THE CONSUMPTION OF TRADITIONAL MEDICINE BY TYPE 2 DIABETES MELLITUS PATIENTS AT THE PUBLIC HEALTH CENTER OF PANJATAN IN THE REGENCY OF KULON PROGO: A CASE STUDY

Background: The consumption of traditional medicine is common in most societies including patients with type 2 diabetes mellitus


INTRODUCTION
Diabetes mellitus is a major health problem in the world. The prevalence of diabetes mellitus in the USA in 2010 included almost 27 million people who were suffering from diabetes mellitus (12.3%), whereas in the UK there were 3.6 million people suffering from diabetes mellitus. The prevalence of diabetes has doubled every 20 years in the UK since the end of the Second World War. Cases of diabetes mellitus also occur in poor countries and developing countries, including Indonesia. Indonesia in 2010 was ninth in the number of people with diabetes mellitus and is predicted to be sixth in 2030 1 .
One of the provinces with a high number of diabetes mellitus sufferers is DI Yogyakarta Province. Diabetes mellitus in Yogyakarta is included in the top ten diseases in the Puskesmas, which is in fifth place based on the profile data of the DIY province health service in 2013. One of the districts in DI Yogyakarta Province where many people suffer from diabetes mellitus is Kulon Progo Regency. Based on data from the Kulon Progo District Health Office, diabetes mellitus is one of the top ten diseases of all age groups, reaching the sixth place in Kulon Progo Regency.
Type 2 diabetes mellitus (T2DM) is one of the categories of diabetes mellitus in which patients with diabetes have hyperinsulinemia but insulin cannot bring glucose into the tissues due to resistance 2 . Severe insulin resistance is caused by a mutation in the insulin receptors, although rarely causing death 3,4 .
In addition to modern medicine, diabetes mellitus sufferers also use traditional medicine in an effort to cure their disease. Traditional medicine is one of the seventeen kinds of health efforts organized under Law No. 36 of 2009 concerning Health 5 . Traditional medicine in Indonesia has developed since centuries ago which can be seen from historical relics in the form of temple reliefs and ancient writings 6 . In addition, traditional combatants usually use traditional medicine which are better known as herbal medicine. Traditional medicine itself is a mixture of ingredients in the form of plants, animal materials, mineral materials, preparation of ingredients, or a mixture of these ingredients and has been applied from generation to generation according to the norms in the community 7 . Strengthening traditional medicine is done by using medicinal plants in primary health services that have been agreed upon in the world at the World Health Organization (WHO) meeting in Almaata in 1978 8 . Since 1991 until now, the WHO has made guideline regulations in research on the efficacy and safety of traditional medicine as an international standard.
Kulon Progo Regency is one of the districts in DI Yogyakarta Province where many people suffer from diabetes mellitus. In addition to modern medicine, people with diabetes mellitus in Kulon Progo Regency also use traditional medicine, both as a supplement and as a basic treatment. This study was conducted with the aim of knowing the motivation of T2DM patients in using traditional medicine and knowing the level of knowledge of T2DM patients regarding diabetes mellitus in general.

RESEARCH METHODS
This study is a qualitative research with case study approach. The main target of this study is T2DM patients at the Public Health Center of Panjatan in Regency of Kulon Progo working area. This study was conducted in the Public Health Center of Panjatan I and Public Health Center of Panjatan II (PP), County of Panjatan, Regency of Kulon Progo in February-March 2017 with the informant variables, namely diabetes mellitus patients who seek treatment at the health center but still use traditional medicines diagnosed with less than 10 years and people with diabetes mellitus who seek treatment at the health center but still use traditional medicines diagnosed 10 years or more. The inclusion criteria are T2DM patient in PP work area and willing to be the participant in this study, while exclusion criteria are diabetes mellitus patient less than 18 years old.
The study data were obtained through observation of the public health centers and Focus Group Discussion (FGD) activities conducted on 56 patients with diabetes mellitus where 26 patients are from Public Health Center of Panjatan I and 30 other patients are from Public Health Center of Panjatan II. The FGD process was recorded using a tape recorder; the atmosphere of the FGD was described in writing by an observer. The FGD activities were done in conjunction with Prolanis activities at the Puskesmas so that the time spent doing FGD was limited. FGD results data were analyzed using qualitative data analysis techniques from Miles and Huberman which included four steps: data collection, data reduction, data presentation, and inferences. In this study the results of the recording of the FGD were transcripted by the researchers and the results of the transcripts were read and analyzed separately by three coders, then grouped into the themes and sub-themes that emerged. After coding was done by the three coders who were second-level students of the Medical Faculty of Family Medicine and had almost the same level of knowledge about traditional medicine and had experience in coding. The coding results were discussed three times to achieve saturation. Presentation of results data was made in the form of a matrix or chart. This approach was done to facilitate conclusions from the field by comparing the suitability of statements from research subjects with the meaning contained in the basic concepts in the study.

RESULTS AND DISCUSSION
Based on FGD results data which have been done in this study, the following findings were found: 1. The motivation of patients using traditional medicine until now.       Looking at the two backgrounds of patient motivation to treat T2DM using traditional medicine above, it can be seen that economic factors and distance are not their consideration. Costs are not considered, as almost all of them get financing from insurance (community health insurance, health insurance of civil servants, or regional health insurance). So also, with the distance, if they actually see that distance is an important consideration then they certainly will not rely on traditional medicine considering there are two public health centers in Panjatan so that the distance between home and the community health center is relatively affordable.
The reason for the use of traditional medicine tends to be multi-factorial but may be related to the perception of the severity of illness, symptoms, and understanding of the disease. In addition, treatment knowledge, availability, and acceptability, in the case of conventional and alternative approaches, tend to influence patient decisions. For example, patients may believe that conventional diabetes mellitus medicines are beneficial in the management of diabetes mellitus, so there is less need for other therapies.
Conversely, chronic conditions that provide pain may be poorly understood by the patient and conventional treatment cannot reduce pain so patients will think to seek additional treatment 9 .
Meanwhile, the reason for patients who have used traditional medicine but now stopped is caused by several things, namely: (1) asked to stop by the doctor, (2) lazy to use, because it is not practical how to mix, or (3) raw materials dilute medicines. Patients who consult physicians and physicians with a variety of medical considerations require that patients discontinue use of traditional medicine to be an important factor encouraging T2DM patients to discontinue use of traditional medicine. It is possible for physicians to recommend discontinuation of traditional medicinal uses due to side effects that may be caused by the medicines used, or inappropriate use of traditional medicines by the patient, whether ingredients, dosage, time, or mode of use. This is in line with the opinions of Hussin and Zhang who suggest that side effects of traditional medicine may occur because there are interactions among medicinal plants, misuse, and improper use of doses and duration of use. In the event of the inappropriateness of the use of such traditional medicine by the patient surely the doctor has to remind or recommend the cessation of the use of traditional medicine 10,11 .  potential for side effects of traditional medicine requires the presence of family doctors who are proactively present in the midst of the community to give their enlightenment.

Type 2 diabetes mellitus patient knowledge of diabetes mellitus
The FGD results obtained the following information that the understanding of T2DM patients about the disease they suffer is various. Some patients understand about their illness; others do not have enough information about T2DM. This needs to be a serious concern for family physicians given the importance of increasing the understanding of T2DM patients about the illness they suffer. In addition, the patient should understand the treatment of T2DM is also very important and can influence the treatment process as well as the chosen healing methods, including the decision on the utilization of traditional medicine. Treatment of T2DM is not an instant treatment that immediately heals, but the process is sustainable over time. Therefore, the understanding of T2DM patients about the healing process is also very important so that patient can undergo treatment process successfully. The importance of increasing the understanding of T2DM patients has an implication on the important role of family doctors. The understanding of family doctors about the use of traditional medicine for patients with T2DM is necessary because there are still many T2DM patients who take traditional medicines to cure their disease.
The results above can be described as in the picture below: Based on the above figure it can be understood that the motivation of high traditional medicine use: (A) is influenced by distrust of doctors, (B) less information about diabetes mellitus disease (duration of medicine consumption, complications that may occur, medicine use effect) and (C) traditional medicine information about the effects of traditional medicine on blood glucose levels, medicine reactions, side effects of traditional medicine). Condition A may change to A 'as well as A' may change to A. This change is strongly influenced by the information received by the patient (depending on the patient-physician communication).
Less information (C) will cause distrust of the doctor's treatment (B). This motivation will turn out to be low in using traditional medicine (A') if it gets sufficient information (C') (regarding diabetes mellitus disease and traditional medicine information) and has high confidence in physician (B'). Sufficient information (C') may also increase confidence in the physician. This sufficient information is obtained from intensive communication between physicians and patients. Good communication between the patients and doctors will result in a good understanding by the patient about the illness they suffer.

CONCLUSION
Based on the results of this study, it can be concluded that the motivation of patients in using traditional medicine is influenced by the level of confidence in the doctor and the level of understanding of patients about the disease, traditional medicine, and other information. Patients decide to use traditional medicine because they do not believe in the treatment of doctors, follow advice of friends or relatives who have already used traditional medicine and according to their success, and feel the effects of traditional medicine to lower blood glucose levels. In addition, the sufferer decides not to use traditional medicine or to stop taking traditional medicine due to full confidence in the doctor, told to quit by the treating doctor, fear of side effects, lazy to use, because it is not practical how to mix, the raw materials dilute the medicine, or there is no effect of traditional medicine on decreased blood glucose levels.
Based on the results of this study, it also can be concluded that patients with T2DM do not all understand the disease they suffer. Some patients with T2DM have a fairly good understanding of the illness they suffer. This information is usually obtained from doctors who provide information when the patient is consulting. Some of the other T2DM patients do not understand what causes their disease, how it needs to be cured, the risks of T2DM disease, and the steps to be taken after contracting T2DM. Some T2DM patients also do not understand how to live healthy to prevent or maintain T2DM that has been suffered in order not to get worse.
Based on the results of this study, the author suggests that T2DM patients need to have the right information about the illness suffered as well as the necessary treatment in order to take the right attitude in the face of the illness as well as determine the healing process. Researchers also suggest that family doctors should be able to properly and wisely respond to the growing and evolving traditional treatment for T2DM disease in the midst of rapid advances in modern medicine. Family doctors need to improve patient knowledge about traditional medicine for T2DM disease in order to educate people about the disease they are facing. For public health centers, researchers have suggested that they need to improve the guidance and supervision of traditional medicine use for T2DM as part of the responsibility of the role of the public health center in providing health services for the community.