Preference, Perception And Predictors Of Herbal Medicine Use Among Malay Women In Malaysia.

Approximately 70% of the world’s population from developing countries prefer herbal medicinal products as a primary source of healthcare. 1 , 2 Herbal medicinal products are medicinal products that consist of a plant, or a concoction of various plants, often used due to its believed beneficial effect, 3 , 4 and are a popular source for disease management and prevention. Within the past decade, there has been a tremendous surge in herbal therapies, as herbs are easily assessable directly from traditional healers or commercially available in many countries, 2 including in Malaysia. Preference towards herbal use is common within the Malay women community 5 and is at higher odds compared to other ethnicities in Malaysia. 6 The use of herbs for medicinal purposes is largely based on theory, beliefs, and experiences that are indigenous to specific cultures. 7 , 8 Herbal remedies are usually preferred over conventional medicine as it is perceived to be important for reasons of health and well-being, including being beneficial during pregnancy. 9 The most common herbs that are used among Malay women are raw herbs and commercialized herbal products. 10 For example, herbs such as Croton caudatus , coconut oil and Cymbopogon citratus are among a few frequently used during pregnancy and in postnatal care among the Malay community. 11 , 12 However, there are significant variations in the popularity of herbs used by Malay women depending on location, 11 , 12 and despite the variety of herbs available, evidence for the safety and efficacy is still limited. 13 Such practice modalities should raise concerns among healthcare professionals and consumers. The common use of herbs among the Malay community is due to the perception that herbal products do not contain harmful chemicals and are free of side effects. 10 , 14 The perception that herbs are natural sources and are therefore safer is also a common misconception observed among herbal users. 15 , 17 Women are also largely affected by recommendations by family and friends, and are known to self-prescribe herbal remedies for treatment or prevention of ailments. 15 , 16 Although allopathic treatments and technologies are abundant, the inability to recognize or feel positive changes may also influence them to try herbal remedies. 15 , 16 Thus, with the steady increase of herbal medicinal products, concerns surrounding their safety must be recognized. The factors that affect herbal use among women may differ from one population to another. It is believed that the popular use of herbs in developing countries is due to the accessibility and availability of the product. 2 , 7 Housewives and those with a lower income were the most frequent users of herbs in the local population. 7 , 8 Recent work in Malaysia demonstrated that those with a more positive attitude and stronger belief towards herbal use had a higher tendency to use herbal medicine. 1 Given that herbal medicines are often portrayed as being harmless, the public may be at an additional risk, which underlies the need to further understand the reasons behind herbal medicine use. Non-disclosure of herbal use is a common scenario among women. 16 The utilization and self-prescribing of herbs for medicinal purposes among women is of particular concern due to the risk of potential safety issues linked, but not limited to, pregnancy, breast-feeding and other maternity complications. In view of this, healthcare professionals must address these issues and furnish appropriate programs to ensure both the public and patients are well-informed. At present there is limited work addressing current predictors of herbal use among Malay women, that may potentially be used to screen high-risk users and develop appropriate educational programs. To address these concerns, an insight into the use of current herbs among Malay women may aid in identifying potential users and optimising management of herbal remedies. The aim of this work is therefore to identify preference, perception and predictors of herbal use among Malay women within the local population.

The study was a cross-sectional study among women in Malaysia. Those that were included were Malay adults aged 18 years old, regardless of their health status. Respondents were included conveniently through self-administered questionnaires, which were distributed by hand, as well as online via email. Questionnaires were distributed by hand in public places such as malls, bus stops and train stations. Incomplete questionnaires were excluded from the study. A total of 384 respondents 18 was required based on an approximate population of 11 290 000 adult women in Malaysia. 19 However, a total of 1200 respondents were targeted to increase the power of the study and to allow for subgroup analysis. From a total of 1200 questionnaires, 817 were distributed by hand and 383 were sent via email, of which 1067 questionnaires were completed (720 by hand and 347 online). Incomplete questionnaires accounted for 133 (11.1%) of the sample population. The survey response rate, defined as the number of completed questionnaires was 88.9% ( Figure 1 ). Figure 1 Flowchart of survey respondent’s selection. Flowchart of survey respondent’s selection. The study has been approved by the appropriate institutional and/or national research ethics committee and has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Ethical approval was obtained from the Research Ethics Committee (Human), under the Medical and Innovation Research Secretariat, Universiti Kebangsaan Malaysia Medical Center (JEP-2018-522). All patients were included with written informed consent. The respondents answered a self-administered questionnaire, face-to-face or online. 20 The questionnaire assessed demographic variables, current use of herbs for health, and perception on the use of herbs for health. 7 , 15 , 21 Face and content validation of the questionnaire of both the face-to-face and online version was undertaken by a panel of five adult women respondents. Feedback was gathered to improve the questionnaire presentation, clarity, and congruency in meaning. Modifications were made and a pilot test of both face-to-face and the online version was performed among 20 respondents. The final version of the questionnaire was personally distributed by the researcher and collected once completed on the same day, or sent online via Facebook or email to potential respondents. Demographic characteristics collected were age, state, marital status, level of education, employment status, average monthly income and health status. Gender and ethnicity were also included to exclude forms that were incorrectly filled by males and non-Malay ethnicities. The definition of herbal use for health was “any products originating from plants and used to preserve or recover health”, as described by the National Institutes of Health (2011). 22 Herbal use was determined based on the statement: Are you currently using herbs or herbal products for health issues? Those that admitted to the use of herbs were then asked further questions such as; monthly expenditure of herbal use, what herbs were used, form of herbs used, type of herbs (raw or commercialized herbs) and what herbs were used for (skin problems, general health, chronic illness, acute illness, specific women’s problems, others). Respondents were also asked where they obtained their herbs (the jungle/around the village, traditional practitioner, agent/distributor, internet, doctor/pharmacist, family/friend, herbal shop, shop/supermarket, own herbs, others). Reasons for herbal use were also determined based on six statements; 7 , 15 easy access of herbal remedy, low cost of herbal remedy, better/faster results compared to conventional medicine, natural taste of herbal drug, health facility is too far, and influence from family or relative or peer. Respondents answered each statement with a “Yes” or “No” response. 7 , 15 , 21 Perception of herbal use for health was assessed based on previous work. 15 This was based on six statements which were; herbal remedies are safer than modern drugs, herbal remedies are effective for managing health problems for women, herbal remedies should be used by all women, herbal remedies may cause problems to women’s overall health, all herbal remedies can safely be used during pregnancy, and I am satisfied with the effect and outcomes of using herbal medicines. Each statement was followed by a “Yes” or “No” response. Data were analysed using SPSS (version 23.0) (IBM Corp. Armonk, NY, USA). Demographic characteristics, herbal use and perception of herbal use were summarized using descriptive statistics. Students’ t -tests and Chi-squared tests were used to compare differences in means and categorical data, respectively. A univariate and multivariate logistic regression was used to determine predictors of herbal use among women. Continuous data were categorised based on its median value. 23 For all analyses, a p-value of <0.05 was considered to be statistically significant.

A total of 1067 respondents from both Peninsular and East Malaysia were included in the study. The average age of the respondents was 36.75±10.72 (range 20–70) years, with a mean monthly income of RM 3587±4542 or USD 872±1104 (range RM 100–60,000 or USD 24–14,592). In general, most of the respondents (n=815, 76.4%) had tertiary education compared to secondary (n=250, 23.4%) and primary education (n=2, 0.2%). A large majority of the women were married (n=760, 71.2%), followed by those that were not married (n=286, 26.8%), divorced (n=14, 1.3%) and widows (n=7, 0.7%). A total of 775 respondents were working (government – n=419, 39.3%; non-government- n=291, 27.2%; self-employed- n=65, 6.1%). The remaining 292 were unemployed (retiree – n=7, 0.7%; unemployed – n=29, 2.7%; housewife – n=194, 18.2%). Of the 1067 respondents, 966 (90.5%) were healthy whilst 101 (9.5%) were currently receiving treatment. A total of 592 (55.5%) respondents admitted to using herbs for health. Herbal users were significantly older (37.2±9.9 years) than those that were not (36.2±11.6 years) (Mann Whitney=128182.5, df(1065), p=0.013). Married women were also more likely to use herbs (n=482, 45.2%) compared to others (χ2=86.36, df(3), p<0.001). It was also noted that employed respondents (n=460, 43.1%) were more likely to use herbs, compared to those that were not (n=132, 12.4%) (χ2=17.19, df(1), p<0.001). When comparing monthly income, herbal users had a lower monthly income (RM 2313±1200 or USD 562±291) compared to those that did not use herbs (RM 5602±6664 or USD 1362±1620) ( t =10.593, df(789), p<0.001). There was also a significant difference between users and health status, with a higher number of herbal users among healthy women (n=519, 48.6%) compared to those receiving treatment (n=73, 6.8%) (χ2=12.7, df(1), p<0.001). The characteristics of herbal use are as stated in Table 1 . Table 1 Characteristics Of Herbal Use Among Malay Women In Malaysia (n=592) Characteristics Mean (SD)/n Range/% Average RM/USD spent on herbs, mean (SD) (range) 105.9 (84.3)/24 (20.5) 0-600/0-145 Form of herbs used, n (%) Raw herbs taken orally 268 43.9 Capsule/tablet/powder taken orally 184 30.1 Drink/tea 111 18.1 External use 48 7.9 Type of herbs, n (%) Raw herbs 407 69.5 Commercialised herbs 167 28.5 Combination of raw and commercialized herbs 12 2.0 Herbs are taken for, n (%) General health 271 43.9 Specific women’s problems 247 40.0 Skin problems 52 8.4 Acute illness 23 3.7 Chronic illness 19 3.1 Others, not specified 4 0.6 Herbs are obtained from, n (%) Traditional practitioner 254 39.0 Internet 146 22.4 The jungle/around the village 116 17.8 Doctor/Pharmacist 55 8.5 Herbal shop 30 4.6 Agent/distributor 28 4.3 Shop/supermarket 8 1.2 Own herbs 7 1.1 Family/friend 5 0.8 Others, not specified 2 0.3 Reasons for herbal use Influence from family/relative/peer 757 70.9 Easy access to herbal remedy 755 70.8 Natural taste of herbal drug 636 59.6 Better/faster results compared to conventional medicine 483 45.3 Low cost of herbal remedy 436 40.9 Health facility is too far 241 22.6 Characteristics Of Herbal Use Among Malay Women In Malaysia (n=592) Raw herbs taken orally Capsule/tablet/powder taken orally Drink/tea External use Raw herbs Commercialised herbs Combination of raw and commercialized herbs General health Specific women’s problems Skin problems Acute illness Chronic illness Others, not specified Traditional practitioner Internet The jungle/around the village Doctor/Pharmacist Herbal shop Agent/distributor Shop/supermarket Own herbs Family/friend Others, not specified Influence from family/relative/peer Easy access to herbal remedy Natural taste of herbal drug Better/faster results compared to conventional medicine Low cost of herbal remedy Health facility is too far Herbs were mainly used for general health (n=271, 43.9%). Specific women’s problems (n=247, 40%) included postnatal (n=212), menstrual problems (n=21), fertility (n=10), endometriosis (n=3) and uterus inflammation (n=1). Among the most popular use of herbs for chronic illness (n=19, 3.1%) was hypertension (n=6), followed by diabetes (n=3). Whilst the most common use for acute illness (n=23, 3.7%) was for the management of allergies (n=12). In general, raw herbs were the most popular herbal remedies used (n=407, 69.5%). The most common raw herb identified was kacip fatimah or Marantodes pumilum which was used for postnatal care ( Table 2 ). A significant number of respondents used commercialized herbal products that were found abundantly and marketed as herbal (jamu/majun) products. In Malaysia, these products are advertised and sold using agents or distributors. The most common among these were various different brands such as Nona Roguy ® (n=32, 5.5%) and Jamu Ratu Malaya ® (n=32, 5.5%) products, which were used for postnatal birth care, skin problems and general health. There were various types of Nona Roguy ® and Jamu Ratu Malaya ® products used. However, the content of these herbal products usually differed from one another and could not be determined. Table 2 Indications Of The Most Common Raw Herb Combinations Used Among Malay Women In Malaysia (n=407) Local Herb Name Scientific Name Uses n (%) Kacip fatimah Marantodes pumilum Postnatal, general health, fertility, diabetes 38 (9) Habatussauda Nigella sativa General health, skin problems, endometriosis 24 (6) Manjakani, asam jawa, kunyit Croton caudatus, Tamarindus indica, Curcuma longa Postnatal 14 (3) Tepayas roots Carica papaya leaves Postnatal, general health, skin problems, menstrual problems 12 (3) Manjakani, serapat roots Croton caudatus, Mapania cuspidate roots Postnatal 9 (2) Sirih rimau Piper porphyrophyllum Postnatal 8 (2) Kunyit, halia, halia Jawa, misai kucing Curcuma longa, Zingiber officinale, Curcuma zanthorrhiza, Orthosiphon stamineus Postnatal 7 (2) Mengkudu leaves, serai kayu leaves Morinda citrifolia leaves, Syzygium polyanthum (Wight) Waplers leaves Postnatal 7 (2) Kunyit, halia, serai Curcuma longa, Zingiber officinale, Cymbopogon Postnatal, general health, skin problems, menstrual problems 7 (2) Kucing galak leaves Acalypha Indica leaves Postnatal 6 (1) Halia bara, jenjulung roots, serapat roots Alpinia purpurata, Dracaena graminifolia roots, Mapania cuspidate roots General health, skin problems, endometriosis 4 (1) Indications Of The Most Common Raw Herb Combinations Used Among Malay Women In Malaysia (n=407) The perception of herbal remedies was assessed ( Table 3 ). A significantly higher number of respondents agreed that herbal remedies would not cause any problems to women’s overall health (n=725, 67.9%) (χ2=137.5, df(1), p<0.001) and that they were satisfied with the effects and outcomes of herbal remedies (n=657, 61.6%) (χ2=57.2, df(1), p<0.001). Despite this, a large majority agreed that not all remedies were safe for pregnant women (n=979, 91.8%) (χ2=744.03, df(1), p<0.001). Table 3 Perception Towards The Use Of Herbal Remedies Among Malay Women In Malaysia (n=1067) Safety And Efficacy Of The Herbal Remedies Yes No n % n % Herbal remedies are safer than modern drugs 540 50.6 527 49.4 Herbal remedies are effective for managing health problems for women 623 58.4 444 41.6 Herbal remedies should be used by all women 446 41.8 621 58.2 Herbal remedies may cause problems to women’s overall health 342 32.1 725 67.9 All herbal remedies can safely be used during pregnancy 88 8.2 979 91.8 I am satisfied with the effect and outcomes of using herbal medicines 657 61.6 410 38.4 Perception Towards The Use Of Herbal Remedies Among Malay Women In Malaysia (n=1067) A comparison was then performed between perceived safety of herbs with the use of herbal remedies among respondents. Respondents that admit to using herbs agreed that it was safer (herb user; n=405, 38% vs non-user: n=187, 17.5%) than modern medicines (χ2=172.2, df(1), p<0.01) and effective (herb user; n=462, 43.3% vs non-user: n=130, 12.2%) in managing health (χ2=215.2, df(1), p<0.01). Those that did use herbs also agreed that it should be used by all women (herb user; n=353, 33.1% vs non-user: n=239, 22.4%) (χ2=173.8, df(1), p<0.01) as it will not cause problems (herb user; n=482, 45.2% vs non-user: n=110, 10.3%) (χ2=109.4, df(1), p<0.01) as they were satisfied with the effects of herbal remedies (herb user; n=535, 50.1% vs non-user: n=57, 5.3%) (χ2=458.3, df(1), p<0.01). A univariate and multivariate logistic regression analysis was performed to identify demographic characteristics that predicted the use of herbs for health ( Table 4 ). Predictors from the univariate analysis with a p-value <0.05 were then included in the multivariate analysis. The multivariate logistic regression model was statistically significant (χ2=203.98, df(795) p<0.001), and demonstrated that marital status and monthly income were significant predictors of herbal use for health when holding all other variables constant. Those that were married were 3.9 times more likely to use herbs than unmarried women (p<0.001). Having an income of <RM 3000 or USD 729 increased the odds of using herbs among women by 6.2 times compared to their counterparts (p<0.001). The model was able to explain 30.4% of the variance in the use of herbs for health and correctly identified 69.7% of the cases. Table 4 Factors Affecting The Use Of Herbs For Health Among Malay Women In Malaysia (n=1067) Beta OR Lower 95% CI Upper 95% CI p-value Demographics (Ref) Univariate Logistic Regression Age (≥35) 0.359 1.432 0.117 0.602 0.004 Education (Tertiary) −0.237 0.789 −0.525 0.05 0.105 Marital status (Married) 1.133 3.105 0.857 1.409 < 0.001 Employment (Employed) 0.571 1.770 0.300 0.842 < 0.001 Monthly income (≥ RM3000/USD729) −1.828 0.161 −2.158 −1.499 < 0.001 Health status (Healthy) −0.809 0.445 −1.263 −0.355 < 0.001 Demographics Multivariate Logistic Regression Age (≥35) 0.139 1.149 −0.199 0.476 0.421 Marital status (Married) 1.376 3.958 1.011 1.741 <0.001 Employment (Employed) −0.045 0.956 −0.787 0.697 0.905 Monthly income (≥ RM3000/USD729) −1.822 0.162 −2.173 −1.471 <0.001 Health status (Healthy) −0.254 0.776 −0.817 0.309 0.377 Factors Affecting The Use Of Herbs For Health Among Malay Women In Malaysia (n=1067)

Herbal remedies are popular in most cultures and are rightfully acknowledged by modern practitioners. 16 , 24 Among women, the use of herbs for health issues is very common and despite the vast numbers of evidence-based modern medicine, it is still preferred. 24 Not surprisingly, approximately half of the respondents admit to taking herbs for health in Malaysia, similar to previous work. 24 The most common of these are in the form of raw plants or prepacked commercialized herbs, which are often taken orally. The increase in the utilization of herbs for medicinal purposes and general health is not only observed in Malaysia, but is common around the world. 2 Therefore, it is essential to facilitate better understanding of its use among the public in order to furnish safe and effective use of herbal medicine. The exploitation of herbs for medicinal purposes may differ depending on location, due to the variation in culture, indication, plant species availability and beliefs. 11 , 25 Among these, Marantodes pumilum, Nigella sativa and Croton caudatus were among the most popular and preferred herbs, similar to previous reports. 8 , 12 , 25 Although both Marantodes pumilum and Croton caudatus were mainly used for postnatal care, there are other common uses such as general health and skin problems. This is also apparent from previous work that details out other indications of Marantodes pumilum and Croton caudatus , which were to relieve muscle and body ache, promote baby’s physical health and intelligence, prevent retained placenta and abortion purposes. 11 It is thus not uncommon for Malay women to use a herbal remedy for multiple purposes, which further underscores the need to educate them on the safe use of herbal medicines. Understanding the perception of herbal use is vital in view of public health issues, and concerns surrounding its safety. Although some herbal medicines have potential in treating illnesses and are widely used, many of them remain untested. 2 Furthermore, the widespread use of herbal remedies is frequently unmonitored. This makes knowledge of potential adverse effects and drug interaction especially when used with modern medicines limited, and promotion of their rational use much more difficult. 9 This becomes even more of a challenge when most women perceive that herbal use is much safer and effective than modern medicines, as observed in the current work. The general perception that herbal remedies are safe and devoid of adverse effects is untrue and misleading. 10 , 14 , 15 It is therefore essential to equip the general public with adequate information on the appropriate use of herbal remedies in an attempt to facilitate a better understanding of the potential risks associated with herbs. In the current work, married Malay women, with a monthly income of less than RM 3000 or USD 729 were predictors of herbal use. The popular use of herbs for postnatal care among married Malay women within the current work as well as previous studies 8 , 11 , 12 further supports these findings. The accessibility and affordability of herbal remedies 1 , 2 could possibly explain the link between lower-income groups and use of herbs. Raw herbs are generously found in Malaysia and as such, are very much cheaper than conventional medicines. 1 , 2 In addition to this, there is a growing culture of herbal agents and distributors within Malaysia, which makes purchasing these products much easier. The ease in obtaining herbs for medicinal use strengthens the need to identify herbal users among Malay women as it may aid healthcare professionals in designing educational programs and activities to reduce unwarranted adverse effects within this population. As such, the aim of the study was successfully achieved. Despite this, there are a few limitations that should be addressed. As with all questionnaire-based studies, the findings of this study are dependent on the honesty of the respondents. It should also be noted that some herbal users may not be fully aware of the categories of herbal remedies. Due to the nature of raw plants or herbs being used, some may categorize the use as nutritional supplements despite using them for medicinal purposes. 22 Furthermore, factors that affect herbal are not limited to those studied, and could also include other predictors such as ineffective use of modern medicine, belief, religion, knowledge and attitude towards herbs used. 15 , 17 To that end, findings from this study suggest a need to focus our attention on providing appropriate programs on herbal medicine, especially among married women of lower-income groups. Despite the popularity of herbal remedies for well-being and health, herbs are capable of producing a wide range of undesirable effects if used too often. Some of these are capable of causing serious injuries and life-threatening conditions. 26 Unfortunately to this day, healthcare professionals have a limited understanding of the potential effects of herbs. The current work also highlights the challenges associated with herbal education, due to the positive perception of herbal use among the study population. Furthermore, due to the common lack of disclosure of herbal use among women, 16 healthcare providers should have an open and non-judgemental conversation with women about the use of herbal remedies to ensure safe and optimum management is achieved. Therefore, health educational programs on herbal use should be developed that address these concerns to ensure appropriate information is delivered.