Knowledge and practices of herb-herb and herb- conventional drug interactions among traditional practitioners in Bamako, Mali Thesis submitted by Sékou BAH As Partial Completion of the Master of Philosophy Degree in International Community Health Supervisor Per Fugelli University of Oslo Department of General Practice and Community Medicine Co-supervisor Dr. Drissa Diallo Institut National de Récherche en Santé Publique Département de Médecine Traditionnelle BP: 1746, Bamako, Mali Tel: 223 22 46 20 Institution Department of General Practice and Community Medicine The Faculty of Medicine University of Oslo May 2002 1 TABLE OF CONTENTS ABBREVIATIONS................................................................................................................................5 SUMMARY.............................................................................................................................................6 DEDICATION........................................................................................................................................9 ACKNOWLEDGEMENTS.................................................................................................................10 CHAPTER 1. INTRODUCTION........................................................................................................11 1. COUNTRY PROFILE. MALI...............................................................................................................11 1.1. Population and geography......................................................................................................11 1.2. Health facilities and health indicators.....................................................................................11 1.3. Evolution of the traditional medicine sector............................................................................12 2. LITERATURE REVIEW.......................................................................................................................13 2.1. Interactions in a pharmacological perspective........................................................................14 2.2. Reviews and studies about herb-conventional drugs interactions...........................................16 2.3. Knowledge and practice among traditional practitioners concerning interactions................18 3. RATIONALE OF THE STUDY..............................................................................................................19 CHAPTER 2. HYPOTHESIS AND OBJECTIVES..........................................................................21 1. HYPOTHESIS....................................................................................................................................21 2. RESEARCH QUESTIONS.....................................................................................................................21 3. OBJECTIVES.....................................................................................................................................21 3.1. General objectives...................................................................................................................21 3.2. Specific objectives....................................................................................................................21 CHAPTER 3. METHODOLOGY......................................................................................................23 1. STUDY AREA AND POPULATION.......................................................................................................23 1.1. Study area................................................................................................................................23 1.2. Study Population.....................................................................................................................23 Inclusion criteria............................................................................................................................24 Exclusion criteria...........................................................................................................................24 1.3. Selection and sample size........................................................................................................25 2. METHOD..........................................................................................................................................26 2.1. Pilot study and training of the research assistant (second interviewer)..................................26 2.2. Cross-sectional survey.............................................................................................................27 2.2.1. Questionnaire: material and data collection..................................................................28 2.2.2. Definition of variables..........................................................................................................29 2.3. Non participant observation....................................................................................................35 3. VALIDITY, RELIABILITY AND REPRESENTATIVENESS OF THE DATA..................................................37 3.1. Validity....................................................................................................................................37 3.2. Reliability................................................................................................................................38 3.3. Representiveness......................................................................................................................38 4- DATA ANALYSIS..............................................................................................................................38 5. ETHICAL CONSIDERATION...............................................................................................................39 CHAPTER 4. RESULTS.....................................................................................................................40 PART 1. PILOT STUDY.......................................................................................................................40 PART 2. CHARACTERISTICS OF THE STUDY SAMPLE..........................................................40 PART 3. KNOWLEDGE ABOUT INTERACTIONS......................................................................42 I. KNOWLEDGE ABOUT HERB-HERB INTERACTIONS.............................................................................42 1. Awareness about herb-herb interactions....................................................................................42 2. Effects reported as results of the interactions between two herbs..............................................42 2 3- Herbs that can interact and the effects resulting from that interactions....................................43 4. Agreement on some statements on herb-herb interactions.........................................................44 5. Level of knowledge of herb-herb interactions............................................................................44 5.1. The level of knowledge of herb-herb interactions according to the profession.......................45 5.2. The level of knowledge of herb-herb interactions according to gender..................................45 5.3. The level of knowledge of herb-herb interactions according to age........................................46 5.4. The level of knowledge of herb-herb interactions according to the background of the practitioners (inherited and not inherited).....................................................................................47 5.5. The level of knowledge of herb-herb interactions according to formal schooling..................47 5.6. The level of knowledge of herb-herb interactions according to the alphabetization in Bambara ........................................................................................................................................................48 5.7. The level of knowledge of herb-herb interactions according to the length of time in work (experience)....................................................................................................................................48 5.8. The level of knowledge of herb-herb interactions according to the attendance to a workshop on collaboration between traditional medicine and modern biomedicine......................................49 6. Practitioner’s perception on their own knowledge of herb-herb interactions............................50 7. Practitioner’s willingness to improve their knowledge of herb-herb interactions.....................50 8. Sources of knowledge of herb-herb interactions........................................................................51 II. KNOWLEDGE ABOUT HERB-DRUG INTERACTIONS..........................................................................52 1. Awareness about herb-drug interactions....................................................................................52 2. Effects reported as results of herb-conventional drug interactions............................................52 3. Most frequent herbs and conventional drugs that can interact..................................................53 4. Agreement on some statements on herb-drug interactions.........................................................54 5. Level of knowledge of herb-drug interactions............................................................................54 5.1. The level of knowledge of herb-drug interactions according to profession.............................55 5.2. The level of knowledge of herb-drug interactions according to gender..................................55 5.3. The level of knowledge of herb-drug interactions according to age.......................................56 5.4. The level of knowledge of herb-drug interactions according to the background (inherited or non-inherited).................................................................................................................................56 5.5. The level of knowledge of herb-drug interactions according to formal schooling..................57 5.6. The level of knowledge of herb-drug interactions according to the length of time in work (experience)....................................................................................................................................57 5.7. The level of knowledge of herb-drug interactions according to the attendance to a workshop on collaboration between traditional medicine and modern biomedicine......................................58 6. Practitioner’s perception on their own knowledge of herb-drug interactions............................59 7. Practitioner’s willingness to improve their knowledge of herb-drug interactions.....................59 8. Sources of knowledge of herb-drug interactions........................................................................60 PART 4. PRACTICE...........................................................................................................................61 I. PRACTICE FROM QUESTIONNAIRE (ANNEX 1)...................................................................................61 A. PRACTICE ABOUT HERB-HERB INTERACTIONS.................................................................................61 1. Categories of medicines used.....................................................................................................61 2. Herbs most frequently used........................................................................................................61 3. Frequency at which practitioners have experienced interactions between different herbs........62 4. Herb-herb combinations used.....................................................................................................63 5. Herbs that can never be taken together and the results of the interactions between them.........64 B. PRACTICE ABOUT HERB-DRUG INTERACTIONS................................................................................65 1. Herbs and conventional drugs that practitioners never use together and the interactions resulting from them.........................................................................................................................66 2. Frequency at which practitioners have experienced interactions between herbs and conventional drug...........................................................................................................................67 3. Herbs and conventional drugs that practitioners asked their patients to take together.............69 C- SPECIFIC QUESTIONS ON PRACTICE.................................................................................................70 1. Information of relevance for herb-herb and herb-conventional drug interactions collected by practitioners from their patients.....................................................................................................71 2. Advices provided by practitioners to patients when giving them herbs......................................71 3. Advices that practitioners gave to their patients about the use of laxative herb with oral conventional drug...........................................................................................................................75 4. Advices that practitioners gave when the herb and the conventional drug have same activity..76 II. PRACTICE FROM THE OBSERVATIONAL DATA..................................................................................77 3 A. Practice about herb-herb interactions.......................................................................................78 1. Practice related to herb-herb interactions checked during observation of 36 consultations.....78 2. Cross analysis of practice related to herb-herb interactions checked during the observation compared with some answers from the questionnaire....................................................................79 B. Practice about herb-drug interactions.......................................................................................81 1. Practice related to herb-drug interaction checked during the 36 consultations........................81 2. Cross analysis of practice related to herb-drug interaction checked during the observation compared with some answers from the questionnaire....................................................................82 CHAPTER 5. DISCUSSION; CONCLUSION; RECOMMENDATIONS.....................................86 I. DISCUSSION.....................................................................................................................................86 II. CONCLUSION................................................................................................................................112 III. RECOMMENDATIONS...................................................................................................................114 REFERENCES...................................................................................................................................116 ANNEX1: QUESTIONNAIRE..........................................................................................................121 ANNEX2 HERBS AND CONVENTIONAL DRUGS THAT CAN BE USED TOGETHER ACCORDING TO WAYS OF ADMINISTRATION......................................................................131 4 ABBREVIATIONS CNOP: Conseil National de l’Ordre des Pharmaciens du Mali DMT: Department of Traditional Medicine DPM: Direction de la Pharmacie et du Médicament GDP: Gross Domestic Product per capita INRSP: Institut National de Récherche en Santé Publique ITMs: Improved Traditional Medicines Km: Kilometer MAO: Monoamine Oxidase MAOIs: Monoamine oxidase inhibitors MSSPA: Ministère de la Santé, de la Solidarité et des Personnes Agées NGO: Non Governmental Organization USD: United States Dollars 5 Knowledge and practices of herb-herb and herb-conventional drug interactions among traditional practitioners in Bamako, Mali Author: Sékou Bah Summary Rationale: Mali is one of the poorest countries in the world with a GDP of 260 USD per capita. The public health expenditure was 10.2% of the GDP in 1999. 59% of the population has access to health facility within 15 km (1). In Mali there is since 1995 an institutional framework that regulates the practice of traditional medicine (2). In the favor of this law healers and herbalists are allowed to open traditional clinics and traditional medicines shops. To improve their state of health, people use both conventional and traditional medicines. Traditional medicine, being a significant element in the cultural patrimony, still remains the main resource for a large majority of people. The accessibility to conventional drugs is however increasing, especially in urban areas. This development can lead to the combination of the two types of medicines. According to the literature herbal medicines can interact with conventional drugs in many ways. It is therefore important to study the knowledge of herb- conventional drug interactions among traditional practitioners. On the other hand one of the objectives of the Department of Traditional Medicine is to develop new medicines (ITMs) from natural plants. The traditional healers and herbalists are the main informants for the DMT in the production of ITMs; therefore to study their knowledge of herb-herb interactions is necessary. General objectives: The general objective was to determine the level of knowledge and the practices regarding herb-herb and herb-conventional drug interactions of the traditional practitioners (healers and herbalists) registered by the Department of Traditional Medicine (DMT) and operating in Bamako. Study Design: Cross sectional descriptive study. 6 Materials and Methods: A total of 256 healers and herbalists were registered by the DMT. Out of them 123 were operating in Bamako. The sample was chosen by convenience and the participants were asked for their verbal informed consent. Interviews using a semi-structured questionnaire were performed with 22 healers and 26 herbalists from September to November 2001 supplemented by 36 consultations using a checklist with 10 healers and two herbalists. The level of knowledge of herb- herb and herb-drug interactions was categorized as low, moderate and high according to the effects reported as results herb-herb and herb-conventional drug interactions. Chi- square, Mann-Whitney and Kruskall-Wallis tests were used for statistical analysis of the data. The level of significance was set at 0,05. Results: Healers and herbalists used four categories of medicines (herbs, ITMs, mineral elements and animal products). The herbs most frequently used were Cassia sieberiana DC, Mitragyna inermis (Willd.) O. Ktze. and Trichilia emetica Vahl. All the practitioners (48/48) were aware of herb-herb interactions. 69% (n=48) of the practitioners were categorized with low level of knowledge of herb-herb interactions. 58% (n=48) of the respondents were aware of herb-drug interactions. The majority 83% (n=48) of the practitioners however, scored low level of knowledge. The healers and herbalists reported thirty-two herb-herb combinations used with T. emetica with Anogeissus leiocarpa (DC) Guill. et Perrott as the mostly used. Swartzia madagascariensis Desv. and Securidaca longepedunculata Fresen. were the herbs that should never be used together or with other herbs mostly cited. Thirteen herbs and eleven drugs were reported as those that the healers and herbalists told patients to take together, but at different times. M. inermis with antimalarial drugs and A. leiocarpa also with antimalarial drugs were the most frequently cited. S. madagascariensis and S. longepedunculata were the herbs reported as not to take with any conventional drugs. Conclusion: The study showed that healers and herbalists have low level of knowledge of both herb-herb and herb-conventional drug interactions. The effects that they reported as results of herb-herb or herb-drug interactions were mainly the positive aspects of the interaction. However there is a room of improvement because the healers and herbalists themselves recognized that their knowledge of herb-drug interactions was low and also they were willing to get more knowledge about interactions. 7 Recommendations: Based on the fact that the level of knowledge of herb-herb and herb-drug interactions is low and the fact that healers and herbalists reported positive effects of interactions, we recommend: - Training healers and herbalists about the possible consequences of herb-drug interactions as well as herb-herb interactions - To do specific study about the interaction that healers and herbalists reported when combining herbs and herbs with conventional drugs. Key words: Healers, Herbalists, Herbs, Improved Traditional Medicines (ITMs), Conventional Drugs, Interactions, Knowledge, Advice. 8 DEDICATION To my wife Hattia Hadji BAH and my son Cheickhna BAH for their patience during my absence. To my whole family in Nampala. 9 ACKNOWLEDGEMENTS I thank the Norwegian Government for the scholarship to do this course and the Head of PHARMADIET Sarl for allowing me to leave my job for the time of this course. I thank my supervisor Per Fugelli whose contributions were essential both in the development and the analysis of this work. I am very grateful for his patience and his constructive criticisms. I thank Dr. Diallo Drissa the head of DMT for his help during the fieldwork and his constructive comments on the first manuscript. I use that opportunity to thank very much Mme Tandina Fatima Sidibé, the second interviewer. Her availability during the fieldwork was essential for the quality of the data collected. Petite soeur je te dits Merci. I thank Berit Smestad Paulsen for her constructive comments on the work and also for her support during my stay in Oslo. Thank you very much. I acknowledge and thank the entire staff in the Institute of International Community Health as well as all my friends and fellows students. I thank sincerely Idrissa Coulibaly and his family in Oslo. Coulibalike “I ni tié, Allah ka i sara”. I acknowledge and thank all the healers and herbalists in Bamako, without their participation this work would not be achieved. Special thanks to Kari, Cecelia and Tore Even. You made my stay in Norway enjoyable. 10