Abstract

Medicinal plant (MP) use supports comprehensiveness of care in Primary Health Care (PHC), enabling appreciation of popular knowledge and self-care. This integrative literature review aims to analyze researches that approach the insertion of using MP in PHC. PICO strategy was used as a guideline in search of evidence, reuniting 18 articles published between January 2015 and August 2020, in the Virtual Health Library and PubMed databases. The variables of analysis were knowledge of PHC healthcare professionals about MP and associated policies, MP use by its users, highlighting their profile, the reasons that lead to the use and lack of security in MP use. The results show insufficient knowledge of healthcare professionals about Integrative and Complementary Practices policies and the medicinal uses of plants. The main users are women, elderly, with low income and education, either in Brazil or other countries. Regarding safety in MP use, frequently there is no correct identification of species, its origin, its preparation and the appropriate dose for each case. Finally, failure to approach these contents during training of healthcare professionals generates less knowledge, less research and more prejudice due to lack of information, impairing incentive and dissemination to the community.

Key words:
Medicinal plants; Medicinal herbs; Primary health care

Introduction

The use of different plants in favor of human objectives is historical, from their application as poisons to their use in curative activities¹1 Firmo WCA, Menezes VJM, Passos CEC, Dias CN, Alves LPL, Dias ICL, Santos Neto M, Olea RSG. Contexto histórico, uso popular e concepção científica sobre plantas medicinais. Cad Pesq São Luís. 2011; 18(especial):90-95., being, in the latter case, called Medicinal Plant (MP). This use was inspired by the empirical observation of practices of other animals, since several species had habits of consuming plants due to injuries²2 Oliveira LST, Cunha e Silva SL, Tavares DC, Santos A, Oliveira GCB. Uso de plantas medicinais no tratamento de animais. Encicl Biosfera 2009; 5(8):1-8..

Through such analysis, human beings began to systematize MP use, reconciling characteristic philosophical and cultural aspects, developing the basis of strands of medicine³3 Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica e Insumos Estratégicos. Uso de medicamentos e medicalização da vida: recomendações e estratégias. Brasília: MS; 2019.. Thus, MP is considered to be capable of alleviating or curing illnesses and has a tradition of being used as a remedy by people in the community⁴4 Agência Nacional de Vigilância Sanitária (Anvisa). Medicamentos fitoterápicos e plantas medicinais [Internet]. Brasília: Anvisa. [acessado 2020 Ago 5]. Disponível em: http://portal.anvisa.gov.br/fitoterapicos
http://portal.anvisa.gov.br/fitoterapico... .

Over the centuries, healthcare has undergone transformations and, today, academic scientific knowledge and the biomedical model centered on the disease are valued, to the detriment of other types of knowledge generation⁵5 Koifman L. O modelo biomédico e a reformulação do currículo médico da Universidade Federal Fluminense. Hist Cienc Saúde Manguinhos 2001; 8(1):49-69.. Thus, the medicalization of life arises, which is a phenomenon of appropriation by medicine, which interferes with the construction and interpretation of concepts, customs and social behaviors.⁶6 Caponi S, Verdi M, Brzozowski FS, Hellmann F, organizadores. Medicalização da Vida: Ética, Saúde Pública e Indústria Farmacêutica. Cien Saude Colet 2012; 17(9):2553-2556. In this context, there is a devaluation of self-care and the connection with nature, with increasing appreciation of modern conventional medicine as the only effective and safe resource⁵5 Koifman L. O modelo biomédico e a reformulação do currículo médico da Universidade Federal Fluminense. Hist Cienc Saúde Manguinhos 2001; 8(1):49-69.^,66 Caponi S, Verdi M, Brzozowski FS, Hellmann F, organizadores. Medicalização da Vida: Ética, Saúde Pública e Indústria Farmacêutica. Cien Saude Colet 2012; 17(9):2553-2556..

On the other hand, social movements and public policies have emerged in recent decades that seek to rescue traditional knowledge and value the promotion and integrality in healthcare, stimulating the human-nature interaction⁷7 Harayama R, Gomes J, Barros R, Galindo D, Santos D. Fórum sobre Medicalização da Educação e da Sociedade. Nota técnica: o consumo de psicofármacos no Brasil [Internet]. 2015. [acessado 2020 Ago 5]. Disponível em: http://medicalizacao.org.br/nota-tecnica/
http://medicalizacao.org.br/nota-tecnica... .

In 1978, with the Alma-Ata declaration, the World Health Organization (WHO) started to recognize MP use and herbal medicines as effective health strategies, validating their curative, prophylactic and palliative properties⁸8 Ibiapina WV, Leitão BP, Batista MM, Pinto DS. Inserção da fitoterapia na atenção primária aos usuários do SUS. Rev Ciênc Saúde Nova Esperança 2014; 12(1):58-68.. In Brazil, the theme was addressed at the 8^th National Conference⁹9 Relatório final da 8a Conferência Nacional de Saúde [Internet]. Brasília; 1986 Mar 17-21. [acessado 2020 Ago 5]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/8_conferencia_nacional_saude_relatorio_final.pdf
https://bvsms.saude.gov.br/bvs/publicaco... , in 1986, defining that alternative healthcare practices should be part of the Unified Health System (SUS - Sistema Único de Saúde), still under construction, allowing users to choose the desired therapy.

After 20 years, with the regulation of the Brazilian National Policy on Integrative and Complementary Practices (PNPIC - Política Nacional de Práticas Integrativas e Complementares)¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Práticas Integrativas e Complementares no SUS - PNPIC-SUS. Brasília: MS; 2006. and the Brazilian National Policy on Medicinal Plants and Herbal Medicines (PNPMF - Política Nacional de Plantas Medicinais e Fitoterápicos)¹¹11 Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica. Política nacional de plantas medicinais e fitoterápicos. Brasília: MS; 2006., the adoption of MP use and phytotherapy in SUS was determined, with a focus on Primary Health Care (PHC) as another form of treatment for diseases, also valuing popular knowledge¹²12 Figueiredo CA, Gurgel IGD, Gurgel GD Jr. A Política Nacional de Plantas Medicinais e Fitoterápicos: construção, perspectivas e desafios. Physis 2014; 24(2):381-400..

Through policies and movements that strengthen Integrative and Complementary Practices (ICP), the objective is to rescue popular knowledge, favoring forms of holistic care that promote sustainability, valuing self-care and active participation of patients throughout the process. With MP use, it is possible to achieve these goals, promoting environmental education, in order to promote health and the recovery of self-care¹³13 Antonio GD, Tesser CD, Moretti-Pires RO. Contribuições das plantas medicinais para o cuidado e a promoção da saúde na atenção primária. Interface (Botucatu) 2013; 17(46):615-633..

Thus, the aim of this study was to analyze research that addressed forms of MP use in PHC, characterizing the profile of these users, factors that promote the use, what is the knowledge of healthcare professionals on the subject and on associated policies, as well as the issue of lack of safety and adequate assistance regarding MP use in PHC.

Method

This is an integrative literature review, an instrument for obtaining, identifying, analyzing and synthesizing publications on a specific topic. The steps were followed: problem identification (defining the theme of the review in the form of a question, called PICO or guiding question); sample selection, definition of research characteristics (categorization of studies and data collection); analysis of studies included in the review, identifying similarities and conflicts; discussion and interpretation of results; presenting knowledge review/synthesis¹⁴14 Ganong LH. Integrative reviews of nursing research. Res Nurs Health 1987;10(1):1-11.^,1515 Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005; 52(5):546-53..

To develop this integrative review, the question was: what is the scientific evidence related to the ways of using MP in PHC?

To search the selected databases (Virtual Health Library - VHL - and US National Library of Medicine - PubMed), the following keywords were used for the search strategy: medicinal plants; medicinal herbs and national list of medicinal plants; primary health care; basic service; primary care; basic care; primary service; primary care; first level of assistance; first level of service; first level of care; first level of health care.

The search for articles was performed by four researchers, using the same criteria, two being responsible for the search in the VHL database and two in the PubMed database. Duplicates were performed blindly, validating the methodology. Two researchers were responsible for selecting the articles. In case of divergence, it was decided to keep the articles in the selection until the full reading stage, checking if they covered the theme of this review.

The selection of the initial sample adopted as inclusion criteria articles that brought in their titles or abstracts elements on MP use in PHC, found in national and international literature, published from January 2015 to August 2020, in Portuguese, Spanish and English. Dissertation theses and reviews were excluded and articles with different methodological designs were accepted, as the guiding question requires coverage of the investigated theme.

Thus, the sample consisted of 1,038 articles, 533 of which were found in the VHL and 505 articles in PubMed, with the application of language and date filters. Nine hundred eighty-one were excluded for the following reasons: titles or abstracts did not fit the theme question or because they were reviews or dissertation theses, leaving 57 articles (Figure 1).

At this stage, all 57 articles were available for reading: 14 articles with public access and four private, accessed through the University supporting this research.

Eleven duplicate articles were discarded, blindly, leaving 46. All of these were read in full and 28 were excluded because they addressed MP use in PHC in a non-exploratory way, not answering the question. Through an analysis of two researchers, 18 articles were established as corpus of analysis, ten from VHL and eight from PubMed (Figure 1).

To study the articles, the thematic analysis technique¹⁶16 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 2013 was used, which consists of the following steps: text skimming, coding, categorization and articulation with the following theoretical frameworks: PNPIC¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Práticas Integrativas e Complementares no SUS - PNPIC-SUS. Brasília: MS; 2006. and PNPMF¹¹11 Brasil. Ministério da Saúde (MS). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica. Política nacional de plantas medicinais e fitoterápicos. Brasília: MS; 2006..

The following categories were then created: “Knowledge of PHC healthcare professionals about MP and associated policies”; “MP users in PHC: profile and factors that lead to use”; “The lack of security in MP use”. Careful reading of each article was adopted, observing these categories, and the same article may be present in more than one section.

Results and discussion

Of the 18 articles selected for analysis, seven were prepared in other countries, namely: Peru, Paraguay, Spain, Mexico, Jamaica, Pakistan and Serbia. Eight studies were published exclusively in Portuguese, four in English, three in Spanish, and three in both Portuguese and English. Revista Ciência e Saúde Coletiva (n = 3) and Journal of Ethnopharmacology (n = 4) stand out with the largest number of articles published on the subject of this review.

The articles were described in Chart 1 as to their authors, year of publication, place of research, published journal, type of study and the main evidence found in the study.

From the results, the importance of discussing different variables that influence MP use in PHC was evidenced, showing the complexity of issues that permeate healthcare. Thus, we highlighted themes that served as the basis for analysis, enabling the relationship between the data and the deepening of the literature to understand the level of knowledge of professionals regarding MP, the characterization of users and MP use with greater safety, in order to answer the PICO question.

Knowledge of PHC healthcare professionals about MP and associated policies

Studies point out the insufficiency of knowledge of healthcare professionals regarding the policies of ICP and the general aspects of MP use. In a survey conducted in forty-five units of Family Health Strategy in the city of Blumenau/SC, 65.6% of healthcare professionals reported knowing the PNPIC, however, they were unable to cite all the practices, thus demonstrating a superficial knowledge of it¹⁷17 Mattos G, Camargo A, Souza CA, Zeni ALB. Plantas medicinais e fitoterápicos na Atenção Primária em Saúde: percepção dos profissionais. Cienc Saude Colet 2018; 23(11):3735-3744..

On the other hand, studies carried out among nurses indicated that 88.7% of respondents in the southern region of the state of RS had a deficit of knowledge of national and public policies for valuing the use and dissemination of complementary therapies - including the PNPMF¹⁸18 Souza ADZ, Heinen HM, Amestoy SC, Mendieta MC, Piriz MA, Heck RM. O Processo de trabalho dos enfermeiros da atenção primária e a Política de Plantas Medicinais/Fitoterápicos. Rev Bras Plantas Med 2016; 18(2):480-487.^,1919 Soares DP, Coelho AM, Silva LEA, Silva RJR, Figueiredo CR, Fernandes MC. Política nacional de práticas integrativas e complementares em saúde: discurso dos enfermeiros da atenção básica. Rev Enferm Centro-Oeste Min 2019; 9:e3265..

Failure to deepen the knowledge of such policies may imply non-adherence to ICP, resulting in the devaluation of this form of care. Thus, it is necessary for professionals to acquire this knowledge for the policy consolidation.

Authors emphasize that, during training, healthcare professionals do not learn about traditional medicine and are often unaware of scientific evidence about MP^20,21. A survey, carried out with nine professionals from a Family Health Unit (FHU) in the rural area of the city of Pelotas/RS, shows that, among the participating professionals, none had disciplines or discussions during their academic trajectory that addressed the theme of MP^21.

Lack of knowledge about MP also leads to insecurity of healthcare professionals in prescribing them, as evidenced in data presented by Mattos et al. (2018), in which respondents were unaware of the plants or herbal medicines contained in RENAME.

On the other hand, 93% of professionals in the same study had knowledge about traditional medicine due to family influences and experiences, with 84.7% having already prescribed or suggested, in the case of non-medical professionals, the therapeutic use of MP¹⁷17 Mattos G, Camargo A, Souza CA, Zeni ALB. Plantas medicinais e fitoterápicos na Atenção Primária em Saúde: percepção dos profissionais. Cienc Saude Colet 2018; 23(11):3735-3744.. On the other hand, others considered this form of origin of superficial knowledge, choosing not to prescribe without scientific deepening in the subject²¹21 Palma JS, Badke MR, Heisler EV, Hick RM, Meincke SMK. Modelos explicativos do setor profissional em relação às plantas medicinais. Rev Pesqui Cuid Fundam 2015; 7(3):2998-3008..

Research shows that limited understanding occurs due to a structural failure of academic teaching plans and institutions in not offering training courses on the topic or encouraging professionals to seek this knowledge²¹21 Palma JS, Badke MR, Heisler EV, Hick RM, Meincke SMK. Modelos explicativos do setor profissional em relação às plantas medicinais. Rev Pesqui Cuid Fundam 2015; 7(3):2998-3008.. However, as demonstrated by Castro et al. (2017), 73% of the sample of professionals were interested in acquiring information²⁰20 Alonso-Castro AJ, Domínguez F, Maldonado-Miranda JJ, Castillo-Pérez LJ, Carranza-Álvarez C, Solano E, Isiordia-Espinoza MA, Del Carmen Juárez-Vázquez M, Zapata-Morales JR, Argueta-Fuertes MA, Ruiz-Padilla AJ, Solorio-Alvarado CR, Rangel-Velázquez JE, Ortiz-Andrade R, González-Sánchez I, Cruz-Jiménez G, Orozco-Castellanos LM. Use of medicinal plants by health professionals in Mexico. J Ethnopharmacol 2017; 198:81-86., via training courses, complementary materials or other sources that addressed MP use in PHC¹⁷17 Mattos G, Camargo A, Souza CA, Zeni ALB. Plantas medicinais e fitoterápicos na Atenção Primária em Saúde: percepção dos profissionais. Cienc Saude Colet 2018; 23(11):3735-3744.^,2121 Palma JS, Badke MR, Heisler EV, Hick RM, Meincke SMK. Modelos explicativos do setor profissional em relação às plantas medicinais. Rev Pesqui Cuid Fundam 2015; 7(3):2998-3008..

Another important aspect addressed by the articles studied is the importance of knowing professionals’ view regarding MP use, since personal opinion reflects on professional practice.

Castro et al. (2017) pointed out that 46% of healthcare professionals and 51% of physicians interviewed believed that patients should not use MP for reasons such as ineffectiveness, lack of scientific basis and lack of safety. However, 54% of these healthcare professionals and 49% of physicians have already made personal use of MP as an alternative therapy, claiming efficacy, due to family tradition and highlighting the reduction in the consumption of allopathic medicines²⁰20 Alonso-Castro AJ, Domínguez F, Maldonado-Miranda JJ, Castillo-Pérez LJ, Carranza-Álvarez C, Solano E, Isiordia-Espinoza MA, Del Carmen Juárez-Vázquez M, Zapata-Morales JR, Argueta-Fuertes MA, Ruiz-Padilla AJ, Solorio-Alvarado CR, Rangel-Velázquez JE, Ortiz-Andrade R, González-Sánchez I, Cruz-Jiménez G, Orozco-Castellanos LM. Use of medicinal plants by health professionals in Mexico. J Ethnopharmacol 2017; 198:81-86.. That is, healthcare professionals are afraid to prescribe, but end up using it for their own treatment.

Of the professionals interviewed in RS, 81.4% acknowledged that the inclusion of policies aimed at including MP use in PHC would be of paramount importance¹⁸18 Souza ADZ, Heinen HM, Amestoy SC, Mendieta MC, Piriz MA, Heck RM. O Processo de trabalho dos enfermeiros da atenção primária e a Política de Plantas Medicinais/Fitoterápicos. Rev Bras Plantas Med 2016; 18(2):480-487.. However, some believe that MP use is effective only as a form of self-care in early-stage diseases and as an adjuvant in palliative diseases²¹21 Palma JS, Badke MR, Heisler EV, Hick RM, Meincke SMK. Modelos explicativos do setor profissional em relação às plantas medicinais. Rev Pesqui Cuid Fundam 2015; 7(3):2998-3008..

As for self-care, it is important to emphasize that the potential for demedicalization presented by ICP does not depend on the way they are applied and used: the proposed experimentation and approach should encourage an expansion of patients’ freedom to feel, reflect, experiment and know themselves to achieve a self-care model²²22 Tesser Charles Dalcanale, Dallegrave Daniela. Complementary and alternative medicine and social medicalization: lack of definitions, risks, and potentials in primary healthcare. Cad Saude Publica 2020; 36(9):e00231519.. Therefore, Macià et al. (2016) add that one cannot forget the essentially popular character of this knowledge, showing an openness to learn and build with the population²³23 Maciá MCD, Grau PE, Carrobé EF. Consumo de plantas medicinales em um barrio de Barcelona: lanecesidad de registrar informáticamente este hábito. Rev Fitoter 2016; 16(1):57-64..

In this sense, Souza et al. (2016) suggest that the insertion of MPs in PHC would become effective if healthcare professionals organized discussion groups with FHU users, exercising interdisciplinary dialogue, practicing health education and understanding the context in which they find yourself inserted¹⁸18 Souza ADZ, Heinen HM, Amestoy SC, Mendieta MC, Piriz MA, Heck RM. O Processo de trabalho dos enfermeiros da atenção primária e a Política de Plantas Medicinais/Fitoterápicos. Rev Bras Plantas Med 2016; 18(2):480-487.. Thus, professional action is established based on a relationship of respect for individuals’ beliefs and values, empowered in their historical and popular knowledge, in the form of a dialogue in which both parties learn about citizenship and heterogeneity of care, fleeing of the logic of attending to only illness²⁴24 Boehs AE, Monticelli M, Wosny AM, Heidemann IBS, Grisotti M. A interface necessária entre enfermagem, educação em saúde e o conceito de cultura. Texto Contexto Enferm 2007; 16(2):307-314.^,2525 Langdon EJ, Wiik FB. Antropologia, saúde e doença: uma introdução ao conceito de cultura aplicado às ciências da saúde. Rev Lat Am Enfermagem 2010; 18(3):459-466..

MP users in PHC: profile and factors that lead to use

Colet et al. (2012), through interviews applied to 446 users of Health Units in the city of Ijuí (RS), found that 81% of respondents use MP, aged 40 to 59 years (44.6% of respondents), 67.7% with an income of up to one and a half minimum wage and 71.5% claim to use them on the advice of relatives²⁶26 Colet CF, Cavalheiro CAN, Dal Molin GT, Cavinatto AW, Schiavo M, Schwambach KH, Oliveira KR. Uso de plantas medicinais por usuários do serviço público de saúde do município de Ijuí/RS. Rev Bras Med Fam Comun 2015; 10(36):1-13..

Another study by Zeni et al. (2017), interviewed 701 individuals from Blumenau, SC, and observed that most of those who used MP were women (78.1%), white (81.6%), married (56.4%) and belonging to class C (56.4%), with a mean age of 43.3 years²⁷27 Zeni ALB, Parisotto AV, Mattos G, Helena ETS. Utilização de plantas medicinais como remédio caseiro na Atenção Primária em Blumenau, Santa Catarina, Brasil. Cienc Saude Colet 2017; 22(8):2703-2712..

Szerwieski et al., 2016, in Itaipulândia (PR), interviewed 252 older adults, also showing the most prevalent use in women (67.58%), with little (up to four years of education) or no education (90.11 % of those who use it), not being economically active (83.52%), receiving up to a monthly minimum wage (97.25%)²⁸28 Szerwieski LLD, Cortez DAG, Bennemann RM, Silva ES, Cortez LER. Uso de plantas medicinais por idosos da atenção primária. Rev Eletron Enferm 2017; 19:1-11..

Data from Colet et al. (2012), Szerwieski et al. (2016) and Zeni et al. (2017) evidence the legacy of a patriarchal society. In this, women became responsible for the domestic maintenance and care of family members²⁹29 Almeida AV, Tavares Mafra SC, Silva EP, Kanso S. A feminização da velhice: em foco as características socioeconômicas, pessoais e familiares das idosas e o risco social. Texto Contexto Enferm 2015; 14(1):115-131. as well as the cultivation of plants³⁰30 Vasconcelos MKP, Lima ARA, Barbieri RL, Heck RM. Medicinal plants used by octogenarians and nonagenarians from a small village in Rio Grande/RS, Brazil. Rev Enferm UFPE 2011; 5(6):1329-1336.. With this, women usually have more information about the MP and end up resorting to them, as they can be obtained in an affordable and accessible way in their own backyards³¹31 Oliveira ER, Menini Neto L. Levantamento etnobotânico de plantas medicinais utilizadas pelos moradores do povoado de Manejo, Lima Duarte - MG. Rev Bras Plantas Med 2012; 14(2):311-320..

The study by Dantas et al. (2019) interviews healthcare professionals and Landless Workers’ Movement (MST) representatives, using focus groups with families and a field diary, and emphasizes the role of encouraging MP use and strengthening popular knowledge in the two settlements surveyed through local centers³²32 Dantas ACMTV, Martelli PJL, Albuquerque PC, Sá RMPF. Relatos e reflexões sobre a atenção primária à saúde em assentamentos da reforma agrária. Physis 2019; 29(2):e290211.. This care converges with the experiences of the MST reported by state health sectors, which go towards the promotion of healthy habits, realization of the right to health and preparation of medicines based on MP³³33 Movimento dos Trabalhadores Rurais Sem Terra (MST). Secretaria Nacional. Relatos de experiência em saúde. Brasília: MST; 2005..

In another reality, the article by Macià et al. (2016), carried out in Barcelona - Spain, interviewed 161 individuals, finding that 85% used plants, 65.7% being women, and 45.2% were illiterate or had only completed elementary school. Although the sample average age was 62.9 years, the age group of 15-40 years (14% of the total) was the one that most reported using MP (97%), while in the group of 65 years or more this value was of 48.2%. Thus, the results in absolute numbers indicate that the profile of MP users is people over 65 years of age, illiterate or who only attended elementary school²³23 Maciá MCD, Grau PE, Carrobé EF. Consumo de plantas medicinales em um barrio de Barcelona: lanecesidad de registrar informáticamente este hábito. Rev Fitoter 2016; 16(1):57-64..

In Peru, taking into account the country’s cultural and ethnic diversity, Valenzuela-Oré et al. (2018)³⁴34 Valenzuela-Ore F, Romaní-Romaní F, Monteza-Facho BM, Fuentes-Delgado D, Vilchez-Buitron E, Salaverry-García O. Prácticas culturales vinculadas al cuidado de la salud y percepción sobre la atención em establecimientos de salud en residentes de centros poblados alto-andinos de Huancavelica, Perú. Rev Peru Med Exp Salud Publica 2018; 35(1):84-92. address the social issue of MP use. Questionnaires were applied to 775 urban and rural villages, and 68.7% of respondents reported always using MP³⁴34 Valenzuela-Ore F, Romaní-Romaní F, Monteza-Facho BM, Fuentes-Delgado D, Vilchez-Buitron E, Salaverry-García O. Prácticas culturales vinculadas al cuidado de la salud y percepción sobre la atención em establecimientos de salud en residentes de centros poblados alto-andinos de Huancavelica, Perú. Rev Peru Med Exp Salud Publica 2018; 35(1):84-92.. However, there is a decrease in the use of traditional medicine in the Peruvian population³⁵35 De la Cruz MG, Malpartida SB, Santiago HB, Jullian V, Bourdy G. Hot and cold: medicinal plant uses in Quechua speaking communities in the high Andes (Callejón de Huaylas, Ancash, Perú). J Ethnopharmacol 2014; 155(2):1093-1117..

In another study in Pakistan, Yaseen et al. (2015) showed that the local population interviewed used MP due to the lack of adequate health services for the treatment of various comorbidities, in addition to being an indigenous cultural and traditional heritage³⁶36 Yaseen G, Ahmad M, Sultana S, Alharrasi AS, Hussain J, Zafar M, Shafiq-Ur-Rehman. Ethnobotany of medicinal plants in the Thar Desert (Sindh) of Pakistan. J Ethnopharmacol 2015; 163:43-59.

37 Lentini F, Di Martino A, Amenta R. Le piante di uso popolar em ell arcipelago dele Pelagie (Ag). L?uomo L?ambient 1995; 19:117-121.^-3838 Sanz-Biset J, Campos-de-la-Cruz J, Epiquién-Rivera MA, Cañigueral S. A first survey on the medicinal plants of the Chazuta valley (Peruvian Amazon). J Ethnopharmacol 2009; 122(2):333-362..

Another article found, which differs from the previous ones, reports the construction of the documentary “Cantos e saberes”, based on the research “Quintais Produtivos e sua relação com a segurança alimentar e nutricional”³⁸38 Sanz-Biset J, Campos-de-la-Cruz J, Epiquién-Rivera MA, Cañigueral S. A first survey on the medicinal plants of the Chazuta valley (Peruvian Amazon). J Ethnopharmacol 2009; 122(2):333-362.. To develop the documentary, the authors carried out a research in order to analyze the knowledge and traditional practices of MP use among women who attend the Horta Group, in Piraquara-PR.

The documentary is a modality that brings the possibility of dialogue between different spheres, with healthcare professionals, researchers and the community, and their realities⁴⁰40 Costa MHBV. Cinema e construção cultural do espaço geográfico. Rev Bras Estud Cin Audiov 2013; 2(3):251-262.^,4141 Black K, Lipscomb VB. The promise of documentary theatre to counter ageism in age-friendly communities. J Aging Stud 2017; 42:32-37., pointing to the humanizing potential of ICP, such as MP, in healthcare, while highlighting the political and commercial repressions that they suffer⁴²42 Azevedo E, Pelicioni MCF. Práticas integrativas e complementares de desafios para a educação. Trab Educ Saúde 2011; 9(3):361-378..

In turn, Tribess et al. (2015), in the Atlantic Forest region of the state of SC, carried out an ethnobotanical survey with local residents. It was noted that the practice of traditional medicine in rural communities acts as an important source of self-care, directly linked to PHC principles in the management of recurrent pathologies.

This study mentions that the Atlantic Forest has one of the greatest MP biodiversity per square meter and, therefore, favors access to various plants. This could serve as a strategy tool for health education practices and encourage forest preservation, providing a significant strengthening of national policies for MP use and directly benefiting the population that uses SUS⁴³43 Tribess B, Pintarelli GM, Bini LA, Camargo A, Funez LA, de Gasper AL, Zeni AL. Ethnobotanical study of plants used for therapeutic purposes in the Atlantic Forest region, Southern Brazil. J Ethnopharmacol 2015; 164:136-146..

Finally, analysis by Caccia-Bava et al. (2017), carried out in 4,249 health units in the state of São Paulo, using data from the First Cycle of the Brazilian National Program for Improving Access and Quality of Primary Care (PMAQ - Primeiro Ciclo do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica), showed MP use more prevalent in large cities and with higher socioeconomic indicators (63.9% of those classified in strata 4, 5 and 6 of the PMAQ), followed by smaller and marginalized cities (55.7% of those classified in the strata 1, 2 and 3 of the PMAQ)⁴⁴44 Caccia-Bava MCGG, Bertoni BW, Pereira MAS, Martinez EZ. Disponibilidade de medicamentos fitoterápicos e plantas medicinais nas unidades de atenção básica do Estado de São Paulo: resultados do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). Cienc Saude Colet 2017; 22(5):1651-1651..

Thus, the need to expand this knowledge in a more comprehensive way in the community and in the healthcare team is made explicit, in order to contemplate the population in a homogeneous way so that they can enjoy the natural and sustainable resources that their territories are able to provide them, always preserving and respecting the cultural aspects of the locality¹²12 Figueiredo CA, Gurgel IGD, Gurgel GD Jr. A Política Nacional de Plantas Medicinais e Fitoterápicos: construção, perspectivas e desafios. Physis 2014; 24(2):381-400..

The lack of security in MP use

Some studies point to the difficulty and problems associated with users’ lack of knowledge about the safety or risks of using MP.

In the work by Szerwieski et al. (2017), it was shown that users did not correctly know contraindications and possible side effects, and said that they used it indiscriminately, believing that, because it was more natural, it could not cause harm²⁸28 Szerwieski LLD, Cortez DAG, Bennemann RM, Silva ES, Cortez LER. Uso de plantas medicinais por idosos da atenção primária. Rev Eletron Enferm 2017; 19:1-11.. Also, Soria et al. (2015) report that in Paraguay, the correct identification of species is complicated because they are marketed by their popular name, which can lead to confusion⁴⁵45 Soria N, Ramos P. Uso de plantas medicinales em la atención primaria de Salud em Paraguay: algunas consideraciones para su uso seguro y eficaz. Mem Inst Investig Cienc Salud 2015; 13(2):8-17..

Soria et al. (2015) argue that including MP in PHC should be guided by its safe and effective use, with the correct identification of the species, its origin, its preparation and the appropriate dose for each case⁴⁵45 Soria N, Ramos P. Uso de plantas medicinales em la atención primaria de Salud em Paraguay: algunas consideraciones para su uso seguro y eficaz. Mem Inst Investig Cienc Salud 2015; 13(2):8-17.. Therefore, it is essential to identify, through pharmacological and toxicological studies, the possible risks related to this practice, as well as to provide scientifically based information to healthcare professionals, establishing a pharmacovigilance program²⁰20 Alonso-Castro AJ, Domínguez F, Maldonado-Miranda JJ, Castillo-Pérez LJ, Carranza-Álvarez C, Solano E, Isiordia-Espinoza MA, Del Carmen Juárez-Vázquez M, Zapata-Morales JR, Argueta-Fuertes MA, Ruiz-Padilla AJ, Solorio-Alvarado CR, Rangel-Velázquez JE, Ortiz-Andrade R, González-Sánchez I, Cruz-Jiménez G, Orozco-Castellanos LM. Use of medicinal plants by health professionals in Mexico. J Ethnopharmacol 2017; 198:81-86..

Furthermore, the Caccia-Bava et al. (2017) revealed that in the state of São Paulo only 5.1% of the total of 467 health units that provide herbal medicines do so with the plant in natura⁴⁴44 Caccia-Bava MCGG, Bertoni BW, Pereira MAS, Martinez EZ. Disponibilidade de medicamentos fitoterápicos e plantas medicinais nas unidades de atenção básica do Estado de São Paulo: resultados do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). Cienc Saude Colet 2017; 22(5):1651-1651..

A possibility of institutionalized and safe expansion of MP use in PHC is the Farmácia Viva program, in the case of Brazil. Farmácia Viva is a pharmaceutical social assistance program that prepares herbal medicines, prescribes and dispenses them in the public health system. It also provides guidance on the use of plants, ensuring efficacy and safety from medicinal gardens with botanical certification²¹21 Palma JS, Badke MR, Heisler EV, Hick RM, Meincke SMK. Modelos explicativos do setor profissional em relação às plantas medicinais. Rev Pesqui Cuid Fundam 2015; 7(3):2998-3008..

With the implementation of Farmácias Viva in PHC, it is possible to work with knowledge and popular uses of plants, associating them with scientific evidence, as well as to produce safe herbal remedies for use by the population, also considering side effects and contraindications of each one of them.

Regarding which MP are most used, the studies showed a very large variability depending on the geographic location, culture, historical and economic factors^{20,26,36,45-47.}

As a limitation of this integrative review, the scarcity of studies describing the knowledge of the general population and professionals about efficacy, forms of administration, drug interactions and adverse effects of MP used in Brazil and worldwide was highlighted.

Final considerations

Scientific evidence related to the ways of using MP in PHC characterize users and bring data about the knowledge of professionals and their safety. Thus, it is concluded that, in PHC, the MP user profile is made up of women, older adults, with low education and income, both in Brazil and in other countries, which highlights the role of women in production, use and transmission of traditional knowledge.

Also, it is evident that during the training of healthcare professionals, the topics of ICP are not addressed, generating less knowledge, more prejudice due to lack of information and leading to less research, resulting in less encouragement and dissemination to the population.

In this context, it is difficult to promote the safe, scientifically based and effective use of MP in PHC, since the lack of knowledge about how to correctly identify the plants, the proper form of use, the recommended dose and the possible drug interactions, adverse effects and toxicities are limiting factors.

However, with adequate professional training, PHC has the potential to develop medicinal gardens or implement the Farmácia Viva, ensuring better access to MP safely and effectively and working with popular knowledge to improve the population’s well-being and self-care.

References

Publication Dates

History