Healthcare Professionals and Patient Perceptions on the Use of Herbal Medicines to Control Diabetes Mellitus and Hypertension in Nigeria

The perception that herbal medicines are generally safe and non-toxic, has all necessitated patients' use of herbs in the management of diabetes and hypertension. The study evaluated healthcare professionals' and patients' perceptions of the use of herbs to control diabetes mellitus (DM) and hypertension . The study utilized a randomized sampling method for the survey; an online form was designed and used for data collection. The questionnaire was sent to professional and non-professional groups having the target population (patients and relatives. The results showed that the majority of the participants stated the use of Vernonia amagdalena in the management of HTN (33.0%) and DM (9.9%). Other plants mentioned include Moringa leaves HTN n (5.5%), DM n(6.6%); Carica papaya ; HTN (9.9%), DM (8.2); Ginger, and DM (12.6%). Dogoyaro/Agbo (4.9%). Notable antidiabetic plants reported in this study include Rauwolfia vomitoria (1.1%), Ugu leaves (2.2%),


INTRODUCTION
The prevalence of diabetes mellitus (DM) is one of the most alarming statistics concerning health problems globally. The major concern regarding this observation relates to the development of the chronic complications associated with DM such as microvascular such as retinopathy, nephropathy, and neuropathy or macrovascular which is cardiovascular disease (CVD) including hypertension, cerebrovascular accidents (CVA), and peripheral vascular disease (PVD). It is well-recognized that DM and Hypertension negatively affect the quality of life in individuals. A non-communicable disease (NCD) is a non-infectious health challenge the complications of diabetes cause considerable morbidity and mortality worldwide and, as such, cannot be spread from one individual to another. The disease condition can progress for a long period in an individual. This condition is otherwise referred to as a chronic disease. Some risk factors may include detrimental diets, inadequate physical activity, smoking, passive smoking, and inordinate use of alcohol (Judith & Erica, 2018). NCDs are frequently dominant in low-income and middleincome countries. The World Health Organization (WHO) estimated that by 2020, 80% of global deaths will be attributed to NCDs. In sub-Saharan Africa (SSA) alone, the NCDs burden is expected to increase by 27% in that time frame (WHO 2013; Andrew et al., 2020).
The major types of NCDs are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), and diabetes (WHO 2021). Excess salt/sodium intake has been attributed to over 4.1 million deaths annually, which is a risk factor for cardiovascular disease. About 1.5 million annual deaths attributable to alcohol use are from NCDs, including cancer (WHO 2021). Over 1.6 million deaths annually can be attributed to low physical activity (James et al., 2018). The practice of nature cure (herbs) provides a way of understanding the scale and scope of the non-communicable disease as a public health crisis (WHO 2021). Hypertension is a common global health challenge. Hypotension is dangerous because it causes the heart to very hard and contributes to atherosclerosis, besides increasing the risk of heart disease and stroke, it can also lead to other conditions such as congestive heart failure, kidney disease, and blindness. About 75 to 80% of the world population use herbal medicines, mainly in developing countries, for primary health care because of their better acceptability with the human body and lesser side effects. In the last three decades, a lot of concerted efforts have been channeled into researching the local plants with hypotensive and antihypertensive therapeutic values (Tabassum, & Ahmad, 2011).
Patients may choose to supplement their pharmacological regimen with dietary supplementation in many forms, like vitamin and/or mineral mixtures, but the most popular supplements taken by the patients are those considered to be of natural origin, (herbal medicine). Regrettably, significant controversy exists regarding the efficacy of dietary supplements in general and that of herbal medicines, particularly regarding pathophysiological factors related to the treatment of patients with type 2 diabetes. The controversy exists because reported efficacy data for many natural products are only in the form of uncontrolled studies and anecdotal reports. Thus, poor quality control measures may also cause inconsistent effects for certain herbal medicines. There is a paucity of consistent and reproducible efficacy data in humans to suggest any recommendations for most herbs or bioactive supplements as adjunct treatments for risk factors related to diabetes. Traditional, complementary, and alternative medicine (TCAM) comprises indigenous healthcare practices that do not include an orthodox healthcare system o intervention. In the African setting, it may account for local herbal medicines or products, and indigenous healthcare practices (James et al., 2018). It is therefore important to access the public opinion on the use of herbs to control this diabetes mellitus and how effective they are in maintaining their blood sugar levels considering the cost burden. The economic burden of orthodox medicines and the major risk factors of NCDs like diabetes and hypertension has been attributed to modernization, the perception that herbal medicines are generally safe and non-toxic, has all necessitated patient's use of herbs in the management of diabetes and other similar conditions hence justifies the need to evaluate the impact of herbal medicines in disease prevention, health promotion, and public health. The study evaluated healthcare professionals' and patients' perceptions of the use of herbs to control diabetes mellitus (DM) and hypertension.

Study design
The study will be a descriptive, cross-sectional study using a questionnaire (online or physical). The survey instrument will be developed based on a literature review of diabetes mellitus, including its medications and preventive measures. A wellstructured questionnaire, which will include three sections. The first section comprises the demographic characteristics of the participants such as age, gender, place of work, and years of experience. The second section will be regarding the knowledge of NCDs, hypertension, and diabetes mellitus in particular and prevalence, and the last section will estimate the attitude and perception of herbal medication in diabetes and its relevance in health promotion, disease prevention, and public health.

Study area and setting
The study will be conducted in Nigeria. Based on the United Nations estimates that the population of Nigeria as of September 2017 was 193.3 million (Worldometers.info, 2017). The pooled hypertension and Diabetes Mellitus (DM) prevalence of 5.77% observed in a meta-analysis suggests that 11.2 million Nigerians (1 out of every 17 adults) are living with DM and hypertension.
Regional differences in the prevalence of DM and hypertension, with the highest rate observed in the South-South region of Nigeria and the lowest rate seen in the North-Western zone (Gezawa et al., 2013).

Sample size determination
Diabetes mellitus and hypertension are major causes of morbidity and mortality both in developing and developed countries like Nigeria, hence, every individual above 18 years of age will be recruited physically or online for the survey. The estimated target population size was two and fifty (250) individuals, drawn from both healthcare providers and patients or patient's relatives, especially those that have previously prescribed, dispensed, or used herbal preparation in the management of diabetes mellitus and hypertension. A total of one hundred and eighty-two (182) online responses were retrieved from the survey, the same was used for the data analysis as presented in chapter three.

Eligibility criteria
Inclusion criteria -patients, patient relatives, who might have directly or indirectly experienced diabetes, current diabetic patients and relatives, and healthcare providers above 18 years of age, from every part of Nigeria.

Sampling methods and study instrument
A randomized sampling method was used for the survey (clearly describe the randomization unambiguously here), and an online form was designed and used for data collection. The form (questionnaire) was sent to professional and nonprofessional groups having the target population (patients and relatives).

Validation of study instrument
The online questionnaire (google form) was designed and forwarded to the project supervisor for content evaluation and modification. The content was evaluated and subsequently corrected by the supervisor. Thereafter, it was sent and distributed across various social media platforms to generate data from healthcare providers, patients, and patient's relatives.

Outcome measures
Healthcare professionals and patient's or patient relatives' perceptions of the use of herbs to control diabetes mellitus (DM) and hypertension, with regards to the type, effectiveness, and relative safety compared to orthodox medicine.

Data analysis
Data generated from the survey were analyzed using one-way analysis of variance (ANOVA) with SPSS software version 23.0, and GraphPad Instat Version 3.0.

RESULTS AND DISCUSSION
Data revealed that more females participated in the study compared to their male counterparts, with a percentage distribution of 54.9% (female) and 45.1% (male) respectively. With

Location of Study Participants
Participants were drawn across Nigeria, as Google form was distributed in all possible social platforms to generate responses. The majority of the participants were Lagos state (13.7%), this was closely followed by Anambra (11.0%), Bayelsa (10.4%), Oyo (7.7%), Delta (7.1%), Akwa Ibom (7.1%), and Imo (6.6%) states, respectively.       Several Nigerian medicinal plants have been reported to possess antidiabetic and antihypertensive properties. The study revealed some species of Nigerian medicinal plants with anti-diabetic and antihypertensive properties based on evidence-based and first-hand experience by healthcare providers, patients, and patient's relatives. Data revealed that more females participated in the study compared to their male counterparts, with a percentage distribution of 54.9% (female) and 45.1% (male) respectively. With a 12.7 standard deviation from the mean (this is presented in Table 1). This could be due to the inability of some persons not having internet access or data subscription as at the time of the survey, etc. The study was conducted nationwide, hence participants were drawn across all the states including FCT of Nigeria, as Google form was distributed on all possible social media platforms to generate responses. The majority of the participants were Lagos State (13.7%), this was closely followed by Anambra (11.0%), Bayelsa (10.4%), Oyo (7.7%), Delta (7.1%), Akwa Ibom (7.1%), and Imo (6.6%), Enugu (6.0%), Rivers and Osun state (4.4% each), FCT (3.8%), Ogun (3.3%), states, respectively. Fewer responses were gotten from the Northern part of Nigeria such as Kwara, Kaduna, which were 2.2% each, and 1.6% from Gombe state (this is shown in Figure 1.). This shows that majority of the participants were from the western part of Nigeria, where most herbal medicines or traditional medicines practice is well known across Nigeria.

Age Distribution and Religion of Participants
It is generally believed that religion always affects the perception and the pattern of how people live and make their choices as regards to management and treatment of certain ailments using orthodox or herbal medicines, respectively. From the survey, it was observed that the majority of study participants were young people, while the rest population was distributed across various age groups. 51.6% out of the total population were between the age group of 26 -39, 36.3% were 40 -59 years of age, 11.0% were between 18 -25 years and only 1.1% were between 60 -79 years old ( Table 2). It is believed that religion affects the lifestyle and use of certain remedies in the management of various disease conditions. Almost all participants (94.5%) were Christians, while 5.5% Muslims were recorded. 65.9% were married, 30.8% were single while 3.3% were either widows or widowers (this is presented in Table 3). Similar results were in a study conducted by Judith and colleagues in 2018, where most of the survey respondents were more of young persons, etc., (Judith & Erica, 2018).

Educational background and Category of participants
Another factor that might influence the use of some (herbal of orthodox) remedies to a very large extent is the level of exposure which could be attributed to the standard or level of education one has acquired. About 2.2% of the participants had no formal education, 4.4% had secondary education, while 93.4% had tertiary educational qualifications, with some having Postgraduate diploma -PGD (12.1%), Master of Science -MSc (39.7%), and Doctor of Philosophy -Ph.D. (20.9%), respectively. 37.4% of the participants had no higher education (this is shown in Table 3.4). Different categories of participants were observed in the study, based on an online form designed to generate their responses. The majority of the participants (25.3%) were healthcare providers, 25.3% were pharmacists, 1.1% were medical doctors, 2.2% were medical laboratory scientists, while 23.1% each were patients and patient's relatives respectively. More than half of the study population (50.5%) were government or public servants, 28.6% were private or NGO workers. Almost all the subjects (74.7%) were staying with their immediate family (i.e., spouse and/or children), while 16.5% stays alone, 2.2% stays with health caregivers, while 6.6% lives with minos ( Table 5).
The social lifestyle of individuals often affects the substances (herbal or orthodox) they consume. Almost all participants use or take salt (93.4%), 39.6% consume alcohol and related substances, 81.3% take sugar while only 3.3% smoke cigarettes. 71.4% participate in a deliberate exercise, and 17.6% reported having experienced food allergies/reactions (Table 6), this also relates to the study by Judith & Erica, (2018). Participants had the correct knowledge on hypertension and diabetes mellitus. 84.6% indicated they know about diabetes, while 83.5% indicated their understanding of hypertension. 13.2% and 24.2% have experienced diabetes and hypertension respectively. Also, a higher percentage of the population affirmed that their relatives currently or have managed either diabetes or hypertension.

Assessment of diabetes and hypertension
It was observed that the majority of the participants assess their blood sugar (28.6%) and pressure (29.7%) once every month. 40.7% of the population uses orthodox medicines while 18.7% sort after herbal medicines in the management and treatment of diabetes and hypertension, respectively. 35.2% and 27.5% had prior knowledge of herbs used in the management of diabetes and hypertension, respectively. Finally, 7.1% believe that herbal medicines are more effective than the conventional medicines currently used in the treatment of diabetes and hypertension. Some of the participants stated that they only check their sugar (22.5%) or blood pressure (18.7%) when symptoms persist (Table 8, shows this information).

Cost-effectiveness of herbal medicines
The cost of treatment is another factor that has been reported to influence the use of medicinal agents by different individuals. A greater proportion of the participants (32.4%) stated that herbal medicines are more cost-effective than their conventional (orthodox) counterparts. Also, 25.3% thought that herbal medicines have helped improve their lifestyle in the management of diabetes and/or hypertension (Table 10). On a general note, many of the participants perceive that herbal medicines are more cost-effective than orthodox medicines.

Correlation Analysis of Categories of Participants and Perception, Previous Knowledge on Diabetes, Hypertension, and the Use of Herbal Medicines
There was significant relationships between the participant's previous knowledge of diabetes, hypertension, and the use of herbal medicines. In line with this, there was a positive significant difference among the participants' category and previous knowledge on diabetes mellitus. Also, participants were not aware of the use of herbal medicines in the treatment of diabetes mellitus and hypertension. It was then observed, among the participants, pharmacists were 100% aware of the use of herbal medicines in the management of diabetes and hypertension. This could be attributed to the undergraduate and postgraduate curriculum currently obtainable in all accredited Schools of Pharmacy.

CONCLUSION
The participants of this study had previous knowledge and use of herbal medicines. Some believe that herbal medicines can relieve disease within a very short period, are effective at the right dosage, have fewer side effects or no side effects at the right doses, and can affect a complete cure if standardized, affordable, and better tolerated in the body. Bitter leaf was the most frequently reported plant used in the management of diabetes and hypertension by study participants. Some stated that Bitter juice helps to check diabetes, while scent leaf (Ocimum gratiscimum) juice and Ugu juice are used for BP control with minimal side effects, quick onset of action, possibilities of treating other unknown diseases, decreased blood sugar, decreased cholesterol level, decreased blood sugar, decreased cholesterol level, easy access, and costeffectiveness. There was a significant difference among participant's category and their previous knowledge and perception of the use of herbal medicines in the management of diabetes and hypertension at p-value < 0.05.