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Current Topics in Nutraceutical Research 360 May 2022 | Volume 20 | Article 22
CURRENT TOPICS IN NUTRACEUTICAL RESEARCH Vol. 20, No. 2, pp. 360–364, 2022
doi: https://doi.org/10.37290/ctnr2641-452X.20:360-364
ISSN 1540-7535 print, ISSN 2641-452X online, Copyright © 2022 by New Century Health Publishers, LLC
www.newcenturyhealthpublishers.com
All rights of reproduction in any form reserved
Research ArticleResearch Article
Parental Attitude and Awareness of the Use of
Complementary and Alternative Medicine for the
Management of Respiratory Tract Infections in
Children: A Cross-Sectional Study from Aseer
Region, Saudi Arabia
Sultan M. Alshahrani
College of Pharmacy, King Khalid University, Abha, Saudi Arabia
Received November 25, 2021; Accepted December 27, 2021
Communicated By: Prof. Chandan Prasad
Respiratory tract infections are considered the major cause of pediatric hospitalization requiring direct supervision by a
clinician. The use of antibiotics that are commonly used for treatment is sometimes associated with the development of
antibiotic resistance and less than desirable treatment outcome. Despite limited clinical evidence, complementary and
alternative medicine is widely used as an alternative to antibiotics worldwide for treatment of respiratory tract infections in
children. Therefore, we decided to explore the parental attitude and awareness regarding the use of the complementary
and alternative medicine for the management or prevention of respiratory tract infections in children in Aseer region, Saudi
Arabia. Over a 4-month period during influenza season, 1,192 parents were administered two sets of seven questionnaires
dealing with attitude and awareness about the complementary and alternative medicine use. The results show that parents
who felt that respiratory tract infections in children do need antibiotics supported the use of the complementary and alterna-
tive medicine modalities. More than half of the participants agreed that the complementary and alternative medicine would
produce fewer side effects on their children’s immunity than antibiotics and produce less bacterial resistance. In conclusion,
the complementary and alternative medicine use for the treatment of respiratory tract infections in children should be based
only on reliable and evidence-based advice.
Keywords: Children, Complementary medicine, Herbal medicine, Respiratory tract infections, Saudi Arabia
Abbreviations Used: Complementary and alternative medicine, CAM; Respiratory tract infections, RTI; Standard deviation, SD
Corresponding Author: Sultan M. Alshahrani, Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha
61441, Saudi Arabia; E-mail: shahrani@kku.edu.sa
INTRODUCTION
RTIs are considered the major cause of pediatric hospital admission
that require direct supervision by a clinician. e spectrum of
RTIs involves dierent micro-organisms including viral, bacterial,
mycobacterial, and fungal infections (Winant et al., 2017; Witt et al.,
2014). e viral infection is the most common cause of infant hos-
pitalization in RTIs (lower RTI—bronchiolitis) in children with age
<2 years (Bramson et al., 2005; Azkur et al., 2014; Guo et al., 2012).
e common viral infections of pediatric bronchioles involve respi-
ratory syncytial virus, parainuenza, human metapneumovirus,
rhinovirus, inuenza, and adenovirus (Maykowski et al., 2018; Paes
et al., 2016).
Due to a high incidence rate, RTIs increase a signicant bur-
den on health, economic, and social welfare (Anonymous, 2001;
Chen and Kirk, 2012; Chow et al., 2013). e prevalence of respi-
ratory infections among children in Saudi Arabia requiring imme-
diate treatment is about 15.4% among population (Fagbo et al.,
2017). e causes of respiratory infections vary from self-limiting
conditions such as the common cold to the more serious acute
RTI including pneumonia. However, most respiratory infections
(14.5%) in children are caused by viruses (Albogami et al., 2018).
Current Topics in Nutraceutical Research 361 May 2022 | Volume 20 | Article 22
Sultan M. Alshahrani Parental Attitudes Toward CAM Use in Children
agree, agree, neutral, disagree, and strongly disagree, respectively).
Subsequently, the Likert scale responses were collapsed into three
categories (agree, neutral, and disagree) and the pooled mean and
standard deviation for agreement, neutral, and disagreement were
assessed to present the responses more clearly.
Ethical Consideration
e data collection processes were standardized, and no personal
information about the participants was collected or stored. e
remaining information was kept condential during the study as
well as during data analysis. e participants were asked for their
consent before the beginning of the survey. ey were neither asked
about their ID nor any personal information. e participation in
the study was completely voluntary.
e World Medical Association Declaration of Helsinki:
Ethical standards for medical research involving human people,
as amended by the 59th WMA (ECM#2021-5415), Seoul, Korea,
was followed in this study. Aside from that, no personally iden-
tiable information about the patients was collected. In addition,
the Research Ethics Committee at King Khalid University (HAPO-
06-B-001) has reviewed and approved this project (Approval No.
REC # 2018-06-24).
RESULTS
Sociodemographic Characteristics
of Participants
e data presented in Table 1 summarize sociodemographic and
the pattern of the CAM use on study participants. Out of the
1,192 participants, 79.61% were female and 47.57% were aged
between 20 years and 30 years. Most of the participants had at least
secondary school degree or higher (secondary school 33.67%,
bachelor’s degree 58.14%, and higher education 4.61%). Parents
(82.8%) had one or two children. Most of the participants were
from urban area (84.14%) and were employed either in government
or private sectors (65% and 28%, respectively). More than two-
third of the participants (71%) were from middle income class
(5,001–9,999 SR/month). According to parents, most of their
children were diagnosed with RTIs at least once a year (64.7%),
and about 80% of these use CAM without any other medications
to treat RTIs. e most used CAM were food (such as soup or juice)
followed by oil rub and aromatherapy (humidier).
e information on the use of CAM for respiratory infection in
children came from a variety of sources including family members
(49.3%), friends and work colleagues (18.0%), social media and
television (28.5%), and previous self-experience (4.2%). e main
reasons to use the CAM in children with RTIs were accessibility
and easiness of CAM use followed by high expense of medical care
(Table 2).
Attitudes Toward Using CAM for
Respiratory Infection in Children
e data presented in Table 3 summarize the parent’s attitudes
toward use of the CAM for the management of RTIs in children.
ere are red ags on most of the RTIs treatments such as cough
syrups and cold medications that are contraindicated to be used for
children under 2 years of age (Anonymous, 2007). Despite limited
evidence, CAM consisting of unconventional practices beyond the
realm of conventional medicine is commonly used worldwide by
parents for treating or preventing various diseases and illnesses in
children (Anonymous, 2008; Lim et al., 2005). is study aims to
explore the parental attitude and awareness regarding the use of
the CAM for the management or prevention of RTIs in children in
Aseer region of the Kingdom of Saudi Arabia.
MATERIALS AND METHODS
Study Design and Data Collection
A structured, self-administered, and validated questionnaire was
derived from previously published study (Lucas et al., 2019) with
input from the experts. A pilot test was then carried out to assess
the validity of the questionnaire. e questionnaire was prepared in
English, while it was also translated to Arabic by a bilingual person.
Before data entry, the survey was back translated to English. It was
allocated through several social media platforms for participants.
e data collection continued during the u season over 4 months
(from April 15th to July 15th). Residents of Aseer region, Saudi
Arabia aged 18 or older with one or more children were included
in the study and were willing to answer the questionnaires. e
participants unwilling to give their consent were omitted. A total
of 1,192 parents (a father or a mother) participated in the survey
voluntarily.
e survey included collection of data on demographics of the
participants and parental attitude and awareness toward using the
CAM for RTIs in children. e questionnaire was written and dis-
tributed using the Google forms platform, survey administration
soware oered by Google. A pilot study was conducted to test the
reliability of demographic characteristics (eight items), attitudes
(seven items), and awareness (seven items). A pilot study was con-
ducted on 12 parents and the Cronbach Alpha factor was deter-
mined to be 0.76. e Cronbach Alpha factor is a measure of the
internal consistency of a test or scale that is expressed as a number
between 0 and 1 (Cronbach, 1951). e higher the number, the
higher the reliability and consistence are (Tavakol and Dennick,
2011). Internal consistency describes the extent to which all the
items in a test measure the same concept or construct and hence
it is connected to the inter-relatedness of the items within the test.
However, these pilot study results were not included in the nal
analysis.
Statistical Analyses
e questionnaires were reviewed for completeness and accuracy
and the data were cleaned, coded, and then entered using the SPSS
version 21 (IBM Corp., Armonk, NY, USA). e sociodemographic
data were analyzed using descriptive analysis. Categorical variables
were reported as frequencies and percentages, and continuous vari-
ables were represented as mean and standard deviation. e mean
scores and standard deviation were calculated for each statement
based on the 5-point Likert scale responses (indicating strongly
Sultan M. Alshahrani Parental Attitudes Toward CAM Use in Children
Current Topics in Nutraceutical Research 362 May 2022 | Volume 20 | Article 22
TABLE 1 | Demographic characteristics of participants.
Item Frequency %
Gender
Male 243 20.39
Female 949 79.61
Age
20–30 567 47.57
31–40 411 34.48
41–50 198 16.61
>50 years old 16 1.34
Educational level
No education 43 3.61
Secondary school 401 33.64
Bachelor’s degree 693 58.14
Post graduate degree (Master’s or PhD) 55 4.61
Number of children
One or Two 987 82.80
More than two 205 17.20
Residence area
Rural area 189 15.86
Urban area 1003 84.14
Employment status
Unempolyed 65 5.45
Government 786 65.94
Private 339 28.44
Student 2 0.17
Income rate/month
3,000–5,000 SR 251 21.06
5,001–9,999 SR 847 71.06
>10,000 94 7.89
How many times your child(ren) may get respiratory infection per a year?
Once 769 64.51
More than once 423 35.49
Do you use CAM alone or with other medications?
Without other medications 953 79.99
With other medications 239 20.01
The commonly use CAM for Children during RTIs?
Anise 156 13.09
Vitamins C 136 11.40
Food (soup, juice…etc.) 415 34.87
Aromatherapy (humidifiers) 189 15.85
Ginger 84 7.05
Oil rubbing 212 17.78
TABLE 2 | Main reasons to use CAM in children with respiratory infection.
Item n (%)
Accessible and Easy to use 349 (29.3)
Expensive medical care 231 (19.4)
Self-limiting infection and no need to seek medical care 459 (38.5)
Long waiting lines at respiratory clinics 153 (12.9)
More than one-third of the participants (43.1%) agree that the
CAM could be eective in children with RTIs because it is eec-
tive in adults. Also, most of the participants do not consult their
doctor before using the CAM in children with RTIs. Almost two-
third of the participants not believing the need of antibiotics in the
management of RTIs, favored the use of the CAM modalities. More
than half of the parents strongly contend the use of the CAM for
philosophical, traditional, or religious reasons.
Awareness of the Use of CAM for RTIs
in Children
e data presented in Table 4 present parents’ awareness toward
using the CAM for RTIs in children. e participants showed good
awareness toward using the CAM in children with RTIs. Most of
the participants disagree to use the CAM for children for long time.
In addition, more than half of the participants agreed that the CAM
would produce fewer side eects on their children’s immunity than
antibiotics. A slightly more than 50% of participants were neutral
regarding the importance of education and learning about the
CAM before using them. Honey was found to be agreed on to be
contraindicated for children <2 years of age.
DISCUSSION
Food, in general, is commonly used in the CAM practice (Lee
et al., 2000; van Tonder et al., 2009; Dixon, 2012; Yau et al., 2021).
e use of nonvitamin and nonmineral dietary supplements are
popular complimentary health approaches that diered by selected
sociodemographic characteristics (Clarke et al., 2015).
RTIs in children are on the rise worldwide (GBD 2015 LRI
Collaborators, 2017). With this there is also a rise in the use of
antibiotics, a traditional therapy, and antibiotics resistance and
treatment failure (van Houten et al., 2019). Consequently, a large
proportion of parents of children with RTIs prefer to use the CAM
modalities (Lucas et al., 2019). To the best of our knowledge, this is
the rst study that discusses the attitudes and awareness of parents
toward use of the CAM for their children diagnosed with RTIs. e
use of the CAM (especially herbal remedies) has become a com-
mon practice among Aseer population since it contains about 70%
of the Saudi Arabia ora with distinctive biodiversity (Bartalis and
Halaweish, 2011). As a result, multiple previous studies have shown
increase in the CAM use among Aseer population as a preventive
measure or a treatment for several diseases and conditions such as
obesity, epilepsy, and diabetes (Alshahrani et al., 2020; Al-Rowais,
2002; Alhazzani et al., 2016).
About 62.3.5% of the participants in the current study disagreed
that they need to consult their physician before using the CAM for
children with RTIs while only 26.2% think that education about
using the CAM is crucial. ese ndings go along with the par-
ticipants’ opinion of their self-experience, religious/traditional
thoughts, and the source of their information. Family member’s
experience was found to be the most common source of informa-
tion. A previous study found that parents can start using the CAM
to treat mild RTIs as initial treatment to avoid using antibiotics.
However, this should not prevent parents from asking medical
Current Topics in Nutraceutical Research 363 May 2022 | Volume 20 | Article 22
Sultan M. Alshahrani Parental Attitudes Toward CAM Use in Children
professional opinion before taking the treatment decision (Ingram
et al., 2013; Neil, 2000).
CONCLUSION
e results of this study show that parents would prefer using the
CAM over antibiotics for the treatment of RTIs in children. e
parental treatment decision would be based on religious, acquain-
tance’s and family advice, availability of the CAM, and severity of
RTIs. In addition, parents showed positive attitudes and awareness
regarding the appropriateness of the CAM use specially the dose,
side eect, and duration of treatment. However, the CAM treat-
ment should be used for treating RTIs in children based only on
reliable and evidence-based advice and use. erefore, there is an
ultimate need to improve parents’ and pediatricians’ knowledge
about the CAM usage to provide optimal treatment.
ACKNOWLEDGMENT
e author would like to thank the King Khalid University for the
administrative and technical support for this research.
CONFLICT OF INTEREST DECLARATION
e author states that there are no conicts of interest to disclose.
TABLE 3 | Parents attitudes toward using CAM for respiratory infection in children.
Item Strongly agree/Agree n (%) Neutral n (%) Strongly disagree/Disagree n (%) Mean (SD)
I think CAM is effective in children with RTIs because it is effective
in adults
514 (43.1) 251 (21.1) 427 (35.8) 3.18 (0.37)
I always need to consult my doctor first before using CAM to
children with RTIs
252 (21.1) 197(16.5) 743 (62.3) 2.41 (0.22)
I don’t want to give my children antibiotics for RTIs, rather I can
give them CAM instead
724 (60.7) 368 (30.9) 100 (8.4) 3.79 (0.30)
I will seek medical care only if the condition is deteriorated 472 (39.6) 547 (45.9) 173 (14.5) 3.38 (0.53)
CAMs are considered supplementary and can’t replace medical
treatment
299 (25.1) 493 (41.4) 400 (33.5) 2.88 (0.09)
I use CAM to my children with RTIs due to philosophical,
traditional, or religious reasons
753 (63.2) 309 (25.9) 130 (10.9) 3.78 (0.43)
Past self-experience to use CAM in the treatment of RTIs or from
family and friends is the major driving force to use it to my children
489 (41.0) 560 (47.0) 143 (12.0) 3.44 (0.74)
TABLE 4 | Parents awareness toward using CAM for respiratory infection in children.
Item Strongly agree/Agree n (%) Neutral n (%) Strongly disagree/Disagree n (%) Mean (SD)
CAM can be used for long time for children 121 (10.1) 243 (20.4) 828 (69.5) 2.13 (0.20)
CAM in general, have fewer side effects on immunity
than medical therapy (antibiotics) 659 (55.3) 347 (29.1) 186 (15.6) 3.63 (0.32)
I stop using CAM once I noticed a side effect 532 (44.6) 467 (39.1) 193 (16.2) 3.44 (0.38)
Education about CAM and its side effects is crucial 312 (26.2) 631 (52.9) 249 (20.9) 3.09 (0.51)
Using CAM for RTIs in children will reduce antibiotics
misuse and bacterial resistance 439 (36.8) 612 (51.3) 141 (11.8) 3.41 (0.13)
Honey as a CAM is contraindicated to be used for
children less than 2 years 961 (80.6) 128 (10.7) 103 (8.6) 4.09 (0.33)
CAM should be used in smaller doses for children than
the adults 731 (61.3) 309 (25.9) 152 (12.8) 3.74 (0.91)
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