8 |

|Others |3 |4.4 |

|Total |68 |100.0 |

|Herbal uses method |

|Eat |30 |44.1 |

|Grinding |3 |4.4 |

|Boiling |32 |47.1 |

|Others |3 |4.4 |

|Total |68 |100.0 |

|Length of using herbal |

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