Abstract
Betel quid chewing is a culturally-rooted oral health risk behavior that is prevalent in many Southeast Asian communities. Among Malaysia’s indigenous community, particularly in isolated areas, data on betel quid chewing remain limited. This study investigated the influencing factors and health perceptions of betel quid use among 180 adults from a Proto-Malay Orang Asli community in Peninsular Malaysia. A validated questionnaire adapted from national health survey gathered data on demographics, betel quid chewing habits, and knowledge and attitude on betel quid use. Descriptive statistics determined prevalence and health behavior, while bivariate and multivariate logistic regressions identified associated factors. The prevalence of current betel quid chewing was 75.9%. Chewing was more common among individuals aged ≥ 40, those with lower education, and those with strong family traditions of chewing. Multivariate analysis showed that older age (AOR = 1.126; 95% CI: 1.071–1.183; p < 0.001) significantly predicted current use. The findings highlight the need for culturally sensitive oral health strategies tailored to each indigenous communities.
Keywords: Orang asli, Betel quid chewing, Indigenous peoples, Oral health, Health behavior
Background
Betel quid chewing is a traditional practice which are prevalent in many parts of Asia particularly in the South and Southeast region [1, 2]. The term ‘betel quid’ refers to the use of betel leaf which is commonly accompanied with other substances such as areca nut and slaked lime, tobacco and spices such as cardamom, saffron and others. The ingredients varies according to different communities and geographical location. Betel quid chewing is a longstanding cultural tradition among indigenous communities and they believe it offers benefits such as pleasure, fresher breath, and stronger teeth [3].While culturally embedded, this practice poses significant public health concerns and has been classified as a Group 1 carcinogen by the International Agency for Research on Cancer [4]. The risk increases significantly when combined with tobacco, contributing to major public health concerns in the Western Pacific Region [5–7].
The Orang Asli, Malaysia’s Indigenous people, comprise diverse ethnolinguistic groups living primarily in rural and forested regions of Peninsular Malaysia. They represent about 0.6% of the Malaysia population and comprised of three main subgroups which are Proto-Malay, Negrito and Senoi [8]. Betel quid chewing is still practiced by the indigenous people in Malaysia as they can induce intoxication and euphoria. It is also a cultural practice of hospitality and most of them will present the guest with betel leaf, areca nut and slaked lime [3, 9]. Some children started chewing betel quid at an early age and they claimed that they copied their elders’ practice while some of them did so as a sign of respect [10, 11]. Despite the cultural significance, the Orang Asli in Malaysia had varying perceptions of the health effects associated with betel quid chewing. Some believed that betel quid had certain health benefits, particularly for oral hygiene while some of them were aware of the detrimental health effects of betel quid chewing such as oral cancer [12].
Despite this, comprehensive and up-to-date data on betel quid use particularly regarding its prevalence, frequency, and associated behaviors among the indigenous communities in remote or isolated settlements remain limited. This lack of epidemiological evidence hampers the design and implementation of targeted public health interventions. Most available research has focused on clinical consequences or urban populations, overlooking behavioral and sociodemographic determinants among Indigenous communities. Understanding the patterns and behaviours of betel quid chewers in these settings is crucial for the development of targeted, culturally sensitive health promotion strategies.
This study aims to address this gap by examining the prevalence of betel quid chewing and to examine its association with sociodemographic characteristics, knowledge, and attitudes among adults from a Proto-Malay Orang Asli community in Peninsular Malaysia. By identifying key demographic predictors and behavioral patterns, the findings may inform more effective, community-centered oral health interventions.
Methodology
The study was granted approval from The Research Ethics Committee of the Research Management Centre, Universiti Teknologi MARA and the Department of Orang Asli Development which is a Malaysian government agency entrusted to oversee the affairs of the Orang Asli (REC/05/2024(PG/FB/18)). Due to the cultural sensitivity of betel quid chewing and the historically limited engagement with indigenous communities, efforts were made to obtain community trust and approval before the study commenced. Discussions about personal health habits required a respectful and non-judgmental approach, and research was limited to one familiar community to maintain cultural appropriateness and participant comfort.
Study Design and Setting
This cross-sectional, community-based quantitative study was conducted in Kampung Orang Asli Pengkalan Tereh, Kluang, Johor, Malaysia which is one of the largest Orang Asli settlements in Peninsular Malaysia. The study was carried out between January and August 2024, with data collection conducted from July 4 to July 7, 2024.
Study Population and Sampling
The target population comprised Orang Asli adults aged 18 years and above residing in the selected village. Based on the Public Sector Open Data from the Department of Orang Asli Development (JAKOA), the total adult population in the village was 259. Using the OpenEpi sample size calculator with a 65% expected prevalence [10], a 5% margin of error, and a 95% confidence interval, the required sample size was estimated to be 180 after adjusting for a 20% non-response rate.
Simple random sampling was applied using address list obtained from the Pejabat Kemajuan Orang Asli Daerah (PKOAD) Kluang. The list of eligible individuals was numbered, and Microsoft Excel was used to randomly select participants.
Inclusion and Exclusion Criteria
Participants were eligible for inclusion if they were Malaysian citizens of Orang Asli ethnicity, aged 18 years and above, residing in Kampung Pengkalan Tereh. All participants were required to be able to understand, read, and write in Bahasa Malaysia and to provide written informed consent prior to participation. Individuals were excluded from the study if they had cognitive impairments that could affect their ability to understand the questionnaire or if they were unable to read or comprehend Bahasa Malaysia.
Study Instrument
A structured, self-administered questionnaire was used, comprising 19 items across three sections: (1) socio-demographic profiles (6 items), (2) betel quid-related behaviors (8 items), (3) knowledge and attitudes (5 items). The questionnaire was adapted from the TECMA 2016 survey developed by the Ministry of Health Malaysia, replacing “smoking” terminology with “chewing betel quid” to reflect study objectives [13].
Validity and Pilot Testing
Content validity was established through expert review by two specialists in Dental Public Health and two specialists from the Oral Medicine and Oral Pathology using the Content Validity Index Method [14]. The Content Validity Index (CVI) for relevance and clarity showed perfect agreement (S-CVI/Ave = 1.00; S-CVI/UA = 1.00). Face validity was evaluated through a pilot test with 15 Orang Asli adults from the study site. Participants provided feedback on comprehension, cultural appropriateness, and structure. Minor modifications were made to enhance clarity and relevance. The average completion time was 8–10 min.
Data Collection Procedures
Following community engagement and formal approval from the village leader (Tok Batin), data collection was conducted through home visits with the assistance of two local volunteers. Prior to this, several meetings were held between the research team and village leaders, as well as respected members of the community. These discussions helped shape culturally appropriate data collection strategies and build trust with the local population. Before participation, the background and aim of the study were clearly explained to all prospective participants. Each participant received a patient information document and provided written informed consent. Trained researchers then administered the structured questionnaire. All collected data were handled confidentially and securely stored in a password-protected database.
Data Analysis
Data were analyzed using IBM SPSS Statistics for Windows, Version 27.0. Descriptive statistics were used to summarise participants’ sociodemographic characteristics and betel quid chewing behaviors. Logistic regression analyses were performed to identify factors associated with current betel quid chewing. Multicollinearity was assessed before regression analysis using variance inflation factors (VIFs).
In the initial stage, crude odds ratios (OR) with 95% confidence intervals were calculated through bivariate logistic regression to assess the unadjusted associations between individual variables and current betel quid chewing. Variables with p-values less than 0.05 in the bivariate analysis were subsequently included in the multivariable logistic regression model to control for potential confounders, and adjusted odds ratios (AOR) were reported. A forward stepwise (Likelihood Ratio) regression method was applied to determine the most significant predictors of chewing behavior. Independent variables with p-values less than 0.05 in the final model were considered statistically significant. Sociodemographic factors such as gender, education level and household income were retained in the final model as these factors have been shown to be associated with betel quid use.
In this study, the researchers applied specific operational definitions to classify betel quid chewing behaviors among the Orang Asli population. A non-chewer was defined as an individual who did not engage in the practice of chewing either betel quid or betel leaf in any form. A betel leaf chewer referred to an individual who chewed betel leaf alone, without the addition of areca nut, slaked lime, or tobacco. In contrast, a betel quid chewer was defined as someone who chewed betel leaf in combination with one or more of the following: areca nut, slaked lime, or tobacco. A current betel quid chewer was classified as an individual who self-reported actively chewing betel quid at the time of the study or who had chewed betel quid at least once in the preceding 30 days. Finally, an ex-betel quid chewer referred to someone who had previously engaged in the habit but had not done so in the last 30 days, including those who had completely ceased the practice.
Results
Table 1 shows the demographic distribution of the participants. A total of 145 Orang Asli adults from Kampung Pengkalan Tereh in Kluang, Johor, participated in the study, yielding a response rate of 80.6%. The sample comprised 43.4% males (n = 63) and 56.6% females (n = 82), with the majority being of Proto-Malay ethnicity (97.2%, n = 141). The largest age group was 18–29 years (31.0%), followed by those aged 50–59 (20.0%), 30–39 and 40–49 (both 19.3%), and 60 years and above (10.3%). Over half of the participants (54.5%) had primary education, while 9.0% had no formal education. Only 3.5% had tertiary qualifications. In terms of employment, 42.8% were self-employed and 42.8% were not working, while the remaining participants worked in the private (12.4%) or government sector (2.1%). Household income data showed that 40.7% earned less than RM1,199 per month, 44.8% earned between RM1,200 and RM2,341, and 14.5% earned more than RM2,342. With regard to chewing behavior, 75.9% (n = 110) were current betel quid chewers, including those who consumed betel quid with areca nut, slaked lime, tobacco, or gambier. A small proportion (2.1%, n = 3) chewed betel leaf alone, while 24.1% (n = 35) were classified as non-chewers.
Table 1.
Sociodemographic characteristics of the Orang Asli participants in Kampung Pengkalan tereh, Johor in Peninsular Malaysia (n = 145)
| Variable | n | % |
|---|---|---|
| Gender | ||
| Male | 63 | 43.4 |
| Female | 82 | 56.6 |
| Ethnic | ||
| Proto-Malay | 141 | 97.2 |
| Senoi | 4 | 2.8 |
| Age | ||
| 18–29 years old | 45 | 31.0 |
| 30–39 years old | 28 | 19.3 |
| 40–49 years old | 28 | 19.3 |
| 50–59 years sold | 29 | 20.0 |
| 60 years old and above | 15 | 10.3 |
| Level of Education | ||
| No formal education | 13 | 9.0 |
| Primary school | 79 | 54.5 |
| Secondary school (Lower) | 15 | 10.3 |
| Secondary school (Upper) | 33 | 22.8 |
| Tertiary education | 5 | 3.4 |
| Occupation | ||
| Government sector | 3 | 2.1 |
| Private sector | 18 | 12.4 |
| Self-employed | 62 | 42.8 |
| Not working | 62 | 42.8 |
| Household Income | ||
| Less than RM 1,199 | 59 | 40.7 |
| Between RM 1,200 – RM 2,341 | 65 | 44.8 |
| More than RM 2,342 | 21 | 14.5 |
| Chewer Category | ||
| Non-chewer | 35 | 24.1 |
| Betel Quid | 107 | 73.8 |
| Betel Leaf | 3 | 2.1 |
1Chewed betel leaf with addition of areca nut/slaked lime/tobacco/gambier
2Chewed betel leaf without addition of areca nut/slaked lime/tobacco/gambier
The data presented in Table 2 explored the knowledge and attitudes towards betel quid chewing among the Orang Asli population. Among those who chewed betel leaf/betel quid, most initiated the habit at age 16 or older (30.3%), with 20.0% starting at 10–12 years and 13.8% at 13–15 years; a small proportion (2.1%) began at age 6 or younger. In the past 30 days, 26.9% reported no chewing, while 15.9% chewed daily. Occasional chewing (1–19 days) was reported by 30.6%. Daily frequency varied: 24.1% chewed once, 18.6% chewed 2–5 times, and 2.1% reported more than 10 times daily. Among current chewers (n = 110), 55.5% sourced ingredients from family, 39.0% from others, and 5.5% purchased them. Social exposure was high, with 71.7% witnessing chewing at home and 99.3% in the village. Nearly half (47.6%) said they would chew if offered, and 40.7% anticipated chewing in the next year. Over two-fifths (43.4%) believed quitting is difficult. Social and emotional perceptions were mixed: 38.6% felt chewing enhances social comfort, and 58.6% agreed it promotes happiness.
Table 2.
Knowledge and attitude of betel quid chewing (n = 145)
| Variable | Category | n | % |
|---|---|---|---|
| Age when first tried chewing betel quid | Never tried | 35 | 24.1 |
| ≤ 6 years | 3 | 2.1 | |
| 7–9 years | 14 | 9.7 | |
| 10–12 years | 29 | 20.0 | |
| 13–15 years | 20 | 13.8 | |
| ≥ 16 years | 44 | 30.3 | |
| Chewing days in past 30 days | Never tried | 35 | 24.1 |
| 0 day | 39 | 26.9 | |
| 1–2 days | 14 | 9.7 | |
| 3–5 days | 12 | 8.3 | |
| 6–9 days | 7 | 4.8 | |
| 10–19 days | 12 | 8.3 | |
| 20–29 days | 3 | 2.1 | |
| 30 days | 23 | 15.9 | |
| Chewing frequency per day (past 30 days) | Never tried | 35 | 24.1 |
| 0 | 39 | 26.9 | |
| 1 | 35 | 24.1 | |
| 2–5 | 27 | 18.6 | |
| 6–10 | 6 | 4.1 | |
| 11–20 | 1 | 0.7 | |
| 21–30 | 1 | 0.7 | |
| > 30 | 1 | 0.7 | |
| Source of betel quid(n = 110) | Grocery/stalls | 6 | 5.5 |
| Other people | 43 | 39.0 | |
| Family member | 61 | 55.5 | |
| Seen anyone chewing at home (past 30 days) | No | 41 | 28.3 |
| Yes | 104 | 71.7 | |
| Seen anyone chewing in village (past 30 days) | No | 1 | 0.7 |
| Yes | 144 | 99.3 | |
| Would chew if offered | No | 76 | 52.4 |
| Yes | 69 | 47.6 | |
| Intention to chew in next 12 months | No | 86 | 59.3 |
| Yes | 59 | 40.7 | |
| Belief: Hard to quit once started | No | 82 | 56.6 |
| Yes | 63 | 43.4 | |
| Belief: Chewing helps at social events | Less comfortable | 59 | 40.7 |
| More comfortable | 56 | 38.6 | |
| No difference | 30 | 20.7 | |
| Belief: Chewing makes people happy | Strongly disagree | 6 | 4.1 |
| Disagree | 54 | 37.2 | |
| Agree | 69 | 47.6 | |
| Strongly agree | 16 | 11.0 |
Table 3 presents perceptions of quitting difficulty and social comfort associated with betel quid chewing across different user categories. Overall, 43.4% believed quitting is difficult, with this view reported by 93.7% of chewers but only 3.2% of non-chewers (χ² = 26.893, p < 0.001).
Table 3.
Knowledge and attitude towards betel quid chewing among the Orang Asli population by chewing categories (n = 145)
| Variable | Definitely thought it is difficult to quit once someone starts betel quid chewing (N = 63) |
Definitely it is not difficult for them to quit once someone starts betel quid chewing (N = 82) |
Chi-Square Value | P-value* | Thought betel quid chewing helps people feel more comfortable at celebrations, parties and social gatherings (N = 56) |
Thought betel quid chewing helps people feel less comfortable at celebrations, parties and social gatherings (N = 59) |
Thought betel quid chewing helps people feel no difference at celebrations, parties and social gatherings (N = 30) |
Chi-Square Value | P-value* | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | |||||
| Non-Chewer | 2 | 3.2 | 33 | 40.2 | 26.893 | < 0.001* | 0 | 0.0 | 29 | 49.2 | 6 | 20.0 | 38.732 | < 0.001* |
| Betel Quid1 | 59 | 93.7 | 48 | 58.5 | 55 | 98.2 | 29 | 49.2 | 23 | 76.7 | ||||
| Betel Leaf2 | 2 | 3.2 | 1 | 1.2 | 1 | 1.8 | 1 | 1.7 | 1 | 3.3 | ||||
*Significant when P-value < 0.05
1Chewed betel leaf with addition of areca nut/slaked lime/tobacco/gambier
2Chewed betel leaf without addition of areca nut/slaked lime/tobacco/gambier
Regarding social comfort, 38.6% agreed that chewing improves comfort at gatherings. Among chewers, 98.2% endorsed this belief, while none of the non-chewers did. Nearly half of non-chewers (49.2%) felt chewing made no difference, and 20.0% believed it reduced comfort (χ² = 38.732, p < 0.001).
Logistic regression was conducted to examine the impact of demographic variables on the likelihood of participants reporting as betel quid chewers (Table 4). The analysis included six independent variables: gender, age, ethnicity, household income, level of education, and occupation. In the simple logistic regression (SLR), age (continuous) was significantly associated with betel quid chewing (OR = 1.119; 95% CI: 1.070–1.171; p < 0.001). The odds of chewing increased with age. Among education levels, those with tertiary education were significantly less likely to chew compared to those with no formal education (OR = 0.056; 95% CI: 0.004–0.863; p = 0.037). Other levels of education showed a similar inverse association but were not statistically significant. Gender, household income, and occupation were not significantly associated with chewing status at the bivariate level. A forward stepwise logistic regression model (Forward LR method) was conducted, including variables with p < 0.05 in the bivariate analysis: age, gender, education level, and household income. In the final model, age remained a statistically significant predictor (AOR = 1.126; 95% CI: 1.071–1.183; p < 0.001), indicating increased likelihood of chewing with advancing age.
Table 4.
Betel leaf/betel quid chewing among Orang Asli and their associated factors by multiple logistic regression (MLR)
| Variable | Chewer n (%) | Non-chewer n (%) | b | SLR Crude OR (95% CI) | p-value | b | MLR Adjusted OR (95% CI) | p-value |
|---|---|---|---|---|---|---|---|---|
| Age (continuous) | Mean = 49.6 | Mean = 38.3 | 0.113 | 1.119 (1.070, 1.171) | < 0.001 *** | 0.119 | 1.126 (1.071, 1.183) | < 0.001 *** |
| Gender | ||||||||
| Male | 55 (87.3%) | 8 (12.7%) | Ref. | Ref. | – | Ref. | Ref. | – |
| Female | 55 (67.1%) | 27 (32.9%) | 0.217 | 1.243 (0.646, 2.390) | 0.509 | 0.217 | 1.243 (0.484, 3.194) | 0.647 |
| Education Level | 0.940 | |||||||
| No formal education | 13 (100.0%) | 0 (0.0%) | Ref. | Ref. | – | Ref. | Ref. | – |
| Primary school | 60 (75.9%) | 19 (24.1%) | –1.034 | 0.356 (0.042, 3.009) | 0.338 | 0.421 | 1.523 (0.128, 18.171) | 0.740 |
| Lower secondary | 12 (80.0%) | 3 (20.0%) | –1.792 | 0.167 (0.017, 1.620) | 0.128 | 0.185 | 1.203 (0.081, 17.819) | 0.898 |
| Upper secondary | 23 (69.7%) | 10 (30.3%) | –1.792 | 0.167 (0.021, 1.299) | 0.105 | 0.493 | 1.637 (0.127, 21.063) | 0.710 |
| Tertiary education | 2 (40.0%) | 3 (60.0%) | –2.890 | 0.056 (0.004, 0.863) | 0.037 * | –0.381 | 0.683 (0.027, 17.271) | 0.820 |
| Household Income | 0.479 | |||||||
| < RM1199 | 45 (76.3%) | 14 (23.7%) | Ref. | Ref. | – | Ref. | Ref. | – |
| – RM1200–RM2341 | 50 (76.9%) | 15 (23.1%) | 0.217 | 1.242 (0.547, 2.819) | 0.610 | 0.030 | 1.031 (0.384, 2.771) | 0.952 |
| >RM2342 | 15 (71.4%) | 6 (28.6%) | –0.160 | 0.852 (0.280, 2.591) | 0.778 | –0.867 | 0.420 (0.086, 2.056) | 0.269 |
Forward LR Multiple Logistic Regression Model was applied. Multicollinearity and interaction terms were checked and not found. Hosmer-Lemeshow test (p = 0.685), classification table (overall correctly classified percentage = 82.8%), and area under the curve (AUC = 0.849) were applied to check the model fitness
P-value is significant at p < 0.05*
No other covariates reached statistical significance after adjustment. Notably, those with higher education (tertiary education) had reduced odds of chewing (AOR = 0.683; 95% CI: 0.027–17.271; p = 0.820), although the result was not significant. Similarly, participants with household incomes exceeding RM2342 had lower odds compared to the lowest income group (AOR = 0.420; 95% CI: 0.086–2.056; p = 0.269). Model diagnostics indicated good fit: Hosmer-Lemeshow goodness-of-fit test (p = 0.685), overall classification accuracy of 82.8%, and area under the ROC curve (AUC) of 0.842, suggesting good discriminative ability. Multicollinearity and interaction effects were assessed and not detected.
Discussion
This study investigated factors associated with betel quid chewing among the Proto-Malay Orang Asli community in one of the largest aboriginal settlements in Peninsular Malaysia. The prevalence of betel quid chewing among the study population was notably high at 75.9%, underscoring the entrenched nature of this practice in the community. This rate is higher than figures reported in other Malaysian indigenous populations and comparable to levels documented in certain South and Southeast Asian rural communities where cultural practices strongly reinforce chewing habits [3, 15–17]. The notably high prevalence of current chewers (75.9%) including users of betel quid mixed with areca nut, lime, tobacco, or gambier underscores the normalization of this behavior in the community. The small group who chewed betel leaf alone (2.1%) likely reflects a declining trend in traditional practices in favor of more addictive or stimulant-enhanced preparations.
The findings on knowledge and attitudes towards betel quid chewing reveal critical psychosocial dynamics that underpin the habit among the Orang Asli. Notably, the perception of quitting difficulty was significantly more prevalent among current chewers, with 93.7% of betel quid users believing it is hard to stop once the habit begins. In contrast, this view was shared by only a small fraction of non-chewers. This stark difference suggests that active chewers may internalize or rationalize the addictive nature of the practice, which can hinder motivation to quit. These findings are consistent with prior research indicating that perceived difficulty in cessation is a barrier to behavior change, especially in culturally-rooted habits such as betel quid chewing and tobacco use [18–20].
Additionally, the belief that chewing betel quid enhances comfort in social settings was highly concentrated among chewers, particularly those who consume it with additives such as tobacco or areca nut. Nearly all betel quid chewers (98.2%) reported feeling more socially comfortable when chewing, whereas none of the non-chewers endorsed this sentiment. This highlights the deep cultural and social reinforcement of the practice. In many indigenous and rural populations, chewing betel quid is not merely a personal behavior but a communal and ceremonial activity tied to identity, hospitality, and social bonding [3, 7, 11, 12]. Such social reinforcement may normalize and perpetuate the behavior, making cessation strategies more complex.
The significant differences in attitudes across chewing categories underscore the importance of culturally tailored interventions. Health promotion programs must address not only the health risks of betel quid but also the perceived social benefits and the internalized difficulty of quitting. Interventions should consider peer influence, social settings, and culturally appropriate alternatives that retain communal value while reducing harm. Understanding these psychosocial determinants is essential for designing effective, empathetic public health messaging in Orang Asli and similar indigenous populations.
This study demonstrated that age was a significant predictor of betel quid chewing in both bivariate and multivariable analyses. Specifically, the odds of chewing increased significantly with each additional year of age. This finding is consistent with previous studies among indigenous populations and rural communities, where betel quid use is often ingrained as a traditional practice that becomes more prevalent with age due to cultural reinforcement and social acceptance [15, 17]. Although not statistically significant after adjustment, a higher level of formal education was associated with reduced odds of chewing. This inverse trend is in line with existing literature showing that greater educational attainment often correlates with increased health awareness and decreased engagement in harmful traditional practices, including betel quid use [15, 17, 21]. The lack of significance in the multivariable model may be due to the small sample size in the higher education group which may underestimate the statistical power to detect meaningful associations.
Contrary to previous studies, gender, household income, and occupation were not significantly associated with chewing behavior. Previous studies have shown mixed results on the gendered nature of betel quid use; some report higher prevalence among females due to social acceptability in certain indigenous contexts, while others highlight male predominance linked to occupational habits [11, 17, 20, 22]. The non-significant results in our study may reflect a culturally specific context where betel quid use is normalized across both genders. Similarly, the absence of a clear income-related pattern could indicate that the practice transcends socioeconomic status within this community.
Given the high prevalence of betel quid chewing among the Orang Asli community targeted, community-based interventions that incorporate culturally sensitive messaging, delivered in local dialects, can enhance engagement and understanding. Collaborative efforts with local leaders, village heads, and traditional practitioners can build trust and facilitate the acceptance of preventive initiatives. Additionally, healthcare providers serving indigenous communities should receive training to deliver brief interventions and cessation counseling tailored to traditional practices.
Limitations
Despite its contributions, the study has several limitations. First, the cross-sectional design precludes inference of causal relationships. Second, data were collected from a single, albeit large, Orang Asli settlement, limiting generalizability to other indigenous communities with different socio-cultural backgrounds. This decision was driven by the culturally sensitive nature of betel quid chewing, which can hinder open disclosure and participation, particularly in less familiar environments. Additionally, indigenous communities in Malaysia are often geographically dispersed and socially guarded, making broader access challenging. Despite this, the selected site provided a meaningful and representative context for understanding chewing behaviors within a well-established Proto-Malay Orang Asli population. Thirdly, self-reported data on chewing practices and attitudes may be subject to recall or social desirability bias, potentially affecting the accuracy of responses.
Conclusion
This study found that betel quid chewing remains highly prevalent among the Proto-Malay Orang Asli adults in Kampung Pengkalan Tereh, Johor, with 75.9% of participants reporting current use. The behavior was significantly associated with increasing age, while other factors such as education level, income, and gender showed no significant association in multivariable analysis. Additionally, perceptions regarding the social acceptability of chewing and the difficulty of quitting were strongly influenced by chewing status, reflecting deep-rooted cultural and social norms. These findings highlight the need for culturally informed public health interventions targeting indigenous populations. Efforts should focus on raising awareness, modifying social perceptions, and offering culturally sensitive interventions that are locally appropriate for each indigenous community.
Acknowledgements
We would like to thank all the students and lecturers of the Doctor in Dental Public Health program for their help and support in data collection, as well as the Faculty of Dentistry and Universiti Teknologi MARA for their approval and support in conducting this study. Our sincere appreciation also goes to the Department of Orang Asli Development (JAKOA) for their administrative assistance and support throughout the study process. We are especially grateful to the village leader (Tok Batin) and the residents of Kampung Pengkalan Tereh for their cooperation, trust, and hospitality.
Funding
Open access funding provided by The Ministry of Higher Education Malaysia and Universiti Teknologi MARA. No funding was received for conducting this study.
Data Availability
The datasets generated from present study are not publicly available due to ethical restrictions and the sensitive nature of the community involved but are available from the corresponding author on reasonable request and with appropriate institutional approval.
Declarations
Conflict of interest
All authors declare that they have no conflict of interest.
Ethical Approval
This study received approval from The Research Ethics Committee of the Research Management Centre, Universiti Teknologi MARA, Malaysia and The Department of Orang Asli Development, Ministry of Rural and Regional Department, Malaysia (REC/05/2024(PG/FB/18)).
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Lee, C-H., Ko, A. M. S., Warnakulasuriya, S., Yin, B-L., Sunarjo, Zain, R. B., et al. (2011). Intercountry prevalences and practices of betel-quid use in South, Southeast and Eastern Asia regions and associated oral preneoplastic disorders: An international collaborative study by Asian betel-quid consortium of South and East Asia. International Journal of Cancer, 129(7), 1741–1751. 10.1002/ijc.25809 [DOI] [PubMed] [Google Scholar]
- 2.Little, M. A., Pokhrel, P., Murphy, K. L., Kawamoto, C. T., Suguitan, G. S., & Herzog, T. A. (2014). Intention to quit betel quid: A comparison of betel quid chewers and cigarette smokers. Oral Health Dent Manag, 13(2), 512–518. PMID: 24984674; PMCID: PMC4383761. [PMC free article] [PubMed] [Google Scholar]
- 3.Khairunjauhari, I. M. M. B. N., Mohd Radzi, N. A., & Wan Mokhtar, I. (2023). Oral health beliefs, perceptions and utilisation of oral health care services among the Indigenous people (Orang Asli) in pahang, malaysia: A qualitative study. Malaysian Journal of Medicine and Health Sciences, 16(6), 18–27. 10.47836/mjmhs.19.6.4 [Google Scholar]
- 4.International Agency for Research on Cancer (Eds.) (2004). IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Betel-quid and Areca-nut chewing and some Areca-nut-derived nitrosamines. IARC monographs on the evaluation of carcinogenic risks to humans. World Health Organization International Agency for Research on Cancer. [PMC free article] [PubMed]
- 5.World Health Organization. Review of Areca (Betel) Nut and Tobacco Use in the Pacific: A Technical Report. Manila: WHO Regional Office for the Western Pacific (2013). Retrieved from https://iris.who.int/bitstream/handle/10665/206910/9789290615699_eng.pdf?sequence=1
- 6.Akhtar, S., Sheikh, A. A., & Qureshi, H. U. (2012). Chewing areca nut, betel quid, oral snuff, cigarette smoking and the risk of oesophageal squamous-cell carcinoma in South Asians: A multicentre case–control study. European Journal of Cancer,48(5), 655–661. 10.1016/j.ejca.2011.06.008 [DOI] [PubMed] [Google Scholar]
- 7.Lam, C. Y., & Gritz, E. R. (2012). Incorporating behavioral research to examine the relationship between betel quid chewing and oral cancer in Taiwan. BioMedicine, 2(4), 160–166. 10.1016/j.biomed.2012.11.001 [Google Scholar]
- 8.Bedford, K. J. A. (2009). Gombak hospital, the Orang Asli hospital. Indonesia and the Malay World,37(107), 23–44. 10.1080/13639810902743032 [Google Scholar]
- 9.Jamil, M. A., Sabri, B. A. M., & Yani, A. A. M. (2025). Exploring betel quid chewing among Orang Asli: A qualitative study. Journal of Community Health,50(2), 235–243. 10.1007/s10900-024-01418-6 [DOI] [PubMed] [Google Scholar]
- 10.Rianti, S., Zamros, Y. Y., Mohamed, N. H., & Shoaib, L. A. (2018). Oral health knowledge, attitudes and practices of 11–12 year old Orang Asli children in Cameron Highland, Malaysia. Southeast Asian Journal of Tropical Medicine and Public Health,49(5), 894–908. 10.13140/RG.2.2.23970.48328 [Google Scholar]
- 11.Chiu, S. E., Hsu, M. H., Kang, C. J., & Chen, S. C. (2024). Perceived stress and betel quid dependence associated with reasons for betel quid chewing among male chewers: A mixed methods study. BMC Oral Health,24(1), 1327. 10.1186/s12903-024-05093-w [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Thilakarathne, B. K. G., Schensul, J. J., & DeMarsilis, A. (2025). Use of betel quid with and without tobacco and challenges to quitting among women attending a rural hospital in Sri Lanka. BMC Oral Health,25(1), 966. 10.1186/s12903-025-06338-y [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Lim, K. H., Teh, C. H., Heng, P. P., Pan, S., Ling, M. Y., Yusoff, M. F. M., et al. (2018). Source of cigarettes among youth smokers in Malaysia: Findings from the tobacco and e-cigarette survey among Malaysian school adolescents (TECMA). Tobacco Induced Diseases,16, 51. 10.18332/tid/96297 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Yusoff, M. S. B. (2019). ABC of content validation and content validity index calculation. Education in Medicine Journal, 11(2), 49–54. 10.21315/eimj2019.11.2.6 [Google Scholar]
- 15.Aye, Y. M., Hong, S. A., Thepthien, B., & Tiraphat, S. (2022). Betel quid chewing and its prevalence and determinants: Data from Myanmar demographic health and survey of 2015–2016. J Public Health (Oxf), 44(2), e181–e91. 10.1093/pubmed/fdab044 [DOI] [PubMed] [Google Scholar]
- 16.Ko, Y. C., Chiang, T. A., Chang, S. J., & Hsieh, S. F. (1992). Prevalence of betel quid chewing habit in Taiwan and related sociodemographic factors. Journal of Oral Pathology and Medicine, 21(6), 261–264. 10.1111/j.1600-0714.1992.tb01007.x [DOI] [PubMed] [Google Scholar]
- 17.Meerjady, S. F., Christopher, G. N. M. T., & Mahmudur, R. (2012). Betel quid chewing and its risk factors in Bangladeshi adults. WHO South-East Asia Journal of Public Health, 1(2), 169–181. [Google Scholar]
- 18.Anees, A. R., & Easton-Carr (2024). The health belief model of behavior change. The health belief model of behaviour change. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK606120/ [PubMed] [Google Scholar]
- 19.Chen, F.-L., Chen, P. Y., Tung, T.-H., Huang, Y.-C., & Tsai, M.-C. (2014). The role of betel-quid chewing in smoking cessation among workers in Taiwan. BMC Public Health,14(1), 755. 10.1186/1471-2458-14-755 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Ghani, W. M. N., Razak, I. A., Yang, Y-H., Talib, N. A., Ikeda, N., Axell, T., et al. (2011). Factors affecting commencement and cessation of betel quid chewing behaviour in Malaysian adults. Bmc Public Health, 11(1), 82. 10.1186/1471-2458-11-82 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Viinikainen, J., Bryson, A., Böckerman, P., Kari, J. T., Lehtimäki, T., Raitakari, O., et al. (2022). Does better education mitigate risky health behavior? A Mendelian randomization study. Economics and Human Biology,46, 101134. 10.1016/j.ehb.2022.101134 [DOI] [PubMed] [Google Scholar]
- 22.Yap, S.-F., Ho, P.-S., Kuo, H.-C., & Yang, Y.-H. (2008). Comparing factors affecting commencement and cessation of betel quid chewing behavior in Taiwanese adults. BMC Public Health,8(1), 199. 10.1186/1471-2458-8-199 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated from present study are not publicly available due to ethical restrictions and the sensitive nature of the community involved but are available from the corresponding author on reasonable request and with appropriate institutional approval.