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Conteúdo (article):

MEDICINAL PLANT USE IN PRIMARY HEALTH CARE: AN INTEGRATIVE REVIEW
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.
Keywords: Plants, Medicinal; Herbs, Medicinal; 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 activities1, 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 injuries2.
Through such analysis, human beings began to systematize MP use, reconciling characteristic philosophical and cultural aspects, developing the basis of strands of medicine3. 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 community4.
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 generation5. 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.6 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 resource5,6.
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 interaction7.
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 properties8. In Brazil, the theme was addressed at the 8th National Conference9, 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)10 and the Brazilian National Policy on Medicinal Plants and Herbal Medicines (PNPMF - Política Nacional de Plantas Medicinais e Fitoterápicos)11, 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 knowledge12.
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-care13.
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/synthesis14,15.
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 1038 articles, 533 of which were found in the VHL and 505 articles in PubMed, with the application of language and date filters. 981 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.
At this stage, all 57 articles were available for reading: 14 articles with public access and 4 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.

Flowchart referring to search results
Figure 1

: the authors.
To study the articles, the thematic analysis technique16 was used, which consists of the following steps: text skimming, coding, categorization and articulation with the following theoretical frameworks: PNPIC10 and PNPMF11.
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.
Chart 1

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 it17.
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 PNPMF18,19.
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 MP20,21. 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 MP21.
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 MP17. On the other hand, others considered this form of origin of superficial knowledge, choosing not to prescribe without scientific deepening in the subject21.
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 knowledge21. However, as demonstrated by Castro et al (2017), 73% of the sample of professionals were interested in acquiring information20, via training courses, complementary materials or other sources that addressed MP use in PHC17,21.
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 medicines20. 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 importance18. 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 diseases21.
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 model22. 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 population23.
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 inserted18. 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 illness24,25.
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 relatives26.
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 years27.
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%)28.
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 members29 as well as the cultivation of plants30. 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 backyards31.
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 centers32. 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 MP33.
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 school23.
In Peru, taking into account the country’s cultural and ethnic diversity, Valenzuela-Oré et al. (2018)34 address the social issue of MP use. Questionnaires were applied to 775 urban and rural villages, and 68.7% of respondents reported always using MP34. However, there is a decrease in the use of traditional medicine in the Peruvian population35.
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 heritage36-38.
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”38. 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 realities40,41, pointing to the humanizing potential of ICP, such as MP, in healthcare, while highlighting the political and commercial repressions that they suffer42.
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 SUS43.
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)44.
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 locality12.

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 harm28. 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 confusion45.
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 case45. 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 program20.
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 natura44.
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 certification21.
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 factors26,45,20,46,36,47.
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
1. Firmo WCA, Menezes VJM, Passos CEC, Dias CN, Alves LPL, Dias ICL, et al. Contexto histórico, uso popular e concepção científica sobre plantas medicinais. Cad. Pesq. São Luís. 2011; 18(especial):90-95.
2. Oliveira LST, Cunha e Silva SL, Tavares DC, Santos A, Oliveira GCB. Uso de plantas medicinais no tratamento de animais. Encicl Biosfera, Goiânia.2009; 5(8):1-8.
3. Brasil. Ministério da Saúde. 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 (DF): Ministério da Saúde; 2019.
4. Agência Nacional de Vigilância Sanitária. Medicamentos fitoterápicos e plantas medicinais [Internet]. Brasília: ANVISA; [acessado 2020 Ago 5]. Disponível em: http://portal.anvisa.gov.br/fitoterapicos
5. Koifman L. O modelo biomédico e a reformulação do currículo médico da Universidade Federal Fluminense. Hist Cienc Saúde Manguinhos. 2001;8(1):49-69. doi:10.1590/S0104-59702001000200003.
6. Caponi S, Verdi M, Brzozowski FS, Hellmann F, organizadores. Medicalização da Vida: Ética, Saúde Pública e Indústria Farmacêutica. Ciênc Saúde Colet. 2012; 17(9):2553-2556.
7. 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/
8. Ibiapina WV, Leitão BP, Batista MM, Pinto DS. Inserção da Fitoterapia na atenção primária aos usuários do SUS. Rev Ciênc Saúde Nova Esperança [periódico na Internet]. 2014 [acessado 2020 Ago 5]; 12(1):58-68. Disponível em: doi: https://doi.org/10.17695/revnevol12n1p60%20-%2070
9. Relatório final da 8a Conferência Nacional de Saúde; 1986 Mar 17-21; Brasília, Brasil. [Internet]. Brasília; 1986 [acessado 2020 Ago 5]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/8_conferencia_nacional_saude_relatorio_final.pdf
10. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Práticas Integrativas e Complementares no SUS - PNPIC-SUS. Brasília (DF): Ministério da Saúde; 2006. 92 p
11. Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Assistência Farmacêutica. Política nacional de plantas medicinais e fitoterápicos. Brasília (DF): Ministério da Saúde, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Departamento de Assistência Farmacêutica: 2006. 60 p.
12. Figueiredo CA, Gurgel IGD, Gurgel GD Jr.Physis Rev Saúde Colet. 2014; 24(2): 381-400. doi: 10.1590/S0103-73312014000200004
13. 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. doi: 10.1590/S1414-32832013005000014
14. Ganong LH. Integrative reviews of nursing research.Res Nurs Health. 1987;10(1):1-
15. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546-53.
16. MINAYO, M. C. S. O desafio do conhecimento: Pesquisa qualitativa em saúde. São Paulo: Hucitec, 2013
17. Mattos G, Camargo A, Souza CA, Zeni ALB. Plantas medicinais e fitoterápicos na Atenção Primária em Saúde: percepção dos profissionais. Ciênc Saúde Colet. 2018; 23(11):3735-3744. doi: 10.1590/1413-812320182311.23572016
18. 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. doi: 10.1590/1983-084X/15_176
19. 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. doi: 10.19175/recom.v9i0.3265
20. Alonso-Castro AJ, Domínguez F, Maldonado-Miranda JJ, Castillo-Pérez LJ, Carranza-Álvarez C, Solano E, et al. Use of medicinal plants by health professionals in Mexico. J Ethnopharmacol. 2017; 198:81-86. doi: 10.1016/j.jep.2016.12.038
21. 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. doi: 10.9789/2175-5361.2015.v7i3.2998-3008
22. Tesser Charles Dalcanale, Dallegrave Daniela. Complementary and alternative medicine and social medicalization: lack of definitions, risks, and potentials in primary healthcare. Cad. Saúde Pública [Internet]. 2020 [cited 2020 Dec 10] ; 36( 9 ): e00231519. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2020000903001&lng=en. Epub Sep 04, 2020. https://doi.org/10.1590/0102-311x00231519.
23. 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.
24. 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. doi: 10.1590/S0104-07072007000200014
25. 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. doi: 10.1590/S0104-11692010000300023
26. Colet CF, Cavalheiro CAN, Dal Molin GT, Cavinatto AW, Schiavo M, Schwambach KH, et al. 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. doi: 10.5712/rbmfc10(36)930
27. Zeni ALB, Parisotto AV, Mattos G, Helena ETS. Utilização de plantas medicinais como remédio caseiro na Atenção Primária em Blumenau, Santa Catarina, Brasil. Ciênc Saúde Colet. 2017; 22(8):2703-2712. doi: 10.1590/1413-81232017228.18892015
28. Szerwieski LLD, Cortez DAG, Bennemann RM, Silva ES, Cortez LER. Uso de plantas medicinais por idosos da atenção primária. Rev Eletrôn Enferm . 2017; 19:1-11. doi: 10.5216/ree.v19.42009
29. 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. doi: 10.15448/1677-9509.2015.1.19830
30. 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. doi: 10.5205/reuol.1262-12560-1-LE.0506201103
31. 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. doi: 10.1590/S1516-05722012000200010
32. Dantas ACMTV, Martelli PJL, Albuquerque PC, Franco de Sá RMP. Relatos e reflexões sobre a Atenção Primária à Saúde em assentamentos da Reforma Agrária. Physis. 2019; 29(2): e290211. doi: 10.1590/s0103-73312019290211
33. Movimento dos Trabalhadores Rurais Sem Terra. Secretaria Nacional. Relatos de experiência em saúde. Brasília: MST; 2005.
34. Valenzuela-Ore F, Romaní-Romaní F, Monteza-Facho BM, Fuentes-Delgado D, Vilchez-Buitron E, Salaverry-García O. Prácticas culturales vinculadas al cuidado de lasalud 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. doi: 10.17843/rpmesp.2018.351.3603
35. 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. doi: 10.1016/j.jep.2014.06.042
36. Yaseen G, Ahmad M, Sultana S, Alharrasi AS, Hussain J, Zafar M, et al. Ethnobotany of medicinal plants in the Thar Desert (Sindh) of Pakistan. J Ethnopharmacol. 2015; 163:43-59. doi: 10.1016/j.jep.2014.12.053
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.
38. 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. doi: 10.1016/j.jep.2008.12.009
39. Starosta JÁ, Anjos MCR. “Cantos e saberes”: processo de construção de um documentário sobre plantas medicinais. RECIISRev Eletrôn Comun Inf Inov Saúde. 2020; 14(1):199-211.doi: 10.29397/reciis.v14i1.1748
40. Costa MHBV. Cinema e construção cultural do espaço geográfico. Rev Bras Estud Cin Audiov. 2013; 2(3):251-262.
41. Black K, Lipscomb VB. The promise of documentary theatre to counter ageism in age-friendly communities. J Aging Stud. 2017; 42:32-37. doi: 10.1016/j.jaging.2017.06.001
42. Azevedo E, Pelicioni MCF. Práticas integrativas e complementares de desafios para a educação. Trab Educ Saúde. 2011; 9(3):361-378. doi: 10.1590/S1981-77462011000300002
43. Tribess B, Pintarelli GM, Bini LA, Camargo A, Funez LA, Gasper AL, et al. Ethnobotanical study of plants used for therapeutic purposes in the Atlantic Forest region, Southern Brazil. J Ethnopharmacol. 2015; 164:136-146. doi:10.1016/j.jep.2015.02.005
44. 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). Ciênc Saúde Colet. 2017; 22(5):1651-1651. doi: 10.1590/1413-81232017225.16722015
45. 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. doi: http://dx.doi.org/10.18004/Mem.iics/1812-9528/2015.013(02)08-017
46. Picking D, Delgoda R, Younger N, Germosén-Robineau L, Boulogne I, Mitchell S. TRAMIL ethnomedicinal survey in Jamaica.J Ethnopharmacol. 2015; 169:314-327. doi:10.1016/j.jep.2015.04.027
47. Zivkovic J, Ilic M, Savikin K, Zdunic G, Ilic A, Stojkovic D. Traditional Use of Medicinal Plants in South-Eastern Serbia: Ethnopharmacological Investigation on the Current Status and Comparison With Half a Century Old Data. Front Pharmacol. 2020; 11:1020. doi: 10.3389/fphar.2020.01020