Complementary and Alternative Medicine Use and its Impact on Quality of Life among Cancer Patients in Freetown, Sierra Leone: Considerations for a Resource-Limited Setting

doi:10.21203/rs.3.rs-5014069/v1

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Complementary and Alternative Medicine Use and its Impact on Quality of Life among Cancer Patients in Freetown, Sierra Leone: Considerations for a Resource-Limited Setting

https://doi.org/10.21203/rs.3.rs-5014069/v1

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Background

Cancer patients are increasingly resorting to complementary and alternative medicine (CAM) to alleviate the effects of the disease and enhance their quality of life (QoL). However, to our knowledge, no study has investigated CAM use and its impact on QoL in patients with cancer in Sierra Leone. Therefore, this study aimed to assess the prevalence of and associated factors with CAM use, and compare the quality of life between CAM users and non-users.

Methods

Data were collected through face-to-face interviews, using an adapted questionnaire. This cross-sectional descriptive study was conducted at three health facilities in Freetown viz Connaught Hospital, Ola During Children's Hospital, and the Water and Stone Clinic. The QoL was assessed using the European Organization for Research and Treatment of Cancer tool. Descriptive analysis was employed and binary logistic regression tests were used to explore the factors associated with CAM use, with statistical significance set at p < 0.05.

Results

In total, 204 participants completed the study. The prevalence of CAM use was 48.5%. Among the various CAMs examined in this study, herbal medicines (48.8%) followed by special foods (19.4%) were the most commonly used forms of CAM. The primary reason for CAM use was the management of cancer complications (43.4%). Over half of the CAM users did not disclose their CAM use to their doctors (53.5%). There was a statistically significant association between CAM use and tertiary education (AOR = 2.68, 95%CI = 1.31–5.49, p = 0.007) and chemotherapy treatment (AOR = 1.91, 95%CI = 1.06–3.46, p = 0.032). There was no considerable impact of CAM on QoL, although financial difficulty was statistically significant among CAM users compared with non-CAM users.

Conclusion

This study revealed that CAM use is prevalent among patients with cancer, with herbal medicines being the most commonly used form, followed by special foods and prayers. Patients primarily obtain information about CAM from family, friends, and relatives, and most do not discuss CAM use with their doctors. Tertiary education and chemotherapy were found to be predictors of CAM use. Regarding the impact of CAM on QoL, only financial difficulty was statistically significant.

Complementary and alternative medicine

cancer patients

Quality of Life

Sierra Leone

Cancer is a major contributor to global morbidity and mortality, with an estimated 20 million new cases and almost 9.7 million deaths reported in 2022 [1]. Sierra Leone has one of the lowest health indices worldwide, with infectious diseases such as malaria, acute respiratory tract infections, and diarrhoeal diseases causing significant morbidity and mortality, particularly among children under five years and pregnant women [2]. Additionally, there has been a notable increase in non-communicable diseases, including cancer, resulting in 1918 new cases and 1334 deaths in 2020, with an overall five-year prevalence of 8880 in 2022 [3].

Although it is possible to prevent or effectively manage some cancers if they are detected early, many patients in low-income settings, such as Sierra Leone, seek medical care only when the illness has advanced because of limited access to early diagnostic services, health-seeking behaviour, lower income, and lower education [4]. Standard cancer management includes surgery, chemotherapy, and radiotherapy. However, these conventional treatment modalities are sometimes associated with untoward adverse medicine effects, expensive, scarce, or unavailable in resource-limited settings [5, 6]. This usually causes patients to turn to complementary and alternative medicine (CAM) as a treatment option or to use it concurrently with conventional cancer therapies [7, 8].

According to the National Center for Complementary and Integrative Health (NCCIH), CAM refers to a diverse group of medical and healthcare systems, practices, and products that are not typically considered part of conventional medicine [9]. According to the NCCIH, CAM therapies are classified into five domains: mind-body interventions (e.g. prayer and music) and biologically based therapies (e.g. herbs, foods, and dietary supplements). Other classifications include alternative medical systems (e.g. homeopathy), energy therapies (e.g. electromagnetic fields), and manipulative and body-based methods (e.g. chiropractic manipulation) [10]. Studies conducted in developed countries, including Israel, Australia, Canada, Europe, New Zealand, and the United States, have revealed that the prevalence of CAM use among cancer patients ranges from 19–57.7% [11–13]. A 23–79% prevalence range has been reported in Africa, including Uganda, Nigeria, Ethiopia, and Ghana [14–19]. This may be because, in Africa, CAM is often used as primary healthcare because of sociocultural factors such as traditional beliefs, influence from friends and families, and lack of availability, access, and financial means to pay for conventional medicine [16, 20–22].

The reasons for CAM use among cancer patients reported in the literature include treatment of complications, slow progression, and fewer adverse effects [23, 24]. Studies conducted in Ethiopia and Malaysia have identified younger age, female sex, high income, higher education, advanced disease stage, comorbidity, and treatment as predictors of CAM use [25].

Cancer patients often use CAM to improve their quality of life (QoL). However, previous studies assessing the impact of CAM use on QoL, found no statistically significant differences between CAM users and non-users [17, 23, 26, 27]. However, other studies have reported a statistically significant association between CAM use and QoL [28, 29], while others have found that users have a lower overall quality of life than non-users [30, 31].

In Sierra Leone, we did not find any evidence that studies on CAM use have been performed in patients with cancer. Therefore, this study aimed to assess the prevalence and pattern of CAM use among cancer patients in three hospitals in Freetown, Sierra Leone. Furthermore, we investigated predictors of CAM use and the impact on patients’ QoL. The findings of this study will provide evidence for healthcare professionals and policymakers to make informed decisions regarding the appropriate use of CAM and to minimise potential associated risks. This will further add to the global body of evidence on CAM use among patients with cancer.

Study Setting and Design

The study was conducted at the oncology clinics of Connaught Hospital (CH), Ola During Children's Hospital (ODCH), and the Water and Stone Clinic (WSC). Connaught and Ola During Children Hospitals are part of the University of Sierra Leone Teaching Hospital Complex. Connaught is a referral hospital that provides a range of surgical and medical services, mainly for adults, whereas ODCH is a referral hospital for paediatric patients. The Water and Stone Clinic is a private healthcare facility that provides urological and oncological services. These health facilities are leading centres that provide oncological care in the capital city of Sierra Leone.

This cross-sectional descriptive study was conducted between December 2023 and April 2024 among cancer patients receiving chemotherapy.

Study Population

Patients and parents attending oncology clinics at the study sites, irrespective of age, disease stage, and time since diagnosis, who received at least one cycle of chemotherapy treatment and consented to participate were included in the study. Patients who refused to participate in the study were also excluded.

Sample Size Determination and Sampling

The sample size was calculated using the following formula:

Where:

n = required sample size, z = level of confidence (z = 1.96), z-statistics for the 95% confidence level, deft = design effect (1.0), and d = desired level of precision or margin of relative error (0.07).

Applying the details above, yielded a sample size of 196 patients. Considering methodological contingencies, the actual sample size for this study was 216, after the addition of 10%. Based on probability proportional to size sampling, the sample sizes for the individual hospitals were 152, 16, and 48 for CH, ODCH, and WSC, respectively. A non-probability convenience sampling technique was used to determine sample size.

Data Collection Tool and Procedure

Data were collected in face-to-face interviews at the study sites using a structured questionnaire adapted from previous studies [17, 23, 32]. The questionnaire comprised four sections. Section A contained the patients’ sociodemographic information (age, gender, marital status, educational level, religion, occupation, and monthly income), whereas, Section B consisted of clinical characteristics and treatment (type and stage of cancer, date of diagnosis, and treatment received). Section C included information on CAM use (type of CAM used, source of information for CAM use, reason for using CAM, reason for not using CAM, and disclosure to healthcare professionals about CAM use). Section D contains QoL assessment information based on the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30 version 3.0) questionnaire. The QoL questionnaire includes a five-item functional scale (physical, role, emotional, cognitive, and social functions), a three-item symptom scale (fatigue, pain, and nausea/vomiting), and six single items to assess symptoms such as (appetite loss, constipation, diarrhoea, dyspnoea, insomnia, and financial difficulties [33]. The extent to which participants experienced symptoms was measured as follows: 1 = not at all, 2 = a little, 3 = quite a bit, and 4 = very much. High scores on the functional and global health measures indicate a better QoL and a high level of functioning, whereas high scores on the symptom scale indicate worsening of symptoms. Before the study, the questionnaire was pre-tested in a hospital that was not part of the study sites for its content and relevance. Corrections were made where necessary and feedback was used to develop the final questionnaire.

Data Analysis

The R version 4.3.2 (2023-10-31 ucrt) and Statistical Package for the Social Sciences software for Windows version 20.0 (IBM Statistics, Armonk, NY, USA) were used to enter and evaluate responses from the questionnaire Categorical variables were described using frequencies and percentages, whereas continuous variables were presented as medians and interquartile ranges. CAM use, the primary outcome and dependent variable in this study, was dichotomous and defined as either using CAM at least once after cancer diagnosis or not using CAM at all after their diagnosis. The characteristics of CAM use, including factors influencing CAM choice, reasons for using and not using CAM, and disclosure to healthcare professionals, were presented as frequencies and percentages. The independent variables were selected after a detailed literature review of the possible factors associated with CAM use, including age, sex, marital status, educational level, occupation, income, treatment, comorbidity, type of cancer, duration of cancer since diagnosis, and stage of cancer.

The characteristics of CAM users and non-users were compared using the chi-squared test. The logistic regression model, along with the crude and adjusted odds ratio with a 95% confidence interval (95% CI), was also computed to explore independent factors of CAM use. Associations with significance levels of less than 0.20 (p < 0.20) from the univariate model were included in the final multivariate model. Hosmer and Lemeshow's goodness-of-fit test was used to check the adequacy of the final model, which fitted the data well with a p-value of 0.940.

According to the EORTC scoring manual, QLQ-C30 items were scored and linearly translated to a 0–100 scale [33]. The Mann–Whitney U test was used to compare QoL between CAM and non-CAM users. Statistical significance was set at a two-sided p-value of < 0.05.

Sociodemographics and Clinical Characteristics of Patients

A total of 216 participants were enrolled, of whom 12 were excluded because they failed to provide informed consent to participate in the study. Thus, 204 patients (CH = 145, ODCH = 14, WSC = 45) with a median (interquartile range) age of 44.5 (33.0–59.0) years participated in the study. Table 1 shows the sociodemographic and clinical characteristics of the patients. Most of the patients were female 146 (71.6%), married 132 (64.7%), had tertiary education 67 (32.8%), employed 131 (64.2%), and earned a monthly income greater than NLe 800 ($30), 98 (48.0%). Most of the patients were diagnosed with breast cancer 131 (64.2%), had lived with cancer for < 1 year 140 (68.6%), in the early stage of the disease 101 (49.5%), have had surgery 124 (60.8%) and did not have any comorbidities 161 (78.9%). Education (p = 0.033) and treatment received (p = 0.025) were factors associated with CAM use.

Table 1

Sociodemographic and clinical characteristics of cancer patients at three health facilities in Freetown (n = 204) [December 2023- April 2024]
Variable	Total n(%) n = 204	CAM Users (%) n = 99	Non-CAM Users(%) n = 105	Chi-square	p-value
Age(years)* Less than 18 18–29 30–39 40–49 50 and above	13(6.4) 33(16.2) 34(16.7) 39 (19.1) 85 (41.6)	5 (5.0) 18 (18.2) 16 (16.2) 18 (18.2) 42 (42.4)	8(7.6) 15 (14.3) 18 (17.1) 21 (20.0) 43 (41.0)	0.728	0.867
Sex* Male Female	62 (30.4) 142 (69.6)	26 (26.3) 73 (73.7)	36 (34.3) 69 (65.7)	0.955	0.328
Marital status** Single Married Divorced	44 (21.6) 132 (64.7) 28 (13.7)	18 (18.2) 67 (67.7) 14 (14.1)	26 (24.8) 65 (61.9) 14 (13.3)	1.310	0.520
Educational status** No education Primary school Secondary school Tertiary	63 (30.9) 13 (6.4) 61 (29.9) 67 (32.8)	38 (38.4) 5 (5.1) 32 (32.3) 24 (24.2)	25 (23.8) 8 (7.6) 29(27.6) 43 (41.0)	8.742	0.033
Occupation** Employed Unemployed	131 (64.2) 73 (35.8)	66 (66.7) 33(33.3)	65 (61.9) 40(38.1)	0.503	0.478
Monthly income** NLe 0 NLe 1-800 Above NLe 800	21 (10.3) 85 (41.7) 98 (48.0)	10 (10.1) 46 (46.5) 43 (43.4)	11 (10.5) 39 (37.1) 55 (52.4)	1.919	0.383
Types of cancer* Breast cancer Burkitt lymphoma Colorectal cancer Ovarian cancer Nephroblastoma Prostate cancer Rhabdomyosarcoma Retinoblastoma	131 (64.2) 1 (0.5) 6 (2.9) 8 (3.9) 2 (1.0) 45 (22.1) 2 (1.0) 9 (4.4)	69 (69.7) 1 (1.0) 4 (4.0) 2 (2.0) 1 (1.0) 16 (16.2) 0 (0.0) 6 (6.1)	62 (47.3) 0 (0.0) 2 (33.3) 6 (75.0) 1 (50.0) 29 (27.6) 2 (1.9) 3 (2.9)	10.629	0.156
*Duration of cancer diagnosis** < 1year 1-5years > 5years	140 (68.6) 58 (28.4) 6 (2.9)	70 (70.7) 28(28.3) 1 (1.0)	70(66.7) 30(28.6) 5 (4.8)	2.561	0.278
Stage of cancer* Early stage Locally advanced stage Metastasize stage	101 (49.5) 70 (34.3) 33 (16.2)	46 (46.5) 39 (39.4) 14 (14.1)	55 (52.4) 31(29.5) 19 (18.1)	2.299	0.317
Treatment received* Surgery Chemotherapy	124 (60.8) 80 (39.2)	68 (68.7) 31 (31.3)	56 (53.3) 49 (46.7)	5.039	0.025
Comorbidity* No Yes	43 (21.10) 161 (78.9)	25 (25.3) 74 (78.1)	18 (17.1) 87 (82.9)	2.014	0.156
This includes data for children under 18 years of age and adult participants, *This includes data for all participants inclusive of those for parents/guardians of those participants less than 18 years of age. Bold figures represent statistically significant finding (p < 0.05), NLe = New Leones, CAM = Complementary and alternative medicines

Prevalence, Characteristics, and Types of CAM Use

Table 2 shows the prevalence, patterns, and characteristics of CAM use among study patients. The prevalence of CAM in this study was 99 (48.5%). The most common sources of information about CAM use were friends, family, and relatives 40 (40.4%). The main reason for using CAM was to manage cancer complications and slow the progression of the disease 43 (43.4%), while about a third, 36 (36.2%) of the non-CAM users stated that the main reason for not using CAM was a lack of belief in CAM. Over half of the CAM users, 51 (51.5%), said that their doctor did not ask them about CAM use, and 53 (53.5%) did not mention their CAM use to their doctor. The key reason for not communicating with doctors was anticipating a negative response 31(15.2%). Concerning doctors' response to CAM use, 25 (54.3%) indicated that their doctors advised them to stop using CAM. Most CAM users did not experience adverse reactions, 79 (79.7%) from CAM use, and 85 (85.8%) of nonusers planned not to use CAM in the future.

Figure 1 shows the types of CAM used by the participants. Some patients used more than one type of CAM. The most common type of CAM were herbal medicines 63 (48.8%) such as Aloe vera, Ginger, Tumeric, and Moringa followed by special foods 25 (19.4%) like

legumes, mushrooms, fatty fish-based products, and prayers 19 (14.7%).

Table 2

Prevalence and pattern of CAM use of cancer patients at three health facilities in Freetown, (December 2023- April 2024)
Variable about CAM use	Frequency	Percentage (%)
Prevalence of CAM use Yes No	99 105	48.5 51.5
Source of information about CAM Personal choice Friends, family, relatives Media (internet, magazine, television) Health practitioner Family beliefs From another patient	36 40 1 10 5 7	36.4 40.4 1.0 10.1 5.1 7.0
Reason for CAM use To manage cancer complications and slow progression To reduce side effects To help relaxation and feel better psychologically To improve your general health and ensure long-term survival To feel more in control over your healthcare To get relieved from a sorcery spell	43 5 14 9 26 2	43.4 5.1 14.1 9.1 26.3 2.0
Reason for not using CAM among nonusers I never heard of it I am afraid of the side effects I don't believe in it The Doctor didn't prescribe it Not to have an additional burden	4 18 36 16 29	3.8 17.1 36.2 15.2 27.6
Did your Doctor ask about CAM use Yes No	48 51	48.5 51.5
Consult with a Doctor about CAM use Yes No	46 53	46.5 53.5
Reason for not consulting with Doctor Anticipating negative response Insufficient information on CAM There is no need to consult with Doctor It was not important for the Doctor to know about my CAM use	31 3 11 8	58.5 5.7 20.8 15.1
Doctors’ response to CAM use Encouraged you to continue using CAM Advise you to stop using Was neutral about using	14 25 7	30.4 54.3 15.2
Adverse reactions from CAM use Yes No Difficult to judge	19 79 1	19.2 79.8 1.0
Would you consider using CAM in the future? Yes No Undecided	2 85 22	2.0 85.8 22.2
CAM = Complementary and alternative medicines

Herbal medicines - include herbs, herbal materials, herbal preparations, and finished herbal products, that contain as active ingredients parts of plants, or other plant materials, or combinations

CAM- complementary and alternative medicines

Others - include (homeopathy, acupuncture)

Figure 1 Types of CAM utilised among cancer patients at three health facilities in Freetown, (December 2023- April 2024)

Predictors of CAM Use

There were statistically significant differences between CAM use and tertiary education (OR = 2.72, 95%CI = 1.34–5.54, p = 0.006) and chemotherapy (OR = 1.91, 95%CI = 1.08–3.40, p = 0.026). After controlling for other variables, tertiary education (AOR = 2.68, 95%CI = 1.31–5.49, p = 0.007) and chemotherapy (AOR = 1.91, 95%CI = 1.06–3.46, p = 0.032) remained significant in the multivariate logistic model. The odds for CAM use in patients with tertiary education were 2.68 times higher than those with lower education. The odds of CAM use among patients who received chemotherapy were 1.91 times higher than those among patients who underwent surgery.

Table 3

Predictors of CAM use among patients with cancer
Variables	P-Value	COR (95% CI)	P-Value	AOR (95% CI)
Age* 18–29 30–39 40–49 50 and above	0.490 0.430 0.587	1 1.38 (0.56–3.39) 1.44 (0.58–3.54) 1.24 (0.57–2.74)	- - -	- - -
Sex Male Female	0.329	1 0.73(0.39–1.36)	- -	- -
Marital Status Single Married Divorced	0.259 0.450	1 0.67 (0.34–1.34) 0.69 (0.27–1.79)	- - -	- - -
Educational Status No education Primary School Secondary School Tertiary	0.155 0.378 0.006	1 2.43 (0.71–8.29) 1.37 (0.68–2.81) 2.72 (1.34–5.54)	0.106 0.285 0.007	1 2.79 (0.80–9.67) 1.49 (0.72–3.07) 2.68 (1.31–5.49)
Occupation Unemployed Employed	0.479	1 1.23 (0.693–2.19)	- -	- -
Monthly Income NLe 0 NLe 1-800 Above NLe800	0.594 0.754	1 0.77 (0.29–2.01) 1.16 (0.45–2.99)	- -	- -
Stage of Cancer Early Stage Locally Advanced Metastasized	0.192 0.754	1 0.67 (0.36–1.23) 1.14 (0.51–2.51)	- -	- -
Duration of cancer < 1year 1-5year > 5years	0.825 0.146	1 1.07 (0.58–1.98) 5.00 (0.57–43.89)	- -	- -
Treatment Surgery Chemotherapy	0.026	1 1.91 (1.08–3.40)	0.032	1.91 (1.06–3.46)
Comorbidity No Yes	0.158	1 1.63 (0.83–3.23)	0.291	- -
This includes data for children under 18 years of age and adult participants, **This includes data for all participants inclusive of those for parents/guardians of those participants less than 18 years of age. Bold figures represent statistically significant finding (p < 0.05), NLe = New Leones, CAM = Complementary and alternative medicines, COR = crude odd ratio, AOR = adjusted odd ratio, CI = confidence interval

Impact of CAM Use on the Quality of Life of Cancer Patients

Table 4 reveals that although the global health status, functional scale, and symptom scale (fatigue, nausea, vomiting, pain, dyspnoea, insomnia, loss of appetite, constipation, and diarrhoea) scores were not statistically significant, financial difficulties were statistically associated with CAM use (p = 0.010).

Table 4

Comparison of Quality of life between users and non-users of CAM
EORCTC QLQ-30	CAM use: Median (IQR)		P-value
EORCTC QLQ-30	CAM users	Non-CAM users	P-value
Global health status	100.00 (66.67, 100.00)	83.33 (66.67, 100.00)	0.706
Functional scale
Physical	100.00 (83.33, 100.00)	100.00 (86.67, 100.00)	0.471
Role	100.00 (83.33, 100.00)	100.00 (100.00, 100.00)	0.827
Emotional	100.00 (75.00, 100.00)	100.00 (75.00, 100.00)	0.916
Cognitive	100.00 (100.00, 100.00)	100.00 (100.00, 100.00)	0.733
Social	100.00 (100.00, 100.00)	100.00 (100.00, 100.00)	0.993
Symptom scale
Fatigue	11.11 (0.00, 44.44)	0.00 (0.00, 33.33)	0.098
Vomiting	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	0.561
Pain	33.33 (0.00, 50.00)	16.67 (0.00, 50.00)	0.156
Dyspnoea	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	0.909
Insomnia	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	0.875
Appetite loss	0.00 (0.00, 0.00)	0.00 (0.00, 33.33)	0.999
Constipation	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	0.299
Diarrhoea	0.00 (0.00, 0.00)	0.00 (0.00, 0.00)	0.826
Financial difficulties	33.33 (0.00, 100.00)	33.33 (0.00, 66.670	0.010

Bold figures represent statistically significant findings (p < 0.05); CAM = Complementary and Alternative Medicine; EORTC-QLQ-30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire 30 items; IQR = Interquartile range.

The results revealed that about half of the patients used CAM, with herbal preparations and special foods being the most commonly used treatments. The primary sources of information about CAM for patients were family, friends, and relatives, and the majority did not discuss CAM use with medical professionals. Tertiary education and chemotherapy were identified as predictors of CAM use. Regarding the influence of CAM on QoL, only financial difficulties were found to be statistically significant.

This study found that approximately 48.5% of patients used CAM, which is comparable to previous research conducted in Turkey (46.4%), Malaysia (46.1%), and Italy (48.9%) [27, 34, 35]. The most common reason for using CAM was to manage cancer complications and slow progression, followed by feeling more in control of their health, which aligns with a study conducted in Lebanon and Ireland [23, 24]. This may be because patients who find conventional treatments inadequate may turn to CAM for a cure, enhance their QoL, and effectively cope with the adverse effects of cancer therapy [36, 37]. Patients are often drawn to CAM because they perceive it as more natural and safer than conventional medicines, and it can offer them a sense of autonomy over their healthcare experience when they feel overwhelmed by the medical system's complexities [38, 39]. Patients' treatment choices can also be significantly influenced by their cultural background, personal views, and experiences, considering that CAM use is linked to the country's heritage [20, 38, 40]. Nevertheless, patients must communicate openly with their healthcare professionals about any CAM treatments they are considering. Careful attention is necessary when integrating complementary and alternative medicine (CAM) with conventional cancer treatments to guarantee safety and avoid possible interactions that may antagonise the efficacy of cancer medications.

However, the prevalence obtained in this study was lower than that reported in Nigeria (66.3%) and Ethiopia (79%) [16, 17] but higher than that reported in Italy (18.1%) and Thailand (25.13%) [31, 32]. The variability in CAM usage across different study settings can be attributed to variances in traditional and societal attitudes towards CAM, study methods, definitions of CAM use, and challenges in accessing affordable conventional cancer care [41].

The predominant type of CAM employed in this study was herbal medicine, followed by special foods and spiritual healing, such as prayer as the secondary modality. This aligns with research conducted in Trinidad and Tobago, and Ethiopia [17, 42]. The popularity of these treatments may be due to the belief that they are both safe and natural and play a crucial role in many cultures. Therefore, their integration into cancer care might provide patients with assurance and familiarity. Although scientific evidence supporting the effectiveness of many traditional therapies in treating cancer may be limited, patients may perceive benefits such as improved well-being, reduced stress, and enhanced emotional support [20]. Although herbal preparations can complement conventional cancer treatments, they should not be used as a substitute for evidence-based medical care.

In addition, the patients in this study employed special foods and spiritual healing practices such as prayer and fasting. Food and dietary approaches may support overall health and well-being during cancer treatment. These foods may provide essential nutrients, antioxidants, and phytochemicals that can strengthen the immune system, reduce inflammation, and support the body's natural healing processes [43]. However, it is crucial to consult healthcare professionals to ensure that dietary choices are safe, appropriate, and supportive of the overall treatment goals. Furthermore, the incorporation of religious beliefs into everyday activities, including prayer and fasting, is a common practice observed by the two major religions, Christianity and Islam in Sierra Leone. Consequently, certain individuals depend entirely on prayer as their sole means of achieving healing [44, 45].

Concerning sources of information on CAM use, most patients select their therapy based on suggestions from family and friends, followed by personal preferences. These findings are comparable to studies done in Nigeria and Turkey [16, 46].

In general, the influence of friends and family on the utilisation of CAM among cancer patients stems from trust, personal experience, emotional support, social and cultural norms, and perceived empathy. Although these social networks can provide valuable guidance and assistance, it is essential for cancer patients to seek advice from healthcare professionals to make informed decisions regarding their treatment options [46].

Regarding the disclosure of CAM use to healthcare professionals, the study results highlighted that the majority of patients did not disclose their CAM use to their doctors, and the doctors also did not ask about CAM use. Furthermore, over half of the patients indicated that the reason for non-disclosure was anticipating a negative response, and there was no need to tell the doctor. The results of this study are consistent with those of other studies conducted in Canada, the United States of America, Jordan, Malaysia, and South Korea [47–49]. Patients may not dislose their use of CAM to healthcare providers for various reasons such as fear of disapproval or judgment. They may believe that their providers are interested only in conventional treatments and are unreceptive to discussing or integrating CAM therapies into their care plans. In addition, patients may assume that their healthcare providers have limited knowledge about CAM or are dismissive of its efficacy and may seek information from other sources [21, 47]. Moreover, when patients fail to disclose CAM use, and healthcare providers do not ask about it, this can result in catastrophic spending for cancer patients, and at worst, in complications and therapeutic failure [25]. It is crucial for healthcare professionals to discuss CAM use with their patients because it can interact harmfully with conventional treatments and other medications, leading to adverse clinical and economic consequences [41, 50]. Open and transparent communication is vital for ensuring safe and effective cancer care. Patients should feel empowered to discuss their health decisions, concerns, and treatment preferences with their healthcare providers, who can offer valuable guidance, support, and expertise in navigating CAM therapies alongside conventional cancer treatments.

Compared with other studies, cancer patients with tertiary education were three times more likely to use CAM than those with lower or no education [25]. Cancer patients with higher educational levels may feel more confident exploring alternative treatment options, such as CAM, alongside conventional therapies. This is because of their increased access to resources and information, which enables them to critically evaluate sources and make informed decisions. Higher education may also correspond to higher income, allowing patients to afford out-of-pocket expenses for CAM treatments that are not covered by insurance. Furthermore, they may also be skeptical of the effectiveness of conventional treatments and the associated untoward reactions, leading them to perceive CAM as a safer and more natural alternative [25, 51]. Healthcare professionals should, therefore, engage in open and non-judgmental discussions with patients about CAM use, regardless of their educational background, to ensure comprehensive and patient-centred care.

Patients on chemotherapy were two times more likely to consume CAM. This finding is consistent with the results of another study [52]. Chemotherapy often demands numerous rounds of treatment over an extended duration, which can span several months or even years. As a result, patients may seek CAM as additional supportive therapy to help manage side effects, improve their quality of life, and enhance their overall well-being [53, 54].

Concerning the impact of CAM on quality of life, except for financial difficulty, our results showed no considerable differences between CAM and non-CAM users. Our study is comparable to other studies done in Ethiopia, South Korea, Lebanon, and Turkey in which there were no significant changes in QoL between CAM consumers and non-CAM consumers [17, 23, 26, 27]. Conversely, other studies have reported an improvement in QoL among cancer patients [28, 29]. Low-resource settings, including Sierra Leone with a monthly minimum wage of 800 new Leones (NLe 800), equivalent to about ($30), pose significant financial barriers for cancer patients accessing conventional treatments such as chemotherapy, surgery, and radiotherapy, some of which are not available in the country. Financial constraints may compel patients to opt for CAM therapies, which may incur costs. Such limitations can restrict the patients' ability to access and pay for these therapies. The resulting financial burden, including concerns over healthcare expenses, medication costs, and income loss due to treatment, can exacerbate emotional and psychological difficulties, negatively impacting overall well-being and quality of life [53]. Addressing these challenges requires a comprehensive approach that addresses socioeconomic disparities and enhances access to cost-effective healthcare services.

This study has several strengths and limitations. First, this study is the first to investigate CAM use among cancer patients and its impact on QoL in Sierra Leone, where cancer management modalities are limited. Given that the three facilities examined in this study were primary referral oncology treatment centres in the country, the results can be generalised to other facilities. However, the paediatric population was minimal and most participants were females, making it difficult to generalize to the male population. Furthermore, we adhered to the strengthening reporting of observational studies (STROBE) guidelines, resulting in a robust study report.

Regarding limitations, the study's cross-sectional design precluded any determination of causal relationships between CAM usage and its potential effects. Additionally, the use of an interviewer-administered response mode may have introduced a response bias, as participants may have felt compelled to provide a socially desirable response. Moreover, the study relied on the participants' memories, which could have led to recall bias. Despite these limitations, the study demonstrated that CAM usage is prevalent, and further research on a larger scale and for a longer period is warranted, considering the small sample size used in this study.

The study demonstrated that cancer patients frequently resort to CAM, with common modalities comprising herbal medicine, followed by special foods and prayer. Patients typically obtain information about CAM from family, friends, and relatives, and fewer than half discuss its use with their healthcare practitioners. Various factors such as tertiary education and chemotherapy were found to be associated with CAM use. Financial difficulties were also found to impact the quality of life of CAM users. The prevalent use of CAM among cancer patients, coupled with the non-disclosure of such usage to healthcare professionals, may compromise patients' health and well-being. Therefore, it is essential for healthcare professionals to initiate discussions with their patients about the usage of CAM and to counsel them about the potential risks and benefits associated with CAM use in conjunction with conventional treatment. Future research should focus on conducting prospective or longitudinal studies, particularly randomised controlled clinical trials, to determine their efficacy and correlation between CAM therapy and QoL.

Ethics approval and consent to participate

Ethical approval was obtained from the Institutional Review Board (IRB) of the College of Medicine and Allied Health Sciences, University of Sierra Leone (COMAHS/IRB/001/2023), and permission to conduct the study was granted by the management of all three hospitals involved. Clinical trial number not applicable. The study's background, aim, and objectives were clearly explained to the participants, who were asked to provide informed consent. Informed consent was obtained from the participants before the commencement of the study. To maintain confidentiality, participants' personal information, such as their names, was not recorded. Only those willing to participate were included in the study, and were not pressured or coerced to do so. Their information was coded and kept confidential to ensure their privacy.

Acknowledgement

We extend our heartfelt gratitude and appreciation to the management and staff of the various hospitals for their invaluable support in conducting this research.

Consent for publication

Not applicable.

Availability of data and materials

Data used in this study is available at, https://zenodo.org/doi/10.5281/zenodo.12724925

Competing interests

The authors declare that they have no conflicts of interest.

Funding

The authors received no funding for this study.

Authors' contributions

OTA, MSS, IOS, NVTB, IFK, TBK, JC, CCJ, ABJ, JSK, RL, LK, JS, and MS were involved in the study conception and design. OTA, MSS, IOS, NVTB, IFK, TBK, JC, CCJ, and MS led and coordinated the investigation and methodology. OTA, MSS, and JSK did the analysis. OTA and MSS prepared the first draft of the manuscript. All authors were involved in writing, reviewing, editing, commenting on the subsequent revisions, approving the final manuscript, and agreeing to submit it for publication.

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No competing interests reported.

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Complementary and Alternative Medicine Use and its Impact on Quality of Life among Cancer Patients in Freetown, Sierra Leone: Considerations for a Resource-Limited Setting

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Abstract

Background

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Introduction

Methods

Study Setting and Design

Study Population

Sample Size Determination and Sampling

Data Collection Tool and Procedure

Data Analysis

Results

Sociodemographics and Clinical Characteristics of Patients

Prevalence, Characteristics, and Types of CAM Use

Predictors of CAM Use

Impact of CAM Use on the Quality of Life of Cancer Patients

DISCUSSION

CONCLUSION

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