J Immigrant Minority Health DOI 10.1007/s10903-014-0013-z
ORIGINAL PAPER
Pharmacy Students’ Use of and Beliefs About Traditional Healthcare Mudassir Anwar • Pauline Norris • James Green • Shirley Au Grace Li • Mandy Ma • Richard Prentice • Audrey Shum • Louisa-Ann Siaw • Sujeong Yoo • Shuyi Zhang
•
Ó Springer Science+Business Media New York 2014
Abstract Health professional students come from many different cultural backgrounds, and may be users of traditional healthcare (also known as ethnomedicine or folk medicine). This study aimed to explore New Zealand pharmacy students’ knowledge and beliefs about traditional healthcare, and to examine whether these changed during the course. A questionnaire was administered to students in 2011 and again in 2013. Students were from a wide range of ethnic groups. Their reported use of traditional healthcare increased (from 48 % in 2011 to 61 % in 2013) and was usually for minor illness or prevention. Non New Zealand European students were more likely to use traditional healthcare. Use of traditional healthcare was relatively common, and after exposure to a biomedical curriculum students seemed to be more, rather than less likely to report using traditional healthcare. Education about traditional healthcare should not be based on the assumption that all healthcare students are unfamiliar with, or non-users of, traditional healthcare. Keywords Traditional medicine Pharmacy Students New Zealand Cultural competence
Background Most countries are experiencing increasing ethnic diversity as a result of a recent dramatic increase in international migration. The number of international migrants more than
M. Anwar P. Norris (&) J. Green S. Au G. Li M. Ma R. Prentice A. Shum L.-A. Siaw S. Yoo S. Zhang School of Pharmacy, University of Otago, Box 56, Dunedin 9054, New Zealand e-mail: [email protected]
doubled between 1975 and 2003 [1]. It is now estimated that 3.1 % of the world’s population are international migrants [2]. In many countries migrants and people from ethnic minority groups experience worse health status and derive less benefit from the healthcare system [3, 4]. As part of the response to this, there is increasing interest in educating healthcare practitioners to provide more culturally-sensitive or culturally competent care [5]. This often includes providing education about the traditional healthcare practices common in ethnic minority communities. Traditional healthcare, sometimes known as ethnomedicine or folk medicine, is defined by the World Health Organization (WHO) as ‘‘the sum total of knowledge, skills, 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’’ [6]. A wide range of traditional healthcare practices are commonly used worldwide (in ethnic minority and majority communities, including Europeans [7]), either as an adjunct to conventional Western healthcare or as a primary method of treatment [6]. It differs from, but overlaps with complementary and alternative medicine (CAM), which has been defined as ‘‘a broad set of health care practices that are not part of that country’s own tradition and are not integrated into the dominant health care system’’ [6]. The WHO notes that in some countries these terms are used interchangeably. Some of the practices that are regarded as CAM in Western countries are traditional treatments in other countries or ethnic groups (such as acupuncture and ayurvedic medicine) but others may not be (osteopathy, chiropractice). Educating health professional students about traditional healthcare in an attempt to increase their competence in dealing with a culturally diverse patient population is
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complicated by the fact that in many countries health professional students themselves come from many different cultural backgrounds, and may be users of traditional healthcare. Students from each ethnic group are likely to have different understandings of health and healthcare, and have experienced different treatments and healthcare systems. Students from some cultures may come from families who routinely use traditional healing practices. This means that health professional educators cannot assume that all students share knowledge (or lack of knowledge) or attitudes (positive or negative) towards traditional healthcare. There is also little research about whether exposure a health professional curriculum, which is very heavily focussed on biomedicine, and neglects or refutes many traditional cultural beliefs about health and illness, changes students’ views. The aim of this study was to explore New Zealand pharmacy students’ knowledge and beliefs about traditional healthcare at the beginning of the pharmacy course, and to examine whether these changed during the course. New Zealand pharmacy students come from a wide range of ethnic groups [8, 9].
Methods Participants The BPharm degree at the University of Otago, New Zealand involves a 1 year introductory health sciences course followed by 3 years of full-time study in the School of Pharmacy. Students were surveyed in their second year of university (i.e. their first year in Pharmacy) and again in their fourth and final year. The questionnaire was completed on paper both times. In 2011 the questionnaire was administered to second year pharmacy students before a lecture. The student authors attended a class and introduced the questionnaire and asked students to complete it. In 2013 the questionnaire was administered to the same cohort (now fourth year students), before a lecture. The second author introduced the questionnaire and asked students to complete it. Lectures are not compulsory, and many students were absent from this lecture. Consequently, students who had been absent were invited to complete it at another lecture four days later. Data Collection A written questionnaire (Table 1) was designed to gauge students’ use of and beliefs about traditional healthcare. The questionnaire was intended to take\5 min to complete and comprised 18 questions.
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Measures Ethnicity and acculturation were explored by asking about country of birth (of the student and of their parents), length of residence in New Zealand, ethnicity, and language(s) spoken with family. Traditional healthcare was defined as being treatment from the students’ cultural heritage or that of another culture. Questions were asked about perceived usefulness, extent of use and reasons for use (amongst students who used traditional healthcare). All students were also asked questions about the role of their family in their use of traditional healthcare. The same questionnaire was used on both occasions. Demographic questions included some standard questions about age and gender. Ethnicity questions were informed by previous research on the ethnic backgrounds of University of Otago pharmacy students, and previous research on acculturation, which often uses language spoken with family as one indicator of acculturation [10]. Other questions were based on the personal experience of the authors (who are themselves from a range of cultural backgrounds), and reported experience of other pharmacy students. For example, in the past some students have reported that their family members send them medicines. Bringing medicines from the home country into New Zealand has also been reported in other research [11]. Question 13 on reasons for using traditional healthcare was drawn in part from Freymann et al. [12], and personal experience of the authors. The questionnaire was piloted on a small sample of undergraduate pharmacy students, and amended accordingly. Analysis Answers to open-ended questions were summarised. Summary statistics were calculated using Microsoft Excel 2010. Statistical tests (McNemar, correlation coefficients and t tests) were performed using SPSS 21. Ethics Ethical approval for the study was given by the School of Pharmacy, University of Otago under delegated authority from the University of Otago Human Ethics committee. We were aware that the students may be concerned about their anonymity. Each time, students were asked to record their student ID number on the detachable front page of the questionnaire. Completed questionnaires were immediately given to a research assistant. In 2011 she allocated a code number to each questionnaire, wrote this on it, and recorded both the student ID number and the code number for each questionnaire on a spreadsheet. The front page was then detached so the questionnaire became anonymous.
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The list of code numbers was kept securely on the research assistant’s computer. In 2013 the students again put their ID numbers on their completed questionnaires and the list was used to identify the appropriate code number to put on them. Front pages were again detached and discarded. Code numbers were used to match responses from the same student in 2011 and 2013. Students were reassured that participation was voluntary. Completing the questionnaire was regarded as implying consent.
Results There were 149 students in the second year Bachelor of Pharmacy (BPharm) class in 2011, and 150 students in the fourth year of the BPharm programme in 2013. In 2011, 111 students were present when the questionnaire was administered and 100 of these returned completed questionnaires, giving a response rate of 90 %. In 2013, 93 were present and 90 returned a completed questionnaire, giving a response rate of 97 %. A further 10 students completed questionnaires in another class 4 days later. Most students completed the
questionnaire within a few minutes. Thus 67 % of the entire class responded in 2011 and in 2013. Sixty-nine students completed both the 2011 and 2013 questionnaires. In 2011, 87 % of students were 19–21 years old and in 2013 82 % were 21–23 years old. Most students were female (63 % in 2011, 68 % in 2013). The modal ethnicity was ‘‘New Zealand European’’ followed closely by ‘‘Chinese’’, and then ‘‘Malay’’ and ‘‘Indian’’. A wide range of other ethnicities were reported by small numbers of students. Around half of the students were born in New Zealand (52 % in 2011 and 43 % in 2013), many were born in Malaysia (24 and 25 %) and the rest were born in 17 other countries (in both 2011 and 2013). Table 2 presents demographic data on the participants. Most of those born in New Zealand had lived all their life (45 % in 2011 and 40 % in 2013) or almost all their life in New Zealand. Most of those born in Malaysia had spent only a few years in New Zealand. Of those born in New Zealand, 21 % (and 16 % in 2013) had at least one parent born outside New Zealand, in a range of countries in Asia, Europe and Africa. Seventy-three percent (65 % in 2013) of the sample reported speaking English with their family, 23 % (23 % in 2013) Chinese, and 15 % (10 % in 2013) Malay.
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2011
2013
37
32
New Zealand European
41
36
Chinese
24
27
Malay
12
10
8 3
8 2
16
17
than non-users at both time points, 2011: Muser 4.4 versus Mnon-user 3.8, t(98) = 3.1, p = .002; 2013: Muser 4.3 versus Mnon-user 3.6, t(98) = 4.1, p \ .001. Users also rated traditional healthcare as more useful for prevention in in 2011, Muser 4.3 versus Mnon-user 3.9, t(97) = 2.4, p = .02, and 2013, Muser 4.2 versus Mnon-user 3.7, t(98) = 3.1, p = .002. Higher perceived usefulness for prevention and treatment were associated with more recent use. This relationship appeared to be stronger in 2013 (usefulness for treatment, r = .34, p = .001; usefulness for prevention, r = .38, p \ .001) than in 2011(usefulness for treatment, r = .24, p = .02; usefulness for prevention, r = .22, p = .03).
New Zealand
52
43
Reasons for Use
Malaysia
24
25
Other
24
32
Table 2 Demographic characteristics of the participants (N = 100 in each year, so the number is the same as the percentage) Characteristic Gender Male Ethnicity
Indian Middle Eastern Other Country of birth
Use of Traditional Healthcare The percentage of students who reported that they used traditional healthcare rose from 48 % in 2011 to 61 % in 2013. In 2011 9 % and in 2013 7 % of respondents reported using it within the last week, an additional 3 and 3 % within the last month, an additional 6 and 17 % more than a month ago, an additional 15 and 15 % more than 6 months ago, and another 15 and 19 % more than a year ago. Of the 69 students who responded both times, there was a clear increase, with 43 % (16/37) of non-users in 2011 having used traditional healthcare in 2013, whereas only 16 % (5/32) of users in 2011 had not used traditional healthcare in 2013, McNemar Test (df = 1) = 4.76, p = .03. The students reported primarily using healthcare from their own culture (in 2011, 44/48 students, in 2013, 56/61).
The most common reasons given for using traditional healthcare were personal experience of its effectiveness in the past, effectiveness in people the participants knew, encouragement by family members, and use being part of the students’ upbringing. The pattern was similar in both years, but in 2013 more students chose each of these reasons. Few students in either year indicated that they thought Western healthcare was less effective, had too many side effects, or was unsafe (Fig. 1). Almost all reported use of traditional healthcare was for minor ailments. Colds and flu, musculo-skeletal problems, digestive problems, and headaches were the most common reasons for use, as well as the prevention of illness or 50 45
2011 2013
40 35 30 25 20
Perceived Usefulness of Traditional Healthcare
15 10
Almost two-thirds of participants considered that traditional healthcare was ‘‘sometimes useful’’ for both the prevention and treatment of illness. Whereas there was a clear increase in reported use over time, the proportion of students selecting ‘‘sometimes useful’’ rose only slightly between 2011 and 2013 for both prevention (52 to 59 %) and treatment (61 to 64 %). Less than 5 % of students believed that traditional healthcare was ‘‘rarely useful’’ or ‘‘useless’’. For the 69 students who completed the questionnaire in both years, there was no change in the perception of usefulness over time, ts(68) \ 1.0. Users of traditional healthcare gave modestly higher ratings of usefulness of traditional healthcare for treatment
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5 0
Fig. 1 Reasons given for using traditional healthcare (n = 100 in each year and students were asked to select any answers that applied to them)
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maintenance of well-being. A wide range of other problems such as pain, fever, depression, stress, minor infections, cold hands and feet, and skin problems were also mentioned. Treatments Used Students were asked to list the products they used, and wrote this in free text, making the responses difficult to classify. Students provided different levels of detail in their answers and these could be classified in different ways, for example by method of administration (oral, soup or tea), or by ingredients (e.g. distinguishing herbal soups from meat based soups). Some students simply said Traditional Chinese Medicine without specifying treatment modalities (like acupuncture or herbal medicines) while others gave specific names for products or mixtures. Some noted that they did not know the English names for the products they used. Nevertheless we attempted to classify products used and quantify their use in the two surveys. Most products reported were taken orally. Herbal products, including soups and medicinal dosage forms, were the most frequently mentioned types of traditional healthcare mentioned by respondents (28 times). In addition, many students reported specific plant-derived products such as garlic [2], ginger [4], gingko [3], echinacea [1], ginseng [2]. Teas were also commonly mentioned [9]. Topical treatments were less common than oral dosage forms: mostly Tiger Balm and other lotions or ointments [16] (with two students reporting use of Arnica, which could be used topically). Physical therapies were sometimes mentioned [16]. These included acupuncture, massage, cupping, acupressure and chiropractice. Spiritual healing was mentioned by two students. Several respondents said that they did not know what the remedy was, or did not know its name. One student wrote simply ‘‘my grandmother knows’’. In 2013 students 84 discrete types of traditional medicine were reported (versus 57 in 2011). Students more frequently reported use of acupuncture, herbs and herbal soups, vitamin C, and a wider range of things that they may not have been previously thought of as traditional healthcare such as arnica, iron tablets, spirulina and chiropractice. Gender, Ethnicity and Family Influences There were no differences by gender in time of last use of traditional healthcare or in perceived usefulness at either timepoint, ts(96–98) \ 1.82. In 2011, fewer respondents (32 %) who identified themselves with New ZealandEuropean ethnicity were users of traditional healthcare, compared to 59 % of those from other ethnic groups, v2
[1] = 3.9, p = .047. In 2013, 36 % of New Zealand European students used traditional healthcare, and 75 % of other ethnicities, v2 [1] = 11.6, p \ .001. Supporting this apparent increase in use of traditional healthcare by overseas born students 60 % (9/15) of overseas born non-users in 2011 were users in 2013, whereas 5 % (1/19) of overseas born users were not users in 2013, McNemar Test (n = 35, df = 1) = 4.9, p = .03. We report this with caution, as it is based on a very small subset of overseas born students who completed the questionnaire at both time points. The percentage of users of traditional healthcare who reported that they were more likely to use it when living at home declined between the two surveys, from 48 % in 2011 to 38 % in 2013. Around a third of participants (35 in 2011 and 32 in 2013) reported being sent or brought medicines by their family. However most of these were Western medicines and only about a third of these students (10 students in 2011 and 11 in 2013) received traditional medicines from their families. Few students reported having disagreements with their families with regards to methods of healthcare, although this rose from nine students to 22 in 2013. Most of the students reported that their families were more convinced of the benefits of traditional healthcare than they were. Comments included: ‘‘Sometimes they believe too much in traditional healthcare’’. Two students explicitly mentioned the impact of the pharmacy course on their views: ‘‘since studying pharmacy, it has kind of discouraged me to use traditional health care’’.
Discussion The students were from a wide range of ethnic groups. Their reported use of traditional healthcare increased between the two surveys. Students primarily used traditional healthcare from their own culture. These were primarily herbal but also included a wide range of other products. Traditional healthcare was used for a variety of health problems, usually for minor illness or prevention. The main reported reasons that students chose to use traditional healthcare were previous experience of the effectiveness of traditional healthcare, family encouragement or because it was part of their culture. Students who were not of New Zealand European ethnicity were more likely to use traditional healthcare. Few students reported having received traditional medicines sent to them by their families and few reported disagreements with their families about treatment of health problems. In order to avoid disrupting classes and to maximise response rate, our questionnaire was very short. This prevented a detailed exploration of participants’ views about traditional healthcare or the circumstances of their use. The
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self-administered nature of the questionnaire and the short time given to complete it may have prevented students providing considered responses. We used the term traditional healthcare because we were particularly interested in students’ use of and attitudes to healthcare from their own culture but defining traditional healthcare is difficult and students may have varied in their interpretation of the term. Many other studies use the term CAM because their interest is primarily in non-orthodox treatment regardless of their cultural background. This makes it difficult to compare our results with those from other studies. The questionnaire was designed for the study, because we did not find any previous questionnaires that addressed all the questions we wanted to include, such as the issue of whether families sent medicines to students. This also means that it is difficult to compare responses to our questionnaire with those from previous studies. The use of a non-validated questionnaire may have led to bias. Our desire to keep the questionnaire short and easy to complete also meant that we did not ask any questions about the use of orthodox healthcare or use any measures of health status. These would have allowed us to explore whether or not use of traditional medicine was associated with ill-health and/ or high use of healthcare in general. Like Freymann et al. [12] we found largely positive attitudes towards traditional healthcare amongst many pharmacy students in an ethnically diverse Pharmacy School. Other studies have also shown positive attitudes [13, 14]. In Pakistan, 60 % of surveyed pharmacy students believed that CAM methods provided real relief of symptoms [15]. In our study we also found that non-users of traditional healthcare had similar attitudes to users. Similarly, studies of practicing pharmacists have found high levels of personal use and interest in alternative medicines [16–19]. To our knowledge this is the first study to investigate how attitudes to traditional healthcare change throughout a pharmacy course. The increased use of traditional healthcare reported during the course could be a real phenomenon or it could be the result of increased reporting. This could be the result of more awareness that the treatments that students have grown up with and take for granted would be regarded by others as traditional healthcare. Robinson and Lorenc [20] note the difficulty of distinguishing traditional treatments from ‘‘common sense’’ or part of daily life. The wider range of treatments reported in 2013 lends some support to this hypothesis. It is also possible that the students felt more comfortable reporting traditional healthcare use in their fourth year of pharmacy school because it had been discussed in a neutral fashion in classes. While Hon et al. [21] did not investigate the same cohort at two time points, they did ask students how they thought studying western medicine had affected their
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attitudes to Traditional Chinese Medicine (TCM). Twentytwo percent reported they had become more positive towards TCM (76 % no change, 2 % more negative). Similarly Tiralongo and Walls found that around 50 % of students reported that learning about CAMs and complementary therapies had positively influenced their attitudes to them [22]. Studies of the effect of medical education on medical students’ attitudes do not shed much light on the question of whether biomedical education may increase awareness or positive attitudes to traditional medicine. Although some researchers have done cross-sectional studies on students at different times during the medical curriculum, very few have done longitudinal studies, i.e. repeated surveys on the same group. Therefore any differences identified could be cohort effects rather than real changes to student’s attitudes and behaviours over time. In cross-sectional studies, Lie and Boker [23] found that a short teaching session on CAM did not change medical students’ already positive attitudes. However Furnham and McGill found that third year medical students were less interested in learning CAM techniques and rated CAM as less effective than first year students [24]. In the only report we found of a longitudinal study, Lie and Boker (2006) found no change in medical students’ attitudes over time [25]. Our results suggest that at the very least, students do not become more negative about traditional practices during their health professional education. This raises questions about the relationship between health professional practice and traditional healthcare. To what extent is attachment to traditional practices a risk to evidence based healthcare? Will professionals who use these practices recommend them to patients, or be influenced by the (non-scientific) explanatory models underlying them? Or could knowledge and use of traditional healthcare better equip students to understand patients in their own and other communities (as it did for health visitors studied in Robinson and Lorenc [20]), and the complexity of health beliefs and healthcare seeking in contemporary society [26]. Should educators discourage traditional views, discuss them explicitly so that students reflect critically on them, or encourage them? Similar rates of use of traditional healthcare by pharmacy students have been reported in very different settings. Freymann et al. [12] found very similar results in an ethnically diverse student group in the UK (43 % using CAM in the last 12 months) and Hon et al. found 38 % of their students in Hong Kong reported using TCM in the past year [21] (compared to 33 and 42 % in our study). However Hon et al. also found that 96 % of students had used TCM at some time in the past and Pokladnikowa [14] also reported very high lifetime rates of use: 92 % of all students reported use of at least on CAM modality. However the definition of CAM in that study included treatments
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like vitamins and minerals which would not usually be thought of as traditional healthcare. Similarly Tiralongo found lifetime rates of use of 93.7 % for what they describe as complementary and alternative medicines and 38.7 % for complementary therapies [22]. The increasing percentage of students in our study who report using traditional healthcare independently of their family may be a result of students becoming older and more independent from their families, and it suggests that patterns of use of traditional healthcare will continue to the next generation. Upper respiratory tract infections were the most commonly reported reason for using TCM in Hon et al. [21] and it was also a common reason reported in our study. Students in Freymann et al.’s study [12] appear to have had more knowledge of the details of ingredients in the products they used. This may suggest that our students are more reliant on their families to provide these remedies, or it may simply be an artefact of study design. Horne et al. [27] also found that students’ ethnic origin was associated with beliefs about medicines, across a range of university courses. In their study Asian students were more likely to believe that western medicine is intrinsically harmful. Remarkably, some papers exploring pharmacy students’ views about traditional healthcare or CAM do not explore the effect of ethnicity on attitudes or use (for example [13, 22] ).
New Contribution to the Literature This study has shown that use of traditional healthcare is relatively common amongst pharmacy students in New Zealand. Contrary to what might be expected, after exposure to a biomedical curriculum students seemed to be more, rather than less likely to report using traditional healthcare. Attempts to educate health professional students about traditional healthcare should not be based on the assumption that all students are unfamiliar with, or nonusers of traditional healthcare. Education should draw on the existing knowledge and cultural familiarity that some students already have with traditional healthcare. Acknowledgments We wish to thank the students who participated in the study, and Vicky McLeod and Sarah Wilson for research assistance. No external funding was obtained for the project.
References 1. Bach S. International migration of health workers: labour and social issues. Geneva: International Labour Office; 2003. 2. International Organisation for Migration. Facts and figures: global estimates and trends. Geneva, Switzerland; 2013. Cited 30 Mar 2013. 3. Klonoff E. Disparities in the provision of medical care: an outcome in search of an explanation. J Behav Med. 2009;32(1):48–63.
4. Hill S, Sarfati D, Blakely T, Robson B, Purdie G, Chen J, et al. Survival disparities in Indigenous and non-Indigenous New Zealanders with colon cancer: the role of patient comorbidity, treatment and health service factors. J Epidemiol Community Health. 2010;64:117–23. 5. Brach C, Fraserirector I. Can cultural competency reduce racial and ethnic health disparities? a review and conceptual model. Med Care Res Rev. 2000;57(Supplement 1):181–217. 6. World Health Organization. Traditional medicine. Geneva, Switzerland; 2008. http://www.who.int/mediacentre/factsheets/ fs134/en/. Cited 10 May 2013. 7. Hatfield G. Encyclopedia of folk medicine: old world and new world traditions. Santa Barbara, California: ABC-CLIO; 2004. 8. Ball D, Norris P, Enlund H, Tagwireyi D, Awad A. Diversity amongst international pharmacy students. Pharm Educ. 2007(3 Oct). 9. Capstick S, Green J, Beresford R. Choosing a course of study and career in pharmacy—student attitudes and intentions across three years at a New Zealand School of Pharmacy. Pharm Educ. 2007;4(15):359–73. 10. Cabassa LJ. Measuring acculturation: where we are and where we need to go. Hisp J Behav Sci. 2003;25(2):127–46. 11. Tongi L. Exploring medications amongst Tongan households in New Zealand: University of Waikato; 2010. 12. Freymann H, Rennie T, Bates I, Nebel S, Heinrich M. Knowledge and use of complementary and alternative medicine among British undergraduate pharmacy students. Pharm World Sci. 2006;28:13–8. 13. Harris I, Kingston R, Rodriguez R, Choudary V. Attitudes towards complementary and alternative medicine among pharmacy faculty and students. Am J Pharm Educ. 2006;70(6):1–8. 14. Pokladnikova J, Lie D. Comparison of attitudes, beliefs, and resource-seeking behavior for CAM among first- and third-year czech pharmacy students. Am J Pharm Educ. 2008;72(2):1–6. 15. Hussain S, Malik F, Hameed A, Ahmed S, Riaz H, Abbasi N. Pakistani pharmacy students’ perception about complementary and alternative medicine. Am J Pharm Educ. 2012;76(2):1–7. 16. Abahussain N, Abahussain E, Al-Oumi F. Pharmacists’ attitudes and awareness towards the use and safety of herbs in Kuwait. Pharm Pract. 2007;5(3):125–9. 17. Koh H, Teo H, Ng H. Pharmacists’ patterns of use, knowledge, and attitudes toward complementary and alternative medicine. J Altern Complement Med. 2003;9(1):51–63. 18. Naidu S, Wilkinson J, Simpson M. Attitudes of Australian pharmacists toward complementary and alternative medicines. Ann Pharmacother. 2005;39(9):1456–61. 19. Robinson N, Lorenc A. Responding to patient demand: community pharmacists and herbal and nutritional products for children. Phytother Res. 2011;25:892–6. 20. Robinson N, Lorenc A. Traditional and complementary approaches to child health. Nurs Stand. 2011;25(38):39–47. 21. Hon E, Lee K, Tse H, Lam L, Tam K, Chu K, et al. A survey of attitudes to Traditional Chinese Medicine in Hong Kong pharmacy students. Complement Ther Med. 2004;12(1):51–6. 22. Tiralongo E, Wallis M. Attitudes and perceptions of Australian pharmacy students towards complementary and alternative medicine: a pilot study. BMC Complement Altern Med. 2008;8(2):1–9. 23. Lie D, Boker J. Development and validation of the CAM Health Belief Questionnaire (CHBQ) and CAM use and attitudes amongst medical students. BMC Med Educ. 2004;4(2):1–9. 24. Furnham A, McGill C. Medical students’ attitudes about complementary and alternative medicine. J Altern Complement Med. 2003;9(2):275–84. 25. Lie D, Boker J. Comparative survey of complementary and alternative medicine (CAM) attitudes, use, and information-
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ORIGINAL PAPER
Pharmacy Students’ Use of and Beliefs About Traditional Healthcare Mudassir Anwar • Pauline Norris • James Green • Shirley Au Grace Li • Mandy Ma • Richard Prentice • Audrey Shum • Louisa-Ann Siaw • Sujeong Yoo • Shuyi Zhang
•
Ó Springer Science+Business Media New York 2014
Abstract Health professional students come from many different cultural backgrounds, and may be users of traditional healthcare (also known as ethnomedicine or folk medicine). This study aimed to explore New Zealand pharmacy students’ knowledge and beliefs about traditional healthcare, and to examine whether these changed during the course. A questionnaire was administered to students in 2011 and again in 2013. Students were from a wide range of ethnic groups. Their reported use of traditional healthcare increased (from 48 % in 2011 to 61 % in 2013) and was usually for minor illness or prevention. Non New Zealand European students were more likely to use traditional healthcare. Use of traditional healthcare was relatively common, and after exposure to a biomedical curriculum students seemed to be more, rather than less likely to report using traditional healthcare. Education about traditional healthcare should not be based on the assumption that all healthcare students are unfamiliar with, or non-users of, traditional healthcare. Keywords Traditional medicine Pharmacy Students New Zealand Cultural competence
Background Most countries are experiencing increasing ethnic diversity as a result of a recent dramatic increase in international migration. The number of international migrants more than
M. Anwar P. Norris (&) J. Green S. Au G. Li M. Ma R. Prentice A. Shum L.-A. Siaw S. Yoo S. Zhang School of Pharmacy, University of Otago, Box 56, Dunedin 9054, New Zealand e-mail: [email protected]
doubled between 1975 and 2003 [1]. It is now estimated that 3.1 % of the world’s population are international migrants [2]. In many countries migrants and people from ethnic minority groups experience worse health status and derive less benefit from the healthcare system [3, 4]. As part of the response to this, there is increasing interest in educating healthcare practitioners to provide more culturally-sensitive or culturally competent care [5]. This often includes providing education about the traditional healthcare practices common in ethnic minority communities. Traditional healthcare, sometimes known as ethnomedicine or folk medicine, is defined by the World Health Organization (WHO) as ‘‘the sum total of knowledge, skills, 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’’ [6]. A wide range of traditional healthcare practices are commonly used worldwide (in ethnic minority and majority communities, including Europeans [7]), either as an adjunct to conventional Western healthcare or as a primary method of treatment [6]. It differs from, but overlaps with complementary and alternative medicine (CAM), which has been defined as ‘‘a broad set of health care practices that are not part of that country’s own tradition and are not integrated into the dominant health care system’’ [6]. The WHO notes that in some countries these terms are used interchangeably. Some of the practices that are regarded as CAM in Western countries are traditional treatments in other countries or ethnic groups (such as acupuncture and ayurvedic medicine) but others may not be (osteopathy, chiropractice). Educating health professional students about traditional healthcare in an attempt to increase their competence in dealing with a culturally diverse patient population is
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complicated by the fact that in many countries health professional students themselves come from many different cultural backgrounds, and may be users of traditional healthcare. Students from each ethnic group are likely to have different understandings of health and healthcare, and have experienced different treatments and healthcare systems. Students from some cultures may come from families who routinely use traditional healing practices. This means that health professional educators cannot assume that all students share knowledge (or lack of knowledge) or attitudes (positive or negative) towards traditional healthcare. There is also little research about whether exposure a health professional curriculum, which is very heavily focussed on biomedicine, and neglects or refutes many traditional cultural beliefs about health and illness, changes students’ views. The aim of this study was to explore New Zealand pharmacy students’ knowledge and beliefs about traditional healthcare at the beginning of the pharmacy course, and to examine whether these changed during the course. New Zealand pharmacy students come from a wide range of ethnic groups [8, 9].
Methods Participants The BPharm degree at the University of Otago, New Zealand involves a 1 year introductory health sciences course followed by 3 years of full-time study in the School of Pharmacy. Students were surveyed in their second year of university (i.e. their first year in Pharmacy) and again in their fourth and final year. The questionnaire was completed on paper both times. In 2011 the questionnaire was administered to second year pharmacy students before a lecture. The student authors attended a class and introduced the questionnaire and asked students to complete it. In 2013 the questionnaire was administered to the same cohort (now fourth year students), before a lecture. The second author introduced the questionnaire and asked students to complete it. Lectures are not compulsory, and many students were absent from this lecture. Consequently, students who had been absent were invited to complete it at another lecture four days later. Data Collection A written questionnaire (Table 1) was designed to gauge students’ use of and beliefs about traditional healthcare. The questionnaire was intended to take\5 min to complete and comprised 18 questions.
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Measures Ethnicity and acculturation were explored by asking about country of birth (of the student and of their parents), length of residence in New Zealand, ethnicity, and language(s) spoken with family. Traditional healthcare was defined as being treatment from the students’ cultural heritage or that of another culture. Questions were asked about perceived usefulness, extent of use and reasons for use (amongst students who used traditional healthcare). All students were also asked questions about the role of their family in their use of traditional healthcare. The same questionnaire was used on both occasions. Demographic questions included some standard questions about age and gender. Ethnicity questions were informed by previous research on the ethnic backgrounds of University of Otago pharmacy students, and previous research on acculturation, which often uses language spoken with family as one indicator of acculturation [10]. Other questions were based on the personal experience of the authors (who are themselves from a range of cultural backgrounds), and reported experience of other pharmacy students. For example, in the past some students have reported that their family members send them medicines. Bringing medicines from the home country into New Zealand has also been reported in other research [11]. Question 13 on reasons for using traditional healthcare was drawn in part from Freymann et al. [12], and personal experience of the authors. The questionnaire was piloted on a small sample of undergraduate pharmacy students, and amended accordingly. Analysis Answers to open-ended questions were summarised. Summary statistics were calculated using Microsoft Excel 2010. Statistical tests (McNemar, correlation coefficients and t tests) were performed using SPSS 21. Ethics Ethical approval for the study was given by the School of Pharmacy, University of Otago under delegated authority from the University of Otago Human Ethics committee. We were aware that the students may be concerned about their anonymity. Each time, students were asked to record their student ID number on the detachable front page of the questionnaire. Completed questionnaires were immediately given to a research assistant. In 2011 she allocated a code number to each questionnaire, wrote this on it, and recorded both the student ID number and the code number for each questionnaire on a spreadsheet. The front page was then detached so the questionnaire became anonymous.
J Immigrant Minority Health Table 1 Questionnaire
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The list of code numbers was kept securely on the research assistant’s computer. In 2013 the students again put their ID numbers on their completed questionnaires and the list was used to identify the appropriate code number to put on them. Front pages were again detached and discarded. Code numbers were used to match responses from the same student in 2011 and 2013. Students were reassured that participation was voluntary. Completing the questionnaire was regarded as implying consent.
Results There were 149 students in the second year Bachelor of Pharmacy (BPharm) class in 2011, and 150 students in the fourth year of the BPharm programme in 2013. In 2011, 111 students were present when the questionnaire was administered and 100 of these returned completed questionnaires, giving a response rate of 90 %. In 2013, 93 were present and 90 returned a completed questionnaire, giving a response rate of 97 %. A further 10 students completed questionnaires in another class 4 days later. Most students completed the
questionnaire within a few minutes. Thus 67 % of the entire class responded in 2011 and in 2013. Sixty-nine students completed both the 2011 and 2013 questionnaires. In 2011, 87 % of students were 19–21 years old and in 2013 82 % were 21–23 years old. Most students were female (63 % in 2011, 68 % in 2013). The modal ethnicity was ‘‘New Zealand European’’ followed closely by ‘‘Chinese’’, and then ‘‘Malay’’ and ‘‘Indian’’. A wide range of other ethnicities were reported by small numbers of students. Around half of the students were born in New Zealand (52 % in 2011 and 43 % in 2013), many were born in Malaysia (24 and 25 %) and the rest were born in 17 other countries (in both 2011 and 2013). Table 2 presents demographic data on the participants. Most of those born in New Zealand had lived all their life (45 % in 2011 and 40 % in 2013) or almost all their life in New Zealand. Most of those born in Malaysia had spent only a few years in New Zealand. Of those born in New Zealand, 21 % (and 16 % in 2013) had at least one parent born outside New Zealand, in a range of countries in Asia, Europe and Africa. Seventy-three percent (65 % in 2013) of the sample reported speaking English with their family, 23 % (23 % in 2013) Chinese, and 15 % (10 % in 2013) Malay.
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2011
2013
37
32
New Zealand European
41
36
Chinese
24
27
Malay
12
10
8 3
8 2
16
17
than non-users at both time points, 2011: Muser 4.4 versus Mnon-user 3.8, t(98) = 3.1, p = .002; 2013: Muser 4.3 versus Mnon-user 3.6, t(98) = 4.1, p \ .001. Users also rated traditional healthcare as more useful for prevention in in 2011, Muser 4.3 versus Mnon-user 3.9, t(97) = 2.4, p = .02, and 2013, Muser 4.2 versus Mnon-user 3.7, t(98) = 3.1, p = .002. Higher perceived usefulness for prevention and treatment were associated with more recent use. This relationship appeared to be stronger in 2013 (usefulness for treatment, r = .34, p = .001; usefulness for prevention, r = .38, p \ .001) than in 2011(usefulness for treatment, r = .24, p = .02; usefulness for prevention, r = .22, p = .03).
New Zealand
52
43
Reasons for Use
Malaysia
24
25
Other
24
32
Table 2 Demographic characteristics of the participants (N = 100 in each year, so the number is the same as the percentage) Characteristic Gender Male Ethnicity
Indian Middle Eastern Other Country of birth
Use of Traditional Healthcare The percentage of students who reported that they used traditional healthcare rose from 48 % in 2011 to 61 % in 2013. In 2011 9 % and in 2013 7 % of respondents reported using it within the last week, an additional 3 and 3 % within the last month, an additional 6 and 17 % more than a month ago, an additional 15 and 15 % more than 6 months ago, and another 15 and 19 % more than a year ago. Of the 69 students who responded both times, there was a clear increase, with 43 % (16/37) of non-users in 2011 having used traditional healthcare in 2013, whereas only 16 % (5/32) of users in 2011 had not used traditional healthcare in 2013, McNemar Test (df = 1) = 4.76, p = .03. The students reported primarily using healthcare from their own culture (in 2011, 44/48 students, in 2013, 56/61).
The most common reasons given for using traditional healthcare were personal experience of its effectiveness in the past, effectiveness in people the participants knew, encouragement by family members, and use being part of the students’ upbringing. The pattern was similar in both years, but in 2013 more students chose each of these reasons. Few students in either year indicated that they thought Western healthcare was less effective, had too many side effects, or was unsafe (Fig. 1). Almost all reported use of traditional healthcare was for minor ailments. Colds and flu, musculo-skeletal problems, digestive problems, and headaches were the most common reasons for use, as well as the prevention of illness or 50 45
2011 2013
40 35 30 25 20
Perceived Usefulness of Traditional Healthcare
15 10
Almost two-thirds of participants considered that traditional healthcare was ‘‘sometimes useful’’ for both the prevention and treatment of illness. Whereas there was a clear increase in reported use over time, the proportion of students selecting ‘‘sometimes useful’’ rose only slightly between 2011 and 2013 for both prevention (52 to 59 %) and treatment (61 to 64 %). Less than 5 % of students believed that traditional healthcare was ‘‘rarely useful’’ or ‘‘useless’’. For the 69 students who completed the questionnaire in both years, there was no change in the perception of usefulness over time, ts(68) \ 1.0. Users of traditional healthcare gave modestly higher ratings of usefulness of traditional healthcare for treatment
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5 0
Fig. 1 Reasons given for using traditional healthcare (n = 100 in each year and students were asked to select any answers that applied to them)
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maintenance of well-being. A wide range of other problems such as pain, fever, depression, stress, minor infections, cold hands and feet, and skin problems were also mentioned. Treatments Used Students were asked to list the products they used, and wrote this in free text, making the responses difficult to classify. Students provided different levels of detail in their answers and these could be classified in different ways, for example by method of administration (oral, soup or tea), or by ingredients (e.g. distinguishing herbal soups from meat based soups). Some students simply said Traditional Chinese Medicine without specifying treatment modalities (like acupuncture or herbal medicines) while others gave specific names for products or mixtures. Some noted that they did not know the English names for the products they used. Nevertheless we attempted to classify products used and quantify their use in the two surveys. Most products reported were taken orally. Herbal products, including soups and medicinal dosage forms, were the most frequently mentioned types of traditional healthcare mentioned by respondents (28 times). In addition, many students reported specific plant-derived products such as garlic [2], ginger [4], gingko [3], echinacea [1], ginseng [2]. Teas were also commonly mentioned [9]. Topical treatments were less common than oral dosage forms: mostly Tiger Balm and other lotions or ointments [16] (with two students reporting use of Arnica, which could be used topically). Physical therapies were sometimes mentioned [16]. These included acupuncture, massage, cupping, acupressure and chiropractice. Spiritual healing was mentioned by two students. Several respondents said that they did not know what the remedy was, or did not know its name. One student wrote simply ‘‘my grandmother knows’’. In 2013 students 84 discrete types of traditional medicine were reported (versus 57 in 2011). Students more frequently reported use of acupuncture, herbs and herbal soups, vitamin C, and a wider range of things that they may not have been previously thought of as traditional healthcare such as arnica, iron tablets, spirulina and chiropractice. Gender, Ethnicity and Family Influences There were no differences by gender in time of last use of traditional healthcare or in perceived usefulness at either timepoint, ts(96–98) \ 1.82. In 2011, fewer respondents (32 %) who identified themselves with New ZealandEuropean ethnicity were users of traditional healthcare, compared to 59 % of those from other ethnic groups, v2
[1] = 3.9, p = .047. In 2013, 36 % of New Zealand European students used traditional healthcare, and 75 % of other ethnicities, v2 [1] = 11.6, p \ .001. Supporting this apparent increase in use of traditional healthcare by overseas born students 60 % (9/15) of overseas born non-users in 2011 were users in 2013, whereas 5 % (1/19) of overseas born users were not users in 2013, McNemar Test (n = 35, df = 1) = 4.9, p = .03. We report this with caution, as it is based on a very small subset of overseas born students who completed the questionnaire at both time points. The percentage of users of traditional healthcare who reported that they were more likely to use it when living at home declined between the two surveys, from 48 % in 2011 to 38 % in 2013. Around a third of participants (35 in 2011 and 32 in 2013) reported being sent or brought medicines by their family. However most of these were Western medicines and only about a third of these students (10 students in 2011 and 11 in 2013) received traditional medicines from their families. Few students reported having disagreements with their families with regards to methods of healthcare, although this rose from nine students to 22 in 2013. Most of the students reported that their families were more convinced of the benefits of traditional healthcare than they were. Comments included: ‘‘Sometimes they believe too much in traditional healthcare’’. Two students explicitly mentioned the impact of the pharmacy course on their views: ‘‘since studying pharmacy, it has kind of discouraged me to use traditional health care’’.
Discussion The students were from a wide range of ethnic groups. Their reported use of traditional healthcare increased between the two surveys. Students primarily used traditional healthcare from their own culture. These were primarily herbal but also included a wide range of other products. Traditional healthcare was used for a variety of health problems, usually for minor illness or prevention. The main reported reasons that students chose to use traditional healthcare were previous experience of the effectiveness of traditional healthcare, family encouragement or because it was part of their culture. Students who were not of New Zealand European ethnicity were more likely to use traditional healthcare. Few students reported having received traditional medicines sent to them by their families and few reported disagreements with their families about treatment of health problems. In order to avoid disrupting classes and to maximise response rate, our questionnaire was very short. This prevented a detailed exploration of participants’ views about traditional healthcare or the circumstances of their use. The
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self-administered nature of the questionnaire and the short time given to complete it may have prevented students providing considered responses. We used the term traditional healthcare because we were particularly interested in students’ use of and attitudes to healthcare from their own culture but defining traditional healthcare is difficult and students may have varied in their interpretation of the term. Many other studies use the term CAM because their interest is primarily in non-orthodox treatment regardless of their cultural background. This makes it difficult to compare our results with those from other studies. The questionnaire was designed for the study, because we did not find any previous questionnaires that addressed all the questions we wanted to include, such as the issue of whether families sent medicines to students. This also means that it is difficult to compare responses to our questionnaire with those from previous studies. The use of a non-validated questionnaire may have led to bias. Our desire to keep the questionnaire short and easy to complete also meant that we did not ask any questions about the use of orthodox healthcare or use any measures of health status. These would have allowed us to explore whether or not use of traditional medicine was associated with ill-health and/ or high use of healthcare in general. Like Freymann et al. [12] we found largely positive attitudes towards traditional healthcare amongst many pharmacy students in an ethnically diverse Pharmacy School. Other studies have also shown positive attitudes [13, 14]. In Pakistan, 60 % of surveyed pharmacy students believed that CAM methods provided real relief of symptoms [15]. In our study we also found that non-users of traditional healthcare had similar attitudes to users. Similarly, studies of practicing pharmacists have found high levels of personal use and interest in alternative medicines [16–19]. To our knowledge this is the first study to investigate how attitudes to traditional healthcare change throughout a pharmacy course. The increased use of traditional healthcare reported during the course could be a real phenomenon or it could be the result of increased reporting. This could be the result of more awareness that the treatments that students have grown up with and take for granted would be regarded by others as traditional healthcare. Robinson and Lorenc [20] note the difficulty of distinguishing traditional treatments from ‘‘common sense’’ or part of daily life. The wider range of treatments reported in 2013 lends some support to this hypothesis. It is also possible that the students felt more comfortable reporting traditional healthcare use in their fourth year of pharmacy school because it had been discussed in a neutral fashion in classes. While Hon et al. [21] did not investigate the same cohort at two time points, they did ask students how they thought studying western medicine had affected their
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attitudes to Traditional Chinese Medicine (TCM). Twentytwo percent reported they had become more positive towards TCM (76 % no change, 2 % more negative). Similarly Tiralongo and Walls found that around 50 % of students reported that learning about CAMs and complementary therapies had positively influenced their attitudes to them [22]. Studies of the effect of medical education on medical students’ attitudes do not shed much light on the question of whether biomedical education may increase awareness or positive attitudes to traditional medicine. Although some researchers have done cross-sectional studies on students at different times during the medical curriculum, very few have done longitudinal studies, i.e. repeated surveys on the same group. Therefore any differences identified could be cohort effects rather than real changes to student’s attitudes and behaviours over time. In cross-sectional studies, Lie and Boker [23] found that a short teaching session on CAM did not change medical students’ already positive attitudes. However Furnham and McGill found that third year medical students were less interested in learning CAM techniques and rated CAM as less effective than first year students [24]. In the only report we found of a longitudinal study, Lie and Boker (2006) found no change in medical students’ attitudes over time [25]. Our results suggest that at the very least, students do not become more negative about traditional practices during their health professional education. This raises questions about the relationship between health professional practice and traditional healthcare. To what extent is attachment to traditional practices a risk to evidence based healthcare? Will professionals who use these practices recommend them to patients, or be influenced by the (non-scientific) explanatory models underlying them? Or could knowledge and use of traditional healthcare better equip students to understand patients in their own and other communities (as it did for health visitors studied in Robinson and Lorenc [20]), and the complexity of health beliefs and healthcare seeking in contemporary society [26]. Should educators discourage traditional views, discuss them explicitly so that students reflect critically on them, or encourage them? Similar rates of use of traditional healthcare by pharmacy students have been reported in very different settings. Freymann et al. [12] found very similar results in an ethnically diverse student group in the UK (43 % using CAM in the last 12 months) and Hon et al. found 38 % of their students in Hong Kong reported using TCM in the past year [21] (compared to 33 and 42 % in our study). However Hon et al. also found that 96 % of students had used TCM at some time in the past and Pokladnikowa [14] also reported very high lifetime rates of use: 92 % of all students reported use of at least on CAM modality. However the definition of CAM in that study included treatments
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like vitamins and minerals which would not usually be thought of as traditional healthcare. Similarly Tiralongo found lifetime rates of use of 93.7 % for what they describe as complementary and alternative medicines and 38.7 % for complementary therapies [22]. The increasing percentage of students in our study who report using traditional healthcare independently of their family may be a result of students becoming older and more independent from their families, and it suggests that patterns of use of traditional healthcare will continue to the next generation. Upper respiratory tract infections were the most commonly reported reason for using TCM in Hon et al. [21] and it was also a common reason reported in our study. Students in Freymann et al.’s study [12] appear to have had more knowledge of the details of ingredients in the products they used. This may suggest that our students are more reliant on their families to provide these remedies, or it may simply be an artefact of study design. Horne et al. [27] also found that students’ ethnic origin was associated with beliefs about medicines, across a range of university courses. In their study Asian students were more likely to believe that western medicine is intrinsically harmful. Remarkably, some papers exploring pharmacy students’ views about traditional healthcare or CAM do not explore the effect of ethnicity on attitudes or use (for example [13, 22] ).
New Contribution to the Literature This study has shown that use of traditional healthcare is relatively common amongst pharmacy students in New Zealand. Contrary to what might be expected, after exposure to a biomedical curriculum students seemed to be more, rather than less likely to report using traditional healthcare. Attempts to educate health professional students about traditional healthcare should not be based on the assumption that all students are unfamiliar with, or nonusers of traditional healthcare. Education should draw on the existing knowledge and cultural familiarity that some students already have with traditional healthcare. Acknowledgments We wish to thank the students who participated in the study, and Vicky McLeod and Sarah Wilson for research assistance. No external funding was obtained for the project.
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