Preference analysis between the use of drugs and plants in pain management in a quilombola community of the state of Ceará , Brazil

Preference analysis between the use of drugs and plants in pain management in a quilombola community of the state of Ceará, Brazil Ádamo Xenofonte Brasil, Maysa de Oliveira Barbosa, Izabel Cristina Santiago Lemos, Cícera Norma Fernandes Lima, Gyllyandeson de Araujo Delmondes, Giovana Mendes de Lacerda, Álefe Brito Monteiro, Diógenes de Queiroz Dias, Andressa de Alencar Silva, George Pimentel Fernandes, Roseli Barbosa, Irwin Rose Alencar de Menezes, Henrique Douglas Melo Coutinho, Cícero Francisco Bezerra Felipe, Marta Regina Kerntopf


INTRODUCTION
The definition of pain is of a sensitive and/or emotional nature experience, linked to a tissue or potential injury, and may be capable of causing some impairment in quality of life (Haeffner et al., 2012).Related to a pathological process or not, pain is among the main reasons that lead the population to seek health services (Holtz and Neto, 2008;Nascimento and Kreling, 2011).In this view, several methods have been sought in the treatment of pain with a view to relief or cure, mainly by those who coexist with chronic pain, arising from conditions such as rheumatic diseases.Among these alternatives, the use of medicinal plants is one of the most common and also the oldest therapies among civilizations (Bavaresco et al., 2016).
In this context, Brazil is one of the countries that has the largest and most important species biodiversity (around 20% of the world total), with an estimated number of 350,000 to 550,000, of which 55,000 are already cataloged.This scenario is due to the tropical characteristics of the country and the distribution of this diversity is wide, considering all regions of the territory (Ribeiro et al., 2014).
In the case of Northeast region, especially the state of Ceará, data estimate that there are approximately 46% of xerophilous species, endemic and little explored in the pharmacological area.However, these are well known among traditional populations and employed in healthcare (Cartaxo et al., 2010).
Hence, the study of popular knowledge has been of great interest by the scientific area, since traditional medicine is able to provide subsidies for sciences, especially when considering the discovery of new medicines for the treatment of various diseases (Badke et al., 2012).Conversely, it should be noted that, with the advancement of public policies and programs, the access to industrialized drugs for the treatment of pain and other diseases has been possible in many communities.It is also believed that, people know how to recognize the most efficient plant species because studies show that the plants with the best biological activity seem to be used by a greater number of people (Medeiros et al., 2013;Portela et al., 2010).
Thus, the objective of this study was to analyze the preference for the use of plants or drugs as therapy for painconsidering the concept of preference as the conscious act of the informant, in choosing a resource at the expense of others who are also availableby a traditional quilombola community with access to both resources.

Description of the study area
The Sítio Arruda community (Figure 1) is located in the municipality of Araripe-CE, approximately 17 km from the urban area, belonging to the Cariri region.Considered as a remaining quilombola area, its Brasil et al. 771 territory was recognized by the Palmares Cultural Foundation (FCP) in May, 2009.However, land regularization by the state of Ceará was only possible in 2015 (FCP, 2009;INCRA, 2015).With a total area of 334 hectares and 39 resident families, Sítio Arruda is situated approximately 528 km from the capital city of Fortaleza which has the following geographic coordinates: Latitude 7°11'51.75"S and Longitude 40°15'32.96".It has a typical soil and vegetation variations of semiarid, flat relief, smoothly undulated with pluvial plain and annual precipitation estimated between 500 and 700 mm.The main economic activity of the locality is subsistence agriculture (Sousa and Fernandes, 2016).

Procedure for data collection and data analysis
The completion of this work obeyed the ethical precepts of research with human beings, highlighted in Resolution 466/2012 of the National Health Council (Brazil Ministério da Saúde, 2012).The approval by the Ethics Committee had an opinion number 1367311.The data collection period was between August, 2016 and January, 2017.An initial visit was made to the locality and, mediated by a community leader, a prior knowledge about the chosen region was provided.The main purpose of this contact was to gain trust, which is indispensable in obtaining information known as the "rapport" technique (Albuquerque et al., 2010).At this time, the proposal of the study was presented to the leader, emphasizing the objectives and the relevance.With authorization given by the community representative, the next step was the composition of the sample.In this way, men and women residing at the site were selected, 21 years and above.
Firstly, a questionnaire for characterizing the socio-demographic profile was applied to all those involved, with an interview performed.The speeches were obtained through the use of a tape recorder.The elaborated script obeyed the semi-structured interview technique, containing 5 questions: 1. Do you prefer the use of plants or "medicine" from the pharmacy for the treatment of pain? 2. What is your opinion about the use of homemade preparations with plants for the treatment of pain? 3. What is your opinion about the use of "pharmacy drugs" (medicines) for the treatment of pain? 4. Have you taken "medicine from the pharmacy" and weed medicine together at the same time (in association) for the treatment of pain?What do you think about using the two together?5. Have you replaced the medicine the doctor prescribed for the use of plants?If so, tell me how it was.If not, why?
The socio-demographic analysis was developed using the simple frequency statistical method.The contents of the interviews were examined through the Collective Subject Discourse (CSD) (Lefevre and Lefevre, 2005), with the help of qualiquantisoft.

Did you replace doctor prescription with plants?
Of the 52 interviewees there were 35 women (67%) and 17 men (33%) who were between 21 and 90 years old, most of them between 30 and 45 years old and married (61.5%).Considering the education level, 33 reported not having completed elementary education, which is *Corresponding author.E-mail: martareginakerntopfm@outlook.com.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License equivalent to 62.5%.The number of non-school children was also highlighted, secondly represented by 13 of the interviewees (26%).Farmer was the predominant profession (57.5%), followed by housewives (25%) and the time of residence in the community ranged from 10 to 40 years.Other details of the socio-demographic profile of the population can be observed in Table 1.
When questioned about the main method of choice for pain treatment, 55.77% of the informants reported a preference for plants, 11.54% stated the use of allopathic drugs, 25% reported that the option depend on the isease and 7.69% said they had no preference.These results on plant choice are similar to those found by other researchers.In a community in the State of Pará, 18 residents were interviewed.Of these informants, 16 (73%) referred and preferred what they call home remedies and 2 (9%) opt for drugs are available at health centers, as evaluated (Flor and Barbosa, 2015).When asked what they think about homemade plant preparations for pain management (Question 2 of the interview), the CSD pointed out five central ideas, which can be seen in Table 2.
It is noted that, thinking about the sense of effectiveness was the most prevalent.This point of view was also defended by quilombola residents, from a community located in Paraíba.Of the 24 interviewees, 60.9% stated that plants have better action than laboratory drugs, and access to them is easier and cheaper (Sales et al., 2009).Giraldi and Hanazaki (2010) emphasize that preference for such resources strengthens the traditional culture of health care and broadens contact with local biodiversity.Also, the use of these resources as a source of treatment is a safer method for many people, since they believe in the healing potential that plants offer besides have fewer adverse effects than industrialized drugs (Oliveira and Santos, 2016;Pedrollo et al., 2016).The data in Table 3 represent the central ideas and CSD on the opinion of population regarding drugs of, allopathic origin.
There is a varied perception of the interviewees when it comes to industrialized drugs.Although the use of drugs present, the justification that the "teas" are better has stood out.However, another point draws attention: the choice between drug and plant depends on the pain.Conversely, the literature shows a shortage of papers that portray the determinants which lead people to choose between medicines and plants and at what point this decision happens.However, some scholars point out possible explanations about the representations of populations, especially the older ones, in view of the allopathic drugs.Many of them believe that the industrialization process makes these compounds more capable of causing adverse reactions, or other damages.This bias reinforces the conception that plants are better, since they are obtained from nature without any intervention that may make it lose its naturalness to promote healing (Lima et al., 2012).
Considering this aspect, in a relevant study Nascimento Regarding the talk about the use of the plant and drug association, according to question 4 of the interview, participants' answers allowed the identification of the central ideas and respective CSD that are presented in Table 4.According to the above, the joint use of plants and medicines for 46 informants is something that corresponds to the danger, clearly defended by the thought of poisoning.The same logic was it very much, I drink the tea first, I prefer it, it's good because it passes the pain, it relieves a lot, it's gone, it's not better, it always worked, I mean, most of the time it happens.The tea solves the pain everything, some pain passes alone; some pain only the tea solves it.I lived my whole life with medicine from the plant, since I was a child, my mother always did it for me, we did not have the ease of today, me and my brothers, everything, when I got sick, was a medicine from the woods, I did not have this hospital business, it was prayer, faith, and tea, and I also treated my son with medicine from the plant!My daughter was saved by faith and mother's medicine.The boy here is all grown up with tea.Everyone uses medicine from the plant and I help a lot of people with medicine from the plant, we did not live without plants because it is better the medicine that we do at home.

CSD -Central Idea B:
The plant is good, but it depends on the type of pain.I always take the tea first, if it does not calm, I take the drug.My pain is very strong, I do not like to take pills, but I take it when I cannot hold it anymore.There are also the boys who have to take them to the hospital, if they do not [tea] it is a more serious disease, then they have to go to the hospital.If it's more urgent, it's a better hospital.When I feel like going to the doctor, I'll go there.God helps me, and I know, I say: you know, this here is not for me to make medicine here!Both the treatment with the plants and the medicines are good because many things I prefer the hospital, but others I prefer the weeds, it depends on the disease.CSD -Central Idea C: Same as water, my daughters do for me, but it does not help.The one who trusts me is my mother, but I do not take.CSD -Central Idea D: It's very good, it works, but I do not use it anymore.Here, we took more as a child, then we grew and became harder for the pain and nowadays it is better to take the same pill and have the hospital.
Here at home, we do not have, because the woman has pain in the knee and it is bad to get pregnant, and there is still this drought, you can not only carry water for a few drinks, it's hard to do it: you have to plant, and then I prefer the medicine.CSD -Central Idea E: They say it's good, but I never took it.* A subject's speech may have more of a central idea.
found in other surveys.Residents of a city in Ceará were also approached about the concomitant use of chemical drugs and plants.Of the 151 informants, 87.1% do not use associated, because they believe that there may be some damage to the organism (Oliveira and Lucena, 2015).
A similar attitude was also found in the center-west region of Rio de Janeiro.Of 998 inhabitants interviewed, 44.1% said, they did not use drugs and plant together.However, this data was not the most relevant.For 47.5% of the participants, the associated use of drugs and plants is performed when the indication of a certain plant is known.
However, they do not explain how this knowledge is determined or if there is any kind of orientation by health professionals (Veiga-Junior, 2008).The next data correspond to the aspects found, when informants were questioned about the plant's replacement of some medicine prescribed by the doctor.Not substituting medicine for the use of plants was the main affirmation given by the participants.The justifications for such conduct were diverse.However, it can be seen that majority could not explain the reasons why they do not stop following the prescription, which becomes a gap that can be worked out in future studies.
However, another study has shown that, the substitution of prescribed drugs by plants is a common act among people especially, those residing in rural areas ranging from 50 to 69 years old.The preponderant factor is in the traditional culture of health care, learned during life (Junior, 2008).The second most prevalent idea is related to the fact that, several participants have never Have you thought?Take medicine forever because of pain?That is bad!CSD -Central Idea B: I never took it for pain, it should be good, but I never took it.There are a lot of people who take and give, I do not know because I do not take that kind of medicine pain, I do not like going to the doctor or hospital."CSD -Central Idea C: I've had it, it's good, but I do not change my tea, I drink tea first.I see the people going to the health centers, to the hospital, I'm not going.I think it is a waste of time because I have everything here, I do not spend with pharmacy medicine, but people get good medicine from the pharmacy as well.And it's good too because the pain passes.Only that in the fight of every day it is my plant, we go to the medicine of pharmacy only when it needs, because we prefer the plant.I only take medicine from the pharmacy because I have many diseases and when there is no way, but the plants are my favorite.CSD -Central Idea D: I never take these medicines because it is difficult, there is a drug that is expensive, we do not always have one, and the pharmacy is in Araripe.Also, you cannot go without asking, we pay R$ 70,00 to go to the city, so we do not use it too much.CSD -Central Idea E: Both the plant and the pharmacy is good.I also take a drug from a pharmacy, but it depends on the type of pain, because there is a disease that only the plant medicine does not work, for my pain in the knee, what happens is the medicine.Taking medicine for woman's pain [menstrual cramps] is lost, are we taking it every month?Also in children, when the plant medicine has no effect [for pain] we take it to the hospital, it solves it.CSD -Central Idea F: I prefer it, since I'm not very sick, just leave some medicine stored for when the pain increases, I just need to take one when it hurts my head and my body.Also, the tablet is faster, you took it, it passed, I think better so it gives more effect.I can no longer live without a pharmacy.CSD -Central Idea G: Before I took it and resolved, today I take, there is a day that passes, there is a day that does not pass.Also, I do not know, after my wife has been taking these remedies her wounds are few.And there are few that it renders, it has a remedy that is like water.*A subject's speech may have more of a central idea.
Although the rise of allopathic medicines has been constant in the present times since access is not always possible, especially when considering the financial factor for acquisition.However, not using allopathic is also a decision of many people.The explanation is given by cultural interfaces, beliefs, and highly valued empirical knowledge (Sales et al., 2009).

Conclusion
The practice of using plants for the treatment of pain among the population of Sítio Arruda is seen as a important aspect in the context of their day to day lives, due to the traditional nature of the knowledge spread among them.This knowledge deserves to be respected, especially when analyzing the historical context that built the community.Even though traditional empirical knowledge is common among the participants, a variety of how this knowledge is assimilated and used in the management of the pain relief and/or treatment conducts is evident.
There was also shortage of studies on the representations and meanings of the preference of inhabitants for traditional localities, considering medicinal No!" "God!"You cannot take both because you can poison.Everyone here knows that you cannot take the two together: the plant and the drug; it is to risk too much!I've never seen anyone poison, but you'd better not risk it.My mother, my mother-in-law, the elders, everyone says they poison.You cannot take it together, the medicine in the forest is strong, very green, and the pharmacy is strong, there you must go to the hospital.We keep the plant medicine when we're taking it from the pharmacy.When I was using the medicine that the doctor gave me, I did not have tea.For example, the day I take ibuprofen, I do not drink the tea.Because here it is, you have tea today, and if it does not solve, the other day you take the pharmacy.One has to take one or the other.Take the two together, do this and you get worse!CSD -Central Idea B: No, I never took it together, they say it poisons, I do not know, the people who say, I've heard many of the old people saying that it poisons if you take both.CSD -Central Idea C: I have the fear of drinking tea because I already take so much pharmacy medicine!CSD -Central Idea D: I never took it, but I do not believe in this business that poisons.CSD -Central Idea E: "I took none, who will say the two together."*A subject's speech may have more of a central idea.No, I never took medicine from the doctor, I never went to the doctor, so I never had to change, because I do not take medicine from the pharmacy, those that the doctor gives.I do not even know what pharmacy medicine is, how would I change it?CSD -Central Idea B: No, if the medicine did not work, I'll find a way back to the hospital.CSD -Central Idea C: I never did this, or I took tea or took medicine, but I never changed it, because I only use it if tea does not solve it, when the pain does not go with tea, when it is very strong, then I look for the medicine in the pharmacy.Sometimes I go to the doctor, if I go, I will not change.

CSD -Central Idea D:
No, but I'm not sure, I never take medicine from the pharmacy so I cannot change.CSD -Central Idea E: I do not live without the medicine of the pharmacy, I am sick, from when I was born.CSD -Central Idea F: Because the medicine from the pharmacy did not work, with faith in God I became good with medicine from the plants.I already had a paracetamol once and it did not work on the day, I took the tea and solved it.I changed it from my son too, the doctor said he had the flu and passed a medicine to him, I did not give it, because the flu you only give a tea of garlic that solves and my girl when she was sick, it was the same way taking the medicine of the pharmacy, I went and did it at home, and she was good.I changed it and she got better.CSD -Central Idea G: No, because if the doctor passed it, it is better to hear, right?I take what the doctor does very well.CSD -Central Idea H: Yes, just a remedy for my girl, because it was very strong.CSD -Central Idea I: I took paracetamol and it was over, I had taken the last one the other day, I made the same tea.*A subject's speech may have more of a central idea.
plants and industrialized drugs specific for pain, as well as for the treatment of diseases in general.Finally, the understanding of singular and collective knowledge enables an important tool for directing care to these people, considering the role of health professionals.It is also shown as a way of preserving and respecting each one's thinking and acting.Thus, it is expected that this work will arouse the interest of researchers in studying more about popular knowledge and health management.

Table 1 .
Distribution of respondents according to age group and socio-demographic variables.

Table 2 .
Relationship between central ideas of question 2, the proportion of responses according to the participants of the research and CSD for question 2.Question 1: "What is your opinion about using homemade plant preparations for the treatment of pain?"

Table 3 .
Relationship between central ideas of question 3, the proportion of responses according to the participants of the research and CSD for question 3.Question 3: What is your opinion about the use of "pharmacy drugs" (medicines) for the treatment of pain?It can poison, I do not use it because I'm afraid.

Table 4 .
Relationship between central ideas of question 4, the proportion of responses according to the participants of the research and CSD for question 4.Question 4: Have you taken "medicine from the pharmacy" and plant medicine together at the same time (in association), for the treatment of pain?What do you think about using the two together?

Table 5 .
Relationship between central ideas of question 5, the proportion of responses according to the participants of the research and CSD for question 5.Question 5: Have you replaced the medicine that the doctor prescribed for the use of plants?If so, tell me how it was.If not, why?