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The Influence of Traditional and Complementary and Alternative Medicine on

Medication Adherence in Honduras

Article  in  Alternative Therapies in Health and Medicine · May 2015

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ORIGINAL RESEARCH
The Influence of Traditional and Complementary
and Alternative Medicine on Medication
Adherence in Honduras
Michael P. Catalino, MS; Reyna M. Durón, MD; Julia N. Bailey, PhD; Kenton R. Holden, MD
ABSTRACT
Background • Adherence to medication is a worldwide
problem and deserves country-specific attention.
Honduras, like many other countries, has allopathic
providers, traditional medicine (TM), and complementary
and alternative medicine (CAM). Understanding a
population’s health behaviors is essential to satisfactory
integration of these systems and successful patient care.
Study Objective • The objective was to identify factors
that influence medication adherence in Honduras.
Design • The research team administered a cross-
sectional, 25-item questionnaire to various neighborhoods
based on national demographic statistics in order to
obtain a quota sample.
Setting • The survey took place in Tegucigalpa, Honduras,
Central America.
Participants • The research team surveyed 614 Hondurans,
aged ≥18 y, within the general population of Tegucigalpa,
the largest and capital city of Honduras, in neighborhoods
representing areas where primarily the lower and middle
classes lived.
Outcome Measures • The primary outcome measure was
a modified Medication Adherence Report Scale (MARS).
Michael P. Catalino, MS, is a graduate of the Duke Global
Health Institute of Duke University in Durham, North
Carolina, and a medical student at Georgetown University
School of Medicine in Washington, DC. Reyna M. Durón,
MD, is the director of the scientific research unit at the
Fundación Lucas para la Salud in Tegucigalpa, Honduras.
Julia N. Bailey, PhD, is a consultant in the scientific
research unit at the Fundación Lucas para la Salud and an
adjunct associate professor in the Department of
Epidemiology of the Fielding School of Public Health at
the University of California, Los Angeles. Kenton R.
Holden, MD, is a visiting professor in the Departments of
22 ALTERNATIVE THERAPIES, MAY/JUNE 2015 VOL. 21,3
Results • The research team collected 610 surveys that
had complete answers to questions about adherence
(610/614, 99.3%) total complete responses to other items
varied. The prevalence of use of TM was 62.8% (381/607).
Nearly one-half, 47.3% (287/607), of all the respondents
had used herbs or teas for health in the prior year, and
26.1% (159/607) of all respondents had received a sobada
(therapeutic rubbing). Respondents with daily private
spiritual devotions (OR = 0.610, P = .018) and diabetes
(OR = 0.154, P = .004) were less likely to report low
adherence. Receiving a sobada and a history of fever were
independently associated with low adherence (OR = 1.718,
P = .017 and OR = 2.226, P < .001, respectively).
Conclusions • Hondurans use both allopathic and TM.
Although private spiritual devotion may help improve
adherence to medication, only use of traditional massage
therapy, the sobada, was associated with decreased
adherence. Effective integration of alternative therapies in
Central America will require proper counseling on how to
combine multiple therapies to maximize the health
benefits. (Altern Ther Health Med. 2015;21(2):##-##.)
Neurology and Pediatrics at the National Autonomous
University of Honduras School of Medicine in Tegucigalpa,
Honduras, and a professor in the Departments of
Neurosciences (Neurology) and Pediatrics at the Medical
University of South Carolina in Charleston.
Corresponding author: Michael P. Catalino, MS
E-mail address: mpc68@georgetown.edu
Catalino—Traditional Medicine, CAM, and Medication Adherence in
Honduras
A
ccording to the World Health Organization (WHO)
in its report “Adherence to Long-term Therapies:
Evidence for Action,” poor adherence to medical
therapy is a worldwide problem of increasing magnitude that
adversely affects both individuals and health systems.1 The
report clearly demonstrates that adherence is influenced by
social, economic, health system–related, disease-related, and,
most important, patient-specific factors. The organization
has estimated that adherence among patients with chronic
diseases is only approximately 50% in developed countries
and is likely lower in developing countries with fewer health
care resources. Data from developing countries are lacking
and, thus, researchers have an incomplete picture of the true
breadth of the problem. Further, as the prevalence of chronic
disease increases worldwide, adherence will become only a
greater concern.
The WHO’s report states that “strong evidence (exists)
that many patients with chronic illnesses, including asthma,
hypertension, diabetes, and HIV/AIDS, have difficulty
adhering to their recommended regimens.” Owing to the
economic burden of diabetes, hypertension, and asthma
alone, policy makers can no longer ignore the issues of cost-
effective management, and poor adherence is a well-known
adversary of effective health care. Data on adherence are
helpful when estimating the treatment gap or the proportion
of people who require medicine but do not receive it.2 Good
adherence ensures that medicine is not only getting to the
patient but that it is acting in the optimal way to ameliorate
the disease burden. In this article, the research team presents
adherence data from a large sample of the population within
a developing country in Central America.
The health system in Honduras, Central America,
comprises a conventional, allopathic health system and a
system of complementary and alternative medicine (CAM),
composed of a variety of self-care modalities. According to the
US National Institutes of Health, CAM consists of a diverse,
ever-changing array of health resources that are not considered
part of the conventional medical system. Nonallopathic therapies
are used globally to prevent and treat illness as well as to
improve overall quality of life.3 According to the “WHO’s report
Traditional Medicine Strategy 2002-2005,” endemic or
traditional medicine (TM) is still commonly used in less-
developed countries; CAM use is increasing in more-developed
countries; and, thus, TM/CAM refers to all nonallopathic or
non-Western medicine.4 The widespread use of TM/CAM can
provide a good entry point for interventions aimed at
improving primary health care, particularly if evidence-based
integration of TM/CAM and allopathic medicine ensures the
safety of mixing these 2 modalities.5-7
Studies have suggested a relationship between spirituality,
social position, gender, TM/CAM use, and medication
adherence that deserves further attention.8-17 These studies
are largely from the United States or the United Kingdom,
and although many include large Hispanic populations, data
from their native countries are needed. Only one study in a
Central American country,18 focused on adherence to oral
Catalino—Traditional Medicine, CAM, and Medication Adherence
in Honduras
contraceptives, has had a larger sample size than the current
study; thus, the current study provides significant data on
this global issue.
To date, it has been reported that spiritual or mind-body
beliefs can influence decisions related to human
immunodeficiency virus (HIV) treatment,12 and a study of
Colombian women with HIV found an association between
social position and adherence to HIV medication.15
According to Gohar et al,8 both gender and TM/CAM use
can play a role in adherence to prescribed medication. Little
is known about how spiritualty, health behaviors, and the use
of TM/CAM in Honduras ultimately affect long-term
medical therapies. Understanding the relationship between
those practices and adherence is important to Honduran
health policy makers and physicians, because successful
health interventions likely require strategic integration of
new healthful behaviors and modified traditional practices.
At the turn of the 21st century, more than one-third
(36.9%) of the documented foreign-born immigrants to the
United States were from Central America19; therefore,
understanding tendencies in native countries toward health
behaviors is also relevant to the population of US immigrants.
The research team’s objective in the current study was to
identify possible factors that influence adherence to
medication and to begin establishing a fund of knowledge for
further research on health-seeking behaviors in Honduras.
MATERIALS AND METHODS
Participants
After performing a pilot study, the research team
administered a formal survey during July and August of
2010. The research team used a quota sampling method to
ensure appropriate sampling of each population strata with
regard to education and income. The final proportions did
not differ dramatically from the actual population, based on
the limited available data.20
The survey was administered to 614 people within the
general population of the largest and capital city of
Tegucigalpa, Honduras. Local Honduran research assistants
selected neighborhoods in and around the city with residents
who reflected the general population of Honduras. Each
neighborhood was so unique that sampling had to be done in
clusters otherwise the process would have been prone to
selection bias. In addition, unsafe or isolated neighborhoods
were avoided.
To capture data for a population consisting primarily of
individuals living in rural and suburban areas, females, and
persons of lower socioeconomic classes, quota sampling of
strategic neighborhoods was necessary to make the sample
representative of the population. The neighborhoods
included (1) Colonia El Pedregal—197/614, 32.1% of the
sample; (2) Plaza Miraflores—159/614, 25.9%; (3) Parque
Central—121/614, 19.7%; (4) Colonia Hato de
Enmedio—117/614, 19.1%; and (5) Colonia
Kennedy—20/614, 3.3%. Those neighborhoods were all
urban, lower-and-middle class ones, but within Plaza
ALTERNATIVE THERAPIES, MAY/JUNE 2015 VOL. 21, 3 23
Miraflores and Parque Central, it was not uncommon to find
individuals from the upper classes and with higher levels of
education. That method of inclusion of individuals from the
upper classes was more convenient than targeting upper-
class neighborhoods directly.
Door-to-door soliciting was used in the neighborhoods,
and an interview was solicited at every house. All persons
older than 18 years within a household were eligible to
participate, with proper consent. Approximately 15% to 20%
of the total urban population in Honduras is enrolled in a
university, and only 35% is enrolled in secondary education.20
This barrier to data collection (ie, lack of literacy) was
confirmed during the study’s pilot survey, when many self-
administered surveys were returned incompletely or
improperly marked. Therefore, the formal survey was
administered by local staff, in semiprivate areas, wearing
nonidentifying street clothes to make respondents more
comfortable when responding to questions about their health.
The ethical standards, the questionnaire, and the study’s
protocol were approved by the Bioethics Committee of the
National Autonomous University of Honduras and by the
Duke University Institutional Review Board for the Protection
of Human Subjects. Verbal informed consent was obtained
from all participants.
Procedures
The research team used a 25-item questionnaire,
providing a 12-month retrospection, to collect data on
demographics, personal medical history, health-seeking
behaviors, TM/CAM use, and adherence to medication
received from a physician. The team attempted to minimize
recall bias by presenting the survey as a public health survey,
not an adherence or TM/CAM survey. However, the team
did not verify responses with other sources and, thus, recall
bias may still have been a concern.
The study’s goal was to cover the most prevalent
TM/CAM modalities. After reviewing TM/CAM modalities
in the literature, the research team consulted Honduran
colleagues who were familiar with the subject and then
performed the pilot study to finalize a succinct list of widely
used local treatments. The final list included (1) herbs and
teas; (2) pills with natural ingredients; (3) acupuncture;
(4) sobada, a traditional healing massage with oils; and
(5) consultations with a curandero, a traditional spiritual
healer, or with a naturista, someone who specializes in herbal
remedies. TM/CAM users were those who used 1 or more
TM/CAM modalities.
The common spirituality markers that the survey used to
measure possible spiritual factors that influenced adherence
were church attendance and private devotion time (ie, prayer
and/or reading the Bible or other spiritual books). Widespread
access to churches exists within Tegucigalpa and illiteracy
should not have been a source of bias because prayer and/or
reading were combined in the same question to measure
private devotional time.
24 ALTERNATIVE THERAPIES, MAY/JUNE 2015 VOL. 21,3
Outcome Measures
The research team applied the Medication Adherence
Report Scale (MARS),21 which has been validated in other
similar studies.22 The original MARS variable consists of a
9-question survey combined with a 5-point scale for each
question. The research team used a modified MARS because
few people earn a secondary education in Honduras; in the
current study, 43.4% of respondents did not have a secondary
education. The team anticipated that a modified survey would
increase the response rate. The questions used for the modified
MARS were adopted from Horne and Weinman,21 revised,
translated into Spanish, and field-tested for the current study.
The modified MARS identified respondents who had
received medicine from a physician for any reason within the
12 months prior to the study and had 1 question with 6
subsidiary adherence questions requiring a “yes” or “no.” The
survey also covered the illnesses that respondents had
experienced during the prior year or were experiencing
currently and included questions about the methods of
treatment used, including spiritual practice.
To measure adherence, the survey asked whether
respondents had ever taken any of 6 actions when using
medication prescribed by a physician: (1) alter the dose;
(2) forget to take the medicine; (3) stop taking it for a while;
(4) only use it when they felt sick; (5) decide to miss a dose
here and there; and (6) not take it if they didn’t have to do so.
The MARS scores, ranging from 0 to 6 based on the number
of “yes” answers to the adherence questions, estimated the
risk of nonadherent behavior relative to other respondents,
with 0 representing behavior that was more adherent and
6 representing behavior that was less adherent. The MARS
variable was dichotomized at the median.
Data Analysis
The survey data were collected on paper questionnaires,
entered, and stored in a form created using EpiInfo
(Atlanta, GA, USA), which allowed the data to be analyzed
using STATA (StataCorp LP, College Station, TX, USA). Upon
blinded consultation between 2 members of the research team
missing or inconsistent data were clarified using the original
surveys as a reference. Sample characteristics were calculated
first; then, crude associations were made; and, finally, a logistic
regression was done to identify the factors independently
associated with the MARS variable. Odds ratios (ORs) were
calculated and tested for significance at the P < .05 level.
RESULTS
Of the 614 surveys recorded, 610 (99.3%) surveys had
answers to the adherence questions (ie, 4 surveys were
discarded because the respondents failed to complete the
essential MARS question for adherence scoring). The total
number of solicited households was not recorded. Other
survey questions with missing data were not discarded but
rather were reported as having missing data, n < 610.
Respondents were mostly from the urban, lower and
middle classes (Table 1). Among the disclosers of
Catalino—Traditional Medicine, CAM, and Medication Adherence in
Honduras
Table 1. Respondents’ Characteristics (N = 614) income—504 of 614 (82.1%), 338 (67.2%) made less than
$5700 per year, based on reported monthly incomes that
  Total n % were lower than $475. A total of 478 of the 610 respondents
answering the adherence question (78.4%) had received
Gender Male 307 50.0
prescribed medicine sometime during the year previous to
  Female 304 49.5 the current study (Table 2).
  Missing data 3 0.5 The research team noted several significant differences
between those who received medicine and those who did
Age, y Mean 41 not. Of the 607 respondents reporting gender, 303 were male
  Median 40 (49.9%), and 304 were female (50.1%). Respondents who
received medicine were more likely to be female (53.5% vs
46.5%, P = .002) and tended to be older (mean age 42.5 y vs
Education Did not study 37 6.0
35.6 y, P < .001).
  Some primary 15 2.4 Of the 607 respondents reporting on church attendance,
  Primary completed 215 35.0 340 respondents attended (56.0%), and 267 did not (44.0%).
  Secondary completed 189 30.8 Those who received medicine were more likely to report
  Some college 113 18.4 weekly church attendance (60.2% vs 40.9%, P < .001) and daily
  College completed 43 7.0 private devotion (56.0% vs 46.2%, P = .046).
  Missing data 2 0.3 A total of 562 of 610 respondents (92.1%) had suffered
from an illness in the year prior to the study. Of the
respondents who did receive medicine, 458 of 478 (95.8%)
Monthly <$53 27 4.4 reported having an illness, whereas 104 of the 132 respondents
Income who did not receive medicine (78.8%) also reported that they
  $53-$158 61 9.9 had an illness (P < .001).
  $159-$264 73 11.9 Having the flu, a fever, and diarrhea were the only
  $265-$370 105 17.1 illnesses not significantly associated with receiving medicine,
  $371-$475 72 11.7 with P = .082, P = .164, and P = .056, respectively. Comparing
  $475+ 165 26.9 recipients and nonrecipients of medicine, 478 versus 132
respondents respectively, the following illnesses were
  Did not know/want to 110 17.9
reported more often by recipients, with the differences
respond
reaching statistical significance: (1) pain—73.6%, versus
Missing data 1 0.2 49.2%, respectively (P < .001); (2) respiratory illness—26.1%
versus 14.4%, respectively (P = .005); (3) dermatological
Employment Unemployed in formal 201 32.7 disease—16.0% versus 4.6%, respectively (P = .001);
workforce (4) diabetes—6.7% versus 0.8%, respectively (P = .007); and
  Employed in formal work- 306 49.8 (5) hypertension—25.0% versus 8.3%, respectively (P < .001).
force The use of TM/CAM was prevalent, with 62.8% of 607
  Self-employed 5 0.8 respondents reporting use of at least 1 modality. Nearly one-
  Student 49 8.0 half (47.3%) of respondents had used herbs or teas for health
in the prior year, and 26.2% of respondents had received a
  Retiree 19 3.1
sobada. The use of natural pills (13.0%), herbs through a
  Housewife 21 3.4 naturista (5.6%), acupuncture (1.8%), and a curandero’s
  Retiree & housewife 1 0.2 spiritual techniques (1.2%) were also reported. Of the 606
  Missing data 12 2.0 who responded to the question about the possibility of
  natural medicine interfering with physician-prescribed
Domicile Urban 555 90.4 medicine, only 151 respondents (24.9%) said they believed
that it could, but this percentage did not differ significantly
  Rural 55 9.0
between those who received and those who did not receive
  Missing data 4 0.7
medicine.
    Compared with respondents who did not use TM/CAM,
Location Parque Central 121 19.7 those respondents who used such therapies were more likely
  Colonia Kennedy 20 3.3 to have had an illness in the year prior to the study (Table 3).
  Colonia Hato 117 19.1 Among users, 94.2% reported having an illness compared
  Plaza Mira Flores 159 25.9 with 88.9% of nonusers (P = .018). Diarrhea and respiratory
illness were the 2 illnesses that were significantly associated
  Colonia Pedregal 197 32.1
with TM/CAM use, with P = .025 and P = .010, respectively.

Catalino—Traditional Medicine, CAM, and Medication Adherence ALTERNATIVE THERAPIES, MAY/JUNE 2015 VOL. 21, 3 25
in Honduras
Table 2. Characteristics of Respondents Who Received Medicine From a Physician in the Year Previous to the Studya

Received Medicine
Total (n = 610) No (n = 132) Yes (n = 478) P Value
Gender
Male 303/607 (49.9%) 82/132 (62.1%) 221/475 (46.5%) .002
Female 304/607 (50.1%) 50/132 (37.9%) 254/475 (53.5%)
Mean Age (y) 40.9 35.6 42.4 <.001
Secondary Education
No 265/608 (43.6%) 65/131 (49.6%) 200/477 (41.9%) .116
Yes 342/608 (56.4%) 66/131 (50.4%) 277/477 (58.1%)
Church (weekly)
No 267/607 (44.0%) 78/132 (59.1%) 189/475 (39.8%) <.001
Yes 340/607 (56.0%) 54/132 (40.9%) 286/475 (60.2%)
Private Devotion (daily)
No 280/607 (46.1%) 71/132 (53.8%) 209/475 (44.0%) .046
Yes 327/607 (53.9%) 61/132 (46.2%) 266/475 (56.0%)
Illness
No 48/610 (7.9%) 28/132 (21.2%) 20/478 (4.2%) <.001
Yes 562/610 (92.1%) 104/132 (78.8%) 458/478 (95.8%)
Pain 412/609 (67.7%) 65/132 (49.2%) 351/477 (73.6%) <.001
Flu 354/609 (58.1%) 68/132 (51.5%) 286/477 (60.0%) .082
Fever 173/602 (28.7%) 31/130 (23.8%) 142/472 (30.1%) .164
Diarrhea 103/610 (16.9%) 15/132 (11.4%) 88/478 (18.4%) .056
Respiratory 143/607 (23.6%) 19/132 (14.4%) 124/475 (26.1%) .005
Dermatologic 81/602 (13.5%) 6/132 (4.6%) 75/470 (16.0%) .001
Depression 171/609 (28.1%) 27/132 (20.4%) 144/477 (30.2%) .028
Arthritis 86/607 (14.2%) 11/132 (8.3%) 75/475 (15.8%) .030
Diabetes 33/607 (5.4%) 1/132 (0.8%) 32/475 (6.7%) .007
Hypertension 130/609 (21.4%) 11/132 (8.3%) 119/477 (25.0%) <.001
TM/CAM User
No 226/607 (37.2%) 50/132 (37.9%) 176/475 (37.1%) .862
Yes 381/607 (62.8%) 82/132 (62.1%) 299/475 (56.9%)
Specific TM/CAM Use
Herbs/teas 287/607 (47.3%) NA NA NA
Therapeutic massage (sobada) 159/607 (26.2%) NA NA NA
Natural pills 79/607 (13.0%) NA NA NA
Herbs (naturista) 34/607 (5.6%) NA NA NA
Acupuncture 11/607 (1.8%) NA NA NA
Spiritual techniques (curandero) 7/607 (1.2%) NA NA NA
NM Interference With Prescribed Medication
No/don’t know 455/606 (75.1%) 100/132 (75.8%) 355/474 (74.9%) .839
Yes 151/606 (24.9%) 32/132 (24.2%) 119/474 (25.1%)

Abbreviations: TM/CAM, traditional medicine/complementary and alternative medicine; NM, natural medicine; NA, not
applicable.

The numerator in each column represents the number of affirmative responses by respondents. The denominator represents
a

the total number of potential affirmative responses in the given stratified sample.

26 ALTERNATIVE THERAPIES, MAY/JUNE 2015 VOL. 21,3 Catalino—Traditional Medicine, CAM, and Medication Adherence in
Honduras
Table 3. Characteristics of Respondents Who Used TM/CAM in the Year Table 4 shows a logistic regression of the
Prior to the Studya variables in Table 2 that showed significant
Used TM/CAM associations with receiving medicine. Females
were more likely than males to have received
No (226, 37.2%) Yes (381, 62.8%) P Value
medication (OR = 1.615, P = .031). Respondents
Gender older than 40 years were nearly twice as likely
Male 123/224 (54.9%) 178/380 (46.8%) .055 as younger individuals to have received
Female 101/224 (45.1%) 202/380 (53.2%) medications (OR = 1.766, P < .020). Those who
Mean Age (y) 41.1 40.8 .216 attended church at least weekly were also more
Secondary Education likely than others to have received medication
No 104/225 (46.2%) 160/380 (42.1%) .324 (OR = 1.754, P = .012). Pain (OR = 2.304,
Yes 121/225 (53.8%) 220/380 (57.9%) P < .001), dermatological disease (OR = 2.637,
Church (weekly) P = .032), and hypertension (OR = .526,
P = .012) were also independently associated
No 96/224 (42.9%) 170/380 (44.7%) .653
with having received medication from a
Yes 128/224 (57.1%) 210/380 (55.3%)
physician.
Private Devotion (daily) Subsequent analysis (Table 5) of those
No 111/224 (49.6%) 167/380 (44.0%) .182 who received medication in the year prior to
Yes 113/224 (50.4%) 213/380 (56.0%) the current study revealed that the mean age
Illness of respondents reporting low adherence to
No 25/226 (11.1%) 22/381 (5.8%) .018 medicine was significantly younger than
Yes 201/226 (88.9%) 359/381 (94.2%) those reporting higher adherence, 38.3 versus
Pain 143/226 (63.3%) 268/380 (70.5%) .065 46.1 years old (P < .001). Older individuals
Flu 124/226 (54.9%) 229/380 (60.3%) .193 tended to be less educated (analysis not
Fever 59/223 (26.5%) 114/376 (30.3%) .313 shown). Private devotion was also significantly
associated with higher adherence to
Diarrhea 28/226 (12.4%) 74/381 19.4%) .025
medication compared with those without
Respiratory 40/224 (17.9%) 103/380 (21.1%) .010
daily private devotion, 62.5% versus 37.5%,
Dermatologic 23/224 (10.3%) 58/375 (15.5%) .072
respectively (P = .003). Illness alone was not
Depression 55/226 (24.3%) 116/380 (30.5%) .102 significantly associated with adherence
Arthritis 29/225 (12.9%) 57/379 (15.0%) .465 (P = .245), but a stratified analysis shows that
Diabetes 12/224 (5.4%) 21/380 (5.5%) .930 some illnesses were significantly associated
Hypertension 43/226 (19.0%) 87/380 (22.9%) .262 high adherence whereas others with low
Abbreviations: TM/CAM, traditional medicine/complementary and adherence.
alternative medicine. For example, those reporting low
adherence more often reported having the
The numerator in each column represents the number of affirmative
a
flu, 67.1% versus 53.4% for those with high
responses by respondents. The denominator represents the total number of adherence (P = .002), or a fever, 40.4% versus
potential affirmative responses in the given stratified sample. 20.6%, respectively (P < .001). On the other
hand, respondents reporting high adherence
Table 4. Logistic Regression of Factors Associated With Receiving more often suffered from diabetes, 11.2%
Medicine From a Physician in the Previous Year versus 1.8%, for respondents with low
OR 95% CI SE z P Value adherence (P < .001), or from hypertension,
Female gender 1.615 1.043 2.500 0.360 2.150 .031 30.4% versus 18.9%, respectively (P = .004).
Age > 40 (y) 1.766 1.096 2.847 0.430 2.330 .020 The only TM/CAM modality associated
Church (weekly) 1.754 1.133 2.716 0.391 2.520 .012 with low adherence was the sobada. Among
Private devotion (daily) 0.819 0.525 1.276 0.185 -0.880 .378 those reporting low adherence, 33.0%
Pain 2.304 1.490 3.564 0.513 3.750 <.001 received a sobada, whereas only 21.4% of
Respiratory disease 1.413 0.795 2.511 0.415 1.180 .239 those reporting high adherence received one
Dermatological disease 2.637 1.086 6.405 1.194 2.140 .032 (P = .004). A logistic regression (Table 6)
Depression 1.235 0.743 2.053 0.320 0.820 .415 showed that respondents were less likely to
Arthritis 0.820 0.383 1.755 0.318 -0.510 .609 report low adherence if they had daily private
Diabetes 4.680 0.599 36.587 4.910 1.470 .141 spiritual devotion (OR = 0.610, P = .018) or
Hypertension 2.526 1.229 5.194 0.929 2.520 .012 diabetes (OR = 0.154, P = .004). TM/CAM use
Abbreviations: OR, odds ratio; CI, confidence interval; SE, standard error. increased the likelihood of reporting low
relative adherence, as did having a fever.

Catalino—Traditional Medicine, CAM, and Medication Adherence ALTERNATIVE THERAPIES, MAY/JUNE 2015 VOL. 21, 3 27
in Honduras
Table 5. MARS of Respondents Who Received Medicine From a Physician in the Year Prior to the Studya

Reported Relative Adherence (MARS)

Highb Lowb P Value
Gender
Male 119/248 (48.0%) 102/227 (44.9%) .506
Female 129/248 (52.0%) 125/227 (55.1%)
Mean Age (y) 46.1 38.3 <.001
Secondary Education
No 96/250 (38.4%) 104/227 (45.8%) .101
Yes 154/250 (61.6%) 104/228 (54.2%)
Church (weekly)
No 88/247 (35.6%) 100/228 (43.9%) .082
Yes 158/247 (64.0%) 128/228 (56.1%)
Private Devotion (daily)
No 93/248 (37.5%) 116/227 (51.1%) .003
Yes 155/248 (62.5%) 111/227 (48.9%)
Illness
No 13/250 (5.2%) 7/228 (3.1%) .245
Yes 237/250 (94.8%) 221/228 (96.9%)
Pain 174/250 (69.6%) 173/227 (76.2%) .105
Flu 133/249 (53.4%) 153/228 (67.1%) .002
Fever 51/247 (20.6%) 91/225 (40.4%) <.001
Diarrhea 45/250 (18.0%) 43/228 (18.9%) .809
Respiratory 56/249 (22.5%) 68/226 (30.1%) .060
Dermatologic 34/247 (13.8%) 41/223 (18.4%) .172
Depression 67/250 (26.8%) 77/227 (33.9%) .091
Arthritis 40/249 (16.1%) 35/226 (15.5%) .863
Diabetes 28/250 (11.2%) 4/225 (1.8%) <.001
Hypertension 76/250 (30.4%) 43/227 (18.9%) .004
TM/CAM User
No 103/249 (41.4%) 73/226 (32.3%) .041
Yes 146/249 (58.6%) 153/226 (67.7%)
Herbs/teas 112/250 (44.8%) 114/228 (50.0%) .255
Therapeutic massage (sobada) 53/248 (21.4%) 75/227 (33.0%) .004
Natural pills 39/248 (15.7%) 30/227 (13.2%) .438
Herbs (naturista) 15/248 (6.0%) 16/225 (7.1%) .641
Acupuncture 3/248 (1.2%) 6/228 (2.6%) .255
Spiritual techniques (curandero) 2/248 (0.8%) 4/226 (1.8%) .349
NM Interference With Prescribed
Medication
No 185/246 (75.2%) 170/228 (74.6%) .872
Yes 61/246 (24.8%) 58/228 (25.4%)

Abbreviations: MARS, Medication Adherence Report Scale; TM/CAM, traditional medicine/complementary and
alternative medicine; NM, natural medicine.

a
The numerator in each column represents the number of affirmative responses by respondents. The denominator
represents the total number of potential affirmative responses in the given stratified sample.
b
High adherence equals a MARS score of lower than or equal to 2 of 6. Low adherence equals a MARS score higher than 2 of 6.

28 ALTERNATIVE THERAPIES, MAY/JUNE 2015 VOL. 21,3 Catalino—Traditional Medicine, CAM, and Medication Adherence in
Honduras
Table 6. Logistic Regression of Factors Influencing Respondents Reporting More Than 2 Nonadherent Behaviors
(ie, a MARS Score Higher Than 2)a
Characteristic OR
Age > 40 y 0.680
Private devotion (daily) 0.610
Flu 1.379
Fever 2.226
Diabetes 0.154
Hypertension 0.798
Therapeutic Massage (sobada) 1.718
Abbreviations: MARS, Medication Adherence Report Scale; OR, odds ratio; CI, confidence interval; SE, standard error.
High adherence equals a MARS score of lower than or equal to 2 of 6. Low adherence equals a MARS score higher than 2 of 6.
a
Among the TM/CAM modalities, a significant association
existed between receiving a sobada in the year prior to the
study and low relative adherence (OR = 1.718, P = .017).
Those reporting a fever were more than twice as likely to
report low adherence (OR = 2.226, P < .001).
DISCUSSION
The data indicated that the people in Tegucigalpa used a
mix of prescribed and complementary or alternative medicine,
ranging from the use of herbs and teas to consultation with
practitioners of TM. Contrary to other studies, neither age
nore education was independently associated with adherence.15
In its analysis, the current research team noticed that older
individuals tended to be less educated. It is possible that having
less education reversed any benefit that age had on adherence.
Even though, in crude analysis, age was associated with
better adherence, this relationship did not persist in the
regression analysis. The average age of diabetics reporting to
primary care clinics in Honduras might be around 50 years
old, based on a single study,23 and the research team found
that diabetes was a strong, independent predictor of high
adherence. Although subject to recall bias, that finding was
significant. A recent study in Honduras has suggested that
people with diabetes and good self-reported adherence were
more likely to benefit from disease-management
interventions.23 This relationship is encouraging, because the
prevalence of chronic diseases in developing countries is
likely to rise with an increasing life span.
The research team’s findings support prior work that
suggests spiritual or mind/body beliefs influence adherence,12
and, further, we add that time spent in private spiritual
devotion can positively influence medication adherence. Such
personal habits can perhaps reinforce the routine
administration of medications needed to adhere to most
regimens. For example, someone with diabetes might need to
take a glyburide pill twice per day, once in the morning and
once at night. Remaining faithful to a daily time of spiritual
devotion may possibly foster faithfulness in taking medications.
People may also be spending time in their church communities
Catalino—Traditional Medicine, CAM, and Medication Adherence
in Honduras
95% CI SE z P Value
0.444 1.042 0.148 -1.770 .076
0.405 0.918 0.127 -2.370 .018
0.909 2.091 0.293 1.510 .131
1.430 3.466 0.503 3.540 <.001
0.043 0.547 0.100 -2.890 .004
0.481 1.323 0.206 -0.880 .381
1.103 2.677 0.389 2.390 .017
for group activities, where they can ask others to pray for their
illnesses, which would remind them to take their medication.
Interestingly, more than a one-quarter of respondents
from the current study’s sample had received a sobada, a
therapy which is scarcely reported in current literature. The
current study found that the individuals who received the
massage could be at risk for poor adherence, as sobada use was
independently associated with reporting nonadherent
behavior. That form of TM/CAM may truly be an alternative
as opposed to a complementary treatment because of its
perceived power to heal when allopathic medicines fail. The
research team met a woman who said she had been suffering
from intractable fever, nausea, vomiting, and severe weakness
for months. Many doctors thought she had an atypical form of
dengue fever, and others tried antibiotics and steroid
medications with no benefit. A friend suggested she try sobada
and within days of the treatment she was apparently healed.
The research team had no way of verifying the truth of this
astonishing anecdote, but the team feels that it does represent a
cultural perception of sobada and its unmatched ability to heal
the sick in Honduras. The other forms of TM/CAM that the
team studied do not have this same reputation, or in the case
of natural healers, are not used often enough to affect the
population at large. Use of the sobada has been documented
in Costa Rica.24 The current study documented its use in
Honduras. Simpson25 has translated sobada as “rubbing;” the
verb sobar refers to therapeutic rubbing, rather than massage,
to distinguish it from masaje, a massage for nonmedical
reasons. In Costa Rica and Honduras, a sobada is typically
given as treatment for gastric upset or diarrhea, ailments
traditionally attributed to pega or empacho by the indigenous
population.24 The symptoms of pega/empacho have been
diagnosed at hospitals as gastroenteritis.25
In contrast to some studies, the current study did not
find any association between many of the TM/CAM
modalities and adherence.8,16 Herbs and teas were the most
widely studied modality, and the current study did not show
any significant increase in nonadherent behavior with their
use. Why might sobada use affect adherence whereas other
ALTERNATIVE THERAPIES, MAY/JUNE 2015 VOL. 21, 3 29
modalities such as herbs and teas do not? The research team
suggests that this relationship may depend on the cultural
perspective of the modality as either alternative or
complementary. A recent study of HIV patients in Uganda
also found no association between herbal medicines and
antiretroviral therapy.17 The researchers observed high rates
(46.6%) of concomitant use of herbal therapy. Patients used
complementary herbal therapy mostly to address symptoms
of HIV or side effects of medications rather than because use
could cure them of the HIV infection.
The current research team asked respondents about the
relative importance of various culturally sensitive means of
curing disease. They most often said prayer to God was very
important (93.2%), followed by a healthy diet (92.9%), access
to physicians (80.7%), and natural medicine (45.3%). Based
on those findings and the other data presented in the current
article, the research team suggests that prayer, private
devotion, herbs and teas, and other forms of natural medicine
are viewed as complementary to allopathic care in Honduras
and, thus, less likely to affect adherence to medication. In
contrast, the sobada may be viewed as an alternative modality.
In Honduras, the lack of resources in the public health
system and the high cost of allopathic medical services are
often noted as reasons why people use TM/CAM. Among
low-income Hispanics and Native Americans in the US state
of New Mexico, family traditions, culture, and severity of
illness appeared to contribute to the use of TM/CAM in a
primary care setting.6 The case is likely similar in Honduras.
Predictors of delays to receipt of health care among Latino
women in New York, New York, included the use of prayer as
a TM/CAM, seeking advice from family members, the use of
other TM/CAM, and chronic diseases.7 Delayed care and
poor adherence inevitably complicate an already increasing,
chronic disease burden. The aim of researchers should,
therefore, include both the development of novel therapies
and a strategic understanding of access to health care and
treatment adherence so that patients feel empowered to
participate in their own healing.
Treatment of epilepsy, for example, is effective but
requires long-term adherence. The treatment gap for epilepsy
in rural areas of Honduras has been estimated to be nearly
60%, and the presence of untreated or nonadherent epilepsy
patients can be devastating to the public health system and
can have social consequences for the individuals themselves.2
In a study of 408 adult patients with epilepsy, nonadherence
to antiepileptic medications was associated with decreased
productivity, lowered quality of life, job loss, and motor
vehicle collisions.26 The estimated cost of epilepsy in the
United States is $12.5 billion annually.27
A study of Hondurans with epilepsy has suggested that
epilepsy adherence is multifactorial.13 Researchers showed
that the majority of patients with epilepsy used multiple
forms of TM/CAM. Similarly, the current study has described
factors such as individual TM/CAM modalities that influence
adherence. This body of data provide valuable insight into
health system effectiveness in Honduras.
30 ALTERNATIVE THERAPIES, MAY/JUNE 2015 VOL. 21,3
In 2002, WHO launched its first global strategy on
TM/CAM. Now, over a decade later, evidence-based practices
are emerging, such as polyherbal treatment of inflammatory
bowel disease,28 but little is known about the sobada. These
alternatives might be able to bridge an effectiveness gap,
defined as an area of medicine that lacks fully effective
treatment, but more research is needed worldwide.29 The
integration of diverse medical paradigms brings with it many
barriers, costs, and possible consequences for the health
system and the individual.30 Evidence on the harm-to-benefit
ratio for TM/CAM and adherence to prescribed medical
therapies seems inconclusive,8-4 particularly as studied in
patients with HIV.31,32 Because TM/CAM modalities are
firmly rooted in culture, medical researchers and clinicians
must be culturally sensitive and not stereotype TM/CAM
users but rather give due diligence to and investigate the
population- or person-specific factors and modalities that
affect adherence. The findings can provide useful country-,
patient-, and modality-specific information for clinicians in
Honduras and other countries with large Latin American
subpopulations.
The current research team encourages clinicians to
understand their patients’ perspectives on illness and to be
aware of all TM/CAM modalities that they use. Clinicians
should ask how a modality will be used in order to identify
its use as either alternative or complementary. Most
important, the team encourages clinicians caring for patients
from Central America or other Latino communities, to ask
specifically about the sobada and spend some extra time
exploring how this modality may affect adherence. Finally,
clinicians should encourage some form of private reflection
each day, which may cultivate a more disciplined mind and
aid in adherence to medications. It is also clear that more
evidence-based practices are needed to establish the
“therapeutically sound use of TM/CAM by providers and
consumers,” a charge from WHO that resonates with many
who desire to bring culturally competent care to those in
need.33
Limitations
The current study has several limitations. Although the
research team attempted to address recall bias by how it
presented the survey to participants, the team could not
verify responses with other sources. The research team could
not confirm the access to health care or financial factors that
could affect medication adherence. Many respondents were
unsure of their monthly income, or they were not comfortable
providing the information to the team. The current study’s
modified MARS variable was likely not as accurate as that
used elsewhere.20,21 The response range for the current study’s
MARS variable was 0 to 6 as compared with 9 to 45 in the
original survey, making the current data less precise and
making it more challenging to see significant trends, but the
team chose the modified scale to make the survey easy to
administer and to ensure a high response rate. As in all cross-
sectional surveys, association does not equal causation.
Catalino—Traditional Medicine, CAM, and Medication Adherence in
Honduras

Nonetheless, the large sample size has provided a sound
perspective on the current state of the above issues in
Honduras.
CONCLUSIONS
Seeking medical attention from allopathic physicians
may be more common in urban areas within Honduras due
to better access to such care and a more Westernized culture.
The link between TM/CAM use and adherence is complex,
and not all TM/CAM modalities adversely affect adherence.
However, the current study suggests that more than three-
fifths of people in Honduras are still seeking traditional
treatment, and one-quarter are receiving a very specific
treatment, the sobada. The research team is uncertain of the
effectiveness of the sobada but encourage future research in
the area due to its prevalence and possible adverse impact on
adherence. Finally, factors influencing adherence are not
uniformly significant within the TM/CAM label, and if
herbal therapies can alleviate symptoms without interacting
with medication or adversely affecting adherence, researchers
can establish a more effective therapeutic role for herbal
medicine. It is important, therefore, for physicians to
acknowledge and pursue those avenues when attempting to
promote good health behaviors for patients using some self-
care modalities. Identifying high-risk patients is critical for
better treatment outcomes. Doing so may help strengthen
the public-health system and protect patients against the
physical and social consequences of illness.
ACKNOWLEDGEMENTS
The research team thanks David Boyd, PhD, and Jen’nan Read, PhD, from the Duke
Global Health Institute for their help with planning this research and designing the
survey.
AUTHOR DISCLOSURE STATEMENT
Funding was provided by the Duke Global Health Institute’s Masters in Science of
Global Health program. No competing financial interests exist.
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