Public’s Perception and Attitude of Herbal Medication for Respiratory Viral Infections

Background: The use of herbal-origin medications is overgrowing, snowballing belief in its absolute safety. However, some herbal medicines have revealed severe adverse events that may reach death. Hence, it is vital to understand the perception and attitude of patients towards using herbal medications. Objectives: This survey analysis goals to gauge patients’ perceptions and attitudes towards herbal medicine to manage respiratory infections. Design and Settings: A self-administered, structured questionnaire was sent to the public online, counting questions on the responders’ demographics and questions about different herbal medications and their use to treat viral respiratory infections. The survey also encompassed questions to evaluate patients’ perceptions and attitudes towards the use of herbal medicine. Data analysis was implemented through SPSS program version 26. Results: Four hundred and eighty-six responders contributed in this questionnaire. 89.92% of the responders were from the west area, and 94.62% had a Saudi nationality. 56.49% were in the age group between 18 to 30 years old. 46.27% were students, while only 23.44% were employees. 53.69% had an income <3000 SR. 18.32% were healthcare practitioners, and 53.85% were physicians. 45.42% of the patients did not use herbal medications over the last year. 44.01% found herbal medicines effective and valuable, and 41.98% of the responders described herbal medicines as operative. Patients’ gender (p-value=0.025) significantly affected patients’ perception of using herbal medications, where females showed a significantly better perception than females. The validity was tested by Mac (0.96), Cronbach (0.958), Guttmann 2 (0.961), and Guttmann 6 (0.973). Conclusion: The attitudes and perceptions of herbal medicine use among patients in Saudi Arabia are scarce. Awareness of the general public about herbal medications should be amended.


INTRODUCTION
In developing countries, most general population faith herbal products over the counter to manage common conditions, largely gastrointestinal and respiratory conditions. [1] In the Middle East, the use of herbal medicine is snowballing, particularly in Saudi Arabia. Furthermore, many patients in advanced countries also prefer to use herbal-origin medications, believing that they are safer. Though, cautious use of herbal medicines should always be measured. [2,3] The use of herbal medications is desired by patients and is measured by general practitioners and family medicine specialists. [4] These medications are usually a first treatment option for mild and common conditions, like upper respiratory tract infections. This is established in the United States, where the use of herbal medications has augmented up to three-fold recently, while patients are using them without consulting their doctors. [5] Also, up to half of the general population in developing countries favour herbal medications compared to chemical medications. [6] In the Saudi community pharmacies, the patients can access a wide range of herbal supplements the counter products in different forms. [7] Nevertheless, the attitude of the patients towards the use of these products is sometimes unsuitable. Most patients use herbal medicines based on their families and friends' endorsements without seeking medical advice. [8] This behaviour accordingly exposes them to a noteworthy hazard of adverse events. [9] Consequently, it is vital to understand the factors persuading patients' different perceptions and attitudes towards herbal medications. [10] For example, some patients might be exaggerated by media advertisements about these agents, while others might be influenced by relative's or friends' experiences in a comparable condition. [11] Some patients also believe that doctors and pharmacists know only about chemical origins medications; hence they do not ask them about medicines of herbal origin. All these factors can lead to momentous complications and events that might harm the health of a large majority of the population. [12] To present, data in Saudi Arabia on the general population's perception and attitudes towards the use of herbal medications for the treatment of viral respiratory infections is still indistinct. Consequently, the contemporary study intentions to discover Saudi perceptions and attitudes.

Study Design
A quantitative, cross-sectional questionnaire study was achieved in Saudi Arabia through a self-administered electronic questionnaire dispersed to the general public over two months. All Saudi citizens were encompassed. On the contrary, incomplete responses or responses from outside Saudi Arabia were omitted.

Data Collection
An online self-developed questionnaire was disseminated to members of the public in all regions in Saudi Arabia. The survey encompassed demographic data (locations, gender, material status, age, responder qualifications, occupational status, and monthly income). Simultaneously, the second part of the questionnaire comprised questions on herbal medicine and its usages. Besides, the resources of information about herbal medications for respiratory viral infections. A 5-point Likert response scale system was used. The survey had been scattered to a convenient sample of public responders. It was through social Media of WhatsApp and telegram, and personal contact. The prompt message is sent every 1-2 weeks. The completed survey and Saudi public will be involved in the final analysis.

Statistical Analyses
According to the previous literature with unlimited population size, the sample was planned, the population percentage of 50%, the confidence level 95% with z score of 1.96 and margin of error of 5% and drop-out rate of 10%. As a result, the calculated sample size will equal a minimum sample of 418 with the power of study of 80%. [13][14][15] The response rate compulsory of calculated sample size at least 60-70 % and above. [15,16] The survey was authenticated through the revision of expert reviewers and pilot testing. Besides, the reliability tests McDonald's ω, Cronbach's α, Guttmann's 2, and Guttmann's six were completed with the study. The data analysis was finalized through the survey monkey system. Besides, the statistical package of social sciences (SPSS), Jeffery's Amazing Statistics Program (JASP), and Microsoft excel sheet version 16 with description and frequency analysis, good fitness analysis, correlation analysis, inferential analysis between independent variables responders. The STROBE (Strengthening the reporting of observational studies in epidemiology statement: guidelines for reporting observational studies) navigated the contemporary study's reporting. [17,18]

RESULTS
Four hundred and eighty-six responders contributed in this online questionnaire. Only participants who accomplished all the sections in the questionnaire were included. The questionnaire's reliability was tested through Mac (0.96), Cronbach (0.958), Guttmann 2 (0.961), and Guttmann 6 (0.973). Sociodemographics of responders and analysis of the questionnaire are shown below.

General Characters of Responders
Out of 486 participants, 89.92% of the responders were from the west area with statistically momentous differences with other regions (p<0.001), and 94.62% had a Saudi nationality. Also, 80.45% were females with statistically significant differences from males (p<0.001), where 59.17% were single. As for the age of the responders, it was characterised into seven sub-categories. The most dominant age group was between 18 and 30 years old, with 56.49% of the responses with statistically significant differences between age groups (p<0.001). All socio-demographic data is shown Table 1. Participants were also inquired if they were working in the medical field. Only 18.32% were healthcare practitioners, while 53.85% of these practitioners were physicians with statistically significant differences with other specialties (p<0.001), as shown in Table 2.

Herbal Medicine Used in Practice
Responders were enquired about their thoughts on using some herbal medications for different indications. 80.39% of the responders thought that herbal medicines most commonly treat seasonal flu. Additionally, 45.42% of the patients did not apply herbal medications over the last year, while 12.08% used them only once. The responders were also requested about their reasons for using herbal medicines. 44.01% found herbal medications effective and useful.
Based on their own involvements, 41.98% of the responders described herbal medicines as effective, as shown in Table 3.

Perception of Patients towards the Use of Herbal Medications for Respiratory Viral Infections
Responders were questioned about their perception and vision towards using herbal medications. They were probed to choose from five Likert scales, starting with "strongly agree" and ending with "strongly disagree. " The average perception scores were ( Also, it was observed that more than a third of the responders were ambiguous about their opinion in all the questions related to their perception towards using herbal medications. There were statistically noteworthy differences between answers in all perception facets (p<0.001), as shown in Table 4.

Healthcare Providers vs. Public
There is no statistically momentous difference between responders healthcare providers and public residents in living regions, gender, nationality and monthly income (p>0.05). However, the age of healthcare providers is higher than the public with (18-

Nationality
There is no statistically major difference between Saudi and non-Saudi in the different regions came from, ages group, gender, material status, educational levels, occupational status, monthly income, healthcare provider or public, and healthcare professionals specialties (p>0.05).

Independent Variable Correlation
There is a confident association between age and material status and monthly income with spearman results (0.738) and (0.566) respectively, while the Kendal taw was (0.678), (0.499) with statistically weighty (p<0.001). In contrast, there was a negative association between age and occupational status with spearman results (-0.582) and Kendal taw (-0.83) with statistically significant (p<0.001).
There was a positive connotation between material status and monthly income of spearman results was (0.518) and Kendal taw (0.476) with statistically significant (p<0.001).
While there was a negative correlation between material status and occupational level, spearman's results were (-0.627) and Kendal taw (-0.580) with statistically momentous (p<0.001). There is a negative correlation between occupational levels and monthly income with spearman results (-0.578) and International Journal of Pharmacology and Clinical Sciences, Vol 10, Issue 4, Oct-Dec, 2021 Kendal taw (-0.501) with statistically significant (<0.001).

DISCUSSION
Herbal medications are gradually used for different mild community conditions, chiefly respiratory tract and oral infections. [19,20] However, recently, some herbal medicines can lead to noteworthy side effects and complications. [21] Hence, patients should be aware of the hazards of using herbal treatments as well as their benefits. They should also be invigorated to seek medical advice before using any herbal products. [ [23] examined Indian patient's and doctors' perceptions about using herbal medicines for different community indications. It exhibited a poor perception in both patients and doctors. Although one-fifth of the included cohort were healthcare professionals, half of them did not use herbal medications over the last year. On the contrary, in patients who used herbal medicines, almost one-half found herbal medicines actual and treasured, and two-fifth of the responders defined herbal medications as effective. Furthermore, nearly half of the responders had a positive perception. Perception of the use of herbal medicines has been assessed in different settings. Foley et al. [24] scrutinised the perception of patients towards using herbal medicines in clinical practice. A cross-sectional study that encompassed 252 patients, Foley et al. [24] verified that patients strongly agree that they would prefer using herbal medications to treat common conditions compared to chemical origin medications. Additionally, patients strongly settled that they should be denoted to a doctor or pharmacist to discuss their herbal medicines. On the contrary, Gupta et al. [25] observed the perception of Indian patients towards using herbal medications. Gupta et al. [25] involved 533 patients in a survey study and validated that the use of herbal medications among the included cohort was 56.6%. However, most patients desired to try chemical medications and used herbal medications as a second-line or alternative.
In the existing study, half of the responders had the negative perception because there was no consciousness program about herbal medications, counting usage with a viral infection. The reports agreed with the perception of educational lectures about herbal use in respiratory viral infection demand, accentuating pharmacists to educate the patients about herbal medications for viral respiratory illness. It is imitated in the high demand for an education session about herbal medicines from most responders. In contrast, there was a poor insight of herbal medications during usage for children or any herbal drug interaction. It is related to the inadequate knowledge and awareness of herbal medicines for viral respiratory illness, including COVID-19. The usage of herbal medications was high by a respiratory viral infection in practice despite poor practice, perception and misapprehensions about them in Saudi Arabia.
Additionally, the present study had some restrictions; the participants' responses depend largely on the responders' subjective opinion towards their use of herbal medications, which could move the reliability of the findings. Nevertheless, it is measured the first study in Saudi Arabia to assess patients' perception of herbal medicines for respiratory viral infection.

CONCLUSION
The Saudi population towards herbal medications is insufficient and needs further improvement. This perception can suggestively impact patients' behaviour and attitude towards using these medications and might distress their health. Hence, it is vital to carry out awareness sessions for the public about herbal medications' hazards and benefits through evidence-based medical information.
In addition, additional studies are desired to observe the perception of patients towards using herbal medicines in other indications.