5.1. Prevalence and patterns of use
The results of this study indicated that more than one-third of cancer patients (36.6%) reported using herbal medicines at least once in the past 12 months. This finding corroborates the results of studies published in Morocco. Indeed, between 11% and 39% of cancer patients have reported the use of medicinal plants as complementary medicine. Nevertheless, this prevalence was slightly higher than the average prevalence recorded in Morocco between 2011 and 2020, which was 31.16% (Aboufaras et al. 2021).
These results are also similar to those found in the Middle East and North Africa (MENA) region. Indeed, 35.5% of Jordanian cancer patients used traditional botanical preparations(Afifi et al. 2010). In North America, the prevalence of herbal use observed among cancer patients is between 38% and 39% in the United States of America and Trinidad and Tobago, respectively(Richardson et al. 2000; Bahall 2017).
However, in Iran, another study found a very high prevalence of 84.1% of patients who used an herbal medicine during chemotherapy sessions (Bazrafshani et al. 2019). This upward trend has been found recently in Europe as well. A study conducted in Germany (2021) showed a high prevalence of herbal medicine use among women with breast or gynecological cancer, 69% (Theuser et al. 2021).
5.2. Determinants and factors of use
5.2.1. Predisposing factors
5.2.1.1. Sociodemographic factors
Only gender was significantly related to use as a determinant and predictor among all of the predisposing sociodemographic variables included in the conceptual model. Herbal medications were used by women more frequently than by men. These empirical findings confirm that women were more likely than males to utilize herbal medicine in the Moroccan cancer population, as previously documented by observational studies conducted in this population in Casablanca and Rabat between 2011 and 2020 (Kabbaj et al. 2012; Samouh et al. 2019).
The relationship between age and prevalence of medicinal plant use does not indicate a significant difference in use among different age categories. However, there was a slightly higher average age among the non-user group. The prevalence was relatively high among those under 40 years of age. The interpretation of the results of the age effect in cross-sectional surveys is completely confusing (Fouladbakhsh and Stommel 2007). As a result, contradictions in results have often been found. Contrary to what was observed, the age group between 41 and 60 years used traditional herbal medicine frequently compared to other age groups in Morocco (Kabbaj et al. 2012). Nevertheless, two other Moroccan studies found no association between the age of participants and the use of complementary medicines, where the predominant modality was herbal medicine(Brahmi et al. 2011; Rahou et al. 2017). A recent descriptive ethnobotanical study found a high frequency in patients aged 40-50 without a significant difference(el Ouahdani et al. 2021).
These results are contradictory with the literature on the use of herbal medicine, natural products that seem to attract older cancer patients (over 60 years old), while young people tend to use mind/body and manipulation approaches (Abdallah et al. 2015).
5.2.1.2. Psychological factors
The majority of the psychological variables tested were associated with herbal medicine use in our study and strongly predicted this use.
More than half of the users of herbal preparations believed that traditional medicine could improve their health, reduce disease symptoms, and cure the disease. This was significantly associated with the prevalence of herbal medicine use and was an independent predictor of the medicine used in this study. On the other hand, respondents who reported that this medicine might have direct or indirect adverse effects used herbal medicine less.
In addition, encouragement of patients by their relatives, belief in the competence of traditional medicine practitioners and the low cost of herbal products, belief in the seriousness of cancer, its psychosocial impact, and the ineffectiveness of conventional treatment were positively associated with herbal medicine use.
No national or international studies have used these variables to investigate their association with herbal medicine use in Morocco or outside Morocco (Neriman I˙nanc¸ et al. 2006; Afifi et al. 2010; Akyol and Öz 2011; Ali-shtayeh et al. 2016). This makes it difficult to discuss the results with other studies, especially in developing countries where the use is mostly traditional. Psychological factors have never been examined for this category of T&CM.
However, the ABCAM questionnaire used, which is based on TCP theory, and the constructs of this conceptual model will allow us to compare our results with the explanatory hypotheses of this model.
Our study confirmed the majority of the hypotheses of this model, except for the explanation of the behavior studied (use of CAM: herbal medicine) by social norms, notably those of the caregivers or care providers. Indeed, normally, high scores of expected benefits are positively associated with the use of complementary medicine. That is, the more positively patients perceive the outcomes of use, the more they use complementary medicine. Patients who use complementary medicine perceive fewer barriers than nonusers. Patients are more likely to use T&CM if it is recommended by family/friends and/or health care providers (Mao et al. 2012).
Thus, the social norms of the providers were not correlated with the social norms of the relatives as predicted by the model according to the PCA analysis we did, and this factor was not associated positively or negatively with the use of herbal medicines in our study. This result could be explained by the lack of communication between the caregiver and the patient, the lack of knowledge of health professionals on the subject, and the nonintegration of complementary and supportive care in the new oncology centers in Morocco, especially since it is a traditional use that is not scientifically based.
Other studies using TPB have shown that perceived family expectations and medical team norms were associated with T&CM use. However, perceived control, including barriers, did not influence T&CM use(Hirai et al. 2008; ben Natan et al. 2016).
In addition, the other psycho-cognitive variables were also associated with the use of plants, such as belief in the severity of cancer, its psychosocial impact, expression of emotions such as anxiety, and ineffectiveness of conventional treatment.
Our results confirmed the importance of psychological factors in explaining and predicting the use of TMs/CAMs in general herbal medicine specifically.
5.2.2. Enabling Variables
We found that herbal medicine use by cancer patients in Beni Mellal was highest among patients from low-income socioeconomic backgrounds. Indicators of this low socioeconomic level were monthly family income, inability to purchase drugs, financial inaccessibility to care, and direct payment for cancer treatment.
The results of the literature regarding the relationship between income, economic level, and utilization of T&CM have been contradictory. This may be due to the different categories of T&CM and cancers included in the studies. In addition, the measurement of income poses a problem of reliability. It is confidential data that cannot be verified, especially since in Morocco, many patients are reluctant to reveal their probably high income to continue to benefit from the indigent health insurance scheme;
The results of our study were contradictory with the literature on T&CM use in Western countries, the majority of which indicates that higher income was a significant predictor of T&CM use in the cancer population(Eisenberg et al. 1998; Tas et al. 2005; Verhoef et al. 2005; Fouladbakhsh and Stommel 2007).
On the other hand, in regard to the use of herbal medicine alone as a T&CM, our results are close to what has been observed on a national scale. Indeed, low-income Moroccan patients used herbal drug preparations more than cancer patients with a high economic level (Samouh et al. 2019). According to this study, patients with a low level of education and income are more sensitive to the use of traditional Moroccan medicine.
Regarding the enabling factors for the use of herbal medicine as complementary medicine, our results also agree with other international studies; monthly income less than expenses was a significant factor for this use in Nigeria (Ajah et al. 2019). Additionally, in America, indigent patients use herbs more than other T&CM modalities (Richardson et al. 2000).
These contradictions could be due to the varying cost of T&CM modalities in the East and West. Modalities such as chiropractic, yoga, homeopathy, and even herbal medicines are more expensive than herbal preparations whose raw material is of low cost, and sometimes the plants are free when they grow spontaneously in nature after the population.
Our research confirmed the same results as previous studies. Indeed, the use of T&CM was not associated with occupation or with accessibility to conventional care(Richardson et al. 2000; Fouladbakhsh et al. 2005; Garland et al. 2013; Chin et al. 2020).
5.2.3. Need Variables
This research confirmed that several health need variables of the T&CM healthcare model (perceived and assessed needs) were related to the use of medicinal plants in the Beni Mellal-Khenifra region. These variables were time since diagnosis, presence and intensity of symptoms experienced by patients (pain, anorexia, insomnia, and fatigue), perceived health status, type of treatment received, number of chemotherapy sessions, regular follow-up of treatment, satisfaction with conventional management, number of coexisting conditions, and follow-up of an anti-cancer diet.
Our results, ethno-pharmacological therefore suggest that herbal medicine was used by cancer patients whose health status was deteriorating because they might have some hope concerning conventional treatment. Health needs are insufficiently addressed in Moroccan ethno-pharmacological studies as determinants or factors of herbal medicine use. This finding corroborates the existing international literature review, where the duration of cancer and multiple chemotherapies were independent predictors of T&CM use in Turkey(Tas et al. 2005). In Norway, the use of T&CM was also associated with the duration of the disease. Patients with cancer for more than 3 months used more T&CM (Kristoffersen et al. 2019). Another study found that the time since diagnosis exceeding 12 months was associated with the use of T&CM (Garland et al. 2013). In our study, these results were confirmed, as the prevalence of use was found to increase significantly between the first and third years after a cancer diagnosis.
The presence and severity of pain was a predictor of T&CM use, including the use of chiropractics, massage, and acupuncture practitioners(Eisenberg et al. 1998; Fouladbakhsh and Stommel 2007). A recent study in Norway found that the use of T&CM was associated with different symptoms presented by cancer patients attracted to it (Kristoffersen et al. 2019). A study specific to herbal medicine found that the presence of diarrhea or constipation was a predictor of use(Bazrafshani et al. 2019).
The coexistence of comorbid conditions could predict the use of herbal medicine in our target population, which confirms previous findings of research on T&CM use by cancer patients (Eisenberg et al. 1998; Fouladbakhsh and Stommel 2007; Bazrafshani et al. 2019).
The modalities of the conventional treatment received by the patient affect his use of T&CM; thus, the follow-up of chemotherapy treatment was associated with the use of T&CM, regardless of the adopted therapeutic strategy (single, multiple, palliative, or curative) (Richardson et al. 2000; Hyodo et al. 2005; Tas et al. 2005). This was found in our study as well since patients who received chemotherapy were more likely to use herbal medicine. In addition, the number of chemotherapy sessions was positively associated with this use. This also corroborates other studies that have found that the use of many of the conventional treatments was associated with the use of T&CM(Patterson et al. 2002). No Moroccan study has explored the association between cancer treatment modalities and herbal use.
In contrast, the likelihood of using medicinal plants does not seem to be affected by the diagnosis of the specific primary cancer, as is the case in our research and other studies (Fouladbakhsh et al. 2005; Bazrafshani et al. 2019; Mwaka et al. 2019).
Certainly, the prevalence was high in patients with breast cancer but without significant difference compared to other categories of cancer. Breast cancer has been found in several studies to be a determinant and predictor of T&CM use(Tas et al. 2005; Alsharif and Mazanec 2019). A large study in Europe found that patients with pancreatic, liver, bone, and brain cancer used these complementary therapies much more than any other group of cancer patients(Molassiotis et al. 2005).
Concerning studies specific to herbal medicine, the association between the type of cancer and the use of plants has rarely been explored, even outside of Morocco. In fact, in Jordan, a single descriptive study also found that breast cancer was the predominant cancer among female users of complementary herbal remedies (50.6%), and lung cancer was the main cancer among male users of these therapies (18.1%) (Afifi et al. 2010). In Morocco, only one study found that patients with breast, uterine, colon, or leukemia cancer are the most frequent users of traditional medicine compared to other cancer patients(Samouh et al. 2019). Regarding the stage of cancer, Rahou and collaborators who looked at T&CM, in general, did not find an association between the stage of cancer and the use of these therapies by women with breast cancer (Rahou et al. 2017).
In contrast to the study by Rahou and colleagues in Rabat, cancer stage was mentioned as a determinant and predictive factor for the use of herbal medicine internationally. Thus, patients with advanced metastatic disease use more herbal products and preparations than other patients (Poonthananiwatkul et al. 2015; Mwaka et al. 2019). The use of all T&CM modalities combined was associated with advanced cancer disease in several countries(Fouladbakhsh et al. 2005; Tas et al. 2005; Garland et al. 2013; Kristoffersen et al. 2019).
This variation in results from other studies is not only due to geographical reasons but also methodological; thus, the design of the questionnaire and the method of administering it could affect the results. It was found that the prevalence would be high if the questionnaire was administered face-to-face compared to the telephone or self-administered questionnaire. In addition, administering the questionnaire by a trained person and presenting a list of drugs in the questionnaire could also increase the proportion of users (Horneber et al. 2012). On the other hand, not integrating T&CM into the clinical setting could negatively affect the rate of use because patients do not feel comfortable disclosing this use (Ernst and Cassileth 1998). Therefore, the prevalence of use at oncology centers is often underestimated (Eisenberg et al. 1998). In contrast, because we studied only herbal medicine, our results may reveal a higher prevalence than the results for the prevalence of herbal medicine if it is combined with other T&CM modalities (Asiimwe et al. 2020).
The analysis provided valuable information on the predictors of the use of herbal medicine by cancer patients for the first time in Morocco. Thus, the predictors of T&CM use in the study setting were gender, pain, emotional impact, social impact, expected benefits, perceived scientific barriers, perceived socioeconomic barriers, and social norms of relatives.
Study Limitations
Most surveys are also subject to bias. For example, selection bias may result from the choice of the study sample. Measurement bias may also have occurred because some individual measures, particularly of some ABCAM questionnaire variables and subjective clinical variables, may be inaccurate.