Meanings of the use of medicinal plants in self-care practices *

* Extracted from the thesis: “Significado de uso de plantas nas práticas de autocuidado em situações de doenças”, Universidade Federal de Pelotas, Faculdade de Enfermagem, Programa de Pós-Graduação em Enfermagem, 2017. 1 Universidade Federal de Santa Maria, RS, Brazil. 2 Universidade Federal de Pelotas, Faculdade de Enfermagem, Pelotas, RS, Brazil. 3 Universitat Rovira i Virgili, Spain. 4 Universidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Rio de Janeiro, RJ, Brazil. ABSTRACT Objective: Understand the meanings people attribute to the use of plants in self-care practices during situations of ailment. Method: Qualitative, exploratory-descriptive research with ethnographic orientation, based on health anthropology with informants selected from a relations network. The sampling was done by semi-structured interviews and participant observations, from April 2015 to February 2017. Results: Seventeen informants participated. The thematic axis emerged in the content analysis: meanings attributed by the informants to the use of medicinal plants. Feelings of love and happiness were unveiled, meanings of helping others, cure practices, family care through plants, comfort, the sense of welfare, among others. Conclusion: The importance of the nursing professional in establishing a therapeutic alliance with the subjects and social groups, aiming at the promotion of health and care completeness.


INTRODUCTION
Selfcare is directly related to the meaning the population attributes to their health care practices at both the subject and social group levels. They are used to diagnose, explain, respond, control, relieve, support, cure, solve or prevent processes that affect health, in real or imagined terms, or without the direct and intentional intervention of professional healers, even when they are a reference for this activity (1) .
Selfcare also implies more rational actions in terms of culture, survival strategy, and cost or benefit, which can be both economic or regading time. These actions are directly related to the incidence and significance that individuals have regarding their way of life and the frequency and recurrence of different types of real or imagined ailments that threaten subjects and their micro-groups (1) .
To understand the different ailment situations, the cultural aspects of the subjects must be considered since they allow to understand the meanings attributed by each person in their form of care. Furthermore, they reflect the symbologies and the form these symbols are shared, also guiding people in a specific cultural group concerning what form of care should be applied to achieve health. Culture and symbols are public and private realities that organize the experience of the subjects. Individuals are incomplete and inconclusive, and complement themselves with culture, not a culture in general but specific forms (2)(3) . Popular knowledge of medicinal plants can be understood as a cultural system, allowing its consideration as a care practice.
This knowledge is found in the popular sector, which mainly comprises the context of family care, including its social network and the community. In society, there are two other sectors that, along with the popular sector, are overlapping and interconnected: the professional (legally recognized health professionals), and the folk (legally unrecognized healing specialists who use complementary therapies, including medicinal plants) (4) .
It is in the popular sector that individuals decide whether to seek and abide by the guidance received in other health sectors and what to do next, alternating or not between different treatment options and even judging the effectiveness of these treatments. Thus, the popular sector acts as the main source and the most immediate care determinant (4) .
Care is tending to life, to remain fighting against death, given that, throughout the evolutionary history of humankind, care has always been present in the different dimensions of the process of living, falling ill, and dying (5) . Care situations are full of emotions and feelings that may or may not be expressed, of representations, beliefs, and life experience. Thus, care is part of self-care practices in ailment situations.
In this sense, it is ensured that every circumstance of care is an anthropological situation and the use of the ethnographic method in studies involving care allows us to understand cultural differences (5) . Anthropological tools make it possible to learn, recognize, and use the multiple information that people (informants) provide. Thanks to this understanding of meanings, emotions are respected, helping not to fall into dissociation from the real needs of this informant in the face of health and ailment situations.
Thus, care is considered one of the self-care practices (1) , which are generally the first activities used regarding the suffering detected in ailment situations (4) , being related to culture's understanding (2) as people organize their lives around what phenomena such as feelings, ideas, facts, events, among others, represent for them which have a central role in human life (6) .
In this scenario of self-care, it is worth highlighting the Integrative and Complementary Health Care Practices (ICHP), which represent a new possibility of health care, aimed at individual needs. In Brazil, they were recognized in 2006 with an increase in supply by the Unified Health Care System (SUS -Sistema Único de Saúde) in 2017 and 2018. Currently, 29 practices are recognized and fostered in the country, the use of medicinal plants among them (7) .
The ICHP represent differentiated therapeutic resources that value welcoming attention, promote self-care, and observe the person fully and in conjunction with the environment and society (8) . The ICHP are believed to contribute significantly not only to the rescue and preservation of cultural diversity but also to establish greater autonomy for the user considering their own care (9)(10) . Given these approaches and considering that medicinal plants are a therapeutic resource that seeks to stimulate the natural mechanisms of disease prevention and health promotion, the following guiding question was elaborated: what are the meanings of the use of medicinal plants as a self-care practice in ailment situations?
This issue is based on the thesis that people attribute different meanings to plants used in self-care practices in their daily life-long care, according to their sociocultural context. To answer the research question and to reach the thesis statement, the following objective was proposed: to understand the meanings that people attribute to the use of plants in self-care practices in ailment situations.

Study deSign and Scenario
This is a qualitative, exploratory, and descriptive research (11)(12)(13) , with an ethnographic orientation (14) . The study was based on the anthropology of health (1,4) conducted in a rural location in the central region of Rio Grande do Sul state -Brazil.

Sample definition
Informants were selected through indication based on the relationship network (15) also known as the "Snow Ball" method (16)  Básica de Saúde), who is a resident and know the region well. It is worth noting that, to achieve a broader range of knowledge regarding the theme, the survey included the informants from 13 to 17, who are children of the informants. The choice was made at random, according to availability and interest in participating in the research, contemplating young people, adults, and elderly, totalizing 17 informants.

data collection
Data collection took place at the informants' homes and was done through semi-structured interviews (13) and participant observations (15) conducted from April 2015 to February 2017. To maintain the anonymity of all participants, they were identified with the letter P, meaning interview participant (informant), followed by the interview order number. It is worth noting that the researcher has no family relationship with the informants but already knew the region, which facilitated access to people and homes, making interviews and observations more fluid and enjoyable for both.
The semi-structured interview allows an interlocution between the interviewer and the interviewee, forming an interaction relationship (12)(13) . A two-part interview script was prepared. The first one contains 11 questions regarding the sociodemographic description of the interviewees. The second consists of eight open guiding questions and eight complementary questions, which address the use of plants in self-care practices by the interviewees.
Note that participant observation is not a research method but a context of behavior from which the researcher uses defined techniques to obtain research data and, after the researcher acquires a personal style adapted to the research field, they can use a variety of data collection techniques to inform on people and their lifestyles (14) .
To organize the observations, a script was created with five items to be observed and recorded in a field journal (11) , covering situations and forms of using plants; the demonstrated care of plants; the process of planting, harvesting and storage; the people involved and how this knowledge is disseminated; and the meanings attributed and expressed during the period in which the plants are used. In this journal, the observations made during the different moments of the field research were recorded. Also, the photographic record of the plants and filming were done during the observations.
The research was constituted of 150 pages of transcribed interviews and field notes, consisting of at least five visits with observations of at least four hours for each informant, with an average total of 20 hours with each interviewee, which totalized 340 hours of interviews and observations.

data analySiS and proceSSing
The results extracted from the different data collection instruments were submitted to the three stages of thematic content analysis, which consists in discovering the meaning cores that comprise a communication (17) . Its operability is distinguished in three stages: pre-analysis, which consists in the choice and organization of the material; material exploration, a classificatory operation aimed at reaching the comprehension core of the text; and result treatment, with inference and interpretations (17) . Thus, the analysis was performed after reading the material, identifying the reality according to the statements and observations of 17 informants, organized into a thematic axis: "meanings attributed by the informants to the use of medicinal plants".

ethical aSpectS
Resolution n.466 of 2012, issued by the National Health Council of the Ministry of Health, which issued the guidelines on research with human beings (18) , was respected. The research project was approved on March

RESULTS
The analysis processes resulted in the relationship network, research informants, and design of the category meanings attributed by the informants to the use of medicinal plants. Figure 1 shows the relationship network formed from the rural UBS secretary, who was identified as a UBS informant since she was responsible for the first indications. The other interviewees were identified by the letter P, meaning participant (informant) of the interview, followed by an interview order number, gender, age, and kinship.
Chart 1 presents the characteristics of the 17 informants who were interviewed.   When asked what the use of plants in ailment situations meant to the interviewees, it was possible to understand and confirm, especially through the observations, that the use is incorporated into their daily lives, bringing specific meanings to each interviewee. In portraying the use of plants during interviews and observations, all informants demonstrated selfless behavior, of being supportive, caring for family, and feeling comfort and well-being, as well as pride of being able to help someone: I am happy to have the plants with me (P2), I feel happy when I use them (P10), I am happy to be able to take care of the plants at home (P8), I even get emotional when speaking so happy that I am to be able to help others with plants (P9) Connected to these feelings of happiness, the observations made through filming and field journal entries present some interviewees smiling when mentioning: The meaning of using plants is transmitted through family relationships, with parents as the most cited, followed by other relatives such as husband/wife, uncles, mother-in-law, cousins, brothers/sisters, and great-grandmother.
I am happy to know that all this knowledge of using plants came from our family, from our culture, here everyone uses plants a lot (P17).
The observations indicated through photographs and records in the field journal that these meanings of care allowed verbal and facial expressions that demonstrated the joy that comes from family life with their ancestors, given that the informants were unanimous in reporting that they learned from people close to their daily life.
There have been reports of learning among friends and neighbors, especially from older people. Books were cited as a form of knowledge to answer questions and obtain clarification on the use of plants.

DISCUSSION
Selfcare practices in which the use of medicinal plants in ailing situations is included occur in both rural areas and urban centers (19) . Therefore, there is no significant variation in popular medicine between rural-urban areas (20) , which justified this research only in the rural setting.
The relationship network features informants aged 24 to 89 years, with ten men and seven women interviewed. The male predominance demystifies previous scientific research on the use of plants, in which the female figure appears as the holder of this knowledge (21)(22) . At the same time, it is in line with research that found an interest in the male population in the consumption of medicinal plants in health care for people (23) . Ten of the interviewees were married, three were widowed, and four were single. Ten were retired (nine were farm workers and one worked in commerce), five were farmers, one a student, and one a watchman.
Concerning religion, thirteen reported being Catholic, two Spiritists, one evangelical, and one from Candomblé. Regarding origin, seven presented native/original ancestry, three were native/original and of Italian descent, two of Italian descent, one of native/German descent, one of African descent, one of Portuguese, Spanish, and French descent, one of native/original and French descent, and one Spanish with Russian descent. The term "native/original" was used in this article to designate the inhabitants already present in Brazil who were denominated Indians by the European settlers. In this regard, note that Brazil is a country of miscegenation of many peoples and cultures, that cultural diversity is a strong characteristic of the Brazilian people and refers to the social customs, such as clothing, cooking, religious manifestations, forms of caring for each other, among other aspects (24) . A study on the use of medicinal plants by black women showed the influence of beliefs, values, and practices related to their use among these families (25) .
It is worth mentioning that the informants are often references for care and are sought by residents to minimize their ailments. The meanings attributed to each person regarding the form of caring and the different meaning of each symbol guide the subjects towards seeking choices of care in search of better health (4) . This reality is also described by an author (1) , who mentions the importance of continuity in maintaining knowledge between generations and that this knowledge is often preserved by culture, with the objective of making knowledge and self-care practices endure.
In this sense, it is worth noting that EMATER integrates young people into rural areas, making them a transformative agent of information, passing on knowledge and experiences through events in Rio Grande do Sul or through radio and television programs as well as publications of their productions (26) .
The informants demonstrated the ability to care for their relatives in their own home by reporting on the importance of sharing their knowledge on care practices through plants. There is often a certain distance between the reality of health care professionals and the reality of other people as the informants of this research. Health care professionals generally encourage the use of industrialized medication in detriment of popular knowledge, without knowing what the person is using to treat or prevent their health issues and those of their families.
Based on the research data, the transmission of knowledge in some families occurs from childhood, with a gradual awareness on the use of medicinal plants in different life stages (22) .
The discourse of P16 and P2 expresses the silencing of health care system users regarding their daily care practices when health care professionals disqualify and do not recognize such practices. At the same time, to preserve them and not break with the established system, users opt for silence in their relationship with the professional in their own care space. There is a deficit in communication between health care professionals and users, and for this dialogue to become possible, health care professionals must know how to listen and respect the beliefs of the subject they care for in order to build a security alliance between conventional medicine and medicinal plants (21) .
The informants´ statements suggest disrespect and devaluation by the physician concerning their care practices, disqualifying their choices and resulting in the fragility of the therapeutic alliance between popular and academic knowledge. These professional attitudes certainly contribute to widening the gap between the professional and the user of the health care system, as does the lack of knowledge by the professionals regarding the health care practices used by the informants.
In this sense, researches (27) that have already proven the existence of practices of associating the use of medicines with medicinal plants for health care have been found. Another study (28) showed that rural women often articulate familiar or popular knowledge with those of the biomedical model, incorporating practices accepted in their social environment to care for their families, ensuring their social role.
In this context, self-care in a restricted level that refers to the representations and practices intentionally applied to the health/disease/attention-prevention process, the subject assumes specific meanings for their daily life in recurrence of the different types of ailments that, real or imagined, threaten themselves, the subjects, and the surrounding micro-groups (1) .
As health professionals, more specifically nurses, it is important to pay attention to these particularities to provide comprehensive care for the subject, contemplating their completeness in the form of caring and understanding the real needs of the subjects within their socioeconomic and cultural context.
The researcher's subjectivity is prominent as a methodological limitation, implying the risk of having some degree of loss in objectification, which may influence the analysis and interpretation of interviews and observations. Also, the understanding of the other and their reality based on their familiarity can present limitations, especially in the observations made. Another limiting factor was the research being conducted in a single municipality of the state of Rio Grande do Sul.
Given this, Nursing has been contributing for greater sedimentation of this practice for the health care of people in ailment situations. Thus, further studies on the subject, with health care professionals in the public and private sectors are recommended, as well as productions that relate self-care practices in different ailment situations to the quality of life and health.
The science of nursing, which has care as its essence, is necessary for the nursing professional to establish a therapeutic alliance with the subjects and social groups, aiming to promote health and comprehensive care.

CONCLUSION
The use of plants by the informants in self-care practices has its own meanings, such as helping others, healing practices, caring for the family, comfort, and a sense of well-being.
The experiences and practices of caring for themselves and others through plants, from the informants' perspective, reveal that the young and elderly walk together in this process of caring for themselves and each other's health through plants, indicating their "love" and "happiness" in using them in their daily lives, as well as the intention to continue this care practice which, according to them, has great value and meaning in their lives. Therefore, such practices allow the reproduction of knowledge over the generations and development of their individual and collective identities.
Health professionals can improve care by inserting themselves in local realities to establish a therapeutic alliance with individual and social subjects that reduces the distances between academic and popular knowledge. To avoid this distancing, the professional must consider that the person cared for has values, beliefs, habits, and customs that are often different from the professional's. The need for the professional to sustain their practice in references that allow them an attitude of co-participation, respect, and appreciation to the set of knowledge and experiences culturally situated, considering the wishes and needs of the cared person as ethical principles is indicated.
This study can help health care professionals, multi-professional health care team, and the society to better understand the choice of self-care practices in different ailment situations. A review in the curriculum matrix of health care programs, especially those in nursing, is suggested to provide theoretical/methodological support on the subject, with a view to health promotion and comprehensive care.