Chinese Culture and Cancer among Malaysian Chinese Cancer Survivors

We conduct a case study on cancer survivors with the aim to investigate the influence of specific social and cultural factors that may have influenced informants’ unhealthy lifestyle and health-seeking behaviour and thus causing the illness cancer. In the 50 in-depth interviews with 50 informants, this report of Chinese culture and cancer was designed to evaluate the role of Chinese culture in causing cancer. In its discussion section, this report focuses on three main themes of cancer diagnosis among the informants: (i) perception of health and illness after cancer, (ii) emotional effects of stress in cancer etiology, and (iii) decision-making and cancer treatment. In summary, several Chinese sociocultural beliefs and practices played their roles in the informants’ ways of living, health-seeking behaviours, and cancer diagnosis. The results suggested that Chinese cultural beliefs and practices influenced the Malaysian Chinese cancer survivors’ perceptions of health, illness, and cancer treatment.


Introduction
Chinese are the second largest ethnic group in Malaysia and they are mostly descendants of Chinese immigrants from the Southern part of China during the 19 th century (Soontiens, 2007).The latest statistics show that individuals of the Chinese ethnic group represent 23 percent of the estimated total Malaysian population of 28.9 million (Department of Statistics Malaysia, 2010).In chronic diseases such as cancer, data from the Malaysia National Cancer Registry (NCR) reports show that Chinese in Malaysia have the highest lifetime risk for cancer (1 in 4), compared with other ethnicities in Malaysia such as Indians (1 in 5) and Malays (1 in 7) (Lim et al., eds. 2003;Lim & Halimah Yahaya, eds. 2004;Lim et al., eds. 2008).
In terms of cancer studies on Malaysian Chinese, a review of the literature undertaken so far shows that majority of the studies focus on biomedical perspectives of the disease, identifying some primary risk factors for various types of cancer contracted by Malaysian Chinese.Some of the most accepted risk factors include cigarette smoking for lung cancer (Menon & Saw, 1979;Gopal et al., 1988;Yaacob Ismail et al., 1990); salted fish consumption and prolonged occupational exposure to particles, formaldehyde, and heat for nasopharyngeal cancer (Armstrong et al., 1979;Armstrong et al., 1983;Armstrong et al., 1998;Armstrong et al., 2000b); and nulliparity, family history, oral contraceptives as well as obesity for breast cancer (Norsa'adah et al., 2005).
Taken together, another observation obtained from the above cancer studies of biomedical perspective on Malaysian Chinese is that, the biomedical identification of risk factors, in most cases, may have contributed the risk factors to the type of lifestyle adopted by the Malaysian Chinese.However, most of the study findings do not elaborate on the sociological perspective of how and why the Chinese type of lifestyle has contributed to the various cancer risk factors among the Chinese community in Malaysia (Menon and Saw, 1979;Yip and Ng, 1996;Hejar et al., 2004;Wong et al., 2008).For example, Hejar et al., (2004: 230) in their study assessing the relation between lifestyle practices and breast cancer risks among Chinese women residing in the Klang Valley of Malaysia suggest that there is a positive association between Chinese women's breast feeding practices and their risk of contracting breast cancer, but half of the participants reported not practicing breast feeding.In this respect, the researchers did not elaborate further on other factors from the sociocultural perspective, such as why breast feeding is not been popular among Chinese women.
As such, for further understanding of the occurrences of cancer in the Chinese community in Malaysia, an additional grasp of cancer contraction from the sociological perspective, besides the normal understanding of cancer from the biomedical perspective, provides a holistic approach to analysing the disease.According to Conrad and Gallagher (eds., 1993: 89 -91), the sociological explanation in the issue of cancer rests upon the facts that some of the principal risk factors identified by professional health care providers associated with cancer are behavioural factors, that is lifestyle and daily activities such as smoking, alcohol drinking, exercise, and diet.To the researchers, a sociological approach observes that these behavioural factors practiced by the individuals in an ethnic community are deeply influenced by the particular community's cultural values and beliefs.The cultural values and beliefs which include religious values and beliefs, influence directly or indirectly, the individuals' attitudes and values about ways of living such as food and drink preferences, living and working environment, ways of relaxing, and patterns of entertaining.In addition, the ethnic community's cultural values and beliefs also influence the individuals' behaviour, particularly their health-related behaviour such as health preventive practices, knowledge on etiology of disease, and perception of health and illness.
The purpose of this report is to investigate the influence of specific social and cultural factors that may have influenced informants' unhealthy lifestyle and health-seeking behaviour and thus causing the illness -cancer.In particular, this report of Chinese culture and cancer was designed to evaluate the role of Chinese culture in causing cancer.In its discussion section, this report focuses on three main themes of cancer diagnosis among the informants: (i) perception of health and illness after cancer, (ii) emotional effects of stress in cancer etiology, and (iii) decision-making and cancer treatment.Each of these themes is discussed at length in turn below.

Setting and Recruitment
This report is part of a larger study by the researcher's doctor of philosophy in medical anthropology to examine the influence of sociocultural factors in influencing lifestyle, health and health-seeking behaviour of the Malaysian Chinese cancer survivors.In the study, the Chinese cancer survivors were recruited from the regular group of Guolin Qigong practitioners at the Lembah Kiara Recreational Park in Taman Tun Dr Ismail, Kuala Lumpur.
In this study, informants' age profile in relation to trend of cancer diagnosis suggests that cancer is diagnosed more often among informants aged between 40 and 59.Among these middle-aged adult informants, most of them are the breadwinner for their family.In achieving their goals to support their family, the demands of long working hours have caused them to most likely ignore their need for regular rest and even the need for health care.As such, this constant work pressure significantly affected their health and they became a risk group for cancer.
With regard to the role that gender plays in the informants' cancer experience, the researcher placed less emphasis on the differences of various cancer risks for men and women as in most biomedical cancer studies.In the initial stage of this study, the ratio of gender employed was according to the gender ratio of Chinese who are with cancer as reported in the Malaysia NCR reports, of which the gender ratio for Chinese ethnicity in Malaysia has been consistently showing 40 percent male and 60 percent female (Lim et al., eds. 2003;Lim & Halimah Yahaya, eds. 2004;Lim et al., eds. 2008).
Next, gaining entry into a research community is the first problem a researcher encounters in a qualitative research.It involves the researcher spending time with the particular community under study and establishing rapport with the people in the community.In this study, in order to show her sincerity to carry out a study on the group of cancer survivors at the Lembah Kiara Recreational Park purely for academic purposes, the researcher in the initial stage also spent much of her time explaining the research objective particularly to ensure the qigong practitioners cum cancer survivors of the ethical issues, particularly confidentiality, to those who are willing to share their life experience and struggle with cancer.In addition, the researcher had on several occasions, joined the qigong practitioners cum cancer survivors in social activities such as moon cake festival celebration and visiting to places of interest within Malaysia.
Consequently, in this study, upon acceptance by the community concern, the researcher gradually convinced the people in the community of her trustworthiness and credibility in researching a topic concerning them.In addition, as a member of the community under study, the researcher also acts as a participant in the community who is observing others.As such, as a part of the social setting, the researcher observed patterns of behaviours, and developed a quality of trust with the informants that later would motivate them to tell and share their experience in the one-to-one interviews between them and the researcher.

Data Collection
Data collection by the researcher took place between March 2007 andJune 2009 (approximately 28 months).Two data collection techniques dominated in this qualitative study, mainly participant observation and interviewing.As a whole, the interviewing process took two methods.Method 1 involved in-depth individual interviews with all the 50 informants, conducted personally by the researcher, and each interview lasted between 60 and 90 minutes.Whereas method 2 involved breakfasts chats with five groups of the informants, of which each breakfast chat group comprised of five to six informants from the study group and each breakfast chat could run from two to three hours.
During fieldwork, the researcher began interviewing with small talk with the informant in order to gather data on the demographic characteristics of the informants which covered sex, age group, income, level of education, living location, religion, occupation and marital status.Then, subsequent interviews formed the basis for conversations between researcher and informant, as well as self-disclosures, thoughts, and emotional changes created by the informant.
The subsequent interviewing process was based on in-depth semi-structured interviews, with open-ended questions so as to allow the informants to talk freely in depth and detail.In this study, the researcher carried out the interviewing task guided by an interview schedule, of which some questions related to the issues of study were pre-planned and were used to ask the informants during the interview.The semi-structured interviews addressed informants' way of living before and after cancer diagnosis (for example, busy lifestyle, working environment, and work-family constraint), impact of cancer, health care access, culture (for example, role of health beliefs, acculturation, religion), social factors (for example, SES, education), barriers to health care and psychosocial care, role of the health care system, patient-physician relationship and medical adherence.
All the interview data were recorded by the researcher as written field notes and were later transcribed before the study was concluded.The process of transcribing the field notes is considered beneficial in facilitating any independent viewers such as the supervisor to researcher, to understand the study better during the phase of data analysis (Poland, 1995;MacLean, et al., 2004).All the participants' names used in the transcribed data are pseudonyms, to ensure confidentiality.Of all the 50 interviewed cases, the researcher identified 15 cases of informants that could provide significant information and insights for the critical analysis of the study.Out of the 50 informants in this study, 15 were most active in elaborating and sharing their lives' experiences while the other 35 showed passive attitudes and gave short answers to the questions in the interview schedule.The field data collected from the passive informants help to triangulate the data collected from the interviews with active informants, and to overcome biases and differences in how public readers rate the individual informant's responses.
Occasionally, in the discussions, the researcher would use the opportunities to triangulate data with the informants on certain issues which had arisen in her fieldwork.Whenever there were doubts in her field notes, she would always try to clarify them by cross-checking with the informants concerned when she saw them the next morning at the park.The researcher would wait for them to complete their qigong exercise for the morning, and had had their 15-minute resting time, before she would pose the questions to them.In addition to cross-checking on previous data, any topics during this casual chat that appeared relevant to the study were recorded in the researcher's fieldwork diary.Here, cross-checking, casual chat, and informal interviews utilised are similar to the data triangulation proposed by Gay (1996), of which data were gathered at different times and social situations, as well as from a variety of people.The use of multiple data collection methods in this qualitative study contributed to the trustworthiness of the data.
Throughout the whole study, the tape recorder was not used to record any forms of discussion between the researcher and informants.This was agreed earlier before fieldwork was carried out.This in turn had produced several positive contributions to the data collection process.For example, informants showed positive responses to most issues raised during the interviews.In many cases, they expressed their views and opinions freely, coupled with their emotions of happiness, sadness and anger.Another important point to mention is that the researcher was allowed to make any notes as and when the chats or discussions among themselves showed element of significance to the study.The informants were not worried at all as long as their words were not audio recorded.For example, Zhen Jie, one of the informants and an ex-tailor aged 56 years, once in a chat with some of the informants, mentioned about her recurrence of breast cancer.She further blamed herself for being too emotional in handling her recent family problems and thus causing the recurrence.News, complaints, or discussions related to the informants and their health and illnesses were mentioned intermittently during their short chats after the morning qigong exercise.

Data Analysis
In this study, data analysis deals with a large amount of field data derived from observing or interviewing research informants.In this context, data analysis was carried out with the objective of "making sense" of those unstructured textual-based field data.In relation to the process of "making sense" of the field data, the following discussions focus on the process of data analysis, which involves identifying and organising field data, followed by a process called unitising whereby the researcher extracted relevant data that contain common meanings.Then, the researcher continued to categorise those data extracted into several categories according to several broad themes, and this process is known as categorising.Later, the various categories of broad themes went through two more processes, synthesising the broad themes and then searching for similar patterns among the themes.Finally, the last process of data presentation involved presenting data based on the meanings emerged and interpreting from the previous synthesised broad themes (Bogdan and Biklen, 1982).

Perceptions of Health and Illness after Cancer
The cultural beliefs of the Chinese community which are seen as a cultural barrier in the medical care of the cancer survivors in this study are superstitious.Majority of the informants have reservation towards mentioning the term 'cancer' during their conversations.To them, explicitly mentioning cancer is a taboo.They strongly believed that discussing the disease in relation to their names will increase the severity of their illnesses, causing them to be isolated from their friends and relatives, or bringing bad luck to the people they talk to.Most of the time, they would prefer to discuss the topic as though it does not concern them.They normally do not associate their names with the disease.This behaviour clearly reveals their thoughts which are filled with superstitious beliefs regardless of their educational background.In relation to the superstitious beliefs, Ying Mei related the following to the researcher: According to Ying Mei, prior to cancer, majority of her friends and family members have the feeling that if they were to spend too much time talking about a kind of terminal illness such as cancer; they might one day be diagnosed as one of them attacked by cancer.And now, after the diagnosis of cancer, she felt most of the cancer patients or survivors including herself are even more reserved in mentioning cancer.Some of them even try to hide their disease, out of fear that the people surrounding them will abandon them by keeping a distance from them.Generally, her circle of friends and relatives feel that having a conversation on cancer will cause the bad luck of cancer to spill-over to them.Ying Mei later commented that her sister-in-law even disallowed her friends to come over to her house to discuss the disease in their home.Her sister-in-law's greatest fear is that the discussion of cancer in their home will cause Ying Mei to have a recurrence of the disease.(Field note: 20 April, 2007) The above account describes how the mentioning of cancer causes unnecessary stress among the informants in this study, by instilling fear of the recurrence of the disease.Similar to the case of Ying Mei, majority of the informants, irrespective of their educational level and socioeconomic status, think that talking about something bad like cancer will cause it to come true.Due to this superstitious belief, most informants, when diagnosed, do not disclose their disease condition to others.However, by doing so, they may not obtain useful information regarding their disease and the choices of treatment method as well as types of proper diet to follow for a cancer patient.
In this study, the existential threat situations occurred amongst informants that were newly diagnosed with cancer.Under these circumstances, two significant issues are highlighted from the findings, where informants are categorised under two categories, i.e., informants subscribing to religion under the situation of existential threat, and informants choosing to live peacefully with the life-threatening disease.These two issues will be discussed in turn below.
Firstly, most informants feel that when one is inflicted with life-threatening illnesses such as cancer, one falls into a state of despair, desolation, and feels that nothing is permanent in the world.At this juncture, they automatically turn to God for comfort and solace, mercy, and His Grace to heal the ailment.Majority of the informants do not particularly subscribe to any religion prior to cancer.Eng, one of the informants, described to the researcher his experiences related to psychological, social, and existential issues, as noted in her field notes: According to Eng, he was an atheist prior to cancer and he used to proclaim himself as a 'free thinker' before diagnosis.However, upon diagnosis as a lymphoma cancer patient, his will to live emerged as the central theme in his journey to fight the deadly disease.His fights for life become intensified during the painful and suffering stages of chemotherapy.Besides Western treatment, he tried many types of complementary and alternative medicines which include qigong, Chinese herbal remedies, supplement diet, ayurvedic, and meditation.It was during the early stages of the turmoil situation in his therapeutic journey that he finally turned to God in a desperate bid to come out of the ailment and be proclaimed a perfectly healthy person.According to Eng, he does not have any particular religion in mind.He just prayed for God's protection and His strength to help him overcome this tough stage.
(Field note: 28 May, 2007) In another situation, Jolene, aged 32 years and a Taoist converted to Christianity, feels very pleased with the prayers offered by the Church members every time they visit her at the hospital.The researcher noticed her experience as follows: Jolene was born in a Taoist family and had not been praying to any particular religion prior to cancer diagnosis, except to recite verses of the Goddess of Mercy in time of danger.However, upon diagnosis as colon cancer, she fell into deep depression as she thought that she was too young to be attacked by such a deadly disease like cancer.Moreover, she just got her baby girl two years ago.Her will to live become more active and when she thought of her baby girl and her happy family.It was under the feelings that her total existence is being threatened that she decided to stand and face the reality.She began to build a network of cancer survivors cum friends to share knowledge regarding cancer matters.During this time, she met with church members who provide prayers to patients in the hospital on a voluntarily basis.According to Jolene, she always feels calm and protected by God whenever the Church members offer prayers to her, whether in the hospital or at her house.(Field note: 25 April, 2007) Further to the above account on Jolene's experiences on fighting for her existence through the support of religion, she had several sessions of religious healing process by one of the experienced spiritual healers attached to a church in town.On one of the occasions the researcher observed, Uncle Joe, a Christian spiritual healer conducting spiritual healing on Jolene through a series of prayers for about an hour.Below is the description of the details of his healing process that the researcher noted in her field notes: During the chemotherapy sessions, Jolene used to feel tired and in pain.She also often suffered from sleepless nights.Her church members then arranged for an experienced spiritual healer, Uncle Joe, aged 85 years, to help her overcome the turmoil period.Uncle Joe's spiritual healing sessions were held in the night time around 8 o'clock.He usually spent about an hour on his healing prayers.He first started with a short prayer, and then followed by reciting some verses in the Bible.He finally signed off with a number of spiritual healing songs.Upon completion of the session, Jolene would feel good and at ease.She claimed that she often got a good night sleep after each spiritual healing session.(Field note: 25 April, 2007) As described in the above accounts of Eng and Jolene, informants strive hard to survive, to fight against the existential crisis created by cancer.In the process of struggling to live, informants relied upon the power of religion to gain strength in order to fight off the deadly disease.
Subsequently, the second issue in relation to the existential threat caused by cancer among informants is that informants chose to live as normal a life as possible and have minimum worries on the life-threatening disease.In this context, informants strongly believed that cancer is an incurable deadly disease.To many of them, the Western treatments on cancer provide some sort of surviving years of 'disease free' notion.The following description was extracted from the researcher's interview notes with Kenny, one of the informants, aged 29 years, who used to be a sales executive prior to cancer: According to Kenny, those who have contracted cancer will normally think that they will not live too long in this world.But, their will to continue to survive has not withered.Thus, these informants begin to accept death as part of their lives, so that they can live in a peaceful manner and starting to accept the ailment as part of their lives, too.To most of the informants, whatever form of cancer treatments do not guarantee a complete recovery.The Western treatments only provide some sorts of surviving years of 'disease free' notion.When such a mental framework is present in a cancer patient, they can live free of stress and worry and this in turn contributes to a better healing process.(Field note: 22 April, 2008) The above account by Kenny describes the issue of 'living peacefully' with the illness.Informants that choose to live peacefully with the disease does not mean they are giving up, instead, this approach shows another method by which informants' intention to live in this world continues to survive in the fight against their existential threat caused by cancer.The informants tend to subscribe to a philosophical belief that if they cannot fight against the disease, they would accept it and live peacefully with it.By doing so, psychologically, the informants presume the disease will not cause them much trouble in the future.

Emotional Effects of Stress in Cancer Etiology
In this report, the findings of this study provide evidence that most middle-aged informants (40-59 years old) regard practices of Confucian values such as 'Ren' (忍), submissive role of women, and family obligations as contributing factors to cancer etiology.Subsequently, the informants relate life with Confucian values such as living in a stressful environment which can result in negative emotions such as anger, fear, anxiety and depression.For the informants, they strongly believe that the prolonged negative emotions in them had ultimately drawn adverse consequences on their well-being.Therefore, in this section, the focus of the discussion is placed on the emotional effects of stress in cancer etiology as a result of Confucian values in the informants' way of life.
First and foremost, before the discussion on the perceived causal relationship between Confucian values and stress in the etiology of cancer, it is significant to elaborate on the informants' perceptions of stress, depression, anger, and anxiety, in cancer etiology.In most cases, when the informants related their lifestyle before and after cancer diagnosis with the abovementioned Confucian values, they considered their life stressful.On a long term period, their inability to adapt to their stressful situations had led to the onset of depression in them.Here, in this study, a number of women informants supported the idea that stress causes cancer or cancer recurrence in survivors.For example, Zhen Jie, one of the informants aged 56 years; in the interview notes reported the association of a stressful life event and the recurrence of her breast cancer.The researcher noted her experience as follows: According to Zhen Jie, ever since her last treatment on breast cancer some years ago, she has been taking very good care of herself, physically and mentally.She would ensure that not to work too hard to tire herself.She would also ensure that she is always happy and in a good mood.This is because she knows very well that anything that is unhappy may cause stress and depression in her.And she had heard much from her group of cancer survivors that stress and depression is the main cause for the recurrence of cancer.However, last year, there was a hot argument among her siblings regarding the allocation of her mother's property.She was being accused of keeping some of her mother's jewellery though she has not done so.Since then she has been in deep depression.It was until one day, she suddenly noticed that she had a lump on her breast again.And this incident had instantly gotten her out of depression and forced her to face the reality that her continuous depressive mood had caused the recurrence.
(Field note: 7 May, 2007) The above notes on Zhen Jie represent one of the widespread beliefs amongst the informants that depression is commonly associated with the etiology of cancer in modern day society.Another popular belief amongst informants on current cancer etiology concerns stress, anxiety and anger.These etiologic factors of cancer involve the theory of Chinese traditional medicine on emotional disturbance and the flow of qi (vital energy) in the body.In this context, the female informants of this study generally believed that due to their excessive anger or anxiety on certain issues such as disagreement between husband and wife, argument between employer and employee, or attitude of an irresponsible husband towards family matters; the negative emotions of anger and anxiety would arise and interrupt the flow of qi in their body and weaken their body immune system which later expedite the development of cancer.The following description was extracted from the researcher's interview notes with Julie, one of the informants, aged 52.
In her younger days throughout her working life, Julie considered herself an impatient and hot-tempered person.As such, she frequently suffered from emotional distress such as anger and anxiety.To a certain extent, she could easily get angry at her superior or office colleagues if things were not going her way.However, after cancer diagnosis, she started to relate her younger day's behaviour with the development of cancer in her.To her surprise, she found that some of the cancer survivors in the same qigong group of hers share the same opinion that a person's character, especially those impatient and hot-tempered ones, can lead to serious diseases like cancer.(Field note: 30 March, 2007) The above description of Julie shows similar health effect with the studies of Sun (1991), Shi and Shi (1992), and Pan (1992) that, intense emotional distress for a long duration could lead to serious damage to physical health which may later cause cancer or recurrence of cancer.
Besides expressing anger and anxiety in cancer etiology, the emotional effects of women informants practising Confucian values highlight the factor of submissiveness in a family in relation to the development of cancer.In this study, most women informants associated their stress with gender role expectations.In meeting the cultural expectations of a good wife and mother, these women informants often adopt the traditional Confucian ideals of being submissive.With this role, they are expected to be silent and submissive to their husbands.In addition, they are expected to practise the Confucian virtue of 'ren' (忍), in dealing with people management.In order to be 'ren' (忍), these women informants are supposed to see things from other people's perspectives and not to hurt or confuse the feelings of particularly their family members.Ultimately, the submissive role of the informants coupled with their 'ren' (忍) practise of selfless contribution in family duties and obligations cause them a certain level of stress.According to the findings of this study, middle-aged women informants who had reported prolonged stress due to their traditional gender role expectations tended to be easily attacked by cancer.
In relation to the issue of women's submissive role in the family, Soo Zhu related the following to the researcher: According to Soo Zhu, she has three teenage daughters but no sons; she has been tortured verbally all these years for not bearing a son for the family.As a result of this state of affairs at home, she has suppressed all her anger and emotional turmoil within herself.Over the years, this lifestyle of hers has supposedly resulted in her developing uterus cancer.As she has commented, she does not blame anyone for her predicament.It was all a result of her submissive following of the Confucian way of life which emphasises the harmony of the family above everything else.As the Chinese teaching goes, when the family is in a peaceful state, everything will be well and prosperous.Hence, she tends to accept the role of the loser as and when she was blamed by her in-laws for not bearing a son for their family, and she chose not to pursue the matter by fighting for her rights.(Field note: 15 May, 2007) The finding on Soo Zhu is found similar to the studies by Watson and Patricia (1991), Tseng (2006) and Tsui (2008).In their studies, the researchers found that over a long period of time, the continuous stress experienced by the women in their families, gradually led them to live under a stressful environment which had adverse consequences on their wellness such as the occurrence of negative emotions.The suppression of their negative emotions, in turn, led to physical dysfunction which hurt the lung and damaged the stomach and spleen and later results in terminal illnesses such as cancer.
The above accounts of the emotional effects of stress in cancer etiology provide convincing evidence that stress is closely related to the onset of cancer amongst the Chinese informants in this study.As such, most informants have been keeping their life after cancer as stress-free and as normal as possible.Most of them shared a common thought that if the situation permitted, cancer patients should not return to paid work immediately after their full treatment.This is so because a stressful environment in the workplace tends to attack and lower the patients' or survivors' immune system.

Decision-Making and Cancer Treatment
In this study, majority of the Malaysian Chinese cancer informants noted that they sought assistance from both Western treatment and Complementary and Alternative Medicine such as TCM upon receiving a cancer diagnosis.Amongst them, some shared the opinion that seeking a second opinion from another, independent physician helped them to understand the type of cancer they have and the treatment options available and later they would be able to make an informed decision on which type of treatment was best for them.Here, one observes that, when faced with a life-threatening condition, these Malaysian Chinese cancer informants and their family members displayed an increased use of health care services.However, things were not the same for most of the informants before their cancer diagnosis.Informants, particularly the male informants, would first consider self-treatment by checking their illness symptoms with a nearby Chinese medical hall and would then buy over-the-counter traditional Chinese herbal remedies in order to release the pain and discomfort caused by their illness.This particular finding is in accordance with a previous study by Kleinman (1980) on Chinese patients and healers in Taiwan and Boston.The findings of his study provide evidence that self-treatment was the first therapeutic intervention in Taiwan.Subsequently, for the Malaysian Chinese informants of this study, majority of them subscribed to the belief that when the need to seek for professional health care providers arises, it indicates a worsening state of their illness and thus more aggressive treatments to control the disease are required.Otherwise, in their opinions, visiting the Western doctors for minor discomfort in their bodies is considered as over-reacting to a small problem.
In relation to informants' decision-making on the need to employ professional medical care based on the factor of the severity level of a disease, Liang Hui related the following to the researcher: Liang Hui believed that most of the Chinese are just like him where do not visit a Western doctor for minor symptoms of illness such as headache, giddiness, nausea, vomiting or breathlessness.They will only seek medical care from a Western doctor when the pain in their body is definitely unbearable or the pain has been continuously attacking them.However, according to Liang Hui, even if the pain in their body has been attacking them constantly but if the pain can be cured temporarily by just taking some rest or by taking some Chinese medicine that they can easily buy from the Chinese medical hall; then, they will still choose not to visit a clinic.On the occasion of cancer diagnosis, Liang Hui however regretted that he had been avoiding an earlier diagnosis as he had taken for granted that his frequent 'bloated stomach' was due to 'wind' or stagnation of qi in the stomach as believed by most Chinese.In order to treat his stomach discomfort, he used to apply ointment as often as necessary for temporarily relieve measure.(Field note: 12 May, 2009) For one of the informants, Confucian teaching on the filial piety of the son becomes an influencing factor over health and illness of the elderly in a Chinese family.Particularly for the eldest son in a family, the Confucian ethical system holds him responsible for the care of the family, which includes seeking medical care, for the elderly parents.The following description was extracted from the researcher's interview notes with Yung Ji, one of the informants: As Yung Ji recalled, he had never been to hospital to seek treatment all his life, until one day he found that his phlegm was mixed with blood.His son was anxious about the incident and forced him to see a doctor in the hospital.According to Yung Ji, that was his first encounter with a Western doctor and after all the tests on him, the doctor finally told his son that he has cancer.As Yung Ji commented, he should not have gone to the doctor in the first place.He considered that whole process of cancer diagnosis as bad luck.(Field note: 30 April, 2009) Another key value in Confucius' teaching that has contributed to the considerations of cancer treatment decision making of the informants in this study relates to the common practice of Confucian ancestor rites amongst the informants.Some of the informants strongly believed that performing ancestor worship during their cancer therapeutic process would enable them to gain spiritual strength from their ancestors.This spiritual strength in turn would provide protection against pain and misfortunes during Western therapies.With the perceived protection from their ancestors, these informants then have complete confidence in the Western cancer treatments.The following description was extracted from the researcher's interview notes with May Li, one of the informants.
May Li recalls she was suffering from colon cancer and was told by her oncologist that it was already in third stage.She had strong feelings that there were two things she needed to do upon diagnosis.First, she must listen to her doctor that she needed a surgery.Second, she needed to perform worship to her ancestors.She would ask her ancestors to help her not to feel so much agony, to protect her from any evil spirit, and to get well soon.She strongly believed that her disease could be due to her normal diet where she might have eaten too much meat.Thus, she opted to become a vegetarian after chemotherapy and she also decided to serve vegetarian dishes to her ancestors during the worship.(Field note: 5 April, 2007) Next, several informants sought guidance from the 'religious counsellor' based in a Chinese temple for a clearer understanding of their 'case' (cancer attack) in terms of disease's cause and solutions.This religious inclination of the informants was mainly due to their strong belief that since modern medicine cannot explain the causes of cancer; therefore, the happening of cancer must be either a divine punishment or possession of evil spirits.According to the informants, divine punishment could be due to informants' inappropriate behaviour such as failure to perform the proper rituals of respect for a dead ancestor.In this context, Yung Ji, a hawker aged 71 years and suffered from lung cancer, related his experience as noted in the researcher's interview notes: According to Yung Ji, he seldom prays in a temple prior to cancer.He did not even spend time on taking care of his ancestor mortar in his house.In relation to his illness, he asked the Deity in a Chinese temple.
The Deity said that Yung Ji had offended his ancestors' spirits because he has not been praying to them all these years.According to Yung Ji, he always leaves the praying tasks and rituals to be done by his wife and his children.Later, the Deity helped him by giving him some 'blessing water' to drink to gain good health in the near future.On top of that, the Deity told Yung Ji to start taking incenses and pray for his ancestors every morning and night, even after his recovery from cancer.(Field note: 30 April, 2009) In another case, Lai Chan, one of the informants, went to a small Chinese Taoist temple near her house and with the help from the temple's 'religious counselor', the attack of cancer in her was explained to be simply due to bad luck.Below are the researcher's interview notes on Lai Chan's experience with a temple's 'religious counselor': According to Lai Chan who has stayed in her husband's family after marriage, ever since her husband's grandfather generation, they have been praying at the Chinese temple especially during Deities' celebrations.Also, when anyone in the family happened to be attacked by any critical illness of which even the Western doctors could not cure; they will then seek the advice from the Deities in the temple.Through the help from a 'religious counselor,' the Deity in the temple disclosed that it was due to the person's bad luck.At times, it could be due to human accidentally meeting bad spirits.According to Lai Chan, there are many reasons why one faces difficulties in life.In her case, she felt that she all of a sudden become ill, before she was contracted with cancer.She went to seek advice from the temple Deities and was told by the Deity (who is in charge of health and medicine) that she had met with a bad spirit (ghost).The Deity then told her to just trust the doctors and let them take care of the healing of the disease.In addition, the Deity instructed her to carry a piece of talisman with her wherever she was going.
(Field note: 27 November, 2008) Similarly, Li Fun, one of the informants, aged 58 years and is a full time housewife attributed her illness to evil spirits.As she emphasized, when one faced with illnesses such as cancer that is threatening one's physical existence in this material world, both Western medicines and supernatural power are needed in order to free one from life predicaments.The following description was extracted from the researcher's interview notes with Li Fun: According to Li Fun, cancer patients certainly ought to have complete faith in the doctor.Otherwise, the patients won't choose him (or her) to treat them.But then, when the situation of the disease is so dangerous and critical, the patients just need to have some kind of supernatural power to help them heal themselves.This is the Chinese beliefs that if they pray to the Deity faithfully and ask for protection, often, they see people with bad condition who will still survive the Western treatments due to their prayers to Deities.As cancer is something so dangerous and can cause many deaths, one thus needs to pray to their Deity.According to Li Fun, the prayers will definitely help a lot in the process of cancer treatment.On top of the oral prayers, the temple's Taoist priest used to distribute two bottles of 'blessed water' to consume as well as to bathe the patient from head to toe.On top of that, they also brought home a 'blessed talisman' which was meant to place under the patient's pillow for protection from further attacks of the evil spirits.
(Field note: 10 December, 2007) From the above descriptions by Yung Ji, Lai Chan, and Li Fun, one observes that Chinese religious beliefs that are well demonstrated among the informants in this study influence their decisions in treating cancer.Here, the study portrayed a pattern of co-existence between Chinese therapies such as Chinese religious rituals and Western treatments in the therapeutic journey of the informants.The above accounts on prayers to ancestors and prayers to Deities, keeping a 'blessed talisman,' and drinking 'blessed water' by the informants are religious practices that are believed to be means to help the informants to alleviate the disease to a certain extent.
Besides performing Taoist religious rituals, some informants in this study, especially those who were more inclined to Buddhist teachings, carried out good deeds, while going through the conventional Western cancer treatments.The complementary treatment of good deeds was performed due to informants' beliefs in the concept of karma.These informants strongly believe that their bad karma which consists of their previous bad doings, had contributed to their cause of cancer.As such, they ought to continuously carry out good deeds in order to proportionately reduce the bad karma accumulated earlier, and in turn, assist in the curing of cancer through Western treatments.In relation to the concept of karma as the cause and solution for cancer, Ying Mei related the following to the researcher: She started to read books on Buddhism when she was attacked by cancer.After reading a few books on the teachings of Buddhism, she believes that she has done something bad in her previous life.Or maybe even in the present life, she may have done a lot of killings in her house -killing the ants.She just could not bear seeing even an ant on the dinner table.In this context, her family members too thought that she must have committed a lot of bad karma and so they have suggested for her to do something good to reduce her sufferings.Thus, she went to join a group of Buddhist friends and they bought some fish from the shop, and then they went to one of the jungle stream where they then released the fish back to the nature.The religious practice is called 'life release' (note 1) in Buddhism.So far, she had also joined another group of Buddhist friends for 'bird release.'For Ying Mei, it is kind of a happy act to perform and she felt good after each of the 'life release' activities.(Field note: 20 April, 2007) In another instance, some of the informants adopted a passive attitude towards cancer, where they thought that they should not make any changes in their lifestyle because cancer can never be cured and death is just a matter of time.In relation to this, one of the informants, Lau, related the following to the researcher: Lau is one of the informants who had adopted the negative attitude of ignoring the severity of the disease.As he is all prepared for the last day to come, he does not see any difference in his illness even if he were to improve his lifestyle by taking more vegetables and fruits.According to him, when it's time for one to go, one just has to go.Nothing can change the reality.Therefore, if one cannot possess the power to change the fact that cancer is a deadly disease, then one should just enjoy the balance of their days they get to spend in this world.However, Lau's life and death philosophy does not represent the opinions of the rest of the informants.Most informants strive to have a longer lifespan even though they are faced with the existential threat as a result of cancer.
(Field note: 9 April, 2008) The above comments by Lau indicated that he had given up hope in surviving his illness, as cancer is generally perceived as a deadly disease.Therefore, he has not opted for treatment, neither Western nor TCM.

Conclusion
This report has identified the main themes that have emerged from the study.Several Chinese sociocultural beliefs and practices played their roles in the informants' ways of living, health-seeking behaviours, and cancer diagnosis.The results suggested that Chinese cultural beliefs and practices influenced the Malaysian Chinese cancer informants' perceptions of health, illness, and cancer treatment.
Chinese cultural beliefs place an emphasis on the concept of yin and yang balance.This belief entails taking care of oneself through maintaining an emotional and physical balance.In the event that one is contracted with cancer, some of the cancer informants resorted to self help by visiting a traditional Chinese medicine (TCM) practitioner, where Chinese herbal remedies are often prescribed so as to restore the balance of yin and yang coupled with the smooth qi flow in the body.Informants in this study considered balancing yin and yang as the optimal way to stay healthy and away from recurrence of cancer.
Next, among the cancer survivors, cancer is viewed as an unpreventable and fatal disease which is related to the Chinese cultural beliefs of fate and fatalism.This coupled with a culture that does not emphasize the importance of self health, led some of the cancer informants to view a cancer diagnosis as a death sentence.In addition, the traditional health belief of the informants is such that Western doctors are only to be visited when pain becomes unbearable, and thus they themselves and their family members finally agree that they are physically ill.This finding of beliefs in fate and fatalism, however, suggests that this particular group of cancer informants felt that it was impossible to change the course of their illness; they thus accepted their situation and adjusted to their changed environment and made a conscious decision to move forward.