Complementary Therapies in Medicine (2014) 22, 304—310
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
Asking patients the right questions about herbal and dietary supplements: Cross cultural perspectives Eran Ben-Arye a,b,c,d,∗, Inbal Halabi b, Samuel Attias e,f,g, Lee Goldstein h, Elad Schiff e,f a
Department of Family Medicine, Complementary and Traditional Medicine Unit, Technion-Israel Institute of Technology, Haifa, Israel b Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel c Clalit Health Services, Western Galilee District, Haifa, Israel d Integrative Oncology Program, The Oncology Service, Lin Medical Center, Israel e Department of Internal Medicine, Bnai Zion Hospital, Haifa, Israel f Department of Integrative Surgery Service, Bnai Zion Hospital, Haifa, Israel g School of Public Health, University of Haifa, Haifa, Israel h Clinical Pharmacology Unit, Internal Medicine C, Haemek Medical Center, Afula, Israel Affiliated to the Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Available online 11 January 2014
KEYWORDS Doctor—patient communication; Dietary supplements; Traditional medicine; Safety; Complementary alternative medicine; Herbs
Summary Background: Use of dietary supplements (DS) during hospitalization carries risks such as reducing drug treatment efficacy and increasing peri-operative complications due to DS—drug interactions and DS side effects. In this study, we aimed to develop socio-cultural-sensitive patient histories to detect DS use amongst hospitalized patients from different backgrounds. Research design and methods: Prospective cohort study of hospitalized patients from June 2009 through March 2010, using mixed quantitative (questionnaires), and qualitative (semi-structured interviews) research methodology to detect DS use. Results: Data were provided by 691 of 895 patients (response rate 77.2%). Of these, 359 (51.9%) reported using DS in the previous year. 168 (46.8%) disclosed DS use following a standard question on DS consumption. 191 (53.2%) respondents disclosed DS use only following further questioning utilizing DS-related keywords. Leading questioning techniques that facilitated admitting DS use included: naming common DS (50.6% disclosure rate), and using traditional/herbal medicine (THM) related keywords (41.3% disclosure rate) such as infusions, teas, herbs picked in the garden. A logistic multivariate regression model indicated that disclosure of DS use, by using THM related keywords was associated with non-Jewish religion [EXP(B) = 3.57, 95% C.I. 1.70—7.50, p = 0.001], dwelling in rural areas (p = 0.004), and having a lower degree of education (p = 0.01).
∗ Corresponding author at: Department of Family Medicine, Complementary and Traditional Medicine Unit, Technion-Israel Institute of Technology, Haifa, Israel. Tel.: +972 52 870 9282; fax: +972 4 851 3059. E-mail address: [email protected] (E. Ben-Arye).
0965-2299/$ — see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctim.2014.01.005
Right questions about herbal and dietary supplements
305
Conclusions: Improved history taking regarding DS use in hospitalized patients can be accomplished by using specific keywords that address socio-cultural diversities as in the following question: ‘‘Do you use any natural, folk, traditional, grandma remedies, herbs picked in the garden, infusions or herbal teas to improve your health?. © 2014 Elsevier Ltd. All rights reserved.
Introduction Dietary supplements, as defined in most countries, include minerals and vitamins as well as herbs intended to supplement the diet by increasing the total dietary intake, or a concentrate, metabolite, constituent, extract, or combination of any of the aforementioned ingredients.1 The use of dietary supplements (DS) during hospitalization has lately attracted clinical interest due to their widespread use as well as potential benefits and risks.2,3 In the US, data from the 2002 to 2007 Adult Complementary and Alternative Medicine File to the National Health Interview Survey (NHIS) indicate an increased number of adults that ever used herbs or supplements involving 55.1 million persons in 2007).4 DS use has social—cultural aspects [e.g. increased use in Asians, American Indians and Alaskan natives]5 which may also influence the type of DS used. Raji et al. studied community-dwelling elderlies in Texas and found that non-Hispanic whites use more vitamin—mineral supplements while black ethnicity was associated with more herbal use.6 The prevalence of DS use in the hospital setting varies in different countries ranging from 15% in Canada7 to 50% and 60% in Italy8 and Australia.9 In Israel, Goldstein and her colleagues reported that although 27% of patients hospitalized in two hospitals used herbal/DS, 94% of the patients had not been asked specifically about herbal consumption by the medical team.10 Also, only 23% of the hospital’s medical files of patients who used DS had any record of such use. In the US general population, the proportion of adult users who disclosed DS use to their health care provider rose, from 33.4% in 2002 to 45.4% in 2007. Although the number of studies on DS use in US hospitals is limited, preliminary studies in surgical and oncological arenas suggest rates of non-disclosure ranging from 33% to 52%.11—13 In California, Leung et al. surveyed 2560 pre-surgical patients in five hospitals and found that 56.4% of DS users did not inform the anesthesiologists before surgery of DS use and that only half of the patients stopped DS use before surgery.14 Mehta et al. analyzed the non-disclosure aspect according to the 2002 NHIS data and found social—cultural correlation of lower disclosure rates of DS use in Hispanic and Asian American adults compared with non-Hispanic white Americans.15 A limited number of studies considered the disclosure aspect from the hospital physicians’ perspective. In Spain, 78% of 105 surgeons and anesthesiologists reported that they did not ask patients about herbal use.16 Limited communication regarding complementary and alternative medicine (CAM) and DS between patients and the health care professions in surgical care was also documented in a Swedish national survey among university hospitals.17 Non-disclosure of DS use may not only hamper doctor—patient communication but may also have significant implications in the hospital setting. From a safety-risk perspective, DS cause concern of adverse events18 during
hospital admission for several reasons. First, the DS may cause adverse reactions (e.g. serotonin syndrome risk related with Hypericum perforatum),19 and may interact with medical treatment. DS—drug interactions may include St. John’s wort causing reduced concentration of oral oxycodone.20 Co-ingestion of coenzyme Q 10 or ginger in patients treated with warfarin increasing the risk of bleeding.21 Potential hypoglycemic effects of herbs (e.g. ginseng), cardiovascular instability (e.g. ephedra), and potentiation of the sedative effect of anesthetics (e.g. kava and valerian).22 The potential for adverse DS effects has lead scholars in the field to recommend routine screening of hospitalized patients for use of DS.23—25 The competence of health care professionals to obtain an accurate anamnesis is fundamental and is emphasized in communication skill courses at medical schools, and in the lifelong training of physicians. Communication skills should take into account many factors, including socio-cultural differences in language and health terminology/concepts. Questioning patients regarding CAM use is no different than questioning on other health aspects. In hospital settings these communicational tasks may be more challenging due to the following reasons: acute medical conditions with timelimited communication26 ; lack of previous acquaintance (compared with primary care setting); and, in addition, patients may perceive the hospital as a bastion of conventional care that is less tolerant of CAM27 making them less willing to disclose CAM use; or simply due to patients’ perception of DS and CAM use as non-important or irrelevant to their medical care during the out-of-ordinary life context of hospital admission.28 In addition, the topic of DS/CAM is underemphasized in physicians training in general29 and knowledge concerning appropriate wording in history taking regarding CAM in variable populations has not been established. In this study, we assessed which questions facilitate detection of DS use in hospitalized patients from diverse socio-cultural backgrounds with the goal of developing a simple and cultural-sensitive communication tool for this setting.
Research design and methods The study was designed as a prospective cohort study of patients hospitalized in 11 departments of a public teaching hospital in Israel. The hospital has 450 beds, and serves a diverse population of rural and urban Jews and nonJews. The study took place between June and March 2009. The ethics committee of the Medical Center reviewed and approved the protocol in accordance with the Helsinki Declaration. Elaboration of the questionnaire: The questionnaire was developed in a stepwise manner by a multi-disciplinary team of researchers that included family and internal medicine
306 specialists trained in integrative medicine and non-MD CAM practitioners. Step I: The development phase of the questionnaire was based on prior research on CAM use in Israel conducted by the Complementary and Traditional Medicine Unit in the Department of Family Medicine, Technion Faculty of Medicine, Israel, and the Clinical Pharmacology Unit at Haemek Medical Center, Afula, Israel.30,31 Step II: The initial questionnaire was validated by 3 focus groups: CM practitioners (12 participants), physicians (12 participants), and patients (12 participants). The focus groups varied by sex and age, education, medical and/or CAM profession, and personal experience with CAM. Focus group participants were requested to comment on questions in the initial questionnaire using a Likert scale for each question’s relevance and comprehension. Participants were requested to write suggestions for improving questions when appropriate, and to add questions as needed. Thereafter, three of the authors (EB, ES, and LG) assessed participants’ response qualitatively, and upon agreement changes were made in the questionnaire. Step III: Based on the focus groups’ appraisals, a refined questionnaire version was formulated and tested in a pilot study with 61 hospitalized patients in two internal medicine departments. The pilot study was performed in order to examine patient’s comprehension of the questions and response to them, as well as for sample size calculation. The main observation in the pilot was that patients often do not comprehend the term DS, and need clarifications regarding this term. Therefore, the research team concluded that: (a) a brief semi-structured interview would accompany the questionnaire, in an attempt to overcome communication barriers. (b) Questionnaires and interviews would be conducted by trained research assistants in order to assure study fidelity. Consequently, the sample size was calculated with Raosoft calculator. Based on previous results showing 45—50% complementary medicine use across different populations across north Israel, we determined the need for 320—340 patients (confidence level 95% alpha-error of 0.05). We estimated that about 50% of respondents would reveal dietary supplements use in the hospitalization setting. Hebrew-written questionnaires were given to patients 18 years and above, who were able to communicate, and provide informed consent. 11 departments participated in this study including 3 departments of internal medicine, OB/GYN, and departments from various surgery specialties. Interviewers approached each and every patient, room by room to assess eligibility and willingness to participate in the study. The survey was conducted by 4th year CAM College students trained in naturopathy. All surveyors completed 8 h of training in communication strategies with patients in general, and specifically regarding DS, in addition to the study procedures. The interviewers were
E. Ben-Arye et al. instructed to question patients beginning with rapport initiation, followed by a questionnaire-based interview. The questionnaire started with a general question ‘‘have you used DS and/or herbs in the previous year for health issues’’. If patients reported such use, then further questions would be asked regarding patterns of use (e.g. length of use, use during admission), and the context of use (reasons for use, who recommended use and disclosure to the family physician and the attending hospital physician). When patients responded with a negative to the initial question, the surveyor would then rephrase the question, using predetermined keywords such as natural substances and remedies, folk/traditional herbs picked in the wild, and vitamins, and would document the keyword that facilitated the disclosure. Interviewers would also document any other keyword (traditional medicines, folk medicine or specific names of DS, etc.) found to be of benefit.
Statistical analysis Interview analysis was performed to detect keywords that disclosed patients’ DS use and their correlation with demographic and socio-cultural variables. Associations of gender, age, education, religion, place of living, and country of birth were determined using demographic and patients’ selfreported data. Data were evaluated using the SPSS software program (version 18; SPSS Inc., Chicago, IL). The Pearson 2 test and Fisher exact test were used to detect differences in the prevalence of categorical variables and demographic data between participants who initially reported of DS use and patients disclosing DS use based on key words detection. Also, a t test was performed to determine whether there were any differences in the continuous variables between the two groups. Specifically, multivariate logistic regression was used to assess univariate associations with the odds ratios of DS use among the interviewees. The logistic regression model included the following variables: age, gender, education, place of birth, residence type, and religion. p < 0.05 was considered statically significant.
Results Data were provided by 691 of 895 patients approached during hospital admission (77.2% response rate). Of the 691 participants providing data, 359 (51.9%) reported using DS in the year prior to the survey. Of the 359 participants using DS, 168 (46.8%) disclosed DS use by referring to the standard question on DS in the questionnaire. Detection of DS use with the other 191 interviewees (53.2%) was facilitated by rephrasing the question with keywords during the interview. Demographic characteristics of the two subgroups of DS users are detailed in Table 1.
Characteristics of DS users detected using keywords versus standard questions DS users, that were detected by keywords were older (p = 0.027), less formally educated (p < 0.0001), resided more in rural areas (p < 0.0001), and were non-Jewish (mainly Arab Muslims, Christians, and Druze; p < 0.0001).
Right questions about herbal and dietary supplements Table 1
307
Demographic characteristics of respondents.
Characteristics
DS users (%) N = 359
DS users disclosed by standard question n = 168
DS users disclosed by keywords n = 191
P value*
Sexa Female:male (%) Mean age in years ± SD (median)
229:130 (63.8:36.2) 60.5 ± 18.5 (63)
105:63 (62.5:37.5) 58.2 ± 18.9 (58.5)
124:67 (64.9:35.1) 62.6 ± 17.9 (65)
NS
Education Elementary school High school Academic
72 (20.1%) 137 (38.3%) 149 (41.6%)
15 (8.9%) 56 (33.3%) 97 (57.7%)
57 (30%) 81 (42.6%) 52 (27.4%)
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
Asking patients the right questions about herbal and dietary supplements: Cross cultural perspectives Eran Ben-Arye a,b,c,d,∗, Inbal Halabi b, Samuel Attias e,f,g, Lee Goldstein h, Elad Schiff e,f a
Department of Family Medicine, Complementary and Traditional Medicine Unit, Technion-Israel Institute of Technology, Haifa, Israel b Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel c Clalit Health Services, Western Galilee District, Haifa, Israel d Integrative Oncology Program, The Oncology Service, Lin Medical Center, Israel e Department of Internal Medicine, Bnai Zion Hospital, Haifa, Israel f Department of Integrative Surgery Service, Bnai Zion Hospital, Haifa, Israel g School of Public Health, University of Haifa, Haifa, Israel h Clinical Pharmacology Unit, Internal Medicine C, Haemek Medical Center, Afula, Israel Affiliated to the Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Available online 11 January 2014
KEYWORDS Doctor—patient communication; Dietary supplements; Traditional medicine; Safety; Complementary alternative medicine; Herbs
Summary Background: Use of dietary supplements (DS) during hospitalization carries risks such as reducing drug treatment efficacy and increasing peri-operative complications due to DS—drug interactions and DS side effects. In this study, we aimed to develop socio-cultural-sensitive patient histories to detect DS use amongst hospitalized patients from different backgrounds. Research design and methods: Prospective cohort study of hospitalized patients from June 2009 through March 2010, using mixed quantitative (questionnaires), and qualitative (semi-structured interviews) research methodology to detect DS use. Results: Data were provided by 691 of 895 patients (response rate 77.2%). Of these, 359 (51.9%) reported using DS in the previous year. 168 (46.8%) disclosed DS use following a standard question on DS consumption. 191 (53.2%) respondents disclosed DS use only following further questioning utilizing DS-related keywords. Leading questioning techniques that facilitated admitting DS use included: naming common DS (50.6% disclosure rate), and using traditional/herbal medicine (THM) related keywords (41.3% disclosure rate) such as infusions, teas, herbs picked in the garden. A logistic multivariate regression model indicated that disclosure of DS use, by using THM related keywords was associated with non-Jewish religion [EXP(B) = 3.57, 95% C.I. 1.70—7.50, p = 0.001], dwelling in rural areas (p = 0.004), and having a lower degree of education (p = 0.01).
∗ Corresponding author at: Department of Family Medicine, Complementary and Traditional Medicine Unit, Technion-Israel Institute of Technology, Haifa, Israel. Tel.: +972 52 870 9282; fax: +972 4 851 3059. E-mail address: [email protected] (E. Ben-Arye).
0965-2299/$ — see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctim.2014.01.005
Right questions about herbal and dietary supplements
305
Conclusions: Improved history taking regarding DS use in hospitalized patients can be accomplished by using specific keywords that address socio-cultural diversities as in the following question: ‘‘Do you use any natural, folk, traditional, grandma remedies, herbs picked in the garden, infusions or herbal teas to improve your health?. © 2014 Elsevier Ltd. All rights reserved.
Introduction Dietary supplements, as defined in most countries, include minerals and vitamins as well as herbs intended to supplement the diet by increasing the total dietary intake, or a concentrate, metabolite, constituent, extract, or combination of any of the aforementioned ingredients.1 The use of dietary supplements (DS) during hospitalization has lately attracted clinical interest due to their widespread use as well as potential benefits and risks.2,3 In the US, data from the 2002 to 2007 Adult Complementary and Alternative Medicine File to the National Health Interview Survey (NHIS) indicate an increased number of adults that ever used herbs or supplements involving 55.1 million persons in 2007).4 DS use has social—cultural aspects [e.g. increased use in Asians, American Indians and Alaskan natives]5 which may also influence the type of DS used. Raji et al. studied community-dwelling elderlies in Texas and found that non-Hispanic whites use more vitamin—mineral supplements while black ethnicity was associated with more herbal use.6 The prevalence of DS use in the hospital setting varies in different countries ranging from 15% in Canada7 to 50% and 60% in Italy8 and Australia.9 In Israel, Goldstein and her colleagues reported that although 27% of patients hospitalized in two hospitals used herbal/DS, 94% of the patients had not been asked specifically about herbal consumption by the medical team.10 Also, only 23% of the hospital’s medical files of patients who used DS had any record of such use. In the US general population, the proportion of adult users who disclosed DS use to their health care provider rose, from 33.4% in 2002 to 45.4% in 2007. Although the number of studies on DS use in US hospitals is limited, preliminary studies in surgical and oncological arenas suggest rates of non-disclosure ranging from 33% to 52%.11—13 In California, Leung et al. surveyed 2560 pre-surgical patients in five hospitals and found that 56.4% of DS users did not inform the anesthesiologists before surgery of DS use and that only half of the patients stopped DS use before surgery.14 Mehta et al. analyzed the non-disclosure aspect according to the 2002 NHIS data and found social—cultural correlation of lower disclosure rates of DS use in Hispanic and Asian American adults compared with non-Hispanic white Americans.15 A limited number of studies considered the disclosure aspect from the hospital physicians’ perspective. In Spain, 78% of 105 surgeons and anesthesiologists reported that they did not ask patients about herbal use.16 Limited communication regarding complementary and alternative medicine (CAM) and DS between patients and the health care professions in surgical care was also documented in a Swedish national survey among university hospitals.17 Non-disclosure of DS use may not only hamper doctor—patient communication but may also have significant implications in the hospital setting. From a safety-risk perspective, DS cause concern of adverse events18 during
hospital admission for several reasons. First, the DS may cause adverse reactions (e.g. serotonin syndrome risk related with Hypericum perforatum),19 and may interact with medical treatment. DS—drug interactions may include St. John’s wort causing reduced concentration of oral oxycodone.20 Co-ingestion of coenzyme Q 10 or ginger in patients treated with warfarin increasing the risk of bleeding.21 Potential hypoglycemic effects of herbs (e.g. ginseng), cardiovascular instability (e.g. ephedra), and potentiation of the sedative effect of anesthetics (e.g. kava and valerian).22 The potential for adverse DS effects has lead scholars in the field to recommend routine screening of hospitalized patients for use of DS.23—25 The competence of health care professionals to obtain an accurate anamnesis is fundamental and is emphasized in communication skill courses at medical schools, and in the lifelong training of physicians. Communication skills should take into account many factors, including socio-cultural differences in language and health terminology/concepts. Questioning patients regarding CAM use is no different than questioning on other health aspects. In hospital settings these communicational tasks may be more challenging due to the following reasons: acute medical conditions with timelimited communication26 ; lack of previous acquaintance (compared with primary care setting); and, in addition, patients may perceive the hospital as a bastion of conventional care that is less tolerant of CAM27 making them less willing to disclose CAM use; or simply due to patients’ perception of DS and CAM use as non-important or irrelevant to their medical care during the out-of-ordinary life context of hospital admission.28 In addition, the topic of DS/CAM is underemphasized in physicians training in general29 and knowledge concerning appropriate wording in history taking regarding CAM in variable populations has not been established. In this study, we assessed which questions facilitate detection of DS use in hospitalized patients from diverse socio-cultural backgrounds with the goal of developing a simple and cultural-sensitive communication tool for this setting.
Research design and methods The study was designed as a prospective cohort study of patients hospitalized in 11 departments of a public teaching hospital in Israel. The hospital has 450 beds, and serves a diverse population of rural and urban Jews and nonJews. The study took place between June and March 2009. The ethics committee of the Medical Center reviewed and approved the protocol in accordance with the Helsinki Declaration. Elaboration of the questionnaire: The questionnaire was developed in a stepwise manner by a multi-disciplinary team of researchers that included family and internal medicine
306 specialists trained in integrative medicine and non-MD CAM practitioners. Step I: The development phase of the questionnaire was based on prior research on CAM use in Israel conducted by the Complementary and Traditional Medicine Unit in the Department of Family Medicine, Technion Faculty of Medicine, Israel, and the Clinical Pharmacology Unit at Haemek Medical Center, Afula, Israel.30,31 Step II: The initial questionnaire was validated by 3 focus groups: CM practitioners (12 participants), physicians (12 participants), and patients (12 participants). The focus groups varied by sex and age, education, medical and/or CAM profession, and personal experience with CAM. Focus group participants were requested to comment on questions in the initial questionnaire using a Likert scale for each question’s relevance and comprehension. Participants were requested to write suggestions for improving questions when appropriate, and to add questions as needed. Thereafter, three of the authors (EB, ES, and LG) assessed participants’ response qualitatively, and upon agreement changes were made in the questionnaire. Step III: Based on the focus groups’ appraisals, a refined questionnaire version was formulated and tested in a pilot study with 61 hospitalized patients in two internal medicine departments. The pilot study was performed in order to examine patient’s comprehension of the questions and response to them, as well as for sample size calculation. The main observation in the pilot was that patients often do not comprehend the term DS, and need clarifications regarding this term. Therefore, the research team concluded that: (a) a brief semi-structured interview would accompany the questionnaire, in an attempt to overcome communication barriers. (b) Questionnaires and interviews would be conducted by trained research assistants in order to assure study fidelity. Consequently, the sample size was calculated with Raosoft calculator. Based on previous results showing 45—50% complementary medicine use across different populations across north Israel, we determined the need for 320—340 patients (confidence level 95% alpha-error of 0.05). We estimated that about 50% of respondents would reveal dietary supplements use in the hospitalization setting. Hebrew-written questionnaires were given to patients 18 years and above, who were able to communicate, and provide informed consent. 11 departments participated in this study including 3 departments of internal medicine, OB/GYN, and departments from various surgery specialties. Interviewers approached each and every patient, room by room to assess eligibility and willingness to participate in the study. The survey was conducted by 4th year CAM College students trained in naturopathy. All surveyors completed 8 h of training in communication strategies with patients in general, and specifically regarding DS, in addition to the study procedures. The interviewers were
E. Ben-Arye et al. instructed to question patients beginning with rapport initiation, followed by a questionnaire-based interview. The questionnaire started with a general question ‘‘have you used DS and/or herbs in the previous year for health issues’’. If patients reported such use, then further questions would be asked regarding patterns of use (e.g. length of use, use during admission), and the context of use (reasons for use, who recommended use and disclosure to the family physician and the attending hospital physician). When patients responded with a negative to the initial question, the surveyor would then rephrase the question, using predetermined keywords such as natural substances and remedies, folk/traditional herbs picked in the wild, and vitamins, and would document the keyword that facilitated the disclosure. Interviewers would also document any other keyword (traditional medicines, folk medicine or specific names of DS, etc.) found to be of benefit.
Statistical analysis Interview analysis was performed to detect keywords that disclosed patients’ DS use and their correlation with demographic and socio-cultural variables. Associations of gender, age, education, religion, place of living, and country of birth were determined using demographic and patients’ selfreported data. Data were evaluated using the SPSS software program (version 18; SPSS Inc., Chicago, IL). The Pearson 2 test and Fisher exact test were used to detect differences in the prevalence of categorical variables and demographic data between participants who initially reported of DS use and patients disclosing DS use based on key words detection. Also, a t test was performed to determine whether there were any differences in the continuous variables between the two groups. Specifically, multivariate logistic regression was used to assess univariate associations with the odds ratios of DS use among the interviewees. The logistic regression model included the following variables: age, gender, education, place of birth, residence type, and religion. p < 0.05 was considered statically significant.
Results Data were provided by 691 of 895 patients approached during hospital admission (77.2% response rate). Of the 691 participants providing data, 359 (51.9%) reported using DS in the year prior to the survey. Of the 359 participants using DS, 168 (46.8%) disclosed DS use by referring to the standard question on DS in the questionnaire. Detection of DS use with the other 191 interviewees (53.2%) was facilitated by rephrasing the question with keywords during the interview. Demographic characteristics of the two subgroups of DS users are detailed in Table 1.
Characteristics of DS users detected using keywords versus standard questions DS users, that were detected by keywords were older (p = 0.027), less formally educated (p < 0.0001), resided more in rural areas (p < 0.0001), and were non-Jewish (mainly Arab Muslims, Christians, and Druze; p < 0.0001).
Right questions about herbal and dietary supplements Table 1
307
Demographic characteristics of respondents.
Characteristics
DS users (%) N = 359
DS users disclosed by standard question n = 168
DS users disclosed by keywords n = 191
P value*
Sexa Female:male (%) Mean age in years ± SD (median)
229:130 (63.8:36.2) 60.5 ± 18.5 (63)
105:63 (62.5:37.5) 58.2 ± 18.9 (58.5)
124:67 (64.9:35.1) 62.6 ± 17.9 (65)
NS
Education Elementary school High school Academic
72 (20.1%) 137 (38.3%) 149 (41.6%)
15 (8.9%) 56 (33.3%) 97 (57.7%)
57 (30%) 81 (42.6%) 52 (27.4%)
