Survey on Aromatherapy Among Healthcare Professionals in Morocco

Background: Herbal remedies and more particularly essential oils are increasingly used throughout the world. In Morocco, the practice of aromatherapy is becoming more and more important, but the knowledge, attitudes, and expectations of healthcare professionals towards essential oils have never been studied. Aim: To assess the attitudes, knowledge, and expectations towards essential oils and aromatherapy of Moroccan healthcare professionals. Methods: We conducted a survey among 205 Moroccan healthcare professionals from different categories using an anonymous electronic questionnaire. Results: The participants to our survey have a good general knowledge and 47.8% of the them have already prescribed or advised essential oils. However, only 10.2% of them considered essential oils as widely available. Moreover, only 3.9% of the respondents judged their theoretical knowledge of essential oils and aromatherapy as perfect, 36.6% considered the lack of information in this field as the limiting factor in prescribing and advising essential oils, and 88.3% were in favor of integrating aromatherapy into their basic training course. The prescription or advice of essential oils are statistically correlated with age, profession, factors mentioned as limiting the prescription and advice of essential oils, and the theoretical knowledge. Conclusion: Empowering healthcare professionals’ capacities could help them overcome their fears and enable them to offer aromatherapy advice to their patients with confidence. This could also help to expand the use of essential oils in Moroccan healthcare facilities.

plants, both in terms of the destruction of infectious pathogens and the management of a large number of symptomatic disorders characteristic of the disease. 9 The National Association for Holistic Aromatherapy (NAHA) describes it as "the art and science of using aromatic essences naturally extracted from plants to balance, harmonize, and promote health in body and mind. It seeks to unify physiological, psychological and spiritual processes to enhance an individual's innate healing process". 10 In Morocco, although it is not currently part of their basic training, aromatherapy is a discipline that is becoming increasingly important among healthcare professionals. However, their knowledge and practices in this field are very varied and have never been evaluated.
Thus, the aim of our study was to conduct a survey among Moroccan healthcare professionals in order to assess their attitudes, knowledge, and expectations towards essential oils and aromatherapy.

Data collection
This survey was conducted over 4 months from March to June 2021. We used an anonymous electronic questionnaire in the French language comprising 19 questions organized into 5 sections: Section 1: Socio-demographic data of the participants (4 questions); Section 2: General knowledge of healthcare professionals regarding essential oils and aromatherapy (7 questions); Section 3: Prescription and advice of essential oils by healthcare professionals (3 questions); Section 4: The availability of essential oils in Morocco (3 questions); Section 5: Integration of aromatherapy in the basic training of healthcare professionals (2 questions).
The questionnaire was developed by the authors and was tested on 5 healthcare professionals. The objectives of the study were well explained to the participants at the beginning of the questionnaire.
The questionnaire file in "Google Forms" format was sent to participants through professional social networks and the link was also published in an electronic magazine (Doc news) dedicated to healthcare professionals. The answers were automatically collected in an Excel file.

Data processing
The collected data were entered and processed on SPSS 21. The Pearson Chi-square test was used to study statistical correlations considering a p-value less than 0.05 as statistically significant.

Socio-demographic data of participants
The total number of participants in this survey is 205 participants. Among these participants, 75.1% are female (n=154) and 24.9% are male (n=51). Forty percent are between 25 and 35 years old (n=82), 30.7% between 35 and 45 years old (n=63), 20.5% between 45 and 55 years old (n=42), and 8.8% over 55 years old (n=18). Regarding the number of years of experience, among the 129 participants who answered this question, 51 (39.5%) have less than 10 years of experience, 57 (44.2%) have between 10 and 20 years of experience and 21 (16.3%) have more than 20 years of experience. On the other hand, 54.1% are pharmacists (n=111), and 35.6% are physicians (n=73). The rest of the participants belong to various professions.

General knowledge of healthcare professionals about essential oils and aromatherapy
Regarding the participants' knowledge of essential oils and aromatherapy, 81.5% of the participants claim to know about aromatherapy, and 94.1% claim to know about essential oils. Likewise, 92.7% of the participants affirmed that essential oils have therapeutic virtues, and 70.7% distinguished essential oils from fixed vegetable oils. On the other hand, 87.3% of the participants considered that essential oils have a certain degree of toxicity (from 1 to 5 on a scale of 0 to 5 of toxicity), and 12.7% considered that they are harmless (Table 1).

Prescription and advice of essential oils by healthcare professionals
Among the healthcare professionals who participated in our survey, 47.8% have already prescribed or advised essential oils. Among the essential oils that were most frequently cited, lavender came first (22.9%), followed by eucalyptus (10.7%), tea tree (6.8%), and peppermint (4.9%). Regarding the opinion of participants on the factors that hinder the prescription and advice of essential oils, 36.6% cited the lack of information and 23.9% mentioned the preference for drugs, which are already integrated into the basic training of healthcare professionals ( Table 2).

Availability of essential oils in Morocco
Among the participants, 55.1% stated that essential oils are moderately available, 31.2% see that essential oils are rarely available and 10.2% affirmed that they are widely available.
The majority of participants (88.3% and 74.6% respectively) stated that essential oils should be more available in pharmacies and hospitals as a therapeutic or alternative treatment ( Table 2).

Integration of Aromatherapy in the basic training of healthcare professionals in Morocco
Among the participants in our survey, 69.8% judged their theoretical knowledge of aromatherapy and essential oils to be average, 3.9% judged their knowledge to be perfect while 26.3% claimed to have no knowledge in this field. On the other hand, almost all participants (88.3%) were in favor of integrating aromatherapy into the training curriculum of healthcare professionals (Table 3).

DISCUSSION
Essential oils are increasingly used in clinical settings as adjuncts to manage many symptoms as well as for general wellness. [11][12][13] Currently, medical aromatherapy is used as a therapeutic or alternative remedy in several hospitals. According to an article published in February 2021, Rosa damascena aromatherapy was shown to reduce anxiety and increases sleep quality in cardiac care unit inpatients. 14  Numerous other studies demonstrate the likely benefits of aromatherapy on humans, including effects on stress, depression, surgical pain, and sleep. [15][16][17] In our study, the majority of participating healthcare professionals were familiar with essential oils and aromatherapy were able to differentiate between essential oils and fixed plant oils and were aware that essential oils have therapeutic properties but also have toxic potential. This demonstrates that the majority of respondents have general knowledge about essential oils.
Half of the participants in this survey (47.8%) claimed to have prescribed or advised essential oils in the past. This characteristic is correlated with the age and profession of the participants. It is also correlated with the factors mentioned by the participants as limiting the prescription and advice of essential oils (Table 4). Furthermore, the essential oils that are the most prescribed or advised by the participants (Lavender, Eucalyptus, Tea Tree, and Peppermint) are those that are commonly used in aromatherapy worldwide. 18 Participants in our study mostly rated the availability of essential oils as moderate to rare and were all in favor of introducing them into pharmacies and hospitals for therapeutic purposes. A recent study showed that after the introduction of an aromatherapy program in a pediatric hospital ward, 89% of the nurses who administered the essential oils to their patients rated the benefit of aromatherapy as 4 or more on a scale of 0 to 10. 19 This demonstrates the undeniable benefit that the introduction of aromatherapy could bring to healthcare facilities in Morocco.
Among the 205 participants in our study, only 8 (3.9%) claimed to have perfect theoretical knowledge of essential oils and aromatherapy. This level of knowledge was positively correlated with the participants'    prescribing and counseling of essential oils (Table 4). These results further confirm those of an American survey of 106 healthcare professionals, which showed that only 22% of the participants felt able to advise essential oils to their patients. 20 In another study conducted in Turkey among 495 medical students, only 7.1% of the students reported having sufficient knowledge about aromatherapy. 21 Almost all respondents (88.3%) supported the idea of integrating aromatherapy into the training curriculum of healthcare professionals. This is consistent with the aforementioned US study in which 75.5% of respondents stated that there is a need for increased training of clinicians in the use of essential oils. 20

LIMITATIONS OF THE STUDY
The limitations of the present study are the low representativeness of professional categories other than physicians and pharmacists and the imbalance between men and women among the respondents.

CONCLUSION
Our study shows that Moroccan healthcare professionals are initiated to aromatherapy and that the advice and prescription of essential oils is a fairly common practice among them. The introduction of theoretical training cycles or the introduction of aromatherapy in the basic training courses of healthcare professionals could allow them to advise or prescribe essential oils with confidence based on scientific evidence. Moreover, the use of essential oils as a means of treatment in healthcare facilities could allow to widen the therapeutic arsenal and to highlight the richness of the vegetation and the biodiversity of Morocco which is a great producer of aromatic plants.
What is already known on this topic?
Essential oils have many known virtues and aromatherapy is gaining an increasing interest among healthcare professionals.
What this study adds?
The lack of training and theoretical knowledge among healthcare professional is the main factor limiting the prescription and use of essential oils.