Citation
Use of herbal products, prescribed medicines and non-prescribed medicines by community-dwelling older women

Material Information

Title:
Use of herbal products, prescribed medicines and non-prescribed medicines by community-dwelling older women
Creator:
Yoon, Saun-Joo Lee
Publication Date:
Language:
English
Physical Description:
leaves : ill. ; 29 cm.

Subjects

Subjects / Keywords:
Complementary therapies ( jstor )
Demography ( jstor )
Diseases ( jstor )
Health care industry ( jstor )
Health status ( jstor )
Herbs ( jstor )
Medical conditions ( jstor )
Medications ( jstor )
Older adults ( jstor )
Women ( jstor )
Dissertations, Academic -- Nursing -- UF ( lcsh )
Nursing thesis, Ph.D ( lcsh )
Greater Orlando ( local )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph.D.)--University of Florida, 1999.
Bibliography:
Includes bibliographical references.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Saun-Joo Lee Yoon.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
The University of Florida George A. Smathers Libraries respect the intellectual property rights of others and do not claim any copyright interest in this item. This item may be protected by copyright but is made available here under a claim of fair use (17 U.S.C. §107) for non-profit research and educational purposes. Users of this work have responsibility for determining copyright status prior to reusing, publishing or reproducing this item for purposes other than what is allowed by fair use or other copyright exemptions. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder. The Smathers Libraries would like to learn more about this item and invite individuals or organizations to contact the RDS coordinator (ufdissertations@uflib.ufl.edu) with any additional information they can provide.
Resource Identifier:
030395129 ( ALEPH )
79830929 ( OCLC )

Downloads

This item has the following downloads:


Full Text










USE OF HERBAL PRODUCTS, PRESCRIBED MEDICINES AND NON-PRESCRIBED MEDICINES BY COMMUNITY-DWELLING OLDER WOMEN
















By

SAUN-JOO LEE YOON

















A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1999





























Copyright 1999 By

Saun-Joo Lee Yoon





























To my husband, Sung-Hwa,
and daughters, Alyssa and Hyunji for

their love, patience, and encouragement














ACKNOWLEDGEMENTS

I wish to thank the members of my supervisory committee for their encouragement and support from the inception of this research study to its completion. I am especially grateful to Dr. Claydell Homne, chairperson of my committee, for her counseling, support and patience throughout my doctoral program.

I extend my sincere appreciation to Dr. Kathleen Long

for her support and encouragement to conduct this research. I am grateful to Dr. Hossein Yarandi for his expertise with the data analyses, and to Dr. Robin West for her encouragement and support throughout the doctoral program. I am especially appreciative of Mr. Jeffery Delafuente for his insight and guidance throughout this endeavor.

I wish to thank my parents and parents-in-law for their support and love from Korea. My infinite thanks go to my husband, Sung-Hwa, and daughters, Alyssa and Hyunji, for their love, patience, support, and confidence. Finally, I am very appreciative of the grant from Alpha Theta Chapter, Sigma Theta Tau International Honor Society and of support from the College of Nursing for providing transportation during data collection.

iv

















TABLE OF CONTENTS

page

ACKNOWLEDGEMENTS . .. iv

LIST OF TABLES . .. vii

ABSTRACT . . viii

CHAPTER I: INTRODUCTION . 1

Introduction . 1
Problem Statement . 6
Research Aims . 9
Research Hypotheses . 10 Research Questions . 10
Operational Definition of Terms 11 Assumptions . .. 12
Limitation . 13
Summary . . 13

CHAPTER II: REVIEW OF LITERATURE . 16

Differences between Alternative
Medicine and Conventional Medicine ...... 16
History of Herbal Products and
Their Use . .. 21
Prevalence of Alternative Medicine
and Herbal Products . 26
Choice Between Alternative and Conventional
Medicines . . 29
Older Women and Health Problems 32
Patterns of Drug Use Among Older
Adults . . .. 37
Polypharmacy . .. 40
Toxicities of Herbal Products and
Possible Interactions with Drugs of
Conventional Medicine . 45




v











CHAPTER III: METHODOLOGY . 50

Research Design . 50
Setting . .. 50
Sample . . 51
Inclusion and Exclusion Criteria 52 Instrument . 53
Operationalization of Variables .. 54 Procedure . .. 60
Data Collection . .. 62
Data Analysis . .. 67

CHAPTER IV: RESULTS . .. 68

Research Design . .. 68
Sample . . 68
Demographic Characteristics of the
Sample . . 71
Research Hypotheses . .. 75
Description of the Research
Questions . .. 88
Other Findings . 93

CHAPTER V: DISCUSSION AND RECOMMENDATIONS .. 95

Discussion and Conclusions 95
Implication for Nursing and
Recommendations . 106

REFERENCES . . 109

APPENDIX A: QUESTIONNAIRE . .. 118

APPENDIX B: CONSENT FORM . 128

APPENDIX C: THE 20 MOST POPULAR ASIAN PATENT MEDICINES
THAT CONTAIN TOXIC INGREDIENTS 133

BIOGRAPHICAL SKETCH . .. 137











vi

















LIST OF TABLES

TABLE page

4.1 Frequency Distribution of Total Sample 70

4.2 Age of Herbal Users, Non-Users, and Total
Sample . . 71

4.3 Demographic Characteristics of the Total Sample,
Herbal Product Users, and Non-Users 74

4.4 Perceived Overall Health by Herbal Users,
Non-Users, and Total Sample . 78

4.5 Perceived Physical Health by Herbal Users
Non-Users, and Total Sample . 79

4.6 Perceived Emotional Health by Herbal Users
Non-Users, and Total Sample . 80

4.7 Types of Health-Related Problems .. 82

4.8 Frequently Used Non-Prescribed Medicines
Taken Regularly . . 86

4.9 Use of Prescribed, Non-Prescribed
Medicines by Sample . 87

4.10 Types of Herbal Products Used by Subjects 89

4.11 Purposes of Using Herbal Products by Subjects
and by Number of Herbal Products .. 90

5.1 Frequencies and Percentages of Females
and Males Aged 65 and Over in a North
Central Florida County . .. 96

5.2 Summary of Races among Females Aged 65
and Over . . .. 97



vii















Abstract of Dissertation Presented to the Graduate School Of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy


USE OF HERBAL PRODUCTS, PRESCRIBED MEDICINES AND
NON-PRESCRIBED MEDICINES BY COMMUNITY-DWELLING OLDER WOMEN

By

Saun-Joo Lee Yoon

May, 1999

Chairperson: Claydell Horne, PhD Major Department: Nursing

As alternative health care is becoming more prevalent among persons in the United States, the use of herbal products is on the increase. Although herbal products are considered to be natural, these products have not been subjected to scientific clinical studies and, therefore, have not been FDA approved. The number of women aged 65 years and older in the US using herbal products is unknown. The purpose of this research is to explore the use of herbal products for medicinal purposes and to compare differences in demographic characteristics and health status between the herbal product users and non-users among community-dwelling older women. Sampling criteria were viii








women 65 years and over and living independently in a North Central Florida county. A random sample was selected from a list of 8,344 women 65 years and over obtained from the State Department of Highway Safety and Motor Vehicles. Structured interviews were completed on 86 subjects.

The interview questionnaire was comprised of three parts including health status and use of conventional medicines, use of herbal products, and demographic data. Data indicated that herbal products were used by 45.3% of the sample in the past 12 months. The total sample reported using a mean of 3.2 prescribed medicines and 3.8 non-prescribed medicines per person. The mean number of herbal products used by the sample was 2.5. The sample reported using a total of 98 herbal products. Subjects reported only 28% of the total number of herbal products used to their health care providers. No differences in demographic characteristics and health status were found between users and non-users of herbal products except in the area of memory problems. More herbal product users claimed memory problems than non-herbal users. It is important for health care providers to be knowledgeable of the use of herbal products in order to provide comprehensive health care to older women and to prevent unintended herbal-drug interactions.





ix

















CHAPTER I
INTRODUCTION

Persons who are 65 and older comprise the fastest

growing age group in the United States. Among 249 million people in the United States, 34 million are aged 65 and older (U.S. Bureau of Census, 1990). In the 65 years and older population, women outnumber men and this gap widens with increasing age (Cobbs & Ralapati, 1998). Older women in this age group have a higher disability rate and are more likely than men to live longer with chronic conditions (Kart, 1994).

Although persons 65 and older represent about 14% of the American population, they consume three times more prescription drugs than their younger counterparts (Gormley, Griffiths, McCracken, & Harrison, 1993). Four out of five people aged 65 and older have at least one chronic disease (Delafuente, 1991), and persons in this age group have almost twice the risk of iatrogenic disease and visit the clinics more often than do younger people (Lamy, 1986). Researchers show that community-dwelling elderly use an average of 4.4 drugs including prescription and


1







2


non-prescription drugs, and about 85% of these persons take two or more drugs (Pollow, Stoller, Foster, & Duniho, 1994).

Many elderly people are dependent on conventional drug therapy to treat their chronic conditions and to maintain their health. The goals of drug therapy in the elderly are to (a) alleviate pain, (b) improve functional capacity, (c) promote quality of life, and (d) prolong life (Sloan, 1992) Multiple drug use in the elderly, even when each drug has a therapeutic purpose, can increase the risk of significant drug-related problems such as adverse drug reactions or drug-drug interactions (Noyes, Lucas, & Stratton, 1996; Sloan, 1992). While the use of multiple prescription and non-prescribed drugs among the elderly has been studied extensively (Chrischilles et al., 1992; Fillenbaum, Horner, Hanlon, Landerman, Dawson, & Cohen, 1996; Helling, Lemke, Selma, Wallace, Lipson, & CornoriHuntley, 1987; Stewart, Moore, May, Marks, & Hale, 1991), little is known about the use of herbal products by this age group and how herbals react when taken with prescribed and/or non-prescribed medicines.

Recently, herbal products have increasingly received attention in the United States as complementary and






3


alternative medicine. Many researchers have used different terms to explain complementary and alternative medicine (CAM) such as unconventional, alternative or complementary, unproven, and unorthodox therapies. Eisenberg, Kessler, Forster, Norlock, Calkins, and Delbanco (1993) defined CAM as medical interventions not taught widely at U.S. medical schools or those not generally available at U.S. hospitals (i.e. acupuncture, chiropractic, and herbal medicine). The definition of CAM was further refined in the CAM Research Methodology Conference in 1995 as a broad domain of healing resources that comprises all health systems, modalities, and practice other than a dominant health system of a particular society in a given historical period (Panel on Definition and Description, CAM Research Methodology Conference, April 1995, 1997).

Recently, attention to CAM has been given by governmental health agencies. Examples include the establishment of the Office of Alternative Medicine (OAM) in National Institutes of Health (NIH) in 1992, and the passage of new regulation of herbal products as dietary supplements in the Dietary Supplement Health and Education Act (DSHEA) in 1994 (Taylor, 1996). Even before the passage of new regulations on herbal products in 1994, sales of





4


herbal products in the United States in 1991 were estimated at over one billion dollars (McCaleb, 1993). Although it may not necessarily reflect the actual use of CAM including herbal medicines, changes in the regulation of herbal products and more research focused on CAM certainly bring higher public interest than ever before.

In the United States, one in three study participants reported using at least one unconventional therapy in the past year (Eisenberg et al., 1993). In the same study, three percent of Americans surveyed used herbal medicines during the past twelve months while approximately 80% of the worldwide population were estimated to depend on traditional herbal medicines (World Health Organization, 1993). According to Eisenberg and colleagues (1993), the majority of people used unconventional therapies for chronic medical conditions, hut not for life-threatening situations. Eisenberg and colleagues (1993) inferred that a substantial number of unconventional therapies were used for nonserious medical conditions, health promotion, or disease prevention.

Because of the variability of complementary and

alternative medicines, natural health food stores selling herbal products are expanding businesses in the United





5


States. The botanical industry has grown from almost nothing to a $1.5 billion industry in 20 years and is expanding at a rate of 15% a year (Marwick, 1995). Herbal products are becoming more familiar to the public because these products are considered to be natural and safe to use without adverse effects and are easy to obtain in the natural health food stores.

Today, people have access to a wide availability of herbal products and many of these products have been imported from foreign countries without strict safety regulations. Herbal products can be toxic and can sometimes be mixed with toxic ingredients with or without knowledge of the user. People can suffer adverse effects because of misinformation about products, possible interactions with conventional drugs, and substance overdose. Because the elderly are a group of people using herbal products for their health care, they are most at risk of suffering adverse effects by using these herbal products alone or combined with conventional drugs.

Because of the increased attention and consumption of herbal products, there must be more i research to study the patterns of herbal use alone or with prescribed and/or nonprescribed medicine. More needs to be known about the






6


prevalence and the reasons for taking herbal products among the elderly as well as possible interactions between drugs of conventional medicine and herbal products.

Problem Statement

It is known that there are altered pharmacological

mechanisms and decreased functional capacity of the major organ systems with aging (Montamat, Cusack, & Vestal, 1989). However, people who are aged 65 and older consume three times more prescription drugs than those under 65 (Gormley, Griffiths, McCracken, & Harrison, 1993). In addition to prescribed medications, the older adults are, also, frequent users of nonprescription drugs (Pollow, Stoller, Foster, & Duniho, 1994). The overall incidence of adverse drug reactions or interactions in the elderly is two to three times higher than the occurrence in their younger counterparts (Nolan, & O'Malley, 1988). These figures, however, do not include reaction or interaction with the use of herbal products.

Most older persons have at least one chronic condition and many have multiple conditions. According to the Administration on Aging, the most frequently occurring conditions per 100 elderly in 1994 included arthritis (50), hypertension (36), heart disease (32), hearing impairments





7


(29), cataracts (17), orthopedic impairments (16), sinusitis (15), and diabetes (10). Women who are aged 65 and older have the highest rate of chronic conditions such as arthritis (U.S. Department of Health and Human Services, 1997).

Eisenberg and colleagues (1993) pointed out that the use of unconventional therapies was not limited to the person's principal medical condition as adjuncts to conventional therapy, but extended to nonserious medical conditions, health promotion, or disease prevention. A full one-third of their study respondents who used unconventional therapies did not use these therapies for any of their principal medical problems (Eisenberg et al., 1993).

According to the earlier study by Eisenberg and

colleagues (1993), prevalence rate of persons 18 years and older who use herbal products in the United States is three percent. However, since the Dietary Supplement Health and Education Act in 1994, the use of herbal products has increased; and since that time, researchers have found an increasing prevalence of herbal product use among persons in the United States. The World Health Organization estimated that traditional herbal medicines were the most









frequently used types of therapies for the majority of people in the world.

There were controversial results relating to the

prevalence of reported use of herbal medicines among age groups in studies conducted in the United States (Eisenberg et al., 1993; Frate, Croom, Frate, Juergens, & Meydrech, 1996) Frate and colleagues (1996) stated that over 70 percent of the adults in their sample used at least one plant-derived medicine during the past year, while three percent of the study population used herbal therapies in the study by Eisenberg and colleagues (1993) Differences in study results may occur because of research methodology, definitions of herbal medicine and plant-derived therapies, and settings of data collection.

The use of herbal products has been studied in certain types of illnesses. Researchers showed the use of herbal products among AIDS patients (Greenblatt, Hollander, McMaster, & Henke, 1991; Kassler, Blanc, & Greenblatt, 1991), Alzheimer's patients (Coleman, Fowler, & Williams, 1995), rheumatoid arthritis patients (Boisset & Fitzcharles, 1994), and cancer patients (Cassileth & Chapman, 1996).

While researchers reported the use of herbal products among disease specific groups of people, very little is





9


known about the prevalence of use of herbal products among the elderly residing the community. Also, little information is available related to the potential adverse effects of herbal products and possible interactions between conventional drugs and herbal products in the elderly.

Research Aims

The purpose of this research is to study the use of herbs and/or herbal products for medicinal use as well as the possible interactions between herbals with prescribed and/or non-prescribed medicines among community-dwelling older women.

Specific Aims

1. To identify the prevalence of use of herbal products

and/or herbs among community-dwelling women 65 years

and older.

2. To identify the purpose for which women 65 and older

take herbal products and/or herbs and to determine

for which physical symptoms or health conditions

women most likely take herbal products.

3. To describe the frequency of use of herbal products

and/or herbs and whether herbal products and/or

herbs are used alone or in combination with prescribed and/or non-prescribed medicines.





10


4. To identify the sources of information related to

herbal products and/or herbs used by women 65 years

and older.

Research Hypotheses

i. There are differences in demographic characteristics

between herbal users and non-herbal users among

women aged 65 and older.

2. There are differences in health status between

herbal users and non-herbal users among women aged

65 and older.

Research Questions

1. What is the prevalence of women aged 65 years and over who use herbal products and/or herbs?

2. What is the purpose for taking herbal products

and/or herbs by women aged 65 years and over? Do

older women take herbal products more for

prevention or for treatment of symptoms?

3. What is the frequency of use of herbal products by older women? Do women who use herbal products use

them continuously over time or on an as needed

basis? Do women who use herbal products use them

alone or in combination with prescribed and/or nonprescribed medicines?








4. What sources do women 65 and over use to obtain

information about the use of herbal products?

Operational Definition of Terms

For the purpose of this research, terms are operationalized as follows: l.Complementary and Alternative Medicine (CAM) is defined

as a broad domain of healing resources that comprises all

health systems, modalities, and practice other than a

dominant health system in the United States. CAM is used

interchangeably with alternative medicine,

unconventional, complementary, or unorthodox therapies.

2. Older woman is defined as a woman 65 years and older. 3. Drugs of conventional medicine include the prescribed

and non-prescribed medicines. Non-prescribed medicines

include vitamins and minerals. Drugs of conventional

medicine can be used interchangeably with conventional

drugs.

5. Herb is defined as a plant or plant part valued for its

medicinal qualities.

6. Herbal product is defined as a product that (a) is

excluded from definition of 'drug' by FDA; and (b) is not labeled as a vitamin, a mineral, or food additive;

and (c) contains active ingredients aerial or

underground parts of plants, other plant material in a





12


crude state or plant preparation, or combinations

preparations; or (d) contains natural organic or

inorganic active ingredients, which are not of plant

origin by tradition, a concentrate metabolite,

constituent, or extract. Herbal products include

herbs hereafter.

7. Conventional medicine is defined as a dominant health

system in the United States which is widely taught

at U.S. medical schools or which is generally available

at the U.S. hospitals.

8. Polypharmacy is defined as the use of four or more

drugs, including both prescribed and non-prescribed

drugs, by a single person.

Assumptions

1. Participants have some knowledge of their health status,

including herbal products and drugs used for health

promotion and care.

2. Participants can identify reasons to choose or not to

choose herbal products.

3. Participants have access to various sources of

information about herbal products.

4. Participants may feel that it is not necessary to

communicate the use of herbal products to their

physicians or other regular health care providers,






13


because herbal products are from natural sources and

considered as dietary supplements.

5.Although herbal products are considered to be safe and

beneficial for maintaining or promoting health conditions

in general, certain herbal products may have potential

toxicity or may interact with certain conventional drugs.

Limitation

The generalizabiiity of results of this study is limited to older women who live independently in north Florida. However, the population is believed to be similar to the populations of older white community-dwelling women in other parts of the United States.

Summary

Persons aged 65 and older are a rapidly growing group in the United States. In an aging population, there is an increase in the number of persons with chronic illnesses who need health care services. As persons age, there is a greater population of women than of men; and women have a higher disability rate than their male counterparts.

The known facts about herbal products are as follows. First, complementary and alternative medicines are receiving increased attention by society. Second, consumption of herbal products has increased and continues





14


to increase among people. Third, few toxicities and benefits of herbal products have been studied and recognized. Finally, primary physicians and other health care providers are not always aware that patients are taking herbal products. That is not only because patients lack knowledge about the contradistinctions of herbal products and conventional drugs but also because primary physicians or health care providers do not ask the patients about the use of herbal products.

However, there are facts that are not known clearly. Since herbal products are more likely to be used for chronic conditions and for maintaining and promoting health status, no known research data exist related to the use of herbal products by older women. Although data are available reflecting the need for better communication between health care professionals and patients to prevent the polypharmacy causing the drug-drug interactions of conventional drugs, little is known about the information related to the prevalence of use of herbal products or potential side effects of herbal products among the older women.

It is important to enhance understanding related to

prevalence of use of herbal products, specific purposes of using herbal products alone or in combination with drugs of






is


conventional medicine as well as differences between herbal product users and non-users among older women. The results of this research give a better understanding about the use of herbal products among older women and encourage extensive communication between health care providers and clients for comprehensive care, which results in improving the quality of life of older women.















CHAPTER II
REVIEW OF LITERATURE


The review of literature pertaining to herbal products research includes summation of the following topics: (a) differences between alternative medicine and conventional medicine; (b) history of herbal products and their use; (c) prevalence of the use of alternative medicine; (d) choice between conventional and alternative medicines; (e) older women and health problems; (f) patterns of drug use among older adults; (g) polypharmacy among the elderly; and (h) toxicities of herbal products and possible interactions of herbal medicines with conventional medicines. Differences between Alternative Medicine and Conventional Medicine

Alternative medicine is often defined as: (a) medical interventions not taught widely at U.S. medical schools or those not generally available at U.S. hospitals; (b) treatments which lack sufficient documentation in the U.S. for safety and effectiveness against specific diseases and conditions; and (c) practices that are not generally reimbursable by health insurance providers (Stalker, 16





17


1995). Seven categories of alternative medical practice are listed by the Office of Complementary and Alternative Medicines, the National Institute of Health (Workshop on Alternative Medicine, 1994). These include (a) mind-body interventions, (b) bioelectromagnetic therapies, (c) alternative systems of medical practice, (d) manual healing methods, (e) pharmacologic and biologic treatments, (f) herbal medicine, and (g) diet and nutrition. Mind-body interventions include psychotherapy, hypnosis, imagery, meditation, biofeedback, support groups, dance therapy, yoga, music therapy, art therapy, prayer, and mental healing. Mind-body intervention helps patients experience and express their illnesses in new ways by using placebo response and spirituality, as well as religion. Bioelectromagnetics (BEM) is the science that studies how living organisms interact with electromagnetic (EM) fields and purports that changes in the body's natural fields may produce physical and behavioral changes. BEM includes blue light treatment, artificial lighting, electroacupuncture, electromagnetic fields, electrostimulation and neuromagnetic stimulation devices, and magnetoresonance spectroscopy.

Worldwide, 70% to 90% of human health care is

delivered by alternative systems of medical practices,





18


varying from self-care according to folk principles to care by organized health care system based on an alternative tradition or practice. There are a variety of practices including acupuncture, traditional oriental medicine, ayurveda, environmental medicine, homeopathic medicine, Native American practices, naturopathic medicine, anthroposophically extended medicine, and Latin American rural practices.

Manual healing methods are based on the understanding that dysfunction of a part of the body affects secondary function of other body parts. These methods include osteopathy, acupressure, Alexander technique, chiropractic medicine, massage therapy, biofield therapeutics, and therapeutic touch (Workshop on Alternative Medicine, 1994).

Pharmacological and biological treatments are an assortment of drugs and vaccines not yet accepted by mainstream medicine, and include but are not limited to, anti-oxidizing agents, cell treatment, metabolic therapy, and oxidizing agents (Ozone, Hydrogen Peroxide) Diet and nutrition devised for the prevention and treatment of chronic disease include changes in dietary lifestyle, diet, Gerson therapy, macrobiotics, megavitamins, and nutritional supplements.





19


Herbal products are mostly a part of plants or plant products that have a long history of traditions in all cultures. Although many drugs commonly used today are of herbal origin, herbal products can be marketed only as food supplements in the United States. Despite the skepticism by Food and Drug Administration (FDA), a growing number of Americans are exhibiting interest in herbal preparations. The increased use of plant medicines has a potential benefit for improving public health, but issues related to safety, efficacy, and appropriateness of medicinal herbs need to be solved (Workshop on Alternative Medicine, 1994).

In contrast to alternative medicine, conventional

medicine is the medical practice that is widely available at American medical schools or in U. S. hospitals, and is considered to be the world's standard health care system among most people in the United States. There are many differences between alternative medicine and conventional medicine. Conventional medicine is based on the empiricism that relies on a mechanistic model; wherein, body and mind are viewed as separate entities with illness being explained in terms of measurable physical phenomena. Therefore, the primary goal of conventional medicine is to bring about measurable objective improvement in disease states. In contrast, one of the primary goals of






20


alternative medicine is to alter the subjective state of the person, which can eventually promote objective improvements in disease states (Burg, 1996).

Conventional medicine and alternative medicine can also be distinguished by their approaches to the role of the patient in treatment (Burg, 1996), by administration of therapies, and by the interaction between the patient and health care provider (Workshop on Alternative Medicine, 1994). In biomedicine, patients receive the standardized treatment and medical advice on the basis of diagnosis or symptomatic categories. In this system, the patientpractitioner interaction is "physician centered." The physician, thus, is the authoritative expert and the patient is a receptive participant (Brunton, 1984). In contrast, alternative medical practitioners tend to individualize treatment and to create elaborate procedures for identifying individual suitability and sensitivity to the interventions. They often apply multiple treatment modalities and judge effectiveness by using subjective and patient derived outcomes (Jonas, 1993). Alternative systems of medicine emphasize a client-centered relationship and patient responsibility in the healing process, which can maximize the collaboration between the medical





21


practitioners and patients, thus enhancing the benefits of a therapy.

Although all complementary medicine practitioners do not share a common epistemology, several principles are common to most of their practices. These include emphasis on the: (a) Patients' feeling rather than their diagnosis;

(b) Holistic view rather than conventional medical view: All aspects of the person (i.e. physical, emotional, mental, and psychosocial health, lifestyle, etc.) are interrelated and must be considered through the process of care; (c) Promotion of the use of a variety of therapeutic options for the purposes of prevention and treatment, and viewing treatment as a process; (d) Maintaining basic ethics of patient care such as do no harm; (e) Balance in a patient's body system, and relationship to other individuals, society, or environment; (f) Production of fewer side effects by using whole foods and herbs rather than using conventional drugs; and (g) Expectation that the patient is not a passive recipient but an active participant through the treatment process (Burg, 1996; Murray, 1994; Workshop on Alternative Medicine, 1994).

History of Herbal Products and Their Use

An herb is defined as a seed-producing annual,

biennial, or perennial that does not develop persistent






22


woody tissue but dies down after flowering. The second definition is a plant or plant part valued for its medicinal, savory, or aromatic qualities (Merriam-Webster's Collegiate Dictionary, 1993). The herbs referred to in this paper are included under the second definition. An herbal medicine is a plant-derived material or preparation with therapeutic or other human health benefits, which contains either raw or processed ingredients from one or more plants (World Health Organization, 1993).

Herbal prescriptions are available for the entire range of medical ailments, including pain, hormonal disturbances, breathing disorders, infections, and chronic debilitating illnesses. These are classified according to their energetic qualities and are prescribed for their action on corresponding organ dysfunction, energy disorders, disturbed internal energy, blockage of the meridians, or seasonal physical demands (Workshop on Alternative Medicine, 1994).

Early humans treated illness by using plants, animal

parts, and minerals that were not part of their usual diet. Herbal medicines using plants and plant products have been utilized in medical practice for thousands of years, and have made a great contribution to maintaining human health.






23


For example, the Ebers Papyrus, the preserved Egyptian manuscripts, were written around 1500 B.C. and contain 876 prescriptions made up of more than 500 different substances including many herbs. De Matefia Medica written in the 1st century A.D. offers about 950 curative substances including 600 plant products and other 350 of animal or mineral origin in Greece and Rome (Ackernecht, 1973) This text explains a description of the plant, an account of its medicinal qualities, methods of preparation, and warnings about undesirable effects. The Arabs preserved a body of knowledge in the Muslim matera medica, which lists more than 2,000 substances, including many plant products (Ackernecht, 1973).

Herbs played an important role in Ayruvedic medicine in India, and were described in Ayruvedic books more than 2000 years ago. The history of Chinese herbal medicine can be traced to the end of the third century B.C. The Encyclopedia of Traditional Chinese Medicine Substances,

the most definitive compilation of China's herbal tradition to date, has evolved from the Classic of the Matera Medica which was written almost 2,000 years ago. Traditional Chinese medicine influenced Korea and Japan and markedly simplified Japanese traditional medicine, called Kampo (Workshop on Alternative Medicine, 1994).





24


In contrast, the United States has a relatively short history of the use of herbal products compared to that of other countries. Early explorers of North America exchanged knowledge with the Native Americans to learn which herbs to use in the New World. Until the early 20th century, plants remained as a mainstay of country medicine, and were used not only by physicians to treat common ills, but also as important home remedies by many families (Buchman, 1980). A textbook of pharmacognosy contained hundreds of medically useful comments on herbs until the 1940s. As medicine evolved with advanced technology in the 20th century, remedies from natural resources were gradually forgotten in modern society. Today, however, many commonly used drugs are of herbal origin. About one-quarter of the prescription drugs dispensed by community pharmacies in the United States contain at least one active ingredient derived from plant material (Workshop on Alternative Medicine, 1994).

Recently, Americans have shown an increased interest

in the use of herbs and herbal medicines due in part to the changing health care system's focus on preventive care as well as interest in natural therapies (Youngkin, & Israel, 1996). There are other factors contributing to an increased interest in herbal products in America. one factor is the wide availability of such products from European countries,






25


China, Japan, South America, and Mexico, in most U.S. health food stores. Secondly, people are willing to try herbs and herbal preparations for chronic illnesses or as an adjunct to other treatment. And, finally, herbs and/or herbal products are generally considered to be less toxic than drugs from conventional medicines (Workshop on Alternative Medicine, 1994).

It is now easier to gain access to herbal products

since they are considered dietary supplements rather than a part of conventional drugs as a consequence of the Dietary Supplement Health and Education Act of 1994. In the United States, $1.5 billion of herbs were sold in 1995, and their sales rate has been growing from 12% to 18% per year averaging about 15% a year (Gray, 1996). There were about 8,000 natural health food stores in the United States in 1995 (Marwick, 1995).

With an increased use of herbal products, safety and toxicity are becoming issues. Although it is generally perceived that natural products are safe, there are risks when these are used because not all herbal remedies are harmless. Herbs or herbal products can be incorrectly identified by manufacturers as nontoxic herbs. Since many herbal products are mixtures, some of them may be toxic, particularly if they are misused. Some ayurvedic botanical





26


products contain high levels of heavy metals that can cause toxic effects. Another threat posed by herbal remedies is a lack of proper knowledge in using them, which results in an overdose causing irreversible organ damage (Marwick, 1995). It is important for herbal product users to collect information about the herbal products prior to their use. Health care providers need be more attentive to thorough history assessments of their clients related to the use of herbal products as well as the use of conventional drugs.

Prevalence of Alternative Medicine and Herbal Products

Alternative medicine has gained in popularity and

respectability in recent years, becoming widely used to promote or to maintain health, to treat diseases, to alleviate symptoms, and to prevent recurrence of illnesses. A 1990 national telephone survey revealed that 34% of Americans reported using at least one alternative medicine in the previous year including 10% who visited alternative practitioners, and spent $13.7 billion on these visits. Americans made more visits to alternative practitioners (425 million) than to primary care physicians (388 million) (Eisenberg et al., 1993).

The results of the study by Paramore (1997) are

consistent with that of Eisenberg and colleagues(1993). Paramore (1997) found that nearly 10% of the U.S.





27


population, almost 25 million persons, saw a professional in 1994 for at least one of the following four therapies: chiropractic, relaxation techniques, therapeutic massage, or acupuncture. The use of alternative medicines was correlated with poor health rather than maintaining or promoting health. The use of alternative medicines was frequently used among middle-aged whites who had more education and higher incomes (Eisenberg et al., 1993; Paramore, 1997). These researchers reported no significant gender differences in the use of four alternative medicines.

Alternative medicines were more frequently used to treat medical conditions such as back problems, insomnia, headache, anxiety, and depression (Eisenberg et al., 1993), and were also used for minor ailments, for health promotion, and as prophylaxis for recurrent problems (Murray & Shepherd, 1993). These therapies were generally used as adjuncts to conventional medicine rather than replacements for conventional medicine, (Eisenberg et al., 1993; Murray & Shepherd, 1993).

Overall, persons with chronic, nonspecific, and hardto-treat illnesses are likely to be frequent users of complementary medicines. Researchers studying polypharmacy among patients attending an AIDS clinic found that 29% of





28


patients with AIDS used alternative medicines during the three month period prior to the interview, and the use of alternative medicines was associated with their stage of illness (Greenblatt, Hollander, McMaster, & Henke, 1991). The use of medicinal herbs was more frequent in HIVinfected patients than in the general population, which showed that 22% of 114 randomly selected HIV-infected patients reported using one or more herbal products in the past three months (Kassler, Blanc, & Greenblatt, 1991).

According to Coleman, Fowler, and Williams (1995), 55% of caregivers of patients with Alzheimer's disease reported that they had tried at least one alternative therapy to improve the patient's memory, including 11% who used herbal medicines. Although the proportion of cancer patients using alternative therapies is a smaller percentage compared with the percentage of all patients who do so, the prevalence of alternative cancer therapy in the United States ranged from a low of 6.4% to a high of 14.7% (Lerner & Kennedy, 1992).

A study in Canada showed that 66% of 235 Canadian

patients with rheumatologic diseases had used alternative therapies in the preceding 12 months. The most frequently used alternative treatment modality was non-prescribed over the counter products including herbs, minerals, and topical remedies (Boisset, & Fitzcharles, 1994).





29


According to Eisenberg and colleagues (1993), the most common types of therapies used were relaxation techniques, chiropractic, and massage. Over a 12 month period, herbal medicines were used by only 3% of Americans surveyed (Eisenberg et al., 1993), while the World Health Organization estimated that 80% of the world population used herbal medicine for some aspect of primary health care (Farnsworth, Akerele, Bingel, Soejarta, & Eno, 1985).

Data from the rural, central Mississippi area (Frate, Croom, Frate, Juergens, & Meydrech, 1996) was close to the prevalence rate from World Health Organization, and showed that over 70% of the adults from the sample of 223 households used at least one plant-derived medicine during the past year. Herbal remedies were frequently used by people who were married, from larger households, of higher socioeconomic status, or who had consulted alternative healers (Brown, & Marcy, 1991) However, there is little factual evidence concerning the use of herbal medicines among the elderly and characteristics of users compared to those of nonusers.

Choice Between Alternative and Conventional Medicines

Despite the advances of conventional medicines,

alternative therapies have received increased attention in the United States and other developed countries, and have





30


been chosen for use in treating various health problems by an increasing number of people (Eisenberg et al., 1993; MacLennan, Wilson & Taylor, 1996; Paramore, 1997). Compared to conventional medicine, alternative medicines rely heavily on the following factors: participation by patients in their own care; the relationship between the expectations of patients, cultural context, and lifestyle activities; and effects on therapeutic outcome of patients' choices of treatment (Workshop on Alternative Medicine, 1994).

In an earlier year, Kronenfeld and Wasner (1982)

focused on the marginalized groups in society to study the relationship between alternative medicine and traditional folk medicine which has developed from ethnographic tradition. In recent studies, researchers have recognized that unconventional therapies are accepted and practiced by a significant number of people, and are believed to be a part of contemporary culture (Eisenberg et al., 1993; MacLennan, Wilson, & Taylor, 1996; Paramore, 1997).

Since significant numbers of persons have recognized the use of alternative medicine, many researchers have investigated factors associated with the choices of alternative therapies. Vincent and Furnham (1996) reported the principal reasons by patients for choosing alternative





31


medicine over conventional medicine. These reasons included

(a) belief in the positive value of alternative medicine,

(b) previous experience of ineffective treatment of conventional medicine, and (c) concern about the adverse effects of medical care.

Other factors influencing the choice of alternative medicine were the poor communication between patients and health care practitioners in conventional medicine, the willingness of alternative practitioners to discuss emotional factors, and the chance to take an active role in their treatment (Vincent and Furnham, 1996) Choices of alternative therapies were influenced by the prognosis for specific diseases such as AIDS, cancer, arthritis, or Alzheimer's disease (Boisset & Fitzcharles, 1994; Cassileth & Chapman, 1996; Coleman, Fowler, & Williams, 1995; Greenblatt, Hollander, McMaster, & Henke, 1991) ; dissatisfaction with the effectiveness of conventional medicine (Cassileth & Chapman, 1996; Sutherland & Verhoef, 1994) ; negative relationship to perceived health status and to health care providers (Sutherland & Verhoef, 1994) ; and a lack of confidence in conventional medicine (McGregor & Peay, 1996).

In summary, a single factor cannot be used to explain the choice of alternative therapies for one's care.






32


According to Kelner and Wellman (1997), many factors influence people in their choice of alternative therapies. Predisposing factors include level of education and age, enabling factors (i.e. income, knowledge, and accessibility of services), and the need for care. Kelner and Wellman (1997) point out individuals in their study who choose to try alternative therapies assume responsibility for their health and well-being. Kelner and Wellman (1997) also indicate that people do not make dichotomous choices between conventional medicine and alternative medicine. Rather, people choose specific kinds of treatments for specific problems, and many use multiple therapies concurrently. In addition, a wide range of possibilities of health care as well as public and private testimonials about successful alternative treatments result in more people deciding to use alternative therapies to cope with their problems and concerns (Kelner & Wellman, 1997).

Older Women and Health Problems

The majority of older Americans are women, and the number of older women will increase continuously. The number of women surpasses the number of men in the age range of 65 years and over, and this gap widens with increasing age (Cobbs & Ralapati, 1998). In 1994, there were 20 million older women and 14 million older men. Among






33


those 85 years and older, there are 44 men for every 100 women; women outnumber men by 100 to 26 over the age of 95; and four out of five centenarians are women. There is a rapid increase in the number of centenarians in the United States (U.S. Bureau of the Census, 1996).

Although a majority of older adults live independently in the community and consider their health to be good or excellent, chronic disease becomes more prevalent with age (Cobbs & Ralapati, 1998). Four out of five people aged 65 and older have at least one chronic disease (Delafuente, 1991) The use of multiple conventional drugs among older adults is a serious issue in the United States (Lamy, 1986; Noyes, Lucas, & Stratton, 1996). Even with functional disability increasing with age, most older women report that they are emotionally vital; but health status, level of disability, and sociodemographic status influence their emotional vitality (Penninx et al., 1998).

Many researchers, who studied the use of conventional drugs among community-dwelling older adults, reported gender differences in the use of conventional drugs (Chrischilles et al., 1992; Fillenbaum et al., 1996; Simons et al., 1992) Based on the data from the Established Populations for Epidemiologic Studies of the Elderly (EPESE), Chrischilles and colleagues (1992) reported that





34


prescription drugs were used by 60-68% of men and 68-78% of women, while non-prescription drug use was 52-68% and 6476% respectively (Chrischilles et al., 1992). While studying community-dwelling older adults, Simons and colleagues (1992) found that 76% of women and 56% of men who used multiple prescription drugs also used multiple non-prescription drugs.

Fillenbaum and colleagues (1996) and Simons and

colleagues (1992) reported that female gender is one of the best predicting factors for the use of non-prescription drugs. Women reported taking more medications than men in each of these studies. Although Lassila and colleagues (1996) did not consider gender as a significant factor associated with the use of number of conventional drugs, most researchers who examined the use of non-prescription drugs accounted for 'female' as an important factor.

Gender difference was recognized in the types of

health problems and health actions as well as in the use of conventional drugs. Musil (1998) reported that there are significant gender differences in psychological and physical health as well as the health actions among older adults residing in the community. The significant gender differences in psychological health were found in anxiety, depression, and body awareness; however, no gender





35


differences were found in self-assessed health and total number of health problems (Musil, 1998).

The gender differences in physical health are that women aged 65 years and over experience more arthritis, cataracts, hypertension, and asthma while their male counterparts have more problems with hearing, ulcers, abdominal hernias, and heart disease (Musil, 1998). By 80 years of age, 70% of women have two or more chronic conditions, most likely arthritis and hypertension, and other common chronic conditions such as heart disease and visual or hearing problems (Cobbs & Ralapati, 1998).

According to a study of health problems and related health actions among older adults (Musil, Ahn, Haug, Warner, Morris, & Duffy, 199B), frequent health actions in response to health problems are the use of non-prescription medicines (83%), self-care activities (72%), use of prescription medicines (539), and professional consultation (43%). The gender differences in health actions suggest that women are more likely to use self-care while men incline towards seeking professional consultation (Musil, 1998) because, historically, women have played a major role in the healing process serving as caregivers of their own families (Burg, 1996). Self-care actions that are frequently used by community-dwelling older women include





36


taking non-prescription medicines, using home remedies, or making lifestyle changes (Musil, 1998).

The results of studies by Musil (1998) and Musil and colleagues (1998) are not surprising when considering frequent self-care actions by women including using home remedies. Burg (1996) states that most female patients may use some form of complementary medicine some time in their lives for their chronic health conditions; and women may use complementary medicines in combination with conventional medicines, which makes health assessment important to evaluate the potential interactive effects.

Although there are no known data specifically looking at women's use of complementary medicine in the United States, Burg (1996) suggested that certain groups of women may utilize complementary medicines based on genderspecific illness patterns and general knowledge about using complementary medicines. These groups of women who may use complementary medicines frequently are people with chronic, non-specific, or difficult for treating illnesses such as arthritis, depression, anxiety, HIV/AIDS, and cancer (Burg, 1996). In summary, it is important to examine health care practices among older women related to the use of herbal products as a part of complementary medicine since women live longer than men in their later stages of life with






37


increasing number of chronic health problems as they age. It is vital to understand the patterns of the use of herbal products in combination with conventional drugs in order to understand and prevent potential interactions between herbal products and conventional drugs. This knowledge and understanding assist health care providers to improve comprehensive health care for older women and subsequently, promote the quality of life of older women.

Patterns of Drug Use Among Older Adults

The population of the United States is 249 million including 34 million people aged 65 years and older (U.S. Bureau of the Census, 1990). The elderly are the fastest growing age group, and continue to grow faster than any other age group in the United States. Although most people are able to carry on their normal activities and functions up to the age of 75 or older, approximately four out of five people aged 65 and older have at least one chronic disease with an average of four diseases per person (Delafuente, 1991). There are many factors influencing drug use in the older adults including disease states, psychosocial factors, physicians who prescribe medications, and advertisement by the pharmaceutical industry (Stewart, 1995). Stewart (1995) states that other factors will influence patterns of drug use in the future such as the






38

development of new drug treatments with expanded coverage of prescription services by government and the influence of private insurers. Other factors associated with drug use in older adults are reported. These include prior drug use, number of health care visits, poorer health or selfperceived poor health, white race, female gender, impaired physical function, depression, hospitalization, insurance coverage, and smoking or drinking alcohol in previous year (Chrischilles et al., 1992; Fillenbaum et al., 1996; Lassila et al., 1996).

While there are great advantages of conventional drug therapy, there are problems associated with and resulting from conventional drug use by older adults. The use of conventional drugs for therapeutic purposes by older adults can contribute to significant drug-related problems because older adults are in an increased risk group due to impaired organ reserve capacity, multiorgan system dysfunction associated with multiple disease states, polypharmacy with drug interactions, and altered pharmacokinetics and pharmacodynamics (Sloan, 1992) other problems associated with conventional drug use include polypharmacy, issues of compliance, drug-drug interactions in combination use of conventional drugs (Chenitz, Salisbury, & Stone, 1990; Lamy, 1986; LeSage, 1990; Noyes, Lucas & Stratton, 1996;






39


Stewart, 1995; Stewart & Cooper, 1994; Swonger & Burbank, 1995).

Several national and community-based studies have provided information on conventional drug use patterns among older adults. Patterns of prescribing practice of conventional drugs by health care providers for older adults have varied over time depending on the data collecting time and geographical differences (Stewart, Moore, May, Marks, & Hale, 1991). Data from the Florida retirement community of Dunedin, a relatively healthy and ambulatory group, were collected during 1978-1979 (May, Stewart, Hale, & Marks, 1982), and 1987-1988 (Stewart et al., 1991). The average number of drugs, including both prescription and non-prescription, taken by the older adults in Dunedin, Florida was 3.2 during the 1978-1979 period (May et al., 1982) and 3.7 in the ten-year overview of the Dunedin study (Stewart et al., 1991).

Researchers in the Iowa Rural Health Study gathered data during 1981-1982 from the community-based, generally elderly population and reported a mean of 2.9 prescribed medicines (Helling, Lemke, Semla, Wallace, Lipson, & Cornoni-Huntley, 1987). Other studies of drug use patterns in the older adults were conducted in North Carolina and Pennsylvania. These studies included urban as well as rural





40


areas as well as a significant proportion of AfricanAmericans. Older adults in the Piedmont area of North Carolina were studied in 1986-1987 (Fillenbaum, Hanlon, Corder, Ziquba-Page, Wall, & Brock, 1993) and in 1989-1990 (Fillenbaum et al., 1996), and researchers reported a mean of 3.4 and 3.7 prescribed drugs per person in the two studies. In the MoVIES Project by Lassila and colleagues (1996), data were collected during 1987-1989 in the rural mid-Monongahela Valley community of Pennsylvania, a largely white (97%), blue-collar population. The result of the MoVIES Project showed subjects used a mean of 2.0 prescription drugs (Lassila et al., 1996).

Despite the differences in the time and the location of the study sites, findings are similar among these studies. When compared cross-sectionally and longitudinally, the proportion of the older adults who took conventional drugs increased with age, as did the number of medications taken (Chrischilles et al., 1992; Fillenbaum et al., 1993; Fillenbaum et al., 1996; Helling et al., 1987; Lassila et al., 1996; May et al., 1982; Stewart et al., 1991).

Polypharmacy

Polypharmacy has been recognized as a problem in the geriatric population (Gormley, Griffiths, McCracken, &






41

Harrison, 1993; Lamy, 1986; Noyes, Lucas, & Stratton, 1996; Shimp, Wells, Brink, Diokno, & Gillis, 1988). The elderly aged 65 and older, who represent only 14% of all American population, consume three times more prescription drugs than people under aged 65 years (Gormley, Griffiths, McCracken, & Harrison, 1993). The use of prescribed drugs has been projected to be 40% of the total drug expenditures in developed countries by year 2030 (Cusack, 1989). The older adults frequently use nonprescription drugs in addition to prescribed medications (Pollow, Stoller, Foster, & Duniho, 1994).

Polypharmacy has been defined in many different ways (LeSage, 1990; Michocki, Lamy, Hooper, & Richardson, 1993; Montamat & Cusack, 1992; Noyes, Lucas, & Stratton, 1996). In Healthy People 2000 (1990), polypharmacy was defined as the use of multiple prescription and nonprescription drugs, especially by elderly with chronic disease, while Noyes, Lucas, and Stratton (1996) considered multiple drug use synonomous with polypharmacy. LeSage (1990) defined polypharmacy as the concurrent use of several different drugs; whereas, Montamat and Cusack (1992) defined polypharmacy as the prescription, administration, or use of more medications than are clinically indicated in a given patient.





42


Other researchers (Michocki, Lamy, Hooper, &

Richardson, 1993) considered polypharmacy only as the use of multiple drugs. Definition of polypharmacy by Michocki and colleagues (1993) was that particular patients received too many drugs, for too long a time, or in exceedingly high doses. Although there is neither a specific number of medications to define polypharmacy, nor a unanimously accepted definition of polypharmacy, polypharmacy consistently represents the use of multiple medications by a single patient (Stewart & Cooper, 1994).

Possible causes of geriatric polypharmacy are multiple health problems; multiple prescribers; noncurrent medication storage; prescription patterns of physicians; and self-medication behavior (LeSage, 1990). Since it has been known that older adults often take a large number of drugs for various reasons, possible adverse consequences of the use of multiple medications exist. These consequences are adverse drug reactions, drug interactions, medication errors, noncompliance, quality of life and functional decline, and high financial cost (LeSage, 1990; Stewart & Cooper, 1994).

Swonger and Burbank (1995) pointed out the problems of polypharmacy and drug misuse associated with both physician and client. Multiple drug regimens are often too






43

Complicated or lack adequate rationale for each individual drug. Multiple chronic conditions of the elderly often require the use of more than one physician, which can lead to poorly coordinated care and adverse drug reactions.

Physician-centered problems are negative attitudes toward older people, difficulty in accurately diagnosing and dosing due to heterogeneity of the elderly, lack of client education about drugs and inadequate follow-up. Client-centered problems are unintentional resulting from a lack of knowledge or special instructions, forgetfulness in taking medicine, confusion, intentional omission, dosage adjustment, sharing drugs with other people, and stretching dosage requirements to save money (Swonger & Burbank, 1995).

Issues related to multiple drug use have been

recognized in other studies (Col, Fanale, & Kronholm, 1990; Michocki, Lamy, Hooper, & Richardson, 1993; Ranelli & Aversa, 1994; Stewart & Caranasos, 1989) Ranelli and Aversa (1994) studied medication-related stress among family caregivers, and reported that 32% of the caregivers had medication-related problems and 19% had difficulty in managing medications. More than half of the caregivers experienced problems in the past year, including scheduling difficulties, compliance problems, difficulty organizing






44

medications for the patient, and lack of professional advice. Although only 7.7% of the total time was spent providing drug-related care by caregivers, medications did contribute to the stress of the caregiving experience (Ranelli & Aversa, 1994).

Compliance is another issue related to polypharmacy.

Many factors were associated with compliance (Noyes, Lucas, & Stratton, 1996; Stewart & Caranasos, 1989) Among the factors related to compliance documented in literature, it was consistently mentioned that the number of medications taken and the complexity of the medication regimens were critical factors for patient's compliance.

One study of compliance rates related to dosage pattern, e.g. number of times per day, showed that compliance rate decreased when the number of times a medication was taken per day increased (Cramer, Mattson, Prevey, Scheyer, & Ouellette, 1989) Cramer and colleagues (1989) found only 39% of compliance rate with four times a day dosage schedule, while reporting 87% of compliance rate when medication was scheduled once a day for the elderly. Prescription of multiple drugs may increase noncompliance and cause adverse drug reactions or clinically significant drug interactions (Col, Fanale, & Kronholm, 1990) Adverse drug reactions are defined broadly by the United States






45

Food and Drug Administration (FDA) as any adverse event associated with the use of a drug in humans (Sills! Tanner, & Milstien, 1986).

According to Col and colleagues (1990), patients admitted to hospitals with medication noncompliance increased, when the number of different medications or the number of physician visits increased. Approximately 28% of hospital admissions among older adults were drug-related, and more specifically, were due to noncompliance (11.4%) and adverse drug reactions (16.8%). Although there are variations in reported hospitalization rates caused by adverse drug reactions, from 6.3% to 16.8% (Col, Fanale, & Kronholm, 1990; Colt, & Shapiro, 1989; Grymonpre, Mitenko, Sitar, Aoki, & Montgomery, 1988; Ives, Bentz, & Gwyther, 1987; Lindley, Tulley, Paramsothy, & Tallis, 1992) it is apparent that adverse drug reactions are serious and costly.

Toxicities of Herbal Products and Possible Interactions

with Drugs of Conventional Medicine

In recent years, the use of herbal products has

increased in developed countries, even though herbals have been a dominant form of health care in developing countries for many years. Although Eisenberg and colleagues reported that three percent of Americans were using herbal products






46


in the early 1990s, this number is assumed to be growing rapidly (Eisenberg et al., 1993).

The risk of potential toxicity of herbal medicines is accelerated by many factors. First of all, herbal medicines are not subject to standard Food and Drug Administration (FDA) tests for safety, effectiveness, and quality control because herbals are not considered conventional drugs but rather dietary supplements. Secondly, many herbal products are imported from foreign countries not mandating safety or manufacturing regulations. Finally, these medicines do not have the active or inactive ingredients listed on the package label (Anderson, 1996). Other factors contributing to the potential problems of using herbal products include

(a) misidentification of a plant, or the unknown or ignored toxicity of a correctly identified plant; (b) persistent use of herbs known to be toxic; (c) difficulty in identification of chopped or mixed herbs; (d) variability in chemical constituents of herbs; (e) problems with nomenclature; (f) difficulty in establishing the cumulative effects of a plant; (g) contamination with heavy metals; and (h) possible adulteration with prescription drugs or with other substances (Drew & Myers, 1997; Huxtable, 1990).

Certain groups of people using herbal products are at higher risk of intoxication than other groups. Huxtable





47


(1990) points out that high risk groups are people using herbs or herbal products for a long time, consumers of large amounts or a wide variety of herbs, babies, the elderly, those with concomitant diseases and concurrent medications, and the malnourished or undernourished. Also, toxicities can be selective depending on gender and cultural groups (De Smet, 1995; Huxtable, 1990). Nevertheless, it is widely perceived that natural products are safe, and people will continue to use herbal medicines in ever-growing numbers (Marwick, 1995).

Although the risk of using herbal medicine is much less than that of using conventional medicine, many researchers suggest that using herbal products is not without risk and, consequently, safety of using these products needs to be considered.

Only nine herbal products are approved by the Food and Drug Administration (FDA) for selected applications (Youngkin & Israel, 1996). Recently, Youngkin and Israel (1996) reviewed the safety of herbal therapies compared to the safety and efficacy data derived from the German Commission E and other biomedical literature for selected commonly used herbs. Among the 56 herbal products reviewed, only seven were approved by the FDA; 36 were considered to be effective for one or more specified complaints by the





48


German Commission E; and only four were approved by both FDA and German Commission E (Youngkin & Israel, 1996).

Drew and Mayers (1997) proposed classification of

adverse effects associated with herbal medicine into two categories, intrinsic and extrinsic effects. Intrinsic effects are those of the herb itself, and are characterized as type A and type B reactions for pharmaceutical purposes. Type A reactions are predictable and dose-dependent including effects with deliberate over-dose or accidental poisoning and interactions with pharmaceuticals. Type B are unpredictable and idiosyncratic reactions.

Extrinsic effects are not related to the herbal medicine itself, but to a problem in manufacture or compounding. Extrinsic effects may result from failing to adhere to a code of Good Manufacturing Practice and include contamination, misidentification, lack of standardization, substitution, adulteration, incorrect preparation and/or dosage, and inappropriate labeling and/or advertising. Extrinsic effects make it difficult for health care practitioners or users of herbal medicines to identify the correct herbal remedies or to assess the adverse effects (Drew & Mayers, 1997).

Information regarding toxicities and safety of herbal medicines is currently limited. The workshop on Alternative





49


Medicine (1994) listed the 20 most popular Asian patent medicines that contain toxic ingredients (see Appendix C). Other authors (Gray, 1996; Youngkin & Israel, 1996) summarized the scientific information and potential adverse effects of selected common herbal remedies. Currently, there is little information available related to interactions of herbal products in combination with the use of conventional drugs, although, it is assumed that there are possibilities of interactions between herbal products and conventional drugs (Drew & Mayers, 1997; Huxtable, 1990; Noyes, Lucas, & Stratton, 1996). More studies are needed to investigate the interactions between herbal products and conventional drugs.

Although the prevalence of the use of herbal products among older women is unknown, it is assumed that women aged 65 years and over consume more herbal products than their younger counterparts. older women report more chronic health problems than younger women. Also, older women attempt to prevent deterioration of health in the later stages of their life. It is clear that older adults are susceptible to medication related problems because of their overall increased use of medication.















CHAPTER III
METHODOLOGY

The purpose of this research was to study the use of herbs and/or herbal products for medicinal use and to compare the differences in demographic characteristics and health status between herbal product users and non-herbal users among community-dwelling older women. This chapter contains the research methodology and is comprised of five sections: research design, setting, sample, instruments, data collection procedure, and data analysis.

Research Design

This research utilized a cross-sectional and

descriptive design to examine the prevalence of herbal product use, the types of the herbs used, and to identify the reasons for use of herbal products among women aged 65 and over. Subjects were categorized into two groups: Group 1, women 65 years and older who used herbal products and Group 2, women 65 years and older who did not use herbal products.

Setting

The setting for this study was a county located in North Central Florida.

50






51


Sample

It was statistically determined that a sample size of 84 subjects (42 subjects in each group) would provide the desired sensitivity to test the study hypotheses. This determination was based on a formulation of 95% power, a medium critical effect size of 0.40 for each of the dependent variables, and a significance level of 0.05 for a two-tailed test of means.

Sampling criteria were women who were 65 years and over and lived in the designated North Central Florida county. The principal investigator requested names and addresses of all women 65 years and older who resided in the selected county from the Division of Drivers' License, State Department of Highway Safety and Motor Vehicles. This list yielded 8,344 names and addresses of women aged 65 and older.

According to Waltz, Strickland, and Lenz (1991), 30% response rate was not unusual in mailed questionnaire surveys. Therefore, it was necessary to select at least three times the number of subjects needed for the total sample of 84 subjects to test the hypotheses. The investigator randomly selected 252 subjects from the total list utilizing the table of random digit (Rand Cooperation, http://www.rand.org/software-and-data/random/digits.txt).





52


After a random selection of names, 252 letters were

mailed to the potential subjects, introducing the study and requesting participation in the study. A return self-addressed, stamped postcard was enclosed with each introductory letter. Of the 252 letters mailed, 53 subjects were included in the sample. Thirty-one more subjects were needed to attain a desired sample size of 84; therefore, 150 additional letters were mailed. From the second group of letters mailed, 33 subjects were included in the sample. Therefore, a total of 86 subjects completed the interview, resulting in 39 subjects in Group 1 (herbal product users) and 47 subjects in Group 2 (non-herbai users).

Inclusion and Exclusion Criteria

The inclusion criteria were as follows: (a) women who were 65 years and older living independently in the community; (b) currently living in the selected county; (c) ability to speak and understand English; and (d) able to verbally communicate with intact memory. Subjects who could respond to the requests for participation were considered to have adequate communication skills and memory ability. Exclusion criteria were as follows: (a) women who had severe health conditions, (b) resided in nursing home or other type of assisted living facility, (c) resided out of





53


the selected county, or (d) unable to contact after multiple attempts.

Instrument

The questionnaire was developed by the investigator because there were no known established questionnaires to perform this study. This questionnaire was used to obtain knowledge related to the prevalence and purpose of use of herbal products and how the herbal products were used with prescribed and non-prescribed medicines among women aged 65 and over. The questionnaire was comprised of three parts:

(a) health status and use of conventional drugs including prescribed and non-prescribed medicines, (b) use of herbal products, and (c) demographic data.

The interview lasted approximately 15-30 minutes for the participants who did not use the herbal products, and were classified as group 2. The participants in this group were asked to answer part A and part C of questionnaire. The interview took approximately 30-45 minutes for the participants who responded 'yes' to the use of herbal products. These participants were classified as group 1. The participants in this group were asked to answer the entire questionnaire Part A (Health Information), Part B (Herbal Product Use Information), and Part C (Demographic Information).





54


Operationalization of Variables Demographic Variables

Demographic characteristics of subjects were examined by six indicators: race, education, income, religious preference, insurance status, and marital status.

Race. Race was a categorical variable coded as white, black, Hispanic-nonwhite, and other.

Education. Education was categorized into four

groups according to the number of years of formal education which the participants completed: less than a high school diploma, high school graduate, less than a college graduate, college graduate, and graduate school and higher.

Income. Income was the total annual household

income of the participant. This measure was coded into four categories reflecting an income range from $0.00 to over $50,000: less than $20,000, $20,000 $34,999, $35,000 $49,999, and $50,000 and above.

Religion. Religious preference of participant was

divided into five categories: None, Protestant, Catholic, Jewish, and other.

Insurance status. Status of insurance was

categorized into five groups: None, Medicare, Medicaid, private insurance, and other.





55


Marital status. Marital status was coded into one of four categories reflecting the status of married, widowed, divorced/separated, or never married. Herbal products variables

Eleven indicators were examined for the variables related to the use of herbal products. These were (a) number and type of herbal products used, (b) general purpose of using herbal products, (c) route, (d) preparation, (e) reasons used, (f) duration of use, (g) effectiveness of herbal products, (h) experience of adverse reactions by using herbs or herbal products, (i) sources of information for use of herbal products, (j) source of payment for herbal product, and (k) physician's awareness about using herbal product.

Number and type of herbal products used. The

participant was asked to list the names of all the herbal products used in the last 12 months. The total number of herbal products used by each participant was counted. The mean number of herbal products used was calculated to measure the average number of herbal products used by the participants. Examination of frequencies identified the most common herbal products used.

General purpose of using herbs or herbal products.

The participant was asked the general purpose of taking





S6


herbal products in the last 12 months. Purposes were categorized into one of three indicators: to treat illness, to maintain or prevent any possible health problems, and both treat and prevent illness.

Route. The route of using herbal products was a categorical variable identified as internal use and external use.

Preparation. Preparation was a categorical variable identified as self-prepared or purchased from a health food store or a regular retail store. Self-prepared herbal product defined the remedy that could not be used directly as it was obtained and thus required preparation time at home such as herbal tea. Purchased included the product that could be used directly without any preparation time after obtaining it such as an herbal tablet or a capsule.

Reasons used. Reasons to use herbal products were

listed based on the types of health problems and were coded from 6 through 29. The codes starting from 6 through 28 were matched with specific illnesses on the Health Information Form in the questionnaire Part A (see Appendix A). Item number 29 was related to the use of herbal products for maintaining current health status or for preventing possible health problems.






57


Duration of use. Duration of using an herbal product was categorized into two groups: used continuously or used only when symptoms occurred. If the herbal product was used continuously, the participant was asked how long the product had been used. If the herbal product was used when symptoms occur, the participant was asked how many times in the last 12 months the product was used.

Effectiveness of herbal product. Effectiveness of herbal product had four indicators that included not at all, somewhat effective, very effective, and don't know.

Experience of adverse reaction. Experience of an adverse reaction from using an herbal product was a dichotomous variable coded zero/no when participant did not experience any adverse reaction and one/yes when the participant experienced any type of adverse reaction. If the answer was yes, the participant was asked what kind of adverse reaction she had experienced.

Sources of information. The participant was asked

where she had obtained the knowledge about herbal products. The sources of information to use herbal products were categorized into nine groups: (a) family members; (b) friends and neighbors; (c) books or magazines; (d) TV, radio, and newspapers; (e) computer Internet; (f) health





58


food stores; (g) health care providers; (h) alternative care practitioners; and (i) others. Health status variables

Eight indicators were utilized to identify the health status and the use of prescribed and non-prescribed medicines related to the health problems. These included

(a) overall health, (b) physical health, (c) emotional health, (d) visit to doctor's or other health care provider's clinic, (e) existence of health problems, (f) seriousness of health problems, (g) number of medications used and medication identification, and (h) use of any herbal products.

Overall health, Physical health, and Emotional ealth.

A visual scale numbered one through five measured

these three variables. One indicated a poor health status and five indicated an excellent health status.

Visit to a health care provider office or clinic.

The participant was asked two sets of questions. One question asked whether she had visited a health care provider office or clinic in the past 12 months. This dichotomous variable was coded no or yes. If the response was yes, a follow-up question asked was what health care provider she had visited. Seven categories included (a) family practitioner, (b) internal medicine, (c) surgeon,





59


(d) gynecologist, (e) nurse practitioner, (f) osteopathic doctor (D. 0.), and (g) others.

Health problems. The participant was asked to

identify her health problems from 23 different illnesses. The answer was coded zero when the problem did not exist and one if the problem existed.

Interference with normal activities. The participant was asked how seriously an illness interfered with her normal activities. Interference with normal activities was measured by a visual scale rating from one to five. One on the visual scale indicated that the health problem did not interfere with normal activities and five indicated that the health problem interfered greatly with normal activities.

Use of medications. The use of medications was a

dichotomous variable coded zero or one for each identified illness. If the answer was yes, the participant was asked to name ail prescribed and non-prescribed medications for each illness.

Use of herbal products. The use of herbal products

was a dichotomous variable coded zero when herbal products had not been used and one when herbal products had been used for each identified illness.





60


Procedure

The investigator obtained the list of names and

addresses of women aged 65 and over who resided in a North Central Florida County from the Department of Motor Vehicle and Safety in Tallahassee, Florida. The number of possible accessible population was identified as 8,344 women in the selected county. From the accessible population, at least 84 participants (42 subjects in each group) were required to meet the effect size.

The investigator used a table of random digits (Rand Cooperation: http://www.rand.org/software-and-data/ random/digits.txt) to select a sample. The Investigator picked a starting point from the table of random digit by closing eyes and pointing pencil on one number. From the starting point of the table of random digits, 252 numbers between 0001 and 8,344 were selected. The numbers selected from the table were matched with the names from the list of accessible population.

Letters were mailed to all 252 potential participants to introduce the purpose of the study and request participation in the study. A return self-addressed, stamped postcard was enclosed with each letter. On the back of the postcard, the investigator requested the return response 'yes, I will participate in the study' and






61


requested a phone number to contact for interview, and 'no, I will not participate in the study.' From the first 252 letters mailed, 53 subjects met the inclusion criteria and completed the interview successfully. It was necessary to recruit at least 31 more subjects for this research study. The investigator repeated the same procedure of random sampling technique for the first mailing list except the first 252 names selected at the first round of sampling were excluded. For the second round of sampling, 150 subjects were calculated to meet the minimum necessary 31 subjects.

The investigator made a telephone call to each participant who returned the postcard indicating a willingness to participate in the study. The investigator had a brief telephone conversation with each subject to arrange the time and the meeting place for the interview. Prior to conducting a structured interview, an informed consent was obtained and a copy of the informed consent and business card of the chairperson were provided to each participant. Each participant was advised of her right as a research participant and the right to decline without penalty.

After an informed consent was obtained, the subject

was asked to answer the questions related to health status,





62


the use of prescribed and non-prescribed medicines, the use of herbal products, and demographic information. The entire interview required approximately 15-45 minutes per subject. The participants were categorized into group 2, if they answered 'no' to question number A76 of Questionnaire Part A (Health Information). The participants in group 2 were not asked to answer Part B (Herbal Product Use Information) and continued to Part C (Demographic Information). The participants were categorized into group 1, if they answered 'yes' to the question number A76 of Questionnaire Part A (Health Information). The participants in group 1 were asked to answer both Part B and Part C. Data collection was completed when the total subjects numbered 86 (39 subjects in group 1 and 47 subjects in group 2). After completion of the interview, the data were entered into a data spreadsheet for analysis.

Data Collection

Data were collected to test the two research

hypotheses and to answer the four research questions. Research Hypotheses

Hypothesis One: There are differences in demographic characteristics of women aged 65 years and older between the herbal users and non-herbal users.





63


Demographic characteristics included education levels, incomes, insurance status, race or religion. To test hypothesis one, all participants were asked to answer the 'Health Information' questionnaire which included whether the participant used herbal products. If the participant used an herbal product, she was asked to answer the 'Herbal Product Information' questionnaire and the 'Demographic Information' questionnaire. If the participant did not use an herbal product, she was asked to answer the 'Demographic Information' questionnaire without 'Herbal Product Information'. Subjects were divided into two groups, one group of herbal product users and another group of non-users, to compare differences in demographic characteristics including education level, income, insurance status, race or religion.

Hypothesis Two: There is a difference in health status between herbal users and non-herbal users. Differences in health status between the two groups was tested by comparing illnesses, number of prescribed and nonprescribed medicines the participant used, perception of the participant's health status, and seriousness of interference of normal activities.





64


Research Questions

Question 1: what was the prevalence of use of herbal products among women 65 years and older?

Three types of information were collected to answer question 1: First, the participant was asked to name the all of the herbal products she had used in the last 12 months. The total number of herbal products used was counted to calculate the average number of herbal products used by all subjects. The most commonly used herbal products were identified within the total group of subjects. Secondly, to identify the period of time herbal products were used, each participant was asked how long herbal products had been used. She was also asked if she ingested the herbal by mouth (internally) or applied the herbal externally. The participant was asked whether she used the herbal on a continual basis or intermittently. Lastly, the participant was asked whether she purchased the herbal product from a store in a ready-to-take form or if she needed to prepare the herbal product prior to its use.

Question 2: What was the purpose for taking herbal

products by women aged 65 years and older? Did older women take herbal products more for prevention or for treatment of symptoms?





65


The following information was collected to identify the purpose for which women 65 and older took herbal products and to determine for which physical symptoms or health conditions women most likely took herbal products. The participant was asked about her overall health, physical health, and emotional health status. The health status was measured by a visual scale with a range of one through five with one representing poor health and five representing excellent health status. The participant was asked the general purpose of taking herbal products to identify whether she took herbals to treat illness, to prevent possible health problems or to maintain her current health status, or for both treatment and preventive purposes.

To identify the specific reasons for using herbal products, the investigator identified common health problems of the subject. The subject was asked the specific reasons for taking the herbal products based on identified common health problems among older women. The perceived benefit of taking the herbal product was identified by the participant and then whether she felt that the herbal product was effective or ineffective. Data of perceived adverse reactions were collected including the types of adverse reaction experienced by the participant.





66


Question 3: What was the frequency of use of herbal

products by older women? Did women who use herbal products use them continuously over time or on an as needed basis? Did women who use herbal products use them alone or in combination with prescribed and/or non-prescribed medicines?

Three types of information were collected to answer

question three. First, the participant was asked the names of prescribed and/or non-prescribed medicines she took for her health problems. This information was later compared with the findings of question two to describe whether the herbal products were used alone or used in combination with the conventional drugs. Secondly, the findings of question three were compared with the findings of question two to describe the use of herbal products alone or in combined use with prescribed and/or non-prescribed medicines. Thirdly, the investigator identified the frequency and dosages of herbal products taken by each subject. Frequency included either continual use or on an as needed basis.

Question 4: What sources did women 65 and over use to obtain information about the use of herbal products?

To identify the source of information related to herbal products used by women 65 years and over, the participant was asked where she obtained information about





67


the herbal products that she was taking. Data related to health insurance status and primary health care provider were collected to identify a possible relationship between types of providers or insurance status and the use of herbal products. Data were collected to determine if the primary physician or other health care provider was aware of her use of herbal products.

Data Analysis

Descriptive statistics were performed to identify the demographic characteristics of the participants, number of medications used, number of herbal medications used, sources of information and reasons for taking herbal medications. Analysis of frequency was used to address each research question. The student t-test and Chi-Square test were used to determine if differences existed between older women who used herbal products and those who did not use herbal products.















CHAPTER IV
RESULTS


This chapter includes a description of the research design, sample, demographic characteristics, and health related characteristics of the sample. Also included in this chapter are the results of the statistical analyses of the data corresponding to the research hypotheses and research questions.

Research Design

This research utilized a cross-sectionai and

descriptive design to examine the prevalence of herbal product use, types of herbal products used by the subjects, and to identify the reasons herbal products were used among women aged 65 and over. The investigator used a random selection process to facilitate the selection of two groups of subjects those who used herbal products and those who did not use herbal products.

Sample

A random sample of women who were 65 years of age and over residing in a North Central Florida county was selected for this study. A total of 8,344 women who were


68





69


registered at the Florida Division of Drivers License, were identified as eligible sample by the State Department of Highway Safety and Motor Vehicles. To obtain a sample size of 84 subjects, three times this number or 252 possible subjects were randomly selected from the 8,344 women (see Table 4.1). Letters were mailed to the 252 possible subjects describing the research purpose and requesting the return of an enclosed postcard to schedule an interview. From this mailing, 16 letters were undeliverable and 101 (40.1%) persons responded. of the 101 respondents who returned the postcards, 53 subjects completed interviews; 29 respondents declined participation; and 19 did not meet inclusion criteria. Thirty-one additional subjects were needed to attain the desired sample size.

An additional group of 150 people was selected for the second mailing to add the needed 31 subjects. Random sampling was repeated from a list of 8,344 persons, excluding the 252 names of the first selection. From the second mailing, 12 letters were undeliverable and 64 (42.7%) persons responded. Of the 64 respondents, 33 subjects completed interviews; 22 respondents declined participation; and nine did not meet inclusion criteria.

In summary, 402 letters were mailed; 28 of the 402

letters were undeliverable, leaving 374 potential subjects.






70


Of 374 potential subjects, 165 (44.1%) responded. Of the total 165 respondents, 86 subjects were completed interview (52%), 51 declined an interview (31%), and 28 did not meet inclusion criteria (17%). Reasons for exclusion were (a) five subjects had severe health problems, making an interview impossible; (b) three subjects resided in nursing homes or other types of assisted living facilities; (c) 12 subjects resided out of the county at the time of the interview; (d) six subjects were deceased; and (e) two subjects were unable to be contacted for the interview. Of the 86 subjects who completed the interview, 39 used herbal products and were assigned to group one and 47 did not use herbal products and were assigned to group two. Table 4.1
Frequency Distribution of Total Sample

Number 1't mailing 2 d mailing Total

letters mailed 252 iso 402
Undeliverable 16 12 28
Excluded respondents 19 9 28
Non-Respondents 135 74 209

Declined Interview 29 22 51
Interview completed 53 33 86






71


Demographic Characteristics of the Sample

The mean age of the sample was 74.9 years with a

standard deviation of 5.55 (range 65 90) (see Table 4.2). The mean age of the 39 subjects of group one who used herbal products was 75.4 years with a standard deviation of

5.80 (range 65 90). The mean age of the 47 subjects of group two who did not use herbal products was 74.4 years with a standard deviation of 5.37 (range 65 87). Table 4.2
Age of Herbal Users, Non-Users, and Total Sample Age Herbal Users Non-Users Total Sample
(n=39) (n=47) (N=86)
Mean years (SD) 75.4 (5.80) 74.4 (5.37) 74.9 (5.55) Group (years) N (%) N M N (%)
65 74 17 (43.6) 24 (51.1) 41 (47.7)
75 84 18 (46.2) 20 (42.6) 38 (44.2)
85 and over 4 (10.2) 3 (6.3) 7 (8.1)

Total Number 39 (100.0) 47 (100.0) 86 (100.0)


Of the total group of subjects, 41 (47.7%) were

married, 37 (43.0%) were widowed, and eight (9.3%) were divorced (see Table 4.3). From the 39 herbal users in the group one, 14 (35.9%) were married; 21 (53.8%) were widowed; and four (10.3%) were divorced. Among the 47 nonusers in the group two, 27 (57.5%) were married; 16 (34.0%) were widowed; and four (8.5%) were divorced.






72


The sample consisted of 85 (98.8%) White Americans and one (1.2%) Black American. No other race was reported. The one Black American was an herbal product user and was placed in group one.

Among the total sample, 27 (31.4%) had some college education; 22 (25.6%) reported graduate level education after completion of college; 21 (24.4%) were high school graduates; 13 (15.1%) had college degrees; and three subjects had less than high school education. Of the 39 herbal product users in group one, three (7.7%) subjects had less than high school education; nine (23.1%) subjects finished high school; 12 (30.8%) had some college education; five (12.8%) subjects were college graduates; and 10 (25.6%) subjects had graduate level education after completion of college. Among the 47 subjects in group two, no one had less than a high school education; 12 (25.5%) completed high school; 15 (31.9%) had some college education; eight (17.0%) were college graduates; and 12 (25.5%) had graduate level education after completion of college.

Annual household income was categorized into four groups: less than $ 20,000, $20,000 $34,999, $35,000 $49,999, $50,000 or more. Seventy-nine (91.9%) subjects responded while seven (8.1%) declined to answer the






73,


question related to income. Eighteen (22.8%) subjects reported their income to be less than $20,000; 23 (29.1%) reported incomes of $20,000 $34,999; 18 (22.8%) reported incomes of $35,000 $ 49,999; and 20 (25.3%) reported their income level to be $50,000 or more per year. Of the 39 herbal product users in group one, household income of eight (23.5%) subjects was less than $20,000; 12 (35.3%) reported their income to be between $20,000 and $34,999; seven (20.6%) reported their income to be between $35,000 and $49,999; and seven (20.6%) reported incomes of $50,000 or more per year. Among 47 non-users in group two, annual household income of 10 (22.2%) subjects was less than $20,000; 11 (24.4%) subjects were between $20,000 and $34,999; 11 (24.4%) reported their income to be between $35,000 and $49,999; and 13 (28.9%) reported an income of $50,000 or greater.

With regards to religious preference, Protestant was the most common religion (58, 67.4%) followed by Catholic (11, 12.8%). Three (3.5%) subjects practiced the Jewish religion; six (7.0%) reported other types of religion; and eight (9.3%) claimed no religious preference. Protestant was main religious preference in both herbal product users (26, 66.7%) and non-users (32, 68.1%).





74


Seventy-nine (92.9%) subjects had Medicare and

supplemental insurance; three (3.5%) reported Medicare as their only insurance; two (2.3%) claimed Medicare and Medicaid; one (1.2%) had only Medicaid; and one (1.2%) had only private insurance. of 39 the herbal product users, 35 (89.7%) had Medicare and supplemental insurance; one (2.6%) had Medicare only; two (5.1%) reported Medicare and Medicaid; one (2.6%) had private insurance. Among 47 nonusers of group two, 44 (93.6%) subjects claimed Medicare and supplemental insurance; two (4.3%) had Medicare only; and one (2.1%) had Medicaid only. The summary of demographic characteristics including marital status, ethnicity, education, annual household income, religion, and insurance status for the total sample, for the group of herbal users, and for the group of non-herbal users is illustrated in Table 4.3.

Table 4.3
Demographic Characteristics of the Total Sample, Herbal Product Users, and Non-users

Herbal Users Non-Users Total Sample Characteristics (n=39) (n=47) (N 86)
Marital Status N (%) N (%) N (%) NS
Married 14 (35.9) 27 (57.5) 41 (47.7)
Widowed 21 (53.8) 16 (34.0) 37 (43.0)
Divorced 4 (10.3) 4 (8.5) 8 (9.3)
Never Married 0 (0.0) 0 (0.0) 0 (0.0)








75


Table 4.3. (continued)

Herbal Users Non-Users Total Sample Characteristics (n=39) (n=47) (N=86)
Ethnicity NS
White American 38 (97.4) 47 (100) 85 (98.8)
African American 1 (2.6) 0 (0.0) 1 (1.2)
Hispanic-nonwhite 0 (0.0) 0 (0.0) 0 (0.0)
Other 0 (0.0) 0 (0.0) 0 (0.0)
Education NS
< High School 3 (7.7) 0 (0.0) 3 (3.5)
=High School 9 (23.1) 12 (25.5) 21 (24.4)
Annual Income NS
< $20,000 8 (23.5) 10 (22.2) 18 (22.8)
$20,000- $34,999 12 (35.3) 11 (24.4) 23 (29.1) $35,000 $49,999 7 (20.6) 11 (24.4) 18 (22.8) 50, 000 7 (20.6) 13 (28.9) 20 (25.3)
Missing Data 5 (12.8) 2 (4.3) 7 (8.1)
Religion NS
Protestant 26 (66.7) 32 (68.1) 58 (67.4)
Catholic 4 (10.3) 7 (14.9) 11 (12.8)
Jewish 1 (2.6) 2 (4.3) 3 (3.5)
Other 4 (10.3) 2 (4.3) 6 (7.0)
None 4 (10.3) 4 (8.5) 8 (9.3)
Insurance NS
Medicare &
Supplement 35 (89.7) 44 (93.6) 79 (92.9)
Medicare only 1 (2.6) 2 (4.3) 3 (3.5)
Medicare &
Medicaid 2 (5.1) 0 (0.0) 2 (2.3)
Medicaid only 0 (0.0) 1 (2.1) 1 (1.2)
Private Ins. Only 1 (2.6) 0 (0.0) 1 (1.2)
NS = Statistically no significant difference between the group of herbal-product users and the group of non-users (P = 0.05)

Research Hypotheses

Research Hypothesis One

The first hypothesis stated that there was a

difference in demographic characteristics of women 65 years






76


or over between the group of herbal product users and the group of non-users. To test the hypothesis, demographic characteristics including age, education levels, marital status, annual household income, and religious preference, were compared between the two groups. Ethnicity was not compared because all subjects except one Black American were identified as White Americans. Insurance status was not compared between the two groups since the total sample had some type of insurance and the large majority had Medicare (98%).

The research hypothesis one was not supported. The ttest was performed to test differences in age between the two groups and no significant difference in mean age was found between the two groups (t 0.76, p=0.45). The two groups were homogeneous with regard to marital status (X2

4.089, p=0.129). There was no significant difference in education between the group of herbal users and the group

of non-users (X2=3.926, p=0.416) There were no significant differences in annual household income (X2 =3.265, p=0.514) and in religious preference (X2=1 .709, p=0.789) between the two groups. In summary, the two groups were not significantly different in demographic characteristics






77


including age, marital status, education, annual household income, and religious preference. Research Hypothesis Two

The second hypothesis stated that there was a

difference in heaith-related characteristics between the group of herbal product users and that of non-herbal users. The health-related characteristics included perception of own health status, number of health care providers who were visited, types of health-related problems and perception of its seriousness, number of health problems, and number of prescribed and non-prescribed medicines.

Perception of health status and health care providers.

Perceptions of health including overall health,

physical health, and emotional health were measured by a visual scale that ranged from one to five. Five on the visual scale represented excellent health; and one on the visual scale represented poor health (see Appendix A). Overall health was rated five on the visual scale by 25 (29.1%) of the total sample; four on the visual scale by 39 (4S.4%); three on the visual scale by 20 (23.3%); and two on the visual scale by two (2.3%). No subject gave a rating of one on the visual scale (see Table 4.4). Among 39 herbal product users in group one, no subject gave a rating of either one or two suggesting poor overall health; nine






78


(23.1%) subjects rated three on the visual scale; 16 (41.0%) subjects rated four; and 14 (35.9%) subjects rated five suggesting excellent overall health. Among 47 nonherbal product users in group two, no subject gave a rating of one; two (4.3%) subjects rated two on the visual scale; 11 (23.4%) subjects rated three; 23 (48.9%) subjects rated four; and 11 (23.4%) subjects rated five. There was no significant difference in perception of overall health between the two groups (X2 = 3.100, p = 0.378) Table 4.4
Perceived Overall Health by Herbal-Users, Non-Users, and Total Sample

Visual Scale Herbal Users Non-Users Total Sample (1-5) (n=39) (n=47) (N=86)
1 (Poor) 0 (0.0%) 0 (0.0%) 0 (0.0%)
2 0 (0.0%) 2 (4.3%) 2 (2.3%)
3 9 (23.1%) 11 (23.4%) 20 (23.3%)
4 16 (41.0%) 23 (48.9%) 39 (45.4%)
5 (Excellent) 14 (35.9%) 11 (23.4%) 25 (29.1%) Total 39 (100.0%) 47 (100.0%) 86 (100.0%)_Physical health was rated two on the visual scale by three (3.5%) subjects; three on the visual scale by 21 (24.4%) subjects; four on the visual scale by 41 (47.7%) subjects; and five on the visual scale by 21 (24.4%) subjects (see Table 4.5).





79


Table 4. 5
Perceived Physical Health by Herbal-Users, Non-Users, and Total Sample

Visual Scale Herbal Users Non-Users Total Sample (1-5) (n=39) (n=47) (N=86)
1 (Poor) 0 (0.0%) 0 (0.0%) 0 (0.0%)
2 1 (2.6%) 2 (4.3%) 3 (3.5%)
3 10 (25.6%) 11 (23.4%) 21 (24.4%)
4 18 (46.2%) 23 (48.9%) 41 (47.7%)
5 (Excellent) 10 (25.6%) 11 (23.4%) 21 (24.4%) Total 39 (100.0 % 47 (100.0%) 86 (100.0%)

Among subjects in group one, no subject gave a rating of one suggesting poor physical health; one (2.6%) subject rated two; 10 (25.6%) subjects rated three; 18 (46.2%) subjects rated four; and 10 (25.6%) subjects rated five suggesting excellent physical health. Among 47 non-herbal product -users in group two, no subject gave a rating of one; two (4.3%) subjects rated two; 11 (23.4%) subjects rated three; 23 (48.9%) subjects rated four; and 11 (23.4%) subjects rated five. There were no significant differences in perception of physical health between the two groups (X2

0.297, p 0.961) .

Emotional health was rated two on the visual scale by one (1.2%) subject; rated three on the visual scale by six (7.0%); rated four by 27 (31.4%); and five or excellent on the visual scale by 52 (60.4%) subjects (see Table 4.6).


1






80


Table 4. 6
Perceived Emotional Health by Herbal-Users, Non-Users, and Total Sample

Visual Scale Herbal Users Non-Users Total Sample
(1-S) (n=39) (N=86)
1 (Poor) 0 (0.0%) 0 (0.0%) 0 (0.0%)
2 1 (2.6%) 0 (0.0%) 1 (1.2%)
3 2 (5.1%) 4 (8.5%) 6 (7.0%)
4 10 (25.6%) 17 (36.2%) 27 (31.4%)
5 (Excellent) 26 (66.7%) 26 (S5.3%) 52 (60.4%) Total 39 (100.0%) 47 (100.0%) 86 (100.0%)


Among subjects in group one, no subject gave a rating of one suggesting poor emotional health status; one (2.6%) subject rated two; two (5.1%) subjects rated three; 10 (25.6%) subjects rated four; and 26 (66.7%) subjects rated five suggesting excellent emotional health. Among subjects in group two, no subject gave a rating of either one or two on the emotional health status; four (8.5%) subjects rated three; 17 (36.2%) subjects rated four; and 26 (55.3%) subjects rated five, which represents excellent emotional health. There was no significant difference in perceived emotional health between the group of herbal product users and that of non-users (X2 =2.761, p = 0.430).

A large number of the total sample visited at least one health care provider in the past 12 months. Eightythree subjects (96.5%) visited at least one health care provider in the past 12 months. Only three subjects (3.5%)





81

had not visited any type of health care provider within the past 12 months. Two of three subjects who did not visit any health care provider were herbal product users.

The mean number of health care providers reported by the sample was 2.56 (SD = 1.38, range 0 7). The average number of health care providers the herbal product users reported was 2.31 (SD = 1.42, range 0 7) in comparison to

2.77 health care providers (SD = 1.32, range 0 6) reported by non-users. There was no significant difference in number of health care providers that the sample had between the group of herbal product users and the group of non-users (t =1.549, p = 0.063). Internal medicine was the most frequently visited specialty reported by 55 (64%) subjects, and the second most frequently visited was family practice reported by 35 (40.7%) subjects.

Types and seriousness of health-related problems.

Among 86 subjects of the total sample, 85 (98.8%) reported at least one or more problems from the 23 categories of health-related problems (see Table 4.7). Of the heaith-related problems reported, arthritis (55.8%), allergies (48.8%), and fatigue (45.3%) were identified as major health-related problems by about half of the total sample followed by back problems (39.5%), digestive problems (34.9%), and urinary problems (32.6%). Other





82


health problems commonly reported by subjects were skin problems (29.1%), heart problems (27.9%), high blood pressure (26.7%), and memory problems (22.1%). The average number of health-related problems reported by each subject was 5.8 problems. The group of herbal users (39 subjects) identified an average of 6.1 health-related problems while an average of 5.5 health-related problems was reported by the group of non-users (47 subjects).

Each health-related problem in 23 different areas was compared between the group of herbal users and that of nonusers. There was significant difference in memory problem between the two groups (X2 = 5.238, p = 0.022). Thirteen subjects in the group of herbal product users reported memory problems while six subjects of the counter part reported memory problems. Differences were not found in other areas of health-related problems between the two groups (see Table 4.7).

Table 4.7
Types of Health-Related Problems (N=86)

Number and Types of Herbal Non- Total
Problems Product Users Users P
users N
No. of Health Problems
X 6.08 5.53 5.78
SD 3.13 3.15 3.13
Range (1-14) (0-12) (0 14)
Arthritis 23 25 48 (55.8) NS





83


Table 4.7 (continued)

Number and Types of Herbal Non- Total
Problems Product Users Users p
users N (%)
Allergies 20 22 42 (48.8) NS

Fatigue (low energy) 17 22 39 (45.3) NS
Back problems 20 14 34 (39.5) NS
Digestive Problems 14 16 30 (34.9) NS

Urinary problems 13 15 28 (32.6) NS
Skin problems 13 12 25 (29.1) NS

Heart problems 9 15 24 (27-9) NS
High Blood Pressure 8 is 23 (26.7) NS
Dizziness 10 9 19 (22.1) NS

Memory problems 13 6 19 (22.1) P=0.02
Anxiety 6 9 15 (17.7) NS
Blood & Circulatory 7 7 14 (16.3) NS

problems
Chronic Pain 9 5 14 (16.3) NS
Cold & Flu 6 8 14 (16.3) NS
Obesity 8 4 12 (14.0) NS

Headache 4 7 11 (12.8) NS
Cancer 2 7 9 (10.5) NS

Diabetes 1 7 8 (9.3) NS
Depression 4 3 7 (8.1) NS
Lung problems 3 4 7 (8.1) NS

Gynecological problems 1 0 1 (1.2) NS
Others 26 28 54 (63.8) NS

Notes: NS = no significant difference between the group ooff
herbal product users and the group of non-users
(P 0.05)

Each subject was asked about the seriousness of

identified health-related problems in her daily living by





84


using a visual scale which ranged from one to five. One represented no interruption in daily living from the health problem, while five represented an extremely serious interruption in daily living from the identified healthrelated problem. Seriousness of each health-related problem was compared between the two groups in all 23 areas. The two groups were homogeneous with respect to seriousness of health-related problems in all areas except obesity. The group of herbal product users and the group of non-users were not homogeneous in regards to seriousness of obesity (Fisher's Exact 2-Tail Test, p = 0.0222) although the two groups were homogeneous with regards to obesity as a

health-related problem (X2=2.557, p=0.129) .

Of all subjects who reported health-related problems, the majority indicated that the seriousness of health problems in their daily living was three, two or one on the visual scale. The seriousness of memory problems in interfering with everyday life was not significantly different between the group of herbal product users and the group of non-users (X2 =2.219, p=0.708) although the two groups were different in the frequency of memory as a health-related problem.





85


Use of prescribed and non-prescribed medicines.

The use of prescribed medicines was reported by 75 (87.2%) of the total sample. The average number of prescribed medicines used by the total sample was 3.20 medicines (SD 2.40; range 0 10); herbal product users reported a mean of 3.00 medicines (SD = 2.21; range 0 8); and non-users reported mean of 3.36 medicines (SD = 2.56; range 0 10). There was no significant difference in the use of prescribed medicines between the group of herbal product users and that of non-users (t=1.75, p=0.08).

All but one of the total sample (98.8%) reported the use of non-prescribed medicines. The mean number of nonprescribed medicines used by the total sample was 3.79 medicines (SD = 1.90; range 0 9); herbal product users reported a mean of 4.18 medicines (SD = 1.94; range 1 9); and non-users reported a mean of 3.47 medicines (SD = 1.82; range 0 to 8).

Of the non-prescribed medicines used by sample, many of them were taken on a regular basis. The most frequently used non-prescribed medicines taken regularly were multivitamin, calcium, vitamin E, vitamin C, and aspirin (see Table 4.8). More than one-third of the total sample was using at least one of these five non-prescribed medicines. of the forty-eight subjects (55.8%) in the total





86


sample who used multivitamins, 22 (56.4%) were herbal product users and 26 (55.3%) were non-herbal product users. Calcium was the second most frequently used non-prescription medicine among the sample. Forty-seven (54.7%) subjects in the total sample were taking calcium including 20 (51.3%) were herbal-product users and 27 (57.4%) were non-users. Forty-one subjects (47.1%) in the total sample were taking Vitamin E; 22 (56.4%) subjects from the herbal-product users and 19 (40.4%) from the nonusers. Among 29 subjects (33.3%) from the total sample who used vitamin C, 18 (46.2%) were herbal-product users; and 11 (23.4%) were non-users. Aspirin was regularly used by 27 subjects (31.4%) in the total sample. Eleven subjects (28.2%) were herbal-product users and 16 (34.0%) were nonusers.

Table 4.8
Frequently Used Non-prescribed Medicines Taken Regularl

Non-prescribed Herbal-Product Non-Users Total
medicines Users (n=39) (n=47) (N 86)
No. (%) No. (%) No. (%)
Multivitamin 22 (56.4) 26 (55.3) 48 (55.8)

Calcium 20 (51.3) 27 (57.4) 47 (54.7)

Vitamin E 22 (56.4) 19 (40.4) 41 (47.1)

Vitamin C 18 (46.2) 11 (23.4) 29 (33.3)

Aspirin 11 (28.2) 16 (34.0) 27 (31.4)






87


There was no significant difference in the number of non-prescribed medicines used between the group of herbal product users and non-users (t=0.69, p=0.49). In summary, the average number of medicines including both prescribed and non-prescribed medicines for each subject of the total sample was 6.99 medicines (SD = 2.85; range 1 17). The average number of total medicines used by herbal product users was 7.18 medicines (SD = 2.80; range 1 17), while the non-herbal product user group used 6.83 medicines (SD 2.9; range 2 15). There was no significant difference in the use of total number of medicines between the two groups (t=0.56, p=0.57). The summary of the use of prescribed, non-prescribed, and total number of medicines used by sample is illustrated in Table 4.9. Table 4.9
Use of Prescribed, Non-prescribed Medicines by Sample (N=86)

Herbal Users Non-Users Total Sample Medicines (n) (n=39) (n 47) (N=86)
x SD x SD x SD
(Min-Max) (Min-Max) (Min-Max)
Total 7.18 2.80 6.83 2.91 6.99 2.85 NS
Medicines (1 17) (2 15) (1 17)

Prescribed 3.00 2.21 3.36 2.56 3.20 2.40
Medicines (0 8) (0 10) (0 10)

Non-prescribed 4.18 1.94 3.47 1.82 3.79 1.90 NS Medicines (1 9) (0 8) (0 9)

NS = Statistically not significant between the group of herbal product users and non-users (p = 0.05)






88




Description of the Research Questions Research Question One

The first research question was stated as, what is the prevalence of use of herbal products among women 65 years and older. Of the total sample of 86 subjects, 39 (45.3%) reported using herbal products in the past 12 months. A total of 98 herbal products were used by the 39 subjects, which averaged 2.51 herbal products per subject (SD = 2.16; range 1 11) The three most commonly used herbal products were Ginkgo Biloba or Ginkgo Biloba with other combinations (12 subjects), garlic tablets and cloves (11 subjects), and Glucosamine with Chondroitin (8 subjects) Ninety-two herbal products (93.9%) were taken orally, while six (6.1%) herbal products were used externally. About three-quarters (76%) of the total number of herbal products were in a ready-to-take form such as tablets, capsules, or liquid preparations; and 24% of the herbal products required some preparation by the subjects. The types of herbal products used by the subjects are illustrated in Table 4.10.






89


Table 4.10
Types of Herbal Products Used by Subjects

Name (n) Name (n)
Ginkgo or Ginkgo combinations Paprika Powder (1)

(12)
Garlic (11) Hot Spicy Pepper (1)

Glucosamine w/ chondroitin (8) Shark Cartilage (2) Aloe (5) Barley Green (1)
Herbal Tea (Parsley, Basil, Grapefruit Seeds Extract (1) Peppermint tea) (4)
Echinacea (4) Anica (1)

Ginger (4) MSM (1)
St. Johns Wort (3) Bakuchi Oil (1)
Vinegar w/Honey (3) Triphala Tea (1)

Primrose (3) Grape Seeds Extract (1)

G.H.3 (2) Spiru-Tein (1)
Ginseng (2) Co Q-10 (1)
Green Tea (2) Acidophilus (1)
Selenium (2) Cod Liver Oil w/ Whole Milk
Flax Oil Complex or Flax Tea Soy Bean Oil Beta Carotene
(2) (1)
Pure Cranberry Juice (1) Lecithin Capsules (1)
Pantothenic Acid (1) Provex (1)
Melatonin (1) Seven Forests (1)
Papaya Capsules (1) Eight Prunes (1)

Manchurian Mushroom Tea (1) Chromium Picolinate (1) Sesame Oil w/ five whole Liver Flush (Mix of Olive
cloves (1) Oil, Lime Juice, Apple Cider
Vinegar, & Red Pepper) (1) Stevia Liquid Extract (1) Calms Forte (1)
Cayenne Pepper Capsules (1) Ghee w/ boiled Butter (1) Nature's Tea (Colon Cleanser) Brewer's Yeast w/ Orange
(1) Juice, or Milk and Honey (1)








90


Research Question Two

The second question was stated as what is the purpose for taking herbal products and/or herbs by women 65 years and over. Do older women take herbal products more for prevention or for treatment of symptoms?

Of the persons taking herbals, 16 (41%) reported using herbal products to maintain health or to prevent possible health problems. Nine subjects (23%) used herbal products for treatment of health problems. Fourteen subjects (36%) used herbal products both to prevent and to treat health problems (see Table 4.11). Of the 98 herbal products used by the subjects, 55 (56.1%) products were used to prevent health problems or to maintain health, while 43 (43.9%) of the herbal products were used to treat health problems. The three major purposes for using herbal products other than prevention were to improve memory, to treat arthritis, and to remedy digestive problems. Table 4.11Purposes of Using Herbal Products by Subjects and by Number of Herbal Products

Reasons to take herbal Subjects No. of Herbal
products (n=39) Products (n=98)
To treat health problems 9 (23%) 43 (43.9%)
To maintain health or
prevent health problems 16 (41%) 55 (56.1%)
For both treatment and
prevention purposes 14 (36%) N/A

Total 39 (100%) 98 (100%)








91


The perceived benefit of taking the herbal products

was also identified. About one-half of the herbal products (47.9%) were perceived by subjects to be somewhat effective or very effective while the effectiveness of 40.6% of herbal products was unknown. only one subject reported any side effect from taking the herbal products. This subject reported diarrhea as a side effect after taking qingerroot tablets for a period of three months. Research Question Three

The research question was stated as what is the

frequency of use of herbal products by women aged 65 and over. Do women who use herbal products use them continuously over time or on an as needed basis? Do women who use herbal products use them alone or in combination with prescribed and /or non-prescribed medicines?

Thirty-nine subjects in group one used a total of 98 herbal products with a mean of 2.51 herbal products per subject (SD = 2.16, range 1 11). Subjects reported that 85.4% of the herbal products used were taken on a continual basis. These products had been used for a mean of 34.8 months with a standard deviation of 92.3 months (range onehalf month 600 months). Fourteen herbal products (14.6%) were used when symptoms occurred. Of the 98 total herbal




Full Text

PAGE 1

86( 2) +(5%$/ 352'8&76 35(6&5,%(' 0(',&,1(6 $1' 12135(6&5,%(' 0(',&,1(6 %< &20081,7<':(//,1* 2/'(5 :20(1 %\ 6$81-22 /(( <221 $ ',66(57$7,21 35(6(17(' 72 7+( *5$'8$7( 6&+22/ 2) 7+( 81,9(56,7< 2) )/25,'$ ,1 3$57,$/ )8/),//0(17 2) 7+( 5(48,5(0(176 )25 7+( '(*5(( 2) '2&725 2) 3+,/2623+< 81,9(56,7< 2) )/25,'$

PAGE 2

&RS\ULJKW %\ 6DXQ-RR /HH
PAGE 3

7R P\ KXVEDQG 6XQJ+ZD DQG GDXJKWHUV $O\VVD DQG +\XQML IRU WKHLU ORYH SDWLHQFH DQG HQFRXUDJHPHQW

PAGE 4

$&.12:/('*(0(176 ZLVK WR WKDQN WKH PHPEHUV RI P\ VXSHUYLVRU\ FRPPLWWHH IRU WKHLU HQFRXUDJHPHQW DQG VXSSRUW IURP WKH LQFHSWLRQ RI WKLV UHVHDUFK VWXG\ WR LWV FRPSOHWLRQ DP HVSHFLDOO\ JUDWHIXO WR 'U &OD\GHOO +RUQH FKDLUSHUVRQ RI P\ FRPPLWWHH IRU KHU FRXQVHOLQJ VXSSRUW DQG SDWLHQFH WKURXJKRXW P\ GRFWRUDO SURJUDP H[WHQG P\ VLQFHUH DSSUHFLDWLRQ WR 'U .DWKOHHQ /RQJ IRU KHU VXSSRUW DQG HQFRXUDJHPHQW WR FRQGXFW WKLV UHVHDUFK DP JUDWHIXO WR 'U +RVVHLQ
PAGE 5

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

PAGE 6

&+$37(5 ,,, 0(7+2'2/2*< 5HVHDUFK 'HVLJQ 6HWWLQJ 6DPSOH ,QFOXVLRQ DQG ([FOXVLRQ &ULWHULD ,QVWUXPHQW 2SHUDWLRQDOL]DWLRQ RI 9DULDEOHV 3URFHGXUH 'DWD &ROOHFWLRQ 'DWD $QDO\VLV &+$37(5 ,9 5(68/76 5HVHDUFK 'HVLJQ 6DPSOH 'HPRJUDSKLF &KDUDFWHULVWLFV RI WKH 6DPSOH 5HVHDUFK +\SRWKHVHV 'HVFULSWLRQ RI WKH 5HVHDUFK 4XHVWLRQV 2WKHU )LQGLQJV &+$37(5 9 ',6&866,21 $1' 5(&200(1'$7,216 'LVFXVVLRQ DQG &RQFOXVLRQV ,PSOLFDWLRQ IRU 1XUVLQJ DQG 5HFRPPHQGDWLRQV 5()(5(1&(6 $33(1',; $ 48(67,211$,5( $33(1',; % &216(17 )250 $33(1',; & 7+( 0267 3238/$5 $6,$1 3$7(17 0(',&,1(6 7+$7 &217$,1 72;,& ,1*5(',(176 %,2*5$3+,&$/ 6.(7&+ YL

PAGE 7

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

PAGE 8

$EVWUDFW RI 'LVVHUWDWLRQ 3UHVHQWHG WR WKH *UDGXDWH 6FKRRO 2I WKH 8QLYHUVLW\ RI )ORULGD LQ 3DUWLDO )XOILOOPHQW RI WKH 5HTXLUHPHQWV IRU WKH 'HJUHH RI 'RFWRU RI 3KLORVRSK\ 86( 2) +(5%$/ 352'8&76 35(6&5,%(' 0(',&,1(6 $1' 12135(6&5,%(' 0(',&,1(6 %< &20081,7<':(//,1* 2/'(5 :20(1 %\ 6DXQ-RR /HH
PAGE 9

ZRPHQ \HDUV DQG RYHU DQG OLYLQJ LQGHSHQGHQWO\ LQ D 1RUWK &HQWUDO )ORULGD FRXQW\ $ UDQGRP VDPSOH ZDV VHOHFWHG IURP D OLVW RI ZRPHQ \HDUV DQG RYHU REWDLQHG IURP WKH 6WDWH 'HSDUWPHQW RI +LJKZD\ 6DIHW\ DQG 0RWRU 9HKLFOHV 6WUXFWXUHG LQWHUYLHZV ZHUH FRPSOHWHG RQ VXEMHFWV 7KH LQWHUYLHZ TXHVWLRQQDLUH ZDV FRPSULVHG RI WKUHH SDUWV LQFOXGLQJ KHDOWK VWDWXV DQG XVH RI FRQYHQWLRQDO PHGLFLQHV XVH RI KHUEDO SURGXFWV DQG GHPRJUDSKLF GDWD 'DWD LQGLFDWHG WKDW KHUEDO SURGXFWV ZHUH XVHG E\ b RI WKH VDPSOH LQ WKH SDVW PRQWKV 7KH WRWDO VDPSOH UHSRUWHG XVLQJ D PHDQ RI SUHVFULEHG PHGLFLQHV DQG QRQSUHVFULEHG PHGLFLQHV SHU SHUVRQ 7KH PHDQ QXPEHU RI KHUEDO SURGXFWV XVHG E\ WKH VDPSOH ZDV 7KH VDPSOH UHSRUWHG XVLQJ D WRWDO RI KHUEDO SURGXFWV 6XEMHFWV UHSRUWHG RQO\ b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

PAGE 10

&+$37(5 ,1752'8&7,21 3HUVRQV ZKR DUH DQG ROGHU FRPSULVH WKH IDVWHVW JURZLQJ DJH JURXS LQ WKH 8QLWHG 6WDWHV $PRQJ PLOOLRQ SHRSOH LQ WKH 8QLWHG 6WDWHV PLOOLRQ DUH DJHG DQG ROGHU 86 %XUHDX RI &HQVXV f ,Q WKH \HDUV DQG ROGHU SRSXODWLRQ ZRPHQ RXWQXPEHU PHQ DQG WKLV JDS ZLGHQV ZLWK LQFUHDVLQJ DJH &REEV t 5DODSDWL f 2OGHU ZRPHQ LQ WKLV DJH JURXS KDYH D KLJKHU GLVDELOLW\ UDWH DQG DUH PRUH OLNHO\ WKDQ PHQ WR OLYH ORQJHU ZLWK FKURQLF FRQGLWLRQV .DUW f $OWKRXJK SHUVRQV DQG ROGHU UHSUHVHQW DERXW b RI WKH $PHULFDQ SRSXODWLRQ WKH\ FRQVXPH WKUHH WLPHV PRUH SUHVFULSWLRQ GUXJV WKDQ WKHLU \RXQJHU FRXQWHUSDUWV *RUPOH\ *ULIILWKV 0F&UDFNHQ t +DUULVRQ f )RXU RXW RI ILYH SHRSOH DJHG DQG ROGHU KDYH DW OHDVW RQH FKURQLF GLVHDVH 'HODIXHQWH f DQG SHUVRQV LQ WKLV DJH JURXS KDYH DOPRVW WZLFH WKH ULVN RI LDWURJHQLF GLVHDVH DQG YLVLW WKH FOLQLFV PRUH RIWHQ WKDQ GR \RXQJHU SHRSOH /DP\ f 5HVHDUFKHUV VKRZ WKDW FRPPXQLW\GZHOOLQJ HOGHUO\ XVH DQ DYHUDJH RI GUXJV LQFOXGLQJ SUHVFULSWLRQ DQG

PAGE 11

QRQSUHVFULSWLRQ GUXJV DQG DERXW b RI WKHVH SHUVRQV WDNH WZR RU PRUH GUXJV 3ROORZ 6WROOHU )RVWHU t 'XQLKR f 0DQ\ HOGHUO\ SHRSOH DUH GHSHQGHQW RQ FRQYHQWLRQDO GUXJ WKHUDS\ WR WUHDW WKHLU FKURQLF FRQGLWLRQV DQG WR PDLQWDLQ WKHLU KHDOWK 7KH JRDOV RI GUXJ WKHUDS\ LQ WKH HOGHUO\ DUH WR Df DOOHYLDWH SDLQ Ef LPSURYH IXQFWLRQDO FDSDFLW\ Ff SURPRWH TXDOLW\ RI OLIH DQG Gf SURORQJ OLIH 6ORDQ f 0XOWLSOH GUXJ XVH LQ WKH HOGHUO\ HYHQ ZKHQ HDFK GUXJ KDV D WKHUDSHXWLF SXUSRVH FDQ LQFUHDVH WKH ULVN RI VLJQLILFDQW GUXJUHODWHG SUREOHPV VXFK DV DGYHUVH GUXJ UHDFWLRQV RU GUXJGUXJ LQWHUDFWLRQV 1R\HV /XFDV t 6WUDWWRQ 6ORDQ f :KLOH WKH XVH RI PXOWLSOH SUHVFULSWLRQ DQG QRQSUHVFULEHG GUXJV DPRQJ WKH HOGHUO\ KDV EHHQ VWXGLHG H[WHQVLYHO\ &KULVFKLOOHV HW DO )LOOHQEDXP +RUQHU +DQORQ /DQGHUPDQ 'DZVRQ t &RKHQ +HOOLQJ /HPNH 6HOPD :DOODFH /LSVRQ t &RUQRUL +XQWOH\ 6WHZDUW 0RRUH 0D\ 0DUNV t +DOH f OLWWOH LV NQRZQ DERXW WKH XVH RI KHUEDO SURGXFWV E\ WKLV DJH JURXS DQG KRZ KHUE£LV UHDFW ZKHQ WDNHQ ZLWK SUHVFULEHG DQGRU QRQSUHVFULEHG PHGLFLQHV 5HFHQWO\ KHUEDO SURGXFWV KDYH LQFUHDVLQJO\ UHFHLYHG DWWHQWLRQ LQ WKH 8QLWHG 6WDWHV DV FRPSOHPHQWDU\ DQG

PAGE 12

DOWHUQDWLYH PHGLFLQH 0DQ\ UHVHDUFKHUV KDYH XVHG GLIIHUHQW WHUPV WR H[SODLQ FRPSOHPHQWDU\ DQG DOWHUQDWLYH PHGLFLQH &$0f VXFK DV XQFRQYHQWLRQDO DOWHUQDWLYH RU FRPSOHPHQWDU\ XQSURYHQ DQG XQRUWKRGR[ WKHUDSLHV (LVHQEHUJ .HVVOHU )RUVWHU 1RUORFN &DONLQV DQG 'HOEDQFR f GHILQHG &$0 DV PHGLFDO LQWHUYHQWLRQV QRW WDXJKW ZLGHO\ DW 86 PHGLFDO VFKRROV RU WKRVH QRW JHQHUDOO\ DYDLODEOH DW 86 KRVSLWDOV LH DFXSXQFWXUH FKLURSUDFWLF DQG KHUEDO PHGLFLQHf 7KH GHILQLWLRQ RI &$0 ZDV IXUWKHU UHILQHG LQ WKH &$0 5HVHDUFK 0HWKRGRORJ\ &RQIHUHQFH LQ DV D EURDG GRPDLQ RI KHDOLQJ UHVRXUFHV WKDW FRPSULVHV DOO KHDOWK V\VWHPV PRGDOLWLHV DQG SUDFWLFH RWKHU WKDQ D GRPLQDQW KHDOWK V\VWHP RI D SDUWLFXODU VRFLHW\ LQ D JLYHQ KLVWRULFDO SHULRG 3DQHO RQ 'HILQLWLRQ DQG 'HVFULSWLRQ &$0 5HVHDUFK 0HWKRGRORJ\ &RQIHUHQFH $SULO f 5HFHQWO\ DWWHQWLRQ WR &$0 KDV EHHQ JLYHQ E\ JRYHUQPHQWDO KHDOWK DJHQFLHV ([DPSOHV LQFOXGH WKH HVWDEOLVKPHQW RI WKH 2IILFH RI $OWHUQDWLYH 0HGLFLQH 2$0f LQ 1DWLRQDO ,QVWLWXWHV RI +HDOWK 1,+f LQ DQG WKH SDVVDJH RI QHZ UHJXODWLRQ RI KHUEDO SURGXFWV DV GLHWDU\ VXSSOHPHQWV LQ WKH 'LHWDU\ 6XSSOHPHQW +HDOWK DQG (GXFDWLRQ $FW '6+($f LQ 7D\ORU f (YHQ EHIRUH WKH SDVVDJH RI QHZ UHJXODWLRQV RQ KHUEDO SURGXFWV LQ VDOHV RI

PAGE 13

KHUEDO SURGXFWV LQ WKH 8QLWHG 6WDWHV LQ ZHUH HVWLPDWHG DW RYHU RQH ELOOLRQ GROODUV 0F&DOHE f $OWKRXJK LW PD\ QRW QHFHVVDULO\ UHIOHFW WKH DFWXDO XVH RI &$0 LQFOXGLQJ KHUEDO PHGLFLQHV FKDQJHV LQ WKH UHJXODWLRQ RI KHUEDO SURGXFWV DQG PRUH UHVHDUFK IRFXVHG RQ &$0 FHUWDLQO\ EULQJ KLJKHU SXEOLF LQWHUHVW WKDQ HYHU EHIRUH ,Q WKH 8QLWHG 6WDWHV RQH LQ WKUHH VWXG\ SDUWLFLSDQWV UHSRUWHG XVLQJ DW OHDVW RQH XQFRQYHQWLRQDO WKHUDS\ LQ WKH SDVW \HDU (LVHQEHUJ HW DO f ,Q WKH VDPH VWXG\ WKUHH SHUFHQW RI $PHULFDQV VXUYH\HG XVHG KHUEDO PHGLFLQHV GXULQJ WKH SDVW WZHOYH PRQWKV ZKLOH DSSUR[LPDWHO\ b RI WKH ZRUOGZLGH SRSXODWLRQ ZHUH HVWLPDWHG WR GHSHQG RQ WUDGLWLRQDO KHUEDO PHGLFLQHV :RUOG +HDOWK 2UJDQL]DWLRQ f $FFRUGLQJ WR (LVHQEHUJ DQG FROOHDJXHV f WKH PDMRULW\ RI SHRSOH XVHG XQFRQYHQWLRQDO WKHUDSLHV IRU FKURQLF PHGLFDO FRQGLWLRQV EXW QRW IRU OLIHWKUHDWHQLQJ VLWXDWLRQV (LVHQEHUJ DQG FROOHDJXHV f LQIHUUHG WKDW D VXEVWDQWLDO QXPEHU RI XQFRQYHQWLRQDO WKHUDSLHV ZHUH XVHG IRU QRQVHULRXV PHGLFDO FRQGLWLRQV KHDOWK SURPRWLRQ RU GLVHDVH SUHYHQWLRQ %HFDXVH RI WKH YDULDELOLW\ RI FRPSOHPHQWDU\ DQG DOWHUQDWLYH PHGLFLQHV QDWXUDO KHDOWK IRRG VWRUHV VHOOLQJ KHUEDO SURGXFWV DUH H[SDQGLQJ EXVLQHVVHV LQ WKH 8QLWHG

PAGE 14

6WDWHV 7KH ERWDQLFDO LQGXVWU\ KDV JURZQ IURP DOPRVW QRWKLQJ WR D ELOOLRQ LQGXVWU\ LQ \HDUV DQG LV H[SDQGLQJ DW D UDWH RI b D \HDU 0DUZLFN f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

PAGE 15

SUHYDOHQFH DQG WKH UHDVRQV IRU WDNLQJ KHUEDO SURGXFWV DPRQJ WKH HOGHUO\ DV ZHOO DV SRVVLEOH LQWHUDFWLRQV EHWZHHQ GUXJV RI FRQYHQWLRQDO PHGLFLQH DQG KHUEDO SURGXFWV 3UREOHP 6WDWHPHQW ,W LV NQRZQ WKDW WKHUH DUH DOWHUHG SKDUPDFRORJLFDO PHFKDQLVPV DQG GHFUHDVHG IXQFWLRQDO FDSDFLW\ RI WKH PDMRU RUJDQ V\VWHPV ZLWK DJLQJ 0RQWDPDW &XVDFN t 9HVWDO f +RZHYHU SHRSOH ZKR DUH DJHG DQG ROGHU FRQVXPH WKUHH WLPHV PRUH SUHVFULSWLRQ GUXJV WKDQ WKRVH XQGHU *RUPOH\ *ULIILWKV 0F&UDFNHQ t +DUULVRQ f ,Q DGGLWLRQ WR SUHVFULEHG PHGLFDWLRQV WKH ROGHU DGXOWV DUH DOVR IUHTXHQW XVHUV RI QRQSUHVFULSWLRQ GUXJV 3ROORZ 6WROOHU )RVWHU t 'XQLKR f 7KH RYHUDOO LQFLGHQFH RI DGYHUVH GUXJ UHDFWLRQV RU LQWHUDFWLRQV LQ WKH HOGHUO\ LV WZR WR WKUHH WLPHV KLJKHU WKDQ WKH RFFXUUHQFH LQ WKHLU \RXQJHU FRXQWHUSDUWV 1RODQ t 2n0DOOH\ f 7KHVH ILJXUHV KRZHYHU GR QRW LQFOXGH UHDFWLRQ RU LQWHUDFWLRQ ZLWK WKH XVH RI KHUEDO SURGXFWV 0RVW ROGHU SHUVRQV KDYH DW OHDVW RQH FKURQLF FRQGLWLRQ DQG PDQ\ KDYH PXOWLSOH FRQGLWLRQV $FFRUGLQJ WR WKH $GPLQLVWUDWLRQ RQ $JLQJ WKH PRVW IUHTXHQWO\ RFFXUULQJ FRQGLWLRQV SHU HOGHUO\ LQ LQFOXGHG DUWKULWLV f K\SHUWHQVLRQ f KHDUW GLVHDVH f KHDULQJ LPSDLUPHQWV

PAGE 16

f FDWDUDFWV f RUWKRSHGLF LPSDLUPHQWV f VLQXVLWLV f DQG GLDEHWHV f :RPHQ ZKR DUH DJHG DQG ROGHU KDYH WKH KLJKHVW UDWH RI FKURQLF FRQGLWLRQV VXFK DV DUWKULWLV 86 'HSDUWPHQW RI +HDOWK DQG +XPDQ 6HUYLFHV f (LVHQEHUJ DQG FROOHDJXHV f SRLQWHG RXW WKDW WKH XVH RI XQFRQYHQWLRQDO WKHUDSLHV ZDV QRW OLPLWHG WR WKH SHUVRQnV SULQFLSDO PHGLFDO FRQGLWLRQ DV DGMXQFWV WR FRQYHQWLRQDO WKHUDS\ EXW H[WHQGHG WR QRQVHULRXV PHGLFDO FRQGLWLRQV KHDOWK SURPRWLRQ RU GLVHDVH SUHYHQWLRQ $ IXOO RQHWKLUG RI WKHLU VWXG\ UHVSRQGHQWV ZKR XVHG XQFRQYHQWLRQDO WKHUDSLHV GLG QRW XVH WKHVH WKHUDSLHV IRU DQ\ RI WKHLU SULQFLSDO PHGLFDO SUREOHPV (LVHQEHUJ HW DO f $FFRUGLQJ WR WKH HDUOLHU VWXG\ E\ (LVHQEHUJ DQG FROOHDJXHV f SUHYDOHQFH UDWH RI SHUVRQV \HDUV DQG ROGHU ZKR XVH KHUEDO SURGXFWV LQ WKH 8QLWHG 6WDWHV LV WKUHH SHUFHQW +RZHYHU VLQFH WKH 'LHWDU\ 6XSSOHPHQW +HDOWK DQG (GXFDWLRQ $FW LQ WKH XVH RI KHUEDO SURGXFWV KDV LQFUHDVHG DQG VLQFH WKDW WLPH UHVHDUFKHUV KDYH IRXQG DQ LQFUHDVLQJ SUHYDOHQFH RI KHUEDO SURGXFW XVH DPRQJ SHUVRQV LQ WKH 8QLWHG 6WDWHV 7KH :RUOG +HDOWK 2UJDQL]DWLRQ HVWLPDWHG WKDW WUDGLWLRQDO KHUEDO PHGLFLQHV ZHUH WKH PRVW

PAGE 17

IUHTXHQWO\ XVHG W\SHV RI WKHUDSLHV IRU WKH PDMRULW\ RI SHRSOH LQ WKH ZRUOG 7KHUH ZHUH FRQWURYHUVLDO UHVXOWV UHODWLQJ WR WKH SUHYDOHQFH RI UHSRUWHG XVH RI KHUEDO PHGLFLQHV DPRQJ DJH JURXSV LQ VWXGLHV FRQGXFWHG LQ WKH 8QLWHG 6WDWHV (LVHQEHUJ HW DO )UDWH &URRP )UDWH -XHUJHQV t 0H\GUHFK f )UDWH DQG FROOHDJXHV f VWDWHG WKDW RYHU SHUFHQW RI WKH DGXOWV LQ WKHLU VDPSOH XVHG DW OHDVW RQH SODQWGHULYHG PHGLFLQH GXULQJ WKH SDVW \HDU ZKLOH WKUHH SHUFHQW RI WKH VWXG\ SRSXODWLRQ XVHG KHUEDO WKHUDSLHV LQ WKH VWXG\ E\ (LVHQEHUJ DQG FROOHDJXHV f 'LIIHUHQFHV LQ VWXG\ UHVXOWV PD\ RFFXU EHFDXVH RI UHVHDUFK PHWKRGRORJ\ GHILQLWLRQV RI KHUEDO PHGLFLQH DQG SODQWGHULYHG WKHUDSLHV DQG VHWWLQJV RI GDWD FROOHFWLRQ 7KH XVH RI KHUEDO SURGXFWV KDV EHHQ VWXGLHG LQ FHUWDLQ W\SHV RI LOOQHVVHV 5HVHDUFKHUV VKRZHG WKH XVH RI KHUEDO SURGXFWV DPRQJ $,'6 SDWLHQWV *UHHQEODWW +ROODQGHU 0F0DVWHU t +HQNH .DVVOHU %ODQF t *UHHQEODWW f $O]KHLPHUnV SDWLHQWV &ROHPDQ )RZOHU t :LOOLDPV f UKHXPDWRLG DUWKULWLV SDWLHQWV %RLVVHW t )LW]FKDUOHV f DQG FDQFHU SDWLHQWV &DVVLOHWK t &KDSPDQ f :KLOH UHVHDUFKHUV UHSRUWHG WKH XVH RI KHUEDO SURGXFWV DPRQJ GLVHDVH VSHFLILF JURXSV RI SHRSOH YHU\ OLWWOH LV

PAGE 18

NQRZQ DERXW WKH SUHYDOHQFH RI XVH RI KHUEDO SURGXFWV DPRQJ WKH HOGHUO\ UHVLGLQJ WKH FRPPXQLW\ $OVR OLWWOH LQIRUPDWLRQ LV DYDLODEOH UHODWHG WR WKH SRWHQWLDO DGYHUVH HIIHFWV RI KHUEDO SURGXFWV DQG SRVVLEOH LQWHUDFWLRQV EHWZHHQ FRQYHQWLRQDO GUXJV DQG KHUEDO SURGXFWV LQ WKH HOGHUO\ 5HVHDUFK $LPV 7KH SXUSRVH RI WKLV UHVHDUFK LV WR VWXG\ WKH XVH RI KHUEV DQGRU KHUEDO SURGXFWV IRU PHGLFLQDO XVH DV ZHOO DV WKH SRVVLEOH LQWHUDFWLRQV EHWZHHQ KHUE£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

PAGE 19

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

PAGE 20

:KDW VRXUFHV GR ZRPHQ DQG RYHU XVH WR REWDLQ LQIRUPDWLRQ DERXW WKH XVH RI KHUEDO SURGXFWV" 2SHUDWLRQDO 'HILQLWLRQ RI 7HUPV )RU WKH SXUSRVH RI WKLV UHVHDUFK WHUPV DUH RSHUDWLRQDOL]HG DV IROORZV &RPSOHPHQWDU\ DQG $OWHUQDWLYH 0HGLFLQH &$0f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f LV H[FOXGHG IURP GHILQLWLRQ RI nGUXJn E\ )'$ DQG Ef LV QRW ODEHOHG DV D YLWDPLQ D PLQHUDO RU IRRG DGGLWLYH DQG Ff FRQWDLQV DFWLYH LQJUHGLHQWV DHULDO RU XQGHUJURXQG SDUWV RI SODQWV RWKHU SODQW PDWHULDO LQ D

PAGE 21

FUXGH VWDWH RU SODQW SUHSDUDWLRQ RU FRPELQDWLRQV SUHSDUDWLRQV RU Gf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

PAGE 22

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

PAGE 23

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

PAGE 24

FRQYHQWLRQDO PHGLFLQH DV ZHOO DV GLIIHUHQFHV EHWZHHQ KHUEDO SURGXFW XVHUV DQG QRQXVHUV DPRQJ ROGHU ZRPHQ 7KH UHVXOWV RI WKLV UHVHDUFK JLYH D EHWWHU XQGHUVWDQGLQJ DERXW WKH XVH RI KHUEDO SURGXFWV DPRQJ ROGHU ZRPHQ DQG HQFRXUDJH H[WHQVLYH FRPPXQLFDWLRQ EHWZHHQ KHDOWK FDUH SURYLGHUV DQG FOLHQWV IRU FRPSUHKHQVLYH FDUH ZKLFK UHVXOWV LQ LPSURYLQJ WKH TXDOLW\ RI OLIH RI ROGHU ZRPHQ

PAGE 25

&+$37(5 ,, 5(9,(: 2) /,7(5$785( 7KH UHYLHZ RI OLWHUDWXUH SHUWDLQLQJ WR KHUEDO SURGXFWV UHVHDUFK LQFOXGHV VXPPDWLRQ RI WKH IROORZLQJ WRSLFV Df GLIIHUHQFHV EHWZHHQ DOWHUQDWLYH PHGLFLQH DQG FRQYHQWLRQDO PHGLFLQH Ef KLVWRU\ RI KHUEDO SURGXFWV DQG WKHLU XVH Ff SUHYDOHQFH RI WKH XVH RI DOWHUQDWLYH PHGLFLQH Gf FKRLFH EHWZHHQ FRQYHQWLRQDO DQG DOWHUQDWLYH PHGLFLQHV Hf ROGHU ZRPHQ DQG KHDOWK SUREOHPV If SDWWHUQV RI GUXJ XVH DPRQJ ROGHU DGXOWV Jf SRO\SKDUPDF\ DPRQJ WKH HOGHUO\ DQG Kf WR[LFLWLHV RI KHUEDO SURGXFWV DQG SRVVLEOH LQWHUDFWLRQV RI KHUEDO PHGLFLQHV ZLWK FRQYHQWLRQDO PHGLFLQHV 'LIIHUHQFHV EHWZHHQ $OWHUQDWLYH 0HGLFLQH DQG &RQYHQWLRQDO 0HGLFLQH $OWHUQDWLYH PHGLFLQH LV RIWHQ GHILQHG DV Df PHGLFDO LQWHUYHQWLRQV QRW WDXJKW ZLGHO\ DW 86 PHGLFDO VFKRROV RU WKRVH QRW JHQHUDOO\ DYDLODEOH DW 86 KRVSLWDOV Ef WUHDWPHQWV ZKLFK ODFN VXIILFLHQW GRFXPHQWDWLRQ LQ WKH 86 IRU VDIHW\ DQG HIIHFWLYHQHVV DJDLQVW VSHFLILF GLVHDVHV DQG FRQGLWLRQV DQG Ff SUDFWLFHV WKDW DUH QRW JHQHUDOO\ UHLPEXUVDEOH E\ KHDOWK LQVXUDQFH SURYLGHUV 6WDONHU

PAGE 26

f 6HYHQ FDWHJRULHV RI DOWHUQDWLYH PHGLFDO SUDFWLFH DUH OLVWHG E\ WKH 2IILFH RI &RPSOHPHQWDU\ DQG $OWHUQDWLYH 0HGLFLQHV WKH 1DWLRQDO ,QVWLWXWH RI +HDOWK :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH f 7KHVH LQFOXGH Df PLQGERG\ LQWHUYHQWLRQV Ef ELRHOHFWURPDJQHWLF WKHUDSLHV Ff DOWHUQDWLYH V\VWHPV RI PHGLFDO SUDFWLFH Gf PDQXDO KHDOLQJ PHWKRGV Hf SKDUPDFRORJLF DQG ELRORJLF WUHDWPHQWV If KHUEDO PHGLFLQH DQG Jf GLHW DQG QXWULWLRQ 0LQGERG\ LQWHUYHQWLRQV LQFOXGH SV\FKRWKHUDS\ K\SQRVLV LPDJHU\ PHGLWDWLRQ ELRIHHGEDFN VXSSRUW JURXSV GDQFH WKHUDS\ \RJD PXVLF WKHUDS\ DUW WKHUDS\ SUD\HU DQG PHQWDO KHDOLQJ 0LQGERG\ LQWHUYHQWLRQ KHOSV SDWLHQWV H[SHULHQFH DQG H[SUHVV WKHLU LOOQHVVHV LQ QHZ ZD\V E\ XVLQJ SODFHER UHVSRQVH DQG VSLULWXDOLW\ DV ZHOO DV UHOLJLRQ %LRHOHFWURPDJQHWLFV %(0f LV WKH VFLHQFH WKDW VWXGLHV KRZ OLYLQJ RUJDQLVPV LQWHUDFW ZLWK HOHFWURPDJQHWLF (0f ILHOGV DQG SXUSRUWV WKDW FKDQJHV LQ WKH ERG\nV QDWXUDO ILHOGV PD\ SURGXFH SK\VLFDO DQG EHKDYLRUDO FKDQJHV %(0 LQFOXGHV EOXH OLJKW WUHDWPHQW DUWLILFLDO OLJKWLQJ HOHFWURDFXSXQFWXUH HOHFWURPDJQHWLF ILHOGV HOHFWURVWLPXODWLRQ DQG QHXURPDJQHWLF VWLPXODWLRQ GHYLFHV DQG PDJQHWRUHVRQDQFH VSHFWURVFRS\ :RUOGZLGH b WR b RI KXPDQ KHDOWK FDUH LV GHOLYHUHG E\ DOWHUQDWLYH V\VWHPV RI PHGLFDO SUDFWLFHV

PAGE 27

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f 3KDUPDFRORJLFDO DQG ELRORJLFDO WUHDWPHQWV DUH DQ DVVRUWPHQW RI GUXJV DQG YDFFLQHV QRW \HW DFFHSWHG E\ PDLQVWUHDP PHGLFLQH DQG LQFOXGH EXW DUH QRW OLPLWHG WR DQWLR[LGL]LQJ DJHQWV FHOO WUHDWPHQW PHWDEROLF WKHUDS\ DQG R[LGL]LQJ DJHQWV 2]RQH +\GURJHQ 3HUR[LGHf 'LHW DQG QXWULWLRQ GHYLVHG IRU WKH SUHYHQWLRQ DQG WUHDWPHQW RI FKURQLF GLVHDVH LQFOXGH FKDQJHV LQ GLHWDU\ OLIHVW\OH GLHW *HUVRQ WKHUDS\ PDFURELRWLFV PHJDYLWDPLQV DQG QXWULWLRQDO VXSSOHPHQWV

PAGE 28

+HUEDO SURGXFWV DUH PRVWO\ D SDUW RI SODQWV RU SODQW SURGXFWV WKDW KDYH D ORQJ KLVWRU\ RI WUDGLWLRQV LQ DOO FXOWXUHV $OWKRXJK PDQ\ GUXJV FRPPRQO\ XVHG WRGD\ DUH RI KHUEDO RULJLQ KHUEDO SURGXFWV FDQ EH PDUNHWHG RQO\ DV IRRG VXSSOHPHQWV LQ WKH 8QLWHG 6WDWHV 'HVSLWH WKH VNHSWLFLVP E\ )RRG DQG 'UXJ $GPLQLVWUDWLRQ )'$f D JURZLQJ QXPEHU RI $PHULFDQV DUH H[KLELWLQJ LQWHUHVW LQ KHUEDO SUHSDUDWLRQV 7KH LQFUHDVHG XVH RI SODQW PHGLFLQHV KDV D SRWHQWLDO EHQHILW IRU LPSURYLQJ SXEOLF KHDOWK EXW LVVXHV UHODWHG WR VDIHW\ HIILFDF\ DQG DSSURSULDWHQHVV RI PHGLFLQDO KHUEV QHHG WR EH VROYHG :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH f ,Q FRQWUDVW WR DOWHUQDWLYH PHGLFLQH FRQYHQWLRQDO PHGLFLQH LV WKH PHGLFDO SUDFWLFH WKDW LV ZLGHO\ DYDLODEOH DW $PHULFDQ PHGLFDO VFKRROV RU LQ 8 6 KRVSLWDOV DQG LV FRQVLGHUHG WR EH WKH ZRUOGn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

PAGE 29

DOWHUQDWLYH PHGLFLQH LV WR DOWHU WKH VXEMHFWLYH VWDWH RI WKH SHUVRQ ZKLFK FDQ HYHQWXDOO\ SURPRWH REMHFWLYH LPSURYHPHQWV LQ GLVHDVH VWDWHV %XUJ f &RQYHQWLRQDO PHGLFLQH DQG DOWHUQDWLYH PHGLFLQH FDQ DOVR EH GLVWLQJXLVKHG E\ WKHLU DSSURDFKHV WR WKH UROH RI WKH SDWLHQW LQ WUHDWPHQW %XUJ f E\ DGPLQLVWUDWLRQ RI WKHUDSLHV DQG E\ WKH LQWHUDFWLRQ EHWZHHQ WKH SDWLHQW DQG KHDOWK FDUH SURYLGHU :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH f ,Q ELRPHGLFLQH SDWLHQWV UHFHLYH WKH VWDQGDUGL]HG WUHDWPHQW DQG PHGLFDO DGYLFH RQ WKH EDVLV RI GLDJQRVLV RU V\PSWRPDWLF FDWHJRULHV ,Q WKLV V\VWHP WKH SDWLHQW SUDFWLWLRQHU LQWHUDFWLRQ LV SK\VLFLDQ FHQWHUHG 7KH SK\VLFLDQ WKXV LV WKH DXWKRULWDWLYH H[SHUW DQG WKH SDWLHQW LV D UHFHSWLYH SDUWLFLSDQW %UXQWRQ f ,Q FRQWUDVW DOWHUQDWLYH PHGLFDO SUDFWLWLRQHUV WHQG WR LQGLYLGXDOL]H WUHDWPHQW DQG WR FUHDWH HODERUDWH SURFHGXUHV IRU LGHQWLI\LQJ LQGLYLGXDO VXLWDELOLW\ DQG VHQVLWLYLW\ WR WKH LQWHUYHQWLRQV 7KH\ RIWHQ DSSO\ PXOWLSOH WUHDWPHQW PRGDOLWLHV DQG MXGJH HIIHFWLYHQHVV E\ XVLQJ VXEMHFWLYH DQG SDWLHQW GHULYHG RXWFRPHV -RQDV f $OWHUQDWLYH V\VWHPV RI PHGLFLQH HPSKDVL]H D FOLHQWFHQWHUHG UHODWLRQVKLS DQG SDWLHQW UHVSRQVLELOLW\ LQ WKH KHDOLQJ SURFHVV ZKLFK FDQ PD[LPL]H WKH FROODERUDWLRQ EHWZHHQ WKH PHGLFDO

PAGE 30

SUDFWLWLRQHUV DQG SDWLHQWV WKXV HQKDQFLQJ WKH EHQHILWV RI D WKHUDS\ $OWKRXJK DOO FRPSOHPHQWDU\ PHGLFLQH SUDFWLWLRQHUV GR QRW VKDUH D FRPPRQ HSLVWHPRORJ\ VHYHUDO SULQFLSOHV DUH FRPPRQ WR PRVW RI WKHLU SUDFWLFHV 7KHVH LQFOXGH HPSKDVLV RQ WKH Df 3DWLHQWVn IHHOLQJ UDWKHU WKDQ WKHLU GLDJQRVLV Ef +ROLVWLF YLHZ UDWKHU WKDQ FRQYHQWLRQDO PHGLFDO YLHZ $OO DVSHFWV RI WKH SHUVRQ LH SK\VLFDO HPRWLRQDO PHQWDO DQG SV\FKRVRFLDO KHDOWK OLIHVW\OH HWFf DUH LQWHUUHODWHG DQG PXVW EH FRQVLGHUHG WKURXJK WKH SURFHVV RI FDUH Ff 3URPRWLRQ RI WKH XVH RI D YDULHW\ RI WKHUDSHXWLF RSWLRQV IRU WKH SXUSRVHV RI SUHYHQWLRQ DQG WUHDWPHQW DQG YLHZLQJ WUHDWPHQW DV D SURFHVV Gf 0DLQWDLQLQJ EDVLF HWKLFV RI SDWLHQW FDUH VXFK DV GR QR KDUP Hf %DODQFH LQ D SDWLHQWnV ERG\ V\VWHP DQG UHODWLRQVKLS WR RWKHU LQGLYLGXDOV VRFLHW\ RU HQYLURQPHQW If 3URGXFWLRQ RI IHZHU VLGH HIIHFWV E\ XVLQJ ZKROH IRRGV DQG KHUEV UDWKHU WKDQ XVLQJ FRQYHQWLRQDO GUXJV DQG Jf ([SHFWDWLRQ WKDW WKH SDWLHQW LV QRW D SDVVLYH UHFLSLHQW EXW DQ DFWLYH SDUWLFLSDQW WKURXJK WKH WUHDWPHQW SURFHVV %XUJ 0XUUD\ :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH f +LVWRU\ RI +HUEDO 3URGXFWV DQG 7KHLU 8VH $Q KHUE LV GHILQHG DV D VHHGSURGXFLQJ DQQXDO ELHQQLDO RU SHUHQQLDO WKDW GRHV QRW GHYHORS SHUVLVWHQW

PAGE 31

ZRRG\ WLVVXH EXW GLHV GRZQ DIWHU IORZHULQJ 7KH VHFRQG GHILQLWLRQ LV D SODQW RU SODQW SDUW YDOXHG IRU LWV PHGLFLQDO VDYRU\ RU DURPDWLF TXDOLWLHV 0HUULDP:HEVWHUnV &ROOHJLDWH 'LFWLRQDU\ f 7KH KHUEV UHIHUUHG WR LQ WKLV SDSHU DUH LQFOXGHG XQGHU WKH VHFRQG GHILQLWLRQ $Q KHUEDO PHGLFLQH LV D SODQWGHULYHG PDWHULDO RU SUHSDUDWLRQ ZLWK WKHUDSHXWLF RU RWKHU KXPDQ KHDOWK EHQHILWV ZKLFK FRQWDLQV HLWKHU UDZ RU SURFHVVHG LQJUHGLHQWV IURP RQH RU PRUH SODQWV :RUOG +HDOWK 2UJDQL]DWLRQ f +HUEDO SUHVFULSWLRQV DUH DYDLODEOH IRU WKH HQWLUH UDQJH RI PHGLFDO DLOPHQWV LQFOXGLQJ SDLQ KRUPRQDO GLVWXUEDQFHV EUHDWKLQJ GLVRUGHUV LQIHFWLRQV DQG FKURQLF GHELOLWDWLQJ LOOQHVVHV 7KHVH DUH FODVVLILHG DFFRUGLQJ WR WKHLU HQHUJHWLF TXDOLWLHV DQG DUH SUHVFULEHG IRU WKHLU DFWLRQ RQ FRUUHVSRQGLQJ RUJDQ G\VIXQFWLRQ HQHUJ\ GLVRUGHUV GLVWXUEHG LQWHUQDO HQHUJ\ EORFNDJH RI WKH PHULGLDQV RU VHDVRQDO SK\VLFDO GHPDQGV :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH f (DUO\ KXPDQV WUHDWHG LOOQHVV E\ XVLQJ SODQWV DQLPDO SDUWV DQG PLQHUDOV WKDW ZHUH QRW SDUW RI WKHLU XVXDO GLHW +HUEDO PHGLFLQHV XVLQJ SODQWV DQG SODQW SURGXFWV KDYH EHHQ XWLOL]HG LQ PHGLFDO SUDFWLFH IRU WKRXVDQGV RI \HDUV DQG KDYH PDGH D JUHDW FRQWULEXWLRQ WR PDLQWDLQLQJ KXPDQ KHDOWK

PAGE 32

)RU H[DPSOH WKH (EHUV 3DS\UXV WKH SUHVHUYHG (J\SWLDQ PDQXVFULSWV ZHUH ZULWWHQ DURXQG %& DQG FRQWDLQ SUHVFULSWLRQV PDGH XS RI PRUH WKDQ GLIIHUHQW VXEVWDQFHV LQFOXGLQJ PDQ\ KHUEV 'H 0DWHULD 0HGLFD ZULWWHQ LQ WKH VW FHQWXU\ $' RIIHUV DERXW FXUDWLYH VXEVWDQFHV LQFOXGLQJ SODQW SURGXFWV DQG RWKHU RI DQLPDO RU PLQHUDO RULJLQ LQ *UHHFH DQG 5RPH $FNHUQHFKW f 7KLV WH[W H[SODLQV D GHVFULSWLRQ RI WKH SODQW DQ DFFRXQW RI LWV PHGLFLQDO TXDOLWLHV PHWKRGV RI SUHSDUDWLRQ DQG ZDUQLQJV DERXW XQGHVLUDEOH HIIHFWV 7KH $UDEV SUHVHUYHG D ERG\ RI NQRZOHGJH LQ WKH 0XVOLP PDWHUD PHGLFD ZKLFK OLVWV PRUH WKDQ VXEVWDQFHV LQFOXGLQJ PDQ\ SODQW SURGXFWV $FNHUQHFKW f +HUEV SOD\HG DQ LPSRUWDQW UROH LQ $\UXYHGLF PHGLFLQH LQ ,QGLD DQG ZHUH GHVFULEHG LQ $\UXYHGLF ERRNV PRUH WKDQ \HDUV DJR 7KH KLVWRU\ RI &KLQHVH KHUEDO PHGLFLQH FDQ EH WUDFHG WR WKH HQG RI WKH WKLUG FHQWXU\ %& 7KH (QF\FORSHGLD RI 7UDGLWLRQDO &KLQHVH 0HGLFLQH 6XEVWDQFHV WKH PRVW GHILQLWLYH FRPSLODWLRQ RI &KLQDnV KHUEDO WUDGLWLRQ WR GDWH KDV HYROYHG IURP WKH &ODVVLF RI WKH 0DWHUD 0HGLFD ZKLFK ZDV ZULWWHQ DOPRVW \HDUV DJR 7UDGLWLRQDO &KLQHVH PHGLFLQH LQIOXHQFHG .RUHD DQG -DSDQ DQG PDUNHGO\ VLPSOLILHG -DSDQHVH WUDGLWLRQDO PHGLFLQH FDOOHG .DPSR :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH f

PAGE 33

,Q FRQWUDVW WKH 8QLWHG 6WDWHV KDV D UHODWLYHO\ VKRUW KLVWRU\ RI WKH XVH RI KHUEDO SURGXFWV FRPSDUHG WR WKDW RI RWKHU FRXQWULHV (DUO\ H[SORUHUV RI 1RUWK $PHULFD H[FKDQJHG NQRZOHGJH ZLWK WKH 1DWLYH $PHULFDQV WR OHDUQ ZKLFK KHUEV WR XVH LQ WKH 1HZ :RUOG 8QWLO WKH HDUO\ WK FHQWXU\ SODQWV UHPDLQHG DV D PDLQVWD\ RI FRXQWU\ PHGLFLQH DQG ZHUH XVHG QRW RQO\ E\ SK\VLFLDQV WR WUHDW FRPPRQ LOOV EXW DOVR DV LPSRUWDQW KRPH UHPHGLHV E\ PDQ\ IDPLOLHV %XFKPDQ f $ WH[WERRN RI SKDUPDFRJQRV\ FRQWDLQHG KXQGUHGV RI PHGLFDOO\ XVHIXO FRPPHQWV RQ KHUEV XQWLO WKH V $V PHGLFLQH HYROYHG ZLWK DGYDQFHG WHFKQRORJ\ LQ WKH WK FHQWXU\ UHPHGLHV IURP QDWXUDO UHVRXUFHV ZHUH JUDGXDOO\ IRUJRWWHQ LQ PRGHUQ VRFLHW\ 7RGD\ KRZHYHU PDQ\ FRPPRQO\ XVHG GUXJV DUH RI KHUEDO RULJLQ $ERXW RQHTXDUWHU RI WKH SUHVFULSWLRQ GUXJV GLVSHQVHG E\ FRPPXQLW\ SKDUPDFLHV LQ WKH 8QLWHG 6WDWHV FRQWDLQ DW OHDVW RQH DFWLYH LQJUHGLHQW GHULYHG IURP SODQW PDWHULDO :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH f 5HFHQWO\ $PHULFDQV KDYH VKRZQ DQ LQFUHDVHG LQWHUHVW LQ WKH XVH RI KHUEV DQG KHUEDO PHGLFLQHV GXH LQ SDUW WR WKH FKDQJLQJ KHDOWK FDUH V\VWHPnV IRFXV RQ SUHYHQWLYH FDUH DV ZHOO DV LQWHUHVW LQ QDWXUDO WKHUDSLHV
PAGE 34

&KLQD -DSDQ 6RXWK $PHULFD DQG 0H[LFR LQ PRVW 86 KHDOWK IRRG VWRUHV 6HFRQGO\ SHRSOH DUH ZLOOLQJ WR WU\ KHUEV DQG KHUEDO SUHSDUDWLRQV IRU FKURQLF LOOQHVVHV RU DV DQ DGMXQFW WR RWKHU WUHDWPHQW $QG ILQDOO\ KHUEV DQGRU KHUEDO SURGXFWV DUH JHQHUDOO\ FRQVLGHUHG WR EH OHVV WR[LF WKDQ GUXJV IURP FRQYHQWLRQDO PHGLFLQHV :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH f ,W LV QRZ HDVLHU WR JDLQ DFFHVV WR KHUEDO SURGXFWV VLQFH WKH\ DUH FRQVLGHUHG GLHWDU\ VXSSOHPHQWV UDWKHU WKDQ D SDUW RI FRQYHQWLRQDO GUXJV DV D FRQVHTXHQFH RI WKH 'LHWDU\ 6XSSOHPHQW +HDOWK DQG (GXFDWLRQ $FW RI ,Q WKH 8QLWHG 6WDWHV ELOOLRQ RI KHUEV ZHUH VROG LQ DQG WKHLU VDOHV UDWH KDV EHHQ JURZLQJ IURP b WR b SHU \HDU DYHUDJLQJ DERXW b D \HDU *UD\ f 7KHUH ZHUH DERXW QDWXUDO KHDOWK IRRG VWRUHV LQ WKH 8QLWHG 6WDWHV LQ 0DUZLFN f :LWK DQ LQFUHDVHG XVH RI KHUEDO SURGXFWV VDIHW\ DQG WR[LFLW\ DUH EHFRPLQJ LVVXHV $OWKRXJK LW LV JHQHUDOO\ SHUFHLYHG WKDW QDWXUDO SURGXFWV DUH VDIH WKHUH DUH ULVNV ZKHQ WKHVH DUH XVHG EHFDXVH QRW DOO KHUEDO UHPHGLHV DUH KDUPOHVV +HUEV RU KHUEDO SURGXFWV FDQ EH LQFRUUHFWO\ LGHQWLILHG E\ PDQXIDFWXUHUV DV QRQWR[LF KHUEV 6LQFH PDQ\ KHUEDO SURGXFWV DUH PL[WXUHV VRPH RI WKHP PD\ EH WR[LF SDUWLFXODUO\ LI WKH\ DUH PLVXVHG 6RPH D\XUHYHGLF ERWDQLFDO

PAGE 35

SURGXFWV FRQWDLQ KLJK OHYHOV RI KHDY\ PHWDOV WKDW FDQ FDXVH WR[LF HIIHFWV $QRWKHU WKUHDW SRVHG E\ KHUEDO UHPHGLHV LV D ODFN RI SURSHU NQRZOHGJH LQ XVLQJ WKHP ZKLFK UHVXOWV LQ DQ RYHUGRVH FDXVLQJ LUUHYHUVLEOH RUJDQ GDPDJH 0DUZLFN f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b RI $PHULFDQV UHSRUWHG XVLQJ DW OHDVW RQH DOWHUQDWLYH PHGLFLQH LQ WKH SUHYLRXV \HDU LQFOXGLQJ b ZKR YLVLWHG DOWHUQDWLYH SUDFWLWLRQHUV DQG VSHQW ELOOLRQ RQ WKHVH YLVLWV $PHULFDQV PDGH PRUH YLVLWV WR DOWHUQDWLYH SUDFWLWLRQHUV PLOOLRQf WKDQ WR SULPDU\ FDUH SK\VLFLDQV PLOOLRQf (LVHQEHUJ HW DO f 7KH UHVXOWV RI WKH VWXG\ E\ 3DUDPRUH f DUH FRQVLVWHQW ZLWK WKDW RI (LVHQEHUJ DQG FROOHDJXHVf 3DUDPRUH f IRXQG WKDW QHDUO\ b RI WKH 86

PAGE 36

SRSXODWLRQ DOPRVW PLOOLRQ SHUVRQV VDZ D SURIHVVLRQDO LQ IRU DW OHDVW RQH RI WKH IROORZLQJ IRXU WKHUDSLHV FKLURSUDFWLF UHOD[DWLRQ WHFKQLTXHV WKHUDSHXWLF PDVVDJH RU DFXSXQFWXUH 7KH XVH RI DOWHUQDWLYH PHGLFLQHV ZDV FRUUHODWHG ZLWK SRRU KHDOWK UDWKHU WKDQ PDLQWDLQLQJ RU SURPRWLQJ KHDOWK 7KH XVH RI DOWHUQDWLYH PHGLFLQHV ZDV IUHTXHQWO\ XVHG DPRQJ PLGGOHDJHG ZKLWHV ZKR KDG PRUH HGXFDWLRQ DQG KLJKHU LQFRPHV (LVHQEHUJ HW DO 3DUDPRUH f 7KHVH UHVHDUFKHUV UHSRUWHG QR VLJQLILFDQW JHQGHU GLIIHUHQFHV LQ WKH XVH RI IRXU DOWHUQDWLYH PHGLFLQHV $OWHUQDWLYH PHGLFLQHV ZHUH PRUH IUHTXHQWO\ XVHG WR WUHDW PHGLFDO FRQGLWLRQV VXFK DV EDFN SUREOHPV LQVRPQLD KHDGDFKH DQ[LHW\ DQG GHSUHVVLRQ (LVHQEHUJ HW DO f DQG ZHUH DOVR XVHG IRU PLQRU DLOPHQWV IRU KHDOWK SURPRWLRQ DQG DV SURSK\OD[LV IRU UHFXUUHQW SUREOHPV 0XUUD\ t 6KHSKHUG f 7KHVH WKHUDSLHV ZHUH JHQHUDOO\ XVHG DV DGMXQFWV WR FRQYHQWLRQDO PHGLFLQH UDWKHU WKDQ UHSODFHPHQWV IRU FRQYHQWLRQDO PHGLFLQH (LVHQEHUJ HW DO 0XUUD\ t 6KHSKHUG f 2YHUDOO SHUVRQV ZLWK FKURQLF QRQVSHFLILF DQG KDUG WRWUHDW LOOQHVVHV DUH OLNHO\ WR EH IUHTXHQW XVHUV RI FRPSOHPHQWDU\ PHGLFLQHV 5HVHDUFKHUV VWXG\LQJ SRO\SKDUPDF\ DPRQJ SDWLHQWV DWWHQGLQJ DQ $,'6 FOLQLF IRXQG WKDW b RI

PAGE 37

SDWLHQWV ZLWK $,'6 XVHG DOWHUQDWLYH PHGLFLQHV GXULQJ WKH WKUHH PRQWK SHULRG SULRU WR WKH LQWHUYLHZ DQG WKH XVH RI DOWHUQDWLYH PHGLFLQHV ZDV DVVRFLDWHG ZLWK WKHLU VWDJH RI LOOQHVV *UHHQEODWW +ROODQGHU 0F0DVWHU t +HQNH f 7KH XVH RI PHGLFLQDO KHUEV ZDV PRUH IUHTXHQW LQ +,9 LQIHFWHG SDWLHQWV WKDQ LQ WKH JHQHUDO SRSXODWLRQ ZKLFK VKRZHG WKDW b RI UDQGRPO\ VHOHFWHG +,9LQIHFWHG SDWLHQWV UHSRUWHG XVLQJ RQH RU PRUH KHUEDO SURGXFWV LQ WKH SDVW WKUHH PRQWKV .DVVOHU %ODQF t *UHHQEODWW f $FFRUGLQJ WR &ROHPDQ )RZOHU DQG :LOOLDPV f b RI FDUHJLYHUV RI SDWLHQWV ZLWK $O]KHLPHUnV GLVHDVH UHSRUWHG WKDW WKH\ KDG WULHG DW OHDVW RQH DOWHUQDWLYH WKHUDS\ WR LPSURYH WKH SDWLHQWnV PHPRU\ LQFOXGLQJ b ZKR XVHG KHUEDO PHGLFLQHV $OWKRXJK WKH SURSRUWLRQ RI FDQFHU SDWLHQWV XVLQJ DOWHUQDWLYH WKHUDSLHV LV D VPDOOHU SHUFHQWDJH FRPSDUHG ZLWK WKH SHUFHQWDJH RI DOO SDWLHQWV ZKR GR VR WKH SUHYDOHQFH RI DOWHUQDWLYH FDQFHU WKHUDS\ LQ WKH 8QLWHG 6WDWHV UDQJHG IURP D ORZ RI b WR D KLJK RI b /HUQHU t .HQQHG\ f $ VWXG\ LQ &DQDGD VKRZHG WKDW b RI &DQDGLDQ SDWLHQWV ZLWK UKHXPDWRORJLF GLVHDVHV KDG XVHG DOWHUQDWLYH WKHUDSLHV LQ WKH SUHFHGLQJ PRQWKV 7KH PRVW IUHTXHQWO\ XVHG DOWHUQDWLYH WUHDWPHQW PRGDOLW\ ZDV QRQSUHVFULEHG RYHU WKH FRXQWHU SURGXFWV LQFOXGLQJ KHUEV PLQHUDOV DQG WRSLFDO UHPHGLHV %RLVVHW t )LW]FKDUOHV f

PAGE 38

$FFRUGLQJ WR (LVHQEHUJ DQG FROOHDJXHV f WKH PRVW FRPPRQ W\SHV RI WKHUDSLHV XVHG ZHUH UHOD[DWLRQ WHFKQLTXHV FKLURSUDFWLF DQG PDVVDJH 2YHU D PRQWK SHULRG KHUEDO PHGLFLQHV ZHUH XVHG E\ RQO\ b RI $PHULFDQV VXUYH\HG (LVHQEHUJ HW DO f ZKLOH WKH :RUOG +HDOWK 2UJDQL]DWLRQ HVWLPDWHG WKDW b RI WKH ZRUOG SRSXODWLRQ XVHG KHUEDO PHGLFLQH IRU VRPH DVSHFW RI SULPDU\ KHDOWK FDUH )DUQVZRUWK $NHUHOH %LQJHO 6RHMDUWD t (QR f 'DWD IURP WKH UXUDO FHQWUDO 0LVVLVVLSSL DUHD )UDWH &URRP )UDWH -XHUJHQV t 0H\GUHFK f ZDV FORVH WR WKH SUHYDOHQFH UDWH IURP :RUOG +HDOWK 2UJDQL]DWLRQ DQG VKRZHG WKDW RYHU b RI WKH DGXOWV IURP WKH VDPSOH RI KRXVHKROGV XVHG DW OHDVW RQH SODQWGHULYHG PHGLFLQH GXULQJ WKH SDVW \HDU +HUEDO UHPHGLHV ZHUH IUHTXHQWO\ XVHG E\ SHRSOH ZKR ZHUH PDUULHG IURP ODUJHU KRXVHKROGV RI KLJKHU VRFLRHFRQRPLF VWDWXV RU ZKR KDG FRQVXOWHG DOWHUQDWLYH KHDOHUV %URZQ t 0DUF\ f +RZHYHU WKHUH LV OLWWOH IDFWXDO HYLGHQFH FRQFHUQLQJ WKH XVH RI KHUEDO PHGLFLQHV DPRQJ WKH HOGHUO\ DQG FKDUDFWHULVWLFV RI XVHUV FRPSDUHG WR WKRVH RI QRQXVHUV &KRLFH %HWZHHQ $OWHUQDWLYH DQG &RQYHQWLRQDO 0HGLFLQHV 'HVSLWH WKH DGYDQFHV RI FRQYHQWLRQDO PHGLFLQHV DOWHUQDWLYH WKHUDSLHV KDYH UHFHLYHG LQFUHDVHG DWWHQWLRQ LQ WKH 8QLWHG 6WDWHV DQG RWKHU GHYHORSHG FRXQWULHV DQG KDYH

PAGE 39

EHHQ FKRVHQ IRU XVH LQ WUHDWLQJ YDULRXV KHDOWK SUREOHPV E\ DQ LQFUHDVLQJ QXPEHU RI SHRSOH (LVHQEHUJ HW DO 0DF/HQQDQ :LOVRQ t 7D\ORU 3DUDPRUH f &RPSDUHG WR FRQYHQWLRQDO PHGLFLQH DOWHUQDWLYH PHGLFLQHV UHO\ KHDYLO\ RQ WKH IROORZLQJ IDFWRUV SDUWLFLSDWLRQ E\ SDWLHQWV LQ WKHLU RZQ FDUH WKH UHODWLRQVKLS EHWZHHQ WKH H[SHFWDWLRQV RI SDWLHQWV FXOWXUDO FRQWH[W DQG OLIHVW\OH DFWLYLWLHV DQG HIIHFWV RQ WKHUDSHXWLF RXWFRPH RI SDWLHQWVn FKRLFHV RI WUHDWPHQW :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH f ,Q DQ HDUOLHU \HDU .URQHQIHOG DQG :DVQHU f IRFXVHG RQ WKH PDUJLQDOL]HG JURXSV LQ VRFLHW\ WR VWXG\ WKH UHODWLRQVKLS EHWZHHQ DOWHUQDWLYH PHGLFLQH DQG WUDGLWLRQDO IRON PHGLFLQH ZKLFK KDV GHYHORSHG IURP HWKQRJUDSKLF WUDGLWLRQ ,Q UHFHQW VWXGLHV UHVHDUFKHUV KDYH UHFRJQL]HG WKDW XQFRQYHQWLRQDO WKHUDSLHV DUH DFFHSWHG DQG SUDFWLFHG E\ D VLJQLILFDQW QXPEHU RI SHRSOH DQG DUH EHOLHYHG WR EH D SDUW RI FRQWHPSRUDU\ FXOWXUH (LVHQEHUJ HW DO 0DF/HQQDQ :LOVRQ t 7D\ORU 3DUDPRUH f 6LQFH VLJQLILFDQW QXPEHUV RI SHUVRQV KDYH UHFRJQL]HG WKH XVH RI DOWHUQDWLYH PHGLFLQH PDQ\ UHVHDUFKHUV KDYH LQYHVWLJDWHG IDFWRUV DVVRFLDWHG ZLWK WKH FKRLFHV RI DOWHUQDWLYH WKHUDSLHV 9LQFHQW DQG )XUQKDP f UHSRUWHG WKH SULQFLSDO UHDVRQV E\ SDWLHQWV IRU FKRRVLQJ DOWHUQDWLYH

PAGE 40

PHGLFLQH RYHU FRQYHQWLRQDO PHGLFLQH 7KHVH UHDVRQV LQFOXGHG Df EHOLHI LQ WKH SRVLWLYH YDOXH RI DOWHUQDWLYH PHGLFLQH Ef SUHYLRXV H[SHULHQFH RI LQHIIHFWLYH WUHDWPHQW RI FRQYHQWLRQDO PHGLFLQH DQG Ff FRQFHUQ DERXW WKH DGYHUVH HIIHFWV RI PHGLFDO FDUH 2WKHU IDFWRUV LQIOXHQFLQJ WKH FKRLFH RI DOWHUQDWLYH PHGLFLQH ZHUH WKH SRRU FRPPXQLFDWLRQ EHWZHHQ SDWLHQWV DQG KHDOWK FDUH SUDFWLWLRQHUV LQ FRQYHQWLRQDO PHGLFLQH WKH ZLOOLQJQHVV RI DOWHUQDWLYH SUDFWLWLRQHUV WR GLVFXVV HPRWLRQDO IDFWRUV DQG WKH FKDQFH WR WDNH DQ DFWLYH UROH LQ WKHLU WUHDWPHQW 9LQFHQW DQG )XUQKDP f &KRLFHV RI DOWHUQDWLYH WKHUDSLHV ZHUH LQIOXHQFHG E\ WKH SURJQRVLV IRU VSHFLILF GLVHDVHV VXFK DV $,'6 FDQFHU DUWKULWLV RU $O]KHLPHUnV GLVHDVH %RLVVHW t )LW]FKDUOHV &DVVLOHWK t &KDSPDQ &ROHPDQ )RZOHU t :LOOLDPV *UHHQEODWW +ROODQGHU 0F0DVWHU t +HQNH f GLVVDWLVIDFWLRQ ZLWK WKH HIIHFWLYHQHVV RI FRQYHQWLRQDO PHGLFLQH &DVVLOHWK t &KDSPDQ 6XWKHUODQG t 9HUKRHI f QHJDWLYH UHODWLRQVKLS WR SHUFHLYHG KHDOWK VWDWXV DQG WR KHDOWK FDUH SURYLGHUV 6XWKHUODQG t 9HUKRHI f DQG D ODFN RI FRQILGHQFH LQ FRQYHQWLRQDO PHGLFLQH 0F*UHJRU t 3HD\ f ,Q VXPPDU\ D VLQJOH IDFWRU FDQQRW EH XVHG WR H[SODLQ WKH FKRLFH RI DOWHUQDWLYH WKHUDSLHV IRU RQHnV FDUH

PAGE 41

$FFRUGLQJ WR .HOQHU DQG :HOOPDQ f PDQ\ IDFWRUV LQIOXHQFH SHRSOH LQ WKHLU FKRLFH RI DOWHUQDWLYH WKHUDSLHV 3UHGLVSRVLQJ IDFWRUV LQFOXGH OHYHO RI HGXFDWLRQ DQG DJH HQDEOLQJ IDFWRUV LH LQFRPH NQRZOHGJH DQG DFFHVVLELOLW\ RI VHUYLFHVf DQG WKH QHHG IRU FDUH .HOQHU DQG :HOOPDQ f SRLQW RXW LQGLYLGXDOV LQ WKHLU VWXG\ ZKR FKRRVH WR WU\ DOWHUQDWLYH WKHUDSLHV DVVXPH UHVSRQVLELOLW\ IRU WKHLU KHDOWK DQG ZHOOEHLQJ .HOQHU DQG :HOOPDQ f DOVR LQGLFDWH WKDW SHRSOH GR QRW PDNH GLFKRWRPRXV FKRLFHV EHWZHHQ FRQYHQWLRQDO PHGLFLQH DQG DOWHUQDWLYH PHGLFLQH 5DWKHU SHRSOH FKRRVH VSHFLILF NLQGV RI WUHDWPHQWV IRU VSHFLILF SUREOHPV DQG PDQ\ XVH PXOWLSOH WKHUDSLHV FRQFXUUHQWO\ ,Q DGGLWLRQ D ZLGH UDQJH RI SRVVLELOLWLHV RI KHDOWK FDUH DV ZHOO DV SXEOLF DQG SULYDWH WHVWLPRQLDOV DERXW VXFFHVVIXO DOWHUQDWLYH WUHDWPHQWV UHVXOW LQ PRUH SHRSOH GHFLGLQJ WR XVH DOWHUQDWLYH WKHUDSLHV WR FRSH ZLWK WKHLU SUREOHPV DQG FRQFHUQV .HOQHU t :HOOPDQ f 2OGHU :RPHQ DQG +HDOWK 3UREOHPV 7KH PDMRULW\ RI ROGHU $PHULFDQV DUH ZRPHQ DQG WKH QXPEHU RI ROGHU ZRPHQ ZLOO LQFUHDVH FRQWLQXRXVO\ 7KH QXPEHU RI ZRPHQ VXUSDVVHV WKH QXPEHU RI PHQ LQ WKH DJH UDQJH RI \HDUV DQG RYHU DQG WKLV JDS ZLGHQV ZLWK LQFUHDVLQJ DJH &REEV t 5DODSDWL f ,Q WKHUH ZHUH PLOOLRQ ROGHU ZRPHQ DQG PLOOLRQ ROGHU PHQ $PRQJ

PAGE 42

WKRVH \HDUV DQG ROGHU WKHUH DUH PHQ IRU HYHU\ ZRPHQ ZRPHQ RXWQXPEHU PHQ E\ WR RYHU WKH DJH RI DQG IRXU RXW RI ILYH FHQWHQDULDQV DUH ZRPHQ 7KHUH LV D UDSLG LQFUHDVH LQ WKH QXPEHU RI FHQWHQDULDQV LQ WKH 8QLWHG 6WDWHV 86 %XUHDX RI WKH &HQVXV f $OWKRXJK D PDMRULW\ RI ROGHU DGXOWV OLYH LQGHSHQGHQWO\ LQ WKH FRPPXQLW\ DQG FRQVLGHU WKHLU KHDOWK WR EH JRRG RU H[FHOOHQW FKURQLF GLVHDVH EHFRPHV PRUH SUHYDOHQW ZLWK DJH &REEV t 5DODSDWL f )RXU RXW RI ILYH SHRSOH DJHG DQG ROGHU KDYH DW OHDVW RQH FKURQLF GLVHDVH 'HODIXHQWH f 7KH XVH RI PXOWLSOH FRQYHQWLRQDO GUXJV DPRQJ ROGHU DGXOWV LV D VHULRXV LVVXH LQ WKH 8QLWHG 6WDWHV /DP\ 1R\HV /XFDV t 6WUDWWRQ f (YHQ ZLWK IXQFWLRQDO GLVDELOLW\ LQFUHDVLQJ ZLWK DJH PRVW ROGHU ZRPHQ UHSRUW WKDW WKH\ DUH HPRWLRQDOO\ YLWDO EXW KHDOWK VWDWXV OHYHO RI GLVDELOLW\ DQG VRFLRGHPRJUDSKLF VWDWXV LQIOXHQFH WKHLU HPRWLRQDO YLWDOLW\ 3HQQLQ[ HW DO f 0DQ\ UHVHDUFKHUV ZKR VWXGLHG WKH XVH RI FRQYHQWLRQDO GUXJV DPRQJ FRPPXQLW\GZHOOLQJ ROGHU DGXOWV UHSRUWHG JHQGHU GLIIHUHQFHV LQ WKH XVH RI FRQYHQWLRQDO GUXJV &KULVFKLOOHV HW DO )LOOHQEDXP HW DO 6LPRQV HW DO f %DVHG RQ WKH GDWD IURP WKH (VWDEOLVKHG 3RSXODWLRQV IRU (SLGHPLRORJLF 6WXGLHV RI WKH (OGHUO\ (3(6(f &KULVFKLOOHV DQG FROOHDJXHV f UHSRUWHG WKDW

PAGE 43

SUHVFULSWLRQ GUXJV ZHUH XVHG E\ b RI PHQ DQG b RI ZRPHQ ZKLOH QRQSUHVFULSWLRQ GUXJ XVH ZDV b DQG b UHVSHFWLYHO\ &KULVFKLOOHV HW DO f :KLOH VWXG\LQJ FRPPXQLW\GZHOOLQJ ROGHU DGXOWV 6LPRQV DQG FROOHDJXHV f IRXQG WKDW b RI ZRPHQ DQG b RI PHQ ZKR XVHG PXOWLSOH SUHVFULSWLRQ GUXJV DOVR XVHG PXOWLSOH QRQSUHVFULSWLRQ GUXJV )LOOHQEDXP DQG FROOHDJXHV f DQG 6LPRQV DQG FROOHDJXHV f UHSRUWHG WKDW IHPDOH JHQGHU LV RQH RI WKH EHVW SUHGLFWLQJ IDFWRUV IRU WKH XVH RI QRQSUHVFULSWLRQ GUXJV :RPHQ UHSRUWHG WDNLQJ PRUH PHGLFDWLRQV WKDQ PHQ LQ HDFK RI WKHVH VWXGLHV $OWKRXJK /DVVLOD DQG FROOHDJXHV f GLG QRW FRQVLGHU JHQGHU DV D VLJQLILFDQW IDFWRU DVVRFLDWHG ZLWK WKH XVH RI QXPEHU RI FRQYHQWLRQDO GUXJV PRVW UHVHDUFKHUV ZKR H[DPLQHG WKH XVH RI QRQSUHVFULSWLRQ GUXJV DFFRXQWHG IRU nIHPDOHn DV DQ LPSRUWDQW IDFWRU *HQGHU GLIIHUHQFH ZDV UHFRJQL]HG LQ WKH W\SHV RI KHDOWK SUREOHPV DQG KHDOWK DFWLRQV DV ZHOO DV LQ WKH XVH RI FRQYHQWLRQDO GUXJV 0XVLO f UHSRUWHG WKDW WKHUH DUH VLJQLILFDQW JHQGHU GLIIHUHQFHV LQ SV\FKRORJLFDO DQG SK\VLFDO KHDOWK DV ZHOO DV WKH KHDOWK DFWLRQV DPRQJ ROGHU DGXOWV UHVLGLQJ LQ WKH FRPPXQLW\ 7KH VLJQLILFDQW JHQGHU GLIIHUHQFHV LQ SV\FKRORJLFDO KHDOWK ZHUH IRXQG LQ DQ[LHW\ GHSUHVVLRQ DQG ERG\ DZDUHQHVV KRZHYHU QR JHQGHU

PAGE 44

GLIIHUHQFHV ZHUH IRXQG LQ VHOIDVVHVVHG KHDOWK DQG WRWDO QXPEHU RI KHDOWK SUREOHPV 0XVLO f 7KH JHQGHU GLIIHUHQFHV LQ SK\VLFDO KHDOWK DUH WKDW ZRPHQ DJHG \HDUV DQG RYHU H[SHULHQFH PRUH DUWKULWLV FDWDUDFWV K\SHUWHQVLRQ DQG DVWKPD ZKLOH WKHLU PDOH FRXQWHUSDUWV KDYH PRUH SUREOHPV ZLWK KHDULQJ XOFHUV DEGRPLQDO KHUQLDV DQG KHDUW GLVHDVH 0XVLO f %\ \HDUV RI DJH b RI ZRPHQ KDYH WZR RU PRUH FKURQLF FRQGLWLRQV PRVW OLNHO\ DUWKULWLV DQG K\SHUWHQVLRQ DQG RWKHU FRPPRQ FKURQLF FRQGLWLRQV VXFK DV KHDUW GLVHDVH DQG YLVXDO RU KHDULQJ SUREOHPV &REEV t 5DODSDWL f $FFRUGLQJ WR D VWXG\ RI KHDOWK SUREOHPV DQG UHODWHG KHDOWK DFWLRQV DPRQJ ROGHU DGXOWV 0XVLO $KQ +DXJ :DUQHU 0RUULV t 'XII\ f IUHTXHQW KHDOWK DFWLRQV LQ UHVSRQVH WR KHDOWK SUREOHPV DUH WKH XVH RI QRQSUHVFULSWLRQ PHGLFLQHV bf VHOIFDUH DFWLYLWLHV bf XVH RI SUHVFULSWLRQ PHGLFLQHV bf DQG SURIHVVLRQDO FRQVXOWDWLRQ bf 7KH JHQGHU GLIIHUHQFHV LQ KHDOWK DFWLRQV VXJJHVW WKDW ZRPHQ DUH PRUH OLNHO\ WR XVH VHOIFDUH ZKLOH PHQ LQFOLQH WRZDUGV VHHNLQJ SURIHVVLRQDO FRQVXOWDWLRQ 0XVLO f EHFDXVH KLVWRULFDOO\ ZRPHQ KDYH SOD\HG D PDMRU UROH LQ WKH KHDOLQJ SURFHVV VHUYLQJ DV FDUHJLYHUV RI WKHLU RZQ IDPLOLHV %XUJ f 6HOIFDUH DFWLRQV WKDW DUH IUHTXHQWO\ XVHG E\ FRPPXQLW\GZHOOLQJ ROGHU ZRPHQ LQFOXGH

PAGE 45

WDNLQJ QRQSUHVFULSWLRQ PHGLFLQHV XVLQJ KRPH UHPHGLHV RU PDNLQJ OLIHVW\OH FKDQJHV 0XVLO f 7KH UHVXOWV RI VWXGLHV E\ 0XVLO f DQG 0XVLO DQG FROOHDJXHV f DUH QRW VXUSULVLQJ ZKHQ FRQVLGHULQJ IUHJXHQW VHOIFDUH DFWLRQV E\ ZRPHQ LQFOXGLQJ XVLQJ KRPH UHPHGLHV %XUJ f VWDWHV WKDW PRVW IHPDOH SDWLHQWV PD\ XVH VRPH IRUP RI FRPSOHPHQWDU\ PHGLFLQH VRPH WLPH LQ WKHLU OLYHV IRU WKHLU FKURQLF KHDOWK FRQGLWLRQV DQG ZRPHQ PD\ XVH FRPSOHPHQWDU\ PHGLFLQHV LQ FRPELQDWLRQ ZLWK FRQYHQWLRQDO PHGLFLQHV ZKLFK PDNHV KHDOWK DVVHVVPHQW LPSRUWDQW WR HYDOXDWH WKH SRWHQWLDO LQWHUDFWLYH HIIHFWV $OWKRXJK WKHUH DUH QR NQRZQ GDWD VSHFLILFDOO\ ORRNLQJ DW ZRPHQnV XVH RI FRPSOHPHQWDU\ PHGLFLQH LQ WKH 8QLWHG 6WDWHV %XUJ f VXJJHVWHG WKDW FHUWDLQ JURXSV RI ZRPHQ PD\ XWLOL]H FRPSOHPHQWDU\ PHGLFLQHV EDVHG RQ JHQGHU VSHFLILF LOOQHVV SDWWHUQV DQG JHQHUDO NQRZOHGJH DERXW XVLQJ FRPSOHPHQWDU\ PHGLFLQHV 7KHVH JURXSV RI ZRPHQ ZKR PD\ XVH FRPSOHPHQWDU\ PHGLFLQHV IUHTXHQWO\ DUH SHRSOH ZLWK FKURQLF QRQVSHFLILF RU GLIILFXOW IRU WUHDWLQJ LOOQHVVHV VXFK DV DUWKULWLV GHSUHVVLRQ DQ[LHW\ +,9$,'6 DQG FDQFHU %XUJ f ,Q VXPPDU\ LW LV LPSRUWDQW WR H[DPLQH KHDOWK FDUH SUDFWLFHV DPRQJ ROGHU ZRPHQ UHODWHG WR WKH XVH RI KHUEDO SURGXFWV DV D SDUW RI FRPSOHPHQWDU\ PHGLFLQH VLQFH ZRPHQ OLYH ORQJHU WKDQ PHQ LQ WKHLU ODWHU VWDJHV RI OLIH ZLWK

PAGE 46

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f 7KH HOGHUO\ DUH WKH IDVWHVW JURZLQJ DJH JURXS DQG FRQWLQXH WR JURZ IDVWHU WKDQ DQ\ RWKHU DJH JURXS LQ WKH 8QLWHG 6WDWHV $OWKRXJK PRVW SHRSOH DUH DEOH WR FDUU\ RQ WKHLU QRUPDO DFWLYLWLHV DQG IXQFWLRQV XS WR WKH DJH RI RU ROGHU DSSUR[LPDWHO\ IRXU RXW RI ILYH SHRSOH DJHG DQG ROGHU KDYH DW OHDVW RQH FKURQLF GLVHDVH ZLWK DQ DYHUDJH RI IRXU GLVHDVHV SHU SHUVRQ 'HODIXHQWH f 7KHUH DUH PDQ\ IDFWRUV LQIOXHQFLQJ GUXJ XVH LQ WKH ROGHU DGXOWV LQFOXGLQJ GLVHDVH VWDWHV SV\FKRVRFLDO IDFWRUV SK\VLFLDQV ZKR SUHVFULEH PHGLFDWLRQV DQG DGYHUWLVHPHQW E\ WKH SKDUPDFHXWLFDO LQGXVWU\ 6WHZDUW f 6WHZDUW f VWDWHV WKDW RWKHU IDFWRUV ZLOO LQIOXHQFH SDWWHUQV RI GUXJ XVH LQ WKH IXWXUH VXFK DV WKH

PAGE 47

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f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f 2WKHU SUREOHPV DVVRFLDWHG ZLWK FRQYHQWLRQDO GUXJ XVH LQFOXGH SRO\SKDUPDF\ LVVXHV RI FRPSOLDQFH GUXJGUXJ LQWHUDFWLRQV LQ FRPELQDWLRQ XVH RI FRQYHQWLRQDO GUXJV &KHQLW] 6DOLVEXU\ t 6WRQH /DP\ /H6DJH 1R\HV /XFDV t 6WUDWWRQ

PAGE 48

6WHZDUW 6WHZDUW t &RRSHU 6ZRQJHU t %XUEDQN f 6HYHUDO QDWLRQDO DQG FRPPXQLW\EDVHG VWXGLHV KDYH SURYLGHG LQIRUPDWLRQ RQ FRQYHQWLRQDO GUXJ XVH SDWWHUQV DPRQJ ROGHU DGXOWV 3DWWHUQV RI SUHVFULELQJ SUDFWLFH RI FRQYHQWLRQDO GUXJV E\ KHDOWK FDUH SURYLGHUV IRU ROGHU DGXOWV KDYH YDULHG RYHU WLPH GHSHQGLQJ RQ WKH GDWD FROOHFWLQJ WLPH DQG JHRJUDSKLFDO GLIIHUHQFHV 6WHZDUW 0RRUH 0D\ 0DUNV t +DOH f 'DWD IURP WKH )ORULGD UHWLUHPHQW FRPPXQLW\ RI 'XQHGLQ D UHODWLYHO\ KHDOWK\ DQG DPEXODWRU\ JURXS ZHUH FROOHFWHG GXULQJ 0D\ 6WHZDUW +DOH t 0DUNV f DQG 6WHZDUW HW DO f 7KH DYHUDJH QXPEHU RI GUXJV LQFOXGLQJ ERWK SUHVFULSWLRQ DQG QRQSUHVFULSWLRQ WDNHQ E\ WKH ROGHU DGXOWV LQ 'XQHGLQ )ORULGD ZDV GXULQJ WKH SHULRG 0D\ HW DO f DQG LQ WKH WHQ\HDU RYHUYLHZ RI WKH 'XQHGLQ VWXG\ 6WHZDUW HW DO f 5HVHDUFKHUV LQ WKH ,RZD 5XUDO +HDOWK 6WXG\ JDWKHUHG GDWD GXULQJ IURP WKH FRPPXQLW\EDVHG JHQHUDOO\ HOGHUO\ SRSXODWLRQ DQG UHSRUWHG D PHDQ RI SUHVFULEHG PHGLFLQHV +HOOLQJ /HPNH 6HPOD :DOODFH /LSVRQ t &RUQRQL+XQWOH\ f 2WKHU VWXGLHV RI GUXJ XVH SDWWHUQV LQ WKH ROGHU DGXOWV ZHUH FRQGXFWHG LQ 1RUWK &DUROLQD DQG 3HQQV\OYDQLD 7KHVH VWXGLHV LQFOXGHG XUEDQ DV ZHOO DV UXUDO

PAGE 49

DUHDV DV ZHOO DV D VLJQLILFDQW SURSRUWLRQ RI $IULFDQ $PHULFDQV 2OGHU DGXOWV LQ WKH 3LHGPRQW DUHD RI 1RUWK &DUROLQD ZHUH VWXGLHG LQ )LOOHQEDXP +DQORQ &RUGHU =LTXED3DJH :DOO t %URFN f DQG LQ )LOOHQEDXP HW DO f DQG UHVHDUFKHUV UHSRUWHG D PHDQ RI DQG SUHVFULEHG GUXJV SHU SHUVRQ LQ WKH WZR VWXGLHV ,Q WKH 0R9,(6 3URMHFW E\ /DVVLOD DQG FROOHDJXHV f GDWD ZHUH FROOHFWHG GXULQJ LQ WKH UXUDO PLG0RQRQJDKHOD 9DOOH\ FRPPXQLW\ RI 3HQQV\OYDQLD D ODUJHO\ ZKLWH bf EOXHFROODU SRSXODWLRQ 7KH UHVXOW RI WKH 0R9,(6 3URMHFW VKRZHG VXEMHFWV XVHG D PHDQ RI SUHVFULSWLRQ GUXJV /DVVLOD HW DO f 'HVSLWH WKH GLIIHUHQFHV LQ WKH WLPH DQG WKH ORFDWLRQ RI WKH VWXG\ VLWHV ILQGLQJV DUH VLPLODU DPRQJ WKHVH VWXGLHV :KHQ FRPSDUHG FURVVVHFWLRQDOO\ DQG ORQJLWXGLQDOO\ WKH SURSRUWLRQ RI WKH ROGHU DGXOWV ZKR WRRN FRQYHQWLRQDO GUXJV LQFUHDVHG ZLWK DJH DV GLG WKH QXPEHU RI PHGLFDWLRQV WDNHQ &KULVFKLOOHV HW DO )LOOHQEDXP HW DO )LOOHQEDXP HW DO +HOOLQJ HW DO /DVVLOD HW DO 0D\ HW DO 6WHZDUW HW DO f 3RO\SKDUPDF\ 3RO\SKDUPDF\ KDV EHHQ UHFRJQL]HG DV D SUREOHP LQ WKH JHULDWULF SRSXODWLRQ *RUPOH\ *ULIILWKV 0F&UDFNHQ t

PAGE 50

+DUULVRQ /DP\ 1R\HV /XFDV t 6WUDWWRQ 6KLPS :HOOV %ULQN 'LRNQR t *LOOLV f 7KH HOGHUO\ DJHG DQG ROGHU ZKR UHSUHVHQW RQO\ b RI DOO $PHULFDQ SRSXODWLRQ FRQVXPH WKUHH WLPHV PRUH SUHVFULSWLRQ GUXJV WKDQ SHRSOH XQGHU DJHG \HDUV *RUPOH\ *ULIILWKV 0F&UDFNHQ t +DUULVRQ f 7KH XVH RI SUHVFULEHG GUXJV KDV EHHQ SURMHFWHG WR EH b RI WKH WRWDO GUXJ H[SHQGLWXUHV LQ GHYHORSHG FRXQWULHV E\ \HDU &XVDFN f 7KH ROGHU DGXOWV IUHTXHQWO\ XVH QRQSUHVFULSWLRQ GUXJV LQ DGGLWLRQ WR SUHVFULEHG PHGLFDWLRQV 3ROORZ 6WROOHU )RVWHU t 'XQLKR f 3RO\SKDUPDF\ KDV EHHQ GHILQHG LQ PDQ\ GLIIHUHQW ZD\V /H6DJH 0LFKRFNL /DP\ +RRSHU t 5LFKDUGVRQ 0RQWDPDW t &XVDFN 1R\HV /XFDV t 6WUDWWRQ f ,Q +HDOWK\ 3HRSOH f SRO\SKDUPDF\ ZDV GHILQHG DV WKH XVH RI PXOWLSOH SUHVFULSWLRQ DQG QRQSUHVFULSWLRQ GUXJV HVSHFLDOO\ E\ HOGHUO\ ZLWK FKURQLF GLVHDVH ZKLOH 1R\HV /XFDV DQG 6WUDWWRQ f FRQVLGHUHG PXOWLSOH GUXJ XVH V\QRQRPRXV ZLWK SRO\SKDUPDF\ /H6DJH f GHILQHG SRO\SKDUPDF\ DV WKH FRQFXUUHQW XVH RI VHYHUDO GLIIHUHQW GUXJV ZKHUHDV 0RQWDPDW DQG &XVDFN f GHILQHG SRO\SKDUPDF\ DV WKH SUHVFULSWLRQ DGPLQLVWUDWLRQ RU XVH RI PRUH PHGLFDWLRQV WKDQ DUH FOLQLFDOO\ LQGLFDWHG LQ D JLYHQ SDWLHQW

PAGE 51

2WKHU UHVHDUFKHUV 0LFKRFNL /DP\ +RRSHU t 5LFKDUGVRQ f FRQVLGHUHG SRO\SKDUPDF\ RQO\ DV WKH XVH RI PXOWLSOH GUXJV 'HILQLWLRQ RI SRO\SKDUPDF\ E\ 0LFKRFNL DQG FROOHDJXHV f ZDV WKDW SDUWLFXODU SDWLHQWV UHFHLYHG WRR PDQ\ GUXJV IRU WRR ORQJ D WLPH RU LQ H[FHHGLQJO\ KLJK GRVHV $OWKRXJK WKHUH LV QHLWKHU D VSHFLILF QXPEHU RI PHGLFDWLRQV WR GHILQH SRO\SKDUPDF\ QRU D XQDQLPRXVO\ DFFHSWHG GHILQLWLRQ RI SRO\SKDUPDF\ SRO\SKDUPDF\ FRQVLVWHQWO\ UHSUHVHQWV WKH XVH RI PXOWLSOH PHGLFDWLRQV E\ D VLQJOH SDWLHQW 6WHZDUW t &RRSHU f 3RVVLEOH FDXVHV RI JHULDWULF SRO\SKDUPDF\ DUH PXOWLSOH KHDOWK SUREOHPV PXOWLSOH SUHVFULEHUV QRQFXUUHQW PHGLFDWLRQ VWRUDJH SUHVFULSWLRQ SDWWHUQV RI SK\VLFLDQV DQG VHOIPHGLFDWLRQ EHKDYLRU /H6DJH f 6LQFH LW KDV EHHQ NQRZQ WKDW ROGHU DGXOWV RIWHQ WDNH D ODUJH QXPEHU RI GUXJV IRU YDULRXV UHDVRQV SRVVLEOH DGYHUVH FRQVHTXHQFHV RI WKH XVH RI PXOWLSOH PHGLFDWLRQV H[LVW 7KHVH FRQVHTXHQFHV DUH DGYHUVH GUXJ UHDFWLRQV GUXJ LQWHUDFWLRQV PHGLFDWLRQ HUURUV QRQFRPSOLDQFH TXDOLW\ RI OLIH DQG IXQFWLRQDO GHFOLQH DQG KLJK ILQDQFLDO FRVW /H6DJH 6WHZDUW t &RRSHU f 6ZRQJHU DQG %XUEDQN f SRLQWHG RXW WKH SUREOHPV RI SRO\SKDUPDF\ DQG GUXJ PLVXVH DVVRFLDWHG ZLWK ERWK SK\VLFLDQ DQG FOLHQW 0XOWLSOH GUXJ UHJLPHQV DUH RIWHQ WRR

PAGE 52

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t %XUEDQN f ,VVXHV UHODWHG WR PXOWLSOH GUXJ XVH KDYH EHHQ UHFRJQL]HG LQ RWKHU VWXGLHV &RO )DQDOH t .URQKROP 0LFKRFNL /DP\ +RRSHU t 5LFKDUGVRQ 5DQHOOL t $YHUVD 6WHZDUW t &DUDQDVRV f 5DQHOOL DQG $YHUVD f VWXGLHG PHGLFDWLRQUHODWHG VWUHVV DPRQJ IDPLO\ FDUHJLYHUV DQG UHSRUWHG WKDW b RI WKH FDUHJLYHUV KDG PHGLFDWLRQUHODWHG SUREOHPV DQG b KDG GLIILFXOW\ LQ PDQDJLQJ PHGLFDWLRQV 0RUH WKDQ KDOI RI WKH FDUHJLYHUV H[SHULHQFHG SUREOHPV LQ WKH SDVW \HDU LQFOXGLQJ VFKHGXOLQJ GLIILFXOWLHV FRPSOLDQFH SUREOHPV GLIILFXOW\ RUJDQL]LQJ

PAGE 53

PHGLFDWLRQV IRU WKH SDWLHQW DQG ODFN RI SURIHVVLRQDO DGYLFH $OWKRXJK RQO\ b RI WKH WRWDO WLPH ZDV VSHQW SURYLGLQJ GUXJUHODWHG FDUH E\ FDUHJLYHUV PHGLFDWLRQV GLG FRQWULEXWH WR WKH VWUHVV RI WKH FDUHJLYLQJ H[SHULHQFH 5DQHOOL t $YHUVD f &RPSOLDQFH LV DQRWKHU LVVXH UHODWHG WR SRO\SKDUPDF\ 0DQ\ IDFWRUV ZHUH DVVRFLDWHG ZLWK FRPSOLDQFH 1R\HV /XFDV t 6WUDWWRQ 6WHZDUW t &DUDQDVRV f $PRQJ WKH IDFWRUV UHODWHG WR FRPSOLDQFH GRFXPHQWHG LQ OLWHUDWXUH LW ZDV FRQVLVWHQWO\ PHQWLRQHG WKDW WKH QXPEHU RI PHGLFDWLRQV WDNHQ DQG WKH FRPSOH[LW\ RI WKH PHGLFDWLRQ UHJLPHQV ZHUH FULWLFDO IDFWRUV IRU SDWLHQWnV FRPSOLDQFH 2QH VWXG\ RI FRPSOLDQFH UDWHV UHODWHG WR GRVDJH SDWWHUQ HJ QXPEHU RI WLPHV SHU GD\ VKRZHG WKDW FRPSOLDQFH UDWH GHFUHDVHG ZKHQ WKH QXPEHU RI WLPHV D PHGLFDWLRQ ZDV WDNHQ SHU GD\ LQFUHDVHG &UDPHU 0DWWVRQ 3UHYH\ 6FKH\HU t 2XHOOHWWH f &UDPHU DQG FROOHDJXHV f IRXQG RQO\ RI FRPSOLDQFH UDWH ZLWK IRXU WLPHV D GD\ GRVDJH VFKHGXOH ZKLOH UHSRUWLQJ b RI FRPSOLDQFH UDWH ZKHQ PHGLFDWLRQ ZDV VFKHGXOHG RQFH D GD\ IRU WKH HOGHUO\ 3UHVFULSWLRQ RI PXOWLSOH GUXJV PD\ LQFUHDVH QRQFRPSOLDQFH DQG FDXVH DGYHUVH GUXJ UHDFWLRQV RU FOLQLFDOO\ VLJQLILFDQW GUXJ LQWHUDFWLRQV &RO )DQDOH t .URQKROP f $GYHUVH GUXJ UHDFWLRQV DUH GHILQHG EURDGO\ E\ WKH 8QLWHG 6WDWHV

PAGE 54

)RRG DQG 'UXJ $GPLQLVWUDWLRQ )'$f DV DQ\ DGYHUVH HYHQW DVVRFLDWHG ZLWK WKH XVH RI D GUXJ LQ KXPDQV 6LOOV 7DQQHU t 0LOVWLHQ f $FFRUGLQJ WR &RO DQG FROOHDJXHV f SDWLHQWV DGPLWWHG WR KRVSLWDOV ZLWK PHGLFDWLRQ QRQFRPSOLDQFH LQFUHDVHG ZKHQ WKH QXPEHU RI GLIIHUHQW PHGLFDWLRQV RU WKH QXPEHU RI SK\VLFLDQ YLVLWV LQFUHDVHG $SSUR[LPDWHO\ b RI KRVSLWDO DGPLVVLRQV DPRQJ ROGHU DGXOWV ZHUH GUXJUHODWHG DQG PRUH VSHFLILFDOO\ ZHUH GXH WR QRQFRPSOLDQFH bf DQG DGYHUVH GUXJ UHDFWLRQV bf $OWKRXJK WKHUH DUH YDULDWLRQV LQ UHSRUWHG KRVSLWDOL]DWLRQ UDWHV FDXVHG E\ DGYHUVH GUXJ UHDFWLRQV IURP b WR b &RO )DQDOH t .URQKROP &ROW t 6KDSLUR *U\PRQSUH 0LWHQNR 6LWDU $RNL t 0RQWJRPHU\ ,YHV %HQW] t *Z\WKHU /LQGOH\ 7XOOH\ 3DUDPVRWK\ t 7DOOLV f LW LV DSSDUHQW WKDW DGYHUVH GUXJ UHDFWLRQV DUH VHULRXV DQG FRVWO\ 7R[LFLWLHV RI +HUEDO 3URGXFWV DQG 3RVVLEOH ,QWHUDFWLRQV ZLWK 'UXJV RI &RQYHQWLRQDO 0HGLFLQH ,Q UHFHQW \HDUV WKH XVH RI KHUEDO SURGXFWV KDV LQFUHDVHG LQ GHYHORSHG FRXQWULHV HYHQ WKRXJK KHUE£LV KDYH EHHQ D GRPLQDQW IRUP RI KHDOWK FDUH LQ GHYHORSLQJ FRXQWULH IRU PDQ\ \HDUV $OWKRXJK (LVHQEHUJ DQG FROOHDJXHV UHSRUWHG WKDW WKUHH SHUFHQW RI $PHULFDQV ZHUH XVLQJ KHUEDO SURGXFWV

PAGE 55

LQ WKH HDUO\ V WKLV QXPEHU LV DVVXPHG WR EH JURZLQJ UDSLGO\ (LVHQEHUJ HW DO f 7KH ULVN RI SRWHQWLDO WR[LFLW\ RI KHUEDO PHGLFLQHV LV DFFHOHUDWHG E\ PDQ\ IDFWRUV )LUVW RI DOO KHUEDO PHGLFLQHV DUH QRW VXEMHFW WR VWDQGDUG )RRG DQG 'UXJ $GPLQLVWUDWLRQ )'$f WHVWV IRU VDIHW\ HIIHFWLYHQHVV DQG TXDOLW\ FRQWURO EHFDXVH KHUE£LV DUH QRW FRQVLGHUHG FRQYHQWLRQDO GUXJV EXW UDWKHU GLHWDU\ VXSSOHPHQWV 6HFRQGO\ PDQ\ KHUEDO SURGXFWV DUH LPSRUWHG IURP IRUHLJQ FRXQWULHV QRW PDQGDWLQJ VDIHW\ RU PDQXIDFWXULQJ UHJXODWLRQV )LQDOO\ WKHVH PHGLFLQHV GR QRW KDYH WKH DFWLYH RU LQDFWLYH LQJUHGLHQWV OLVWHG RQ WKH SDFNDJH ODEHO $QGHUVRQ f 2WKHU IDFWRUV FRQWULEXWLQJ WR WKH SRWHQWLDO SUREOHPV RI XVLQJ KHUEDO SURGXFWV LQFOXGH Df PLVLGHQWLILFDWLRQ RI D SODQW RU WKH XQNQRZQ RU LJQRUHG WR[LFLW\ RI D FRUUHFWO\ LGHQWLILHG SODQW Ef SHUVLVWHQW XVH RI KHUEV NQRZQ WR EH WR[LF Ff GLIILFXOW\ LQ LGHQWLILFDWLRQ RI FKRSSHG RU PL[HG KHUEV Gf YDULDELOLW\ LQ FKHPLFDO FRQVWLWXHQWV RI KHUEV Hf SUREOHPV ZLWK QRPHQFODWXUH If GLIILFXOW\ LQ HVWDEOLVKLQJ WKH FXPXODWLYH HIIHFWV RI D SODQW Jf FRQWDPLQDWLRQ ZLWK KHDY\ PHWDOV DQG Kf SRVVLEOH DGXOWHUDWLRQ ZLWK SUHVFULSWLRQ GUXJV RU ZLWK RWKHU VXEVWDQFHV 'UHZ t 0\HUV +X[WDEOH f &HUWDLQ JURXSV RI SHRSOH XVLQJ KHUEDO SURGXFWV DUH DW KLJKHU ULVN RI LQWR[LFDWLRQ WKDQ RWKHU JURXSV +X[WDEOH

PAGE 56

f SRLQWV RXW WKDW KLJK ULVN JURXSV DUH SHRSOH XVLQJ KHUEV RU KHUEDO SURGXFWV IRU D ORQJ WLPH FRQVXPHUV RI ODUJH DPRXQWV RU D ZLGH YDULHW\ RI KHUEV EDELHV WKH HOGHUO\ WKRVH ZLWK FRQFRPLWDQW GLVHDVHV DQG FRQFXUUHQW PHGLFDWLRQV DQG WKH PDOQRXULVKHG RU XQGHUQRXULVKHG $OVR WR[LFLWLHV FDQ EH VHOHFWLYH GHSHQGLQJ RQ JHQGHU DQG FXOWXUDO JURXSV 'H 6PHW +X[WDEOH f 1HYHUWKHOHVV LW LV ZLGHO\ SHUFHLYHG WKDW QDWXUDO SURGXFWV DUH VDIH DQG SHRSOH ZLOO FRQWLQXH WR XVH KHUEDO PHGLFLQHV LQ HYHUJURZLQJ QXPEHUV 0DUZLFN f $OWKRXJK WKH ULVN RI XVLQJ KHUEDO PHGLFLQH LV PXFK OHVV WKDQ WKDW RI XVLQJ FRQYHQWLRQDO PHGLFLQH PDQ\ UHVHDUFKHUV VXJJHVW WKDW XVLQJ KHUEDO SURGXFWV LV QRW ZLWKRXW ULVN DQG FRQVHTXHQWO\ VDIHW\ RI XVLQJ WKHVH SURGXFWV QHHGV WR EH FRQVLGHUHG 2QO\ QLQH KHUEDO SURGXFWV DUH DSSURYHG E\ WKH )RRG DQG 'UXJ $GPLQLVWUDWLRQ )'$f IRU VHOHFWHG DSSOLFDWLRQV
PAGE 57

*HUPDQ &RPPLVVLRQ ( DQG RQO\ IRXU ZHUH DSSURYHG E\ ERWK )'$ DQG *HUPDQ &RPPLVVLRQ (
PAGE 58

0HGLFLQH f OLVWHG WKH PRVW SRSXODU $VLDQ SDWHQW PHGLFLQHV WKDW FRQWDLQ WR[LF LQJUHGLHQWV VHH $SSHQGL[ &f 2WKHU DXWKRUV *UD\
PAGE 59

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

PAGE 60

6DPSOH ,W ZDV VWDWLVWLFDOO\ GHWHUPLQHG WKDW D VDPSOH VL]H RI VXEMHFWV VXEMHFWV LQ HDFK JURXSf ZRXOG SURYLGH WKH GHVLUHG VHQVLWLYLW\ WR WHVW WKH VWXG\ K\SRWKHVHV 7KLV GHWHUPLQDWLRQ ZDV EDVHG RQ D IRUPXODWLRQ RI b SRZHU D PHGLXP FULWLFDO HIIHFW VL]H RI IRU HDFK RI WKH GHSHQGHQW YDULDEOHV DQG D VLJQLILFDQFH OHYHO RI IRU D WZRWDLOHG WHVW RI PHDQV 6DPSOLQJ FULWHULD ZHUH ZRPHQ ZKR ZHUH \HDUV DQG RYHU DQG OLYHG LQ WKH GHVLJQDWHG 1RUWK &HQWUDO )ORULGD FRXQW\ 7KH SULQFLSDO LQYHVWLJDWRU UHTXHVWHG QDPHV DQG DGGUHVVHV RI DOO ZRPHQ \HDUV DQG ROGHU ZKR UHVLGHG LQ WKH VHOHFWHG FRXQW\ IURP WKH 'LYLVLRQ RI 'ULYHUVn /LFHQVH 6WDWH 'HSDUWPHQW RI +LJKZD\ 6DIHW\ DQG 0RWRU 9HKLFOHV 7KLV OLVW \LHOGHG QDPHV DQG DGGUHVVHV RI ZRPHQ DJHG DQG ROGHU $FFRUGLQJ WR :DOW] 6WULFNODQG DQG /HQ] f b UHVSRQVH UDWH ZDV QRW XQXVXDO LQ PDLOHG TXHVWLRQQDLUH VXUYH\V 7KHUHIRUH LW ZDV QHFHVVDU\ WR VHOHFW DW OHDVW WKUHH WLPHV WKH QXPEHU RI VXEMHFWV QHHGHG IRU WKH WRWDO VDPSOH RI VXEMHFWV WR WHVW WKH K\SRWKHVHV 7KH LQYHVWLJDWRU UDQGRPO\ VHOHFWHG VXEMHFWV IURP WKH WRWDO OLVW XWLOL]LQJ WKH WDEOH RI UDQGRP GLJLW 5DQG &RRSHUDWLRQ KWWSZZZUDQGRUJVRIWZDUH DQG GDWDUDQGRPGLJLWVW[Wf

PAGE 61

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f DQG VXEMHFWV LQ *URXS QRQKHUEDO XVHUVf ,QFOXVLRQ DQG ([FOXVLRQ &ULWHULD 7KH LQFOXVLRQ FULWHULD ZHUH DV IROORZV Df ZRPHQ ZKR ZHUH \HDUV DQG ROGHU OLYLQJ LQGHSHQGHQWO\ LQ WKH FRPPXQLW\ Ef FXUUHQWO\ OLYLQJ LQ WKH VHOHFWHG FRXQW\ Ff DELOLW\ WR VSHDN DQG XQGHUVWDQG (QJOLVK DQG Gf DEOH WR YHUEDOO\ FRPPXQLFDWH ZLWK LQWDFW PHPRU\ 6XEMHFWV ZKR FRXOG UHVSRQG WR WKH UHTXHVWV IRU SDUWLFLSDWLRQ ZHUH FRQVLGHUHG WR KDYH DGHTXDWH FRPPXQLFDWLRQ VNLOOV DQG PHPRU\ DELOLW\ ([FOXVLRQ FULWHULD ZHUH DV IROORZV Df ZRPHQ ZKR KDG VHYHUH KHDOWK FRQGLWLRQV Ef UHVLGHG LQ QXUVLQJ KRPH RU RWKHU W\SH RI DVVLVWHG OLYLQJ IDFLOLW\ Ff UHVLGHG RXW RI

PAGE 62

WKH VHOHFWHG FRXQW\ RU Gf XQDEOH WR FRQWDFW DIWHU PXOWLSOH DWWHPSWV ,QVWUXPHQW 7KH TXHVWLRQQDLUH ZDV GHYHORSHG E\ WKH LQYHVWLJDWRU EHFDXVH WKHUH ZHUH QR NQRZQ HVWDEOLVKHG TXHVWLRQQDLUHV WR SHUIRUP WKLV VWXG\ 7KLV TXHVWLRQQDLUH ZDV XVHG WR REWDLQ NQRZOHGJH UHODWHG WR WKH SUHYDOHQFH DQG SXUSRVH RI XVH RI KHUEDO SURGXFWV DQG KRZ WKH KHUEDO SURGXFWV ZHUH XVHG ZLWK SUHVFULEHG DQG QRQSUHVFULEHG PHGLFLQHV DPRQJ ZRPHQ DJHG DQG RYHU 7KH TXHVWLRQQDLUH ZDV FRPSULVHG RI WKUHH SDUWV Df KHDOWK VWDWXV DQG XVH RI FRQYHQWLRQDO GUXJV LQFOXGLQJ SUHVFULEHG DQG QRQSUHVFULEHG PHGLFLQHV Ef XVH RI KHUEDO SURGXFWV DQG Ff GHPRJUDSKLF GDWD 7KH LQWHUYLHZ ODVWHG DSSUR[LPDWHO\ PLQXWHV IRU WKH SDUWLFLSDQWV ZKR GLG QRW XVH WKH KHUEDO SURGXFWV DQG ZHUH FODVVLILHG DV JURXS 7KH SDUWLFLSDQWV LQ WKLV JURXS ZHUH DVNHG WR DQVZHU SDUW $ DQG SDUW & RI TXHVWLRQQDLUH 7KH LQWHUYLHZ WRRN DSSUR[LPDWHO\ PLQXWHV IRU WKH SDUWLFLSDQWV ZKR UHVSRQGHG n\HVn WR WKH XVH RI KHUEDO SURGXFWV 7KHVH SDUWLFLSDQWV ZHUH FODVVLILHG DV JURXS 7KH SDUWLFLSDQWV LQ WKLV JURXS ZHUH DVNHG WR DQVZHU WKH HQWLUH TXHVWLRQQDLUH 3DUW $ +HDOWK ,QIRUPDWLRQf 3DUW % +HUEDO 3URGXFW 8VH ,QIRUPDWLRQf DQG 3DUW & 'HPRJUDSKLF ,QIRUPDWLRQf

PAGE 63

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

PAGE 64

0DULWDO VWDWXV 0DULWDO VWDWXV ZDV FRGHG LQWR RQH RI IRXU FDWHJRULHV UHIOHFWLQJ WKH VWDWXV RI PDUULHG ZLGRZHG GLYRUFHGVHSDUDWHG RU QHYHU PDUULHG +HUEDO SURGXFWV YDULDEOHV (OHYHQ LQGLFDWRUV ZHUH H[DPLQHG IRU WKH YDULDEOHV UHODWHG WR WKH XVH RI KHUEDO SURGXFWV 7KHVH ZHUH Df QXPEHU DQG W\SH RI KHUEDO SURGXFWV XVHG Ef JHQHUDO SXUSRVH RI XVLQJ KHUEDO SURGXFWV Ff URXWH Gf SUHSDUDWLRQ Hf UHDVRQV XVHG If GXUDWLRQ RI XVH Jf HIIHFWLYHQHVV RI KHUEDO SURGXFWV Kf H[SHULHQFH RI DGYHUVH UHDFWLRQV E\ XVLQJ KHUEV RU KHUEDO SURGXFWV Lf VRXUFHV RI LQIRUPDWLRQ IRU XVH RI KHUEDO SURGXFWV Mf VRXUFH RI SD\PHQW IRU KHUEDO SURGXFW DQG Nf SK\VLFLDQn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

PAGE 65

KHUEDO SURGXFWV LQ WKH ODVW PRQWKV 3XUSRVHV ZHUH FDWHJRUL]HG LQWR RQH RI WKUHH LQGLFDWRUV WR WUHDW LOOQHVV WR PDLQWDLQ RU SUHYHQW DQ\ SRVVLEOH KHDOWK SUREOHPV DQG ERWK WUHDW DQG SUHYHQW LOOQHVV 5RXWH 7KH URXWH RI XVLQJ KHUEDO SURGXFWV ZDV D FDWHJRULFDO YDULDEOH LGHQWLILHG DV LQWHUQDO XVH DQG H[WHUQDO XVH 3UHSDUDWLRQ 3UHSDUDWLRQ ZDV D FDWHJRULFDO YDULDEOH LGHQWLILHG DV VHOISUHSDUHG RU SXUFKDVHG IURP D KHDOWK IRRG VWRUH RU D UHJXODU UHWDLO VWRUH 6HOISUHSDUHG KHUEDO SURGXFW GHILQHG WKH UHPHG\ WKDW FRXOG QRW EH XVHG GLUHFWO\ DV LW ZDV REWDLQHG DQG WKXV UHTXLUHG SUHSDUDWLRQ WLPH DW KRPH VXFK DV KHUEDO WHD 3XUFKDVHG LQFOXGHG WKH SURGXFW WKDW FRXOG EH XVHG GLUHFWO\ ZLWKRXW DQ\ SUHSDUDWLRQ WLPH DIWHU REWDLQLQJ LW VXFK DV DQ KHUEDO WDEOHW RU D FDSVXOH 5HDVRQV XVHG 5HDVRQV WR XVH KHUEDO SURGXFWV ZHUH OLVWHG EDVHG RQ WKH W\SHV RI KHDOWK SUREOHPV DQG ZHUH FRGHG IURP WKURXJK 7KH FRGHV VWDUWLQJ IURP WKURXJK ZHUH PDWFKHG ZLWK VSHFLILF LOOQHVVHV RQ WKH +HDOWK ,QIRUPDWLRQ )RUP LQ WKH TXHVWLRQQDLUH 3DUW $ VHH $SSHQGL[ $f ,WHP QXPEHU ZDV UHODWHG WR WKH XVH RI KHUEDO SURGXFWV IRU PDLQWDLQLQJ FXUUHQW KHDOWK VWDWXV RU IRU SUHYHQWLQJ SRVVLEOH KHDOWK SUREOHPV

PAGE 66

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n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f IDPLO\ PHPEHUV Ef IULHQGV DQG QHLJKERUV Ff ERRNV RU PDJD]LQHV Gf 79 UDGLR DQG QHZVSDSHUV Hf FRPSXWHU ,QWHUQHW If KHDOWK

PAGE 67

IRRG VWRUHV Jf KHDOWK FDUH SURYLGHUV Kf DOWHUQDWLYH FDUH SUDFWLWLRQHUV DQG Lf RWKHUV +HDOWK VWDWXV YDULDEOHV (LJKW LQGLFDWRUV ZHUH XWLOL]HG WR LGHQWLI\ WKH KHDOWK VWDWXV DQG WKH XVH RI SUHVFULEHG DQG QRQSUHVFULEHG PHGLFLQHV UHODWHG WR WKH KHDOWK SUREOHPV 7KHVH LQFOXGHG Df RYHUDOO KHDOWK Ef SK\VLFDO KHDOWK Ff HPRWLRQDO KHDOWK Gf YLVLW WR GRFWRUnV RU RWKHU KHDOWK FDUH SURYLGHUnV FOLQLF Hf H[LVWHQFH RI KHDOWK SUREOHPV If VHULRXVQHVV RI KHDOWK SUREOHPV Jf QXPEHU RI PHGLFDWLRQV XVHG DQG PHGLFDWLRQ LGHQWLILFDWLRQ DQG Kf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f IDPLO\ SUDFWLWLRQHU Ef LQWHUQDO PHGLFLQH Ff VXUJHRQ

PAGE 68

Gf J\QHFRORJLVW Hf QXUVH SUDFWLWLRQHU If RVWHRSDWKLF GRFWRU f DQG Jf RWKHUV +HDOWK SUREOHPV 7KH SDUWLFLSDQW ZDV DVNHG WR LGHQWLI\ KHU KHDOWK SUREOHPV IURP GLIIHUHQW LOOQHVVHV 7KH DQVZHU ZDV FRGHG ]HUR ZKHQ WKH SUREOHP GLG QRW H[LVW DQG RQH LI WKH SUREOHP H[LVWHG ,QWHUIHUHQFH ZLWK QRUPDO DFWLYLWLHV 7KH SDUWLFLSDQW ZDV DVNHG KRZ VHULRXVO\ DQ LOOQHVV LQWHUIHUHG ZLWK KHU QRUPDO DFWLYLWLHV ,QWHUIHUHQFH ZLWK QRUPDO DFWLYLWLHV ZDV PHDVXUHG E\ D YLVXDO VFDOH UDWLQJ IURP RQH WR ILYH 2QH RQ WKH YLVXDO VFDOH LQGLFDWHG WKDW WKH KHDOWK SUREOHP GLG QRW LQWHUIHUH ZLWK QRUPDO DFWLYLWLHV DQG ILYH LQGLFDWHG WKDW WKH KHDOWK SUREOHP LQWHUIHUHG JUHDWO\ ZLWK QRUPDO DFWLYLWLHV 8VH RI PHGLFDWLRQV 7KH XVH RI PHGLFDWLRQV ZDV D GLFKRWRPRXV YDULDEOH FRGHG ]HUR RU RQH IRU HDFK LGHQWLILHG LOOQHVV ,I WKH DQVZHU ZDV \HV WKH SDUWLFLSDQW ZDV DVNHG WR QDPH DOO SUHVFULEHG DQG QRQSUHVFULEHG PHGLFDWLRQV IRU HDFK LOOQHVV 8VH RI KHUEDO SURGXFWV 7KH XVH RI KHUEDO SURGXFWV ZDV D GLFKRWRPRXV YDULDEOH FRGHG ]HUR ZKHQ KHUEDO SURGXFWV KDG QRW EHHQ XVHG DQG RQH ZKHQ KHUEDO SURGXFWV KDG EHHQ XVHG IRU HDFK LGHQWLILHG LOOQHVV

PAGE 69

3URFHGXUH 7KH LQYHVWLJDWRU REWDLQHG WKH OLVW RI QDPHV DQG DGGUHVVHV RI ZRPHQ DJHG DQG RYHU ZKR UHVLGHG LQ D 1RUWK &HQWUDO )ORULGD &RXQW\ IURP WKH 'HSDUWPHQW RI 0RWRU 9HKLFOH DQG 6DIHW\ LQ 7DOODKDVVHH )ORULGD 7KH QXPEHU RI SRVVLEOH DFFHVVLEOH SRSXODWLRQ ZDV LGHQWLILHG DV ZRPHQ LQ WKH VHOHFWHG FRXQW\ )URP WKH DFFHVVLEOH SRSXODWLRQ DW OHDVW SDUWLFLSDQWV VXEMHFWV LQ HDFK JURXSf ZHUH UHTXLUHG WR PHHW WKH HIIHFW VL]H 7KH LQYHVWLJDWRU XVHG D WDEOH RI UDQGRP GLJLWV 5DQG &RRSHUDWLRQ KWWSZZZUDQGRUJVRIWZDUHBDQGBGDWD UDQGRPGLJLWVW[Wf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n\HV ZLOO SDUWLFLSDWH LQ WKH VWXG\n DQG

PAGE 70

UHTXHVWHG D SKRQH QXPEHU WR FRQWDFW IRU LQWHUYLHZ DQG nQR ZLOO QRW SDUWLFLSDWH LQ WKH VWXG\n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

PAGE 71

WKH XVH RI SUHVFULEHG DQG QRQSUHVFULEHG PHGLFLQHV WKH XVH RI KHUEDO SURGXFWV DQG GHPRJUDSKLF LQIRUPDWLRQ 7KH HQWLUH LQWHUYLHZ UHTXLUHG DSSUR[LPDWHO\ PLQXWHV SHU VXEMHFW 7KH SDUWLFLSDQWV ZHUH FDWHJRUL]HG LQWR JURXS LI WKH\ DQVZHUHG nQRn WR TXHVWLRQ QXPEHU $ RI 4XHVWLRQQDLUH 3DUW $ +HDOWK ,QIRUPDWLRQf 7KH SDUWLFLSDQWV LQ JURXS ZHUH QRW DVNHG WR DQVZHU 3DUW % +HUEDO 3URGXFW 8VH ,QIRUPDWLRQf DQG FRQWLQXHG WR 3DUW & 'HPRJUDSKLF ,QIRUPDWLRQf 7KH SDUWLFLSDQWV ZHUH FDWHJRUL]HG LQWR JURXS LI WKH\ DQVZHUHG n\HVn WR WKH TXHVWLRQ QXPEHU $ RI 4XHVWLRQQDLUH 3DUW $ +HDOWK ,QIRUPDWLRQf 7KH SDUWLFLSDQWV LQ JURXS ZHUH DVNHG WR DQVZHU ERWK 3DUW % DQG 3DUW & 'DWD FROOHFWLRQ ZDV FRPSOHWHG ZKHQ WKH WRWDO VXEMHFWV QXPEHUHG VXEMHFWV LQ JURXS DQG VXEMHFWV LQ JURXS f $IWHU FRPSOHWLRQ RI WKH LQWHUYLHZ WKH GDWD ZHUH HQWHUHG LQWR D GDWD VSUHDGVKHHW IRU DQDO\VLV 'DWD &ROOHFWLRQ 'DWD ZHUH FROOHFWHG WR WHVW WKH WZR UHVHDUFK K\SRWKHVHV DQG WR DQVZHU WKH IRXU UHVHDUFK TXHVWLRQV 5HVHDUFK +\SRWKHVHV +\SR WKH VLV 2QH 7KHUH DUH GLIIHUHQFHV LQ GHPRJUDSKLF FKDUDFWHULVWLFV RI ZRPHQ DJHG \HDUV DQG ROGHU EHWZHHQ WKH KHUEDO XVHUV DQG QRQKHUEDO XVHUV

PAGE 72

'HPRJUDSKLF FKDUDFWHULVWLFV LQFOXGHG HGXFDWLRQ OHYHOV LQFRPHV LQVXUDQFH VWDWXV UDFH RU UHOLJLRQ 7R WHVW K\SRWKHVLV RQH DOO SDUWLFLSDQWV ZHUH DVNHG WR DQVZHU WKH n+HDOWK ,QIRUPDWLRQn TXHVWLRQQDLUH ZKLFK LQFOXGHG ZKHWKHU WKH SDUWLFLSDQW XVHG KHUEDO SURGXFWV ,I WKH SDUWLFLSDQW XVHG DQ KHUEDO SURGXFW VKH ZDV DVNHG WR DQVZHU WKH n+HUEDO 3URGXFW ,QIRUPDWLRQn TXHVWLRQQDLUH DQG WKH n'HPRJUDSKLF ,QIRUPDWLRQn TXHVWLRQQDLUH ,I WKH SDUWLFLSDQW GLG QRW XVH DQ KHUEDO SURGXFW VKH ZDV DVNHG WR DQVZHU WKH n'HPRJUDSKLF ,QIRUPDWLRQn TXHVWLRQQDLUH ZLWKRXW n+HUEDO 3URGXFW ,QIRUPDWLRQn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nV KHDOWK VWDWXV DQG VHULRXVQHVV RI LQWHUIHUHQFH RI QRUPDO DFWLYLWLHV

PAGE 73

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f RU DSSOLHG WKH KHUEDO H[WHUQDOO\ 7KH SDUWLFLSDQW ZDV DVNHG ZKHWKHU VKH XVHG WKH KHUEDO RQ D FRQWLQXDO EDVLV RU LQWHUPLWWHQWO\ /DVWO\ WKH SDUWLFLSDQW ZDV DVNHG ZKHWKHU VKH SXUFKDVHG WKH KHUEDO SURGXFW IURP D VWRUH LQ D UHDG\WRWDNH IRUP RU LI VKH QHHGHG WR SUHSDUH WKH KHUEDO SURGXFW SULRU WR LWV XVH 4XHVWLRQ :KDW ZDV WKH SXUSRVH IRU WDNLQJ KHUEDO SURGXFWV E\ ZRPHQ DJHG \HDUV DQG ROGHU" 'LG ROGHU ZRPHQ WDNH KHUEDO SURGXFWV PRUH IRU SUHYHQWLRQ RU IRU WUHDWPHQW RI V\PSWRPV"

PAGE 74

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£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

PAGE 75

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

PAGE 76

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

PAGE 77

&+$37(5 ,9 5(68/76 7KLV FKDSWHU LQFOXGHV D GHVFULSWLRQ RI WKH UHVHDUFK GHVLJQ VDPSOH GHPRJUDSKLF FKDUDFWHULVWLFV DQG KHDOWK UHODWHG FKDUDFWHULVWLFV RI WKH VDPSOH $OVR LQFOXGHG LQ WKLV FKDSWHU DUH WKH UHVXOWV RI WKH VWDWLVWLFDO DQDO\VHV RI WKH GDWD FRUUHVSRQGLQJ WR WKH UHVHDUFK K\SRWKHVHV DQG UHVHDUFK TXHVWLRQV 5HVHDUFK 'HVLJQ 7KLV UHVHDUFK XWLOL]HG D FURVVVHFWLRQDO DQG GHVFULSWLYH GHVLJQ WR H[DPLQH WKH SUHYDOHQFH RI KHUEDO SURGXFW XVH W\SHV RI KHUEDO SURGXFWV XVHG E\ WKH VXEMHFWV DQG WR LGHQWLI\ WKH UHDVRQV KHUEDO SURGXFWV ZHUH XVHG DPRQJ ZRPHQ DJHG DQG RYHU 7KH LQYHVWLJDWRU XVHG D UDQGRP VHOHFWLRQ SURFHVV WR IDFLOLWDWH WKH VHOHFWLRQ RI WZR JURXSV RI VXEMHFWV WKRVH ZKR XVHG KHUEDO SURGXFWV DQG WKRVH ZKR GLG QRW XVH KHUEDO SURGXFWV 6DPSOH $ UDQGRP VDPSOH RI ZRPHQ ZKR ZHUH \HDUV RI DJH DQG RYHU UHVLGLQJ LQ D 1RUWK &HQWUDO )ORULGD FRXQW\ ZDV VHOHFWHG IRU WKLV VWXG\ $ WRWDO RI ZRPHQ ZKR ZHUH

PAGE 78

UHJLVWHUHG DW WKH )ORULGD 'LYLVLRQ RI 'ULYHUV /LFHQVH ZHUH LGHQWLILHG DV HOLJLEOH VDPSOH E\ WKH 6WDWH 'HSDUWPHQW RI +LJKZD\ 6DIHW\ DQG 0RWRU 9HKLFOHV 7R REWDLQ D VDPSOH VL]H RI VXEMHFWV WKUHH WLPHV WKLV QXPEHU RU SRVVLEOH VXEMHFWV ZHUH UDQGRPO\ VHOHFWHG IURP WKH ZRPHQ VHH 7DEOH f /HWWHUV ZHUH PDLOHG WR WKH SRVVLEOH VXEMHFWV GHVFULELQJ WKH UHVHDUFK SXUSRVH DQG UHTXHVWLQJ WKH UHWXUQ RI DQ HQFORVHG SRVWFDUG WR VFKHGXOH DQ LQWHUYLHZ )URP WKLV PDLOLQJ OHWWHUV ZHUH XQGHOLYHUDEOH DQG bf SHUVRQV UHVSRQGHG 2I WKH UHVSRQGHQWV ZKR UHWXUQHG WKH SRVWFDUGV VXEMHFWV FRPSOHWHG LQWHUYLHZV UHVSRQGHQWV GHFOLQHG SDUWLFLSDWLRQ DQG GLG QRW PHHW LQFOXVLRQ FULWHULD 7KLUW\RQH DGGLWLRQDO VXEMHFWV ZHUH QHHGHG WR DWWDLQ WKH GHVLUHG VDPSOH VL]H $Q DGGLWLRQDO JURXS RI SHRSOH ZDV VHOHFWHG IRU WKH VHFRQG PDLOLQJ WR DGG WKH QHHGHG VXEMHFWV 5DQGRP VDPSOLQJ ZDV UHSHDWHG IURP D OLVW RI SHUVRQV H[FOXGLQJ WKH QDPHV RI WKH ILUVW VHOHFWLRQ )URP WKH VHFRQG PDLOLQJ OHWWHUV ZHUH XQGHOLYHUDEOH DQG bf SHUVRQV UHVSRQGHG 2I WKH UHVSRQGHQWV VXEMHFWV FRPSOHWHG LQWHUYLHZV UHVSRQGHQWV GHFOLQHG SDUWLFLSDWLRQ DQG QLQH GLG QRW PHHW LQFOXVLRQ FULWHULD ,Q VXPPDU\ OHWWHUV ZHUH PDLOHG RI WKH OHWWHUV ZHUH XQGHOLYHUDEOH OHDYLQJ SRWHQWLDO VXEMHFWV

PAGE 79

2I SRWHQWLDO VXEMHFWV bf UHVSRQGHG 2I WKH WRWDO UHVSRQGHQWV VXEMHFWV ZHUH FRPSOHWHG LQWHUYLHZ bf GHFOLQHG DQ LQWHUYLHZ bf DQG GLG QRW PHHW LQFOXVLRQ FULWHULD bf 5HDVRQV IRU H[FOXVLRQ ZHUH Df ILYH VXEMHFWV KDG VHYHUH KHDOWK SUREOHPV PDNLQJ DQ LQWHUYLHZ LPSRVVLEOH Ef WKUHH VXEMHFWV UHVLGHG LQ QXUVLQJ KRPHV RU RWKHU W\SHV RI DVVLVWHG OLYLQJ IDFLOLWLHV Ff VXEMHFWV UHVLGHG RXW RI WKH FRXQW\ DW WKH WLPH RI WKH LQWHUYLHZ Gf VL[ VXEMHFWV ZHUH GHFHDVHG DQG Hf WZR VXEMHFWV ZHUH XQDEOH WR EH FRQWDFWHG IRU WKH LQWHUYLHZ 2I WKH VXEMHFWV ZKR FRPSOHWHG WKH LQWHUYLHZ XVHG KHUEDO SURGXFWV DQG ZHUH DVVLJQHG WR JURXS RQH DQG GLG QRW XVH KHUEDO SURGXFWV DQG ZHUH DVVLJQHG WR JURXS WZR 7DEOH )UHTXHQF\ 'LVWULEXWLRQ RI 7RWDO 6DPSOH 1XPEHU VW PDLOLQJ QG PDLOLQJ 7RWDO OHWWHUV PDLOHG 8QGHOLYHUDEOH ([FOXGHG UHVSRQGHQWV 1RQ5HVSRQGHQWV 'HFOLQHG ,QWHUYLHZ ,QWHUYLHZ FRPSOHWHG

PAGE 80

'HPRJUDSKLF &KDUDFWHULVWLFV RI WKH 6DPSOH 7KH PHDQ DJH RI WKH VDPSOH ZDV \HDUV ZLWK D VWDQGDUG GHYLDWLRQ RI UDQJH f VHH 7DEOH f 7KH PHDQ DJH RI WKH VXEMHFWV RI JURXS RQH ZKR XVHG KHUEDO SURGXFWV ZDV \HDUV ZLWK D VWDQGDUG GHYLDWLRQ RI UDQJH f 7KH PHDQ DJH RI WKH VXEMHFWV RI JURXS WZR ZKR GLG QRW XVH KHUEDO SURGXFWV ZDV \HDUV ZLWK D VWDQGDUG GHYLDWLRQ RI UDQJH f 7DEOH $JH RI +HUEDO 8VHUV 1RQ8VHUV DQG 7RWDO 6DPSOH $JH +HUEDO 8VHUV Q f 1RQ Q 8VHUV f 7RWDO 6DPSOH 1 f 0HDQ \HDUV 6'f f f f *URXS \HDUVf 1 bf 1 bf 1 bf f f f f f f DQG RYHU f f f 7RWDO 1XPEHU f f f 2I WKH WRWDO JURXS RI VXEMHFWV bf ZHUH PDUULHG b f ZHUH ZLGRZHG DQG HLJKW bf ZHUH GLYRUFHG VHH 7DEOH f )URP WKH KHUEDO XVHUV LQ WKH JURXS RQH bf ZHUH PDUULHG bf ZHUH ZLGRZHG DQG IRXU bf ZHUH GLYRUFHG $PRQJ WKH QRQn XVHUV LQ WKH JURXS WZR bf ZHUH PDUULHG bf ZHUH ZLGRZHG DQG IRXU bf ZHUH GLYRUFHG

PAGE 81

7KH VDPSOH FRQVLVWHG RI bf :KLWH $PHULFDQV DQG RQH bf %ODFN $PHULFDQ 1R RWKHU UDFH ZDV UHSRUWHG 7KH RQH %ODFN $PHULFDQ ZDV DQ KHUEDO SURGXFW XVHU DQG ZDV SODFHG LQ JURXS RQH $PRQJ WKH WRWDO VDPSOH bf KDG VRPH FROOHJH HGXFDWLRQ bf UHSRUWHG JUDGXDWH OHYHO HGXFDWLRQ DIWHU FRPSOHWLRQ RI FROOHJH bf ZHUH KLJK VFKRRO JUDGXDWHV bf KDG FROOHJH GHJUHHV DQG WKUHH VXEMHFWV KDG OHVV WKDQ KLJK VFKRRO HGXFDWLRQ 2I WKH KHUEDO SURGXFW XVHUV LQ JURXS RQH WKUHH bf VXEMHFWV KDG OHVV WKDQ KLJK VFKRRO HGXFDWLRQ QLQH bf VXEMHFWV ILQLVKHG KLJK VFKRRO bf KDG VRPH FROOHJH HGXFDWLRQ ILYH bf VXEMHFWV ZHUH FROOHJH JUDGXDWHV DQG bf VXEMHFWV KDG JUDGXDWH OHYHO HGXFDWLRQ DIWHU FRPSOHWLRQ RI FROOHJH $PRQJ WKH VXEMHFWV LQ JURXS WZR QR RQH KDG OHVV WKDQ D KLJK VFKRRO HGXFDWLRQ bf FRPSOHWHG KLJK VFKRRO bf KDG VRPH FROOHJH HGXFDWLRQ HLJKW bf ZHUH FROOHJH JUDGXDWHV DQG bf KDG JUDGXDWH OHYHO HGXFDWLRQ DIWHU FRPSOHWLRQ RI FROOHJH $QQXDO KRXVHKROG LQFRPH ZDV FDWHJRUL]HG LQWR IRXU JURXSV OHVV WKDQ RU PRUH 6HYHQW\QLQH bf VXEMHFWV UHVSRQGHG ZKLOH VHYHQ bf GHFOLQHG WR DQVZHU WKH

PAGE 82

TXHVWLRQ UHODWHG WR LQFRPH (LJKWHHQ bf VXEMHFWV UHSRUWHG WKHLU LQFRPH WR EH OHVV WKDQ bf UHSRUWHG LQFRPHV RI bf UHSRUWHG LQFRPHV RI DQG bf UHSRUWHG WKHLU LQFRPH OHYHO WR EH RU PRUH SHU \HDU 2I WKH KHUEDO SURGXFW XVHUV LQ JURXS RQH KRXVHKROG LQFRPH RI HLJKW bf VXEMHFWV ZDV OHVV WKDQ bf UHSRUWHG WKHLU LQFRPH WR EH EHWZHHQ DQG VHYHQ bf UHSRUWHG WKHLU LQFRPH WR EH EHWZHHQ DQG DQG VHYHQ bf UHSRUWHG LQFRPHV RI RU PRUH SHU \HDU $PRQJ QRQXVHUV LQ JURXS WZR DQQXDO KRXVHKROG LQFRPH RI bf VXEMHFWV ZDV OHVV WKDQ bf VXEMHFWV ZHUH EHWZHHQ DQG bf UHSRUWHG WKHLU LQFRPH WR EH EHWZHHQ DQG DQG bf UHSRUWHG DQ LQFRPH RI RU JUHDWHU :LWK UHJDUGV WR UHOLJLRXV SUHIHUHQFH 3URWHVWDQW ZDV WKH PRVW FRPPRQ UHOLJLRQ bf IROORZHG E\ &DWKROLF bf 7KUHH bf VXEMHFWV SUDFWLFHG WKH -HZLVK UHOLJLRQ VL[ bf UHSRUWHG RWKHU W\SHV RI UHOLJLRQ DQG HLJKW bf FODLPHG QR UHOLJLRXV SUHIHUHQFH 3URWHVWDQW ZDV PDLQ UHOLJLRXV SUHIHUHQFH LQ ERWK KHUEDO SURGXFW XVHUV bf DQG QRQXVHUV bf

PAGE 83

6HYHQW\QLQH bf VXEMHFWV KDG 0HGLFDUH DQG VXSSOHPHQWDO LQVXUDQFH WKUHH bf UHSRUWHG 0HGLFDUH DV WKHLU RQO\ LQVXUDQFH WZR bf FODLPHG 0HGLFDUH DQG 0HGLFDLG RQH bf KDG RQO\ 0HGLFDLG DQG RQH bf KDG RQO\ SULYDWH LQVXUDQFH 2I WKH KHUEDO SURGXFW XVHUV bf KDG 0HGLFDUH DQG VXSSOHPHQWDO LQVXUDQFH RQH bf KDG 0HGLFDUH RQO\ WZR bf UHSRUWHG 0HGLFDUH DQG 0HGLFDLG RQH bf KDG SULYDWH LQVXUDQFH $PRQJ QRQn XVHUV RI JURXS WZR bf VXEMHFWV FODLPHG 0HGLFDUH DQG VXSSOHPHQWDO LQVXUDQFH WZR bf KDG 0HGLFDUH RQO\ DQG RQH bf KDG 0HGLFDLG RQO\ 7KH VXPPDU\ RI GHPRJUDSKLF FKDUDFWHULVWLFV LQFOXGLQJ PDULWDO VWDWXV HWKQLFLW\ HGXFDWLRQ DQQXDO KRXVHKROG LQFRPH UHOLJLRQ DQG LQVXUDQFH VWDWXV IRU WKH WRWDO VDPSOH IRU WKH JURXS RI KHUEDO XVHUV DQG IRU WKH JURXS RI QRQKHUEDO XVHUV LV LOOXVWUDWHG LQ 7DEOH 7DEOH 'HPRJUDSKLF &KDUDFWHULVWLFV RI WKH 7RWDO 6DPSOH +HUEDO 3URGXFW 8VHUV DQG 1RQXVHUV &KDUDFWHULVWLFV +HUEDO 8VHUV Q f 1RQ Q 8VHUV f 7RWDO 6DPSOH 1 f 0DULWDO 6WDWXV 1 bf 1 bf 1 bf 16 0DUULHG f f f :LGRZHG f f f 'LYRUFHG f f f 1HYHU 0DUULHG f f f

PAGE 84

7DEOH FRQWLQXHGf &KDUDFWHULVWLFV +HUEDO 8VHUV Q f 1RQ Q 8VHUV f 7RWDO 6DPSOH 1 f (WKQLFLW\ :KLWH $PHULFDQ f f f 16 $IULFDQ $PHULFDQ f f f +LVSDQLFQRQZKLWH f f f 2WKHU f f f (GXFDWLRQ +LJK 6FKRRO f f f 16 +LJK 6FKRRO f f f &ROOHJH *UDGXDWH f f f A&ROOHJH *UDGXDWH f f f *UDGXDWH 6FKRRO f f f $QQXDO ,QFRPH f f f 16 f f f f f f f f f 0LVVLQJ 'DWD f f f 5HOLJLRQ 3URWHVWDQW f f f 16 &DWKROLF f f f -HZLVK f f f 2WKHU f f f 1RQH f f f ,QVXUDQFH 0HGLFDUH t 6XSSOHPHQW f f f 16 0HGLFDUH RQO\ f f f 0HGLFDUH t 0HGLFDLG f f f 0HGLFDLG RQO\ f f f 3ULYDWH ,QV 2QO\ f f f 16 6WDWLVWLFDOO\ QR VLJQLILFDQW GLIIHUHQFH EHWZHHQ WKH JURXS RI KHUEDOSURGXFW XVHUV DQG WKH JURXS RI QRQXVHUV S f 5HVHDUFK +\SRWKHVHV 5HVHDUFK +\SRWKHVLV 2QH 7KH ILUVW K\SRWKHVLV VWDWHG WKDW WKHUH ZDV D GLIIHUHQFH LQ GHPRJUDSKLF FKDUDFWHULVWLFV RI ZRPHQ \HDUV

PAGE 85

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bf 7KH UHVHDUFK K\SRWKHVLV RQH ZDV QRW VXSSRUWHG 7KH W WHVW ZDV SHUIRUPHG WR WHVW GLIIHUHQFHV LQ DJH EHWZHHQ WKH WZR JURXSV DQG QR VLJQLILFDQW GLIIHUHQFH LQ PHDQ DJH ZDV IRXQG EHWZHHQ WKH WZR JURXSV W S f 7KH WZR JURXSV ZHUH KRPRJHQHRXV ZLWK UHJDUG WR PDULWDO VWDWXV [ S f 7KHUH ZDV QR VLJQLILFDQW GLIIHUHQFH LQ HGXFDWLRQ EHWZHHQ WKH JURXS RI KHUEDO XVHUV DQG WKH JURXS RI QRQXVHUV [ S f 7KHUH ZHUH QR VLJQLILFDQW GLIIHUHQFHV LQ DQQXDO KRXVHKROG LQFRPH [ S f DQG LQ UHOLJLRXV SUHIHUHQFH [f S f EHWZHHQ WKH WZR JURXSV ,Q VXPPDU\ WKH WZR JURXSV ZHUH QRW VLJQLILFDQWO\ GLIIHUHQW LQ GHPRJUDSKLF FKDUDFWHULVWLFV

PAGE 86

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f 2YHUDOO KHDOWK ZDV UDWHG ILYH RQ WKH YLVXDO VFDOH E\ bf RI WKH WRWDO VDPSOH IRXU RQ WKH YLVXDO VFDOH E\ bf WKUHH RQ WKH YLVXDO VFDOH E\ bf DQG WZR RQ WKH YLVXDO VFDOH E\ WZR bf 1R VXEMHFW JDYH D UDWLQJ RI RQH RQ WKH YLVXDO VFDOH VHH 7DEOH f $PRQJ KHUEDO SURGXFW XVHUV LQ JURXS RQH QR VXEMHFW JDYH D UDWLQJ RI HLWKHU RQH RU WZR VXJJHVWLQJ SRRU RYHUDOO KHDOWK QLQH

PAGE 87

f VXEMHFWV UDWHG WKUHH RQ WKH YLVXDO VFDOH f VXEMHFWV UDWHG IRXU DQG bf VXEMHFWV UDWHG ILYH VXJJHVWLQJ H[FHOOHQW RYHUDOO KHDOWK $PRQJ QRQ KHUEDO SURGXFW XVHUV LQ JURXS WZR QR VXEMHFW JDYH D UDWLQJ RI RQH WZR bf VXEMHFWV UDWHG WZR RQ WKH YLVXDO VFDOH bf VXEMHFWV UDWHG WKUHH bf VXEMHFWV UDWHG IRXU DQG bf VXEMHFWV UDWHG ILYH 7KHUH ZDV QR VLJQLILFDQW GLIIHUHQFH LQ SHUFHSWLRQ RI RYHUDOO KHDOWK EHWZHHQ WKH WZR JURXSV b S f 7DEOH 3HUFHLYHG 2YHUDOO +HDOWK E\ +HUEDO8VHUV 1RQ8VHUV DQG 7RWDO 6DPSOH 9LVXDO 6FDOH f +HUEDO 8VHUV Q f 1RQ8VHUV Q f 7RWDO 6DPSOH 1 f 3RRUf bf bf bf bf bf bf bf bf bf bf bf bf ([FHOOHQWf bf bf bf 7RWDO bf bf bf 3K\VLFDO KHDOWK ZDV UDWHG WZR RQ WKH YLVXDO VFDOH E\ WKUHH bf VXEMHFWV WKUHH RQ WKH YLVXDO VFDOH E\ bf VXEMHFWV IRXU RQ WKH YLVXDO VFDOH E\ bf VXEMHFWV DQG ILYH RQ WKH YLVXDO VFDOH E\ bf VXEMHFWV VHH 7DEOH f

PAGE 88

7DEOH 3HUFHLYHG 3K\VLFDO +HDOWK E\ +HUEDO8VHUV 1RQ 8VHUV DQG 7RWDO 6DPSOH 9LVXDO 6FDOH +HUEDO 8VHUV 1RQ 8VHUV 7RWDO 6DPSOH f Q f Q f 1 f 3RRUf bf bf bf bf bf bf bf bf bf bf bf bf ([FHOOHQWf bf bf bf 7RWDO bf bf bf $PRQJ VXEMHFWV LQ JURXS RQH QR VXEMHFW JDYH D UDWLQJ RI RQH VXJJHVWLQJ SRRU SK\VLFDO KHDOWK RQH bf VXEMHFW UDWHG WZR bf VXEMHFWV UDWHG WKUHH bf VXEMHFWV UDWHG IRXU DQG bf VXEMHFWV UDWHG ILYH VXJJHVWLQJ H[FHOOHQW SK\VLFDO KHDOWK $PRQJ QRQKHUEDO SURGXFW XVHUV LQ JURXS WZR QR VXEMHFW JDYH D UDWLQJ RI RQH WZR bf VXEMHFWV UDWHG WZR bf VXEMHFWV UDWHG WKUHH bf VXEMHFWV UDWHG IRXU DQG bf VXEMHFWV UDWHG ILYH 7KHUH ZHUH QR VLJQLILFDQW GLIIHUHQFHV LQ SHUFHSWLRQ RI SK\VLFDO KHDOWK EHWZHHQ WKH WZR JURXSV b S f (PRWLRQDO KHDOWK ZDV UDWHG WZR RQ WKH YLVXDO VFDOH E\ RQH bf VXEMHFW UDWHG WKUHH RQ WKH YLVXDO VFDOH E\ VL[ bf UDWHG IRXU E\ bf DQG ILYH RU H[FHOOHQW RQ WKH YLVXDO VFDOH E\ bf VXEMHFWV VHH 7DEOH f

PAGE 89

7DEOH 3HUFHLYHG (PRWLRQDO +HDOWK E\ +HUEDO8VHUV 1RQ8VHUV DQG 7RWDO 6DPSOH 9LVXDO 6FDOH +HUEDO 8VHUV 1RQ 8VHUV 7RWDO 6DPSOH f Q f Q f 1 f 3RRUf bf bf bf bf bf bf bf bf bf bf bf bf ([FHOOHQWf bf bf bf 7RWDO bf bf bf $PRQJ VXEMHFWV LQ JURXS RQH QR VXEMHFW JDYH D UDWLQJ RI RQH VXJJHVWLQJ SRRU HPRWLRQDO KHDOWK VWDWXV RQH bf VXEMHFW UDWHG WZR WZR bf VXEMHFWV UDWHG WKUHH bf VXEMHFWV UDWHG IRXU DQG bf VXEMHFWV UDWHG ILYH VXJJHVWLQJ H[FHOOHQW HPRWLRQDO KHDOWK $PRQJ VXEMHFWV LQ JURXS WZR QR VXEMHFW JDYH D UDWLQJ RI HLWKHU RQH RU WZR RQ WKH HPRWLRQDO KHDOWK VWDWXV IRXU bf VXEMHFWV UDWHG WKUHH bf VXEMHFWV UDWHG IRXU DQG bf VXEMHFWV UDWHG ILYH ZKLFK UHSUHVHQWV H[FHOOHQW HPRWLRQDO KHDOWK 7KHUH ZDV QR VLJQLILFDQW GLIIHUHQFH LQ SHUFHLYHG HPRWLRQDO KHDOWK EHWZHHQ WKH JURXS RI KHUEDO SURGXFW XVHUV DQG WKDW RI QRQXVHUV bf S f $ ODUJH QXPEHU RI WKH WRWDO VDPSOH YLVLWHG DW OHDVW RQH KHDOWK FDUH SURYLGHU LQ WKH SDVW PRQWKV (LJKW\ WKUHH VXEMHFWV bf YLVLWHG DW OHDVW RQH KHDOWK FDUH SURYLGHU LQ WKH SDVW PRQWKV 2QO\ WKUHH VXEMHFWV bf

PAGE 90

KDG QRW YLVLWHG DQ\ W\SH RI KHDOWK FDUH SURYLGHU ZLWKLQ WKH SDVW PRQWKV 7ZR RI WKUHH VXEMHFWV ZKR GLG QRW YLVLW DQ\ KHDOWK FDUH SURYLGHU ZHUH KHUEDO SURGXFW XVHUV 7KH PHDQ QXPEHU RI KHDOWK FDUH SURYLGHUV UHSRUWHG E\ WKH VDPSOH ZDV 6' UDQJH f 7KH DYHUDJH QXPEHU RI KHDOWK FDUH SURYLGHUV WKH KHUEDO SURGXFW XVHUV UHSRUWHG ZDV 6' UDQJH f LQ FRPSDULVRQ WR KHDOWK FDUH SURYLGHUV 6' UDQJH f UHSRUWHG E\ QRQXVHUV 7KHUH ZDV QR VLJQLILFDQW GLIIHUHQFH LQ QXPEHU RI KHDOWK FDUH SURYLGHUV WKDW WKH VDPSOH KDG EHWZHHQ WKH JURXS RI KHUEDO SURGXFW XVHUV DQG WKH JURXS RI QRQXVHUV W S f ,QWHUQDO PHGLFLQH ZDV WKH PRVW IUHTXHQWO\ YLVLWHG VSHFLDOW\ UHSRUWHG E\ bf VXEMHFWV DQG WKH VHFRQG PRVW IUHTXHQWO\ YLVLWHG ZDV IDPLO\ SUDFWLFH UHSRUWHG E\ bf VXEMHFWV 7\SHV DQG VHULRXVQHVV RI KHDOWKUHODWHG SUREOHPV $PRQJ VXEMHFWV RI WKH WRWDO VDPSOH bf UHSRUWHG DW OHDVW RQH RU PRUH SUREOHPV IURP WKH FDWHJRULHV RI KHDOWKUHODWHG SUREOHPV VHH 7DEOH f 2I WKH KHDOWKUHODWHG SUREOHPV UHSRUWHG DUWKULWLV bf DOOHUJLHV bf DQG IDWLJXH bf ZHUH LGHQWLILHG DV PDMRU KHDOWKUHODWHG SUREOHPV E\ DERXW KDOI RI WKH WRWDO VDPSOH IROORZHG E\ EDFN SUREOHPV bf GLJHVWLYH SUREOHPV bf DQG XULQDU\ SUREOHPV bf 2WKHU

PAGE 91

KHDOWK SUREOHPV FRPPRQO\ UHSRUWHG E\ VXEMHFWV ZHUH VNLQ SUREOHPV bf KHDUW SUREOHPV bf KLJK EORRG SUHVVXUH bf DQG PHPRU\ SUREOHPV bf 7KH DYHUDJH QXPEHU RI KHDOWKUHODWHG SUREOHPV UHSRUWHG E\ HDFK VXEMHFW ZDV SUREOHPV 7KH JURXS RI KHUEDO XVHUV VXEMHFWVf LGHQWLILHG DQ DYHUDJH RI KHDOWKUHODWHG SUREOHPV ZKLOH DQ DYHUDJH RI KHDOWKUHODWHG SUREOHPV ZDV UHSRUWHG E\ WKH JURXS RI QRQXVHUV VXEMHFWVf (DFK KHDOWKUHODWHG SUREOHP LQ GLIIHUHQW DUHDV ZDV FRPSDUHG EHWZHHQ WKH JURXS RI KHUEDO XVHUV DQG WKDW RI QRQn XVHUV 7KHUH ZDV VLJQLILFDQW GLIIHUHQFH LQ PHPRU\ SUREOHP EHWZHHQ WKH WZR JURXSV ^b S f 7KLUWHHQ VXEMHFWV LQ WKH JURXS RI KHUEDO SURGXFW XVHUV UHSRUWHG PHPRU\ SUREOHPV ZKLOH VL[ VXEMHFWV RI WKH FRXQWHU SDUW UHSRUWHG PHPRU\ SUREOHPV 'LIIHUHQFHV ZHUH QRW IRXQG LQ RWKHU DUHDV RI KHDOWKUHODWHG SUREOHPV EHWZHHQ WKH WZR JURXSV VHH 7DEOH f 7DEOH 7\SHV RI +HDOWK5HODWHG 3UREOHPV 1 f 1XPEHU DQG 7\SHV RI 3UREOHPV +HUEDO 3URGXFW XVHUV 1RQ 8VHUV 7RWDO 8VHUV 1 bf 3 1R RI +HDOWK 3UREOHPV ; 6' 5DQJH f f f $UWKULWLV f 16

PAGE 92

7DEOH FRQWLQXHGf 1XPEHU DQG 7\SHV RI +HUEDO 1RQ 7RWDO 3UREOHPV 3URGXFW 8VHUV 8VHUV S XVHUV 1 bf $OOHUJLHV f 16 )DWLJXH ORZ HQHUJ\f f 16 %DFN SUREOHPV f 16 'LJHVWLYH 3UREOHPV f 16 8ULQDU\ SUREOHPV f 16 6NLQ SUREOHPV f 16 +HDUW SUREOHPV f 16 +LJK %ORRG 3UHVVXUH f 16 'L]]LQHVV f 16 0HPRU\ SUREOHPV f KD LL R R $Q[LHW\ f 16 %ORRG t &LUFXODWRU\ f 16 SUREOHPV &KURQLF 3DLQ f 16 &ROG t )OX f 16 2EHVLW\ f 16 +HDGDFKH f 16 &DQFHU f 16 'LDEHWHV f 16 'HSUHVVLRQ f 16 /XQJ SUREOHPV f 16 *\QHFRORJLFDO SUREOHPV f 16 2WKHUV f 16 1RWHV 16 QR VLJQLILFDQW GLIIHUHQFH EHWZHHQ WKH JURXS RI KHUEDO SURGXFW XVHUV DQG WKH JURXS RI QRQXVHUV S f (DFK VXEMHFW ZDV DVNHG DERXW WKH VHULRXVQHVV RI LGHQWLILHG KHDOWKUHODWHG SUREOHPV LQ KHU GDLO\ OLYLQJ E\

PAGE 93

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nV ([DFW 7DLO 7HVW S f DOWKRXJK WKH WZR JURXSV ZHUH KRPRJHQHRXV ZLWK UHJDUGV WR REHVLW\ DV D KHDOWKUHODWHG SUREOHP >b S f 2I DOO VXEMHFWV ZKR UHSRUWHG KHDOWKUHODWHG SUREOHPV WKH PDMRULW\ LQGLFDWHG WKDW WKH VHULRXVQHVV RI KHDOWK SUREOHPV LQ WKHLU GDLO\ OLYLQJ ZDV WKUHH WZR RU RQH RQ WKH YLVXDO VFDOH 7KH VHULRXVQHVV RI PHPRU\ SUREOHPV LQ LQWHUIHULQJ ZLWK HYHU\GD\ OLIH ZDV QRW VLJQLILFDQWO\ GLIIHUHQW EHWZHHQ WKH JURXS RI KHUEDO SURGXFW XVHUV DQG WKH JURXS RI QRQXVHUV [ S f DOWKRXJK WKH WZR JURXSV ZHUH GLIIHUHQW LQ WKH IUHTXHQF\ RI PHPRU\ DV D KHDOWKUHODWHG SUREOHP

PAGE 94

8VH RI SUHVFULEHG DQG QRQSUHVFULEHG PHGLFLQHV 7KH XVH RI SUHVFULEHG PHGLFLQHV ZDV UHSRUWHG E\ bf RI WKH WRWDO VDPSOH 7KH DYHUDJH QXPEHU RI SUHVFULEHG PHGLFLQHV XVHG E\ WKH WRWDO VDPSOH ZDV PHGLFLQHV 6' UDQJH f KHUEDO SURGXFW XVHUV UHSRUWHG D PHDQ RI PHGLFLQHV 6' UDQJH f DQG QRQXVHUV UHSRUWHG PHDQ RI PHGLFLQHV 6' UDQJH f 7KHUH ZDV QR VLJQLILFDQW GLIIHUHQFH LQ WKH XVH RI SUHVFULEHG PHGLFLQHV EHWZHHQ WKH JURXS RI KHUEDO SURGXFW XVHUV DQG WKDW RI QRQXVHUV W S f $OO EXW RQH RI WKH WRWDO VDPSOH bf UHSRUWHG WKH XVH RI QRQSUHVFULEHG PHGLFLQHV 7KH PHDQ QXPEHU RI QRQ SUHVFULEHG PHGLFLQHV XVHG E\ WKH WRWDO VDPSOH ZDV PHGLFLQHV 6' UDQJH f KHUEDO SURGXFW XVHUV UHSRUWHG D PHDQ RI PHGLFLQHV 6' UDQJH f DQG QRQXVHUV UHSRUWHG D PHDQ RI PHGLFLQHV 6' UDQJH WR f 2I WKH QRQSUHVFULEHG PHGLFLQHV XVHG E\ VDPSOH PDQ\ RI WKHP ZHUH WDNHQ RQ D UHJXODU EDVLV 7KH PRVW IUHTXHQWO\ XVHG QRQSUHVFULEHG PHGLFLQHV WDNHQ UHJXODUO\ ZHUH PXOWLYLWDPLQ FDOFLXP YLWDPLQ ( YLWDPLQ & DQG DVSLULQ VHH 7DEOH f 0RUH WKDQ RQHWKLUG RI WKH WRWDO VDPSOH ZDV XVLQJ DW OHDVW RQH RI WKHVH ILYH QRQSUHVFULEHG PHGLFLQHV 2I WKH IRUW\HLJKW VXEMHFWV bf LQ WKH WRWDO

PAGE 95

VDPSOH ZKR XVHG PXOWLYLWDPLQV bf ZHUH KHUEDO SURGXFW XVHUV DQG bf ZHUH QRQKHUEDO SURGXFW XVHUV &DOFLXP ZDV WKH VHFRQG PRVW IUHTXHQWO\ XVHG QRQSUHVFULSWLRQ PHGLFLQH DPRQJ WKH VDPSOH )RUW\VHYHQ bf VXEMHFWV LQ WKH WRWDO VDPSOH ZHUH WDNLQJ FDOFLXP LQFOXGLQJ bf ZHUH KHUEDOSURGXFW XVHUV DQG bf ZHUH QRQXVHUV )RUW\RQH VXEMHFWV bf LQ WKH WRWDO VDPSOH ZHUH WDNLQJ 9LWDPLQ ( bf VXEMHFWV IURP WKH KHUEDOSURGXFW XVHUV DQG bf IURP WKH QRQn XVHUV $PRQJ VXEMHFWV bf IURP WKH WRWDO VDPSOH ZKR XVHG YLWDPLQ & bf ZHUH KHUEDOSURGXFW XVHUV DQG bf ZHUH QRQXVHUV $VSLULQ ZDV UHJXODUO\ XVHG E\ VXEMHFWV bf LQ WKH WRWDO VDPSOH (OHYHQ VXEMHFWV bf ZHUH KHUEDOSURGXFW XVHUV DQG bf ZHUH QRQn XVHUV 7DEOH )UHTXHQWO\ 8VHG 1RQSUHVFULEHG 0HGLFLQHV 7DNHQ 5HJXODUO\ 1RQSUHVFULEHG PHGLFLQHV +HUEDO3URGXFW 8VHUV Q f 1R bf 1RQ Q 1R 8VHUV f bf 7RWDO 1 f 1R bf 0XOWLYLWDPLQ f f f &DOFLXP f f f 9LWDPLQ ( f f f 9LWDPLQ & f f f $VSLULQ f f f

PAGE 96

7KHUH ZDV QR VLJQLILFDQW GLIIHUHQFH LQ WKH QXPEHU RI QRQSUHVFULEHG PHGLFLQHV XVHG EHWZHHQ WKH JURXS RI KHUEDO SURGXFW XVHUV DQG QRQXVHUV W S f ,Q VXPPDU\ WKH DYHUDJH QXPEHU RI PHGLFLQHV LQFOXGLQJ ERWK SUHVFULEHG DQG QRQSUHVFULEHG PHGLFLQHV IRU HDFK VXEMHFW RI WKH WRWDO VDPSOH ZDV PHGLFLQHV 6' UDQJH f 7KH DYHUDJH QXPEHU RI WRWDO PHGLFLQHV XVHG E\ KHUEDO SURGXFW XVHUV ZDV PHGLFLQHV 6' UDQJH f ZKLOH WKH QRQKHUEDO SURGXFW XVHU JURXS XVHG PHGLFLQHV 6' UDQJH f 7KHUH ZDV QR VLJQLILFDQW GLIIHUHQFH LQ WKH XVH RI WRWDO QXPEHU RI PHGLFLQHV EHWZHHQ WKH WZR JURXSV W J f 7KH VXPPDU\ RI WKH XVH RI SUHVFULEHG QRQSUHVFULEHG DQG WRWDO QXPEHU RI PHGLFLQHV XVHG E\ VDPSOH LV LOOXVWUDWHG LQ 7DEOH 7DEOH 8VH RI 3UHVFULEHG 1RQSUHVFULEHG 0HGLFLQHV E\ 6DPSOH 1 f 0HGLFLQHV Qf +HUEDO 8VHUV Q f ; 6' 0LQ0D[f 1RQ8VHUV Q f ; 6' 0LQ0D[f 7RWDO 1 ; 0LQ 6DPSOH f 6' 0D[f 7RWDO s s 16 0HGLFLQHV f f ‘ f 3UHVFULEHG s s s 0HGLFLQHV f f f 1RQSUHVFULEHG s s s 16 0HGLFLQHV f f f 16 6WDWLVWLFDOO\ QRW VLJQLILFDQW EHWZHHQ WKH JURXS RI KHUEDO SURGXFW XVHUV DQG QRQXVHUV S f

PAGE 97

'HVFULSWLRQ RI WKH 5HVHDUFK 4XHVWLRQV 5HVHDUFK 4XHVWLRQ 2QH 7KH ILUVW UHVHDUFK TXHVWLRQ ZDV VWDWHG DV ZKDW LV WKH SUHYDOHQFH RI XVH RI KHUEDO SURGXFWV DPRQJ ZRPHQ \HDUV DQG ROGHU 2I WKH WRWDO VDPSOH RI VXEMHFWV bf UHSRUWHG XVLQJ KHUEDO SURGXFWV LQ WKH SDVW PRQWKV $ WRWDO RI KHUEDO SURGXFWV ZHUH XVHG E\ WKH VXEMHFWV ZKLFK DYHUDJHG KHUEDO SURGXFWV SHU VXEMHFW 6' UDQJH f 7KH WKUHH PRVW FRPPRQO\ XVHG KHUEDO SURGXFWV ZHUH *LQNJR %LORED RU *LQNJR %LORED ZLWK RWKHU FRPELQDWLRQV VXEMHFWVf JDUOLF WDEOHWV DQG FORYHV VXEMHFWVf DQG *OXFRVDPLQH ZLWK &KRQGURLWLQ VXEMHFWVf 1LQHW\WZR KHUEDO SURGXFWV bf ZHUH WDNHQ RUDOO\ ZKLOH VL[ bf KHUEDO SURGXFWV ZHUH XVHG H[WHUQDOO\ $ERXW WKUHHTXDUWHUV bf RI WKH WRWDO QXPEHU RI KHUEDO SURGXFWV ZHUH LQ D UHDG\WRWDNH IRUP VXFK DV WDEOHWV FDSVXOHV RU OLTXLG SUHSDUDWLRQV DQG b RI WKH KHUEDO SURGXFWV UHTXLUHG VRPH SUHSDUDWLRQ E\ WKH VXEMHFWV 7KH W\SHV RI KHUEDO SURGXFWV XVHG E\ WKH VXEMHFWV DUH LOOXVWUDWHG LQ 7DEOH

PAGE 98

7DEOH 7\SHV RI +HUEDO 3URGXFWV 8VHG E\ 6XEMHFWV 1DPH Qf 1DPH Qf *LQNJR RU *LQNJR FRPELQDWLRQV f *DUOLF f *OXFRVDPLQH Z FKRQGURLWLQ f $ORH f +HUEDO 7HD 3DUVOH\ %DVLO 3HSSHUPLQW WHDf f (FKLQDFHD f *LQJHU f 6W -RKQV :RUW f 9LQHJDU Z+RQH\ f 3ULPURVH f *+ f *LQVHQJ f *UHHQ 7HD f 6HOHQLXP f )OD[ 2LO &RPSOH[ RU )OD[ 7HD f 3XUH &UDQEHUU\ -XLFH f 3DQWRWKHQLF $FLG f 0HODWRQLQ f 3DSD\D &DSVXOHV f 0DQFKXULDQ 0XVKURRP 7HD f 6HVDPH 2LO Z ILYH ZKROH FORYHV f 6WHYLD /LTXLG ([WUDFW f &D\HQQH 3HSSHU &DSVXOHV f 1DWXUHnV 7HD &RORQ &OHDQVHUf f 3DSULND 3RZGHU f +RW 6SLF\ 3HSSHU f 6KDUN &DUWLODJH f %DUOH\ *UHHQ f *UDSHIUXLW 6HHGV ([WUDFW f $QLFD f 060 f %DNXFKL 2LO f 7ULSKDOD 7HD f *UDSH 6HHGV ([WUDFW f 6SLUX7HLQ f &R 4 f $FLGRSKLOXV f &RG /LYHU 2LO Z :KROH 0LON 6R\ %HDQ 2LO %HWD &DURWHQH f /HFLWKLQ &DSVXOHV f 3URYH[ f 6HYHQ )RUHVWV f (LJKW 3UXQHV f &KURPLXP 3LFROLQDWH f /LYHU )OXVK 0L[ RI 2OLYH 2LO /LPH -XLFH $SSOH &LGHU 9LQHJDU t 5HG 3HSSHUf f &DOPV )RUWH f *KHH Z ERLOHG %XWWHU f %UHZHUnV
PAGE 99

5HVHDUFK 4XHVWLRQ 7ZR 7KH VHFRQG TXHVWLRQ ZDV VWDWHG DV ZKDW LV WKH SXUSRVH IRU WDNLQJ KHUEDO SURGXFWV DQGRU KHUEV E\ ZRPHQ \HDUV DQG RYHU 'R ROGHU ZRPHQ WDNH KHUEDO SURGXFWV PRUH IRU SUHYHQWLRQ RU IRU WUHDWPHQW RI V\PSWRPV" 2I WKH SHUVRQV WDNLQJ KHUE£LV bf UHSRUWHG XVLQJ KHUEDO SURGXFWV WR PDLQWDLQ KHDOWK RU WR SUHYHQW SRVVLEOH KHDOWK SUREOHPV 1LQH VXEMHFWV bf XVHG KHUEDO SURGXFWV IRU WUHDWPHQW RI KHDOWK SUREOHPV )RXUWHHQ VXEMHFWV bf XVHG KHUEDO SURGXFWV ERWK WR SUHYHQW DQG WR WUHDW KHDOWK SUREOHPV VHH 7DEOH f 2I WKH KHUEDO SURGXFWV XVHG E\ WKH VXEMHFWV bf SURGXFWV ZHUH XVHG WR SUHYHQW KHDOWK SUREOHPV RU WR PDLQWDLQ KHDOWK ZKLOH bf RI WKH KHUEDO SURGXFWV ZHUH XVHG WR WUHDW KHDOWK SUREOHPV 7KH WKUHH PDMRU SXUSRVHV IRU XVLQJ KHUEDO SURGXFWV RWKHU WKDQ SUHYHQWLRQ ZHUH WR LPSURYH PHPRU\ WR WUHDW DUWKULWLV DQG WR UHPHG\ GLJHVWLYH SUREOHPV 7DEOH 3XUSRVHV RI 8VLQJ +HUEDO 3URGXFWV E\ 6XEMHFWV DQG E\ 1XPEHU RI +HUEDO 3URGXFWV 5HDVRQV WR WDNH KHUEDO 6XEM HFWV 1R RI +HUEDO SURGXFWV Q f 3URGXFWV Q f 7R WUHDW KHDOWK SUREOHPV 7R PDLQWDLQ KHDOWK RU bf bf SUHYHQW KHDOWK SUREOHPV )RU ERWK WUHDWPHQW DQG bf bf SUHYHQWLRQ SXUSRVHV bf 1$ 7RWDO bf bf

PAGE 100

7KH SHUFHLYHG EHQHILW RI WDNLQJ WKH KHUEDO SURGXFWV ZDV DOVR LGHQWLILHG $ERXW RQHKDOI RI WKH KHUEDO SURGXFWV bf ZHUH SHUFHLYHG E\ VXEMHFWV WR EH VRPHZKDW HIIHFWLYH RU YHU\ HIIHFWLYH ZKLOH WKH HIIHFWLYHQHVV RI b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f 6XEMHFWV UHSRUWHG WKDW b RI WKH KHUEDO SURGXFWV XVHG ZHUH WDNHQ RQ D FRQWLQXDO EDVLV 7KHVH SURGXFWV KDG EHHQ XVHG IRU D PHDQ RI PRQWKV ZLWK D VWDQGDUG GHYLDWLRQ RI PRQWKV UDQJH RQH KDOI PRQWK PRQWKVf )RXUWHHQ KHUEDO SURGXFWV bf ZHUH XVHG ZKHQ V\PSWRPV RFFXUUHG 2I WKH WRWDO KHUEDO

PAGE 101

SURGXFWV XVHG E\ WKH VXEMHFWV bf ZHUH XVHG LQ FRPELQDWLRQ ZLWK SUHVFULEHG RU QRQSUHVFULEHG PHGLFLQHV WR WUHDW KHDOWK SUREOHPV 7ZHQW\QLQH KHUEDO SURGXFWV bf ZHUH XVHG DORQH IRU WUHDWLQJ KHDOWK SUREOHPV UHSRUWHG E\ WKH VXEMHFWV )LIW\ILYH KHUEDO SURGXFWV bf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f VXEMHFWV XVHG ERRNV RU PDJD]LQHV Ef VXEMHFWV ZHUH LQIRUPHG E\ IDPLO\ PHPEHUV Ff VXEMHFWV XVHG IULHQGV DQG QHLJKERUV DQG Gf VXEMHFWV XVHG WHOHYLVLRQ UDGLR RU QHZVSDSHUV 2WKHU VRXUFHV XVHG WR JDLQ LQIRUPDWLRQ ZHUH DOWHUQDWLYH KHDOWK FDUH SUDFWLWLRQHUV KHDOWK FDUH SURYLGHUV KHDOWK IRRG VWRUHV DQG QHZVOHWWHUV 1R VXEMHFW UHSRUWHG REWDLQLQJ LQIRUPDWLRQ IURP WKH ,QWHUQHW

PAGE 102

2WKHU )LQGLQJV 1LQHW\VL[ bf RI WKH WRWDO RI KHUEDO SURGXFWV XVHG E\ WKH VDPSOH ZHUH SXUFKDVHG ZLWK VHOISD\PHQW E\ VXEMHFWV 7ZR KHUEDO SURGXFWV bf ZHUH REWDLQHG IUHH IURP UHODWLYHV RI VXEMHFWV +HDOWK LQVXUDQFH FRPSDQLHV GLG QRW SD\ IRU DQ\ KHUEDO SURGXFWV XVHG E\ VXEMHFWV $PRQJ KHUEDO SURGXFWV UHSRUWHG E\ VXEMHFWV KHUEDO SURGXFWV bf ZHUH QRW UHSRUWHG WR WKH KHDOWK FDUH SURYLGHUV RI WKH VXEMHFWV ZKLOH KHUEDO SURGXFWV bf ZHUH UHSRUWHG WR WKH KHDOWK FDUH SURYLGHUV 2I KHUEDO SURGXFW XVHUV VXEMHFWV bf UHSRUWHG WKHLU XVH RI KHUEDO SURGXFWV WR WKHLU KHDOWK FDUH SURYLGHUV $OWKRXJK VXEMHFWV ZKR UHSRUWHG WKHLU XVH RI KHUEDO SURGXFWV QRW DOO KHUEDO SURGXFWV XVHG E\ WKHVH VXEMHFWV ZHUH UHSRUWHG WR WKHLU KHDOWK FDUH SURYLGHU ZKLFK LQGLFDWHG RQO\ SDUW RI WKH KHUEDO SURGXFWV WKH\ XVHG ZHUH UHSRUWHG :KLOH KHUEDO SURGXFWV IURP D WRWDO RI KHUEDO SURGXFWV FRQVXPHG E\ VXEMHFWV ZKR UHSRUWHG WKHLU XVH RI KHUEDO SURGXFWV RQO\ RI KHUEDO SURGXFWV ZHUH UHSRUWHG WR WKHLU KHDOWK FDUH SURYLGHUV +HDOWK FDUH SURYLGHUV ZKR ZHUH WKH PRVW IUHTXHQWO\ LQIRUPHG RI WKH XVH RI KHUEDO SURGXFWV ZHUH LQWHUQLVWV E\ HLJKW VXEMHFWV DQG IDPLO\ SUDFWLFHV E\ IRXU VXEM HFWV

PAGE 103

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

PAGE 104

&+$37(5 9 ',6&866,21 $1' 5(&200(1'$7,216 7KH SXUSRVH RI WKLV UHVHDUFK ZDV WR H[SORUH WKH XVH RI KHUEDO SURGXFWV IRU PHGLFLQDO SXUSRVHV DQG WR FRPSDUH GLIIHUHQFHV LQ GHPRJUDSKLF FKDUDFWHULVWLFV DQG LQ FKDUDFWHULVWLFV RI KHDOWK VWDWXV EHWZHHQ WKH JURXS RI KHUEDO SURGXFW XVHUV DQG WKH JURXS RI QRQXVHUV DPRQJ FRPPXQLW\GZHOOLQJ ZRPHQ DJHG \HDUV DQG RYHU 'DWD ZHUH H[DPLQHG IURP D UDQGRP VDPSOH RI ZRPHQ DJHG \HDUV DQG RYHU UHVLGLQJ LQGHSHQGHQWO\ LQ D 1RUWK &HQWUDO )ORULGD FRXQW\ 7KLV FKDSWHU SUHVHQWV D GLVFXVVLRQ RI WKH ILQGLQJV DQG WKH FRQFOXVLRQV RI WKH VWXG\ DFFRUGLQJ WR WKH K\SRWKHVHV DQG UHVHDUFK TXHVWLRQV 7KLV FKDSWHU DOVR SUHVHQWV UHFRPPHQGDWLRQV IRU IXWXUH UHVHDUFK DQG LPSOLFDWLRQV IRU QXUVLQJ SUDFWLFH 'LVFXVVLRQ DQG &RQFOXVLRQV 7KH GDWD LQGLFDWHG WKDW WKH JURXS RI KHUEDO SURGXFW XVHUV DQG WKH JURXS RI QRQXVHUV ZHUH KRPRJHQHRXV LQ GHPRJUDSKLF FKDUDFWHULVWLFV LQFOXGLQJ DJH PDULWDO VWDWXV HWKQLFLW\ OHYHO RI HGXFDWLRQ OHYHO RI LQFRPH UHOLJLRXV

PAGE 105

SUHIHUHQFH DQG LQVXUDQFH VWDWXV :LWK RQH H[FHSWLRQ WKH JURXSV ZHUH DOVR KRPRJHQHRXV LQ FKDUDFWHULVWLFV UHODWHG WR WKHLU KHDOWK VWDWXV 7KHUH ZDV D VWDWLVWLFDOO\ VLJQLILFDQW GLIIHUHQFH LQ WKH UHSRUWHG LQFLGHQFH RI PHPRU\ SUREOHPV EHWZHHQ WKH WZR JURXSV ZLWK WKH JURXS XVLQJ KHUEDO SURGXFWV UHSRUWLQJ D KLJKHU LQFLGHQFH 'HPRJUDSKLF &KDUDFWHULVWLFV RI WKH 6DPSOH $FFRUGLQJ WR WKH 86 %XUHDX RI WKH &HQVXV UHVLGHQWV ZKR DUH \HDUV DQG RYHU FRPSULVH b RI WKH WRWDO UHVLGHQW SRSXODWLRQ LQ WKLV 1RUWK &HQWUDO )ORULGD FRXQW\ 86 %XUHDX RI WKH &HQVXV f§86 &HQVXV 'DWD &67)$ 6XPPDU\ /HYHO 6WDWHf§&RXQW\ KWWSZZZFHQVXVJRYFJL ELQGDWDPDSFQW\" f 7KH UDWLR RI IHPDOHV WR PDOHV LQ WKH \HDUV DQG RYHU JURXS LQ WKLV FRXQW\ ZDV b DQG b UHVSHFWLYHO\ VHH 7DEOH f 7DEOH )UHTXHQFLHV DQG 3HUFHQWDJHV RI )HPDOHV DQG 0DOHV $JHG DQG 2YHU LQ D 1RUWK &HQWUDO )ORULGD &RXQW\ 1 fr *HQGHU )UHTXHQF\ 3HUFHQWDJH )HPDOH 0DOH r &HQVXV E\ WKH 86 %XUHDX RI WKH &HQVXV )HPDOHV ZKR ZHUH \HDUV DQG RYHU LQ WKLV FRXQW\ ZHUH FRPSULVHG RI b ZKLWH b EODFN b +LVSDQLF RULJLQ b $VLDQ RU 3DFLILF ,VODQGHU DQG OHVV WKDQ b

PAGE 106

$PHULFDQ ,QGLDQ (VNLPR RU $OHXW 86 %XUHDX RI &HQVXV f§86 &HQVXV 'DWD &67)$ 6XPPDU\ /HYHO 6WDWHf§&RXQW\ KWWSYHQXVFHQVXVJRYFGURPORRNXSf VHH 7DEOH f 7DEOH 6XPPDU\ RI 5DFHV DPRQJ )HPDOHV DJHG DQG RYHU 1 fr 5DFH )UHTXHQF\ 3HUFHQW :KLWH %ODFN +LVSDQLF RULJLQ $VLDQ RU 3DFLILF ,VODQGHU $PHULFDQ $OHXW ,QGLDQ (VNLPR RU 5DFH ZDV QRW LGHQWLILHG RQ WKH OLVW RI SRWHQWLDO VXEMHFWV IURP WKH 6WDWH 'HSDUWPHQW RI +LJKZD\ 6DIHW\ DQG 0RWRU 9HKLFOHV 7KHUHIRUH LW ZDV QRW SRVVLEOH WR NQRZ WKH UDFH GLVWULEXWLRQ RI WKH VDPSOH ,Q VSLWH RI D UDQGRP VDPSOLQJ SURFHGXUH IURP VXEMHFWV bf ZHUH :KLWH $PHULFDQV DQG RQH bf ZDV $IULFDQ $PHULFDQ 7KH UDFLDO GLVWULEXWLRQ IRU QRQUHVSRQGHQWV IRU SHUVRQV ZKR GHFOLQHG LQWHUYLHZV RU SHUVRQV ZKR ZHUH H[FOXGHG IURP WKH VWXG\ ZDV XQNQRZQ 7KHUH DSSHDUV WR EH DQ XQGHUUHSUHVHQWDWLRQ RI $IULFDQ $PHULFDQV DQG RWKHU PLQRULWLHV LQ WKLV VDPSOH 7KH UHDVRQV IRU WKLV XQGHU UHSUHVHQWDWLRQ RI $IULFDQ $PHULFDQV DQG RWKHU PLQRULWLHV DUH XQNQRZQ 7KH SRVVLEOH UHDVRQV PD\ EH WKDW $IULFDQ $PHULFDQV \HDUV DQG RYHU DUH OHVV OLNHO\

PAGE 107

WKDQ :KLWH $PHULFDQV WR Df KDYH D GULYHUV OLFHQVH Ef UHVSRQG WR UHTXHVWV IRU SDUWLFLSDWLRQ LQ UHVHDUFK DQG Ff WR DJUHH WR DQ LQWHUYLHZ 7KH OHYHO RI HGXFDWLRQ RI WKH VDPSOH ZDV VOLJKWO\ KLJKHU WKDQ WKH DYHUDJH HGXFDWLRQDO OHYHO RI WKH &RXQW\ VWXGLHG $FFRUGLQJ WR WKH GDWD RI 86$ FRXQWLHV SURYLGHG E\ WKH 86 %XUHDX RI WKH &HQVXV WKH SHUFHQWDJH RI FROOHJH JUDGXDWHV ZDV b DPRQJ SHUVRQV \HDUV DQG RYHU LQ LQ WKLV 1RUWK &HQWUDO )ORULGD FRXQW\ 86 %XUHDX RI WKH &HQVXV 86$ &RXQWLHV f ,Q WKH VWXG\ VDPSOH b ZHUH FROOHJH JUDGXDWHV RU SRVWJUDGXDWHV b UHSRUWHG VRPH \HDUV RI FROOHJH HGXFDWLRQ DQG b JUDGXDWHG IURP KLJK VFKRRO 7KH HGXFDWLRQDO OHYHO RI WKLV VDPSOH LV FRQVLVWHQW ZLWK RWKHU VWXGLHV ZKLFK UHODWHG WR WKH XVH RI DOWHUQDWLYH PHGLFLQHV (LVHQEHUJ HW DO (OLDVRQ .UXJHU 0DUN t 5DVPDQQ f 7KH UHVXOWV RI WKLV VWXG\ VKRZHG WKDW WKHUH ZDV QR VLJQLILFDQW GLIIHUHQFH LQ WKH OHYHO RI HGXFDWLRQ EHWZHHQ WKH JURXS RI KHUEDO SURGXFW XVHUV DQG WKH JURXS RI QRQXVHUV ,Q FRQFOXVLRQ WKHUH ZDV QR GLIIHUHQFH EHWZHHQ VXEMHFWV ZKR XVHG KHUEDO SURGXFWV DQG WKRVH ZKR GLG QRW XVH KHUEDO SURGXFWV UHODWHG WR GHPRJUDSKLF FKDUDFWHULVWLFV LQFOXGLQJ PDULWDO VWDWXV OHYHO RI HGXFDWLRQ DQQXDO LQFRPH UHOLJLRXV SUHIHUHQFH DQG LQVXUDQFH VWDWXV

PAGE 108

)LQGLQJV UHODWHG WR UDFH ZHUH LQFRQFOXVLYH GXH WR D VPDOO VDPSOH VL]H RI $IULFDQ $PHULFDQV &KDUDFWHULVWLFV RI +HDOWK 6WDWXV $PRQJ WKH VDPSOH RI VXEMHFWV bf VXEMHFWV YLVLWHG DW OHDVW RQH W\SH RI KHDOWK FDUH SURYLGHU LQ WKH SDVW PRQWKV DQG DYHUDJHG GLIIHUHQW W\SHV RI KHDOWK FDUH SURYLGHUV 6' UDQJH f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

PAGE 109

WR LQWHUUXSW GDLO\ DFWLYLWLHV DQG UHODWLYHO\ ZHOO FRQWUROOHG ZLWK PHGLFDWLRQV $OO RI WKH VXEMHFWV LQ WKLV VWXG\ ZHUH WDNLQJ DW OHDVW RQH SUHVFULEHG RU QRQSUHVFULEHG PHGLFLQH 7KH QXPEHU RI PHGLFDWLRQV UHSRUWHG E\ WKHVH VXEMHFWV D PHDQ RI SUHVFULEHG PHGLFLQHV QRQSUHVFULEHG PHGLFLQHV DQG FRPELQHG PHGLFLQHVf ZHUH ZLWKLQ WKH UDQJH UHSRUWHG LQ SUHYLRXV VWXGLHV 5HSRUWV RI SUHVFULSWLRQ GUXJ XVH E\ FRPPXQLW\ GZHOOLQJ HOGHUV KDYH UDQJHG IURP DYHUDJHV RI WR PHGLFDWLRQV ZKHUHDV ILJXUHV RQ QRQSUHVFULSWLRQ GUXJ XVDJH KDYH UDQJHG IURP WR 'DUQHOO 0XUUD\ 0DUW] t :HLQEHUJHU 3ROORZ 6WROOHU )RUVWHU t 'XQLKR 6KLPS $VFLRQH *OD]HU t $WZRRG f :KLOH YLWDPLQV DQG PLQHUDO SURGXFWV ZHUH FRQVLGHUHG DV QRQ SUHVFULEHG PHGLFLQHV LQ WKH SUHVHQW VWXG\ LW LV XQFOHDU LI WKHVH SURGXFWV ZHUH FRQVLGHUHG DV PHGLFDWLRQV LQ WKH SUHYLRXV VWXGLHV 7KH GDWD IURP WKH SUHVHQW VWXG\ VXJJHVW WKDW bf VXEMHFWV IURP D WRWDO RI VXEMHFWV SUDFWLFH D VHOIFDUH UHJLPHQ E\ XVLQJ PXOWLSOH YLWDPLQV DQG PLQHUDOV WR PDLQWDLQ WKHLU KHDOWK 8VH RI +HUEDO 3URGXFWV %DVHG RQ SULRU UHVHDUFK WKH XVH RI KHUEDO SURGXFWV UDQJHV IURP WKUHH SHUFHQW WR b 3DVW VWXGLHV KDYH YDULHG LQ JHRJUDSKLFDO DUHDV DV ZHOO DV DJH RI VXEMHFWV

PAGE 110

(LVHQEHUJ HW DO )UDWH HW DO :+2 f 7KH UHVXOWV RI WKLV VWXG\ LQ D 1RUWK &HQWUDO )ORULGD FRXQW\ LQGLFDWHG WKDW RI FRPPXQLW\GZHOOLQJ ZRPHQ \HDUV DQG RYHU DUH XVHUV RI KHUEDO SURGXFWV %RWK PHQ DQG ZRPHQ \HDUV DQG RYHU ZHUH VWXGLHG E\ (LVHQEHUJ DQG FROOHDJXHV f )UDWH DQG FROOHDJXHV f DQG :+2 f DQG WKH SUHYDOHQFH RI XVH RI KHUEDO SURGXFWV IURP WKHVH VDPSOHV ZHUH UHSRUWHG WR EH b b DQG b UHVSHFWLYHO\ $OWKRXJK LW LV GLIILFXOW WR FRPSDUH WKH UHVXOWV RI WKHVH VWXGLHV EHFDXVH RI WKH GLIIHUHQW FKDUDFWHULVWLFV RI WKH VDPSOHV GDWD IURP WKH SUHVHQW VWXG\ VXJJHVW WKDW WKH XVH RI KHUEDO SURGXFWV DPRQJ ROGHU ZRPHQ LV FRPPRQ DOPRVW RQH RI WZR ROGHU ZRPHQf 7KH SULPDU\ XVH RI KHUEDO SURGXFWV E\ WKLV VDPSOH ZDV IRU SUHYHQWLRQ DQG VHOIWUHDWPHQW 7KH XVH RI KHUEDO SURGXFWV IRU WKH SXUSRVH RI SUHYHQWLRQ RI KHDOWK SUREOHPV ZDV PRUH SUHYDOHQW WKDQ WKH XVH RI KHUE£LV IRU VHOIWUHDWPHQW DPRQJ ZRPHQ LQ WKLV VWXG\ 0RVW RI WKH KHUEDO SURGXFWV bf ZHUH WDNHQ RQ D FRQWLQXDO EDVLV UDWKHU WKDQ DV LQWHUPLWWHQW XVH 7KH XVH RI KHUEDO SURGXFWV LQ WKLV VWXG\ ZDV PRUH OLNHO\ WR EH D UHDG\PDGH IRUP IRU HDV\ XVDJH VXFK DV WDEOHWV DQG FDSOHWV UDWKHU WKDQ XVLQJ SDUWV RI WKH RULJLQDO SODQW DQG IXUWKHU SUHSDULQJ WKH KHUE IRU XVH 7KH SUDFWLFH RI WDNLQJ D WDEOHW RU FDSVXOH LV LQ V\QFKURQ\ ZLWK

PAGE 111

WKH FXUUHQW 86 VRFLHWDO DWWLWXGH RI D TXLFN IL[ 7KLV VDPSOH ZDV PRUH OLNHO\ WR GLJHVW WKH KHUE LQWHUQDOO\ UDWKHU WKDQ DSSO\LQJ WKH KHUE H[WHUQDOO\ 7KH PRVW FRPPRQO\ FRQVXPHG KHUEDO SURGXFWV LQ WKLV VWXG\ ZHUH *LQNJR %LORED RU *LQNJR FRPELQDWLRQV JDUOLF *OXFRVDPLQH ZLWK &KRQGURLWLQ DORH KHUEDO WHDV (FKLQDFHD DQG JLQJHU (OLDVRQ DQG FROOHDJXHV f LQGLFDWHG WKDW WKH PRVW FRPPRQO\ XVHG KHUEDO SURGXFWV LQ WKHLU VWXG\ ZHUH JDUOLF *LQVHQJ *LQNJR %LORED (YHQLQJ SULPURVH RLO (FKLQDFHD DQG $OIDOID )UDWH DQG FROOHDJXHV f UHSRUWHG WKDW OHPRQ DORH FDVWRU WXUSHQWLQH WREDFFR DQG JDUOLF ZHUH WKH PRVW IUHTXHQWO\ PHQWLRQHG SODQWGHULYHG PHGLFLQHV $FFRUGLQJ WR (UQVW f WKH SRSXODU KHUEDO SURGXFWV DUH (FKLQDFHD *DUOLF *ROGHQVHDO *LQVHQJ 6DZ SDOPHWWR DORH 0D KXDQJ DQG FUDQEHUU\ 7KH W\SHV RI FRPPRQO\ XVHG KHUEDO SURGXFWV LQ WKLV VWXG\ ZHUH FRQVLVWHQW ZLWK SUHYLRXV VWXGLHV (OLDVRQ HW DO (UQVW )UDWH HW DO f LGHQWLI\LQJ JDUOLF *LQNJR %LORED DORH DQG (FKLQDFHD DV FRPPRQO\ FRQVXPHG KHUEDO SURGXFWV 7KH JURXS RI KHUEDO SURGXFW XVHUV LQ WKH SUHVHQW VWXG\ LQGLFDWHG WKDW WKH\ LGHQWLILHG PRUH PHPRU\ SUREOHPV WKDQ WKH JURXS RI QRQXVHUV KRZHYHU WKH JURXS RI KHUEDO SURGXFW XVHUV GLG QRW FRQVLGHU WKDW PHPRU\ SUREOHPV DIIHFWHG WKHLU HYHU\GD\ OLYLQJ PRUH VHULRXVO\ WKDQ

PAGE 112

QRQXVHUV $V D UHVXOW *LQNJR %LORED ZDV WKH PRVW IUHTXHQWO\ XVHG KHUEDO SURGXFW E\ ROGHU ZRPHQ LQ WKLV VWXG\ *LQJNR %LORED ZDV XVHG WR PDLQWDLQ SUHVHQW PHPRU\ VWDWXV WR LPSURYH PHPRU\ RU WR SUHYHQW SRVVLEOH PHPRU\ SUREOHPV 7KH UHVXOWV RI WKLV VWXG\ LQGLFDWHG WKDW D YDULHW\ RI KHUEDO SURGXFWV ZDV XVHG IRU VHOIWUHDWPHQW DQG VHOIFDUH EDVHG RQ VHOIGLDJQRVLV E\ ROGHU ZRPHQ )URP WKH OLVW RI KHDOWK SUREOHPV VHH $SSHQGL[ $f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b RI KHUEDO SURGXFWV WKDW

PAGE 113

VXEMHFWV XVHG ZDV QRW NQRZQ ,Q VSLWH RI QRW UHFRJQL]LQJ DQ LPPHGLDWH EHQHILW RI XVLQJ KHUEDO SURGXFWV UHDVRQV IRU XVLQJ WKHVH KHUEDO SURGXFWV FRQWLQXDOO\ ZHUH WKDW WKH\ ZRXOG QRW EH KDUPIXO DQG WKH SURGXFWV ZRXOG EH EHQHILFLDO WR WKH SHUVRQ VRPHZD\ RU VRPHGD\ ,VVXHV 5HODWHG WR 8VH RI +HUEDO 3URGXFWV ,W ZDV DSSDUHQW WKDW PDQ\ ROGHU ZRPHQ KDYH XVHG KHUEDO SURGXFWV IRU WKHLU KHDOWK FDUH SUDFWLFH DORQJ ZLWK FRQYHQWLRQDO PHGLFLQHV EDVHG RQ WKHLU RZQ MXGJHPHQW DERXW KHDOWK DQG WKH KHUEDO SURGXFWV +RZHYHU WKLV VWXG\ LGHQWLILHG D IHZ SUREOHPV RI XVLQJ WKH KHUEDO SURGXFWV LQ VSLWH RI WKHLU SHUFHLYHG EHQHILW DV QDWXUDO SURGXFWV 7KH ILUVW LGHQWLILHG SUREOHP UHODWHG WR WKH LQJUHGLHQWV RI WKH KHUEDO SURGXFW :KHQ VXEMHFWV LQIRUPHG WKH LQYHVWLJDWRU RI WKH KHUEDO SURGXFW WKH\ XVHG WKHUH ZDV PRUH WKDQ RQH LQJUHGLHQW FRQWDLQHG LQ WKH SURGXFW 7KH LQJUHGLHQWV ZHUH ZULWWHQ RQ WKH ODEHO LQ YHU\ VPDOO OHWWHUV ZKLFK ROGHU DGXOWV ILQG GLIILFXOW WR UHDG 7KHUHIRUH VXEMHFWV GLG QRW NQRZ H[DFWO\ ZKDW LQJUHGLHQWV ZHUH EHLQJ FRQVXPHG 6HFRQGO\ WKH LQYHVWLJDWRU LGHQWLILHG WKDW VXEMHFWV ZHUH LQFRQVLVWHQW LQ WKH GRVH RI KHUE£LV WDNHQ VLQFH WKH GRVDJH YDULHG EHWZHHQ EUDQGV RI WKH VDPH KHUEDO SURGXFWV 7KLUGO\ DOWKRXJK LW ZDV FODLPHG WKDW VRPH KHUEDO SURGXFWV ZHUH VDIHU WKDQ FRQYHQWLRQDO PHGLFLQHV LQ FOLQLFDO WHVWV RI WKH

PAGE 114

VDIHW\ RI KHUEDO SURGXFWV (UQVW f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

PAGE 115

WKH LPSRUWDQFH RI NQRZOHGJH UHODWHG WR SRVVLEOH GUXJ LQWHUDFWLRQV DVVRFLDWHG ZLWK WKH XVH RI KHUEDO SURGXFWV ,PSOLFDWLRQ IRU 1XUVLQJ DQG 5HFRPPHQGDWLRQV 7KLV VWXG\ KDV LPSRUWDQW LPSOLFDWLRQV IRU QXUVLQJ SUDFWLFH :LWK WKH NQRZOHGJH WKDW DSSUR[LPDWHO\ b RI ZRPHQ RYHU \HDUV RI DJH XVH VRPH IRUP RI KHUEDO SURGXFW DQG WKH PDMRULW\ GR QRW GLVFXVV WKLV XVH RI KHUE£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

PAGE 116

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£LV 3HUVRQV ZKR XVH KHUE£LV DUH PRUH OLNHO\ WR FODLP PHPRU\ SUREOHPV WKDQ WKRVH ZKR GR QRW XVH KHUE£LV $O]KHLPHUn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

PAGE 117

KHUEDO SURGXFWV PRUH OLNHO\ WR KDYH PHPRU\ SUREOHPV WKDQ WKRVH ZKR GR QRW WDNH KHUE£LV $V ZLWK DQ\ LQWHUYHQWLRQ VWXGLHV QHHG WR EH GRQH WR YDOLGDWH WKH HIIHFWLYHQHVV RI WKH LQWHUYHQWLRQ ,W DSSHDUV WKDW LQ WKH SDVW KHDOWK FDUH SURIHVVLRQDOV KDYH EDVLFDOO\ LJQRUHG WKH XVH RI KHUEDO SURGXFWV E\ WKHLU FOLHQWV 0DUNHWLQJ WKURXJK UDGLR WHOHYLVLRQ DQG ZULWWHQ PHGLD KDV JUHDWO\ LPSDFWHG WKH XVH RI WKHVH SURGXFWV 7KH EHQHILWV YHUVXV ULVNV RI KHUEDO XVH DUH XQNQRZQ
PAGE 118

5()(5(1&(6 $FNHUNQHFKW ( + f 7KHUDSHXWLFV )URP WKH SULPLWLYHV WR WKH WK FHQWXU\ 1HZ
PAGE 119

&KULVFKLOOHV ( $ )ROH\ :DOODFH 5 % /HPNH + 6HPOD 7 3 +DQORQ 7 *O\QQ 5 2VWIHOG $ 0 t *XUDOQLN 0 f 8VH RI PHGLFDWLRQ E\ SHUVRQV DQG RYHU 'DWD IURP WKH (VWDEOLVKHG 3RSXODWLRQV IRU (SLGHPLRORJLF 6WXGLHV RI WKH (OGHUO\ -RXUQDO RI *HURQWRORJ\ 0HGLFDO 6FLHQFHV 0O0O &REEV ( / t 5DODSDWL $ 1 f +HDOWK RI ROGHU ZRPHQ 0HGLFDO &OLQLFV RI 1RUWK $PHULFD f &RO 1 )DQDOH ( t .URQKROP 3 f 7KH UROH RI PHGLFDWLRQ QRQFRPSOLDQFH DQG DGYHUVH GUXJ UHDFWLRQV LQ KRVSLWDOL]DWLRQV RI WKH HOGHUO\ $UFKLYHV RI ,QWHUQDO 0HGLFLQH &ROHPDQ / 0 )RZOHU / / t :LOOLDPV 0 ( f 8VH RI XQSURYHQ WKHUDSLHV E\ SHRSOH ZLWK $O]KHLPHUnV GLVHDVH -RXUQDO RI $PHULFDQ *HULDWULFV 6RFLHW\ &ROW + t 6KDSLUR $ 3 f 'UXJLQGXFHG LOOQHVV DV D FDXVH IRU DGPLVVLRQ WR D FRPPXQLW\ KRVSLWDO -RXUQDO RI $PHULFDQ *HULDWULFV 6RFLHW\ &UDPHU $ 0DWWVRQ 5 + 3UHYH\ 0 / 6FKH\HU 5 t 2XHOOHWWH 9 / f +RZ RIWHQ LV PHGLFDWLRQ WDNHQ DV SUHVFULEHG" $ QRYHO DVVHVVPHQW WHFKQLTXH -RXUQDO RI $PHULFDQ 0HGLFDO $VVRFLDWLRQ &XVDFN % f 3RO\SKDUPDF\ DQG FOLQLFDO SKDUPDFRORJ\ ,Q %HFN (Gf *HULDWULF UHYLHZ V\OODEXV $ FRUH FXUULFXOXP LQ JHULDWULF PHGLFLQH SS f 1HZ
PAGE 120

,OO 'H 6PHW 3$*0 f +HDOWK ULVNV RI KHUEDO UHPHGLHV 'UXJ 6DIHW\ 'LHWDU\ 6XSSOHPHQW +HDOWK DQG (GXFDWLRQ $FW RI f 3XEOLF /DZ G &RJUHVV )HGHUDO )RRG 'UXJ DQG &RVPHWLF $FW 67$7 67$7 'UHZ $ t 0\HUV 6 3 f 6DIHW\ LVVXHV LQ KHUEDO PHGLFLQH ,PSOLFDWLRQV IRU WKH KHDOWK SURIHVVLRQV 0HGLFDO -RXUQDO RI $XVWUDOLD (LVHQEHUJ 0 .HVVOHU 5 & )RUVWHU & 1RUORFN ) ( &DONLQV 5 t 'HOEDQFR 7 / f 8QFRQYHQWLRQDO PHGLFLQH LQ WKH 8QLWHG 6WDWHV 3UHYDOHQFH FRVWV DQG SDWWHUQV RI XVH 7KH 1HZ (QJODQG -RXUQDO RI 0HGLFLQH (OLDVRQ % & .UXJHU 0DUN t 5DVPDQQ 1 f 'LHWDU\ VXSSOHPHQW XVHUV 'HPRJUDSKLFV SURGXFW XVH DQG PHGLFDO V\VWHP LQWHUDFWLRQ -RXUQDO RI $PHULFDQ %RDUG RI )DPLO\ 3UDFWLFH (UQVW ( f +DUPOHVV KHUEV" $ UHYLHZ RI WKH UHFHQW OLWHUDWXUH 7KH $PHULFDQ -RXUQDO RI 0HGLFLQH )DUQVZRUWK 1 5 $NHUHOH %LQJHO $ 6 6RHMDUWD ' t (QR = f 0HGLFLQDO SODQWV LQ WKHUDS\ %XOOHWLQ RI :RUOG +HDOWK 2UJDQL]DWLRQ )LOOHQEDXP * +DQORQ 7 &RUGHU ( + =LTXED3DJH 7 :DOO : ( t %URFN f 3UHVFULSWLRQ DQG QRQSUHVFULSWLRQ GUXJ XVH DPRQJ EODFN DQG ZKLWH FRPPXQLW\UHVLGLQJ HOGHUO\ $PHULFDQ -RXUQDO RI 3XEOLF +HDOWK )LOOHQEDXP * +RUQHU 5 +DQORQ 7 /DQGHUPDQ / 5 'DZVRQ 9 t &RKHQ + f )DFWRUV SUHGLFWLQJ FKDQJH LQ SUHVFULSWLRQ DQG QRQSUHVFULSWLRQ GUXJ XVH LQ D FRPPXQLW\UHVLGLQJ EODFN DQG ZKLWH HOGHUO\ SRSXODWLRQ -RXUQDO RI &OLQLFDO (SLGHPLRORJ\

PAGE 121

)UDWH $ &URRP ( 0 )UDWH % -XHUJHQV 3 t 0H\GUHFK ( ) f 8VH RI SODQWGHULYHG WKHUDSLHV LQ D UXUDO ELUDFLDO SRSXODWLRQ LQ 0LVVLVVLSSL -RXUQDO RI WKH 0LVVLVVLSSL 6WDWH 0HGLFDO $VVRFLDWLRQ *RUPOH\ ( $ *ULIILWKV 0F&UDFNHQ 3 1 t +DUULVRQ 0 f 3RO\SKDUPDF\ DQG LWV HIIHFW RQ XULQDU\ LQFRQWLQHQFH LQ D JHULDWULF SRSXODWLRQ %ULWLVK -RXUQDO RI 8URORJ\ *UD\ 0 $ f +HUEV 0XOWLFXOWXUDO IRON PHGLFLQHV 2UWKRSDHGLF 1XUVLQJ f *UHHQEODWW 5 0 +ROODQGHU + 0F0DVWHU 5 t +HQNH & f 3RO\SKDUPDF\ DPRQJ SDWLHQWV DWWHQGLQJ DQ $,'6 FOLQLF 8WLOL]DWLRQ RI SUHVFULEHG XQRUWKRGR[ DQG LQYHVWLJDWLRQDO WUHDWPHQWV -RXUQDO RI $FTXLUHG ,PPXQH 'HILFLHQF\ 6\QGURPHV *U\PRQSUH 5 ( 0LWHQNR 3 $ 6LWDU 6 $RNL ) < t 0RQWJRPHU\ 3 5 f 'UXJDVVRFLDWHG KRVSLWDO DGPLVVLRQV LQ ROGHU PHGLFDO SDWLHQWV -RXUQDO $PHULFDQ *HULDWULFV 6RFLHW\ +HDOWK\ 3HRSOH f 1DWLRQDO KHDOWK SURPRWLRQ DQG GLVHDVH SUHYHQWLRQ REMHFWLYH S :DVKLQJWRQ '& 86 'HSDUWPHQW RI +HDOWK DQG +XPDQ 6HUYLFHV +HOOLQJ /HPNH + 6HPOD 7 3 :DOODFH 5 % /LSVRQ 3 t &RUQRQL+XQWOH\ f 0HGLFDWLRQ XVH FKDUDFWHULVWLFV LQ WKH HOGHUO\ 7KH ,RZD 5XUDO +HDOWK 6WXG\ -RXUQDO RI $PHULFDQ *HULDWULFV 6RFLHW\ +X[WDEOH 5 f 7KH KDUPIXO SRWHQWLDO RI KHUEDO DQG RWKHU SODQW SURGXFWV 'UXJ 6DIHW\ 6XSSO fB ,YHV 7 %HQW] ( t *Z\WKHU 5 ( f 'UXJUHODWHG DGPLVVLRQV WR D IDPLO\ PHGLFLQH LQSDWLHQW VHUYLFH $UFKLYHV RI ,QWHUQDO 0HGLFLQH -RQDV : % f (YDOXDWLQJ XQFRQYHQWLRQDO PHGLFDO SUDFWLFHV -RXUQDO RI 1,+ 5HVHDUFK

PAGE 122

.DUW & 6 f 7KH UHDOLWLHV RI DJLQJ $Q LQWURGXFWLRQ WR JHURQWRORJ\ WK HGf %RVWRQ $OO\Q DQG %DFRQ .DVVOHU : %ODQF 3 t *UHHQEODWW 5 f 7KH XVH RI PHGLFLQDO KHUEV E\ +XPDQ ,PPXQRGHILFLHQF\ 9LUXVLQIHFWHG SDWLHQWV $UFKLYHV RI ,QWHUQDO 0HGLFLQH .HOQHU 0 t :HOOPDQ % f +HDOWK FDUH DQG FRQVXPHU FKRLFH 0HGLFDO DQG DOWHUQDWLYH WKHUDSLHV 6RFLDO 6FLHQFH t 0HGLFLQH .URQHQIHOG t :DVQHU & f 7KH XVH RI XQRUWKRGR[ WKHUDSLHV DQG PDUJLQDO SUDFWLWLRQHUV 6RFLDO 6FLHQFH RI 0HGLFLQH /DP\ 3 3 f 7KH HOGHUO\ DQG GUXJ LQWHUDFWLRQV -RXUQDO RI $PHULFDQ *HULDWULFV 6RFLHW\ /DVVLOD + & 6WRHKU 3 *DQJXOL 0 6HDEHUJ ( & *LOE\ ( %HOOH 6 + t (FKHPHQW $ f 8VH RI SUHVFULSWLRQ PHGLFDWLRQV LQ WKH HOGHUO\ UXUDO SRSXODWLRQ 7KH 0R9,(6 3URMHFW 7KH $QQDOV RI 3KDUPDFRWKHUDS\ /HUQHU t .HQQHG\ % f 7KH SUHYDOHQFH RI TXHVWLRQDEOH PHWKRGV RI FDQFHU WUHDWPHQW LQ WKH 8QLWHG 6WDWHV &$ /H6DJH f 3RO\SKDUPDF\ LQ JHULDWULF SDWLHQWV 1XUVLQJ &OLQLFV RI 1RUWK $PHULFD /LQGOH\ & 0 7XOOH\ 0 3 3DUDPVRWK\ 9 t 7DOOLV 5 & f ,QDSSURSULDWH PHGLFDWLRQ XVH LV D PDMRU FDXVH RI DGYHUVH GUXJ UHDFWLRQV LQ HOGHUO\ SDWLHQWV $JH DQG $JHLQJ 0DF/HQQDQ $ + :LOVRQ + t 7D\ORU $ : f 3UHYDOHQFH DQG FRVW RI DOWHUQDWLYH PHGLFLQH LQ $XVWUDOLD /DQFHW 0DUZLFN & f *URZLQJ XVH RI PHGLFLQDO ERWDQLFDOV IRUFHV DVVHVVPHQW E\ GUXJ UHJXODWRUV -RXUQDO RI $PHULFDQ 0HGLFDO $VVRFLDWLRQ

PAGE 123

0D\ ) ( 6WHZDUW 5 % +DOH : ( t 0DUNV 5 f 3UHVFULEHG DQG QRQSUHVFULEHG GUXJ XVH LQ DQ DPEXODWRU\ HOGHUO\ SRSXODWLRQ 6RXWKHUQ 0HGLFDO -RXUQDO 0F&DOHE 5 6 f 5HJXODWLRQ RI GLHWDU\ VXSSHOPHQW +HDULQJ EHIRUH WKH 6XEFRPPLWWHH RQ +HDOWK DQG WKH (QYLURQPHQW RI WKH &RPPLWWHH RQ (QHUJ\ DQG &RPPHUFH +RXVH RI 5HSUHVHQWDWLYHV VHULHV QR f :DVKLQJWRQ '& UG 86 &RQJUHVV +RXVH RI 5HSUHVHQWDWLYHV 0F*UHJRU t 3HD\ ( 5 f 7KH FKRLFH RI DOWHUQDWLYH WKHUDS\ IRU KHDOWK FDUH 7HVWLQJ VRPH SURSRVLWLRQV 6RFLDO 6FLHQFH RI 0HGLFLQH 0LFKRFNL 5 /DP\ 3 3 +RRSHU ) t 5LFKDUGVRQ 3 f 'UXJ SUHVFULELQJ IRU WKH HOGHUO\ $UFKLYHV RI )DPLO\ 0HGLFLQH 0RQWDPDW 6 & t &XVDFN % f 2YHUFRPLQJ SUREOHPV ZLWK SRO\SKDUPDF\ DQG GUXJ PLVXVH LQ WKH HOGHUO\ &OLQLFV LQ *HULDWULF 0HGLFLQH 0RQWDPDW 6 & &XVDFN % t 9HVWDO 5 ( f 0DQDJHPHQW RI GUXJ WKHUDS\ LQ WKH HOGHUO\ 7KH 1HZ (QJODQG -RXUQDO RI 0HGLFLQH 0XUUD\ t 6KHSKHUG 6 f $OWHUQDWLYH RU DGGLWLRQDO PHGLFLQH" 6RFLDO 6FLHQFH RI 0HGLFLQH 0XUUD\ 0 7 f 1DWXUDO PHGLFLQH $ UDWLRQDO DOWHUQDWLYH ,Q 0 7 0XUUD\ (Gf 1DWXUDO DOWHUQDWLYHV WR RYHUWKHFRXQWHU DQG SUHVFULSWLRQ GUXJV S f 1HZ
PAGE 124

1RODQ / t 2n0DOOH\ f 3UHVFULELQJ IRU WKH HOGHUO\ 3DUW 6HQVLWLYLW\ RI WKH HOGHUO\ WR DGYHUVH GUXJ UHDFWLRQV -RXUQDO RI $PHULFDQ *HULDWULFV 6RFLHW\ 1R\HV 0 $ /XFDV 6 t 6WUDWWRQ 0 $ f 3ULQFLSOHV RI JHULDWULF SKDUPDFRWKHUDS\ -RXUQDO RI *HULDWULF 'UXJ 7KHUDS\ f 3DQHO RQ 'HILQLWLRQ DQG 'HVFULSWLRQ &$0 5HVHDUFK 0HWKRGRORJ\ &RQIHUHQFH $SULO f 'HILQLQJ DQG GHVFULELQJ FRPSOHPHQWDU\ DQG DOWHUQDWLYH PHGLFLQH $OWHUQDWLYH 7KHUDSLHV f 3DUDPRUH / & f 8VH RI DOWHUQDWLYH WKHUDSLHV (VWLPDWHV IURP WKH 5REHUW :RRG -RKQVRQ )RXQGDWLRQ 1DWLRQDO $FFHVV WR &DUH 6XUYH\ -RXUQDO RI 3DLQ DQG 6\PSWRP 0DQDJHPHQW 3HQQLQ[ % *XUDOQLN 0 6LPRQVLFN ( 0 .DVSHU )HUUXFFL / t )ULHG / 3 f (PRWLRQDO YLWDOLW\ DPRQJ GLVDEOHG ROGHU ZRPHQ 7KH ZRPHQnV KHDOWK DQG DJLQJ VWXG\ -RXUQDO RI $PHULFDQ *HULDWULFV 6RFLHW\ 3ROORZ 5 / 6WROOHU ( 3 )RUVWHU / ( t 'XQLKR 7 6 f 'UXJ FRPELQDWLRQV DQG SRWHQWLDO IRU ULVN RI DGYHUVH GUXJ UHDFWLRQ DPRQJ FRPPXQLW\n GZHOOLQJ HOGHUO\ 1XUVLQJ 5HVHDUFK 5DQHOOL 3 / t $YHUVD 6 / f 0HGLFDWLRQ UHODWHG VWUHVVRUV DPRQJ IDPLO\ FDUHJLYHUV $PHULFDQ -RXUQDO RI +RVSLWDO 3KDUPDF\ 6KLPS / $ $VFLRQH ) *OD]HU + 0 t $WZRRG % ) f 3RWHQWLDO PHGLFDWLRQUHODWHG SUREOHPV LQ QRQLQVWLWXWLRQDOL]HG HOGHUO\ 'UXJ ,QWHOOLJHQFH DQG &OLQLFDO 3KDUPDF\ 6KLPS / $ :HOOV 7 %ULQN & $ 'LRNQR $ & t *LOOLV / f 5HODWLRQVKLS EHWZHHQ GUXJ XVH DQG XULQDU\ LQFRQWLQHQFH LQ HOGHUO\ ZRPHQ 'UXJ ,QWHOOLJHQFH DQG &OLQLFDO 3KDUPDF\

PAGE 125

6LOOV 0 7DQQHU / $ t 0LOVWLHQ % f )RRG DQG 'UXJ $GPLQLVWUDWLRQ PRQLWRULQJ RI DGYHUVH GUXJ UHDFWLRQV $PHULFDQ -RXUQDO RI +RVSLWDO 3KDUPDF\ 6LPRQV / $ 7HWW 6 6LPRQV /DXFKODQ 5 0F&DOOXP )ULHGODQGHU < t 3RZHOO f 0XOWLSOH PHGLFDWLRQ XVH LQ WKH HOGHUO\ 8VH RI SUHVFULSWLRQ DQG QRQSUHVFULSWLRQ GUXJV LQ DQ $XVWUDOLDQ FRPPXQLW\ VHWWLQJ 7KH 0HGLFDO -RXUQDO RI $XVWUDOLD 6ORDQ 5 : f 3ULQFLSOH RI GUXJ WKHUDS\ LQ JHULDWULF SDWLHQWV $PHULFDQ )DPLO\ 3K\VLFLDQ 6WDONHU ) f (YLGHQFH DQG DOWHUQDWLYH PHGLFLQH 0W 6LQDL -RXUQDO RI 0HGLFLQH 6WHZDUW 5 % f 'UXJ XVH LQ WKH HOGHUO\ ,Q & 'HODIXHQWH t 5 % 6WHZDUW (GVf 7KHUDSHXWLFV LQ WKH HOGHUO\ QG HG SS f &LQFLQQDWL 2+ +DUYH\ :KLWQH\ %RRNV 6WHZDUW 5 % t &DUDQDVRV f 0HGLFDWLRQ FRPSOLDQFH LQ WKH HOGHUO\ 0HGLFDO &OLQLFV RI 1RUWK $PHULFD 6WHZDUW 5 % t &RRSHU : f 3RO\SKDUPDF\ LQ WKH DJHG 3UDFWLFDO VROXWLRQV 'UXJV t $JHLQJ 6WHZDUW 5 % 0RRUH 0 7 0D\ ) ( 0DUNV 5 t +DOH : ( f &KDQJLQJ SDWWHUQV RI WKHUDSHXWLF DJHQWV LQ WKH HOGHUO\ $ WHQ\HDU RYHUYLHZ $JH DQG $JHLQJ 6XWKHUODQG / 5 t 9HUKRHI 0 f :K\ GR SDWLHQWV VHHN D VHFRQG RSLQLRQ RU DOWHUQDWLYH PHGLFLQH" -RXUQDO RI &OLQLFDO *DVWURHQWHURORJ\ f 6ZRQJHU $ t %XUEDQN 3 0 f $Q RYHUYLHZ RI GUXJ XVH DQG PLVXVH DPRQJ WKH HOGHUO\ ,Q $ 6ZRQJHU t 3 0 %XUEDQN (GVf 'UXJ WKHUDS\ LQ WKH HOGHUO\ SS f %RVWRQ -RQHV DQG %DUWOHWW

PAGE 126

7D\ORU f +HUEDO PHGLFLQH DW D FURVV URDGV (QYLURQPHQWDO +HDOWK 3HUVSHFWLYHV 86 %XUHDX RI WKH &HQVXV f *HQHUDO SRSXODWLRQ VWDWLVWLFV (FRQRPLFV DQG 6WDWLVWLFV $GPLQLVWUDWLRQ :DVKLQJWRQ '& 86 *RYHUQPHQW 3ULQWLQJ 2IILFH 86 %XUHDX RI WKH &HQVXV f &XUUHQW SRSXODWLRQ UHSRUWV VSHFLDO VWXGLHV 6L[W\ILYH SOXV LQ WKH 8QLWHG 6WDWHV :DVKLQJWRQ '& 86 *RYHUQPHQW 3ULQWLQJ 2IILFH 86 'HSDUWPHQW DQG +HDOWK DQG +XPDQ 6HUYLFHV f 9LWDO DQG KHDOWK VWDWLVWLFV 3UHYDOHQFH RI VHOHFWHG FKURQLF FRQGLWLRQV 8QLWHG 6WDWHV 6HULHV 'DWD IURP WKH 1DWLRQDO +HDOWK 6XUYH\ 1R 86 'HSDUWPHQW RI +HDOWK DQG +XPDQ 6HUYLFH &HQWHUV IRU 'LVHDVH &RQWURO DQG 3UHYHQWLRQ 1DWLRQDO &HQWHU IRU +HDOWK 6WDWLVWLFV '++6 3XEOLFDWLRQ 1R 3+6f 9LQFHQW & t )XUQKDP $ f :K\ GR SDWLHQWV WXUQ WR FRPSOHPHQWDU\ PHGLFLQH" $Q HPSLULFDO VWXG\ %ULWLVK -RXUQDO RI &OLQLFDO 3V\FKRORJ\ :DOW] & ) 6WULFNODQG / t /HQ] ( 5 f 0HDVXUHPHQW LQ QXUVLQJ UHVHDUFK QG HGf 3KLODGHOSKLD )$ 'DYLV &RPSDQ\ :RUOG +HDOWK 2UJDQL]DWLRQ f 5HVHDUFK JXLGHOLQHV IRU HYDOXDWLQJ WKH VDIHW\ DQG HIILFDF\ RI KHUEDO PHGLFLQHV :RUOG +HDOWK 2UJDQL]DWLRQ 5HJLRQDO 2IILFH IRU WKH :HVWHUQ 3DFLILF 0DQLOD :RUOG +HDOWK 2UJDQL]DWLRQ :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH &KDQWLOO\ 9$f f $OWHUQDWLYH PHGLFLQH ([SDQGLQJ PHGLFDO KRUL]RQV $ UHSRUW WR WKH 1DWLRQDO ,QVWLWXWH RI +HDOWK RQ DOWHUQDWLYH PHGLFDO V\VWHPV DQG SUDFWLFHV LQ WKH 8QLWHG 6WDWHV :DVKLQJWRQ '& 86 *RYHUQPHQW 3ULQWLQJ 2IILFH 6XSHULQWHQGHQW RI 'RFXPHQWV
PAGE 127

$33(1',; $ 48(67,211$,5(

PAGE 128

48(67,211$,5( ,19(67,*$725 6$81-22 <221 &2//(*( 2) 1856,1* 81,9(56,7< 2) )/25,'$ '$7( ,1,7,$/ ,'

PAGE 129

3$57 $ +($/7+ ,1)250$7,21 ,' $ +RZ ZRXOG \RX UDWH \RXU RYHUDOO KHDOWK 3RRU ([FHOOHQW $ +RZ ZRXOG \RX UDWH \RXU SK\VLFDO KHDOWK 3RRU ([FHOOHQW $ +RZ ZRXOG \RX UDWH \RXU HPRWLRQDO KHDOWK 3RRU ([FHOOHQW $ +DYH \RX YLVLWHG D PHGLFDO GRFWRU RU RWKHU KHDOWK FDUH SURYLGHU LQ WKH SDVW PRQWKV 1R
PAGE 130

*R EDFN WR VHULRXVQHVV WR GHWHUPLQH WKH XVH RI PHGLFDWLRQV +DYH \RX WDNHQ DQ\ PHGLFLQHV LQFOXGLQJ SUHVFULSWLRQ DQG RYHUWKHFRXQWHU GUXJV" ,I \HV ZRXOG OLNH WR NQRZ ZKDW NLQGV RI PHGLFLQHV \RX KDYH EHHQ WDNLQJ WR VROYH WKLV KHDOWK SUREOHP 4XHVWLRQV $ WKURXJK $f 3UREOHPV 1R
PAGE 131

3UREOHP ,OOQHVVHV 6HULRXVQHVVr 8VH RI 1DPH RI 0HGLFDWLRQV 0HGLFDWLRQV 1R
PAGE 132

$ 1RZ ZRXOG OLNH WR DVN \RX DERXW XVH RI VRPH RWKHU NLQGV RI UHPHGLHV WR WDNH FDUH RI \RXU KHDOWK SDUWLFXODUO\ KHUEV +DYH \RX HYHU XVHG DQ\ W\SH RI KHUEV RU KHUEDO SURGXFWV LQ WKH ODVW PRQWKV" 1R
PAGE 133

,' 3$57 % ,1)520$7,21 $%287 +(5%$/ 352'8&76 $1' +(5%6 % 1RZ ZRXOG OLNH WR NQRZ ZKDW NLQGV RI KHUEV RU KHUEDO UHPHGLHV \RX KDYH XVHG LQ WKH ODVW PRQWKV &RXOG \RX OLVW WKRVH" B % )RU ZKDW UHDVRQ KDYH \RX WDNHQ KHUEV RU KHUEDO SURGXFWV LQ WKH ODVW PRQWKV" WR WUHDW LOOQHVV WR PDLQWDLQ RU SUHYHQW DQ\ SRVVLEOH KHDOWK SUREOHPV ERWK DQG 1RZ ZRXOG OLNH WR DVN \RX DERXW HDFK KHUEDO SURGXFW \RX PHQWLRQHG DERYH 3OHDVH XVH WKH 3DUW %O 4XHVWLRQQDLUH WR GRFXPHQW HDFK KHUEDO SURGXFW LQIRUPDWLRQf

PAGE 134

,' 3DUW %O &RQWLQXHG IURP 3DUW %f 1RZ ZRXOG OLNH WR DVN \RX DERXW HDFK KHUE \RX PHQWLRQHG DERYH 1DPH RI WKH KHUEDO SURGXFW KHUE % +RZ GR \RX XVH LW" LQWHUQDOO\ % 'LG \RX SUHSDUH LW DW VHOISUHSDUHG % :KDW LV WKH UHDVRQ WR FKRRVH IURP WR f" H[WHUQDOO\ KRPH WR XVH LW RU EX\ LW" SXUFKDVHG XVH WKLV KHUEDO SURGXFW KHUE $OOHUJLHV $Q[LHW\ $UWKULWLV %DFN SUREOHPV %ORRG DQG FLUFXODWRU\ SUREOHPV &DQFHU &KURQLF SDLQ &ROGV DQG IOX 'HSUHVVLRQ 'LDEHWHV 'LJHVWLYH SUREOHPV 'L]]LQHVV )DWLJXHORZ HQHUJ\f *\QHFRORJLFDO SUREOHPV +HDGDFKH +HDUW SUREOHPV +LJK EORRG SUHVVXUH /XQJ SUREOHPV 0HPRU\ SUREOHPV 2EHVLW\ 6NLQ SUREOHPV 8ULQDU\ SUREOHPV 2WKHUV PDLQWDLQ RU SUHYHQW WKH SRVVLEOH KHDOWK SUREOHPV % 'R \RX XVH WKLV KHUEDO SURGXFW KHUE FRQWLQXRXVO\ RU RQO\ ZKHQ \RX KDYH V\PSWRPV" FRQWLQXRXVO\ KRZ ORQJ PRQWK ZKHQ V\PSWRPV KDYH RFFXUUHG KRZ PDQ\ WLPHV D \HDU WLPHV % +RZ PXFK GR \RX WKLQN LW LV HIIHFWLYH IRU \RX" QRW DW DOO VRPHZKDW HIIHFWLYH YHU\ HIIHFWLYH GRQnW NQRZ

PAGE 135

% +DYH \RX H[SHULHQFHG DQ\ W\SH RI VLGH HIIHFW E\ XVLQJ WKLV KHUEDO SURGXFW KHUE" QR \HV VSHFLI\f % :KHUH GLG \RX JHW WKH LQIRUPDWLRQ DERXW WKLV KHUEDO SURGXFW KHUEPD\ FLUFOH PRUH WKDQ RQHf" IDPLO\ PHPEHUV IULHQGV DQG QHLJKERUV ERRNV RU PDJD]LQHV 79 UDGLR QHZVSDSHUV FRPSXWHU LQWHUQHW KHDOWK IRRG VWRUHV KHDOWK FDUH SURYLGHUV DOWHUQDWLYH FDUH SUDFWLWLRQHUV RWKHUV % +RZ GR \RX SD\ IRU LW" ,QVXUDQFH 6HOISD\ 2WKHUV %OOO +DYH \RX HYHU WDONHG WR \RXU GRFWRUV RU RWKHU KHDOWK FDUH SURYLGHUV DERXW WKH XVH RI WKLV KHUEKHUEDO SURGXFW" \HV :KRP GLG \RX WDON WR f QR

PAGE 136

,' 3$57 & '(02*5$3+,& ,1)250$7,21 &O '2% & $UH \RX PDUULHG ZLGRZHG GLYRUFHG VHSDUDWHG QHYHU PDUULHG & 'R \RX FRQVLGHU \RXUVHOI DV :KLWH %ODFN +LVSDQLFQRQZKLWH 2WKHU & :KDW LV WKH KLJKHVW JUDGH RU IRUPDO VFKRROLQJ \RX FRPSOHWHG +LJK VFKRRO +LJK VFKRRO &ROOHJH JUDGXDWH &ROOHJH JUDGXDWH !*UDGXDWH VFKRRO ,V \RXU DQQXDO LQFRPH :KDW LV \RXU UHOLJLRXV SUHIHUHQFH QRQH 3URWHVWDQW &DWKROLF -HZLVK 2WKHU & :KDW W\SH RI LQVXUDQFH GR \RX KDYH" QRQH 0HGLFDUH 0HGLFDLG 3ULYDWH LQVXUDQFH 2WKHU 7KLV LV WKH HQG RI WKH TXHVWLRQQDLUH 7KDQN \RX YHU\ PXFK IRU \RXU SDUWLFLSDWLRQ

PAGE 137

$33(1',; % &216(17 )250

PAGE 138

0% ,%,, ,QIRUPHG &RQVHQW WR 3DUWLFLSDWH LQ 5HVHDUFK 7KH 8QLYHUVLW\ RI )ORULGD +HDOWK 6FLHQFH &HQWHU *DLQHVYLOOH )ORULGD
PAGE 139

3URFHGXUHV IRU 7KLV 5HVHDUFK
PAGE 140

&RPSHQVDWLRQ IRU 5HVHDUFK 5HODWHG ,QMXU\ ,1,$ ,Q WKH XQOLNHO\ HYHQW RI \RX VXVWDLQLQJ D SK\VLFDO RU SV\FKRORJLFDO LQMXU\ ZKLFK LV SUR[LPDWHO\ FDXVHG E\ WKLV VWXG\ SURIHVVLRQDO PHGLFDO RU SURIHVVLRQDO GHQWDO RU SURIHVVLRQDO FRQVXOWDWLYH FDUH UHFHLYHG DW WKH 8QLYHUVLW\ RI )ORULGD +HDOWK 6FLHQFH &HQWHU ZLOO EH SURYLGHG ZLWKRXW FKDUJH +RZHYHU KRVSLWDO H[SHQVHV ZLOO KDYH WR EH SDLG E\ \RX RU \RXU LQVXUDQFH SURYLGHU
PAGE 141

$VVHQW 3URFHGXUH LI DSSOLFDEOHf >$VVHQW LV WKH SURFHGXUH XVHG WR REWDLQ DJUHHPHQW WR SDUWLFLSDWH LQ WKH UHVHDUFK IURP D VXEMHFW VXFK DV D FKLOG ZKR FDQQRW JLYH OHJDO FRQVHQW@ 6LJQDWXUHV 6XEMHFWnV 1DPH 7KH 3ULQFLSDO RU &R3ULQFLSDO ,QYHVWLJDWRU RU UHSUHVHQWDWLYH KDV H[SODLQHG WKH QDWXUH DQG SXUSRVH RI WKH DERYHGHVFULEHG SURFHGXUH DQG WKH EHQHILWV DQG ULVNV WKDW DUH LQYROYHG LQ WKLV UHVHDUFK SURWRFRO 6LJQDWXUH RI 3ULQFLSDO RU &R3ULQFLSDO 'DWH ,QYHVWLJDWRU RU UHSUHVHQWDWLYH REWDLQLQJ FRQVHQW
PAGE 142

$33(1',; & 7+( 0267 3238/$5 $6,$1 3$7(17 0(',&,1(6 7+$7 &217$,1 72;,& ,1*5(',(176

PAGE 143

7KH 0RVW 3RSXODU $VLDQ 3DWHQW 0HGLFLQHV 7KDW &RQWDLQ 7R[LF ,QJUHGLHQWV 3URGXFW 1DPH 0DQXIDFWXUHU 7R[LF ,QJUHGLHQWV $QVHQSXQDZ 7DEOHWV &KXQJ /LHQ 'UXJ :RUNV +DQNRZ &KLQD FLQQDEDU PHUFXU\ FKORULGHf 3URGXFW 1DPH 0DQXIDFWXUHU %H]RDU 6HGDWLYH 3LOOV /DQ]KRX )R &L 3KDUPDFHXWLFDO )DFWRU\ /DQ]KRX &KLQD 7R[LF ,QJUHGLHQWV FLQQDEDU b RU b 3URGXFW 1DPH 0DQXIDFWXUHU &RPSRXQG .DQJZHLOLQJ :R =KRX 3KDUPDFHXWLFDO )DFWRU\ =KH -LDQJ &KLQD 7R[LF ,QJUHGLHQWV FHQWLSHGH VFRORSHQGUDf b 3URGXFW 1DPH 0DQXIDFWXUHU 7R[LF ,QJUHGLHQWV 'DKXR /XRGDQ %HLMLQJ 7XQJ -HQ 7DQJ %HLMLQJ &KLQD FHQWLSHGH VFRORSHQGUDf 3URGXFW 1DPH 0DQXIDFWXUHU 'DQVKHQ 7DEOHWHR 6KDQJKDL &KLQHVH 0HGLFLQH :RUNV 6KDQJKDL &KLQD 7R[LF ,QJUHGLHQWV EDURQLDO 3URGXFW 1DPH 0DQXIDFWXUHU )UXFWXV 3UVLFD &RPSRXQG 3LOOV /DQ]KRX )R &L 3KDUPDFHXWLFDO )DFWRU\ /DQ]KRX &KLQD 7R[LF ,QJUHGLHQWV FDQQDELV LQGLFD VHHG f 3URGXFW 1DPH 0DQXIDFWXUHU )XFKLQJVXQJ1 &UHDP 7LDQMLQ 3KDUPDFHXWLFDOV &RUS 7LDQMLQ &KLQD 7R[LF ,QJUHGLHQWV IOXRFLQRORQH DVWRXQG f 3URGXFW 1DPH 0DQXIDFWXUHU .ZHL /LQJ &KLQD &KDQJFKXQ &KLQHVH 0HGLFLQHV t 'UXJV 0DQXIDFWRU\ &KDQJ &KXQ &KLQD 7R[LF ,QJUHGLHQWV FLQQDEDU

PAGE 144

3URGXFW 1DPH 0DQXIDFWXUHU .\XVKLQ +HDUW 7RQLF .\XVKLQ 6HL\DNX &R /WG 7RN\R -DSDQ 7R[LF ,QJUHGLHQWV WRDG YHQRP EDURQLDO 3URGXFW 1DPH 0DQXIDFWXUHU /DU\QJLWLV 3LOOV &KLQD ']HFKXDQ 3URYLQFLDO 7R[LF ,QJUHGLHQWV 3KDUPDFHXWLFDO )DFWRU\ &KHQJWX %UDQFK ERUD[ b WRDGFDNH b 3URGXFW 1DPH 0DQXIDFWXUHU /HXQJ 3XL .HH 3LOOV /HXQJ 3XL .HH 0HGLFDO )DFWRU\ 7R[LF ,QJUHGLHQWV +RQJ .RQJ GRYHUnV SRZGHU RSLXP SRZGHUf f 3URGXFW 1DPH 0DQXIDFWXUHU /X6KHQ:DQ 6KDQJKDL &KLQHVH 0HGLFLQH :RUNV 6KDQJKDL &KLQD 7R[LF ,QJUHGLHQWV WRDG VHFUHWLRQ 3URGXFW 1DPH 0DQXIDFWXUHU 1DVDOLQ .ZDQJFKRZ 3KDUPDFHXWLFDO ,QGXVWU\ &R .ZDQJFKRZ &KLQD 7R[LF ,QJUHGLHQWV FHQWLSHGH b 3URGXFW 1DPH 0DQXIDFWXUHU 7R[LF ,QJUHGLHQWV 1XL +XDQJ &KLHK 7X 3LHQ 7XQJ -HQ 7DQJ %HLMLQJ &KLQD ERUQHR FDPSKRU 3URGXFW 1DPH 1LX +XDQJ ;LDR
PAGE 145

3URGXFW 1DPH 0DQXIDFWXUHU 7R[LF ,QJUHGLHQWV :DWVRQnV )ORZHU 3DJRGD &DNHV $6 :DWVRQ t &R /WG +RQJ .RQJ SLSHUD]LQH SKRVSKDWH Bf 3URGXFW 1DPH 0DQXIDFWXUHU 7R[LF ,QJUHGLHQWV ;LDR +XR /XR 'DQ /DQ]KRX )R &L 3KDUPDFHXWLFDO )DFWRU\ /DQ]KRX &KLQD DFRQLWH b 6RXUFH 2ULHQWDO +HUE $VVRFLDWLRQ 6WDWH RI &DOLIRUQLD 'HSDUWPHQW RI +HDOWK 6HUYLFHV -DQXDU\ B UHTXLUHV GRFWRUnV SUHVFULSWLRQ $GDSWHG IURP :RUNVKRS RQ $OWHUQDWLYH 0HGLFLQH f

PAGE 146

%,2*5$3+,&$/ 6.(7&+ 6DXQ-RR /HH
PAGE 147

, FHUWLI\ WKDW KDYH UHDG WKLV VWXG\ DQG WKDW LQ P\ RSLQLRQ LW FRQIRUPV WR DFFHSWDEOH VWDQGDUGV RI VFKRODUO\ SUHVHQWDWLRQ DQG LV IXOO\ DGHTXDWH LQ VFRSH DQG TXDOLW\ DV D GLVVHUWDWLRQ IRU WKH GHJUHH RI 'RFWRU RI 3KLORVRSK\ &OD\GHOO +RUQH &KDLU $VVRFLDWH 3URIHVVRU RI 1XUVLQJ FHUWLI\ WKDW KDYH UHDG WKLV VWXG\ DQG WKDW LQ P\ RSLQLRQ LW FRQIRUPV WR DFFHSWDEOH VWDQGDUGV RI VFKRODUO\ SUHVHQWDWLRQ DQG LV IXOO\ DGHTXDWH LQ VFRSH DQG TXDOLW\ DV D GLVVHUWDWLRQ IRU WKH GHJUHH RI 'RFWRU RI 3KLORVRSK\ LnLEMKE. .DWKOHHQ /RQJ n 3URIHVVRU RI 1XUVLQJ FHUWLI\ WKDW KDYH UHDG WKLV VWXG\ DQG WKDW LQ P\ RSLQLRQ LW FRQIRUPV WR DFFHSWDEOH VWDQGDUGV RI VFKRODUO\ SUHVHQWDWLRQ DQG LV IXOO\ DGHTXDWH LQ VFRSH DQG TXDOLW\ DV D GLVVHUWDWLRQ IRU WKH GHJUHH RI ARAWRU 3KLORVRSK\ +RVVHLQ n$DUDQGL $VVRFLDWH 3URIHVVRU RI 1XUVLQJ FHUWLI\ WKDW KDYH UHDG WKLV VWXG\ DQG WKDW LQ P\ RSLQLRQ LW FRQIRUPV WR DFFHSWDEOH VWDQGDUGV RI VFKRODUO\ SUHVHQWDWLRQ DQG LV IXOO\ DGHTXDWH LQ VFRSH DQG TXDOLW\ DV D GLVVHUWDWLRQ IRU WKH GHJUHH RI 'RFWRU RI 3KLORVRSK\ 5RELQ :HVW $VVRFLDWH 3URIHVVRU RI 3V\FKRORJ\ FHUWLI\ WKDW KDYH UHDG WKLV VWXG\ DQG WKDW LQ P\ RSLQLRQ LW FRQIRUPV WR DFFHSWDEOH VWDQGDUGV RI VFKRODUO\ SUHVHQWDWLRQ DQG LV IXOO\ DGHTXDWH LQ VFRSH DQG TXDOLW\ DV D GLVVHUWDWLRQ IRU WKH GHJUHH RI 'RFWRU RI 3KLORVRSK\ LIXHQL n3URIHVVRU RI 3KDUPDF\

PAGE 148

7KLV GLVVHUWDWLRQ ZDV VXEPLWWHG WR WKH *UDGXDWH )DFXOW\ RI WKH &ROOHJH RI 1XUVLQJ DQG WR WKH *UDGXDWH 6FKRRO DQG ZDV DFFHSWHG DV SDUWLDO IXOILOOPHQW RI WKH UHTXLUHPHQWV IRU WKH GHJUHH RI 'RFWRU RI 3KLORVRSK\ 0D\ 'HDQ *UDGXDWH 6FKRRO


xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID E59YLSRVF_6ML6O7 INGEST_TIME 2014-09-22T18:09:45Z PACKAGE AA00025274_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES


USE OF HERBAL PRODUCTS, PRESCRIBED MEDICINES AND
NON-PRESCRIBED MEDICINES BY COMMUNITY-DWELLING
OLDER WOMEN
By
SAUN-JOO LEE YOON
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1999

Copyright 1999
By
Saun-Joo Lee Yoon

To my husband, Sung-Hwa,
and daughters, Alyssa and Hyunji
for
their love, patience, and encouragement

ACKNOWLEDGEMENTS
I wish to thank the members of my supervisory committee
for their encouragement and support from the inception of
this research study to its completion. I am especially
grateful to Dr. Claydell Horne, chairperson of my
committee, for her counseling, support and patience
throughout my doctoral program.
I extend my sincere appreciation to Dr. Kathleen Long
for her support and encouragement to conduct this research.
I am grateful to Dr. Hossein Yarandi for his expertise with
the data analyses, and to Dr. Robin West for her
encouragement and support throughout the doctoral program.
I am especially appreciative of Mr. Jeffery Delafuente for
his insight and guidance throughout this endeavor.
I wish to thank my parents and parents-in-law for their
support and love from Korea. My infinite thanks go to my
husband, Sung-Hwa, and daughters, Alyssa and Hyunji, for
their love, patience, support, and confidence. Finally, I
am very appreciative of the grant from Alpha Theta Chapter,
Sigma Theta Tau International Honor Society and of support
from the College of Nursing for providing transportation
during data collection.
iv

TABLE OF CONTENTS
page
ACKNOWLEDGEMENTS iv
LIST OF TABLES vii
ABSTRACT viii
CHAPTER I: INTRODUCTION 1
Introduction 1
Problem Statement 6
Research Aims 9
Research Hypotheses 10
Research Questions 10
Operational Definition of Terms .... 11
Assumptions 12
Limitation 13
Summary 13
CHAPTER II: REVIEW OF LITERATURE 16
Differences between Alternative
Medicine and Conventional Medicine 16
History of Herbal Products and
Their Use 21
Prevalence of Alternative Medicine
and Herbal Products 2 6
Choice Between Alternative and Conventional
Medicines 29
Older Women and Health Problems 32
Patterns of Drug Use Among Older
Adults 37
Polypharmacy 40
Toxicities of Herbal Products and
Possible Interactions with Drugs of
Conventional Medicine 45
v

CHAPTER III: METHODOLOGY 50
Research Design 50
Setting 50
Sample 51
Inclusion and Exclusion Criteria .... 52
Instrument 53
Operationalization of Variables 54
Procedure 60
Data Collection 62
Data Analysis 67
CHAPTER IV: RESULTS 68
Research Design 68
Sample 68
Demographic Characteristics of the
Sample 71
Research Hypotheses 75
Description of the Research
Questions 88
Other Findings 93
CHAPTER V: DISCUSSION AND RECOMMENDATIONS 95
Discussion and Conclusions 95
Implication for Nursing and
Recommendations 106
REFERENCES 109
APPENDIX A: QUESTIONNAIRE 118
APPENDIX B: CONSENT FORM 12 8
APPENDIX C: THE 20 MOST POPULAR ASIAN PATENT MEDICINES
THAT CONTAIN TOXIC INGREDIENTS 133
BIOGRAPHICAL SKETCH 137
vi

LIST OF TABLES
TABLE page
4.1 Frequency Distribution of Total Sample 70
4.2 Age of Herbal Users, Non-Users, and Total
Sample 71
4.3 Demographic Characteristics of the Total Sample,
Herbal Product Users, and Non-Users 74
4.4 Perceived Overall Health by Herbal Users,
Non-Users, and Total Sample 78
4.5 Perceived Physical Health by Herbal Users
Non-Users, and Total Sample 79
4.6 Perceived Emotional Health by Herbal Users
Non-Users, and Total Sample 80
4.7 Types of Health-Related Problems 82
4.8 Frequently Used Non-Prescribed Medicines
Taken Regularly 86
4.9 Use of Prescribed, Non-Prescribed
Medicines by Sample 87
4.10 Types of Herbal Products Used by Subjects .... 89
4.11 Purposes of Using Herbal Products by Subjects
and by Number of Herbal Products 90
5.1 Frequencies and Percentages of Females
and Males Aged 65 and Over in a North
Central Florida County 96
5.2 Summary of Races among Females Aged 65
and Over 97
vii

Abstract of Dissertation Presented to the Graduate School
Of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
USE OF HERBAL PRODUCTS, PRESCRIBED MEDICINES AND
NON-PRESCRIBED MEDICINES BY COMMUNITY-DWELLING
OLDER WOMEN
By
Saun-Joo Lee Yoon
May, 1999
Chairperson: Claydell Horne, PhD
Major Department: Nursing
As alternative health care is becoming more prevalent
among persons in the United States, the use of herbal
products is on the increase. Although herbal products are
considered to be natural, these products have not been
subjected to scientific clinical studies and, therefore,
have not been FDA approved. The number of women aged 65
years and older in the US using herbal products is unknown.
The purpose of this research is to explore the use of
herbal products for medicinal purposes and to compare
differences in demographic characteristics and health
status between the herbal product users and non-users among
community-dwelling older women. Sampling criteria were
viii

women 65 years and over and living independently in a North
Central Florida county. A random sample was selected from a
list of 8,344 women 65 years and over obtained from the State
Department of Highway Safety and Motor Vehicles. Structured
interviews were completed on 86 subjects.
The interview questionnaire was comprised of three parts
including health status and use of conventional medicines,
use of herbal products, and demographic data. Data indicated
that herbal products were used by 45.3% of the sample in the
past 12 months. The total sample reported using a mean of 3.2
prescribed medicines and 3.8 non-prescribed medicines per
person. The mean number of herbal products used by the sample
was 2.5. The sample reported using a total of 98 herbal
products. Subjects reported only 28% of the total number of
herbal products used to their health care providers. No
differences in demographic characteristics and health status
were found between users and non-users of herbal products
except in the area of memory problems. More herbal product
users claimed memory problems than non-herbal users. It is
important for health care providers to be knowledgeable of
the use of herbal products in order to provide comprehensive
health care to older women and to prevent unintended
herbal-drug interactions.
IX

CHAPTER I
INTRODUCTION
Persons who are 65 and older comprise the fastest
growing age group in the United States. Among 249 million
people in the United States, 34 million are aged 65 and
older (U.S. Bureau of Census, 1990). In the 65 years and
older population, women outnumber men and this gap widens
with increasing age (Cobbs & Ralapati, 1998). Older women
in this age group have a higher disability rate and are
more likely than men to live longer with chronic conditions
(Kart, 1994).
Although persons 65 and older represent about 14% of
the American population, they consume three times more
prescription drugs than their younger counterparts
(Gormley, Griffiths, McCracken, & Harrison, 1993). Four out
of five people aged 65 and older have at least one chronic
disease (Delafuente, 1991), and persons in this age group
have almost twice the risk of iatrogenic disease and visit
the clinics more often than do younger people (Lamy, 1986).
Researchers show that community-dwelling elderly use an
average of 4.4 drugs including prescription and
1

2
non-prescription drugs, and about 85% of these persons take
two or more drugs (Pollow, Stoller, Foster, & Duniho,
1994).
Many elderly people are dependent on conventional drug
therapy to treat their chronic conditions and to maintain
their health. The goals of drug therapy in the elderly are
to (a) alleviate pain, (b) improve functional capacity, (c)
promote quality of life, and (d) prolong life (Sloan,
1992). Multiple drug use in the elderly, even when each
drug has a therapeutic purpose, can increase the risk of
significant drug-related problems such as adverse drug
reactions or drug-drug interactions (Noyes, Lucas, &
Stratton, 1996; Sloan, 1992). While the use of multiple
prescription and non-prescribed drugs among the elderly has
been studied extensively (Chrischilles et al., 1992;
Fillenbaum, Horner, Hanlon, Landerman, Dawson, & Cohen,
1996; Helling, Lemke, Selma, Wallace, Lipson, & Cornori-
Huntley, 1987; Stewart, Moore, May, Marks, & Hale, 1991),
little is known about the use of herbal products by this
age group and how herbáis react when taken with prescribed
and/or non-prescribed medicines.
Recently, herbal products have increasingly received
attention in the United States as complementary and

3
alternative medicine. Many researchers have used different
terms to explain complementary and alternative medicine
(CAM) such as unconventional, alternative or complementary,
unproven, and unorthodox therapies. Eisenberg, Kessler,
Forster, Norlock, Calkins, and Delbanco (1993) defined CAM
as medical interventions not taught widely at U.S. medical
schools or those not generally available at U.S. hospitals
(i.e. acupuncture, chiropractic, and herbal medicine). The
definition of CAM was further refined in the CAM Research
Methodology Conference in 1995 as a broad domain of healing
resources that comprises all health systems, modalities,
and practice other than a dominant health system of a
particular society in a given historical period (Panel on
Definition and Description, CAM Research Methodology
Conference, April 1995, 1997) .
Recently, attention to CAM has been given by
governmental health agencies. Examples include the
establishment of the Office of Alternative Medicine (OAM)
in National Institutes of Health (NIH) in 1992, and the
passage of new regulation of herbal products as dietary
supplements in the Dietary Supplement Health and Education
Act (DSHEA) in 1994 (Taylor, 1996). Even before the passage
of new regulations on herbal products in 1994, sales of

4
herbal products in the United States in 1991 were estimated
at over one billion dollars (McCaleb, 1993). Although it
may not necessarily reflect the actual use of CAM including
herbal medicines, changes in the regulation of herbal
products and more research focused on CAM certainly bring
higher public interest than ever before.
In the United States, one in three study participants
reported using at least one unconventional therapy in the
past year (Eisenberg et al., 1993). In the same study,
three percent of Americans surveyed used herbal medicines
during the past twelve months while approximately 80% of
the worldwide population were estimated to depend on
traditional herbal medicines (World Health Organization,
1993). According to Eisenberg and colleagues (1993), the
majority of people used unconventional therapies for
chronic medical conditions, but not for life-threatening
situations. Eisenberg and colleagues (1993) inferred that a
substantial number of unconventional therapies were used
for nonserious medical conditions, health promotion, or
disease prevention.
Because of the variability of complementary and
alternative medicines, natural health food stores selling
herbal products are expanding businesses in the United

5
States. The botanical industry has grown from almost
nothing to a $1.5 billion industry in 20 years and is
expanding at a rate of 15% a year (Marwick, 1995). Herbal
products are becoming more familiar to the public because
these products are considered to be natural and safe to use
without adverse effects and are easy to obtain in the
natural health food stores.
Today, people have access to a wide availability of
herbal products and many of these products have been
imported from foreign countries without strict safety
regulations. Herbal products can be toxic and can sometimes
be mixed with toxic ingredients with or without knowledge
of the user. People can suffer adverse effects because of
misinformation about products, possible interactions with
conventional drugs, and substance overdose. Because the
elderly are a group of people using herbal products for
their health care, they are most at risk of suffering
adverse effects by using these herbal products alone or
combined with conventional drugs.
Because of the increased attention and consumption of
herbal products, there must be more research to study the
patterns of herbal use alone or with prescribed and/or non-
prescribed medicine. More needs to be known about the

6
prevalence and the reasons for taking herbal products among
the elderly as well as possible interactions between drugs
of conventional medicine and herbal products.
Problem Statement
It is known that there are altered pharmacological
mechanisms and decreased functional capacity of the major
organ systems with aging (Montamat, Cusack, & Vestal,
1989). However, people who are aged 65 and older consume
three times more prescription drugs than those under 65
(Gormley, Griffiths, McCracken, & Harrison, 1993). In
addition to prescribed medications, the older adults are,
also, frequent users of nonprescription drugs (Pollow,
Stoller, Foster, & Duniho, 1994). The overall incidence of
adverse drug reactions or interactions in the elderly is
two to three times higher than the occurrence in their
younger counterparts (Nolan, & O'Malley, 1988). These
figures, however, do not include reaction or interaction
with the use of herbal products.
Most older persons have at least one chronic condition
and many have multiple conditions. According to the
Administration on Aging, the most frequently occurring
conditions per 100 elderly in 1994 included arthritis (50),
hypertension (36), heart disease (32), hearing impairments

7
(29), cataracts (17), orthopedic impairments (16),
sinusitis (15), and diabetes (10). Women who are aged 65
and older have the highest rate of chronic conditions such
as arthritis (U.S. Department of Health and Human Services,
1997).
Eisenberg and colleagues (1993) pointed out that the
use of unconventional therapies was not limited to the
person's principal medical condition as adjuncts to
conventional therapy, but extended to nonserious medical
conditions, health promotion, or disease prevention. A full
one-third of their study respondents who used
unconventional therapies did not use these therapies for
any of their principal medical problems (Eisenberg et al.,
1993).
According to the earlier study by Eisenberg and
colleagues (1993), prevalence rate of persons 18 years and
older who use herbal products in the United States is three
percent. However, since the Dietary Supplement Health and
Education Act in 1994, the use of herbal products has
increased; and since that time, researchers have found an
increasing prevalence of herbal product use among persons
in the United States. The World Health Organization
estimated that traditional herbal medicines were the most

frequently used types of therapies for the majority of
people in the world.
There were controversial results relating to the
prevalence of reported use of herbal medicines among age
groups in studies conducted in the United States (Eisenberg
et al., 1993; Frate, Croom, Frate, Juergens, & Meydrech,
1996). Frate and colleagues (1996) stated that over 70
percent of the adults in their sample used at least one
plant-derived medicine during the past year, while three
percent of the study population used herbal therapies in
the study by Eisenberg and colleagues (1993). Differences
in study results may occur because of research methodology,
definitions of herbal medicine and plant-derived therapies,
and settings of data collection.
The use of herbal products has been studied in certain
types of illnesses. Researchers showed the use of herbal
products among AIDS patients (Greenblatt, Hollander,
McMaster, & Henke, 1991; Kassler, Blanc, & Greenblatt,
1991), Alzheimer's patients (Coleman, Fowler, & Williams,
1995), rheumatoid arthritis patients (Boisset &
Fitzcharles, 1994), and cancer patients (Cassileth &
Chapman, 1996).
While researchers reported the use of herbal products
among disease specific groups of people, very little is

9
known about the prevalence of use of herbal products among
the elderly residing the community. Also, little
information is available related to the potential adverse
effects of herbal products and possible interactions
between conventional drugs and herbal products in the
elderly.
Research Aims
The purpose of this research is to study the use of
herbs and/or herbal products for medicinal use as well as
the possible interactions between herbáis with prescribed
and/or non-prescribed medicines among community-dwelling
older women.
Specific Aims
1. To identify the prevalence of use of herbal products
and/or herbs among community-dwelling women 65 years
and older.
2. To identify the purpose for which women 65 and older
take herbal products and/or herbs and to determine
for which physical symptoms or health conditions
women most likely take herbal products.
3. To describe the frequency of use of herbal products
and/or herbs and whether herbal products and/or
herbs are used alone or in combination with
prescribed and/or non-prescribed medicines.

10
4. To identify the sources of information related to
herbal products and/or herbs used by women 65 years
and older.
Research Hypotheses
1. There are differences in demographic characteristics
between herbal users and non-herbal users among
women aged 65 and older.
2. There are differences in health status between
herbal users and non-herbal users among women aged
65 and older.
Research Questions
1. What is the prevalence of women aged 65 years and
over who use herbal products and/or herbs?
2. What is the purpose for taking herbal products
and/or herbs by women aged 65 years and over? Do
older women take herbal products more for
prevention or for treatment of symptoms?
3. What is the frequency of use of herbal products by
older women? Do women who use herbal products use
them continuously over time or on an as needed
basis? Do women who use herbal products use them
alone or in combination with prescribed and/or non-
prescribed medicines?

11
4.What sources do women 65 and over use to obtain
information about the use of herbal products?
Operational Definition of Terms
For the purpose of this research, terms are
operationalized as follows:
1. Complementary and Alternative Medicine (CAM) is defined
as a broad domain of healing resources that comprises all
health systems, modalities, and practice other than a
dominant health system in the United States. CAM is used
interchangeably with alternative medicine,
unconventional, complementary, or unorthodox therapies.
2. Older woman is defined as a woman 65 years and older.
3. Drugs of conventional medicine include the prescribed
and non-prescribed medicines. Non-prescribed medicines
include vitamins and minerals. Drugs of conventional
medicine can be used interchangeably with conventional
drugs.
5. Herb is defined as a plant or plant part valued for its
medicinal qualities.
6. Herbal product is defined as a product that (a) is
excluded from definition of 'drug' by FDA; and (b) is
not labeled as a vitamin, a mineral, or food additive;
and (c) contains active ingredients aerial or
underground parts of plants, other plant material in a

12
crude state or plant preparation, or combinations
preparations; or (d) contains natural organic or
inorganic active ingredients, which are not of plant
origin by tradition, a concentrate metabolite,
constituent, or extract. Herbal products include
herbs hereafter.
7. Conventional medicine is defined as a dominant health
system in the United States which is widely taught
at U.S. medical schools or which is generally available
at the U.S. hospitals.
8. Polypharmacy is defined as the use of four or more
drugs, including both prescribed and non-prescribed
drugs, by a single person.
Assumptions
1. Participants have some knowledge of their health status,
including herbal products and drugs used for health
promotion and care.
2. Participants can identify reasons to choose or not to
choose herbal products.
3. Participants have access to various sources of
information about herbal products.
4. Participants may feel that it is not necessary to
communicate the use of herbal products to their
physicians or other regular health care providers,

13
because herbal products are from natural sources and
considered as dietary supplements.
5. Although herbal products are considered to be safe and
beneficial for maintaining or promoting health conditions
in general, certain herbal products may have potential
toxicity or may interact with certain conventional drugs.
Limitation
The generalizability of results of this study is
limited to older women who live independently in north
Florida. However, the population is believed to be similar
to the populations of older white community-dwelling women
in other parts of the United States.
Summary
Persons aged 65 and older are a rapidly growing group
in the United States. In an aging population, there is an
increase in the number of persons with chronic illnesses
who need health care services. As persons age, there is a
greater population of women than of men; and women have a
higher disability rate than their male counterparts.
The known facts about herbal products are as follows.
First, complementary and alternative medicines are
receiving increased attention by society. Second,
consumption of herbal products has increased and continues

14
to increase among people. Third, few toxicities and
benefits of herbal products have been studied and
recognized. Finally, primary physicians and other health
care providers are not always aware that patients are
taking herbal products. That is not only because patients
lack knowledge about the contradistinctions of herbal
products and conventional drugs but also because primary
physicians or health care providers do not ask the patients
about the use of herbal products.
However, there are facts that are not known clearly.
Since herbal products are more likely to be used for
chronic conditions and for maintaining and promoting health
status, no known research data exist related to the use of
herbal products by older women. Although data are available
reflecting the need for better communication between health
care professionals and patients to prevent the polypharmacy
causing the drug-drug interactions of conventional drugs,
little is known about the information related to the
prevalence of use of herbal products or potential side
effects of herbal products among the older women.
It is important to enhance understanding related to
prevalence of use of herbal products, specific purposes of
using herbal products alone or in combination with drugs of

15
conventional medicine as well as differences between herbal
product users and non-users among older women. The results
of this research give a better understanding about the use
of herbal products among older women and encourage
extensive communication between health care providers and
clients for comprehensive care, which results in improving
the quality of life of older women.

CHAPTER II
REVIEW OF LITERATURE
The review of literature pertaining to herbal products
research includes summation of the following topics: (a)
differences between alternative medicine and conventional
medicine; (b) history of herbal products and their use; (c)
prevalence of the use of alternative medicine; (d) choice
between conventional and alternative medicines; (e) older
women and health problems; (f) patterns of drug use among
older adults; (g) polypharmacy among the elderly; and (h)
toxicities of herbal products and possible interactions of
herbal medicines with conventional medicines.
Differences between Alternative Medicine and Conventional
Medicine
Alternative medicine is often defined as: (a) medical
interventions not taught widely at U.S. medical schools or
those not generally available at U.S. hospitals; (b)
treatments which lack sufficient documentation in the U.S.
for safety and effectiveness against specific diseases and
conditions; and (c) practices that are not generally
reimbursable by health insurance providers (Stalker,
16

17
1995). Seven categories of alternative medical practice are
listed by the Office of Complementary and Alternative
Medicines, the National Institute of Health (Workshop on
Alternative Medicine, 1994). These include (a) mind-body
interventions, (b) bioelectromagnetic therapies, (c)
alternative systems of medical practice, (d) manual healing
methods, (e) pharmacologic and biologic treatments, (f)
herbal medicine, and (g) diet and nutrition. Mind-body
interventions include psychotherapy, hypnosis, imagery,
meditation, biofeedback, support groups, dance therapy,
yoga, music therapy, art therapy, prayer, and mental
healing. Mind-body intervention helps patients experience
and express their illnesses in new ways by using placebo
response and spirituality, as well as religion.
Bioelectromagnetics (BEM) is the science that studies how
living organisms interact with electromagnetic (EM) fields
and purports that changes in the body's natural fields may
produce physical and behavioral changes. BEM includes blue
light treatment, artificial lighting, electroacupuncture,
electromagnetic fields, electrostimulation and
neuromagnetic stimulation devices, and magnetoresonance
spectroscopy.
Worldwide, 70% to 90% of human health care is
delivered by alternative systems of medical practices,

18
varying from self-care according to folk principles to care
by organized health care system based on an alternative
tradition or practice. There are a variety of practices
including acupuncture, traditional oriental medicine,
ayurveda, environmental medicine, homeopathic medicine,
Native American practices, naturopathic medicine,
anthroposophically extended medicine, and Latin American
rural practices.
Manual healing methods are based on the understanding
that dysfunction of a part of the body affects secondary
function of other body parts. These methods include
osteopathy, acupressure, Alexander technique, chiropractic
medicine, massage therapy, biofield therapeutics, and
therapeutic touch (Workshop on Alternative Medicine, 1994).
Pharmacological and biological treatments are an
assortment of drugs and vaccines not yet accepted by
mainstream medicine, and include but are not limited to,
anti-oxidizing agents, cell treatment, metabolic therapy,
and oxidizing agents (Ozone, Hydrogen Peroxide). Diet and
nutrition devised for the prevention and treatment of
chronic disease include changes in dietary lifestyle, diet,
Gerson therapy, macrobiotics, megavitamins, and nutritional
supplements.

19
Herbal products are mostly a part of plants or plant
products that have a long history of traditions in all
cultures. Although many drugs commonly used today are of
herbal origin, herbal products can be marketed only as food
supplements in the United States. Despite the skepticism by
Food and Drug Administration (FDA), a growing number of
Americans are exhibiting interest in herbal preparations.
The increased use of plant medicines has a potential
benefit for improving public health, but issues related to
safety, efficacy, and appropriateness of medicinal herbs
need to be solved (Workshop on Alternative Medicine, 1994).
In contrast to alternative medicine, conventional
medicine is the medical practice that is widely available
at American medical schools or in U. S. hospitals, and is
considered to be the world's standard health care system
among most people in the United States. There are many
differences between alternative medicine and conventional
medicine. Conventional medicine is based on the empiricism
that relies on a mechanistic model; wherein, body and mind
are viewed as separate entities with illness being
explained in terms of measurable physical phenomena.
Therefore, the primary goal of conventional medicine is to
bring about measurable objective improvement in disease
states. In contrast, one of the primary goals of

20
alternative medicine is to alter the subjective state of
the person, which can eventually promote objective
improvements in disease states (Burg, 1996).
Conventional medicine and alternative medicine can
also be distinguished by their approaches to the role of
the patient in treatment (Burg, 1996), by administration of
therapies, and by the interaction between the patient and
health care provider (Workshop on Alternative Medicine,
1994). In biomedicine, patients receive the standardized
treatment and medical advice on the basis of diagnosis or
symptomatic categories. In this system, the patient-
practitioner interaction is "physician centered." The
physician, thus, is the authoritative expert and the
patient is a receptive participant (Brunton, 1984). In
contrast, alternative medical practitioners tend to
individualize treatment and to create elaborate procedures
for identifying individual suitability and sensitivity to
the interventions. They often apply multiple treatment
modalities and judge effectiveness by using subjective and
patient derived outcomes (Jonas, 1993) . Alternative systems
of medicine emphasize a client-centered relationship and
patient responsibility in the healing process, which can
maximize the collaboration between the medical

21
practitioners and patients, thus enhancing the benefits of
a therapy.
Although all complementary medicine practitioners do
not share a common epistemology, several principles are
common to most of their practices. These include emphasis
on the: (a) Patients' feeling rather than their diagnosis;
(b) Holistic view rather than conventional medical view:
All aspects of the person (i.e. physical, emotional,
mental, and psychosocial health, lifestyle, etc.) are
interrelated and must be considered through the process of
care; (c) Promotion of the use of a variety of therapeutic
options for the purposes of prevention and treatment, and
viewing treatment as a process; (d) Maintaining basic
ethics of patient care such as do no harm; (e) Balance in a
patient's body system, and relationship to other
individuals, society, or environment; (f) Production of
fewer side effects by using whole foods and herbs rather
than using conventional drugs; and (g) Expectation that the
patient is not a passive recipient but an active
participant through the treatment process (Burg, 1996;
Murray, 1994; Workshop on Alternative Medicine, 1994).
History of Herbal Products and Their Use
An herb is defined as a seed-producing annual,
biennial, or perennial that does not develop persistent

22
woody tissue but dies down after flowering. The second
definition is a plant or plant part valued for its
medicinal, savory, or aromatic qualities (Merriam-Webster's
Collegiate Dictionary, 1993). The herbs referred to in this
paper are included under the second definition. An herbal
medicine is a plant-derived material or preparation with
therapeutic or other human health benefits, which contains
either raw or processed ingredients from one or more plants
(World Health Organization, 1993).
Herbal prescriptions are available for the entire
range of medical ailments, including pain, hormonal
disturbances, breathing disorders, infections, and chronic
debilitating illnesses. These are classified according to
their energetic qualities and are prescribed for their
action on corresponding organ dysfunction, energy
disorders, disturbed internal energy, blockage of the
meridians, or seasonal physical demands (Workshop on
Alternative Medicine, 1994).
Early humans treated illness by using plants, animal
parts, and minerals that were not part of their usual diet.
Herbal medicines using plants and plant products have been
utilized in medical practice for thousands of years, and
have made a great contribution to maintaining human health.

23
For example, the Ebers Papyrus, the preserved Egyptian
manuscripts, were written around 1500 B.C. and contain 876
prescriptions made up of more than 500 different substances
including many herbs. De Materia Medica written in the 1st
century A.D. offers about 950 curative substances including
600 plant products and other 350 of animal or mineral
origin in Greece and Rome (Ackernecht, 1973). This text
explains a description of the plant, an account of its
medicinal qualities, methods of preparation, and warnings
about undesirable effects. The Arabs preserved a body of
knowledge in the Muslim matera medica, which lists more
than 2,000 substances, including many plant products
(Ackernecht, 1973).
Herbs played an important role in Ayruvedic medicine
in India, and were described in Ayruvedic books more than
2000 years ago. The history of Chinese herbal medicine can
be traced to the end of the third century B.C. The
Encyclopedia of Traditional Chinese Medicine Substances,
the most definitive compilation of China's herbal tradition
to date, has evolved from the Classic of the Matera Medica
which was written almost 2,000 years ago. Traditional
Chinese medicine influenced Korea and Japan and markedly
simplified Japanese traditional medicine, called Kampo
(Workshop on Alternative Medicine, 1994).

24
In contrast, the United States has a relatively short
history of the use of herbal products compared to that of
other countries. Early explorers of North America exchanged
knowledge with the Native Americans to learn which herbs to
use in the New World. Until the early 20th century, plants
remained as a mainstay of country medicine, and were used
not only by physicians to treat common ills, but also as
important home remedies by many families (Buchman, 1980). A
textbook of pharmacognosy contained hundreds of medically
useful comments on herbs until the 1940s. As medicine
evolved with advanced technology in the 20th century,
remedies from natural resources were gradually forgotten in
modern society. Today, however, many commonly used drugs
are of herbal origin. About one-quarter of the prescription
drugs dispensed by community pharmacies in the United
States contain at least one active ingredient derived from
plant material (Workshop on Alternative Medicine, 1994).
Recently, Americans have shown an increased interest
in the use of herbs and herbal medicines due in part to the
changing health care system's focus on preventive care as
well as interest in natural therapies (Youngkin, & Israel,
1996). There are other factors contributing to an increased
interest in herbal products in America. One factor is the
wide availability of such products from European countries,

25
China, Japan, South America, and Mexico, in most U.S.
health food stores. Secondly, people are willing to try
herbs and herbal preparations for chronic illnesses or as
an adjunct to other treatment. And, finally, herbs and/or
herbal products are generally considered to be less toxic
than drugs from conventional medicines (Workshop on
Alternative Medicine, 1994).
It is now easier to gain access to herbal products
since they are considered dietary supplements rather than a
part of conventional drugs as a consequence of the Dietary
Supplement Health and Education Act of 1994. In the United
States, $1.5 billion of herbs were sold in 1995, and their
sales rate has been growing from 12% to 18% per year
averaging about 15% a year (Gray, 1996). There were about
8,000 natural health food stores in the United States in
1995 (Marwick, 1995).
With an increased use of herbal products, safety and
toxicity are becoming issues. Although it is generally
perceived that natural products are safe, there are risks
when these are used because not all herbal remedies are
harmless. Herbs or herbal products can be incorrectly
identified by manufacturers as nontoxic herbs. Since many
herbal products are mixtures, some of them may be toxic,
particularly if they are misused. Some ayurevedic botanical

26
products contain high levels of heavy metals that can cause
toxic effects. Another threat posed by herbal remedies is a
lack of proper knowledge in using them, which results in an
overdose causing irreversible organ damage (Marwick, 1995).
It is important for herbal product users to collect
information about the herbal products prior to their use.
Health care providers need be more attentive to thorough
history assessments of their clients related to the use of
herbal products as well as the use of conventional drugs.
Prevalence of Alternative Medicine and Herbal Products
Alternative medicine has gained in popularity and
respectability in recent years, becoming widely used to
promote or to maintain health, to treat diseases, to
alleviate symptoms, and to prevent recurrence of illnesses.
A 1990 national telephone survey revealed that 34% of
Americans reported using at least one alternative medicine
in the previous year including 10% who visited alternative
practitioners, and spent $13.7 billion on these visits.
Americans made more visits to alternative practitioners
(425 million) than to primary care physicians (388 million)
(Eisenberg et al., 1993).
The results of the study by Paramore (1997) are
consistent with that of Eisenberg and colleagues(1993).
Paramore (1997) found that nearly 10% of the U.S.

27
population, almost 25 million persons, saw a professional
in 1994 for at least one of the following four therapies:
chiropractic, relaxation techniques, therapeutic massage,
or acupuncture. The use of alternative medicines was
correlated with poor health rather than maintaining or
promoting health. The use of alternative medicines was
frequently used among middle-aged whites who had more
education and higher incomes (Eisenberg et al., 1993;
Paramore, 1997). These researchers reported no significant
gender differences in the use of four alternative
medicines.
Alternative medicines were more frequently used to
treat medical conditions such as back problems, insomnia,
headache, anxiety, and depression (Eisenberg et al., 1993),
and were also used for minor ailments, for health
promotion, and as prophylaxis for recurrent problems
(Murray & Shepherd, 1993). These therapies were generally
used as adjuncts to conventional medicine rather than
replacements for conventional medicine, (Eisenberg et al.,
1993; Murray & Shepherd, 1993).
Overall, persons with chronic, nonspecific, and hard-
to-treat illnesses are likely to be frequent users of
complementary medicines. Researchers studying polypharmacy
among patients attending an AIDS clinic found that 29% of

28
patients with AIDS used alternative medicines during the
three month period prior to the interview, and the use of
alternative medicines was associated with their stage of
illness (Greenblatt, Hollander, McMaster, & Henke, 1991).
The use of medicinal herbs was more frequent in HIV-
infected patients than in the general population, which
showed that 22% of 114 randomly selected HIV-infected
patients reported using one or more herbal products in the
past three months (Kassler, Blanc, & Greenblatt, 1991).
According to Coleman, Fowler, and Williams (1995), 55%
of caregivers of patients with Alzheimer's disease reported
that they had tried at least one alternative therapy to
improve the patient's memory, including 11% who used herbal
medicines. Although the proportion of cancer patients using
alternative therapies is a smaller percentage compared with
the percentage of all patients who do so, the prevalence of
alternative cancer therapy in the United States ranged from
a low of 6.4% to a high of 14.7% (Lerner & Kennedy, 1992).
A study in Canada showed that 66% of 235 Canadian
patients with rheumatologic diseases had used alternative
therapies in the preceding 12 months. The most frequently
used alternative treatment modality was non-prescribed over
the counter products including herbs, minerals, and topical
remedies (Boisset, & Fitzcharles, 1994).

29
According to Eisenberg and colleagues (1993), the most
common types of therapies used were relaxation techniques,
chiropractic, and massage. Over a 12 month period, herbal
medicines were used by only 3% of Americans surveyed
(Eisenberg et al., 1993), while the World Health
Organization estimated that 80% of the world population
used herbal medicine for some aspect of primary health care
(Farnsworth, Akerele, Bingel, Soejarta, & Eno, 1985).
Data from the rural, central Mississippi area (Frate,
Croom, Frate, Juergens, & Meydrech, 1996) was close to the
prevalence rate from World Health Organization, and showed
that over 70% of the adults from the sample of 223
households used at least one plant-derived medicine during
the past year. Herbal remedies were frequently used by
people who were married, from larger households, of higher
socioeconomic status, or who had consulted alternative
healers (Brown, & Marcy, 1991). However, there is little
factual evidence concerning the use of herbal medicines
among the elderly and characteristics of users compared to
those of nonusers.
Choice Between Alternative and Conventional Medicines
Despite the advances of conventional medicines,
alternative therapies have received increased attention in
the United States and other developed countries, and have

30
been chosen for use in treating various health problems by
an increasing number of people (Eisenberg et al., 1993;
MacLennan, Wilson & Taylor, 1996; Paramore, 1997). Compared
to conventional medicine, alternative medicines rely
heavily on the following factors: participation by patients
in their own care; the relationship between the
expectations of patients, cultural context, and lifestyle
activities; and effects on therapeutic outcome of patients'
choices of treatment (Workshop on Alternative Medicine,
1994).
In an earlier year, Kronenfeld and Wasner (1982)
focused on the marginalized groups in society to study the
relationship between alternative medicine and traditional
folk medicine which has developed from ethnographic
tradition. In recent studies, researchers have recognized
that unconventional therapies are accepted and practiced by
a significant number of people, and are believed to be a
part of contemporary culture (Eisenberg et al., 1993;
MacLennan, Wilson, & Taylor, 1996; Paramore, 1997).
Since significant numbers of persons have recognized
the use of alternative medicine, many researchers have
investigated factors associated with the choices of
alternative therapies. Vincent and Furnham (1996) reported
the principal reasons by patients for choosing alternative

31
medicine over conventional medicine. These reasons included
(a) belief in the positive value of alternative medicine,
(b) previous experience of ineffective treatment of
conventional medicine, and (c) concern about the adverse
effects of medical care.
Other factors influencing the choice of alternative
medicine were the poor communication between patients and
health care practitioners in conventional medicine, the
willingness of alternative practitioners to discuss
emotional factors, and the chance to take an active role in
their treatment (Vincent and Furnham, 1996). Choices of
alternative therapies were influenced by the prognosis for
specific diseases such as AIDS, cancer, arthritis, or
Alzheimer's disease (Boisset & Fitzcharles, 1994; Cassileth
& Chapman, 1996; Coleman, Fowler, & Williams, 1995;
Greenblatt, Hollander, McMaster, & Henke, 1991);
dissatisfaction with the effectiveness of conventional
medicine (Cassileth & Chapman, 1996; Sutherland & Verhoef,
1994); negative relationship to perceived health status and
to health care providers (Sutherland & Verhoef, 1994); and
a lack of confidence in conventional medicine (McGregor &
Peay, 1996) .
In summary, a single factor cannot be used to explain
the choice of alternative therapies for one's care.

32
According to Kelner and Wellman (1997), many factors
influence people in their choice of alternative therapies.
Predisposing factors include level of education and age,
enabling factors (i.e. income, knowledge, and accessibility
of services), and the need for care. Kelner and Wellman
(1997) point out individuals in their study who choose to
try alternative therapies assume responsibility for their
health and well-being. Kelner and Wellman (1997) also
indicate that people do not make dichotomous choices
between conventional medicine and alternative medicine.
Rather, people choose specific kinds of treatments for
specific problems, and many use multiple therapies
concurrently. In addition, a wide range of possibilities of
health care as well as public and private testimonials
about successful alternative treatments result in more
people deciding to use alternative therapies to cope with
their problems and concerns (Kelner & Wellman, 1997).
Older Women and Health Problems
The majority of older Americans are women, and the
number of older women will increase continuously. The
number of women surpasses the number of men in the age
range of 65 years and over, and this gap widens with
increasing age (Cobbs & Ralapati, 1998) . In 1994, there
were 20 million older women and 14 million older men. Among

33
those 85 years and older, there are 44 men for every 100
women; women outnumber men by 100 to 26 over the age of 95;
and four out of five centenarians are women. There is a
rapid increase in the number of centenarians in the United
States (U.S. Bureau of the Census, 1996).
Although a majority of older adults live independently
in the community and consider their health to be good or
excellent, chronic disease becomes more prevalent with age
(Cobbs & Ralapati, 1998). Four out of five people aged 65
and older have at least one chronic disease (Delafuente,
1991). The use of multiple conventional drugs among older
adults is a serious issue in the United States (Lamy, 1986;
Noyes, Lucas, & Stratton, 1996). Even with functional
disability increasing with age, most older women report
that they are emotionally vital; but health status, level
of disability, and sociodemographic status influence their
emotional vitality (Penninx et al., 1998).
Many researchers, who studied the use of conventional
drugs among community-dwelling older adults, reported
gender differences in the use of conventional drugs
(Chrischilles et al., 1992; Fillenbaum et al., 1996; Simons
et al., 1992). Based on the data from the Established
Populations for Epidemiologic Studies of the Elderly
(EPESE), Chrischilles and colleagues (1992) reported that

34
prescription drugs were used by 60-68% of men and 68-78% of
women, while non-prescription drug use was 52-68% and 64-
76% respectively (Chrischilles et al., 1992). While
studying community-dwelling older adults, Simons and
colleagues (1992) found that 76% of women and 56% of men
who used multiple prescription drugs also used multiple
non-prescription drugs.
Fillenbaum and colleagues (1996) and Simons and
colleagues (1992) reported that female gender is one of the
best predicting factors for the use of non-prescription
drugs. Women reported taking more medications than men in
each of these studies. Although Lassila and colleagues
(1996) did not consider gender as a significant factor
associated with the use of number of conventional drugs,
most researchers who examined the use of non-prescription
drugs accounted for 'female' as an important factor.
Gender difference was recognized in the types of
health problems and health actions as well as in the use of
conventional drugs. Musil (1998) reported that there are
significant gender differences in psychological and
physical health as well as the health actions among older
adults residing in the community. The significant gender
differences in psychological health were found in anxiety,
depression, and body awareness; however, no gender

35
differences were found in self-assessed health and total
number of health problems (Musil, 1998).
The gender differences in physical health are that
women aged 65 years and over experience more arthritis,
cataracts, hypertension, and asthma while their male
counterparts have more problems with hearing, ulcers,
abdominal hernias, and heart disease (Musil, 1998). By 80
years of age, 70% of women have two or more chronic
conditions, most likely arthritis and hypertension, and
other common chronic conditions such as heart disease and
visual or hearing problems (Cobbs & Ralapati, 1998).
According to a study of health problems and related
health actions among older adults (Musil, Ahn, Haug,
Warner, Morris, & Duffy, 1998), frequent health actions in
response to health problems are the use of non-prescription
medicines (83%), self-care activities (72%), use of
prescription medicines (53%), and professional consultation
(43%). The gender differences in health actions suggest
that women are more likely to use self-care while men
incline towards seeking professional consultation (Musil,
1998) because, historically, women have played a major role
in the healing process serving as caregivers of their own
families (Burg, 1996). Self-care actions that are
frequently used by community-dwelling older women include

36
taking non-prescription medicines, using home remedies, or
making lifestyle changes (Musil, 1998).
The results of studies by Musil (1998) and Musil and
colleagues (1998) are not surprising when considering
freguent self-care actions by women including using home
remedies. Burg (1996) states that most female patients may
use some form of complementary medicine some time in their
lives for their chronic health conditions; and women may
use complementary medicines in combination with
conventional medicines, which makes health assessment
important to evaluate the potential interactive effects.
Although there are no known data specifically looking
at women's use of complementary medicine in the United
States, Burg (1996) suggested that certain groups of women
may utilize complementary medicines based on gender-
specific illness patterns and general knowledge about using
complementary medicines. These groups of women who may use
complementary medicines frequently are people with chronic,
non-specific, or difficult for treating illnesses such as
arthritis, depression, anxiety, HIV/AIDS, and cancer (Burg,
1996). In summary, it is important to examine health care
practices among older women related to the use of herbal
products as a part of complementary medicine since women
live longer than men in their later stages of life with

37
increasing number of chronic health problems as they age.
It is vital to understand the patterns of the use of herbal
products in combination with conventional drugs in order to
understand and prevent potential interactions between
herbal products and conventional drugs. This knowledge and
understanding assist health care providers to improve
comprehensive health care for older women and subsequently,
promote the quality of life of older women.
Patterns of Drug Use Among Older Adults
The population of the United States is 249 million
including 34 million people aged 65 years and older (U.S.
Bureau of the Census, 1990) . The elderly are the fastest
growing age group, and continue to grow faster than any
other age group in the United States. Although most people
are able to carry on their normal activities and functions
up to the age of 75 or older, approximately four out of
five people aged 65 and older have at least one chronic
disease with an average of four diseases per person
(Delafuente, 1991). There are many factors influencing drug
use in the older adults including disease states,
psychosocial factors, physicians who prescribe medications,
and advertisement by the pharmaceutical industry (Stewart,
1995). Stewart (1995) states that other factors will
influence patterns of drug use in the future such as the

38
development of new drug treatments with expanded coverage
of prescription services by government and the influence of
private insurers. Other factors associated with drug use in
older adults are reported. These include prior drug use,
number of health care visits, poorer health or self-
perceived poor health, white race, female gender, impaired
physical function, depression, hospitalization, insurance
coverage, and smoking or drinking alcohol in previous year
(Chrischilles et al., 1992; Fillenbaum et al., 1996;
Lassila et al., 1996).
While there are great advantages of conventional drug
therapy, there are problems associated with and resulting
from conventional drug use by older adults. The use of
conventional drugs for therapeutic purposes by older adults
can contribute to significant drug-related problems because
older adults are in an increased risk group due to impaired
organ reserve capacity, multiorgan system dysfunction
associated with multiple disease states, polypharmacy with
drug interactions, and altered pharmacokinetics and
pharmacodynamics (Sloan, 1992). Other problems associated
with conventional drug use include polypharmacy, issues of
compliance, drug-drug interactions in combination use of
conventional drugs (Chenitz, Salisbury, & Stone, 1990;
Lamy, 1986; LeSage, 1990; Noyes, Lucas & Stratton, 1996;

39
Stewart, 1995; Stewart & Cooper, 1994; Swonger & Burbank,
1995).
Several national and community-based studies have
provided information on conventional drug use patterns
among older adults. Patterns of prescribing practice of
conventional drugs by health care providers for older
adults have varied over time depending on the data
collecting time and geographical differences (Stewart,
Moore, May, Marks, & Hale, 1991). Data from the Florida
retirement community of Dunedin, a relatively healthy and
ambulatory group, were collected during 1978-1979 (May,
Stewart, Hale, & Marks, 1982), and 1987-1988 (Stewart et
al., 1991). The average number of drugs, including both
prescription and non-prescription, taken by the older
adults in Dunedin, Florida was 3.2 during the 1978-1979
period (May et al., 1982) and 3.7 in the ten-year overview
of the Dunedin study (Stewart et al., 1991).
Researchers in the Iowa Rural Health Study gathered
data during 1981-1982 from the community-based, generally
elderly population and reported a mean of 2.9 prescribed
medicines (Helling, Lemke, Semla, Wallace, Lipson, &
Cornoni-Huntley, 1987). Other studies of drug use patterns
in the older adults were conducted in North Carolina and
Pennsylvania. These studies included urban as well as rural

40
areas as well as a significant proportion of African-
Americans. Older adults in the Piedmont area of North
Carolina were studied in 1986-1987 (Fillenbaum, Hanlon,
Corder, Ziquba-Page, Wall, & Brock, 1993) and in 1989-1990
(Fillenbaum et al., 1996), and researchers reported a mean
of 3.4 and 3.7 prescribed drugs per person in the two
studies. In the MoVIES Project by Lassila and colleagues
(1996), data were collected during 1987-1989 in the rural
mid-Monongahela Valley community of Pennsylvania, a largely
white (97%), blue-collar population. The result of the
MoVIES Project showed subjects used a mean of 2.0
prescription drugs (Lassila et al., 1996).
Despite the differences in the time and the location
of the study sites, findings are similar among these
studies. When compared cross-sectionally and
longitudinally, the proportion of the older adults who took
conventional drugs increased with age, as did the number of
medications taken (Chrischilles et al., 1992; Fillenbaum et
al., 1993; Fillenbaum et al., 1996; Helling et al., 1987;
Lassila et al., 1996; May et al., 1982; Stewart et al.,
1991).
Polypharmacy
Polypharmacy has been recognized as a problem in the
geriatric population (Gormley, Griffiths, McCracken, &

41
Harrison, 1993; Lamy, 1986; Noyes, Lucas, & Stratton, 1996;
Shimp, Wells, Brink, Diokno, & Gillis, 1988). The elderly
aged 65 and older, who represent only 14% of all American
population, consume three times more prescription drugs
than people under aged 65 years (Gormley, Griffiths,
McCracken, & Harrison, 1993). The use of prescribed drugs
has been projected to be 40% of the total drug expenditures
in developed countries by year 2030 (Cusack, 1989). The
older adults frequently use nonprescription drugs in
addition to prescribed medications (Pollow, Stoller,
Foster, & Duniho, 1994).
Polypharmacy has been defined in many different ways
(LeSage, 1990; Michocki, Lamy, Hooper, & Richardson, 1993;
Montamat & Cusack, 1992; Noyes, Lucas, & Stratton, 1996).
In Healthy People 2000 (1990), polypharmacy was defined as
the use of multiple prescription and nonprescription drugs,
especially by elderly with chronic disease, while Noyes,
Lucas, and Stratton (1996) considered multiple drug use
synonomous with polypharmacy. LeSage (1990) defined
polypharmacy as the concurrent use of several different
drugs; whereas, Montamat and Cusack (1992) defined
polypharmacy as the prescription, administration, or use of
more medications than are clinically indicated in a given
patient.

42
Other researchers (Michocki, Lamy, Hooper, &
Richardson, 1993) considered polypharmacy only as the use
of multiple drugs. Definition of polypharmacy by Michocki
and colleagues (1993) was that particular patients received
too many drugs, for too long a time, or in exceedingly high
doses. Although there is neither a specific number of
medications to define polypharmacy, nor a unanimously
accepted definition of polypharmacy, polypharmacy
consistently represents the use of multiple medications by
a single patient (Stewart & Cooper, 1994).
Possible causes of geriatric polypharmacy are multiple
health problems; multiple prescribers; noncurrent
medication storage; prescription patterns of physicians;
and self-medication behavior (LeSage, 1990). Since it has
been known that older adults often take a large number of
drugs for various reasons, possible adverse consequences of
the use of multiple medications exist. These consequences
are adverse drug reactions, drug interactions, medication
errors, noncompliance, quality of life and functional
decline, and high financial cost (LeSage, 1990; Stewart &
Cooper, 1994) .
Swonger and Burbank (1995) pointed out the problems of
polypharmacy and drug misuse associated with both physician
and client. Multiple drug regimens are often too

43
complicated or lack adequate rationale for each individual
drug. Multiple chronic conditions of the elderly often
require the use of more than one physician, which can lead
to poorly coordinated care and adverse drug reactions.
Physician-centered problems are negative attitudes
toward older people, difficulty in accurately diagnosing
and dosing due to heterogeneity of the elderly, lack of
client education about drugs and inadequate follow-up.
Client-centered problems are unintentional resulting from a
lack of knowledge or special instructions, forgetfulness in
taking medicine, confusion, intentional omission, dosage
adjustment, sharing drugs with other people, and stretching
dosage requirements to save money (Swonger & Burbank,
1995).
Issues related to multiple drug use have been
recognized in other studies (Col, Fanale, & Kronholm, 1990;
Michocki, Lamy, Hooper, & Richardson, 1993; Ranelli &
Aversa, 1994; Stewart & Caranasos, 1989). Ranelli and
Aversa (1994) studied medication-related stress among
family caregivers, and reported that 32% of the caregivers
had medication-related problems and 19% had difficulty in
managing medications. More than half of the caregivers
experienced problems in the past year, including scheduling
difficulties, compliance problems, difficulty organizing

44
medications for the patient, and lack of professional
advice. Although only 7.7% of the total time was spent
providing drug-related care by caregivers, medications did
contribute to the stress of the caregiving experience
(Ranelli & Aversa, 1994).
Compliance is another issue related to polypharmacy.
Many factors were associated with compliance (Noyes, Lucas,
& Stratton, 1996; Stewart & Caranasos, 1989) . Among the
factors related to compliance documented in literature, it
was consistently mentioned that the number of medications
taken and the complexity of the medication regimens were
critical factors for patient's compliance.
One study of compliance rates related to dosage
pattern, e.g. number of times per day, showed that
compliance rate decreased when the number of times a
medication was taken per day increased (Cramer, Mattson,
Prevey, Scheyer, & Ouellette, 1989). Cramer and colleagues
(1989) found only 391 of compliance rate with four times a
day dosage schedule, while reporting 87% of compliance rate
when medication was scheduled once a day for the elderly.
Prescription of multiple drugs may increase noncompliance
and cause adverse drug reactions or clinically significant
drug interactions (Col, Fanale, & Kronholm, 1990). Adverse
drug reactions are defined broadly by the United States

Food and Drug Administration (FDA) as any adverse event
associated with the use of a drug in humans (Sills, Tanner
& Milstien, 1986).
According to Col and colleagues (1990), patients
admitted to hospitals with medication noncompliance
increased, when the number of different medications or the
number of physician visits increased. Approximately 28% of
hospital admissions among older adults were drug-related,
and more specifically, were due to noncompliance (11.4%)
and adverse drug reactions (16.8%). Although there are
variations in reported hospitalization rates caused by
adverse drug reactions, from 6.3% to 16.8% (Col, Fanale, &
Kronholm, 1990; Colt, & Shapiro, 1989; Grymonpre, Mitenko,
Sitar, Aoki, & Montgomery, 1988; Ives, Bentz, & Gwyther,
1987; Lindley, Tulley, Paramsothy, & Tallis, 1992), it is
apparent that adverse drug reactions are serious and
costly.
Toxicities of Herbal Products and Possible Interactions
with Drugs of Conventional Medicine
In recent years, the use of herbal products has
increased in developed countries, even though herbáis have
been a dominant form of health care in developing countrie
for many years. Although Eisenberg and colleagues reported
that three percent of Americans were using herbal products

46
in the early 1990s, this number is assumed to be growing
rapidly (Eisenberg et al., 1993).
The risk of potential toxicity of herbal medicines is
accelerated by many factors. First of all, herbal medicines
are not subject to standard Food and Drug Administration
(FDA) tests for safety, effectiveness, and quality control
because herbáis are not considered conventional drugs but
rather dietary supplements. Secondly, many herbal products
are imported from foreign countries not mandating safety or
manufacturing regulations. Finally, these medicines do not
have the active or inactive ingredients listed on the
package label (Anderson, 1996). Other factors contributing
to the potential problems of using herbal products include
(a) misidentification of a plant, or the unknown or ignored
toxicity of a correctly identified plant; (b) persistent
use of herbs known to be toxic; (c) difficulty in
identification of chopped or mixed herbs; (d) variability
in chemical constituents of herbs; (e) problems with
nomenclature; (f) difficulty in establishing the cumulative
effects of a plant; (g) contamination with heavy metals;
and (h) possible adulteration with prescription drugs or
with other substances (Drew & Myers, 1997; Huxtable, 1990).
Certain groups of people using herbal products are at
higher risk of intoxication than other groups. Huxtable

47
(1990) points out that high risk groups are people using
herbs or herbal products for a long time, consumers of
large amounts or a wide variety of herbs, babies, the
elderly, those with concomitant diseases and concurrent
medications, and the malnourished or undernourished. Also,
toxicities can be selective depending on gender and
cultural groups (De Smet, 1995; Huxtable, 1990).
Nevertheless, it is widely perceived that natural products
are safe, and people will continue to use herbal medicines
in ever-growing numbers (Marwick, 1995).
Although the risk of using herbal medicine is much
less than that of using conventional medicine, many
researchers suggest that using herbal products is not
without risk and, consequently, safety of using these
products needs to be considered.
Only nine herbal products are approved by the Food and
Drug Administration (FDA) for selected applications
(Youngkin & Israel, 1996). Recently, Youngkin and Israel
(1996) reviewed the safety of herbal therapies compared to
the safety and efficacy data derived from the German
Commission E and other biomedical literature for selected
commonly used herbs. Among the 56 herbal products reviewed,
only seven were approved by the FDA; 36 were considered to
be effective for one or more specified complaints by the

48
German Commission E; and only four were approved by both
FDA and German Commission E (Youngkin & Israel, 1996).
Drew and Mayers (1997) proposed classification of
adverse effects associated with herbal medicine into two
categories, intrinsic and extrinsic effects. Intrinsic
effects are those of the herb itself, and are characterized
as type A and type B reactions for pharmaceutical purposes.
Type A reactions are predictable and dose-dependent
including effects with deliberate over-dose or accidental
poisoning and interactions with pharmaceuticals. Type B are
unpredictable and idosyncratic reactions.
Extrinsic effects are not related to the herbal
medicine itself, but to a problem in manufacture or
compounding. Extrinsic effects may result from failing to
adhere to a code of Good Manufacturing Practice and include
contamination, misidentification, lack of standardization,
substitution, adulteration, incorrect preparation and/or
dosage, and inappropriate labeling and/or advertising.
Extrinsic effects make it difficult for health care
practitioners or users of herbal medicines to identify the
correct herbal remedies or to assess the adverse effects
(Drew & Mayers, 1997).
Information regarding toxicities and safety of herbal
medicines is currently limited. The workshop on Alternative

49
Medicine (1994) listed the 20 most popular Asian patent
medicines that contain toxic ingredients (see Appendix C).
Other authors (Gray, 1996; Youngkin & Israel, 1996)
summarized the scientific information and potential adverse
effects of selected common herbal remedies. Currently,
there is little information available related to
interactions of herbal products in combination with the use
of conventional drugs, although, it is assumed that there
are possibilities of interactions between herbal products
and conventional drugs (Drew & Mayers, 1997; Huxtable,
1990; Noyes, Lucas, & Stratton, 1996). More studies are
needed to investigate the interactions between herbal
products and conventional drugs.
Although the prevalence of the use of herbal products
among older women is unknown, it is assumed that women aged
65 years and over consume more herbal products than their
younger counterparts. Older women report more chronic
health problems than younger women. Also, older women
attempt to prevent deterioration of health in the later
stages of their life. It is clear that older adults are
susceptible to medication related problems because of their
overall increased use of medication.

CHAPTER III
METHODOLOGY
The purpose of this research was to study the use of
herbs and/or herbal products for medicinal use and to
compare the differences in demographic characteristics and
health status between herbal product users and non-herbal
users among community-dwelling older women. This chapter
contains the research methodology and is comprised of five
sections: research design, setting, sample, instruments,
data collection procedure, and data analysis.
Research Design
This research utilized a cross-sectional and
descriptive design to examine the prevalence of herbal
product use, the types of the herbs used, and to identify
the reasons for use of herbal products among women aged 65
and over. Subjects were categorized into two groups: Group
1, women 65 years and older who used herbal products and
Group 2, women 65 years and older who did not use herbal
products.
Setting
The setting for this study was a county located in
North Central Florida.
50

51
Sample
It was statistically determined that a sample size of
84 subjects (42 subjects in each group) would provide the
desired sensitivity to test the study hypotheses. This
determination was based on a formulation of 95% power, a
medium critical effect size of 0.40 for each of the
dependent variables, and a significance level of 0.05 for a
two-tailed test of means.
Sampling criteria were women who were 65 years and
over and lived in the designated North Central Florida
county. The principal investigator requested names and
addresses of all women 65 years and older who resided in
the selected county from the Division of Drivers' License,
State Department of Highway Safety and Motor Vehicles. This
list yielded 8,344 names and addresses of women aged 65 and
older.
According to Waltz, Strickland, and Lenz (1991), 30%
response rate was not unusual in mailed questionnaire
surveys. Therefore, it was necessary to select at least
three times the number of subjects needed for the total
sample of 84 subjects to test the hypotheses. The
investigator randomly selected 252 subjects from the total
list utilizing the table of random digit (Rand Cooperation,
http://www.rand.org/software and data/random/digits.txt).

52
After a random selection of names, 252 letters were
mailed to the potential subjects, introducing the study and
requesting participation in the study. A return
self-addressed, stamped postcard was enclosed with each
introductory letter. Of the 252 letters mailed, 53 subjects
were included in the sample. Thirty-one more subjects were
needed to attain a desired sample size of 84; therefore,
150 additional letters were mailed. From the second group
of letters mailed, 33 subjects were included in the sample.
Therefore, a total of 86 subjects completed the interview,
resulting in 39 subjects in Group 1 (herbal product users)
and 47 subjects in Group 2 (non-herbal users).
Inclusion and Exclusion Criteria
The inclusion criteria were as follows: (a) women who
were 65 years and older living independently in the
community; (b) currently living in the selected county; (c)
ability to speak and understand English; and (d) able to
verbally communicate with intact memory. Subjects who could
respond to the requests for participation were considered
to have adequate communication skills and memory ability.
Exclusion criteria were as follows: (a) women who had
severe health conditions, (b) resided in nursing home or
other type of assisted living facility, (c) resided out of

53
the selected county, or (d) unable to contact after
multiple attempts.
Instrument
The questionnaire was developed by the investigator
because there were no known established questionnaires to
perform this study. This questionnaire was used to obtain
knowledge related to the prevalence and purpose of use of
herbal products and how the herbal products were used with
prescribed and non-prescribed medicines among women aged 65
and over. The questionnaire was comprised of three parts:
(a) health status and use of conventional drugs including
prescribed and non-prescribed medicines, (b) use of herbal
products, and (c) demographic data.
The interview lasted approximately 15-30 minutes for
the participants who did not use the herbal products, and
were classified as group 2. The participants in this group
were asked to answer part A and part C of questionnaire.
The interview took approximately 30-45 minutes for the
participants who responded 'yes' to the use of herbal
products. These participants were classified as group 1.
The participants in this group were asked to answer the
entire questionnaire Part A (Health Information), Part B
(Herbal Product Use Information), and Part C (Demographic
Information).

54
Operationalization of Variables
Demographic Variables
Demographic characteristics of subjects were examined
by six indicators: race, education, income, religious
preference, insurance status, and marital status.
Race. Race was a categorical variable coded as
white, black, Hispanic-nonwhite, and other.
Education. Education was categorized into four
groups according to the number of years of formal education
which the participants completed: less than a high school
diploma, high school graduate, less than a college
graduate, college graduate, and graduate school and higher.
Income. Income was the total annual household
income of the participant. This measure was coded into four
categories reflecting an income range from $0.00 to over
$50,000: less than $20,000, $20,000 - $34,999, $35,000 -
$49,999, and $50,000 and above.
Religion. Religious preference of participant was
divided into five categories: None, Protestant, Catholic,
Jewish, and other.
Insurance status. Status of insurance was
categorized into five groups: None, Medicare, Medicaid,
private insurance, and other.

55
Marital status. Marital status was coded into one
of four categories reflecting the status of married,
widowed, divorced/separated, or never married.
Herbal products variables
Eleven indicators were examined for the variables
related to the use of herbal products. These were (a)
number and type of herbal products used, (b) general
purpose of using herbal products, (c) route, (d)
preparation, (e) reasons used, (f) duration of use, (g)
effectiveness of herbal products, (h) experience of adverse
reactions by using herbs or herbal products, (i) sources of
information for use of herbal products, (j) source of
payment for herbal product, and (k) physician's awareness
about using herbal product.
Number and type of herbal products used. The
participant was asked to list the names of all the herbal
products used in the last 12 months. The total number of
herbal products used by each participant was counted. The
mean number of herbal products used was calculated to
measure the average number of herbal products used by the
participants. Examination of frequencies identified the
most common herbal products used.
General purpose of using herbs or herbal products.
The participant was asked the general purpose of taking

56
herbal products in the last 12 months. Purposes were
categorized into one of three indicators: to treat illness,
to maintain or prevent any possible health problems, and
both treat and prevent illness.
Route. The route of using herbal products was a
categorical variable identified as internal use and
external use.
Preparation. Preparation was a categorical variable
identified as self-prepared or purchased from a health food
store or a regular retail store. Self-prepared herbal
product defined the remedy that could not be used directly
as it was obtained and thus required preparation time at
home such as herbal tea. Purchased included the product
that could be used directly without any preparation time
after obtaining it such as an herbal tablet or a capsule.
Reasons used. Reasons to use herbal products were
listed based on the types of health problems and were coded
from 6 through 29. The codes starting from 6 through 28
were matched with specific illnesses on the Health
Information Form in the questionnaire Part A (see Appendix
A). Item number 29 was related to the use of herbal
products for maintaining current health status or for
preventing possible health problems.

57
Duration of use. Duration of using an herbal product
was categorized into two groups: used continuously or used
only when symptoms occurred. If the herbal product was used
continuously, the participant was asked how long the
product had been used. If the herbal product was used when
symptoms occur, the participant was asked how many times in
the last 12 months the product was used.
Effectiveness of herbal product. Effectiveness of
herbal product had four indicators that included not at
all, somewhat effective, very effective, and don't know.
Experience of adverse reaction. Experience of an
adverse reaction from using an herbal product was a
dichotomous variable coded zero/no when participant did not
experience any adverse reaction and one/yes when the
participant experienced any type of adverse reaction. If
the answer was yes, the participant was asked what kind of
adverse reaction she had experienced.
Sources of information. The participant was asked
where she had obtained the knowledge about herbal products.
The sources of information to use herbal products were
categorized into nine groups: (a) family members; (b)
friends and neighbors; (c) books or magazines; (d) TV,
radio, and newspapers; (e) computer Internet; (f) health

58
food stores; (g) health care providers; (h) alternative
care practitioners; and (i) others.
Health status variables
Eight indicators were utilized to identify the health
status and the use of prescribed and non-prescribed
medicines related to the health problems. These included
(a) overall health, (b) physical health, (c) emotional
health, (d) visit to doctor's or other health care
provider's clinic, (e) existence of health problems, (f)
seriousness of health problems, (g) number of medications
used and medication identification, and (h) use of any
herbal products.
Overall health, Physical health, and Emotional health.
A visual scale numbered one through five measured
these three variables. One indicated a poor health status
and five indicated an excellent health status.
Visit to a health care provider office or clinic.
The participant was asked two sets of questions. One
question asked whether she had visited a health care
provider office or clinic in the past 12 months. This
dichotomous variable was coded no or yes. If the response
was yes, a follow-up question asked was what health care
provider she had visited. Seven categories included (a)
family practitioner, (b) internal medicine, (c) surgeon,

59
(d) gynecologist, (e) nurse practitioner, (f) osteopathic
doctor (D. 0.), and (g) others.
Health problems. The participant was asked to
identify her health problems from 23 different illnesses.
The answer was coded zero when the problem did not exist
and one if the problem existed.
Interference with normal activities. The participant
was asked how seriously an illness interfered with her
normal activities. Interference with normal activities was
measured by a visual scale rating from one to five. One on
the visual scale indicated that the health problem did not
interfere with normal activities and five indicated that
the health problem interfered greatly with normal
activities.
Use of medications. The use of medications was a
dichotomous variable coded zero or one for each identified
illness. If the answer was yes, the participant was asked
to name all prescribed and non-prescribed medications for
each illness.
Use of herbal products. The use of herbal products
was a dichotomous variable coded zero when herbal products
had not been used and one when herbal products had been
used for each identified illness.

60
Procedure
The investigator obtained the list of names and
addresses of women aged 65 and over who resided in a North
Central Florida County from the Department of Motor Vehicle
and Safety in Tallahassee, Florida. The number of possible
accessible population was identified as 8,344 women in the
selected county. From the accessible population, at least
84 participants (42 subjects in each group) were required
to meet the effect size.
The investigator used a table of random digits (Rand
Cooperation: http://www.rand.org/software_and_data/
random/digits.txt) to select a sample. The Investigator
picked a starting point from the table of random digit by
closing eyes and pointing pencil on one number. From the
starting point of the table of random digits, 252 numbers
between 0001 and 8,344 were selected. The numbers selected
from the table were matched with the names from the list of
accessible population.
Letters were mailed to all 252 potential participants
to introduce the purpose of the study and request
participation in the study. A return self-addressed,
stamped postcard was enclosed with each letter. On the back
of the postcard, the investigator requested the return
response 'yes, I will participate in the study' and

61
requested a phone number to contact for interview, and 'no,
I will not participate in the study.' From the first 252
letters mailed, 53 subjects met the inclusion criteria and
completed the interview successfully. It was necessary to
recruit at least 31 more subjects for this research study.
The investigator repeated the same procedure of random
sampling technique for the first mailing list except the
first 252 names selected at the first round of sampling
were excluded. For the second round of sampling, 150
subjects were calculated to meet the minimum necessary 31
subj ects.
The investigator made a telephone call to each
participant who returned the postcard indicating a
willingness to participate in the study. The investigator
had a brief telephone conversation with each subject to
arrange the time and the meeting place for the interview.
Prior to conducting a structured interview, an informed
consent was obtained and a copy of the informed consent and
business card of the chairperson were provided to each
participant. Each participant was advised of her right as a
research participant and the right to decline without
penalty.
After an informed consent was obtained, the subject
was asked to answer the questions related to health status,

62
the use of prescribed and non-prescribed medicines, the use
of herbal products, and demographic information. The entire
interview required approximately 15-45 minutes per subject.
The participants were categorized into group 2, if they
answered 'no' to question number A76 of Questionnaire Part
A (Health Information). The participants in group 2 were
not asked to answer Part B (Herbal Product Use Information)
and continued to Part C (Demographic Information). The
participants were categorized into group 1, if they
answered 'yes' to the question number A76 of Questionnaire
Part A (Health Information). The participants in group 1
were asked to answer both Part B and Part C. Data
collection was completed when the total subjects numbered
86 (39 subjects in group 1 and 47 subjects in group 2).
After completion of the interview, the data were entered
into a data spreadsheet for analysis.
Data Collection
Data were collected to test the two research
hypotheses and to answer the four research questions.
Research Hypotheses
Hypo the sis One: There are differences in demographic
characteristics of women aged 65 years and older between
the herbal users and non-herbal users.

63
Demographic characteristics included education levels,
incomes, insurance status, race or religion. To test
hypothesis one, all participants were asked to answer the
'Health Information' questionnaire which included whether
the participant used herbal products. If the participant
used an herbal product, she was asked to answer the
'Herbal Product Information' questionnaire and the
'Demographic Information' questionnaire. If the
participant did not use an herbal product, she was asked
to answer the 'Demographic Information' questionnaire
without 'Herbal Product Information'. Subjects were
divided into two groups, one group of herbal product users
and another group of non-users, to compare differences in
demographic characteristics including education level,
income, insurance status, race or religion.
Hypothesis Two: There is a difference in health status
between herbal users and non-herbal users. Differences in
health status between the two groups was tested by
comparing illnesses, number of prescribed and non-
prescribed medicines the participant used, perception of
the participant's health status, and seriousness of
interference of normal activities.

64
Research Questions
Question 1: What was the prevalence of use of herbal
products among women 65 years and older?
Three types of information were collected to answer
question 1: First, the participant was asked to name the
all of the herbal products she had used in the last 12
months. The total number of herbal products used was
counted to calculate the average number of herbal products
used by all subjects. The most commonly used herbal
products were identified within the total group of
subjects. Secondly, to identify the period of time herbal
products were used, each participant was asked how long
herbal products had been used. She was also asked if she
ingested the herbal by mouth (internally) or applied the
herbal externally. The participant was asked whether she
used the herbal on a continual basis or intermittently.
Lastly, the participant was asked whether she purchased the
herbal product from a store in a ready-to-take form or if
she needed to prepare the herbal product prior to its use.
Question 2: What was the purpose for taking herbal
products by women aged 65 years and older? Did older women
take herbal products more for prevention or for treatment
of symptoms?

65
The following information was collected to identify
the purpose for which women 65 and older took herbal
products and to determine for which physical symptoms or
health conditions women most likely took herbal products.
The participant was asked about her overall health,
physical health, and emotional health status. The health
status was measured by a visual scale with a range of one
through five with one representing poor health and five
representing excellent health status. The participant was
asked the general purpose of taking herbal products to
identify whether she took herbáis to treat illness, to
prevent possible health problems or to maintain her current
health status, or for both treatment and preventive
purposes.
To identify the specific reasons for using herbal
products, the investigator identified common health
problems of the subject. The subject was asked the specific
reasons for taking the herbal products based on identified
common health problems among older women. The perceived
benefit of taking the herbal product was identified by the
participant and then whether she felt that the herbal
product was effective or ineffective. Data of perceived
adverse reactions were collected including the types of
adverse reaction experienced by the participant.

66
Question 3: What was the frequency of use of herbal
products by older women? Did women who use herbal products
use them continuously over time or on an as needed basis?
Did women who use herbal products use them alone or in
combination with prescribed and/or non-prescribed
medicines?
Three types of information were collected to answer
question three. First, the participant was asked the names
of prescribed and/or non-prescribed medicines she took for
her health problems. This information was later compared
with the findings of question two to describe whether the
herbal products were used alone or used in combination with
the conventional drugs. Secondly, the findings of question
three were compared with the findings of question two to
describe the use of herbal products alone or in combined
use with prescribed and/or non-prescribed medicines.
Thirdly, the investigator identified the frequency and
dosages of herbal products taken by each subject. Frequency
included either continual use or on an as needed basis.
Question 4: What sources did women 65 and over use to
obtain information about the use of herbal products?
To identify the source of information related to
herbal products used by women 65 years and over, the
participant was asked where she obtained information about

67
the herbal products that she was taking. Data related to
health insurance status and primary health care provider
were collected to identify a possible relationship between
types of providers or insurance status and the use of
herbal products. Data were collected to determine if the
primary physician or other health care provider was aware
of her use of herbal products.
Data Analysis
Descriptive statistics were performed to identify the
demographic characteristics of the participants, number of
medications used, number of herbal medications used,
sources of information and reasons for taking herbal
medications. Analysis of frequency was used to address each
research question. The student t-test and Chi-Square test
were used to determine if differences existed between older
women who used herbal products and those who did not use
herbal products.

CHAPTER IV
RESULTS
This chapter includes a description of the research
design, sample, demographic characteristics, and health
related characteristics of the sample. Also included in
this chapter are the results of the statistical analyses of
the data corresponding to the research hypotheses and
research questions.
Research Design
This research utilized a cross-sectional and
descriptive design to examine the prevalence of herbal
product use, types of herbal products used by the subjects,
and to identify the reasons herbal products were used among
women aged 65 and over. The investigator used a random
selection process to facilitate the selection of two groups
of subjects - those who used herbal products and those who
did not use herbal products.
Sample
A random sample of women who were 65 years of age and
over residing in a North Central Florida county was
selected for this study. A total of 8,344 women who were
68

69
registered at the Florida Division of Drivers License, were
identified as eligible sample by the State Department of
Highway Safety and Motor Vehicles. To obtain a sample size
of 84 subjects, three times this number or 252 possible
subjects were randomly selected from the 8,344 women (see
Table 4.1). Letters were mailed to the 252 possible
subjects describing the research purpose and requesting the
return of an enclosed postcard to schedule an interview.
From this mailing, 16 letters were undeliverable and 101
(40.1%) persons responded. Of the 101 respondents who
returned the postcards, 53 subjects completed interviews;
29 respondents declined participation; and 19 did not meet
inclusion criteria. Thirty-one additional subjects were
needed to attain the desired sample size.
An additional group of 150 people was selected for the
second mailing to add the needed 31 subjects. Random
sampling was repeated from a list of 8,344 persons,
excluding the 252 names of the first selection. From the
second mailing, 12 letters were undeliverable and 64
(42.7%) persons responded. Of the 64 respondents, 33
subjects completed interviews; 22 respondents declined
participation; and nine did not meet inclusion criteria.
In summary, 402 letters were mailed; 28 of the 402
letters were undeliverable, leaving 374 potential subjects.

70
Of 374 potential subjects, 165 (44.1%) responded. Of the
total 165 respondents, 86 subjects were completed interview
(52%), 51 declined an interview (31%), and 28 did not meet
inclusion criteria (17%) . Reasons for exclusion were (a)
five subjects had severe health problems, making an
interview impossible; (b) three subjects resided in nursing
homes or other types of assisted living facilities; (c) 12
subjects resided out of the county at the time of the
interview; (d) six subjects were deceased; and (e) two
subjects were unable to be contacted for the interview. Of
the 86 subjects who completed the interview, 39 used herbal
products and were assigned to group one and 47 did not use
herbal products and were assigned to group two.
Table 4.1
Frequency Distribution of Total Sample
Number
1st mailing
2nd mailing
Total
letters mailed
252
150
402
Undeliverable
16
12
28
Excluded respondents
19
9
28
Non-Respondents
135
74
209
Declined Interview
29
22
51
Interview completed
53
33
86

71
Demographic Characteristics of the Sample
The mean age of the sample was 74.9 years with a
standard deviation of 5.55 (range 65 - 90) (see Table 4.2).
The mean age of the 39 subjects of group one who used
herbal products was 75.4 years with a standard deviation of
5.80 (range 65 - 90). The mean age of the 47 subjects of
group two who did not use herbal products was 74.4 years
with a standard deviation of 5.37 (range 65 - 87).
Table 4.2
Age of Herbal Users, Non-Users, and Total Sample
Age
Herbal Users
(n=39)
Non
(n=
-Users
47)
Total Sample
(N=8 6)
Mean years (+SD)
75.4 (+5.80)
74 .
4 (+5.37)
74
.9 (+5.55)
Group (years)
N (%)
N (
%)
N
(%)
65 - 74
17 (43.6)
24
(51.1)
41
(47.7)
75 - 84
18 (46.2)
20
(42.6)
38
(44.2)
85 and over
4 (10.2)
3
(6.3)
7
(8.1)
Total Number
39 (100.0)
47
(100.0)
86
(100.0)
Of the total
group of subjects,
41 (47.7%)
were
married, 37 (43.0%
) were widowed,
and
. eight (9.
3%)
were
divorced (see Table 4.3). From the 39 herbal users in the
group one, 14 (35.9%) were married; 21 (53.8%) were
widowed; and four (10.3%) were divorced. Among the 47 non¬
users in the group two, 27 (57.5%) were married; 16 (34.0%)
were widowed; and four (8.5%) were divorced.

72
The sample consisted of 85 (98.8%) White Americans and
one (1.2%) Black American. No other race was reported. The
one Black American was an herbal product user and was
placed in group one.
Among the total sample, 27 (31.4%) had some college
education; 22 (25.6%) reported graduate level education
after completion of college; 21 (24.4%) were high school
graduates; 13 (15.1%) had college degrees; and three
subjects had less than high school education. Of the 39
herbal product users in group one, three (7.7%) subjects
had less than high school education; nine (23.1%) subjects
finished high school; 12 (30.8%) had some college
education; five (12.8%) subjects were college graduates;
and 10 (25.6%) subjects had graduate level education after
completion of college. Among the 47 subjects in group two,
no one had less than a high school education; 12 (25.5%)
completed high school; 15 (31.9%) had some college
education; eight (17.0%) were college graduates; and 12
(25.5%) had graduate level education after completion of
college.
Annual household income was categorized into four
groups: less than $ 20,000, $20,000 - $34,999, $35,000 -
$49,999, $50,000 or more. Seventy-nine (91.9%) subjects
responded while seven (8.1%) declined to answer the

73
question related to income. Eighteen (22.8%) subjects
reported their income to be less than $20,000; 23 (29.1%)
reported incomes of $20,000 - $34,999; 18 (22.8%) reported
incomes of $35,000 - $ 49,999; and 20 (25.3%) reported
their income level to be $50,000 or more per year. Of the
39 herbal product users in group one, household income of
eight (23.5%) subjects was less than $20,000; 12 (35.3%)
reported their income to be between $20,000 and $34,999;
seven (20.6%) reported their income to be between $35,000
and $49,999; and seven (20.6%) reported incomes of $50,000
or more per year. Among 47 non-users in group two, annual
household income of 10 (22.2%) subjects was less than
$20,000; 11 (24.4%) subjects were between $20,000 and
$34,999; 11 (24.4%) reported their income to be between
$35,000 and $49,999; and 13 (28.9%) reported an income of
$50,000 or greater.
With regards to religious preference, Protestant was
the most common religion (58, 67.4%) followed by Catholic
(11, 12.8%). Three (3.5%) subjects practiced the Jewish
religion; six (7.0%) reported other types of religion; and
eight (9.3%) claimed no religious preference. Protestant
was main religious preference in both herbal product users
(26, 66.7%) and non-users (32, 68.1%) .

74
Seventy-nine (92.9%) subjects had Medicare and
supplemental insurance; three (3.5%) reported Medicare as
their only insurance; two (2.3%) claimed Medicare and
Medicaid; one (1.2%) had only Medicaid; and one (1.2%) had
only private insurance. Of 39 the herbal product users, 35
(89.7%) had Medicare and supplemental insurance; one (2.6%)
had Medicare only; two (5.1%) reported Medicare and
Medicaid; one (2.6%) had private insurance. Among 47 non¬
users of group two, 44 (93.6%) subjects claimed Medicare
and supplemental insurance; two (4.3%) had Medicare only;
and one (2.1%) had Medicaid only. The summary of
demographic characteristics including marital status,
ethnicity, education, annual household income, religion,
and insurance status for the total sample, for the group of
herbal users, and for the group of non-herbal users is
illustrated in Table 4.3.
Table 4.3
Demographic Characteristics of the Total Sample, Herbal
Product Users, and Non-users
Characteristics
Herbal Users
(n=39)
Non
(n=
-Users
47)
Total Sample
(N—8 6)
Marital Status
N
(%)
N
(%)
N
(%) NS
Married
14
(35.9)
27
(57.5)
41
(47.7)
Widowed
21
(53.8)
16
(34.0)
37
(43.0)
Divorced
4
(10.3)
4
(8.5)
8
(9.3)
Never Married
0
(0.0)
0
(0.0)
0
(0.0)

75
Table 4.3. (continued)
Characteristics
Herbal Users
(n=39)
Non
(n=
-Users
47)
Total Sample
(N=8 6)
Ethnicity
White American
38
(97.4)
47
(100)
85
(98.8)
NS
African American
1
(2.6)
0
(0.0)
1
(1.2)
Hispanic-nonwhite
0
(0.0)
0
(0.0)
0
(0.0)
Other
0
(0.0)
0
(0.0)
0
(0.0)
Education
< High School
3
(7.7)
0
(0.0)
3
(3.5)
NS
=High School
9
(23.1)
12
(25.5)
21
(24.4)
12
(30.8)
15
(31.9)
27
(31.4)
^College Graduate
5
(12.8)
8
(17.0)
13
(15.1)
> Graduate School
10
(25.6)
12
(25.5)
22
(25.6)
Annual Income
< $20,000
8
(23.5)
10
(22.2)
18
(22.8)
NS
$20,000- $34,999
12
(35.3)
11
(24.4)
23
(29.1)
$35,000 - $49,999
7
(20.6)
11
(24.4)
18
(22.8)
> 50,000
7
(20.6)
13
(28.9)
20
(25.3)
Missing Data
5
(12.8)
2
(4.3)
7
(8.1)
Religion
Protestant
26
(66.7)
32
(68.1)
58
(67.4)
NS
Catholic
4
(10.3)
7
(14.9)
11
(12.8)
Jewish
1
(2.6)
2
(4.3)
3
(3.5)
Other
4
(10.3)
2
(4.3)
6
(7.0)
None
4
(10.3)
4
(8.5)
8
(9.3)
Insurance
Medicare &
Supplement
35
(89.7)
44
(93.6)
79
(92.9)
NS
Medicare only
1
(2.6)
2
(4.3)
3
(3.5)
Medicare &
Medicaid
2
(5.1)
0
(0.0)
2
(2.3)
Medicaid only
0
(0.0)
1
(2.1)
1
(1-2)
Private Ins. Only
1
(2.6)
0
(0.0)
1
(1.2)
NS - Statistically no significant difference between the
group of herbal-product users and the group of non-users
(p = 0.05)
Research Hypotheses
Research Hypothesis One
The first hypothesis stated that there was a
difference in demographic characteristics of women 65 years

76
or over between the group of herbal product users and the
group of non-users. To test the hypothesis, demographic
characteristics including age, education levels, marital
status, annual household income, and religious preference,
were compared between the two groups. Ethnicity was not
compared because all subjects except one Black American
were identified as White Americans. Insurance status was
not compared between the two groups since the total sample
had some type of insurance and the large majority had
Medicare ( 98%) .
The research hypothesis one was not supported. The t-
test was performed to test differences in age between the
two groups and no significant difference in mean age was
found between the two groups (t= 0.76, p=0.45). The two
groups were homogeneous with regard to marital status (x/!-
4.089, p=0.129). There was no significant difference in
education between the group of herbal users and the group
of non-users (xi=3.926, p=0.416). There were no significant
differences in annual household income (x2=3.265, p=0.514)
and in religious preference (x”=1.709, p=0.789) between the
two groups. In summary, the two groups were not
significantly different in demographic characteristics

77
including age, marital status, education, annual household
income, and religious preference.
Research Hypothesis Two
The second hypothesis stated that there was a
difference in health-related characteristics between the
group of herbal product users and that of non-herbal users.
The health-related characteristics included perception of
own health status, number of health care providers who were
visited, types of health-related problems and perception of
its seriousness, number of health problems, and number of
prescribed and non-prescribed medicines.
Perception of health status and health care providers.
Perceptions of health including overall health,
physical health, and emotional health were measured by a
visual scale that ranged from one to five. Five on the
visual scale represented excellent health; and one on the
visual scale represented poor health (see Appendix A).
Overall health was rated five on the visual scale by 25
(29.1%) of the total sample; four on the visual scale by 39
(45.4%); three on the visual scale by 20 (23.3%); and two
on the visual scale by two (2.3%) . No subject gave a rating
of one on the visual scale (see Table 4.4). Among 39 herbal
product users in group one, no subject gave a rating of
either one or two suggesting poor overall health; nine

78
(23.11) subjects rated three on the visual scale; 16
(41.01) subjects rated four; and 14 (35.9%) subjects rated
five suggesting excellent overall health. Among 47 non-
herbal product users in group two, no subject gave a rating
of one; two (4.3%) subjects rated two on the visual scale;
11 (23.4%) subjects rated three; 23 (48.9%) subjects rated
four; and 11 (23.4%) subjects rated five. There was no
significant difference in perception of overall health
between the two groups (%¿ = 3.100, p = 0.378).
Table 4.4
Perceived Overall Health by Herbal-Users, Non-Users, and
Total Sample
Visual Scale
(1-5)
Herbal Users
(n=39)
Non-Users
(n=47)
Total Sample
(N=86)
1 (Poor)
0
(0.0%)
0
(0.0%)
0
(0.0%)
2
0
(0.0%)
2
(4.3%)
2
(2.3%)
3
9
(23.1%)
11
(23.4%)
20
(23.3%)
4
16
(41.0%)
23
(48.9%)
39
(45.4%)
5 (Excellent)
14
(35.9%)
11
(23.4%)
25
(29.1%)
Total
39
(100.0%)
47
(100.0%)
86
(100.0%)
Physical health was rated two on the visual scale by
three (3.5%) subjects; three on the visual scale by 21
(24.4%) subjects; four on the visual scale by 41 (47.7%)
subjects; and five on the visual scale by 21 (24.4%)
subjects (see Table 4.5).

79
Table 4.5
Perceived Physical
Health by
Herbal-Users,
Non
-Users, and
Total Sample
Visual Scale
Herbal Users
Non
-Users
Total Sample
(1-5)
(n=
39)
(n=
47)
(N=
86)
1 (Poor)
0
(0.0%)
0
(0.0%)
0
(0.0%)
2
1
(2.6%)
2
(4.3%)
3
(3.5%)
3
10
(25.6%)
11
(23.4%)
21
(24.4%)
4
18
(46.2%)
23
(48.9%)
41
(47.7%)
5 (Excellent)
10
(25.6%)
11
(23.4%)
21
(24.4%)
Total
39
(100.0 %)
47
(100.0%)
86
(100.0%)
Among subjects in group one, no subject gave a rating
of one suggesting poor physical health; one (2.6%) subject
rated two; 10 (25.6%) subjects rated three; 18 (46.2%)
subjects rated four; and 10 (25.6%) subjects rated five
suggesting excellent physical health. Among 47 non-herbal
product users in group two, no subject gave a rating of
one; two (4.3%) subjects rated two; 11 (23.4%) subjects
rated three; 23 (48.9%) subjects rated four; and 11 (23.4%)
subjects rated five. There were no significant differences
in perception of physical health between the two groups (%2
= 0.297, p - 0.961) .
Emotional health was rated two on the visual scale by
one (1.2%) subject; rated three on the visual scale by six
(7.0%); rated four by 27 (31.4%); and five or excellent on
the visual scale by 52 (60.4%) subjects (see Table 4.6).

80
Table 4.6
Perceived Emotional Health by Herbal-Users, Non-Users, and
Total Sample
Visual Scale
Herbal Users
Non
-Users
Total Sample
(1-5)
(n=
39)
(n=
47)
(N-
86)
1 (Poor)
0
(0.0%)
0
(0.0%)
0
(0.0%)
2
1
(2.6%)
0
(0.0%)
1
(1.2%)
3
2
(5.1%)
4
(8.5%)
6
(7.0%)
4
10
(25.6%)
17
(36.2%)
27
(31.4%)
5 (Excellent)
26
(66.7%)
26
(55.3%)
52
(60.4%)
Total
39
(100.0%)
47
(100.0%)
86
(100.0%)
Among subjects in group one, no subject gave a rating
of one suggesting poor emotional health status; one (2.6%)
subject rated two; two (5.1%) subjects rated three; 10
(25.6%) subjects rated four; and 26 (66.7%) subjects rated
five suggesting excellent emotional health. Among subjects
in group two, no subject gave a rating of either one or two
on the emotional health status; four (8.5%) subjects rated
three; 17 (36.2%) subjects rated four; and 26 (55.3%)
subjects rated five, which represents excellent emotional
health. There was no significant difference in perceived
emotional health between the group of herbal product users
and that of non-users (%“ =2.761, p = 0.430) .
A large number of the total sample visited at least
one health care provider in the past 12 months. Eighty-
three subjects (96.5%) visited at least one health care
provider in the past 12 months. Only three subjects (3.5%)

81
had not visited any type of health care provider within the
past 12 months. Two of three subjects who did not visit any
health care provider were herbal product users.
The mean number of health care providers reported by
the sample was 2.56 (SD = 1.38, range 0 - 7). The average
number of health care providers the herbal product users
reported was 2.31 (SD = 1.42, range 0-7) in comparison to
2.77 health care providers (SD = 1.32, range 0-6)
reported by non-users. There was no significant difference
in number of health care providers that the sample had
between the group of herbal product users and the group of
non-users (t =1.549, p = 0.063) . Internal medicine was the
most frequently visited specialty reported by 55 (64%)
subjects, and the second most frequently visited was family
practice reported by 35 (40.7%) subjects.
Types and seriousness of health-related problems.
Among 86 subjects of the total sample, 85 (98.8%)
reported at least one or more problems from the 23
categories of health-related problems (see Table 4.7). Of
the health-related problems reported, arthritis (55.8%),
allergies (48.8%), and fatigue (45.3%) were identified as
major health-related problems by about half of the total
sample followed by back problems (39.5%), digestive
problems (34.9%), and urinary problems (32.6%). Other

82
health problems commonly reported by subjects were skin
problems (29.1%), heart problems (27.9%), high blood
pressure (26.7%), and memory problems (22.1%). The average
number of health-related problems reported by each subject
was 5.8 problems. The group of herbal users (39 subjects)
identified an average of 6.1 health-related problems while
an average of 5.5 health-related problems was reported by
the group of non-users (47 subjects) .
Each health-related problem in 23 different areas was
compared between the group of herbal users and that of non¬
users. There was significant difference in memory problem
between the two groups {%2 = 5.238, p = 0.022). Thirteen
subjects in the group of herbal product users reported
memory problems while six subjects of the counter part
reported memory problems. Differences were not found in
other areas of health-related problems between the two
groups (see Table 4.7).
Table 4.7
Types of Health-Related Problems (N=86)
Number and Types of
Problems
Herbal
Product
users
Non-
Users
Total
Users
N (%)
P
No. of Health Problems
X
6.08
5.53
5.78
SD
3.13
3.15
3.13
Range
(1-14)
(0-12)
(0 - 14)
Arthritis
23
25
48 (55.8)
NS

83
Table 4.7 (continued)
Number and Types of Herbal Non- Total
Problems Product Users Users p
users N (%)
Allergies
20
22
42
(48.8)
NS
Fatigue (low energy)
17
22
39
(45.3)
NS
Back problems
20
14
34
(39.5)
NS
Digestive Problems
14
16
30
(34.9)
NS
Urinary problems
13
15
28
(32.6)
NS
Skin problems
13
12
25
(29.1)
NS
Heart problems
9
15
24
(27.9)
NS
High Blood Pressure
8
15
23
(26.7)
NS
Dizziness
10
9
19
(22.1)
NS
Memory problems
13
6
19
(22.1)
ha
ii
o
o
Anxiety
6
9
15
(17.7)
NS
Blood & Circulatory
7
7
14
(16.3)
NS
problems
Chronic Pain
9
5
14
(16.3)
NS
Cold & Flu
6
8
14
(16.3)
NS
Obesity
8
4
12
(14.0)
NS
Headache
4
7
11
(12.8)
NS
Cancer
2
7
9
(10.5)
NS
Diabetes
1
7
8
(9.3)
NS
Depression
4
3
7
(8.1)
NS
Lung problems
3
4
7
(8.1)
NS
Gynecological problems
1
0
1
(1.2)
NS
Others
26
28
54
(63.8)
NS
Notes: NS = no significant difference between the group of
herbal product users and the group of non-users
(p = 0.05)
Each subject was asked about the seriousness of
identified health-related problems in her daily living by

84
using a visual scale which ranged from one to five. One
represented no interruption in daily living from the health
problem, while five represented an extremely serious
interruption in daily living from the identified health-
related problem. Seriousness of each health-related problem
was compared between the two groups in all 23 areas. The
two groups were homogeneous with respect to seriousness of
health-related problems in all areas except obesity. The
group of herbal product users and the group of non-users
were not homogeneous in regards to seriousness of obesity
(Fisher's Exact 2-Tail Test, p = 0.0222) although the two
groups were homogeneous with regards to obesity as a
health-related problem [%¿-2.557, p=0.129).
Of all subjects who reported health-related problems,
the majority indicated that the seriousness of health
problems in their daily living was three, two or one on the
visual scale. The seriousness of memory problems in
interfering with everyday life was not significantly
different between the group of herbal product users and the
group of non-users (x2=2.219, p=0.708) although the two
groups were different in the frequency of memory as a
health-related problem.

85
Use of prescribed and non-prescribed medicines.
The use of prescribed medicines was reported by 75
(87.2%) of the total sample. The average number of
prescribed medicines used by the total sample was 3.20
medicines (SD = 2.40; range 0 - 10); herbal product users
reported a mean of 3.00 medicines (SD = 2.21; range 0 - 8);
and non-users reported mean of 3.36 medicines (SD = 2.56;
range 0 - 10). There was no significant difference in the
use of prescribed medicines between the group of herbal
product users and that of non-users (t=1.75, p=0.08).
All but one of the total sample (98.8%) reported the
use of non-prescribed medicines. The mean number of non-
prescribed medicines used by the total sample was 3.79
medicines (SD = 1.90; range 0-9); herbal product users
reported a mean of 4.18 medicines (SD = 1.94; range 1 - 9);
and non-users reported a mean of 3.47 medicines (SD = 1.82;
range 0 to 8) .
Of the non-prescribed medicines used by sample, many
of them were taken on a regular basis. The most frequently
used non-prescribed medicines taken regularly were
multivitamin, calcium, vitamin E, vitamin C, and aspirin
(see Table 4.8). More than one-third of the total sample
was using at least one of these five non-prescribed
medicines. Of the forty-eight subjects (55.8%) in the total

86
sample who used multivitamins, 22 (56.4%) were herbal
product users and 26 (55.3%) were non-herbal product users.
Calcium was the second most frequently used
non-prescription medicine among the sample. Forty-seven
(54.7%) subjects in the total sample were taking calcium
including 20 (51.3%) were herbal-product users and 27
(57.4%) were non-users. Forty-one subjects (47.1%) in the
total sample were taking Vitamin E; 22 (56.4%) subjects
from the herbal-product users and 19 (40.4%) from the non¬
users. Among 29 subjects (33.3%) from the total sample who
used vitamin C, 18 (46.2%) were herbal-product users; and
11 (23.4%) were non-users. Aspirin was regularly used by 27
subjects (31.4%) in the total sample. Eleven subjects
(28.2%) were herbal-product users and 16 (34.0%) were non¬
users .
Table 4.8
Frequently Used Non-prescribed Medicines Taken Regularly
Non-prescribed
medicines
Herbal-Product
Users (n=39)
No. (%)
Non
(n=
No.
-Users
47)
(%)
Total
(N=86)
No. (%)
Multivitamin
22
(56.4)
26
(55.3)
48
(55.8)
Calcium
20
(51.3)
27
(57.4)
47
(54.7)
Vitamin E
22
(56.4)
19
(40.4)
41
(47.1)
Vitamin C
18
(46.2)
11
(23.4)
29
(33.3)
Aspirin
11
(28.2)
16
(34.0)
27
(31.4)

87
There was no significant difference in the number of
non-prescribed medicines used between the group of herbal
product users and non-users (t=0.69, p=0.49). In summary,
the average number of medicines including both prescribed
and non-prescribed medicines for each subject of the total
sample was 6.99 medicines (SD = 2.85; range 1 - 17). The
average number of total medicines used by herbal product
users was 7.18 medicines (SD = 2.80; range 1 - 17), while
the non-herbal product user group used 6.83 medicines (SD =
2.9; range 2 - 15). There was no significant difference in
the use of total number of medicines between the two groups
(t=0.56, p=0.57). The summary of the use of prescribed,
non-prescribed, and total number of medicines used by
sample is illustrated in Table 4.9.
Table 4.9
Use of Prescribed, Non-prescribed Medicines by Sample
(N=86)
Medicines (n)
Herbal Users
(n=39)
X SD
(Min-Max)
Non-Users
(n=47)
X SD
(Min-Max)
Total
(N=8 6
X
(Min-
Sample
)
SD
Max)
Total
7.18
+2.80
6.83
±2.91
6.99
±2.85
NS
Medicines
(1 -
17)
(2 -
15)
(1 â– 
17)
Prescribed
3.00
±2.21
3.36
±2.56
3.20
±2.4 0
Medicines
(0 -
8)
(0 -
10)
(0 -
10)
Non-prescribed
4.18
±1.94
3.47
±1.82
3.79
±1.90
NS
Medicines
(1 -
9)
(0 -
8)
(0 -
9)
NS = Statistically not significant between the group of
herbal product users and non-users (p = 0.05)

Description of the Research Questions
Research Question One
The first research question was stated as, what is the
prevalence of use of herbal products among women 65 years
and older. Of the total sample of 86 subjects, 39 (45.3%)
reported using herbal products in the past 12 months. A
total of 98 herbal products were used by the 39 subjects,
which averaged 2.51 herbal products per subject
(SD = 2.16; range 1 - 11). The three most commonly used
herbal products were Ginkgo Biloba or Ginkgo Biloba with
other combinations (12 subjects), garlic tablets and cloves
(11 subjects), and Glucosamine with Chondroitin (8
subjects). Ninety-two herbal products (93.9%) were taken
orally, while six (6.1%) herbal products were used
externally. About three-quarters (76%) of the total number
of herbal products were in a ready-to-take form such as
tablets, capsules, or liquid preparations; and 24% of the
herbal products required some preparation by the subjects.
The types of herbal products used by the subjects are
illustrated in Table 4.10.

89
Table 4.10
Types of Herbal Products Used by Subjects
Name (n) Name (n)
Ginkgo or Ginkgo combinations
(12)
Garlic (11)
Glucosamine w/ chondroitin (8)
Aloe (5)
Herbal Tea (Parsley, Basil,
Peppermint tea) (4)
Echinacea (4)
Ginger (4)
St. Johns Wort (3)
Vinegar w/Honey (3)
Primrose (3)
G.H.3 (2)
Ginseng (2)
Green Tea (2)
Selenium (2)
Flax Oil Complex or Flax Tea
(2)
Pure Cranberry Juice (1)
Pantothenic Acid (1)
Melatonin (1)
Papaya Capsules (1)
Manchurian Mushroom Tea (1)
Sesame Oil w/ five whole
cloves (1)
Stevia Liquid Extract (1)
Cayenne Pepper Capsules (1)
Nature's Tea (Colon Cleanser)
(1)
Paprika Powder (1)
Hot Spicy Pepper (1)
Shark Cartilage (2)
Barley Green (1)
Grapefruit Seeds Extract (1)
Anica (1)
MSM (1)
Bakuchi Oil (1)
Triphala Tea (1)
Grape Seeds Extract (1)
Spiru-Tein (1)
Co Q-10 (1)
Acidophilus (1)
Cod Liver Oil w/ Whole Milk
Soy Bean Oil Beta Carotene
(1)
Lecithin Capsules (1)
Provex (1)
Seven Forests (1)
Eight Prunes (1)
Chromium Picolinate (1)
Liver Flush (Mix of Olive
Oil, Lime Juice, Apple Cider
Vinegar, & Red Pepper) (1)
Calms Forte (1)
Ghee w/ boiled Butter (1)
Brewer's Yeast w/ Orange
Juice, or Milk and Honey (1)

90
Research Question Two
The second question was stated as what is the purpose
for taking herbal products and/or herbs by women 65 years
and over. Do older women take herbal products more for
prevention or for treatment of symptoms?
Of the persons taking herbáis, 16 (41%) reported using
herbal products to maintain health or to prevent possible
health problems. Nine subjects (23%) used herbal products
for treatment of health problems. Fourteen subjects (36%)
used herbal products both to prevent and to treat health
problems (see Table 4.11). Of the 98 herbal products used
by the subjects, 55 (56.1%) products were used to prevent
health problems or to maintain health, while 43 (43.9%) of
the herbal products were used to treat health problems. The
three major purposes for using herbal products other than
prevention were to improve memory, to treat arthritis, and
to remedy digestive problems.
Table 4.11
Purposes of Using Herbal Products by Subjects and by Number
of Herbal Products
Reasons to take herbal
Subj ects
No.
of Herbal
products
(n=
=39)
Products (n=98)
To treat health problems
To maintain health or
9
(23%)
43
(43.9%)
prevent health problems
For both treatment and
16
(41%)
55
(56.1%)
prevention purposes
14
(36%)
N/A
Total
39
(100%)
98
(100%)

91
The perceived benefit of taking the herbal products
was also identified. About one-half of the herbal products
(47.9%) were perceived by subjects to be somewhat effective
or very effective while the effectiveness of 40.6% of
herbal products was unknown. Only one subject reported any
side effect from taking the herbal products. This subject
reported diarrhea as a side effect after taking gingerroot
tablets for a period of three months.
Research Question Three
The research question was stated as what is the
frequency of use of herbal products by women aged 65 and
over. Do women who use herbal products use them
continuously over time or on an as needed basis? Do women
who use herbal products use them alone or in combination
with prescribed and /or non-prescribed medicines?
Thirty-nine subjects in group one used a total of 98
herbal products with a mean of 2.51 herbal products per
subject (SD = 2.16, range 1 - 11). Subjects reported that
85.4% of the herbal products used were taken on a continual
basis. These products had been used for a mean of 34.8
months with a standard deviation of 92.3 months (range one-
half month - 600 months). Fourteen herbal products (14.6%)
were used when symptoms occurred. Of the 98 total herbal

92
products used by the subjects, 14 (14.3%) were used in
combination with prescribed or non-prescribed medicines to
treat health problems. Twenty-nine herbal products (29.6%)
were used alone for treating health problems reported by
the subjects. Fifty-five herbal products (56.1%) were taken
for the purpose of maintaining health and/or preventing
possible health problems. Data indicated that, of 41 herbal
products used for treating health problems, 27 were taken
on continual basis, while 14 of 49 herbal products were
used only when symptoms occurred.
Research Question Four
The research question was stated as what sources do
women 65 years and over use to obtain information about
herbal products? The primary sources used by the subjects
to obtain information related to the use of herbal products
were as follows: (a) 22 subjects used books or magazines;
(b) 19 subjects were informed by family members; (c) 16
subjects used friends and neighbors; and (d) 14 subjects
used television, radio or newspapers. Other sources used to
gain information were alternative health care
practitioners, health care providers, health food stores,
and newsletters. No subject reported obtaining information
from the Internet.

93
Other Findings
Ninety-six (98%) of the total of 98 herbal products
used by the sample were purchased with self-payment by
subjects. Two herbal products (2%) were obtained free from
relatives of subjects. Health insurance companies did not
pay for any herbal products used by subjects.
Among 98 herbal products reported by 39 subjects, 71
herbal products (72.4%) were not reported to the health
care providers of the subjects, while 27 herbal products
(27.6%) were reported to the health care providers. Of 39
herbal product users, 16 subjects (41%) reported their use
of herbal products to their health care providers. Although
16 subjects who reported their use of herbal products, not
all herbal products used by these 16 subjects were reported
to their health care provider, which indicated only part of
the herbal products they used were reported. While 48
herbal products from a total of 98 herbal products consumed
by 16 subjects who reported their use of herbal products,
only 27 of 48 herbal products were reported to their health
care providers. Health care providers who were the most
frequently informed of the use of herbal products were
internists by eight subjects and family practices by four
subj ects.

94
In summary, the research findings did not show
differences in demographic characteristics and in the
characteristics of health status between the group of
herbal product users and non-users. However, herbal product
users reported significantly more memory problems than the
group of non-users although perceived seriousness of memory
problems in daily living was not significantly different
between the two groups.
Research results indicated that many older women in
the community used herbal products for the purposes of
preventing possible health problems and for promoting their
current health status as well as for treating health
problems. Major resources for obtaining the information
about herbal products were media, mainly magazines and
newsletters. Many herbal products taken by subjects were
not reported to health care providers and no payment for
herbal products was made by health insurance.

CHAPTER V
DISCUSSION AND RECOMMENDATIONS
The purpose of this research was to explore the use of
herbal products for medicinal purposes and to compare
differences in demographic characteristics and in
characteristics of health status between the group of
herbal product users and the group of non-users among
community-dwelling women aged 65 years and over.
Data were examined from a random sample of women aged
65 years and over residing independently in a North Central
Florida county. This chapter presents a discussion of the
findings and the conclusions of the study according to the
hypotheses and research questions. This chapter also
presents recommendations for future research and
implications for nursing practice.
Discussion and Conclusions
The data indicated that the group of herbal product
users and the group of non-users were homogeneous in
demographic characteristics including age, marital status,
ethnicity, level of education, level of income, religious
95

96
preference and insurance status. With one exception, the
groups were also homogeneous in characteristics related to
their health status. There was a statistically significant
difference in the reported incidence of memory problems
between the two groups, with the group using herbal
products reporting a higher incidence.
Demographic Characteristics of the Sample
According to the U.S. Bureau of the Census, residents
who are 65 years and over comprise 9.2% of the total
resident population in this North Central Florida county
(U.S. Bureau of the Census: 1990—US Census Data C90STF1A
Summary Level: State—County, http://www.census.gov/cgi-
bin/datamap/cnty?12=001). The ratio of females to males in
the 65 years and over group in this county was 60.9% and
39.1% respectively (see Table 5.1).
Table 5.1
Frequencies and Percentages of Females and Males Aged 65
and Over in a North Central Florida County (N=16,765)*
Gender
Frequency
Percentage
Female
10,203
60.9
Male
6, 562
39.1
* 1990 Census by the U.S. Bureau of the Census
Females, who were 65 years and over in this county
were comprised of 81.2% white; 17.0% black; 1.3% Hispanic
origin; 0.3% Asian or Pacific Islander; and less than 0.1%

97
American Indian, Eskimo, or Aleut (U.S. Bureau of Census:
1990—US Census Data C90STF3A Summary Level: State—County,
http://venus.census.gov/cdrom/lookup/908144154) (see Table
5.2) .
Table 5.2
Summary of Races among Females aged 65 and over (N=10,203)*
Race
Frequency
Percent
White
8,287
81.2
Black
1,738
17.0
Hispanic
origin
135
1.3
Asian or
Pacific
Islander
34
0.3
American
Aleut
Indian,
Eskimo, or
9
0.1
Race was not identified on the list of potential
subjects from the State Department of Highway Safety and
Motor Vehicles. Therefore, it was not possible to know the
race distribution of the sample. In spite of a random
sampling procedure, from 86 subjects, 85 (98.8%) were White
Americans and one (1.2%) was African American. The racial
distribution for non-respondents for persons who declined
interviews or persons who were excluded from the study was
unknown. There appears to be an under-representation of
African Americans and other minorities in this sample. The
reasons for this under representation of African Americans
and other minorities are unknown. The possible reasons may
be that African Americans 65 years and over are less likely

98
than White Americans to (a) have a drivers license; (b)
respond to requests for participation in research; and (c)
to agree to an interview.
The level of education of the sample was slightly
higher than the average educational level of the County
studied. According to the data of USA counties 1996
provided by the U.S. Bureau of the Census, the percentage
of college graduates was 34.6% among persons 25 years and
over in 1990 in this North Central Florida county (U.S.
Bureau of the Census, USA Counties 1996). In the study
sample, 37.7% were college graduates or postgraduates,
31.4% reported some years of college education, and 24.4%
graduated from high school. The educational level of this
sample is consistent with other studies which related to
the use of alternative medicines (Eisenberg et al., 1993;
Eliason, Kruger, Mark, & Rasmann, 1997) . The results of
this study showed that there was no significant difference
in the level of education between the group of herbal
product users and the group of non-users.
In conclusion, there was no difference between
subjects who used herbal products and those who did not use
herbal products related to demographic characteristics
including marital status, level of education, annual
income, religious preference, and insurance status.

99
Findings related to race were inconclusive due to a small
sample size of African Americans.
Characteristics of Health Status
Among the sample of 86 subjects, 83 (96.5%) subjects
visited at least one type of health care provider in the
past 12 months and averaged 2.56 different types of health
care providers (SD = 1.38, range 0-7). Health care
providers were aware of only about one-fourth of the total
number of herbal products used, which meant that
three-quarters of herbal products consumed by older women
were unknown to their health care providers. Even though
subjects identified and visited their health care
providers, they did not share information related to the
use of herbal products.
Perception of health was examined by asking subjects
about their own perception of overall health, physical
health, and emotional health. Most subjects perceived that
their overall health, physical health, and emotional health
were good or excellent for their age, although the sample
reported an average of 5.8 health-related problems and
reported taking an average of more than three prescribed
medicines each. Most subjects considered their health-
related problems not extremely serious, not serious enough

100
to interrupt daily activities, and relatively well
controlled with medications.
All of the subjects in this study were taking at least
one prescribed or non-prescribed medicine. The number of
medications reported by these subjects (a mean of 3.20
prescribed medicines, 3.79 non-prescribed medicines and
combined 6.99 medicines) were within the range reported in
previous studies. Reports of prescription drug use by
community dwelling elders have ranged from averages of 1.5
to 6.1 medications; whereas, figures on non-prescription
drug usage have ranged from 1.3 to 4.6 (Darnell, Murray,
Martz, & Weinberger, 1986; Pollow, Stoller, Forster, &
Duniho, 1994; Shimp, Ascione, Glazer, & Atwood, 1985).
While vitamins and mineral products were considered as non-
prescribed medicines in the present study, it is unclear if
these products were considered as medications in the
previous studies. The data from the present study suggest
that 71 (82.6%) subjects from a total of 86 subjects
practice a self-care regimen by using multiple vitamins and
minerals to maintain their health.
Use of Herbal Products
Based on prior research, the use of herbal products
ranges from three percent to 80%. Past studies have varied
in geographical areas as well as age of subjects.

101
(Eisenberg et al., 1993; Frate et al., 1996; WHO, 1993).
The results of this study in a North Central Florida county
indicated that 461 of community-dwelling women 65 years and
over are users of herbal products. Both men and women 18
years and over were studied by Eisenberg and colleagues
(1993), Frate and colleagues (1996), and WHO (1993) and the
prevalence of use of herbal products from these samples
were reported to be 3%, 70% and 80% respectively.
Although it is difficult to compare the results of
these studies because of the different characteristics of
the samples, data from the present study suggest that the
use of herbal products among older women is common (almost
one of two older women). The primary use of herbal products
by this sample was for prevention and self-treatment. The
use of herbal products for the purpose of prevention of
health problems was more prevalent than the use of herbáis
for self-treatment among women in this study. Most of the
herbal products (85.6%) were taken on a continual basis
rather than as intermittent use.
The use of herbal products in this study was more
likely to be a ready-made form for easy usage, such as
tablets and caplets, rather than using parts of the
original plant and further preparing the herb for use. The
practice of taking a tablet or capsule is in synchrony with

102
the current U.S. societal attitude of a "quick fix." This
sample was more likely to digest the herb internally rather
than applying the herb externally.
The most commonly consumed herbal products in this
study were Ginkgo Biloba or Ginkgo combinations, garlic,
Glucosamine with Chondroitin, aloe, herbal teas, Echinacea,
and ginger. Eliason and colleagues (1997) indicated that
the most commonly used herbal products in their study were
garlic, Ginseng, Ginkgo Biloba, Evening primrose oil,
Echinacea, and Alfalfa. Frate and colleagues (1996)
reported that lemon, aloe, castor, turpentine, tobacco, and
garlic were the most frequently mentioned plant-derived
medicines. According to Ernst (1998), the popular herbal
products are Echinacea, Garlic, Goldenseal, Ginseng, Saw
palmetto, aloe, Ma huang, and cranberry. The types of
commonly used herbal products in this study were consistent
with previous studies (Eliason et al., 1997; Ernst, 1998;
Frate et al., 1996) identifying garlic, Ginkgo Biloba,
aloe, and Echinacea as commonly consumed herbal products.
The group of herbal product users in the present study
indicated that they identified more memory problems than
the group of non-users; however, the group of herbal
product users did not consider that memory problems
affected their everyday living more seriously than

103
non-users. As a result, Ginkgo Biloba was the most
frequently used herbal product by older women in this
study. Gingko Biloba was used to maintain present memory
status, to improve memory, or to prevent possible memory
problems.
The results of this study indicated that a variety of
herbal products was used for self-treatment and self-care
based on self-diagnosis by older women. From the list of
health problems (see Appendix A) identified by older women
in this study, arthritis was the most frequently mentioned
problem by both herbal product users and non-users. The
subjects who used herbal products reported frequent use of
Glucosamine with chondrotin for the treatment of arthritis.
Many older women in this study were concerned about
possible high blood pressure and heart problems and
frequently used garlic to maintain their current health
status and to prevent possible cardiovascular problems.
Information about herbal products was obtained mainly
through media such as magazines, books, newsletters, and
television. Other sources of herbal product information
were commonly family members, friends, and neighbors. About
half of the herbal products used by subjects were believed
to be somewhat effective or very effective. The
effectiveness of more than 40% of herbal products that

104
subjects used was not known. In spite of not recognizing an
immediate benefit of using herbal products, reasons for
using these herbal products continually were that they
would not be harmful and the products would be beneficial
to the person someway or someday.
Issues Related to Use of Herbal Products
It was apparent that many older women have used herbal
products for their health care practice along with
conventional medicines based on their own judgement about
health and the herbal products. However, this study
identified a few problems of using the herbal products in
spite of their perceived benefit as natural products. The
first identified problem related to the ingredients of the
herbal product. When subjects informed the investigator of
the herbal product they used, there was more than one
ingredient contained in the product. The ingredients were
written on the label in very small letters, which older
adults find difficult to read. Therefore, subjects did not
know exactly what ingredients were being consumed.
Secondly, the investigator identified that subjects were
inconsistent in the dose of herbáis taken since the dosage
varied between brands of the same herbal products. Thirdly,
although it was claimed that some herbal products were
safer than conventional medicines in clinical tests of the

105
safety of herbal products (Ernst, 1998), the herbal and
drug interactions or herbal and herbal interactions are
basically unknown. Therefore, there were potential risks
for subjects who were taking herbal products in combination
with conventional medicines for treating their problems.
Many health care providers did not ask their clients
about the use of herbal products and, therefore, did not
recognize the use of herbal products by their clients. As a
result, it is possible for health care providers to make
erroneous decisions in prescribing conventional medications
to clients, if the knowledge of herbal product use by their
clients is unknown.
Finally, although more than one-half of the herbal
products was believed to be effective, persons using herbal
products have little to no basis for judging effectiveness
of the products. Subjects were not in sure of the
effectiveness of approximately less than one-half of the
herbal products used in this study and this was the major
reason that some subjects discontinued use of the herbal
product. Duration of use of herbal products showed a wide
range of time the product was taken.
In summary, there are no requirements to demonstrate
safety and efficacy through clinical testing or for use of
herbal products. This lack of requirement does not negate

106
the importance of knowledge related to possible drug
interactions associated with the use of herbal products.
Implication for Nursing and Recommendations
This study has important implications for nursing
practice. With the knowledge that approximately 50% of
women over 65 years of age use some form of herbal product,
and the majority do not discuss this use of herbáis with
their health care providers, it behooves nurses to include
questions about the use of herbal products as a routine
part of their history taking process. This information
should not only be obtained from women with chronic
illnesses, but also from women who are preventive care.
Nurses need a better understanding of the herbal
products that people use since they are often the first
health care providers to interview individuals seeking
medical assistance. It is believed that most nurses have
minimal knowledge related to the use of herbal products. It
is recommended that information about herbal products be
included in nursing education curriculum and that
continuing education programs be offered for practicing
practitioners.
There are also implications for future research on the
topic of the use of herbal products. Researchers need to
examine the use of herbal products among different ethnic

107
groups, different age groups, and in different geographical
settings. Further studies are needed to examine the
possible interactions between herbal products and
conventional medicines. Intervention or case-controlled
studies could help to determine the effectiveness of the
use of herbal products to maintain health, to prevent
illness, or to treat specific disease conditions.
Little is known about the relationship between the use
of herbal products and memory loss. Findings from this
study suggest that there is a difference between persons
with perceived memory problems who use herbal products and
those who do not use herbáis. Persons who use herbáis are
more likely to claim memory problems than those who do not
use herbáis. Alzheimer's Disease and related memory
disorders are more common among older women than any other
age or gender group. Also, there are few scientifically
supported interventions for most memory disorders.
Therefore, it is not surprising that older women are
actively seeking help for this problem. Research needs to
be done to replicate this finding. Also, researchers should
identify the relationships between the use of herbal
products and memory problems. For example, are persons with
memory problems more likely to take herbal products than
those without memory problems; or are persons who take

108
herbal products more likely to have memory problems than
those who do not take herbáis. As with any intervention,
studies need to be done to validate the effectiveness of
the intervention.
It appears that in the past, health care professionals
have basically ignored the use of herbal products by their
clients. Marketing through radio, television, and written
media has greatly impacted the use of these products. The
benefits versus risks of herbal use are unknown. Yet, as
any product taken alone or in combination with conventional
medicines, herbal products need to be examined for
effectiveness, risks, and safety rather than to be left to
the individual persons or the marketplace for the
determination of these factors.

REFERENCES
Ackerknecht, E. H. (1973) . Therapeutics: From the
primitives to the 20th century. New York: Hefner Press.
Anderson, L. A. (1996). Concern regarding herbal
toxicities: Case reports and counseling tips. The Annals
of Pharmacotherapy, 30, 79-80.
Boisset, M., & Fitzcharles, M. A. (1994).
Alternative medicine use by rheumatology patients in a
universal health care setting. The Journal of
Rheumatology, 21, 148-152.
Brown, J. S., & Marcy, S. A. (1991). The use of
botanicals for health purposes by members of a prepaid
health plan. Research in Nursing and Health, 14, 339-
350.
Brunton, S. A. (1984) . Physicians as patient
teachers. Western Journal of Medicine, 141, 855-860.
Buchman, D. D. (1980). Herbal medicine. New York:
Gramercy Publishing Co.
Burg, M. A. (1996). Women's use of complementary
medicine: Combining mainstream medicine with alternative
practices. Journal of Florida Medical Association, 83,
482-488.
Cassileth, B. R., & Chapman, C. C. (1996).
Alternative and complementary therapies. Cancer, 77,
1026-1034.
Chenitz, W. C., Salisbury, S., & Stone, J. T.
(1990). Drug misuse and abuse in the elderly. Issues in
Mental Health Nursing, 11, 1-16.
109

110
Chrischilles, E. A., Foley, D. J., Wallace, R. B.,
Lemke, J. H., Semla, T. P., Hanlon, J. T., Glynn, R. J.,
Ostfeld, A. M., & Guralnik, J. M. (1992). Use of
medication by persons 65 and over: Data from the
Established Populations for Epidemiologic Studies of the
Elderly. Journal of Gerontology: Medical Sciences, 47,
Ml37-Ml 44.
Cobbs, E. L., & Ralapati, A. N. (1998). Health of
older women. Medical Clinics of North America, 82 (1),
127-144.
Col, N., Fanale, J. E., & Kronholm, P. (1990). The
role of medication noncompliance and adverse drug
reactions in hospitalizations of the elderly. Archives
of Internal Medicine, 150, 841-845.
Coleman, L. M., Fowler, L. L., & Williams, M. E.
(1995). Use of unproven therapies by people with
Alzheimer's disease. Journal of American Geriatrics
Society, 43, 747-750.
Colt, H. G., & Shapiro, A. P. (1989). Drug-induced
illness as a cause for admission to a community
hospital. Journal of American Geriatrics Society, 37,
323-326.
Cramer, J. A., Mattson, R. H., Prevey, M. L.
Scheyer, R. D., & Ouellette, V. L. (1989). How often is
medication taken as prescribed?: A novel assessment
technique. Journal of American Medical Association, 261,
3273-3277.
Cusack, B. J. (1989). Polypharmacy and clinical
pharmacology. In J. Beck (Ed.), Geriatric review
syllabus: A core curriculum in geriatric medicine (pp.
127-136). New York: American Geriatric Society.
Darnell, J.C., Murray, M. D., Martz, B. L., &
Weinberger, M. (1986) . Medication use by ambulatory
elderly: An in-home survey. Journal of the American
Geriatrics Society, 34, 1-4.
Delafuente, J. C. (1991). Perspectives on geriatric
pharmacotherapy. Pharmacotherapy, 11, 222-224.

Ill
De Smet, P.A.G.M. (1995). Health risks of herbal
remedies. Drug Safety, 13, 81-93.
Dietary Supplement Health and Education Act of 1994
(1994) . Public Law 103-417, 103d Cogress. Federal Food,
Drug, and Cosmetic Act. 108 STAT.4325-108 STAT.4328.
Drew, A. K., & Myers, S. P. (1997) . Safety issues in
herbal medicine: Implications for the health
professions. Medical Journal of Australia, 166, 538-541.
Eisenberg, D. M., Kessler, R. C., Forster, C.,
Norlock, F. E., Calkins, D. R., & Delbanco, T. L.
(1993). Unconventional medicine in the United States:
Prevalence, costs, and patterns of use. The New England
Journal of Medicine, 328, 246-252.
Eliason, B. C., Kruger, J., Mark, D., & Rasmann, D.
N. (1997). Dietary supplement users: Demographics,
product use, and medical system interaction. Journal of
American Board of Family Practice, 10, 265-271.
Ernst, E. (1998). Harmless herbs? A review of the
recent literature. The American Journal of Medicine,
104, 170-178.
Farnsworth, N. R., Akerele, 0., Bingel, A. S.,
Soejarta, D. D., & Eno, Z. (1985). Medicinal plants in
therapy. Bulletin of World Health Organization, 63, 965-
981.
Fillenbaum, G. G., Hanlon, J. T., Corder, E. H.,
Ziquba-Page, T., Wall, W. E., & Brock, D. (1993).
Prescription and nonprescription drug use among black
and white community-residing elderly. American Journal
of Public Health, 83, 1577-1582.
Fillenbaum, G. G., Horner, R. D., Hanlon, J. T.,
Landerman, L. R., Dawson, D. V., & Cohen, H. J. (1996).
Factors predicting change in prescription and
nonprescription drug use in a community-residing black
and white elderly population. Journal of Clinical
Epidemiology, 49, 587-593.

112
Frate, D. A, Croom, E. M., Frate, J. B., Juergens,
J. P., & Meydrech, E. F. (1996). Use of plant-derived
therapies in a rural biracial population in Mississippi.
Journal of the Mississippi State Medical Association,
37, 427-429.
Gormley, E. A., Griffiths, D. J., McCracken, P. N.,
& Harrison, G. M. (1993). Polypharmacy and its effect on
urinary incontinence in a geriatric population. British
Journal of Urology, 71, 265-269.
Gray, M. A. (1996). Herbs: Multicultural folk
medicines. Orthopaedic Nursing, 15(2), 49-56.
Greenblatt, R. M., Hollander, H., McMaster, J. R., &
Henke, C. (1991). Polypharmacy among patients attending
an AIDS clinic: Utilization of prescribed, unorthodox,
and investigational treatments. Journal of Acquired
Immune Deficiency Syndromes, 4, 136-143.
Grymonpre, R. E., Mitenko, P. A., Sitar, D. S.,
Aoki, F. Y., & Montgomery, P. R. (1988). Drug-associated
hospital admissions in older medical patients. Journal
American Geriatrics Society, 36, 1092-1098.
Healthy People 2000 (1990). National health
promotion and disease prevention objective, p. 67.
Washington DC: US Department of Health and Human
Services.
Helling, D. K., Lemke, J. H., Semla, T. P., Wallace,
R. B., Lipson, D. P., & Cornoni-Huntley, J. (1987).
Medication use characteristics in the elderly: The Iowa
65+ Rural Health Study. Journal of American Geriatrics
Society, 35, 4-12.
Huxtable, R. J. (1990). The harmful potential of
herbal and other plant products. Drug Safety, 5 (Suppl.
2J_, 126-136.
Ives, T. J., Bentz, E. J., & Gwyther, R. E. (1987).
Drug-related admissions to a family medicine inpatient
service. Archives of Internal Medicine, 147, 1117-1120.
Jonas, W. B. (1993). Evaluating unconventional
medical practices. Journal of NIH Research, 5, 64-67.

113
Kart, C. S. (1994). The realities of aging: An
introduction to gerontology (4th ed.)/ Boston: Allyn and
Bacon.
Kassler, W. J., Blanc, P., & Greenblatt, R. (1991).
The use of medicinal herbs by Human Immunodeficiency
Virus-infected patients. Archives of Internal Medicine,
151, 2281-2288.
Kelner, M., & Wellman, B. (1997). Health care and
consumer choice: Medical and alternative therapies.
Social Science & Medicine, 45, 203-212.
Kronenfeld, J. J., & Wasner, C. (1982). The use of
unorthodox therapies and marginal practitioners. Social
Science of Medicine, 16, 1119-1125.
Lamy, P. P. (1986). The elderly and drug
interactions. Journal of American Geriatrics Society,
34, 586-592.
Lassila, H. C., Stoehr, G. P., Ganguli, M., Seaberg,
E. C., Gilby, J. E., Belle, S. H., & Echement, D. A.
(1996). Use of prescription medications in the elderly
rural population: The MoVIES Project. The Annals of
Pharmacotherapy, 30, 589-595.
Lerner, I. J., & Kennedy, B. J. (1992). The
prevalence of questionable methods of cancer treatment
in the United States. CA, 42, 181-191.
LeSage, J. (1990). Polypharmacy in geriatric
patients. Nursing Clinics of North America, 26, 273-289.
Bindley, C. M., Tulley, M. P., Paramsothy, V., &
Tallis, R. C. (1992). Inappropriate medication use is a
major cause of adverse drug reactions in elderly
patients. Age and Ageing, 21, 294-300.
MacLennan, A. H., Wilson, D. H., & Taylor, A. W.
(1996). Prevalence and cost of alternative medicine in
Australia. Lancet, 347, 569-573.
Marwick, C. (1995). Growing use of medicinal
botanicals forces assessment by drug regulators. Journal
of American Medical Association, 273, 607-609.

114
May, F. E., Stewart, R. B., Hale, W. E., & Marks R.
G. (1982). Prescribed and non-prescribed drug use in an
ambulatory elderly population. Southern Medical Journal,
75, 522-528.
McCaleb, R. S. (1993). Regulation of dietary
suppelment: Hearing before the Subcommittee on Health
and the Environment of the Committee on Energy and
Commerce, House of Representatives (series no. 103-57).
Washington, DC: 103rd US Congress, House of
Representatives.
McGregor, K. J., & Peay, E. R. (1996). The choice of
alternative therapy for health care: Testing some
propositions. Social Science of Medicine, 43, 1317-1327.
Michocki, R. J., Lamy, P. P., Hooper, F. J., &
Richardson, J. P. (1993). Drug prescribing for the
elderly. Archives of Family Medicine, 2, 441-444.
Montamat, S. C., & Cusack, B. (1992). Overcoming
problems with polypharmacy and drug misuse in the
elderly. Clinics in Geriatric Medicine, 8, 143-158.
Montamat, S. C., Cusack, B. J., & Vestal, R. E.
(1989) . Management of drug therapy in the elderly. The
New England Journal of Medicine, 321, 303-309.
Murray, J., & Shepherd, S. (1993). Alternative or
additional medicine? Social Science of Medicine, 37,
983-988.
Murray, M. T. (1994). Natural medicine: A rational
alternative. In M. T. Murray (Ed.), Natural alternatives
to over-the-counter and prescription drugs (p. 29). New
York: William Morrow and Company, Inc.
Musil, C. M. (1998). Gender differences in health
and health actions among community-dwelling elders.
Journal of Gerontological Nursing, 24(2), 30-38.
Musil, C. M., Ahn, S., Haug, M., Warner, C., Morris,
D., & Duffy, E. (1998) . Health problems and health
actions among community-dwelling older adults: Results
of a health diary study. Applied Nursing Research,
11(3), 138-147.

115
Nolan, L., & O'Malley, K. (1988). Prescribing for
the elderly: Part I. Sensitivity of the elderly to
adverse drug reactions. Journal of American Geriatrics
Society, 36, 142-149.
Noyes, M. A., Lucas, D. S., & Stratton, M. A.
(1996). Principles of geriatric pharmacotherapy. Journal
of Geriatric Drug Therapy, 10(3), 5-35.
Panel on Definition and Description, CAM Research
Methodology Conference, April 1995 (1997) . Defining and
describing complementary and alternative medicine.
Alternative Therapies, 3(2), 49-57.
Paramore, L. C. (1997). Use of alternative
therapies: Estimates from the 1994 Robert Wood Johnson
Foundation National Access to Care Survey. Journal of
Pain and Symptom Management, 13, 83-89.
Penninx, B., Guralnik, J. M., Simonsick, E. M.,
Kasper, J. D., Ferrucci, L., & Fried, L. P. (1998).
Emotional vitality among disabled older women: The
women's health and aging study. Journal of American
Geriatrics Society, 46, 807-815.
Pollow, R. L., Stoller, E. P., Forster, L. E., &
Duniho, T. S. (1994). Drug combinations and potential
for risk of adverse drug reaction among community¬
dwelling elderly. Nursing Research, 43, 44-49.
Ranelli, P. L., & Aversa, S. L. (1994). Medication-
related stressors among family caregivers. American
Journal of Hospital Pharmacy, 51, 75-79.
Shimp, L. A., Ascione, F. J., Glazer, H., M., &
Atwood, B. F. (1985). Potential medication-related
problems in non-institutionalized elderly. Drug
Intelligence and Clinical Pharmacy, 19, 766-772.
Shimp, L. A., Wells, T. J., Brink, C. A., Diokno, A.
C., & Gillis, G. L. (1988) . Relationship between drug
use and urinary incontinence in elderly women. Drug
Intelligence and Clinical Pharmacy, 22, 786-787.

116
Sills, J. M., Tanner, L. A., & Milstien, J. B.
(1986). Food and Drug Administration monitoring of
adverse drug reactions. American Journal of Hospital
Pharmacy, 43, 2764-2770.
Simons, L. A., Tett, S., Simons, J., Lauchlan, R.,
McCallum, J., Friedlander, Y., & Powell, I. (1992).
Multiple medication use in the elderly: Use of
prescription and non-prescription drugs in an Australian
community setting. The Medical Journal of Australia,
157, 242-246.
Sloan, R. W. (1992). Principle of drug therapy in
geriatric patients. American Family Physician, 45, 2709-
2718.
Stalker, D. F. (1995). Evidence and alternative
medicine. Mt. Sinai Journal of Medicine, 62, 132-143.
Stewart, R. B. (1995). Drug use in the elderly. In
J. C. Delafuente & R. B. Stewart (Eds.), Therapeutics in
the elderly (2nd ed., pp. 174-189). Cincinnati, OH:
Harvey Whitney Books.
Stewart, R. B., & Caranasos, G. J. (1989).
Medication compliance in the elderly. Medical Clinics of
North America, 73, 1551-1563.
Stewart, R. B., & Cooper, J. W. (1994). Polypharmacy
in the aged: Practical solutions. Drugs & Ageing, 4,
449-461.
Stewart, R. B., Moore, M. T., May, F. E., Marks, R.
G., & Hale, W. E. (1991). Changing patterns of
therapeutic agents in the elderly: A ten-year overview.
Age and Ageing, 20, 182-188.
Sutherland, L. R., & Verhoef, M. J. (1994). Why do
patients seek a second opinion or alternative medicine?
Journal of Clinical Gastroenterology, 19(3), 194-197.
Swonger, A. K., & Burbank, P. M. (1995). An overview
of drug use and misuse among the elderly. In A. K.
Swonger & P. M. Burbank (Eds.), Drug therapy in the
elderly (pp. 28-34). Boston: Jones and Bartlett.

117
Taylor, D. (1996). Herbal medicine at a cross roads.
Environmental Health Perspectives, 104, 924-928.
U.S. Bureau of the Census (1990). General population
statistics. Economics and Statistics Administration.
Washington DC: U.S. Government Printing Office.
U.S. Bureau of the Census (1996). Current population
reports, special studies, Sixty-five plus in the United
States. Washington DC: U.S. Government Printing Office.
U.S. Department and Health and Human Services
(1997). Vital and health statistics: Prevalence of
selected chronic conditions: United States, 1990-1992,
Series 10: Data from the National Health Survey, No.
194, US Department of Health and Human Service, Centers
for Disease Control and Prevention, National Center for
Health Statistics, DHHS Publication No. (PHS) 97-1522.
Vincent, C., & Furnham, A. (1996). Why do patients
turn to complementary medicine? An empirical study.
British Journal of Clinical Psychology, 35, 37-48.
Waltz, C. F., Strickland, 0. L., & Lenz, E. R.
(1991) . Measurement in nursing research (2nd ed.) .
Philadelphia: F.A. Davis Company.
World Health Organization (1993). Research
guidelines for evaluating the safety and efficacy of
herbal medicines: World Health Organization Regional
Office for the Western Pacific, Manila; World Health
Organization.
Workshop on Alternative Medicine (Chantilly, VA)
(1994). Alternative medicine: Expanding medical
horizons. A report to the National Institute of Health
on alternative medical systems and practices in the
United States. Washington, DC: U.S. Government Printing
Office, Superintendent of Documents 1994.
Youngkin, E. Q., & Israel, D. A. (1996). A review
and critique of common herbal alternative therapies.
Nurse Practitioner, 21(10), 39, 43-46, 49-52.

APPENDIX A
QUESTIONNAIRE

QUESTIONNAIRE
INVESTIGATOR: SAUN-JOO YOON
COLLEGE OF NURSING
UNIVERSITY OF FLORIDA
DATE
INITIAL
ID #
119

120
PART A
HEALTH INFORMATION
ID#
A1 How would you rate your overall health:
1 1111
1 2 3 4 5
Poor Excellent
A2 How would you rate your physical health:
1 1111
1 2 3 4 5
Poor Excellent
A3 How would you rate your emotional health:
1 1111
1 2 3 4 5
Poor Excellent
A4 Have you visited a medical doctor or other health care
provider in the past 12 months:
0. No 1. Yes
(If yes, continue to A5, and if the answer is no, go
to A6 on next page.)
A5 What is the specialty of your doctor or health care
provider? (You may have more than one.)
1. Family Practitioner
2. Internal Medicine
3. Surgeon
4. Gynecologist
5. Nurse Practitioner
6. Osteopath doctor (D.O.)
7. Others:
Now, I am going to read a list of health problems or
illnesses. Please tell me if you have experienced this health
problem in the past 12 months (Questions A6 through A28).
Go back to identified problems to determine seriousness.
If it has been a problem, I would like to know how much it has
interfered with your normal activities (Questions A29 through
A51) .

121
Go back to seriousness to determine the use of
medications. Have you taken any medicines including
prescription and over-the-counter drugs? If yes, I would like
to know what kinds of medicines you have been taking to solve
this health problem (Questions A52 through A74).
Problems
No Yes
Illnesses
Seriousness*
Use of
medications
No Yes
Name of
medications
A6.
0
1
Allergies
A29.
1 2
3
4
5
A52 .
0
1
A7 .
0
1
Anxiety
A30 .
1 2
3
4
5
A53 .
0
1
A8 .
0
1
Arthritis
A31.
1 2
3
4
5
A54 .
0
1
A9 .
0
1
Back
Problems
A32 .
1 2
3
4
5
A55 .
0
1
A10.
0
1
Blood and
circulatory
problems
A3 3 .
1 2
3
4
5
A5 6.
0
1
All .
0
1
Cancer
A3 4 .
1 2
3
4
5
A57 .
0
1
A12 .
0
1
Chronic
pain
A3 5.
1 2
3
4
5
A58 .
0
1
A13.
0
1
Cold and
flu
A3 6.
1 2
3
4
5
A59.
0
1
A14 .
0
1
Depression
A3 7 .
1 2
3
4
5
A60 .
0
1
A15.
0
1
Diabetes
A3 8 .
1 2
3
4
5
A61 .
0
1
A16.
0
1
Digestive
problems
A3 9.
1 2
3
4
5
A62 .
0
1
All.
0
1
Dizziness
A4 0 .
1 2
3
4
5
A63 .
0
1
A18 .
0
1
Fatigue(low
energy)
A41 .
1 2
3
4
5
A64 .
0
1

122
Problem
Illnesses
Seriousness*
Use
of
Name of
Medications
Medications
No Yes
No
Yes
A19.
Gynecologic-
A42 .
A65.
0 1
al problems
1 2
3
4
5
0
1
A20.
Headache
A43 .
A6 6.
0 1
1 2
3
4
5
0
1
A21.
Heart
A4 4 .
A67 .
0 1
problems
1 2
3
4
5
0
1
A22 .
High blood
A4 5.
A68 .
0 1
pressure
1 2
3
4
5
0
1
A23.
Lung
A4 6.
A69.
0 1
problems
1 2
3
4
5
0
1
A2 4 .
Memory
A4 7 .
A70.
0 1
problems
1 2
3
4
5
0
1
A2 5.
Obesity
A48 .
A71 .
0 1
1 2
3
4
5
0
1
A2 6.
Skin
A4 9.
A72 .
0 1
problems
1 2
3
4
5
0
1
A27 .
Urinary
A50 .
A73.
0 1
problems
1 2
3
4
5
0
1
A2 8 .
Others:
A51.
A7 4 .
0 1
1 2
3
4
5
0
1
• Seriousness:
1 1 1 1 1
1 2 3 4 5
not at all extremely
serious
A75. Are you taking any other over-the-counter medicines or
non-prescribed medicines?
0. No 1. Yes
(If yes, list the name of medicines. )

123
A76. Now, I would like to ask you about use of some other
kinds of remedies to take care of your health, particularly
herbs. Have you ever used any type of herbs or herbal products
in the last 12 months?
0. No 1. Yes
Please, skip Part B and go to Part C if the answer to A75 is
no. Continue the questionnaire Part B, if the answer to A75
is yes.

124
ID#
PART B
INFROMATION ABOUT HERBAL PRODUCTS AND HERBS
B1. Now, I would like to know what kinds of herbs or herbal
remedies you have used in the last 12 months. Could you list
those?
1._
2.
3.
4.
5.
6.
7 .
8.
9.
10.
B2. For what reason have you taken herbs or herbal products
in the last 12 months?
1. to treat illness
2. to maintain or prevent any possible health problems
3. both 1 and 2
Now, I would like to ask you about each herbal product you
mentioned above.
(Please use the Part B-l Questionnaire to document each
herbal product information.)

125
ID#
Part B-l (Continued from Part B)
Now, I would like to ask you about each herb you mentioned
above.
Name of the herbal product / herb:
B3.1 How do you use it?
0. internally
B4.1 Did you prepare it at
0. self-prepared
B5.1 What is the reason to
(choose from 6 to 29)?
1.externally
home to use it or buy it?
1. purchased
use this herbal product / herb
6.
Allergies
18 .
7.
Anxiety
19.
8 .
Arthritis
20.
9.
Back problems
21.
10.
Blood and circulatory
problems
22 .
11.
Cancer
23 .
12.
Chronic pain
24 .
13.
Colds and flu
25.
14.
Depression
26.
15.
Diabetes
27.
16.
Digestive problems
28 .
17 .
Dizziness
29.
Fatigue(low energy)
Gynecological problems
Headache
Heart problems
High blood pressure
Lung problems
Memory problems
Obesity
Skin problems
Urinary problems
Others
maintain or prevent the
possible health problems
B6.1 Do you use this herbal product / herb continuously or
only when you have symptoms?
0. continuously: how long month
1. when symptoms have occurred: how many times a year
times
B7.1 How much do you think it is effective for you?
1. not at all
2. somewhat effective
3. very effective
4. don't know

126
B8.1 Have you experienced any type of side effect by using
this herbal product / herb?
0. no 1. yes (specify)
B9.1 Where did you get the information about this herbal
product / herb(may circle more than one)?
1. family members 2. friends and neighbors
3. books or magazines 4. TV, radio, newspapers
5. computer internet 6. health food stores
7. health care providers
8. alternative care practitioners
9. others
B10.1 How do you pay for it?
1. Insurance 2. Self-pay 3. Others
Bll.l Have you ever talked to your doctors or other health
care providers about the use of this herb/herbal product?
1. yes (Whom did you talk to: )
0.
no

127
ID#
PART C
DEMOGRAPHIC INFORMATION
Cl DOB: / /
C2 Are you:
1.married
2 . widowed
3. divorced / separated
4. never married
C3 Do you consider yourself as:
1. White
2. Black
3. Hispanic-nonwhite
4 . Other
C4 What is the highest grade or formal schooling you
completed:
1.
< High school
2 .
High school
3 .
< College
graduate
4 .
College graduate
5.
>Graduate school
Is
your annual
income:
1.
< $20,000
2 .
$20,000 -
34,999
3.
$35,000 -
49,999
4 .
> $50,000
What is your
religious preference
1.
none
2.
Protestant
3.
Catholic
4 .
Jewish
5.
Other
C7 What type of insurance do you have?
1. none 2. Medicare 3. Medicaid
4.Private insurance 5. Other
This is the end of the questionnaire. Thank you very much
for your participation.

APPENDIX B
CONSENT FORM

MB# IBI-I998
Informed Consent to Participate in Research
The University of Florida
Health Science Center
Gainesville, Florida 32610
You are being invited to participate in a research study. This form is designed to
provide you with information about this study. The Principal Investigator or
representative will describe this study to you and answer any of your questions.
If you have any questions or complaints about the informed consent process or
the research study, please contact the Institutional Review Board (IRB), the
committee that protects human subjects, at (352) 846-1494.
1. Name of Subject
2. Title of Research Study
Use of Herbal Products, Prescribed Medicines and Non-Prescribed
Medicines Among Community-Dwelling Older Women
3. a. Principal Investigator(s) and Telephone Number(s)
Saun-Joo L. Yoon, BSN, MSN (352) 392-3754
b. Sponsor of the Study (if any)
N/A
4. The Purpose of the Research
The purpose of this research is to identify the use of herbs and/or herbal
products for medicinal use, to compare differences in demographic
characteristics and health status between herbal product users and non¬
users, and to identify the possible interactions between herbáis with
prescribed and/or non-prescribed medicines among community-dwelling
older women.
129
KeuiseJ 6/95

130
5.Procedures for This Research
Your name was randomly selected from a list of women 65 years of age
and over who live in Alachua County. When you responded 'yes, I will
participate in the study', you were called to schedule a time and place for a
short interview. You will be asked to read and sign a consent form to
participate in the study and will have the right to decline without penalty. After
an informed consent is obtained, you will be asked to answer the questions
related to your health status, the use of prescribed and non-prescribed
medicines, the use of herbal products, and demographic information. The entire
interview will require approximately 15-30 minutes. Your name will not be
used or placed on the interview form. A code number will be used on the form
and only the investigator will have access to your name. All information you
give will be kept confidential. All information will be grouped together and no
person will be identified.
6.Potential Health Risks or Discomforts
There are no potential health risks or discomforts associated with this
particular research study. If you wish to discuss these or any other discomforts
you may experience, you may call the Principal Investigator listed in #3 of this
form.
7.Potential Health Benefits to You or to Others
There will be no direct benefit to the subjects for participating in this
study. However, the information that will be learned from this research will be
beneficial to health care providers for better understanding the patterns of use
of herbal products, and for more sensitive care for older women. The
information that will be learned from this study will be beneficial for society in
general to realize that there are potential risks of reactions or interactions by
using herbal products alone or in combination with prescribed and/or non-
prescribed medicines.
8.Potential Financial Risks
There will be no financial risks associated with this research.
9.Potential Financial Benefits to You or to Others
There will be no financial benefits associated with participating in this
research.
Revised 6/9'S

131
10.Compensation for Research Related Injury: INI/A
In the unlikely event of you sustaining a physical or psychological injury which is
proximately caused by this study:
professional medical; or professional dental; or professional
consultative
care received at the University of Florida Health Science Center will be provided
without charge. However, hospital expenses will have to be paid by you or your
insurance provider. You will not have to pay hospital expenses if you are being
treated at the Veterans Administration Medical Center (VAMC) and sustain any
physical injury during participation in VAMC-approved studies.
11.Conflict of Interest
There is no conflict of interest involved with this study beyond the professional
benefit from academic publication or presentation of the methods, results and
conclusions of the study.
12. Alternatives to Participating in this Research Study
You are free not to participate in this study. If you choose to participate, you are
free to withdraw your consent and discontinue participation in this research study
at any time without this decision affecting your medical care. If you have any
question regarding your rights as a subject, you may phone the Institutional Review
Board (IRB) office at (352) 846-1494.
13. Withdrawal From this Research Study
If you wish to stop your participation in this research study for any reason, you
should contact Saun-Joo L. Yoon at (352) 392-3754 . You may also contact the
Institutional Review Board (IRB) Office at (352) 846-1494.
14.Confidentiality
The University of Florida and the Veterans Administration Medical Center will
protect the confidentiality of your records to the extent provided by Law. The
Study Sponsor, Food and Drug Administration and the Institutional Review Board
have the legal right to review your records.
Revised 6/9S

132
15. Assent Procedure (if applicable): [Assent is the procedure used to obtain
agreement to participate in the research from a subject, such as a child, who
cannot give legal consent]
16. Signatures
Subject's Name
The Principal or Co-Principal Investigator or representative has explained the nature and
purpose of the above-described procedure and the benefits and risks that are involved in this
research protocol.
Signature of Principal or Co-Principal Date
Investigator or representative obtaining consent
You have been informed of the above-described procedure with its possible benefits and
risks and you have received a copy of this description. You have given permission for your
participation in this study.
Signature of Subject or Representative Date
If you are not the subject, please print your name
and indicate one of the following:
The subject's parent
The subject's guardian
A surrogate
A durable power of attorney
A proxy
Other, please explain:
Signature of Witness
Date
If a representative signs and if appropriate, the subject of this research should indicate
assent by signing below.
Subject's signature
Date
RcviicJ 6/95

APPENDIX C
THE 20 MOST POPULAR ASIAN PATENT MEDICINES
THAT CONTAIN TOXIC INGREDIENTS

The 20 Most Popular Asian Patent
Medicines That Contain Toxic Ingredients
1. Product Name:
Manufacturer:
Toxic Ingredients:
Ansenpunaw Tablets
Chung Lien Drug Works, Hankow, China
cinnabar (mercury chloride)
2 . Product Name:
Manufacturer:
Bezoar Sedative Pills
Lanzhou Fo Ci Pharmaceutical Factory,
Lanzhou, China
Toxic Ingredients:
cinnabar 2% or 10%
3. Product Name:
Manufacturer:
Compound Kangweiling
Wo Zhou Pharmaceutical Factory,
Zhe Jiang, China
Toxic Ingredients:
centipede (scolopendra) 10%
4. Product Name:
Manufacturer:
Toxic Ingredients:
Dahuo Luodan
Beijing Tung Jen Tang, Beijing, China
centipede (scolopendra)
5. Product Name:
Manufacturer:
Danshen Tableteo
Shanghai Chinese Medicine Works,
Shanghai, China
Toxic Ingredients:
baronial
6. Product Name:
Manufacturer:
Fructus Pérsica Compound Pills
Lanzhou Fo Ci Pharmaceutical Factory,
Lanzhou, China
Toxic Ingredients:
cannabis indica seed ( )
7. Product Name:
Manufacturer:
Fuchingsung-N Cream
Tianjin Pharmaceuticals Corp.,
Tianjin, China
Toxic Ingredients:
fluocinolone astound ( )
8. Product Name:
Manufacturer:
Kwei Ling China
Changchun Chinese Medicines & Drugs
Manufactory, Chang Chun, China
Toxic Ingredients:
cinnabar
134

135
9. Product Name:
Manufacturer:
Kyushin Heart Tonic
Kyushin Seiyaku Co., Ltd.,
Tokyo, Japan
Toxic Ingredients:
toad venom, baronial
10. Product Name:
Manufacturer:
Laryngitis Pills
China Dzechuan Provincial
Toxic Ingredients:
Pharmaceutical Factory,
Chengtu Branch
borax 30%, toad-cake 10%
11. Product Name:
Manufacturer:
Leung Pui Kee Pills
Leung Pui Kee Medical Factory,
Toxic Ingredients:
Hong Kong
dover's powder (opium powder) ( )
12. Product Name:
Manufacturer:
Lu-Shen-Wan
Shanghai Chinese Medicine Works,
Shanghai, China
Toxic Ingredients:
toad secretion
13. Product Name:
Manufacturer:
Nasalin
Kwangchow Pharmaceutical Industry
Co., Kwangchow, China
Toxic Ingredients:
centipede 5%
14. Product Name:
Manufacturer:
Toxic Ingredients:
Nui Huang Chieh Tu Pien
Tung Jen Tang, Beijing, China
borneo camphor
15. Product Name:
Niu Huang Xiao Yan Wan, Bezoar
Antiphlogistic Pills
Manufacturer:
Soochow Chinese Medicine Works,
Toxic Ingredients:
Kiangsu, China
realgar 19.23%
16. Product Name:
Manufacturer:
Pak Yuen Tong Hou Tsao Powder
Kwan Tung Pak Yuen Tong Main Factory,
Toxic Inqredients:
Hong Kong
scorpion 10%
17. Product Name:
Manufacturer:
Toxic Ingredients:
Po Ying Tan Baby Protector
Po Che Tong Poon Mo Um, Hong Kong
camphor 20%
18. Product Name:
Manufacturer:
Superior Tabellae Berberini HCI
Min-Kang Drug Manufactory, I-Chang,
China
Toxic Ingredients:
berberini HCI ( )

136
19. Product Name:
Manufacturer:
Toxic Ingredients:
Watson's Flower Pagoda Cakes
A.S. Watson & Co., Ltd., Hong Kong
piperazine phosphate (_)
20. Product Name:
Manufacturer:
Toxic Ingredients:
Xiao Huo Luo Dan
Lanzhou Fo Ci Pharmaceutical Factory,
Lanzhou, China
aconite 42%
Source: Oriental Herb Association, State of California
Department of Health Services. January 28, 1992.
_: requires doctor's prescription
Adapted from Workshop on Alternative Medicine (1994)

BIOGRAPHICAL SKETCH
Saun-Joo Lee Yoon received a Bachelor of Science in
Nursing degree from the Seoul National University, Seoul,
Korea in 1980. She received a Master of Science in
Nursing degree from the University of Florida,
Gainesville, Florida in 1992. Her professional experience
includes oncology, medical, and orthopedic nursing. She
also has experience in oncology nursing as a Clinical
Nurse Specialist. She is a currently a member of Sigma
Theta Tau International Honor Society of Nursing,
Southern Nursing Research Society, and the Oncology
Nursing Society.
137

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Claydell Horne, Chair
Associate Professor of
Nursing
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
i'ibjhb+K
Kathleen Long '
Professor of Nursing
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of ^o^tor cyf Philosophy.
Hossein 'Aarandi
Associate Professor of
Nursing
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Robin West
Associate Professor of
Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
ifueni
'Professor of Pharmacy

This dissertation was submitted to the Graduate
Faculty of the College of Nursing and to the Graduate
School and was accepted as partial fulfillment of the
requirements for the degree of Doctor of Philosophy.
May, 1999
Dean, Graduate School