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Abstract
Objection The objective of this study was to assess attitudes towards the use of Traditional Chinese Medicine (TCM) for COVID-19 among Chinese immigrants in Canada during the early stage of the COVID-19 pandemic.
Methods A cross-sectional study was conducted in April 2020 in Canada. Individuals aged 16 or older who were of Chinese origin and living in Canada at the time of the survey were invited to participate in an online survey. Descriptive and univariate statistics were performed to describe participant attitudes towards various preventive and treatment measures for COVID-19. Multiple logistic regression was used to identify independent associations with sociodemographic factors and attitudes.
Results A total of 754 eligible respondents were included in the analysis. 65.8% of the participants were female, 77.2% had a university degree or higher and 28.6% were 55 years of age or older. Overall, 48.8% of the study participants believed that TCM was effective in preventing COVID-19% and 46.2% would use TCM if they had COVID-19-related symptoms. However, the corresponding numbers for western medicine were 20.8% and 39.9%, which were statistically lower (p<0.01). Older participants (55+vs <35, OR=3.55 (95% CI 2.05 to 6.14); 35–54 vs <35, OR=1.98 (95% CI 1.27 to 3.08)) and those who were dissatisfied with their income (OR=2.47(95% CI 1.56 to 3.92)) were more likely to believe TCM was effective against COVID-19. Similarly, older participants (55+vs <35, OR=3.13 (95% CI 1.79 to 5.46); 35–54 vs <35, OR=2.25 (95% CI 1.35 to 3.74)), females (OR=1.60 (95% CI 1.15 to 2.23)), and those born in mainland China (OR=10.49 (95% CI 2.32 to 47.39)) were more likely to use TCM if they had symptoms of COVID-19.
Conclusion Despite the lack of scientific evidence to support its use, TCM was widely believed by Chinese immigrants in Canada to be an effective means of preventing COVID-19 and many also stated they would use it if they were experiencing symptoms of COVID-19.
- epidemiology
- public health
- COVID-19
- complementary medicine
Data availability statement
Data are available on request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
Our work examines the opinions, beliefs and actions of the Canadian Chinese immigrant community towards Traditional Chinese Medicine for COVID-19 prevention.
We were able to obtain a large sample size through online recruitment methods.
Knowledge user and community collaborator organisations have been involved in the research design and project execution, and the survey tool was revised based on their input.
The study is limited by its cross-sectional nature and by the use of snowball sampling for recruitment, so these findings are not necessarily representative.
Introduction
According to Statistics Canada, Ontario is home to more than 50% of all Chinese immigrants in Canada, most of whom live in the Greater Toronto Area (GTA).1 Canada reported its first imported COVID-19 case in GTA from mainland China.2 In the ensuing weeks, most COVID-19 cases in Canada were from China. Given their high geographic density and their close ties with the homeland, Chinese immigrants in the GTA became the most vulnerable immigrant population in Canada in the early stage of the outbreak. In mid-February, around 70–80 individuals per day were still arriving in the GTA from Hubei Province, and many more from other parts of China.3 Thus, compared with other Canadians, Chinese individuals living in the GTA had more frequent and close interactions with people from areas severely affected by COVID-19 and thus had a significantly higher risk of infection. Chinese communities in Canada, and around the world, were at especially high risk for confusion, fear, anxiety, discrimination and panic related to COVID-19.4–7 It is also likely that many Chinese immigrants were actively searching for reliable information and advice on COVID-19 prevention. This has enabled rumours and misinformation to spread on social media.8 9
Traditional Chinese Medicine (TCM), the origins of which can be traced back thousands of years, has a culturally significant role as a traditional medicine among Chinese populations and its use is often integrated with western medicines.10 TCM encompasses a broad range of therapies, such as herbal medicine, acupuncture, massage, Qigong and dietary therapy.10 Ever since the COVID-19 outbreak started, TCM has been officially promoted in China by government officials, state media and medical experts as an integral part of the COVID-19 prevention and treatment plan.11–15 Specifically, according to Chinese state media, the State Administration of TCM claimed there are six effective TCM recipes for COVID-19.11–15 In addition, TCM is easily available and is not subject to the same strict regulations as Western medicine is (in both China and Canada). This, coupled with the lack of other effective means against COVID-19, has made TCM a popular preventive measure in mainland China despite the lack of scientific evidence.16 Several news reports have highlighted how these mixed messages are leading to confusion in Chinese communities in Canada, and how many individuals are profiting from promoting unproven remedies.17–19
As part of the Canada’s COVID-19 rapid response plan, a Chinese community-based COVID-19 epidemiological project was launched in March 2020 and this current study was derived from that larger project.20 The objective of this current study was to assess the attitudes towards the use of TCM in relation to Western medicine among Chinese immigrants in Canada during the early stage of the COVID-19 pandemic. We hypothesised that Chinese Canadians would believe more in TCM than in Western medicine as a means to prevent COVID-19. Further, we investigated sociodemographic factors associated with belief in and presumed use of TCM, and we anticipated that older adults and new immigrants would be more likely to use TCM.
Methods
Study design and participants
An online cross-sectional survey in both Chinese and English was conducted from 2 April 2020 to 20 April 2020. Chinese immigrants, aged 16 or older, who had been born in China but currently lived in or would be living in Canada for at least 6 months were invited to participate. The survey questionnaire was delivered through various methods including WeChat (85.5% of participants), emails (7.7%) and Chinese media homepage links (6.8%). Potential participants were required to read a brief statement describing the study, anonymity assurance and participant rights. They then had to click a button saying they consented to participating before they could start the survey. Participation was anonymous so, in order to avoid possible multiple submissions, there were no incentives for participation and IP addresses of submissions were tracked. Identifiers, such as WeChat ID and IP address were removed before analysis. The questionnaire consisted of two parts. The first part collected general information about participants. The second part surveyed the perceptions and actions related to COVID-19, including knowledge of COVID-19. In addition to being asked about their beliefs in the effectiveness of different prevention methods against COVID-19 in this section of the survey, participants were also asked what they would do if they were experiencing symptoms of COVID-19. Participants were also surveyed on the psychological impacts of COVID-19 and on their appraisal of crisis management by Canadian health authorities, but these results are not covered in this paper.
Outcome variables
Respondents were given a list of statements and asked to indicate whether the statement was correct. One of the statements was ‘Traditional Chinese medicine can prevent COVID-19.’ If participants responded ‘yes’ to this statement, they were regarded as believing TCM was effective in preventing COVID-19 (‘belief in TCM’). Similarly, participants were asked if they agreed that ‘Western medicine can prevent COVID-19.’ In a separate question, participants were asked ‘What would you do if you start showing typical symptoms of COVID-19?’ On the list of potential response options were ‘consume Traditional Chinese Medicine,’ ‘consume Western medicine,’ ‘contact family doctor,’ ‘contact for COVID-19 testing,’ and ‘self-isolation.’ Further details on the survey items and response options can be found in online supplemental appendix.
Supplemental material
Covariates included in the model were age group, gender, marital status, educational attainment, current residing province, household income satisfaction and self-rated health. Income satisfaction (five-point Likert-type scale, reduced to a three-point scale for analysis) was used to reflect their subjective assessment of wealth and socioeconomic status. For the convenience of analysis, we combined the five categories of psychological feelings into three categories, which are dissatisfied, neutral and satisfied.
Public involvement
Knowledge users and community collaborators are an integral part of the research team and they directly participated in the research design and project execution. Before collecting data, this project was well promoted in the Chinese community in Canada. The final survey tool was revised based on the input from many organisations and collaborators. Since May 2020, Chinese communities and study participants have been receiving research updates through the media, Zoom public forums and several community organisation websites (such as www.cniw.org). The Confederation of Chinese Alumni Associations is the official knowledge user and the Center for New Immigrants Wellbeing is the official community partner of the project.
Data analysis
A descriptive analysis was conducted to show the distribution of sociodemographic characteristics of the sample, stratified by outcome variables. Comparisons between categorical groups were analysed using Pearson’s χ2 test. The independent association between selected independent variables and TCM belief/practice was estimated using ORs and 95% CIs as an estimate of the relative risk from multivariate logistic regression models, adjusted for potential clustering and confounding. Based on univariate logistic analysis, any variable whose univariate test had a p<0.20 was considered as a candidate for the multivariate model. Missing data were not included into the analyses.
Forest plots were used to present ORs and the corresponding 95% CIs from the multivariate models. Two-sided tests with a significance level of 0.05 were used. The data analyses were performed with SPSS statistical software (V.21.0, IBM). The forest plot was produced using Stata software (V.16.0, StataCorp).
Results
A total of 764 individuals responded to the survey, 757 of which completed the informed consent and were eligible to participate. Of the eligible respondents, 754 (258 males and 496 females) participants completed at least 50% of the survey questions, and these participants were included in our data analysis. Table 1 details the characteristics of study participants.
Characteristics of study participants (n=754)
When being asked to choose which prevention measures participants believed were effective against COVID-19, using TCM (48.8% (368/754)) was the most popular prevention measures among the options given (table 2). In contrast, only 20.8% (157/754) of people believed that Western medicine was effective in preventing COVID-19. In addition, more males believed in Western medicine compared with females (26.4% vs 17.9%, p=0.008). Interestingly, 81.5% (128/157) of those who believed Western medicine was effective also believed TCM was effective at preventing COVID-19. While there were very few who believed in Western medicine but not TCM (3.8% (29/754)), there was a number who believed in TCM but not Western medicine (31.8% (240/754)). Nearly half of participants did not believe either TCM nor Western medicine could prevent COVID-19 (47.3% (357/754)) and a small portion believed both were effective (16.9% (128/754)).
Participants’ beliefs in the effectiveness of Traditional Chinese Medicine (TCM) and/or Western medicine in preventing COVID-19
Table 3 describes the results for what participants would do if they were experiencing symptoms of COVID-19. Overall, more than 90% of participants indicated that they would self-isolate (97.1%) and contact local public health agents for the COVID-19 test (91.6%), while only 55.2% would contact their family doctor. The results further suggest that 46.2% would take TCM and, as expected, females (50.8%) were more likely than males (37.2%) to take TCM (p<0.001). The corresponding proportion for taking Western medicine was 39.9% and there was no significant difference between genders. Of those who would use Western medicine, most would also use TCM (74.0% (223/301)). Approximately 1 in 10 would use Western medicine but not TCM (10.3% (78/754)), while approximately one in six would use TCM but not Western medicine (16.6% (125/754)). Just under half of participants would not use either TCM nor Western medicine (43.5% (328/754)), and just under one third would use both (29.6% (223/754)).
Measures participants agreed they would take after the appearance of COVID-19-related symptoms
Based on descriptive analyses, we further assessed factors associated with belief in TCM and presumed usage. After univariate logistic regression analysis (table 4), variables with p values less than 0.20 were considered as candidates for the multiple logistic regression analysis, including: gender, age, birth place, length of stay in Canada, education level, employment status, income satisfaction, and health status, for the ‘belief in TCM’ for preventing COVID-19 outcome; and gender, age, birth place, stay in Canada, marital status, education, health worker, living status, and income satisfaction, for the ‘usage of TCM’ if participants believed they had COVID-related symptoms outcome. Forest plots were used to display adjusted ORs from the multivariate logistic regression (figure 1). As expected, older people were more likely to believe in TCM for prevention against COVID-19 than their younger counterparts (35–54 vs under 35, OR (95% CI)=1.98 (1.27 to 3.08); 55 or older vs under 35, OR (95% CI)=3.55 (2.05 to 6.14)). Similarly, older people would be more likely to use TCM if they believed they had COVID-related symptoms (35–54 vs under 35, OR (95% CI)=2.25 (1.35 to 3.74); 55 or older vs under 35, OR (95% CI)=3.13 (1.79 to 5.46)). Although females and males did not differ in their beliefs of TCM as an effective preventive measure, females were more likely than males to agree that they would use TCM if they believed they had COVID-related symptoms (OR (95% CI)=1.60 (1.15 to 2.23)). Participants who did not live alone were more likely than those living alone to use TCM if they had COVID-19 symptoms (OR (95% CI)=1.85 (1.02 to 3.36). Compared with those who were satisfied with their income, those who were dissatisfied were more likely than to believe TCM was effective at preventing COVID-19 (OR (95% CI)=2.47 (1.56 to 3.92)). However, income satisfaction had no significant association with whether or not participants would use TCM if they had symptoms of COVID-19. Further, those born in mainland China were more likely than those born elsewhere to use TCM if they had COVID-19-related symptoms (OR (95% CI)=10.49 (2.32 to 47.39), but they were not more likely to believe it was effective for prevention. The level of educational attainment was not associated with either outcome variable.
Multiple logistic regression for (A) believes TCM is effective at preventing COVID-19 and (B) Would use TCM if they had COVID-related symptoms. Variables with p value under 0.20 in the univariate logistic regression analysis were included in this multiple logistic regression analysis. TCM, Traditional Chinese Medicine.
Univariate logistic regression analyses for belief in TCM effectiveness and presumed use of TCM for COVID-19
Discussion
Consistent with our hypothesis, TCM is regarded by many Chinese immigrants in Canada as an effective means of COVID-19 prevention and treatment, despite a lack of scientific evidence to support its use. According to the 2016 Statistics Canada report, people of Chinese origin account for about 5% of the total population.21 In general, overseas Chinese populations share similar cultures and lifestyles,22 23 and it is likely that their belief and practices towards TCM are close as well and this could explain why we did not find an association between length of stay in Canada and attitudes towards TCM. Moreover, because of these similarities, these results have broad implications, warranting further investigation to determine the actual effectiveness of TCMs against COVID-19 and their safety in this use. If evidence refutes claims of effectiveness, this should be communicated to members of these communities.
Our study results suggest older Chinese immigrants were more confident in the effectiveness of TCM for preventing and managing the symptoms of COVID-19. Those born in mainland China were more likely to say they would use TCM if they had symptoms of COVID-19. For belief in effectiveness for prevention, there was no statistical significance observed between participants born in mainland China and those born elsewhere (figure 1). These findings may be related to the participants’ closeness to mainland China, where TCM was widely promoted and used for managing COVID-19 at the start of the pandemic.11–15 We suspect the association with age could be related to older immigrants perhaps having more traditional upbringings than younger generations. The lack of association between length of stay in Canada suggests beliefs in TCM persist even after living in Canada for longer periods of time where participants would be more exposed to Westernised medicines and beliefs about health. With respect to the association between belief in TCM and lower levels of income satisfaction, this could be explained by how, in China, TCM is traditionally more affordable and thus accessed more than Western medicine by families with less economic resources, resulting in these families having more experience with TCMs than families which were more well-off. Under the current public medical framework in China, although Western medicines and treatments were dominant, many TCMs still occupied a considerable market due to their mild side effects and potential for benefit.24 25 While TCMs may be unlikely to cause direct harms, indirect harm could result from over-reliance on TCMs, thus potentially delaying or outright avoiding seeking care from practitioners of Western medicine. Indeed, medical professionals have cautioned against non-evidence-based therapies as potential sources of harm associated with the COVID-19 pandemic.26
While it is not surprising to observe gender differences in this study, explanations may not be straightforward. Several possible explanations exist. For one, to a large extent, females usually take on the role of caregiver for their family members and thus need to pay more attention to health-related information.27 Moreover, as mentioned in previous literature on COVID-19, women in China tended to have a more optimistic attitudes towards the pandemic outcome and were more likely to adopt more preventive behaviours than men.28
The large portions of participants who said they would not take either TCM or Western medicine for prevention or for COVID-19 symptoms suggests that many participants were well aware that nothing had yet been proven effective for either prevention or treatment of symptoms. Interestingly, while nearly one-third of participants believed in TCM but not Western medicine, for prevention, only one-sixth said they would use TCM but not Western medicine if they had symptoms of COVID-19. This finding suggests that participants were more comfortable relying on only TCM for prevention, and less comfortable relying on only TCM in the case of symptoms. Indeed, we found significant overlap between participants who would use both TCM and Western medicine if they had COVID-19 symptoms. This finding fits with previous research which found that two-thirds of older Chinese immigrants in Canada use a combination of TCM and Western health services to support their health.29 Thus, the preference for using both TCM and Western medicine among our participants could reflect this general trend among Chinese immigrants to integrate the two medicines, but it could also reflect current messaging around the COVID-19 treatment protocols and research in China that supports integration of TCM and Western medicine.12 30
Our study has several limitations. The first limitation is due to the fact that this survey was conducted online. Thus, by no means was the study sample representative to the entire Chinese population in Canada, especially considering how the use of snowball sampling may have introduced selection bias. The results are also more applicable to Chinese immigrants from mainland China given they are over-represented in our sample. Nonetheless, the use of online recruitment and survey administration was chosen as it allowed the rapid recruitment of a large sample. Second, those willing to participate in the survey are likely more concerned about the epidemic, which inevitably leads to a self-selection bias. Thirdly, due to restrictions on the length of our survey, we could not get enough detailed information about the specific types participants would use. However, it can be safely assumed TCM in this survey would be understood as herbal medicine or over-the-counter manufactured traditional medicine.31 32 Additionally, we did not ask participants about if they had any barriers to accessing TCM or Western medicine, which might have affected their responses on whether they would use TCM or Western medicine if they were experiencing symptoms. Finally, we did not ask participants if they had previously used TCM for other purposes, so it is not possible to say how their belief in TCM for COVID-19 prevention or presumed use of TCM if they were symptomatic differs from their general beliefs and practices related to TCM.
Conclusion
The results indicate that TCM is believed by many Chinese immigrants in Canada to be effective, and likely is frequently used, for COVID-19. Future studies are warranted to explore the reasons behind the observed phenomena. More importantly, given TCM’s wide acceptance for a variety of uses by Chinese populations around the world and, given its wide acceptance by Chinese immigrants in Canada for COVID-19, its general lack of proven efficacy and safety for COVID-19 should be properly communicated.
Data availability statement
Data are available on request.
Ethics statements
Patient consent for publication
Ethics approval
This study was approved by the Interdisciplinary Committee on Ethics in Human Research (ICEHR), Memorial University of Newfoundland, file number 20201772-ME. All participants signed consent to participate statement included in the questionnaire via the internet.
Acknowledgments
The authors wish to acknowledge Confederation of Chinese Alumni Associations (CCAA, knowledge user), Centre for New Immigrants Wellbeing (CNIW, partner) and other collaborating organisations, the Chinese Media across Canada, volunteers and all study participants.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
YK, LGS and FS contributed equally.
Presented at The abstract of this paper was decided to be presented at the 2020 American College Epidemiology Annual Meeting, ACE 2020 Annual Meeting, Advancing Health Equity-Epidemiologic Research, Education, Policy and Practice, 21 September 2020–23
September 2020, as a poster presentation. The poster’s abstract will be published in 'Poster Abstracts' in American Epidemiology Journal.
Contributors All authors had full access to all the data in this study and take responsibility for integrity of the data and the accuracy of the data analysis. PPW is the corresponding author and primary investigator. YK, LGS and FS contributed equally and share the first authorship. PPW and YK conceived of and designed the study; YW developed the online survey questionnaire and completed data collection. PPW, FS and YK acquired funding. LY, WZ and XW supervised data collection. YK, LGS, FS and YZ analysed and interpreted the data. YK and LGS wrote the original draft of the manuscript. All authors contributed to reviewing and editing the manuscript.
Funding This study was supported by the New Frontiers Research Fund (NFRF-2019-00012 to PPW) through the Canadian Institute of Health Research (CIHR), Shandong Provincial Youth Innovation Team Development Plan of Colleges and Universities (2019-6-156, Lu-Jiao to FS), Scientific Research Projects of Universities in Shandong Province (J18KB069 to YK), the National Nature Science Foundation of China (20003560 to YK and 8182719 to FS), Natural Science Foundation of Shandong Province (ZR2020MH340 to YK), and the Project of Medical and Health Science and Technology Development in Shandong Province (2017WS832 to YK).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.