Introduction
With the progress and development of health sciences, the number of elderly people in the world increases every year; as a result, there is a greater need to improve the health and quality of life of the elderly. Discovering new treatment methods, prevention strategies, improving healthy behaviors and using medications can lead to improvements in health and medical services. Dealing with drug-related problems in elderly patients and vulnerable people are one of challenges of health systems. The use of herbal medicines is one of the most widely used methods in complementary medicine around the world. Studies have shown that the elderly use different natural and herbal products and believe that these products are harmless because they are natural and use them on their own or with the advice of others. Although the prescription of herbal medicines is also done by physicians, their prescription is still not very common.
Methods
This is a secondary analysis study with a cross-sectional design. Secondary data are data that have been collected in the past for other purposes; based on these data, secondary analysis is done for new purposes. The samples were collected in 2020 from among the paper prescriptions of older men and women aged ≥60 years referred to 84 pharmacies in Tehran, Iran by random cluster sampling method. The sample size was estimated to be 1593 copies by using Cochran’s formula. 335 paper prescriptions were collected from pharmacies covered by Tehran University, 573 from pharmacies covered by Shahid Beheshti University of Medical Sciences, and 685 from pharmacies covered by Iran University of Medical Sciences. The final number of collected samples was 1591.
A researcher-made questionnaire was used to record the information related to the elderly including demographic characteristics, the name of pharmacy, the municipal area where the pharmacy located, the number and name of medications prescribed, drug groups, and the type of insurance covered, the information related to the physicians prescribed the medications including age, sex, type of expertise, and work experience. The collected data were analyzed using descriptive statistics including mean and dispersion indices and inferential statistics including chi-square test and independent t-test in SPSS software, version 24. The significance level was set at 0.05.
Results
The mean age of participants was 70.51±7.84 years; 54% were female and 46% were male; 36.6% had primary education and 1214(76.3%) were married. In total, 1568 had insurance (98.6%). The mean age and work experience of physicians were 53.25±11 and 25.5±10.5 years respectively; 415(26.1%) were female and 1176(73.9%) were male; 402(25%) were general practitioners and 1189(75%) were specialists. The mean number of drugs in each prescription was 3.7; herbal medicines were prescribed in only 79 cases (5%). Among 79 paper prescriptions containing herbal medicines, 70(92.1%) had one herbal medicine, 5(6.6%) had two herbal medicines, and 1 (1.3%) had five herbal medicines. Laxatives (Psyllium and Cilax) were the most prescribed medications with 22.8%, followed by amnesia therapy (Ginkgo) with 13.8%, tonic and rejuvenator drugs (Ginseng) with 11.5%, prostate treatment drugs with 11.4% and antitussive and expectorants with 10.3%.The chi-square test results showed a statistically significant relationship between the educational level of the elderly and prescription of herbal medicines (P=0.018), insurance and prescription of herbal medicines (P=0.004) and polypharmacy and prescription of herbal medicines (P=0.000), while the prescription of herbal medicines had no significant relationship with the gender and marital status of the elderly. In addition, there was no significant relationship between the gender of physicians prescribed the medicines and the prescription of herbal medicines. The rate of prescription by general practitioners was 5.7%, and by specialists was 4.7%, but no significant relationship was found between them. The results of the independent t-test showed no significant relationship of the age of the elderly, the age of physicians and their work experience with the prescription of herbal medicine, but there was a significant relationship between the number of prescribed medicines and the prescription of herbal medicines (P=0.000). Among the specialists, those expert in infectious diseases prescribed the most herbal medicines (14%), followed by physical medicine specialists (12%), orthopedics (9.2%), neurologists (7.6%), and gastroenterologists (7.5%). Chi-square test results showed a significant relationship between the expertise of physicians and prescription of herbal medicines (P=0.042).
Discussion
The results of this study showed that despite the desire of the elderly to use herbal medicines, physicians are not interested in prescribing herbal medicines. In the prescription of herbal medicines, education level, age, having insurance, the number of prescribed medicines, and the physicians’ expertise had a significant role. Further studies for investigating the knowledge, attitude and practice of physicians regarding the prescription of herbal medicines are recommended. Considering the interest of the elderly in herbal medicines, policy makers should have proper planning to increase the production of various herbal medicines with appropriate doses. Holding regular training courses to increase knowledge and change the attitude of physicians can play an effective role in prescribing more herbal medicines.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1400.144).

Funding
This study was funded by the University of Social Welfare and Rehabilitation Sciences.

Authors' contributions
Conceptualization, methodology, investigation, initial draft preparation: Malihe Saboor and Zhale Zandieh; editing & review: Ahmad Delbari.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank the staff of Geriatrics Research Center, University of Social Welfare and Rehabilitation Sciences, and all participants for their support and cooperation.


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