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sking patients the right questions abouterbal and dietary supplements: Crossultural perspectives

ran Ben-Aryea,b,c,d,∗, Inbal Halabib, Samuel Attiase,f,g,ee Goldsteinh, Elad Schiffe,f

Department of Family Medicine, Complementary and Traditional Medicine Unit, Technion-Israel Institutef Technology, Haifa, IsraelFaculty of Medicine, Technion-Israel Institute of Technology, Haifa, IsraelClalit Health Services, Western Galilee District, Haifa, IsraelIntegrative Oncology Program, The Oncology Service, Lin Medical Center, IsraelDepartment of Internal Medicine, Bnai Zion Hospital, Haifa, IsraelDepartment of Integrative Surgery Service, Bnai Zion Hospital, Haifa, IsraelSchool of Public Health, University of Haifa, Haifa, IsraelClinical Pharmacology Unit, Internal Medicine C, Haemek Medical Center, Afula, Israel Affiliated to theaculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israelvailable online 11 January 2014

KEYWORDSDoctor—patientcommunication;Dietary supplements;Traditional medicine;Safety;Complementaryalternative medicine;Herbs

SummaryBackground: Use of dietary supplements (DS) during hospitalization carries risks such as reducingdrug treatment efficacy and increasing peri-operative complications due to DS—drug interac-tions and DS side effects. In this study, we aimed to develop socio-cultural-sensitive patienthistories to detect DS use amongst hospitalized patients from different backgrounds.Research design and methods: Prospective cohort study of hospitalized patients from June 2009through March 2010, using mixed quantitative (questionnaires), and qualitative (semi-structuredinterviews) research methodology to detect DS use.Results: Data were provided by 691 of 895 patients (response rate 77.2%). Of these, 359 (51.9%)reported using DS in the previous year. 168 (46.8%) disclosed DS use following a standard questionon DS consumption. 191 (53.2%) respondents disclosed DS use only following further questioning

utilizing DS-related keywords. Leading questioning techniques that facilitated admitting DS use included: naming common DS (50.6% disclosure rate), and using traditional/herbal medicine(THM) related keywords (41.3% disclosure rate) such as infusions, teas, herbs picked in the gar-den. A logistic multivariate regression model indicated that disclosure of DS use, by using THMrelated keywords was associated with non-Jewish religion [EXP(B) = 3.57, 95% C.I. 1.70—7.50,p = 0.001], dwelling in rural areas (p = 0.004), and having a lower degree of education (p = 0.01).

∗ Corresponding author at: Department of Family Medicine, Complementary and Traditional Medicine Unit, Technion-Israel Institute ofechnology, Haifa, Israel. Tel.: +972 52 870 9282; fax: +972 4 851 3059.

E-mail address: eranben@netvision.net.il (E. Ben-Arye).

965-2299/$ — see front matter © 2014 Elsevier Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.ctim.2014.01.005

Right questions about herbal and dietary supplements 305

Conclusions: Improved history taking regarding DS use in hospitalized patients can be accom-plished by using specific keywords that address socio-cultural diversities as in the followingquestion: ‘‘Do you use any natural, folk, traditional, grandma remedies, herbs picked in the

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Introduction

Dietary supplements, as defined in most countries, includeminerals and vitamins as well as herbs intended to supple-ment the diet by increasing the total dietary intake, ora concentrate, metabolite, constituent, extract, or com-bination of any of the aforementioned ingredients.1 Theuse of dietary supplements (DS) during hospitalization haslately attracted clinical interest due to their widespreaduse as well as potential benefits and risks.2,3 In the US, datafrom the 2002 to 2007 Adult Complementary and Alterna-tive Medicine File to the National Health Interview Survey(NHIS) indicate an increased number of adults that everused herbs or supplements involving 55.1 million persons in2007).4 DS use has social—cultural aspects [e.g. increaseduse in Asians, American Indians and Alaskan natives]5 whichmay also influence the type of DS used. Raji et al. stud-ied community-dwelling elderlies in Texas and found thatnon-Hispanic whites use more vitamin—mineral supplementswhile black ethnicity was associated with more herbal use.6

The prevalence of DS use in the hospital setting varies indifferent countries ranging from 15% in Canada7 to 50% and60% in Italy8 and Australia.9 In Israel, Goldstein and her col-leagues reported that although 27% of patients hospitalizedin two hospitals used herbal/DS, 94% of the patients hadnot been asked specifically about herbal consumption by themedical team.10 Also, only 23% of the hospital’s medical filesof patients who used DS had any record of such use. In the USgeneral population, the proportion of adult users who dis-closed DS use to their health care provider rose, from 33.4%in 2002 to 45.4% in 2007. Although the number of studies onDS use in US hospitals is limited, preliminary studies in sur-gical and oncological arenas suggest rates of non-disclosureranging from 33% to 52%.11—13 In California, Leung et al. sur-veyed 2560 pre-surgical patients in five hospitals and foundthat 56.4% of DS users did not inform the anesthesiologistsbefore surgery of DS use and that only half of the patientsstopped DS use before surgery.14 Mehta et al. analyzed thenon-disclosure aspect according to the 2002 NHIS data andfound social—cultural correlation of lower disclosure ratesof DS use in Hispanic and Asian American adults comparedwith non-Hispanic white Americans.15 A limited number ofstudies considered the disclosure aspect from the hospitalphysicians’ perspective. In Spain, 78% of 105 surgeons andanesthesiologists reported that they did not ask patientsabout herbal use.16 Limited communication regarding com-plementary and alternative medicine (CAM) and DS betweenpatients and the health care professions in surgical carewas also documented in a Swedish national survey amonguniversity hospitals.17

Non-disclosure of DS use may not only hamperdoctor—patient communication but may also have signifi-cant implications in the hospital setting. From a safety-riskperspective, DS cause concern of adverse events18 during

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ospital admission for several reasons. First, the DS mayause adverse reactions (e.g. serotonin syndrome riskelated with Hypericum perforatum),19 and may inter-ct with medical treatment. DS—drug interactions maynclude St. John’s wort causing reduced concentration ofral oxycodone.20 Co-ingestion of coenzyme Q 10 or gin-er in patients treated with warfarin increasing the risk ofleeding.21 Potential hypoglycemic effects of herbs (e.g.inseng), cardiovascular instability (e.g. ephedra), andotentiation of the sedative effect of anesthetics (e.g. kavand valerian).22 The potential for adverse DS effects hasead scholars in the field to recommend routine screeningf hospitalized patients for use of DS.23—25 The competencef health care professionals to obtain an accurate anam-esis is fundamental and is emphasized in communicationkill courses at medical schools, and in the lifelong train-ng of physicians. Communication skills should take intoccount many factors, including socio-cultural differencesn language and health terminology/concepts. Questioningatients regarding CAM use is no different than question-ng on other health aspects. In hospital settings theseommunicational tasks may be more challenging due tohe following reasons: acute medical conditions with time-imited communication26; lack of previous acquaintancecompared with primary care setting); and, in addition,atients may perceive the hospital as a bastion of conven-ional care that is less tolerant of CAM27 making them lessilling to disclose CAM use; or simply due to patients’ per-eption of DS and CAM use as non-important or irrelevanto their medical care during the out-of-ordinary life contextf hospital admission.28 In addition, the topic of DS/CAMs underemphasized in physicians training in general29 andnowledge concerning appropriate wording in history takingegarding CAM in variable populations has not been estab-ished.

In this study, we assessed which questions facilitateetection of DS use in hospitalized patients from diverseocio-cultural backgrounds with the goal of developing aimple and cultural-sensitive communication tool for thisetting.

esearch design and methods

he study was designed as a prospective cohort study ofatients hospitalized in 11 departments of a public teach-ng hospital in Israel. The hospital has 450 beds, and serves

diverse population of rural and urban Jews and non-ews. The study took place between June and March 2009.

aration.Elaboration of the questionnaire: The questionnaire was

eveloped in a stepwise manner by a multi-disciplinary teamf researchers that included family and internal medicine

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pecialists trained in integrative medicine and non-MD CAMractitioners.

Step I: The development phase of the questionnaire wasbased on prior research on CAM use in Israelconducted by the Complementary and Tradi-tional Medicine Unit in the Department of FamilyMedicine, Technion Faculty of Medicine, Israel, andthe Clinical Pharmacology Unit at Haemek MedicalCenter, Afula, Israel.30,31

Step II: The initial questionnaire was validated by 3focus groups: CM practitioners (12 participants),physicians (12 participants), and patients (12 par-ticipants). The focus groups varied by sex and age,education, medical and/or CAM profession, andpersonal experience with CAM. Focus group par-ticipants were requested to comment on questionsin the initial questionnaire using a Likert scalefor each question’s relevance and comprehension.Participants were requested to write suggestionsfor improving questions when appropriate, andto add questions as needed. Thereafter, three ofthe authors (EB, ES, and LG) assessed partici-pants’ response qualitatively, and upon agreementchanges were made in the questionnaire.

tep III: Based on the focus groups’ appraisals, a refinedquestionnaire version was formulated and tested ina pilot study with 61 hospitalized patients in twointernal medicine departments. The pilot studywas performed in order to examine patient’s com-prehension of the questions and response to them,as well as for sample size calculation. The mainobservation in the pilot was that patients often donot comprehend the term DS, and need clarifica-tions regarding this term. Therefore, the researchteam concluded that: (a) a brief semi-structuredinterview would accompany the questionnaire, inan attempt to overcome communication barriers.(b) Questionnaires and interviews would be con-ducted by trained research assistants in order toassure study fidelity. Consequently, the sample sizewas calculated with Raosoft calculator. Based onprevious results showing 45—50% complementarymedicine use across different populations acrossnorth Israel, we determined the need for 320—340patients (confidence level 95% alpha-error of 0.05).We estimated that about 50% of respondents wouldreveal dietary supplements use in the hospitaliza-tion setting.

Hebrew-written questionnaires were given to patients8 years and above, who were able to communicate, androvide informed consent. 11 departments participated inhis study including 3 departments of internal medicine,B/GYN, and departments from various surgery specialties.

nterviewers approached each and every patient, roomy room to assess eligibility and willingness to participaten the study. The survey was conducted by 4th year CAM

ollege students trained in naturopathy. All surveyorsompleted 8 h of training in communication strategiesith patients in general, and specifically regarding DS, inddition to the study procedures. The interviewers were

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E. Ben-Arye et al.

nstructed to question patients beginning with rapportnitiation, followed by a questionnaire-based interview.he questionnaire started with a general question ‘‘haveou used DS and/or herbs in the previous year for healthssues’’. If patients reported such use, then further ques-ions would be asked regarding patterns of use (e.g. lengthf use, use during admission), and the context of usereasons for use, who recommended use and disclosure tohe family physician and the attending hospital physician).hen patients responded with a negative to the initial

uestion, the surveyor would then rephrase the question,sing predetermined keywords such as natural substancesnd remedies, folk/traditional herbs picked in the wild, anditamins, and would document the keyword that facilitatedhe disclosure. Interviewers would also document any othereyword (traditional medicines, folk medicine or specificames of DS, etc.) found to be of benefit.

tatistical analysis

nterview analysis was performed to detect keywords thatisclosed patients’ DS use and their correlation with demo-raphic and socio-cultural variables. Associations of gender,ge, education, religion, place of living, and country ofirth were determined using demographic and patients’ self-eported data. Data were evaluated using the SPSS softwarerogram (version 18; SPSS Inc., Chicago, IL). The Pearson �2

est and Fisher exact test were used to detect differencesn the prevalence of categorical variables and demographicata between participants who initially reported of DS usend patients disclosing DS use based on key words detection.lso, a t test was performed to determine whether thereere any differences in the continuous variables between

he two groups. Specifically, multivariate logistic regres-ion was used to assess univariate associations with thedds ratios of DS use among the interviewees. The logisticegression model included the following variables: age, gen-er, education, place of birth, residence type, and religion.

< 0.05 was considered statically significant.

esults

ata were provided by 691 of 895 patients approached dur-ng hospital admission (77.2% response rate). Of the 691articipants providing data, 359 (51.9%) reported using DSn the year prior to the survey. Of the 359 participants usingS, 168 (46.8%) disclosed DS use by referring to the stan-ard question on DS in the questionnaire. Detection of DSse with the other 191 interviewees (53.2%) was facilitatedy rephrasing the question with keywords during the inter-iew. Demographic characteristics of the two subgroups ofS users are detailed in Table 1.

haracteristics of DS users detected usingeywords versus standard questions

S users, that were detected by keywords were olderp = 0.027), less formally educated (p < 0.0001), residedore in rural areas (p < 0.0001), and were non-Jewish

mainly Arab Muslims, Christians, and Druze; p < 0.0001).

Right questions about herbal and dietary supplements 307

Table 1 Demographic characteristics of respondents.

Characteristics DS users (%)N = 359

DS users disclosedby standardquestion n = 168

DS users disclosedby keywordsn = 191

P value*

Sexa 229:130 105:63 124:67 NSFemale:male (%) (63.8:36.2) (62.5:37.5) (64.9:35.1)Mean age in years ± SD (median) 60.5 ± 18.5 (63) 58.2 ± 18.9 (58.5) 62.6 ± 17.9 (65) .027

EducationElementary school 72 (20.1%) 15 (8.9%) 57 (30%) <.0001High school 137 (38.3%) 56 (33.3%) 81 (42.6%) <.0001Academic 149 (41.6%) 97 (57.7%) 52 (27.4%) <.0001

Place of residenceUrban 283 (78.8%) 152 (90.5%) 131 (68.6%) <.0001Rural 76 (21.2%) 16 (9.5%) 60 (31.4%)

ReligionJewish 266 (74.1%) 146 (86.9%) 120 (62.8%) <.0001Non-Jewisha 93 (25.9%) 22 (13.1%) 71 (37.2%)

Country of birthIsrael 171 (47.6%) 80 (47.6%) 91 (47.6%) NSOther country 188 (52.4%) 88 (52.4%) 100 (52.4%)

NS, non-significant p > .05 SD = standard deviation.a fied a

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Majority of non-Jewish respondents (85 of 93) were self-identi* p-Value relates to comparison of DS users disclosed by standar

There was a similar gender distribution as well as country ofbirth in both groups (Table 1). A logistic multivariate regres-sion model was conducted to assess the independency ofthe above variables. Participants who disclosed DS use bykeyword facilitation (compared with participants disclosingDS use following standard question) were associated withnon-Jewish religion [EXP(B) = 3.020, 95% C.I. 1.401—6.509,p = 0.005], rural place of residence [EXP(B) = 3.201, 95%C.I. 1.456—7.036, p = 0.004], lower degree of education

[EXP(B) = 4.347, 95% C.I. 2.090—9.042, p < 0.0001], non-Israeli born EXP(B) = 1.976, 95% C.I. 1.098—3.555, p = 0.023],and older age [EXP(B) = 1.016, 95% C.I. 1.001—1.032,p = 0.039] (see Table 2).

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Table 2 Logistic multivariate regression model in the DS-users gfacilitation with interviewees disclosing DS use following the stand

Variables B P value

Age 0.016 0.039

Non-Jewish religion 1.105 0.005

Rural place of residence 1.163 .004

EducationElementary 1.469 <0.0001

High school 0.954 <0.0001

Country of birthOther country 0.681 0.023

Constant −2.365

CI, confidence interval.

s Arab Muslims, Christians, and Druze.stion vs. disclosed by keywords.

eywords and categories that revealed DS users

n Table 3, we present categories based on keywordshat revealed DS use among interviewees who ini-ially did not disclose this use when asked a standarduestion. From a practical perspective, we decided toroup four keywords under a category we named tradi-ional/herbal medicine (THM). The keywords under thisategory include: ‘‘natural’’, ‘‘folk/traditional/grandma

emedies’’, ‘‘infusions/teas’’, and ‘‘herbs picked in the gar-en’’. In a secondary analysis, we found that using one orore of the four THM sub-categories revealed DS use in 79

f the 191 (41.3%) non-disclosing interviewees in response

roup comparing interviewees disclosing DS use by keywordsard question.

EXP(B) 95% C.I. for EXP(B)

Lower Upper

1.016 1.001 1.0323.020 1.401 6.5093.201 1.456 7.036

4.347 2.090 9.0422.596 1.557 4.327

1.976 1.098 3.555

308

Table 3 Keyword-based categories that revealed DS useamong interviewees initially non-disclosing DS use.

Category Number of intervieweestraced by this category(% out of 191 DS usersdisclosed by keywords)

Naming some commonDS (e.g. Echinacea,garlic)

96 (50.6)

Vitamins 56 (29.3)Garden grown herbsa 44 (23)Traditional/folk/remediesa 24 (12.6)Natural remediesa 18 (9.4)Teas/infusionsa 18 (9.4)Minerals 18 (9.4)Remedies that

strengthen health14 (7.3)

Remedies you buy inpharmacy with noprescription

10 (5.2)

Asking by specificdiseases

8 (4.2)

Health-motivatedcooking

7 (3.7)

Remedies mentioned inTV, health programs,books, etc.

5 (2.6)

Asking on specific DSbrands

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generic category. 79 of the 191 (41.3%) interviewees disclosedDS use by one or more of the THM sub-categories.

o the standard question. 41.3% of the non-disclosingnterviewees, responded to one or more of the THMelated keywords, whereas 50.6% responded to keywordshat named common DS. A logistic multivariate regressionodel indicated that participants who disclosed DS usey THM keywords were non-Jewish religion [EXP(B) = 3.57,5% C.I. 1.70—7.50, p = 0.001], rural [EXP(B) = 3.02, 95% C.I..41—6.46, p = 0.004], with a lower degree of educationEXP(B) = 2.77, 95% C.I. 1.27—6.04, p = 0.01].

Compared with ‘‘naming common DS’’ (e.g. specificerbal remedies used in Israel, e.g. Echinacea, garlic),he THM keywords revealed DS use in rural (22% vs. 53%

< 0.0001), non-Jewish (30% vs. 62% p < 0.0001), Israeli-orn (39% vs. 73% p < 0.0001), and younger (64.9 ± 16.7 vs.5.9 ± 16.7, p = 0.03) respondents.

iscussion

any of the studies published on DS use focus on aspectsf prevalence, demographic characterization of users,atients’ motives for DS use, and implications of such usen the patient—physician—CAM practitioner triangle.32—34 In

his study, we focused on a more basic aspect: Do we knowow to ask our patients about the herbs and DS they use forreating their medical problems? We found that less thanalf of the patients surveyed disclosed such use following a

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E. Ben-Arye et al.

tandard question on ‘‘herbs and supplements used in pre-ious year for treating your medical problem’’. DS use wasevealed in the majority of users (53.2%) by the facilitationf specific keywords. This finding has implications both onuture studies regarding DS use, as well as on daily clini-al work. Future studies that assess various aspects of DSse should incorporate socio-cultural sensitive terms of DShat are appropriate for the study’s population. Failure to doo may compromise the study’s validity. In addition, physi-ians should be aware of challenges in communication witharious populations regarding DS, and acquire appropriateeywords that facilitate accurate history taking.

In our study, two major keyword-associated categoriesevealed more than 90% of initially non-disclosing DS users:aming common DS (disclosure of 50.6% of DS users) and these of THM keywords (41.3%). Indeed, we suggest that DSse disclosure may increase by using the following keywordsn addition to a standard question on DS use: Do you useS or herbs including products picked in the garden, infu-ions/teas, natural/folk/traditional remedies, or productsimilar to [name some common DS] for your health issues?

In previous studies, we reported that Israeli Arabs useraditional herbal medicine significantly more than Israeliews.35,36 In the current study, we found that detectingS use by THM-related keywords was more effective inrab patients, residents of rural areas, and people with

ower degree of education. The association of these threeariables may be relevant to Western societies that pro-ide health services to people with similar socio-culturalackgrounds. Several studies conducted among culturalinorities in the US and other developed countries suggest a

inkage between socio-cultural background and the specificse of traditional and herbal medicine.5,37 Furthermore, aew studies suggest the DS use may characterize two distinc-ive socio-cultural traits: moderate to high socio-economicS users using ‘‘modern’’ DS (drug-like tablets/capsules),nd consumers of traditional and herbal non-processed sup-lements who are associated more with social—culturalinorities.6,38,39 Although much more research is warranted

o verify these two distinct populations of DS users, thenclusion of THM keywords in patients’ anamnesis may notust enhance DS use disclosure, but may also facilitate bet-er communication with cultural minority groups affiliatedith THM use.

Our study’s major limitation is pertinent to local socio-ultural characteristics and communication patterns. Thesepecific cultural characteristics may have contributed to theeluctance of interviewees from minority groups to discloseS use in apparently conventional setting associated withhe dominant Israeli medical practice. Potential intervie-ees’ hesitation to disclose DS use may be related to biasederception regarding the definition of DS (e.g. is the tea

pick in my garden considered DS?). Also, this hesitationay be related to a judgmental contextual perception of DSedical use (e.g. disclosing the use of apparently primitive

ome-made remedies versus sophisticated high-tech hospi-al interventions). Future studies related to DS use shouldnclude qualitative methodologies to increase the validity

f such research, and to inform the medical community onnamnestic nuisances. Another study limitation was the lackf Arabic and Russian versions of questionnaires that mayave discouraged patients from minority groups to disclose

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DS use. In addition, a follow-up study should be conductedto evaluate the suggested key words for revealing DS use, inorder to confirm their anamnestic sensitivity.

Conclusions

We suggest that anamnesis regarding DS use can be facil-itated, particularly in societies with cultural diversity, bythe use of THM-related keywords, as well as mentioningnames of common DS. We recommend educating physiciansregarding DS associated communication barriers and theircorresponding pragmatic facilitators. We hope that theserecommendations will promote a better and safer communi-cation between physicians and the diverse populations theyserve, as well as improve validity of future studies in thisfield.

Conflict of interest

All authors declare of no conflicts of interest.

Acknowledgments

We acknowledge Ms. Silvi Auerbach, Ms. Rita Stern, Ms.Anat Melamed, Ms. Ramzia Sarouzi, Ms. Alexandra Kamladi-nov, Ms. Shani Shitrit, Ms. Nur Zahawa, Ms. Wafa Halabi,Ms. Rana Huri, Ms. Riham Hanifes, Ms. Missa Abu-Hussein,Ms. Rachel Alberg, Ms. Meital Attias, Ms. Yulia Korshov, Ms.Dikla Cogan, Ms. Marina Ukon and Ms. Michal Fassoua fortheir contribution in interviewing patients; Mr. Alon Raz formethodological counseling and Ms. Ronit Leiba for the sta-tistical analysis.

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