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Research Article

Herbal Products Use Among Chronic Patients and its Impact on Treatments Safety and Efficacy: A Clinical Survey in the Jordanian Field

Reem A. Issa and Iman A. Basheti

Objectives: To assess the current use of herbal products among chronically ill patients in Jordan and to review the impact of the used herbal products on their treatments safety and efficiency. Materials and Methods: This study was a questionnaire based cross-sectional study conducted between March and June, 2016. The developed and validated questionnaire consisted of 2 different forms, one for patients with chronic diseases and one for the community pharmacists. Patients and pharmacists were randomly recruited into this study by pharmacy students skilled to perform the data collection. Results: About 376 patients were recruited into this study (mean age 43 years, 54% female). About 216 (57.4%) were using 43 different herbal products. The most common chronic diseases suffered by the patients were hypertension, diabetes and hyperlipidemia. Males and older patients were more likely to experience unsafe or inefficient use of herbal products. Only 54.2% of the patients informed their pharmacists of their use of herbal products. A minority of the pharmacists (8.2%) reported very good knowledge of herbal products use and herbs-drugs interactions and only (11.3%) always ask their patients about their use of any herbal products. Conclusion: Many chronically ill patients in Jordan use herbal products for the management of their chronic conditions. Inefficient use is common mainly amongst males. Patients and pharmacists are not communicating as needed regarding patients use of herbal products. New strategies need to be implemented in the country to resolve these vital issues.

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  How to cite this article:

Reem A. Issa and Iman A. Basheti, 2017. Herbal Products Use Among Chronic Patients and its Impact on Treatments Safety and Efficacy: A Clinical Survey in the Jordanian Field. Trends in Medical Research, 12: 32-44.

DOI: 10.3923/tmr.2017.32.44

Received: October 20, 2016; Accepted: November 21, 2016; Published: December 15, 2016


Natural products have been reported since ancient’s history to be used by human kind and are still used world wild for health promotion and treatment of diseases1. Despite all the recent developments in drug industry, herbs remain to be used often in treatments of common ailments rather than conventional drugs2. More commonly, they are used as adjunct therapy to conventional pharmaceuticals, as a safer and more affordable system of health care3. Regardless of the reasons, patients using herbal medicines in combination with conventional medications, especially those used for chronic conditions, should be assured that the treatments they are using are safe and effective as what they are supposed to be4,5.

Pharmacists are found in an ideal position to discuss with their patients the use of herbal supplements when pharmacological treatments are prescribed. Lack of dialog between the pharmacists and their patients about the use of herbal supplements is alarming and has been previously highlighted6. Patients with chronic conditions were found unaware of the risks due to the herb-drug interactions, leading to unsafe and inefficient treatments7. Studies shed light on the importance of pharmacists asking the patients about their use of any herbal products along with their conventional medications8. In addition, patients should be provided with science-based information on dosage, contraindications and efficacy for their herbal treatments by their community pharmacists9.

Despite significant progress made in implementing the WHO traditional medicine strategy 2014–2023 (http://apps. around the world, there are numerous challenges related to herbal products safety and quality, research and development, education and training of practitioners, in addition to information provision and communication between pharmacists and their patients. To resolve these challenges, provision of education for the pharmacist is essential10. More clinical based study is needed to guide towards the appropriate use of herbal medicines in our health systems11.

Previous studies have shown that herbal products use is very common among Jordanians12,13. Many of the herbal products remain untested and their uses are either poorly monitored or not monitored at all14,15. Hence, it is important to evaluate the appropriate use of herbal products in the country, especially for patients using medications for treating their chronic conditions at the same time16.

The aims of this study include determining the prevalence of use of herbal products by patients with chronic diseases living in Jordan, prevalence of inefficient use of these products, role of the pharmacist in this area and factors associated with the use of these products.


This cross-sectional study was conducted between March and June, 2016. Randomly selected community pharmacies distributed between Eastern Amman and Western Amman (capital of Jordan) were visited and invited to participate in the study. All pharmacists who studied at the same selected pharmacies during the study period were asked to participate in the study. Patients visiting the participating pharmacies were also approached randomly to participate in the study. Patient’s inclusion criteria included those who were common customers at the recruited pharmacy and come back to the same pharmacy at least bimonthly to receive their medications, diagnosed with a chronic diseases, above the age of 18 and have been living in Jordan over 1 year.

Pharmacy students enrolled in the phyotherapy course at the Applied Science Private University for the year 2015/2016 (n = 45) were trained to assist in carrying out the data collection part of the study. Each student approached 15-25 pharmacists. Verbal consent was obtained from the participants (pharmacists and patients) before study entry. Ethical approval for the study was obtained from Applied Science Private University, Faculty of Pharmacy research committee.

Data collection tool was a face to face pre-developed questionnaire by the study investigators (Appendix 1). Appendix 1 and 2 show questionnaires for pharmacists and patients respectively, both included closed (using 5 likert scale) and open questions prepared by the principal researchers. Part A of the questionnaire was designed to collect socio-demographic characteristics for the pharmacists/patients, while part B was designed to collect information regarding use of herbal products, source of knowledge about herbal products and overall experience. The questionnaires underwent face validation following its review by expert researchers in the field. The questionnaire was also distributed to pharmacists (n = 10) and pharmacy students (n = 10) to assess the questionnaires for clarity. All submitted comments were taken into consideration by the researchers and used in developing the final version of the questionnaires.

Participating pharmacists were interviewed at their pharmacies and they were asked about their level of education, years of experience, their pharmacy average daily selling rate Jordanian Dinar (JD). Part B investigated pharmacist’s role in advising their patients on the use of prescribed and non-prescribed herbal products simultaneously with patient’s chronic medications, their level and source of knowledge regarding the available pharmaceutical herbal products, their involvement in investigating patient’s present treatments looking for possible interactions or contraindications, their counseling practices when selling prescribed herbal products to patients with a medical history, the references they use for assessing possible interactions between the conventional medications and herbal products and their experience about the efficiency and safety of the herbal products used by their chronic patients.

For the participating patient’s, questions involved documenting their history of herbal use (mainly for treating chronic conditions), indications, source of advice and knowledge on herbal products, whether their health care providers were aware of this use and their experience regarding the efficiency and safety of the herbal products they used for their chronic conditions along their conventional medications.

Following data collection, the reported most frequently used herbal products by the patients were reviewed in term of their efficiency and safety for treating the conditions the patients declare they used it for. Herbs and Natural Supplements-An Evidence Based Guide17 was used to complete this part of the study, in addition to a number of peer-reviewed published clinical, in vitro and in vivo studies. In order to rate the claimed efficiencies of the herbal products used by study participants for treating common chronic conditions, a comprehensive list of the herbal products used to treat the top 5 chronic conditions described by the patients was prepared (Appendix 2). The Appendix 2 also shows the gender and the age group of the patients per chronic condition. The Appendix 2 helped in correlating some of the socio-demographic factors associated with the inefficient use of these herbal products among the chronic patients.

Data analysis: Statistical analysis was performed using Statistical Package for Social Sciences (SPSS version 20, Chicago, IL, US). Descriptive analysis was carried out to determine the frequencies calculated for the categorical variables.

Based on the number of licensed pharmacies (1,568) and the number of population (4,000,000) in Amman, sample size was calculated using a margin of error of 5%, confidence level of 95% and response distribution of 50%, a minimum of 309 pharmacies and 385 patients were needed.


Socio-demographic characteristics: Out of the approached pharmacies in the study (294), 200 agreed to participate and complete the questionnaire, resulting in a response rate of 68%. The majority (47.4%) had less than 5 years working experience, while few (22.7%) had a working experience of 5-10 years and some (29.9%) had more than 10 years working experience. All pharmacists had a bachelor of pharmacy degree or higher and all were licensed as a trained pharmacist. The majority (79.4%) of the pharmacists were allocated in Western Amman (higher socioeconomic areas of Amman). The average daily income was above 400 JD (1 US dollars = 0.71 JD) for the majority of pharmacists (65.5%). Some pharmacists (28.4%) reported an income in the range of 200-399 JD and few (6.2%) reported less than 200 JD income.

A total of 376 out of 400 patients who were approached to participate in the study agreed to participate and complete the questionnaire, giving a response rate of 94% with an average age of 42.92±15.21 (Mean±SD) years. Majority of patients were females (54.3%), Jordanians (87.2%) and residence of Western Amman (71.3%). About half of the patients (49.0%) had a university degree.

All patients were using conventional medications for their chronic diseases which involved diabetes mellitus type one and type two (22.3%), hypertension (22.3%) and hyperlipidemia (9.6%). Many patients (45.0%) had diverse health disorders including heart problems, arthritis, hormonal disorders, asthma, obesity, irritable bowel syndrome, atherosclerosis, anemia, migraine and osteoporosis.

Herbal products use by patients: All participating patients (n = 376) had chronic diseases. When these patients were asked how frequent they use herbal products for treating their health conditions (chronic and non-chronic diseases), more than half of the patients (n = 216 and 57.4%) revealed that they use them with frequencies ranging from often-usually-always, with no significant variations between the two genders (Females: n = 128, 63%, males: n = 88, 23.4%). Among the most frequently used products, 43 different herbal products were reported. Table 1 shows the top 10 used herbal products by study patients. The most common reported herbal products used were garlic (n = 28), sage (n = 20), roselle and anise (n = 16).

Factors associated with inefficient use of herbal products: Analyzing the comprehensive list of the herbal products used by the study patients to treat their chronic diseases (Appendix 2), out of all patients reported use of herbal products (n = 216), 76 out of the 156 cases (48.72%) were found to be using at least one inefficient herbal remedy. A proportion of (45.45%) of the male patients with relatively high frequency (40 cases) were using 10 ineffective products that were not supported by any evidence for their claimed use, (e.g., herbal mixture for treating hypertension with or without diabetes or lipedemia). These patients were equally distributed between the age groups 40-59 and 60+ years old. Regarding female patients, only (28.1%) of them with a frequency of (36 cases) were found using 8 ineffective products to treat their chronic conditions not supported by any evidence.

Table 1:
Frequencies for the top 10 commonly used herbal products for the treatment of different chronic and non-chronic health conditions by study patients (n = 216)
*No significant differences were found between both genders

They were distributed between younger age groups (20-60 years), when compared with the male patients (Table 2).

Knowledge and beliefs about herbal products use among patients: In answering the question whether the patients inform their pharmacists when they are using herbs before requesting their medications, majority of patients (54.2%) reported to rarely inform their pharmacists about using herbal products (Fig. 1). Results showed that 58.1 and 50.9% of the male and female patients, respectively had a low awareness regarding the role of their pharmacist in assessing potential herb-drug interactions, with no significant variations among the 2 genders.

Many patients (45.8%) reported that they ask their pharmacist for alternative herbal products that are useful for their medical conditions (with frequencies ranging from often-usually-always). Results showed significant variations (p<0.05) between the 2 genders as shown in Fig. 2. Nevertheless, both genders revealed less interest in the role of the pharmacist advising them on alternative herbal products for treating their chronic conditions, with the majority 51.1 and 57.0% of males and females patients respectively, reported to rarely ask their pharmacist for any herbal treatments.

Table 2:
Association between patient’s gender and age with the frequencies and percentages (%) of the reported use of herbal remedies in treating specific chronic conditions by study patients (n = 216)
*Calculated using data from Appendix 2

Fig. 1:
Frequencies of patients who reported informing their pharmacist of their herbal products use before requesting their chronic medications (n = 376)

Fig. 2:
Frequencies of patients who reported to ask their pharmacists for alternative herbal products that would be useful for treating their chronic conditions (n = 376)

Both genders showed almost similar experiences when they were asked if they have ever suffered from potential side effects, that they could correlate to the use of herbs along with their chronic medications (Fig. 3). While (53.2%) of the patients answered with rarely, a proportion of (14.9%) of the chronic patients said that they experienced some side effects or interactions, which could be caused by using their conventional medications with certain herbs. Comparing the two genders, 56.9 and 48.8% of the female and male patients respectively, showed a rare frequencies of these interactions, with no significant variations.

Among the interviewed patients, (41.4%) of them said that they believe with the high efficiency of treatments by herbal products, which was rated as the major factor for their use. Moreover, these patients also believe with the ability of treatments by herbal products to always or usually decrease the frequencies for conventional medications used to treat the same conditions (Fig. 4).

Fig. 3:Frequencies of patients who complained for potential side effects caused by herb-drug interactions (n = 376)

Fig. 4:
Proportion of chronically ill patients who believed in the high efficiency of herbal products and their ability to decrease the frequency of conventional medications used (n = 376)

Where (51.0%) of the female patients said they do always or usually get this benefit from herbal products use, only (30.3%) of the male patients get this benefit, with significant variations (p<0.05) between the 2 genders.

Regarding the patient’s source of knowledge for using medicinal herbs, 40.4% of them said that they depend on the internet. Their second source was the pharmacist (22.3%), followed by their MD which contributed to only (13.8%). A proportion (23.4%) of the patients depend on other sources, including their local herbalist, friends and family, TV, books and magazines or traditional recipes inherited via generations. By comparing both genders, female patients showed to depend more on the internet (females: 41.2% and males: 39.5%). Never the less, male patients showed to depend more on the pharmacist (males: 27.9% and females: 17.6%), with no significant variations among the gender of the patients. Only minority of the female (15.7%) and male (11.6%) patients showed to depend on their MD.

Knowledge and beliefs about herbal products use among the pharmacist: When pharmacists were asked to evaluate their knowledge about the use of herbal products for treating common chronic diseases, the evaluation for the majority of the pharmacists (47.4%) was average, while 25.8% believed they have a good amount of knowledge and only 8.2% believed that they have very good knowledge.

When pharmacists were asked to assess their knowledge about potential herbs-drugs interactions, the majority (39.2%) reported slight knowledge, while 34.0% of them reported average knowledge and only 22.6% of them reported a good/very good level of knowledge.

As for the pharmacist’s source of knowledge about herbal products use and their potential interactions with drugs, a majority of pharmacists (33.3%) reported their universities (during their B. Pharmacy degree or D. Pharmacy degree). The rest reported the internet (27.8%), published papers and books (19.4%) and different life experiences from friends, family, medical companies, advertisements and herbalists (19.5%).

When pharmacists were requested to evaluate how frequently they ask their chronically ill patients about their use of any herbal products, only (11.3%) of pharmacists said they always ask, other (58.8%) of the pharmacists reported to usually ask and about 3rd of the pharmacists (29.9%) reported to rarely ask.

Regarding recommending chronically ill patients to use herbal products in combination with their conventional medications, majority of the pharmacists (45.4%) reported recommending herbal use. Other pharmacists (32.0%) reported to sometimes recommend herbal use and the rest of the pharmacists (22.7%) never recommended herbal products use to their patients.


This is the first study conducted in Jordan to reveal important information regarding chronically ill patient’s use of herbal products. Most of the participants in this study believed in the high efficiency of herbal products, being the driving force for them to use it frequently. The study showed that more than half of the chronically ill patients use at least one herbal product. Female were shown to be more frequent users of herbal products than male patients. This could be due to the fact that female participants use herbal products to treat also acute health conditions as well as chronic diseases. Hypertensive patients, with or without diabetes and dyslipidemia were found to be the most frequent users of herbal products in this study. High use of herbal products results in higher cases of inefficient use18 more side effects and interactions with chronic medications19.

Use of herbal products by chronically ill patients has been acknowledged by previous studies conducted in Jordan and in the Middle Eastern countries. Qunaibi et al.20 reported 48% of patients in Jordan to be using herbal products for treating their medical conditions, mainly hypertension and diabetes. Patients justified their use of the herbal products by the claimed safety and efficiency of the herbal medicine in the country. A study conducted in Palestine showed that majority of hypertensive patients (86%) and more than half of the diabetic patients (52%) used at least one type of medicinal herbs21.

The herbal products used by the patients in this study were found to be relatively safe plants that are commonly used on daily basis as food or beverage (Table 1). However, according to the literature, many of these products failed to show evidences for their claimed uses. The study sheds light on the inefficient use of herbal products mainly by male patients.

Many of the interviewed patients reported that they experienced some side-effects, which could be a consequence for the reported improper use of the medicinal herbs coincidently with conventional chronic medications. In a recent similar study conducted in Palestine, Al-Ramah et al.7 reported that about 60% of the chronically ill patients used at least one medicinal herb, with about 22% experiencing at least one inefficient herbal product use. Males and older patients were also more likely to experience inefficient use of herbal products7.

This study unveiled interesting facts about causes leading to the inefficient use of herbal products among chronically ill patients. Patients rarely inform their pharmacists about their use of herbal products. Only 11% of the patients ask their pharmacists to make a recommendation for herbal treatments that can be used to improve their health conditions. Female patients were less interested than males in the role of the pharmacist as an adviser for herbal product’s use. Other cause reported in this study leading to the inefficient use of herbal products was the source of patient’s knowledge about herbal products use. Most patients depend on the internet to obtain knowledge in this study. The community pharmacist came 2nd in this domain. Nevertheless, only 8% of pharmacists reported to have very good knowledge in this study. Such results are not surprising considering that only about one third of the pharmacists reported receiving education about the safe and efficient use of herbal products through their educational courses at their universities. Majority of the pharmacists depended on other less science-based evidences and trusted sources such as the internet. Consequently, only 11% of the pharmacists said they always ask their chronically ill patients about their use of herbal products. Hence, chronically ill patients need to be educated about the role of the pharmacist regarding the efficient and safe use of the herbal products. Also, pharmacy students need to receive full education in this area at their pharmacy schools and to have their skills to update and upgrade their knowledge continuously following graduation to become independent long-term self-learners.

Limitations of this study include that the study was performed through a group of pharmacies allocated mainly in the western areas of Amman, Jordan, therefore it might not be representative to the practice in other parts of the city or other cities in the country. The references used to review the claimed efficiencies of the herbal products used to treat the chronic conditions reported in this study were not all very recent, although efforts were made to use the most available recent resources. The data collected were done through pharmacy students. Although, the students were trained well on the collection of data, some issues, such as social bias issues could have immerged. Answers of the pharmacists and patients could have been affected by the researcher being a pharmacist. Study sample size was restricted by researcher’s time available for data-gathering.


The use of herbal products is a common practice among Jordanian chronically ill patients. Pharmacists should be aware of the common herbal products uses, especially for treating common conditions and to be able to evaluate and discuss its efficiency and safety with their patients using science-based evidences.

A high frequency of scientifically unsupported uses of some herbal products that claimed to treat chronic conditions was found. A substantial proportion of patients did not inform their pharmacists about herbal products use, therefore to avoid any possible negative outcomes, better counseling and communication between patients and pharmacists are recommended.


The authors would like to thank the pharmacists and the patients who accepted to participate in the study and were 3 very kind to give us their time. We acknowledge pharmacist Malak Shoukokani pharmacist Mohamad Ghabayn for their help in this study. Also, the authors are grateful to the Applied Science Private University, Amman, Jordan, for the financial support and publication fees granted for this reasearch project.

Appendix 1: Study questioners forms 1 and 2

Appendix 2: Top five chronic conditions among the interviewed patients (n = 376), with their self-choices of herbal remedies

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