SUBMITTED 6 OCT 21 1 REVISION REQ. 11 NOV 21; REVISION RECD. 30 NOV 21 2 ACCEPTED 12 DEC 21 3 ONLINE-FIRST: JAN 2022 4 DOI: https://doi.org/10.18295/squmj.1.2022.007 5 6 Knowledge, Attitudes and Practices Regarding Traditional and 7 Complimentary Medicine in Oman 8 Hassan Al-Riyami,1 Ahmed Al-Maskari,1 *Sunil K. Nadar,2 Mohammed 9 Almaskari3 10 11 1Directorate of Nursing and 2Department of Medicine, Sultan Qaboos University Hospital, 12 Muscat, Oman; 3Oman College of Medical Sciences, North Sharqiyah, Ibra, Oman 13 *Corresponding Author’s e-mail: sunilnadar@gmail.com 14 15 Abstract 16 Objectives: The aim of the study was to assess the knowledge, attitudes and practices with 17 regards to traditional medicine in Oman and to assess the factors that lead to its use. Methods: 18 This was a cross sectional questionnaire-based study. All Omani nationals above the age of 18 19 were eligible to be enrolled. The questionnaire consisted of questions regarding the knowledge, 20 attitudes and use of traditional medicine. Results: There were 598 (out of 700) responses to the 21 questionnaire (response rate of 85.4%) of which 552 (mean age 33.6±7.7 years; 345 or 62.5% 22 male) were complete. Majority of the respondents (90%) are aware of the different types of 23 traditional medicine(TM). A high percentage (81.5%) feel that it is effective. 67.8% had tried at 24 least one method. These were older (34.5±7.8 years vs 31.8±7.2 years, p<0.001) and mostly male 25 (72.1% vs 42.1%, p<0.001) and in full time employment (73% vs 27%). Herbal medications 26 (65.7%) and traditional massage (60.4%) were the most common form of TM that was practiced. 27 Women tended to go more for herbal medications (69.2%) and massage (63.4%), while, for men 28 cupping was the most popular (65.1%) followed by herbal medications (64.4%) and massage 29 (59.2%). Back pain was the most common condition for which TM was used with only a small 30 mailto:sunilnadar@gmail.com percentage reporting any side effects. Conclusion: There is widespread use of TM among the 31 urban population in Oman. Better understanding of their benefits will help incorporate them into 32 modern health care services. 33 Keywords: Traditional and complementary medicine; knowledge and attitudes 34 35 Advances in Knowledge 36  This study is the first in the region to evaluate the knowledge attitudes and practices of 37 traditional medicine among the urban population in Oman 38  It shows that traditional medicine is still widely practiced in Oman 39 40 Application to Patient Care 41  Understanding the use of traditional medicinal practices will help physicians evaluate 42 patients better and helps get better histories from patients when they present in hospitals 43 with side effects or complications related to any of these practices 44  This will help to formulate plans from a governmental level to try to integrate better these 45 traditional practices with modern health care 46 47 Introduction 48 Traditional medicine (TM) is a term broadly used to refer to various forms of indigenous medicine 49 that are practiced by communities native to a particular region, such as the traditional Chinese 50 medicine system, the Indian Ayurvedic system and the Greco-Arabian Unani system of medicine. 51 The WHO defines TM as health practices, approach, knowledge, and beliefs incorporating plant, 52 animal, and mineral based medicines, spiritual therapies, manual techniques, and exercises applied 53 singularly or in combination to treat, diagnose, and prevent illness or maintain wellbeing.1;2 The 54 terms “complementary” and “alternative” medicine are used to refer to a broad set of health care 55 practices that are not part of a country’s own tradition, or not integrated into its dominant health 56 care system, but part of another countries traditional practices.1 For example, Acupuncture and 57 Indian ayurvedic practices are part of traditional Chinese and Indian medicine respectively, but 58 many western countries consider them as a complimentary or alternative practice as it is not part 59 of their own traditional practices. Traditional, complementary and alternative health practices are 60 very common and the WHO estimates that around 70-80% of the population in both developing 61 and developed countries use it either on its own or alongside modern therapies.2 62 63 The use and form of TM practices varies from country to country and indeed even between regions 64 in a particular country.3 It forms part of the culture in many Asian and African countries.3;4 Many 65 of these practices like the Indian Ayurvedic system or the African or Chinese systems are centuries 66 old and have been handed down from generation to generation either by word of mouth or by 67 written script. Some of these practices are related to the use of herbs or animal or plant products 68 or might be related to physical practices such as traditional massages, acupuncture, exercises, or 69 other practices such as cupping and branding.2;4 In the past, in many developing countries, 70 practitioners of TM were the only source of health care in remote villages due to poor access to 71 modern hospitals and doctors which were expensive and at times miles away.5 With improved 72 access to modern health care in developing countries, the number of these practitioners of TM has 73 dwindled considerably.6 Despite this, many of these practices are embedded in the culture and 74 customs of many communities and these traditional practices coexist along with modern hospitals 75 and modern medicine.4 76 77 There is now a renewed interest in traditional and complementary practices in the western world 78 and indeed even in many developing countries.4;7 They are considered to be more natural and 79 therefore free from side effects of harmful chemicals. Patients also tend to turn to them for chronic 80 conditions such as diabetes, hypertension or chronic aches and pains typically back pain. Even a 81 decade ago, a study from Australia suggested that around 70% of the population has used at least 82 one form of complementary medication with an estimated annual expenditure of more than US 83 dollars 3 billion in 2007 on traditional and complementary medications.8 More recently, in the 84 United states around 32 billion dollars were spent on complimentary medicine in 2012 and it is 85 expected to reach around 60 billion dollars in 2021.(7) The Global market for complimentary 86 medicines is estimated to be around 100 billion US dollars and expected to rise to more than 400 87 billion US dollars in 2028.9 88 89 In Oman, there is a rich heritage in the use of traditional health medicine which has been practiced 90 for centuries.10 Oman has a rich biodiverse flora and fauna due to its varied terrain of mountains, 91 deserts and river beds (Wadis) which has led to herbal medications that are unique to this region.11 92 They have also been influenced greatly by their historic ties with other civilisations. Oman has a 93 history of trade for many centuries with countries in Africa, the Indian subcontinent and even far 94 off places such as Europe and China. As a result, some of the traditional practices in Oman have 95 derived important aspects from these civilisations.11;12 Some of the common practices in Oman 96 include traditional massages with herbal oils, branding (known locally as Wassam), cupping 97 (known locally as hijama), herbal medications and more recently acupuncture.12 98 99 With urbanisation of the Omani population and the improved access to modern health care even 100 in rural areas of the country, it is not clear whether patients still seek out these traditional practices. 101 The aim of this study is to assess the knowledge, attitudes, and practices among the general Omani 102 population with regards to the traditional medical practices. We also sought to find out the factors 103 that affect the utilisation of these practices. The findings of this study can help governmental 104 institutions devise strategies to control and incorporate the use of traditional practices in modern 105 medicine. 106 107 Methods 108 Patient recruitment: 109 This was a cross-sectional questionnaire based study conducted among general population in 110 Muscat, Oman. Ethical approval was granted by the medical research ethics committee, college of 111 medicine and health sciences at sultan Qaboos University prior to commencing the study. The 112 study was conducted between November 2019 and March 2020. All adults above the age of 18 113 were eligible to take part in the study. We excluded those under the age of 18 and those not willing 114 to participate. A convenience sampling method was employed. The subjects were recruited from 115 malls and public places during health promotion events. It was also posted as a link and circulated 116 on social media. Prior to filling in the questionnaire, the rationale and reason for conducting the 117 study was explained to the participants and they signed a consent statement on the questionnaire. 118 Those filling in the electronic questionnaire had to tick a box stating that they have read the 119 rationale for the study and understood it and consented to taking part. 120 121 Questionnaire development: 122 The questionnaire was self-developed and derived from other similar studies.6, 8, 13, 14, 15 It consisted 123 of 21 items in two sections. The first part comprised of the demographic data of the participants 124 and consisted of five questions. The second part of the questionnaire (16 items) collected data 125 about the participants’ knowledge, attitudes and practices with regards to the traditional medical 126 practices. To test knowledge, each participant was asked five (yes or no) questions about the use 127 of the TMs, potential risks of TMs, side effects of TMs, and the need of TMs training. The 128 respondents' attitudes and practices were measured using 11 (yes or no) questions that focussed on 129 the history of TM use, promoting these methods to others, method efficacy, and desire to use it 130 again. This questionnaire was devised in Arabic, and was modified, reviewed and adjusted based 131 on interviewing lay members of the public regarding the various traditional practices that are 132 available in Oman. It was piloted on 50 volunteers and minor adjustments were made to the 133 language to remove ambiguity and improve clarity and used in the final questionnaire. No 134 questions were deleted following the pilot. The final chronbachs alpha was around 0.78, 0.83 and 135 0.79 for the knowledge, attitude and practice questions respectively with the overall alpha value 136 of 0.81, which is acceptable level of reproducibility. 137 138 Statistics: 139 Sample size estimations were made according recommendations for population based cross 140 sectional questionnaire studies, where a minimum of 384 to 400 participants are required for a 141 standard error of 5%.16 The data were analyzed using SPSS version 21 software (IBM corp. 142 Armonk, NewYork USA). All data are described as either percentages or mean ± standard 143 deviation or median (interquartile range). Students t test, Mann-Whiney U test or chi-square test 144 were used as appropriate. Binary logistic regression was used to predict use of any TM practice as 145 a whole or individually. The demographic factors were used as predictors. A p value of <0.05 was 146 considered to be significant. The data has been stored securely in a password protected file that is 147 only accessible by the investigators. 148 149 Results 150 A total of 700 questionaires were distributed of which 598 replies were received (response rate of 151 85.4%), of which 46 were incomplete. Therefore 552 (mean age 33.6±7.7 years; 345 or 62.5% 152 male) responses were included in the final analysis. There were 32 diabetics (5.8%), 22 (4%) 153 hypertensive, 14(2.5%) with heart disease. Majority of the respondents (491 or 88.4%) who did 154 not have any of these risk factors. Most of the respondents were in full time employment (78.1%) 155 with another 3.4% in full time education. Nearly three quarters of the respondents had completed 156 a university diploma degree or higher [Table 1]. 157 158 Table 2 shows the results of the general knowledge and attitudes towards traditional medicine 159 practices. Majority of people know about/are aware of the different types of traditional methods 160 such as Wassam – 476 (86.2%), cupping 495(89.7%), traditional massage 427 (77.4%) herbal 161 medications 461 (83.5%) and acupuncture 384 (69.6%). Although most feel that traditional 162 medicine is not better than modern medicines (80.3%), a high percentage (81.5%) feel that it is 163 effective and around two-thirds (374 or 67.8%) said that they had tried at least one traditional 164 method. Of those who had tried it, majority (310 out of 374 or 82.8%) found it was useful with 165 only a small percentage 31 out of 374(8.2%) saying they had some form of side effects. 166 167 Most of those who had used it said they would try it again (85.2%), though only a small percentage 168 said they would recommend its use to others(36.1%). Of those who have not tried it, most did not 169 have any specific reason for not trying, but 30.8% said that they did not know enough of it to try 170 it. There was no significant difference between the attitudes and practices between men and women 171 apart from the fact that there was a significant higher proportion of men who had tried some form 172 of traditional medicine than women(p<0.001), with men also more likely to try it again (p<0.001). 173 174 Those who had tried at least one traditional practice were older (34.5±7.8 years vs 31.8±7.2 years, 175 p<0.001) and mostly male (72.1% vs 42.1%, p<0.001) as compared to those who did not try it 176 [Table 3]. 78.2% of males had tried some form of traditional medicine as compared to 50.2% of 177 women. Most of those who had tried a traditional practice were in active employment (73% of 178 those employed) with only a third of those in full time education and just over half of those who 179 were unemployed or retired. However, there was no difference with regards to educational status. 180 Similarly having any cardiovascular risk factor also did not influence their use of TM practices. 181 182 The type of TM practice utilised did not vary according to age, sex employment status or 183 educational status [Table 4]. Herbal medications (65.7%) and traditional massage (60.4%) were 184 the most common form of TM that was practiced. Women tended to go more for herbal 185 medications (69.2%) and massage (63.4%) rather the other forms of TCA (cupping 29.8%, wassam 186 24%, and acupuncture 11.5%). Meanwhile, more than half of men have tried all forms of TM 187 practices apart from wassam (46.6%) and acupuncture (21.8%), with cupping being the most 188 common (65.1%) followed by herbal medications (64.4%) and massage (59.2%). A high 189 proportion of patients with diabetes (66.6%) and hypertension (72%) have tried herbal 190 medications, with a high proportion saying that they specifically used it to lower blood sugar 191 (56.2%) or blood pressure (77.2%). 192 193 Table 5 shows the distribution of the type of TCA practice with the condition treated. Back pain 194 was the most common condition for which TM was used and majority had tried traditional massage 195 (74.2%), cupping (69.3%) and herbal medications (62.3%) for this. Acupuncture was the least 196 common practice, and again, when tried, was mainly for back pain. The other conditions for which 197 TM was used were headache, abdominal pain, “nerve” pain and swelling. 198 199 Binary logistic regression revealed that age (p<0..001) and gender (p<0.001) strongly predicted 200 the use of any traditional practice. The other factors such as educational or employment status were 201 not predictive. Gender also specifically predicted the use of Wassam (p<0.001), cupping 202 (p<0.001), and acupuncture (p>0.001). Knowledge regarding a specific practice predicted their 203 use in wassam (p=0.04), cupping (p<0.001), massage (p<0.001) and herbal medications (p<0.001). 204 Employment status was only predictive of the use of herbal medication (p=0.01) 205 206 Discussion 207 In Oman, there appears to be continued widespread use of TM practices for a range of ailments. 208 The proportion of people who had used some form of TM in this study is 67.8% which is similar 209 to that reported in other studies from countries such as Ethiopia,13 Nigeria,14 Ghana,15 India,6 210 China,17 and South Africa.18 As in other countries, it is usually used mainly for chronic conditions 211 that do not respond to modern medications or for which there is no cure such as diabetes, low back 212 pain, muscular pain etc. It is interesting that many of those who have used it say that they tolerated 213 it well and found it useful and would recommend its use. Patterns of use however suggest that the 214 more physical forms of traditional practices such as massage, acupuncture, branding and cupping 215 are used more by men, whilst women tend to use herbal medications more than other forms. This 216 is consistent across different cultures.6, 13-18 217 218 Consistent with other studies, herbal therapy was the most common form of TM that was utilised 219 in this study group.15;19 Herbal medications can be used for a wide variety of ailments and are 220 considered to be safe and generally free from side effects as it is derived from naturally occurring 221 plants and herbs. Traditional herbal therapy is common in many cultures usually with the 222 indigenous herbs and plants that are unique to that particular country or region. Studies from the 223 Middle-East have demonstrated a high level of use of herbal medications for many ailments and 224 especially during pregnancy. 20,21 Many of the traditional Omani herbal medications contain rose 225 water, lime and local honey which are plentiful in the hilly ranges of Jebal Akhdar.11;12 The leaves, 226 resin, bark and sap of plants found in these hills are also used extensively in the herbal preparations. 227 11;12 In addition, the Dhofar region of Oman is famous for frankincense which has been used for 228 centuries as an incense as well as for its medicinal properties.22 Frankincense forms a part of many 229 of the Omani herbal medications, both as a paste, as an inhalant, an ointment or even for ingestion. 230 In view of this abundance of local medicinal herbs and plants, it is therefore not surprising that 231 this was the most common form of TM in this study. The use of herbal medications is widespread 232 and generally unregulated in most countries and although they appear to be well tolerated in the 233 current study, patients may develop unexpected side effects especially with prolonged or excessive 234 use. It is therefore recommended to include a history of ingestion of herbal medications as part of 235 the routine work up of patients. 21 236 237 Traditional Massage therapy is common all over the world and is used for a variety of conditions. 238 It has been shown to decrease muscular and joint pain, labour pain, improve mood, reduce anxiety, 239 improve quality of sleep and reduce blood pressure in the short term,23 although data on long term 240 benefits are lacking.24 However, it is readily available, presumed safe and often has an immediate 241 effect on pain and mood and hence its popularity.25 There are various mechanisms to explain the 242 effects of massage on pain and mood. The pressure and local heat caused by rubbing and 243 massaging improves blood flow and local vasodilatation. There are also neuro-hormonal changes 244 such as increased dopamine and decreased noradrenaline levels, changes in parasympathetic 245 activity, and changes in neuronal excitability after massage.26 This was the second most common 246 form of TM practice among the current study population. However as with the other forms of TM, 247 it appears to be predominantly used by males and employed individuals. It was the second most 248 common form of TM used by women. and used for most indications. 249 250 Branding is a common practice among many countries.27 This involves applying a hot metal object 251 to the affected part of the body and the third degree burns so caused are considered to be a form of 252 counter irritant to the original disease. Although this is dangerous and potentially harmful,28 it is 253 widely practiced in many countries and known by different names such as “Wassam” in Oman, 254 “Guboow” in Somalia, “kaiy” in Libya etc.27 Despite its popularity, there have been many case 255 reports of complications related to branding.12;28 It was not the most commonly used practice in 256 the present study cohort and was used mainly by older men. However, interestingly, almost half 257 of the men who had practiced some form of TM said that they had used it, suggesting that it is still 258 popular despite the pain and the potential harm. 259 260 Cupping therapy is another common traditional physical method of treatment in many parts of 261 Asia and the Middle-east and is growing in popularity in the west. There are two types of cupping 262 either wet cupping (Or Hijama as it is known in Oman)or dry cupping. It involves the application 263 of a bamboo, glass or plastic cup at the area of treatment. Vacuum is then created either manually 264 or by electromagnetic suction inside the cup to draw the skin into the cup. In wet cupping, blood 265 is drawn into the cup via a small incision made prior to the application of the cup, while in dry 266 cupping, no blood is drawn. The mechanism of action of cupping is not clear, and many theories 267 have been proposed. Some suggest that it acts by triggering a diffuse noxious inhibitory control or 268 by the removal of oxidants and the decrease of oxidative stress locally. Others hypothesise that 269 this therapy drains excess fluids; increases blood flow to skin and muscles; and stimulates the 270 peripheral nervous, neurohormone, circulatory, and immune systems.29 There are numerous 271 clinical trials and meta-analysis of its use in a variety of conditions such as back pain, neck pain 272 migraine, hypertension and chronic obstructive pulmonary disease.29-31 The results are variable, 273 with some studies showing benefit compared to placebo or standard therapy whilst others did not. 274 Interest in cupping has increased after some celebrity athletes have been shown to use it.32 In this 275 cohort, less than half of those who had used some form of TM had used cupping, similar to 276 Wassam, demonstrating that there is still considerable interest in this form of therapy. 277 278 Acupuncture was the least common of the TM utilised in this study. Acupuncture is a Chinese TM 279 practice that involves the placing of needles in special locations that can affect the pain sensations. 280 It is suggested that by affecting afferent nerve signalling, acupuncture can lead to the release of 281 endogenous opioids and thereby reduce pain.33 Although it has been around in Chinese traditional 282 practice for many centuries, it is only within the last few decades that it has been gaining popularity 283 and acceptance in much of the western world.34 Inconsistent clinical results, limited availability 284 (as it has to be provided by specially trained professionals) and misconceptions about its use such 285 as pain and other complications limit its availability and overall appeal as compared to other forms 286 of TM.35 It is interesting to note that other “painful” and potentially harmful practices such as 287 wassam (branding) were more popular than acupuncture. This could be due to familiarity with 288 wassam as it has been practiced in the region for a long time. 289 290 There were no clear demographic factors that could predict the use of TM. As in other studies from 291 the region, massage therapy and herbal medications were used by both men and women, while 292 men also used the more “painful” physical therapies such as wassam, cupping and acupuncture.19 293 TM was used by a high proportion of those in active employment as compared to students and 294 those not in active employment, perhaps reflecting the cost implications of using TM. 295 296 One of the limitations of this study was that this was confined to the urban areas of the capital city 297 of Muscat in Oman. The use and views of the population living in rural areas might be different. 298 Similarly, the present cohort had a high proportion of young, educated and employed individuals 299 suggesting a higher socioeconomic status (although we did not collect data on household income). 300 The views and practices of those who are older and who have not got formal education beyond 301 primary school might be different and are not represented in the current survey. Similarly, the 302 practices and attitudes towards traditional medicine in the rural areas of Oman, might be different. 303 Despite these limitations, the sample size of this study was high and it gives an insight into the 304 knowledge, attitudes and practices relating to traditional medicine in modern day Oman. 305 Additionally this is the first study to assess the attitudes of the Omani population regarding 306 traditional medical practices. 307 308 This study has demonstrated the widespread use of TM practices among the urban population in 309 Oman. The use of TM practices is deeply embedded in the social culture of the population with 310 many using it and feeling benefit. In many countries, efforts have been undertaken to try and 311 integrate these practices to complement modern health care.2,3,5,6 Although this study has given an 312 insight into the practices and attitudes, more research is required to help understand the local TM 313 practices better, so that they can be fully integrated into the local health care. Many patients seem 314 to find benefit in these traditional practices, and utlising them to complement modern health care 315 can go a long way in improving the overall health of the population. Care should also be given to 316 educate the population regarding the ill effects of some of the poorly understood practices such as 317 branding or untested herbal concoctions, which can give rise to serious complications 318 319 Conclusion 320 Despite the availability and ease of access to modern health care, there is still widespread use of 321 traditional medicinal practices alongside modern medicine in urban Oman. Traditional practices 322 are part of the culture and heritage of various communities, though these practices appears to be 323 used less frequently by the younger age group as compared to the older population. More needs to 324 be done to educate the public regarding the ill effects of some of the more harmful methods of TM, 325 while at the same time a better understanding of the mechanisms underlying the benefits of some 326 of these practices is needed to help integrate them better into the local health services. 327 328 Conflict of Interest 329 The authors declare no conflicts of interest. 330 331 Funding 332 No funding was received for this study. 333 334 Authors’ Contribution 335 HAR and AAM collected the data. AAM, SN and MAM contributed to the manuscript writing. 336 SN analysed the data. 337 338 References 339 (1) Traditional medicine: Definitions. 2021. 22-5-2021. 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Exp Ther Med 2015 432 Oct;10(4):1247-52. 433 434 Table 1: Demographic features of the respondents 435 Numbers (%) Age (years) 33.6±7.7 Gender Male Female 345 (62.5) 207(37.5) Diabetic 32 (5.8) Hypertensive 22 (4) Heart disease 14 (2.5) No cardiovascular risk factors 491 (88.9) Employment Student Full time employed Retired/Unemployed 19 (3.4) 431 (78.1) 102 (18.5) Educational status Less than secondary school Completed secondary school Diploma or higher 24 (4.3) 118(21.4) 410 (74.3) 436 Table 2: Knowledge and attitudes regarding traditional and complementary medicine practices 437 Number (%) Male (n=345)(%) Female(n=207)(%) P value Are you aware of: Wassam Cupping Massage Herbal medications Accupuncture 476 (86.2) 495 (89.7) 427 (77.4) 461(83.5) 384 (69.6) 291(84.3) 314(91) 253(73.3) 286(82.8) 232(67.2) 185(89.3) 181(87.4) 174(84.1) 175(84.5) 152(73.4) 0.09 0.1 0.04 0.6 0.1 Do you feel traditional medicine is effective? 450 (81.5) 291(84.3) 159(76.8) 0.02 Do you think it is better than modern medicine? 109 (19.7) 69(20) 40(19.3) 0.8 Have you ever tried any? 374 (67.8) 270(78.2) 104(50.2) <0.001 Did you try it for Hypertension (n=22) 17 (77.2) (n=15) 13(86.6) (n=7) 4 (57.1) 0.1 Did you try it for reducing blood sugar (n=32) 18 (56.2) (n=17) 10(58.8) (n=15) 8(53.3) 0.6 For those who had tried it (n=374) Was it useful? Did you have any side effects? Will you try it again in future Did you use it alongside modern medications Would you recommend its use 315 (84.2) 31 (8.2) 319 (85.2) 186 (49.7) 135 (36.1) (n=270) 228(84.4) 21(7.7) 163(78.7) 125(60.3) 103(49.7) (n=104) 87(83.6) 10(9.6) 89(85.5) 61(58.6) 31(29.8) 0.5 0.6 <0.001 0.07 0.1 If you have not used any, why not? (n=178) Not effective Don’t know where available Expensive Don’t know enough of it No specific reason 67 (37.6) 4(2.2) 8(4.4) 55 (30.8) 168 (94.3) (n=75) 37(49.3) 4(5.3) 7(9.3) 32(42.6) 70(93.3) (n=103) 30(29.1) 0 1(0.9) 23(22.3) 98(95.1) 0.04 Analysis by Chi-square test 438 439 Table 3: Characteristics of respondents who have tried any form of traditional treatment 440 Not tried (n=178)(%) Tried (n=374)(%) P value Age (years) 31.8±7.2 34.5±7.8 <0.001* Sex Male Female 75 (42.1%) 103(57.9%) 270 (72.1%) 104 (27.9%) <0.001 Employment status Student Employed Unemployed/retired 13(7.3%) 116(65.1%) 49 (27.6%) 6 (1.6%) 315(84.2%) 53 (14.2%) <0.001 Educational status Primary school or less Secondary school Diploma or higher 8(4.4%) 34(19.1%) 138(76.5%) 18(4.8%) 84(22.4%) 272(72.8%) 0.4 Co-morbidites Diabetes Hypertension Heart disease 7(3.9%) 7(3.9%) 3(1.6%) 15(4%) 25(6.6%) 11(2.9%) 0.9 0.19 0.38 Analysis by chi-square test, except * which is by students t-test 441 442 Table 4: Characteristics of those trying each different modality of traditional practice (n=374). 443 Tried Wassam (n=151) Tried cupping (n=207) Tried massage (n=226) Tried Herbal (n=246) Tried acupuncture (n=71) Age (years) 34.6±7.8 34.8±7.5 34.2±8.2 34.9±8.5 35.9±9.4 Sex Male(n=270) Female(n=104) 126(83.4%) 25(16.6%) 176(85%) 31(15%) 160(70.7%) 66(29.3%) 174(70.7%) 72(29.3%) 59(83%) 12(17%) Employment status Student Employed Unemployed 2(1.3%) 135(89.4%) 14 (9.3%) 2 (0.9%) 180 (86.9%) 25 (12.2%) 3(1.3%) 192(84.9%) 31(13.8%) 3(1.3%) 199(80.8%) 44 (17.9%) 0 62(87.3%) 9(12.7%) Educational status Primary school or less Secondary school Diploma or higher 6 (3.9%) 40 (26.4%) 105(69.7%) 13(6.2%) 53(25.6%) 141(68.2%) 10(4.4%) 62(27.4%) 154(68.2%) 16(6.5%) 50(20.3%) 170(69.2%) 5(7%) 20(28.1%) 46(64.2%) Diabetic (n=15) 7 (4.6%) 7 (3.3%) 6(2.6%) 10(4%) 3(4.2%) Hypertensive (n=25) 7 (4.6%) 17(8.2%) 14(6.1%) 18(7.3%) 6(8.4%) Heart disease (n=11) 7 (4.6%) 7 (3.3%) 5(2.2%) 7(2.8%) 3(4.2%) 444 Table 5: Distribution of the traditional practice with the symptom 445 Wassam (n=151) Cupping (n=207) Traditional massage (n=226) Herbal medications (n=246) Acupuncture (n=71) For headache (n=110) 44 77 69 73 28 For backpain (n=202) 75 140 150 126 43 For abdominal pain (n=126) 55 43 67 100 10 For nerve pain (n=147) 57 97 106 103 31 For Jaundice (n=62) 48 34 25 31 7 For swelling (n=36) 19 18 22 29 4 446