Herbal medicine use during COVID-19 in Bulgaria: integration patterns and motivations for treatment choice in a cross-sectional online survey

During the COVID-19 pandemic, herbal medicine use - encompassing medicinal plants and phytoproducts - was widely reported globally, yet the therapeutic strategies, integration patterns, and motivations behind treatment choices remain poorly understood in Eastern European contexts. Bulgaria has a long-standing ethnobotanical tradition and diverse medicinal plant heritage, making it a relevant setting for this research. This study examined therapeutic approaches, motivations for treatment choices, and the role of demographic factors among surveyed Bulgarian adults who had experienced COVID-19. A cross-sectional online survey was conducted between July 2022 and September 2023 among 513 adult residents of Bulgaria, recruited via non-probability snowball sampling. Data on COVID-19 status, therapeutic approaches, and motivations for treatment choices were collected. Associations between demographic characteristics (age, sex, education and employment status), therapeutic behaviour and the recoded motivation category were assessed using Pearson’s Chi-square test, Cramer’s V, and multinomial logistic regression. Of 513 participants, 62.8% ( n = 322) reported having had COVID-19, of whom 84.8% ( n = 273) were symptomatic and applied treatment. Among symptomatic participants, 85.7% ( n = 234) consulted a physician, while 14.3% ( n = 39) self-medicated without medical consultation. Among symptomatic participants, 33.7% (n = 92) relied exclusively on conventional therapy, 52.0% (n = 142) received combined conventional and herbal therapy, and 14.3% (n = 39) were classified in the exclusive or initial herbal self-medication group, hereafter ‘herbal self-medication’ (including participants who used only herbal treatment and those who initially self-treated with herbal medicine before switching to conventional therapy). The most frequently selected motivation category was combined conventional and herbal therapy to prevent complications (44.0%, n = 120). No statistically significant association was found between any of the examined demographic factors - sex, age, education, and employment status - and therapy choice (p > 0.05 for all comparisons; Cramer’s V < 0.11). A statistically significant descriptive association was found between recoded motivation category and therapeutic approach (χ² = 199.476, df = 4, p < 0.001; Cramer’s V = 0.604), though this association is likely inflated by conceptual overlap between the two variables. A reclassification sensitivity analysis, in which participants with an initial herbal-to-conventional treatment sequence were reassigned to the combined-treatment group, confirmed that both the demographic findings and the therapeutic approach–motivation association remained materially unchanged. Employment status showed a nominally significant association with recoded motivation category at the uncorrected level (χ² = 10.240, df = 4, p = 0.037; Cramer’s V = 0.137), though this did not remain significant after Bonferroni correction for multiple comparisons (corrected α = 0.00625). Within this surveyed sample, herbal medicine appeared to play a substantial complementary, rather than alternative, role in COVID-19 management. Therapeutic approach showed a stronger descriptive association with the recoded motivation category than with demographic characteristics, though this association should not be interpreted as an independent causal relationship, given the conceptual overlap between the two variables. The predominantly integrative therapeutic model, combined with high levels of physician consultation, suggests that healthcare providers and public-health communication should actively enquire about and document herbal medicine use, especially when it is combined with conventional treatment, to support patient-centred counselling and safety monitoring. These findings further support proactive discussion of herbal medicine use between healthcare providers and patients, with particular attention to their beliefs and attitudes, to ensure safe integration with conventional treatments.