1. INTRODUCTION:

Complementary and alternative medicine (CAM) includes health and therapeutic practices that are not accounted as modern treatments and its methods and effectiveness are different from biologic or common medicine. In CAM treatments, the physician treats the patient as a whole and has no focus on a special disease or disorder (1, 2). CAM includes as wide range of treatments such as physical treatments, medicinal plants, energy therapy, and body-mind therapies (3).

During few recent years, Usage of CAM has been increased throughout the world and different CAMs have been accepted largely by communities (4,5). Hydrotherapy is not an exception as well and in recent years, it has been paid attention increasingly and many studies have been done in this regard (6). Hydrotherapy is one of alternative treatments that leads to recovery and promotion of health by using natural healing effects of water (7). This treatment is based on hydrodynamic principles and creates several sensational stimulations by water temperature and weight loss. Also, water characteristics help active movements of joints and improve blood circulation and motor abilities (8). In scientific literatures, there are other names for hydrotherapy including physiotherapy in water, treatment with washing (9) and pool therapy (10). Hydrotherapy can decrease pain and recover joint range of motion. Costantino study (2014) on 56 elders showed that hydrotherapy is effective on backache (9). In addition, the study of Mazloum et al. (2014) on patients with hemophilia type A (11), Naumann (2014) in fibromyalgia (12), Al-Qubaeissy (2013) in rheumatoid arthritis (13), Schencking (2013) in osteoarthritis (14), Castro-sanchez (2012) in multiple sclerosis (15, 16) and Hay (2013) in rehabilitation of chronic effects of ankle fracture (17) showed that hydrotherapy reduced significantly the pain (11). Nevertheless, hydrotherapy can increase motor range of hip joints of patients with inherited spastic paralysis (18) and movement range of knee joints (11). Hydrotherapy can increase balance and walking of patients after disorders such as brain stroke (19). In addition, hydrotherapy in skin disorders is common including burning scars in a way that 92% cases with burning are treated by this method in USA. Reduction of microbial load, cleanness of burning surface, removing dead tissues, easy separation of scar tissue, physiotherapy, and patient’s comfort (20) are among hydrotherapy effects on burning scars. Hydrotherapy is also applied on skin diseases such as psoriasis and atopic dermatitis and has reduced disease intensity (21). In addition, hydrotherapy with hot water improves muscle resistance in gymnasts (22). Hydrotherapy with cold water can reduce pains resulted from sport injuries (23-26). Considering to advantages of hydrotherapy in different studies, a health care provider especially nurses should know the increasing models of such treatment for a holistic care with focus on integrity of human existence because they play important role in presenting health services and patients may ask them such treatments like other complementary and alternative treatments and if nurses have enough knowledge, they can give appropriate information to patients and help them in decision making (27). It should be noted that it is necessary to be aware of important dimensions such as satisfaction from cares provided and demographic variables of users because application of all complementary and alternative treatments is affected by demographic and cultural factors. Evidences show that in undeveloped communities which access poorly to bio-medical services, even people with dangerous diseases want to be treated by traditional physicians while in developed countries, bio-medical services are more available for people and they use complementary and alternative treatments for health improvement and prevention (28). Since this treatment has not been studied regarding frequency, clinical complaints leading to using such treatment and above mentioned factors, and previous studies investigated this treatment on a certain disorder or symptom, the aim of this study was to investigate the effectiveness of hydrotherapy in more common cases in Kerman, Iran.

2. METHOD AND MATERIAL:

2.1. Study design and setting

This was a descriptive-analytic study conducted in Besat clinic of Kerman. This is the only educational center that serves specialty and subspecialty cares to outpatient in Kerman. Kerman is the largest city in southeast of Iran, with a population of more than 722,000.

2.2. Sampling and sample size

Conveninece sampling was used to select the subjects. In order to estimate sample size, the following formula was used:

The amount of p and 1-p were considered by 0.5 in order to estimate maximum sample size. Based on this formula, the estimated sample size was 385. In addition, to consider the probability of droup out 100 extra subjets were added to estemated sample size.

2.3. Instrument

To collect the data, a two-part questionnaire has been used. The first part was about demographic data (such as age, gender, marital status, educational degree, job, income, having chronic disease) and the second part was about the frequency of using hydrotherapy, problems and diseases that persuade the user to use such method and his/her satisfaction from this method. The amount of usage has been measured by yes or no answers and if the answer is yes, it has been estimated based on patient’s report on number of using the technique in last year. Patient’s complaints or problems include; 1- backache, 2- pain in knee, 3- other chronic pains, 4- headache (migraine), 5- kidney stone, 6- depression, 7- anxiety, 8- psychological disorder, 9- skin disease, 10- allergy, 11- obesity, 12- thinness, 13- anorexia nervosa, 14- chronic fatigue, 15- insomnia, and 16- others. Also, amount of satisfaction was measured by using an eight item scale about accessibility, harmlessness, ease of usage, relief of problem, no interference with daily activities, no concern for interfering with other therapeutic methods, feeling well after using treatment and suggesting the method to others. This scale was scored by Likert’s five point scale (4= very satisfied, 3= satisfied, 2= unsatisfied, 1= very unsatisfied and 0= no idea). Based on mean scores of the satisfaction scale, the scores were variable ranging from zero to four and higher score shows higher satisfaction from using hydrotherapy. The mean scores ³ 2.5 considered as satisfied and the mean scores below 2.5 considered as unsatisfied. In order to obtain content and face validity, books, sources and opinions of ten faculty members of Isfahan University of Medical Science who has trained in CAM was used and the questionnaire has been assessed regarding clarity, easy usage and the time required for its completion. Nevertheless, in order to determine reliability of satisfaction from hydrotherapy, a pilot study was done on 10 persons of the target population who used hydrotherapy and internal consistency of the scale was calculated. The Cronbach’s alpha value was 0.91. Once again, Cronbach’s alpha was calculated (0.93) for all people who used hydrotherapy (n=58).

2.4. Data collection and analysis

In present study, the target population was all clients refering to Besat clinic of Kerman. People older than 15 years with mental and physical ability to answer the questions were eligible to participate in the study. The questionnaires were given to subjects in order to be completed in form of self-report. In case the subject was illiterate, the questionnaire was completed by the researcher. Sampling was taken from beginning of June to late June 2015. Data were analyzed by SPSS version 18. Descriptive statistic (frequency, percentage, mean and standard deviation) was applied to describe amount of usage and satisfaction from hydrotherapy and logetsic regression was used to determine the relation between demographic characteristics and being user of hydrotherapy. Significance level was considered by 0.05.

2.5. Ethical consideration

Kerman University of Medical Science (KUMS) approved this project. After approval, the permission offered to the management of Basat clinic. The researcher offered some oral information to the participants including the goals and objectives of the study, the confidentiality and anonymity of the data, and that they were free to withdraw from the study at any time. Verbal consent was given individually.

3. RESULT:

3.1. Socio-demographic characteristics

In total, 453 participants were assessed. The mean age of participants was 39.24 ± 13.21 years. Nearly 60% of them were women. More than 85% were married. Less than 20% and 10% were illiterate and unemployed respectively. Less than 35% had less than 500000 toman (nearly 450 US dollar) incomes monthly. Less than 45% of participants lived in the non capital cities. 79.9% of participants had at least one chronic disease and the most prevalent diseases were anemia (16.6%), hypertension (15.9%) and hernia disk (15.2%) respectively (Table 1). Note 20 clients rejected to participate in the study, so the drop out value was 4.35%. In addition 7 questionnaires had missing values so these questionnaires were omitted from analysis.

Table 1. Description of the study sample (n= 453)

Variables	Frequency*	Valid percent
Age (yr)
15-25	75	16.6
26-35	125	27.6
36-45	120	26.4
> 45	133	29.4
Sex Male	183	40.4
Female	270	59.6
Marital status Single	62	13.7
Married	391	86.3
Education Illiterate	80	17.7
Under Diploma	137	30.2
Diploma	97	21.4
Academic degree	139	30.7
Job
Housewife	220	48.6
Unemployed	34	7.5
Employed	183	40.4
Pensioner	16	3.5
Family income per month (Toman^§) < 500000	158	34.9
500000-1000000	149	32.9
1000001- 1500000	108	23.8
> 1500000	38	8.4
Living place Capital city	255	56.3
Non capital city	198	43.7
Disease
No chronic disease	91	20.1
Rheumatoid arthritis/ Osteoarthritis	45	12.1
Hernia disc	69	15.2
Anemia	75	16.6
Migraine	61	13.5
Hypertension	72	15.9
Diabetes	53	11.7
Neuropsychological disease	67	14.8
Asthma/ Allergy	39	8.6
Chronic skin disease	18	4.0
Thyroid disease	22	4.9
Heart disease	46	10.2
* The variables that had less than total 500 frequencies are because of missing values. § Iran currency (nearly each US dollar is equal to 3200 toman)

3.2. Findings

Totally 12.8% (n = 58) of the participants had used hydrotherapy in the previous year. The frequency of using hydrotherapy varied between 1 to 30 times (median = 3, mode = 3). The most prevalent causes of using hydrotherapy were knee pain (37.9%), backache (27.6%), chronic skin disease (8.6%), and depression (6.9%). Other less prevalent causes of using hydrotherapy were chronic fatigue, anxiety, headache (migraine), and psychological disorder.

The mean score of satisfaction of using hydrotherapy was 2.82 ± 0.99 that meant participants were satisfied of using hydrotherapy. According to different aspects of satisfaction, 71.2% of participants were satisfied about continued access to the procedure, 86.4% were satisfied about ease of use, 81.3% were satisfied about safety of hydrotherapy, 72.8% believed that using hydrotherapy did not interfere with their daily activities, 83%were satisfied of relief of symptoms, 88.1% did not have any concern about existing any interaction between hydrotherapy and other therapies, 91.5% had good feeling after use of hydrotherapy and 89.8% recommended hydrotherapy to others.

To check the association between being user of hydrotherapy and socio-demographic characteristics, univariate logistic regression was performed. We further adjusted the model using multivariate logistic regression (Table 2). Based on the results, we did not found any association between being user of hydrotherapy and socio-demographic characteristics.

Table 2. Uni-factor logistic regression Model for being user of medicinal plants, With Adjustment for All Listed Variables

Variables	Uni-factor logistic regression			Multifactor logistic regression
Variables	OR*	CI**	P value	OR	CI	P value
Age (yr)
15-25	1		0.81	1		0.27
26-35	0.75	0.31-1.82	0.53	0.62	0.23-1.73	0.37
36-45	1.0	0.43-2.34	1.0	0.96	0.32-2.84	0.94
> 45	1.08	0.48-2.47	0.85	1.58	0.50-4.92	0.43
Sex Female	1			1
Male	2.16	1.23-3.77	0.007	2.07	0.78-5.48	0.14
Marital status Single	1			1
Married	0.84	0.39-1.82	0.66	0.91	0.33-2.51	0.86
Education Illiterate	1		0.42	1		0.41
Under Diploma	1.75	0.67-4.63	0.26	2.08	0.72-5.99	0.17
Diploma	2.08	0.76-5.69	0.15	2.54	0.76-8.49	0.13
Academic degree	2.20	0.85-5.69	0.11	2.94	0.82-10.5	0.10
Job
Housewife	1		0.10	1		0.79
Unemployed	1.33	0.43-4.17	0.62	0.73	0.16-3.27	0.68
Employed	2.12	1.17-3.85	0.01	1.14	0.37-3.46	0.82
Pensioner	1.43	0.30-6.74	0.65	0.57	0.09-3.68	0.56
Family income per month (Toman^§) < 500000	1		0.39	1		0.79
500000-1000000	1.07	0.52-2.18	0.86	0.79	0.36-1.73	0.56
1000001- 1500000	1.77	0.87-3.59	0.11	0.87	0.35-2.17	0.77
> 1500000	1.26	0.43-3.65	0.68	0.55	0.15-1.96	0.36
Living place Capital city	1			1
Non capital city	0.70	0.40-1.24	0.22	0.85	0.44-1.63	0.62
Disease
No chronic disease	1			1
At least one chronic disease	1.66	0.76-3.64	0.20	1.48	0.64-3.41	0.36
* Odds ratio ** Confidence interval § Iran currency (nearly each US dollar is equal to 3200 toman)

4. DISCUSSION:

The results showed that 12.8% of users have applied hydrotherapy in the previous year that is different from percentages obtained in other studies. For example, the study done by Banitehrani et al. (2008) showed that 5.7% of Tehrani people used hydrotherapy a year before the study. Concerning that studies conducted on hydrotherapy are different from each other regarding methodology such as target population, criteria of participation, instrument, it can be expected that frequency of hydrotherapy is different in various studies. Also, it should be noted that insurance companies do not cover cost of such treatment in Iran and this may reduce the application of hydrotherapy. The most common reason for using hydrotherapy was pain and the most common factor related to the pain was knee pain and backache. Since sampling was done from the selected population, frequency of many disorders can be explained compared to non-selected or society-based populations. In one hand, it can be expected that in the sampling center, people are benefited from therapeutic outcomes of hydrotherapy more than its promotion of health and prevention outcomes. In addition, pain is one of chronic signs and evidences indicate that hydrotherapy is used in more chronic conditions (3). Therefore, this finding is in direction of present evidences and suggests that hydrotherapy is used to treat musculoskeletal disorders (29, 30).

According to findings, the highest satisfaction associated with ‘good feeling after treatment’ and the lowest satisfaction associated with ‘continuous access to the treatment’. The latter is unlike the evidences because studies show that one of reasons for public acceptance and the increasing application of CAM is that some users believe that they are more accessible than other treatments (31). Therefore, in macro management level of health affairs, authorities should pay more attention to train healthcare providers about on hydrotherapy. In addition, the facilities of hydrotherapy should be offered more easily and accessible for all kind of people.

Findings showed that there is no relationship between usage of hydrotherapy and demographic variables which is in disagreement with other studies. Results suggest that there is relationship between gender, educational level and economic status and CAM usage (28). It seems that this finding can associate with methodological differences such as target population, sample size (in present study) and studies under comparison.

Application of hydrotherapy can be accompanied with other modern treatments in clinical condition especially chronic diseases. Therefore, it is impossible to measure net effect of hydrotherapy in present study and it is suggested to be studied by clinical trials. One of limitations of this study is related to recall bias so that concerning usage of hydrotherapy in last year, if patients use this treatment several times for different diseases, they may not remember accurately number of using such treatment. Also, since this study has been done in a clinic, amount of its usage in the society cannot be properly predicted. Therefore, it is suggested that other studies are done on a large sample throughout the society in order to measure application of hydrotherapy.

5. CONCLUSION:

According to the findings, the highest frequency of clinical complaints in users of hydrotherapy associated with musculoskeletal pain. The results of this study might help researchers to develop new hypotheses for future studies on hydrotherapy. Further clinical trials are suggested to study the effect of hydrotherapy on musculoskeletal pain, skin disorders, psychological disorders such as depression and anxiety, and chronic fatigue.

6. ACKNOWLEDGMENTS:

Special thanks to all clients who took part in this study. The authors appreciate the personnel at the Besat clinic for their contribution in data collection.

7. AUTHOR CONTRIBUTIONS:

‘Author FG’ designed the study, wrote the protocol and managed the literature searches, and wrote the first draft of the manuscript. ‘Author MD’ performed the statistical analysis, provided advice for the study design and helped in writing the manuscript. ‘Author AS’ gathered the data, provided advice for the study design and ‘Author MS’ provided advice for the study design and helped in writing the manuscript. All authors read and approved the final manuscript.

8. DISCLOSURE:

There is no conflict of interest to be declared.

9. FINANCIAL DISCLOSURE:

This study funded by Kerman University of Medical Science.

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Received on 06.11.2015 Modified on 26.11.2015

Asian J. Nur. Edu. and Research. 2016; 6(2): 249-254.

DOI: 10.5958/2349-2996.2016.00048.3