Behavioral Prevention, Treatment, and Rehabilitation of Using Western and Chinese Medicines or Herbal Products among the Public in Response to COVID-19 in Hong Kong: A Cross-Sectional Study

The coronavirus disease 2019 (COVID-19) pandemic occurred in Hong Kong for more than two years. This article conducted a cross-sectional study for participants to investigate the behavioral prevention, treatment, and rehabilitation of using Western medicines or herbal products for COVID-19 in Hong Kong. A questionnaire was designed and performed over 2 weeks from 1 May to 15 May 2022. It consisted of five parts with around 20 questions conducted including sociodemographic information, prevention, treatment, rehabilitation of COVID-19, and also the sources of information. The pattern usage of Chinese or Western medicines for COVID-19 was studied after data collection. 318 people participated in this survey, and only 311 were qualified. The sociodemographic information, e.g., personal educational level, and behavior for the prevention of COVID-19, which included wearing masks (98.7%), using alcohol hand sanitizer (83.0%), washing hands frequently (82.4%), avoiding crowds (53.1%), and staying home more often (50.6%). Western medicines, such as antipyretic drugs, antitussive drugs, and pain reliever drugs, whilst Chinese medicines, such as Lianhua Qingwen Jiaonang, Huoxiang Zhengqi San or Wan, and Nin Jiom Pei Pa Koa, were most commonly used in the treatment and rehabilitation periods of COVID-19. Herbal products, including lemon, honey, ginger, and herbal tea, were used as a daily diet to fight against COVID-19. Based on the result findings, Chinese medicines or herbal products were used during the COVID-19 pandemic, but most of the participants used an unknown Chinese medicine practitioner's prescription and self-administered Chinese medicine. The pattern of Chinese medicines and Western medicines' usage in the prevention, treatment, and rehabilitation of COVID-19 was also investigated; this showed a statistically significant association between the variables according to gender, age, and Chinese or Western medicines for further investigation.


Introduction
In the late December 2019, there was an outbreak of pneumonia with unknown etiology emerged in Wuhan of Hubei Province, China.Chinese scientists identifed that it was coronavirus and named it "severe acute respiratory syndrome coronavirus-2" (SARS-CoV-2) [1,2].Te World Health Organization (WHO) called this coronavirus disease act COVID-19 and declared it a public health emergency of international concern on 30th January 2020 [3].COVID-19 was defned as a global pandemic, which potentially required a coordinated international response among 25 countries worldwide, including Southeast Asia and Europe, such as Tailand, Republic of Korea, Japan, Philippines, Vietnam, United States, and United Kingdom [4].As of 16th May 2022, there have been 519,105,112 confrmed cases of COVID-19, and 6,266,324 deaths globally documented by WHO [5].
Te frst confrmed case in Hong Kong was recorded on 23rd January 2020 and announced by the Center for Health Protection (CHP) [6].Hong Kong recorded 1,208,740 confrmed cases of COVID-19 and 9361 deaths as of 16 May 2022 [7].Compared with other countries around the world, Hong Kong had a relatively low number of COVID-19 confrmed cases despite being an international travel hub and its proximity to Wuhan, China.Since Hong Kong's government implemented multiple measures before the frst case of COVID-19 was diagnosed, Hong Kong also focused on primary care including the usage of public primary care clinics as part of an enhanced surveillance program together with accident and emergency departments, as well as triaging patients with suspected infections to hospitals [8].It was a multipronged infection control to achieve zero COVID-19 infection [9,10].Nevertheless, the main challenge to Hong Kong's health system was the rising number of COVID-19 infections and a lack of sufcient hospitalbased intervention for the infected COVID-19 patients [11].
Personal behavior is one of the important things for primary care.According to WHO, there is some health advice on personal behavior, such as wearing masks, avoiding crowds, washing hands frequently, using alcohol hand sanitizer, staying home more often, and working at home [12].Growing evidence has shown that Western medicines and herbal foods or products are the possible methods to prevent, treat, and rehabilitate COVID-19.Complementary and alternative medicines are benefcial for COVID-19 by improving immune system function [13].Western medicines including vitamin and mineral supplements, e.g., vitamin C, vitamin D, vitamin B, and zinc boost the immune system versus viruses.Paracetamol, antihistamines, antiasthmatics, and ivermectin are greatly reducing the risk of COVID-19 exacerbation [14].Herbal foods or products are the common approaches to people for the prevention, treatment, and rehabilitation of COVID-19.In early 2020, traditional Chinese medicines (TCM) such as Tinospora cordifolia (Willd.)Miers, Withania somnifera (L.) Dunal, Scutellaria baicalensis Georgi., and Curcuma longa L. are efective during this worrisome coronavirus pandemic, which utilized with over 90% efcacy to inhibit the SARS-CoV-2, cure, or reduce the COVID-19 symptoms [15].Daily diet or dietary supplements provide a potentially convenient and accessible way for COVID-19 recovery that shortens the rehabilitation period [16].
According to a previous investigation, people buy blindly and herd medicines because of the panic and fear surrounding the pandemic combined with misinformation from social and digital media, leading to global medicine shortages, and tend to self-medication for combating the COVID-19 infections [17].Meanwhile, Bangladesh applied high preventive measures for COVID-19 by the public, and there were a considerable number of participants taking preventive medicines and herbal foods/products [18].Is this same as the Hong Kong situation?Tus, its survey-based research started with the behavioral prevention of COVID-19, which aimed to explore the prevalence and patterns of using Western medicines or herbal products used among Hong Kong residents during the COVID-19 pandemic for three stages including prevention, treatment, and rehabilitation periods.Te pattern of Chinese medicines and Western medicines' usage in the prevention, treatment, and rehabilitation of COVID-19 based on age and gender, as well as Chinese and Western medicines, was investigated independently and analyzed.

Participants.
Participants must be aged 18 years or above who can be eligible to participate in this survey but are not limited to their sociodemographic backgrounds.Data collection was conducted both in-person and online using purposive sampling to recruit participants.An online survey was conducted using a Google questionnaire on social media platforms, including Facebook, WhatsApp, WeChat, and Email, while an in-person survey was done by Registered Chinese Medicine Practitioner face-to-face with participants.Tey were asked for written consent before taking the survey, either online or in-person modes.If the participant was chosen for the online survey, they must click the "Yes" button after written consent to start the survey, as well as proceed to the next section until the questionnaire is completed.Tis is an open-end questionnaire.Participants were only required to fll out the multiple choices and write short answers for preventing any mistakes or data redundancy.Te major concepts were compared to the differences in participants' usage of traditional Chinese medicines or Western medicines for three stages including prevention, treatment, and rehabilitation periods, which were supplementary with the sociodemographic and sources of information.

Evidence-Based Complementary and Alternative Medicine
According to the post hoc test, the Bonferonni correction for the multiple comparisons of prevention, treatment, and rehabilitation by adjusted signifcant level to α' � 0.017.Tis showed the percentages of prevention, treatment, and rehabilitation for males and females with χ 2 and p value.
According to the post hoc test, the Bonferonni correction for the multiple comparisons of prevention, treatment, and rehabilitation by adjusted signifcant level to α' � 0.017.Tis showed the percentages of prevention, treatment, and rehabilitation for Chinese and Western medicines with χ 2 and p value.23.2% of males and 34.8% of females were in the prevention stage, obtaining χ 2 (1, 578) � 9.609 and p � 0.002 compared with treatment and rehabilitation stages.41.2% of males and 54.7% of females were in the treatment stage, obtaining χ 2 (1, 578) � 10.539 and p � 0.001 compared with prevention and rehabilitation stages.35.7% of males and 10.5% of females were in the rehabilitation stage, obtaining χ 2 (1, 578) � 49.966 and p ≤ 0.001 compared with prevention and treatment stages (Table 6).

Discussion
Tis research has highlighted the behavioral prevention, treatment, and rehabilitation of using Western medicines or herbal products among the public in response to the Hong Kong COVID-19 pandemic.
Te practice preventive measures against COVID-19 include wearing masks, using alcohol hand sanitizer, washing hands frequently, avoiding crowds, and staying home more often which were the personal hygiene monitoring according to the Hong Kong Government and World Health Organization (WHO) suggestions.
Wearing a mask was efective to prevent the spread of COVID-19 because it is primarily based on respiratory droplets and aerosols or close contact [20].Alcohol hand sanitizer usually consisted of n-propanol, which was believed to damage the virus membrane and distribute its decoupling and protein synthesis.It was an anti-infectious agent for killing pathogens in the hands [21].
Washing hands frequently might stop the spread of COVID-19 with soap and running water, which were the critical importance for removing a virus or pathogen within the hands, and preventing the droplets from the infected person or direct contact with the contaminated materials [22].
Avoiding crowds and social distance decreased an individual's likelihood of contracting COVID-19 by reducing its transmission through person-to-person interaction, especially in preventing the social community outbreak [23].
Staying home more often or working at home minimized contact with others, reducing the spread of SARS-CoV-2 among participants and the risk of infection [24].Tus, nearly a hundred percent of participants wore a mask, and above eighty percent of participants used alcohol hand sanitizer as well as washed hands frequently which were the common practice preventive measures against COVID-19.
Only a few participants (9.1%) were taking herbal food or products for the prevention of COVID-19 compared with Western medicines or supplements (15.7%).More than 61.6% of participants did not take any herbal food or Western medicines.Since the specifc drugs and vaccines were not yet to be developed, taking herbal food or products might be an alternative COVID-19 preventive therapies [25].Some participants with COVID-19 would be recovered without needing to go to the hospital or take any herbal food and Western medicines [26].
Western medicine or vitamin supplements, such as C, D, B, multivitamins (86.9%), and zinc (14.8%) were frequently chosen by participants because these might have a benefcial efect, potentially reducing SARS-CoV-2 viral load and length of hospitalization, which enhanced the immune function and reduced the risk of COVID-19 infection [27], whilst herbal foods or products included herbal soup Evidence-Based Complementary and Alternative Medicine (66.4%), and herbal tea (39.4%) was in a higher percentage for the participants' selection.Yi Mi Fang Feng and Wu Shen Tang were the traditional Chinese herbal soups that detoxifed the lung and enhanced the immune system, relieving upper respiratory tract infections by dispelling wind and cold [28].52.9% of participants used Chinese medicine to treat COVID-19, and 41.1% of them were self-administered Chinese medicine and did not know the Chinese medicine practitioner's prescription.Lianhua Qingwen Jiaonang (67.0%) was the most common one for self-administered Chinese medicine.In the previous research, Lianhua Qingwen Jiaonang possessed antiviral and antiinfammatory actions that inhibited the SARS-CoV-2 virus replication and reduced viral content in the cytomembrane and cytoplasm, as well as suppressed cytokine overactivation.Tis signifcantly ameliorated the symptoms of cough, fever, and fatigue, which increased the efective rate and shortened the recovery rate in patients [29].Other Chinese medicines such as Nin Jiom Pei Pa Koa (20.6%),Huoxiang Zhengqi San or Wan (17.5%),Yinqiao San (12.4%), and Jinhua Qinggan Keli (12.4%) were lower in percentage usage in contrast to Lianhua Qingwen Jiaonang, which used to regulate the efects on an immune system.
Besides, a daily diet was another important part of treating COVID-19.Lemonade (48.8%), tea (e.g., black tea, green tea, and pu'er tea) (46.3%), and honey (30.5%) were the most popular.Tis was not surprising that 48.8% of participants selected lemonade as a daily diet.It consisted of ascorbic acid for the body's health but no evidence could "boost" or "supercharge" an immune system to prevent infections and treatment of COVID-19 [30].Black tea, green tea, and pu'er tea contained polyphenols that could inhibit the antiviral activities against positive-sense single-stranded RNA virus (SARS-CoV-2) for the treatment of COVID-19 [31].Honey was a neutral therapy because of its ability to attenuate acute infammation by enhancing immune response.It also improved the comorbid conditions and antiviral activities of an enveloped virus SARS-CoV-2 for patients with COVID-19 [32].
Te usage of Western medicine was around 61.9%, which was a little bit higher than Chinese medicine, and half of the participants (54%) were known the physician-prescribed Western medicines.Antipyretic drugs (e.g., ibuprofen and paracetamol) (69.1%), antitussive drugs (42.6%), pain reliever drugs (41.9%), and anti-infammatory drugs (39.0%) were the most commonly used for the treatment of COVID-19.Since antipyretic drugs such as ibuprofen and acetaminophen were usually taken by individuals to reduce the discomfort of fever and to shorten the duration of viral illness, ibuprofen demonstrated superior efcacy in fever reduction compared to paracetamol in the previous study [33].Te antitussive drugs appeased efects on the lung and respiratory infections that infuenced the binding afnity for the main protease (Mpro) of SARS-CoV-2, as an anti-viral agent for the treatment of COVID-19 [34].Pain reliever drugs were required to reduce pain, as the COVID-19 infection was associated with myalgias, referred pain, and widespread hyperalgesia [35].Because SARS-CoV-2 was a rapid self-replication virus, a large number of infammatory for cell infltration led to acute lung injury, acute respiratory distress syndrome (ARDS), and death.Antiinfammatory drugs were efective for altering susceptibility to infection and modifying the expression of angiotensinconverting enzyme 2 (ACE2), as well as the cell entry receptor for SARS-CoV-2.Tis also modulated the replication of SARS-CoV-2 in host cells and enhanced the immune response to SARS-CoV-2 for the treatment of COVID-19 [36].
Tere were a high proportion of participants who used Chinese medicine for the rehabilitation of COVID-19.However, half of the participants (50%) were unknown of the Chinese medicine practitioner's prescription.Te usage of Lianhua Qingwen Jiaonang (40.7%) served as a selfadministered Chinese medicine in the rehabilitation stage and was still at a high percentage, which is the same as the treatment period.Huoxiang Zhengqi San or Wan was the second highest proportion and was diferent from the treatment period using Nin Jiom Pei Pa Koa (13.6%).Huoxiang Zhengqi San or Wan formula treated gastrointestinal-type colds and improved clinical symptoms, as well as patient prognosis, which could pave a complementary medicine for rehabilitation [37].Te daily diet in rehabilitation was alike to the treatment, lemonade (38.6%), tea (e.g., black tea, green tea, and pu'er tea) (38.6%), and honey (29.8%), as well as ginger tea (24.6%) frst appeared.Te ginger tea possessed an anti-infammatory efect and ameliorative efect in musculoskeletal and rheumatism patients by inhibiting cyclooxygenase and lipoxygenase pathway in synovial fuid during the rehabilitation period [38].
Comparatively, only 24.2% of participants would use herbal foods or products in the rehabilitation of COVID-19, which consisted of lemon (41.1%), honey (37.9%), ginger (27.6%), and herbal tea (25.9%), and discussed the prevention and treatment before.Tere were other herbal foods or products such as Cordyceps-related products (15.5%) and Ganoderma-related products (12.1%).Its bioactive constituents produced the interleukin, such as (IL)-1β, IL-2, IL-6, IL-8, IL-10, and IL-12, and tumor necrosis factor (TNF)-α, phagocytosis stimulation of immune cells, and nitric oxide production for the stimulation of infammatory response via mitogen-activated protein kinase pathway to modulate or enhance the functions of an immune system [39].
Te percentage of participants who used medicinal soup (23.8%) in the rehabilitation was much greater than that of the Western medicines (16.5%) because some medicinal soups were suitably used in either the prevention or rehabilitation of COVID-19.In contrast to the Western medicines for the treatment stage, there was a diferent percentage between pain reliever drugs (41.7%), antitussive drugs (39.6%), antipyretic drugs (e.g., ibuprofen and paracetamol) (39.6%), and anti-infammatory drugs (29.2%).Tis percentage of Western drugs indicated that participants were more required to kill the myalgias, referred pain, and hyperalgesia during the rehabilitation period.
Participants received information about Chinese medicines or Western medicines for COVID-19 from family, Evidence-Based Complementary and Alternative Medicine friends, and relatives mainly.Tese were the primary sources, which directly afected the personal feeling and played an important role in immediate action fight against COVID-19.Around 40% of participants believed in their knowledge to decide the usage of Chinese medicines or Western medicines during COVID-19, and there existed a risk of the wrong selection.
Technology was changing with each passing day, and the sources of information also come from the Internet, TV or newspaper, and social media.Participants received the wrong message because of spreading misinformation surrounding COVID-19 [40].Only a few participants listen to and follow the instructions from the Chinese medicine practitioner or Western physician and Chinese medicine pharmacist or Western medicine pharmacist, as a result, decreased the recovery rate and increased the death rate from COVID-19.Tus, participants' sociodemographic background was related to their manner of the sources of information received for the Chinese medicines or Western medicines of COVID-19.
Tree hypotheses were stated: Do (i) gender or (ii) age afect the pattern of Chinese medicines and Western medicines' usage in the prevention, treatment, and rehabilitation of COVID-19?(iii) Can Chinese medicines and Western medicines' usage afect the prevention, treatment, and rehabilitation of COVID-19?(i) No signifcant association between gender when using Chinese medicine, but Western medicine with a signifcant association (Table 2) based on the post hoc test for Bonferonni correction, multiple comparisons between prevention, treatment, and rehabilitation stages for COVID-19.It showed the p values of prevention (0.984) (Table 5) and treatment (0.108) (Table 5) were insignifcant that were higher than α � 0.05, and only the p value of rehabilitation (0.013) was signifcant.Tis indicated females with a high proportion used Western medicines than males in the rehabilitation stage (Table 5).(ii) No signifcant association between age either in Chinese medicine or Western medicine usage for COVID-19 (Table 3).(iii) It also indicated that there was no signifcant association between the Chinese and Western medicines used for COVID-19 (Table 4).However, the p values were signifcant for the three combinations when the Bonferonni correction was applied with an adjusted signifcant level (α' � 0.017) (Table 6).Surprisingly, participants used Chinese medicines for the rehabilitation of COVID-19 triple that of Western medicines (10.5%).It may be Chinese medicines for reinvigoration (Guben Peiyuan) within the body's functions during the rehabilitation stage, such as Lianhua Qingwen Jiaonang and Huoxiang Zhengqi San or Wan, which were also used to prevent or treat long-term COVID-19.

Limitations
Te data collection for the questionnaire relied on the website.Tis may have data redundancy and afect the data accuracy as the survey was anonymous.Some participants did not know the data entry system and give misleading information.Besides, the sample size of this survey was a little limited; it cannot represent the whole population in Hong Kong using Chinese and Western medicines or herbal products during the prevention, treatment, and rehabilitation periods.Tis was only a small population investigation.

. Conclusion
Te original article concluded that sociodemographic information related to personal behavior prevention.Generally, participants with good behavior measure for preventing COVID-19.Several Western medicines or herbal products, daily diets, as well as medicinal soups were used for the treatment and rehabilitation of COVID-19.Some participants used an unknown Chinese medicine practitioner's prescription, and self-administered Chinese medicine was the most common.Participants were unknown with the physician-prescribed Western medicines, and it might appear as medicine abuse without a practitioner's prescription.Te pattern of Chinese medicines and Western medicines' usage in the prevention, treatment, and rehabilitation of COVID-19 was the core part; it has shown the statistically signifcant association between the variables according to gender, age, and Chinese or Western medicines.Te topic of this article was just the beginning of an investigation; it required further development of the Chinese medicines with herbal-drug interaction for participants to fght against COVID-19 based on the abovementioned pattern of the prevention, treatment, and rehabilitation periods.

2. 3 .
Questionnaire.Te questionnaire was developed by the Chinese Medicinal Pharmacy research team from Te Technological and Higher Education Institute of Hong Kong and the Hong Kong Chinese Medicine Pharmacists Association.Its contents consisted of fve parts with around 20 questions (S1 File.Questionnaire for English and Chinese version).

Figure 5 :
Figure 5: Participants' diferent types of daily diet in the treatment of COVID-19.

Figure 6 :
Figure 6: Participants' diferent types of self-administered Western medicines in the treatment of COVID-19.

Figure 10 :
Figure 10: Use of Western medicines in the rehabilitation of COVID-19.

Figure 11 :
Figure11: Sources of information for participants.
2.1.Study Design and Sampling.Tis was a cross-sectional survey study performed over 2 weeks from 1st May to 15th May 2022 using a self-administered questionnaire.Te study was approved by the Survey and Behavioral Research Ethics Committee of the Faculty of Science and Technology, Te Technological and Higher Education Institute of Hong Kong, Tsing Yi, New Territories, Hong Kong, China.

Table 1 :
Sociodemographic information for participants.
Figure 4: Participants' diferent types of self-administered Chinese medicines in the treatment of COVID-19.

Table 2 :
Chinese medicines and Western medicines used for COVID-19 depend on gender.

Table 3 :
Chinese medicines or Western medicines used for COVID-19 depend on age.

Table 4 :
Chinese or Western medicines used in the prevention, treatment, and rehabilitation of COVID-19.Evidence-Based Complementary and Alternative Medicine 3.6.3.Chinese or Western Medicines.People who used Chinese medicines for the prevention, treatment, and rehabilitation periods of COVID-19 were 23.2%, 41.2%, and 35.7%, respectively, whilst those who used Western medicines for the prevention, treatment, and rehabilitation periods of COVID-19 were 34.8%, 54.7%, and 10.5%.A chisquare test was conducted and calculated obtaining χ 2 (2, 578) � 50.359 and p ≤ 0.001 (Table

Table 5 :
Bonferonni correction for the multiple comparisons among prevention, treatment, and rehabilitation stages for COVID-19.

Table 6 :
Bonferonni correction for the Chinese or Western medicines used in the prevention, treatment, and rehabilitation stages for COVID-19.