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Singapore Med J 2011; 52(4) : 252
Original Article
School of Medical
Sciences,
Universiti Sains
Malaysia,
Kubang Kerian
16150,
Malaysia
Chew KS, MD,
MMed
Senior Lecturer
Tan TW
Medical Student
Ooi YT
Medical Student
Correspondence to:
Dr Chew Keng-
Sheng
Tel: (60) 19986 9520
Fax: (60) 9765 9630
Email: cksheng74@
yahoo.com
Influence of Chinese cultural health
beliefs among Malaysian Chinese in a
suburban population: a survey
Chew K S, Tan T W, Ooi Y T
ABSTRACT
Introduction: In a multiethnic nation, it is not
uncommon for doctors to encounter patients of
different cultural backgrounds. Often, patients’
cultural beliefs influence their perception of
health and illnesses, and their treatment option.
Many Chi nese cultura l beliefs are infl uenced by the
Taoist concept of yin-yang balance.
Methods: We interviewed 50 Malaysian Chinese
from the general public of a suburban population
in order to unravel the impact of Chinese cultural
health beliefs on their decision-making, and this
was compared with the opinions of 50 Chinese
medical students from second to final year.
Convenience sampling was then applied.
Results: From the sur vey, 78 percent of t he general
public believed that ‘too much heat’ or ‘too
much coldness’ in the body could cause diseases.
Compared to the medica l students, a significantly
higher number of the respondents held such
belief s, including th e beliefs that a bdominal colic is
due to exces sive ‘wind’ in t he abdomen , consuming
certain food can dispel wind from the body, and
the importance of observing taboos during the
confinement period after delivery. The majority
of respondents from both groups believed that it
is acceptable to comb ine both traditional Chinese
medicine and modern medicine.
Conclusion: There is a discrepancy in the extent
to which these beliefs influence the perception of
health and illnesses among the general public and
among medical students. Healthcare providers
need to be aware of such beliefs and practices
regarding traditional Chinese medicine among
their Chinese patients.
Keywords : cultura l background , Malaysia , modern
medicine, traditional Chinese medicine
Singapore Med J 2011; 52(4): 252-256
INTRODUCTION
Malaysia is a multiethnic, multicultural and multilingual
society with a population of about 28.3 million people
(as of July 2009).(1) The majority of its population in
2004 consisted of Malays (50.4%), Chinese (23.7%),
indigenous groups (11%), Indians (7.1%) and other races
(7.8%).(2) Each ethnic group in Malaysia is rich in its own
culture and traditions.
Culture,denedasanintegratedsharedpatternof
learned convictions and behaviours,(3) has permeated
and inuenced health-seeking decisions among the
various Malaysian ethnic groups. With such diverse
ethnicities, Malaysians’ perception of health and
illnesses, healthcare expectations as well as treatment
choices are often heavily coloured by their cultural
beliefs and practices.(3-6) It is not uncommon for
physicians to encounter patients from different cultural
backgrounds, be it in the emergency department,
outpatient clinics or wards.(3) Within their local practice
context,doctorsshouldpossessknowledgeofsomeof
theseculturalbeliefs thatmayinuencetheirpatients’
decisions. Furthermore, many traditional medications
have side effects that may be compounded by potential
Table I. Demographic data of the respondents.
Demographic No. (%)
General public Medical students
(n = 50) (n = 50)
Mean age ± SD (yrs) 43.7 ± 17.7 22.0 ± 1.1
Gender
Male 22 (44) 22 (44)
Female 28 (56) 28 (56)
Religion
Buddhism 25 (50) 36 (72)
Taoism 25 (50) 0
Christianity 0 14 (28)
Occupation
Medical students 50 (100)
Self-employed 5 (10)
Employee 9 (18)
Retiree 2 (4)
School students 10 (20)
Housewife 22 (44)
Others 2 (4)
SD: standard deviation
Singapore Med J 2011; 52(4) : 253
drug interactions when the patient uses both traditional
and modern medicine together.(7) Although cultural
inuence on health and the practice of traditional
medicine are not one and the same entity, they are
intrinsicallylinked.
Traditional Chinese medicine (TCM) views the
body,soul andspirit as anintegrated whole withwell-
balanced yin-yang forces, and considers man and his
environmenttobelinkedasoneentity.(3,7) Yin and yang
is a dialectical Taoist concept that is deeply embedded
in the Chinese culture. According to this philosophy, the
yin and yang are complementary opposite forces that
are interconnected and interdependent.(3) Everything
has both the yin and yang aspects, and together with
the ‘qi’ energy, these complementary forces control
the multifaceted relationship between humans and
their surroundings.(3) Within the health context, an
imbalance in these two forces or in the ‘qi’ results in
illnesses.(7) Many patients who use TCM, therefore,
believe that modern medicine is not holistic enough, as
it disregards the interaction between the individual and
his environment.(7)
Many commonly held Chinese cultural health
beliefs among Malaysian Chinese have been elucidated
in length in a previous article by Ariff and Beng in
2006,(3) but the extent to which these beliefs affect the
attitude and behaviour of Chinese patients has not been
well studied. Therefore, we formulated a set of questions
based on some of the beliefs mentioned in the previous
study(3) so as to evaluate the extent to which common
cultural Chinese beliefs inuence the perception of
health and illnesses among the Chinese residing in
Senai,atransittownsituated25 kmnorthwestof Johor
Bahru, Malaysia.(8)
METHODS
This was a cross-sectional voluntary interview study
conducted over a period of two months starting from
June 2009. Convenience sampling was applied. The
participants were briefed on the purpose of the study,
i.e. to determine the extent to which cultural beliefs
inuencetheirperception, andnot toproveor disprove
the accuracy of these beliefs from a scientic point of
view.We randomly interviewed adult residents aged ≥
18 years in housing areas around Senai town using a
bilingual (English and Chinese) questionnaire (Appendix
1). Categorical data analysis was conducted using the
Statistical Package for the Social Sciences version
12.0.1 (SPSS Inc, Chicago, IL, USA). We repeated the
questionnaire on 50 medical students of Chinese ethnicity
fromyear twoto yearve,andcomparedtheresponses
of the two groups.
RESULTS
Out of the 50 respondents from the general public, 22
(44%) were male. This was matched with 22 males
(44%) among the 50 Chinese medical students (Table I).
Theresultsof the inuenceof Chinese culturalbeliefs,
Table II. Comparison of respondents who agreed with statements regarding cultural beliefs.
Statements that respondents agreed on No. (%)
General Medical p-value
public students
1. Certain diseases are caused by ‘too much heat’ or ‘too much coldness’ in the body. 39 (78.0) 41 (82.0) 0.617
2. Fever is due to excessive heat inside the body. 44 (88.0) 27 (54.0) < 0.001
3. One should consume less amount of rice or totally abstain from taking rice when having fever. 31 (62.0) 14 (28.0) 0.001
4. Joint pain/rheumatism is due to excessive ‘wind’ accumulated in that joint. 21 (42.0) 8 (16.0) 0.004
5. Abdominal colic is due to excessive ‘wind’ accumulated in the abdomen. 33 (66.0) 22 (44.0) 0.027
6. Consuming certain fruits like jackfruits or watermelon can precipitate excessive ‘wind’ 22 (44.0) 17 (34.0) 0.305
to enter the body.
7. Consuming certain vegetables like bean sprout can precipitate excessive ‘wind’ 21 (42.0) 18 (36.0) 0.539
to enter the body.
8. Consuming certain food like garlic and ginger can help dispel ‘wind’ from the body. 45 (90.0) 32 (64.0) 0.002
9. Consuming certain ‘toxic’ food like crabs and prawns can cause skin diseases with rashes. 45 (90.0) 42 (84.0) 0.372
10. Exposure to rain water can cause respiratory tract infection. 23 (46.0) 14 (28.0) 0.062
11. In chickenpox, consuming beans can leave behind spotty scars. 35 (70.0) 15 (30.0) < 0.001
12. In chickenpox, consuming soy sauce can leave behind black marks. 33 (66.0) 27 (54.0) 0.221
13. Consuming certain ‘heaty’ food or herbs/spices can result in miscarriages. 12 (24.0) 19 (38.0) 0.130
14. After childbirth, a woman must observe a period of confinement and taboos. 48 (96.0) 39 (78.0) 0.007
15. After childbirth, a woman must not wash her hair during the period of confinement. 29 (58.0) 20 (40.0) 0.072
16. After childbirth, a woman must take ‘hot’ food like ginger and red wine during the period 48 (96.0) 33 (66.0) < 0.001
of confinement.
17. After childbirth, a woman must not be exposed to excessive wind or water, as it can cause 40 (80.0) 24 (48.0) 0.001
‘wind-related’ illnesses such as chronic joint pain.
Chi-square test is employed for the categorical data analysis.
Singapore Med J 2011; 52(4) : 254
the attitude toward TCM and the practice of TCM
among our respondents are shown in Tables II and III,
respectively. The mean age of the general public was
43.7 ± 17.7 years, while that of the more homogeneous
group of medical students was 22.0 ± 1.1 years. Half of
the respondents from the general public were Taoists and
half were Buddhists. None indicated Christianity as a
religion. On the other hand, 14 (28%) medical students
wereChristiansand36(72%)wereBuddhists,butnone
was a Taoist. Nevertheless, we believed that Taoism and
Buddhism may often be mixed and practiced together
among many Malaysian Chinese, and as such, we
anticipatedfew differencesin theinuencesofChinese
cultural beliefs between these two groups. However,
contrary to expectation, our subgroup analysis in Table
IV shows few differences even between Christian and
Buddhist medical students with regard to the impact of
some of the selected cultural beliefs.
DISCUSSION
It is believed that disease results from an obstruction to
any of the ow of yin-yang channels.(3,7) For example,
a ear infection is thought to be due to ‘excessive heat’,
and therefore, the restoration of balance can be achieved
by avoiding ‘hot’ food such as scrambled eggs and
by increasing the intake of ‘cold’food such as winter
melon.(6)
The majority (78%) of respondents from the general
public interviewed agreed that ‘too much heat’ or ‘too
much coldness’ in the body could cause certain diseases.
Thisisgenerallyinagreementwiththeyin-yangconcept.
Disruptionoftheyin-yangbalanceinthebodyisbelieved
toresultin diseasesthat manifestinthe weakersideof
the two forces, e.g. when the yang becomes stronger,
symptoms such as heaty rash and fever arise, but when
the yin becomes stronger, symptoms of cough and cold
arise.(9) The majority (80%) of the medical students
interviewed also subscribed to this concept.
However, when asked the next question “Do
you believe that fever is due to excessive heat inside
the body?”, a signicant difference in the number
of respondents who agreed was observed between
respondents from the general public and the medical
students (88% vs. 54%, p < 0.001). This could be due
tothemedicalstudents’supercialunderstandingofthe
inuence of this particular Chinese cultural belief on
health, or the fact that they regarded this belief as hearsay
when judged in the light of modern medicine.
Nevertheless, as the mean age of the general public
was higher than that of the medical students (43.7 ± 17.7
vs.22.0±1.1years),theagefactormayhaveinuenced
the perceptions of the respondents. Interestingly, two
recent studies conducted in Taiwan found that one of the
signicantlyassociatedpredisposingfactorsinuencing
TCM use is age.(10,11) In both studies, TCM use in Taiwan
peakedinindividualsaged30–40years.(11,12)
No. (%) p-value
General Medical
public students
1. Ever sought traditional Chinese medicine. 47 (94.0) 33 (66.0) < 0.001
2. Would rather choose traditional Chinese medicine alone as the initial choice of treatment. 25 (50.0) 3 (6.0) < 0.001
3. Believe that modern medicine, comprising ‘manufactured’ drugs can weaken the body’s 44 (88.0) 35 (70.0) 0.027
immune system.
4. Believe that it is acceptable to combine both traditional Chinese medicine and modern 45 (90.0) 46 (92.0) 0.727
medicine for consumption.
5. Would be uncomfortable to reveal to their doctor that he/she has taken traditional 48 (96.0) 49 (98.0) 0.558
Chinese medicine prior to consultation.
Chi-square test is employed for categorical data analysis.
Table III. Attitude and practice regarding traditional Chinese medicine among the respondents.
Table IV. Subgroup analysis of medical students according to religion.
Statements that medical students agreed on No. (%) p-value
Buddhist Christian
(n = 36) (n = 14)
1. Certain diseases are caused by ‘too much heat’ or ‘too much coldness’ in the body. 33 (91.7) 8 (57.1) 0.040
2. Consuming certain food like garlic and ginger can help dispel ‘wind’ from the body. 25 (69.4) 11 (30.6) 0.198
3. Consuming certain ‘toxic’ food like crabs and prawns can cause skin diseases with rash. 30 (83.3) 12 (85.7) 0.837
4. After childbirth, a woman must observe a period of confinement and taboos. 28 (77.8) 11 (78.6) 0.951
Chi-square test is employed for categorical data analysis.
Singapore Med J 2011; 52(4) : 255
Other cultural beliefs that a signicantly higher
number of respondents from the general public agreed
on included the following: joint pain/rheumatism is due
to excessive ‘wind’ accumulated in that joint; abdominal
colic is due to excessive ‘wind’ in the abdomen;
consuming certain food can dispel ‘wind’ from the body;
and observing certain taboos during the connement
period after delivery of a baby is important. A comparable
number of medical students and respondents from the
general public believed that consuming certain ‘toxic’
foodlike crabsandprawnscancause skindiseases and
rash. This is not surprising given the fact that medical
students learn that food allergy manifests as rashes, and
itisalsoawell-knownfactthatconsumingseafoodmay
cause allergy. Hence, there is a discrepancy in the extent
to which cultural beliefs inuence the perception of
health and illnesses among our respondents.
Furthermore, the majority of the respondents and
medical students agreed that it is acceptable to combine
TCM and modern medicine (90% and 92%, respectively),
and admitted that they would be uncomfortable to reveal
to their doctors if they have used TCM prior to their
medicalconsultation(96%and98%,respectively).The
signicanceofthisiscompoundedbythefactthatmost
TCM decoctions are prepared and boiled by the family
members at home; thus, decoctions prepared in an
unscienticway(e.g.withoutastandardisedamountof
water used, or with differing temperatures and duration
of heating) can result in variable dosages, resulting in
adversesideeffectsifthedosetakenbythepatientistoo
high. In addition, there are many possible interactions
when both modern medicine and TCM are taken
together.(7)
In terms of pregnancy and the postpartum
connement period, an overwhelming majority of
respondentsfromthegeneralpublic(96%)interviewed
believed unequivocally that all mothers should observe
aperiodof connement.This periodof connement is
also known as ‘zuo yuezi’in Chinese, or translated as
‘the sitting month’, as the women literally sit or stay
in bed for many hours and are not allowed to leave
the home.(12) Many agreed that certain taboos must be
observed,including theadvice notto washhair(56%),
increasing the consumption of certain ‘hot’ food like
ginger and red wine (96%), and avoiding exposure to
wind or water (80%). These taboos are not only common
in Malaysia, but are also commonly observed in many
Chinese communities worldwide.(12)
Besides the confounding inuence of age, as
elucidated earlier, education level is another limitation
ofthisstudy,as it mayalso inuencetheperception of
these two groups. While the medical students would
homogenously have had post secondary education, the
education level of the respondents from the general public
wasunknownandcouldwellhavebeenverydiverse.This
is especially so, as 22 of the 28 female respondents from
the general public were housewives. Their education
level may have coloured their preferences for healthcare
treatment modalities.
Our study has shown that there is a discrepancy in
the extent of inuence that cultural health beliefs have
on medical students and members of the general public
in Senai. Healthcare providers should be reminded that
whenpatientsfall sick,their goal isto recoverquickly,
regardless of whether they use TCM or modern medicine,
as long as the treatment is effective and affordable.
Unfortunately, combining TCM and modern medicine
can result in potential adverse drug reactions.
REFERENCES
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the-world-factbook/geos/my.html. Accessed May 30, 2010.
3. Ariff KM, Beng KS. Cultural health beliefs in a rural family
practice: a Malaysian perspective. Aust J Rural Health 2006;
14:2-8.
4. Chen PC. Socio-cultural foundations of medical practice in rural
Malay communities. Med J Malaysia 1974; 29:2-6.
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Singapore Med J 2011; 52(4) : 256
Appendix I
Section A: Demographic data
Gender: Male/Female
Age: _____________________________________________
Occupation: _______________________________________
Religion: __________________________________________
Section B: Influence of Chinese cultural health beliefs
Do you believe that
1. Certain diseases are caused by ‘too much heat’ or ‘too much coldness’ Yes/No
in the body (disruption of yin-yang balance)?
2. Fever is due to excessive heat inside the body? Yes/No
3. One should consume less amount of rice or totally abstain from taking rice when having fever. Yes/No
4. Joint pain/rheumatism is due to excessive ‘wind’ accumulated in that joint? Yes/No
5. Abdominal colic is due to excessive ‘wind’ accumulated in the abdomen? Yes/No
6. Consuming certain fruits like jackfruit or watermelon can precipitate excessive wind to enter the body? Yes/No
7. Consuming certain vegetables like bean sprout can precipitate excessive wind to enter the body? Yes/No
8. Consuming certain food like garlic and ginger can help dispel wind from the body? Yes/No
9. Consuming certain ‘toxic’ food like crabs and prawns can cause skin diseases with rash? Yes/No
10. Exposure to rain water can cause respiratory tract infection? Yes/No
11. In chickenpox, consuming beans can leave behind spotty scars? Yes/No
12. In chickenpox, consuming soy sauce can leave behind black marks? Yes/No
13. Consuming certain ‘heaty’ food or herbs/spices can result in miscarriages? Yes/No
14. After childbirth, a woman must observe a period of confinement and taboos? Yes/No
15. After childbirth, a woman must not wash her hair during the period of confinement? Yes/No
16. After childbirth, a woman must take ‘hot’ food like ginger and red wine during the period of confinement? Yes/No
17. After childbirth, a woman must not be exposed to excessive wind or water as it can cause ‘wind-related’ Yes/No
illnesses such as chronic joint pain?
Section C
1. Have you ever sought traditional Chinese medicine (TCM)? Yes/No
2. Would you rather choose TCM alone as the initial choice of treatment? Yes/No
3. Do you believe that modern medicine, comprising ‘manufactured’ drugs can weaken the body’s Yes/No
immune system?
4. Do you believe that it is acceptable to combine both TCM and modern medicine together for Yes/No
consumption?
5. If you have taken TCM prior to visiting your doctor, would you be uncomfortable to reveal to your Yes/No
doctor that you have taken TCM prior to the consultation?