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Medical and health science Students' knowledge, attitude, and practice towards complementary and alternative medicine in University of Gondar

Open AccessPublished:September 22, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101148

      Abstract

      Background

      Complementary and alternative medicine (CAM) is a well-known medical science that uses a variety of therapeutic strategies and approaches to effectively prevent and treat a wide range of human ailments. Determining graduating medical and health science students' knowledge, attitude, and practice regarding CAM can help in the integration of these systems into the health care system at large in a healthy manner. Therefore, this study aimed to assess the level of Knowledge, Attitude, and Practice (KAP) of CAM among the University of Gondar (UOG) graduating medical and health science students.

      Methods

      An institutional-based cross-sectional study was conducted from June 13 to July 26, 2021, at the University of Gondar, college of medicine and health science, Gondar, Northwest Ethiopia. Descriptive statistics were calculated for baseline characteristics. Bivariate and multivariate logistic regression were used to identify the association between dependent and independent variables.

      Results

      The study included 302 students, making the response rate 98.05%. The mean age of the participants was 23.5 ± 1.4 years. About 80(26.5%) of respondents appeared to have good knowledge. Knowledge about CAM was significantly greater among pharmacy students compared to medical students at 4.852(95% CI-1.831, 12.859). About 86% of students had a positive attitude toward CAM. This study revealed that females had 0.042 times less likely positive attitude towards CAM than male students (95%CI-0.008, 0.210). The most common CAM modality amongst all was nutritional therapy, at 35.8%. Regarding to students' overall practice, 101(33.5%) of students had good practice. pharmacy students had 2.527 times more good practice than medical students (95% CI-1.001, 6.379). Whereas, nursing students were 0.375 times less likely to have good practice than medical students (95% CI-0.141, 0.999).

      Conclusion

      As the finding of this study indicates, despite students' positive attitudes towards CAM, their knowledge and practice are poor.

      Keywords

      Abbreviations

      AOR
      Adjusted Odds Ratio
      CAM
      Complementary and Alternative Medicine;
      CI
      Confidence Interval
      COR
      Crude Odds Ratio
      ETB
      Ethiopian Birr
      FMHACA
      Food, Medicine and Health Care Administration and Control Authority
      HI
      Health Informatics
      HO
      Health Officer
      KAP
      Knowledge, Attitude and Practices
      MoSH
      Minister of science and health education
      OR
      Odds Ratio
      SoP
      School of Pharmacy
      SPSS
      Statistical Package for the Social Sciences
      UOG
      University of Gondar
      WHO
      World Health Organization

      1. Background

      The terms “complementary” and “alternative” medicine are used to describe a wide range of healthcare methods that are not part of a country's traditional medical practices or are not integrated into its main healthcare system.
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      Attitudes and perceptions of medical and health science students towards CAM in many countries were generally positive. The lack of evidence supporting CAM practices was considered to be the major barrier to more students using CAM and advising their patients to use CAM in the future.
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      A cross-sectional survey conducted in China indicated that most of the undergraduates had a positive attitude toward CAM. Also, 72.3% of those who had not attended CAM courses wanted to know more about CAM.
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      In addition, a study conducted in Wollo showed that there was a statistically significant difference in knowledge and attitude between those class years who had received CAM lectures and those who have not received lectures.
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      Assessment of knowledge and attitude of wollo university pharmacy students towards complementary and alternative medicine, north east Ethiopia.
      Even though CAM is increasingly being taught at medical schools across the world, only a few studies have been conducted to examine health professional students' attitudes toward CAM and its necessity of CAM.
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      • et al.
      Attitude of Saudi medical students towards complementary and alternative medicine.
      The use of CAM therapies has been increasing in the majority of Ethiopian populations, but the debate about the clinical efficacy of these therapies has been controversial amongst many medical professionals.
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      Due to poor access to health services, comparatively low cost, low level of technological input, and growing economic importance of CAM make Ethiopians have a positive and respected attitude towards CAM, yet very little attention is paid to the integration of the practice of traditional medicine into the formal health system.
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      and community members.
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      • Getahun K.A.
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      ,

      Chali BU, Hasho A, Koricha NB. Preference and practice of traditional medicine and associated factors in jimma town, southwest Ethiopia. Evid base Compl Alternative Med. 202120; 2021.

      However, there is still a scarcity of information on CAM use among health professional students. Thus, the current research was conducted simultaneously among students from various branches of health sciences. Even though CAM plays a major role in Ethiopian society, understanding of the scope and features of these practices is limited, and it has not yet been thoroughly explored if such practices are based on sufficient information about their safety and efficacy. Furthermore, there is also limited evidence on the scientific basis for the safety and efficacy of the majority of CAM practices. Therefore, determining graduating medical and health science students' knowledge, attitude, and practice regarding CAM can help in the integration of these systems into the health care system at large in a healthy manner, because today's graduating students are the healthcare professionals of the next generation who will influence the creation and application of related policies in the future. Therefore, this study was designed to assess the level of KAP of CAM among the University of Gondar graduating medical and health science students.

      2. Methods

      2.1 Study area and period

      This study was conducted at University of Gondar, College of medicine and health science, from June 13 to July 26, 2021. University of Gondar is found in Gondar town. Gondar is a wide, oldest, and historical town situated in, Amhara regional state, North West Ethiopia. It is located 750 km from Addis Ababa, the capital city of Ethiopia, and 180 km from Bahir Dar, the capital city of Amhara National Regional State. According to the 2019 national census conducted by the central statistical agency of Ethiopia, the total population size of Gondar town was estimated to be 500,788. UOG is one of the oldest institutions in Ethiopia. Established as the Public Health College and training campus center and it has been serving the community since 1954. University of Gondar has five campuses but the study was conducted on the college of medicine and health science campus.

      2.2 Study design and participants

      An institutional-based cross-sectional study was conducted on knowledge, attitude, and practice towards CAM among graduating medical and health science students at University of Gondar. All graduating medical and health science students, enrolled in an undergraduate program at the University of Gondar during the study period were included. And those students who were not available on campus during the data collection period were excluded.

      2.3 Sample size and sampling procedure

      An appropriate sample was estimated by using a single proportion formula.
      • Lwanga S.K.
      • Lemeshow S.
      • Organization W.H.
      Sample Size Determination in Health Studies: A Practical Manual.
      P = 50% level of knowledge, was used, as there was no study conducted in the study area to the best of literature search made. Since the population was drawn from the gross population of 1034, which is < 10,000, the required final sample size was determined after applying the correction factor. A sample size of 308 was estimated by using a 5% margin of error, a 95% confidence interval with a probable non-respondent of 10%. A stratified random sampling technique was used and the final sample was classified into 12 departments. Then a proportional number of students were randomly selected for this study according to their department and gender (Fig. 1).

      2.4 Study variables

      The dependent variables of the study were knowledge, attitude, and practice. And age, gender, the field of study, duration of the study, types of student accommodation, place of birth, and parents' educational status were independent variables.

      2.5 Data collection instrument and procedure

      A self-administered questionnaire printed as a hard copy was used as the instrument for data collection. The questionnaire contained both closed-ended and open-ended questions. It was adapted and developed following a detailed review of previous relevant works,
      • Ashraf M.
      • Saeed H.
      • Saleem Z.
      • et al.
      A cross-sectional assessment of knowledge, attitudes and self-perceived effectiveness of complementary and alternative medicine among pharmacy and non-pharmacy university students.
      • Awad A.
      • Al-Ajmi S.
      • Waheedi M.
      Knowledge, perceptions and attitudes toward complementary and alternative therapies among Kuwaiti medical and pharmacy students.
      • Emiru Y.K.
      Community pharmacists' knowledge, attitude and professional practice behaviors towards dietary supplements: results from a multi-center study in Ethiopia.
      with some modifications. The questionnaire was constructed in the English language and it was pre-tested on 15 students. The final version of the pre-tested questionnaire was composed of four sections for collecting data on the socio-demographic, knowledge, attitude, and practice of study subjects, with a total of 31 questions. It also included a question concerning knowledge, attitude, and practice of 10 CAM modalities. An explanation of the purpose of the research was given to participants. Those who agreed to take part in the study were given the questionnaires and were asked to return them anonymously after being completed. The data was collected by three 5th year undergraduate pharmacy students from different graduating medical and health science students. However, the data collectors were not included in the current study.
      The questionnaire was pre-tested for content, design, readability, and comprehension on 5% of the total sample size (15 medical and health science students who were attending class at the University of Gondar, and who were not included in the final analysis). Based on the result of the pre-test, corrections and modifications were made as necessary. The reliability of the questionnaire was checked with a Cronbach's Alpha value of 0.705. The data collectors were given one day of training on the instruments and method of data collection and the purpose of the study was clearly explained. On-spot checking of the filled and returned questionnaire for accuracy and completeness of data was done daily. Data collectors explained the contents of the questionnaire to the respondents during data collection time.

      2.6 Data analysis

      SPSS version 20 (IBM-SPSS Inc, Armonk, NY) was used to enter the collected data and run the analysis. Demographic characteristics of respondents such as gender, age, the field of study, and place of birth were analyzed by using percentages and frequency. The summarized results were presented using tables and charts. A bivariate analysis was done to assess the association of one independent variable with a dependent. A variable with p values below 0.25 in the bivariate analysis is considered a candidate variable for multivariate logistic regression. In the final model, variables having a p-value < 0.05 were considered as independently associated factors. The strength of the association of the variable was described by using the odds ratio and 95% confidence level. Means and standard deviations were used to summarize Likert scale questions. Spearman test was employed to compare students' KAP mean scores for CAM and demographic characteristics. Seven statements were used to assess knowledge and attitudes, and eight statements were for practice. A score greater or equal to 4 was considered to reflect adequate knowledge and a positive attitude, while the cut-off value of >4 was considered to reflect good practice toward CAM.
      • Emiru Y.K.
      Community pharmacists' knowledge, attitude and professional practice behaviors towards dietary supplements: results from a multi-center study in Ethiopia.
      In interpreting the results, all Likert scale replies with a degree of agreement were deemed positive, whilst all responses with a degree of disagreement were considered negative.
      • James P.B.
      • Bah A.J.
      Awareness, use, attitude and perceived need for Complementary and Alternative Medicine (CAM) education among undergraduate pharmacy students in Sierra Leone: a descriptive cross-sectional survey.

      2.7 Ethical considerations

      The study was ethically approved by the ethical review committee of the School of Pharmacy, University of Gondar, with an approval number of UoG-SoP-290/2021. Verbal informed consent was obtained from each participant before data collection. They were informed that questionnaires would be anonymous and confidential. Their involvement in the study was fully voluntary, and withdrawal at any stage if students refused to participate was assured. The names of the participants were not recorded anywhere on the questionnaire, and also, ensuring the respect, dignity, and freedom of each subject participating in the study was done.

      3. Results

      3.1 Socio-demographic characteristics of students

      A total of 308 respondents were approached to participate in the study. Of them, 302(186 male and 116 female) with a response rate of 98.05% were participated. Ages ranged from 20 to 29 years, with a mean age of 23.5 ± 1.4 years. Regarding the field of study, 28.5% of students were in medicine and about 62.6% of the participants were 4th year. While 28.8% of the students' mothers were unable to read and write, almost 40% of the students' fathers had a diploma or above. As shown in Table 1, the monthly income of over 47.7% of respondents' parents ranged between 1000 and 5000. Regarding students' accommodation, 64.9% of students used the university restaurant. Of all the participants, the majority (57.0%) of the students originated from urban areas (Table 1).
      Table 1Socio-demographic characteristics of graduating medical and health science students (N = 302).
      CharacteristicsFrequencyPercent%
      Gender
       Male18661.6
       Female11638.4
      Age
       ≤2522474.2
       >257825.8
      Field of study
       Medicine8628.5
       Pharmacy278.9
       Nursing309.9
       Midwifery258.3
       Health officer247.9
       Aesthesia144.6
       Optometry144.6
       Physiotherapy134.3
       Environmental and occupational health155
       Health informatics
       Psychiatry165.3
       Medical laboratory144.6
      247.9
      Duration of study
       418962.6
       5278.9
       68628.5
      Educational status of mother
       Unable to read and write8728.8
       Able to read and write6320.9
       Primary school (1–8)4414.6
       Secondary school (9–12)3912.9
       Diploma and above6922.8
      Educational status of father
       Unable to read and write3712.3
       Able to read and write7825.8
       Primary school (1–8)3611.9
       Secondary school (9–12)289.3
       Diploma and above12340.7
      Monthly income of parents
       <10004615.2
       1000-500014447.7
       >500011237.1
      Types of student accommodation
       Cafe19664.9
       Non café10635.1
      Place of birth
       Urban17257
       Rural13043

      3.2 Knowledge of students about CAM

      Out of the total participants, only 80(26.5%) of respondents appeared to have good knowledge. 39.7% of students claimed to know enough about CAM. More than half of the students said they know enough about the indications for different types of CAM for specific medical conditions like headaches, stomach discomfort, and arthritis. About 33.4% stated they know enough about herbal medicine contraindications in general and for specific patient groups like those with hypertension or kidney disease (Table 2).
      Table 2Descriptive analysis of knowledge questionnaire (N = 302).
      QuestionsVery poor n (%)Poor n (%)Acceptable n (%)Good n (%)Very good n (%)
      Generally, I have sufficient information toward CAM91(30.1)91(30.1)70(23.2)37(12.3)13(4.3)
      I have sufficient information about the efficiency and effectiveness of CAM94(31.1)94(31.1)67(22.2)36(11.9)11(3.6)
      I have sufficient information about the adverse effects of CAM98(32.5)96(31.8)52(17.2)37(12.3)19(6.3)
      I have sufficient information about the dosage and administration of CAM120(39.7)93(30.8)45(14.9)30(9.9)14(4.6)
      I have sufficient information about indications of some forms of CAM for specific medical conditions such as headache, abdominal pain, arthritis, etc.,77(25.5)64(21.2)83(27.5)50(16.6)28(9.3)
      I have sufficient information about drug herbal interactions116(38.4)87(28.8)55(18.2)32(10.6)12(4)
      I have sufficient information about contraindication of herbal medicines and in special groups of patients for example with hypertension or kidney disease115(38.1)86(28.5)47(15.6)37(12.3)17(5.6)

      3.3 Associated factors related to knowledge about CAM

      Knowledge about CAM was significantly greater among pharmacy students compared to medical students at 4.852(95% CI-1.831, 12.859). However, nursing students were less knowledgeable than medical students 0.130(95% CI-0.028, 0.608). Students who came from parents' monthly incomes of between 1000 and 5000 were 2.802 times more knowledgeable than students, who came from parents' monthly incomes of less than 1000 ETB 2.802(95% CI-1.136, 6.911). However, there are no significant statistics between knowledge and educational level of parents and place of birth as indicated in (Table 3).
      Table 3Bivariate analysis of socio-demographic characteristics associated with knowledge of CAM among graduating medical and health science students (N = 302).
      Knowledge levelCORP-valueAORP-value
      Poor n (%)Good n (%)
      Field of studyMedicine58(19.2)28(9.3)1
      Pharmacy8(2.6)19(6.3)0.57(0.23–1.43)0.2324.85(1.83–12.86)0.001
      Nursing28(9.3)2(0.7)2.8(0.89–8.88)0.0790.13(0.03–0.61)0.009
      Midwifery21(7)4(1.3)0.08(0.02–0.44)0.0030.37(0.11–1.24)0.108
      Health officer21(7)3(1)0.23(0.06–0.86)0.0290.26(0.07–1.00)0.051
      Anesthesia12(4)2(0.7)0.17(0.04–0.72)0.0160.23(0.04–1.18)0.078
      Optometry13(4.3)1(0.3)0.20(0.04–1.08)0.0610.17(0.02–1.44)0.105
      Physiotherapy8(2.6)5(1.6)0.10(0.01–0.81)0.0321.13(0.32–4.00)0.865
      Environmental and occupational health13(4.3)2(0.7)0.74(0.19–2.92)0.6660.29(0.06–1.46)0.133
      Health informatics16(5.3)00.0000.9980.0000.998
      Psychiatry11(3.6)3(1)0.18(0.03–0.99)0.0480.54(0.13–2.27)0.403
      Medical laboratory13(4.3)11(3.6)0.32(0.07–1.46)0.1410.45(0.09–2.18)0.319
      Duration of study4th year156(52)33(11)1
      5th year8(2.6)19(6.3)0.44(0.24–0.79)0.0023.88(1.10–13.64)0.034
      6th year58(19.2)28(9.3)4.92(1.92–12.61)0.0060.80(0.28–2.34)0.688
      Educational status of the motherUnable to read and write63(21)23(7.6)1
      Able to read and write42(14)22(7.3)1.21(0.58–2.52)0.6120.51(0.14–1.88)0.309
      Primary school (1–8)34(11.3)10(3.3)1.74(0.81–3.71)0.1560.72(0.22–2.38)0.595
      Secondary school (9–12)30(10)9(3)0.97 (0.40–2.40)0.9550.73(0.23–2.30)0.585
      Diploma and above53(17.6)16(5.1)0.99(0.39–2.52)0.9890.92(0.30–2.85)0.887
      0.630
      Educational status of the fatherUnable to read and write26(8.6)10(3.3)1
      Able to read and write51(17)26(8.6)1.37(0.59–3.18)0.4681.19(0.44–7.49)0.407
      Primary school (1–8)26(8.6)11(3.6)1.81(0.96–3.43)0.0672.53(0.77–8.30)0.126
      Secondary school (9–12)23(7.6)6(2)1.50(0.66–3.43)0.3321.60(0.51–5.02)0.425
      Diploma and above96(32)27(9)0.93(0.43–2.51)0.8821.01(0.30–3.40)0.984
      0.033
      Monthly income of parents<100027(9)19(6.3)1
      1000-5000108(36)36(12)2.50(1.17–5.11)0.0172.80(1.14–6.91)0.025
      >500087(29)25(8.3)1.16(0.65–2.08)0.6180.96(0.48–1.89)0.897
      0.589
      Place of birthUrban131(43.4)41(13.6)1
      Rural91(30.1)39(13)0.73(0.44–1.22)0.2300.83(0.38–1.80)0.633

      3.4 Attitude of students towards CAM

      Assessment of student's attitudes towards CAM indicates 260(86%) of respondents had a positive attitude (Table 4). The mean attitudinal score was 25.73 ± 6.104, which indicates a positive attitude toward CAM as it is above the arbitrary mid-value of 17.5. According to the results of this study, 63.9% of students agreed with the statement that Health science students should be knowledgeable about CAM, and consulting in this field is part of health professionals' duties. Also, more than 67.9% of students believed that herbal/nutritional supplements should be dispensed according to the health professional's prescription.
      Table 4Descriptive analysis of attitude questionnaire (N = 302).
      QuestionsStrongly disagree n (%)Disagree n (%)Neutral n (%)Agree n (%)Strongly agree n (%)
      CAM has a positive impact on public health20(6.6)29(9.6)73(24.2)107(35.4)73(24.2)
      The therapeutic efficacy of CAM may be considerable17(5.6)31(10.3)84(27.8)101(33.4)69(22.8)
      Health science students should be knowledgeable about CAM and consulting in this field is part of health professionals' duties17(5.6)31(10.3)61(20.2)98(32.5)95(31.5)
      Herbal/nutritional supplements should dispense according to the health professional's prescription9(3)30(9.9)58(19.2)111(36.8)94(31.1)
      Herbal/nutritional supplements should be sold in pharmacies under pharmacist's supervision16(5.3)28(9.3)76(25.2)81(26.8)101(33.4)
      Price is an important factor for recommending Herbal/nutritional supplements to customers14(4.6)35(11.6)71(23.5)82(27.2)100(33.1)
      Customers usually are influenced by health professional's comments about CAM17(5.6)54(17.9)70(23.2)80(26.5)81(26.8)

      3.5 Associated factors related to attitude towards CAM

      Analysis by binary logistic regression indicated no significant difference in attitude toward CAM among the fields of graduating students. This study shows that females had 0.042 times less likely positive attitudes toward CAM than male students 0.042(95% CI-0.008, 0.210). students whose fathers' educational level was primary school had 0.149 less likely positive attitudes than students whose fathers' educational level was unable to read and write 0.149(95% CI 0.025, 0.900). But there is no significance between attitude and field of study, educational status of the mother, monthly income, and place of birth (Table 5).
      Table 5Bivariate analysis of socio-demographic characteristics associated with an attitude of CAM among graduating medical and health science students (N = 302).
      Attitude levelCORP-valueAORP-value
      Negative n (%)Positive n (%)
      GenderMale40(13.3)146(48.3)1
      Female2(0.7)114(37.7)0.06(0.02–0.27)0.000.04(0.01–0.21)0.00
      Field of studyMedicine11(3.6)75(25)1
      Pharmacy027(9)2.27(0.74–6.97)0.1511.08(0.20–5.67)0.930
      Nursing4(1.3)26(8.6)538491614.30.998217800965.40.998
      Midwifery5(1.6)20(6.6)2.17(0.53–8.79)0.2790.67(0.11–3.95)0.660
      Health officer024(8)1.33(0.35–5.13)0.6750.30(0.07–2.38)0.310
      Anesthesia3(1)11(3.6)538491614.30.998184309764.40.998
      Optometry5(1.6)9(3)1.22(0.25–5.91)0.8030.56(0.08–3.89)0.55
      Physiotherapy013(4.3)0.60(0.14–2.51)0.4840.34(0.05–2.31)0.270
      Environmental and occupational health015(5)5384491614.30.99204746327.60.998
      Health informatics7(2.3)9(3)538491614.30.998159512313.10.998
      Psychiatry1(0.3)13(4.3)0.43(0.11–1.66)0.2200.25(0.04–1.20)0.080
      Medical laboratory6(2)18(6)4.33(0.46–40.46)0.1984.78(0.40–57.32)0.218
      Educational status of the motherUnable to read and write13(4.3)73(24.3)1
      Able to read and write11(3.6)53(17.6)1.07(0.44–2.55)0.8881.599(0.697–30.328)0.113
      Primary school (1–8)4 (1.3)40 (13.3)0.91(0.37–2.28)0.8472.822(0.427–18.643)0.282
      Secondary school (9–12)3(1)36 (12)1.90(0.5–6.380)0.3013.255(0.575–18.428)0.182
      Diploma and above11(3.6)58(19.3)2.28(0.59–8.71)0.2301.70(0.29–9.82)0.55
      Educational status the fatherUnable to read and write5(1.6)31(10.3)1
      Able to read and write18(6)59(19.6)0.80(0.27–2.38)0.6840.166(0.021–1.308)0.088
      Primary school (1–8)3(1)34(11.3)0.42(0.20–0.91)0.0270.15(0.03–0.90)0.038
      Secondary school(9–12)2(0.7)27(9)1.46(0.40–5.39)0.5730.56(0.08–3.67)0.547
      Diploma and above14(4.3)109(36)1.73(0.37–8.09)0.4840.64(0.07–5.20)0.679
      0.336
      Monthly income of parents<10004(1.3)42(14)1
      1000-500019(6.3)125(41.4)2.15(0.69–6.70)0.1892.71(0.63–11.62)0.180
      >500019(6.3)93(31)1.34(0.67–2.68)0.4011.72(0.69–4.31)0.249
      Place of birthUrban32(10.6)163(54)1
      Rural10(3.3)97(32)0.53(0.25–1.12)0.0940.76(0.24–2.42)0.638

      3.6 Practice of students toward CAM

      Regarding students' overall practice, 101(33.5%) of students had good practice, however, the majority 201(66.5%) of the respondents showed poor practice towards CAM. Of the total participants, only 8.9% of students reported that they always recommend herbal/nutritional supplements to patients with confidence about their effectiveness, and about 13.2% check whether a particular supplement taken by a consumer interacts with her/his prescription medicines. The majority of students claimed that they had never studied some scientific references regarding CAM (Table 6).
      Table 6Descriptive analysis of practice questionnaire (N = 302).
      QuestionsNever n (%)Rarely n (%)Sometimes n (%)Often n (%)Always n (%)
      I always allot enough time to have understanding on CAM117(38.7)100(33.1)42(13.9)31(10.3)12(4)
      I have studied some scientific references regarding to CAM126(41.7)85(28.1)50(16.6)26(8.6)15(5)
      I could refer to valid web pages and scientific references relevant to CAM in case of needed78(25.8)86(28.5)70(23.2)49(16.2)19(6.3)
      I always recommend herbal/nutritional supplements to patients with confidence about their effectiveness70(23.2)67(22.2)79(26.2)59(19.5)27(8.9)
      I always ask consumer's medical history when I recommend these products69(22.8)75(24.8)61(20.2)54(17.9)43(14.2)
      I always check whether particular supplement taken by consumer interact with her/his prescription medicines72(23.8)69(22.8)65(21.5)56(18.5)40(13.2)
      I always inform patients about drug supplement interactions71(23.5)77(25.5)47(15.6)60(19.9)47(15.6)
      I always inform patients about possible adverse effects of herbal/nutritional supplements76(25.2)70(23.2)55(18.2)55(18.2)46(15.2)

      3.7 Associated factors related to practice towards CAM

      In bivariate logistic regression analysis, duration of study and field of study were associated with practice. From the duration of the study, 5th year students had 4.18 times more good practice than 4th year students (95% CI-1.225, 14.256). As indicated in Table 7, pharmacy students had 2.53 times more good practice than medical students (95% CI-1.001, 6.379). Whereas, nursing students, on the other hand, were 0.375 times less likely to have good practice than medical students (95% CI-0.141, 0.999). As a result of multiple regression analyses, these demographics were found to have a significant relationship with attitude. However, there are no significant statistics between the attitude and educational status of a student's parents.
      Table 7Bivariate analysis of socio-demographic characteristics associated with practice of CAM among graduating medical and health science students (N = 302).
      Practice levelCORP-valueAORP-value
      Poor n (%)Good n (%)
      Field of studyMedicine50(16.6)36(12)1
      Pharmacy9(3)18(6)1.2(0.47–3.04)0.7012.53(1.00–6.38)0.050
      Nursing23(7.6)7(2.6)3.33(1.06–10.53)0.0400.38(0.14–0.99)0.050
      Midwifery23(7.6)2(0.7)0.51(0.16–1.66)0.2610.62(0.18–2.20)0.459
      Health officer19(6.3)5(1.6)0.15(0.03–0.77)0.0230.20(0.04–1.12)0.068
      Anesthesia11(3.6)3(1)0.44(0.12–1.59)0.2090.55(0.14–2.19)0.393
      Optometry11(3.6)3(1)0.46(0.10–2.08)0.3100.54(0.11–2.59)0.442
      Physiotherapy4(1.3)9(3)0.46(0.10–2.08)0.3100.58(0.12–2.80)0.493
      Environmental and occupational health10(3.3)5(1.6)3.75(0.89–15.81)0.0724.17(0.94–18.60)0.061
      Health informatics16(5.3)00.83(0.22–3.23)0.7921.00(0.24–4.22)0.998
      Psychiatry14(4.6)00.0000.9980.0000.998
      Medical laboratory15(5)9(3)0.67(0.16–2.77)0.5770.82(0.19–3.53)0.785
      Duration of study in year4th year142(47)47(15.6)1
      5th year9(3)18(6)0.46(0.27–0.79)0.0054.18(1.23–14.26)0.022
      6th year50(18.6)36(12)2.78(1.12–6.89)0.0271.65(0.58–4.70)0.345
      Educational status of the motherUnable to read and write63(21)23(7.6)1
      Able to read and write39(13)25(8.3)0.78(0.39–1.56)0.4840.71(0.23–2.14)0.541
      Primary school (1–8)30(10)14(4.6)1.37(0.67–2.79)0.3870.99(0.36–2.69)0.980
      Secondary school (9–12)22(7.3)17(5.6)0.99(0.44–2.25)0.9941.01(0.37–2.76)0.980
      Diploma and above47(15.6)22(7.3)1.65(0.73–3.71)0.2251.69(0.66–4.31)0.270
      0.727
      Educational status the fatherUnable to read and write28(9.3)8(2.6)1
      .Able to read and write49(18.3)28(9.3)0.55(0.23–1.32)0.1790.95(0.27–3.37)0.931
      Primary school (1–8)24(8)13(4.3)1.10(0.61–1.99)0.7491.75(0.65–4.74)0.269
      Secondary school(9–12)19(6.3)10(3.3)1.05(0.48–2.22)0.9121.15(0.43–3.07)0.775
      Diploma and above81(27)42(14)1.02(0.43–2.38)0.9731.02(0.38–2.75)0.968

      3.8 Assessment of student's KAP about specific CAM modalities

      In this study, participants reported that they knew a lot about nutritional therapy 108(35.8%), massage 101(33.4%) and herbal therapy 90(29.8%). Among the participants, 124(41.1%) agreed on the effectiveness of massage, music therapy 93(30.8%), and herbal therapy 90(29.8%), but as indicated in Table 8, the majority of students never used acupuncture 234(77.5%), hypnotism 224(74.2%), and yoga 187(61.9%).
      Table 8Students practice towards CAM modalities (N = 302).
      ModalitiesNever n (%)Rarely n (%)Sometimes n (%)Often n (%)Always n (%)
      Acupuncture234(77.5)47(15.6)13(4.3)5(1.7)3(1)
      Acupressure185(61.3)51(16.9)29(9.6)30(9.9)7(2.3)
      Nutrition therapy76(25.2)49(16.2)74(24.5)68(22.5)35(11.6)
      Herbal therapy62(20.5)62(20.5)76(25.2)72(23.8)30(9.8)
      Music therapy99(32.8)45(14.9)66(21.9)61(20.2)31(10.3)
      Aqua therapy173(57.3)40(13.2)43(14.2)29(9.6)17(5.6)
      Massage81(26.8)63(20.9)73(24.2)54(17.9)31(10.3)
      Meditation156(51.7)54(17.9)40(13.2)32(10.6)20(6.6)
      Yoga187(61.9)54(17.9)34(11.3)19(6.3)8(2.6)
      Hypnotism224(74.2)36(11.9)20(6.6)14(4.6)8(2.6)

      3.9 Association of demographic characteristics and mean KAP scores

      The Spearman test was employed to compare students' KAP mean scores for CAM between genders, age, monthly income of parents, and duration of the study. Significant differences in KAP responses were observed throughout the study; however, significant differences between males and females were observed only in attitude and practice, with p < 0.05. A significant difference was not observed in monthly income, the educational level of parents, and the type of student accommodation (P > 0.05) (Table 9).
      Table 9Mean scores of KAP towards CAM among graduating medical and health science students (N = 302).
      CharacteristicsKnowledge scoreP-valueAttitude score (Mean ± SD)P-valuePractice score (Mean ± SD)P-value
      (Mean ± SD)
      Gender
       Male2.29(1.021)0.5813.39(0.854)0.00**2.64(1)0.039*
       Female2.23(0.874)4.13(0.691)2.40(1.084)
      Age
      ≤252.28(0.995)0.6813.66(0.891)0.8892.49(1.037)0.106
      >252.23(0.875)3.71(0.815)2.72(1.025)
      Duration of study
       42.11(0.911)3.6(0.899)2.36(0.983)
       53.3(0.85)0.003**4.05(0.569)0.023*3.19(0.997)0.001**
       62.3(0.922)3.72(0.864)2.76(1.054)
      Educational status of mother
      Unable to read and write2.28(1.052)0.5373.65(0.914)0.5372.45(1.024)0.713
      Able to read and write2.42(1.063)3.59(0.878)2.66(1.136)
      Primary school (1–8)2.21(0.842)3.65(0.788)2.57(0.887)
      Secondary school (9–12)2.29(0.856)3.94(0.777)2.64(1.087)
      Diploma and above2.14(0.895)3.65(0.91)2.48(1.034)
      Educational status of father
      Unable to read and write2.31(0.912)0.1473.68(0.839)0.1473.34(1.005)0.338
      Able to read and write2.39(1.128)3.47(0.953)2.58(1.092)
      Primary school (1–8)2.45(0.926)3.76(0.832)2.86(1.016)
      Secondary school (9–12)2.11(0.765)3.79(0.784)2.57(0.876)
      Diploma and above2.16(0.921)3.75(0.852)2.48(1.046)
      Monthly income of parents
       <10002.57(1.094)0.333.86(0.815)0.432.57(1.127)0.98
       1000-50002.21(0.981)3.62(0.897)2.56(1.019)
       >50002.22(0.873)3.66(0.859)2.52(1.032)
      Types of student accommodation
       Cafe2.27(0.987)0.873.61(0.908)0.0562.53(1.062)0.616
       Non café2.27(0.932)3.8(0.79)2.57(0.997)
      Place of birth
       Urban2.2(0.911)0.2113.68(0.892)0.9272.50(1.013)0.475
       Rural2.36(1.030)3.67(0.0848)2.60(1.070)

      3.10 Demographic characteristics associated with KAP of CAM modalities

      More than 51.85% of the pharmacy students knew something about yoga, massage therapy (48.15%), and herbs (33.33%), On the other hand, 14.81% of pharmacy students never heard about hypnosis. Moreover, more than 33.33% of the pharmacy students had just heard about acupuncture but did not know of it.

      3.11 Correlation between KAP

      Spearman rank correlation revealed significant positive linear correlations between knowledge-attitude (r = 0.155, p < 0.001), knowledge-practice (r = 0.513, p < 0.001), and attitude-practice (r = 0.224, p < 0.001). As shown in Table 10, there were significant correlations between knowledge and attitude, knowledge and practice, and attitude and practice.
      Table 10Correlation between knowledge, attitude, and practice scores.
      VariableCorrelation coefficientP-value
      Knowledge-attitude0.155
      Correlation is significant at the 0.01 level (2 – tailed).
      0.007
      Knowledge-practice0.513
      Correlation is significant at the 0.01 level (2 – tailed).
      0.000
      Attitude-practice0.224
      Correlation is significant at the 0.01 level (2 – tailed).
      0.000
      a Correlation is significant at the 0.01 level (2 – tailed).

      4. Discussions

      Our study recorded a higher overall response rate of 98.05%. This is higher than another study conducted in Kuwait,
      • Awad A.
      • Al-Ajmi S.
      • Waheedi M.
      Knowledge, perceptions and attitudes toward complementary and alternative therapies among Kuwaiti medical and pharmacy students.
      Sierra Leone,
      • James P.B.
      • Bah A.J.
      • Kondorvoh I.M.
      Exploring self-use, attitude and interest to study complementary and alternative medicine (CAM) among final year undergraduate medical, pharmacy and nursing students in Sierra Leone: a comparative study.
      and Pakistan.
      • Ashraf M.
      • Saeed H.
      • Saleem Z.
      • et al.
      A cross-sectional assessment of knowledge, attitudes and self-perceived effectiveness of complementary and alternative medicine among pharmacy and non-pharmacy university students.
      The use of the dorm-to-dorm data collection method is likely linked to the increased response from study participants. In this study, the proportion of males (61.6%) in the sample was higher than females (38.4%) but slightly higher than the study conducted in Bangladesh 56%, unlike the studies conducted in Pakistan 26.3% and Malaysia 26.3%.
      • Jamshed S.Q.
      • Khan M.U.
      • Ahmad A.
      • Elkalmi R.M.
      Knowledge, perceptions, and attitudes toward complementary and alternative medicines among pharmacy students of a Malaysian Public University.
      This is somewhat expected due to the total number of graduating male students being higher than females. 57.0% of the students originated from urban areas. It is lower than a study conducted in Bangladesh in which 82% of the students were from urban areas.
      • Saha B.L.
      • Seam M.O.R.
      • Islam M.M.
      • et al.
      General perception and self-practice of complementary and alternative medicine (CAM) among undergraduate pharmacy students of Bangladesh.
      In this study, 70.37% of pharmacy students appeared to have better knowledge of CAM than non-pharmacy students, like a study conducted in Pakistan.
      • Ashraf M.
      • Saeed H.
      • Saleem Z.
      • et al.
      A cross-sectional assessment of knowledge, attitudes and self-perceived effectiveness of complementary and alternative medicine among pharmacy and non-pharmacy university students.
      This might be because they have had formal education in CAM. The highest level of knowledge was observed in nutritional therapy, 35.8%, followed by massage therapy, 33.4%, which is similar but slightly higher than a previous study conducted in Malaysia, in which nutritional therapy was 25.3%, followed by massage therapy at 17%.
      • Jamshed S.Q.
      • Khan M.U.
      • Ahmad A.
      • Elkalmi R.M.
      Knowledge, perceptions, and attitudes toward complementary and alternative medicines among pharmacy students of a Malaysian Public University.
      Unlike the study conducted in Nigeria
      • Ahwinahwi U.
      • Chukwudi K.
      Perception and use of complementary and alternative medicine (CAM) among undergraduate students in a Nigerian university.
      and Ghana,
      • Ameade E.P.
      • Amalba A.
      • Helegbe G.K.
      • Mohammed B.S.
      Medical students' knowledge and attitude towards complementary and alternative medicine–A survey in Ghana.
      in which herbal therapy is the most known modality. This might be due to that nutritional supplement is always prescribed for patients in our setting and students are familiar with this modality. And as indicated in our result most of our participants were originated from urban areas so they might not be familiar with herbal therapy. More than 51.85% of the pharmacy students knew something about yoga and 48.15% about massage therapy. This is lower than previously reported studies in Pakistan, yoga 55.8% and massage 55%,
      • Ashraf M.
      • Saeed H.
      • Saleem Z.
      • et al.
      A cross-sectional assessment of knowledge, attitudes and self-perceived effectiveness of complementary and alternative medicine among pharmacy and non-pharmacy university students.
      this might be attributed to the fact that massage and yoga are less known and practiced modalities in Ethiopia.
      The current study indicates that 86% of students had positive attitudes towards CAM, which is lower than previously reported studies in Bangladesh which showed that 90% of the students had positive attitudes towards CAM, while 10% had negative attitudes towards it.
      • Saha B.L.
      • Seam M.O.R.
      • Islam M.M.
      • et al.
      General perception and self-practice of complementary and alternative medicine (CAM) among undergraduate pharmacy students of Bangladesh.
      This might be due to that our study was conducted on all health professional students, not only on pharmacy students. In the current study, male participants have more positive attitudes than female participants about CAM, which is different from previous studies conducted in China.
      • Xie H.
      • Sang T.
      • Li W.
      • et al.
      A survey on perceptions of complementary and alternative medicine among undergraduates in China.
      These differences might be explained by the gender variations, in which more than half of the total participants were males.
      According to this study, pharmacy students have a more positive attitude toward CAM than medical and nursing students. This is in contrast to a study conducted in Sierra Leone, which found that final-year medical students have a more positive attitude toward CAM than pharmacy and nursing students.
      • James P.B.
      • Bah A.J.
      • Kondorvoh I.M.
      Exploring self-use, attitude and interest to study complementary and alternative medicine (CAM) among final year undergraduate medical, pharmacy and nursing students in Sierra Leone: a comparative study.
      As indicated in our result, pharmacy students were more knowledgeable than the other 11 departments and this might attribute to their positive attitude. Students whose father's educational level was primary school, have 85.1% less likely positive attitude than students whose father's educational level, can't read and write, this might be due to parents whose educational status was primary school might have awareness about modern medicine than traditional medicine.
      When compared to medical students, pharmacy students access more information by referring to reputable web pages and scientific references related to CAM when needed. This is somewhat comparable to a study conducted in Sierra Leone,
      • James P.B.
      • Bah A.J.
      • Kondorvoh I.M.
      Exploring self-use, attitude and interest to study complementary and alternative medicine (CAM) among final year undergraduate medical, pharmacy and nursing students in Sierra Leone: a comparative study.
      in which pharmacy students gathered the majority of their information regarding complementary and alternative medicine from journals than medical students. This could be due to the effect of the CAM course, which they have learned during their second year of study; motivating them to be curious for knowing more about it.
      According to the results of this study the most known and practiced CAM modality among study subjects was nutritional therapy, unlike a study conducted on community members in Debre tabor,
      • Aragaw T.J.
      • Afework D.T.
      • Getahun K.A.
      Assessment of knowledge, attitude, and utilization of traditional medicine among the communities of Debre Tabor Town, Amhara Regional State, North Central Ethiopia: a cross-sectional study.
      in which the majority of participants use herbal therapy and study conducted on hypertensive patients in Gondar town (67.5% of respondents use herbal-based medicine).
      • Asfaw Erku D.
      • Basazn Mekuria A.
      Prevalence and correlates of complementary and alternative medicine use among hypertensive patients in Gondar town, Ethiopia.
      But this finding (around 21% of students “never” or “rarely” used herbal therapy) is almost similar to a study conducted in the Kingdom of Bahrain, in which approximately 18.8–33.3% of the participating physicians never used herbal medicines,
      • Hilal M.
      • Hilal S.
      Knowledge, attitude, and utilization of herbal medicines by physicians in the Kingdom of Bahrain: a cross-sectional study.
      this difference might be because university students might develop different self-use practices and health-related recommending habits during university times.
      Some interesting results were found when combining the demographic profile of participants with three KAP variables. Although 5th year students are more likely to be knowledgeable and have better practice in CAM, the results do not show any significant differences between the duration of study in attitude. This implies that attitudes might be influenced by some other underlying factors, like gender and the students' fathers' educational status. And this study also shows no significant association between the educational level of parents with the knowledge and practice of CAM. This is similar to a previous study conducted in Saudi Arabia, in which no association was found between the practice of CAM and the educational level of parents.
      • Khan A.
      • Ahmed M.E.
      • Aldarmahi A.
      • et al.
      Awareness, self-use, perceptions, beliefs, and attitudes toward complementary and alternative medicines (CAM) among health professional students in King Saud bin Abdulaziz University for Health Sciences Jeddah, Saudi Arabia.
      This indicates that practice might be affected by other factors, like a field of study.
      Considering the correlation coefficients show a strong relationship between KAP components, the greater the participants' knowledge, the more likely they have a positive attitude and practice towards CAM. And knowledge has a greater impact on practice than attitude. Furthermore, according to the findings of the correlation analysis, an attitude has a positive and significant impact on practice, making it critical to identify the attitude influencers to improve CAM.

      4.1 Study limitations

      It was impossible to analyze the factors that influence students' knowledge, attitude, and practice over time because of the cross-sectional design. And some students were less familiar with CAM modalities, which could have had some effect on the results.

      5. Conclusions

      This study assesses the level of knowledge, attitude, and practice of graduating medical and health science students towards CAM, and found that; despite students' positive attitudes, their total understanding and practice wear limited. This study also revealed that pharmacy students (Those who had attended CAM courses) have more knowledge and attitudes than other departments (Those who had not attended CAM courses). As a result, it is critical to incorporate CAM into the curricula of all health professional's education programs.

      Availability of data and materials

      The data used to support the findings of this study are available from the corresponding author on reasonable request.

      Funding

      This study has not received any support from any funding agency in the public, commercial, or not-for-profit sectors.

      Authors' contributions

      Conception and design of study: Hareg Zewdu Alehegn, Elias Teklie Asiferaw, Zerihun Gudisa Welda, Yohannes Kelifa Emiru, seid mufti hussen, Zemene Demelash Kflie, Chilot Abiyu Demeke. analysis and/or interpretation of data: Hareg Zewdu Alehegn, Zemene Demelash Kflie, Chilot Abiyu Demeke, Drafting the manuscript: Hareg Zewdu Alehegn, Elias Teklie Asiferaw, Zerihun Gudisa Welda, Yohannes Kelifa Emiru, revising the manuscript critically for important intellectual content: Hareg Zewdu Alehegn, Elias Teklie Asiferaw, Zerihun Gudisa Welda, Yohannes Kelifa Emiru, seid mufti hussen, Zemene Demelash Kflie, Chilot Abiyu Demeke, Approval of the version of the manuscript to be published (the names of all authors must be listed): Hareg Zewdu Alehegn, Elias Teklie Asiferaw, Zerihun Gudisa Welda, Yohannes Kelifa Emiru, seid mufti hussen, Zemene Demelash Kflie, Chilot Abiyu Demeke.

      Conflicts of interest

      A conflict of interest occurs when an individual's objectivity is potentially compromised by a desire for financial gain, prominence, professional advancement or a successful outcome. CEGH Editors strive to ensure that what is published in the Journal is as balanced, objective and evidence-based as possible. Since it can be difficult to distinguish between an actual conflict of interest and a perceived conflict of interest, the Journal requires authors to disclose all and any potential conflicts of interest.

      Declaration of competing interest

      The authors have not declared any conflict of interests.

      Acknowledgments

      The authors would like to thank University of Gondar, College of medicine and health science, for allowing doing this research and for ethical approval. The authors are grateful to graduating medical and health science students who consented to participate in this study.

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