CHAPTER 1: INTRODUCTION1.

1 Background of the StudyAccordingto WHO, (2012), herbal medicine can be defined as medicine that is made out ofplants and is common in many societies in the world including Kenya. When theherbal medicine is used in ways other than traditional, it becomes complementary and alternativemedicine (CAM). Other names for CAM are alternative medicine or nonconventional(Wootton, 2015). Therefore, CAM is the opposite of conventional or what wecommonly call western medicine (Wieland et al, 2011).Complementaryand alternative medicine cannot beignored considering it is vital for health care. It is estimated thatapproximately 80% of the world’s population rely on CAM, in one way or the other, for health care. Also, accordingto Eisenberg et al (2012), an estimated 80% of the people indeveloping countries and 80% of Africans rely on CAM tomeet their primary health care needs.

The annual global market CAM in year 2010 was over US$60 billion and is growingsteadily at a rate of fifteen to twenty-five percent (WHO, 2013).  Many countries in the world including some Asian countrieslike China, India and Sri Lanka have realized much success in developing their CAM sector. In these countries, the medicines are verydeveloped, have good documents, and used not only at the family, community, andprimary health care levels, but even in hospitals where they offer secondaryand tertiary care (Barrett, 2013). Also,herbal practices in these countries have better curriculum and are systematic andcomprehensive (Verma, and Singh, 2011;WHO, 2013).   Long before the advent of conventional medicine inAfrica, traditional medicines, including the use of herbs was the main remedyfor nearly all ailments (Verma, andSingh, 2011). Today, notwithstanding the increasing use of modernmedicine in countries like Nigeria and Ghana, CAM useis also hugely practiced and many continue to rely on it for their health careparticularly in psychiatric care.  InKenya, about 70% to 75% of the population rely on CAM for their primaryhealth care.

Also, herbal medicine is the first line of treatment for more than60% of children with high fever resulting from malaria (WHO, 2013). There is,on average, one traditional medical practitioner for every 400 people, comparedto one doctor to 12,000 people in Kenya (WHO, 2013). It has also been notedthat CAM is also used to treat people with psychiatric care. Studiesacross the world of patients consulting providers of CAMin low- and middle-income countrieshave reported high but varying rates of psychiatric disorders, depending on themethods employed and the disorders examined. Saeed et al (2010), did a study inPakistan and found 61% prevalence of diagnoses using a Psychiatric AssessmentSchedule.

The most common psychiatric condition was major depressive disorderat 24%, then anxiety disorder at 15% and finally psychosis only at 4%. Abbo etal (2011), mentioned that Uganda after doing a study on patients who had usedCA, that the patients at 60.2% had psychiatric disorders based on the DSM-IVstandard. Ngoma et al (2013) did for Tanzania and found that 49% of thepatients who used CAM had psychiatric disorders mainly depression and anxiety.Mbwayo et al (2013), did theirs in Kenya and noted that overall 64.

2% of thosewho used CAM had psychiatric disorders with a huge percentage havingdepression, anxiety and Schizophrenia.  Thesesignificant figures show that studying about the prevalence of CAM use amongpsychiatric patients is important and necessary. Indeed,various researchers have found that CAM is real, very accessible, cheap,culturally adequate, and is consistently being argued as an easily accessiblehealth care system that can aid and complement government’s efforts at ensuringquality and equitable health care. In some rural communities, CAM is the onlyform of health care that is available, affordable and accessible (Darko, 2012).

Thus, the study willseek to investigate the prevalenceof CAM use among psychiatric patients in Kabarnet Sub County considering thelack of similar studies in the area.  1.2 Statement of the problemThe WorldHealth Organization acknowledges that CAM has become a necessary, readilyavailable and useful way to treat many diseases.

However, while the global market of CAM products is big and quicklygrowing, the potential of this sub-sector remains un-tapped in Kenya and theregion, despite being well endowed in cultural and natural resources. Further,the absence of a supportive policy environment is key among the impendingfactors (National Council forPopulation and Development, 2015). In spite of the fact that manymedical practitioners are unaware of the CAM quality, many patients still seemto be willing to use CAM to sort out their health problems. There is thus aneed to look at the prevalence of CAM use to treat psychiatric disorders amongpatients at Kabarnet Sub County hospitals.  Thestudy area for the research is KabarnetSub County, Baringo County. The Sub county is chosen because ofits peculiar challenges in health care delivery which include lack ofhospitals/clinics, poor access to conventional health care, and inadequatehealthcare professionals, inadequate modern diagnostic and surgical equipment.In addition, there is no documented data on the use of CAM among psychiatricdisorders. Further, given the limited resources and time, focusing on all thecommunities in the county would be practically impossible.

1.3 Research Objectives1.3.1 Main ObjectivesToestablish the prevalence of use of complementary and alternative medicine amongpsychiatric patients at Kabarnet Sub County Hospitals, Baringo County1.3.2 Specific Objectives       i.           To establish therate of use of complementary and alternative medicine among psychiatricpatients at Kabarnet Sub County Hospitals      ii.           To determine thedemographic characteristics of patients using complementary and alternativemedicine among psychiatric patients at Kabarnet Sub County Hospitals    iii.

           To establish the types of complementaryand alternative medicines used by psychiatric patients at Kabarnet sub-countyHospital.   iv.           To assess the extentto which complementary and alternative medicine used concomitantly withconventional medicines. 1.4 StudyVariablesThe independent variables in the study will be the age and gender ofpsychiatric patients; income, education level and religion of psychiatricpatients; length of illness of the psychiatric patients, conditions for whichCAM products were used for. The dependent variable will be CAM use among psychiatric patients.

This willbe measured using the frequency of CAM use, occasions upon which the usebecomes relevant and the level of use. The outcome variable will be the effects of CAM use on patients and willinclude the tests after CAM use that show health improvements or alterations orno change at all. 1.5Rationale for the StudyThe study will be beneficial first to patients withpsychiatric disorders with information about the available CAM in use to treatpsychiatric disorders in Kenya and how they can interact with what drugs havebeen known to work. Secondly, the study will help the Kabarnet sub-countyHospitals with information on complementary and alternative medicines forpsychiatric disorders which will then help them work on an inclusion andcomplimentary policy that will help manage the process of treatment in linewith the new WHO policy. Thirdly, the study will be helpful to the Ministry ofhealth either initiate or revise their policies touching on complementary andalternative medicines for psychiatric disorders.

Lastly, the study will beuseful to the nursing education to first get knowledge on complementary andalternative medicines for psychiatric disorders and secondly further studies inthe area.           CHAPTER 2: LITERATURE REVIEW2.1 IntroductionThischapter will look at the prevalence of CAM to treat psychiatric Disorder thedemographics of CAM users and some of the notable examples of CAM inpsychiatric disorders.

2.2 Prevalence of CAM to treat PsychiatricDisorderTraditionaland herbal medicine has taken the new name, complementary and alternativemedicine (CAM). CAM refers to those healing and diagnostic disciplines thatexist largely outside the institutions where orthodox or conventional healthcare is provided (Shaikh and Hatcher,2015).The relationship between usersatisfaction with conventional medicine and prevalence of use of CAM is subtleand complex.

Large epidemiological studies in Western countries show that CAMusers are no less satisfied with conventional medicine than non-CAM-users(Eisenberg et al, 2011; Saeed et al, 2010). That is, using CAM is not simplydue to dissatisfaction with conventional treatment. Repeatedly, CAM usersreport that using both forms of care together is more useful than either alone(Eisenberg et al, 2011; Darko, 2012). However, CAM users do complain about thequality of the doctor-patient relationship during the brief consultationstypical of conventional medicine (Heiligers et al, 2010). In addition to moresatisfying consultations, the philosophies behind CAM have a persuasive appealwhich users find compelling. Incontrast, conventional medicine is described by CAM users as disjointed andimpersonal, and ultimately disempowering (Barrett, 2014). Whereas conventionaldoctors may be more interested in objective improvements – or changes inpsychopathology, perhaps even measured on a rating scale – CAM practitionersacknowledge and take seriously all subjective changes, thus validating thepatient and their experience (Zollman and Vickers, 2011).

While psychiatristsacknowledge the importance of spirituality and religion, and are more willingthan other physicians to talk about them with patients (Curling et al, 2011),they are unlikely to supply a worldview which is as appealing and satisfying asthe philosophies motivating CAM use.Curlinget al (2011) mentioned that the treatment of psychiatric disorders in low- andmiddle- income countries (LMIC) is poor and that there is need to considerurgent delivery of proper health services to the people. It has been found thatthe epidemiological and health services offered in 58 countries that fall inthe LMIC have poor health services (Heiligers et al, 2010). It showed that thenumber of health personnel like doctors and nurses were very low at less than60%. Therefore,using CAM is becoming a very attractive way to ensure that health services aregiven to communities that need it (Jilik, 2013). CAM is quickly beingincorporated into the main health systems and are used to help build up theconventional medicines particularly on patients in rural areas where CAM iseasily available. 2.

3 Demographics of CAM users andpsychiatric DisordersCurrentpublished work show that CAM as used among male psychiatric patients in Africa rangefrom 8% to 15% (Jensen, 2011).Unfortunately, most of these studies involved males and females who may not bereflective of the general population of psychiatric patients in Africa. Many ofthe studies were conducted in countries other than Kenya, where attitudestoward unconventional therapies may be different based on gender hence the needfor the present study. Additionally, most studies measure CAM use in males andfemales who have chronic conditions or who were sampled at health carefacilities (Jensen, 2011).

Further, according to Otieno (2011), herbal medicineis more easily accessible to the female rural populace, who constitute agreater proportion of the total population of the country, especially in thenorthern and eastern regions of Kenya where modern medical facilities arebarely adequate. According to Sawyer et al (2012), access to essentialmedicines is severely restricted by lack of resources and poverty and the studyseemed to indicate that females used CAM more than females. However, the studywas generalized and did not look at the same demographics among psychiatricpatients as this study will do.   Moreover,although many studies identified the increasing prevalence of CAM usethroughout the world, only a few reported on how patients perceived theefficacy of this healthcare modality in specific diseases and what demographicsdominate the use of CAM for psychiatric disorders (Clement et al, 2012).According to Clement et al, (2012) the major factor contributing to theincreasing popularity of CAM in developed countries and their sustained use indeveloping countries is the perception that herbal remedies are efficacious,and in some cases more so than allopathic medicines.

Examples ofCAMS Used Concomitant to Conventional DrugsClement et al (2012) discovered that 86.6%believed that herbal medicine were equally or more efficacious thanorthodox/conventional medicines for specific ailments and diseases. Accordingto Mensah, the potency and effectiveness of CAM havebeen proven through research. CAM therapies haveshown remarkable success in healing acute as well as chronic diseases (Shaikh and Hatcher, 2015). Buor(2011), for instance discovered that there is a kind of psychological securityin the medical approaches of the herbal medicine man which is able to relieve apatient of strong psychic pressure. CAM medicine provides more effective treatments to certainhealth problems such as boils, tuberculosis, stroke, arthritis, epilepsy,asthma, infertility, hernia, hypertension, diabetes, malaria, depression,mental illness and disease prevention as well as for the ageing population,where modern medicine has either failed to produce equally good results or hassimply ignored the need for systematic attention and research (Darko, 2012).Also, in cases of sexually transmitted diseases, typhoid fever, yellow fever,menstrual and fertility problems, herbal medicines are considered effective (Shaikh and Hatcher, 2015).

Herbalmedicines have also shown a wide range of efficacy in the treatment of variousdiseases such as breast, cervical and prostate cancers, skin infections,jaundice, scabies, eczema, typhoid, erectile dysfunctions, snakebite, gastriculcer, cardiovascular disorders and managing HIV/AIDS (Verma and Singh, 2011).  Significantly, it is evident that some CAM have been recognized internationally for the treatmentof psychiatric diseases (IUPAC, 2011).Herbs remain the foundation for a large amount of commercial medications usedtoday for the treatment of psychiatric problems (IUPAC, 2011). For instance, Artemisinin which is extracted fromthe Chinese herbal wormwood plant, Artemisia annua’ is the basis of mosteffective psychiatric drugs the world has ever known (WHO, 2013). Westernresearchers learned of the plant, for the first time, in the 1980s, but hadbeen used in China for almost 2000 years to treat mental problems. However, dueto skepticism surrounding the drug, it was only until 2004 that WHO approved ofit for use internationally (IUPAC, 2011).Artemisinin is also effective in combating other diseases and has demonstratedsignificant potential for the treatment of cancer and schistosomiasis (IUPAC, 2011; Shaikh and Hatcher, 2015).

 Moreover,the Neem tree (Azadirachta indica), which is indigenous to West Africa,is effective in the treatment of several diseases. The bark of the Neem tree isperceived to be effective in the management of schizophrenia (Davies, 2014). In addition to this,Davies, accounts that East Indians use it to make a strong soap that cures skindiseases. Africans also chew it to clean their teeth and it works as well asbrushing with toothpaste, and supposed to be healthier for the gums. More so,the plant Curcuma Longa is perceived to be effective in the treatment ofmany mental disease (Davies,2014).                CHAPTER 3: METHODOLOGY3.

1 Research Design A cross-sectional study using descriptive surveydesign will be undertaken on patients with psychiatric disorder in KabaranetSub County hospitals. The phenomenon investigated will be the prevalence of useof CAM among psychiatric patients. In a cross-sectional study no attempt ismade to change behavior or conditions34.

Things are measured as is.The study design also enables one to obtain information about the situation athand at one specific time. It shows the current situation of the conditionunder study in the desired population.

 3.2 Study variable The independent variables in the study will be the ageand gender of psychiatric patients; income, education level and religion ofpsychiatric patients; length of illness of the psychiatric patients, conditionsfor which CAM products were used for. The dependent variable will be CAM useamong psychiatric patients.

3.3 study areaThe study will be carried out at Kabarnet Sub Countylocated in Baringo County covering an area of approximately 136.8 squarekilometers. It borders West Pokot county to the north and northeast, NakuruCounty to the west, Uasin Gishu County to the south and southwest.It is a government health facility  located in Kaprogonya sub –location ,Kapropita  Lacation ,Kabarnet division,Baringo central constituency  inBaringo  County.The hospital has a bedcapacity of  160  beds in general and psychiatric and 11 cots .

There are 117 medical personnelHospital staff including 83 Nurses and clinical officers, 18 lab techniciansand 10 Doctors. 3.4 Study population The study population in this study will be allpsychiatric patients in Kabarnet Sub County hospitals during the period ofstudy.  3.4.

1 Inclusion Criteria Psychiatric patients in Kabarnet Sub County hospitalfor at least 2months. Healthcare providers, relatives of psychiatry patients whoseminimental exam is below 23 of Kabarnet Sub County hospital will be included inthe study. All those persons above who will consent to participate in thestudy.  3.4.

2 Exclusion Criteria Psychiatric patients in Kabarnet Sub County hospitals whowill not consent to participate in the study will be excluded.  3.5 Sample size determination Sample size will be 30 psychiatry patients out of the100 target population will be selected. 30 psychiatric patient’s represents 30%of the target population a percentage that (Kothari, 2004) say is acceptable.3.

6 Sampling Technique Simple random sampling technique will be used to select 30 psychiatricpatients out of the 100 target population will be selected. 30 psychiatricpatients represents 30% of the target population. Simple random sampling isuseful to get a representative number and reduce bias.3.7 Data collection The researchers who are medically trained will be usedto get the required data from the patients.

All the respondents will sign the consent formindicating their willingness to participate in this study. They will be assuredof confidentiality, the purpose of study, the potential benefits and possiblerisks associated with participation explained to them. Two questionnaires willbe used, including a questionnaire for psychiatric patients and healthcareprofessionals or the relative to the patient. A standardized questionnaire forconventional healthcare practitioners will be self- administered. Thisquestionnaire will be used to determine concomitant use of CAM and conventionalmedicines, report adverse effects of CAM use, use of CAM by conventional healthcare practitioners and their perception concerning CAM.  3.

7.1 Pre-testing Pre-testing of research tools will be conducted in MoiTeaching and Referral Hospital. This will be done on 3 (10%) Psychiatricpatients. This will be done to ensure validity and reliability of researchinstruments. Corrections will be made where necessary in order to make sure thequestions asked provide the required information.  3.8 Data Analysis and Presentation Statistical analysis is essential for making sense ofquantitative information.

Statistics are either descriptive or inferential.Descriptive statistics, generated in the course of data analysis in the presentstudy, will be used to describe and synthesize the data. The software programStatistical Package for the Social Sciences (SPSS) will be employed for dataanalysis. Frequencies for each variable will be generated and organized intotables using SPSS. A chi-square test will be used to determine the associationbetween CAM use and each of the independent variables related to demographiccharacteristics; a P value < 0.

05 will be considered to be statisticallysignificant. 3.9 EthicalConsiderationAll permission will be sought form Baraton Universityethics committee, the County and Sub County offices and the patients andhospitals themselves.