Hybridization between biomedicine and alternative medicine in COVID-19 care in a neo-rural population of Córdoba, Argentine

We propose to investigate if the use and knowledge of medicinal plants and alternative medicine influence the adoption of biomedical strategies in dealing with COVID-19 - such as the use of masks, social isolation, and vaccination - in a context of a neo-rural population. The “neo-ruralism” phenomenon is a gradual displacement of urban middle classes to small rural locations. We collected data through online questionnaires, using the Google Forms platform in the “Paravachasca Valley”, Córdoba, Argentine. Our sample size was 208 people. The questionnaires, anonymous, contained multiple choice questions about attitudes and opinions concerning prophylactic strategies against COVID-19. To test whether the use or knowledge of medicinal plants is associated with trust in the efficiency and adoption of biomedical strategies, we used a chi-square test of independence. We verified that the knowledge about medicinal plants is related to distrust and reluctance to the adoption of the use of masks, social isolation, and vaccination. Also, our results suggest that alternative medicine users are afraid of the vaccine effects. In this plural medical context of a neo-rural population, belief in alternative medicines for the treatment of COVID-19 can be an obstacle to immunization programs.


INTRODUCTION
The hybridization of biomedicine with traditional or alternative medicine has been widely discussed in ethnobiological literature (Ladio and Albuquerque 2014;Nascimento et al. 2018;Santos et al. 2023).Ethnobiologists aim to understand possible processes of competition or complementation, among several sub-processes that permeate the interaction of medical systems (Ladio and Albuquerque 2014).The tragic context of the COVID-19 pandemic has opened an interesting perspective of analysis on the use of different medical systems since people all over the world needed to seek treatments from different sources for a completely new disease.In this context of instability, the search for new information about prevention and treatment is favored (Soldati et al. 2015) and the hybridization process could gain space in human groups of different origins.
During the pandemic, the different medical systems had to adapt quickly.From a biomedical point of view, information was constantly updated by scientific committees and health authorities, but three strategies have been established as essential to deal with the SARS-CoV-2 virus: the use of masks, isolation, and vaccination.Cheng et al. (2021) showed that masks are particularly effective in preventing COVID-19 in combination with social distancing.Watson et al. (2022) estimated that vaccinations prevented 14.4 million deaths from COVID-19.Until the moment we wrote this manuscript, no biomedical drug has been shown to be effective in the treatment of COVID-19.Local and regional medical systems (according to Dunn's, 1976 denomination) also responded quickly to the threats of the SARS-CoV-2 virus.Regional medical systems, such as Chinese medicine and Ayurveda (also called alternative medicine) have adapted previously used strategies to prevent and treat other illnesses as a way to deal with COVID-19 (Mirzaie et al. 2020).The same happened with local medical systems, present in small rural and indigenous communities in different parts of the world (Gumbo et al. 2021;Andrade et al. 2022).
Few studies have analyzed how people mix information and practices from different medical systems in the pandemic context, but there are some clues about how the hybridization process behaves for other diseases in general, in different populations.In rural communities, recent studies show that the hybridization between the local and cosmopolitan (biomedical) medical systems has led to the complementarity of both systems (Nascimento et al. 2018;Zank and Hanazaki 2017), even demonstrating that local botanical knowledge grows together with biomedical knowledge through time (Santoro and Albuquerque 2021).Such studies analyze the complementarity from the perspective of the concomitant knowledge of medicinal plants and industrial drugs.In the urban context, some studies also show a complementarity from this perspective and found similar results (Belliard and Ramírez-Johnson 2005;Waldstein 2006).However, in recent years, researchers have drawn attention to the increasing number of city dwellers who follow philosophies associated with the use of medicinal plants as opposed to allopathy (Ladio and Albuquerque 2014; Luján and Martínez 2017), and vaccination (Attwell et al. 2018;Hornsey et al. 2020).
In the duality between rural and urban, there are also the so-called "neo-rural"(Luján and Martínez 2017; Quirós 2019) environments, the result of the increasingly recurrent amenity migration -the urban-to-rural movement of people based on the draw of natural and cultural amenities (see, for example, Gosnell and Adams 2009).The comparison of rural or urban environments with neo-rural environments becomes complex, since the latter configures a middle ground, in which peculiarities of different environments are mixed.Latin American rural studies analyze neo-ruralism as part of the process of new ruralities and new urban-rural relations.(Quirós 2019).This movement of people from the city to the countryside is usually accompanied by a feeling of returning to nature and a denial of what comes from the city, including biomedicine (Mccool and Kruger 2003;Abreu et al. 2015).In the context of the COVID-19 pandemic, access to biomedical tools can be essential for individual and community survival, and the denial of this access represents a strong threat to public health.
In our study, we propose to evaluate the hybridization of medical systems in the pandemic context, mainly considering attitudes towards vaccination, isolation, and mask use (from biomedicine) and the use and knowledge of medicinal plants and other strategies from alternative medicine.We carried out our study in the Paravachasca Valley, in the province of Córdoba, Argentina.This region is already known for presenting the phenomenon of neo-rurality, with the intense use of medicinal plants (Arias Toledo et al. 2007a;Lujan and Martínez 2017).Considering the scenario, in which neo-rural environments can lead to a denial of what come from the city, we hypothesize that the hybridization of medical systems in the pandemic context of Paravachasca Valley leads to a situation of competition.Therefore, we predict that the use and/or knowledge about medicinal plants and alternative medicine negatively affects the perception of the effectiveness and adoption of preventive practices against COVID-19 arising from biomedicine, such as the use of masks, isolation, and vaccination.We also verified whether the use of medicinal plants is associated with distrust of vaccination.

Paravachasca Valley
The Paravachasca Valley is a region that comprises several small valleys, mountainous areas, and a part of the Chaco-Pampean plain, in Córdoba, Argentina (Figure 1).The natural vegetation is a mixing xerophyte arboreal vegetation with species from the Chaqueña province and grasses from the 'pampas steppe' (Luti et al. 1979).It is characterized by a city, Alta Gracia, and several small rural communities, with a hierarchy of communes, among which stand out Anisacate, Villa La Bolsa, Valle de Anisacate, Villa Los Aromos, La Serranita and La Rancherita, all these settled on the banks of the Anisacate river (Alta Gracia Digital 2020) and/or at the side of Route 5.In each of the communes, there is a medical dispensary (Primary Health Attention Center) where vaccination was carried out during our study.The total population of these six communes is 6396 people (INDEC 2010).
The population composition is heterogeneous: Hispanic mestizo descendants and city dwellers coming from distinct parts of the country have settled in the region (Arias Toledo et al. 2007 a,b;Trillo et al. 2016).The valley has experienced sustained population growth for a few years as a result of internal migration, which has turned it into a dynamic and complex territorial space, with the increasingly frequent predominance of the population of urban origin (Robbiati et al. 2020).Due to the beauty of the landscape and the presence of historic sites of native Comechingon settlements and Jesuit buildings, tourism is one of the main economic activities of the region (Martínez et al. 2006), and many of the buildings are summer houses, inhabited only for one season of the year.However, there has been a significant wave of amenity migration since the beginning of the pandemic, as happened in many parts of the world (Nelson and Frost 2022) that has resulted in the occupation of

Pandemic situation in Argentine during our research
We collected data between July and August 2021.At the beginning of August 2021, Argentina recorded Santoro et al. 2023.Hybridization between biomedicine and alternative medicine in COVID-19 care in a neo-rural population of Córdoba, Argentine Ethnobiol Conserv 12:22 more than 100,000 deaths from COVID-19, reaching a maximum of 4,357 deaths per day in May of the same year (Ministerio de Salud de la Nación 2022).The average case confirmation between July and August 2021 was 105000 cases per day (Ministerio de Salud de la Nación 2022).
The Argentine government established several mandatory preventive measures during the pandemic period.For example, through Decree 297/2020, the Argentine government established the measure of "Preventive and Obligatory Social Distance" (ASPO) from the 20th of March 2020 to the 31st of January 2021.Therefore, during our research, social isolation in recreational activities was recommended by national health authorities, but not prohibited.Throughout 2021, the use of masks was mandatory in any public space, subject to non-compliance fines, according to each province (Ministerio de Salud de la Nación 2022).
The vaccination against COVID-19 started in December 2020, but from May 2021, there was a great intensification of the vaccination campaign (Ministerio de Salud de la Nación 2022).In August 2021, there were six vaccines available in Argentine territory.In September, about 70% of the population had already received at least one dose (Ministerio de Salud de la Nación 2022).

Data collection
We collected data through online questionnaires, using the Google Forms platform (Additional File 1).The questionnaires were disseminated through local Facebook and WhatsApp local groups between July and August 2021.We shared our research in 20 WhatsApp groups in the region, including buying and selling groups, communal neighborhood groups, and groups about health dispensaries.We also publish on the Facebook pages of each commune and in Facebook buying and selling groups in the region.Before answering the questionnaire, participants were presented with a short text about the research (Additional File 1) and had to agree to participate before proceeding.The questionnaires were completely anonymous and participants had the option of not answering any of the questions if they did not feel comfortable.
The questionnaires contained multiple choice questions such as: Do you think that the use of a mask reduces the risk of contagion and spread of the virus?Do you use mask?Do you think social distancing decreases the risk of contamination?Do you do social distancing?Do you think vaccination is effective against the virus?Did you get vaccinated or do you plan to get vaccinated?The answers to these questions were graded between agreeing and disagreeing (see Additional File 1).We also asked if people knew about medicinal plants or any strategies other than those mentioned in our questionnaire to treat and/or prevent Covid-19 (see Additional File 1).One of the questions in the questionnaire was the participant's place of residence.Considering that our focus was the neo-rural population, we excluded participants from the city of Alta Gracia and considered only people who lives in one of the six communes.

Data analysis
To test whether the use or knowledge of medicinal plants is associated with the prophylactic attitudes against COVID-19, the perception of the efficacy and risk of vaccines and willingness to be vaccinated we used a chi-square test of independence.For this, we used the number of records in each category organized in a contingency table.All analyses were performed in the R (CTR 2019), and p values ≤ 0.05 were considered significant.

Sampled population and attitudes toward Covid-19
Our survey had the participation of 208 people (18-81 years), including 152 women (73%), 51 men (24.5%), 2 identified with non-binary gender (0.9%) and 3 people did not answer about their gender.All participants currently live in one of the six communes in the valley.Most participants (166, 80%) lived in urban areas before living in the Paravachasca Valley, 22 (10.5%)previously lived in another rural area and only one person has lived in the Valley since birth.Few participants (20) did not respond about where they lived before moving to the Valley.The vast majority of participants (157, 75.5%) had formal higher education (college or similar), 33 (15.8%) people had secondary education (high school) and 2 people (0.9%) had primary education.Only 18 people did not answer about their educational level.Below we put the profile of people regarding their knowledge of medicinal plants and alternative medicine, the use of masks, social isolation, and vaccination.
Medicinal plants and Alternative medicine -A total of 65 (31%) people reported knowing medicinal plants or other strategies from alternative medicine to prevent and/or treat Covid-19, totaling 43 different strategies.The participants mentioned between 1 and 4 therapeutic strategies, totaling 29 medicinal plants and 15 other alternative medicines.In our questionnaire, we only asked about the plants that people knew and/or used to prevent or treat COVID-19, but we do not have data on how they were used, where Santoro et al. 2023.Hybridization between biomedicine and alternative medicine in COVID-19 care in a neo-rural population of Córdoba, Argentine Ethnobiol Conserv 12:22 they learned and how people understood that those plants were useful for this specific disease.The most cited medicinal plants were ginger (11 citations), echinacea (7 citations), garlic, eucalyptus, and lemon (4 citations each), all of exotic origin and easily found in local stores (fresh, dried, or in supplement form).Considering that plant citations were given by online forms, we were unable to collect and identify the cited botanical species.However, in order to have an overview of the botanical species used, the possible botanical species related to each common name are shown in Table 1 of the supplementary material 2. This inferred scientific name arises from understanding this data as a primary source of information, as described in Rosso and Scarpa (2012).Among other alternatives besides medicinal plants are the use of colloidal plata, chlorine dioxide, honey (3 citations each), vitamin C (2 citations), and healthy food (1 citation), among others (see supplementary material 2).
Use of masks -The majority of participants (172, 82%) believes that the use of masks prevents the spread of the virus in some way, 31 (15%) people believe that it does not and 5 people did not want to comment on their effectiveness.Regarding the use of the mask, 11 (5%) people say they never use it because for them the mask represents a health risk, 22 (10.5%)people say they prefer not to use it, but use it only when it is mandatory (such as to enter some establishments), 83 (40%) people say they use it them only indoors and 93 (44%) people use them every time they leave home.It is important to emphasize that among people who know medicinal plants to prevent or treat COVID-19, only 26,1% use masks whenever they leave home while this number rises to 53.1% among people who do not know.
Social distance -Most participants (161, 77.4%) believe that social distancing prevents the spread of the virus, 33 (16%) people believe that it does not affect anything, and 12 (5.8%)people said they cannot or do not want to give an opinion on social distancing.Regarding practicing distancing, 107 (51%) people say they avoid contact with people who are not part of their daily lives, 59 (28%) people say they would like to be more isolated but find it difficult to comply with isolation, 25 (12%) people would not do social isolation, but end up doing it as a consequence of government measures and 14 (6.7%) people say they do not practice isolation.Among people who know medicinal plants to prevent or treat COVID-19, only 36% practice social distancing while this number rises to 58.4% among people who do not know.

Tested Hypothesis
We verified that the knowledge of medicinal plants or other alternative medicine strategies for the treatment or prevention of COVID-19 is related to the perception of effectiveness of protective measures such as use of masks (x-squared = 217.37,p-value = 2.2 e-16), social distancing (x-squared = 217.93,p-value = 2.2 e-16), and the COVID-19 vaccine (x-squared = 15.029,p-value = 0.004642).The knowledge about medicinal plants other alternative medicine strategies to deal with COVID-19 is also related to the adoption of those prophylactic measures, namely the use of protective masks (x-squared = 18,299, p-value = 0.0003815), social distancing (x-squared = 11,986, p-value = 0.00743) and vaccination (x-squared = 13,899, p-value = 0.0009591).
We can see this contrast when we compare for example the difference in the percentage of people who believe that the use of mask, isolation and vaccination are effective against the COVID-19 virus among the group of people who know and/or use alternative medicine and the group of people who don't: 73%, 64% and 50% respectively in the first group, against 88.8%, 83.2% and 72% in the last group.The same contrast is observed among people who effectively wear the mask whenever they leave home -27% in the first group against 53,14% in the last group; practice social isolation thoroughly -37% in the first group against 58% in the last group; and have already vaccinated -58,46% in the first group against 81,3% in the last group.
Additionally, the knowledge or use of medicinal plants for the treatment or prevention of COVID-19 is also related to the perception of the risk of taking the COVID-19 vaccine (x-squared = 22.128, p-value = 0.000189).Illustrating this difference, 43% of people who know and/or use alternative medicine to deal with Covid-19 believe that Covid-19 vaccines can cause any health damage, against only 14% of people who do not know and/or use medicine alternative in the pandemic context.versity.Considering the origin of most of the research participants we can characterize the environment of our research with characteristics very similar to those described by Ladio and Albuquerque (2014) about urban environments: systems where different symbolic, economic, and cultural contexts coexist with a strong mass media presence.Also, the vast majority of people also have higher formal education.
Despite being a population that shares the feeling of returning to nature, currently living in a rural area with a great diversity of botanical resources, -in contrast with populations from urban environmentsfew people reported knowing medicinal plants to treat or prevent COVID-19, when compared to studies in other urban or rural localities (Andrade et al. 2022, Khadka et al. 2021, Villena-Tejada et al. 2021).This low proportion can be explained by multiple factors, such as the short period of experimentation, given that COVID-19 is a very recent disease, in addition to the absence of a consolidated knowledge transmission network that allows knowledge about medicine to be shared.We noticed this possible absence in the low consensus among the few plants cited.Considering that the majority of the population has recently migrated to the Valley, this transmission network is also very new, and many people probably still retain their transmission networks of knowledge based on urban logic, through the mass media and internet groups.
In spite of the low consensus, the most cited plants in our study converge with the most cited plants to deal with COVID-19 in other rural and urban localities (Andrade et al. 2022, Khadka et al. 2021, Villena-Tejada et al. 2021, Wannes and Tounsi 2020) such as ginger, garlic and eucalyptus, plants generally used for other respiratory conditions.Perhaps because it is a new disease, exotic plants predominate in the medicinal collection of several populations (Medeiros 2013), including rural ones (Andrade et al. 2022).Even though the plant origin was not surveyed through the questionnaire, we are aware that the vast majority of plants cited in our study can be purchased in health food stores or pharmacies, in the form of capsules (as is the case with Maca, Echinacea, Ginkgo and Green tea), unlike what occurs in rural populations.The extensive mention of this type of plant, in addition to other strategies bought in the same places by the same forms (such as colloidal plata, melatonin, spirulin and vitamin C), reaffirms the characteristic behavior of inhabitants of urban centers.Indeed, the set of therapeutic strategies mentioned comes from multiple types of alternative medicine, featuring the heterogeneity of people's origins and showing that, currently, this set of knowledge does not yet belong to a consolidated local medical system.
Regarding the use and reliance on biomedical strategies, we saw that more than half of the participants agree that the three main preventive measures (use of masks, isolation and vaccination) contribute to reducing the spread of the virus and practice it.However, there is a significant proportion of the population that is very doubtful or rejects the COVID -19 vaccine (between 11% and 22%), the use of masks (between 5% and 15%), and the isolation strategy (between 6.7% and 16%).This, although small, is still worrying if we consider, for example, that the refusal rate of more than 10% can be sufficient to undermine the population benefits of vaccination against COVID-19 (DeRoo et al. 2020).According to the WHO ( 2019) vaccine hesitancy is one of the greatest threats to public health at a global level.Our study showed that, among the three strategies mentioned, vaccination is in fact the one with the highest rejection rate.
Several studies address the anti-vaccine movement during the pandemic and relate this behavior mainly to the lack of information, miss-information, and distrust in vaccines (Allington et al. 2021, Fieselmann et al. 2022, Muhajarine et al. 2021).Few studies, however, analyzed the use and beliefs of the three strategies against COVID-19 together.Among these few studies, Taylor and Asmundson (2021) aimed to analyze specifically the anti-masks attitudes and found that it is linked to disregard for social distancing and antivaccination attitudes, but mainly with psychological reactance -a motivational response to rules, regulations, or attempts at persuasion that are perceived as threatening one's sense of control, autonomy, or freedom of choice (Brehm and Brehm 1981).They found a proportion of anti-masks similar to that found in our study and point out that people who object to wearing masks are a small but highly vocal minority of individuals fueled by social media.
The role of social media is crucial in people's behavior during the pandemic (Rochel de Camargo 2020; Suarez-Lledo and Alvarez-Galvez 2021).Numerous studies found associations between the use of social media as an information source about COVID-19 and vaccine hesitancy (Allington et al. 2020;2021;Bertin et al. 2020;Freeman et al. 2020;Jennings et al. 2021;Romer and Jamieson 2020).We have no information on how the transmission networks of knowledge about COVID-19 occur in the Paravachasca Valley, but we can assume that social media have a great influence on the participants' attitudes, considering that the same questionnaires were disseminated by such media and the type of information cited as alternative medicine are quite popular on the internet.
Overall, our results point to a proportion of antibiomedical behavior during the pandemic similar to other populations in different parts of the world, but we draw attention to the relationship of this type of behavior with the use of and beliefs in alternative medicine.Regarding our hypothesis, all of our predic- Santoro et al. 2023.Hybridization between biomedicine and alternative medicine in COVID-19 care in a neo-rural population of Córdoba, Argentine Ethnobiol Conserv 12:22 tions were confirmed.Thus, people who know medicinal plants and alternative strategies to prevent o treat COVID-19 are less likely to trust and adopt the preventive measures suggested by biomedicine.Therefore, we can infer that there is a situation of competition between the use of the biomedical system and the use of other alternative medical systems in the context of COVID-19.
New studies in rural populations show that the hybridization between biomedicine and the local medical system happens in a cooperative way, where strategies from both systems coexist and complement each other (Nascimento et al. 2018; Santoro and Albuquerque 2020; Zank and Hanazaki 2017).In urban environments, a behavior of denial of biomedicine has been noticed in people who mainly use alternative medicine (Ladio and Albuquerque 2014; Pochettino et al. 2012).However, these studies deal with the concomitant use of allopathy and the use of medicinal plants, none of them deals with vaccination strategies, the use of masks and isolation.Indeed, respecting vaccination, our results are consistent with several studies in non-pandemic contexts, which show that users of alternative medicines were more vaccine-hesitant (e.g., Cassell et al. 2006;Fong and Fong 2002;Gellin et al. 2000;Wilson et al. 2005;Zuzak et al. 2008).According to Hornsey et al (2020), one possible conclusion that can be drawn from this is that trusting in alternative medicines results in people becoming more vaccine-hesitant.An alternative possibility is that vaccine hesitancy and the use of alternative medicine are both downstream consequences of a third factor: distrust in conventional treatments.Our results point to the second possibility: alternative medicine users are not only vaccination hesitant but also reluctant to any health official strategy about COVID-19 (using face masks, social distancing, etc.).In addition, they are also more likely to believe in the possible harm that the vaccine can cause.
Here we find a common point also mentioned in other works on preventive measures against COVID-19: distrust in what comes from the hegemonic culture, as is the case of biomedicine (Allington et al. 2020, Taylor andAsmundson 2021).Based on our results and comparing them with other studies (Allington et al. 2021, Fieselmann et al. 2022, Muhajarine et al. 2021, Taylor and Asmundson 2021), we can say that a neo-rural population, the result of recent migration in search of greater contact with nature, does not differ from urban populations in terms of the proportion of people who deny biomedical strategies to prevent COVID-19.However, within this type of population, we can see that the use of alternative medicine is indicative of this denial.

LIMITATIONS
The main limitations of our study refer to how we were able to sample the population of the Paravachasca Valley.Because the study was conducted during the pandemic, our sample is limited to people who use the social media we targeted.However, we believe that the part of the valley's population that does not use such media does not correspond to the neo-rural population that we seek to access, but rather to people who have been in the region for longer.Furthermore, due to this same limitation, in which our only form of data collection was the online questionnaire, we were unable to identify the plants mentioned and, therefore, we did not delve into the specific characteristics of the plants.

CONCLUSION
There are several alternative medical systems being used by the study population, without much convergence in order to sustain a single consolidated local medical system.In this medical context, our results show that belief in alternative medicines for the treatment of COVID-19 can be an obstacle to immunization programs.People in this neo-rural environment who use medicinal plants and other therapeutic strategies from different medical systems, other than the biomedical one, probably do so because they distrust any information of biomedical origin.Marcar apenas uma oval.
No, nunca lo uso y creo que su uso implica un riesgo para la salud 6.

15.
Marcar uma oval.Add File 3. other resources of alternative medicine cited by participants and the number of citations.

DISCUSSION
The study population corresponds to the majority of urban origin of recent residence in the Paravachasca Valley, confirming what previous studies speculated about the occupation of the region in recent years(Robbiati et al. 2020), as a result of amenity migration.This configures a scenario of great cultural di-Santoro et al. 2023.Hybridization between biomedicine and alternative medicine in COVID-19 care in a neo-rural population of Córdoba, Argentine Ethnobiol Conserv 12:22
Santoro et al. 2023.Hybridization between biomedicine and alternative medicine in COVID-19 care in a neo-rural population of Córdoba, Argentine Ethnobiol Conserv 12:22