Consumers’ Perceptions of Chinese Vs. Western Medicine
Francis Piron, Chan Wai Ching, Esme Cheong Ai Peng, and Ho Lee Ching (2000) ,"Consumers’ Perceptions of Chinese Vs. Western Medicine", in NA - Advances in Consumer Research Volume 27, eds. Stephen J. Hoch and Robert J. Meyer, Provo, UT : Association for Consumer Research, Pages: 125-130.
TCM has existed for more than two thousand years, and forms a natural part of the Chinese cultural mosaic. Chinese commonly use medical ingredients to brew tonics, and herbal soups and cooling teas as part of a healthy diet. However, when Western medicine is available, as it is in Singapore where consumers are better educated, patients also seek medical help from Western healthcare (1996 Report by the Committe of Traditional TCM) as it is deemed more reliable and safer and is regulated by the government. Moreover it has proven itself scientifically well in terms of effectiveness and efficacy. Hence, Western medicine is often recognized as the dominant form of health practice in Singapore. However, in recent years, interest in TCM has resurfaced as a form of alternative treatment and its development has been supported by the World Health Organisation (WHO) (1996 Report by the Committee of Traditional TCM). TCM and acupuncture are being studied in Australia, the UK, Europe and Hong Kong. In China and Japan, the use of traditional Chinese herbal medicines is studied for therapeutic values in the treatment of chronic hepatitis, rheumatoid arthritis, high blood pressure, eczema, AIDS and certain cancers. A report in the Detroit News (27/8/98) highlights the growing interest among Americans in TCM as a form of alternative cure: patients with unsuccessful conventional treatments have turned to Chinese alternatives, such as acupuncture. To suit the lifestyles of faster-paced societies, marketing strategies in Asia have changed. Traditional medical halls and supermarkets offer pre-packed, ready-to-use mixtures of herbs with Chinese and English instructions, soups and jelly in foodcourts or shopping centers, and advertise on the Internet. Some medical manufacturers also produce ready-made powders or sweets. This departs from the traditional retailing of Chinese medical ingredients to delivering ready-to-consume products. Medical halls have also adopted modern retailing methods in terms of layouts, displays of products, payment methods (use of debit and credit cards), availability of gift vouchers and membership cards (Straits Times, 14 April, 1998). Some medical halls have even set up web pages to keep up with societys information needs. RESEARCH OBJECTIVES To reflect on these trends and practices, we compare consumers perceptions of Chinese and Western medicines. With a unique mixture of oriental and occidental cultures, Singapore, where this study took place, has well-established systems of Eastern and Western healthcare. Definition of Traditional TCM "
TCM has existed for more than two thousand years, and forms a natural part of the Chinese cultural mosaic. Chinese commonly use medical ingredients to brew tonics, and herbal soups and cooling teas as part of a healthy diet. However, when Western medicine is available, as it is in Singapore where consumers are better educated, patients also seek medical help from Western healthcare (1996 Report by the Committe of Traditional TCM) as it is deemed more reliable and safer and is regulated by the government. Moreover it has proven itself scientifically well in terms of effectiveness and efficacy. Hence, Western medicine is often recognized as the dominant form of health practice in Singapore.
However, in recent years, interest in TCM has resurfaced as a form of alternative treatment and its development has been supported by the World Health Organisation (WHO) (1996 Report by the Committee of Traditional TCM). TCM and acupuncture are being studied in Australia, the UK, Europe and Hong Kong. In China and Japan, the use of traditional Chinese herbal medicines is studied for therapeutic values in the treatment of chronic hepatitis, rheumatoid arthritis, high blood pressure, eczema, AIDS and certain cancers. A report in the Detroit News (27/8/98) highlights the growing interest among Americans in TCM as a form of alternative cure: patients with unsuccessful conventional treatments have turned to Chinese alternatives, such as acupuncture.
To suit the lifestyles of faster-paced societies, marketing strategies in Asia have changed. Traditional medical halls and supermarkets offer pre-packed, ready-to-use mixtures of herbs with Chinese and English instructions, soups and jelly in foodcourts or shopping centers, and advertise on the Internet. Some medical manufacturers also produce ready-made powders or sweets. This departs from the traditional retailing of Chinese medical ingredients to delivering ready-to-consume products. Medical halls have also adopted modern retailing methods in terms of layouts, displays of products, payment methods (use of debit and credit cards), availability of gift vouchers and membership cards (Straits Times, 14 April, 1998). Some medical halls have even set up web pages to keep up with societys information needs.
To reflect on these trends and practices, we compare consumers perceptions of Chinese and Western medicines. With a unique mixture of oriental and occidental cultures, Singapore, where this study took place, has well-established systems of Eastern and Western healthcare.
Definition of Traditional TCM
"The harmony of nature"- a set of intricate and harmonious links between heaven (tian), earth (di), and man (ren), (the "three forces" (sancai))Bis central to Chinese culture. For traditional Chinese:
their world view conceived a harmonious co-operation of all matters in the universe, arising form the fact that they were all parts of a hierarchy of wholes forming a cosmic and organic pattern and obeying the internal dictates of their own nature. (Ho and Lisowski , 1993 p.12)
Man, like everything else in the world, is made up of the five xings (wuxing): Water, fire, wood, metal and earth. As any other entity in the whole universe, man is ruled by a macrocosmic combinations of Yin and Yang (Table 1).
The Yin and Yang, two opposite and complementary cosmological forces, make up the qi, a component of all forms and the fabric of which all things are made. The Yin and Yang merge to produce the five elements (wuxing) which diffuse in harmony, and the four seasons proceed.
Components within the body correspond to the Yin, Yang, and five xings:
the heart, the small intestines and the tongue are associated with Fire, the kidneys and the ears with Water and the gall-bladder and the eyes with Wood, the lungs, the large intestines and the nose with Metal and the stomach, the spleen and the moth with Earth. (Ho & Lisowski, 1993, p. 17)
Yin and Yang continually ebb and flow: Health, tranquillity and well-being depend on their harmonious equilibrium. Hence, the chief cause of all diseases is a disequilibrium or an imbalance of Yin and Yang, creating illnesses or in extreme cases, death.
Traditional TCM recognizes three important illness-inducing factors:
1) external agents (e.g., climate, infections) classified as Yang factors,
2) internal disfunctions, termed as Yin factors
3) accidental and traumatic injuries, considered to be partly Yin and partly Yang.
To remedy, TCM doctors prescribe harmony-restoration treatments in the form of herbal medicine, [Herbal medicine: plants and animal extracts consumed in the form of tea] applying surgery, acupuncture, [Acupuncture: insertion of needles into the body at precise points to guide the flow of energy within the body.] moxibustion, [Moxibustion: burning of the herb moxa (Artermesia vulgaris) on the surface of the skin] massage, [Massage: also commonly known by its Chinese name "Tui Na"] breathing exercises, [Breathing exercises: normally encompasses Qi Gong and Tai Chi (Source: A Report on "Using the Internet as a Tool to Educate the Public in the Use of TCM in Toronto" by Raymond Tsang (1997))] diet. Syndromes are healed as a whole rather than individually. The TCM physician treats the entire person, using both physical and mental aspects to cure illnesses. These principles are based on the Huangdi Neijing (the Yellow Emperors manual), the Shanghanlun (Treatise of Febrile Diseases) of Zhang Ji (AD 150 to 219), the Maijing of Wang Shuhe (AD265 to 317) and the Great Pharmacopoeia in the 16th century (Ho and Lisowski 1993).
Another concept is the Taoists perspective of the body as a microcosm: Good health is maintained when the body and its organs, like the external world, are well harmonized. When bodily functions are chaotic, disease happens. To Taoists, a lack of " rest" (jing) causes ill health, resulting in bodily disharmony. Coincidentally, the English word " dis-ease" is a perfect translation of this definition, coinciding with the modern Western knowledge of ensuring good health only through the easing of all bodily functions. Taoists should not over-exert the body or destabilize the jing, the essential material for survival, and should keep their mind tranquil. Healing is done by natural stimulation of the bodys own ability to return to good health.
THE YIN-YANG PRINCIPLE
Different Modalities of TCM
Acupuncture, herbal medicines, and tuina are different forms of TCM. Acupuncture, one of the earliest forms of medicine, has existed for more than 5000 years and views the body as consisting of a life force flowing through a network of meridians, in addition to the nervous system. Ill health affects the life flow and is treated by inserting a sterilized fine needle at certain points of the meridian network to restore the energy flow in the body.
Acupuncture is used to treat "chronic pain, drug addiction, as a local anesthetic and as a form of preventive medicine" (The Readers Digest Medical Question and Answer Book p.42). Highly specialized and patient-specific, it is a popular alternative medicine in the Western world: An estimated 3000 American physicians incorporate acupuncture into their practices. In Europe, 75% of practicing acupuncturists are medical doctors.
Herbal medicines, along with plant, mineral and animal extracts are drunk as tea (Raymond Tsang 1997). Herbal cures use dried rather than chemically processed herbs to maximize the effectiveness of the treatment and harmonize side effects. Herbal medicine relies on the belief that the natural minerals of plants offset health defects. A person suffering from humidity or rain-based arthritis may consider herbal treatment from herbs with the energy required to prevent the invasion of cold and damp air. For instance The sea vine, a seaside plant with energy in its bark to keep free from the constant attack of cold, damp air would then do well.
The third form of TCM, tuina, is the science of body massage and is not further discussed here.
Evidence of the Coexistence of Chinese and Western Medicines
Recent research on illness and health care behavior recognizes the coexistence of Western and various forms of traditional medicines in developing and in emerging countries (Quah 1988; Unschuld 1989; Lee and Cheung 1988; Hogg, Mitchell and Chung 1997). Although Western medicine is the dominant form of treatment (Lee and Cheung 1988), multiple health care traditions exist in most modern societies (Hogg, Mitchell and Chung 1997). Forty five per cent of Singaporeans had never consulted TCM practitioners while 19% had consulted one within the last year (Report by the Committee of TCM 1996). This phenomenon is labeled a "dual utilization of traditional and modern medical systems," occurs in societies undergoing swift modernization and is due to "pragmatic acculturation," "accessibility of health services," and "the persons subjective perception of using the service" (Quah 1988:2). Further, traditional practices are not merely surviving but are established traditional ways of healing, actively interacting with modern practices in health-related behavior: Consumers use traditional and Western medical sciences as part of their network of choices, however appropriate for their health needs (Quah 1988-4; Tee 1994). The choice may be finalized based on accessibility of health services and a persons subjective perception of the benefits of using the service.
Consumers selection of a medical system may also be affected by the differences inherent to each system. The Chinese approach is based on a philosophic-scientific approach as compared to the Westerns cause-and-effect approach (Table 2). The latter views all phenomena as cause-effect sequences where theories "sum up the phenomena and formulate a logical explanation to explain the relationship and nature between entities" (Lee 1996, p.12). Western medicine relies on rigorous scientific studies and research that seek empirical proof to all phenomena. Hence, its healthcare is very materialistic: It is primarily concerned with the material aspect of the body and only accounts for what exists in the physical aspect in terms of science (Stone 1999).
A COMPARISON OF CHINESE AND WESTERN MEDICINE
UTILIZATION OF TCM BY RESPONDENTS FROM CHINESE MEDICAL HALL/WESTERN PHARMACIES
The Chinese view adopts a holistic approach, incorporating the "existence of the concrete and observable, to the hidden and supernatural" (Lee 1996, 12). TCM is based on the "three forces" (sancai) and good health is maintained only when man maintains good relationship with heaven and earth, balancing yin and yang. Hence, the Chinese approach is holistic whereas the Western rationale is scientific and theory-based.
Consequently, the differences in approaches may lead to diverging conceptions on health treatments and analysis. In Western medicine diseases are "due to the invasion of germs, viruses and bacteria in the body or abnormal hormonal imbalances or cell mutations which lead to foreign growths and tumors" (Lee 1996, p.13). In contrast, traditional TCM regards illnesses as a disharmony in the sancai, imbalances in the yin and yang. Thus, the sickness can have both external (the environment) and internal (body, mind and spirit) causes (Kim 1998).
In sum, TCM and Western medicine have the potential to become complementary, thus benefiting patients with improved options. (Table 3 illustrates both groups usage of TCM). These are good reasons for consumer researchers to understand both medical systems and the consumers perceptions of each system. To that effect, this study is designed to assess consumers perceptions of Chinese and Western medicine.
We have learned on Asian conceptions (gould 1991), traditional societies in transition (Tse, Belk and Zhou 1989), and even the use of TCM in a non-Asian environment (Hogg, Mitchell and Chung 1997). In spite of the research above, there is still little scholarly, seminal evidence on which to frame the hypotheses of interest to this study. Therefore, the following hypotheses are formulated from conversations with experts, casual observation of society and of shoppers visiting TCM halls, and from feedback gathered from a preliminary study.
We infer that older individuals, being less acculturated, would tend to assess Chinese physicians expertise more positively than the younger, more Western educated generations. Therefore, we suggest that
H1: Older consumers will rate TCM physicians expertise higher than will younger consumers.
For basic reasons of acculturation, we submit that consumers educated in traditional, Chinese language schools might have a more positive perception of TCM physicians expertise than those consumers educated in English language schools. The two forms of education clearly emphasize different approaches: one focuses on "chineseness" while the other focuses on primarily Western values. It follows that consumers who were educated in a Chinese environment may associate more deeply with expressions of Chinese culture, such as medicine. Thus, we infer that
H2: Consumers brought up in a Chinese language stream of education will display a more positive perception of TCM physicians expertise than consumers brought up in an English language stream of education.
The next two hypotheses attempt to assess whether consumers who favor one of the two systems of medicine have different perceptions of Chinese and Western medicines.
H3a: Consumers who visit Chinese medical halls perceive significant differences between the mean scores of two comparable medicines (i.e., one Chinese and one Western medicine).
H3b: For consumers who visit pharmacies perceive significant differences between the mean scores of two comparable medicines (i.e., one Chinese and one Western medicine).
RESEARCH DESIGN AND METHODOLOGY
Studies reporting a consumer-oriented approach to TCM are rare (Hogg, Mitchell and Chung 1997). Most of the information relevant to this study came from business publications, such as The Economist (Nov. 7, 1998), newspaper articles, as in The International Herald Tribune (Nov. 12, 1998), and theses (Lee 1994). In addition, knowledge was gained from dialogs with TCM experts, such as medical halls shopkeepers, covering their perceptions and consumption of TCM. From these preliminary steps, nine attributes affecting the perception of TCM were derived and used in a pilot questionnaire administered to 15 respondents. Minor changes were made in response to comments made by the respondents prior to finalizing the questionaire. Five of the nine factors were retained: accessibility, safety, reliability, family influence and effectiveness
Primary Data Collection
The questionnaire comprises four sections. The first focuses on respondents perception and consumption of TCM, and on the 5 factors affecting the choice of medicine. The second section deals with the use of TCM for different ailments (e,g., headache, heart and kidney ailments). Section 2 aims at understanding the contemporary role of TCM. Five-point bipolar differential scales (definite use of Western medicine vs. definite use of TCM) were used to assess consumers choice of Chinese or Western medications.
The third section investigates the five factors (accessibility, safety, reliability, family influence and effectiveness) role in deciding on Chinese and Western medications, using five types of Chinese and Western off-the-counter drugs. For each ailment, respondents ranked the medications for each attributes perceived importance on five-point bipolar scales. The final section covered demographic/socioeconomic data (i.e., gender, dialect group, age, occupation, level of education achieved, language stream of education (i.e., Chinese vs. English), number of family members living in the household, personal income/allowance).
Sample Design and Data Collection
One hundred and fifty Chinese customers were surveyed via bilingual, Chinese-English, questionnaires on weekdays and weekend days in downtown Singapore, outside of 3 pharmacies (2 western & 1 TCM pharmacies). One hundred and twenty instruments were usable.
Frequency distributions quantified the utilization of TCM (Tables 2 and 3) and the percentage of male/female consumers. Independent sample t-tests compared differences in the means of the independent variables (e.g. accessibility, safety) between consumers of TCM and Western medicine. Pearson correlations tested significant relationships between both groups demographic descriptors, and between demographic data (age, dialect group and language stream) and whether the respondents diet was based on Yin and Yang, their consumption of Chinese tonics for health maintenance, and factors influencing the respondents knowledge of TCM. Finally, multidimensional scaling (MDS) extracted the samples similarities/differences in the 5 factors affecting choice of healthcare.
RESULTS AND DISCUSSION
Usage of TCM
As indicated in Table 3, regardless of survey location, both samples report at least bimonthly consumption of TCM. Of the four types of TCM preparations, Western pharmacy consumers prefer that which is commercially prepared and sold in shops, while TCM halls consumers prefer the self-prepared preparations from animal sources. The other two types are self-prepared preparations from plant sources and special preparations from TCM physicians.
Yin-Yang Focused Diet, Knowledge of Dietetic Restraints, Consumption of Chinese Tonics
Only 50% of the TCM consumers balance the Yin-Yang in their diet, and no significant differences (a=.05) were found on that basis between TCM and Western pharmacy consumers. As some food is believed to decrease or eliminate the effectiveness of TCM, dietetic restraints (e.g., food taboos are carrots, radish, orange and tea) have to be observed for about two days. Over half (55%) of the TCM respondents and one third (38.3 %) of the Western pharmacy consmers were cognizant of the dietetic restraints. Only 13.3% of the respondents never use tonics.
Sources of information about TCM and Perception of TCM Physicians Expertise
Family members and friends are the main source of information about TCM for most respondents. Other significant sources are press and broadcast media, and TCM physicians. On a scale of 1 to 7 (more to less highly qualified), TCM hall consumers rating of TCM physicians as more qualified (x=3.68) is significant different (a=.05) from pharmacy consumers rating (x=4.16).
Choice between Chinese and Western Medicine
Given a list of illnesses to treat, consumers indicated their preference of Chinese or Western medicine: Most respondents favored Western medicine to treat major illnesses like heart diseases, cancer and kidney problem. But, most respondents preferred TCM for loss of appetite, rheumatism and sprains. However, for anaemia and asthma, each group of consumers stuck to its own form of medicine as favorite treatment.
Age discriminates significantly (a=.01) on the perception of TCM physicians qualifications: Older consumers perceive TCM physicians as more qualified than younger consumers, thus supporting H1. The second hypothesis proposes a relationship between language stream of education and perception of TCM physicians. ChineseBeducated consumers perceive TCM practitioners expertise more favorably (p<.001) than English-educated consumers: we cannot reject H2.
The third hypothesis investigates consumers perceptions of TCM and Western medicine attributes. To that purpose, 5 ailments (diarrhoea, sore throat, fever, sprains and acne) were selected along with 5 pairs (TCM/Western medicine) of comparable medications and 5 attributes. Neither sample of consumers perceived significant (a=.05) overall differences between the medications making up each pair of stimuli. However, significant (a=.05) differences were perceived between paired medications on individual characteristics. For instance, TCM and Western pharmacy groups of consumers perceived Po Chai pills (TCM for diarrhoea) to be significantly (a=.05) more available than their Western equivalent, carbon pills. Both groups perceived families to be significantly (a=.05) more influential in the consumption of Po Chai pills, which were also found safer by both groups, than carbon pills. TCM consumers find Po Chai pills to be significantly (a=.05) more effective than carbon pills.. Altogether, it appears that both groups of consumers have a better perception of Po Chai pills than carbon pills. We also note the significant influence that the family holds in the consumption of traditional medicine for diarrhoea.
Pi Pa Gao and lozenges were the selected medications for sore throats. Neither group perceived significant (a=.05) differences between the medications with respect to ease of purchase, reliability, effectiveness, safety and family influence, the 5 factors investigated in this study. For treatment of fever, Ying Qiao and Panadol were used in our experiment. Both groups perceived Panadol to be superior on all factors to Ying Qiao (a=.05). However, when treating sprains, a reverse phenomenon is observed: both samples valued the TCM, medicated plasters, significantly higher (a=.05) than its western counterpart, "Deep Heat," on all five factors. Concerning the treatment of acne, we used pearl powder as TCM, and "Oxy" as Western medication. Both panels of consumers perceived the TCM to be significantly (a=.05) more available and influenced by family than "Oxy" which was deemed more reliable (a=.05) and safer (a=.05) by Western pharmacy consumers only.
In summary, we identify two areas of discussion: the perception of TCM practitioners and the perception of TCM for some ailments. From this study we infer that the perception ofTCM physicians expertise is certainly culture grounded: Older consumers and those who were educated in a stronger Chinese cultural environment view TCM physicians more favorably than younger consumers and those raised in a Western, English-speaking environment. A simple visit to a TCM hall clearly conveys the cultural aspect of TCM. Only Chinese characters are used to describe the medications and ingredients, and dried plants and animal parts or bodies are displayed in glass jars along with posters showing stereotypical older Chinese sages sipping steaming cups of herbal teas. Western pharmacies are plainer and, while displaying bilingual posters on occasion, appear void of Chinese cultural displays. This may explain why those consumers who are more grounded in Chinese culture evaluate TCM practitioners more favorably: they offer a more comfortable, reassuring, familiar environment. Also, older consumers may be less fluent in English than their younger, English-educated neighbors who may then be undergoing progressive acculturation. In addition, a traditional Chinese cultural characteristic, the importance of the family in decision-making is recognized by both samples throughout the survey.
There is no apparent pattern of superiority of TCM over Western medicine, or vice versa: Panadol and some TCM, such as Po Chai pills and medicated plasters are evaluated more highly by either group. It may then be that TCM consumers are willing to switch to Western medication, and conversely for Western pharmacy consumers, when deemed appropriate. This issue had not been considered in the present study and may need to be in future research. However, it seems that Western pharmacy consumers are more concerned with issues of reliability and safety in medication, issues that are clearly attached to science. It may then be that to those consumers, some aspects of TCM may be perceived as less scientifically tested than Western medications.
Finally, it is important to note that the medications used in this survey are for minor ailments. It would be interesting to learn consumers perceptions of both medical systems for more serious, or even life-threatening, ailments. Clearly, there is a need for Western medicine to better understand the contribution of TCM, and maybe consider it as a complementary health science. [As this research is being revised, the National University of Singapore has announced that first-year medical students can select TCM and acupuncture electives, while all fourth- and fifth-year students will learn key concepts of TCM practices (The Straits Times, "The Sticking point," August 16, 1999).]
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Francis Piron, Nanyang Technological University
Chan Wai Ching, Nanyang Technological University
Esme Cheong Ai Peng, Nanyang Technological University
Ho Lee Ching, Nanyang Technological University
NA - Advances in Consumer Research Volume 27 | 2000
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