Comparison of Adherence to the Use of Herbal Medicine with Conventional Medicine in Hypertensive Patients at Lempake Public Health Center , Samarinda City

Background: Hypertension is major health problem worldwide, including Indonesia. The use of herbal medicines for hypertension has increased in the past decade. The price of herbal medicines considered cheaper with fewer side effects. This study tried to see the level of adherence to the use of medicine by hypertensive patients in community health center at Samarinda City, East Kalimantan. Methods: This study conducted at Lempake Community Health Center in Samarinda City from July until August 2017. The subjects of this study are 63 hypertensive patients and meet the sample criteria set by the researchers. The study interviewing hypertensive patients with MMAS (Morisky Medication Adherence Scale) questionnaire. Results: The results showed 56% of hypertensive patients also use herbal other than conventional medicine. Soursop (Annona muricata) leaves, salam (Syzygium polyanthum) leaves, and cucumber (Cucumis sativus) fruit were the most frequent herbal medicines used by hypertensive patients. The mean blood pressure of herbal medicine users was significantly lower when compared with conventional medicine users for systolic (p=0.004; 95% CI -19.8 – -3.8) and diastolic blood pressure (p=0.038; 95% CI -9.6 – -0.29). The mean score of MMAS in herbal medicine users was significantly higher when compared with conventional medicine users (p=0.004; 95% CI 0.31 – 1.6). This suggests that patients are more adherent in using herbal than the conventional medicine for hypertension. Conclusion: The result of the study shows the need for herbal and conventional medicine education for hypertension in the community. The result also shows better patient adherence to herbal medicine compared to conventional medicine, as the promising future of herbal medicine for hypertension. (Health Science Journal of Indonesia 2018;9(2):82-6)

Hypertension is a condition when blood pressure increases chronically.Hypertension happens when the heart works harder to pump blood to meet the needs of oxygen and nutrients in the body.Hypertension may interfere with the functioning of other organs, especially vital organs such as the heart and kidneys.The hypertension criteria are the result of measurement of systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg 1 .Hypertension prevalence in Indonesia is 25.8%, with the highest prevalence in Bangka Belitung (30.9%), followed by South Kalimantan (30.8%),East Kalimantan (29.6%) and West Java (29.4%) 2 .
Herbal medicine defined as traditional medicine derived from plants, including herbs, herbal materials, herbal preparations, and finished herbal products that contain active ingredients in parts of plants 3 .Data from Ministry of Health Republic Indonesia shows that 49% of households use traditional herbal medicine.Sixty percent of Indonesians adult stated that they had ever been drinking herbal medicine, and 90% of them stated that there was a benefit of drinking herbal medicine 4 .
Traditional herbal medicine has been widely practiced in Indonesia.The use of herbal medicine for hypertension has increased in the past decade.The price of herbal medicines is considered cheaper with fewer side effects 5 .Research about herbal medicine usage for hypertension as the most frequent chronic diseases in Indonesia is still limited.To the best of our knowledge, there is no published research about the herbal medicine adherence for hypertension.Based on the above information, the aim of the study is to know the differences between herbal and conventional medicine adherence in hypertensive patients particularly at the primary healthcare settings.

METHODS
This study was conducted at Lempake Community Health Center in Samarinda City from July until August 2017.Lempake is a district in Samarinda City dominantly transmigrant people from Java.Sociocultural for herbal medicine from Javanese people are higher than others ethnic.The subjects of this study were 63 hypertensive patients and met the sample criteria set by the researchers.Research variables include blood pressure, herbal and conventional medicine use for hypertension and adherence to herbal and conventional medicine for hypertension.
Inclusion criteria are all hypertension patients who came to the Lempake Public Health Center and willing to participate in the study.Exclusion criteria are patients who have any other chronic diseases related to hypertension, like diabetes or heart diseases.The study uses non-random sampling or convenience sampling.All hypertension patients got lowering blood pressure drug from the public health center, but in the interview, researchers asked about whether they use any herbal medicines or not.
Researchers measured blood pressure using mercury tensimeter which is available in the public health centers.Patients were measured three times every one minute and took the average of systolic and diastolic value.There was one researcher who did the blood pressure measurement and one researcher who did the interview.There were blinding the principle by using two separate room for blood pressure measurement and interview to the patients.Each researcher did not know the level of the patient's blood pressure or status of their medication.The study protocol was approved by the Research Ethics Committee on Faculty of Medicine Mulawarman University.
Data were obtained from the medical record and interview using questionnaires to hypertension patients at the community health center.Level of adherence to herbal and conventional medicine for hypertension were measured by MMAS (Morisky Medication Adherence Scale) questionnaire.We performed a preliminary study for 10 patients to validate the questionnaire.There were 8 questions in MMAS: ever forget to take medicines; ever not taking medicines in last 2 weeks; stop taking medicines when feeling worse with medicines; ever forget to bring medicines when travelling; take medicines yesterday; when feel better stops taking medicines; have problems adhering to take medicine; have problem remembering to take medicine 6 .MMAS-8 questionnaire showed in Table 1.Obtained data were then statistically analyzed by independent t-test using PSPPIRE 1.0.1 software with the level of confidence at 95% (p <0.05).

RESULTS
The result of the study shows thirty-five (56%) hypertension patients reported using herbal medicine.The most frequent herbal medicines used by hypertensive patients are soursop (Annona muricata) leaves (39.4%), salam (Syzygium polyanthum) leaves (30.3%) and cucumber (Cucumis sativus) fruit (30.3%).Table 2 and 3 show characteristics of respondent and types of herbal medicine in this study.The mean blood pressure of herbal medicine users was significantly lower when compared with conventional medicine users for systolic (p=0.004;95% CI -19.8 --3.8) and diastolic blood pressure (p=0.038;95% CI -9.6 --0.29).The mean score of MMAS in herbal medicine users was significantly higher when compared with conventional medicine users (p=0.004;95% CI 0.31 -1.6).Levene's test for MMAS score with significance = 0.559 and it means equal variance assumed.Figure 1 and 2 show differences of blood pressure and MMAS score between herbal and conventional medicine users.

DISCUSSION
The results of this study show that 56% of hypertensive patients use herbal medicines as complementary therapies.This is the similar result with another research found that almost half of the respondent in Indonesia use herbal medicine, with a quarter of the respondent use herbal medicine for treating hypertension 7 .Similar result with another study found that 70.9% of patients with hypertension also uses natural medicines 8 .It also found the soursop leaves, salam leaves, and cucumber fruit are the most frequent herbal medicine used by hypertensive patients.The results of this study are slightly different from the national standard antihypertensive herbal formulation consisting of medicinal plant extracts, including celery (Apium graveolens) herbs and whiskers cat (Orthosiphon aristatus) leaves.These herbal medicines have been officially recommended for hypertension by the Ministry of Health, Republic of Indonesia 5 .
The result of this study shows that systolic and diastolic blood pressure of herbal medicine users was lower than conventional one.This is the similar result with another study that the decrease in diastolic blood pressure in conventional drug combination with natural medicine was better than that of conventional drug alone 9 .Other study found that patients who underwent conventional medicine along with herbal medicine, had a better quality of life, compared to patients who only underwent herbal medicine 10 .
All of these medicinal plants have the scientific base for antihypertensive effects.The results of this study show that hypertensive patients use soursop leaves to lower blood pressure.This is in accordance with studies showing that extracts of soursop leaves can significantly reduce blood pressure without affecting heart rate 11 .The hypotension effect of soursop leaves extracts through a peripheral mechanism involving calcium ion antagonists with blockade of calcium ion channels 12 .The hypotension effect of soursop leaves is caused by alkaloid content such as coreximine, anomurine, and reticulin, as well as some components of essential oils such as b-caryophyllene 13 .The results of this study show that hypertensive patients use salam leaves to lower blood pressure.The mechanism of action of salam leaves as antihypertensive through the binding of adrenergic and cholinergic beta receptors with nitric oxide 14 , and through ACE inhibition 15 .It shows that hypertensive patients use cucumbers to lower blood pressure.This is in accordance with studies showing that administration of cucumber juice can decrease diastolic blood pressure between treatment groups compared with the control group 16 .
The result of this study shows that MMAS score for herbal medicine was higher than conventional medicine.This suggests that patients are more adherent in using herbal than the conventional medicine for hypertension.Adherence to treatment is mainly influenced by the patient perception towards the effectiveness of treatment and the health care quality (its availability and affordability, and the relationship between patient and provider).In the event where care provided by a conventional health system is dissatisfactory, patients seem more likely to use alternative care known as herbal medicine 17 .Interest in herbal medicines was commonly attributed to three main reasons: lack of funds to go to the hospital, pressure from relatives and friends, and the desire for a complete cure 18 .Many factors could play a role in the decision-making, including previous experience with the conventional drug, openness to herbal therapy, and cost associated with conventional drug and herbal therapy 19 .
This study has limitations.First, we conducted interviews at a community health center in Samarinda City, East Kalimantan.Our results could not be generalized to other regions without caution and studies.Second, we interviewed patients who came to the interview sites.If this convenience sampling had better medication adherence than those who were not surveyed, our findings of adherence level could be overestimated.However, our study focused on the comparison between herbal medicine and conventional drug users.Thus, the potential sampling bias is less likely to influence our results.
In conclusion, the results showed 56% of hypertensive patients also use herbal medicine other than conventional medicine.Soursop (Annona muricata) leaves, salam (Syzygium polyanthum) leaves, and cucumber (Cucumis sativus) fruit were the most frequent herbal medicines used by hypertensive patients.The mean blood pressure of herbal medicine users was significantly lower when compared with conventional medicine users for systolic and diastolic blood pressure.The mean score of MMAS in herbal medicine users was significantly higher when compared with conventional medicine users.This suggests that patients are more adherent in using herbal than the conventional medicine for hypertension.The result of the study shows the need for herbal and conventional medicine education for hypertension in the community.The result also shows better patient adherence to herbal medicine compared to conventional medicine, as the promising future of herbal medicine for hypertension.

Morisky
Medication Adherence Scales: MMAS-8 1 Do you sometimes forget to take your pills? 2 People sometimes miss taking their medications for reasons other than forgetting.Thinking over the past two weeks, were there any days when you did not take your medicine?3 Have you ever cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it?4 When you travel or leave home, do you sometimes forget to bring along your medicine?5 Did you take all your medicine yesterday?6 When you feel like your symptoms are under control, do you sometimes stop taking your medicine?7 Taking medicine every day is a real inconvenience for some people.Do you ever feel hassled about sticking to your treatment plan? 8 How often do you have difficulty remembering to take all your medicine?(a) Never/rarely; (b) Once in a while; (c) Sometimes; (d) Usually; (e) All the time.

Table 2 .
Characteristics of respondents at Lempake Community Health Center, Samarinda City, 2017

Table 3 .
Types of herbal medicine used by respondent at Lempake Community Health Center, Samarinda City, 2017