key: cord-1044008-zxmypyyt authors: Frost, Rachael; Bhamra, Sukvinder Kaur; Pendry, Barbara; Heinrich, Michael title: Covid-19 and herbal practice: A UK practitioner survey date: 2021-09-21 journal: Adv Integr Med DOI: 10.1016/j.aimed.2021.09.003 sha: 80d49e13b2234d7a328750854909a9f67df0b787 doc_id: 1044008 cord_uid: zxmypyyt OBJECTIVES: To identify the effect of the Covid-19 pandemic on UK herbal medicine practice and how herbal medicine practitioners are supporting people with Covid-19. DESIGN: Mixed-methods e-survey. METHODS: The survey link was distributed through professional associations and social media. Quantitative data were descriptively summarised and qualitative data were analysed using content analysis. RESULTS: Results from 59 responses indicated a profound effect of the pandemic on herbal medicine practice, with a move to remote working and a reduction in client numbers. Practitioners reported prescribing a wide range of medicinal plants, chiefly Glycyrrhiza glabra L. and Echinacea spp. alongside providing information and advice. Few reported inter-professional collaboration. CONCLUSIONS: Herbal practitioners need to build on current collaborations, research and experience to develop consistent approaches to support people with mild-moderate Covid-19 symptoms. More systematic exploration of herbal medicine practice during and as a consequence of the pandemic is needed. WHAT IS ALREADY KNOWN ABOUT THE TOPIC: • The Covid-19 pandemic has had a large impact on all types of healthcare; • The impact on herbal medicine practice is unclear. WHAT THIS PAPER ADDS: • The Covid-19 pandemic has substantially affected UK herbal medicine practice; • A wide range of medicinal plants are currently used by herbal practitioners to support people with Covid-19; • Herbal practitioners need to develop consistent holistic approaches to support people with mild-moderate symptoms of Covid-19; Herbal medicine is consistently the most popular form of complementary medicine [1] , mostly using over-the-counter products without the consultation of a healthcare professional [2] . A 2018 representative national survey suggested only 26/4862 (0.005%) of the public in England visited a herbal practitioner in the previous 12 months [3] . UK Herbal medicine typically includes Western herbal medicine (WHM), Ayurveda and Traditional Chinese Medicine (TCM). Practitioners usually practice face-to-face in a clinic or from home [4] . UK herbal medicine is provided outside the UK National Health Service, in essence mostly privately via herbal practitioners or via informal networks. Since professional regulation is voluntary and members may be registered with more than one body. or may not be registered at all, no estimate of total number of UK herbal practitioners is feasible. However data from 2004 estimated that there were 1300 herbal practitioners registered with voluntary bodies in the UK [5] . On 11 March 2020, the World Health Organisation declared the outbreak of SARS-Cov-2 (Covid-19) a pandemic. In response to this, on 23 rd March 2020 a UK lockdown was imposed to halt transmission, leading to closure of businesses that were deemed non-essential [6] . Whilst herbal medicine practitioners were not specifically mentioned in the guidance, complementary medicine services were not deemed as essential and many therapies such as acupuncture and massage cannot be practiced at a social distance, leading to the temporary closure of complementary medicine premises. Restrictions were gradually lifted from May 2020 onwards for 'other medical and health services', with further restrictions implemented gradually from Sep 2020 onwards. Guidance from herbal practitioner bodies advised remote working where possible and safe. Few studies have mapped the impact of the pandemic on complementary and alternative medicine (CAM) practitioners. One preprint Norwegian survey found just over a third of providers (223/581) continued providing care during the Norwegian lockdown, offering video (57%) and telephone (47%) consultations in addition to face-to-face (44%) [7] . However, only 18 (3.1%) respondents were herbal medicine practitioners. Currently, the effect of the pandemic on herbal medicine practice is unclearit is possible that practitioners could have seen an increase in client demand due to the UK National Health Service (NHS) being overstretched, or that all demand would be reduced in light of restrictions. It is also unclear how herbal practitioners are supporting people with Covid-19 during the pandemic, and the herbal medicines and lifestyle recommendations made. We therefore carried out a mixed-methods survey to identify: -How herbal practitioners' practices have changed in response to Covid-19 -Common medicinal plants that were used to support people with symptoms of Covid-19 by practitioners -Advice sought from and given by herbal practitioners regarding Covid-19 -If/how herbal practitioners are working with NHS or CAM providers in response to Covid-19 -Resources used by herbal practitioners to find information on Covid-19 A mixed-methods online survey was developed, targeting UK WHM, TCM and Ayurvedic practitioners. The survey asked about changes to herbal practice since Covid-19, medicinal plants used to support people with Covid-19, other supplement and lifestyle recommendations, interprofessional working and practitioner demographics. Responses were not mandatory for any questions. Ethical approval was obtained from UCL ethics committee (ref 14097/003). The survey was distributed Jun-Nov 2020 through professional associations including the National Institute of Medical Herbalists (NIMH), the College of Practitioners of Phytotherapy (CPP) and the Register of Chinese Medicine (with one reminder email) and on social media platforms (i.e. Facebook and LinkedIn). Ayurvedic and other TCM associations were approached but did not respond. The total number approached could not be determined as there was overlap in membership across the different recruitment routes. Quantitative results were analysed using descriptive statistics and qualitative results from open-ended questions were analysed using content analysis. The survey received 59 responses overall, with variable response rates for each question. Table 1 reports respondent demographics. Respondents were largely female Western herbal medicine practitioners in England in their mid-fifties, who worked part time with an average of 35 clients per month. They had practiced on average for 15.8 years. Part time 24 (59%) Herbal medicine practitioners reported a drastic effect upon usual practice. Few completely paused their herbal practice (n=4/59), but the majority moved to an online-only practice (n=47/59). Events such as herb walks were cancelled (n=17), while some implemented additional precautions when cleaning dispensaries (n=27) or changed how clients collected herbal medicines (n=24). Only three participants reported no changes to their practice. Most had noticed a change to their caseload (see Table 2 ), particularly a reduction in seeing non-Covid patients. Just over half of respondents (33, 56%) had seen patients with suspected Covid-19 (mean 13 patients range 0-100), and 16 (27%) had seen patients with a confirmed diagnosis (mean 11 patients, range 0-60). To support patients with Covid-19, 31 herbalists responded reporting 59 medicinal plants and Anti-inflammatory (9), antiviral (7), adrenal support (3), demulcent (2), respiratory tonic (3), cough management (1), expectorant (1) immune system and mucous membrane maintenance (1) Immune support or modulation (10), antimicrobial (2), antiviral (2), anti-inflammatory (1), requested by patients (1), prevention of cytokine storm (1) detoxifier (1) Andrographis paniculata (Burm.f.) Nees 8 26% Immune support/modulation (5), antiviral (4), bitter (2), has evidence base (1), antimicrobial (1), cooling (1), eliminates toxins (1), adaptogen (1), liver stimulant (1) Inula helenium L. Lung or respiratory support (6), circulatory (2), digestive support (2) (1), fever management (1) Hypericum perforatum L. Antiviral (3), nervine tonic for anxiety or exhaustion (2), liver support (1) Note: not all respondents listed a rationale, and most listed multiple rationales Twenty three out of 29 respondents had recommended vitamins or supplements, mainly vitamin D (n=14). Other commonly reported vitamins and supplements included Vitamin C (n=8), zinc (n=6) and essential oil steam inhalation (n=3). A minority mentioned probiotics (n=1), fish oils (n=1), multivitamin (n=1), mushrooms (n=2), garlic (n=2), nigella seed (n=1), quercetin (n=2), green tea (n=1), certain foods (n=1), cocoa (n=1) and vitamin K (n=2). For wider support (e.g. with mood, wellbeing), 46 medicinal plants were reported by 23 practitioners (see Table 4 ), chiefly lemon balm (Melissa officinalis), skullcap (Scutellaria lateriflora), Siberian ginseng (Eleutherococcos senticosus) and St John's Wort (Hypericum perforatum). Wider support included prescribing relaxing or anxiolytic herbs, with some immune system support and adaptogens also prescribed. Note: not all respondents listed a rationale, and most listed multiple rationales Most practitioners (n=32) were not working with other healthcare professionals. Those who were, tended to work with other herbal practitioners (n=16) or CAM practitioners (n=10). Qualitative responses indicated that working with other herbalists largely involved discussions about supporting people with Covid-19 and best practices (n=10), for example: "Sharing of research and experience with colleagues by phone/video calls." A minority worked with health food shops (n=3), NHS professionals (n=6) or pharmacies (n=1). Some reported working with the NHS through a support programme for front line workers (n=4) or working in the NHS in another profession (n=2). Five respondents mentioned being involved more in their community, including sharing traditional knowledge (n=1), giving general Covid-19 advice (n=1), continuing an existing lifestyle programme (n=1), using medicinal plants preventatively (n=1), socially distanced medicinal plant walks and supplying medicinal plants to local shops (n=1). Four reported other professional activities, including conducting webinars (n=1), being involved in research (n=2), attending webinars (n=1), teaching (n=1), developing practitioner guidance (n=1) and working with a professional body (n=1). For their own information, herbal medicine practitioners reported mainly consulting information from research databases (34/59), webinars from other herbalists (33/59), NHS guidance (29/59), Public Health England guidance (28/59) and professional body guidance (CPP 18, NIMH 12, other 18). The Covid-19 pandemic has substantially impacted UK herbal medicine practice. Most practitioners worked remotely, noting a reduction in client numbers. Practitioners reported supporting clients by providing information and advice, recommending Vitamin D and prescribing medicinal plants with antiviral and immunomodulatory activity, chiefly Glycyrrhiza glabra L. and Echinacea spp, as well anxiolytic plants for wider support. Few reported inter-professional collaboration. [9] . Adjunctive treatment with Echinacea and Ginger tablets increased resolution of coughing, muscle pain and breathlessness, in one RCT of 100 outpatients [10] . Thailand has approved the use of A. paniculata for a pilot clinical study in the treatment of mild Covid-19 infections [11] whilst Iran has approved the use of four traditional herbal products [12] . The World Health Organisation published a statement supporting research into traditional medicines for Covid-19 in Africa [13] . Medicinal plants have received comparably less research attention in the UK's medical sector. A March 2020 statement from NIMH encouraged practitioners to distance themselves from any spurious claims of 'cures' for Covid-19 [14] . Only one herbal medicine trial is running in the UK so far, of Sambucol Black Elderberry liquid [15] . With the relatively widespread use of herbal medicines sourced over the counter, there clearly was an increase in usage, but there is no information on this available. The move to remote working reflects practitioners following professional body guidance, and is likely to be easier for herbal practitioners than for therapies requiring contact (e.g. massage). Remote working was also observed in Norwegian CAM practitioners [7] . It has benefits such as flexibility and greater client reach, but may enhance digital exclusion and limits the possibility of clinical examination. Whilst this survey is the first to document UK herbal practitioners' response to the Covid-19 pandemic, it is limited by the low response rate. Sample demographics are consistent with that of other WHM practitioner surveys [4] but the data relating to TCM or Ayurvedic practice are too limited to allow conclusions. We did not ask about the impact of Covid-19 on the medicinal plant supply chain. Although this issue was not spontaneously raised by respondents, it may have affected the choice of medicinal plants to use. As the survey was designed at the start of the pandemic, we were unable to collect data on supporting people with long Covid. It is now estimated 1.46% of those who have had Covid are experiencing long Covid in the UK, defined as symptoms persisting for more than four weeks after suspected Covid-19 infection that cannot be explained by another cause, most commonly fatigue, shortness of breath, muscle ache and loss of smell [16] . Although there is little evidence for herbal medicines for long Covid at present, potentially similar conditions such as chronic fatigue show some evidence for fatigue improvement through herbal medicines [17] , with established approaches to treatment [18] . This may be a promising avenue for further research. The Covid-19 pandemic has substantially affected UK herbal medicine practice. There is a need for herbal practitioners to build on current collaborations, research and experience to develop consistent approaches to support people with mild-moderate symptoms of Covid-19. The survey highlights the need for a more systematic exploration of herbal medicine practice during and as a consequence of the pandemic. Prevalence of use of complementary and alternative medicine (cam) by patients/consumers in the uk: Systematic review of surveys Herbal medicine : Who cares ? The changing views on medicinal plants and their roles in British lifestyle Complementary medicine use, views, and experiences: A national survey in England Practitioners of Western herbal medicine and their practice in the UK: beginning to sketch the profession British Government Calls for Regulation of Herbal and Acupuncture Practitioners in UK Guidance: Staying at home and away from others (social distancing) The impact of COVID-19 on complementary and alternative medicine providers: a cross-sectional survey COVID-19: Is There Evidence for the Use of Herbal Medicines as Adjuvant Symptomatic Therapy? Herbal Medicine for the Treatment of Coronavirus Disease 2019 (COVID-19): A Systematic Review and Meta-Analysis of Randomized Controlled Trials The effects of combination of Zingiber officinale and Echinacea on alleviation of clinical symptoms and hospitalization rate of suspected COVID-19 outpatients: a randomized controlled trial Herbal Covid treatment cleared, vaccine registration opens Iran finds herbal medicines effective in COVID-19 treatment WHO supports scientificallyproven traditional medicine 2020 National Institute of Medical Herbalists. A statement prepared by the National Institute of Medical Herbalists about COVID-19 infection East Kent researchers trial black elderberry liquid as a treatment for Covid-19 2021 Coronavirus (COVID-19) latest insights 2021 Medicinal herbs for managing fatigue symptoms in patients with idiopathic chronic fatigue: A PRISMA compliant updated systematic review and J o u r n a l P r e -p r o o f meta-analysis of randomized controlled trials based on the GRADE approach Chronic fatigue syndrome No funding is reported for this work. RF is a Western herbal medicine practitioner. RF, MH, SB and BP conceptualised the idea and designed the survey. RF collected and analysed the survey data. RF drafted the manuscript with input from MH, SB and BP. All authors have read and approved the final manuscript. RF is a Western herbal medicine practitioner. The other authors declare no conflict of interest.