Prevalence and associated factors of complementary and integrative medicine use in patients afflicted with COVID-19

A new coronavirus was identified at the end of 2019, known as the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), responsible for coronavirus disease 2019 (COVID-19). This virus has infected nearly 240 million people globally, and over 5 million cases of death have been reported [1]. While the efforts to find effective treatments for COVID-19 continue, some people have opted to use complementary and alternative medicine (CIM) to prevent or treat COVID-19. Although various definitions of CIM exist, in this article, practices or products falling out of conventional medicine are considered as CIM [2].

In general, CIM is considered safe, especially in India, China, and Iran [3, 4]. Traditional Persian medicine (TPM) is one of CIM’s oldest and most popular branches. In this regard, TPM is a holistic branch of medicine that has roots in humoral medicine and has been practiced for around 7,000 years. The Islamic Golden Age was a glorious era in history when many learned people, such as Avicenna (980–1037 AD), made considerable contributions to the advancement of medicine [5‐7]. According to sages of TPM, innate heat is described as a necessary component for all of the body’s organs to complete their tasks. Therefore, innate heat’s weakness could render individuals susceptible to acute and chronic diseases [8]. On the other hand, lung inflammation, cough, and dyspnea are common manifestations of COVID-19 [9]. These signs and symptoms are described as “Zigh Alnafas” (shortness of breath), “Sorfeh” (cough), and “Tab and Homma ” (fever) in TPM sources [10]. In this regard, the sages of TPM believed the accumulation of some thick and viscous materials in the lungs to be the main cause of cough and dyspnea. Therefore, medicine or therapy that increases innate heat while also reducing lung inflammation and swelling will prevent the disease’s progression [8, 11].

Plants have been commonly used for medicinal purposes for over 5,000 years [12, 13]. Many studies have evaluated the effect of herbal medicine and other complementary therapies for COVID-19 [14‐16]. Plants such as butterbur (Petasites hybridus), German chamomile (Matricaria recutita), Echinacea spp., and many others have been supported by scientific studies to alleviate respiratory disease symptoms [14, 17, 18]. Furthermore, some traditional Chinese herbal medicine has been seen to possess antiviral effects, possibly inhibiting viral particles’ proliferation [19‐21]. Such medication was reported to have successfully treated severe acute respiratory syndrome (SARS) during its epidemic in 2002 [15, 22, 23]. Another study reported immunomodulatory effects of some herbs such as Henna (Lawsonia alba), eastern purple coneflower (Echinacea purpurea), Ceylon leadwort (Plumbagozeylanica ), and velvetleaf (Cissampelos Pareira) in enhancing the immune system and, possibly, protecting the body against SARS-CoV-2 [15].

To the best of our knowledge, the prevalence and associated factors of CIM use in patients with COVID-19 have not been studied in Fars province, Iran. This study aims to evaluate the prevalence and associated factors of CIM use (particularly herbal remedies) by patients with COVID-19 in Fars province, Iran.

The present study found that 69% of patients who experienced COVID-19 used CIM specifically to treat this disease. Briefly put, it seems that younger people, patients with academic degrees, and patients living in urban areas used significantly more CIM to treat COVID-19. Our results align well with several studies proposing that CIM therapy has become a popular therapeutic method for preventive and treatment purposes nowadays [26‐28].

Moeini et al.‘s study revealed that although 71.65% of the normal population of Babol, a Northern city in Iran, had used complementary and alternative medicine throughout their lives, only 6.21% of them visited a complementary medicine therapist to receive these medications. In addition, they demonstrated that herbal remedies were the most common complementary medicine (58.30%) among the normal population in Babol [29]. Furthermore, Montazeri et al. reported that only about one-third of the patients who suffered cancer in Tehran, Iran, used complementary and alternative medicine for their disease. In addition, their study reported that praying and spiritual health were the most common CAM used among patients with cancer [30]. On the other hand, Abolhassani et al.‘s study, which was conducted on 5,000 patients of the Iranian population who had used complementary medicine and Iranian traditional medicine, revealed that energy therapy and praying, followed by food regime and fasting were the most common types of complementary medicine that they used. Accordingly, only 11.6% of these patients preferred using herbal remedies to treat their disease [4].

Several studies have been conducted on the prevalence of CIM use in Shiraz, Fars province. For instance, Dastgheib et al. revealed that 31.3% of patients referring to dermatology clinics reported using CIM for their dermatologic conditions [31]. Moreover, Hashempur et al. found that 75.3% of the patients with diabetes mellitus in Shiraz used at least one kind of CIM during their disease period [5]. On the other hand, Molavi Vardanjani et al. demonstrated that up to 97% of lactating women used CIM in their breastfeeding period [32]. Although the prevalence of CIM use was different in these various conditions, Shiraz is the biggest province and the largest referral medical center in Southern Iran, so the results of studies conducted in Shiraz could be a reasonable representation of the population of Southern Iran areas.

In our study, certain demographic characteristics were found to play a role in the likelihood of patients using CIM, especially herbal remedies. The younger population and patients with higher educational levels were more inclined to practice this kind of medication. On the other hand, CIM usage was not associated with the sex of the patients and their marital status. A similar study suggested sex and educational level as factors associated with herbal medicine usage [33]; however, our results only agree with the latter. Moreover, most of the patients in our study who used CIM were outpatients. On the other hand, the multivariable logistic regression revealed that the most important factors affecting CIM use were being under 50 years old and being an outpatient. These findings may be explained by a lower degree of concern for drug interactions between herbal and conventional medicine among outpatients and younger patients in comparison with older and hospitalized patients. Also, it seems that outpatients usually use self-medication and traditional and home remedies, while those hospitalized are treated according to the established protocols.

Ginger (98.9%), thyme (95.3%), black cumin (74.3%), and quince seed (73%) were the most commonly used herbs among the participants in our study. The therapeutic effects of some of these herbs have been recently evaluated in the treatment of COVID-19. A study by Safa O. et al. [34] revealed that ginger could affect COVID-19 treatment by increasing the recovery rate of clinical symptoms, including cough, fever, and fatigue, as well as paraclinical features such as C-reactive protein and thrombocytopenia. In another study, luteolin, a flavonoid existing in medicinal herbs like thyme, garlic, and chamomile tea, was mentioned to contain therapeutic, in this case, antiviral, activity [35‐37]. Moreover, garlic is known to have potentially healing effects against pulmonary symptoms associated with COVID-19. Also, evidence shows that certain compounds existing in garlic contain anti-inflammatory and antiviral activities [35, 38]. Ang L. et al. [39] also faced significant results regarding herbal medication’s effectiveness when integrated with conventional medicine, suggesting the likelihood of herbal remedies playing an evident role in treating COVID-19.

On the other hand, it should be considered that the effects of herbal remedies or other complementary medicines are not limited to the antivirus effect against COVID-19. Some of the herbal remedies reported by the patients in this study, such as ginger, thyme, black cumin, jujube, and licorice, have immunomodulatory, bronchodilatory, anti-inflammatory, antioxidant, antihistaminic, and antitussive activities [40‐45], so they could be effective in the treatment of other viral and non-viral diseases as well.

Patients were familiarized with herbal medicine through several different methods. Over half of them were acquainted with these medications via friends, family, and apothecaries. Other sources the patients used to find herbal consumption remedies for the treatment of COVID-19 included, in order or frequency, news, television and radio, internet and social media, articles, books, and magazines. In another study, Mekuria AB et al. [46] found families and friends to be more than half of the participants’ main source for pursuing herbal remedies, followed by previous herbal medicine users, media, and traditional healers; these are in line with the results of our study. This reveals that the majority of patients using CIM earn their information from unverified sources, which may not provide enough knowledge about herbal remedies and CIM, as well as possible side effects, proper dosage for consumption, and contraindications of these medications. Although our patients did not report any side effects of herbal remedies during their COVID-19 course, evidence indicates that some side effects include diarrhea, abdominal pain, throat pain, constipation, headache, hypertension, hypotension, hypoglycemia, etc. [47]. Moreover, some documents cautioned about the long-term adverse effect of using herbal remedies, as well as drug interactions among the patients with COVID-19 [48, 49]. Therefore, it is strongly advised that patients seeking CIM consult with a reliable physician who can provide them with accurate scientific information regarding CIM, including herbal remedies.

Unsupervised consumption is a major concern regarding CIM [50]. Almost all our study participants being treated with CIM did not consult with their doctor, mostly due to either not feeling the need to mention it or not trusting the caretakers’ knowledge of traditional medicine. Similarly, other studies revealed that the majority of the participants who used CIM (often recommended by their friends and peers) did not consult with their doctor [51, 52].

It seems that raising public awareness about the possible advantages and disadvantages of herbal remedies through social media can greatly benefit people seeking this kind of treatment. Nevertheless, unsupervised use of some products containing a mixture of herbs could result in allergic reactions, toxicity, and in severe cases, organ failures [12, 53]. In this regard, making use of telemedicine, distributing text messages, preparing photos and videos to post on social media, distributing standard pamphlets and brochures, and having trained CIM practitioners present in television and radio programs are recommended to augment the knowledge, attitude, and practices of the society.

Many adverse effects have been mentioned in the literature regarding the herbal medicines used by COVID-19 patients in our study. Gastrointestinal side effects like heartburn, burping, diarrhea, and general stomach discomfort are reported in ginger users [54]. For thyme, side effects such as digestive upset, headache, and dizziness are reported [55]. Black cumin can cause allergic reactions, constipation, stomach upset, and vomiting [56]. Besides the direct side effects, using CIM may cause a delay in starting standard effective treatments for the patient. This delay can lead to poor outcomes, especially in diseases with acute or progressive courses such as COVID-19.

The most important aspect of our study was conducting it on patients in the initial period of the emergence of COVID-19. Hence, the people who used complementary medicine against COVID-19 were not affected by the results of experimental studies and clinical trials. In other words, the results of this study portray the original beliefs of the study population about the effects of traditional medicine in the prevention and treatment of COVID-19 regardless of clinical studies. Accordingly, the authors suggest designing further studies to evaluate the prevalence of CIM use among COVID-19 patients when several clinical trials have revealed the efficacy of some mono-herbal, poly-herbal, and other complementary medicine in the treatment of COVID-19.

Our study faces some limitations. First, the patients were interviewed a few weeks after their treatment; thus, the patients may be subject to recall bias. Second, the checklist used in this study was researcher-crafted, suggesting that an extended standard questionnaire might be able to provide more insight into our topic of research. Next, our study only included the first months of the COVID-19 pandemic. We recommend that the trend of CIM use for the treatment of COVID-19 be studied in a more extended time frame. Furthermore, although several forms of herbal remedies, including package form, medicine, and dietary supplements, are available in Iran, we did not distinguish between these forms. Therefore, the authors recommend evaluating the patients’ preferences to choose each form of herbal remedy in further studies. Moreover, hospitalization was not considered as an outcome of using herbal and complementary medicine in patients with COVID-19 in this study; this issue can be explored in future studies. This study focused on CIM use during COVID-19, disregarding the overall attitude and routine CIM use before the pandemic. Next, the time taken to improve was not considered an outcome of the study because the data about when the patients started their CIM use was not collected. Finally, our study was single-center in nature, while multi-centered studies may provide a broader view concerning the treatment of COVID-19 with CIM.

In many cases, the use of CIM, especially herbal remedies, in COVID-19 patients is ill-advised. Ginger, thyme, black cumin, and quince seed were among the most commonly used medicinal herbs in our population of patients who experienced COVID-19. It is necessary for patients, as well as physicians in conventional medicine, to be made aware of the indications, contraindications, advantages, and side effects of CIM, especially herbal remedies, to encourage the appropriate use of these treatments.