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APHXXX10.1177/1010539519893801Asia Pacific Journal of Public HealthOsman et al

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Asia Pacific Journal of Public Health

Demographic and Socioeconomic 2020, Vol. 32(1) 42­–48

© 2020 APJPH
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https://doi.org/10.1177/1010539519893801
DOI: 10.1177/1010539519893801

Care–Seeking Behavior Among journals.sagepub.com/home/aph

Foreign Workers in Malaysia

Ahmad Farid Osman, PhD1 , Muzalwana Abdul Talib, PhD1,

Khaled Tafran, MEc1, Makmor Tumin, PhD1, and Chin Sieng Chong, MEc1

Abstract
Foreign workers in Malaysia face various barriers in accessing health care, which results in many of them being unable to
obtain appropriate medical treatment in case of sickness. This study investigates the foreign workers’ health care–seeking
behavior and the demographic and socioeconomic variables that influence it. Data were collected from 502 foreign workers
using a self-administered questionnaire. Multiple logistic regression was used to estimate the influence of demographic
and socioeconomic variables on health care–seeking behavior among foreign workers. In cases of severe sickness, 20.5%
of foreign workers stated that they will not go or are unlikely to go to a clinic or hospital. The multiple logistic regression
revealed that foreign workers’ tendency to avoid medical treatment is associated with gender, marital status, monthly
income, preferred language of communication, and work classification. Nonetheless, in cases of mild sickness, demographic
and socioeconomic variables do not influence foreign workers’ health care–seeking behavior.

Keywords
health care–seeking behavior, foreign workers, Malaysia, demographic, socioeconomic

What We Already Know
In a number of past studies, several demographic and socio-
economic factors like gender, age, marital status, work clas-
sification, education background, income, and language
were found to affect the utilization of health care services
among foreign workers, although some other studies suggest
different findings.
What This Article Adds
This study concludes that the significance of effect of demo-
graphic and socioeconomic factors on tendency of getting
treatment when sick among foreign workers in Malaysia
depends on the severity of sickness. None of the mentioned
factors significantly affect the tendency of getting treatment
in the case of mild sickness. On the other hand, gender, mari-
tal status, work classification, income, and language were
found to significantly affect tendency of getting treatment in
the case of severe sickness.
to join the high-income countries in the next few years.1 The
official language is Malay, although the vast majority of citi-
zens speak English as a second language. The good eco-
nomic conditions in Malaysia attract large numbers of
foreign workers from neighboring countries. In July 2017,
there were around 1.76 million documented foreign workers
in Malaysia, from Indonesia (40.6%), Nepal (22.8%),
Bangladesh (12.5%), Myanmar (7.2%), India (6.5%),
Pakistan (3.4%), the Philippines (3.2%), and other countries
(3.9%).2 However, the actual number of foreign workers is
significantly larger when taking into consideration the huge
quantity of undocumented workers in Malaysia, estimated to
be around 1.3 million people.3
The health status of foreign workers is an imperative pub-
lic health issue,4,5 especially when such individuals come
from countries with a lower health status than the host coun-
try. In fact, the vast majority of foreign workers in Malaysia
1
University of Malaya, Kuala Lumpur, Malaysia

Corresponding Author:
Introduction Ahmad Farid Osman, Ungku Aziz Centre for Development Studies,
Faculty of Economics and Administration, University of Malaya, Kuala
Malaysia is a developing country of 30 million people with a Lumpur, 50603, Malaysia.
per capita income of 9508 USD (2016 data), and it is expected Email: faridosman@um.edu.my
Osman et al
are from countries that have significantly lower health status
than Malaysia, reflected by lower life expectancy and per
capita health spending. The World Development Indicators
published by the World Bank listed Malaysia at a better posi-
tion in terms of life expectancy and per capita health spend-
ing in 2015 compared with Bangladesh, Nepal, Indonesia,
the Philippines, India, Pakistan, and Myanmar.1
By law, foreign workers are required to undergo a medical
check-up as a prerequisite for obtaining a working visa.
However, as mentioned earlier, a large fraction of foreign
workers are illegal, and so their health status is not moni-
tored. Moreover, there is some evidence to suggest that a sig-
nificant number of foreign workers obtain fabricated medical
reports from their countries,6 which increases the risk of
transmitting diseases to Malaysia.5
Malaysian policies regarding foreign workers have been
described as “poor” and not aimed at protecting migrant
workers’ rights, being instead mainly targeted at protecting
locals from any negative implications.3,7 Foreign workers in
Malaysia suffer from low wages, a poor living environment,
and exploitation.3,8 Moreover, there are disparities in health
care coverage and accessibility between local and foreign
workers.3 As a result, a significant fraction of foreign work-
ers face difficulties in accessing health care,6 which contrib-
utes to undermining their health conditions, increasing the
risk of illness among them, and transmitting diseases to the
local community.
Demographic and socioeconomic factors are key predic-
tors of migrant workers’ health as well as their treatment-
seeking behavior.8-12 Peng et al12 studied the health
care–seeking behavior of 2478 migrant workers in China
and found that the incidence of seeking treatment in case of
illness is significantly lower in workers with less education
and a lower household income. The same study found that
gender, age, and occupation do not influence migrant work-
ers’ tendency to seek treatment.12 Moreover, studies from
Thailand found that gender, age, marital status, and work
classification significantly influence foreign workers’
health care–seeking behavior.10,11 To the best of our knowl-
edge, no research has investigated the health care–seeking
behavior of foreign workers in Malaysia and the influence
of demographic and socioeconomic factors on this behav-
ior, and so this study aims to fill this research gap. In this
research, health care–seeking behavior was analyzed by
studying the respondents’ tendency to seek medical treat-
ment based on severity of sickness: mild and severe sick-
ness. It is a different approach of analyzing health
care–seeking behavior to the mentioned studies in China
and Thailand that use other variables to represent health
care–seeking behavior such as utilization of health services
and time to visit the health centers. In other words, this
study was aimed to identify demographic and socioeco-
nomic factors associated with health care–seeking behavior
among foreign workers in Malaysia in two different cases,
namely mild and severe sickness.
43
Materials and Methods
The study employed self-administered questionnaires that
were distributed to 502 foreign workers in urban areas of
Kuala Lumpur, Malaysia. The respondents were guided by
enumerators to respond to the questionnaire to avoid misin-
terpretation. Based on the total number of documented for-
eign workers recorded in July 2017, that is, around 1.76
million, a sample of 502 respondents is considered adequate
to be a representative sample of the population. Between
February and June 2018, respondents were approached in a
number of different targeted areas, including workplaces
(construction areas, security guard houses, shops, etc), pub-
lic areas (shopping malls, bus and train stations, etc), and
workers’ accommodation provided by their employers. The
direct interaction between enumerators and respondents
resulted in a full response rate (100%). We used a quota sam-
pling technique, in which we made sure that the distribution
of respondents’ countries of origin resembled that of the
population proportion of such groups of foreign workers in
Malaysia.2 The distribution of sampled foreign workers by
countries for this study are as follows: Indonesia (42.63%),
Nepal (21.51%), Bangladesh (18.53%), Myanmar (7.17%),
India (6.18%), Pakistan (1.39%), the Philippines (1.59%),
and other countries (0.99%). In addition, the percentages of
respondents by gender and working sectors were also con-
trolled to reflect the true population of documented foreign
workers in Malaysia. The distribution of foreign workers in
the sample and population are presented in Table A1 in the
appendices (Supplementary Material; available online).
Our enumerators were local Malaysians who were able to
distinguish foreign workers by their appearance and accent.
To confirm that the respondent was a foreign worker, he or
she was asked about their country of origin prior to being
given the questionnaire. For respondents who are yet to be
able to understand Malay/English well, assistance was
acquired from their friends who understood the languages
better. All respondents were informed that their responses
would be kept confidential and that the data collected would
be analyzed at aggregate level for research purposes only.
All questions were in both Malay and English, in the same
questionnaire.
The questionnaires first asked respondents about their
demographic and socioeconomic information; that is, gen-
der, age, education, marital status, working classification,
monthly income, and preferred language for communication.
Next, respondents were asked the following two questions:
“If you are experiencing mild sickness (eg, headache, mild
fever, flu infection), what is the likelihood that you will go to
a clinic or hospital for treatment?” And “If you are experi-
encing severe sickness (eg, high fever, injury, diarrhea), what
is the likelihood that you will go to a clinic or hospital for
treatment?” The following options were given to the respon-
dents to choose from for each question: (1) will not go, (2)
unlikely to go, (3) more likely to go, and (4) will go. This
44
study defined mild sickness as illness that normally can be
treated by taking over-the-counter medications. On the other
hand, severe sickness is defined as illness that normally
requires consultation with medical practitioners, or illness or
injury that requires minor or major surgery, or illness that
requires admission for inpatient treatment.
In the statistical analyses, to perform logistic regressions,
we transformed the 4-point Likert-type scale into a dummy
variable, where “1” stands for will not go and unlikely to go
and “0” represents more likely to go and will go. The result-
ing dummy variable, therefore, represent the respondents’
tendency to avoid health care treatment in cases of mild and
severe sickness.
The statistical analyses were performed in two stages. In
the first, bivariate analyses (χ2 tests) were used to examine if
there were statistical differences in respondents’ health care–
seeking behavior according to their demographic and socio-
economic affiliations. The demographic and socioeconomic
variables that revealed significant variations in health care–
seeking behavior in the bivariate analyses were taken to the
second stage, the multiple logistic regression, to examine the
factors associated with health care–seeking behavior among
foreign workers. A 5% significance level was used for statis-
tical significance, and statistical analyses were performed
using SPSS 20.0 (IBM Corp, Armonk, NY).
Results
Table A2 in the appendices (Supplementary Material) pres-
ents the respondents’ characteristics through seven demo-
graphic and socioeconomic variables. The majority of
respondents were male (78.0%) and aged 30 years and below
(65.3%). About 42.4% of the participants were married.
Malay was the preferred language for communication for
82.8% of the respondents, whereas 11.3% preferred English
and 5.7% preferred another language.
In all, 37.05% of the respondents received primary educa-
tion, with slightly more than half of them received secondary
education (51.6%). A total of 11.35% had tertiary education.
About 32.0% of the respondents worked in the service indus-
try, 24.1% in construction, 22.1% in manufacturing, and
21.7% in other industries. The majority of the respondents
(62.7%) earned between 1000 and 2000 Malaysia Ringgits
(MYR; 1 USD ~ 4 MYR, as of January 2018) a month, while
around a third earned more than 2000 MYR.
For mild sickness, about 82.6% of the respondents stated
that they will not or are unlikely to seek medical assistance
by visiting a clinic or hospital. Moreover, the bivariate analy-
ses did not identify any significant variations in foreign
workers’ health care–seeking behavior, according to their
demographic and socioeconomic affiliations; for details see
Table A3 in the appendices (Supplementary Material).
Therefore, foreign workers’ health care–seeking behavior in
case of mild sickness was not analyzed using multiple logis-
tic regression.
Asia Pacific Journal of Public Health 32(1)
Table 1 illustrates the incidence of seeking treatment in
case of severe sickness among foreign workers, distributed
by their demographic and socioeconomic characteristics. In
total, 20.5% of foreign workers stated that they will not go or
are unlikely to go to a clinic or hospital in case of severe
sickness. The bivariate analyses revealed significant gender
differences in health care–seeking behavior, with men dis-
playing a lower tendency to seek medical treatment than
woman (P < .001). Foreign workers’ behavior also varied
according to their marital status (P = .003), working classi-
fication (P = .005), monthly income (P = .017), and pre-
ferred language (P = .016). However, foreign workers’
behavior did not show significant variation based on their
age and education.
Table 2 presents the results of the multiple logistic regres-
sion of demographic and socioeconomic variables associated
with the tendency to avoid obtaining medical treatment in
case of severe sickness. The regression revealed that men
were about 7 times more likely to avoid treatment than
women (odds ratio [OR] = 7.008; P < .001). Nonmarried
foreign workers were about 1.8 times more likely to avoid
treatment than married foreign workers (OR = 1.779; P =
.030). Foreign workers working in the manufacturing indus-
try were about 5.5 times less likely to avoid medical treat-
ment than their counterparts working in the service industry
(OR = 0.183; P < .001). The 5.5 value was obtained based
on the formula 1/odds ratio, that is, 1/0.183.
Table 2 also shows that foreign workers making less than
1000 MYR (~ 250 USD) a month were 3.8 times more likely
to avoid a medical visit than those who make more than 2000
MYR a month (OR = 3.754; P = .004). Respondents whose
preferred language for communication was classified as
“other” (not English or Malay) were 2.7 times more likely to
skip treatment than those who preferred the Malay language
for communication (OR = 2.712; P = .021).
Discussion
The findings of this research revealed that the vast majority
(82.6%) of foreign workers in Malaysia are likely to avoid
seeking medical treatment in case of mild sickness. However,
what is more worrying is that more than 20% of foreign
workers are likely to skip seeking treatment even if they are
facing severe sickness.
Previous research on foreign workers in Malaysia showed
that they suffer from various barriers when accessing health
care, including a lack of insurance coverage as well as finan-
cial and locational barriers.6 These barriers may explain our
findings on the foreign workers’ tendency of such workers to
avoid seeking medical treatment, which emphasizes the
importance of introducing new policies for improving for-
eign workers’ health status and behavior in seeking treat-
ment, as well as their working conditions in general.3
The results of this study showed that foreign workers’ ten-
dency to avoid seeking medical treatment is higher among
Osman et al 45

Table 1. Incidence of the Tendency to Seek Treatment in Case of Severe Sickness Among Foreign Workers in Malaysia, Characterized
by Demographic and Socioeconomic Variables; Bivariate Analyses.

Seeking Treatment Not Seeking treatment

Variable n (%) n (%) Pa

Gender
Male 295 (75.26) 97 (24.74) .000
Female 104 (94.55) 6 (5.45)
Age (years)
≤30 255 (77.74) 73 (22.26) .267
31-40 100 (84.75) 18 (15.25)
>40 44 (78.57) 12 (21.43)
Education
Primary 148 (79.57) 38 (20.43) .494
Secondary 209 (80.69) 50 (19.31)
Tertiary 42 (73.68) 15 (26.32)
Marital status
Nonmarried 217 (75.09) 72 (24.91) .003
Married 182 (85.45) 31 (14.55)
Work classification
Manufacturing 104 (93.69) 7 (6.31) .005
Construction 91 (75.21) 30 (24.79)
Services 121 (75.16) 40 (24.84)
Other 83 (76.15) 26 (23.85)
Monthly income (MYR)
<1000 20 (60.61) 13 (39.39) .017
1000-2000 252 (80.00) 63 (20.00)
>2000 127 (82.47) 27 (17.53)
Preferred language for communication
Malay 336 (80.77) 80 (19.23) .016
English 46 (80.70) 11 (19.30)
Other 17 (58.62) 12 (41.38)
Total 399 (79.48) 103 (20.52)

Abbreviation: MYR, Malaysian Ringgit (1 USD ~ 4 MYR, as of January 2018).

a
P value of the χ2 independence test.

low-income workers, and this result accords with previous
findings from China.12 Low income and poverty are key fac-
tors undermining access to health care and health out-
comes.13-20 In fact, foreign workers are more vulnerable than
local poor people as they face higher risks and more life chal-
lenges. Moreover, financial barriers to health care are well
documented among migrants.21 These facts emphasize that
policies aimed at improving the health care–seeking behav-
ior of foreign workers should target workers with the lowest
income.
The influence of gender and marital status on health care–
seeking behavior is well reported in the literature.10,11,22-24
The current study revealed that men are more likely to skip
medical visitations than women, which accords with the
findings of Naing et al10 and Aung et al11 on migrant workers
in Thailand. Moreover, the results brought evidence that
nonmarried workers are more likely to avoid treatment. This
finding is in-line with research from China, where it was
found that single individuals have a significantly lower
tendency to seek medical treatment than married migrant
workers.10 This suggests that men and nonmarried foreign
workers should be given priority in policies targeted at
improving foreign workers’ health care–seeking behavior.
Language is a well-documented barrier to accessing
health care.25-30 As shown by this study, foreign workers
whose preferred spoken language is not Malay or English are
more likely to avoid seeking medical treatment than their
counterparts. The provision and utilization of medical inter-
preters in health centers is essential to help foreign workers
in improving their treatment-seeking behavior. Moreover,
encouraging foreign workers to join programs to learn the
local language may also have good results in this regard.
According to the findings of this research, manufacturing
workers have a higher tendency for seeking medical visita-
tion than workers in the service industry. Unlike in service
sector, most of workers in manufacturing sector (like those
working in big factories) have access to panel clinics pro-
vided by their employers for free treatment and medication,
46 Asia Pacific Journal of Public Health 32(1)

Table 2. Demographic and Socioeconomic Variables Associated With the Tendency to Avoid Medical Treatment in Case of Severe
Sickness Among Foreign Workers in Malaysia; Multivariate Logistic Regressionsa.

Variable β SE P OR [95% CI]

Gender
Female Ref
Male 1.947 0.454 .000 7.008 [2.877-17.071]
Marital status
Nonmarried 0.576 0.265 .030 1.779 [1.059-2.991]
Married Ref
Work classification
Services Ref
Manufacturing −1.699 0.452 .000 0.183 [0.075-0.444]
Construction −0.041 0.327 .901 0.960 [0.506-1.821]
Other 0.122 0.325 .707 1.130 [0.598-2.136]
Income (MYR)
<1000 1.323 0.454 .004 3.754 [1.543-9.138]
1000-2000 0.451 0.304 .138 1.570 [0.865-2.848]
>2000 Ref
Preferred language for communication
Malay Ref
English −0.190 0.393 .629 0.827 [0.383-1.786]
Other 0.998 0.432 .021 2.712 [1.163-6.321]
Constant −3.597 0.551 .000 0.027

Abbreviations: SE, standard error; OR, odds ratio; CI, confidence interval; MYR, Malaysian Ringgit (1 USD ~ 4 MYR, as of January 2018).
a
Dependent variable is a dummy where “1” stands for “will not go” or “unlikely to go” for treatment, while “0” stands for “will go” or “more likely to go”
for treatment in case of severe sickness.

which encourages the workers to visit clinics when sick.
Most of workers in the service industry (like those working
in small marketing and sales companies, restaurants, and
residential security guard houses) have to pay on their own
(out of pocket) for the cost of treatment and medication. This
could be the reason behind this finding. A study from China
and another from Thailand found that work classification
influenced migrant workers’ health-seeking behavior.10,11
Hence, it is important that policies for enhancing the health
care–seeking behavior of foreign workers should be
industry-specific.
In-line with previous research from Thailand, our results
revealed that education is not associated with foreign work-
ers’ health care–seeking behavior.10 However, another
study from China showed some evidence to suggest that
education affects migrant workers’ health care–seeking
behavior.12
Similarly, the current study proved that age does not influ-
ence foreign workers’ health care–seeking behavior, which
confirms the findings of Peng et al.12 However, Naing et al10
found that age in Thailand does influence the health care–
seeking behavior of migrant workers who use public health
care facilities, but not those who use private ones. This con-
tradictory finding suggests that the demographic and socio-
economic determinants of health care–seeking behavior vary
across countries and perhaps across populations within the
same country.
Limitations of the Study
The best efforts have been taken to only approach docu-
mented foreign workers (for instance by asking for the type
of “i-kad” (an identification card for foreigners issued by the
Immigration Department of Malaysia) that they possess.
However, we cannot totally guarantee that all respondents
were legal foreign workers due to several possible reasons,
including the possession of a fake card. Since the scope of
this study was to only include documented foreign workers,
this factor was not included as one of the variables.
Mode of payment, although is an important variable affect-
ing tendency in getting treatment was not included in the
analysis. This is because this study focuses on demographic
and socioeconomic variables only. However, we believe that
the inclusion of the working sectors variable to a certain
extent indirectly represents the influence of mode of payment
based on the argument given above. Nevertheless, including
the mode of payment as one of the variables to replace work-
ing sectors could slightly change the estimated ORs.
Conclusions
It is alarming that a significant portion of foreign workers in
Malaysia are likely to avoid seeking medical treatment when
becoming unwell. Policymakers should develop new strate-
gies for improving the health care–seeking behavior of
Osman et al
foreign workers in order to provide good health status for
them as well as the local community. The findings of this
research suggest that such policies should be industry-spe-
cific and focus primarily on foreign workers who are male
and unmarried, as well as those whose preferred language for
communication is not Malay or English.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: We
would like to acknowledge the financial support provided by the
Equitable Society Research Cluster (research grant: RP018D-
14SBS) and the Ungku Aziz Centre for Development Studies,
Faculty of Economics and Administration, University of Malaya
(research grant: PD006-2017).
Ethical Approval
The written ethical approvals were granted by the University of
Malaya (Approval Number: UM.TNC2/UMREC-164). All the
answers and information of the participants were kept confidential
and only used for the study purpose.
Informed Consent
Informed consent was obtained from all individual participants par-
ticipated in the survey.
ORCID iD
Ahmad Farid Osman https://orcid.org/0000-0001-9007-4908
Supplemental Material
Supplemental material for this article is available online.
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