A survey into the utilization of probiotics and medicinal plants among individuals afflicted with gastrointestinal disorders in healthcare institutions in Saïda, Algeria

ABSTRACT

Aim: Functional gastrointestinal (GI) disorders are recognized as a major public health concern worldwide. These disorders involve persistent digestive symptoms indicative of digestive tract dysfunction.

Materials and Methods: A survey examining the utilisation of probiotics and medicinal plants as supplementary treatments was conducted on 160 patients with GI disorders at healthcare institutions in Saïda from March to April 2023 using questionnaires that had been previously adapted and tested for reliability with Cronbach’s alpha test. Raw data collected through the questionnaires were transferred to a database and analysed using SPSS software.

Results: Overall, 49.38% of participants possessed knowledge of or actively utilised probiotics; such awareness was strongly associated with the participants’ educational attainment (p = 0.029). The noteworthy probiotic supplements were Biocharbon (36.09%), Lactocil (15.38%), Smebiocta (13.61%), Ultrabiotic Adult (12.43%), Effidigest (12.43%), and Ultralevure (7.69%). During crisis, individuals tended to consume natural goods rich in probiotics, including yoghurt (13.26%) and fermented milk (8.60%), as well as foods rich in prebiotic fibre, including vegetables (18.99%), fruits (13.26%), wheat (9.67%), bran (7.52%), rye (6.81%), and oat flakes (6.45%). Additionally, 77.56% of patients used medicinal plants during crises, with Mentha spicata (12.2%), Thymus vulgaris (11.3%), Pimpinella anisum (8.5%), Cuminum cyminum (8.0%), Punica granatum (7.8%), Trachyspermum ammi (7.5%), and Senna acutifolia (7.0%) being the more commonly favoured options in phytotherapy. The main focus of these herbs was to alleviate bloating (57%), constipation (30.12%), and diarrhoea (12.87%) (p < 0.001). The most frequently utilised plant parts were leaves (47.30%), seeds (25.21%), and bark (13.21%). Most patients (82.91%) favoured infusion as their preferred consumption method, and approximately 85.43% believed in phytotherapy’s ability to extend symptomatic relief.

Conclusion: The understanding of probiotics is still in its infancy, whereas phytotherapy is more widely accepted by patients. Nonetheless, patients are open to the exploration of natural alternatives to conventional medicines.

KEYWORDS:

• Survey
• probiotics
• prebiotics
• medicinal plants
• gastrointestinal disorders
• patients
• Saïda

1. Introduction

The gut microbiota is increasingly considered a symbiotic partner and an additional organ that contributes to the proper physiological functioning of the body [1]. Dysbiosis, defined as an imbalance in the population of gut microbiota, has important functional consequences and has been implicated in numerous digestive pathologies (e.g. chronic inflammatory bowel disease, colorectal cancer), obesity, and autism [2].

Gastrointestinal (GI) diseases are common globally, and most populations use medicinal plants possessing several metabolites with active principles as the first-line treatment for relieving or preventing various digestive/GI disorders. However, observations have led to the emergence of numerous studies on treatments aimed at restoring the balance of intestinal microbiota through probiotic or faecal microbiota transplantation [2].

Medicinal plants with therapeutic properties have been used for thousands of years, and advancements in scientific knowledge and technology have enabled a better control of the plants’ doses and therapeutic effects [3]. Ethnopharmacological knowledge may be beneficial for the discovery and development of novel, safe, and affordable medicines [4]. Recently, considerable attention has been paid to pharmacognostic, phytochemical, and pharmacological studies investigating traditional medicinal plants. Moreover, many preclinical and clinical studies have evaluated the potential biological activities of natural medicines and have demonstrated the diverse biological effects of a wide range of plant-derived compounds in various classes of chemical groups. These active compounds are currently used for ethnomedical purposes. Consequently, several pharmaceutical companies have recently renewed their strategies in natural product research to discover potential sources and new molecules for drug development.

Since the beginning of the 21st century, scientific interest in probiotics has substantially increased, partly because of recent knowledge about the gut microbiota and its role in health and disease and also because of the growth in probiotic consumption and sales [5]. Currently, probiotics are available as functional foods, dietary supplements, and medicines. Commercial products come in a wide variety and in different presentations (capsules, tablets, envelopes, bottles, foods, dietary supplements, milk formulas, etc.) with varying doses and microbial compositions, thereby making the selection of probiotics difficult in clinical practice [6].

The combination of these two natural remedies (namely, probiotics and medicinal plants) could dethrone conventional treatments by virtue of their efficacy and absence of side effects, leading to promising therapeutic prospects. In this context, we conducted a survey on 160 patients who were interviewed during gastroenterology consultations from March to April 2023 in the gastroenterology departments of healthcare institutions in Saïda (Ahmed Medaghri Hospital and some local public health facilities), with the aim of examining patients’ knowledge regarding the use of probiotics and medicinal plants as treatment for GI disorders while exploring their perceptions of these natural remedies.

2. Materials and methods

2.1. Survey locations

The wilaya of Saïda, renowned for its abundance of springs, is situated in the northwest region of Algeria, specifically at coordinates 34° 50′ 00″ north, 0° 09′ 00″ E. It is located in the southern foothills of the Atlas mountain range at the northern boundary of the southern Oranais plateaus [7].

The municipality of Saïda is situated in the central part of the Saïda Province, approximately 164 km southeast of Oran and 461 km west of Algiers. The region is adjacent to the wilaya of Mascara in the north, the wilaya of El-Bayadh in the south, the wilaya of Sidi-Bel-Abbès in the west, and the wilaya of Tiaret in the east. The administrative division of Saïda comprises 16 municipalities across six districts [7]. Saïda covers an area of 74.7 km² and is regarded as an important metropolitan hub that serves as the capital of the wilaya, daïra, and commune. The city has a population of approximately 139,377 and population density of 1,864 persons per square kilometre [8]. The northern boundary of the area is defined by the Ouled Khaled commune, whereas the eastern boundary is marked by the El Hassasna commune. It is bordered by the Doui Thabet commune in the west and is adjacent to the Ain El Hadjar commune in the south (Figure 1).

Figure 1. Map showing the geographical location of the wilaya of Saïda.

2.2. Study progression

The survey was conducted on 160 patients with intestinal disorders (89 women and 71 men) of different ages using a questionnaire (Appendix), which was administered at Ahmed Medaghri Hospital and some local public health facilities from 19 March to 24 April 2023. The questionnaire was divided into two sections: (i) the first section focused on the participants’ knowledge and use of probiotics, as well as the nature of their daily diet, whereas (ii) the second section sought to ascertain whether the participants used medicinal plants to improve their intestinal comfort and to determine the method and frequency of medicinal plant use as natural remedy. The reliability and validity of this questionnaire were confirmed using Cronbach’s alpha coefficient [9]; we obtained a score of 0.727 for 53 items.

Throughout the study, the anonymity and confidentiality of the participants were preserved, and the respondents were informed that they were free to participate (or not participate) in this study after obtaining their oral consent. This study strictly adhered to ethical standards and ensured voluntary participation based on an informed understanding among the respondents. We also intend to keep all participants informed of the data analysis results and progress of our research, if they express interest.

2.3. Data analysis

Raw data collected through the questionnaires were transferred to a database and analysed using SPSS software version 27 (IBM Corp., Armonk, NY, USA). Comparative tests were performed using Pearson’s chi-squared test, with the link significance threshold set at 5%. The strength of the relationship between two variables was determined using the correlation coefficient (r). The significance of the relationship and the goodness-of-fit of the model were measured using the p-value.

The importance of a plant for a given group was evaluated using the usage value (UV), which refers to the use of a species. The UV was calculated as follows:

$\mathit{UV}=\sum _{\mathit{I}=1}^{\mathit{In}}{U}_i/\mathit{n}$

where Ui denotes the number of uses mentioned by informant i and n refers to the total number of informants interviewed.

3. Results

3.1. Characteristics of informants

3.1.1. Sex and age

The study population comprised 89 women (55.6%) and 71 men (44.4%), with a female-to-male sex ratio of 1.25. The survey population had an average age of 40 years (range: 14–83 years), and 26.3% (n = 42) were in the 41–50-year age bracket (Table 1).

Table 1. Demographic data of informants.

Variable	Category	Frequency (n = 160)	Pourcentage (%)
Gender	Male Female	71 89	44.4% 55.6%
Patient age (Years)	≤20 21–30 31–40 41–50 51–60 ≥ 61	15 35 34 42 17 17	9.4% 21.9% 21.3% 26.3% 10.6% 10.6%
Patient education level	Illiterate Primary middle Secondary university Ullage	26 8 0 43 72 11	16.3% 5.0% 00% 26.9% 45.0% 6.9%
Patient symptom profile
Digestive disorders	Bloating Constipation Diarrhea	98 62 29	51.9% 32.8% 15.3%
Behavior adopted in the face of the disorder	Consulted a doctor Buy treatment Treat yourself with traditional remedies	56 75 62	29.0% 38.9% 32.1%
Efficiency of conventional treatment	Efficient Inefficient Ullage	139 18 3	86.9% 11.3% 1.8%
Effect of conventional treatment	Immediate effect late effect temporary effect Ullage	42 69 37 12	26.3% 43.1% 23.1% 7.5%

3.1.2. Education level

The education level was diverse among patients, with 16.3% never having attended school, 5.0% having interrupted their studies in primary school, 26.9% having stopped their studies in high school or being still in school, and 45% having achieved university level. However, during the study period, none of the patients had a middle education level (Table 1).

3.1.3. Digestive disorders

Bloating, constipation, and abundant diarrhoea were reported in 51.9%, 32.8%, and 15.34% of patients, respectively (Table 1).

3.1.4. Behaviour adopted in the face of GI disorders

The behaviour observed among patients in the event of intestinal problems varied. In particular, 29% chose to consult a doctor, 38.9% opted to buy medicines from a pharmacist, and 32.1% preferred to treat themselves with traditional remedies (Table 1).

3.1.5. Efficiency and effect of conventional treatment

Conventional therapy was perceived by 88.54% of patients to be temporarily effective. The effect of the treatment was reportedly immediate in 26.3% of patients but delayed in 43.1% of patients. Additionally, 23.1% of patients reported temporary relief only (Table 1).

3.2. Probiotic axis

3.2.1. Correlation between knowledge of probiotics and education level

Among the respondents, those who never attended school (5%), who stopped their studies in primary school (1.25%), or reached secondary school (11.88%) had knowledge of probiotics. No patient was enrolled and/or interrupted in college. Those in academics (29.86%) showed more knowledge about probiotics (Figure 2).

Figure 2. Correlation between knowledge of probiotics and education level.

In this study, the majority of respondents (49.38%) were in academics. The relatively high level of knowledge regarding probiotics in these respondents was directly significantly correlated with their education level (p=0.029). This was attributable to an awareness of a major interest in this natural alternative and to the knowledge acquired at this level of instruction.

3.2.2. Knowledge and use of probiotic supplements

Out of the patients interviewed, 36.09%, 15.38%, 13.61%, 12.43%, and 12.43% knew about and/or used Biocharbon, Lactocil, Smebiocta, Ultrabiotic Adult, and Effidigest, respectively. Furthermore, 7.69% of patients had knowledge and/or used ultralight drugs, whereas only 1.18% of patients knew about and/or used Ultrabiotic Infantile and Enterogermina (Figure 3).

Figure 3. Knowledge and/or use of probiotic supplements.

3.2.3. Evaluation of probiotic supplement use according to digestive disorders

Patients in the midst of an aerocholia crisis were accustomed to consuming probiotic supplements available on the Algerian market, such as Biocharbon (34.28%), Lactocil (15.23%), Ultrabiotic Adult (14.28%), Effidigest (13.33%), Smebiocta (11.42%), Ultralevure (7.61%), Enterogermina (1.9%), and Ultrabiotic Infantile (1.9%). When constipated, patients reported using Biocharbon (44.11%), Lactocil (26.47%), Effidigest (10.29%), Ultralevure (7.35%), Ultrabiotic Adult (7.35%), Smebiocta (2.94%), and Enterogermina (1.47%) (Figure 4). When suffering from gastroenteritis, patients tended to take mainly Smebiocta (31.7%), followed by Biocharbon (29.26%), Ultrabiotic Adult (14.63%), Effidigest (12.19%), Ultralevure (7.31%), and Lactocil/Ultrabiotic Infantile (2.43%). Pearson’s chi-squared test for relative importance values indicated statistically significant differences between the probiotic supplements used for GI disorders (p < 0.001).

Figure 4. Evaluation of the use of probiotic supplements according to digestive disorders.

3.2.4. Evaluation of diet according to the frequency of consumption

Patients in the midst of crisis tended to consume natural products rich in probiotics, such as yoghurt (13.26%) and fermented milk (8.60%). The same applied to the consumption of potentially fibre-rich prebiotic products, such as vegetables (18.99%), fruits (13.26%), wheat (9.67%), rye (7.52%), barley (6.81%), and oatmeal (6.45%). Pearson’s chi-squared test for relative importance values indicated significant differences between attributes of prebiotic/probiotic use by patients (p = 0.029) (Figure 5).

Figure 5. Evaluation of the diet according to the frequency of consumption.

3.2.5. Preference between fermented natural products and industrial food supplements

The results of patient survey revealed that 79.13% of patients preferred fermented natural products, whereas 19.13% preferred industrial dietary supplements. Only 1.74% of surveyed patients expressed that they preferred the combination of both (Figure 6).

Figure 6. Distribution of the number of patients according to the preference between fermented natural products and industrial food supplements.

3.3. Medicinal plant axis

3.3.1. Distribution of medicinal plant use according to digestive disorders

Medicinal plants belonging to the Apiaceae and Lamiaceae families (31.2% and 29.4%, respectively) were the most frequently utilised plants in herbal therapies for treating functional digestive disorders (Table 2). These plants were primarily used to relieve symptoms of bloating (57%), constipation (30.12%), and diarrhoea (12.87%). These digestive disorders showed a significant correlation with the use of these herbs to relieve symptoms (p < 0.001) (Figure 7).

Figure 7. Distribution of medicinal plant use according to digestive disorders.

Table 2. Plants used by patients as a remedy for gastrointestinal disorder.

Vernacular name	Scientific name	Family	Citation count	Citation frequency (%)	UV Value
Mint	Mentha spicata	Lamiaceae	70	12,2%	0.55
Thym	Thymus vulgaris	Lamiaceae	65	11,3%	0.53
Anis	Pimpinella Anisum L	Apiaceae	49	8,5%	0.38
Cumin	Cuminum cyminum L	Apiaceae	46	8,0%	0.35
Pomegranate crusts	Punica granatum L.	Punicaceae	45	7,8%	0.35
Ajowan seed	Tachyspermum ammi	Apiaceae	43	7,5%	0.31
Sana Makia	Senna acutifolia L	Fabaceae	40	7,0%	0.3
Artemisia	Artemisia herba alba	Astéraceae	33	5,7%	0.21
Cinnamon	Cinnamomum verum	Lamiaceae	29	5,0%	0.22
Linen seed	Linum usitatissimum	Linaceae	27	4,7%	0.2
Juniperus	Cupressus sempervirens	Cupressaceae	24	4,2%	0.18
Fennel seed	Foeniculum vulgare	Apiaceae	24	4,2%	0.18
Turmeric	Curcuma longa	Zingiberaceae	24	4,2%	0.16
Camomile	Anthemis arvensis	Astéraceae	23	4,0%	0.19
Parsley	Petroselinum crispum	Apiaceae	17	3,0%	0.13
Liquorice	Glycyrrhiza foetida	Fabaceae	11	1,9%	0.08
Great basil	Ocimum basilicum	Lamiaceae	5	0,9%	0.03
Total	15	08	575	100,0%	/

3.3.2. Parts of plants used

The surveyed patients used various plant parts to treat different GI disorders, with the leaves being the most commonly used part (47.30%), followed by the grains (25.22%). Other parts such as shells (13.22%), roots (6.09%), flowers (4.17%), and peeled leaves (4%) were also utilised (Figure 8).

Figure 8. Parts of plants used.

3.3.3. Preparation method

Overall, 82.91% of the interviewed patients opted for herbal infusions, 11.39% preferred to use the medicinal plants in powder form, and only 5.70% used them as decoctions. Statistical analysis revealed a significant correlation between the dose and mode variables (p < 0.001) (Figure 9).

Figure 9. Distribution of the number of patients according to the mode of plant use and daily dose.

3.3.4. Relationship between natural remedies and lull phases

In the calm phase, only 0.65% of patients continued taking the probiotics, whereas 98.06% preferred daily intake of teas, especially peppermint. Furthermore, 0.29% of patients confirmed that they did not stop using both remedies during this phase (Figure 10).

Figure 10. Assessment of the relationship between prolongation of the calm phase and intake of natural remedies.

When patients were asked about the effect of remedies on the prolongation of the calm phase, 85.43% of patients expressed their belief that the medicines could effectively prolong the calm phase. Additionally, they believed that these remedies could play a beneficial role in maintaining remission. In contrast, 14.57% did not report a link between the intake of these drugs and the prolongation of the calm phase, questioning the ability of remedies to influence this period. This suggests that the respondents were aware of the effectiveness of natural remedies in prolonging the calm phase.

4. Discussion

Probiotics have surged in popularity over recent years and are categorised as medications, nutritional supplements, and medical devices. Probiotic strains fulfil particular requirements established by the World Health Organization in 2002, which include the ability of strains to withstand ingestion, confer clinical benefits, and not cause any negative effects. Research focusing on probiotics has considerably increased in the scientific community, particularly studies investigating the advantages, efficacy, therapeutic improvement, and prescription of prospective probiotic strains. As a natural option, probiotics are globally acknowledged and stand out from conventional treatments owing to their exceptional efficacy and lack of unwanted effects. In Algeria, studies on probiotics, with a specific emphasis on isolating, identifying, and improving native strains, are limited. Furthermore, concrete data on prescriptions and awareness among medical personnel and patients regarding this remarkable therapeutic resource are utterly absent, primarily because of a lack of awareness.

In this study, the majority of respondents (49.38%) were in academics. The relatively high level of knowledge regarding probiotics in these respondents was directly significantly correlated with their education level (p=0.029). This was attributable to an awareness of a major interest in this natural alternative and to the knowledge acquired at this level of instruction.

In the United States, Betz et al. [10] discovered that 43% of individuals were familiar with the phrase ‘probiotic’ and observed that individuals with a higher education level were more likely to be aware of the term ‘probiotic’ (p < 0.000) than those with a lower education level. Younger patients (p = 0.011) and those with a higher education level (p = 0.001) demonstrated a greater likelihood of familiarity with probiotics than older individuals or those with a lower education level. A study conducted in Australia revealed that 58.9% of participants were acquainted with and utilised probiotics. These consumers were primarily women, younger, and more educated (p<0.05) and exhibited greater awareness of intestinal health and healthier general behaviours such as fruit consumption and physical activity [11]. According to a separate study conducted in India, 91.6% of individuals were familiar with probiotics, and 39.41% of university students were knowledgeable about the availability of probiotic products owing to promotion and marketing efforts [12]. Nevertheless, a study conducted in Saudi Arabia indicated a significant lack of awareness of probiotics. Merely 26% of participants were aware of probiotics, and their primary source of information was social networks. Participants who had obtained a university degree showed a higher level of understanding of probiotics, with 70% of them having considerable knowledge (p = 0.015) [13].

The findings of our study align with those of previous studies on the understanding of this therapeutic alternative among those with high education level. The prevalence of probiotics in a country is determined by its geographical location and the level of public health awareness within its culture. Algeria suffers from a notable lack of knowledge regarding the comprehension and application of probiotics, particularly in comparison to more developed nations in the realm of healthcare and preventative medicine. The limited accessibility and availability of probiotics in pharmacies and stores, potentially higher costs, inadequate information campaigns promoting the health benefits of probiotics, traditional food practices that do not prioritise fermented foods (which are a natural source of probiotics), greater preference among patients for traditional or herbal remedies rather than industrial dietary supplements, and a medical approach that primarily involves gastroenterologists within the municipality, indicating a limited understanding of probiotics at the local level, are all factors contributing to this situation.

Based on our interactions with patients, we determined that the probiotic supplements Biocharbon and Lactocil were becoming increasingly popular in Algeria (36.09% and 15.38%, respectively), primarily because of their lower cost than other products in the market. Additionally, extensive advertising of probiotics over recent years has emphasised the various health benefits associated with their consumption. An important consequence of this advertising is the heightened prominence of probiotics in the media and their collective consciousness. Various forms of advertising, including TV commercials, print advertisements, social media promotions, and Internet campaigns, have effectively emphasised the potential advantages of probiotics, particularly in relation to digestive and immune well-being. Nevertheless, Ultrabiotic and Smebiocta are commonly prescribed by gastroenterologists, making them more frequently utilised. This underscores the substantial effect of health professionals’ recommendations on patient preferences and decisions regarding dietary supplements. Dietary supplements contain probiotic strains, specifically Lactobacillus plantarum. Other present microorganisms included Acidophilus, Bifidobacterium lactis, and B. shorti. The medicine Ultralevure contains the yeast Saccharomyces boulardii CNCM I-745. Multiple investigations in 2020, including the research conducted by Kaźmierczak et al. [14], have confirmed the beneficial impact of L. plantarum 299v consumption on the microorganisms present in the intestines and have also provided a comprehensive overview of the role played by L. plantarum 299v in the treatment of specific disorders, including cancer, irritable bowel syndrome, and Clostridium difficile infections. The efficacy of S. boulardii CNCM I-745, which releases multiple digestion enzymes, including the highly efficient sucrase, has been demonstrated in several studies. Saccharomyces cerevisiae activates intestinal enzymes, transporters, and other yeast enzymes. S. boulardii CNCM I-745 enhances the activity of digestive enzymes and the digestion and absorption of nutrients [15]. Indeed, bifidobacteria and lactobacilli are the most advantageous species, as they promote the stimulation of intestinal peristalsis, enhance the wetness of faecal matter, and contribute to a higher generation of Short-Chain Fatty Acids (which influences the movement of the gut) [16]. Moreover, a recent study has demonstrated that Bifidobacterium breve produces significant quantities of extracellular polysaccharides and effectively treats dextran sulphate sodium-induced colitis by reducing the oxidative stress in the colon [17].

In our study, the results of evaluation regarding probiotic supplement use according to digestive disorders indicated that patients in the midst of an aerobic crisis and period of constipation were accustomed to consuming probiotic supplements available in the Algerian market, principally Biocharbon (34.28% and 44.11%, respectively) and Lactocil (15.23% and 26.47%, respectively). Patients with gastroenteritis tended to take mainly Smebiocta (31.7%), followed by Biocharbon (29.26%) and Ultrabiotic Adult (14.63%). Pearson’s chi-squared test for relative importance values indicated statistically significant differences between the probiotic supplements used for GI disorders (p < 0.001).

Mouhib demonstrated that a majority (74%) of patients perceive enhancing intestinal transit issues as a favourable outcome of probiotics. Additionally, the reduction in antibiotic-induced diarrhoea and the enhancement of vaginal flora were also regarded as advantages, with proportions of 34% and 22%, respectively. Probiotics are mostly associated with a 66% improvement in digestive comfort, with fewer effects on enhancing the immune system (36%) and lowering oedema (35%) [18]. According to a recent survey of general practitioners, probiotics are the most frequently recommended treatments for transit issues. Of the doctors surveyed, 61.3% prescription probiotics for abdominal pain. Additionally, 76.6% of these physicians recommended probiotics for transit problems, with 75.2% specifically suggesting probiotics for diarrhoea and 56.2% for constipation. Nevertheless, when it comes to abdominal bloating, 68.6% of respondents stated that they prescribed it [19]. Further studies revealed that all the surveyed pharmacists endorsed the use of probiotics to varying degrees. These products are primarily used to prevent digestive disorders. Specifically, they are used in (85.7%) of cases to prevent diarrhoea associated with antibiotic therapy, (80.9%) to prevent traveler’s diarrhoea, and (76.2%) to improve other GI diseases such as constipation, bloating, and flatulence [20].

In our study, the results of evaluation regarding diet according to the frequency of consumption showed that patients in the midst of crises tended to consume natural products rich in probiotics, such as yoghurt (13.26%) and fermented milk (8.60%). The same applied to the consumption of potentially fibre-rich prebiotic products, such as vegetables (18.99%), fruits (13.26%), and wheat (9.67%). Pearson’s chi-squared test for relative importance values indicated significant differences between attributes of prebiotic/probiotic use by patients (p = 0.029).

In a 2007 survey conducted on a sample of individuals, it was discovered that 37% of the participants used probiotics with the intention of enhancing their immunological health, whereas 41% used probiotics to improve their digestive health [21]. In 2015, a separate study revealed that 41% of patients admitted to hospitals utilised probiotics for the purpose of restoring their digestive system, whereas 11% used them to sustain their immunological health. The survey revealed that a mere 18% of patients were utilising prebiotics for the purpose of enhancing digestion, whereas a larger proportion of 36% were employed probiotics to restore the overall health of their gut [10]. Moreover, a Canadian study revealed that yoghurt was the predominant method of delivering probiotics, as corroborated in 2015 by Betz et al., which the majority (66%) of probiotic products consumed were in the form of yoghurt. These results were consistent with our previous findings [10,22]. Furthermore, a study conducted by Xiao et al. in patients with chronic diarrhoea indicated the efficacy of Lactobacillus acidophilus in yoghurt. This revealed a reduction in abdominal pain, stool frequency, and distension. L. acidophilus will be able to act visceral sensitivity by increasing the opioid and cannabinoid receptors in the intestinal mucosa [23–25]. However, Hadjimbei et al. demonstrated that the lactic ferments S. Thermophilus and Lactobacillus bulgaricus are types of probiotics that enhance the functioning of the intestines, reduce the intensity of infectious diarrhoea, have a positive impact on diarrhoea after antibiotic treatment, and improve the elimination of Helicobacter pylori by 5 to 15% [26,27]. Based on a recent evaluation conducted by So et al. [28] and the International Scientific Association for Probiotics and Prebiotics Consensus [29], fibres can be categorised as follows:

• Accepted prebiotic fibres are those with extensive scientific evidence supporting their potential to selectively modify microbial groups, resulting in benefits for the host. The category consists of β-fructans (inulin and FOS), galactans (GOS), lactulose, and breast milk oligosaccharides (HMO).

• Prebiotic candidate fibres, such as arabinoxylans (AXOS), xylo-oligosaccharides (XOS), and resistant starches, have a high potential for prebiotic effects.

• Food fibres include substances such as maltodextrins, refinoses, hemicellulose, cellulose, and pectin.

Randomised research has demonstrated that the advantages of fibre consumption are associated with the ability of fibre to regulate helpful bacteria and decrease the presence of bad bacteria. Regarding acknowledged prebiotic fibres, studies involving fructans have demonstrated a higher abundance of Bifidobacterium taxon in comparison with the control group [30, 31–35]. Furthermore, consumption of small amounts of agave inulin leads to significant changes in the composition of the intestinal microbiota, including an increase in the levels of various species such as Bifidobacterium adolescentis [31], B. breve, Bifidobacterium longum, and Bifidobacterium pseudolongum. Similar effects were also observed after consuming chicory inulin, specifically in the species Bifidobacterium faecale/B. adolescentis, B. longum/B. breve, Bifidobacterium catenulatum/pseudocatenulatum/kashiwanohense, and Bifidobacterium bifidum [36]. The increase in bifidobacteria can have an indirect impact on other bacterial groups, such as butyrate-producing bacteria, through bacterial cross-feeding processes. These mechanisms play crucial roles in the intricate environment of the GI tract [37,38]. During the quiet phase, patients may disregard the importance of consuming a diet abundant in probiotics, which is likely to facilitate disease recurrence.

Despite the growing popularity of probiotics, patients remained sceptical about choosing industrial probiotic supplements over naturally fermented foods. Approximately 79.13% of patients preferred natural fermented products, whereas 19.13% opted for industrial food supplements because of their mistrust in pharmaceutical companies and doubts about their ability to market fully compliant products.

An Australian study revealed that 55.5% of those who used probiotics expressed a preference for natural food sources over probiotics and prebiotics, whereas only 16.3% favoured industrial supplements and 28.2% had no specific choice. In addition, 59.5% of probiotic users did not have any concerns regarding the ongoing use of probiotics. Nevertheless, 21.7% of them identified the cost as a hindrance to their ongoing use [11]. In 2018, a study found that nearly 50% of healthcare professionals preferred food over probiotic drugs. This is because food contains various components such as vitamins, minerals, and fibres that work together with probiotics to enhance digestive health. Additionally, foods help maintain the stability of consumed probiotics [39].

Numerous global ethnopharmacological and ethnobotanical investigations have been conducted to compile a catalogue of medicinal plants and ascertain their therapeutic applications within the context of diverse traditional pharmacopoeias. Algeria, with its abundant cultural diversity influenced by its history, and biodiversity influenced by its geographical location and climate, has cultivated extensive traditional expertise in herbal therapy and the management of chronic illnesses. The significance of traditional medicine within the Algerian health system is underscored by the frequency with which the population utilises this knowledge, as evidenced by many sources [40,41]. The following text contains comprehensive data regarding the Apiaceae (31.2%) and Lamiaceae (29.4%) families, which are frequently used by individuals to alleviate stomach discomfort. These plants have eupeptic, spasmolytic, antiseptic, and carminative properties, making them suitable for relieving disorders such as dyspepsia, aerophagia, meteorism, functional colopathy, gastritis, gastroesophageal reflux, and infantile colic [42]. The survey revealed that the use of traditional herbal therapies was still prevalent and in high demand among residents of the municipality of Saïda. These plants were primarily used to relieve symptoms of bloating (57%), constipation (30.12%), and diarrhoea (12.87%). These digestive disorders showed a significant correlation with the use of these herbs to relieve symptoms (p<0.001). These results are consistent with the findings of previous studies from other parts of Algeria [43–47] and numerous nations worldwide [48–54], highlighting the significance of medicinal plants as a means of providing medical treatment.

In this study, the leaves (47.30%) were the most commonly used plant part among patients. Surveys conducted in Algeria showed that the use of leaves for medicinal purposes is prevalent. In the Tebessa region of eastern Algiers, leaves account for 58.09% of medicinal applications, followed by fruit crusts at 16.19%, and seeds at 12.85% [43]; Similarly, in Adrar, located in southwestern Algeria, leaves are also the most commonly used part of the plant, accounting for 60.37% of medicinal applications [46]. Multiple studies across different global locations have consistently identified a common pattern in the utilisation of plant leaves for therapeutic applications. In Niger, 35% of the foliage is utilised and 22% of it being composed of bark [50]. In Morocco, leaves are favoured at a rate of 42% [55]. In China and Thailand, leaves account for 54% of their use [56]. Similarly, in Togo, they were used at a rate of 55.88%, whereas in Niger they reached 47.8% [48,57]. In Ethiopia, leaves are used at 44% and roots at 29% [58]. In Iran, they were preferred by 22% [59], whereas in Izmir, Turkey, their use was 36% [53,60]. In the western Anatolia region, leaves were predominant at 26%, results consistent with those of Griday et al. [61]. The prevalence of leaf usage is attributed to its primary function as the primary site of photosynthesis in plants, making it a key component of the natural pharmacopoeia for synthesising numerous active compounds, particularly those with potent pharmacological effects against specific conditions [62,63]. Furthermore, plant leaves frequently contain abundant active substances such as polyphenols, flavonoids, and essential oils, which are likely to exert beneficial effects on well-being. These chemicals can mitigate GI diseases such as inflammation by enhancing digestion and calming the stomach [64].

The findings suggest that infusion at 82.91% was the predominant mode of usage, which is consistent with the findings of prior studies [43,44,50,51]. Statistical analysis revealed a significant correlation between the dose and mode variables (p<0.001). Out of the patients interviewed, only 0.63% used little spoons, 9.49% used large spoons, and 19.62% used small cups; the majority (70.25%) used large cups. This difference is related to the plant type. These data imply that the active chemicals in leaves can be removed and absorbed more efficiently when steeped in hot water, leading to improved digestion in the digestive system. This phenomenon occurs because of the enhanced solubility of specific chemicals in hot water, which enables their extraction and absorption to occur more effectively [65,66].

In conclusion, our survey of 160 patients with GI disorders at public health facilities in Saïda revealed that Biocharbon (36.09%) was the most widely used probiotic supplement, followed by Lactocil (15.38%) and Smebiocta (13.61%), and that medicinal plants from the Apiaceae and Lamiaceae families (31.2% and 29.4%, respectively) were the most widely used. Medicinal plants were used to relieve bloating (57%), constipation (30.12%), and diarrhoea (12.87%). Leaves were the most commonly used plant part (47.30%), and infusion was the most frequently employed mode of usage (82.91%). Overall, the knowledge of probiotics is still in its infancy, and their use is limited. Potential opportunities include (i) testing medicinal plants in vitro and in vivo using animal models to evaluate their therapeutic capabilities; (ii) clinical research on the synergies between bioactive compounds derived from medicinal plants and probiotic strains for therapeutic and preventive applications; and (iii) marketing Algerian probiotic strains to reduce costs and emphasise their effectiveness, as compared to that of major pharmaceutical strains.

Authors’ contributions

All authors contributed to the study conception and design. LAT, YB, SA analyzed, and interpretation of the data. LAT wrote the first draft of the manuscript. KH reviewed and revised the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The participants were given the choice to decline or to proceed to answer the survey questions and completion of the survey indicated informed consent.

Acknowledgments

The authors would like to thank Pr. T. Sitayeb and Dr. A. Kefifa for her valuable help in statistical analysis. We would also like to thank A. Saci and ZA. Mohammed-Chikouche for their contributions to the execution of the survey.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Appendix :

Patient questionnaire

I. Basic information

1. The age of the patient

2. The sexe of the patient

3. Intellectual level of the patient

II. Patient’s symptom profile questionnaire

• (1) Do you occasionally or regularly suffer from intestinal disorders/discomfort?

  1. Yes

  2. No

• (2) What kind of trouble ?

  1. Bloting

  2. Constipation

  3. Diarrhea

• (3) What attitude do you take to these disorders?

  1. Consult a doctor

  2. Buy in treatment from a pharmacist

  3. Treat with traditional remedies

• (4) Do you know probiotics?

  1. Yes

  2. No

• (5) Among the following dietary supplements/probiotic drugs, which do you buy or know?

  1. Ultra-Levure

  2. Adult Ultrabiotics

  3. Infant Ultrabiotics

  4. Smebiocta

  5. Effidigest

  6. Entrogermina

  7. Lactocil

  8. Biocharbon

  • (6) What is the nature of your diet?

  • (6.1) Made from milk products:

  1. Fermented milk

  2. Raw milk

  3. Yoghurt

  4. Cheese (camembert, gruyère…)

  • (6.2) Made from fibre-rich products:

    1. Vegetables (Lettuce, cabbage, etc.)

    2. Fruit

  • (6.3) From cereals:

    1. Wheat

    2. Rye

    3. Barley

    4. Oatmeal

• (7) How often do you take them?

  1. Daily

  2. During the troubles

  3. After the trouble

• (8) In cases where you have tested one or both, what do you prefer?

  1. Fermented natural products

  2. Industrial food supplement

  • (9) which plants do you use to relieve your disorders?

  • (9.1) Name of plant: __________

  • (9.2) Part used: ______________

  • (9.3) How to use it: ___________

  • (9.4) Dose used: _____________

  • (9.5) Use frequency: __________

  • (10) Do you continue to take these natural remedies when you’re feeling better?

  1. Phytotherapy

  2. Probiotic

  • (11) If so, do these remedies prolong the lull phase?

    1. Yes

    2. No