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Socio-Cultural Knowledge and Perceptions of Jamu

Socio-Cultural Knowledge and Perceptions of Jamu

Socio-cultural Knowledge and Perceptions of Consumption Risk: Local Wisdom of Urban Javanese Community and Its Relation to the Integration of Traditional Jamu into Formal System in

Indra Wijaya

Master Program of Medicine, Faculty of , Padjadjaran University, Jatinangor 45363, Sumedang, Indonesia

Abstract Although the role of traditional medicinal system (jamu) in Indonesia is increasing, there are no studies on the clients’ perceptions of the risk of consuming jamu products. This paper addresses this gap by examining the perceptions of jamu and the risk of consuming among the consumers in the city of , Indonesia. Sixty interviews took place between June and July 2010. The participants were thirty selected clients of jamu sellers in the streets and local markets where jamu products are sold. They were chosen on the basis of age, gender and socio-economic background. The software QSR NUDIST was employed to analyze the data. This study shows that two thirds of local jamu consumers in Yogyakarta had a good understanding about the therapeutic uses of jamu. The research results indicate that jamu products were consumed by all ages and across different levels of education and socio-economic background. Although the participants were aware about some potential risks of consuming jamu, the data show that their attitudes towards and perceptions of jamu were generally positive among all age groups and social groups. This finding supports the idea that an improved understanding of the attitudes towards and the perceptions of jamu and its consumption is important, considering the increasing popularity of traditional medicine in Indonesia.

Keywords: jamu, traditional medicine, risk perception, local consumers

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Pengetahuan Sosio-budaya serta Persepsi tentang Risiko Konsumsi Jamu: Kearifan Lokal Masyarakat Jawa Perkotaan dan Kaitannya dengan Integrasi Pengobatan Jamu Tradisional ke Sistem Kesehatan Formal di Indonesia

Abstrak Meskipun peran sistem pengobatan tradisional (jamu) di Indonesia meningkat, belum ada penelitian mengenai persepsi masyarakat tentang risiko mengkonsumsi produk jamu. Artikel ini membahas masalah tersebut dengan meneliti persepsi tentang jamu dan risiko mengkonsumsi obat tradisional di kalangan konsumen di kota Yogyakarta, Indonesia. Enam puluh wawancara berlangsung di Kota Yogyakarta antara bulan Juni dan Juli 2010. Tiga puluh orang yang dipilih adalah pembeli jamu di jalanan dan di pasar lokal tempat produk jamu dijual. Mereka dipilih berdasarkan usia, jenis kelamin, dan latar belakang sosial-ekonomi. Software QSR NUDIST digunakan untuk menganalisis data. Penelitian ini menunjukkan bahwa dua pertiga dari konsumen jamu lokal di Yogyakarta memiliki pemahaman yang baik tentang manfaat jamu. Hasil penelitian menunjukkan bahwa jamu dikonsumsi oleh konsumen segala usia dengan berbagai tingkat pendidikan serta latar belakang sosial-ekonomi. Meskipun responden menyadari risiko yang mungkin timbul akibat mengkonsumsi jamu, data menunjukkan bahwa dalam semua kelompok usia dan kelompok sosial, sikap dan persepsi mereka tentang jamu umumnya positif. Hasil penelitian ini menunjang pendapat bahwa seiring dengan meningkatnya popularitas pengobatan tradisional di Indonesia, peningkatan pemahaman akan sikap terhadap dan persepsi tentang konsumsi jamu sangat penting.

Kata kunci: jamu, pengobatan tradisional, persepsi risiko, konsumen jamu lokal

Introduction modern systems can solve The term traditional medicine is much of the problems by providing used to explain the traditional medical basic health care services for the people practice in existence even before the in developing countries, particularly advent of modern medicine. Due to its the underserved majority.3,4 Many of intrinsic qualities, unique and holistic the traditionally used medicinal approaches as well as its accessibility contain pharmacologically active and affordability, it continues to be the compounds and are used in the best alternative care available for the preparation of traditional medicine in majority of the global population.1,2 those countries.5,6 Experience from many countries such Jamu is the Indonesian traditional as those in South East suggests that has been practiced that integration of traditional and for many centuries in the Indonesian

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community to maintain good health prescribed drugs and self and to treat .7 Jamu has are indirect effects.15,16,17,18 acquired a potential benefit, both In a review on TM, an analysis of economically and clinically. This paper the published data revealed that many intends to address this topic by reports of -induced interactions lack analyzing the data collected from jamu crucial documentation on temporal consumers in the city of Yogyakarta, relations and on a positive identification , Indonesia. This paper is divided of the involved.19,20,21 Indonesian into two sections. Firstly, it will discuss traditional herbal medicine is called the information about traditional jamu “jamu”, a claimed to have medicine and the consumers’ originated in the Medang or Mataram perceptions of the potential risks of Kingdom, a Hindu-Buddhist kingdom consuming jamu in the relevant that flourished between the 8th and 10th literature; secondly, the paper will centuries CE and was based in Central examine the perceptions of jamu and Java, and later in East Java.22 Although the risk of consuming traditional heavily influenced by Indian , medicine among the consumers.8,9 the vast Indonesian archipelago makes The Health Organisation both its practices and plants variable.23 (WHO) defines traditional medicine With increasing popular demand for (TM) as the sum of knowledge, skills , both in Asia and and practices based on the theories, internationally, this trade grew to 7.2 beliefs and experiences of different trillion Rupiah (US$786 million) in year cultures that are used to maintain health, 2010 in Indonesia.24 as well as to prevent, diagnose, improve The traditional pharmacopecia or treat physical and mental illnesses.10,11 (jamu) in Indonesia includes a huge Most people who use traditional range of herbal preparations. Jamu may medicine consider this kind of be obtained at kiosks and shops to be ‘‘natural’’ and thus ‘‘safe’’; throughout Yogyakarta in the form of a however, many of these therapies, like commercially prepared packet other medical treatments, have the designed to make a single glass of potential to be directly or indirectly medicine. Jamu is also sold by harmful,12,13,14 even if the true incidence ambulant sellers (jamu gendong) that of complementary medicine induced normally produce jamu from fresh adverse effects is unknown. Toxic ingredients (mainly fresh leaves, roots, effects, allergic reactions, lack of quality fruits and rhizomes) and sell their control, contaminations, interactions products on the streets or in the city with concomitant medications are to be markets. The main products of jamu considered direct effects, while missed gendong consist of some popular jamu diagnoses, disregarding contra- such as kunir asem (mixture of Curcuma indications, delaying more effective domestica rhizomes and treatments, discontinuation of fruits), beras kencur (rice powder and

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cabe (Kaempferia americans rhizomes). streets and in the local markets where Originally from Yogyakarta and jamu products are sold. In order to have regions, jamu gendong until a diversified sample that reflected now is largely consumed by different consumers, the sample has been .24,25,26 chosen on the basis of age, gender and The studies available regarding socio-economic background. These the jamu system are mainly those of parameters have been considered to be ethnopharmacology which are based relevant as they could influence on rather general works that document perceptions and uses of traditional the use and constituents of medicine. The study looked at risks substances used medicinally.27,28 For representations in a range of adults (age the greatest part, these ethnobotanical comprised between 25 and 65) with inventories present botanical and occupations from the primary to third pharmacologic data disembodied from economic sectors. The interviews their social and cultural contexts; they consisted of open ended questions and cannot accommodate theoretical or intended to gain insights on knowledge conceptual issues, and in fact contain and practice of as well as attitude little by way of analysis, or even towards traditional medicine, motivation interpretation.29,30 They lack careful and frequency for the consumption of attention to the specific circumstances jamu and perception of risk of and contexts in which plant utilization consumption of traditional jamu. Some occurs- i.e., data regarding mode of questions aimed to know if the preparation and gathering of medicinal participants had some recommendations plants.Therefore, this present study for promotion and integration of explores both biological and traditional medicine with the behavioural and cultural parameters to conventional system.1,2,9,10 formulate questions within the broad The interview objectives and outlines of a human ecology that seek procedures were clarified, and an to understand human-plant assurance was given of the ethical interactions in the most comprehensive principles of inquiry, guaranteeing sense and to assess the impact of such participants’ anonymity and data behaviours on health. The purpose of confidentiality. The participants were this study is to investigate attitude and asked to give their written formed risk perception concerning traditional consent to participate in the research. medicine in Indonesia.31,32,33 Interviews lasted from 30 min to 45 h and were tape recorded, while written field notes were made Methodology contemporaneously. The recordings Sixty TM interviews took place in were manually transcribed verbatim. the city of Yogyakarta between June and The transcriptions were then imported July 2010. The participants were thirty into a computer using software for selected clients of jamu sellers in the qualitative coding and analysis.8,9

132 Socio-cultural Knowledge and Perceptions of Jamu Consumption Risk: Local Wisdom of Urban Javanesse Community and Its Relation to the Integration of Traditional Jamu Medicine into Formal Health System In Indonesia (Indra Wijaya)

Results and Discussion Regarding the motivation of buying The 58% of the participants were jamu, more than 60% of the clients female. Their educational levels varied interviewed, especially the young from primary education (primary mothers with several children, affirmed school) to higher education (high school that it was better to use traditional jamu or College and University). None of the instead of allopathic for participants had a health care minor health complaints as jamu has no occupation. Regarding the total age and is freshly made so it is distribution, of the total number of the richer in active ingredients and thus participants, 15 (25%) were 25-35 years more effective.8,9,10,21,24 of age, 15 (25%) were 36-45 years of age, Other clients expressed their 15 (25%) were 46-55 years of age and the satisfaction with the traditional jamu as remaining 15 (25%) were 56-65 years of they affirmed that the jamu sellers were age. Illiterates, those who can read and able to customize the jamu products and write, and those who have had modern drinks by adding different concentration education at elementary or senior high of active ingredients (more spicy or less school levels accounted for 47%, 28% spicy, etc.) according to the taste of the and 25%, respectively.8,9,21 client and also his/her health About 79% of the participants, requirements. As the interviews show, especially women, were buying jamu at the fact that some jamu sellers know the least once every 10 days, with 15% of customer preferences and his/her health them buying jamu every 5-7 days. The needs and health history is an aspect majority of them (71%) believed in the which is particularly considered by the importance of consuming natural jamu consumers when deciding where to buy products and traditional medicine for jamu.8,21,23 maintaining health. The majority of the Two-thirds (forty out of sixty) of the participants (82%) came from the city, jamu consumers, especially the women 10% from the urban areas close to in their reproductive age and the elderly Yogyakarta and 8% from other areas of who are chronically ill, emphasized how Java. this aspect was particular important to Participants with a relatively lower them.8,21 socioeconomic level than their counter- Another important motivation parts in the urban areas, showed a given by the clients, especially the older tendency for greater utilization of ones (age group between 56-65 years old), traditional medicine than the rest of the was that jamu represents a medical participants. In terms of gender and Javanese tradition: these clients jamu consumption, there was a higher emphasized how jamu is something that rate of use by women than men for jamu: pertains to the . The overall, 64% of women had used jamu motivation to buy jamu among the and other Javanese traditional medicine younger age groups (25-35 years old) can as compared with 36% of men.8,21 be explained by “social” factors. Social

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networks seem to form the main source of medicines. Despite its positive information about herbal medicines and contribution, traditional health care jamu, and the experiences of others’ are system may also incorporate some trusted a great deal. In the present study, harmful practices and beliefs.31,27,36 two-thirds of the participants believe that In the present finding, 67% of the jamu has wide acceptance in their local healers employed one or more harmful communities. However, 82% of them traditional practices or at least they affirmed that there is a form of believe in the importance of such therapeutic syncretism, according to practices. Some of the jamu sellers which people easily switch from one time suggested taking pharmaceutical drugs of medicine to the other tended and they along with their traditional also use modern care, if this is easily medicaments. This could be not only accessible.8,21,14 dangerous health-wise, but also wastage Immediate associations with jamu of resources on the part of the poor and herbal medicines included such patient. The direct consequences of such words as “safe,” “natural” and “pure.” It form of drug use can to treatment is clear that these words themselves failure, adverse effects and express the sense of reassurance and resistance.29,30 safety of the consumption of jamu Worrisome and unpredictable products stated by the consumers interactions between medicinal herbs interviewed, as most of them (45 out of and modern drugs may take place which 60) felt that natural products and could increase or decrease the medicines do not pose any danger. pharmacological or toxicological effect of Many participants also felt that jamu either or both components.8 works gently and slowly in comparison The jamu vendors at some with conventional medicines, and that Jamu at Yogyakarta generally ask the they are less powerful. Women were consumer about the manner he/she more likely than men to associate them wants to drink jamu: e.g. mild, warm or both with being healthy (56% vs 44%) hot jamu. If a consumer wants to drink and natural (58% vs 42%). Across the warm jamu, they will put in the jamu mix ages, younger people (25-35s) were a certain amount of and they will much less likely than any other age add the dose of this fruit for the hot group to think of herbal medicines as jamu. Besides stomach aches and alternative (53%). Only a small minority diarrhea, hot jamu, containing a high (e.g. 12 out of 60) cited concerns about quantity of Piper fruit, can also present purity, contamination and interaction some levels of toxicity. It must be noted with other drugs, and every group was that according to some Government able to identify at least one instance of a data, the fruit of Piper retrofractum or risk associated with herbal medicine. Javanese pepper has lethal dose and Only a small percentage (7%) said that high sign of toxicity when administered “it depends on the treatment” when subchronically in animals.17 Moreover, asked to assess the safety of herbal in the last years there have been several

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cases of difficulty in the process of birth college degree) commented that they at the Sardjito Hospital,Yogyakarta. 8,9,17 were concerned about taking herbal According to the in situ medicines, such as jamu at the same time pharmacological test, the of jamu as conventional ones, and some spoke of product might inhibit uterine the greater convenience of being able to contraction due to the action of piperine use both types. These data are coherent . On the other hand, jamu kunir with other studies emphasizing how asem consisting of kunir (rhizomes of there was no clear understanding of Curcuma domestica) and asem (fruits of negative interrelations for the Tamarindus indica), might cause consumption of chemical and natural at high dose and it is not recommended drugs.23,28,14 to consume during early period of Nearly two-thirds (i.e., 42) of the . The active constituents of participants, especially the younger ones this jamu product have not been clearly and the ones who were 50+ thought they determined.8,9,11,17 would see a doctor if they experienced A survey of the literature indicates any side-effects and another one in ten that a number of herbs present in jamu would seek hospital treatment.23,28 have anti-platelet (, , Although pharmacological effects of , ) and anticoagulant jamu constituents have been recorded, (coumarin-containing herbs like red there is an apparent lack of records or clover) properties and could potentially written data reporting the effectiveness interact with nonsteroidal anti- of jamu, especially of jamu gendong. To inflammatory drugs with an increased assure the proper use of such products, risk of bleeding and prolonged clotting the Indonesian government has divided time respectively.33 Although herb- the medicinal plants in three categories acetaminophen interactions are not based on the way they are prepared and common, the possibility of such based on their efficacy; i.e., jamu, interactions has been mentioned as standardized herbal medicines and regards ginkgo and supplements phytomedicines (fitofarmaka). All containing coumarin derivatives like preparations have to meet basic safety and red clover.34 It is criteria.36,37,38 reasonable to assume that the combined The majority of the interviews use of acetaminophen and herbs (92%) indicated that the government containing salicylate (meadow-sweet should support jamu and other forms of and willow) can result in traditional medicine. Training of jamu nephrotoxicity.35 producers and traditional healers was Many jamu consumers interviewed strongly felt to be important for the see no problems in taking jamu products improvement of the service and should alongside chemical medicines. Few focus on dosage determination and side people, especially the young ones with a effects, while 40% stated hygienic high level of education (University or preparation and administration of

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traditional medical preparations as Some participants, especially the elderly, equally important. Traditional jamu affirmed that any clinical trials should makers also care about hygiene, be required for jamu, as an old man in sanitation and chemical contaminations his 60’s put it, “We have been drinking from biological or non-biological and producing jamu since centuries here sources.36,37 so we know that the plants used in jamu Jamu makers have to be trained on are perfectly safe and good for health.” hygienic production methods and for Young participants and the ones with a semi-modern technologies. One-fourth higher level of education also felt that (i.e.,15) of the participants, especially the regulating jamu may not be entirely older clients (age group 56-65 years old) feasible or necessary for small home- believed that herbal medicines such as based producers. As an interviewee industrial jamu, were regulated. About pointed out: “However, management of one-third (i.e., 21) of the consumers jamu is not only related to health issues. affirmed that they prefer consuming It also concerns other issues, such as industrial jamu and not the jamu sold by trade, human resources and the the jamu sellers in the local markets development of small-scale jamu because they estimated that industrial traders.”8,9,22,28,34 jamu was safer as it underwent some controls. The majority of the consumers (i.e., 45) affirmed that it is important that Conclusion herbal medicines and jamu products are The findings of this study show that regulated. Almost three-quarters (i.e.,48) the knowledge regarding the medical believe that jamu products should be use of jamu by the local consumers regulated to the same standard as interviewed in this study is good, conventional medicine.36,37,38 although they are not always aware Despite these affirmations, in a about the risks involved in its quite contradictory way, the majority of consumption. Results indicated that the consumers, especially the elderly treatment is sought by all age groups and the middle-aged consumers, and across different levels of education affirmed that they did not perceive any and socio-economic background. risk by consuming jamu from the street Therefore, jamu seems to be popular not vendors and did not have any only among the aging population of the complaints in terms of hygiene or safety city but also among the younger issues. As a woman in her late fifties put generations. Although the participants it, “I totally trust this jamu seller and she are aware of some potential risks has been producing jamu since many involved in the consumption of jamu, years… she learnt how to produce jamu this study shows that consumers’ from her mother and she is an expert in attitudes towards and perceptions of mixing the plants and the roots. I am jamu are generally positive among all sure that the jamu she prepares is safer age groups and social groups. The and healthier than any industrial jamu.” questions related to efficacy and safety

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