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Background: Nephrolithiasis, also known as kidney stones, is the third most prevalent issue affecting the urinary tract, following urinary tract infections and prostate illnesses. Approximately 12% of the global population experiences this condition at some point, encompassing individuals of all ages, genders, and races. Regrettably, the current medical landscape lacks a pharmacological intervention that can effectively treat or prevent the recurrence of kidney stones. Consequently, people turn to herbal medicine as a viable option. Aim: Evaluate the use and perception of herbal medicine among patients residing in Karbala, documenting their herbal products and evaluating patients’ knowledge, practice, and attitude toward herbal remedies and possible factors behind using herbal remedies as an alternative to conventional medications. Method: Two-hundred and sixty-six patients diagnosed with kidney stones in Karbala joined this survey, a cross-sectional design between October 2022 and March 2023, using a questionnaire administered to patients. In face-to-face meetings, participants completed a multicomponent questionnaire comprising 26 items in three parts. The data acquired were analyzed using a statistical package for social sciences; Chi-square was used to correlate some variables, and P-values of <0.05 were considered significant. Results: A significant proportion of individuals aged 20 to 49 exhibited a high level of education, with 50.8% possessing a university degree. Conversely, 9.4% of patients were illiterate. Most individuals within the sample were employed, with only 7.5% identified as students and 4.5% classified as jobless. Most participants, precisely 76.3%, were found to be married, while a smaller proportion, approximately 18.4%, were identified as unmarried. A mere 5.3% of the individuals under consideration were identified as widows, whereas there were no instances of divorce among them. The present study evaluated patients’ knowledge, attitudes, and practice (KAP) outcomes, revealing suboptimal levels of knowledge, neutral attitudes, and poor practice toward herbal therapy. Moreover, the data analysis revealed a noteworthy association between educational attainment and knowledge score, as well as gender and attitude toward herbal products. The findings additionally documented twelve herbal medicines used by patients, with Zea mays and Barley emerging as the most often employed remedies among the remaining options. Conclusion: Most patients lack proper knowledge regarding herbal remedies, and most seek herbal products due to their low cost, relative recommendation, and belief that herbal medications are safe. The most used treatments were Zea mays and barley, which were reasonably priced and famous for their use.
Nephrolithiasis refers to the condition commonly recognized as kidney stones, often referred to as renal calculi. These crystal concretions typically form within the kidney [1]. It is the most common illness affecting the urinary system, impacting about 12% of the global population. Furthermore, it is a prevalent cause of urinary tract infections and prompts patients to seek immediate medical or surgical assessment [2, 3].
The prevalence of nephrolithiasis has been widely acknowledged as a systemic condition associated with an increased likelihood of developing chronic kidney diseases, end-stage renal failure, nephrolithiasis-induced bone disease, cardiovascular diseases, diabetes, and hypertension [4, 5, , 7, 8]. According to epidemiological data, it has been observed that approximately 5% of females and 12% of males encounter kidney stones at some point in their lives [9]. Moreover, research has demonstrated an annual recurrence rate ranging from 10% to 23%, with a 50% recurrence rate observed within 5 to 10 years and a 75% recurrence rate within a 20-year timeframe [10]. The increased prevalence of nephrolithiasis has been noted in most European countries, Southeast Asia, and Middle Eastern countries [11]. Similarly, Iraq has a high prevalence rate of nephrolithiasis, where patients with kidney stones constitute more than half of all urological patients in Iraqi hospitals [12]. Studies have found that risk factors for kidney stone formation primarily stem from Iraq’s geographical location in the Middle East, situated within the stone belt area. The key contributors to nephrolithiasis include the hot, dry climate, dehydration, and economic and dietary factors [13, 14].
The global utilization of herbal medicine is on the rise, with nearly 80% of the population relying on these products to manage various health conditions [15, 16]. Research conducted in Iraq has revealed that a significant proportion of patients suffering from various disorders, ranging from 71.6% to 76.4%, use herbal products as a form of treatment [17, 18, 19]. Patients often turn to herbal therapy as an alternative approach due to the lack of effective pharmaceutical interventions for treating and preventing kidney stone recurrences [20]. While several studies have been conducted in Iraq investigating the prevalence and types of kidney stones [14, 21, 22], none have specifically focused on the herbal remedies utilized by patients in this context. Consequently, this study aims to assess the utilization and perception of herbal medicine among patients residing in Karbala. The study seeks to document the herbal products used by these patients and evaluate their knowledge, practices, and attitudes toward herbal remedies. Additionally, the study aims to identify potential factors that influence the use of herbal remedies as an alternative to conventional medications.
Study Design
A cross-sectional survey was conducted between October 2022 and March 2023. A total of 290 patients were initially approached to participate in the survey, and after applying exclusion criteria, 266 respondents were included. The study focused on patients diagnosed with kidney stones and was conducted in various private and public clinics and hospitals in Holly Karbala, a populous governorate in the southern region of Iraq.
Data Collection
Data were collected through face-to-face interviews with patients in the selected clinics. Each interview lasted 25-30 minutes, during which participants provided consent for participation. The study was approved by the Ethical Board of Al Zahrawi University College (AZUC Ref No.08/2/2023). The required sample size was calculated using the Danial equation [23, 24]. \[n=(Z)^{2}\times P\frac{(1-P)}{d^2}\] where: n = required sample size, Z = statistic corresponding to a 95% confidence level (1.96), P = expected prevalence (set to 76% based on previous studies in Iraq [18]), d = maximum tolerable error for prevalence estimate (e.g., \(\pm\)0.05).
Questionnaire
The survey instrument used in this study was developed after an extensive literature review and was tailored to address the study’s specific objectives [25, 26, 27, 28, 29. 30]. The questionnaire consisted of 26 closed-ended questions categorized into three sections.
The introductory section included demographic questions such as name, gender, age, education level, marital status, and employment status. The second part of the questionnaire assessed patients’ knowledge, attitudes, and practices (KAP) related to herbal medicine use for nephrolithiasis management. The knowledge section contained eight closed-ended questions assessing patients’ understanding of relevant information. The responses were assigned numerical values (1 for positive, 0 for negative), and the cumulative score was used to categorize knowledge levels. The attitude section comprised four questions with responses on a five-point Likert scale. The attitude score was categorized based on a specified range. The practice section included seven closed-ended questions, each with a binary response (1 for positive, 0 for negative). The practice score was categorized into levels based on a predetermined scale [25, 31, 32].
Cronbach’s coefficient was used to assess the internal consistency reliability of the questionnaire, resulting in a coefficient of 0.724, meeting acceptable standards for internal consistency.
The final section included two open-ended questions. The first question aimed to understand participants’ preferences for herbal medicine use, and the second question sought a comprehensive list of specific herbal products used by each patient.
The study enrolled adult participants (aged 20 years and older) diagnosed with kidney stones by a healthcare professional. Exclusion criteria included incomplete forms, younger participants, and those with self-diagnosed conditions. The questionnaire’s content logic was validated by a panel of professionals, including pharmacy Ph.D. holders and practicing physicians. The questionnaire was also translated into Arabic by native speakers with expertise in English linguistics (Ph.D.).
Statistical Analysis
Data analysis in this study was conducted using SPSS Version 26, a widely used statistical software in the social sciences (Chicago, USA). Descriptive statistics were employed to summarize demographic variables and responses related to knowledge, attitudes, and practices (KAP). Frequencies (F) and percentages (%) were used to summarize categorical variables, while mean (M) and standard deviation (SD) were utilized for continuous variables. The KAP scores were computed for each participant, and the Pearson correlation coefficient (r) was employed to assess relationships between variables. Statistical significance was defined as a P-value below 0.05.
Demographic Characteristics of Patients
The analysis presented in Table 1 indicated no statistically significant differences (p > 0.05) between genders. The distribution of kidney stones was slightly higher in males (52.3%) than females (47.7%). Furthermore, the incident rate analysis (Figure 1) revealed a prevalence of 35.34% in males compared to 29.7% in females. The study identified a higher prevalence of kidney stones among individuals aged 20-39 years, with a noticeable decrease among older age groups.
In terms of education, the majority of patients (50.8%) had obtained a university-level education. A significant portion reported having a secondary education, while a smaller number had primary education or lacked formal education. Additionally, more than three-quarters of the patients were married, with a smaller proportion being unmarried or widowed, and none were reported as divorced.
Regarding employment status, the data showed that a combined 88% of participants were engaged in various jobs. In contrast, 7.5% were students, and a minority were unemployed.
| Properties | Groups | N (266) | % | SD | P value |
|---|---|---|---|---|---|
| Gender | Male | 139 | 52.3% | 0.500 | 0.562 |
| Female | 127 | 47.7% | |||
| Age Group | 20-29 | 77 | 28.9% | 1.381 | 0.012 |
| 30-39 | 68 | 25.6% | |||
| 40-49 | 48 | 18.0% | |||
| 50-59 | 38 | 14.3% | |||
| >59 | 35 | 13.2% | |||
| Level of Education | Illiterate | 25 | 9.4% | 0.986 | 0.000 |
| Primary | 33 | 12.4% | |||
| Secondary | 73 | 27.4% | |||
| University | 135 | 50.8% | |||
| Marital State | Married | 203 | 76.3% | 0.737 | 0.000 |
| unmarried | 49 | 18.4% | |||
| Divorced | 0 | 0.0% | |||
| Widow | 14 | 5.3% | |||
| Employment | Self-employed | 58 | 21.8% | 0.688 | 0.000 |
| government employed | 176 | 66.2% | |||
| Student | 20 | 7.5% | |||
| Unemployed | 12 | 4.5% |
Figure 1: Incidence Rate Among Patient gGender
KAP Analysis of Patient
Upon conducting an analysis of Knowledge, Attitude, and Practice (KAP) about the utilization of herbal medicine, the gathered data indicated that most participants exhibited inadequate knowledge and practice, with percentages of 53.3% and 59%, respectively. Additionally, 45.9% of the participants had a neutral attitude toward herbal medicine.
| KAP | Level | M (Std) | N (266) | Percentage |
|---|---|---|---|---|
| Knowledge | High Knowledge level (6-8) | 3.4 (1.66) | 30 | 11.2 |
| Moderate Level Knowledge (4-5) | 94 | 35.3 | ||
| Poor Level Knowledge (0-3) | 142 | 53.3 | ||
| Attitude | Positive attitude (16-20) | 13.25(2.92) | 67 | 25.18 |
| A neutral attitude (12-15) | 122 | 45.86 | ||
| Negative attitude (0-11) | 74 | 33.2 | ||
| Practice | Good Practice (6-7) | 3.2 (1.97) | 26 | 9.77 |
| Fair Practice (4-5) | 83 | 31.2 | ||
| Poor Practice (0-3) | 157 | 59.0 |
Upon correlating KAP scores with various patient characteristics, a significant positive correlation was found between knowledge scores and the level of education (P-value = 0.00). Furthermore, male patients demonstrated slightly higher knowledge scores compared to female patients. In terms of attitude scores, the data showed a statistically significant association with gender. Specifically, male participants exhibited more positive attitudes towards herbal remedies than their female counterparts (P-value = 0.04). However, other factors assessed in Table 3 did not show a statistically significant association.
| Variables | Statistics | Knowledge | Attitude | Practice |
|---|---|---|---|---|
| Gender | Person’s R | -0.061 | -0.125 | 0.029 |
| P-value | 0.324 | 0.041 | 0.641 | |
| Marital State | Person’s R | -0.005 | -0.018 | -0.070 |
| P-value | 0.934 | 0.771 | 0.253c | |
| Employment | Person’s R | 0.004 | -0.1 | 0.070 |
| P-value | 0.946 | 0.103 | 0.253c | |
| Level of Education | Person’s R | 0.228 | 0.00 | -0.082 |
| P- value | 0.000 | 0.997 | 0.181 |
The last section of the survey provided an overview of the herbal remedies that patients use to manage kidney stones, as depicted in Figure 2.
Figure 2: Percent Usage of Herbal Products by Patients
Table 4 provides a comprehensive compilation of the utilized herbal remedies, listing their common names, corresponding plant parts, and methods of administration. The nomenclature of all medicinal plant names has been validated by the Pharmacognosy Department at Al-Zahrawi University College and confirmed by Assistant Professor Sukeyna Abbas Aliwy from Baghdad University Herbarium, College of Science. Extensive literature review has also been conducted to ascertain the notable use of these herbs in managing kidney stones. The data also indicates that most herbal medications were administered in the form of decoctions. Furthermore, the pricing of these medicines varied between less than 5000 ID and 10,000 ID, as shown in Figure 3.
Figure 3: Price Range of Herbal Remedies used by Participants
The data presented highlights the similarity in affordability between herbal medicines priced below 5000 ID and those priced between 6000 ID and 10000 ID, with respective percentages of 43.38% and 44.12%. Products falling within the price range of 10,000 to 15,000 ID exhibited a relatively modest proportion of 12.5%. The study’s findings also provided insights into the specific recommendations for herbal remedies. Additionally, the results indicated that 66.9% of patients reported utilizing herbal medicines, while 33% reported not using such products.
Most patients adhered to the guidance and suggestions provided by acquaintances and family members who had previously used these products. Approximately 25% of patients (16%) sought advice from herbalists regarding their healthcare practices. A limited number of individuals followed the guidance provided by healthcare professionals. This is illustrated in Figure 4.
| Plant | Common name | Part use | Method of preparation | Action According to a | Cost range |
| reference from Literature | |||||
| Zea mays | Maiz | Corn silk | Infusion (corn silk tea) | Diuretic agent [33, 34] | 6000-10000 ID |
| Hordeum vulgare | Barley | Seeds | decoction | Diuretic [35] | <5000 ID |
| Nigella sativa | Black seed | Seeds | decoction | Kidney stone [36, 37] | 6000-10000 ID |
| Apium graveolens | Celery | Seeds | decoction | Diuretic [36] | 10000-15000 ID |
| Zingiber officinale | Ginger | Rhizome | decoction | Kidney stone [39] | 6000-10000 ID |
| Berberis vulgaris | Barberry | Roots | decoction | nephrolithiasis, Antioxidant, | <5000 ID |
| diuretic, and anti-inflammatory [37] | |||||
| Cuminum cyminum | Cumin | Seeds | decoction | Kidney stone [37, 38] | 6000-10000 ID |
| Raphanus sativus | Radish | Leaves | decoction | Diuretic, lithotriptic [37] | <5000 ID |
| Taraxacum officinale | Dandelion | Arial part | decoction | Diuretics [40, 41] | <5000 ID |
| Trigonella foenum-graecum | Fenugreek | Seeds | decoction | kidney stone [42] | <5000 ID |
| Urtica dioica | Stinging nettle | Leaves | decoction | Kidney stone [36] | 6000-10000 ID |
| Ocimum basilicum | Basil | Leaves | decoction | Diuretics [39] |
<5000 ID |
Figure 4: Price Range of Herbal Remedies Used by Participants
The global prevalence and incidence of kidney stones are increasing [11]. Numerous risk factors associated with the occurrence of kidney stones have been identified in the literature, and these risks vary among different population groups. Environmental factors have also been found to play a role in the development of nephrolithiasis [33]. The findings of this study indicate a higher prevalence of kidney stones among males than females. This result is consistent with previous research showing a greater incidence rate of nephrolithiasis in males than females [34, 35, 36]. Hormones such as estrogens and androgens may contribute to the increased susceptibility of men to nephrolithiasis [38]. Estrogen, for example, increases the production of citric acid, which counteracts the formation of kidney stones [39].
In terms of age, our data indicates that individuals aged 20-39 had a higher prevalence of kidney stones than those in their forties and fifties, which is consistent with previous investigations [1, 38]. Previous studies have suggested a potential correlation between job status and the incidence of nephrolithiasis [33, 38]. However, our study primarily included employed individuals, with only a small proportion being unemployed, making it difficult to establish a clear association.
The study findings reveal significant associations between KAP scores and participant demographics. Notably, education level was positively correlated with knowledge scores. However, it’s important to note that overall, participants demonstrated inadequate understanding of herbal treatments. Many patients need to pay more attention to classifying their kidney stones and understanding potential interactions between medications/herbal remedies and diseases/herbal remedies. The data also showed a weak correlation between herbal practices and patient variables, raising concerns about potentially incorrect usage regardless of education or age. Concerning attitudes, a significant correlation was observed between gender and attitude, though most patients held a neutral attitude toward herbal products. A common belief among patients is that herbal products are safe and cost-effective.
Furthermore, a significant proportion of participants (66.9%) reported using herbal treatments, similar to other studies on Iraqi populations that found around 76% engagement in such practices [18]. Patients primarily relied on advice from acquaintances and loved ones (36.09%) rather than self-study, consultations with herbalists, or healthcare professionals. This reliance on self-diagnosis and treatment based on others’ experiences raises concerns. Patients commonly believe that herbal medications are safe and have no interactions with pharmaceutical treatments. However, the study highlighted a lack of understanding and adherence to proper herbal product usage. A substantial portion (57.1%) showed a lack of awareness about potential drug-herbal interactions, which could compromise patient well-being. For instance, corn silk, a widely used remedy, has been found to interact with certain drugs [40, 42].
The final section of the study compiled the herbal interventions used for treating nephrolithiasis. Zea mays (corn silk) and barley were commonly employed compared to other products. Their affordability, with prices below 10,000 ID, makes them accessible to most patients. Decoction was the primary method of preparation. Existing literature supports the use of all mentioned herbal medicines to varying degrees in treating kidney stones. Economic feasibility, accessibility, personal disposition, and the perception of herbal medicines as free from adverse effects are the primary determinants influencing patients’ choices. Ultimately, the effectiveness of these interventions is often reliant on others’ experiences and recommendations. The utilization of herbal medicine underscores the importance of further comprehensive research to understand their applications and societal implementation.
The findings of this survey suggest that a significant portion of the population utilizes herbal treatments for kidney stones. However, many individuals require a better understanding and application of herbal medicine, alongside a lack of strong inclination towards its use. Various herbal products, such as Zea mays and barley, were commonly chosen due to their perceived effectiveness and cost-effectiveness.
This research paper received no external funding.
The authors declare no conflicts of interest.
All authors contributed equally to this paper. They have all read and approved the final version.
Informed consent was obtained from all participates in the study as needed.
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