People worldwide have been using medicinal herbs to improve or treat their health conditions before the inception of conventional medicine. Over time, the world has seen an increased demand for herbal products.¹ African traditional medicine (ATM) particularly herbal medicine (HM) has been part of health care in African countries, and its contributions to the primary health care (PHC) system are well known in some parts of the African continent.² South Africa categorises indigenous HM as ATM, whereas Homeopathy, Ayurveda, Traditional Chinese Medicine, Unani Tibb, and Western Herbal Medicine, as complementary medicine (CM).³ However, these modalities are not acknowledged as part of the national healthcare system.⁴ South Africa, which is a country rich in indigenous medicinal plants, has approximately 30 000 plant species, accounting for almost 10% of the world’s higher plant species.⁵ A large proportion (60%–80%) of the South African population uses herbal products for the treatment of ailments and cultural practices.⁶

These practices are derived from the indigenous knowledge and experiences possessed by communities. Indigenous knowledge (IK) is regarded as the knowledge that has been acquired outside the educational system. It is easily transferred in a community that shares common cultural concepts and who speaks the same language.⁷ Indigenous knowledge is central to the social, cultural and spiritual beliefs of these communities.⁸ The deep-rooted indigenous knowledge of HM is evident in the decision-making and usage of HM.⁹ Moreover, a personal, family and community-positive experience, easeof availability, perceived lack of side effects and patients’ experience or witness of unfavourable behaviour of healthcare providers (HCPs) is a push factor towards using HM.¹⁰

Herbal products can either be obtained from a traditional health practitioner (THP), herbal markets or pharmacies as well as being available as home-made remedies.¹¹ South Africa has taken various initiatives to promote the safety, efficacy, labelling and traditional use of HM.¹² However, most of these are not registered by the South African Health Products Regulatory Authority (SAHPRA) and have not undergone quality control tests and their safety is unknown.^13,14 According to the World Health Organization (WHO), HM comprised herbs, herbal materials and preparations and finished products that contain plants as active constituents.¹⁵ These herbs may contain more than 150 active constituents that may affect the pharmacokinetics of prescribed medicines and cause adverse effects.¹⁶ These adverse effects range from an allergic reaction, gastrointestinal upset, coagulation abnormalities, cerebral haemorrhage, liver damage and possible death.^17,18

In South Africa, herbal products are sold at herbal markets or by THP as herbal concoctions, packaged in recyclable plastic bottles or paper with labels that do not provide the full ingredients of the herb.¹⁹ These herbal concoctions are a mixture of different plant species or a single plant to treat various health ailments.²⁰ Patients use these herbal concoctions concurrently with prescribed medicines without the knowledge of the implications of HDIs.^21,22 Research shows that desperate patients use HM to complement prescribed medicines such as antihypertensive, hypoglycaemic, antiarrhythmic, anticoagulant, antiretroviral and antidepressants.^12,16 Moreover, a review conducted to assess the severity of HDIs in patients who co-administer HM and prescribed medicines showed that patients taking warfarin, insulin, aspirin and/or statins, reported evident interactions with herbal products including: (1) sage, (2) flaxseed, (3) cranberry, (4) Camelia sinesis, (5) Hypericum perforatum, (6) Ginkgo biloba and (7) Matricaria chamomile.^23,24 For example, acetylsalicylic acid as an antiplatelet agent is the most drug that interacts with HMs, followed by warfarin that can interact with Ginkgo biloba and Hypericum perforatum, leading to increased bleeding.²⁵ Amlodipine an antihypertensive drug when combined with Ginkgo biloba changes the pharmacokinetic interactions of amlodipine through the metabolism of CYP3A4 enzyme.²⁶

Several studies conducted in South Africa confirmed that consumers do not disclose the use of HM to their healthcare providers.^27,28,29 The non-disclosure prevents the discussion and recording of potential HDIs by HCPs.³⁰ Additionally, the non-registration of most HM exacerbates the risk of HDIs.¹⁴ Several studies have explored the reasons why patients use HM^31,32,33, but within the South African context, there is a dearth of information regarding patients’ knowledge about herb-drug interaction.

This study sought to provide an in-depth description of the use of HM through focus group discussions (FGD) with patients attending PHC clinics in three provinces – Gauteng, Free State and Mpumalanga, South Africa.

The themes and subthemes identified in this study offer a comprehensive description of factors that influence the use of HM among patients visiting PHC clinics.

The study revealed that the driving force behind the use of HM is easy accessibility, lower cost and the perception of having no side effects. The findings also found that respondents follow what their forefathers have been doing by using HM. These findings are similar to studies conducted in South Africa^38,39 and support the notion that HM plays a role in the lives of the population of South Africa.

Because of the lack of knowledge and personal perceptions, respondents raised their concerns about the side effects they are experiencing while using prescribed medicine.^40,41,42 As part of the consultation and the right of the patient to be informed, HCPs need to discuss the benefits and risks of the prescribed medication with patients.^43,44 In order to better understand HM and HDIs, an expansion of knowledge of pharmacodynamics and pharmacokinetics of HM is essential. Patients need to hear about HM directly from HCPs to limit HDIs.⁴⁵

Respondents reported that they started using HM upon recommendation by people who have personal experience with HM and television advertisements. This finding indicates that HM in the community and society at large is an important issue as people are sharing information about medicinal plants or herbs among themselves. This can be attributed to the historical African culture of sharing information about medicinal herbs orally from generation to generation.⁴⁶ Moreover, various media advertisements have increased awareness and have given HM respect and credibility.^10,39,41,47

During the discussion, most FG respondents confirmed the co-administration of HM and prescribed medication. Concurrent use of these modalities is a common practice, especially in patients with chronic conditions.²³ This is because of patients simultaneously seeking treatment from both conventional and traditional or complementary health systems for the same ailment.⁴⁸

Even though a small fraction of respondents felt that using HM and prescribed medicine is wrong, they took this decision because of how they felt, not necessarily because they had the knowledge regarding HDI. This highlights the importance of educating patients about the danger of co-administering HM and prescribed medicine and possible HDIs.^23,49,50

Herbal medicines contain hundreds of active ingredients that may interact and cause modification of prescribed medication.⁴⁸ This study revealed a low awareness of potential herb-drug interaction where most of the respondents mentioned that they were not aware of the potential interaction of herbs and prescribed medication. A similar study carried out by Ezuruike and Prieto⁵¹ showed that 60% of participants who took HM alongside prescribed medicine are unaware of the identity of HM being taken, which exacerbates the risks of the HDIs. A study conducted in South Africa showed similar results where consumers purchase HM products from herbalists and traditional healers, packaged in containers with the contents not being stated.²⁰ These findings demonstrate that patients do not have knowledge of HDIs, and there is a need for continuous education of patients about HDIs.

Respondents in this study mentioned that they do not disclose the use of HM to their HCPs. This shows that patients are not forthcoming with their use of HM when consulting in the PHC clinics. A possible reason could be the perceived unpleasant behaviours of PHC nurses mentioned in the study.^27,31 Respondents confirmed that they experience unpleasant behaviours from nurses during clinic visits. This behaviour of PHC nurses could weaken the ability of the health system and compromise the quality of patient care.

Respondents also mentioned that doctors and nurses do not have time to give an explanation about their conditions or treatment during the consultation. This may be because of a few HCPs having to deal with the volume of patients in a short time.⁵² A study conducted in a hospital in South Africa reported that nurses experience a high patient load, staff absenteeism and burnout.⁵³ This calls for stakeholders to come up with interventions to combat workload and absenteeism to create favourable conditions for both patients and HCPs. Education about the use of HM requires a sensitive approach that depends on listening and spending time with the patients.⁴⁵

The findings of this study revealed that there is a lack of knowledge and awareness of the risks that may be with the co-administration of HM and prescribed medicines. Within the identified themes, participants believed anecdotes from community members and family, cultural background and positive experiences of HM. These findings can be used to develop interventions aimed at preventing possible HDIs.