Perspectives on reflexology: A qualitative approach

Abstract

Introduction

Reflexology is the systematic practice of applying some pressure to particular points on the feet and hands to impact on health of related parts of the body.

Objective

To explore the practitioners' perspectives of reflexology in Malaysia.

Methods

Data was collected using face-to-face semi-structured interviews with practitioners in Malaysia. The interviews were conducted in the Malay language and recorded. Interview conversations were translated and transcribed verbatim. Responses relating to different themes were identified in each of the interviews and a coding frame was developed. For each theme, the relevant data enabled a description of the range of views and experiences. Data collection and analysis were conducted concurrently and recruitment was stopped when saturation had been reached. All respondents gave written consent for their participation.

Results

The findings show that reflexology treatment nowadays has been accepted as one of the ways to maintain general health. Practitioners believe that reflexology is able to detect some problems in to the body, which can make patients aware of a health condition and seek further treatment. However, if reflexology is not performed correctly, it may cause negative effects such as pain and bruises. Some practitioners voiced concern that illegal activities are taking place in unethical reflexology centers.

Conclusions

Empowering the practitioner as a professional would help gain the public's trust and confidence in their treatment. Strict enforcement of regulation related to illegal conduct in reflexology centers will improve people's perception of the practice.

Graphical abstract

1. Introduction

Reflexology is the systematic practice of applying some pressure to particular points on the feet and hands to impact the health of related parts of the body.¹ Each pressure point acts as a sensor on the feet and hands and is linked with specific parts of the body.^{2, 3} These sensors will be stimulated by applying the reflexology technique in order to improve the blood and energy circulation, giving a sense of relaxation and maintaining homeostasis.^{4, 5} Reflexology sessions can be improved with other elements such as aromatherapy, peaceful music, and good environment settings.⁶ There is a term in reflexology called reflex zone therapy. Reflex zone therapy is where the body is divided into ten longitudinal zones, from the top of the head down to the feet. In reflex zone therapy, there are five zones on each side of the body. Each zone diverges off down the arm and circumscribes one digit on the hand, and also continuing straight down the body and down the leg to line up with a toe on the respective foot. Practitioners choose a suitable technique to be applied to reflex zone therapy to gain optimized efficiency and impact.

Instead of an alternative therapy, reflexology is a complementary therapy, linked to other treatments that a patient has already had based on reflexology maps.^{4, 5} Complementary therapies are nowadays widely used in palliative care or to alleviate a problem without dealing with the underlying cause in order to improve a patient's emotional, physiological and spiritual health and increase the value of their life.⁷

Two methods of reflexology that are accepted internationally are the Ingham method and Rwo Shur method. The first method does not use any tools in its practice whereas the second method utilizes tools such as wooden sticks.^{4, 5}

There are five theories that explain how reflexology actually has impacts on health.⁸ The first and second basic theories are related to energy. Energy theory advocates that body parts can communicate using electromagnetic fields,⁹ and the communication can be blocked based on the surrounding fields.¹⁰ The third theory indicates that energy flow can be restored, and the fourth is about a blocked pathway which can be opened.⁹ The last theory proposes that reflexology can break up the lactic acid crystals that are usually deposited in the feet and allow energy to flow efficiently.⁸

Modern reflexology techniques have been used for the last 60 years and now more scientific and clinical research has been conducted because of its positive effects in reducing and alleviating symptoms, especially those associated with chronic conditions such as diabetes mellitus, hypertension and muscular diseases. Reflexology generally does not cause any harmful effects as long as necessary precautions are taken with patients with special medical conditions such as blood clot disorder, cancer and heart failure.

Each person has a different body system so results from reflexology treatment could vary from one person to another.^{11, 12} Based on the latest research conducted, reflexology seems to be effective in helping body systems return to their natural state.¹ One of the most significant current discussions in reflexology is its effectiveness in helping to tackle several symptoms of disease.¹ Level of disease conditions and pain are reduced as the patients receive reflexology. It has been suggested by a Swiss study that patients having reflexology sessions show significant decrease in the amount of medication they require.¹ As a complementary therapy, reflexology seems to work better together with conventional treatment to treat chronic diseases that alter the normal physiological functions of the body.^{11, 12}

One of the most significant current discussions in reflexology practice is around aspects of health, safety and hygiene. Other than that, the principles and practice of reflexology as a complementary therapy is important to ensure the application of this therapy is reliable.

Until now, no study has been conducted to understand practitioners' perception of reflexology. This study serves to provide insight from reflexology practitioners on the development and regulation of reflexology practice in Malaysia.

The outcome of this study will reveal the perspective of practitioners on reflexology and its treatment in Malaysia for the first time. We can understand socio-cultural influences on help-seeking behavior and reasons for delaying seeking help among symptomatic patients with reflexology. The findings of this novel study will provide the healthcare authorities with an overview on the extent, barriers to and facilitators of reflexology among healthcare professionals in Malaysia. Research in this area is very important so that policymakers can formulate strategies and implement activities that can monitor the development of reflexology.

2. Methodology

Data was collected in face-to-face semi-structured interviews with practitioners in Malaysia. There is no comprehensive list of practitioners in Malaysia that could serve as a sampling frame to obtain a sample including different specialization and position. The interview focused on development of reflexology, perceptions of effectiveness of reflexology, experiences and use of health services (modern and traditional practices) and respondents' perception.

Interviews were conducted at a time and location convenient for the respondents. The interviews were conducted in the Malay language and audiotaped. Voice recording were translated, transcribed verbatim and anonymized to ensure confidentiality. In order to ensure consistency, one researcher (NHE) conducted the whole interviews and then the transcripts were analyzed individually by all four researchers. The themes and the corresponding codes were then presented by each researcher. Discussions and reconciliation of the ideas were done before the final concepts and themes were confirmed.

Responses relating to different themes were located in each of the interviews and a coding frame was developed. For each theme, the relevant data enabled a description of the range of views and experiences.

Data collection and analysis were conducted concurrently and recruitment was stopped when saturation was reached. All respondents provided written consent to participation.

Data was coded and analyzed to identify common descriptive themes, which were grouped into clusters. Thematic analysis was used to identify themes and subthemes. Ethical approval was obtained from the Universiti Teknologi MARA Research Ethics Committee [600-RMI(5/1/6) 19-12-2014].

3. Results

The interview session was stopped at five practitioners, as it had already reached the saturation point where all practitioners gave quite similar answers. The mean age for all respondents involved was 34. The demographic summary for all respondents is shown in Table 1.

Table 1.

Demographic summary for all respondents.

Practitioner	Gender	Age	Education	Marital status	Occupation
1	Male	29	Training centre for disabled	Single	Reflexology practitioner
2	Female	36	University	Married	Traditional health care services practitioner
3	Female	31	–	Single	Spa Worker
4	Male	33	–	Single	Reflexology practitioner
5	Male	42	University	Married	Reflexology practitioner

The outcomes identified were categorized under specific themes.

3.1. Credentials and training received

All of the practitioners had good qualifications in reflexology treatment and have certification from various institutions. None of them are practicing reflexology because of inherited knowledge from their family but one of them learnt it from senior staff at her spa. The following answers are typical from the interview session:

I was trained in the arts of reflexology at a local massage parlor for the blind located in Brickfields. I studied for 2½ years. (Practitioner 1)

I studied for a diploma in complementary medicine at Aimst. I was the first batch for this course. I learnt the origins of foot massage, Malay massage, and general healthcare management. And then I pursued reflexology at a community college. (Practitioner 3)

Some people conduct classes so we have to attend the class for 18 months. For the whole period of studying, they will teach the theories and the practice. We will receive a certificate but before that we must undergo a test to see whether we pass or fail. (Practitioner 4)

In addition, the practitioners also have great experience in practicing reflexology. They have already practiced reflexology for many years:

It was a long time ago when I started to work in this premises and conducting my own reflexology session when I have extra time. (Practitioner 3)

I have been practicing reflexology for 7 years. (Practitioner 4)

I've been practicing this for many years. Last year I was asked to teach reflexology to the inmates in prisons, organized by the prison administration of Malaysia. (Practitioner 5)

Their knowledge is not limited to theory and practice about reflexology, as they also understand about human anatomy:

I studied a lot including anatomy and physiology of the human body. (Practitioner 1)

The feet have multiple pressure points and the same goes to our body. (Practitioner 2)

There I met a lecturer who specialized in this field; a specialist who was an expert about nerves and taught me about body systems. (Practitioner 3)

What is clear from all the data is that most reflexology practitioners are qualified to practice on their clients due to their knowledge and already gained qualifications.

3.2. Keeping clients well

Practicing reflexology treatment in our life is one of the ways for us to maintain a good level of health. With all the experiences that the practitioners had in this field, they agreed that reflexology treatment is a part of body health care. Here are some of the statements from the interview session:

[Reflexology] helps our body relax after we over-use it. It also helps to reduce stress and as we know stress may lead to many other health problems. (Practitioner 1)

[I wholly agree that foot massage] can act as a healthcare practice because for example the veins of our heart and liver have their own specific pressure points on the feet. So putting some pressure on the heart vein's pressure point, with the correct techniques, helps the blood to flow efficiently in the vein. When there is no problem with our blood flow, many diseases related to our body can be avoided, or at least can be reduced. (Practitioner 2)

[Reflexology is a complementary treatment but] it helps a lot in the management and cure of many diseases. [In my opinion,] reflexology is a way of maintaining general health and wellbeing, and should] be practiced routinely. (Practitioner 3)

Based on their experiences and knowledge, they stated that reflexology treatment is helpful to a patient's condition instead of detrimental:

As long as I've been in this line of work, I've never had a patient return to complain they are suffering more pain; all of them feel better after treatment. (Practitioner 1)

[This treatment is] not detrimental to a patient's condition. But maybe it also depends on customer's condition itself. (Practitioner 3)

If a patient sometimes gets worse after a massage, it is usually nothing serious. But it normally does not happen. Usually patients feel better after a session. They feel lighter and more comfortable. (Practitioner 4)

3.3. Diagnostic purpose

When the practitioners discussed how they would know if there any problem in the body system, most of them stated that they are able to diagnose a client's health problems, though two said they did not:

Usually I can detect a patient's problem due to the pain suffered when suitable pressure is applied to a specific point (Practitioner 1)

When I massaged [a client], I found out there were problems with his body system. (Practitioner 3)

We can detect if a patient has any abnormalities while doing this reflexology. Sometimes, we do not have to touch the affected area but we can detect the abnormalities just by looking at the expression of the patient. This is called the knowledge of diagnostic. (Practitioner 5)

We only massage specific points but we cannot predict accurately where the affected area of the body system is. (Practitioner 2)

If there are problems, those are just theories. We can't predict if a patient has a headache or heart problems. Some people were coincidentally predicted correctly. (Practitioner 4)

The practitioners suggest clients with chronic disease to seek further treatment with a doctor but do not recommend modern medicine:

Once I detect the problems I will advise for the patient to consult a doctor. (Practitioner 1)

Usually if patients have problems, we will recommend for treatment to be done, but if the condition is too serious, we will definitely recommend they seek treatment from a specialist. (Practitioner 4)

I'll suggested them to see the doctor if their disease is chronic. We as masseuses have no right to condemn any other practitioners. (Practitioner 5)

Different clients have different body health conditions and the practitioners must know how to handle such conditions. Based on the interview session conducted, most of practitioners know how to handle special conditions:

[I personally think that] if you have fever, you should try massage first but if it still does not heal overnight then it would be advisable to consult a doctor the following day. (Practitioner 4)

There are certain patients for which we can't perform reflexology, for example those with heart problems. Because when we do reflexology, the heart will beat faster. It may cause a more serious problem. This also occurs in patients whose blood sugar level is too high and pregnant women under 5 months gestation. (Practitioner 4)

For hypertensive patients we can't massage upwards. This will make the blood pressure shoot up and exacerbate the condition. (Practitioner 5)

3.4. Regulation and enforcement

Many premises misuse the title 'reflexology center' as a cover for their immoral activities. Practitioners have their own opinion regarding this matter and mostly agree that stricter regulation is required and higher authorities should be involved to stop the problem getting worse. Certifications and licenses are the most important factors:

I admit that there are parties who misuse this license. I think that the higher authorities need to be stricter in handling this issue. (Practitioner 1)

[I work for this premise as a reflexology practitioner but the] owner of this premises also has certification for reflexology treatment and [runs another premise in the Kuala Lumpur area.] But both of these premises have their own licenses. It is important because many people or premises misuse the title of reflexology center. (Practitioner 3)

Here, every practitioner has their own certificate [but the techniques might be different. Before initiating a massage we must first ask them about their conditions]. So if the practitioners don't have a qualification, they might not know about this and put the customer at risk. (Practitioner 4)

I have negative views on individuals who use reflexology as means of conducting immoral acts. I find that it is very inappropriate and it gives a bad image to certified reflexology practitioners like me. It took a long time to get this certificate. I asked an officer at the Klang municipalities if I can get a license for my reflexology and hijama (cupping therapy) business. A local council officer and another local council committee member were involved to endorse the license. Both officer and committee member said that they will not endorse or give approval because too many reflexology centers have been involved in illegal businesses. Due to that, all the application has been put on hold. (Practitioner 5)

Practitioners seem to agree with the implementation of a form about a client's background, existing diseases and much more. But they found it difficult and did not have enough time to do it.

As for this form, I admit that it will be difficult for us to fill in the forms since we're blind. (Practitioner 1)

Previously, I filled in the forms and put them a proper file, but I do not have enough assistance to do this any more. So I have stopped doing it, but personally I really agree that it would be a good approach to improve reflexology treatment. (Practitioner 3)

I agree that the authorities should implement the form-filling procedure to ease our job and so that we can take extra measures. Sometimes we need to rush, and there is no time to fill in any forms, but it is nevertheless a good implementation. (Practitioner 4)

Creating a reflexology association in Malaysia may help reflexology therapy to become acknowledged, so that people are aware of it and will take the opportunity to take charge of their health. It also the safest way to manage any problems that happen related to reflexology as it easier for customers or enforcement can trace the practitioner. This is reflected in the dialogue from several practitioners:

Maybe it can help us to be recognized as professional practitioners. (Practitioner 2)

It is actually necessary because in case anything happens related to reflexology treatment, we can refer to the responsible person. Don't forget that the government needs to make sure all practitioners register under this association before treating customers, so if anything goes wrong, it is easier for customers or enforcement to trace the practitioner. (Practitioner 1)

3.5. Professionalism

Regarding professionalism, practitioners stated they are professional. When asked about it, they gave different personal opinions about why:

I believe that reflexology is a professional line of work because we follow all the steps and procedures. (Practitioner 1)

Yes [we are professional] because we does not practice anything against the regulation, and we having the certificates and a license to run this type of practice. All the practitioners that offer this treatment in our premises have this qualification and this treatment has become more important in health care nowadays. (Practitioner 3)

Reflexology is actually a professional line of work because we are not just any masseuse; we are trained reflexologists and we focus on massage. (Practitioner 4)

Yes [we are professional] because many studies have shown that reflexology can actually give many benefits to our health. (Practitioner 5)

4. Discussion

An exploratory qualitative approach was used because no previous study had been conducted in this area. A qualitative content analysis elicited beliefs and values from the respondent that not normally conveyed in quantitative survey study.

Based on all the data gathered from the interview sessions, reflexologists generally consider that reflexology treatment nowadays has been accepted as one of the ways to maintain general health.

4.1. Credentials and training received

All practitioners have qualified certification, great knowledge and experience regarding reflexology, human anatomy, physiology and related problems. This enables people to put trust and confidence in their treatment. However, reflexology is not recognized by law and so does not require formal training. Practitioners who took part in the interview were not only proficient in massaging techniques on points of reflex but also knowledgeable in term of human physiology and anatomy. There are many education courses available related to reflexology and practiced by many massage therapists. Such courses do not teach any medical practice, and nor do they replace existing treatment.¹³ Practitioners have qualified certification from various institutions and many years' experiences practicing reflexology. They also have expertise in doing reflexology treatment using various types of apparatus such as stone, horn and wooden sticks, based on the patients' conditions.

4.2. Diagnostic purpose

Reflexology involves differential diagnosis where practitioners are able to diagnose a patient's body condition. It is impossible to name the medical condition in simple words, but it is actually the condition where the practitioners manage to identify any imbalances in the body system.¹⁴ They are able to explain and relate causes why some problems could happen with our body. This helps clients be aware of health conditions and so they can seek further treatment if necessary. Detection of patient's medical conditions in reflexology involves observation, asking, listening and palpation. Practitioners observe each patient's eyes, skin, hair and facial expressions, which indirectly shows their physical discomfort and level of stress.¹⁵ Practitioners can ask about and listen to clients' general health level, which can be affected by various factors such as psychological and emotional aspects. It is crucial to build empathy so that patients can put more trust in the reflexologists, leading to meaningful therapeutic relationships.^{15, 16}

4.3. Keeping clients well

The practitioners also believed that reflexology will reduce risk and help to handle some diseases if synergized with modern treatment methods.

The collaboration between this complementary therapy, with correct techniques and procedures, and modern medicine seems the best way to maintain general health. As reflexology is a complement to existing modern medicines, it is a good way to improve the well-being of patients.^{17, 18} Based on practitioners' experience, most clients believed that having routine reflexology treatment (with the correct technique) will enhance their body health and indirectly increase their quality of life. Routine reflexology could help reduce stress levels, and as we know stress may trigger many diseases.^{19, 20} The reflexologists did not have any clients complaining that their general health had become worse. They also think that good practitioners can help the client, based on their level of body health.

4.4. Regulation and enforcement

Implementation of patients' assessment forms before reflexology sessions can help practitioners monitor customers' health condition after each session. Some people such as pregnant women in their first trimester cannot have this treatment. Moreover, if reflexology is not performed correctly it may have adverse effects.

Setting up an association for reflexology treatment in Malaysia, to which all practitioners should register if they want to practice reflexology professionally, would help patients or responsible authorities trace practitioners if they are not practicing correctly according to right techniques and procedures. Some practitioners voiced concern that some irresponsible reflexology centers are being used for illegal conduct. This can affect other practitioners' business and make a bad impression about reflexology. Responsible authorities should be stricter, with more frequent monitoring of the premises that offer reflexology treatment. Involvement from responsible authorities to set up more regulation is crucial to prevent these problems from getting worse.

4.5. Professionalism

Practicing reflexology and doing diagnoses would be illegal for someone that claims they are a practitioner but does not have any license related. So it is compulsory for each practitioner to have their own license.

Professional are actually the people who are qualified in the position. In our study, the practitioners, all of whom have qualified certification and licenses, considered themselves as professional since they focus on reflexology treatment and practicing it professionally with correct techniques and procedures. With worldwide recognition of Malaysian reflexologists, reflexology treatment could increase in scale concomitant with modern medical development.^{21, 22}

4.6. Limitations of the study

This study was conducted in a small group. For more meaningful interpretations of practitioners' subjective perceptions, future studies should be conducted with larger samples and involve more beneficial themes. Furthermore, the interviews should be conducted in a more relaxed environment so that practitioners can express their opinions more freely. The gap that exists between facilitator and practitioners can affect each opinion. Spontaneous interview sessions would facilitate an exploration of practitioners' perception of their superiors in term of problem diagnosis, the way they handling customers with different health conditions and the involvement of responsible authorities in order to focus on their efforts to maintain people's quality of life.

5. Conclusion and implications for further research

The collaboration between this complementary therapy, with correct techniques and procedures, and modern medicine seems the best way to maintain general body health. Involvement of responsible authorities and strict regulation related to illegal conduct in reflexology centers, which can give a bad name to practitioners, will improve people's perception of reflexology. Empowering practitioners as professionals can help to improve people's perception of and confidence in reflexology treatment.

Conflict of interest

None.