Introduction

Complementary and alternative medicine (CAM) refers to a diverse range of medical practices and products that are not typically part of conventional Western medicine1. Although CAM practices have ancient origins, they have gained widespread acceptance and popularity worldwide in recent decades1,2. In Middle Eastern countries, particularly Palestine, CAM practices such as Islamic healing and traditional Arabic medicine are deeply rooted in cultural and religious traditions, whereas other modalities, such as homeopathy, have been introduced more recently and have gradually gained popularity3,4. These methods are used not only for disease prevention but also for alleviating various symptoms, and they are considered an integral part of healthcare by many individuals5.

The widespread use of CAM is influenced by multiple factors. These include concerns about the side effects of synthetic drugs, fear or mistrust of hospitals, cultural adherence, and the perception that CAM is both highly effective and safer due to its natural origins6,7. Additionally, ease of access, lower cost, and strong media promotion contribute to the increasing demand and popularity of CAM. Many individuals believe that CAM therapies produce quick effects with minimal side effects, further encouraging their usage6,7.

Although Palestine has set up medical facilities to meet international standards and uses evidence-based practices provided by medical staff, patients still use CAM for their disease in addition to standard therapy8,9. This is due to their belief that, by doing so, they are achieving the maximum benefit from their treatment, in addition to the patient’s conviction of the benefits6. Moreover, recommendations from family, friends, or even healthcare providers may influence patients’ decisions to use CAM, particularly when conventional treatments fail to provide relief10.

The existing body of literature on CAM predominantly focuses on prevalence assessments11,12,13, with limited attention given to the psychological aspects of CAM acceptance and patient satisfaction13. Despite numerous studies investigating the prevalence of CAM usage, there is a notable scarcity of evidence concerning patient satisfaction with CAM use, particularly in the Palestinian context. Additionally, the establishment of data concerning CAM types and categories used in Palestine is still explicitly needed among patients with specific ailments such as osteoarthritis14,15,16 to convey a better understanding of CAM use and prevalence.

Osteoarthritis is one of the most prevalent musculoskeletal disorders, particularly among elderly individuals, and is a leading cause of disability worldwide. Conventional treatments primarily focus on symptom management through pharmacologic interventions such as nonsteroidal anti-inflammatory drugs, physical therapy, and, in severe cases, surgical intervention. However, the chronic nature of OA, potential side effects of long-term medication use, and limited curative options have led many patients to explore CAM as a supplementary or alternative treatment approach17,18,19. In addition to physical and spiritual CAM practices, many osteoarthritis patients also turn to herbal remedies and dietary supplements20. These compounds are often perceived as safer, more natural alternatives to pharmaceuticals and are widely used in Middle Eastern cultures8,9. Studies from various countries have reported that CAM therapies such as herbal remedies, acupuncture, massage, dietary supplements, and spiritual healing are commonly used by OA patients to manage pain and improve their quality of life17,18,19,21. Despite this global trend, data on the types, prevalence, and patient satisfaction with CAM use among OA patients in Palestine remain limited. This highlights the need for localized studies to understand how cultural, social, and economic factors shape CAM use in specific populations.

This study aimed to explore the use of CAM among osteoarthritis patients in the northern region of Palestine. Specifically, this study sought to determine the prevalence of CAM use, identify the various types of CAM therapies utilized, and assess patients’ overall satisfaction with these therapies. This descriptive cross-sectional study relies on data collected through a structured survey. By examining the types and frequency of CAM use, as well as patient satisfaction, this study hopes to provide a foundational understanding that can inform future research and healthcare practices related to CAM use in osteoarthritis management in Palestine.

Metods

Study design and population

This descriptive cross-sectional study was conducted to determine the prevalence of CAM use among osteoarthritis patients in the northern region of Palestine and to assess their satisfaction with these therapies. The study was conducted after approval was obtained from the relevant authorities at selected hospitals across northern Palestinian cities: Nablus (An-Najah National University Hospital, Rafidia Governmental Hospital), Qalqilia (Darwish-Nazzal Governmental Hospital), Tulkarm (Thabet-Thabet Governmental Hospital), and Salfit (Yasser Arafat Hospital). Data collection took place between August 2023 and January 2024.

The target population consisted of patients with a confirmed diagnosis of osteoarthritis who received care at the participating hospitals during the study period. The inclusion criteria required participants to be residents of one of the northern cities on the West Bank, aged 18 years or older, and capable of completing the questionnaire. Patients who declined participation or were unable to complete the survey were excluded from the study.

Patients with stable chronic comorbidities such as hypertension, diabetes mellitus, or cardiovascular disease were included, provided that these conditions were under medical control and did not interfere with their ability to participate in the interview. However, patients with acute medical illnesses, cognitive impairment, or communication difficulties were excluded to avoid potential bias in data reliability.

Sample size and calculation

On the basis of a study conducted on patients with OA in 201922, an estimation of the population was used. The sample size was calculated via Raosoft23, with a 95% confidence level, 5% margin of error, and 50% response distribution. A sample size of 375 participants was initially determined and then rounded to 400 to minimize bias. Patients were recruited via the convenience sampling method. All eligible patients encountered by the research team at the selected hospitals were invited to participate. Those who agreed were asked to complete a structured, primarily closed-ended questionnaire.

Measures and data collection

Between August 2023 and January 2024, face‒to-face interviews were conducted across multiple hospitals to collect data on the use of CAM among patients diagnosed with OA. The questionnaire was developed in Arabic and is based on previously validated instruments used in Palestinian studies by Sawalha4 and Zyoud28, which were both administered in Arabic and culturally adapted to the Palestinian context. The content and structure were further refined through a comprehensive literature review to ensure alignment with the objectives of the current study. To confirm validity, the questionnaire was reviewed by a panel of five experts in orthopedics, clinical pharmacy, and biostatistics, who assessed the relevance and clarity of each item in relation to the study goals. The internal consistency reliability was tested via Cronbach’s alpha, which yielded a coefficient of 0.752, indicating acceptable reliability. Additionally, the tool incorporates selected elements from validated international CAM questionnaires, with modifications to fit the cultural and social characteristics of the local population24,25,26,27,28. The questionnaire underwent content validation by a panel of experts in orthopedics, alternative medicine, clinical pharmacy, and biostatistics. Its clarity and readability were pretested in 21 participants as a pilot study.

The instrument included items covering sociodemographic data such as age, sex, education level, monthly income, marital status, place of residence, employment status, and presence of comorbidities. It also included questions on the types of medications used. Furthermore, it details the use of CAM, including the specific types utilized and the patients’ satisfaction levels, which are assessed on the basis of their perceived benefit from CAM therapies28.

The participants were selected through a convenience sampling approach. To limit recall bias, the participants were asked only about their CAM use within the six months preceding the study. Structured response options were provided to facilitate recall and ensure data accuracy.

The research team personally administered the questionnaire to each participant face-to-face, ensuring accurate responses and providing clarification when needed. Each interview lasted approximately 10–20 min.

Data and statistical analysis

The data were analysed via the IBM Statistical Package for the Social Sciences (SPSS) version 21, with descriptive statistics for demographic information. The Mann‒Whitney U test was used to compare continuous variables, whereas the chi-square test or Fisher’s exact test was used for categorical variables. The correlation between satisfaction level and the use of CAM modalities was evaluated via Spearman’s rank correlation coefficient. The significance threshold was established at a p value of less than 0.05.

Ethical considerations

The study protocol was approved by the Institutional Review Board (IRB) of An-Najah National University [IRB Reference #: Med. August 2023/18]. The necessary approval was obtained from the local health authorities. The research adhered to the principles of the Declaration of Helsinki. The participants were informed about the purpose of the study, and written consent was obtained before their participation. Confidentiality and privacy were maintained throughout the study, with access to patient data restricted to the research team.

Results

Demographic and general characteristics of the patients

In this study, 399 patients were included. More than half of the participants were females (62.4%), and 41.4% of the participants were aged 57-67.9 years, were married (79.7%), lived in a village (59.1%), and had a monthly income between 2000 and 5000 New Israeli Shekel (NIS) (58.4%). Additionally, 67.2% of the respondents were diagnosed with OA within one year or less than five years. The demographic details of the patients are shown in Table 1.

Table 1 Demographic information and general characteristics of the participants (n = 399).
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CAM use among OA patients

Among the 399 patients, 63.2% used CAM. A total of 47.4% used massage therapy, 35.3% used physiotherapy, 9% used folk medicine, and 5.3% used acupuncture. The most common folk medicine practices reported by participants included the use of heated olive oil for massage or as joint compresses; herbal infusions such as thyme, chamomile, anise, and marjoram; and the use of honey and black seeds as traditional home remedies for pain and inflammation. A few participants also reported engaging in bone setting and cupping, both of which remain commonly practiced within Palestinian communities as part of inherited folk and religious healing traditions. A detailed distribution of CAM methods is shown in Table 2. Among the participants, 14.8% used Ruqyah, 11.8% used honey, 10.8% used black seed, 8.3% used cupping, and 6.5% used a diet, as shown in Table 3.

Table 2 Types of CAM used by participants.
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Table 3 Types of prophetic medicine used by the participants (n = 399).
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Herbal supplement use among OA patients

Among the 399 OA patients, 199 (49.9%) reported using at least one herbal medicine. Table 4 shows the herb use among the patients; 27.1% of the respondents used olive oil (Olea europaea L.), 19.8% used chamomile (Matricaria chamomilla L.), 15.3% used Anise (Pimpinella anisum L.), 14.8% used Marjoram (Origanum majorana), and 10.3% used Thyme (Thymus vulgaris L.).

Table 4 Types of herbs used by participants (n = 399).
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Supplement use among OA patients

Among the OA participants, 106 (26.6%) reported using supplements. Among those who used supplements, 19.3% took vitamin D supplements, and 17% used calcium supplements (Table 5). Other supplements, such as iron, multivitamins, and magnesium, were used less commonly.

Table 5 Types of supplementations used by the participants (n = 399).
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Satisfaction level among patients using CAM

A Spearman correlation coefficient was calculated, as shown in Table 6, to assess the relationship between satisfaction levels and the use of CAM among the respondents. The results indicated a significant positive relationship between satisfaction level and the use of CAM (r = 0.115, p = 0.022).

Table 6 Satisfaction level among patients using CAM.
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In addition to the general correlation between satisfaction and the use of CAM, a more detailed analysis was conducted to explore the relationship between satisfaction and the use of specific CAM treatments, as shown in Table 7. Spearman’s rho correlation results revealed several significant positive relationships between satisfaction and specific CAM modalities. Specifically, a strong positive relationship was found between satisfaction levels and the use of massage creams and olive oil (r = 0.478, p value = 0.000) and between satisfaction levels and the consumption of olive oil (r = 0.219, p value = 0.000). Additionally, there were significant positive relationships between satisfaction and the use of folk medicine (r = 0.223, p value = 0.000), acupuncture (r = 0.119, p value = 0.017), physiotherapy (r = 0.407, p value = 0.000), and ruqyah (r = 0.125, p value = 0.012).

Table 7 Spearman’s correlation between satisfaction level and use of CAM treatments (n = 399).
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Moreover, satisfaction levels were positively associated with the use of certain herbs, including thyme (r = 0.166, p value = 0.001), chamomile (r = 0.213, p value = 0.000), anise (r = 0.128, p value = 0.010), and marjoram (r = 0.175, p value = 0.000). However, the analysis also revealed a negative and nonsignificant relationship between satisfaction and the use of cupping (r = -0.012, p value = 0.809), honey (r = -0.052, p value = 0.296), and black seeds (r = -0.008, p value = 0.866). Additionally, there was a positive but nonsignificant relationship between satisfaction and the use of diet (r = 0.049, p value = 0.325).

Discussion

In this study, a total of 399 OA patients participated, with the majority being female (62.4%), married (79.7%), and residing in villages (59.1%). Most were within the age range of 57–67.9 years, and a substantial portion had been diagnosed with OA within the past five years. These demographics align with global trends where OA incidence increases with age and is more common among women29. The rural predominance might also indicate greater cultural adherence to traditional therapies in these communities.

CAM usage was reported by 63.2% of the participants. The most commonly practiced methods were massage therapy (47.4%) and physiotherapy (35.3%), followed by folk medicine and acupuncture. This reflects a strong cultural and traditional belief in hands-on and movement-based therapies, which are often perceived as effective and safe. The low use of acupuncture might be attributed to limited access, cost, or cultural unfamiliarity with the technique.

In addition to these physical and manual therapies, several participants reported using various folk medicine practices that are deeply rooted in Palestinian culture. These included the application of heated olive oil for massage or compression for joint pain; the consumption of herbal infusions such as thyme, chamomile, anise, and marjoram; and the use of honey and black seeds as natural remedies for inflammation and pain relief. Some also mentioned bone setting and cupping, both of which remain common folk and religious healing practices in local communities. These findings align with those of previous studies emphasizing the persistence of traditional home-based remedies as part of primary healthcare behaviors in Middle Eastern populations8,9,24,25.

In Malaysia, a study reported that 63.9% of arthritis patients utilized CAM, similar to our study, with vitamin supplements (48.2%) and herbal drugs (26.4%) being the most common30. On the other hand, a study in Morocco reported that 46% of patients used at least one CAM practice, including cupping therapy and traditional cautery31, which is considerably lower than our finding of 63.2% among OA patients. This difference may be attributed to variations in cultural attitudes, the prominence of prophetic medicine in Palestinian society, and easier access to traditional practitioners in rural communities.

Almost half (49.9%) of the OA patients used herbal medicine, similar to a study performed in Iran32. Olive oil was the most frequently used herb, followed by chamomile, anise, marjoram, and thyme. These findings are consistent with local traditions that promote the use of natural remedies for joint pain and inflammation. The widespread use of herbs indicates a high level of trust in natural products, possibly due to accessibility and cultural familiarity. In Saudi Arabia, 67% of rheumatoid arthritis patients use CAM, with honey (15%), ginger (13%), turmeric (11%), and black seeds (8%) being among the most frequently used products33.

*The frequent use of these herbs among OA patients may be linked to their perceived therapeutic benefits, which have also been supported by several scientific reports. Olive oil (Olea europaea L.) contains oleocanthal, a phenolic compound with anti-inflammatory activity comparable to that of nonsteroidal anti-inflammatory drugs26,27. Chamomile (Matricaria chamomilla L.) and thyme (Thymus vulgaris L.) exhibit antioxidant and analgesic properties that may help reduce inflammation and joint pain28,29. In contrast, scientific evidence for anise (Pimpinella anisum L.) and marjoram (Origanum majorana L.) is still limited, although both are traditionally used to relieve muscle stiffness and inflammation30.

With respect to dietary supplements, vitamin D and calcium were the most frequently used products among the participants. The popularity of these materials reflects their awareness of their role in bone metabolism and joint health. Studies have shown that vitamin D deficiency may contribute to cartilage degeneration and that supplementation can improve musculoskeletal function; however, evidence of its direct impact on osteoarthritis symptoms remains mixed31,32,33. These findings indicate that while many patients rely on herbal and nutritional approaches, their clinical effectiveness varies and requires further controlled studies. *.

The use of dietary supplements was also notable, with 26.6% of patients reporting use, primarily vitamin D and calcium. These supplements are known to support bone and joint health, and their use suggests a growing awareness among patients of the importance of nutritional support in managing OA34. However, the relatively lower use compared with herbal remedies may reflect limited financial resources or a preference for more traditional approaches. In the same Saudi Arabian study, vitamin D (47%) and calcium (37%) were the most frequently used supplements among CAM users33.

A significant positive correlation was found between overall satisfaction and CAM use. Specifically, high satisfaction was associated with massage therapy, physiotherapy, olive oil, and spiritual healing methods such as ruqyah. These findings suggest that therapies that combine physical support with cultural or spiritual support may increase patient satisfaction. For example, a study conducted in India assessed CAM use among patients with chronic diseases, including rheumatoid arthritis. The study revealed that 42.7% of rheumatoid arthritis patients used CAM, and among these users, 56.6% reported satisfaction in terms of effectiveness, whereas 54.1% expressed global satisfaction with CAM therapies. These findings suggest that a substantial proportion of arthritis patients find CAM treatments beneficial35. Similarly, a study in Turkey reported that 76% of arthritis patients utilized at least one form of CAM in the previous year. Among these, massage therapy was used by 28.4% of patients, and many participants perceived various CAM modalities as very effective36. These findings further support the notion that CAM therapies are commonly used and appreciated by arthritis patients for their perceived benefits.

On the other hand, cupping, honey, and black seeds were not significantly associated with satisfaction and, in some cases, were slightly negatively correlated. This finding indicates that not all traditional practices lead to favourable patient experiences and underlines the importance of evaluating CAM outcomes critically. This could be due to several factors. First, some practices, such as cupping, although culturally endorsed, may involve discomfort or side effects, such as skin bruising, which may negatively affect patient satisfaction. Similarly, the therapeutic efficacy of black seed and honey might not be immediately observable in OA symptom relief, leading to lower satisfaction scores despite their cultural or religious significance.

Additionally, the expectation gap may play a role. Patients who try CAM with high hopes for quick relief might become dissatisfied if the results are not as effective or as fast as expected. This underscores the need for proper patient education about realistic outcomes and the evidence (or lack thereof) supporting each CAM modality. It is also possible that the way these therapies are administered (i.e., quality, dosage, guidance) affects satisfaction. In unregulated settings where patients use CAM based on hearsay or traditional knowledge without professional supervision, inconsistent results are common and may diminish patient satisfaction.

These findings emphasize the necessity of developing culturally sensitive yet evidence-based health education programs. Healthcare professionals should engage in open conversations with patients about CAM, guiding them toward safe, effective, and integrated approaches to OA management. With this in mind, we can infer from the data that the use of CAM is prevalent among Palestinians in our surveyed areas, who come from various sociodemographic areas, occupations, and ages, which aligns with findings from various studies37,38. Furthermore, the overall level of satisfaction among CAM users was notably positive, indicating perceived benefits in symptom management, which is consistent with similar reports in the literature39. While CAM practices are widely used across different countries and cultures, the frequency of use and the level of satisfaction reported vary significantly on the basis of cultural, social, and individual factors. Therefore, more comprehensive research is warranted to better understand the effectiveness and safety of specific CAM modalities, especially in the context of chronic conditions such as osteoarthritis.

Strengths and limitations of the study

This study provides valuable insights into CAM use among Palestinian OA patients, addressing misconceptions and risks. Its comprehensive data collection, encompassing demographic and clinical factors, offers valuable guidance for policymakers and healthcare providers. However, our study has several limitations. First, the use of datasets based on self-reports increases the potential for recall bias, and the cross-sectional design is inadequate for causality because it fails to offer a sense of change over time. In addition, there is a lack of generalizability because patients who did not want to participate or seek treatment at the surveyed sites were also excluded, potentially leading to selection bias. This study did not investigate the effect of CAM use on a patient’s quality of life, and the lack of a control group prevents further investigation of variations in outcomes. Nevertheless, this research fills an important gap and provides a foundation for future work in this area.

Conclusions

This study highlights the widespread use of CAM among osteoarthritis patients in northern Palestine, with 63.2% of participants utilizing various CAM therapies, including herbal plants, supplements, and prophetic medicine. The high prevalence of CAM use emphasizes the importance of understanding the factors influencing its adoption and integrating these therapies into patient care. Despite the popularity of CAM, satisfaction levels vary across different therapies, with some modalities, such as massage therapy and physiotherapy, being associated with increased patient satisfaction. Conversely, certain traditional practices, such as cupping and honey, resulted in lower levels of satisfaction, suggesting the need for further evaluation of their effectiveness.

Healthcare providers should consider the growing use of CAM and ensure that patients are informed about the potential benefits and risks, particularly concerning interactions with conventional treatments. Given the significant prevalence of CAM use, further research is necessary to establish a more comprehensive understanding of its impact on OA management and patient outcomes. Future studies should explore the long-term effects of CAM and the role it can play alongside conventional therapies in improving the quality of life of osteoarthritis patients in Palestine and similar regions.