Pharmacy Students’ Use of and Beliefs About Traditional Healthcare

ORIGINAL PAPER

Pharmacy Students’ Use of and Beliefs About TraditionalHealthcare

Mudassir Anwar • Pauline Norris • James Green • Shirley Au •

Grace Li • Mandy Ma • Richard Prentice • Audrey Shum •

Louisa-Ann Siaw • Sujeong Yoo • Shuyi Zhang

� Springer Science+Business Media New York 2014

Abstract Health professional students come from many

different cultural backgrounds, and may be users of tradi-

tional healthcare (also known as ethnomedicine or folk

medicine). This study aimed to explore New Zealand

pharmacy students’ knowledge and beliefs about tradi-

tional 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 tradi-

tional 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

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 cultur-

ally-sensitive or culturally competent care [5]. This often

includes providing education about the traditional health-

care practices common in ethnic minority communities.

Traditional healthcare, sometimes known as ethnomedicine

or folk medicine, is defined by the World Health Organi-

zation (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 pre-

vention, 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 Wes-

tern healthcare or as a primary method of treatment [6]. It

differs from, but overlaps with complementary and alter-

native 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 medi-

cine) 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

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]

123

J Immigrant Minority Health

DOI 10.1007/s10903-014-0013-z

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 sys-

tems. 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 atti-

tudes (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 com-

pleted 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 question-

naire 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. Lec-

tures 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.

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 lan-

guage(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 ques-

tions 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 spo-

ken 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 recor-

ded 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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Table 1 Questionnaire


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Table 1 continued


123

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 admin-

istered 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.

Table 1 continued


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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).

Perceived Usefulness of Traditional Healthcare

Almost two-thirds of participants considered that tradi-

tional 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 ques-

tionnaire in both years, there was no change in the per-

ception of usefulness over time, ts(68) \ 1.0.

Users of traditional healthcare gave modestly higher

ratings of usefulness of traditional healthcare for treatment

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 tra-

ditional 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).

Reasons for Use

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 rea-

sons. 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

Table 2 Demographic characteristics of the participants (N = 100 in

each year, so the number is the same as the percentage)

Characteristic 2011 2013

Gender

Male 37 32

Ethnicity

New Zealand European 41 36

Chinese 24 27

Malay 12 10

Indian 8 8

Middle Eastern 3 2

Other 16 17

Country of birth

New Zealand 52 43

Malaysia 24 25

Other 24 32

0

5

10

15

20

25

30

35

40

45

5020112013

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 Chi-

nese 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 pro-

ducts, including soups and medicinal dosage forms, were

the most frequently mentioned types of traditional health-

care 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 some-

times mentioned [16]. These included acupuncture, mas-

sage, cupping, acupressure and chiropractice. Spiritual

healing was mentioned by two students. Several respon-

dents 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 medi-

cine 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 health-

care 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 ZealandEu-

ropean 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 over-

seas 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 hav-

ing disagreements with their families with regards to

methods of healthcare, although this rose from nine stu-

dents 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: ‘‘Some-

times they believe too much in traditional healthcare’’.

Two students explicitly mentioned the impact of the

pharmacy course on their views: ‘‘since studying phar-

macy, 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 tradi-

tional healthcare from their own culture. These were pri-

marily 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 tra-

ditional healthcare were previous experience of the effec-

tiveness 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 fami-

lies 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 pre-

vented a detailed exploration of participants’ views about

traditional healthcare or the circumstances of their use. The


123

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 tradi-

tional 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 symp-

toms [15]. In our study we also found that non-users of

traditional healthcare had similar attitudes to users. Simi-

larly, 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 health-

care reported during the course could be a real phenome-

non 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 distin-

guishing 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

attitudes to Traditional Chinese Medicine (TCM). Twenty-

two 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 comple-

mentary 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 med-

ical students were less interested in learning CAM tech-

niques 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 phar-

macy students have been reported in very different settings.

Freymann et al. [12] found very similar results in an eth-

nically 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). How-

ever 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 stu-

dents reported use of at least on CAM modality. However

the definition of CAM in that study included treatments


123

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 expo-

sure to a biomedical curriculum students seemed to be

more, rather than less likely to report using traditional

healthcare. Attempts to educate health professional stu-

dents about traditional healthcare should not be based on

the assumption that all students are unfamiliar with, or non-

users 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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Pharmacy Students’ Use of and Beliefs About Traditional Healthcare