2.3. Data collection

Researchers collected information through focus groups, semi-structured interviews, and non-participatory observations between June and August 2016. Each collection method employed a specific guideline (Tables 2 and 3). Field notes assisted= in data documentation from non-participatory observations. Voice recorder aide= d to register information referred by the participants in the focus groups and semi-structured interviews. Recording quality was optimal for proper transcription and further analysis. The average length of focus grou= ps was 52 minutes (range 35-60 minutes) of semi-structured interviews was 25 minutes (range 12-39 minutes), and of non-participatory observations was 2.5 hours (range 1-4 hours).

Table 2. Focus groups guidelines.

Andean Traditional Medicine (ATM)

What are the advantages and disadvantage= s of the use of ATM?

Why do people choose ATM for healing?

Do you know about cases of malpractice i= n ATM? If the answer is yes, which one’s?

What is the role of faith in ATM?

Modern Medicine (MM)

Is there any advantage of using the isol= ated active compound of a plant instead of the whole plant for treating diseases= ?

Integration of ATM and MM

How would you define ATM and MM?

What would be the result from the combin= ed use of ATM and MM?

In ATM, the spirituality of the healer i= n the healing process is essential. How can this criterion be applied in MM?=

How can Andean pathologies* such as ‘mal= del arco iris’, ‘susto’, ‘mal= aire’, ‘mal ojo’, and ‘shungo’ be treated from the vision of MM?<= /span>

* Definitions of Andean Pathologies:

‘Mal del arco iris’ is triggered by the rainbow or solar spectrum action in stagnant waters. The person gets sick w= hen walking near these places. This disease is common among young women. The ma= jor symptoms are depression, asthenia, muscle pain, vesicles, and pustules in t= he legs or the entire body.

‘Susto’ or ‘= Espanto’ is produced by unpleasant experiences such as accidents, violent episodes, or distress with an emotional impact on the patient. Characteristics of this disease are nervousness, lack of appetite,= and loss of sleep.

'Mal aire’ i= s caused when strong winds are present while a person walks through cemeteries or pl= aces with hidden treasures (‘burials’) or contact with cold air. Its major sympt= oms are dizziness, headache, vomiting, stomach pain, fainting, and general body discomfort.

‘Mal ojo’ is generated by a person who throws an intense gaze with affection or hatred towards another. Children are more likely to suffer from this discomfort. A= mong the characteristic symptoms are fainting, nervousness, pale face, headache, diarrhea, vomiting, and fever. In children, it is common to observe astheni= a, constant crying, and crusting in the eyes.

‘Shungo’ is = a liver condition caused by sudden falls that change this organ's original position= . It is seen mainly in children and commonly manifests with stomach pain, asthen= ia, vomiting, and fever. Treatment comprises the relocation of the liver.<= /o:p>

= ;

Table 3. Semi-structured interview guidelines.

Practice of ATM<= /span>

What are the diseases you commonly treat= ?

How do you diagnose a disease?

What are the plants you use for treating diseases?

What are the reasons for choosing the pl= ants you use to treat a disease?

Where do you obtain medicinal plants?

How do you use medicinal plants? Mixed p= reparations or alone?

What method of preparation of medicinal = plants do you commonly use to cure a disease?

What part/s of the plant do you use to t= reat a disease?

How do you guarantee the efficacy of your treatments?

What complications can occur when tradit= ional medical treatments are applied?

Integration of ATM and MM

When a patient comes to you with any ail= ment or symptom, is it you who diagnoses the disease or is the diagnosis provide= d by a physician?

2.4.       Data analysis

Based on a preliminary bibliographic sea= rch was the collected information grouped into two major categories, respective= ly: a) Opportunities in the practice of ATM, and b) Challenges in its potential integration with MM. Common clusters of themes generated subcategories (cod= es) within the main ones. Three researchers individually revised the emerging c= ode system to confirm the extraction of all codes. Discrepancies were solved through discussions to reach a consensus or to fine-tune codes. Researchers performed a qualitative con= tent analysis using Atlas.ti software (version 8.3.0= ). Three researchers individually read the field notes from the non-participat= ory observations and the transcriptions of focus groups and semi-structured interviews to fine tune code content. Furthermore, two researchers, experts= in the topic, reviewed the content to confirm the accurateness of the coding processes. Analysis of the information continued until data saturation was reached for all codes.

3.      =          RESULTS AND DISCUSSION

Fourteen subcategories associated with the two pre-defined major categories were identified: a) Opportunities in the practice of ATM and b) Challenges in its potential integration with MM (Table 4).

Table 4. Main categories and subcategories.

Opportunities in the practice of ATM

Reasons for consultation

Reported efficacy

Accessibility

Touristic attraction

Disease conception

Relationship physician-patient and healer-patient<= /span>

Challenges in the potential integration = of ATM and MM

New generations

Therapeutic methods

Poisoning, adverse effects, and interactions

Complex clinical cases

Combined use of ATM and MM

Regulation and control of the medical practice

Trainin= g in ethnomedicine and ethnopharmacology

Model of intercultural health

= 3.1.      =     Major category: Opportunities in the practice of A= TM

Reasons for consultation

Cultural influence seems to play an esse= ntial role in preferring ATM. In this context, medicinal infusions appear to be o= ne of the most common forms of therapy:

In the house, the mother or the father frequently suggest drinking medicinal plant infusions to feel better (Ramiro, physician).

TM's importance becomes relevant in Latin America countries because it is part of their culture and traditions (Finerman & Sackett, 2003; Te= ne et al., 2007). The current permanence of ATM seems associated with i= ts confirmed therapeutic benefits to treat muscular pain, body malaise, menstr= ual cycle alteration, headache, nausea, among others (Torri, 2013; Tinitana et al., 2016; Andrade et al., = 2017). In addition, there is evidence that active compounds isolated from medicinal plants are used in TM (Orrego-Escobar, 2015). O= ne of the significant milestones in the research field of antineoplastic properti= es is paclitaxel (Nikolic et al., 2011).

Reported efficacy

Users emphasized the perceived efficacy of ATM against diseases for which they did not find improvement with MM:

Babies commonly suffer from= ‘shungo’ [a disorder conceived from ATM and described in Table 2]. The physician only prescribes (…) Pedialyte® [a commercial oral rehydrat= ion solution] and nothing else. Then the parents bring the baby to people who k= now about ancestral medicine, and they diagnose it as ‘shu= ngo’ (...) [with ATM treatment] the baby is fine, next day (Al= ejandra, young user).

Consulted users also reported a percepti= on of greater efficacy and immediate improvement achieved with ATM than with MM:<= o:p>

Suppose that I suffer from = stomach pain. The physician prescribes me a pill, some syrup, so many pills! (...) The plants possess= more effect than pills: sometimes, with a single type of plant, the pain is gone rapidly (Gabriel, young user).

The reported ATM practices are associate= d with the fact that Andean wisdom has adopted those medicinal practices with confirmed efficacy, while the non-efficacy ATM practices fall into disuse (Vides-Porras & Álvarez- Castańeda, 2013). As stated by Karunamoorthi et al.= (2013) showed herbal medicine a healing power in the treatment of certain diseases= . Compared to the drug dosage, the immediate e= ffect of ATM compared with MM probably relies on a higher dose of active compound= in the plant. Another explanation for the effect enhancement is the presence of other herbal composites, absent in the pharmacological form.

Accessibility

The affordable cost of ATM stands out as= one of the reasons for encouraging its use:

A medical appointment with a physician costs about thirty or forty American dollars. Then I prefer going= to a traditional healer (Humberto, adult user).

ATM offers prompt access to health care = by not being over-saturated as with MM:

If my patient cannot access= the website [to schedule a medical appointment] or public medical attention tak= es too much time because of the long queues (...) If my patient is not receiving medical attention at the hospital when required because there is availabili= ty in thirty or forty days (…), the disease will worsen (Santiago, physician).

The rise of h= ealth cost in Latin America, Asia, and Africa positioned TM as a more accessible option (Galabuzi et al., 2010). Diverse factors= such as economic aspects, migration, and in most cases the inefficiency of Natio= nal Health System associated with MM supports ATM use. Patients reject MM shortcomings such as inadequate coverage and access problems to health services. In addition, the compulsory journey to other cities for laboratory tests or evaluation by specialists, deterioration of the physician-patient relationship, absence of satisfactory therapeutic results, and short-time medical appointments influence their preferences (Lingard et al., 20= 02). Over-saturation of the Public Health System compels the application of the rule, which is in line with the international standard, of a maximum time l= imit of 15 minutes to provide Health Services in Public Institutions.=

T= ouristic attraction

The practice = of ATM at the herb markets of Cuenca appears as a touristic attraction for foreign= ers who visit the place:

I realized that the process= of ‘limpia’ [a traditional practice for a spiritual cleansing carried out with a bouquet of plants tied in the shape of a broom] was considered a tourist attraction. In the observations course, groups of foreigners were interested spectators of this ancestral practice (non-participatory observation re= port directed to Rebeca, healer).

Community-Bas= ed Tourism (CBT) generates an integral development characterized by a positive impact on the regional economy and dual preservation of its cultural elemen= ts and natural resources (Morales González, 2008). Thus, community members participate in a co-responsible manner for the development of appropriate environmental and tourism policy issues (Maldonado-Era= zo et al., 2020).

Perhaps one o= f the more sensitive aspects of this matter is the intellectual appropriation of ancestral wisdom. Misappropriation occurs when the development of ATM pract= ices occurs in a different context than the original. Besides, when a Government Regulatory Institution endorses health tourism, adequate control over the efficacy and safety of the offered traditional treatments is guaranteed and= so perceived by the patient who is also a consumer of this potential health/tourism alternative (Majeed et al., 2017).<= /p>

Disease conception

Healers associate the patient's discomfo= rt with an internal or external energy imbalance, whereas MM physicians explain disease by understanding the physio-pathological processes occurring in the organism. Hence, physicians ignore how to treat ATM pathologies related to energy imbalance:

A physician can talk about diseases, but never about energy (Fernando, young user).

It is a spiritual exercise.= You strengthen your emotions, all your vital energy (...) A whole consciousness about the relationship with Nature, with the animals (Enrique, healer).

Unlike MM, which separates spirit and ma= tter, body and soul, ATM conceives them as a fundamental entity. Andean worldview comprehends a disease as an energy imbalance, and its treatment comprises restoring it. In ATM, healing processes involve magic-religious principles = that combine rational and magical thinking. Rationality allows the healer to res= olve a body dysfunction, while magic enables to cure of a spiritual, psychic, or emotional disorder (Bautista-Valarezo et al.= , 2020). There is a considerable increase = in patients using TM to treat emotional disorders, mainly depression or anxiet= y (Armijos et al., 2014).

Relationship physician-patient and healer-patien= t

A poor physician-patient relationship al= so influences preference for ATM. Healers treat patients with respect, conside= ring them as peers who share the same beliefs and customs:

Sometimes, physicians treat= their patients disparagingly. Seeing them as peasants, they are mistreated, witho= ut respect. If patients come without taking a shower [because] maybe they come from remote= sites with no access to water (...) physicians treat them with contempt. Therefore, people prefer traditional medicine (Ruth, physician).

There is still a need to sensitize health personnel about knowing their patients’ customs and practices. It could pro= mote tolerance, respect, and attachment, positively affecting the treatment and preventing potentially harmful interactions between conventional and alternative therapies (Zörgo et al., 201= 8).

= ;

= 3.2.      =     Major category 2: Challenges in the potential integration of ATM with MM

New generation= s

An essential factor influencing a future potential extinction of ancestral wisdom is the recognition of MM in the National Health System of the country. Over time, if the lack of access to information regarding ATM persists, it could be displaced and forgotten:

Our grandparents practiced traditional medicine. They know how to cure (...) That traditions are being forgo= tten (...) they no longer exist (Alejandra, young user).

Public bibliographic or documented sourc= es on ATM are scarce. Ancestral wisdom spread is beneficial not only for users but also for healers. Having access to reliable sources of information supports continuing training:

I have a booklet about how = to perform ‘limpias’. By reading it, a healer can = learn how to accomplish this process (Dolores, healer).

Besides, new generations of healers are interested in conveying their ancestral wisdom accompanied by scientific evidence to show its efficacy:

We possess information that= we are currently collecting. At some point, we are going to publish it into a scie= ntific journal because we want to show that ATM is trustworthy as the other medici= ne [MM] (Enrique, healer).

Lack of interaction among the healers and their communities hinders the oral transmission of ancestral knowledge. You= ng people who seem to show little or no interest in knowing and preserving traditional wisdom appear to be influenced by the Government's recognition = of MM but not TM within the National Health System (Jensen et al., 2011= ). Therefore, there is a need to collect and spread ancestral wisdom and traditions in mass media to promote its conservation (= Kamsu-Foguem & Foguem, 2014).

Protection and preservation of ancestral wisdom are essential to ensure its appropriate integration with MM. It is necessary to record ATM knowledge through a method that enables scientific validation of the traditional healing procedures and the therapeutic benefi= ts of herbal resources (World Health Organization, 2002). In this context, intellectual property matters demand special attention (Tupper, 2009). It is advisable to protect ancestral wisdom by complying with existing or new intellectual property rights regulations without being or becoming an impediment to the production of new scientific knowledge derived from traditional wisdom (World Health Organization, 2013; Ijaz & Boon, 2018)= .

Therapeutic me= thods

It appears to be a widespread belief tha= t TM employs natural treatments, whereas MM uses synthetic drugs to treat diseas= es, considering both as different and unrelated therapeutic methods. Participan= ts recognized ATM therapy as a healing treatment; unlike MM drugs, which seem harmful to them:

It is better to drink homem= ade infusions than going to the physician (...) Because medical doctors use che= micals (...) We do not use them (Esther, healer).

Vegetable supplies serve to prepare traditional remedies, an essential source of therapeutic agents. A lack of knowledge about patent medicines’ origin becomes clear since many are derivatives of natural products (Balunas & = Kinghor, 2005). Both ATM and MM use active chemical compounds to treat diagnosed pathologies. With MM, the active compound is administered in an isolated and dosed form and through pharmaceutical formulations specially designed to favor an adequate concentration of the d= rug in the target organ or receptor. In ATM, the active compound is administered together with others present in the plant, hindering an accurate dosage.

Poisoning, adverse effects, and interactions

Nescience could lead to misuse of ATM. MM physicians have identified cases of intoxication, adverse effects, or lack = of efficiency of prescribed pharmacological treatment because of interactions = with the active compounds of medicinal plants:

There are interactions betw= een drugs and a mixture of plants. The active compounds will interact with each other, and [the pharmacological action] will be canceled or enhanced (Ruth, physicia= n).

Patients rely on TM because of its proven efficacy but must be careful when using natural products. It is impossible = to dismiss an interaction with other drugs that could generate adverse effects= in the patient (Asher et al., 2017). There are medicinal plants that cause few= or no side effects when they are used alone. When combined with prescribed dru= gs, they could produce serious health problems. For example, ginseng antagonizes the pharmacological effect of warfarin (Dong et al., 2017).

Complex clinical cases

One of the most critical limitations of = ATM healers is the therapeutic inexperience to recognize, treat or cure diseases that compromise a patient’s life. Clinical complications can lead to a seve= re dysfunction or even to death when not being opportunely remitted to a MM specialist:

Patients come to us being u= nable to solve their medical issues. For example, they previously consulted ‘sobadores’ [traditional healers who are expert in bone and muscle-related illnesses] which aggravated the femur fracture (Álvaro, physician).<= o:p>

As for childbirth, I have s= een many unfair practices. For instance, if the child is transverse, the mother need= s a cesarean. When the healers try to ‘accommodate’ it, this practice could cau= se a complication, and the child or the mother can die. This procedure could dam= age the uterus= (Ruth, physician).

Although some TM procedures possess prov= en effectiveness, this is not the case for all of them in situations of immine= nt risk. Thus, the ability to identify potential threats is of great importance when performing ATM practices while avoiding engaging the user in an adverse case (World Health Organization, 2000).

C= ombined use of ATM and MM

The combined = use of ATM with the therapy prescribed by the physician seems to be a common pract= ice, especially regarding the treatment of chronic diseases in senior adults:

I have diabetes. Sometimes,= I help myself with medication and infusions that I prepare at home. You know diabe= tes treatment is complicated (...), so I treat it with pills and infusions (Amelia, senior adult user).

In Australia,= Europe, and North America, the combined use of TM and MM’s has increased, especially treating and controlling chronic diseases (World Health Organization, 2002). Integration of TM and MM seems to generate greater adherence to prescribed pharmacological treatment and to favor a better physician-patient relations= hip (Vides Porras & Álvarez Castańeda, 2013).

Regulation and control of the medical practice

The absence of a regulatory entity to pr= event and control ATM malpractice allows people without knowledge and with the so= le intention of generating profits, commercialize or perform procedures with no therapeutic effects that may even cause adverse severe or undesired effects= :

One thing is traditional me= dicine performed by expert healers, and another is charlatanism. We have to be very attentive to it (Ramiro, physician).

Both in MM and ATM, it is workable to id= entify positive behavior: knowledge/wisdom of the physician/healer, efficacy, and commitment. Likewise, it is possible to observe improper conduct such as deceptive marketing and unscrupulous manipulation for profit in both cases. However, in TM's case, irresponsible behavior could be favored by a lack of Government regulations and non-existent control (World Health Organization, 2002). Indeed, legislative efforts frequently focus on the MM practices neglecting other sectors, such as TM (Peltzer &= amp; Pengpid, 2019).

Training in ethnomedicine and ethnopharmacology<= o:p>

Physicians perceive the need to be train= ed on the therapeutic use of medicinal plants and their possible adverse effects = and interactions when combined with MM drugs:

They [the patients] always ask: With what infusion should I take this pill? If I say: With cinnamon infusion, they as= k: Is it a plant with ‘hot’ properties? If I say: You can take this pill with lemonade, they say: Not so! It has ‘cold’ properties [type of ancestral classification of plants: hot and cold, based on their general pharmacologi= cal activity described in ATM]. Hence, we have to study this way of classify= ing plants to know how to adapt our prescriptions to them and for gaining the patient’s trust (Ruth, physician).

National trai= ning programs with the endorsement of the Ministry of Public Health of Ecuador h= ave encouraged healers to share their wisdom and experiences with other colleag= ues and physicians. These events involve the participation of physicians who le= arn about ATM and actively contribute to integrating it with MM:

I have taken part since 198= 5. I was a leader of the National Health Council. We were pioneers at the beginning.= We have trained people at a national level, almost in all provinces= (Dolores, healer).

We all are trying to attend= the courses (.= ..) These courses come from many years ago. I took part in these studies togeth= er with physicians. These courses gather a sizeable group of people (Sara, healer).

MM practitioners’ training in ATM matters could significantly improve the physician-patient relationship and the treatment and adherence, even preventing possible interactions between drugs and medicinal plants (Taddei et al., 199= 9).

Effective pro= motion of the combined use of ATM and MM relies on patients, healers, and physicia= ns' active interaction. The Ecuadorian Health System must encourage the academic community to develop programs for training in health matters and support scientific research to promote its effective integration with MM (Hita, 2014). However, the achievement of this aim sho= uld be cautiously analyzed, as in other environments such as politics, religion, or science where absolute hegemonies provoke paralysis and involution, which m= ay also be the case of ancestral wisdom (World Health Organization, 2013; Herr= era et al., 2019).

Model of intercultural health<= /u>

Ecuador is attempting to develop an intercultural Public Health Model involving ATM. Thus, primary health care units should locate ATM providers and train them for the promotion and development of collaboration:

I am a midwife <= span lang=3DEN-US style=3D'mso-bidi-font-size:9.0pt'>(...) I go to the hospit= al where I help women to give birth, together with the physicians (Sara, healer)= .

There is a current tendency for private = Health Centers in Ecuador to offer combined TM and MM therapies:=

We want to offer a different alternative service. My brother is a physician and he and our father, who i= s a 'Yachak' [a main traditional healer recognized in= ATM], cooperate (Enrique, healer).

The official regulation of ATM practices promotes and supports good practices and fair access, ensuring the authenticity, safety, and efficacy of traditional therapies. Establishing t= his regulation must be cautious since, by ‘conventionalizing’ its practices, it could increase the cost of services, devaluing or suppressing their cultural identity and minimizing its social role (Herrera et al., 2019; Krach et al., 2018). The Government regulation or the freedom to proceed in TM cannot be limited by = each other. It is possible to identify and build intermediate processes. Future research in this area will allow the development of flexible integration methods that encourages healers, physicians, and users to develop regulatio= ns and establish a proper regulatory entity (Hu & Cal= duch, 2017).

<= ![if !supportLists]>3.3.=           Limita= tions and recommendations for future research

Our findings are limited to the case study area. A wider group of participants is desirable = for future research to achieve more precise documentation of the crucial factors affecting the integration of ATM and MM in Ecuador.

<= o:p>

4.&n= bsp;            = ; CONCLUSIONS

ATM is a cruc= ial component of the cultural identity of Andean Latin America countries. This cultural influence could be one reason users prefer it as a first health ca= re option instead of MM. Lower costs for ATM services compared to MM seem to reinforce this preference. In addition, is accessibility among other a posi= tive characteristic of ATM favoring its attention. There is no need to schedule = an appointment, as with MM. Also, the relationship users maintain with healers= is much closer since the healer considers the patient equal and vice versa. Besides, given the relevance of ATM as a constituent of indigenous community culture and the worldwide growing interest in using TM, traditional practic= es can be promoted as community-based tourism. Policies are required to fortify properly associated praxis, such as the conservation of biodiversity, especially regarding those linked to the use of medicinal plants in ATM.

Health/disease conception is different for ATM and MM. Users perceived ATM treatments as m= ore effective than the ones from MM. This appreciation seems to be attributed to the fact that ATM heals spiritual harm besides bodily diseases. Medicinal plants are the basis of ATM treatment, given the perception that ‘natural plants are harmless’. Also, the noticeable judgment exists that chemical dr= ugs could generate adverse side effects. Unawareness of active compounds being present in medicinal plants can lead to improper usage and the appearance of adverse effects or unwanted interactions when they are administered together with MM drugs.<= /o:p>

In this conte= xt, research and regulatory policies should establish official protocols for preventing and controlling adverse reactions associated with ATM and MM combined therapies. The absence of a government entity regulating ATM pract= ices seems to favor the presence of charlatans who perform therapeutic procedures without ancestral knowledge. Precise and updated regulations encourage medicinal plants rational use involving defined dosage and respect for biodiversity and traditional wisdom. Therefore, a regulatory framework and scientific research are crucial for the proper integration of ATM and MM.

Alt= hough the joint use of ATM and MM seems to have scarce acceptance, scientific evidence supports the achievement of better results with its combined use. = In this regard, the exchange of valuable knowledge and experiences must be encouraged through continuous training, paying attention to the intellectual property rights of indigenous communities.

Sum= marizing, MM and ATM’s integration requires an initial agreement between healers and physicians on therapeutic practices, responsible use of medicinal plants by patients, and the proper guidelines for conserving ancestral wisdom. Likewi= se, studies on the therapeutic application of medicinal plants are also require= d to promote their rational use.

DECLARATIONS

Ethics approval and consent to participate=

The Bioethics Committee of the San Franc= isco University from Quito, Ecuador, approved the study (code 2016-084E). All participants provided written informed consent for being part of this resea= rch and the publication of obtained results. This publication used pseudonyms f= or anonymity.

Availability of data and materials

Please contact the correspo= nding author for data requests.

Competing interest

The authors have declared t= hat no potential competing interest exists.

Funding

The authors a= re grateful for the financial support from the ‘Direcc= ión de Investigación de la Universidad de Cuenca, E= cuador’ [Reseach Office of the University of Cuenca, Ec= uador] through the research project ‘Uso de = plantas medicinales: perspectiva de los curand= eros del cantón Cuenca’ [Use of medicinal plants: perspective of the healers of the Cuenca canton].

Author’s contributions=

AOP and LHT d= esigned the study. VQG and DGL conducted the fieldwork. AOP, VQG, DGL, GBL, and RA performed the data analysis. AOP, VQG, and DGL drafted the manuscript. All authors read and approved the final manuscript.

Acknowledgments

The authors gratefully acknowledge the healers, physicians, and Andean Traditional Medi= cine users for sharing their experiences and insights with them. They also acknowledged the expert assistance of M. Campoverde and L. Brito in the execution of this study.

REFERENCES

Andrade, J. M., = Lucero Mosquera, H., & Armijos, C. (2017). Ethnobotany of Indigenous Saraguros: medicinal plants used by community healers ‘Hampiyacha= kkuna’ in the San Lucas Parish, Southern Ecuador. BioMed Research International= , 2017, 20 pp. https://doi.org/10.1155/2017/9343724

Armijo= s, C., Cota, I., & Gonzá= lez, S. (2014). Traditional medicine applied by the Saraguro yachakkuna: A preliminary approach to the use of sacr= ed and psychoactive plant species in the southern region of Ecuador. Journal of Ethnobiology and Ethnomedicine, 10(26), 12 pp. https://doi.org/10.1186/1746-4269-10-26
Asher, G. N., Corbett, A. H= ., & Hawke, R. L. (2017). Common herbal dietary supplement-drug interactions. American Family Physician, 96(2), 101-107. www.aafp.org/afp

Baluna= s, M. J., & Kinghorn, A.= D. (2005). Drug discovery from medicinal plants. Life Sciences, 78(5), 431-441. https://doi.org/10.1016/j.lfs.2005.09.012

Bautista-Valarezo, E., Duque, V., Verdugo Sánchez, A. E., Dávalos-Batalla= s, V., Michels, N. R. M., Hen= drickx, K., & Verhoeven, V. (2020). Towards an indigenous definition of health:= an explorative study to understand the indigenous Ecuadorian people's health a= nd illness concepts. International Journal for Equity in Health, 19<= /i>(101), 8 pp. https://doi.org/10.1186/s12939-020-1142-8

Dobos<= /span>, G., & Tao, I. (2011).= The model of western integrative medicine: The role of Chinese medicine. Chi= nese Journal of Integrative Medicine, 17(1), 11-20. https://doi.org/10.1007/s11655-011-0601-x

Dong, H., Ma, J., Li, T., X= iao, Y., Zheng, N., Liu, J., Gao, Y., Shao, J., & Jia, L. (2017). Global deregulation of ginseng products may be a safety hazard to warfarin takers:= Solid evidence of ginseng-warfarin interaction. Scientific Reports, 7(1), 11 pp. https://doi.org/10.1038/s41598-017-05825-9

Finerm= an, R., & Sackett, R. (20= 03). Using home gardens to decipher health and healing in the Andes. Medical Anthropology Quarterly, 17(4), 459-482. https://doi.org/10.1525/maq.2003.17.4.459

Galabu= zi, C., = Agea, J. G., Fungo, B. L., & Kamoga, R. M. N. (20= 10). Traditional medicine as an alternative form of health care system: A preliminary case study of Nangabo sub-county, C= entral Uganda. African Journal of Traditional, Complementary and Alternative Medicines, 7(1), 11-16. https://doi.org/10.4314/ajtcam.v7i1.5722= 4

Herrera, D., Hutchins, F., = Gaus, D., & Troya, C. (2019). Intercultural healt= h in Ecuador: an asymmetrical and incomplete project. Anthropology and Medici= ne, 26(3), 328-344. https://doi.org/10.1080/13648470.2018.1507102

Hita, S. R. (2014). Salud, globalización e intercultu= ralidad: Una mirada antropológica a la situación de los= pueblos indígenas de Sudamérica [Health, globalization and interculturalism: an anthropological approach to= the situation of indigenous peoples in South America]. Ciencia e Saude Coletiva= , 19(10), 4061-4069. https://doi.org/10.1590/1413-812320141910.09372014

Hu, Q., & Cald= uch, R. M. (2017). = On traditional Chinese medicine regulation in China: How quality and safety of= use are insured. Pharmacological Research, 119, 371-372. https://doi.org/10.1016/j.phrs.2017.02.025

Ijaz, N., & Boon, H. (2= 018). Statutory regulation of traditional medicine practitioners and practices: T= he need for distinct policy making guidelines. Journal of Alternative and Complementary Medicine, 24(4), 307-313. https://doi.org/10.1089/acm.2017.0346

Jensen, L. A., Arnett, J. J= ., McKenzie, J., & Jensen, L. A. (2011). Globalization and cultural identi= ty. In: S. Schwartz, K. Luyckx, & V. Vignoles (= Eds.), Handbook of Identity Theory and Research (pp. 285–301). Springer. https://doi.org/10.1007/978-1-4419-7988-9-13

Kamsu-= Foguem, B., & Foguem, C. (2014). Could telemedicine enhance traditional medicine practices? Eu= ropean Research in Telemedicine, 3(3), 117-123. https://doi.org/10.1016/j.eurtel.2014.08.001

Karuna= moorthi, K., = Jegajeevanram, K., Vijayalakshmi, J., & Mengistie, E. (201= 3). Traditional medicinal plants: A source of phytotherape= utic modality in resource-constrained health care settings. Journal of Evidence-Based Complementary and Alternative Medicine, 18(1), 67= -74. https://doi.org/10.1177/2156587212460241

Krah, E., de Kruijf, J., & Ragno, = L. (2018). Integr= ating traditional healers into the health care system: Challenges and opportuniti= es in rural Northern Ghana. Journal of Community Health, 43(1), 157-163. https://doi.org/10.1007/s10900-017-0398-4

Lahari= ya, C. (2018). ‘Ayushman Bhar= at’ Program and universal health coverage in India. Indian Pediatrics, <= i>55(6), 495-506.

Lingard, L., Tallett, S., & Rosenfield, J. (2002). Culture and physician-patient communicatio= n: a qualitative exploration of residents' experiences and attitudes - PubMed. <= i>Annals of the Royal College of Physicians and Surgeons of Canada, 35(6), 336-340.

Majeed, S., Lu, C., & <= span class=3DSpellE>Javed, T. (2017). The journey from an allopathic to n= atural treatment approach: A scoping review of medical tourism and health systems.= European Journal of Integrative Medicine, 16, 22-32. https://doi.org/10.1= 016/j.eujim.2017.10.001

Maldonado-Erazo,= C. P., del Río-Rama, M. de la C., Noboa-Vińan, P.,= & Álvarez-García, J. (2020). Community-based tourism in Ecuador: Community ventures of the provin= cial and cantonal networks. Sustainability, 12(15), 30 pp. https://doi.org/10.3390/SU12156256

Mathez= -Stiefel, S., = Boillat, S., & Rist, S. (2007). Promoting the divers= ity of worldviews: an ontological approach to biocultural diversity. In: Endoge= nous Development and Bio-cultural Diversity. The interplay of worldviews, globalization and locality (p= p. 67-81). ETC/COMPAS.

Morales González= , M. (2008). żEtnoturismo o turismo indígena? [Etnotourism<= /span> or indigenous tourism?]. Teoría y Praxis, 4(5), 123-136. https://doi.org/10.22403/uqroomx/typ05/09

Nikolic, V. D., Savic, I. M., Savic, I. M., Nikolic, L. B., Stankovic,= M. Z., & Marinkovic, V. D. (2011). Paclitaxel = as an anticancer agent: Isolation, activity, synthesis and stability. Central European Journal of Medicine, 6(5), 527-536. https://doi.org/10.2478/s11536-011-0074-5

Orrego= Escobar, E. F. (2015). Latin-American plants as a source of new antineoplastic drugs, current situation and new opportunities against cancer. Medwave, 15(3), = p. e6121. https://doi.org/10.5867/ medwave.2015.03= .6121

Peltzer, K., & Pengpid, S. (2019). A survey of the training of traditional, complementary, and alternative medicine in universities in Thailand. Jou= rnal of Multidisciplinary Healthcare, 12, 119-124. https://doi.org/10.2147/JMDH.S189644

Taddei= , G., = Santillana, M., Romero, J., & Romero, M. (1999). Aceptación y uso de herbolaria en medicina familiar [Acceptance and use of herbal medicine= in family medicine]. Salud Pública de México, = 41(3), 216-220.

Tene, V., Malagón, O= ., Finzi, P. V., Vidari, G., Armijos, C., & Zaragoza, T. (2007). An ethnobotanical survey of medicinal pl= ants used in Loja and Zamora-Chinchipe, Ecuador. = Journal of Ethnopharmacology, 111(1), 63-81. https://doi.org/10.1016/j.jep.2006.10.032

Tinitana, F., Rios, M., Romero-Benavides, J. C., de la Cruz Rot, M., & Pardo-de-Santayana, M. (2016). = Medicinal plants sold at traditional markets in southern Ecuador. Journal of Ethnobiology and Ethnomedicine, 12(29), 18 pp. https://doi.org/10.1186/s13002-016-0100-4

Torri, M. C. (2013). Percep= tions and uses of plants for reproductive health among traditional midwives in Ecuador: Moving towards intercultural pharmacological practices. Midwife= ry, 29(7), 809-817. https://doi.org/10.1016/j.midw.2012.06.018

Tupper, K. W. (2009). Ayahu= asca healing beyond the Amazon: the globalization of a traditional indigenous entheogenic practice. Global Networks, 9(1), 117-136. https://doi.org/10.1111/j.1471-0374.2009.00245.x

Vides Porras, A., & Álvarez Castańeda, A. (2013). La medicina tradicional como un modelo = de atención integral en salud [Traditional medicin= e as a model of comprehensive health care]. Revista = UVG, 58-60. http://uvg.edu.gt/publicaciones/revista/volumenes/numero-25/7_la%20medicina= %20tradicional.pdf

World Health Organization. = (2000). General guidelines for methodologies on research and evaluation of traditional medi= cine. Available at https://apps.who.int/iris/handle/10665/66783=

World Health Organization. = (2002). Medicina tradicional: necesidades crecientes y = potencial [Traditional medicine: growing needs and potential]. Available at https://apps.who.int/iris/handle/10665/67296

World Health Organization. = (2013). Estrategia de la OMS s= obre medicina tradicional 2014-2023 [WHO strategy on traditional medicine 2014-2023]. Available at www.who.int

World Health Organization. = (2019). Traditional, complementary and integrative medicin= e. Available at https://www.who.int/traditional-complementary-integrative-medicine/about/en= /

Zörgo, S., Purebl, G., & Zana, Á. (2018). A qualitative study of culturally embedd= ed factors in complementary and alternative medicine use. BMC Complementary= and Alternative Medicine, 18(25), 11 pp. https://doi.org/10.1186/s12= 906-018-2093-0