COVID-19 home remedy consumption and perceived effectiveness among adult population in Brunei Darussalam: a PLS-SEM approach

Traditionally passed down across generations, home remedies, classified as Complementary and Alternative Medicine (CAM), address minor health issues. The origins of these remedies vary among cultures. The SARS-CoV-2 virus, causing COVID-19, primarily affects the respiratory system. With widespread COVID-19 vaccination, most cases now exhibit mild upper respiratory symptoms. Various cultures and religions embrace home remedies and complementary therapies to alleviate mild COVID-19 symptoms, sometimes adjunctive to conventional medicine. Nurses, as promoters of holistic care, play a role in transcultural nursing, understanding patients’ cultural preferences for remedies in managing COVID-19 guiding evidence-based self-management education.

In late 2019, a novel coronavirus disease emerged in Wuhan City, Hubei Province, China [1]. The World Health Organization officially designated it a global pandemic on March 11, 2020, after careful consideration [2]. As of July 26, 2023, the cumulative global tally stood at 768,560,727 confirmed cases with 6,952,522 reported deaths [3]. Brunei Darussalam recorded its first 2019-nCoV case in March 2020, responding with a Movement Control Order to curb the spread of virus. Despite an apparent halt in community transmission in May 2020, new COVID-19 cases emerged in early August 2021, signalling the onset of the second wave and leading to a partial lockdown [4, 5]. As of July 26, 2023, Brunei reported 309,561 confirmed COVID-19 cases with 2 deaths [6]. Approaching its fourth year, COVID-19 is no longer classified as global public health emergency but acknowledged as an enduring health challenge.

Defining “home remedies” poses a challenge due to cultural variations, with terms like traditional medicine, fold medicine, CAM, and natural remedies used interchangeably. Cultural and social factors influence the utilisation of home remedies, which may be viewed as self-management. This study considers home remedies, incorporating identified terms and specifying ingredients found at home for treating illnesses.

In nursing, acknowledging patients’ cultural practices and traditional medicine is advantageous. Despite debates on traditional medicine’s scientific validity, overlooking patients’ cultural context may diminish care quality [7]. Nurses should consider patients’ use of home remedies, but must also inform them about the risk, benefits and contradictions with conventional medicine. Respecting patient autonomy involves promoting choices in treatment plans, but not disclosing risks may lead to harm [8]. In South Africa, discussing herb-drug interaction with patients is challenging due to nurses’ limited herbal medicine knowledge or patients’ non-disclosure on their herbal medicine consumptions [9]. Amid resource shortages in the pandemic, understanding local home remedies becomes crucial for nurses to ensure safe practices.

Globally, numerous experiments explored natural sources for potential COVID-19 remedies. In Brunei, studies on home remedies exists in the form of ethnomedicine, yet none specifically address COVID-19. A cross-sectional study examines the prevalence of general traditional medicine use [10], while another investigates prevalence and predictive factors for CAM use [11].

The aim was to investigate the usage of COVID-19 home remedies among the adult population in Brunei. The objectives were: 1) To estimate the prevalence of home remedy usage for COVID-19 among Brunei’s adult population; 2) To establish the perception, attitude, and practice of utilising home remedy for COVID-19 among Brunei’s adult population in relation to sociodemographic factors; 3) To investigate, by demographic stratification, the prevalence as well as the perception, attitude, and practice of COVID-19 home remedies; and 4) To develop a structural model based on the perception, attitude, and practice data to explain home remedy usage in the adult Brunei population.

This research seeks to bridge the gap between traditional and modern medicine, offering valuable insights into home remedies used by Bruneian residents and its efficacy for COVID-19. The study’s outcomes will the Ministry of Health and stakeholders, guiding health education for those favouring home remedies. Additionally, it will assist nurse educators and professionals in formulating guidelines for COVID-19 patient care, enhancing understanding of prevalent home remedies and Bruneian adults’ attitudes and beliefs. The findings will also contribute to researchers’ comprehension of Bruneian adults’ health-seeking behaviour and treatment intentions.

Significant findings derived from this study have the potential to contribute to: the formulation of evidence-based guidelines for healthcare professionals regarding the utilisation of COVID-19 home remedies; fostering comprehension of societal cultures and lifestyles, thereby cultivating acceptance of the utilisation of COVID-19 home remedies and traditional medicine in conjunction with conventional medical practices among healthcare personnel; and developing a comprehensive citizen’s guide aimed at assisting individuals afflicted by COVID-19 in the proper and secure self-care practices.

A literature review explored existing evidence on COVID-19 patients using home remedies for manging mild symptoms. Employing a PEO format, review focused on literature published in English between 2018 to 2022. Searches were conducted on PubMed Central, Springer Link, and Science Direct to identify research gaps.

An literature overview identified two main themes regarding home remedy use for managing COVID-19 symptoms: studies on traditional medicinal plants, and the utilisation of CAM.

Literature findings suggest an initial exploration of numerous plants traditionally used, now under review and experimentation for potential medicinal properties in the treatment of COVID-19. African traditional medicine, encompassing Cameroonian and West African medicinal plants, was among the recognised established traditional remedies mentioned [12‐14]. One review centred on a Saudi Arabian medicinal plant, commonly known as Black Seed [15], another explored traditional medicine in Iran [16], and several others examined essential oil in Brazil [17] and India [18]. Studies conducted in India explored the potential properties of natural products [19], traditional medicinal plants [20], the efficacy of Siddha Medicinal decoctions [21], and Ayurveda Rasayana for antiviral effects and immune system enhancement [22]. Lastly, an investigation on the efficacy and mechanism of a Chinese herb [23]. This indicates that numerous literary works have already explored the study of traditional medicine derived from plants.

Mentioned CAM modalities include Ayurvedic Medicine, Chinese Traditional Medicine, and Siddha Medicine. A study addressed CAM’s role in preventing and treating COVID-19 [24], while others explored CAM use alongside allopathic drugs [25‐27], and natural pharmacy’s role in relief and prevention [24, 28‐30]. One study examined CAM prevalence and predictive factors during the first COVID-19wave [31]. Overall, the literature highlights the CAM utilisation not only for symptoms management but also perceived prevention of COVID-19.

The study employed a cross-sectional design via an online survey with an estimated sample size based on Brunei’s total recovered COVID-19 cases (160,954 cases as of July 1, 2022). The required sample size was considering ± 5% margin of error, 50% prevalence, 95% confidence interval, and a 20% potential loss. I anticipated 95% CI is (45%, 55%),calculated using Scalex SP calculator [32]. The eligibility criteria for participants were as follows.

The target participants were: 1) People who were infected with COVID-19 in Brunei Darussalam between March 2020 to February 2023; 2) People who used home remedies with or without the use of modern medicine during COVID-19 infection; 3) Aged 18 and above; and 4) Citizens and permanent residents of Brunei Darussalam.

Meanwhile, the exclusion criteria was other respiratory infections.

Data collection utilised a self-developed survey drawing from literature and a cross-sectional survey on patients’ general home remedy use in Germany [33] and a Brunei Darussalam study on traditional medicine prevalence [10]. Permission to adapt to the Brunei study was obtained. The questionnaire covers three sections: socio-demographic, participants’ COVID-19 experiences, and home remedy consumption during COVID-19 infections. To ensure participant eligibility, the online questionnaire was designed to only accept the responses of those who are eligible for the survey using the ‘Display Logic’ and ‘Skip Logic’ functions available on the platform.

After ethical approval from the university, and permission from the four Brunei District Office (Brunei-Muara, Tutong, Belait, and Temburong), the survey link was disseminated nationwide. Gatekeepers from the District Offices received emails explaining the dissemination process. The gatekeepers then digitally shared a poster containing the survey link and research details with the Penghulu (Chiefs), who then circulated it to all Village Heads in their respective Mukims (subdivisions of a district), reaching members of the village.

Data collected from the online questionnaire was extracted from Qualtrics and imported into Microsoft Excel for the process of data analysis. The statistical analysis of the data included descriptive statistics used to describe the sociodemographic characteristics of the respondents (age, gender, race, education level, employment status, monthly income, religion, and marital status), their experience with COVID-19 infection (symptoms experienced and hospitalisation), consumption of general home remedy and COVID-19 home remedy, their practice of COVID-19 home remedy use (with modern medicine, vitamins or supplements, source of ingredients, reason, knowledge, types of home remedy, and perceived effectiveness), and their attitude towards the general use of home remedy (perceived safety, reason for perceived safety, and opinion on home remedy). Sub-group analysis including Pearson's chi-square test and Fisher's exact test was computed for the variables in relation to the COVID-19 home remedy use and the perceived effectiveness of the types of home remedy. Multivariate analysis including Partial Least Squares Structural Equation Modelling (PLS-SEM) was applied to determine the correlations between the factors ‘Experience’, ‘Opinion’, ‘Safety’, ‘Source’, ‘Reason’ and ‘Knowledge’, and outcomes measured, ‘Home Remedy Use’ and ‘Effective’. Attitude and opinion refers to their perceived effectiveness of the types of home remedy they are using, the perceived safety of home remedy and their opinion of how effective the COVID-19 home remedy would be with modern medicine. Practice refers to their previous experience of using home remedy in general, where they get their supply of home remedy ingredients and their reasons for using the home remedy. All statistical analysis was computed using R version 4.2.1 (2022–06-23) and RStudio 2022.07.1 + 554. P-value less than 0.05 is considered statistically significant.

The selection of Partial Least Squares Structural Equation Modelling (PLS-SEM) for the data analysis was motivated by the unique capability of this method to yield results that were unattainable through alternative methodologies. The study comprised of two distinct outcomes and related factors. Therefore, further to univariate analysis that explores factors to each outcome, structural equation modelling (SEM) was used to establish multivariate link between all the factors to both outcomes, simultaneously. Upon further exploration, PLS-SEM was suitable with the structure and distribution of data of this study.

Ethics approval was obtained from the Ethics Committee of PAPRSB Institute of Health Sciences (UBD/PAPRSBIHSREC/2022/31) on December 6, 2022. Permission to extract data was obtained from the four District Offices in Brunei Darussalam. Approval to recruit pretesting samples was obtained from the Director, Office of Vice-Chancellor (Research)/ Chair, University Research Ethics Committee (UREC) of Universiti Brunei Darussalam. All participant-identifying information such as name and any identification number, was not collected to ensure participants’ anonymity and confidentiality. Online data collection ensured no direct contact with research participants. Informed consent was obtained before starting the online questionnaire, and participants need to click the “I agree” statement or “I decline” if they refuse to participate. The dataset stored on a password-protected computer was only accessible by the research team and will be deleted five years after the completion of study.

Table 6 showed significant associations with COVID-19 home remedy use in gender (p < 0.001), race (p = 0.001), education level (p < 0.001), employment status (p < 0.001), monthly income (p < 0.001), religion (p < 0.001), and marital status (p = 0.001). No significant associations were observed regarding the participants’ sociodemographic characteristics and the perceived effectiveness of COVID-19 home remedy. Among non-users of COVID-19 home remedy (N = 240), 80% were female, 92% were Malay, 87% had higher education, and 41% were government servants. Most non-users had a monthly income of over B$2000 (43%), practiced Islam (93%), and married (51%). Of users (N = 624), 52% were female, 84% are Malay, 76% had higher education, and 45% were from the private sector or self-employed. Higher income correlates with increased COVID-19 home remedy use. All users practiced Islam, and 61% were unmarried.

There were no significant associations reported in Table 7 between COVID-19 home remedy consumption as well as the perceived effectiveness of COVID-19 home remedy with the severity of COVID-19 infection.

Table 8, revealed significant associations between COVID-19 home remedy consumption and experience with general home remedy use (p < 0.001), safety perception due to traditional practice (p < 0.001), and home remedy opinion (p < 0.001). A notable association exists between perceived safety due to natural sources and the perceived effectiveness of COVID-19 home remedy (p = 0.044). Most COVID-19 home remedy users have prior general home remedy experience (93%), while non-users lack the experience of using general home remedy (92%). Almost half of the COVID-19 home remedy users perceived it as safe (49%), contrasting with all non-users of COVID-19 home remedy perceiving is as unsafe. Over half of the COVID-19 home remedy users were uncertain about home remedy efficacy compared to or in addition to modern medicine (54%), while non-users of COVID-19 home remedy think it works (61%). Those perceiving safety in natural sources finds COVID-19 home remedy ineffective or less effective (36%), while others find it effective or very effective (25%).

Table 9 illustrates significant associations between the perceived effectiveness of COVID-19 home remedy and various ingredient sources, including those obtained from the supermarket (p < 0.001), given by friends/family (p < 0.001), personal gardens (p < 0.001), Chinese dispensary (p = 0.003), and purchases from overseas (p < 0.001). Furthermore, significant associations were observed with specific reasons for using COVID-19 home remedy, such as relieving symptoms (p < 0.001), family recommendations (p < 0.001), viewing it as cure (p < 0.001), and preventing severe infection (p < 0.001). All listed knowledge sources exhibit significant associations with the perceived effectiveness of COVID-19 home remedy. Additionally, certain types of COVID-19 home remedies, including clove (p < 0.001), lemon (p < 0.001), coconut (p < 0.001), eucalyptus oil (p < 0.001), traditional/ herbal cough syrup (p = 0.003), and turmeric (p = 0.002), show significant associations with perceived effectiveness.

Among those perceiving COVID-19 home remedy as ineffective or less effective, ingredients were mostly sourced from the supermarket (34%) and given by friends or family (18%), primarily for symptom relief (32%) and family recommendations (25%), with knowledge on home remedy from family members (28%), other people (25%), social media (24%), internet searches (19%), self-learning, and books/magazines (1.3%). They mostly use cloves (31%) and lemon (31%).

In contrast, those perceiving COVID-19 home remedy as effective or very effective, mainly obtained ingredients from the supermarket (70%) and friends or family (70%), emphasising symptom relief (92%) and family recommendations (69%), with prevalent knowledge of home remedies from family members (85%), social media (70%), internet searches (55%), people’s recommendations (53%), self-learning (39%), and books/ magazine (16%). The most commonly used COVID-19 home remedies among this group were cloves (69%) and lemon (69%), followed by coconut (31%), eucalyptus oil (16%), traditional/ herbal cough syrup (7.5%), and turmeric (7.5%).

To further explore the results of the collected data, Partial Least Squares Structural Equation Modelling (PLS-SEM) was used to model the relationship between endogenous factors including ‘Experience’, ‘Safety’, ‘Source’, ‘Opinion’, ‘Reason’, and ‘Knowledge’ towards the two main outcomes – the intention of COVID-19 home remedy use and perceived effectiveness, among Brunei adult population which is shown in Fig. 1. The structural equation model demonstrated that ‘Experience’ appears to be a central endogenous variable that affects the decision on the use of COVID-19 home remedy. This relationship is mediated by ‘Safety’, ‘Source’, and ‘Opinion’ which have significant contributions to the outcome, accounting for 98.2% of the variance explained (R-square = 0.982). On the other hand, ‘Experience’ is also central to the relationship towards the perceived effectiveness of COVID-19 home remedy usage. We observed that this relationship is mediated by ‘Reason’ and ‘Knowledge’ which has an important contribution towards this outcome, accounting for 32.3% of the variance explained (R-square = 0.323). With the respective structural model, the path coefficients are presented in Table 10. After adjusting for confounding variables, we observed that ‘Source’ (β = 0.915) is the main enabler for home remedy use (Adjusted R-square = 0.982). While ‘Reason’ (β = 0.300) and ‘Knowledge’ (β = 0.305) are important contributors towards perceived effectiveness (Adjusted R-square = 0.321).

Table 11 presents the measurement model whereby the reliability and convergent validity of the PLS-SEM model. Cronbach’s alpha statistics indicated that all the constructs had good to excellent internal consistency reliability except for the ‘Safety’ domain (alpha = 0.116). In the same vein, ‘Safety’ also had Average Variance Explained (AVE) lower than 0.5, indicating that the latent variance may not be completely captured by the items. However, these items were not dropped as they are conceptually important.

The study revealed a higher prevalence COVID-19 home remedy usage (72.2%) in Brunei compared to earlier reports in other countries during the 2020 pandemic outbreak. Iran and The Netherland reported 69% [34] and 68% [31], respectively, for complementary and integrative medicine use. South African university students and academic staff reported a significantly lower with traditional medicine use at 30.4% [35]. In contrast, Brunei’s study demonstrated a higher prevalence among those with higher education (76%) than those with lower education levels (24%). Despite being the first study of its kind on COVID-19 home remedy use in Brunei, the 70% prevalence of prior general home remedy use exceeds a 2007 study’s finding (59%) in Brunei [10] indicating a rising trend in home remedy as well as complementary and integrative medicine utilisation in modern healthcare.

This study explores the perception, attitude, and practice of COVID-19 home remedy of adults in Brunei using PLS-SEM. The result from the PLS-SEM suggests a substantial impact of general home remedy consumption experience on participants’ decisions to consume home remedy for COVID-19, with mediating factors such as perceived safety, ingredient accessibility, and participant opinions on the home remedies influencing this relationship. The findings suggest that participants’ trust in the safety of the home remedy sems from their past experiences in safely using its ingredients.

In the contemporary era, where knowledge is easily accessible, individuals seek knowledge on COVID-19 home remedy through various channels, including social media and the Internet. While social media constituted a notable knowledge source for our participants (30%), this study showed that a higher proportion acquired knowledge from family members (36%). A previous study on general home remedies in Germany found that consumers predominantly obtained information from family members (80%) [33]. Conversely, in a study involving pharmacists noted that patients learned about COVID-19 home remedy primarily through social media and media (73.5%) and self-decision (73.1%), surpassing information obtained through healthcare prescriptions after seeking CAM (65.9%) [36].

Furthermore, another prominent motivation for our participants in using home remedy is familial recommendation (32%). This postulates a crucial influence of personal motivation and close social networks, as only 16% reported using home remedy based on the recommendations from other individuals. A study investigating factors influencing COVID-19 preventive behaviour found that individuals can be socially influenced when trusted individuals in their social circle adhere to a social norm [37]. A global systematic review highlighted that people primarily turn to CAM due to their expectations of its benefits, discontentment with conventional medicine, and the perceived safety of CAM [38]. In addition, Western population tend to be internally motivated, while Asian populations lean towards external motivation influenced by social networks. In contrast, affordability, accessibility, and tradition play pivotal roles influencing factors for the African population [38]. A Hong Kong study on predictors of the intention to use Traditional Chinese Medicine applying the theory of planned behaviour exhibited that attitude towards Traditional Chinese Medicine was strongly influenced by subjective norms, perceived behavioural control, and knowledge, indicating the impact of advice from others in encouraging individuals to seek Traditional Chinese Medicine [39].

Interestingly, while a substantial portion of our participants utilised the COVID-19 home remedy to alleviate symptoms, they predominantly perceived it as less or not effective. Despite this perception, they majority considered it safe for use and continued its application, even with uncertainty regarding its compatibility with modern medicine and perceptions of reduced efficacy. These findings suggest a dual motivation, influenced both internally and externally, guiding individuals in their choice to resort to home remedies. Further research could explore deeper into distinguishing the relative influence of family compared to friends and strangers, particularly within the Asian population.

Participants in this study consumed COVID-19 home remedies, aligning with a systematic review by Soltani et al. in 2022, which highlighted six individual types [40]. In contrast, our study found users reporting consumption of cloves, lemon, honey, coconut, eucalyptus oil, habbatussauda, traditional/herbal cough syrup, and turmeric. The subsequent discussion explores the usage of these home remedies in comparison with findings from various studies worldwide.

Learning from Italy, the efficient management of mild-to-moderate COVID-19 patients at home, it reduces the pressure on their healthcare system minimising the socio-psychological impact on patients, albeit the lack of experiments to support the observed management with home therapy at that time [53]. Revised in 2021, Brunei Darussalam’s Ministry of Health published an online guide of the COVID-19 self-management at home for home-isolation patient, which included simple symptom management with over-the-counter medications and simple home remedies. For instance, paracetamol for fever, cough syrup for cough, lozenges or gargling with salt water for sore throat, and antihistamine or nasal decongestant for rhinitis [54]. While the guidebook incorporated various at-home self-management suggestions, it still lacked comprehensive recommendations on home remedies. Therefore, the findings from this study could contribute to fill the knowledge gap in the guidebook as the commonly used COVID-19 home remedies were identified in the Brunei adult population, supported by empirical evidence.

The population of the study may only be true to patients with the same socio-characteristics. Since Brunei has a diverse cultural background mix, the cultural impact may only be generalised to the Bruneian population and around the ASEAN regions. There was not enough data needed to analyse how the remedies were being consumed. The study was also limited to only people who have contracted COVID-19, and this study did not investigate those who use home remedy to prevent COVID-19 infection and to recover after infection, such as long-COVID or post-COVID conditions. Furthermore, this study did not examine the co-morbidities such as hypertension and diabetes mellitus among the participants of study. It would be recommended in further research that these limitations be addressed to provide deeper knowledge on the topic of COVID-19 home remedies.