Journal of Ethnopharmacology 137 (2011) 305311

Contents lists available at ScienceDirect

Journal of Ethnopharmacology
journal homepage: www.elsevier.com/locate/jethpharm

The prevalence of herbal medicine home use and concomitant

use with pharmaceutical medicines in Jamaica
David Picking a , Novie Younger b , Sylvia Mitchell c , Rupika Delgoda a,
a
b
c

Natural Products Institute, University of the West Indies, Mona, Kingston 7, Jamaica
Tropical Metabolic Research Institute, University of the West Indies, Mona, Kingston 7, Jamaica
Medicinal Plant Research Group, Biotechnology Centre, University of the West Indies, Mona, Kingston 7, Jamaica

a r t i c l e

i n f o

Article history:
Received 5 January 2011
Received in revised form 20 May 2011
Accepted 22 May 2011
Available online 27 May 2011
Keywords:
Polypharmacy
Drugherb interactions
Adverse drug interactions
Self medication

a b s t r a c t
Ethnopharmacological relevance: The work described in this paper aimed to study the prevalence of herbal
medicine use in treating illness and concomitant use with pharmaceutical medicines in Jamaica.
Materials and methods: A survey using a structured questionnaire was administered by a trained interviewer to randomly selected adults in systematically selected households within randomly selected urban
and rural clusters. Categorical data analysis was performed using Stata version 10 software.
Results: 91.4% (372/407) of selected people agreed to participate. 72.6% (270/372) self-medicated with
herbs within the previous year. Commonly treated were illnesses of the respiratory system (RS,
77.8% (210/270)), gastro-intestinal tract (GIT, 53.3% (144/270)) and health maintenance using tonics
(29.6% (80/270)). 26.7% (72/270) of respondents used pharmaceuticals concomitantly with medicinal
plants. Commonly treated were illnesses of the RS (20.4% (55/270)), GIT (13.7% (37/270)) and hypertension (10.0%(27/270)). 19.4% (14/72) of physicians knew of such practices. There was signicant
association of herb use with/without drugs with age (p < 0.001), employment status (p < 0.001), religion (p = 0.004), gender (p = 0.02) and educational level (p = 0.031). Thus prevalence of herb use alone
was greatest amongst people aged 3544 and 4554 years; those employed; Rastafarians; those without health insurance; males and people who had completed secondary education. Whilst prevalence of
concomitant herbdrug use was greater amongst people aged 65 years and older; those retired; those of
religions other than Rastafarians and Christians, females and people who had attained primary education
and below.
Conclusions: Self-medication with herbs in Jamaica is highly prevalent and highest for self-limiting conditions of the RS, GIT and health maintenance with tonics. Concomitant herb and drug use is highest
for self-limiting conditions of the RS, GIT and hypertension, and the use of combined therapy highlights
the need for investigations on potential drugherb interactions. Physicians have limited awareness and
knowledge of such concomitant usage, further highlighting the need for increased dialogue with patients,
knowledge of medicinal plants and their uses and a heightened pharmacovigilance to avoid adversities
that may arise from potential drugherb interactions.
2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Jamaica has a history of reliance on herbal medicine (Asprey
and Thornton, 1953, 1954, 1955a, 1955b); with a growing body of
medicinal plant research (Mitchell and Ahmad, 2006) and a number
of surveys reporting extensive use of herbal teas to date (Landman
and Hall, 1983; Michie, 1992; Gardner et al., 2000; Delgoda et al.,
2004, 2010). These ndings lend support to the World Health

Corresponding author at: Natural Products Institute, Faculty of Pure and Applied
Sciences, University of the West Indies, Mona, Jamaica. Tel.: +876 9702574;
fax: +876 9702574.
E-mail address: thejani.delgoda@uwimona.edu.jm (R. Delgoda).
0378-8741/$ see front matter 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.jep.2011.05.025

Organisation (WHO, 2002) estimate that up to 80% of the population in developing countries use traditional herbal medicine for
primary health care. The Beijing Declaration, published by the WHO
(2008), calls for a partnership between modern and traditional
herbal medicine to help bridge the equity gap in public health and
highlights the importance of research to support the development
of traditional herbal medicine in delivering appropriate, safe and
effective treatments.
Surveys conducted by our laboratories in 2004 (Delgoda et al.,
2004) and 2006 (Delgoda et al., 2010) targeted sub-groups of people
taking prescription medicines to identify concomitant drugherb
use, a practice known in some instances to contribute to unfavorable interactions leading to possible adverse drug reactions (ADRs).
One of the most widely reported cases of an ADR with a herb is that

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D. Picking et al. / Journal of Ethnopharmacology 137 (2011) 305311

of St. Johns wort (SJW) (Hypericum perforatum) with immunosuppressant drug cyclosporin (Krasowski and Blau, 2011). A number
of studies found that concomitant use of SJW and cyclosporin signicantly lowered blood concentrations of the drug (Barone et al.,
2000; Breidenbach et al., 2000; Karliova et al., 2000). SJW has also
been shown to lower blood concentrations of the HIV protease
inhibitor indinavir and digoxin (Cheng, 2000; Piscitelli et al., 2000).
ADRs involving drugherb/nutrient include those with grapefruit
juice which is known to inhibit a number of key drug metabolizing
enzymes (Delgoda and Westlake, 2004).
In this latest survey we targeted a wider population in both
urban and rural communities in Jamaica to quantitatively identify
the prevalence of herbal medicine home use in the treatment of
specic illnesses and concomitant use of herbs with pharmaceutical medicines. In reporting the ndings of this latest survey we aim
to provide health care professionals with information on the use
of herbal medicines in primary health care and to launch further
laboratory investigations into likely herbdrug interactions, a key
aspect of herbal medicine safety.

2. Subjects and methods

In 200809 a total of 407 people were invited to participate in
a cross-sectional study in three locations, one urban and two rural:
Kingston in St. Andrew, Dallas in St. Andrew and Flagstaff in St.
James, using a structured questionnaire.
Jamaica is made up of 14 parishes each of which is sub-divided
into enumeration districts (EDs). The number of households to be
surveyed in each location was established in proportion to the size
of that location and the appropriate number of EDs was then randomly selected. Each household was systematically selected and
one adult per household was selected at random and interviewed.
ED maps, population data and survey guidelines were sourced
through the Statistical Institute of Jamaica (STATIN).
Interviews were completed at various times of the day, during the week and at weekends in face-to-face interviews with one
interviewer who was trained to avoid bias and to cross examine
participants to ascertain reliability of the obtained results.
The survey used a modied TRAMIL questionnaire to gather
information on the use of medicinal plants for treatment or prophylaxis of illnesses, details of plant parts used, source of plant
material, preparation method, herb combinations, dosages, reason
for use, source of knowledge, contraindications, side effects and
polypharmacy. TRAMIL (2010) is a Caribbean wide applied research
programme and online database that aims to document and scientically evaluate the efcacy and safety of medicinal plants used
for primary health care. Following the TRAMIL methodology a list
of the most prevalent health conditions affecting the local population, identied based upon data from the Jamaican Ministry of
Health (MOH, 2006), was included in the questionnaire.
Demographic information (number of rooms, numbers of occupants and relationship to interviewee, numbers of children and
numbers attending school, years in the area, age, gender, religion, education level attained, reading ability, employment status,
health insurance) was collected and interviewees were categorized
accordingly.
For the purposes of the study medicinal plants/medicinal
herbs/bush medicines were dened as any plant or part of plants
used to prepare home remedies and pharmaceutical drugs included
both prescription and over-the-counter (OTC) medicines.
In completing interviews, respondents anonymity was maintained by ensuring that no names, addresses, details of family
histories or other details that might identify an individual were
recorded, in line with University of the West Indies ethical guidelines.

Table 1
Characteristics of people interviewed about their use of herbal medicine in the last
12 months.
Characteristic
Interviews
Completed
Declined
Used herbal medicine to treat illness or maintain health in
last 12 months
Yes
No
Where respondent had not used herbal medicine the main
reason stated was
Lack of knowledge
Think it is unsafe, doctors are safer
Never needed to
Do not know
Just use as tea (not for medicinal purpose)

Sample size (%)

372 (91.4)
35 (8.6)

270 (72.6)
102 (27.4)

27 (26.5)
20 (19.6)
15 (14.7)
13 (12.7)
27 (26.5)

Plants identied by respondents with medicinal uses were collected during the survey, pressed and identied by Mr. Patrick
Lewis, Botanist and Herbarium Curator at the University of the West
Indies, Mona, Jamaica.
Data entry utilized Epidata version 3.1 and categorical data analysis was carried out using the statistical package STATA version
10 (StataCorp) to provide measures of frequency and association
between variables.

3. Results
Table 1 identies the characteristics of people interviewed about
their use of medicinal plants to treat illness or maintain health in the
last 12 months. A total of 407 people were invited to participate in
the survey and 91.4% agreed to do so and were included in the study.
The study population that indicated their use of medicinal plants
to treat illness and maintain health in the previous 12 months was
72.6%.
Respondents who had not specically used medicinal plants to
treat illness or maintain health in the last 12 months cited a number
of reasons such as lack of knowledge and safety concerns. 26.5%
indicated that they had used medicinal plants just as teas but not
to treat illness or maintain health and were therefore not included
in the survey.
Tables 2 and 3 give demographic and socioeconomic details,
respectively, for the study group. There was signicant association
of herb use with/without drugs with age (p < 0.001) and employment status (p < 0.001). Prevalence of herb use alone was lowest in
people aged 65 years and older and highest in 3544 and 4554
year-olds whilst concomitant herbdrug use was highest in people
aged 65 years and older and lowest in 1824 year-olds.
Prevalence of herb use alone was lowest amongst the retired and
highest amongst those employed whilst concomitant herbdrug
use was highest in the retired and lowest in students.
There was also statistically signicant association of herb use
with educational level (p = 0.031), gender (p = 0.02), possession of
health insurance (p = 0.007) and religion (p = 0.004).
Prevalence of herb use alone was lowest in those with tertiary
education and highest in those who had completed secondary education whilst concomitant herbdrug use was highest in those with
education up to primary level or below and lowest in those with
tertiary education.
Prevalence of herb use alone was highest amongst male respondents, those without health insurance and Rastafarians whilst
prevalence of concomitant herbdrug use was highest amongst
female respondents and those of other religions.

D. Picking et al. / Journal of Ethnopharmacology 137 (2011) 305311

307

Table 2
Sample size and in bracket prevalence (%) of non herb use, herb use only and concomitant herbdrug use in demographic groups and percent (%) distribution of sociodemographic groups in study sample.
Demographic index
Residence
Rural
Urban
Age group (years)
1824
2534
3544
4554
5564
6574
75
Gender
Female
Male
Religion
Christian
Rastafarian
Other
None
Total

Non herb use

Herb use alone

Herb & drug use

Total

62 (24.1)
40 (34.8)

139 (54.1)
59 (51.3)

56 (21.8)
16 (13.9)

257 (69.1)
115 (30.9)

16 (36.4)
21 (28.4)
17 (26.1)
12 (17.4)
17 (35.4)
9 (25.7)
10 (27.8)

26 (59.1)
42 (56.8)
41 (63.1)
45 (65.2)
21 (43.8)
11 (31.4)
11 (30.5)

2 (4.5)
11 (14.8)
7 (10.8)
12 (17.4)
10 (20.8)
15 (42.9)
15 (41.7)

44 (11.9)
74 (19.9)
65 (17.5)
69 (18.6)
48 (12.9)
35 (9.4)
36 (9.7)

72 (31.2)
30 (21.3)

110 (47.6)
88 (62.4)

49 (21.2)
23 (16.3)

231 (62.1)
141 (37.9)

81 (27.5)
1 (4.8)
4 (50.0)
16 (33.3)

150 (51.0)
18 (85.7)
1 (12.5)
28 (58.3)

63 (21.4)
2 (9.5)
3 (37.5)
4 (8.3)

294 (79.2)
21 (5.7)
8 (2.2)
48 (12.9)

102 (27.4)

198 (53.2)

72 (19.3)

372

Area of residence (urban/rural), reading level, occupation and

household crowding were not signicant correlates of medicinal
plant use alone or with pharmaceutical drugs.
Thus prevalence of herb use alone was greatest amongst people aged 3544 and 4554 years; those employed; people who
had completed secondary education; males; Rastafarians and
those without health insurance (Tables 2 and 3). Whilst the
prevalence of concomitant herbdrug use was greater amongst
people aged 65 years and older; those retired; people who had
attained primary education and below; females and those of other
religions.
Table 4 details the body systems and health conditions treated
with medicinal plants alone and concomitantly with pharmaceutical drugs within the study sample. The conditions most commonly

identied were self limiting illnesses of the respiratory system (RS)

and gastro-intestinal tract (GI tract), and the maintenance of health
using herbal tonics. Within the study sample, more than a quarter of respondents indicated their concomitant use of medicinal
plants with pharmaceutical drugs with the most commonly selfmedicated conditions for this sub-population being illnesses of the
RS, GI tract and hypertension. The concomitant use of medicinal
plants and pharmaceutical drugs was not limited to treatments
for the same condition for example a respondent might take a
pharmaceutical drug for hypertension and also self medicate with
medicinal plants for a cold or bellyache.
Respondents across the three locations identied their use of
116 different medicinal plants in the previous 12 months. Table 5
lists the top 50 with the most frequently cited being Momordica

Table 3
Sample size and in bracket prevalence (%) of non herb use, herb use alone, concomitant herbdrug use and total response in socio-economic groups and percent (%) distribution
of socio-economic groups in study sample.
Socioeconomic index
Education level
Primary or lower
Secondary
Post-secondary
Reading level
Good
Fair
Poor
Cannot read
Occupational eld
Business
Health, science
Ed.Agr, tran, sec
Domestic
Other
Employment status
Employed F/T
Employed P/T
Unemployed
Retired
Student
Health insurance
Yes
No
Crowding index
Yes
No
Total

Non herb use

Herb use alone

Herb & drug use

Total

21 (25.6)
58 (24.8)
18 (45)

40 (48.8)
136 (58.12)
17 (42.5)

21 (25.6)
40 (17.1)
5 (12.5)

82 (23.0)
234 (65.7)
40 (11.2)

61 (27.4)
20 (27.0)
13 (27.1)
6 (28.6)

125 (56.0)
38 (51.4)
24 (50.0)
9 (42.9)

37 (16.6)
16 (21.6)
11 (22.9)
6 (28.6)

223 (60.9)
74 (20.2)
48 (13.1)
21 (5.7)

42 (28.0)
8 (32.0)
20 (21.3)
8 (22.9)
9 (33.3)

83 (55.3)
8 (32.0)
58 (61.7)
23 (65.7)
12 (44.4)

25 (16.7)
9 (36.0)
16 (17.0)
4 (11.4)
6 (22.2)

150 (45.3)
25 (7.5)
94 (28.4)
35 (10.6)
27 (8.2)

45 (25.8)
6 (23.1)
32 (32.3)
14 (22.6)
5 (50.0)

107 (61.5)
17 (65.4)
49 (49.5)
19 (30.6)
5 (50.0)

22 (12.6)
3 (11.5)
18 (18.2)
29 (46.8)
0 (0.0)

174 (46.9)
26 (7.0)
99 (26.7)
62 (16.7)
10 (2.7)

27 (41.5)
75 (24.4)

24 (36.9)
174 (56.7)

14 (21.5)
58 (18.9)

65 (17.5)
307 (82.5)

51 (24.5)
49 (31.6)
100

119 (57.2)
73 (47.1)
192

38 (18.3)
33 (21.3)
71

208 (57.3)
155 (42.7)
372

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D. Picking et al. / Journal of Ethnopharmacology 137 (2011) 305311

Table 4
Number of individuals and in bracket prevalence (%) of herb use for treating specied illnesses with herbs alone, herbs together with drugs and percent (%) distribution of
reported illnesses treated with herbs in the study sample (n = 270).
Popular use or disease treated

Herb only

Herb & druga

Total herb use

Respiratory system (asthma, cold/u/sore throat/cough, cold in belly, sinusitis)

GI tract (diarrhea, constipation, vomiting, bellyache/gas, ulcer, hemorrhoid, worms)
Tonic (washout & blood cleanse)
Hypertensionb
Musculoskeletal (arthritis, backache, sprain)
Mental health (insomnia, nerves, depression)
Headache
Skin (rash, fungal infection, acne)
Gynecological (menstrual problems, broids, infertility, infection)
Cardiovascular system (high cholesterol, peripheral vascular disease, heart valve disease, coronary heart disease)
Diabetes (type II)
Injury (burn, wound/cut/bruise)
Genito-urinary (bladder, cystitis)
Prostate problems
Teeth (teething, toothache)
Eyes

155 (57.4)
107 (39.6)
63 (23.3)
15 (5.5)
27 (10.0)
26 (9.6)
22 (8.14)
21 (7.8)
9 (3.3)
4 (1.5)
4 (1.5)
8 (2.9)
5 (1.8)
3 (1.1)
3 (1.1)
3 (1.1)

55 (20.4)
37 (13.7)
17 (6.3)
27 (10.0)
12 (4.4)
9 (3.3)
4 (1.5)
5 (1.8)
6 (2.2)
9 (3.3)
8 (3.0)
2 (0.7)
3 (1.1)
2 (0.7)
1 (0.4)
1 (0.4)

210 (77.8)
144 (53.3)
80 (29.6)
42 (15.5)
39 (14.4)
35 (13.0)
26 (9.6)
26 (9.6)
15 (5.5)
13 (4.8)
12 (4.4)
10 (3.7)
8 (3.0)
5 (1.8)
4 (1.5)
4 (1.5)

a
b

N.B. drug use is not limited to drugs taken for the same condition being treated by herbs.
Hypertension listed separately from cardiovascular disease due to high level of prevalence.

Table 5
The top fty medicinal plants most commonly used by herbal medicine users (n = 270), ranked by prevalence.
Scientic name

Family

Local name

Momordica charantia L.
Bryophyllum pinnatum (Lam.) Oken
Aloe vera (L.) Burm. f.
Eupatorium odoratum L.
Annona muricata L.
Zingiber ofcinale Roscoe
Solanum torvum Sw.
Allium sativum L.
Piper amalago L.
Gliricidia sepium (Jacq.) Kunth ex Walp.
Stachytarpheta jamaicensis Hutch. & Dalziel
Clerodendrum thomsoniae Balf.
Andrographis paniculata (Burm. f.) Nees
Rivina humilis L.
Morinda citrifolia Hunter
Opuntia cochenillifera (L.) Mill.
Polyscias guilfoylei (W. Bull) L.H. Bailey
Cymbopogon citratus (DC.) Stapf
Chenopodium ambrosioides L.
Rhytidophyllum tomentosum (L.) Mart.
Bidens reptans (L.) G. Don
Petiveria alliacea L.
Desmodium canum Schinz & Thell.
Priva lappulacea (L.) Pers.
Citrus aurantiifolia (Christm.) Swingle
Hyptis verticillata Jacq.
Picramnia antidesma Sw.
Artocarpus altilis (Parkinson) Fosberg
Cassia alata L.
Bambusa vulgaris Wendl. ex Nees
Lippia alba (Mill.) N.E. Br. ex Britton & P. Wilson
Picrasma excelsa (Sw.) Planch.
Pothomorphe umbellata (L.) Miq.
Bidens pilosa L.
Cassia occidentalis L.
Mentha piperita L.
Pimenta spp. Lindl.
Pseudelephantopus spicatus (Juss. ex Aubl.) C.F. Baker
Smilax spp. L.
Argemone mexicana L.
Mikania micrantha Kunth
Psidium guajava L.
Terminalia catappa L.
Achyranthes indica (L.) Mill.
Alysicarpus vaginalis (L.) DC.
Cannabis sativa L.
Cecropia peltata L.
Cola acuminata (P. Beauv.) Schott & Endl.
Cordia globosa (Jacq.) Kunth
Justicia pectoralis Jacq.

Cucurbitaceae
Crassulaceae
Xanthorrhoeaceae
Asteraceae
Annonaceae
Zingiberaceae
Solanaceae
Amaryllidaceae
Piperaceae
Fabaceae
Verbenaceae
Lamiaceae
Acanthaceae
Phytolaccaceae
Rubiaceae
Cactaceae
Araliaceae
Poaceae
Amaranthaceae
Gesneriaceae
Asteraceae
Phytolaccaceae
Fabaceae
Verbenaceae
Rustaceae
Lamiaceae
Picramniaceae
Moraceae
Fabaceae
Poaceae
Verbenaceae
Simaroubaceae
Piperaceae
Asteraceae
Fabaceae
Lamiaceae
Myrtaceae
Asteraceae
Smilacaceae
Papaveraceae
Asteraceae
Myrtaceae
Combretaceae
Amarantaceae
Fabiaceae
Cannabaceae
Urticaceae
Malvaceae
Boraginaceae
Acanthaceae

Cerasee
Leaf of Life
Sinkle Bible
Jack-in-the-Bush
Soursop
Ginger
Susumber
Garlic
Jointer
Maranga
Vervine
Rice & Peas
Rice Bitters
Dogblood
Noni
Tuna
Aralia
Fever Grass
Semicontract
Search-mi-Heart
Marigold
Guinea Hen Weed
Strongback
Fasten-pon-coat
Lime
John Charles
Majoe Bitters
Bread Fruit
King of the Forest
Bamboo
Colic Mint
Bitter Wood
Cowfoot
Spanish Needle
Dandelion
Peppermint
Pimento
Dog Tongue
Sarsaparilla
Thistle
Quaco Bush
Guava
Almond
Devils Horsewhip
Medina
Ganja
Trumpet Tree
Bissy
Black Sage
Fresh Cut

n
114
93
68
61
41
37
35
34
28
27
26
25
24
22
21
20
19
16
15
15
13
13
11
11
9
9
9
8
8
7
7
7
7
6
6
6
6
6
6
5
5
5
5
4
4
4
4
4
4
4

%
42.2
34.4
25.2
22.6
15.2
13.7
13.0
12.6
10.4
10.0
9.6
9.3
8.9
8.2
7.8
7.4
7.0
5.9
5.6
5.6
4.8
4.8
4.1
4.1
3.3
3.3
3.3
3.0
3.0
2.6
2.6
2.6
2.6
2.2
2.2
2.2
2.2
2.2
2.2
1.9
1.9
1.9
1.9
1.5
1.5
1.5
1.5
1.5
1.5
1.5

D. Picking et al. / Journal of Ethnopharmacology 137 (2011) 305311

Table 6
Characteristics of people engaging in concomitant use of herbs and pharmaceutical
drugs (n = 72), ranked by prevalence.
Characteristic

Medical practitioner is aware of the use of herbs

14
7
Medical practitioner asked whether herbs were
used
Reasons given for the concomitant use of herbs and medicines
9
They work well together
4
Pharmaceutical drug alone not good
6
Too many side effects with pharmaceutical drug
8
Pharmaceutical drug expensive
8
No harm in taking both together
35
Not taking pharmaceutical drug for same
condition
Has experienced side effects from the practice of
0
polypharmacy
Who would side effects, if any, be reported to
Doctor
25
6
Nurse
1
Family member

%
19.4
9.7

12.5
5.5
8.3
11.1
11.1
48.6
0.0

34.7
8.3
1.4

charantia (Cerasee), Bryophyllum pinnatum (Leaf of Life), Aloe vera

(Sinkle Bible) and Eupatorium odoratum (Jack-in-the-Bush).
Table 6 identies characteristics of the sub-population of concomitant herbdrug users with 26.7% identifying their use of
medicinal plants concomitantly with pharmaceutical drugs in the
previous 12 months. Only 19.4% indicated that their medical practitioner was aware of their use of herbs with only a fraction stating
that they were asked if they used herbs by the practitioner.
When asked why they used herbs with pharmaceutical drugs
nearly half of respondents indicated that they were not using them

309

for the same condition. Other reasons cited included that they
worked well together, there was no harm in taking both together,
pharmaceutical drugs were too expensive, pharmaceutical drugs
had too many side effects and that pharmaceutical drugs alone were
no good.
None of the respondents reported experiencing side effects
when taking drugs and herbs together. However if side effects were
to be experienced a third of respondents stated that they would
prefer to tell their doctor. 16.7% stated that if given the choice they
would choose an herbal medicine rather than a prescription drug.
A majority of concomitant herbdrug users were able to identify the pharmaceutical drugs they had taken with herbs in the
previous 12 months (Table 7). Some of the most common drugs
cited included hydrochlorothiazide (HZT) for hypertension and
uid retention, metformin for diabetes, salbutamol (Ventolin) for
bronchospasm and enalapril for hypertension and obstructive heart
failure.
Over a third of concomitant herbdrug users stated that they
took pharmaceutical drugs and herbs within hours of each other
whilst nearly two thirds alternated each type on different days.
Nearly half of the respondents took medicinal plants for the same
condition as at least one of the pharmaceutical drugs taken and
these plants are highlighted in bold type in Table 7. For example
some respondents who took metformin for diabetes also indicated
that they self medicated with Cerasee, Chicken Weed, Noni, Rice
Bitters, Sinkle Bible and Tuna for the same condition. Commonly
used combinations of pharmaceutical drugs and herbs, taken for the
same condition, were metformin hydrochloride with cerasee and
sinkle bible, hydrochlorothiazide (HZT) with Noni and salbutamol
(Ventolin) with garlic.

Table 7
Pharmaceutical drugs taken by respondents (n = 72), ranked by prevalence and associated medicinal plants taken concomitantly.
Pharmaceutical drug

Medicinal plant (common namea )

Almond, Aralia, Barsley, Cerasee, Chicken Weed, Cows Tongue, Coconut, Dandelion,
Fasten-pon-coat, Ginger, Jack-in-the-Bush, Jackie Saddle, John Charles, Maranga, Noni, Jointer,
Peppermint, Pimento, Rice Bitters, Rosemary, Sarsaparilla, Sinkle Bible, Soursop, Vervine
Barsley, Bissy, Cerasee, Chicken Weed, Colic Mint, Dandelion, Fevergrass, Garlic, Jack-in-the-Bush,
John Charles, Maranga, Noni, Rice Bitters, Rice & Peas, Search-mi-heart, Sinkle Bible, Soursop,
Susumber, Tuna
Aralia, Breadfruit, Cerasee, Dogblood, Fresh Cut, Garlic, Jack-in-the-Bush, Leaf of Life, Maranga,
Jointer, Rice & Peas, Seaweed, Sinkle Bible, Soursop, Susumber, Vervine,
Cerasee, Chicken Weed, Ginger, Jack-in-the-Bush, Leaf of Life, Maranga, Noni, Sarsaparilla,
Search-mi-heart, Vervine
Aralia, Cerasee, Fasten-pon-coat, Fever Grass, Ginger, Garlic, Jack-in-the-Bush, John Charles, Leaf
of Life, Maranga, Sinkle Bible, Soursop, Tuna
Breadfruit, Cerasee, Jack-in-the-Bush, Marigold, Maranga, Pear, Search-mi-heart, Spanish Needle,
Susumber, Thistle
Fever Grass, Jack-in-the-Bush, Noni, Maranga, Soursop
Cerasee, Ginger, Jack-in-the-Bush, Leaf of life, Sarsaparilla, Search-mi-heart, Vervine
Aralia, Jointer, Fever Grass, Garlic, Ginger, John Charles, Leaf of Life, Sinkle Bible, Soursop,
Susumber, Trumpet Tree
Breadfruit, Fasten-pon-coat, Garlic, Ginger, Jack-in-the-Bush, Leaf of Life, Marigold, Maranga,
Pear, Jointer, Search-mi-heart, Spanish Needle, Rice & Peas, Sinkle Bible, Susumber, Tuna
Dogblood, Noni
Fasten-pon-coat, Garlic, Leaf of Life, Rice & Peas, Sinkle Bible, Soursop, Susumber, Tuna
Breadfruit, Garlic, Jack-in-the-Bush, Marigold, Maranga, Pear, Search-mi-heart, Sinkle Bible,
Soursop, Spanish Needle
Ginger, Leaf of Life, Jointer, Sarsaparilla, Sinkle Bible, Strongback
Cerasee, Leaf of Life, Search-mi-heart
Dogblood, Jack-in-the-Bush, Maranga, Noni, Susumber, Thistle
Cerasee, Ginger, Jack-in-the-Bush, Leaf of life, Sarsaparilla
Cerasee, Chicken Weed
Barsley, Cerasee, Chicken Weed, Dandelion, Golden Seal, Noni, Rice Bitters, Sinkle Bible
Cerasee, Jack-in-the-Bush, Leaf of Life, Peppermint, Semi-contract, Sinkle Bible, Tuna, Vervine
Cerasee, Dogblood, Garlic, Jointer, Rice & Peas, Susumber
Cerasee, Garlic, Ginger, Leaf of Life, Maranga, Sarsaparilla, Tuna

Hydrochlorothiazide (HZT)

10

13.9

Metformin

10

13.9

Salbutamol (Ventolin)

12.5

Enalapril

8.3

Aspirin

6.9

Simvastatin

5.5

Atenolol
Furosemide
Hydralazine

3
3
3

4.2
4.2
4.2

Nifedipine

4.2

Atorvastatin (Lipitor)
Bendroumethiazide & reserpine
Captopril

2
2
2

2.8
2.8
2.8

Carvedilol (Talliton)
Loratadine (Claritin)
Diclofenac
Digoxin (Lanoxin)
Gliclazide (Diamicron)
Glyburide (Glynase)
Ibuprofen
Piroxicam (Feldene)
Ranitidine

2
2
2
2
2
2
2
2
2

2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8
2.8

a
Scientic names of medicinal plants not listed in Table 5 include: Barsley = Ocimum campechianum; Chicken Weed = Salvia serotina; Coconut = Cocus mucifera; Cows
Tongue = Polypodium phyllitidis; Jackie Saddle = Peperomia amplexicaulis; Pear = Persea americana; Rosemary = Rosmarinus ofcinalis.
N.B. medicinal plants taken for the same condition as a pharmaceutical drug are highlighted in bold.

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D. Picking et al. / Journal of Ethnopharmacology 137 (2011) 305311

4. Discussion
This survey was the rst to be carried out on households, targeting a population of herbal medicine users on their practices of
herbdrug concomitant use in Jamaica. A previous survey by our
laboratory reported on medicinal plant use within a population of
pharmaceutical drug users for any ailment (Delgoda et al., 2010)
and specically for diabetes, hypertension and GI tract infections
(Delgoda et al., 2004). In this latest study we report the prevalence
of concomitant herbdrug use in this population of home users
as 26.7%. It is interesting to note that in this latest survey and a
recent survey (Delgoda et al., 2010), no statistically signicant difference was seen in medicinal plant use between urban and rural
respondents. This contrasts with two previous surveys (Gardner
et al., 2000; Delgoda et al., 2004).
Results from our latest survey reveal that respondents, who
had little or no schooling, were retired and aged 65 years or
older, demonstrated a greater tendency to practice concomitant
herbdrug use. This contrasts with ndings in the population
of pharmaceutical drug users (Delgoda et al., 2010) where concomitant herbdrug use, amongst those with no schooling, was
comparable to those with tertiary education and was not found to
be linked signicantly with employment status or age. Concomitant herbdrug use in the elderly raises particular concern about
possible adverse drug reactions (ADRs) resulting from herbdrug
interactions. A meta-analysis of 68 observational studies in the
UK reported that ADR-related hospitalisations, resulting from
drugdrug interactions, are four times higher in older than in
younger patients and may account for as many as 17% of elderly
admissions. The authors of the report go on to suggest that
the majority of these admissions are preventable as they result
from predictable drug interactions (Beijer and de Blaey, 2002). In
Australia repeat ADR-related hospitalisations in the elderly account
for up to a third of events (Zhang et al., 2007).
Pharmacodynamic changes in old age lead to increased complexity of interactions between polypharmacy, co-morbidity,
altered pharmacokinetics and pharmacodynamic sensitivity. In
addition, due to age related chronic diseases and the increased prescription of prophylactic drugs those aged 65 and over receive a
disproportionate number of drugs (Wynne and Blagburn, 2010),
for example in the UK, 45% of total prescriptions dispensed
(Department of Health, 2004). In the over 65s multiple medication
use has been identied as a major contributor to the development
of potentially serious ADRs (Haider et al., 2009; Stegemann et al.,
2010; Steinman and Hanlon, 2010; Wynne and Blagburn, 2010).
Hypertension in Jamaica is the seventh leading cause of death in
the general population but the fourth in those aged 60 years old and
over (MOH, 2006). In the sub-population of concomitant herbdrug
user hypertension was identied as the third most commonly selfmedicated condition and in addition six of the ten pharmaceutical
drugs most commonly prescribed were for hypertension. In the UK,
cardiovascular drugs are amongst those most implicated in ADRs
in the elderly (Pirmohamed et al., 2004; Patel et al., 2007).
Herbs taken for hypertension concomitantly with antihypertensive drugs included: garlic with hydralazine, nifedipine,
bendroumethiazide/reserpine and captopril; pear leaf and
breadfruit leaf with nifedipine and captopril. Two of these antihypertensive drugs are known to be metabolized by human CYP450
enzymes; nifedipine is metabolized by CYP3A4 and captopril by
CYP2D6. To date, in vitro and in vivo studies on the drug interactions of garlic have yielded contradictory results indicating both
possible inhibition and induction of CYP3A4. Clinical investigations
have identied a number of potential pharmacokinetic interactions, highlighting the need for patients taking drugs that are
CYP3A4 substrates to be monitored when there is concomitant use
with garlic (Colalto, 2010). Preliminary in vitro work has identied

potential inhibition of CYP3A4 by pear leaf (Agbonon et al., 2010).

Given the already high risk of drugdrug interactions in the elderly
it is clear that research is urgently required to screen commonly
used medicinal plants to reduce the risks of potential herbdrug
interactions. In vitro laboratory investigations are currently underway in our laboratory using human CYP450 enzymes to investigate
the potential for herbdrug interactions in some of the most commonly used Jamaican medicinal plants and the key phytochemicals
identied from them (Shields et al., 2008; Badal et al., 2011).
In reviewing the perceived safety of concomitant herbdrug
use there is signicant difference between the sub-population of
herbdrug users in this latest survey and the pharmaceutical drug
users previously surveyed. Delgoda et al. (2010) reported that the
overwhelming majority of respondents did not consider the concomitant use of both types of medicine to be harmful. In this latest
survey the response was far less clear with 48.6% of respondents
indicating that the medicinal plants used were not taken for the
same condition. This appears to indicate a perception that if the
two types of medicine are taken together for different illnesses
they are unlikely to interact and are therefore safe. However 59% of
concomitant herbdrug users indicated some awareness of the possible dangers stating that they alternated the days on which they
took the two types of medicine compared to 39% who took both on
the same day. Whilst some awareness of the potential dangers is
clear, the level of understanding is low. Alternating the days may
not be sufcient time to avoid potential interaction given that different drugs take different periods for clearance which can vary
from several hours to several days.
The level of underreporting to physicians of concomitant
herbdrug use in this latest survey (19.4%) is similar to that reported
in a number of studies (Bristol et al., 2008): 28% of patients in one
study (Cockayne et al., 2005) and 23% in another (Robinson and
McGrail, 2004). Reasons cited for non-disclosure were expectation
of a negative reaction from the doctor, the perception that there
was no need to report such use and the fact that they were simply not asked (Robinson and McGrail, 2004). Physician awareness
of concomitant herbdrug use and the percentage of physicians
proactively asking patients are in line with two previous surveys
in Jamaica (Delgoda et al., 2004, 2010). Research in neighbouring
Trinidad and Tobago (Clement et al., 2005; Clement, 2009), previously cited by Delgoda et al. (2010) revealed a higher percentage of
physicians asking their patients about their use of herbs. Physicians
were found to be more accepting of herbal medicine use in their
patients but exhibited poor knowledge of herbs leading to a gap in
communication. The level of concomitant herbdrug use reported
in primary care centres at 29% was close to that reported in our sub
population of concomitant herbdrug users (25.9%) (Clement et al.,
2005; Clement, 2009).
This study is not without limitation. Some degree of bias may
have been introduced if selection of subjects had been limited to
a particular time or day of the week despite efforts to interview
at different times and days of the week. Estimates may have been
subjected to recall bias if people had problems recalling herbs and
pharmaceutical drugs prior to interview.

5. Conclusion
This latest survey shows that self medication with medicinal
plants continues to be highly prevalent in Jamaica (72.6%) and is
highest for conditions of the respiratory system, gastro-intestinal
tract and health maintenance. Concomitant herbdrug use is highest for conditions of the respiratory system, gastro-intestinal tract
and hypertension. Such concomitant use is most prevalent in the
retired and those aged over 65 years; amongst those who have had
primary education or below, and contrary to common belief, was

D. Picking et al. / Journal of Ethnopharmacology 137 (2011) 305311

independent of whether the respondent lived in a rural or urban

location. Physicians awareness of herb drug co-use was particularly low (19.4%) and draws attention to the fact that there exists a
gap in communication between patient and physician in relation to
self medication with herbs. With a practice of co-medication, there
exists the possibility for drugherb interactions and information
gathered in this survey will help initiate laboratory based investigations for those combinations that may lead to potential adverse
drug reactions. Herbs found to be used in combination with drugs in
this study, will undergo screens for potential CYP450 enzyme mediated pharmacokinetic interactions. A better understanding of herb
pharmacokinetics is an aspect of herb safety with the potential to
increase physician awareness and knowledge and to enable greater
integration into Jamaicas national healthcare system, in line with
the 2008 Beijing Declaration that calls for a partnership between
modern and traditional medicine to help bridge the equity gap in
public health.
Acknowledgements
We thank the Commonwealth Scholarship Commission, the
University of the West Indies Postgraduate Research Fund, the Environmental Foundation of Jamaica, the Forest Conservation Fund
and the International Foundation for Science (Sweden) for funding
support.The authors express their gratitude to respondents who
so graciously gave their time and generously shared their traditional knowledge during the survey. We thank and acknowledge
the hard work and dedication of Devon Lindsay who helped coordinate and manage the survey across the three areas. Community
leaders and others for facilitating the surveys, guidance in their
areas and botanical collection: Kelvin Clarke, Mike Grizzle the late
Mr Black, Melinda Brown, Dolphy Powell, Mr Dallas and Gareld
McNaughton.
References
Agbonon, A., Gadegbeku, K., Aklikokou, K., Gbeassor, M., Akpagana, K., Tam, T., Arnason, J., Foster, B., 2010. In vitro inhibitory effects of West African medicinal and
food plants on human cytochrome P450 3A subfamily. Journal of Ethnopharmacology 128, 390394.
Asprey, G.F., Thornton, P., 1953. Medicinal plants of Jamaica Part I. West Indian
Medical Journal 2, 233252.
Asprey, G.F., Thornton, P., 1954. Medicinal plants of Jamaica Part II. West Indian
Medical Journal 3, 1741.
Asprey, G.F., Thornton, P., 1955a. Medicinal plants of Jamaica Part III. West Indian
Medical Journal 4, 6982.
Asprey, G.F., Thornton, P., 1955b. Medicinal plants of Jamaica Part IV. West Indian
Medical Journal 4, 145168.
Badal, S., Williams, S., Huang, G., Francis, S., Vendantam, P., Dunbar, O., Jacobs, H.,
Tzeng, T.J., Gangemi, J., Delgoda, R., 2011. Cytochrome P450 1 enzyme inhibition
and anticancer potential of chromene amides from Amyris plumieri. Fitoterapia
82, 230323.
Barone, G., Gurley, B., Ketel, B., Lightfoot, M., Abul-Ezz, S., 2000. Drug interaction between St Johns wort and cyclosporin. Annals of Pharmacotherapy 34,
10131016.
Beijer, H., de Blaey, C., 2002. Hospitalisations caused by adverse drug reactions
(ADR): a meta-analysis of observational studies. Pharmacy World and Science
24, 4654.
Breidenbach, T., Hoffmann, M., Becker, T., Schlitt, H., Klempnauer, J., 2000.
Drug interaction of St Johns wort with cyclosporin. The Lancet 355,
1912.
Bristol, M., Sonnad, S., Guerra, C., 2008. Uninformed complementary and alternative
supplement use: a risky behavior for cardiovascular patients. Complementary
Health Practice Review 13, 100109.
Cheng, T.O., 2000. St. Johns wort interaction with digoxin. Archives of Internal
Medicine 160, 2548.
Clement, Y., Williams, A., Khan, K., Bernard, T., Bhola, S., Fortune, M., Medupe, O.,
Nagee, K., Seaforth, C., 2005. A gap between acceptance and knowledge of herbal

311

remedies by physicians: the need for educational intervention. BMC Complementary and Alternative Medicine 5, 2029.
Clement, Y., 2009. Herbal self-medication at primary health care facilities in
Trinidad. Journal of Alternative and Complementary Medicine 15, 67.
Cockayne, N., Duguid, M., Sheneld, G., 2005. Health professionals rarely record
history of complementary and alternative medicines. British Journal of Clinical
Pharmacology 59, 254258.
Colalto, C., 2010. Herbal interactions on absorption of drugs: mechanism of action
and clinical risk assessment. Pharmacological Research 62, 207227.
Delgoda, R., Westlake, A.C.G., 2004. Herbal interactions involving cytochrome p450
enzymes: a mini review. Toxicological Reviews 23, 239249.
Delgoda, R., Ellington, C., Barrett, S., Gordon, N., Clarke, N., Younger, N., 2004. The
practice of polypharmacy involving herbal and prescription medicines in the
treatment of diabetes mellitus, hypertension and gastrointestinal disorders in
Jamaica. West Indian Medical Journal 53, 400404.
Delgoda, R., Younger, N., Barrett, C., Braithwaite, J., Davis, D., 2010. The prevalence of
herb use in conjunction with conventional medicines in Jamaica. Complementary Therapies in Medicine 18, 1320.
Department of Health, 2004. Prescriptions Dispensed in the Community: Statistics
for 19932003. Department of Health, London.
Gardner, J., Grant, D., Hutchinson, S., Wilks, R., 2000. The use of herbal teas and
remedies in Jamaica. West Indian Medical Journal 49, 331335.
Haider, S., Johnell, K., Weitoft, G., Thorslund, M., Fastbom, J., 2009. The inuence of
educational level on polypharmacy and inappropriate drug use: a register based
study of more than 600,000 older people. Journal of the American Geriatrics
Society 57, 6269.
Karliova, M., Treichel, U., Malago, M., Frilling, A., Gerken, G., Broelsch, C.E., 2000.
Interaction of Hypericum perforatum (St. Johns wort) with cyclosporin A
metabolism in a patient after liver transplantation. Journal of Hepatology 33,
853855.
Krasowski, M.D., Blau, J.L., 2011. Drug interactions with St. Johns wort. In: Dasgupta,
A., Hammett-Stabler, C.A. (Eds.), Herbal Supplements: Efcacy, Toxicity, Interactions With Western Drugs and Effects on Clinical Laboratory Tests. John Wiley
and Sons Inc., New Jersey, pp. 275290.
Landman, J., Hall, J., 1983. The dietary habits and knowledge of folklore of pregnant
Jamaican women. Ecology of Food and Nutrition 12, 203210 (Abstract).
Michie, C., 1992. The use of herbal remedies in Jamaica. Annals of Tropical Paediatrics
12, 3136 (Abstract).
Ministry of Health (MOH), 2006. Epidemiological Prole of Selected Health Conditions and Services in Jamaica 19902002. Ministry of Health, Jamaica.
Mitchell, S., Ahmad, M., 2006. A review of medicinal plant research at the University of the West Indies Jamaica, 19482001. West Indian Medical Journal 55,
243269.
Patel, H., Bell, D., Molokhia, M., Srishanmuganathan, J., Patel, M., Car, J., Majeed,
A., 2007. Trends in hospital admissions for adverse drug reactions in England:
analysis of national hospital episode statistics 19982005. BMC Clinical Pharmacology 7, 9.
Pirmohamed, M., James, S., Meakin, S., Green, C., Scott, A., Walley, T., Farrar, K., Park,
K., Breckenbridge, A., 2004. Adverse drug reactions as a cause of admission to
hospital: prospective analysis of 18820 patients. British Medical Journal 329,
1519.
Piscitelli, S.C., Burstein, A.H., Chaitt, D., Alfaro, R.M., Falloon, J., 2000. Indinavir concentrations and St Johns wort. The Lancet 355, 547548.
Robinson, A., McGrail, M., 2004. Disclosure of CAM use to medical practitioners:
a review of qualitative and quantitative studies. Complementary Therapies in
Medicine 12, 9098.
Shields, M., Niazi, U., Badal, S., Yee, T., Sutcliffe, M.J., Delgoda, R., 2008. Inhibition of
CYP1A1 by Quassinoids found in Picrasma excelsa. Planta Medica 74, 15.
StataCorp. Stata Statistical Software: Release 10. College Station, TX.
Stegemann, S., Ecker, F., Maioc, M., Kraahs, P., Wohlfart, R., Breitkreutz, J., Zimmer,
A., Bar-Shalom, D., Hettrich, P., Broegmann, B., 2010. Geriatric drug therapy:
neglecting the inevitable majority. Ageing Research Reviews 9, 384398.
Steinman, M., Hanlon, J., 2010. Managing medications in clinically complex elders:
theres got to be a happy medium. Journal of the American Medical Association
304, 15921601.
TRAMIL. Program of applied research for traditional popular medicine in
the Caribbean. http://www.funredes.org/endacaribe/traducciones/tramil.html
(accessed 12.09.10).
World Health Organisation (WHO), 2002. WHO Traditional Medicine Strategy
20022005, http://www.who.int/medicines/publications/traditionalpolicy/en/
index.html (accessed 12.12.08).
World Health Organisation (WHO), 2008. WHO Beijing Declaration 2008,
http://www.who.int/medicines/areas/traditional/congress/beijing declaration/
en/index.html (accessed 15.09.10).
Wynne, H., Blagburn, J., 2010. Drug treatment in an ageing population: practical
implications. Maturitas 66, 246250.
Zhang, M., DArcy, C., Holman, J., Preen, D., Brameld, K., 2007. Repeat adverse
drug reactions causing hospitalisations in older Australians: a population-based
longitudinal study 19802003. British Journal of Clinical Pharmacology 63,
163170.