Abstract
The coronavirus disease 2019 (COVID-19) pandemic has adversely affected working life all over the world, and the employees with the highest risk of transmission have been those in the health sector. Since there are currently no effective treatments for COVID-19, there have been numerous attempts to find alternative treatments for both the spread of the infection and its treatment. These efforts have included the use of herbal extracts to boost immunity and reduce the likelihood of contracting the infection. This study explored the attitudes of healthcare workers toward the consumption of COVID-19 herbal medicine (HM) products. This is an online, cross-sectional observational study. In total, 1335 participants were reached. It was observed that 722 (54%) of them preferred herbal treatments during the pandemic period. The attitudes of HM toward 327 (45.3%) healthcare workers and 395 (54.7%) general population participants were examined. Both groups had high rates of use of HM as a COVID-19 preventive measure (68.8 percent and 67.1 percent, respectively). While its use was higher among healthcare workers during infection (OR: 2.00, 95% CI: 1.32–3.03), its use was higher in the non-healthcare group for post-COVID problems (OR: 0.51, 95% CI: 0.35–0.74). The opinion of healthcare professionals was that HM was more efficient (OR: 1.59, 95% CI: 1.19–21.15). All participants’ main incentive to utilize HM was family advice (n = 194, 26.9%). A total of 90 (12.4%) participants reported side effects. Vomiting-nausea were the most typical adverse effects (38.9%). The herb most frequently utilized was ginger (54%). Healthcare workers use HM at rates that are the same as those of the general population. Both its use during infections and the idea that it is effective are more common among healthcare professionals than in the general population.
Keywords: COVID-19, healthcare workers, herbal medicine
1. Introduction
Herbal treatments, which are a part of traditional medicine in Asian countries, have been used since ancient times.[1] In developing countries, it has found widespread use due to its affordability, low side-effect profiles, natural origin, and effectiveness, according to user experiences.[2] Herbal product use in developed countries is increasing over time.[3] In Turkey, the use of herbal treatments is extremely common and is given in traditional and complementary medicine outpatient clinics in public and private hospitals. According to state law, alternative and complementary medicine practices can only be treated by medical doctors and dentists with a certificate obtained after training.
Microorganisms are the most common workplace risk for people working in healthcare. The probability of exposure to many infectious agents is quite high for healthcare workers, especially viruses that cause respiratory system infections. Exposure occurs mostly during contact with patients. The coronavirus disease 2019 (COVID-19) emerged in China and spread rapidly all over the world, causing a serious number of deaths and health problems at the global level. During the pandemic period, healthcare workers were the most at risk in terms of contracting the disease and recurring infections. The death of the doctor who gave the first warnings about the coronavirus epidemic in the Wuhan region of China after being infected with the virus had worldwide repercussions. The struggle to find drugs to prevent and treat the epidemic is still ongoing.[4] Since no effective treatment has yet been found, well-known medicinal plants with antiviral properties are preferred as an extra treatment against COVID-19.[5] Medical herbs help reduce the symptoms of viral disorders. There is evidence to suggest that herbal remedies can be effective for COVID-19. There is also the use of herbal medicine (HM) as a complementary treatment in COVID-19 by adding it to contemporary medical treatments.[6] At the same time, thanks to the anti-inflammatory effects of some plant biochemical components, it is thought that they may be effective in reducing the subsequent neurological, respiratory, and cardiovascular complications of COVID-19.[7] HM and their bioactive fractions are potentially useful in preventive and supportive COVID-19 measures. It is thought that some HM may be effective in the pathogenesis of illness by preventing SARS-CoV-2 replication and entry into host cells.[8]
The aim of this study is to reveal the attitudes of healthcare workers, who are at risk of contracting COVID-19 infection continuously during the pandemic due to their profession, towards HM consumption. At the same time, information was obtained about the demographic characteristics, information sources, most frequently used medicinal plants, and their side effects for HM users.
2. Material and methods
2.1. Study design and study population
The current study includes an online cross-sectional observational study conducted in Turkey between March 1 and April 30, 2022. Responses were collected online using Google Forms. The questionnaire was prepared in Turkish by the authors. The final survey was pre-tested by 5 healthcare workers and 5 people from the general population. The pretrial population was not included in the study. Facebook®, Twitter®, Instagram®, and WhatsApp® were used to invite participants to the study. The survey was first distributed to the first-degree relatives of the patients who applied to the ethics committee hospital and to the workers of the ethics committee hospital. Later, the survey link was distributed to workers at some hospitals in Turkey, and participants were asked to share the link using social networking platforms. The aims and objectives of the research were clearly explained at the beginning of the questionnaire. After the explanation, in the first question, they were asked whether they were over the age of 18 and would like to participate in the survey voluntarily. If a positive answer was given, the other questions moved on. Therefore, all participants were exempt from written informed consent. The next part of the questionnaire consists of 2 parts. In the first part, in addition to the socio-demographic characteristics of the participants such as age and gender, whether they are health workers and their occupations were asked. Those who answered “yes” to the “are you a health worker?” question were included in the health worker group, and those who answered “no” were included in the non-health worker group. In the second part, questions such as whether the participants used herbal products during the COVID-19 pandemic and, if they did, when they used them, the source of the information, and their side effects were asked. In addition, they were asked whether they had a COVID-19 infection, if they did, how many times they had it, and whether they preferred HM during the infection period and against possible complications after COVID-19. The authors did not have access to information that could identify individual participants during or after data collection.
2.2. Sample size
Using the G-Power program, the required sample size was calculated to be a total of 567 participants, with a margin of error of 5% and a confidence interval of 95%. Initially, the authors decided that the survey would remain open for 2 months, regardless of the number of participants. The survey was completed by 1335 participants at the end of the determined time. The study was carried out on 722 HM users during the pandemic period.
2.3. Ethical review
This study obtained ethical approval, numbered 15/2532, by the ethics committee of Ankara Ataturk Sanatorium Training and Research Hospital.
2.4. Statistical analysis
The SPSS for Windows 23.0 program was used to analyze all of the data. Demographic data were compared among subjects in the non-health worker group and healthcare workers using a chi-square test for analyses of categorical variables. A binary logistic regression analysis was conducted to determine the factors associated with attitudes toward HM between the 2 groups. A multivariate logistic regression analysis was performed considering that different age, gender, and education levels may affect the reading and understanding of the online questionnaire and the answers given. The adjusted odds ratios were calculated by adjusting age, gender, and education levels. Results were evaluated at a 95% confidence interval and a significance level of P .05.
3. Results
A total of 1335 people participated in the survey, and the number of participants using HM included in the study was 722 (54%). Most participants (n = 280, 38.8%) were in the 40 to 49 age group. Two-thirds of the participants (n = 487, 67.5%) were married, with 51.2% (n = 370) women. The majority were university graduates (n = 451, 62.5%). Those working in a health-related job made up 45.3 percent (n = 327). There was a history of chronic disease among 218 (30.2%) participants. While 473 (65.5%) of the participants were infected with COVID-19 at least once, 47 (6.5%) had never been vaccinated (Table 1). Age, gender, and rates of living alone were similar in both the healthcare worker and non-healthcare worker groups among HM users (P > .05). The rate of university graduates was higher in the healthcare worker group (68.5%). While half of the non-healthcare workers had 3 vaccinations, almost half of the healthcare workers had more than 3 vaccinations. As expected, the rates of contracting the COVID-19 infection were higher in the healthcare worker group (Table 2). Among the 1335 participants who filled out the survey, there was no significant difference between the 2 groups in terms of using herbal treatment (OR: 0.99, 95% CI: 0.81–1.24). In addition to being similar in both groups, we found that a quarter of HM-user participants during the pandemic did not prefer HM before the pandemic (OR: 0.95, 95% CI: 0.68–1.34). We calculated that there was a 33% increase in the use of HM with the pandemic (75–100%). The use of herbal treatments for preventive purposes against COVID-19 was extremely high in both groups (67.1% and 68.8%). Among participants infected at least once with COVID-19 (n = 473), we found that it was twice as popular among healthcare workers during the infection (OR: 2.00, 95% CI: 1.32–3.03). For post-COVID complications, we observed that its use was higher in the non-healthcare worker group at the same rate (OR: 0.51, 95% CI: 0.35–0.74). Healthcare workers thought that HM was more effective (OR: 1.59, 95% CI: 1.19–2.15). Healthcare workers were more likely to recommend HM to others (OR: 2.42, 95% CI: 1.73–3.37). Similar values were obtained when probabilities were adjusted for age, gender, and education level (Table 3). Family advice (n = 194, 26.9%) was the main motivator for all participants to use HM. The second most common recommendation was social media and the internet (n = 165, 22.9%). A total of 90 (or 12% of the user group) participants reported side effects (Table 4). The most common side effects were nausea-vomiting (38.9%) and diarrhea (30%). Ginger was the most commonly used herb in both the general population (54.3%) and healthcare workers (75%). Turmeric was the most commonly used HM in the non-healthcare worker group (57%). The most common HM products used during the COVID-19 pandemic are shown in Figure 1.
Table 1.
Demographic data (n = 722).
| Age | |
| 18–29 | 141 (19.5) |
| 30–39 | 180 (24.9) |
| 40–49 | 280 (38.8) |
| 50< | 121 (16.8) |
| Gender | |
| Female | 370 (51.2) |
| Male | 352 (48.8) |
| Marital status | |
| Single/divorced/widowed | 235 (32.5) |
| Married | 487 (67.5) |
| Education | |
| Lower education | 49 (6.8) |
| High school | 147 (20.4) |
| Vocational schools | 75 (10.4) |
| University | 451 (62.5) |
| Health workers | 327 (45.3) |
| Doctors | 115 (35.2) |
| Pharmacists | 21 (6.5) |
| Nurses | 74 (22.6) |
| Healthcare assistant | 63 (19.3) |
| Others | 54 (16.5) |
| Chronic disease history | 218 (30.2) |
| Chronic respiratory disease | 51 (7.1) |
| Number of infected with COVID-19 | |
| 0 | 249 (34.5) |
| 1 | 366 (50.7) |
| ≥2 | 107 (14.8) |
| Total infected participants | 473 (65.5) |
| Number of COVID-19 vaccine | |
| 0 | 47 (6.5) |
| 1–2 | 180 (24.9) |
| 3 | 307 (42.5) |
| 4–5 | 188 (26.0) |
(%) column percentages.
COVID-19 = coronavirus disease 2019.
Table 2.
Characteristics of participants using herbal medicine.
| Non-health worker group n = 395 (54.7) | Health workers n = 327 (45.3) | All n = 722 | |
|---|---|---|---|
| Age | |||
| 18–29 | 70 (17.7) | 71 (21.7) | 0.14 |
| 30–39 | 98 (24.8) | 82 (25.1) | |
| 40–49 | 167 (42.3) | 113 (34.6) | |
| 50< | 60 (15.2) | 61 (18.7) | |
| Gender | |||
| Female | 208 (52.7) | 162 (49.5) | 0.44 |
| Male | 187 (47.3) | 165 (50.5) | |
| Marital status | |||
| Single/divorced/widowed | 130 (32.9) | 105 (32.1) | 0.82 |
| Married | 265 (67.1) | 222 (67.9) | |
| Education | |||
| Lower education | 26 (6.6) | 23 (7.0) | 0.01* |
| High school | 92 (23.3) | 55 (16.8) | |
| Vocational schools | 50 (12.7) | 25 (7.6) | |
| University | 227 (57.5) | 224 (68.5) | |
| Chronic disease history | 112 (28.4) | 106 (32.4) | 0.23 |
| Chronic respiratory disease | 28 (7.1) | 23 (7.0) | 0.97 |
| Number of infected with COVID-19 | |||
| 0 | 149 (37.7) | 100 (30.6) | 0.04* |
| 1 | 201 (50.9) | 165 (50.5) | |
| ≥2 | 45 (11.3) | 62 (18.9) | |
| Total infected participants | 246 (62.2) | 227 (69.4) | |
| Number of COVID-19 vaccine | |||
| 0 | 31 (7.8) | 16 (4.9) | 0.001* |
| 1–2 | 133 (33.7) | 47 (14.4) | |
| 3 | 200 (50.6) | 107 (32.7) | |
| 4–5 | 31 (7.8) | 157 (48.0) | |
(%) column percentages.
P < .05.
COVID-19 = coronavirus disease 2019.
Table 3.
Participants’ attitudes toward herbal medicine.
| Non-health worker group (ref.) | Health workers | OR (95% CI) | Adjusted OR† (95% CI) | |||
|---|---|---|---|---|---|---|
| Have you used herbal medicine during the pandemic period? | ||||||
| (n = 1335) | Yes | 395 (54.1) | 327 (54.0) | 0.99 (0.81–1.24) | 1.05 (0.84–1.30) | |
| No | 335 (45.9) | 278 (46.0) | ||||
| Would you prefer herbal medicine before the pandemic? | ||||||
| (n = 722) | Yes | 298 (75.4) | 244 (74.6) | 0.95 (0.68–1.34) | 0.92 (0.65–1.29) | |
| No | 97 (24.6) | 83 (25.4) | ||||
| When did you use herbal medicine? | ||||||
| I used it for protection against COVID-19 | ||||||
| (n = 722) | Yes | 265 (67.1) | 225 (68.8) | 1.08 (0.79–1.48) | 1.07 (0.78–1.47) | |
| No | 130 (32.9) | 102 (31.2) | ||||
| I used it when I was infected with COVID-19 | ||||||
| (n = 473) | Yes | 160 (65.0) | 179 (78.9) | 2.00 (1.32–3.03)* | 2.06 (1.35–3.12)* | |
| No | 86 (35.0) | 48 (21.1) | ||||
| I used it against possible complications after COVID-19 | ||||||
| (n = 473) | Yes | 115 (46.7) | 70 (30.8) | 0.51 (0.35–0.74)* | 0.50 (0.34–0.73)* | |
| No | 131 (53.3) | 157 (69.2) | ||||
| Do you think that the herbal products you use are effective? | ||||||
| (n = 722) | Yes | 175 (44.3) | 183 (56.0) | 1.59 (1.19–2.15)* | 1.62 (1.21–2.19)* | |
| No | 220 (55.7) | 144 (44.0) | ||||
| Would you recommend the herbal medicine you use to others? | ||||||
| (n = 722) | Yes | 240 (60.8) | 258 (78.9) | 2.42 (1.73–3.37)* | 2.44 (1.74–3.43)* | |
| No | 155 (39.2) | 69 (21.1) | ||||
(%) column percentages.
COVID-19 = coronavirus disease 2019.
P < .05.
Adjusted with age, gender, and education level.
Table 4.
Recommendation resources and side effects of herbal medicine users.
| Non-health worker group | Health workers | All | |
|---|---|---|---|
| Who recommended you take herbal medicine? (n = 722) | |||
| My family recommended | 114 (28.9) | 80 (24.5) | 194 (26.9) |
| Doctor recommended | 49 (12.4) | 92 (28.1) | 141 (19.5) |
| Recommendation on social media and the internet | 96 (24.3) | 69 (21.1) | 165 (22.9) |
| Herbalist recommended | 84 (21.3) | 45 (13.8) | 129 (17.9) |
| Pharmacist recommended | 52 (13.2) | 41 (12.5) | 93 (12.9) |
| Did the herbal medicine you used have any side effects? (n = 722) | |||
| Yes | 90 (12.5) | ||
| No | 632 (87.5) | ||
| What side effects did you encounter while using herbal medicine? (n = 90) | |||
| Nausea-vomiting | 35 (38.9) | ||
| Diarrhea | 27 (30.0) | ||
| Stomachache | 25 (27.8) | ||
| Skin allergy | 17 (18.8) | ||
| Headache | 12 (13.3) | ||
(%) column percentages.
Figure 1.
The most common herbal medicine products used during the coronavirus disease 2019 pandemic. HM = herbal medicine.
4. Discussion
This study investigated the attitudes of healthcare workers towards HM products during the COVID-19 pandemic in comparison with the general population. Herbal products are frequently used in our country.[9,10] In our study, the frequency of use was 54 percent. The rate of HM use was similar in both groups. In a study in Vietnam, of which 47.8 percent were healthcare workers, the frequency of HM use in the pandemic was found to be 49 percent.[11] In another study with a larger sample size in Saudi Arabia, the prevalence of HM use in the pandemic was found to be 14.9%.[12] In the current study, 25% of the participants stated that they did not use HM before the epidemic. We found that the use of herbal products increased by 33 percent during the pandemic period. All throughout the world, people utilize herbal items and dietary supplements to improve their health or treat issues related to their health.[12] Studies on the use of HM by healthcare workers in the COVID-19 pandemic are limited. In a study on dietitians in our country, HM use was found to be 44.5 percent.[13] A study conducted in Japan showed that maoto, an HM, may be useful for preventing the spread of COVID-19 among healthcare workers. In a small-group study, those who used Maoto infected significantly fewer participants with SARS-CoV-2 than the control group. In the SARS epidemic, 3160 healthcare workers in China used HM in addition to medical treatments. Side effects were extremely rare in the group using HM; it was observed that there were no influenza-like symptoms and a good immunological response.[14]
The 3 most preferred herbs in our study were ginger (54%), linden (50%), and turmeric (48%). While turmeric (57%) was the most preferred HM among healthcare workers, ginger (75%) was the most preferred in the non-healthcare worker group. In a study conducted in Jordan, half of the participants reported using one or more natural remedies; the most commonly used natural products were citrus fruits (78.8%), honey (63.0%), and ginger (53.1%) in the second wave of the pandemic.[15] In Vietnam, ginger (79%), honey (75%), and garlic (65%) were the 3 most commonly used HM products during the COVID-19 pandemic. According to all these studies, we concluded that ginger is used quite frequently. We see that honey and garlic are widely used in the pandemic.
In our study, the most common reason for HM’s recommendation was family advice, and social media was the second source of recommendation. Similar to our study, family advice and social media have been mentioned as common sources of recommendation and suggestion in studies conducted in Saudi Arabia[12] and Jordan.[15] Medical doctors and herbalists were the most common sources of information in Vietnam.[11] While the recommendation resources for HM in the non-healthcare worker group were similar for all participants, healthcare workers stated that they were more highly recommended by the doctor. The reason for this may be that some of the healthcare workers are already doctors and work with doctors.
Although there are not enough studies on the use of HM as a preventative against COVID-19, its protective effect against the common cold is based on experience.[16] We found that the rates of believing that HM is protective were high in both groups using HM (67% and 68%, respectively). The rate of unvaccinated participants in our study group was extremely low. The fact that the vaccine provides a milder course of the disease rather than being definitively protective may explain this high level of protection. HM use was twice as high among healthcare personnel during COVID-19 infection. Its use against complications of COVID-19 was lower at the same rates. To date, the treatment of COVID-19 has been symptomatic and supportive in cases without respiratory failure. There is no definitively effective drug available for the treatment of COVID-19. Various antiviral drugs (Remdesivir) and antimalarial drugs (Chloroquine) have been tried. The conclusion is that although the viral load shows a slight decrease, there is no improvement in the mortality rate of the patients.[17] Anticoagulants are used to alleviate the complications associated with COVID-19.[18] We think that during the pandemic period, healthcare professionals prefer HM more during infection because they can follow up-to-date information more easily, and they also prefer medical treatments against COVID-19 complications. Healthcare workers thought that HM was more effective. Effectiveness may vary depending on the participants’ perspective. This difference may have been due to the fact that healthcare workers, and especially doctors, could better evaluate the symptoms and the disease.
Herbal and natural treatments have been shown to be a safe choice with few side effects when used consciously.[19,20] In our study, only a few of the participants reported side effects (n = 90, 12.4%). Gastrointestinal complaints were prominent. The most common side effects were nausea-vomiting, diarrhea, and abdominal pain. Similar side effects were seen in other studies conducted during the pandemic period.[12]
Compared to data obtained through a face-to-face interview, some of the collected data may be biased, as data obtained online may have underreported HM uses. Another bias may be the higher socio-cultural levels of healthcare workers compared to the general population. Healthcare workers are also more knowledgeable about health. For this reason, participant compliance may be higher for these individuals. In conclusion, HM has the same usage rates among healthcare workers as the general population. Its use during infection in healthcare workers is more common than in the general population, and its use against possible post-COVID complications is higher in the general population. Healthcare workers think that HM is more effective.
Author contributions
Conceptualization: Ömür Güngör, Husnu Baykal.
Formal analysis: Ömür Güngör.
Funding acquisition: Ömür Güngör.
Investigation: Ömür Güngör.
Methodology: Ömür Güngör.
Project administration: Ömür Güngör, Husnu Baykal.
Resources: Ömür Güngör, Husnu Baykal.
Software: Ömür Güngör.
Supervision: Ömür Güngör, Husnu Baykal.
Validation: Ömür Güngör.
Visualization: Ömür Güngör.
Writing – original draft: Ömür Güngör.
Writing – review & editing: Ömür Güngör.
Abbreviations:
- COVID-19
- coronavirus disease 2019
- HM
- herbal medicine
The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Güngör Ö, Baykal H. Attitudes toward herbal medicine for COVID-19 in healthcare workers: A cross-sectional observational study. Medicine 2023;102:38(e35176).
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