KATHMANDU UNIVERSITY MEDICAL JOURNAL

Health Literacy and Complementary and Alternative Medicine

Use among Type 2 Diabetes Mellitus Patients in the Northeast
of Thailand
Charoencheewakul C,1 Laohasiriwong W,2 Suwannaphant K,3 Sopon A4

ABSTRACT
Background

Globally, type 2 Diabetes Mellitus is in increasing trend. With its chronic and incurable
Doctor of Public Health Program, Faculty of Public
1

Health, Khon Kaen University, natures, type 2 diabetes patients have been increasingly seeking various regiments
to relive their sufferings. However, magnitude and influencing factors are still unclear.
2
Faculty of Public Health, Khon Kaen University,
Khon Kaen. Objective
3
Sirindhorn College of Public Health, Khon Kaen, To identify prevalence of complementary and alternative medicine among type 2
Thailand.
diabetes patients and the association between health literacy and its use in the
Thailand Healthy Life Style Administered Office,
4 Northeast region of Thailand.
Ministry of Public Health, Thailand.
Method

This cross-sectional study aimed to determine the prevalence of Complementary

Corresponding Author and Alternative Medicine use and the roles of health literacy on its use among
type 2 diabetes patients in the Northeast Region of Thailand. A total of 1,012 type
Wongsa Laohasiriwong
2 diabetes mellitus patients were systematic randomly selected to response to a
Faculty of Public Health, structured questionnaire interview. The generalized linear mixed model was applied
to identify factors associated with it.
Khon Kaen University,
Result
Khon Kaen, 40002, Thailand.
There were 30.89% (95% CI: 28.25 to 33.67) of type 2 diabetes patients used
E-mail: drwongsa@gmail.com complementary and alternative medicine. Majority of these patients (52.23%, 95%
CI: 49.30 to 55.15) had sufficient level of health literacy related to complementary
and alternative medicine. Type 2 diabetes patients who had sufficient to excellent
Citation
levels of health literacy had 2.64 times higher Odds of complementary and alternative
Charoencheewakul C, Laohasiriwong W, medicine use (95% CI: 1.91 to 3.65) when compared with those who had inadequate
Suwannaphant K, Sopon A. Health Literacy and to problematic levels of health literacy. Others covariates that were also associated
Complementary and Alternative Medicine Use
among Type 2 Diabetes Mellitus Patients in the with complementary and alternative medicine use were had adequate income
Northeast of Thailand. Kathmandu Univ Med J. (ORadj. = 2.52; 95% CI: 1.81 to 3.52), had HbA1C < 7 (OR Adj. = 2.50; 95%CI: 1.86 to
2019;66(2):107-13.
3.37) and had comorbidity (OR Adj. = 2.07; 95%CI: 1.57 to 2.73).

Conclusion

About thirty percent of type 2 diabetes patients used complementary and alternative
medicine. Health literacy, economic status, comorbidity and diabetic control had
strong influence on complementary and alternative medicine use.

KEY WORDS
Health literacy, Diabetes Mellitus, Northeast of Thailand

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Original Article VOL. 17|NO. 2|ISSUE 66|APRIL-JUNE. 2019

INTRODUCTION use. The study population were type 2 diabetes mellitus

patients aged 18 years and older, who were diagnosed
Diabetes is a serious, chronic metabolic disease caused by
by the physician in respective health institutions in the
either insufficient production of insulin, or ineffectively
Northeast region. The sample size was calculated by using
utilization of the produced insulin by the body.1 The global
the sample size estimation formula for multivariable
prevalence (age-standardized) of diabetes has nearly
regression analysis to identify the association between
doubled since 1980 which is increasing from 4.7 to 8.5%
independent variables and categorical data outcome of
in the adult population and it is expected that this number
with the sample size of 1,113. The sample size was then
will be twofold by 2025.2-5 Diabetes Mellitus (DM) is not
adjusted to control the over-fitting, using the rho (ρ) of
only ranked as the eighth leading cause of death among
0.06 and variance inflation factor (VIF) equal to 2.50.
both sexes but also was the fifth leading cause of death in
Therefore, the total samples was 1,120. A Multi stage
women.2
random sampling was used to select the samples from 4
DM is a common metabolic disorder that is increasing sub-districts, among 4 districts of 4 provinces.
health burden in Thailand as well as increased DM-related
The research tool was a structured questionnaire which was
deaths by almost 21.1% between 2012 and 2014.6-8 The
developed according to the research questions and relevant
estimated prevalence of DM in Thailand was approximately
literatures. The questionnaire consists of the demographic
8.3% (95% CI; 7.7 to 8.9) among adult >15 years with a
and socioeconomics characteristics, knowledge on type
higher prevalence in females 9.6% (95% CI; 8.9 to 10.4)
2 DM and CAM, attitude on CAM, health literacy, health
than in males 6.5% (95% CI; 5.6 to 7.4), in 2003.6-10 The
behaviors, CAM use, health status and clinical outcomes.
prevalence of type 2 DM was 10.4% among adults in the
The questionnaire was tested by 5 experts for the content
Northeast, the highest among all regions, of which it was
validity. The reliability test was conducted among 30 types
9% among males and 11.7% among females.11
2 patients was tested in others provinces. The Cronbach’s
Nowadays, there are broad varieties of health services in alpha coefficient of this questionnaire was ≥ 0.7. The
Thailand, ranges from self-caring, over the counter drugs, information was collected using a questionnaire interview
traditional treatments, folk treatments, private clinics, by trained interviewers.
public hospitals and private hospital.9,12 Complementary and
Demographic and socioeconomic characteristics: age was
Alternative Medicine (CAM) is board range of treatments
categorized into 2 age groups; 1) younger 60 yrs., and 2)
that are used in addition to, complementary, or instead
60 yrs. and older; occupation as 1) agriculturist 2) beside
of, alternative, standard or conventional western medical
agriculturist including government/state enterprise/
treatments. CAM may include herbs, dietary supplements,
employees/trade/ business; household average monthly
mega dose vitamins, herbal preparations, special teas,
income as 1) < 5,000 baht and 2) ≥ 5,000 baht. Health
acupuncture, massage therapy, magnet therapy, spiritual
behaviors was classified into 1) poor to average levels
healing, and meditation.13,14
of behaviors and 2) good behaviors. Knowledge was
Thai traditional medicine and alternative medicine have classified as; low level (score 0-59%, average level (score
included in the National Health Service development plan 60-79%), high level (score ≥ 80%). Attitude towards CAM
(No. 10) indicated that “Every hospital must provide Thai was classified as poor attitude (score < 29.34), average
traditional medicine that people can rely on it.15,16 People attitude (score 29.34-47.66) and good attitude (score ≥
with poor health literacy, often lack knowledge or have 47.67). Health literacy on DM and CAM was classified into
misinformation about nature and causes of disease of inadequate to problematic score > 64 and 50-64), and
which they may not understand the relationship between sufficient to excellence (score 35-49, and 20-34), BMI was
health determinants and health outcomes.12,17 The classified into 3 groups of normal and underweight: BMI
Northeast is the largest but poorest region of the country < 23 kg/m2,overweight (BMI: 23-24.9 kg/m2) and obesity
with the highest number of type 2 DM patients. Therefore, (BMI ≥ 25 kg/m2, Latest blood glucose levels were classified
this study aimed to identify prevalence of CAM use among as 1) > 130 mg/dl and 2) ≤ 130 mg/dl. Glycated hemoglobin
type 2 DM patients and the association between health (HbA1C) was divided into 1) > 7 mg% and 2) ≤ 7 mg%.
literacy and CAM use in the Northeast region of Thailand.
The categorical variables were analyzed and described
The results could be used as evident for health and other
as frequency and percentage whereas presented mean,
relevant sectors to set appropriate plans for appropriate
standard deviation and median for continuous variables.
use of CAM.
Crude odds ratios and their 95% confidence intervals
(CI) and p-value were calculated by using simple logistic
regression. The dependent variables which had p <0.25
METHODS
were processed to multivariable analysis using the
This cross-sectional study aimed to determine the generalized linear mixed model (GLMM) analysis to
prevalence of CAM use among type 2 DM patients and estimate the association between health literacy and CAM
identify the association between health literacy and CAM use among type 2 DM patients and when controlled other

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covariates. Backward elimination was used as the method 1 13 1.17

for variable selection to obtain the final model. The p-value 2-3 261 23.30
less than 0.05 was considered as statistically significant.
4-5 568 50.71
The written informed consent was taken from all the ≥6 278 24.82
individuals after explaining the study objectives. The Status in family
Ethical Committee of Khon Kaen University approved this Head of family 444 39.64
study (reference no. HE 612105).
Family member 676 60.36
Average monthly household income (Baht)

RESULTS <5,000 75 6.70

5,000-9,999 370 33.04
Majority of the respondents were women (69.77%) with the
10,000-19,999 448 40.00
average age of 60.50 ± 11.26 years old. Most of them were
≥20,000 227 20.26
married (78.93%), finished primary education (79.46%) and
were agriculturists (74.11%). Almost half lived in a family Mean: 14,156.88, SD: 13,495.46, Median: 10, 000 Min: 3,000, Max:
150,000
with 4-5 members (50.71%). About one-third had family
Average monthly household expenditure
monthly income of 5,000-9,999 baht (33.04%), 54.82% had
debt. Only 16.70% had active social role. Almost all were in <5,000 152 13.57

the Universal Health Coverage Scheme (UC) of which they 5,000-9,999 434 38.75
pay a copayment of 30 Baht per visit for curative care at the 10,000-19,999 385 34.38
health facilities they registered (table 1). ≥20,000 149 13.30
Mean: 11,697.77, SD: 10,942.00, Median: 9,000 Min: 2,500, Max:
Table 1. Personal and socioeconomic factors of type 2 diabetes 150,000
in Northeast Region (n=1,120)
Debt
Demographic and socioeconomic Number % No 450 40.18
characteristics Yes 670 59.82
Gender Adequacy of income
Male 347 30.98 Not enough without debt 31 2.77
Female 773 69.02 Not enough with debt 398 35.54
Age (Years) Enough without saving 511 511
< 50 191 17.05 Enough with saving 180 16.07
50-59 299 26.70 Role in society
60-69 419 37.41 No 933 83.30
≥ 70 211 18.84 Yes 187 16.70
Average: 60.50 years old, SD: 11.26, Median = 61 Min: 25, Max: 98 Community Leader 26 2.32
Marital status Village health volunteer 111 9.91
Single 29 2.59 Fund manager/Committee 50 4.46
Marriage 884 78.93 Health insurance
Divorce/Widow/Separated 207 18.48 No Health insurance 20 1.79
Educational attainment Universal Coverage Scheme 1,036 92.50
No formal education 39 3.48 Government or State Enterprise Officer 36 3.21
Primary school 890 79.46 Social Security Scheme 28 2.50
Secondary school 92 8.21
High school 74 6.61 About one third (35.54%) of the DM patients were obese
(BMI: 25 to 29.9 kg/m2). Almost half of the respondents
Bachelor degree or higher 25 2.24
(49.38%) had poor control of plasma glucose of which their
Occupation
latest plasma glucose level was higher than 130 mg/dl,
Farmer 830 74.11
38.03% of these patients had HbA1C ≥ 7 mg%. Moreover,
Government officer/State enterprise 19 1.70 48.12% of them were suffered from the congenital disease
Employee 4 0.36 more than diabetes. In addition, 66.52% of them were
Worker 83 7.41 taken one medicines a day for the treatments of DM and
Merchant 81 7.23 average expenditure per month was less than 5,000 baht
Unemployment 103 9.20 (88.12%) However, most of them don’t had complication
Family size (Person) with eye, kidney, foot or paralysis (table 2).

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Table 2. Health Status of type 2 diabetes in North-East Region Injection only 24 2.14
(n=1,120)
Both Oral medicine and Injection 50 4.46
Health Status Number Percentage Average Health Expenditure (Baht per
month)
Body mass index (kg/m2)
< 500 987 88.13
Underweight (<18.5) 44 3.93
500-999 72 6.42
Normal (18.5 to 22.9) 320 28.57
≥ 1,000 61 5.45
Overweight (23 to 24.9) 267 23.84
Average: 258.88, SD: 1,141.21, Median: 50 Min: 0, Max: 30,000
Obesity (≥25) 489 43.67
Years of diagnosed with diabetes (years) Most of the type 2 DM patients had average level of
<5 229 20.45
knowledge on health 72.77% (95%CI: 70.08 to 75.03) and
25.45% (95%CI: 22.98 to 28.08) had high level of knowledge
≥5 891 79.55
(table 3).
Latest fasting plasma glucose (mg/dl)
Table 3. Level of knowledge on DM and CAM of type 2 diabetes
≥130 657 58.66
in the Northeast Region (n=1,120)
70-129 462 41.25
<70 1 0.09 Knowledge Level Number Percentage 95% CI
Blood sugar level before the latest Low level (Score 0-59%) 20 1.79 1.15 to 2.75
>130 553 49.38 Average level (Score 60- 815 72.77 70.08 to 75.30
79%)
70-130 567 50.63
High level (Score ≥80%) 285 25.45 22.98 to 28.08
HbA1C
Average: 16.97, SD: 2.17, Median: 17 Min: 6, Max: 20
<7 694 61.96
7-8 333 29.73 Table 4 indicate the attitude toward CAM of type 2 diabetes
≥9 93 8.31 in Northeast Region. Almost 2- thirds of the respondents
Complications
had poor on CAM (61.96%: 95%CI: 59.08 to 64.78) whereas
37.23% (95%CI: 34.44 to 40.11) had average level of
Eye complication
attitude.
No 1,052 93.93
Table 4. Attitude towards CAM of type 2 diabetes in Northeast
Yes 68 6.07
Region (n=1,120)
Kidney degenerative/Dialysis
No 1,073 95.80 Attitude Level Number Percentage 95% CI

Yes 47 4.20 Poor attitude (score < 694 61.96 59.08 to 64.76
29.34)
Foot Complication
Average attitude (score 417 37.23 34.44 to 40.11
No 1,092 97.50 29.34 – 47.66)
Yes 28 2.50 Good attitude (score 9 0.80 0.41 to 1.15
Paralysis ≥47.67)

No 1,111 99.20 Average: 34.29, S7.D: 6.31, Median: 33 Min: 11, Max: 55

Yes 9 0.80 Health literacy in this study assess the level of difficulty that
Ischemic heart disease the respondent encountered in accessing, understanding,
No 1,111 99.20 appraising health information and making decision on
Yes 9 0.80 health practices. It was found that more than half of the
Others DM patients had sufficient level of health literacy (52.68%,
No 1,097 97.95 95%CI: 49.72 to 60.59) and 34.29% (95% CI: 31.56 to 37.12)
Yes 23 2.05
had problematic level of health literacy (table 5).
Comorbidity of DM Table 5. Health Literacy (Difficulty in accessing to health
No 581 51.88
information, understanding, appraising and making decision) of
type 2 diabetes in the Northeast Region (n=1,120)
Yes 539 48.12
Hypertension 506 45.18 Health literacy level Number Percentage 95% CI
Others 70 6.25 Inadequate (> 64 points) 73 6.52 0.21 to 8.12
Diabetes Treatment Regimens Problematic (50 - 64 384 34.29 31.56 to 37.12
points)
Oral Medicine only 1,046 93.39
Sufficient (35 - 49 points) 585 52.23 49.30 to 55.15
1 Tablet 745 66.52
Excellent (20 - 34 points) 78 6.96 5.61 to 8.615
2 Tablet 301 26.88
Average: 47.98, SD: 11.33, Median: 45 Min: 20, Max: 80

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The prevalence of CAM use during the past one year among Average Monthly Household Income (Baht 0.550
type 2 DM was 30.89% (95% CI: 28.25 to 33.67). Among per Month)
the users, massage and herbal medicine were the most <10,000 445 31.91 1
popular type of CAM with 16.96% and 15.63%, respectively. ≥10,000 675 30.22 0.92 0.71 to 1.20
The other types such as naturopathy, acupressure and Average Monthly Household Expenditure 0.367
supplementary food were used among few CAM users (Baht per Month)
(table 6). <10,000 586 32.08 1
≥10,000 534 29.59 0.89 0.69 to 1.15
Table 6. CAM use among type 2 diabetes in the Northeast Adequacy of income <0.001
Region (n=1,120)
Enough with saving/ 429 17.72 1
Enough with no
CAM use Number Percentage 95% CI
saving
Did not use 774 69.11 66.33 to 71.75
Not enough without 691 39.07 2.98 2.23 to 3.99
Use 346 30.89 28.25 to 33.67 debt/ Not enough
Massage 190 16.96 14.87 to 19.28 with debt

Herbal 175 15.63 13.61 to 17.87 Body Mass Index (kg/m2) 0.242

Acupressure 1 0.09 0.01 to 0.63 <23 364 28.57 1

Supplementary food 1 0.09 0.01 to 0.63 ≥23 756 32.01 1.78 0.89 to 1.55

Naturopathy 2 0.18 0.04 to 0.71 Latest fasting plasma glucose level (mg/dl) 0.004
≥130 657 27.55 1

In the bivariate analysis using simple logistic regression, <130 463 35.64 1.46 1.13 to 1.88
the individual factors that were statistically significant with HbA1C (%) <0.001
CAM use of type 2 diabetes patients in Northeast Region, ≥7 426 23.47 1
Thailand with statistical significant (p-value ≤ 0.25) were <7 694 35.45 1.79 1.36 to 2.35
age ≥ 60 years (OR=1.17), was family member (OR=1.36), Comorbidity of DM <0.001
had adequate of income (OR=1.78), body mass index ≥ No 581 23.06 1
23 (OR=1.78), latest of fasting plasma glucose level<130
Yes 539 39.33 2.16 1.67 to 2.80
(OR=1.46), HbA1c <7 mg% (OR=1.79), had comorbidity
Knowledge level <0.001
(OR=2.16), had high knowledge level (OR=1.77) and had
Low – average 835 27.66 1
sufficient to excellent levels of health literacy (OR=3.37). All
these factors were processed into the final multiple logistic High 285 40.35 1.77 1.34 to 2.34
model by using GLMN with backward elimination with Attitude level 0.310
statistically significant at p-value <0.05 (table 7). Poor 694 31.99 1
Average – good 426 29.11 0.87 0.67 to 1.34

Table 7. The factor associated with CAM use of type 2 diabetes Health literacy level <0.001
in the Northeast Region (n=1,120) Inadequate – 457 16.85 1
Problematic
Factors N % Crude 95% CI P- Sufficient – Excel- 663 40.57 3.37 2.52 to 4.50
OR Value lent
Gender 0.801
Male 347 31.41 1 The final model of multivariable analysis by using
Female 773 30.66 0.97 0.73 to 1.27 Generalized Linear Mixed Model (GLMM) with the
Age 0.221 backward elimination technique that controlled the
<60 490 28.98 1 clustering effect. The factors associated with CAM use of
≥60 630 32.38 1.17 0.91 to 1.52 type 2 diabetes in Northeast of Thailand, when control
Educational attainment 0.863
other covariates were had sufficient to excellent levels of
health literacy (ORadj. =2.64; 95% CI: 1.91 to 3.65; p-value
No formal educa- 929 31.00 1
tion/Primary school <0.001). Other covariates that associated with CAM use
Secondary school/ 191 30.37 0.97 0.69 to 1.36
were: had adequate income (ORadj. =2.52; 95% CI: 1.81
High school school/ to 3.52; p-value <0.001), HbA1c <7 mg% (ORadj. =1.25;
Bachelor degree or 95% CI: 1.86 to 3.37; p-value <0.001) and had comorbidity
higher
(ORadj. =2.07; 95% CI: 1.57 to 2.73; p-value = <0.001) (table
Status in Family 0.019 8).
Head of family 676 28.25 1
Family member 444 34.91 1.36 1.05 to 1.76

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Table 8. Factors associated with CAM use of type 2 diabetes in usage of type 2 diabetes had been observed by previous
the Northeast Region (n=1,120) studies as having association with complementary and
alternative medicine use through influence of media and
Factors N % Crude OR 95% CI P-
OR Adj. Value recommendations of health professional.24,25 Easily access
Health Literacy level <0.001
to information can lead to more complementary and
alternative use in Jordan.26 Simultaneously, people with
Inadequate – 457 16.85 1 1
Problematic higher education were more likely to use complementary
Sufficient – 663 40.57 3.37 2.64 1.91 to
and alternative medicine along with the conventional
Excellent 3.65 treatment.24,27 In contrast, a study among type 2 diabetes
Adequacy of income <0.001 in Eastern Mediterranean Region indicated no statistically
Inadequate 429 17.72 1 1
significant association between education and CAM use in
their multivariable analysis models, of which patients used
Adequate 691 39.07 2.98 2.52 1.81 to
3.52 CAM because of friend recommendations.28-30
HbA1C (%) <0.001 When considered their illness conditions such as having
≥7 426 23.47 1 1 comorbidity, those who had commodity were more likely
<7 694 35.45 1.79 2.50 1.86 to to use CAM. (ORadj. = 2.07) of which this study found that
3.37 about 45% had hypertension. In addition, the good clinical
Had comorbidity <0.001 outcome also associated with CAM that the DM patients
No 581 23.06 1 1 who had good control of sugar level (Hb A1C < 7 mg%)
Yes 539 39.33 2.16 2.07 1.57 to use CAM more than (ORadj. = 2.50) the patients whose
2.73 Hb A1C was ≥ 7 mg%. A study in Singapore indicated that
blood sugar level was associated with alternative medicine
DISCUSSION used.31 Our finding founded that about 16% used massage
services with was similar with the alternative health report
This present study observed that about 30% of the type 2 of Strategy and Plan Division, Ministry of Public Health
DM used CAM of which about half used massage services (October 1997) indicated that the most popular alternative
and another half used herbal medicines. This proportion medical used was massage because it was well known
was much lower than those found in a study among diabetes among Thai people and believe in it. Income is also a main
patients in 2005 in Ubon Ratchathani Province, Thailand factor for using complementary and alternative medicine
which indicated prevalence of CAM use was 47.8%, and (ORadj. = 2.52). Since only some herbal medicines were
was also lower than studies in Taiwan (61 percent), South covered be the universal coverage health insurance, the
Korea (65 percent), and India (67.7 percent).18-21 However, use were rather limited to those who could afford them.
CAM use in our finding was higher than those in the United A study in Iran indicated that hospitalized patients who
Kingdom (17 percent),and Australia (23.6 percent).22,23 The had higher income were more likely to use complementary
possible reasons for lower prevalence of CAM use even medicine.32 However, few study found that the usage
when compared with those found in the Northeast of of alternative medicine of chronic pain patient was not
Thailand in 2005 might be the influence from campaigns associated with income.33
to reduce or stop inappropriate use of medicines both
modern and CAM to prevent chronic kidney disease (CKD) The strengths of the present study include the regionally
which is a common and severe complication of type 2 representative samples to determine the prevalence of
DM in Thailand. Our finding indicated about 40 percent CAM use among type 2 DM patients and identify the
of the respondent had average to good attitude on association between health literacy and its use among
CAM, they might be those 30 percent that used CAM. In the Northeast DM population of Thailand and relay on the
addition, about 17 percent used massages which related responses of the patients. Therefore, further qualitative
to occupational musculoskeletal disorders and another study which represent all areas of Thailand will be great
16% used herbal medicines. It is expected that DM patients strength to conclude the findings in an effective manner.
would use CAM with better understanding which relater
with their health literacy that reflect their capacity to obtain,
understand and process common health information to CONCLUSION
make appropriate decisions regarding health. This was The study indicated that about 30 percent of type 2 DM
supported by our findings that DM patients with sufficient patients used complementary and alternative medicine.
to excellent levels of health literacy were more likely to Health literacy was highly associated with complementary
use CAM (ORadj. = 2.64) when compared to those who did and alternative medicine use when consider the
not use. Having access to health information and health influenced of their health status of having hypertension
service, communication skill, decision making skill, self- as hypertension, effectively control blood sugar level and
management skill also associated with alternative medical income.

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KATHMANDU UNIVERSITY MEDICAL JOURNAL

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