Blackwell Publishing AsiaMelbourne, AustraliaAJRAustralian Journal of Rural Health1038-52822005 National Rural Health

Alliance Inc.? 200514128Original ArticleCULTURAL HEALTH BELIEFS IN A RURAL FAMILY PRACTICEK. M. ARIFF AND K. S. BENG

Aust. J. Rural Health (2006) 14, 28

Original Article
Cultural health beliefs in a rural family practice:
A Malaysian perspective
Kamil M. Ariff and Khoo S. Beng
Department of Family Medicine, Penang Medical College, Penang, Malaysia

Abstract
Background: Understanding the sociocultural dimension of a patients health beliefs is critical to a successful
clinical encounter. Malaysia with its multi-ethnic population of Malay, Chinese and Indian still uses many
forms of traditional health care in spite of a remarkably
modern rural health service.
Objective: The objective of this paper is discuss traditional health care in the context of some of the cultural
aspects of health beliefs, perceptions and practices in the
different ethnic groups of the authors rural family practices. This helps to promote communication and cooperation between doctors and patients, improves clinical
diagnosis and management, avoids cultural blind spots
and unnecessary medical testing and leads to better
adherence to treatment by patients.
Discussion: Includes traditional practices of hot
and cold, notions of Yin-Yang and Ayurveda, cultural
healing, alternative medicine, cultural perception of
body structures and cultural practices in the context
of womens health. Modern and traditional medical
systems are potentially complementary rather than
antagonistic. Ethnic and cultural considerations can be
integrated further into the modern health delivery
system to improve care and health outcomes.
KEY WORDS: alternative medicine, child health,
cultural healing, traditional medicine, womens health.

Introduction
Modern medicine has been practised in Malaysia for
several decades and the extent of rural health care services in Malaysia extending to remote communities is
remarkable. A variety of traditional health care systems
that reflect the cultural concept of the universe of

Correspondence: Dr Khoo S. Beng, Department of Family

Medicine, Penang Medical College, No. 4, Sepoy Lines Road,
Penang 10450, Malaysia. Email: sbkhoo@pmc.edu.my
Accepted for publication 19 October 2005.
2006 The Authors
Journal Compilation 2006 National Rural Health Alliance Inc.

the various ethnic groups still coexist with modern

health care systems and are widely used by Malaysian
communities.
In this paper, the authors attempt to highlight some
of the health beliefs, perceptions and practices relating
to a variety of common illnesses encountered in their
rural family practices.

The concept of culture

Culture can be seen as an integrated pattern of learned
beliefs and behaviours that are shared among groups
and include thoughts, styles of communicating, patterns
of interaction, views of roles and relationships, values,
practices and customs.1 Culture can be seen as an inherited lens through which the individual perceives and
understands the world that he/she inhabits and learns
how to experience it emotionally, and to behave in it in
relation to other people, supernatural forces or Gods,
and the natural environment.2
Understanding the sociocultural dimensions underlying a patients health values, beliefs and behaviours is
critical to a successful outcome of a clinical encounter.
These include variations in patient perceptions of health
and illnesses, recognition of symptoms, threshold for
seeking care, ability to communicate symptoms to a
provider, ability to understand the management strategy,
expectations of care and adherence to preventive measures and medications.3
The distinction between disease and illness provides
physicians an avenue to identify the influences of culture
on the disease experience. Disease is the objective, measurable pathophysiology that creates the illness and illness is the meaning of the disease to the individual be
it of natural (fall with fracture), supernatural (Gods
will, witches or malevolent spirit) or metaphysical (bad
air or seasonal change) aetiology.4

Traditional medicine
Traditional Chinese medicine views the body, soul and
spirit as an integrated whole (Tables 1, 2). The Chinese
doi: 10.1111/j.1440-1584.2006.00747.x

CULTURAL HEALTH BELIEFS IN A RURAL FAMILY PRACTICE

What is already known on this subject:

Encounters between physicians and patients
from different cultural backgrounds are
commonplace in a country with a multitude
of cultures as in Malaysia.
Patients perceptions of health, expectations
for care, treatment choices, advance health
care planning and other aspects of care are
influenced by class, culture and religion.

TABLE 1:

What this study adds:

Most clinicians lack the information to
understand how culture influences the clinical
encounter. Many are inadequately trained to
face the challenges of providing quality care
to socially and culturally diverse populations.
Discussion of traditional health care in the
context of some of the cultural aspects of
health beliefs, perceptions and practices in
the different ethnic groups helps to enhance
understanding and integration of traditional
health care into the modern health system.

Chronic illnesses

Chronic illnesses

Long-term western medication will weaken the body systems.

Medication once started has to be taken for life.
No complaint means the illness is under control.

Diabetes mellitus

Termed as sweet urine in Chinese dialect, high blood sugar is not thought to be associated with
the illness.
Urine that attracts ants is indicative of diabetes.
The fact that wounds heal easily excludes diabetes.
Refrain from eating rice.

Hypertension

Perceived to be a state when there is too much blood in the body. Giddiness and headache is
caused by excessive blood rising to the head. This leads to practice of blood letting (bekam)
by making tiny cuts on the scalp at the back of the head.
Attributed to excessive body heat. Avoidance of hearty food like red meat and durians, bitter food
items like bitter gourd and star fruits are believed to lower blood pressure.
Taking medicine only when there is giddiness or headache. No complaint means hypertension is
under control.

Bronchial asthma

Inhalers to be avoided in children as they tend to get addicted to them.

Attributed to coldness or mother taking too much cold food during pregnancy.
Avoidance of fruits, vegetables, icy water, taking baths at night.

understanding of nature and the cosmos is expressed in

three important philosophical concepts:
1. There are 12 main channels in the human body
through which chi (vital forces) moves. Health
implies that the chi is flowing normally between the
organs, disease occurs if there is obstruction to any
of the channels.
2. Yin Yang, the symbolic power of hot and cold is
a dialectical concept that attempts to explain
phenomena that appear to be simultaneously
dependent on and in opposition to each other.
3. Wu-hsing are five elements distributed to the five
most important organs in the body. Liver is
associated with wood, heart with fire, spleen with
earth, lungs with metal and kidneys with water.
A person enjoys perfect health when she or he has a
strong and unobstructed flow of chi under the influence

of well-balanced yin-yang forces and is in harmony with

the five elements. Balance can be restored by dietary
changes to compensate for the effects of excess of hot
or cold, and traditional medicines, herbs and medical
practices, which include coining, cupping, pinching,
steam baths and inhalation, balming and moxibustion.
The Indian system of medicine, Ayurveda (knowledge of life) is comprised of three primary forces
(dosha) called Vata, Pitta and Kapha. Each dosha represents characteristics derived from the five elements of
space, air, fire, water and earth. Each element represents
different organs of the body. The state of equilibrium
between the dosha is perceived as a state of health, the
state of imbalance as disease.
The notions of hot and cold from the yin-yang and
Ayurvedic systems do not pertain to actual temperature
but to a symbolic power contained in food, herbs, med 2006 The Authors
Journal Compilation 2006 National Rural Health Alliance Inc.

4
TABLE 2:

K. M. ARIFF AND K. S. BENG

Child health

Common febrile illness

Believed that the child has to be wrapped up in thick clothing to allow all the heat to dissipate.
May lead to febrile fits.
Several ways of relieving fever such as coining and cupping of the body, pinching of the skin at
bridge of the nose that may result in multiple bruises that gives rise to suspicion of child abuse.
Prolonged fever is termed as chut than (typhoid fever) by the Chinese. Will seek traditional
treatment of rubbing a hard-boiled egg over the body to look for presence of fine black hairs
sticking to the egg to confirm the diagnosis.
Abstinence from eating rice may lead to additional loss of weight.

Measles

Caused by excessive heat and toxins.

Preference for cooling traditional medicines and spiritual cure.
Delay in manifestation of rash causes considerable anxiety.

Mumps

Paste of vinegar mixed with blue dye is painted in the shape of a tiger over the parotid gland by
someone born in the year of the tiger (Chinese).

Chicken pox

Caused by excessive heat.

Restriction of toxic food prawns, crabs, certain type of fish.
Taking beans will leave spotty scars; soya sauce, black marks.
Rainwater and morning dew believed to result in lung infection.
Linked to a Hindu Goddess, household members required to keep to vegetarian diet until child
recovers.

Circumcision

Male circumcision widely practised between the age of 612 years.

Belief that local anaesthetics may paralyse the nerves causing erectile dysfunction in later life.
Female circumcision widely practised on Muslim infants usually on the seventh or 40th day of
birth, must be differentiated from genital mutilation as practised in Africa/Arabia. A sterile
needle is used to make a scratch on the clitoris or its sheath, the area is dabbed with a cotton
and the blood shown to the parents or caregiver.

Behavioural problems
Congenital deformities

Attributed to malevolent spirit.

Attributed to bad experience and encounters during pregnancy.

icines, mental states, illnesses, natural and supernatural

forces. Because health is defined as a balance between
these elements, ill health is treated by adding hot or
cold foods or medicines to the diet in order to restore
balance.
Arthritis, colds, menstrual periods and joint pains are
considered cold diseases whereas constipation, diarrhoea, rashes and ulcers are perceived as hot diseases.
Hot medicines include aspirin, cod liver oil, iron and
vitamins whereas cold medicines are milk of magnesia,
sodium bicarbonate and mannitol.2
The concept of wind related illness is common to
many eastern cultures. To some it can mean rheumatic
problems like pain in the muscles (fibromyalgia) and
joints (arthralgia). To others it means the presence or
excessive accumulation of air in body organs such as the
stomach (flatulence) and head (headache or behavioural
problems), and for tendency for wind to enter the
uterus during the post-partum period if care is not
taken. Certain fruits (water melon and jackfruit) and
vegetables (bean sprouts and long beans) are claimed to
cause excessive wind. Others like garlic and ginger are
believed to dispel the wind.
2006 The Authors
Journal Compilation 2006 National Rural Health Alliance Inc.

Perception of blood and inner

structure of the body
To most people the inner structure of the body is a
matter of mystery and speculation. This inside the
body image influences peoples perception and presentation of bodily complaints. A patient complaining of a
pain in the stomach may be referring to virtually anywhere in the abdominal cavity. A common Chinese
belief is that death can result if the serpanginous lesion
of herpes zoster extends all round the waist or chest.
The human experience of blood as a vital liquid
circulating within the body, and which appears at the
surface at times of injury, illness, menstruation or child
birth provides the basis for lay theories about a variety
of illnesses.2 In general, these illnesses are ascribed to
changes in its:
Volume high blood pressure due to too much blood.
Consistency thin blood causing anaemia.
Temperature hot illnesses (furunculosis, abscess, skin
rashes) caused by heat in the blood.
Quality impurities in the blood (sexually transmitted
disease, thyrotoxicosis).

CULTURAL HEALTH BELIEFS IN A RURAL FAMILY PRACTICE

TABLE 3:

Womens health

Menstruation

Perceived as dirty blood that needs to be cleansed from the body every month.
Anxiety arises when periods are missed or menstrual flow is scanty.
Medication is often sought for increasing the menstrual flow.
Considered as a state of weakness when bathing is restricted to the body to avoid
exposure of the head to cold.
Menstruating women considered as unclean, are not allowed to enter places of
worship or involve in spiritual ceremonies.

Physiological vaginal discharge

Physiological vaginal discharge during the wet period of the menstrual cycle is
perceived to be the cause or the effect of weakness of the body. Often medical
consultation involves seeking drugs to dry up the discharge.
Assessment, reassurance and patient education are all that is needed.

Post-partum practices and

taboos

Observed for a period of 44 days by the Malays, 30 days by the Chinese, 40 days
by the Indians.
Strict precautions taken to avoid exposure to cold and wind to prevent future
complications and illnesses.
Effort to nourish and maintain mother in a heated state by: use of warm clothes
and stockings, avoidance of water, confinement to the room or home, avoidance
of fruits and vegetables and toxic food like prawns, certain fish and crabs,
excessive intake of ginger, teel-seed oil, prunes and medicinal herbs, being
served five to six meals a day.
Body massage with medicated oil and heat application using hearth stone wrapped
in herbs are applied to the lower abdomen and lower back to restore the muscle
tones.
Herbs will be added to the baths taken at end of confinement period.

Domestic violence

Seldom revealed to the doctor or public in order to save face.

Polluting power menstrual blood causing weakness in

men.
Some Chinese believe that venepuncture not only
upsets the bodys natural balance, but also weakens the
person because the body does not replenish the lost
blood.

Somatisation
Somatisation is defined as a lack of awareness that a
physical symptom has a psychogenic cause. Depression
is commonly presented as physical symptoms as Asians
are thought to be reserved in expressing their feelings,
avoiding open emotional displays in order to conceal
weakness and maintain social harmony.5 Mental illnesses especially those with overt behavioural pathology
are stigmatised in all cultures especially so among the
Chinese. Psychotic illnesses are often attributed to bad
genes and the concept of losing face if seen to receive
treatment at a psychiatric clinic.6

Womens health
Traditional images of the vulnerable menstruating
womans unclean or shameful menstrual blood were

couched in the language of health and cleanliness. Most

of them take health precautions during their periods
to avoid invasion by infection and germs. These
include herbal medicines, keeping warm, not washing
ones hair, and avoiding baths, heavy exercises, iced or
raw foods (Table 3). Menstruating Muslim women are
not allowed to fast during the holy month of Ramadan.
In many religious faiths they are prohibited from entering places of worship. Many Asian cultures prohibit
sexual intercourse during menstruation for it is believed
to be dangerous to women (it can cause a fever in the
womb) and also to men.7
Pregnancy and childbirth are both biological and
social events, the transition of a social status of woman
to that of a mother. Certain taboos about diet, dress
and behaviour are designed to protect the pregnancy
and mark the transition between social statuses.2
Throughout pregnancy it is believed that the developing
child is vulnerable to evil spirits. Adherence to prescribed taboos and rituals provides some kind of assurance that everything possible is being performed to
minimise that risk, thus lessening the feelings of guilt or
responsibility. For many Malays, Chinese and Indians,
pregnancy is perceived to be a hot state or a time of
increased heat. They avoid hot foods such as meat,
2006 The Authors
Journal Compilation 2006 National Rural Health Alliance Inc.

eggs, nuts, herbs and spices and take foods that have a
cooling effect such as milk products, fruits and vegetables. Over-heating is thought to result in miscarriages
and skin rashes, under-heating in bronchial asthma
and cough.
Most cultures observe a special post-partum period
of rest and seclusion of between 20 and 44 days during which time the woman is confined to her home,
looked after by other women and has to eat a special
diet and observes special taboos.8 During this period,
in contrast to pregnancy period, hot food like ginger,
teel-seed oil, prunes and red wine are encouraged.
Cold foods like vegetables and fruits are avoided lest
they clot the uterine blood and impede the flow, causing it to go backwards into the body and cause nervousness or insanity. Exposure to wind and water is
avoided lest these forces will enter the body and cause
wind related illnesses such as chronic joint pain,
bodyache, headache, dyspepsia and abdominal pain in
later life.
Traditional Asian values place women in secondary
roles to men. Deference to authority, ability to maintain
harmony within the family, non-assertiveness and selfeffacement are valued virtues in the Asian women.
Revealing family problems to outsiders is looked upon
harshly by the community as it brings shame and humiliation to the entire family.9 The health care worker may
not understand the logic of saving face, but must
attempt to understand to gain rapport and trust in cases
of domestic violence.

End-of-life care
In western culture truth telling is encouraged hope
appears to be upheld through patients autonomy and
active participation in treatment choices and regimens.
In Chinese culture hope is best maintained through the
familys absorption of the impact of the illness and
diagnosis, and through the familys control of medical
information transmitted to the patient with an awareness of the potential physical or emotional harm that
truth telling might bring. Filial duties and obligations
form the principal basis for non-disclosure.10
Some traditional Chinese may be reluctant to write
advance directive documents; they honour spoken
words and many believe that speaking about death can
bring about an earlier death. Great lengths may be taken
to ensure that individuals die at home because some
believe the soul of the deceased inhabits the site of
death.10
Although the final outcome of death is the same for
all humans, cultures vary in how they conceptualise
death and what happens when a person dies. The
Hindus and Buddhist envision a circular pattern of life
and death where a person is thought to die and is reborn
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K. M. ARIFF AND K. S. BENG

with a new identity. Christians and Muslims view death

as occurring only once; the deceased sheds this bodily
form but continues on in spirit where the faithful believers are rewarded with eternal joy in heaven and the
sinners suffer in hell. In certain religious segments the
dead and living coexist, the dead (ancestral spirits) can
influence the wellbeing of the living. Death anxiety is
relatively lower among death-affirming societies than
among death-denying or death-defying cultures.11

Symbolic or cultural healing

In many traditional societies, mental illness is usually
dealt with by folk healers such as the Chinese and Indian
mediums, and the Malay traditional healers (bomohs).12
Cultural healing relies on language, rituals and manipulation of powerful cultural symbol, thus it often takes
place at many levels simultaneously: psychological,
physical, social, cultural and spiritual (Table 4). Finkler
found that it was ineffective for the psychoses but useful
for neurotic disorders, psychophysiological problems
and somatised syndromes. It enables patients to abandon their sick roles, return to normal behaviour and
eliminate the feeling of being sick.13

Alternative medicine
Despite the advances in western medicine the use of
medicinal herbs in both raw and proprietary forms
remains popular among Asian communities. One of the
reasons is the belief that these medicinal products are
harmless and without side-effects because of their natural origin, but in recent years many products have
been found to be reformulated, relabelled and new indications added to some, unannounced.14
It is important to see folk healers in a balanced way
and to avoid both over-idealisation seeing them and
the communities they work among as natural and holistic, living in peaceful harmony with nature and with one
another and overcriticism seeing them and their
communities as somehow primitive, degenerative,
incompetent and underdeveloped.15
Patients seek the care of traditional healers if western
treatment does not bring relief, if the diagnosis bears a
negative prognosis (long-term or incurable illness) or if
surgery is advised. The traditional treatment may either
replace or be used along with western medicine a mix
and match approach.16

Integration of modern and traditional

health care systems
Understanding the different cultural background and
traditional practice of patients will help physicians to
provide better rapport and care to patients.

CULTURAL HEALTH BELIEFS IN A RURAL FAMILY PRACTICE

TABLE 4:

Cultural healing

Case vignette on spiritual/cultural healing

Mysterious neurological illness
A 46-year-old Malay man presented at the authors practice complaining of weakness and numbness at the lateral aspect of his
left leg and foot for two months. He was a lorry driver and also supported his income by slaughtering cattle for supply to a beefseller. He was very worried that he would end up paralysed. He had consulted three traditional healers prior to consulting the
author and the reasons offered by the healers for his problem were as follows:
1. With the first spiritual healer, he was told that during the course of his work, he had stepped on an object in which a benda
hangat (implying evil spirit) resided. The insult or anger incurred by the evil spirit had affected his leg. He underwent some
therapy with incantations, massage and rituals, but the problem persisted.
2. The second healer renowned for his skills in treating herpes infection, a bomoh kayap, confirmed the patients suspicion that
it was due to herpes infection and offered him some herbal pastes to massage the affected part accompanied by strict advice
on food restrictions. However, the problem persisted.
3. A third traditional healer was consulted whose explanation was more realistic and logical to the patient. The patient was
told that he had slaughtered a cow that was bisa (toxic, possessed by an evil spirit). As he slaughtered the animal, she
struggled and the spirit had found a new habitat in the patients leg!
Examination of this patient showed that he had weakness of dorsiflexion and eversion of his left foot and some loss of sensation
to pin-prick on the dorsal aspect of the affected foot. He had suffered an injury to the back of his left knee (popliteal fossa) during
martial arts (silat) training about two weeks prior to the onset of his problem. A diagnosis of lateral popliteal injury was made
and the patient was advised not to massage the affected leg. With a clear explanation of his problem, counselling and lots of
reassurance he gradually recovered. He continues to wear a talisman to protect him against bovine evil spirits!

1. Some of the misconceptions such as the fatality of

herpes zoster lesion encircling the waist can be
rectified through good communication skills and
patient education.
2. Practices of avoiding certain food may be harmless
provided they do not interfere with the patients
nutritional status; taking easily digestible food
during fever and throat infection reinforces the
western concept of advice.
3. Awareness of the various physical methods used to
remove forces from the body of a child places us
in a better position of differentiating it from child
abuse.
4. Somatisation is common in general practice. Time
is needed to assess the underlying psychosocial
problems and to screen for depression rather than
treating symptomatically with drugs.
5. The appropriate approach to a suspected case of
domestic violence is to convey an attitude of concern
and respect, ensure confidentiality and to ask
directly whether his/her injuries or complaints are
the results of an assault by someone he/she knows.
6. Tactfulness is necessary in dealing with truth telling.
It would be advisable to assess how much the patient
knows, whether he/she would like to know the truth,
his/her coping strategy and explanation to carers the
disadvantages of collusion. It is preferable to have
the consent of both parties before breaking the news.
7. Discussing psychosexual issues is a taboo in our
society. Health professionals need to take the initial
step to re-ensure and educate those patients

diagnosed or treated for malignancy that it is all

right to continue with their sexual activities.
8. Folk healers explain ill health in wider, more
familiar cultural terms involving the social,
psychological and spiritual aspects of their patients
lives. Patients find this explanation satisfying
because it matches their own expectations and
subjective emotional experience of ill health.17

Implication for medical education

Health professionals must be attentive to cultural influences in medicine because as Shwartz suggests, much
of what medicine does is designed to make people live
more comfortably within their own usually unanalysed,
cultural requirements. Ethnic and cultural considerations should be integrated further into the health delivery system to improve care and health outcomes.18

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