Alternative treatment methods have been used for the treatment of disease and to improve health for hundreds of years. Studies on the incidence of alternative treatment usage in the community have shown a constantly increasing rate ^[1]. It is reported that 42.1% of the U.S. population use alternative treatment method. The cost of alternative treatment has been calculated as USD 22.6 billion for 1990, increasing to USD 32.7 billion for 1997 ^[2]. Another study from the same country has revealed that 33.8% of the people spend more on alternative treatment methods than they do on conventional treatment methods ^[3]. The rate of having used an alternative treatment method at least once is 48% in Australia, 70% in Canada, 38% in Belgium, 90% in Germany and 75% in France ^[4]. While there are no comprehensive studies to show the rate of alternative treatment usage in Turkey generally, some local studies in treatment centers, mostly concerned with chronic disease, have shown that alternative treatments are used by a high percentage of the patients. For example, studies on cancer patients have shown alternative treatment usage rates of 41.1%, 50.0% and 61.0% ^{[5, 6, 7]}. Plants were the most commonly used alternative treatment method in all three studies. Another study with allergic patients has shown that 38.0% use alternative treatment methods, usually with plants ^[8].

Although modern treatment methods are being developed rapidly and many new drugs are produced, patients seem to use alternative treatment methods at an increasing rate ^{[2, 4]}. The main reasons for this tendency are: (a) dissatisfaction with the results obtained from health carers and related institutions, (b) discomfort because of the side effects of drugs and other treatment methods, (c) financial cost of the treatment (especially medication) and care services, (d) not having a say in their health status and their treatment and (e) treatment that is technological and not individualized ^{[9, 10]}. However, not being able to access health care should also be seen as an important factor for the usage of alternative treatment methods, especially in developing countries. For example, the percentage of those who are not able to access health care and use alternative treatments is about 80% in Africa ^[4]. Another aspect of alternative medicine methods is that they have cultural and traditional properties. Some alternative treatment methods may therefore be kept locally and the usage rates found by studies may be much lower than the actual rate ^{[2, 4]}.

The preferred alternative treatment method changes from country to country. While acupuncture is used commonly across the world ^{[4, 11]}, the most commonly used alternative treatment methods in the U.S.A. and Canada are massage, chiropractic manipulation, vitamin-mineral support and acupuncture ^{[3, 12, 13]}. Studies from Turkey have shown that herbal medicine usage is more common as an alternative treatment method ^{[5, 6, 7, 8]}. We therefore aimed to determine the rate of herbal medicine usage in Turkey and why and how it was used.

The study was carried out between January 1, 2004 and December 31, 2004. A total of 19,022 people were informed by e-mail at the beginning and invited to participate in the study. The e-mail had concise information on the study and the subjects were asked to visit the internet address containing the questionnaire and complete the form. The Internet Protocol (IP) numbers of those visiting the internet address were logged to prevent the same person from completing more than one questionnaire. The participants were asked their preferred herbal treatment methods, any herbal treatment methods for cancer treatment they knew of or had heard of, and their age and sex. The results of participants under 18 were not recorded and not included in the study. The study is of the descriptive type and MS Access software and SPSS for Windows version 11.0 was used to evaluate the results. The questions included in the questionnaire are shown in Table 1.

13,025 of the 19,022 study subjects answered the questionnaire but 3.132 responded that they had never used herbal treatment methods and did not continue with the other sections. As a result, the completed questionnaires of 9,893 subjects were considered valid and included in the study. This shows that 75.9% of the participants had used a herbal treatment method at least once.

48.4% of the participants were female and 51.6% male with an average age of 31.3 ± 9.1 (30.6 ± 8.8 for the females and 32.0 ± 9.5 for the males). We had participants from all 81 Turkish provinces. Most participants were from Istanbul, Ankara or Izmir (17.5%, 13.7% and 10.9% respectively).

Of the 19,022 subjects sent information on the study, 13025 (68.4%) were willing to participate. 75.9% of the participants reported that they had used a herbal treatment method at least once. When we take into consideration that the main conditions for participating in the study were to have an email address and to be able to access the Internet, the participants would be expected to have a high socioeconomic status level and to not reflect the country population in general. However the following led us to believe it is possible to project the group's results to the general community: the ages of the subjects that were sent emails varied widely (18-83 years), members and participants were present from every province of the country and the sex distribution was balanced (48.4% males and 51.6% females). The web site which accepted members had various sections (history, entertainment, general culture, news, etc.) in addition to health and medicinal plants and this also made it possible to obtain information from the general community. We can therefore say that 75.9% of Turkish people over 18 years of age have used a herbal medication at least once according to this study.

When we compare our results with those from other countries, it is seen that the percentage of those who have used a herbal medication at least once in Turkey is higher than the rate of alternative treatment usage in countries such as the U.S.A., Australia, Canada, Belgium and France ^{[2, 4]}. The studies carried out in the above countries have determined the rate of usage for all alternative treatment methods and this rate is therefore much higher in Turkey.

Although studies on the frequency of alternative treatment usage in Turkey are usually interested in the treatment of chronic disease such as cancer ^{[5, 6, 7]} and allergies ^[8] our results indicate that the most common condition for which information was obtained over the year for herbal treatment was hair loss and hair care (5.4%). It may therefore be stated that most of the community is interested in using herbal medication for cosmetic reasons. The main reasons for this may be the emphasis placed on herbal/natural additives in advertisements, the high cost of cosmetic applications, and the common interest in cosmetic applications by rich and poor alike. Hemorrhoids were second in the list of the diseases gathering the most interest with 4.1% and this could be due to a reluctance to be examined. Table 2 shows that only 1.06% of the subjects accessed during the year were related to cancer and other associated conditions. The community seems to be using herbal treatments more for cosmetic reasons and for conditions that could generally be prevented with preventive measures than chronic medical conditions that currently have a high mortality. The most accessed health-related subjects, shown in Table 2, provide information on both herbal treatments and the general condition of the society. The fact that complaints related to peptic ulcer, gastritis and other similar problems were placed third may be an indication of the preference for spicy, hard-to-digest food containing lots of fat in many parts of the country. Health problems such as infection and high fever and more serious conditions requiring urgent treatment such as myocardial infarction and angina, were not investigated by the participants and this is a positive indication of the community's approach to health-related matters.

Nettle was the medicinal plant investigated most often by the participants throughout the year (Table 3). Nettle is also prominent worldwide among the medicinal plants: it has been shown to be the alternative treatment method used most often by cancer patients in Turkey ^{[5, 7]}, it is consumed as food in many parts of the country ^[14] and it has been used in many parts of the world to treat conditions such as arthritis, anemia, asthma, diabetes mellitus, hypertension, hemorrhoids, heavy menstrual bleeding, gout, neuralgia, prostate hypertrophy and hair loss ^{[15, 16, 17]}. Research has also shown that it has an inducing effect on T-lymphocytes ^{[18, 19]}. It will be beneficial to investigate all of these properties of nettle in a comprehensive manner, combine scientifically valid information on its efficacy and usage, to convert the plant into medicinal form if appropriate and enable modern medicine to take advantage of its properties. Other plants frequently investigated by the participants during our study were also plants investigated and used widely worldwide (Table 3) ^{[15, 16, 17]}.

We thought early in the study that the main reason for using medicinal plants would be chronic diseases with a high mortality rate such as cancer and asked participants "What herbal treatment methods, if any, are used in your community for cancer treatment?" and 2,984 participants responded. 44.9% of those answering this questions stated that nettle was used for cancer treatment in their community. Most plants used for cancer treatment were generally well-known and studied plants (Table 4). However some (seven) participants from Southern Turkey stated that the myrtle plant was also used for cancer treatment in their community. This plant has generally been studied in relation to diabetes mellitus treatment ^[20] and we did not find any note on its anticancerogenic effect on MEDLINE.

When the participants were asked why they were interested in herbal treatment methods, 32.6% answered that they were hoping they would help the treatment of themselves or someone they knew (Table 4). However, other studies have shown discontent with the healthcare service received as the top reason ^{[9, 10]}. While financial difficulties were one of the main reasons for preferring alternative treatment methods in previous studies, they were last among the reasons in our study. The option 'I am not ill but I am interested in herbal drugs to live better', not present in previous studies, was selected by more than 20% of the participants and may indicate that people want to decide how to improve their health.

Although it is commonly believed that most current drugs are synthetic in origin, six of the 20 most commonly prescribed drugs in 1996 were natural products and 50% of these 20 drugs were associated with natural ingredients, showing the importance of herbal products in drug production and usage ^[21]. Although herbal drugs are investigated extensively, especially for the treatment of cancer, viral disease and infertility, inadequate information is being released due to the intense competition in the drug industry ^[21]. Comprehensive studies on the community usage of drugs are therefore extremely important and should be repeated often and with a wider scope.

In conclusion, Turkey has a higher rate of alternative medicine usage compared to other countries where similar studies have been conducted and comprehensive and regular studies are required to show changes over time. Scientific and academic institutions should take the initiative to prepare comprehensive sources of scientific information on the Internet, one of the easiest ways to access information, in the country's own language to prevent the community from obtaining false information on alternative treatment methods and medicinal plants and being misdirected.

Table 1. Questions included in the questionnaire

< back to text

Table 2. The 10 Most Commonly Studied Conditions/Health Problems

Table 3. The 10 Medicinal Plants Examined Most Frequently

< back to text

Table 4. The Top 10 Plants Reported as being used for Cancer Treatment

< back to text

Table 5. Distribution of the answers to "Why are you interested in herbal alternative treatment methods?"