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Abstract
The use of traditional medicine is a global phenomenon, and the WHO advocated its appropriate integration into modern healthcare systems. However, there is a hot debate about the legitimacy of traditional medicine among the general public. Here, we investigated the debate in the Chinese digital context by analysing 1954 responses related to 100 questions about traditional Chinese medicine (TCM) treatment against COVID-19 on the Zhihu platform. Attitude function theory was applied to understand the reasons underlying public attitudes.
Results showed that Zhihu users generally held a supportive attitude toward TCM. Their attitudes mainly came from their own experience and traditional media. The general users were more negative while medical professionals were more positive toward TCM. Ego defence (eg, derogating evidence sources) was used the most to support attitudes, followed by value expression (eg, believing in science). Supporters showed fewer expressions of faith (eg, the use of TCM is a kind of faith), politics (eg, supporting TCM is about politics) and science value (eg, TCM is a field of science), fewer ego defence, more patriotism and cultural confidence expressions (eg, TCM is a cultural pride) and more knowledge explanation (eg, TCM accelerates the metabolism of phlegm) than expected. Opposers showed fewer utilitarian and knowledge functions, fewer expressions of patriotism and more expressions of faith, politics and economics, but more ego defence functions than expected. Opposing posts were more likely to attract engagement than supporting and neutral posts. Posts that mentioned attitude functions generally attracted more engagement.
Our findings indicate that TCM debate in modern China is not only relevant to medical science and health, but also rooted deeply in cultural ideology, politics and economics. The findings can provide global insights into the development of proactive policies and action plans that will help the integration of traditional medicine into modern healthcare systems.
- COVID-19
- Public Health
- Social Media
Data availability statement
Data are available upon reasonable 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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WHAT IS ALREADY KNOWN ON THIS TOPIC
Previous research on traditional Chinese medicine (TCM) only focused on the general attitudes of the public towards TCM, failing to reveal the reasons behind these attitudes.
WHAT THIS STUDY ADDS
This study innovatively applied functional attitude theory to understand why people support or oppose TCM.
In addition, we further explored the sources of attitudes, the differences in attitudes among people of different professions, and the differences in attitude functions among people of different professions.
In addition, in the discussion of TCM treatment of COVID-19, it is still unclear which attitudes attract the most public participation and which reason (attitude function) attracts public participation.
This study fills this gap and examines which attitudes most attract public participation and which attitudinal functions are more likely to attract audiences.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The results of this study will provide information for the government, media and experts to enhance the image of traditional medicine globally, and find ways to establish public trust in traditional medicine.
Introduction
The use of traditional medicine is a global phenomenon. According to the WHO, ‘Traditional medicine … is the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement, or treatment of physical and mental illness’. Among the WHO’s 194 Member States, 170 countries/areas have reported on the use of herbal medicines and other forms of traditional medicines. As traditional medicine can play an important and catalytic role in achieving universal health coverage,1 many countries have already taken steps to integrate practices, products and practitioners of traditional medicine into their national healthcare systems. It is therefore imperative for research to support the development of proactive policies and action plans that will help such integration.
The COVID-19 pandemic offers a valuable opportunity to investigate the potential opportunities and obstacles to the integration of traditional medicine into modern healthcare systems. The pandemic witnessed globally the heightened use and research of traditional medicines as potential solutions for gaps in the prophylactic and therapeutic measures against the virus.2 While the WHO had been affirming support for COVID-19 traditional medicine research, there was not a consensus about the safety and effectiveness of traditional medicine in the treatment of COVID-19. This thus ignited a debate on whether and how traditional medicine should play a role in fighting against COVID-19.
Such a debate was especially salient in the general public of China as it manifested the century-long conflict between traditional Chinese medicine (TCM) and Western medicine. In the early 20th century, Western medicine was first introduced to China and had a profound impact on the Chinese medical field.3 Western medicine was presented as a complete theoretical system that was developed based on modern human anatomy, cell microbiology, histopathology and advanced instruments. It has developed evidenced-based methods for disease diagnosis and treatment. Unlike Western medicine, TCM is a discipline with a unique theoretical system, rich clinical experience and thinking methods. TCM takes a holistic approach to human health and develops diagnosis and treatment methods based on a combination of natural sciences, humanities and social sciences. However, due to the inability of TCM to achieve accurate diagnosis and ensure the stability of treatment effects, TCM is criticised as ‘unscientific’.4 5 With the outbreak of the COVID-19 pandemic, the debate reignited on the internet. Some people support TCM in treating COVID-19, arguing that it has experienced the test of time. At the same time, many people support TCM to show their loyalty to the country, rather than based on science.6 In addition, some critics question the scientific validity of TCM in treating COVID-19.7
Therefore, this study aims to examine the diverse public attitudes on the use of TCM in fighting against COVID-19 in China. Understanding public attitudes, though only locally in China for this study, can offer global insights into good practices that can help integrate traditional medicine and modern healthcare systems. To achieve the research aim, we investigated the discourse of TCM treatment of COVID-19 on Zhihu, the largest Chinese question-and-answer social media platform. Zhihu has demonstrated a huge impact on people’s health attitudes in China. Zhihu has demonstrated a huge impact on people’s health attitudes in China. Zhihu has over 100 million average monthly active users8 and 14.2 million average monthly subscribing members in 2023.9 It has become one of the biggest communication platforms for health-related topics in China, as approximately 15% of the user-generated content on Zhihu is health-related. Particularly, discussions about TCM treatment of COVID-19 have received an extremely high level of participation, reaching 18 000 question threads and 26 million views. The platform provides in-depth discussions on controversial topics in health and science as it is argued to suffer less online censorship to protect knowledge-based discussions.10 11 Thus, the platform provides valuable data sources for us to understand public attitudes on TCM treatment of COVID-19.
We first examined the stances, differentiations and sources of public attitudes toward TCM treatment of COVID-19. As previous research focused only on the public attitudes towards TCM and failed to reveal the reasons behind those attitudes, this study also innovatively applied functional attitude theory to further understand why people support or oppose TCM. In addition, as the Zhihu platform can provide audiences’ feedback on the content through functions of agreement and comment, we also examined which attitudes and what expressions of attitude functions could attract the most audience participation.
Historical development of disputes between Chinese and Western medicine
Before the founding of the People’s Republic of China (PRC), Chinese and Western medicine were mainly opposed to each other, and there was a fierce struggle between the two sides for the survival or abolition of Chinese medicine. After the founding of the PRC, the policy of attaching equal importance to TCM and Western medicine was gradually established and formulated (Figure 1).
The evolution of policies on traditional Chinese medicine (TCM) (drawn by the authors).
Although TCM has been supported by the Chinese government at the legal level, there are still many sceptical voices from the public about the effect of TCM on COVID-19. The main doubts are the following: (a) the concepts of TCM theory such as ‘yin’ and ‘yang’, are nebulous and even metaphysical12; (b) the four diagnostic methods of TCM, looking, smelling, asking and feeling, are not as accurate as machines13; (c) the explanation of aetiology and pathogenesis in TCM is pseudoscientific12; and (d) TCM is obsolete, and accordingly, it is necessary to rely on modern science to reinterpret TCM.14
In practice, however, surveys showed that the public generally has a positive attitude toward the effectiveness of TCM treatment. An online study survey of 3000 Chinese people found that 24.40% had experience with TCM treatment and considered it effective, most had no experience with TCM treatment but were interested in receiving it (50.57%), only 12.27% people opposed TCM.15
In the treatment of COVID-19, the Chinese government uses TCM as one of the therapies.16 Surveys showed that the treatment of COVID-19 by TCM is accepted by the public to a certain extent. A study of 2039 Chinese people in 2020 showed that 73.4% of the participants were confident or extremely confident in TCM treatment for COVID-19, and only 0.2% had no confidence.17 A study of 1121 asymptomatic COVID-19 patients towards TCM in Shanghai Fangcang Hospital in 2022 found that 91.35% of the patients were willing to receive TCM treatment, while 8.65% were not.18 A study on college students using TCM to treat COVID-19 showed that 82% of the 313 participants held a supportive attitude, 16% held a neutral attitude and 2.4% held a negative attitude.19
Although these studies provide some preliminary insights into the public’s attitude towards this issue, they only used convenient sampling and lacked samples that reflect the opinions of the entire nation. Therefore, we will conduct a content analysis of related questions and responses on Zhihu, the largest question-and-answer platform in China, to explore this question at the national level, and raise our first question:
RQ1: What is the attitude of Zhihu netizens towards TCM treatment of COVID-19?
Sources of attitude
Faced with health crises, people usually have a high demand for information and tend to seek information from sources they trust.20 People can obtain health-related information from various sources, such as traditional media,21 family and friends22 and social media.23 Different sources may have different attitudes towards TCM, so we want to explore which sources are cited when people express their attitudes on TCM treatment of COVID-19, and propose RQ2:
RQ2: What are the sources of Zhihu netizens’ attitudes on TCM treatment of COVID-19?
Profession and attitude toward TCM treatment of COVID-19
In addition, the profession of users may influence their attitude. According to social identity theory, individuals construct their sense of self by associating with social categories or group memberships.24 When individuals align themselves with a specific group, they tend to imitate the characteristics of the group.25 Previous research showed that compared with non-medical students, medical students were more worried about the unclear pharmacological and toxicological properties of Chinese herbs.19 However, another study showed that people with a medical education background were more supportive of TCM than others, with only 1% holding a negative attitude.26 Therefore, whether people in the medical profession were more or less likely to support TCM treatment of COVID-19 is still a controversial topic that is worth further investigation, so we raise our RQ3:
RQ3: Are there any differences in attitudes toward TCM treatment of COVID-19 among people with different professions?
Attitude functions
Functional attitude theory suggests that attitudes serve specific goals that are driven by underlying needs and motivations and have different functions.27 28 The same attitude may have different functions for different people.27 Therefore, if we want to persuade people more effectively, it is necessary to understand the functions of attitudes and to match persuasive messages with people’s attitude functions. Since most of the previous studies on people’s discussion of the effect of TCM treatment for COVID-19 only examined the attitude level and lacked research on why people support or oppose TCM, we use functional attitude theory to help us understand the reasons behind it.
Katz identified four functions of attitudes: utilitarian (or adjustment function), value-expressive, ego-defensive and knowledge function.27 The utilitarian function is a means of achieving desired goals or avoiding unexpected ones.27 In terms of the attitudes on the effect of TCM on COVID-19, people’s attitudes may form based on whether TCM can effectively cure this disease. The knowledge function serves to satisfy people’s need to understand the world.27 In the discussions of the effect of TCM on treating COVID-19, people who have not been infected with COVID-19 may form their attitude based on scientific evidence that they learnt, rather than expressing their values or protect his/her interests.
Katz believed that the ego defence function protects a person’s self-image and identity through defensive mechanisms, enabling people to avoid unhappiness from themselves or the external world, helping individuals deal with their insecurities and protecting their self-esteem. In the debate about the effect of TCM in treating COVID-19, people may resort to hatred or disparaging sources to protect their egos and justify their attitudes.27 The value-expressive function serves to satisfy people’s need to express their attitudes consistent with their values and concepts.27 For example, some people’s support for TCM to treat COVID-19 may stem from patriotic values.
We will use the four functions of attitudes as a theoretical framework to understand the reasons why people hold relevant attitudes. In addition, the attitudes of those who support and oppose TCM treatment of COVID-19 may form attitudes based on different attitude functions. Therefore, we propose our RQ4 and RQ5:
RQ4: What attitude functions are reflected in netizens' attitudes toward TCM treatment of COVID-19?
RQ5: Are there differences in attitude functions between people who support and oppose TCM treatment of COVID-19?
In addition, respondents with different professions may form their attitudes based on different functions. People with pharmaceutical backgrounds have more medical knowledge29 and we expect them to be more likely to support attitudes based on the knowledge function than the general public. The media acts as a bridge of communication between the government, health organisations and the public, and as a window for the public to obtain accurate information and scientific facts.30 Hence, people in the media industry may be more likely to base their attitude on the knowledge function than the general public. We expect the general public may be more likely to base their attitude on the value-expressive and ego-defensive attitude functions than the former two groups.
RQ6: Are there differences in the attitude functions among people with different professions?
To measure the impact of attitude functions on the audiences, previous studies have used public participation variables such as ‘like’, and ‘comment’, as indicators.31–33 While the traditional engagement variable ‘like’ may indicate the emotional resonance with the audience, Zhihu has a special engagement button, ‘agree’, which means the users cognitively processed the message and found it in line with their attitudes. Even though ‘comment’ does not indicate agreement, it can still reflect public attention to the issue and facilitate public conversations and common understandings.
Since different attitudes may resonate differently with the audience, we raise RQ7:
RQ7: Which attitude attracted the most public engagement?
In addition, we also want to understand the persuasiveness of different attitude functions among people with different attitudes, and raise RQ8:
RQ8: Which expression of attitude functions can increase public engagement for TCM-supporting posts and which expression of attitude functions can public engagement for TCM-opposing posts?
Method
Sample selection
We conducted a content analysis of the responses related to the effect of TCM treatment on COVID-19 on the Zhihu platform, the largest online question-and-answer community in China, from 1 December 2019 (the outbreak began in Wuhan) to 28 February 2023 (when the number of confirmed cases decreased).34 Zhihu was chosen because of its diverse content community, large user base, high daily activity16 and its large volume of discussions concerning TCM and COVID-19.
We used Python to retrieve questions that contained 160 groups of keywords on Zhihu. The keyword groups were formed by pairing two keywords (one represents TCM, while the other represents COVID-19) together, such as “TCM+COVID-19” and “the name of Chinese herb+COVID-19” (see online supplemental material 1). A total of 134 questions and their 8762 corresponding responses were downloaded. As responses with too few words could not reflect attitude functions, we selected responses with 300 or more characters. After excluding irrelevant responses, a total of 100 questions and their 1954 corresponding responses were included in the analysis. The number of agrees, comments and likes of the 1954 responses were downloaded.
Supplemental material
Coding procedure
We used a combination of inductive and deductive methods and identified nine themes of the four attitude functions (see online supplemental material 2). We also coded users’ attitudes toward TCM treatment of COVID-19 (positive, negative and neutral), the source of their attitude (personal experience, media, other people’s experience, social media, books or magazines, not mentioned), and the profession of the respondent (general users, medical professionals, and medical staff, media practitioners). User engagement variables (the number of agree, comments and likes) were downloaded from the Zhihu platform.
Supplemental material
Reliability test
Four coders who are Chinese speakers coded all the data. Inter-coder reliability was calculated by coding a random subsample (n=391 or 20.01%) of the data. Krippendorff’s alpha of the variables ranged from 0.82 to 0.99.
Statistical analysis
We used descriptive analysis to answer RQ1, RQ2 and RQ4. As RQ3, RQ5 and RQ6 all examined the differences among divergent groups, we used χ2 tests to answer them. As the engagement variables were over-dispersed count outcome variables, we used another two kinds of non-parametric statistical analysis. To answer RQ7, we used Kruskal-Wallis tests to examine which attitude attracted the most public engagement. To answer RQ8, we ran a series of negative binomial regressions to examine the effect of attitude functions on engagement. A schematic illustration regarding the logical relationship of all RQs and statistical analysis methods is shown in figure 2.
The relationship of RQs and statistical analysis methods. TCM, traditional Chinese medicine.
Patient and public involvement
Neither patients nor the general public were involved in the design and conduct of this study.
Results
In response to RQ1, we found that most Zhihu users held a supportive attitude toward TCM (59.9%, n=1170), while some people held a negative attitude (16.6%, n=324) and 23.5% (n=460) were neutral. In response to RQ2, our data showed that people’s attitudes toward COVID-19 treatment of TCM mainly came from their own experience (N=390, 20.0%) and traditional media reports (N=275, 14.1%). A small number of users’ attitudes came from magazines, journals and books (N=118, 6.0%), social media (N=86, 4.4%) and hearsay (N=63, 3.2%). In response to RQ3, χ2 tests showed that there were significant differences among people with different professions in terms of attitude, χ2=21.02, p<0.001 (table 1). Post hoc analysis showed that the general users were more negative while medical professionals were more positive toward TCM.
The attitude functions of people with different professions
In response to RQ4, table 2 shows that all four attitude functions (utilitarian attitudes, value-expressive function, ego-defensive function, knowledge function) were reflected in netizens’ attitudes toward TCM treatment of COVID-19. Specifically, ego defence functions (posing of threats; appeals to hatred and repressed impulses) were mentioned the most, followed by value expression (believing in science). The least mentioned function was value expression (faith) and value expression (politics).
The attitude functions of netizens of different attitudes
To examine the differences between the attitude functions of netizens who support and those who oppose TCM (RQ5), we ran a cross-tabulation between attitude and attitude functions. As shown in table 2, all function variables were significantly different among people of different attitudes (p<0.01). Particularly, post hoc analyses demonstrated that supporters showed fewer faith, politics and science value expressions, fewer ego defence functions, more patriotism and cultural confidence expressions and more knowledge functions than expected. Opposers showed fewer utilitarian and knowledge functions, fewer expressions of patriotism and more expressions of faith, politics and economics, but more ego defence functions than expected. Those who held a neutral attitude toward TCM showed more utilitarian functions, fewer ego and knowledge functions, fewer expressions of patriotism and more expressions of faith, politics and science beliefs than expected.
To examine the differences in the attitude functions among people with different professions (RQ6), we ran a cross-tabulation between profession and attitude functions. Table 3 shows that there were significant differences among people of different professions in terms of the two ego defence functions (posing of threats/appeals to hatred and repressed impulses, χ2=15.09, p<0.001; derogate sources of information, χ2=7.64, p<0.05). Post hoc analysis showed that the general users showed more of the ego defence functions while the media used much less of them than expected. There were also significant differences among people of different professions in terms of the knowledge function, χ2=65.88, p<0.001. Post hoc analysis showed that medical professionals and media practitioners showed more knowledge function in their posts than did the general users.
The attitude of people with different professions
In response to RQ7, Kruskal-Wallis tests showed there were significant differences among the three groups with different attitudes in receiving ‘agree’ (Kruskal-Wallis=17.20, df=2, p<0.001), comments (Kruskal-Wallis=15.41, df=2, p<0.001) and likes (Kruskal-Wallis=7.52, df=2, p<0.05), see table 4. Pairwise comparisons showed that opposing posts of TCM (n=1092.75) were more likely to receive ‘agree’ than those that supported TCM (n=962.00, p<0.001) and were neutral towards TCM (n=935.76, p<0.001). Opposing posts (n=1086.20) were also more likely to receive comments than supporting posts (n=959.52, p<0.001) and neutral posts (n=946.68, p<0.001). Similarly, opposing posts (n=1048.28) were more likely to receive ‘likes’ than neutral posts (n=943.48), p<0.05. Supporting posts and neutral posts did not differ in receiving user engagements.
Attitude and public engagement
As the engagement variables were overdispersed count outcome variables, we ran a series of negative binomial regressions to examine the effect of attitude functions on engagement (three for TCM-supporting posts and three for TCM-opposing posts) to answer RQ8. Table 5 shows that posts that mentioned attitude functions generally attracted more engagement (for details, see online supplemental material 3). For posts that support TCM, the mentioning of ego defence (posing of threats; appeals to hatred and repressed impulses), ego defence (derogate sources of information), value expression (faith), value expression (believing in science), value expression (economic benefit), had a positive effect on engagement. In contrast, the mentioning of utilitarian function, value expression (patriotism, cultural confidence) and value expression (politics) decreased engagement. The mentioning of knowledge decreased the number of agree while having a positive effect on that of like.
Supplemental material
The effect of persuasive techniques and attitude functions on engagement
For posts that oppose TCM, the mentioning of utilitarian function, ego defence (posing of threats; appeals to hatred and repressed impulses), ego defence (derogate sources of information), value expression (believing in science) and value expression (economic benefit) had a positive effect on engagement. In contrast, value expression (patriotism, cultural confidence) and value expression (faith) reduced engagement. Similarly, the mentioning of knowledge de the number of agree while a positive effect on that of like.
To sum up, the difference between posts that support and oppose TCM was that utilitarian function was negatively related to engagement for TCM-supporting posts while positively related to engagement for TCM-opposing posts. Expressing the value of faith increased ‘agree’ for TCM-supporting posts but decreased ‘agree’ for TCM-opposing posts. The similarity between the two was that expressing the value of patriotism and cultural confidence decreased engagement for both TCM-supporting posts and TCM-opposing posts.
Discussion
Being an essential element in China’s public health system against the COVID-19 pandemic, TCM has attracted profound debates on its effectiveness in treating the disease. In this study, we provided an in-depth analysis of user-generated content about the role of TCM in treating COVID-19 on a Chinese social media, Zhihu. Our study allows a better understanding of how Chinese netizens perceive the use of TCM during the COVID-19 pandemic, how different functions can support their attitudes and how expressions of functions are effective in promoting their stands. Such understandings can provide global insights into good practices that help the integration of traditional medicine and modern healthcare systems.
Our findings first confirmed that Zhihu has emerged as an important digital media platform for TCM communication during the COVID-19 pandemic. The findings provided a picture of the attitudes toward the role of TCM in COVID-19 on Zhihu, regarding their stands, differentiations and sources. Overall, the findings showed that most of the responses were from ordinary people, rather than professionals. They held a positive attitude toward the use of TCM in containing the pandemic, with 16% being the opposite. However, regarding public engagement, posts from opposers received more numbers of agrees, likes and comments. Thus, the platform Zhihu seemed to attract more supporters to post about TCM on COVID-19 but more opposers who engaged with the TCM-related posts on the platform. Personal experiences and traditional media information, rather than scientific evidence from journals and books, were found to be the major sources of users’ attitudes. Only a limited number of health professionals joined in the discussions and they were more supportive than general users and media users. The above findings together suggest that the discussions of TCM on Zhihu were generally held among users who may not be experts in TCM. This echoes Yang’s findings about scientific discussions on Zhihu in China, showing the rise of citizen science communicators and inadequate communications among general citizens and scientists on digital media platforms.10
Our findings further demonstrated a multilayer conflict underlying the attitude of TCM treatment of COVID-19. Supporters of TCM viewed it as relevant to Chinese cultural identity and pride and tended to provide explanations of the treatment mechanisms. In contrast, opposers tended to defend their stands by appealing to hatred and derogating the evidence sources that the supporters used. They likely viewed the use of TCM in treating COVID-19 as a kind of faith and a strategy for economic and political purposes. Such differences in attitude functions between supporters and opposers reflected a multilayer conflict regarding the role of TCM treatment of COVID-19. At the science layer, there seems to be a lack of consensus among the public on what kind of evidence can be seen as solid to support the effectiveness of TCM. At the ideology layer, while TCM is a valuable tradition in Chinese culture, it is accused as superstitious from the perspective of modern science.12
Furthermore, our findings revealed that the TCM debate in modern China is not only relevant to medical science and health, but also rooted deeply in cultural ideology, politics and economics. In general, most expressions of attitude functions, such as the functions of ego defence and value expressions, could attract audiences’ engagement, regardless of the stands of posts. In particular, the use of TCM as an economic strategy seemed also to be accepted by the public for countering the economic dominance of Western pharmaceutical companies such as Pfizer during the pandemic, which is new to the literature. This may be because the economic order underlying the COVID-19 treatment (eg, medicines, vaccines) is closely related to international economics and politics. Expressions about patriotism, faith and explanations of TCM treatment mechanisms seemed to show counteractive effects. These counteractive expressions somehow aligned with the ideology and science conflict that we have discussed underlying TCM. This alignment suggests that, for audiences, such conflicts also exist when they have to evaluate the role of TCM in the pandemic. As a consequence, they avoid those conflicts and reduce their engagement in respective expressions.
Some expressions of functions were found to have divergent effects in supporting different stands toward TCM. Expressions of utilitarianism were found to reduce agreement from audiences for supporting posts but to increase them for opposing posts. This contrast suggests that supporting TCM based solely on the seemly treatment effect without concerning other aspects of TCM is commonly considered unacceptable for audiences. Additionally, associating TCM with faith was found to be positive for supporting posts while negative for opposing posts. These findings suggest that those who support TCM were based on faith concern. Though opposers consider the practices of TCM as superstition, these practices are the core elements of Chinese culture that have been widely accepted in the Chinese’s daily life. This is consistent with the findings of previous surveys regarding the public interest in TCM for their disease treatment.15
The above findings have significant implications for global health and its policies. First, our findings indicate that digital media platforms like Zhihu can offer space for the public, scientists and the media to exchange their views and knowledge more fairly about controversial medical issues like traditional medicine, not only in China but also in the global context. Scientists who are experts in traditional medicine research should play their roles in developing the scientific dialogue about traditional medicine in the digital media environment. The WHO and governments of various countries should also take advantage of digital media for traditional medicine communication, to get feedback from the public on appropriate ways to integrate traditional medicine into their national healthcare systems.
Second, the multilayer conflict identified from the public perception of TCM is expected to be globally common across other traditional, integrative, complementary and alternative medicines (TICAM). While the public can often recognise TICAM’s deep cultural and ideological traditions, they lack consensus on whether and how TICAM should be supported by scientific evidence as prophylactic and therapeutic measures against diseases. Our findings indicate that, though Chinese people continue to accept TCM as a traditional cultural practice, it is not solely because of its effectiveness (ie, utility and utilitarian) in treatment. The scientific status of TCM matters. Thus, the scientists of TICAM and health departments should try to develop scientific criteria about solid evidence for TICAM and communicate those criteria to the public to achieve a consensus. Through this consensus, health departments can develop the scientific status of TICAM and thus integrate them appropriately into their national healthcare systems with public acceptance. But what health departments should further notice is that people can accept traditional medicine solely based on cultural ideology and faith without proper scientific evidence, which may bring global challenges to the safety of traditional medicine practices. Education and communication programmes should be developed to reduce such potentially harmful practices of TICAM.
Third, our findings suggest that economics and politics may gradually play roles in public policies of traditional medicine. We found that the Chinese public approved of TCM as an economic strategy for the Chinese government during health emergencies like the pandemic. This suggests that, at least in the context of China, TCM may have been considered an economic strategy for changing the order of local and international economics and its associated politics. While how these factors can drive the global practices of traditional medicine remains unknown, they will inevitably be intertwined together to affect citizens’ evaluation of TCM in modern China and its related policies. Future research should focus on how economic and political drivers can play roles in local and global practices of traditional medicine and its implications for global health. Thus, not only should public health and communication practitioners play their roles in understanding the practices of TICAM and their legitimisation in modern healthcare systems, but also scholars from other social science disciplines such as social psychology, sociology, politics and economics.
The study has a few limitations. First, though Zhihu is argued to suffer less online censorship to protect knowledge-based discussions, we cannot rule out the possibility of such censorship.10 Also, as Zhihu tends to attract well-educated populations, the research findings cannot be overgeneralised to the entire population of Chinese netizens. Second, we conducted our analyses based solely on textual data. Other modes of data such as figures and external links may also be presented in the responses. Future research should include these elements in their data analysis to capture a more comprehensive understanding.
Conclusion
The use of traditional medicine has become a global phenomenon and its appropriate integration into modern healthcare systems is imperative. Through the investigation of public discourses of TCM treatment against COVID-19, we demonstrated a profound debate about TCM in the Chinese digital context, highlighting both opportunities and obstacles for traditional medicine to be a part of national healthcare systems. While TCM was considered relevant to Chinese cultural identity and pride, it was accused of superstitions and lacking proper scientific evidence. As we expect that this conflict is globally common across other traditional and alternative medicines, we suggest that scientists and health departments should make use of digital media to develop the scientific status of traditional medicines, so that they can be appropriately integrated into modern healthcare systems with public acceptance. In addition, economic and political factors were also found to impact the public’s acceptance of TCM in the Chinese context. Future research should examine whether and how those factors also play roles in global practices of traditional and alternative medicines and what are the global health implications.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
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
Handling editor Helen J Surana
Contributors DW is responsible for the overall content as guarantor. The conception and design were performed by DW, JL and VKWW. The acquisition of data was performed by JZ. The analysis and interpretation of data were performed by DW and JL. All authors wrote and reviewed the manuscript.
Funding This research was funded by the Science and Technology Development Fund of Macau SAR (005/2022/ALC) and the Macau University of Science and Technology Faculty Research Grant (FRG-22-039-FA).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
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.