Background

Influenza is a common illness worldwide, typically lasting 2 to 5 days1, but it can cause severe complications particularly among vulnerable groups. Globally, influenza affects about 1 billion individuals each year, leading to 3–5 million severe illnesses and more than 290,000 respiratory-related deaths, with significant health and economic burdens worldwide2. Current management strategies primarily depend on annual vaccinations and antiviral treatments, such as oseltamivir1,3, However, the frequent changes in virus antigenic structures complicate vaccine production, and antiviral agents are associated with resistance and the need for stockpiling4. With these shortcomings in conventional medicine, different communities all over the word including Palestinians have increasingly turned to herbal medicine and other forms of Complementary and Alternative Medicines (CAM)5.

CAM is a broad term that encompasses a wide range of healthcare practices, products, and medications used concurrently with (complementary) or in place of (alternative) conventional treatments6. Herbal remedies, probiotics, and nutritional supplements are commonly used to support immunity and relieve influenza-related symptoms, and these practices remain deeply embedded in Palestinian cultural traditions5,6. Despite widespread use, national guidance on safe CAM practices, dosing, and herb–drug interactions remains limited, creating an important public health gap3,7.

Ongoing research has explored the use of CAM for influenza and influenza-like illnesses, but the available evidence on their efficacy and safety remains limited and of low certainty, and no CAM modality is currently recommended as standard treatment. Several studies have been carried out within the Palestinian population to evaluate the use of CAM for various medical conditions, revealing a high prevalence of use8,9,10,11,12,13,14,15,16,17. However, a lack of research that examines the utilization of CAM for influenza prevention and/or treatment despite its cultural relevance.

Therefore, the present study aimed to determine the prevalence of CAM use among Palestinians for influenza treatment and/or prevention, to identify the most commonly used CAM products and practices, to explore the sources that promote their use during influenza season, to determine where these CAM products are obtained, and to examine the reasons for using or avoiding CAM. Furthermore, the study assessed the correlation between clinical and sociodemographic factors and CAM usage in managing influenza among Palestinians.

Methods

Study design

A descriptive cross-sectional study was conducted from December 2023 to March 2024 in the West Bank, Palestine.

Study population

The study involved Palestinians aged 18 years and above, including both males and females. Participants were excluded if they were unable to complete the questionnaire due to mental or physical limitations or if they chose not to participate.

Sample population and size

As per the Palestinian Central Bureau of Statistics in 2023, the total population in the West Bank, Palestine is 3,256,906. Based on this reference population, a minimum sample size of 385 participants is required for this study. The sample size was calculated using Raosoft sample size calculator available at: http://www.raosoft.com/samplesize.html, with a margin of error set at 0.05 and a confidence level of 95%. A non-probability online sampling approach was used, with efforts to reach diverse demographic groups.

Data collection instrument

The data was collected using a questionnaire in Arabic, originally written in English and then translated into Arabic. This questionnaire was created following a thorough review of literature8,10, research aims and objectives. The initial draft underwent evaluations for content and validity. The validity check occurred in two stages: first, a panel of academicians familiar with questionnaire design, clinical and community pharmacists, and experts in the fields of complementary medicine assessed the questionnaire for content validity. Based on their feedback and suggestions, the questionnaire was revised. In the second stage, a pilot study was conducted with an updated survey. The survey was piloted with a group of 20 people to improve the clarity and readability of the survey items, as well as to ensure their relevance to the intended target population. Following the pilot study, further adjustments were considered. Pilot data was excluded from the final analysis.

Reliability and validity

The questionnaire content was validated by a panel of experts (Content Validity Index [CVI] = 0.85) and piloted to ensure clarity and face validity. The sections analysed in this manuscript consist of single items and multi-response checklists (CAM use, types of CAM, reasons for use/non-use, and sources of information/products), which were not designed as additive psychometric scales. Consequently, internal consistency indices such as Cronbach’s alpha are not applicable to these descriptive measures.

Survey content

The final questionnaire instrument consists of five sections (Supplementary file 1) as follows:

  • The first section included the socio-demographic, which contains questions regarding age, gender, education level, monthly income, marital status, region of residence, Employment status, and occupation.

  • The second section of the questionnaire consists of questions related to clinical characteristics; smoking status, health status, presence of chronic diseases, medications, exercising, flu symptoms frequency and nature, hospitalization, flu treatment choice, and flu vaccination status.

  • The third section consists of questions to determine the experience and perceptions on complementary and alternative medicine use.

  • The fourth section consists of questions to determine the sources of information and reason to use or not using CAM.

  • The fifth section: Source of herbal products.

Survey distribution and administration

The final questionnaire was self-administered through a Google Form platform from December 2023 to March 2024. Eligible participants received the survey link through emails, WhatsApp messages, and text messages. Various methods were used to find and enrol eligible participants, including direct contact by the research team and sharing the survey link on social media platforms.

Ethical approval

The study protocol was approved by the Research Ethics Committee of Al-Quds University (Archived number: 372/REC/2024). Prior to their involvement, each participant provided informed consent, and respondents were informed about the questionnaire content. Participants’ information and data were coded, and privacy was highly considered. All methods were performed in accordance with the relevant guidelines and regulations.

Statistical analysis

Following data collection, data were extracted and logged in an Excel workbook (Microsoft office MS, 2013). Before the analysis data cleaning, coding and grouping were carried out.

Data was summarized using descriptive statistics. The chi-square test was applied to test relationships between variables. All variables collected through the questionnaire was presented by calculating the frequency (%) for binary variables and the mean± standard deviation (SD) for continuous variables.

The chi-square test was used to assess associations between categorical variables; clinical/sociodemographic characteristics and CAM use. This test was selected due to its suitability for assessing whether the differences in proportions among groups are statistically significant. Multivariate regression analysis was conducted to identify potential predictors of CAM use for influenza symptoms management as dependent variable. independent variables entered into the model included age, gender, education level, income, employment status, medications use, exercise, hospitalized from influenza complications, smoking status, treatment modalities use for influenza management, health status generally, flu symptoms frequency, and flu vaccination status. The reference categories were selected based on their relevance and prevalence in clinical settings. Results were reported as odd ratios (ORs) with 95% confidence interval (95%CI), a P value of less than 0.05 was considered statistically significant. All analyses were conducted using R software, Version 3.4.3.

Results

Sociodemographic characteristics

A total of 386 participants participated in this study, with 23 being excluded due to missing data. Due to the various methods used to identify and recruit eligible participants, such as social media, determining the response rate was not feasible.

The sociodemographic characteristics of the participants by CAM use are presented in Table 1. The majority of participants were young females, university students, and single. The majority lived in urban areas, and income levels varied across the sample. The mean age was 25.6 ± 9.3 years. More than one-third of participants worked in the medical field.

Table 1 Sociodemographic characteristics of participants by CAM use (n = 363).
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Clinical characteristics

As shown in Table 2, most of participants, were non-smokers and reported good to very good health. Only 7.7% reported having chronic diseases, and 7.7% were taking medications for chronic conditions. Within the group, 48.2% experienced flu symptoms two or more times in the past year, of those 20 has been admitted to the hospital.

Concerning exercise habits, 68.6% of the participants did not exercise, while 31.2% exercised more than once a week. Only 9.1% received the flu vaccine this year. Regarding flu symptoms, 9.6% did not experience flu symptoms, while 22.6% experienced symptoms once, 17.9% twice, and 48.2% more than twice. For managing flu symptoms, 18.2% preferred pharmaceutical drugs, 12.2% used CAM, the majority favored both at 52.9%, and 16.6% did not prefer either. Hospitalization due to influenza symptoms was low, with only 5.5% reporting such an occurrenc.

Table 2 Clinical characteristics of participants (n = 362).
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Source of CAM

Table 3 displays the sources of herbal medicine. Out of the participants, 239 (66%) obtained their herbs from herbal medicine stores, 167 (46.1%) from friends and family, 105 (29%) from supermarkets, and 63 (17.4%) from pharmacies.

Table 3 Herbal medicine sources.
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Source of information about CAM

Table 4 details where study participants acquired information regarding CAM use. 67.7% (247 participants), sought information from Family or Friends. Mass media, such as newspapers, radio, and TV, was a significant source for 62% (225 participants). Books or magazines were less commonly used, with only 21.8% (79 participants) referencing them. The Internet was utilized by 64.2% (233 participants) for information. Pharmacists were a source for 23.1% (84 participants). Other sources, unspecified, accounted for 3.6% (12 participants).

Table 4 Sources of information about CAM use for the entire study participant.
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Types of CAM used for flu treatment and prevention and in general

Herbal medicine was the most commonly used category for flu treatment and/or prevention by 239 (65.9%), as shown in Table 6. It is also apparent from Table 5 that herbal medicines, were reported to be used by 327 (89.1%) of the participants in general.

The top five herbs used for flu treatment and/or prevention were sage 162(44.8), chamomile 148(40.9%), anise 144(39.8%), peppermint 126(34.8%), and thyme 117(32.3%).

While Manipulative and body-based methods were least likely used for flu treatment and/or prevention 19(5.2%), it is used in general by 155(42.7%) of the participants.

Table 6 displays that prayer and Quran was the most common mind-body medicine method used for treatment and/or flu prevention by 22.1%, 17.1% respectively. An alternative medical system was used only by 42 participants (11%). The massage was the most prominent manipulation and body-based method by 68(18.8) participants for flu treatment and/or prevention. It is also apparent from Table 6 that vitamin D 115(31.8%) was mostly used for treatment and/or prevention of flu.

Table 5 CAM categories, their frequencies and percentages of use.
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Table 6 Types of CAM of each category used, their frequencies and percentages.
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Purpose of CAM usage and reason of not use among participants

Table 7 details the reported purposes for using CAM among participants within the last 12 months. The primary reason, chosen by 63.4% of participants, was to improve the immune system. Next, 52.9% utilized CAM to assist in the treatment of diseases, while 47.4% used it to reduce pain. Psychological comfort was a reason for 44.4% of the users. Maintaining or promoting health and preventing disease was a goal for 51.8% of CAM users. Minimizing the adverse effects of conventional medicine was noted by 19.6%. There was also a small proportion (5.5%) who used CAM for other unspecified reasons.

Table 7 The purpose of using CAM among all participants.
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Table 8 details the reasons participants (n = 62) provided for not using CAM. Only one participant, indicated that they do not believe CAM is relevant to disease treatment. The majority, 9.9%, do not trust in the effectiveness of CAM. Some concerns about the adverse effects of CAM were expressed by 4.7% of the participants. Interestingly, none of the participants cited a lack of knowledge about CAM as a reason for not using it. Other unspecified reasons were given by 2.4% of the respondents.

Table 8 Reasons for not using CAM (n = 62 participants answer this question).
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Relationship of participants’ CAM use for influenza management and their socio-demographic and clinical characteristics

The analysis indicated that there was no significant correlation between the presence of chronic disease, use of chronic medications, or hospitalization due to influenza and the use of CAM. Conversely, the study revealed a significant relationship between CAM usage and experiencing flu symptoms (p-value = 0.001), with no notable differences based on sociodemographic factors. Tables 1 and 2 provide a summary of the analysis output.

Multivariable logistic regression analysis: factors influencing CAM use for influenza management

Table 9 presents the analyses that explores the various factors impacting the use of CAM in managing influenza. In the multivariable logistic regression model, most sociodemographic and clinical variables were not statistically significant associated with CAM use. However, treatment preferences showed statistical associations; participants who preferred pharmaceutical drugs (OR = 0.35, 95% CI: 0.17–0.73, p = 0.005) and those who used neither CAM nor pharmaceutical drugs (OR = 0.19, 95% CI: 0.08–0.44, p < 0.001) were significantly less likely to report CAM use compared with those who reported using both.

Table 9 Multivariable logistic regression Analysis, factors influencing CAM use for influenza Management.
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Discussion

This study is the first to evaluate the prevalence and patterns of CAM use for managing influenza among Palestinians. The results indicate that CAM is widely used, demonstrating its cultural acceptance and availability. These findings align with earlier studies that reported significant CAM usage in Palestine for various health issues and contribute to the existing literature by emphasizing its importance during influenza outbreaks8,9,10,11,12,13,14,15,16,17,18.

This study revealed that most participants had used at least one method of CAM for influenza treatment and prevention, with herbal therapies being the most preferred modality. Globally, herbal remedies are commonly used for respiratory infections due to their perceived effectiveness and cultural acceptance19. Studies conducted in Iran, Southeast Asia, and Africa have emphasized the widespread adoption of traditional herbal remedies for respiratory infections20,21,22. The specific herbs employed may differ based on regional availability and cultural practices.

In our study, herbal medicine emerged as the most popular choice, with significant preference for sage, chamomile, and anise (p < 0.01), reflecting strong cultural accessibility. Various herbal remedies were widely used for different ailments in our sample, with olive oil being the most commonly reported product. Participants may perceive it as beneficial based on reports of antioxidant, anti-proliferative, anti-inflammatory, and neuroprotective properties although its clinical role in influenza management remains uncertain23. However, olive oil was not extensively used for flu symptom management (p > 0.05), indicating that its role may be more cultural and traditional than therapeutic.

Further research focusing on CAM during pregnancy in Palestine has revealed that the top five herbs are anise, peppermint, sage, chamomile, and cinnamon17. It is interesting to note that the herbs commonly used for flu in our study are also popular during pregnancy in a separate study. This trend suggests that the most commonly used herbs in Palestine serve various purposes due to their social acceptance, availability, and traditional use, which influences patients’ beliefs in their effectiveness.

In our study, about half of the participants preferred to use both CAM and pharmaceutical drugs for managing influenza symptoms. Meanwhile, participants who relied on pharmaceutical drugs exclusively (p = 0.005) or did not use either option (p < 0.001) were significantly less. Treatment preference emerged as the only significant predictor of CAM use, likely reflecting personal beliefs and cultural comfort with self-management and herbal remedies, rather than sociodemographic or clinical factors.

Our findings align with previous indicating a connection between influenza symptoms and CAM use18. This suggests that flu symptoms are frequently associated with CAM usage. Many individuals with flu symptoms tend to underestimate the necessity of consulting doctors, presuming that these symptoms will naturally improve by boosting their immunity with herbal remedies. It’s crucial to educate patients on seeking medical advice for persistent or worsening symptoms. Integrating complementary medicine with conventional treatments under supervision can enhance patient outcomes. Healthcare providers should encourage open discussions about complementary medicine to provide safe and effective care. The low influenza vaccine uptake alongside high reliance on CAM suggests that some individuals may prioritize natural remedies over preventive medical measures, underscoring the need for targeted public health education.

Interestingly, a considerable proportion of participants perceived CAM to be more affordable than conventional treatments. This perception aligns with global trends, where cost considerations often drive individuals towards CAM, particularly in low-resource settings where conventional healthcare may be inaccessible or unaffordable. However, the study did not explore the effectiveness of CAM compared to conventional medicine comprehensively. Future research could investigate the comparative effectiveness of CAM and conventional treatments for influenza management, considering factors such as symptom relief, treatment duration, and healthcare costs.

Regarding the source of information, family and friends emerged as the primary sources of information about CAM, followed by mass media and the internet. The heavy reliance on family, friends, and the internet for CAM information highlights the influence of informal sources and the potential for misinformation. This highlights the role of interpersonal networks and digital platforms in shaping health-seeking behaviours and disseminating health information. Comparatively, studies from Western countries often emphasize the influence of the internet and social media on CAM awareness and decision-making. However, the reliance on family and friends for CAM information appears consistent across diverse cultural contexts, indicating the importance of social networks in health-related decision-making. Furthermore, it is noteworthy to mention that most participants in this study do not choose to seek advice regarding CAM use from specialists like pharmacists or other healthcare providers. This indicates a need to improve communication and trust between healthcare providers and patients regarding CAM.

Further, the majority of participants acquired herbs from herbal stores, followed by friends or family, supermarkets, and then pharmacies. Herbal stores were significantly more associated with CAM use (p < 0.01), highlighting the popularity and availability of herbal remedies. Herbal stores signify trust in specialized retailers, while friends and family show influence from personal connections. Supermarkets offer convenience, and pharmacies provide a clinical setting. The varied sources reflect the multifaceted nature of herbal consumption in daily life.

Our findings have clear public health implications, since many people seek CAM for various reasons, including immune system enhancement, disease treatment support, pain relief, and psychological comfort. It’s important to provide appropriate education on its use. Safety considerations are important, as unsupervised CAM use may lead to herb–drug interactions or delays in seeking medical care. Healthcare providers must give adequate guidelines on CAM use, so patients can get the right guidance and avoid toxic doses.

Strengths and limitations

This study had several noteworthy strengths. First, this study was the first to focus on exploring the use of CAM for managing influenza symptoms in Palestine. Second, we used a validated questionnaire, which made the data collection more reliable and accurate. Finally, the study considered cultural traditions and beliefs which influence the use of CAM.

While the study provides valuable insights, several limitations should be acknowledged. Firstly, the cross-sectional design limits causal inference and longitudinal assessment of CAM utilization patterns. Longitudinal studies could provide a more comprehensive understanding of CAM utilization trends over time. The study employed a non-probability online sampling approach, and despite broad circulation efforts, certain demographic subgroups may still have been underrepresented; thus, the findings should be interpreted with caution. Additionally, the study relied on self-reported data, which may be subject to recall bias and social desirability bias. As a result of recruitment through online platforms and social media, the exact number of individuals receiving the survey link was unclear. This uncertainty hindered the calculation of the response rate and may have introduced non-response bias. Future research could incorporate objective measures of CAM usage, such as national records or biomarker analysis, to validate self-reported data. Furthermore, the study focused solely on CAM utilization for influenza management, overlooking other respiratory infections and health conditions.

Additionally, the study did not assess the clinical efficacy or safety of the CAM products used, which limits the ability to determine their actual therapeutic effectiveness for influenza management. The majority of participants are students, which may limit generalizability.

Overall, our findings show that CAM is frequently used as a complementary approach to manage influenza symptoms, underscoring the need for rigorous evidence to inform its safe and appropriate use. This use should be approached cautiously, given the potential for herb–drug interactions and the risk of substituting CAM for necessary medical care, and professional guidance is essential to support safe and most effective health outcomes.

Conclusion

This research emphasizes the widespread use of CAM, especially herbal remedies, for managing influenza among Palestinians. While it reflects global CAM trends, cultural factors shape its application in Palestine. Acknowledging this reliance on CAM is vital for stakeholders to improve healthcare policies and public health outcomes. Understanding the cultural relevance of these practices can enhance patient care and encourage collaboration between traditional and modern healthcare providers.

Educational initiatives are essential for informing the public about the safe use of herbal remedies, preventing adverse interactions with medications, and importance of seeking timely medical care. Furthermore, healthcare providers should be encouraged to engage proactively with patients about their CAM use to enhance communication, build trust, and ensure coordinated care. Developing clear national, evidence-based guidance on CAM practices—including when, how, and for whom CAM is appropriate—can further support safe integration into healthcare settings.

Ongoing dialogue among communities, practitioners, and policymakers is crucial for developing culturally sensitive and scientifically sound healthcare solutions. Strengthening collaboration between conventional healthcare providers and traditional practitioners will support safer CAM integration and promote better influenza management outcomes.