Factors associated with utilization of traditional Chinese medicine by white collar foreign workers living in Taiwan

Taiwan, a modern Chinese country, has a National Health Insurance Scheme (NHIS) that provides coverage of general medical expenses to virtually all of its citizens and foreign workers [1]. Included in the NHIS are both modern allopathic medical care and traditional Chinese medicine (TCM). Although allopathic medicine is more predominant, over 3,700 licensed doctors of TCM practice in 2,500 hospitals and clinics around the country [1]. Patients are free to choose any health care provider registered under the NHIS for their care, without the need for approval by a gatekeeper.

The number of foreign residents in Taiwan has increased from 30,000 in 1991 to almost 293,000 in 2005 [2]. Much of this population is South East Asian but a significant number, around 15%, are professional/skilled or white collar workers from the United States, Australia, Canada and Europe [3]. There have been few studies of non-Asian foreign workers living in Taiwan and little is known about how this high level of TCM availability is accessed and used by this population. Previous studies about TCM utilization were mostly among people with a Chinese ethnic background [4‐7]. Few have investigated TCM use by Western workers in an Asian country.

Anderson and Newman's model of health service utilization views an individual's use of health services as a function of predisposing factors (factors that exist prior to the health service utilization), enabling factors (the individual's ability to secure services), and need factors (the individual's illness level and health status) [8]. Their model provided a useful basis in a previous study investigating the use of complementary and alternative medicine among Chinese-American families in the United States [9]. The objectives of this study were to investigate the prevalence and patterns of TCM use among non-Asian white-collar workers living in Taiwan, and examine factors likely to influence utilization of TCM. Identification of factors indicating likelihood of TCM utilization was based on Anderson and Newman's model of health service utilization [8].

This study demonstrated that 45% of non-Asian white collar workers had utilized one or more types of the TCM therapies in Taiwan. There is an absence of knowledge concerning the use of traditional Chinese herbs/medicine and joint manipulation by non-Asian populations, but the rate was believed to be low. Acupuncture however, is becoming adopted as a form of health care in many countries, with utilization rates of 10 % reported in Australia, 9% in the UK, and 19% in Austria, [10‐13]. Chen et al (2006) indicated a national TCM usage prevalence of 28.4% in the year 2001, and 62.5% of the population using TCM at least once during the 6-year period from 1996 to 2001 under Taiwan's NHIS [14]. The two most frequent types of TCM used in this study were traditional Chinese herbs/medicine and acupuncture, which is similar to patterns of use by the national population [14, 15].

Participants used TCM predominantly for muscular and joint problems (59.6%). The other most common reasons or conditions stated were lung or respiratory complaints (18.1%); to promote wellness and quality of life (16.0%); stress (12.8%); fatigue and tiredness (11.7%) and digestive problems (10.6%). Chi et al. (1996) found the most common reasons for TCM use in Taiwan were musculoskeletal complaints (21%), injuries (15.3%) and digestive complaints (11.4%) [16]. Chen et al. (2006) reported similar reasons for TCM utilization in Taiwan [14]. Kang et al. (1998) also indicated the most common conditions treated by TCM practitioners were muscular problems (59.9%), bone fractures (35.5%), fatigue and weakness (25.8%) and respiratory conditions (25%) [17]. Different categorizations of study groups and reasons for seeking TCM in these studies limit the comparability of these findings to the results of this study. Nevertheless, participants utilized TCM for reasons akin to those of local TCM users. Almost two thirds (70.2%) of participants stated the treatment they received was effective. There is no comparative research on use of TCM by Westerners in Taiwan or elsewhere in Asia. Perspectives of effectiveness and communication between patients and health providers can be expected to vary between cultures [18]. A UK study of patient perspectives of complementary and alternative medicine (CAM) services under the National Health Services showed satisfaction with clinical care was high, with 81% indicating their problem had improved very much, moderately or slightly [19]. Singh et al. (2004) found 79% of CAM users from an Indian community living in South Africa reported positive outcomes after treatment [20].

The non-Asian workers in this study who had a family member or friend to help in use of TCM were more than twice as likely to be TCM users (OR 2.47). This result suggested that foreigners in Taiwan needed assistance in using TCM, which could be due to limitations in local language ability, lack of familiarity with TCM theories and treatment, and cultural differences. In Canada, Kelner and Wellman also found personal recommendation of a particular practitioner by a friend or family member was the main reason given by users for their choice of acupuncture and TCM [21]. The high association between very good to adequate information about TCM services in Taiwan and use of these services also suggests knowledge of TCM services affected the likelihood of utilization. A similar importance of patient knowledge of services available was also demonstrated in previous studies [13, 18, 20, 22]. Eisenberg (1993) and Coe (1999) also reported the most common reason identified for not using CAM is a lack of knowledge about what these services provide [18, 23]. Participants with an intermediate to advanced ability to read Chinese were most likely to be TCM users (OR 3.26). As an enabling factor, a high ability to read Chinese is also an indicator of acculturation i.e. knowledge of and/or experience with cultural nuances, values and practices in Taiwan. Chinese characters not only represent lexical vocabulary, but also contain symbols or radicals related to Chinese culture and tradition which affects how the characters are interpreted. Thus, the significance of this result was not unexpected. Participants with a high ability to read Mandarin were likely to have a better knowledge of TCM and better understanding and communication with TCM providers.

A significantly associated predisposing factor influencing TCM use in this study was age. This finding is consistent with Chen et al (2006), who reported that TCM utilization in Taiwan peaked in individuals around 30 years old and within the age ranges found to be significant in other findings of CAM utilization [14, 21, 24, 25]. Australian findings also demonstrated individuals between 25–44 years old were more likely to use CAM [22].

A higher likelihood was found between participants who had visited a modern allopathic doctor about a health problem in the previous year (OR 2.67). This result is consistent with other findings in Taiwan where use of both modern allopathic medicine and TCM are available [26]. Acupuncture patients have shown a positive association with the use of other health services [27]. Other research including that from Eisenberg (2001) and the World Health Organization (2000) also suggest many CAM users seek these therapies when allopathic medical treatment is ineffective or undesirable and when a combination of both treatment methods may be superior to only one [10, 28‐30]. In Taiwan the high availability and affordability of both modern allopathic medicine and TCM may also enable utilization of both, but further research is required to examine whether TCM is used as a complement to or a substitute for allopathic medicine.

This study found the prevalence of TCM utilization by non-Asian white collar foreign workers in Taiwan was higher than that in studies in the general population reported in Western countries. Predisposing factors (age), enabling factors (ability to read Chinese, family and friends available to assist in TCM use, and information on TCM services) and need factors (visit to an allopathic medical doctor), were the factors significantly associated with TCM use. Additionally, enabling factors appear to be more influential in the utilization of TCM by this population than predisposing or need factors under the model of health service utilization used in this study. This study provides new information on the pattern of TCM use by Western workers in an Asian country. Our results suggest that Western workers are likely to try traditional medicine that is different from that in their cultural background when Western allopathic medical services are also available and affordable. Strategies could be developed to overcome enabling factor-related barriers to increase access by Westerners to TCM services.