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. 2023 Sep 29;30:16–22. doi: 10.1016/j.echu.2023.08.002

Public Awareness of the Traditional and Complementary Medicine Act Governing Chiropractic in Malaysia: A Survey of Adults in Klang Valley

Yi Kai Wong a,⁎, Michael Thomas Haneline b, Kok Leong Tan c
PMCID: PMC10562678  PMID: 37822922

Abstract

Objective

This study aimed to assess the level of awareness of the traditional and complementary medicine law governing chiropractic among adults in Klang Valley, Malaysia.

Methods

A cross-sectional study was conducted of patients attending the following 4 health care services: medicine, dentistry, pharmacy, and chiropractic. The study ran from July to November 2018. Data were collected through self-administered questionnaires and reported using descriptive statistics. Variables included demographic characteristics and awareness of the Traditional and Complementary Medicine Act 2016 (Act 775).

Results

We obtained 440 responses, 186 (42.3%) from men and 254 (57.7%) from women, with ages ranging from 18 to 81 years. The majority of respondents (97.3%) were Malaysian from the non-Malay ethnic group. Almost half (47.5%) of the respondents had a bachelor's degree. The awareness of the traditional and complementary medicine law governing chiropractic was low (4.8%). Binary logistic regression revealed marital status as the only significant predictor of awareness of the Traditional and Complementary Medicine Act, with married individuals showing higher awareness (adjusted odds ratio: 2.77; 95% CI, 1.38-5.58).

Conclusion

For this sample of adults, the awareness of the Traditional and Complementary Medicine Act 2016 governing chiropractic was found to be low. As the regulation of chiropractic is still new in Malaysia and other Asian countries, efforts are needed to increase public awareness to ensure the safety and quality of chiropractic services.

Key Indexing Terms: Awareness, Chiropractic, Government Regulation, Malaysia, Traditional Medicine Practitioners

Introduction

The profession of chiropractic, which traces its origins back to the inaugural adjustment performed by Dr. Daniel D. Palmer in 1895, has experienced considerable growth and international recognition over the years.1, 2, 3, 4, 5, 6, 7 This growth is not merely in terms of practice but also in the establishment of regulatory frameworks across multiple countries. The journey of chiropractic regulation began in the United States, with Illinois becoming the first state to recognize and license chiropractic in 1913.1, 2, 3, 4, 5, 6, 7 This recognition marked a milestone, setting a precedent for other regions to follow. In Canada, Alberta emerged as the pioneer in chiropractic licensing in 1923.1, 2, 3, 4, 5, 6, 7 The wave of regulation then reached Europe, with the Canton of Zürich, Switzerland, enacting the first legislation to regulate chiropractic in 1939.1, 2, 3, 4, 5, 6, 7

These individual efforts culminated in the formation of international organizations dedicated to chiropractic. Established in 1906 at the Palmer School of Chiropractic, the Universal Chiropractors’ Association (UCA) emerged as one of the pioneering organizations in the profession.8 The UCA aimed to address the burgeoning demands of the profession by providing insurance to its members and establishing a legal division overseen by Tom Morris, who had previously served as Wisconsin's lieutenant governor. Following the UCA's establishment, the International Chiropractic Association was established in 1926, followed by the European Chiropractors’ Union in 1932.9 These organizations aimed to unify and represent the global chiropractic community. A notable achievement was the World Chiropractic Summit in 1987, which led to the creation of the World Federation of Chiropractic. The World Federation of Chiropractic's recognition as a non-governmental organization in official relations with the World Health Organization in 1997 further solidified the standing of chiropractic in the global health care landscape.10

In Asia, Hong Kong, the Philippines, Thailand, and Malaysia have recognized and regulated chiropractic by law.11, 12, 13, 14 Hong Kong was the first in Asia to legislate chiropractic in 1993, followed by the Philippines in 1997.11,12 In 2007, Thailand's Ministry of Public Health licensed chiropractic.13 In Malaysia, chiropractic is classified as a traditional and complementary medicine (TCM) practice area.15 The Malaysian Ministry of Health established the Malaysian Traditional and Complementary Medicine Division in 2004. In 2006, Traditional and Complementary Medicine Units were created in selected Malaysian Ministry of Health facilities to integrate traditional and complementary medicine within the national health care system.

The first Traditional and Complementary Medicine Act (Act 756) was published in Malaysia in 2013.16 However, Act 756 was replaced by the Traditional and Complementary Medicine Act 2016 (Act 775),14,16 which was published on March 10, 2016, and came into force on August 1, 2016.15,17 Following the enforcement of Act 775, the Traditional and Complementary Medicine Council was formed on January 16, 2017, to regulate TCM services in Malaysia. With the Council's recommendation, the Malaysian Minister of Health recognized chiropractic as a practice area under Act 775 on August 1, 2017.18 The recent revision of the Fees (Medical) (Amendment) Order 2017 under the Fee Act 1951 (Act 209) included chiropractic services in the public hospital fee structure.19 This marked significant progress for the integration of chiropractic into the Malaysian health care system. However, the framework for the regulation of TCM professions in Malaysia, including chiropractic, is still under development and will require further refinements to ensure comprehensive oversight and standardization.

The enforcement of Act 775 was carried out in 3 stages to regulate TCM practices. The first stage recognized 7 practice areas, including traditional Malay medicine, traditional Chinese medicine, traditional Indian medicine, homeopathy, chiropractic, osteopathy, and Islamic medical practice.18 The Federation of Complementary and Natural Medical Associations Malaysia was designated as the organization overseeing chiropractic and osteopathy on August 1, 2017.20 The second stage, enforced on March 1, 2021, began the registration of all TCM practitioners in Malaysia, including chiropractors. The timing of the final stages of the enforcement of Act 775 has not yet been announced by the Ministry of Health Malaysia.

The importance of studying people's awareness of a law, such as the Traditional and Complementary Medicine Act, is crucial for public safety, informed decision-making, and the overall development of chiropractic practice in Malaysia. When people know that a profession is subject to regulation, it can instill confidence in prospective patients and reassure them that the government has set standards for quality and safety. This understanding is essential for the public to make informed decisions about their health care choices and for the development of the chiropractic profession in Malaysia. Studies in other health care professions, such as medicine and dentistry, have shown that public awareness of regulatory frameworks significantly impacts patient trust and health care-seeking behaviors.21,22 Given the relatively recent recognition of chiropractic in several Asian countries, understanding public awareness in this context becomes even more vital.

Despite the regulation of chiropractic in Asia since 1993, only 4 out of 48 countries in the Asian region have recognized, accepted, and licensed Doctors of Chiropractic. This limited recognition and integration can lead to potential challenges in ensuring standardized care, patient safety, and professional accountability. Moreover, without proper recognition and integration into the public health care system, patients might not have access to qualified chiropractic care, leading to potential health risks from unlicensed practitioners. Our study focuses on Malaysia, 1 of the countries in the Asian region, to assess the public's awareness of the Traditional and Complementary Medicine Act governing chiropractic. By understanding the level of public awareness, we can gauge the effectiveness of the act's implementation and its impact on public perception and trust in chiropractic services. Therefore, the purpose of this study was to determine the public's awareness of the TCM law governing chiropractic among adults in Klang Valley, which comprises a heavily populated area that includes Kuala Lumpur and several surrounding cities.

Methods

Ethics

The study was approved by the International Medical University Joint Committee on Research and Ethics.

Study

This cross-sectional study invited adults aged 18 years and above residing in Malaysia. The study was conducted from July to November 2018 in private health care centers in Klang Valley covering the following 4 health care disciplines: chiropractic, medical, dental, and pharmacy. The selection of these health care centers was based on convenience sampling and included the health care centers that were most accessible to us. This method was chosen due to the constraints of time and resources.

The questions for the present study were from a questionnaire used in a larger study (master thesis), which includes sections on participants’ demographics, public utilization of chiropractic, public awareness of chiropractic, regulation of chiropractic, and patients’ trust in chiropractic. The questionnaire was reviewed and vetted by the Board of the Association of Chiropractic Malaysia to ensure its relevance and validity. Specifically, the questions related to the regulation of chiropractic included the following: (1) Is there any law in Malaysia which governs chiropractic? (Yes; No); (2) If Yes, which law in Malaysia governs chiropractic? (Allied Health Profession Act; Dental Act; Medical Act; Traditional and Complementary Medicine Act)

The inclusion criteria were as follows: (1) aged 18 years and above; (2) residing in Malaysia; (3) able to understand the objective of the research; (4) literate in either English, Malay, or Chinese language; and (5) participants were invited regardless of their familiarity with chiropractic. The exclusion criteria were as follows: (1) chiropractic practitioners in Malaysia; and (2) chiropractic students in Malaysia.

The sample size was calculated using PS Power and Sample Size Calculation software (Vanderbilt University), with a confidence level set at 95%, a sampling frame population at 13,000, and a prevalence of TCM usage at 55.6%.23 After adding 20% for nonrespondents, the calculated sample size was 440. The respondents were proportionately distributed among the 4 health care disciplines, with each discipline providing 110 respondents.

Survey

Data were collected using a self-administered printed questionnaire, which included questions about the participants’ demographics and 2 questions about the awareness of the TCM law as stated above. The questionnaires were enclosed in an envelope and passed on to the participants by the center's staff. Questionnaires were collected from the centers by the investigator at the end of the study period. Data were entered into a spreadsheet and double-checked for accuracy.

A total of 475 questionnaires were distributed among these health care centers. The distribution was done by the staff at these centers, and the answered questionnaires were collected by the investigator at the end of the study period. All the questionnaires were returned, giving a response rate of 100%. However, 35 of these questionnaires were incomplete and thus were excluded from the final analysis, leaving us with 440 completed questionnaires.

Data Analysis

Statistical analysis was carried out using Statistical Package for the Social Sciences Statistics Version 25 (IBM Corp). We used binary logistic regression, and the level of significance was set at P < .05. Odds ratios and 95% CIs were calculated as a measurement of association between an independent variable and the outcome. All variables associated with the level of awareness of TCM law governing chiropractic in the univariate analyses were included in the initial multivariate model. Variables were excluded from the final logistic model if they were not associated with a level of awareness, and their removal from the model did not materially affect the association of other variables in the model based on the algorithm proposed by Hosmer and Lemeshow.

Results

Of the 475 questionnaires distributed within Klang Valley from July to November 2018, a total of 440 completed questionnaires were received. The number of completed questionnaires was collected from the following disciplines: chiropractic (110), medical (110), dental (110), and pharmacy (110). The demographics of the respondents are listed in Table 1.

Table 1.

Social Demographic Characteristics of the Incomplete Responses (n = 35)

Characteristics n (%)
Sex Male 186 (42.3)
Female 254 (57.7)
Age, y ≤35 283 (67.2)
(n = 421) 36-55 114 (27.1)
≥56 24 (5.7)
Nationality Malaysian 428 (97.3)
Non-Malaysian 12 (2.7)
Ethnicity Malay 171 (38.9)
Non-Malay 269 (61.1)
Marital status Married 188 (43.1)
(n = 436) Not currently married 248 (56.9)
Highest education level Primary school 14 (3.2)
Secondary school 77 (17.5)
College/diploma 107 (24.3)
Bachelor's degree 209 (47.5)
Master's degree 24 (5.4)
PhD/post-doctorate 6 (1.4)
Other 3 (0.7)
Employment status Employed 283 (64.4)
(n = 439) Unemployed 156 (35.6)
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Of all respondents, 8.9% (39) believed that a law governing chiropractic exists in Malaysia, whereas 91.1% (401) were either unsure or believed that no such law exists. Among these respondents, 53.8% (21) correctly identified the correct law, which was the Traditional and Complementary Medicine Act. Thus, approximately 4.8% (95% CI, 2.8-6.8) of the respondents were aware of the Traditional and Complementary Medicine Act.

Marital status was a significant predictor of awareness of the Traditional and Complementary Medicine Act. Specifically, being married was associated with higher odds of being aware of the Act (adjusted odds ratios: 2.77; 95% CI, 1.38-5.58). Sex, age, nationality, ethnicity, education level, and employment status were not significant predictors in the model.

Discussion

The present study provides insight into the amount of public awareness of the law regulating the practice of chiropractic. Public awareness of the Traditional and Complementary Medicine Act is important, as the law protects patients from receiving care from untrained people who may be claiming to offer chiropractic services. Thus, public awareness of the regulation is crucial for public safety and informed decision-making for all stakeholders. The Malaysian government has provided standards for the quality and safety of chiropractic care, and our study has shown that greater public awareness is needed.

In recent years, Malaysia has made strides in the regulation of traditional and complementary medicine, including chiropractic practices. The Traditional and Complementary Medicine Act, introduced and enforced in 2016, stands as a testament to this progress. This act was not just a preliminary move but a definitive regulatory framework for various traditional and complementary medicine practices in the country. With the enforcement of this act, chiropractic practices in Malaysia are now under a clear set of guidelines and standards, ensuring standardized care, patient safety, and professional accountability.

In this study, we found the majority (95.2%) of the sample of the population was not aware of this act. The Malaysian Ministry of Health has made efforts to increase awareness through workshops and briefings, such as the 8th International Traditional & Complementary Medicine Conference, Exhibition and Carnival and the 9th International Traditional and Complementary Medicine Conference.24, 25, 26 Information about the Traditional and Complementary Medicine Act is prominently featured on the Ministry's official website, specifically on their dedicated page for the act.27 However, the frequency and reach of these notifications might not have been sufficient, or the methods used might not have been effective in capturing the attention of the broader public. This suggests that there's a need for more targeted and frequent public awareness campaigns, possibly leveraging digital platforms and community influencers, to ensure that the public comprehends the implications of this act fully.

Our study found that marital status was a significant predictor of awareness of the act, with married individuals showing higher odds of being aware. This could be attributed to the possibility that married individuals have more exposure to health-related information.28,29 However, it is important to note that this association does not imply causation, and further research is needed to explore the underlying mechanisms of this association.

Chiropractors play a multifaceted role in the health care landscape, not only as treatment providers but also as educators, advocates, and gatekeepers for the health and well-being of their patients.30 In the context of the Traditional and Complementary Medicine Act, their role becomes even more pronounced. It is essential for patients to understand the regulatory framework that governs chiropractic practice, not merely for legal compliance but as a foundation for trust and transparency.31

Awareness of the act is important for several reasons. Firstly, it ensures that patients recognize the standards and regulations chiropractors adhere to, empowering them to make informed health care decisions.31 This is particularly important given that shared decision-making, where patients are actively involved in their health care decisions, has been identified as a key component to improve the quality of care delivered.32 Secondly, it reassures patients that their chiropractor operates under a recognized regulatory framework, which inherently promises a certain level of quality and safety.30 This awareness can significantly enhance the trust between the patient and the practitioner.30 Furthermore, by incorporating discussions about the act during consultations, chiropractors can also inspire patients to champion the importance of regulated chiropractic care within their communities.30

While some might argue that discussing an “Act” could detract from valuable treatment time, it is an invaluable investment in patient education and trust-building.33 Ensuring compliance with the act not only safeguards the public by guaranteeing standardized care but also reinforces the credibility of the chiropractic profession. It serves as a testament to the profession's commitment to transparency, quality, and, above all, patient safety.33

The regulation of chiropractic is a relatively new phenomenon in the Asian region. Only a few countries, such as Thailand, the Philippines, and Hong Kong, have regulations in place. In contrast, the United States has over 50 chiropractic regulation boards, each representing a state.34, 35, 36 Policymakers in Malaysia could draw valuable lessons from these countries. Some of these lessons include the establishment of clear practice guidelines, continuous professional development requirements, stringent licensing examinations, and public awareness campaigns about the benefits and safety of chiropractic care.37 Implementing such measures can not only enhance the effectiveness of the Traditional and Complementary Medicine Act but also elevate the standard of chiropractic care in Malaysia.

The significance of understanding the regulatory frameworks in health care, such as the Traditional and Complementary Medicine Act, cannot be understated. While this study primarily focused on gauging the awareness levels of the Act in Malaysia, it inadvertently highlighted a broader issue—the general lack of research on public awareness of health care regulations, both locally and internationally.38 Our findings underscore the importance of expanding research efforts to encompass a more diverse cross-section of the Malaysian populace. A notable observation from our study was the absence of significant associations between awareness of the act and various demographic variables, including sex, age, nationality, ethnicity, education level, and employment status.39 This observation suggests that these demographic factors might not play a pronounced role in influencing awareness about the act. However, it is essential to approach this finding with caution, as other studies have shown varied relationships between demographic factors and awareness of health care regulations.40

It has been recognized that there are challenges when addressing TCM regulation in Asian countries.41 Policymakers and health care professionals in Malaysia, particularly those involved in chiropractic practice, should consider these findings when developing strategies to increase public awareness about chiropractic regulation. This study also provides a foundation for future research on public awareness of chiropractic regulation in other countries or regions, which could lead to a more comprehensive understanding of this issue globally. Finally, the findings could inform the development of educational materials and campaigns aimed at increasing public understanding of chiropractic regulation under the Traditional and Complementary Medicine Act.

Limitations and Future Studies

This study was not conducted on a population-weighted sample, so it is less likely to be representative of the general population. Weighted samples are used to adjust the results of a study to bring them more in line with what is known about a population. Sampling was also done by convenience rather than random sampling, which also limits the generalizability of the study's findings. Due to limited time and resources, this study was not able to cover all states in Malaysia, only the Klang Valley area. A future study with a larger sample that covers all states in Malaysia is indicated to obtain a more comprehensive awareness of the Traditional and Complementary Medicine Act. It is possible that our study was underpowered and, therefore, was unable to detect small effects or that the effects of these variables were context-specific. Future research should consider exploring these possibilities.

Future studies examining the differences in awareness and regulatory practices across different countries could offer valuable insights for both policymakers and practitioners. Policymakers, in particular, could consider implementing more robust and widespread public awareness campaigns, potentially leveraging mass media and social media platforms. Regular monitoring and evaluation of the act's enforcement could help assess its effectiveness and inform necessary adjustments.

Conclusion

The awareness of the Traditional and Complementary Medicine Act governing chiropractic was low in our sample of adults in Klang Valley, Malaysia. This indicates a need for increased public education and awareness initiatives. Our study identifies being married as a predictor of higher awareness of the act. As the regulation of chiropractic is still new in Malaysia and other Asian countries, it is crucial to increase public awareness to ensure the safety and quality of chiropractic services.

Funding Sources and Conflicts of Interest

This study was funded by the International Medical University, Malaysia, with the Research Project No.: MSPH I-2018(01). No conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): Y.K.W., M.T.H.

Design (planned the methods to generate the results): Y.K.W., M.T.H., K.L.T.

Supervision (oversight, organization and implementation): Y.K.W., M.T.H., K.L.T.

Data collection/processing (experiments, organization, or reporting data): Y.K.W., M.T.H., K.L.T.

Analysis/interpretation (analysis, evaluation, presentation of results): Y.K.W., M.T.H., K.L.T.

Literature search (performed the literature search): Y.K.W.

Writing (responsible for writing a substantive part of the manuscript): Y.K.W., M.T.H., K.L.T.

Critical review (revised manuscript for intellectual content): Y.K.W., M.T.H., K.L.T.

Practical Applications.

  • •

    The study reveals a low level of awareness about the Traditional and Complementary Medicine Act 2016 (Act 775) among adults in Klang Valley, Malaysia.

  • •

    There is a gap in public knowledge about chiropractic regulation.

  • •

    The findings underscore the need for increased public education and awareness initiatives about chiropractic regulation, which could contribute to improved public health outcomes and patient safety.

Alt-text: Unlabelled box

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