Miri Hospital Pharmacy...

Sarawak Journal of Pharmacy 1 (2015) 41-57

41 Journal Homepage: http://jknsarawak.moh.gov.my/spj/

View on Traditional Complementary Medicine of Outpatient in Miri Hospital

Voon Yit Kian1, Zukifli bin Mahmood1, Azarin Hanim Abdul Aziz1, Ahmad Syafiq Ahmad

Izani1, Kuan Hsieng Yew1, Ong Woei Jye1, Kamarudin Ahmad1

1Miri Hospital Pharmacy Department

Corresponding author name and email: Kamarudin Ahmad (kamarudin_a @moh.gov.my)

Introduction: Complementary and alternative medicine widely used as self-care to treat

illness or to promote own health especially in developed countries. In Malaysia, medical

practised in diverse ethnicity, such as Chinese Traditional Medicine, Ayuverda, Qi Gong.

Affirmed effectiveness towards complementary and alternative medicine shown association

with demographic feature and purpose of use of Complementary and Alternative Medicine in

common severe medication for instance Diabetes Mellitus, Hypertension. This may

contribute psychosocial factor to severe medication compliance.

Objectives: This study introduced to study the purpose of the use of Complementary and

Alternative Medicine and its sensed effectiveness in severe illness management among

outpatients in Hospital Miri.

Methods: The study designed as cross-sectional study. 245 outpatients adult age more than

18 years old with severe illness recruited voluntarily into study and interviewed face-to-face

using NAFKAM International TCAM Questionnaire (I-TCAM-Q). This tool comprises of

three items on current status of TCAM use, demographic and view.

Results and Discussion: Indian is minor ethnic group in Sarawak and the study group in this

study (3.5%) whereas other ethnic group like Chinese (35.5%), Malay (34%), and other

Bumiputera (27%) responded. Half of the respondents claim use of herbal medicine,



supplement and self-help practices besides prescribed medication regardless of race. Level of

education and social economic status showed association with prevalence of herbal medicine

and supplement usage significantly with p value



higher educational status, and patients with chronic diseases (4) (5) (6) (7). Among East

Asian countries, Malaysia had among the highest rate of CAM use, alongside Japan (75%)

and South Korea (75%) (3) . Siti et al. (2009) reported the prevalence of CAM use among

Malaysians was 55.6% (8).

Malaysia has many medical systems that practised by a diverse ethnicity, such as

Malay, Chinese, Indian, and indigenous races. These practices collectively referred as CAM

in this study. Major systems of medicine practiced in Malaysia include ayurveda, traditional

Chinese medicine, spiritualists, traditional birth attendants, and others who use home

remedies (9). Other complementary and alternative medicines also exist in Malaysia such as

meditation, prayer, homeopathy and chiropractic.

The Malay community practice seeing bomoh (shaman), the makbidan (midwife) and

the mudin (religious man who performs circumcision on boys) and consuming traditional

Malay medicine. These medical practices are especially popular among Malay in rural areas

and rely on practical experience and observation handed down orally and in writing from

generation to generation (9). The Chinese community practice tai chi, qigong, acupuncture,

and consuming traditional Chinese medicine. Chinese traditional medicine believed to have

introduced into Malaysia by Chinese migrants working in the tin mines and still used in urban

centre. Chinese medical practitioners hold high status and known as sinseh (9). The Indian

community practice ayurveda, yoga, aromatherapy and consuming traditional India medicine.

Most of medicines used are of vegetable, mineral, and animal origin in forms of medical

tablets, oils, ointments, and herbal powders (9). In Malaysia, community of one race will

also seek CAM of other race in their aim for improvement in general health.

The Ministry of Health (MOH), Malaysia has foreseen the importance of TCAM and

impact of practicing unregulated TCAM and producing unregulated herbal medicine in

Malaysia thus they have created The Complementary Medicine Unit in 1996. The

Complementary Medicine Unit is in charge coordinates and carries out policies on the use of

TCAM with the aim of integrating TCAM into the national health care delivery system (10).

With that in mind the unit have drafted The Traditional and Complementary Medicine (TCM)



Act 2013 which will come into force in mid next year after the ministry has finalised the

regulations supporting the Act, said Health Minister Datuk Seri S. Subramaniam (11). This

effort could in future improve the overall quality, safety and efficacy of TCAM in Malaysia.

Beside, TCAM should also be proven to be scientifically efficacious and safe to be use so it

can improved patient confident toward the TCAM thus raising patient perceived

effectiveness.

TCAM use popularised and has received much attention worldwide despite question

about TCAM safety, effectiveness and lack of national standard to standardise TCAM

practice (12). There are several studies that reported the prevalence and association between

CAM use with demographic features (3, 13, 14). However, only a few studies reported the

perceived effectiveness CAM by the patient (15, 16). To date, there are only a few published

literatures on the use of CAM that focused on specific disease population, such as

hypertension, diabetes mellitus and breast cancer instead of general population (15-17).

This study initiated to study the purpose of use of CAM and its perceived

effectiveness in outpatient population in Miri Hospital, Sarawak. We aimed to determine the

common types of CAM, its purpose and relationship between the uses of CAM with patients’

demographic features.

Methods

A cross-sectional study conducted between October and November 2014 to patients in

Miri Hospital by using the adopted NAFKAM International TCAM Questionnaire (I-TCAM-

Q). The tools comprise of three components on current status of alternative medication use,

user perception and demographic. Respondents recruited by purposive sampling at the

Outpatient Pharmacy (OPD). Inform consent given to the respondent before we conduct face-

to-face interviews by trained interviewers.

Our inclusion criteria based on patient with any chronic disease, age more than 18

years old and able to understand either in Malay or English. We exclude patient who do not

have chronic disease, age less than 18 years old.



The targeted sample size was 245 individuals, based on the following assumptions:

prevalence of TCAM use (63.9%), a confidence level of 90%, a standard deviation of 0.5,

and a margin of error (confidence interval) of +/- 10%

Statistical Analysis

The elements on current status of alternative medication use, user perception and

demographic are analysed through association mainly by using chi-square and Fisher-exact

test. A P-value of RM 3000). We did not have many respondents from “non-formal

education” group that have visited CAM health care providers. However, more than half of

our respondents receive secondary or tertiary education.

Table 5 shows the association between patients’ socio-demographic characteristics

with the use of herbal medicine and dietary supplements. There are significant associations

seen between monthly household incomes, types of occupation and underlying diseases with

the intake of herbal medicine and dietary supplements. More than half of the Malay, Chinese

and the native Sarawak found to be consuming herbal medicines and dietary supplements.



More than three quarter respondents who used herbs and supplements are those from age

range of 31-50 years old. Patients who have both endocrine disorder and cardiovascular

disorder are the highest user of herbs and supplement while few consume for bone and joint

disorders.

Table 6 displays the association of patients’ socio-demographic characteristics with

self-help practices. There is a significant association between the monthly household

incomes of patients with self-help practices that patients are carrying out. More than 50% of

any race turns to self-help practices. This can also seen between patients with professional

and non-professional occupation. Most of the outpatients that carry out self-help practices

have underlying cardiovascular disorders. These self-help practices include engaging in yoga,

qigong, tai chi, attending ceremonial events and performing prayers to improve their health.

Table 7 summarises the various purpose of CAM. Our data shows, there is an

association between the use of CAM and its purpose. In most of cases, respondents use CAM

for improving their well-being by using herbal, supplements and self-help practice. Less than

20% used CAM for acute illness while about 30% meant CAM for treating long-term health

condition.

Perceived effectiveness of CAM

Table 8 shows there is an association between CAM and its perceived

effectiveness by the respondents. Based on patients’ own perception, more than 50% of the

respondents claimed the perceived effect is moderate and about 30% perceived CAM very

effective.



Table 1 Demographic characteristics of study population

n %

Gender

Male 115 57.50

Female 85 42.50

Race

Malay 71 35.50

Chinese 68 34.00

Indian 7 3.50

Others 54 27.00

Age

16-30 30 15.00

31-45 78 39.0

46-60 73 36.6

>60 19 9.50

Marital Status

Single 38 19.00

Married 162 81.00

Table 2 Socio-economic characteristics of study population

n %

Education

Primary 29 14.50

Secondary 122 61.00

University 46 23.00

No Formal Education 3 1.50

Income

RM3000 37 18.50

Occupation

Professional 68 34.00

Non-Professional 62 31.00

Self-Employed 44 22.00

Student 6 3.00

Retired 20 10.00



Table 4 Association of patients’ socio-demographic characteristics with visiting healthcare

providers**

n (%) Yes P-value

Sex

Male 115 (57.5%) 62 (53.9%) 0.106

Female 85 (42.5%) 36 (42.4%)

Race

Malay 71 (35.5%) 30 (42.3%)

0.002 Chinese 68 (34.0%) 41 (60.3%)

Indian 7 (3.5%) 7 (100.0%)

Others 54 (27.0%) 20 (37.0%)

Age

16-30 30 (15.0%) 11 (36.7%)

0.212 31-45 78 (39.0%) 42 (53.8%)

46-50 73 (36.5%) 33 (45.2%)

>60 19 (9.5%) 12 (63.2%)

Level of Education

Primary 29 (14.5%) 17 (58.6%)

0.181* Secondary school 122 (61.0%) 53 (43.4%)

University 46 (23.0%) 27 (58.7%)

Non Formal Education 3 (1.5%) 1 (33.3%)

Monthly household income

RM3000 37 (18.5%) 18 (48.6%)

Occupation

Professional 68 (34.0%) 33 (48.5%)

0.084

Non-Professional 62 (31.0%) 36 (58.1%)

Self Employed 44 (22.0%) 14 (31.8%)

Student 6 (3.0%) 3 (50.0%)

Retired 20 (10.0%) 12 (60.0%)

Underlying Disease

Cardiovascular Disorders 63 (31.5%) 30 (47.6%)

0.149 Endocrine Disorders 29 (14.5%) 15 (51.7%)

Respiratory Disorders 28 (14.0%) 11 (39.3%)

Endocrine & Cardiovascular Disorders 25 (12.5%) 8 (32.0%)

Bone & Joint Disorders 13 (6.5%) 7 (53.8%)

Others 42 (21.0%) 27 (64.3%)

*Fisher’s exact test

** Health care providers include physicians, chiropractors, homeopathy, acupuncturist,

traditional Malay and Chinese medicine practitioners, ayurveda, spiritual healers and herbalists



Table 5 Association of patients’ socio-demographic characteristics with the use of herbal

medicine and dietary supplements

n (%) Yes P-value

Sex

Male 115(57.5%) 74(64.3%) 0.259

Female 85(42.5%) 48(56.5%)

Race

Malay 71 (35.5%) 43 (60.6%)

0.566 Chinese 68 (34.0%) 45 (66.2%)

Indian 7 (3.5%) 3 (42.9%)

Others 54 (27.0%) 31 (57.4%)

Age

16-30 30 (15.0%) 16 (53.3%)

0.105 31-45 78 (39.0%) 42 (53.8%)

46-50 73 (36.5%) 49 (67.1%)

>60 19 (9.5%) 15 (78.9%)

Level of Education

Primary 29 (14.5%) 11 (37.9%)

0.042* Secondary school 122(61.0%) 78 (63.9%)

University 46 (23.0%) 31 (67.4%)

No Formal Education 3 (1.5%) 2 (66.7%)


RM3000 37 (18.5%) 34 (27.9%)

Occupation

Professional 68 (34.0%) 50 (73.5%)

0.000 Non-Professional 62 (31.0%) 37 (59.7%)

Self Employed 44 (22.0%) 16 (36.4%)

Student 6 (3.0%) 2 (33.3%)

Retired 20 (10.0%) 17 (85.0%)

Underlying Disease

Cardiovascular Disorders 63 (31.5%) 37 (58.7%)

0.005

Endocrinologic Disorders 29 (14.5%) 15 (51.7%)

Respiratory Disorders 28 (14.0%) 16 (57.1%)

Endocrine & Cardiovascular Disorders 25 (12.5%) 23 (92.0%)

Bone & Joint Disorders 13 (6.5%) 4 (30.8%)

Others 42 (21.0%) 27 (64.3%)




Purpose of CAM use

Table 6 Association of patients’ socio-demographic characteristics with self help practices

n (%) Yes P-value

Sex

Male 115(57.5%) 81(70.4%) 0.391

Female 85(42.5%) 55(64.7%)

Race

Malay 71(35.5%) 46(64.8%)

0.189 Chinese 68(34.0%) 49(72.1%)

Indian 7(3.5%) 7(100.0%)

Others 54(27.0%) 34(63.0%)

Age

16-30 30(15.0%) 22(73.3%)

0.845 31-45 78(39.0%) 54(69.2%)

46-50 73(36.5%) 48(65.8%)

>60 19(9.5%) 12(63.2%)

Level of Education

Primary 29(14.5%) 20(69.0%)

0.162* Secondary school 122(61.0%) 77(63.1%)

University 46(23.0%) 37(80.4%)

No Formal Education 3(1.5%) 2(66.7%)


RM3000 37(18.5%) 31(83.8%)

Occupation

Professional 68(34.0%) 43(63.2%)

0.613* Non-Professional 62(31.0%) 46(74.2%)

Self Employed 44(22.0%) 28(63.6%)

Student 6(3.0%) 4(66.7%)

Retired 20(10.0%) 15(75.0%)

Underlying Disease

Cardiovascular Disorders 63(31.5%) 39(61.9%) 0.828

Endocrinologic Disorders 29(14.5%) 19(65.5%)

Respiratory Disorders 28(14.0%) 20(71.4%)

Endocrinologic& Cardiovascular Disorders 25(12.5%) 18(72.0%)

Bone & Joint Disorders 13(6.5%) 9(69.2%)

Others 42(21.0%) 31(73.8%)




Table 7 The use of CAM and its purpose

n Yes (%) P value

Visiting CAM healthcare providers 98

For Acute Illness 16(16.30)

0.000 To treat long term health condition 31(31.60)

To improve well being 51(52.00)

Use Of Herbal Medicine and Dietary

Supplements

122


0.000* To treat long term health condition 28(23.00)


Self Help 136


0.000 To treat long term health condition 31(22.80)



Table 8 The use of CAM and its perceived effectiveness

n Yes (%) P value

Visiting CAM healthcare providers 98

Very 33(33.70)

0.000* Somewhat 59(60.20)

Not at all 3(3.10)

Don’t know 2(2.00)

Use Of Herbal Medicine and Dietary

Supplements

122

Very 35(28.70)

0.000* Somewhat 80(65.60)

Not at all 1(0.80)


Self Help 136

Very 51(37.50)

0.000* Somewhat 76(55.90)

Not at all 3(2.20)





Discussion

In demographic feature, the number of male respondent is slightly higher than female

in to visit physician in last 12 months followed by traditional Chinese medicine and

traditional Malay medicine during this study. In general, female gender had been associated

with use of TCAM in many studies (18). In comparison with baseline study in Malaysia

asthmatic population shows that female were more likely to uses TCAM than men, which

contradicts with this study (19, 20). Since the male population in Miri is higher than female,

the result from the gender comparison is justifiable (10).

Respondents with education level up till secondary school and university are more

likely to visit physician, followed by TCM, TMM and herbalist. These numbers show that

higher educational levels of the respondent also play a major role in TCAM in their daily life.

In contrast, poverty status doesn’t show any prevalence with other studies (18) found that

higher income was prior in use of TCAM as ways to improve health and well-being (18).

However poverty status did not influence the preference of the respondents towards the

TCAM (19).

Visiting Traditional Chinese Medicine (TCM) practitioner is one of the most popular

choice uses by patient in Malaysia which is consistent with the finding from WHO

Traditional Medicine Strategy 2000- 2005 (8). An estimated of US$ 500 million spent each

year on TCAM alone in Malaysia. Chinese Medicine (CM) has its origin more than 2500

years ago, which influenced by the teachings and written works of great herbalists,

acupuncturists, philosophers and physicians which further enlarge people belief in TCM (9,

21). Majority of respondent in this study is Chinese which often seek TCM practitioner

however TCM is also popular among Malay, Indian and the Native. TCM highlight on

restoring balance to body, where in disease state the opposing life forces of yin and yang

were not in balance, this might explain the preference of the choice TCM for treatment of

long-term health condition by patient as restoring balance to the body is a long-term approach

to the body (22).



Our data also show scarcity of users in Ayurveda and Homeopathy because of lack of

practitioner providing service. Siti ZM et al (2009) found that both Ayurveda and

Homeopathy is not popular in Malaysia where less than 2% of population use the modalities

for health problem and maintaining health (13).

Herbs are the most popular supplements among our respondents. Similar study by Siti

ZM et al (2009) shows that herbs commonly used where more than 20% of population use

herbs for health problem as well as health maintenance (8).

Praying is one of the most popular self-help practice, one of the reason that could

explain the high popularity of this practice could be because of majority of the study

respondent are Malay (35.5%) and most Malay are Muslims that practice performing prayer

regularly and are familiar to the practice(8). Study conducted by Reza MF et al (2002) have

shown the physical activities involved in performing salat could helps in the rehabilitation

process in disabled geriatric patients by improving blood flow and increasing muscoskeletal

fitness which explain could the scientific theory behind the high perceived effectiveness

behind self-praying (23). This is in contrast with study conducted by Siti ZM et al. (2009),

which less than 3% of population use prayer for health reason on their approach for health

problem and health maintenance.

Self-help practice such as Qi gong also received a high perceived effectiveness which

is consistent with the review by Rogers CE et al (2009) where they have shown that Qi gong

are able to improve physical function, reduce blood pressure, fall risk, depression and anxiety

(24).

Acupuncture rated to have a high perceived effectiveness in relative to other

modalities. In China, it have exist for more than 3000 years where needles is use in this

modalities to remove the blockage of Qi which result in disease.(25) Acupuncture is a



collection of different technique which includes acupressure, Shiatsu, auriulotherapy,

moxibustion and many more (25). In recent year, evidence have supported the neurochemical

basis of acupuncture where relative to deep insertion and continuous manipulation the use of

electrical stimulation shown to be even more effective in triggering the release of

neuropeptide. It has shown to be effectives to control various types of pain, depression,

addiction, gastrointestinal disease, and stroke (25).The scientific evidence presented

supported the respondent perceived effectiveness on acupuncture.

Limitation

The data of this study collected through interview where the participant needed to

recall the use of TCAM from the past 6 month thus recall bias is unavoidable. Besides, self-

reported study may not represent the actual result as patient could have overstate or

understate the effectiveness of the medical intervention. We try to lessen this bias by

conducting face-to-face interview by a trained interviewer, Finally, this study is a community

based survey where the participants are Hospital Miri outpatient population and thus because

of the difference in demographic feature of community of East and West Malaysia the study

cannot truly represent the national population. However the special racial diversity in

Sarawak is worth to explore and researched since no baseline data is available on the pattern

of TCAM use in Sarawak.

Conclusion

In the local community, traditional remedies commonly sought after to accelerate the

process of healing and in maintaining health. It has evolved to reflect different philosophical

backgrounds and cultural origins. The practice of modern medicine may be widespread but

the use of traditional medicine is still popular and because hope to a better life.



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