Complementary Therapies in Clinical Practice 33 (2018) 156–163

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Utilization of traditional and complementary medicine in Indonesia: Results T

of a national survey in 2014–15
Supa Pengpida,b, Karl Peltzerc,d,∗
a
ASEAN Institute for Health Development, Mahidol University, Salaya, Thailand
b
Department of Research & Innovation, University of Limpopo, Turfloop, South Africa
c
Department for Management of Science and Technology Development, Ton Duc Thang University, Ho Chi Minh City, Viet nam
d
Faculty of Pharmacy, Ton Duc Thang University, Ho Chi Minh City, Viet nam

A R T I C LE I N FO A B S T R A C T

Keywords: Background and purpose: Scant information exists about traditional, complementary and alternative medicine
Household survey (TCAM) use in Indonesia, which prompted investigating its prevalence and correlates in Indonesia.
Indonesia Materials and methods: Participants were 31,415 individuals 15 years and older that participated in the cross-
Traditional medicine sectional Indonesia Family Life Survey in 2014–15.
Self-treatment
Results: In all, 24.4% had used a traditional practitioner and/or traditional medicine in the past four weeks, and
Utilization
32.9% had used complementary medicine in the past four weeks. In adjusted logistic regression analysis, being
of older age, being a Muslim, residing in an urban area or on Java, being unhealthy, having a chronic condition,
having depression symptoms, experiencing sleep disturbance, and having high social support were associated
with both current traditional practitioner and/or medicine use and complementary medicine use.
Conclusion: The study shows a high prevalence of TCAM use in Indonesia and several sociodemographic and
health related factors of its use were identified.

1. Introduction combination to maintain well-being, as well as to treat, diagnose or

prevent illness” (p.1) [7]. Complementary and Alternative Medicine refers
The use of traditional and complementary health care has increased to “a broad set of health-care practices that are not part of a country's
in recent years in Association of Southeast Asian (ASEAN) member own tradition and are not integrated into the dominant health-care
states, including Indonesia [1–3]. It is estimated that a large proportion system (p.1).” [7].
of the population in ASEAN utilizes traditional health care [4]. A large In 2012, more than 280,000 traditional and alternative medicine
national household survey in 2013 in Indonesia found that 30.4% of practitioners were registered with the Ministry of Health of Indonesia
households utilized traditional health care [5]. In previous surveys in [8]. Most of these practitioners (96.2%) were using traditional treat-
Indonesia, among respondents who had consulted a health facility in ment methods, and 3.8% were using complementary health care tech-
the past four weeks, 38.3% in 2007 and 15.2% in 2000 had used tra- niques such as acupuncture treatment methods [9]. In a review of
ditional medicine for self-medication [6]. However, these reports did studies in nine high-income countries, the prevalence of 12-month
not assess the use of traditional and complementary medicine in general traditional, complementary and alternative medicine (TCAM) provider
or for specific illness conditions for a recent reference period, such as use averaged 21.1% [10], and a study on 32 mainly high-income
currently (in the past 4 weeks), and the reports failed to include a countries found that the past 12-month prevalence averaged 26.4%,
comprehensive analysis of correlates of traditional and complementary with a range of under 10% in some Eastern European countries to over
medicine use in Indonesia. This resulted in the need to conduct an 50% in mainland China, Korea and the Philippines [11].
analysis of more recent national data on Indonesia to address the As reviewed in Peltzer and Pengpid [11], determinants of TCAM or
shortcomings of the previous research. Traditional medicine includes TCAM provider use may include sociodemographic factors (female
“diverse health practices, approaches, knowledge and beliefs in- gender, middle age, higher or lower education, low religious involve-
corporating plant, animal, and/or mineral based medicines, spiritual ment, higher income, urban or rural residence) and health-related
therapies, manual techniques and exercises applied singularly or in factors (chronic disease, poor physical and mental health, inadequate

∗
Corresponding author. Ton Duc Thang University, Ho Chi Minh City, Viet nam.
E-mail address: [email protected] (K. Peltzer).

https://doi.org/10.1016/j.ctcp.2018.10.006
Received 27 February 2018; Received in revised form 9 October 2018; Accepted 9 October 2018
1744-3881/ © 2018 Elsevier Ltd. All rights reserved.
S. Pengpid, K. Peltzer Complementary Therapies in Clinical Practice 33 (2018) 156–163

health care access, and satisfaction with TCAM services). psychiatric/psychological treatment, use of antidepressant, tranqui-
The aim of this study was to estimate the prevalence of traditional lizing or sleeping pills, c) other treatment and d) no treatment (p. BOOK
and complementary medicine use and its sociodemographic and health- IIIB – 9) [12].
related factors in a national population survey in Indonesia. Health care utilization in the past four weeks was assessed with the
questions, “Within the last 4 weeks have you been to or been visited by
2. Materials and methods a … a) public hospital, b) public health center, c) private hospital, d)
polyclinic, private clinic, medical center, e) private physician, f) nurse,
2.1. Sample and procedure paramedic, midwife practitioner and h) traditional practitioner.” Those
who responded “Yes” to any of the health care visit types were asked,
Cross-sectional data were analysed from the “Indonesia Family Life “How much did you pay out of pocket for out-patient care during the
Survey (IFLS-5)“, a demographic and health survey, the fifth wave last 4 weeks?” (p. BOOK IIIB – 39)12
(IFLS-5) of which was completed in 2015 [12]. For the baseline survey, Self-treatment in the past four weeks was measured with the ques-
this national community survey collected data at the household and tion, “During the past 4 weeks, have you ever a) consumed over-the-
individual level using multistage stratified sampling from 321 enu- counter modern medicines, b) traditional herbs or traditional medicine
meration areas (EAs) in 13 of 27 Indonesian provinces, which were for treatment, c) topical medicines (such as eye drops, cream, medical
selected because they represent 83% of the Indonesian population [12]. plaster, ointment and the like), e) vitamins or supplements, and f)
At the household level, several randomly selected members of the massage, coining?” Those who responded with “Yes” to any type of self-
household were asked for detailed individual information. The sam- treatment were asked, “What was the approximate total cost to pur-
pling frame of the baseline survey was based on households from 321 chase or make that medicine during the last 4 weeks?” (p. BOOK IIIB –
enumeration areas (EAs) (20 households were randomly selected from 37) [12].
each urban EA, and 30 households were selected from each rural EA) in Current (past 4 weeks) use of traditional practitioners and/or
13 of 27 Indonesian provinces that were selected as representative of medicine was defined as 1) any current use of traditional treatment for
83% of the Indonesian population in 1993; more details in Strauss et al. any chronic condition, 2) a traditional practitioner visit in the past
[12] In the IFLS-5, 31,415 individuals 15 years and older were inter- month, and 3) self-treatment with traditional medicine in the past
viewed with complete traditional and complementary medicine use month, and the current use of complementary medicine included self-
measurements. A computer-assisted personal interview system (CAPI) treatment with vitamins or supplements and massage or coining in the
was used for the interviews, and the data were entered using CSPro past four weeks.
[12]. In the IFLS-5, “the dynasty or household recontact rate was 92%
and for the individual target households (including split off households 3.2. Exposure variables
as separate) the recontact rate was 90.5%.” [12] The questionnaire was
developed in English and initially translated into Bahasa Indonesia by The socio-demographic factor questions included age, sex, education,
survey staff and then retranslated into English by two independent, religion, residential status and province. Subjective economic status
outside translators [12]. Most of the interviews were conducted in was assessed with the question “Please imagine a six-step ladder where
Bahasa Indonesia (national language), and when needed, local inter- on the bottom (the first step) stand the poorest people and on the
viewers used additional local languages [12]. The entire questionnaire highest step (the sixth step) stand the richest people. On which [eco-
was tested during a full-scale pretest on 393 household members nomic] step are you today?” The response options ranged from (1)
(stratified by age, sex, education and rural and urban residence) [12]. poorest to (6) richest (p. BOOK IIIA – 13) [12]. The responses were
The IFLS has been approved by the ethics review boards of RAND and coded as poor economic status (economic steps 1 and 2), medium
the University of Gadjah Mada in Indonesia [12]. Written informed economic status (step 3) and rich economic status (steps 4 to 6).
consent was obtained from all the respondents prior to the assessments Religiosity was assessed with the question, “How religious are you?”
[12]. (responses: “very religious, religious, somewhat religious and not re-
In previous studies [8,9] in 40 mainly high-income countries, the ligious”) (p. BUKU IIIA – 56) [12]. The responses were grouped into
prevalence of 12-month TCAM provider use averaged 23.7%. The 1 = not religious or somewhat religious, 2 = religious and 3 = very
sample size was calculated based on Epidemiological Information (Epi- religious.
Info) (Centers for Disease Control and Prevention, Atlanta, GA; USA) Self-rated health status was assessed with one item: “In general, how
using an acceptable margin error of 1%, design effect 1, at confidence is your health?” (response options ranged from 1 = very healthy to
level 99%. The minimum sample size was 11,855. In the IFLS-5, the 4 = unhealthy) (p. BOOK IIIB – 4) [12]. The responses were grouped
sample size was 31,415. into 1 = somewhat unhealthy or unhealthy, 2 = somewhat healthy,
and 3 = very healthy.
3. Measures Tobacco use was measured with two questions: 1) “Have you ever
chewed tobacco, smoked a pipe, smoked self-rolled cigarettes, or
3.1. Outcome variable smoked cigarettes/cigars?” (yes, no) and 2) “Do you still have the habit,
or have you totally quit?” (still have, quit) (p. BOOK IIIB – 2) [12].
Treatment type for chronic medical conditions was assessed with the Depression symptoms were measured with the Centers for
question, “Has a doctor/paramedic/nurse/midwife ever told you that Epidemiologic Studies Depression Scale (CES-D: 10 items), and scores of
you had … ?” (“hypertension, diabetes or high blood sugar, heart at- 15 or more were indicative of having (severe) depression symptoms
tack, coronary heart disease, angina or other heart problems, stroke, [13] (Cronbach's alpha 0.69).
asthma, other lung conditions, liver, cancer or malignant tumor, ar- Sleep disturbance was measured with five questions from the Patient-
thritis/rheumatism, high cholesterol (total or LDL), prostate illness, Reported Outcomes Measurement Information System (PROMIS) sleep
kidney disease, stomach or other digestive diseases, emotional, ner- disturbance measure [14]. A sample item was, “I had difficulty falling
vous, or psychiatric problems, and memory-related disease”) (yes, no) asleep.” Responses ranged from 1 = not at all to 5 = very much
(p. BOOK IIIB – 8f.) [12]. For each chronic condition, the respondents (Cronbach's alpha = 0.69). Sleep disturbance was defined as scores
were asked, “Are you taking the following treatments to treat X con- from 3 to 5 on the averaged mean items.
dition and its complications?” The responses were coded into a) tradi- Life satisfaction was measured with one item, “Please think about
tional medicine, b) modern medicine, including insulin injection, che- your life as a whole. How satisfied are you with it?” (response options
motherapy, surgery, radiation therapy, physical/occupational therapy, ranged from 1 = completely satisfied to 5 = not at all satisfied) (p.

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BOOK IIIA – 13) [12]. High life satisfaction was defined as “completely hypertension (3.5%) (see Table 2).
satisfied or very satisfied.”
Social support/capital was assessed with 4 items on participation in 4.3. Health care utilization in the past four weeks
1) community meetings, 2) voluntary labor, 3) activities to improve the
village/neighborhood, and 4) religious activities in the past 12 months. Among seven different health care agencies, traditional practi-
The response options for these items were “yes” or “no” [12] (Cron- tioners had the third highest prevalence of use in the past four weeks
bach's alpha 0.59). Respondents who answered “yes” on 2–4 items were (4.2%), after nurse, paramedic or midwife practitioners (5.6%) and
considered to have high social capital. public health centers (5.0%). The prevalence of self-treatment with
Health care access was measured with the question, “Concerning traditional medicine in the past four weeks was 19.7%, the use of
your health care, which of the following is true? It is less than adequate massage or coining for self-treatment was 26.5%, and the use of vita-
for my needs, just adequate or more than adequate for my needs.” (p. mins or supplements for self-treatment was 9.7%, while over-the-
BOOK IIIA – 13)12 counter modern medicine use for self-treatment was 51.8%.
Among the five different self-treatment modalities, the average ex-
3.3. Data analysis penditure in the past four weeks was highest for vitamins or supple-
ments (36,940 rupiah), followed by traditional medicines (20,238 ru-
Descriptive statistics were used to describe the sample and the oc- piah) and massage or coining (14,899 rupiah). Among the seven
currence of different types of health care utilization. Logistic regression different health care agencies used in the past four weeks, the average
analysis was conducted to calculate the crude and adjusted odds ratios expenditure was lowest for public health centers (27,922 rupiah), fol-
(ORs) with 95% confidence intervals (CIs) to determine the associations lowed by traditional practitioners (56,157 rupiah) representing the
between the sociodemographic and health variables and traditional second lowest average expenditure (see Table 3).
practitioner and/or medicine use and complementary medicine use,
separately. All the variables that were statistically significant in the 4.4. Satisfaction with and payment for health care visits
bivariate analyses were subsequently added into the multivariable
models. Potential multicollinearity between the independent variables Among those who had attended any health care service in the past
was assessed with variance inflation factors, none of which exceeded four weeks, the highest satisfaction rates for last health care visit were
critical values. P < 0.05 was considered significant. Cross-section reported for nurse, paramedic or midwife practitioners (89.1%), fol-
analysis weights were applied to match the 2014 Indonesian population lowed by private physicians (87.1%), traditional practitioners (85.7%)
[12]. Both the 95% confidence intervals and the P-values were adjusted and private hospitals (85.2%), while lower satisfaction rates were found
considering the survey design of the study. All statistical analyses were for public hospitals (73.7%), public health centers (75.5%) and poly-
conducted using STATA software version 13.0 (Stata Corporation, clinics (76.5%). Health insurance paid the least often for health care
College Station, TX, USA). visits to traditional practitioners (0.2%) and nurse, paramedic or mid-
wife practitioners (1.2%) and the most often for public hospital visits
4. Results (65.0%) (see Table 4).

4.1. Sample characteristics 4.5. Associations with current traditional and complementary medicine use

The sample characteristics are described in Table 1. The sample In the adjusted logistic regression analysis, being of older age,
included 31,515 adults (15 years and above) (mean age 40.0 years, having a lower education level, being a Muslim, being very religious,
SD = 15.1). The majority (60.6%) of the participants were 30–59 years residing in an urban area or on Java, being unhealthy, having a chronic
old, 52.4% were female, 59.6% had a high school or higher education, condition, having depression symptoms, experiencing sleep dis-
and 46.7% rated themselves as having a medium economic status. The turbance, having high social support or capital and having inadequate
large majority (93.4%) of the participants were Muslim, 62.0% con- health care access were associated with current traditional practitioner
sidered themselves religious and 16.3% considered themselves very and/or medicine use. Being middle aged (30–59 years), having a higher
religious, 52.1% were residing in urban areas, and 54.6% lived on Java. education level, having higher subjective economic status, being a
Nearly four in five of the participants rated their health as healthy or Muslim, being not or somewhat religious, residing in urban areas, re-
very healthy, 34.9% had a chronic condition, 32.3% were currently siding on Java or Sumatra, being unhealthy, having a chronic condi-
using tobacco, 6.9% had depression symptoms, and 16.5% had some tion, using tobacco currently, having depression symptoms, experien-
sleep disturbance. More than one in ten (14.5%) of the participants had cing sleep disturbance, having higher life satisfaction and having higher
low life satisfaction, 36.6% had high social support or capital and social support or capital were associated with current complementary
20.7% felt their health care was inadequate for their needs. One in four medicine use (see Table 5).
participants (24.4%) had used a traditional practitioner and/or tradi-
tional medicine in the past four weeks, and 32.9% of the participants 5. Discussion
had used complementary medicine in the past four weeks (see Table 1).
The study found that in a large national adult sample in Indonesia in
4.2. Current treatment of chronic conditions 2014–15, current or past-month traditional practitioner and/or medi-
cine use was 24.4% and that complementary medicine use was 32.9%.
For diagnosed hypertension, 7.2% of the participants were currently This finding may be similar to that of previous studies: a large national
taking traditional medicine only, 26.4% were taking only modern household survey in Indonesia [5] found that 30.4% of households
medicine, 3.5% were taking traditional and modern medicine, 4.5% utilized traditional health care in 2013, and another study found that
were receiving other treatment and 58.4% were not receiving any 38.3% of health care attendees used traditional medicine to self-medi-
treatment. The highest prevalence of current traditional medicine use cate in 2007 in Indonesia [6]. Using a different reference period (12
only was for cancer or malignant tumor (14.4%), followed by arthritis/ months) and focusing on TCAM provider use, somewhat similar rates
rheumatism (11.3%), high cholesterol (11.3%), stroke (10.2%), dia- were found in a previous review (21.1%) [10] and in a 32-country study
betes (9.9%) and kidney disease (9.7%). The highest prevalence of both (26.4%) [11]. Among chronic disease patients in three lower Mekong
traditional and modern medicine use was for diabetes (11.2%), fol- countries, a past-year prevalence of 24%–27% for consulting TCAM
lowed by stroke (6.5%), arthritis or rheumatism (4.8%) and providers was found [15]. In this study, use of a traditional practitioner

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Table 1
Sample characteristics.
Variable Sample N (%) Current traditional practitioner and/or medicine use N Current complementary medicine use N (%)
(%)

Sociodemographics
All Age in years (range 15–101), M = 40.0, SD = 15.1 31415 6866 (24.4) 9839 (32.9)
15-29 10741 (28.1) 1686 (17.0) 3236 (32.5)
30-59 17743 (60.6) 4325 (26.7) 5840 (34.1)
60 or more 2925 (11.4) 855 (30.4) 763 (27.1)
Sex
Male 14688 (47.6) 3226 (24.5) 4823 (34.3)
Female 16727 (52.4) 3640 (24.3) 5016 (31.6)
Education
High school or Higher education 20735 (59.6) 4226 (22.5) 6837 (35.1)
None or elementary 10655 (40.4) 2634 (27.1) 2998 (29.6)
Economic background
Poor 7677 (24.8) 1701 (24.7) 2164 (30.5)
Medium 14779 (46.7) 3224 (24.4) 4718 (33.2)
Rich 8951 (28.5) 1939 (24.1) 2956 (34.3)
Religion
Other 3161 (6.6) 504 (18.0) 746 (24.4)
Islam 28239 (93.4) 6360 (24.8) 9088 (33.5)
Religiosity
Not/somewhat 7294 (21.7) 1528 (22.8) 2500 (35.8)
Religious 18924 (62.0) 4109 (24.3) 5797 (32.1)
Very religious 5136 (16.3) 1211 (26.7) 1523 (32.0)
Residence
Rural 12877 (47.9) 2523 (22.4) 3672 (30.1)
Urban 18532 (52.1) 4343 (26.2) 6167 (35.4)
Region
Sumatra 7219 (23.0) 1354 (19.0) 1986 (27.6)
Java 17111 (54.5) 4285 (26.5) 6246 (35.6)
Main island groups 7079 (22.5) 1227 (18.1) 1607 (22.3)
Health and support
Self-rated health status
Unhealthy 6632 (21.0) 2049 (34.0) 2451 (38.7)
Healthy 18791 (59.5) 3761 (22.4) 5708 (31.7)
Very healthy 5992 (19.5) 1056 (20.2) 1680 (30.3)
Having a chronic condition 10355 (34.9) 4641 (34.3) 5394 (39.8)
Current tobacco use 9826 (32.3) 2179 (24.7) 3264 (34.6)
Depression symptoms 2273 (6.9) 638 (31.7) 821 (38.3)
Sleep disturbance 5573 (16.5) 1627 (30.3) 2112 (40.0)
Life satisfaction (high) 4386 (14.5) 1037 (25.7) 1290 (30.3)
Social support/capital (high) 10484 (36.6) 2715 (28.1) 3748 (36.7)
Health care is inadequate for my needs 6370 (20.7) 1659 (28.6) 1953 (33.2)

Table 2
Current treatment of chronic conditions and its complications (N = 31415).
Diagnosed chronic condition N (%) Traditional medicine Modern medicine Traditional and modern Other treatment % No treatment %
% % medicine %

Hypertension 4202 7.2 26.4 3.5 4.5 58.4

(13.8)
Diabetes or high blood sugar 779 (2.7) 9.9 42.6 11.2 2.7 33.5
Asthma 1000 (2.8) 3.5 32.5 1.7 4.3 58.0
Other lung conditions 618 (1.9) 4.1 18.1 1.8 5.4 70.6
Heart attack, coronary heart disease, angina, or 559 (1.9) 6.2 27.3 2.7 5.4 58.2
other heart problems
Liver 334 (1.0) 8.0 11.1 1.1 4.9 74.9
Stroke 309 (1.0) 10.2 27.0 6.5 3.0 43.2
Cancer or malignant tumor 210 (0.6) 14.4 20.7 2.6 6.3 56.0
Arthritis/rheumatism 1729 (5.5) 11.3 29.5 4.8 4.5 50.0
High cholesterol (Total or LDL) 1393 (4.5) 11.3 21.4 3.2 5.1 58.9
Prostate illness 124 (1.1) 3.8 15.3 0.4 9.1 71.3
Kidney disease (except for tumor or cancer) 462 (1.5) 9.7 14.5 3.2 9.0 63.5
Stomach or other digestive disease 4376 5.3 25.2 2.7 3.5 63.3
(12.9)
Emotional, nervous, or psychiatric problems 93 (0.2) 5.6 20.9 0.0 4.4 68.9
Memory related disease 87 (0.2) 6.8 28.1 0.4 3.0 61.8

in the past four weeks was 4.2%, which may be similar to the result of than in the form of obtaining herbal remedies from traditional practi-
6.9% found for alternative medicine out-patient care in the past 15 days tioners. This result was also found in a South African community-based
reported by a national survey in India [16]. The use of traditional study [17].
medicine in this study seems to be higher in the form of self-treatment In agreement with some previous studies [15,16,18–24], this study

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Table 3
Health care utilization in the past four weeks.
Variable N (%) Average costs over 4 weeks in Rupiahb M (SD)

Visit of a public hospital, public health center, private hospital, clinic, health worker or doctor's practice or been visited by a health worker or doctor?

Public hospital (General or Speciality) 487 (1.5) 246350 (863717)

Public health center/Auxiliary center 1725 (5.0) 27922 (502928)
Private hospital 356 (1.0) 279825 (499991)
Polyclinic, private clinic, medical center 589 (1.7) 109633 (483393)
Private physician (general practitioner, specialist, dentist, family doctor) 1187 (3.7) 145488 (337693)
Nurse, paramedic, midwife practitioner 1772 (5.6) 68030 (878887)
Traditional practitioner (shaman, wiseman, Chinese herbalist, masseur, acupuncturist, etc.)a 1268 (4.2) 56157 (120070)
Self-treatment during the past four weeks

Consumed over-the-counter modern medicine (like bodrexin, inzana, paramex) 15823 (51.8) 11436 (152053)
Used topical medicines (like eye drops, cream, medical plaster, ointment and the like) 8301 (27.8) 12332 (123293)
Consumed traditional herbs or traditional medicines as treatment 5499 (19.7) 20238 (116319)
Used vitamin/Supplements 3178 (9.7) 36940 (117428)
Massage/coining 7700 (26.5) 14899 (298214)

a
Purpose of last visit: Massage (84.5%) and consultation, treatment of illness, traditional/herbal medicine, other (15.5%).
b
US$ = 13700 Rupiah.

found that sociodemographic factors (older age or middle age, Muslim ability of those with a higher economic status to afford to use com-
religion, religiousness and high social capital) were associated with plementary medicine [27]. Most previous studies [15,18–20] found an
traditional and/or complementary medicine use. However, com- association between rural residence and traditional and/or com-
plementary medicine use seemed to decline after age 60 years in this plementary medicine use, and some studies reported an association
study. This may be because the older generation in Indonesia has per- between urban residence [29] and traditional and/or complementary
haps been less exposed to self-treatment with vitamins and dietary medicine use, while in this study, urban dwellers were more likely than
supplements. “As a majority of Indonesians are Muslims, therapy based rural dwellers to use traditional and complementary medicine. This
on the religion of Islam is fairly common (p.50).” [25] It is possible that result concurs with the findings of a previous large study in 2013 [5] in
people with strong religiosity hold beliefs that are congruent with tra- Indonesia but not with those of a study in 2000 [6] in Indonesia. It is
ditional and complementary medicine use and are thus more attracted possible that the utilization of medicinal plants in urban areas has in-
to using those forms of medicine. Various studies found that being fe- creased over the years because of the implementation of government
male was associated with TCAM provider use [15,16,22,26], but this programs to promote the utilization of garden land as media for the
study did not find any sex difference. Insignificant sex differences in cultivation of medicinal plants in the city [31]. Moreover, this study
traditional and/or complementary medicine use were also found in a found that among the major study regions, Java had the highest pre-
study in Malaysia, a country with cultural similarities with Indonesia valence of traditional and complementary medicine use. The reasons for
[27], Myanmar [18] and Laos [19]. this finding will need further investigations.
This study found associations between lower education and tradi- In concordance with previous studies [15,21,22,26,32,33], this
tional medicine use and between higher education and complementary study found that perceiving poorer health status, having a chronic
medicine use. Higher formal education was also found to be associated condition, feeling depressed, and experiencing sleep disturbance were
with TCAM self-help practices among chronic disease patients in three associated with both traditional and complementary medicine use. The
lower Mekong countries [15], and higher education was found to be explanation for these findings could be that persons with chronic con-
associated with complementary medicine use among chronic disease ditions, including mental conditions and poorer health status, engage in
patients in Malaysia [27]. Other studies found mixed results in terms of increased health-seeking behavior such as utilizing a variety of avail-
educational status and traditional and complementary medicine use able health sources, particularly alternatives to conventional medicine
[16,22,25,28–30]. This study's finding that those with higher socio- [34,35]. Further, in this study, inadequate health care access was as-
economic status (educational level and economic status) were more sociated with traditional medicine use. A similar result was found in a
likely to use complementary medicine than those with lower socio- Lebanese national adult survey in which persons with unmet health
economic status may be related to higher education leading to higher needs were more likely to resort to utilizing complementary and al-
use of scientifically more reliable complementary medicine and the ternative medicine than those whose health needs were met [21]. In

Table 4
Satisfaction and payment of last health care visit in the past four weeks.
Type of health service provider Satisfaction with last visit Insurance

Satisfactory % Somewhat satisfactory Not or far from satisfactory Paid for all or some of the last
% % visit %

Public hospital (General or Speciality) 73.7 15.6 10.7 65.0

Public health center/Auxiliary center 75.5 17.3 7.1 45.0
Private hospital 85.2 9.6 5.2 47.1
Polyclinic, private clinic, medical center 76.5 20.3 3.2 37.8
Private physician (general practitioner, specialist, dentist, family 87.1 9.1 3.8 13.1
doctor)
Nurse, paramedic, midwife practitioner 89.1 9.3 1.6 1.2
Traditional practitioner (shaman, wiseman, Chinese herbalist, 85.7 12.3 2.0 0.2
masseur, acupuncturist, etc.)

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Table 5
Associations with current traditional and complementary medicine use.
Variable Current traditional practitioner and/or medicine use Current complementary medicine use

Crude Odds Ratio Adjusted Odds Ratio Crude Odds Ratio Adjusted Odds Ratio

Age in years
15-29 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
30-59 1.78 (1.68, 1.88)*** 1.73 (1.61, 1.86)*** 1.08 (1.03, 1.13)** 1.16 (1.09, 1.24)***
60 or more 2.13 (1.97, 2.32)*** 1.87 (1.60, 2.10)*** 0.77 (0.72, 0.84)*** 0.85 (0.76, 0.95)**
Sex
Male 1 (Reference) 1 (Reference) 1 (Reference)
Female 1.01 (0.97, 1.06) – 1.13 (1.03, 1.13)** 1.03 (0.96, 1.12)
Education
High school or Higher education 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
None or elementary 1.28 (1.22, 1.34)*** 1.25 (1.17, 1.34)*** 0.78 (0.75, 0.81)*** 0.80 (0.75, 0.85)***
Economic background
Poor 1 (Reference) – 1 (Reference) 1 (Reference)
Medium 0.98 (0.93, 1.04) 1.14 (1.08, 1.20)*** 1.07 (0.99, 1.15)
Rich 0.97 (0.91, 1.03) 1.19 (1.12, 1.26)*** 1.14 (1.05, 1.23)**
Religion
Other 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
Islam 1.51 (1.36, 1.67)*** 1.40 (1.24, 1.58)*** 1.56 (1.42, 1.71)*** 1.31 (1.18, 1.45)***
Religiosity
Not/somewhat 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
Religious 1.09 (1.02, 1.15)** 1.01 (0.93, 1.09) 0.85 (0.80, 0.89)*** 0.89 (0.83, 0.96)***
Very religious 1.23 (1.14, 1.33)*** 1.15 (1.05, 1.27)** 0.84 (0.79, 0.90)*** 0.95 (0.86, 1.04)
Residence
Rural 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
Urban 1.23 (1.18, 1.29)*** 1.23 (1.09, 1.39)*** 1.28 (1.22, 1.33)*** 1.13 (1.06, 1.20)***
Region
Sumatra 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
Java 1.54 (1.43, 1.64)*** 1.38 (1.22, 1.56)*** 1.45 (1.36, 1.54)*** 1.47 (1.37, 1.58)***
Main island groups 0.94 (0.85, 1.04) 0.93 (0.83, 1.05) 0.75 (0.69, 0.82)*** 0.80 (0.73, 0.87)***
Health and support
Self-rated health status
Unhealthy 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
Healthy 0.56 (0.53, 0.59)*** 0.61 (0.57, 0.66)*** 0.74 (0.70, 0.78)*** 0.69 (0.64, 0.74)***
Very healthy 0.49 (0.46, 0.53)*** 0.54 (0.49, 0.60)*** 0.69 (0.64, 0.74)*** 0.65 (0.60, 0.71)***
Having a chronic condition 2.21 (2.11, 2.32)*** 2.04 (1.94, 2.14)*** 1.61 (1.54, 1.68)*** 1.72 (1.04, 1.81)***
Current tobacco use 1.03 (0.98, 1.08) – 1.13 (1.08, 1.18)*** 1.09 (1.00, 1.18)*
Depression symptoms 1.48 (1.36, 1.61)*** 1.24 (1.11, 1.37)*** 1.29 (1.19, 1.40)*** 1.16 (1.04, 1.29)**
Sleep disturbance 1.44 (1.35, 1.52)*** 1.31 (1.23, 1.41)*** 1.46 (1.38, 1.54)*** 1.35 (1.25, 1.45)***
Life satisfaction (low) (base = high) 1.09 (1.02, 1.16)* 0.94 (0.87, 1.02) 0.87 (0.82, 0.93)*** 0.84 (0.80, 0.91)***
Social support/capital (high) (base = low) 1.37 (1.31, 1.44)*** 1.30 (1.20, 1.42)*** 1.31 (1.21, 1.37)*** 1.26 (1.19, 1.34)***
Health care is inadequate for my needs (base = adequate) 1.32 (1.25, 1.40)*** 1.11 (1.04, 1.19)** 1.02 (0.97, 1.08) –

***P < 0.001; **P < 0.01; *P < 0.05.

this study, tobacco use was positively associated with complementary gastrointestinal ailments, injuries, and genitourinary ailments and, to a
medicine use, while a study on older Americans observed a negative lesser degree, for cancers, psychiatric and neurological problems, and
association between cigarette smoking and complementary medicine endocrine, metabolic or nutritional problems [16]. In our study, the
use [36]. It is possible that those who can afford to buy cigarettes are proportion of traditional medicine use relative to modern medicine use
also more likely to buy complementary medicines, and current tobacco and to no treatment for chronic conditions was higher than the pro-
users are more likely than non-users to suffer from illness conditions portions found in the Indian study [16]. This result shows the im-
needing treatment, including self-treatment with complementary portance of traditional medicine use for chronic conditions in In-
medicines. In this study, satisfaction with the last health care visit with donesia. Among outpatients with chronic diseases in Malaysia, the
a traditional practitioner was high (85.7%). Similar levels of satisfac- highest level of complementary and alternative medicine use was re-
tion were found in a study on Lebanese adults in which 90% of the ported for diabetes mellitus (35.5%), dyslipidemia (5.6%), hyperten-
respondents reported being satisfied with complementary and alter- sion (4.7%), osteoarthritis (2.2%), stroke (1.6%), and cancer (0.3%)
native medicine [21], and in lower Mekong countries, more than 80% [27]. In Taiwan, among seven types of chronic conditions in adults,
of participants perceived consultations with different types of TCAM TCAM use was highest for arthritis and arthropathy [37].
providers as very or somewhat helpful [15]. According to Kusuma et al. [38], traditional medicine is widely used
In this study, among chronic conditions, the highest prevalence of for the treatment of stroke. In a systematic review [39], the prevalence
current traditional medicine only use was found for cancer or malignant of TCAM use among cardiac patients was found to be common, with a
tumor (14.4%), followed by arthritis/rheumatism (11.3%), high cho- wide variation ranging from 4% to 61%. In population surveys in sev-
lesterol (11.3%), stroke (10.2%), diabetes (9.9%), kidney disease eral ASEAN countries, the use of TCAM for hypertension ranged from
(9.7%), liver disease (8.0%), hypertension (7.2%) and memory-related 1.9% in Laos to 13.4% in Myanmar and 15.3% in Cambodia [3], and
disease (6.8%). Other studies generally also found a high prevalence of TCAM use was 27% in a clinical hypertension sample in Malaysia [40].
traditional and complementary medicine use for chronic conditions, Similarly, Tsai et al. [41] found in a large sample of primary hy-
although the prevalence rate varied by condition. In India, the pre- pertensive patients in the National Health Insurance Research Database
valence of alternative medicine use among 16 conditions was highest in Taiwan that 12.1% had used TCAM for the treatment of hyperten-
for ear problems, skin problems, musculoskeletal problems, sion. In a small study (n = 82) of hypertensive health center patients in

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Indonesia, 57.3% of the patients were using herbal medicine [42]. chronic diseases and mental disorders. It is recommended that in-
Matheka and Demaio [43] note that “traditional and complementary formation on the use of TCAM be incorporated into clinical practice and
therapies are extensively used by patients as adjuvant or as replacement professional education by including TCAM modules in the medical and
treatment to the conventional prescribed drugs for the treatment of health sciences curriculum. Continuing education and training work-
diabetes (p.2).” The prevalence of herbal and dietary supplement use in shops should be provided for service providers in order to enhance their
the past 12 months among chronic kidney disease patients in Thailand knowledge and skills on evidence based use of TCAM.
was 45%, of which 17% was for the treatment of kidney diseases [44]. The study found a strong correlation between having chronic con-
The highest prevalence of both traditional and modern medicine use ditions and comorbidities, such as depression and sleep disturbance,
in this study was for diabetes (11.2%), followed by stroke (6.5%), ar- and TCAM use. This finding may indicate that a large proportion of the
thritis or rheumatism (4.8%) and hypertension (3.5%). In a study on the population may either self-treat rather than seeking biomedical health
recipients of national health insurance in Taiwan, the coprescription of care or use TCAM as a complement to biomedical medicine, which is
Chinese herbal products and conventional drugs was 14.1% [45]. In a often linked to a lack of adherence to biomedical prescription medi-
study in South Korea, the parallel use of TCAM with conventional cations. It should be asked whether underfunding of the biomedical
medicine was found to be common among chronic disease patients, health care system or the efficacy of TCAM leads to the high TCAM
particularly patients with hypertension or joint diseases, while parallel utilization among chronic and mental illness patients. To answer this
use was lower among patients with diabetes [46]. The concurrent use of question, further research is needed, but there is potential for possibly
traditional and modern medicine can increase the risk of possible herb- subsidizing (proven) effective TCAM modalities in this large sub-
drug interactions [45,47]. population [49].
In this study, among seven different types of health service provi-
ders, consultation or treatment costs were second lowest for traditional 6. Conclusions
practitioners, after public health centers. In India, the average ex-
penditure for alternative medicine was lower than that for modern The study confirms the high prevalence of traditional and com-
medicine [16], and in South Africa, the average cost ($21) for the last plementary medicine use in Indonesia. Sociodemographic and health-
visit to a traditional healer was higher than the average cost for any related factors such as older age, socioeconomic status, religion, re-
other health service user type [20]. In this study, in many cases, the ligiosity, urban residence, and poor physical and mental health status
health care expenditure for the last visit was paid by health insurance were found to be associated with traditional and complementary
for public and private health care (e.g., 45.0% for public health centers medicine use. Health care providers should educate patients on TCAM
and 47.1% for private hospitals) but not for traditional practitioner use and on combining the use of TCAM and biomedical medicine, with
visits. This finding shows that people are prepared to pay a limited a particular focus on older and less educated patients and those with
amount for care and treatment by traditional health practitioners. chronic diseases and mental disorders. Further research is needed to
Considering the high concurrent use in this study of traditional and validate and replicate the study findings, including the assessment of
modern medicine, particularly among chronic disease patients, it is the motivation of TCAM use, the disclosure of TCAM use to the patient's
important for health care providers to assess the concurrent use of health care provider, and the scientific investigation of the efficacy of
traditional or complementary medicine and modern medicine to avoid specific herbal remedies used.
potential drug interactions [27]. According to the action plan of the
Strategic Plan of the Ministry of Health for the Year 2015–2019 in In- Conflicts of interest
donesia, “in 2015, 1532 health centers were recorded to have organized
traditional health services, or 15.7% of 9754 health centers in 34 pro- The authors declare no conflict of interest.
vinces in Indonesia. Health centers are deemed to have organized tra-
ditional health services if they meet one of the criteria below: 1. Health Acknowledgements
center has health personnel who have been trained in traditional health
care; 2. Health center implements health self-care programme on tra- The research was conducted based on the IFLS-5 carried out by
ditional health potions and skills; 3. Health center carries out devel- RAND (http://www.rand.org/labor/FLS/IFLS.html). We thank RAND
opment activities that include collecting data of traditional health, for granting access to the survey data and the study participants who
improving facilities for registration/licensing and technical guidance as provided the survey data.
well as monitoring traditional and complementary health services
(p.33).” [48]. Authors' contributions

5.1. Study limitations SP and KP conceptualized the study, analysed and wrote the paper.
All authors read and approved the final version of the manuscript.
This study had several limitations. The self-reported assessment of
most of the study measures may have its limitations. More details re- Appendix A. Supplementary data
garding the type of herbal remedies or other complementary medicine
could have been assessed, and this should be done in future studies. Supplementary data to this article can be found online at https://
Furthermore, this study was based on cross-sectional data, and we doi.org/10.1016/j.ctcp.2018.10.006.
therefore cannot ascribe causality to any of the associated factors in the
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