Medicinal & Aromatic Plants
Open Access

Knowledge, Attitudes and Practices (KAP) Towards Medicinal Plants among Malaysian Consumers

Nalini Arumugam^{* *}Correspondence: Nalini Arumugam, School of Agriculture & Biotechnology, Faculty of Bioresource and Food Industry, Universiti Sultan Zainal Abidin (UniSZA), Kuala Terengganu, Malaysia, Tel: +60 9-668 8888, Email:

Author info »

Introduction

Medicinal Plants (MPs) are commonly used by the local people as an alternative for health care. However, the extent to which consumers’ are knowledgeable on the benefits of medicinal plants cannot be ascertained as there is a lack of research being carried out to access the level of knowledge especially in Malaysia context. Furtheremore, the knowledge about medicinal plants were transferred by verbal communication from one generation to another and lead to poor transmission in tranferring the knowledge. The usage of medicinal plants is categorized under Complementary and Alternative Medicine (CAM).

Malaysian medicinal plants consumption

Salleh [1] reported that Malaysia imported approximately RM 1.2 billion herbal products for consumption every year. This figure is in rising trend as Rezai et al. identify that shifts in lifestyle and self-medication are main factors leading to the rised popularity of herbal medicine among Malaysians [2]. Therefore, entrepreneurs should well-versed about herbal purchasing trend of customers for instance how, how much, what and where is the product being bought to be a competitor in the herbal industry [3].

Herbal medicine has long been known for its beneficial effects. Alsarhan et al. [4] reviewed 10 most important medicinal plants in Malaysia as an alternative for synthetic antioxidants. In addition, Ghazali et al. [5] points out that cancer patients consumed Goniothalamus umbrosus, Typhonium flagelliforme, Myrmecodia pendens, Strobilanthes crispus and Clinacanthus nutans to fight against the cancer cells growth. Therefore, they suggested specific research on Malaysia herbs with anticancer properties should be performed to formulate an effective therapeutic approach as these plants contain high amount of phenolic compounds which could help in healing process.

Sekar et al. [6] also acknowledged 10 medicinal plants in Malaysia that contain hypoglycemic properties. They were normally consumed by diabetic patients. However it is recommended for more pharmacological and toxicological research to verify the potential of these plants. Abu Bakar et al. [7] had recognized 76 Malaysian medicinal plants that posseses anti-inflammatory agents with Melicope ptelefolia and Portulaca oleracea having strongest antiinflammatory activity.

Knowledge on medicinal plants

Knowledge is required to utilise the potentials of medicinal plants. As Hisham et al. [8] mentioned, adequate information is needed prior to use any herbal medicines and product. Normally, the traditional medicine man or ‘bomoh’ passed the traditional herbal knowledge from generation to generation via verbal communication (Lin, 2005).

The Department of Education (DOE) South Africa [9] has recommended the integration of Indigenous Knowledge (IK) and knowledge about medicinal plants to be included into the school science curriculum. This is a good initiative proposed to educate people about medicinal plants at an early age. Education on the importance and safety of herbal medicine is a requirement in pharmacy curriculum to ensure the quality of the local universities [10]. The ethnobotanical knowledge on medicinal plants and their uses by aboriginal cultures are important not only for the conservation of local knowledge and biodiversity but also to encourage community health care and role in drug development [11].

The younger people appear to be quite familiar with the good impacts of herbal medicine and food supplements. However they have lack experience and knowledge on them [12]. A study conducted by Suleiman [13] revealed that herbal medicine was frequently used by people but they have lack of knowledge on its correct usage. Awad and Al-Shaye [14] stated that there is a need for seeking medical officers advice before using herbal medicines. Jantan [15] stressed that pharmacists are the right persons to advise and educate people on herbal products therefore they need to have knowledge on the chemical constituents, contraindication, dosage, dose form, possible side effects, pharmacology and clinical controlled trials. They should always be updated with new scientific information on herbal products.

Attitude towards medicinal plants

Attitude is the perceptive, motivational, emotional and cognitive beliefs that influence the practice or behaviour of an individual in a positive or negative way. Attitudes are learned by observing behaviour of people in environments with different social and economic pressures [16]. A research carried out by Deshpande [17] on attitude of consumers proved that they are going green especially in the cosmetics market that used natural or herbal components. Jantan stated that consumers belief that no side effects from natural products and their dissatisfaction with modern medicine lead to popularity of herbal medicines. Majority of respondents among pregnant women in Nigeria consumed herbs during their pregnancy. They believed the use of herbal medicine is safe, natural, higher accessibility and cultural belief to treat many illnesses. Furthermore, herbal products were generally cheap compared to conventional medicine.

Practice of medicinal plants

The medicinal plants practitioners used the mixture of medicinal plant based on their formulations with prayers, religious or ritual recites before hands them to their patients [10]. The usages of medicinal plants as traditional medicine increased due to awareness on the effectiveness to cure the disease. A review on Malaysian traditional medicinal plants with therapeutic properties had listed 10 most important antioxidant plants that are naturally exist in many different parts of plants used to cure numerous ailments [4]. This is supported by a review by Smith et al. [18] stated that consumers gain benefits from medicinal plants through maintenance of health and treatment of illnesses. According to Sulaiman et al. majority of the respondents among urban community in Klang Valley believed that herbal product can enhance health related quality of life and relieve of serious of diseases. Medicinal plants were the most common treatment among diabetic patients which used by 84.9% of the respondents [19]. However, less than half of them consulted with their doctors on their usage. Increase of insulin secretion, reduction resistance against insulin and decrease the level of bad fats are the antidiabetic effects of medicinal plants [20].

Despite of medicinal plants benefit towards health; it can also act as pesticides. Chemical pesticide is the conventional and favourable way by farmers to encounter pest infestation through faster and easier method. However, major negative side effects either towards human, environment or other animals had initiated farmers to look for alternative plant-based pesticides. “Ecofriendlyagrochemicals” as proposed by Govil and Sanjib [21] could be potential and practical solution to prevent the consequences toward environment. Major factors of misuse of medicinal plants are misconception, ignorance, criminal intentions and accidental poisoning [22] therefore intensive public awareness about the medicinal plants is essential to avoid the misuse of plants [23].

East coast economic region

East Coast Economic Region include all the states in East Coast of Peninsular Malaysia; Kelantan, Terengganu and Pahang also included Northern of Johor (Mersing). The total area covered is 66,736 kilometer squares or 51% from the total area of Peninsular Malaysia. Abundance of land and natural resources are able to be utilized to boost the economy in East Coast region. Agriculture sector is one of the 12 National Key Economic Areas (NKEAs) incorporated in Economic Transformation Program (ETP).

Rohana et al. stated that there is a need for herbal industry to reduce the dependency towards imported raw materials. This can be achieved by empowering the producers of plant materials (nurseries) and farmers to fulfil the needs of herbal product and species commercialization. Thus, a good coordination between farmers and manufacturers is essential to balance the demand and supply in the chain. This initiative will ensure continuous supply of high quality herbal plants to fulfil every level of supply chain and Malaysia becoming the hub regional for medicinal plants.

Research Methodology

Theoretical framework

This study proposed the conceptual framework adapted and modified from Wan [24], as shown below (Figure 1). Eckman and Walker [25] claimed that KAP studies are more cost-effective and conserve resources than other social research methods because they are tightly focused and limited in scope. The KAP model proposes that knowledge about any practices (behaviour) will determine how the person’s attitude towards the behaviour then the attitude will display through the practices [26].

Figure 1: The conceptual framework of the study.

Independent and dependent variables

The independent variables for this study are knowledge on and attitude towards medicinal plants as components to determine the practice of medicinal plants. This study defined practice as consumption of medicinal plants.

Questionnaire design

The questionnaire was designed semi-strucured, a combination of open and close ended questions. The instruments applied for this study has been adapted and modified from the literature of the previous research conducted to suit with the current research. Questions related to KAP elements were recoreded based on a 10 point Likert-scale of interval with 1 ‘Strongly Disagree to 10 ‘Strongly Agree’.

Population and sample

The study was conducted in the east coast economic region (ECER) Terengganu, Kelantan, Pahang and Mersing, Northern of Johor, Malaysia. The respondents were chosen using the convenient sampling to identify respondents from the mass population [27]. The sampling population for this study was 300 subjects as recommended by Awang [28] following the 10-to-1 ratio sampling. There were 30 items in the questionnaire of this study, 10 items for knowledge, attitude and practice are equally distributed.

Data analysis

Analysis of data was conducted to transform the raw data into meaningful information by performing descriptive and inferential statistics using the International Business Machines Corporation Statistical Package for Social Sciences (IBM SPSS) Version 21.0 software. Descriptive analysis was carried out to retrieve the information of the respondents such as age, gender, religion, ethnic, marital status, education level, occupation, monthly income and locality. The relationship between demographic variables and knowledge, attitude and practice of medicinal plants were identified through Chi-Square Statistics. The cross tabulation of the demographic variables and knowledge, attitude and practice would show the correlation status and Chi-Square is responsible to test wether to accept or reject the null hypothesis. Multiple regression were used to determine the interaction between knowledge and attitude (independent variables) with practice (dependent variable). If the significant value was less than 0.05, we concluded that there was significant relationship between the independent and dependent variables. In addition, Pearson-Correlation Analysis determined the strength of relationship between knowledge and attitude with practice.

Results and Discussion

Profile of medicinal plants consumers

This section presents the results of the demographic profiles of medicinal plants consumers’, sources of knowledge about medicinal plants, frequency of use, and the medicinal plants that are known by consumers. Descriptive analysis was carried out to retrieve the information of the respondents such as age, gender, religion, ethnic, marital status, education level, occupation, monthly income and locality. There were 143 (47.7%) male and 157 (52.3%) female consumers with response rate of 75% from the study. The consumers mostly were married (66.3%). This could imply that the medicinal plants were popular among women for post-partum treatment and enhance reproductive system for male. This findings is correspondent with the survey by Sulaiman et al. which reported that herbal product consumption was important for female compared to male by means of 16.4% of the respondents consumed herbal products for the treatment of menstrual problem. Hussain et al. found that Labisa pumila is the most frequent herbal used in South-East Asian countries specifically among married woman. Moreover, a survey on attitude of medical students in Ghana showed 67.9% average attitude of female students have better attitude than male [29].

Majority of the subjects in this study were also Muslims and Malays as they are the main population in the East Coast area. The highest number of medicinal plants consumers are between 20 to 29 years old (n=93, 31.0%) compared to other age category showed the positive attitude towards medicinal plants from the youth population. This finding is supported by Zimmerman and Kandiah which showed that younger people appear to be quite familiar with good impacts of herbal medicine and food supplements. Moreover, 55.3% of the consumers had higher education background showing that wider awareness among them and more concern with health by choosing natural based products. A study among the American adults found that higher education was related with the increasing usage of herbal supplements [30]. Sulaiman et al. found that 53.4% of herbal consumers among Malaysian adults have tertiary level of education.

Sixty-seven percent of the consumers were from rural while 33% were from urban area. This study was congruent with those reported by Jazul that people lived in rural area were more exposed to medicinal plants due to the availability and accessibility of these plants in their locality [31]. Furthermore, traditional medicine using medicinal plant still become the primary health care system of resource poor communities in Medan as the result of easily accessible and the most affordable source of treatment [32]. Half of the respondents consumed medicinal plants only if necessary or recommended, whereas 73 persons (24.3%) taken for daily. There are 52 people (17.3%) consume once a week and 6.3% (n=19) respondents once a month. Kautsar et al. discussed the buying trends of herbal based products in Malaysia based on the frequency of usage herbal medicine, customer loyalty and buying intention [33]. Consumption of herbal products also influenced by the culture and ethnic according to the study by Aziz and Tey [34] and supported by Mitha et al. [35]. Besides that, Ching et al. mentioned that the chronic diseases suffered by the individuals also impact the usage of herbal goods. The most source of knowledge is from older generation 88.7% and 70.7% are family and friends who recommended the usage [36].

According to Jantan, herbal consumers measure the effectiveness based on the length of time herbal medicines have been used and handed down from generation to generation and most of them are strong believers and preservers of tradition. Besides that, 70% of the respondents referring to online sources as nowadays utilization of internet is widening and the information also world wide. Information regarding the herbal product promotion and sale by many websites in the internet becomes a famous source of reference among the consumers and practotioners.

Chi-square test

Chi-square test of independence was computed to assess the relationship between the demographic variables ; gender, age, marital status, education, occupation, monthly income and locality with consumers attitude. Furthermore, it displays that only marital status has rejected the null hypothesis. The data of knowledge on, attitude towards and practice of medicinal plants were transformed from interval scale to categorical before analysed. The cross tabulation of the variables will show either the hypothesis accepted or rejected. The results of Chi-Square was illustrated in Table 1.

Table 1: Results of Chi-square analysis.

According to Jazul, people live in rural area are more exposed to medicinal plants due to the availability and accessibility of these plants in their locality. Mohd Zahran et al. claimed that age and marital status contribute to the main factor in consuming herbal based products [37].

Multiple regression analysis

The multiple regression analysis is used to analyse the statistical significance between the knowledge and attitude (independents) towards practice (dependant variables). The results revealed value of R² = 0.574 meaning that both independent variables; knowledge and attitude together fitted 57.4% of the variance (R square) towards practice of medicinal plants. Therefore, both independent variables have significant relationship with the dependent variable. The unstandardized B coeffecient (0.041) is positive value point out positive relationship as the knowledge and attitude increase, the practice also will increase. The knowledge increase by (0.287) and attitude by (0.609) and can be simplified by the equation as follows:

Practice = 0.041 + (0.287) Knowledge + (0.609) Attitude

Jantan suggested there is a need for pharmacists and physicians to have adequate knowledge about traditional herbal medicine in order for them to consult the community on the importance, quality, safety and appropriate use of herbal products. A total of 270 (98.5%) among respondents agree about the importance towards Traditional Medicine (TM) health education about the risks and benefits [38] showing that the awareness regarding the knowledge of TM based on survey conducted at Plateau, Nigeria. Jantan denied although medicinal plants have been utilized in folk medicine for a long time it cannot just be claimed safe therefore, it is a requirement for manufacturers to include the information regarding the contraindications and possible side effects before registering the crude drugs for commercialization however, there are less concern of some people specifically herbal traders that medicinal plants are natural. The belief that herbal can improve ones’ health living among people in the developed countries for example United Kingdom, Australia and the remaining of Europe and North America become major purpose looking for herbal therapy. Moreover, those with chronic diseases can easily misperception with claims on herbal products as long as that gives hope thus they are willingly to spend money on alternative therapies for self-medication [15]. Ghimire et al. supported that adult people tend to have more probability for chronic diseases therefore they tend to combine herbal remedies and drug medicines [39].

Pearson correlation analysis

The Table 2 below confirms that a significant positive relationship exists between knowledge on and attitude towards the practice of MPs. Knowledge and practice illustrates moderate relationship whereas attitude and practice has a strong relationship. A finding from a survey in Trinidad Venezuela showing that most of the herbal users agreed that herbal products are effective and some believed herbal products are more effective compared to modern medicines [40]. Hence, Ekor study is congruent with the outcome of this research that relationship attitude and practice are stronger than knowledge and practice where people will consume the medicinal plants when they have good attitudes and beliefs [41-47].

Table 2: Pearson correlation value.

Conclusion

This study is anticipated positive behaviour on medicinal plants consumption. Scientific research also need to be conducted for reliable and trusted evidence to rise the confidence among the consumers. Furthermore, it will helps to empower the local community in enhancing their economic status. The outcome from this study on the level of knowledge towards medicinal plants of people showed there is a need for an aggressive promotion to create awareness among people about existence of various medicinal plants species with valuable benefits.

Acknowledgement

This work was supported by the Special Research Grant Scheme (SRGS) with project code UniSZA/2017/SRGS/27.

References

1. Salleh MN. The forest can cure all ills: Myth or reality. In Proceedings of the seminar - Medicinal Plants. In: Cure for the 21st Century. Nair MNB & Ganapathi N (eds.), Universiti Putra Malaysia, Serdang, Malaysia, 1998; p: 1-6.
2. Rezai G, Mohamed Z, Shamsudin MN, Zahran MZ. Effect of consumer demographic factors on purchasing herbal products online in Malaysia. International Journal of Social, Management, Economics and Business Engineering 2013;7:2380–2386.
3. Ismail S, Mohd Mokhtar SS. Buying patterns of herbal-based  products in Malaysia. IJMS 2017;24:91–118.
4. Alsarhan A, Sultana N, Al-Khatib A, Rafiq M, Kadir A. Review on some Malaysian traditional medicinal plants with therapeutic properties. J Basic Appl Sci 2014;10:149–159.
5. Ghazali WASW, Alim AA, Kannan TP, Ali NAM, Abdullah NA, Mokhtar KI. Anticancer properties of Malaysian herbs: a review. USM Arch Orofac Sci 2016;11:19–25.
6. Sekar M, Zulhilmi M, Hamdi AY, Nabila N, Zahida Z, Shafiq M. Ten commonly available medicinal plants in Malaysia used for the treatment of diabetes-a review. Asian J Pharm Clin Res 2014;7:1-5.
7. Abu Bakar FI, Abu Bakar MF, Abdullah N, Endrini S, Rahmat A. A Review of Malaysian Medicinal Plants with Potential Anti-Inflammatory Activity. Adv Pharmacol Sci 2018;2018:1-13.
8. Hisham MM, Madhu MVDT. International market scenario of traditional indian herbal drugs-india declining. Int J Green Pharm 2009;184-190.
9. Curriculum Assessment and Policy Statement (CAPS) document physical sciences grades 10-12: Department of Education (DOE.). Pretoria: Government Printers. 2011
10. Jantan I. The real value of medicinal plants in traditional health care. In: Proceedings of the Seminar- Medicinal Plants: Cure for the 21st Century. Nair MNB & Ganapathi N (eds.), Universiti Putra Malaysia, Serdang. Malaysia. 1998;pp:20-24.
11. Sheng-Ji P. Ethnobotanical approaches of traditional medicine studies: Some experiences from Asia. Pharm Biol 2001;39:74–79.
12. Zimmerman C, Kandiah J. A pilot study to assess students' perceptions, familiarity, and knowledge in the use of complementary and alternative herbal supplements in health promotion. Altern Ther Health Med 2012;18:28-33.
13. Suleiman AK. Attitudes and beliefs of consumers of herbal medicines in Riyadh, Saudi Arabia. J Community Med Health Educ 2014;4.
14. Awad A, Al-Shaye D. Public awareness, patterns of use and attitudes toward natural health products in Kuwait:A cross-sectional survey. BMC Complement Altern Med 2014;14:105.
15. Jantan I. The scientific values of malaysian herbal products. Jurnal Sains Kesihatan Malaysia 2006;4:59–70.
16. Tarkang EE. Knowledge, attitudes and perceptions regarding HIV/AIDS and sexual behaviours among senior secondary school learners in Kumba, Cameroon. Health (San Francisco), USA, 2009.
17. Deshpande SM. Study of current market scenario & marketing prospects against changing attitude of consumers towards buying of Ayurvedic medicines in India. Int J Bus and Manag Inven 2015;4:48–54.
18. Smith-Hall C, Larsen HO, Pouliot M. People, plants and health: a conceptual framework for assessing changes in medicinal plant consumption. J Ethnobiol Ethnomed 2012;8:43.
19. Sheikhrabori A, Dehghan M, Ghaedi F. Complementary and alternative medicine usage and its determinant factors among diabetic patients : An Iranian case. J Evid Based Complementary Altern Med 2017;22:449–454.
20. Adusumilli PS, Ben-Porat L, Pereira M, Roesler D, Leitman M. The prevalence and predictors of herbal medicine use in surgical patients. J Am Coll Surg 2004;198:583-590.
21. Govil JN, Sanjib B. Neem Oil: biological activities and usage. “Recent progress in medicinal plants” (RPMP)” Fixed Oils and Fats of Pharmaceutical Importance, Studium Press. 2012;33.
22. Vij K. Text Book of Forensic Medicine and Toxicology: Principles and Practice. (2nd edn), Churchill BI Livingstone, New Delhi. 2002.
23. Jha P, Karmacharya S, Balla M, Chettri M, Shrestha B, Prakash Sharma O. Misuses of medicinal and aromatic plants as poisons:A study of plant poisoning cases in Nepal. Sustainable Use of Biological Resources in Nepal 2010;245–249.
24. Wan TTH. A transdisciplinary approach to health policy, research, and evaluation. Int J Public Pol 2014;10:161–177.
25. Eckman K, Walker R. Knowledge, attitudes and practice (KAP) Survey-summary report for the Duluth Lakeside stormwater reduction project (LSRP). Duluth: Water Resources Center, University of Minnesota. 2008.
26. Alzghoul BI, Abdullah NAC. Psychosocial theories and pain management practices: A review of empirical research. Mediterr J Soc Sci 2015;6: 60–67.
27. Awang Z. SEM made simple a gentle approach to learning structural equation modelling. Bandar Baru Bangi: MPWS Rich Publication Sdn. Bhd. 2015.
28. Ameade EPK, Amalba A, Helegbe GK, Mohammed BS. Herbal medicine: A survey on the knowledge and attitude of medical students in tamale, Ghana. Peak J Med Plant Res 2015;3:1–8.
29. Rashrash M, Schommer JC, Brown LM. Prevalence and predictors of herbal medicine use among adults in the United States. J Patient Exp 2017;4:108–113.
30. Jazul JP, Catublas HAL. Knowledge, attitudes and practices in the use of herbal medicine: The case of urban and rural mothers in the Philippines. 2016;43:1–16.
31. Siregar RS, Supriana T, Haryanti S. The effect of consumers’ perception to the satisfaction of use of traditional medicines in Medan The effect of consumers’ perception to the satisfaction of use of traditional medicines in Medan. Earth & Environ Sci 2018;122:1–5.
32. Kautsar AP, Moniek Ayunovani FS, Surahman E. The influence of demographic, social system, communication system, and herbal characteristics on purchase decisions of herbal medicine in Indonesia, 2016;4:235–238.
33. Aziz Z, Tey NP. Herbal medicines: Prevalence and predictors of use among Malaysian adults. Complement Ther Med 2009;17:44–50.
34. Mitha S, Nagarajan V, Babar MG, Ahmad Siddiqui MJ, Qasim Jamshed S. Reasons of using complementary and alternative medicines ( CAM ) among elderly Malaysians of Kuala Lumpur and Selangor states : An exploratory study. J Young Pharm 2013;5:50–53.
35. Ching SM, Zakaria ZA, Paimin F, Jalalian M. Complementary alternative medicine use among patients with type 2 diabetes mellitus in the primary care setting: A cross-sectional study in Malaysia. BMC Complement Altern Med 2013;13:148.
36. Mohd Zahran MZ, Rezai G, Mohamed Z. Predicting Consumer Intention to Shop Herbal Products Online: An Empirical Investigation. In: 2nd  International Conference On Management (2nd ICM 2012) Proceeding. 2012;984–995.
37. Ohemu TL, Sariem CN, Dafam DG, Ohemu BO, Okwori VA, Olotu PN, et al. Knowledge, Attitude and Practice of Traditional Medicine Among People of Jos North Local Government Area of Plateau State, Nigeria. Int J Pharmacogn and Phytochem Res 2017;9:1353–1358.
38. Ghimire K, Banerjee J, Gupta AK, Dahal P. Phytochemical constituents and pharmacological uses of medicinal plant achyranthes aspera: a review. World J Pharm Res 2015;4:470–489.
39. Ekor M. The growing use of herbal medicines: Issues relating to adverse reactions and challenges in monitoring safety. Front. Pharmacol, 2014;10:1–10.
40. Adeleke AO. Investigation into the factors affecting the attitudes of consumers towards the consumption of herbal medicines in Nigeria. European J Bus Manag 2015;7(26):9-20.
41. Awang Z, Mohamad M. A step by step guide in writing proposal for postgraduate students. Bandar Baru Bangi: MPWS Rich Publication. 2016.
42. Awang Z, Afthanorhan A, Mamat M. The Likert scale analysis using parametric based Structural Equation Modeling (SEM). Computational Methods in Social Sciences 2016;4:13–21.
43. Nik Hazlina NH, Azidah AK, Wan Mohd WB, Intan IH, Dayang MM, Norlela S, et al. A pilot study on the safety and cardiovascular effects of BioLabisiaTM on post-menopausal women. Int Med J 2009;16:137-48.
44. Kotler P, Keller KL, Koshy A, Jha M. Marketing management- A South Asian perspective. (14th edn), In: New Delhi: Dorling Kindersley (India) Pvt. Ltd. 2014.
45. Naresh B, Reddy DB. Impact of perception on consumer purchase behavior of Herbal Product in India. Indian J Res 2016;5:233-235.
46. Robbins SP, Judge TA. Organizational behavior (15th edn), New Jersey: Pearson Education, USA. 2013.