Pharm World Sci (2006) 28:13–18 DOI 10.1007/s11096-005-2221-z
RESEARCH ARTICLE
Knowledge and use of complementary and alternative medicine among British undergraduate pharmacy students Heike Freymann Æ Timothy Rennie Æ Ian Bates Æ Sabine Nebel Æ Michael Heinrich
Received: 16 November 2004 / Accepted: 14 August 2005 / Published online: 11 May 2006 Springer Science + Business Media B.V. 2006
Abstract Aim: Attitudes and practice concerning complementary and alternative medicine (CAM) are currently an area of considerable importance. However, little is known about the overall importance of CAM in groups of health care professionals. Therefore, the primary objective was to analyse the knowledge about and use of CAM in an ethnically diverse student population at the London School of Pharmacy. Methods: A questionnaire was administered to students (264 completed questionnaires, response rate: 59.1%) and in-depth interviews were carried out with a sample of seven students. Results: Forty-three percent reported using at least one type of CAM during the last 12 months. The types of CAM used that were most frequently mentioned include aromatherapy, Traditional Chinese Medicine (TCM) and medicinal herbalism. TCM was reported by students of Chinese origin and by students from other ethnic backgrounds. However, Ayurvedic (Indian) medicine and medicine from Africa were only used in cultures from which the users originated. The study shows that a large number of herbal medical products were commonly reported by students of pharmacy. Conclusion: The knowledge about and use of CAM is widespread among this group of future health care professionals and the students also expressed a strong interest in the topic. Indepth studies on the knowledge and use of CAM
H. Freymann Æ S. Nebel Æ M. Heinrich (&) Centre for Pharmacognosy and Phytotherapy, The School of Pharmacy, University of London, 29–39 Brunswick Square, London, WC1N 1AX, UK E-mail:
[email protected] Tel.: +44-207-753-5846 Fax: +44-207-753-5909 T. Rennie Æ I. Bates Department of Practice and Policy, The School of Pharmacy, University of London, 29–39 Brunswick Square, London, WC1N 1AX, UK
among other health care professionals and among ethnic minorities are urgently needed and may help to better manage the treatment of minor disorders as well as chronic diseases. Keywords Ayurvedic medicine Æ Complementary and alternative medicine Æ Herbal medicine Æ Higher education Æ Knowledge Æ Pharmacy students Æ Traditional Chinese Medicine Æ Traditional medicine Æ United Kingdom
Introduction Many people use complementary and alternative medicine (CAM) for different health problems such as anxiety, or allergic disorders, as well as minor ailments or chronic diseases [1]. In several surveys 20–33% of the UK’s population claimed to regularly use CAM alone or in addition to orthodox or conventional medicine and treatments [2, 3, 4, 5]. While for simplicity the term ‘orthodox’ and ‘conventional medicine’ is used here to describe licensed medicinal products typically comprising a single characterized chemical entity [6], the term CAM applies to over 700 different treatments and use in a large variety of diagnostic methods [7]. Some of them such as herbal and homeopathic medicines are well known in Europe, while others have their origins in other cultural settings e.g. Ayurvedic and Traditional Chinese Medicine. Some important CAM disciplines as Chiropractic and Osteopathy are well regulated by Acts of Parliament but for other disciplines no regulation exists in the UK [8]. Some practitioners providing Ayurvedic and Chinese medicine follow the rules and regulations of their country of origin e.g. the ‘Indian Medicine Central Council’ established in 1970 in India, or the Chinese government. The overall situation with respect to the numerous forms of CAM was at the centre of the
123
14
influential House of Lord’ report (UK) [9], which among others recommended a more systematic study of the various groups of CAM. Also, it should be noted that while certain forms of treatment are considered to be CAM in one country, in others this may well be an established form of treatment (as are many phytomedicines in Continental Europe). The aim of this project was to better understand the use of herbal medicinal products (HMPs), medicinal plants (MPs) and other natural remedies among a culturally diverse undergraduate student population at The School of Pharmacy, University of London (ULSOP) building on experiences during our previous studies on rural non-European populations [10]. For the survey two characteristics of the study population were important: 1. The students were all pharmacy students, so a general knowledge of and an interest in the subject can be assumed. 2. They belong to different ethnic groups living in London, representing a wide cultural variety mostly being the offspring of immigrants who came to the UK during the 1960s and 1970s or being foreign students. The School’s curriculum is based on the indicative syllabus of the Royal Pharmaceutical Society of Great Britain and includes both applied and basic sciences. Pharmacognosy and related topics are largely taught during the second year of study. During this year and in the last year some lectures dedicated to CAM are also included. Overall pharmacognosy has much fewer contact hours than it has in many continental European countries.
Method The study was conducted during in 2004 at the ULSOP. Approval for the study was obtained from the relevant senior staff involved in the administration of the School and all Course leaders involved. The study was anonymous, voluntary and informants were free to withdraw at any time. The quantitative study The study used survey methods, both self-completed questionnaire and semi-structured interviews, to estimate the extent of CAM use and knowledge among the students. Since no model for the questionnaire existed, it was developed taking into consideration information received informally during the years from students and data available on CAM in the UK. It was piloted with a small sample (three 1st year students and two Ph.D.
123
Pharm World Sci (2006) 28:13–18
students in pharmacy) and modified based on the feedback received. The questionnaire was administered in January of 2004 and included open and closed questions, which asked about the students’ own and their families’ use of CAM, as well as their attitude towards various aspects of HMP & MP (scaled questions). In order to gain a deeper and more detailed understanding about the students’ opinion, two questions asked the students to provide descriptive accounts about how HMPs and natural remedies were used. This will also guide further surveys on this topic. Data on these questions are reported here using the number assigned to the student (ID) and are based on a content analysis of the interviews. A range of students’ socio-demographic details (age, gender, ethnicity, year of study) were also collected. First, second and fourth year students had 20 minutes time to fill in the questionnaire at the end of a lecture. For the third year students, the questionnaire was handed out at the beginning of a lecture, and was then collected the next day during the same lecture period. Statistical analysis Data were analysed using SPSS 12.0. The analysis of quantitative data included the generation of frequency data and summary statistics. The v2 test was chosen to test for statistical association. For all cases a p value less than 0.05 was accepted as conferring statistical significance. Responses to the questionnaire were analysed descriptively by gender, age, year of study, and place of birth of the students, their mother and father and for each of their grandparents, the students’ nationality, their ethnicity, their languages spoken at home and their mother tongue. Qualitative study Semi-structured individual interviews were conducted ‘in-depth’ with seven students. The students who participated in the quantitative part of the study were asked whether they would be willing to participate in some further interviews and the ones who agreed were contacted by email. The interviews were carried out after analysis of the questionnaire and were used for obtaining a more detailed understanding of reasons and rationales behind the use of CAM and HMPs. The interviews took place in the School of Pharmacy and were audio taped. The interviews lasted between 23 and 45 minutes. Key areas of the interviews included the students’ interest, their experience and their definition of traditional medicine, the distribution of traditional medicine in their families and community,
Pharm World Sci (2006) 28:13–18
possibilities to safeguard the family knowledge for future generation and a discussion about selling CAM in a pharmacy and the reason why mainly students with Asian/African background study pharmacy at ULSOP. The interviews were conducted by the first author after detailed discussion about the scope and strategy between her and the corresponding author. Results Students’ characteristics Two hundred and sixty-four of 447 potential responders returned the questionnaire (59.1% response rate). The distribution between the sexes at ULSOP (total students: female 441–64.9%, male 238–35.1%) was reflected in the overall distribution of responders, but more female students participated in the survey (female 190–72.8%, male 71–27.2%, 3 missing). The average age of the students was 20.8 years, ranging from 18 to 47 (standard deviation: 3.5). Thirty-seven percent of the students responding were born abroad while 87.8% of their parents and 90.8% of their grandparents were born in a foreign country. In 2004 as in previous years most students were of an Asian ethnic background (71.8%) and among this group 54.1% of the students were British East Indians (Table 1). Nearly 10% (9.8%) were Black or Black British students and 9.4% of the students had a White ethnic background. Only 5.9% of all the students at ULSOP had a White British background. Type and frequency of CAM use Forty-three percent (113 students) of the students reported using CAM during the last 12 months; 16.3% had used CAM during the last week (43 students), 19.7% (52 students) during the last month and 32.6% (86 students) during the last year. There was no significant difference in the use between female and male students. Table 1 Ethnic background of undergraduate students at the School of Pharmacy
15
The types of complementary and alternative medicine most frequently used (listing more than one use was possible) were Aromatherapy (26.8%), Traditional Chinese Medicine (25%), Western medical herbalism (25%, Fig. 1), Ayurvedic medicine (19.6%), homeopathy (14.3%) and acupuncture (10.7%). Other therapies such as chiropractic, reflexology, Bach flowers, acupressure were used less than 5% (Fig. 1). In contrast to another study [11], the students were not asked about the meaning and principles of the CAM disciplines they mentioned. Ayurvedic medicine was reported to be used exclusively in its cultures of origin, i.e. by Indian (90.9%) and Pakistani students (9.1%) whereas ‘Traditional Chinese Medicine’ (TCM), was used among all ethnic groups in the survey (Table 2). Seventy percent of all Chinese students used ‘Traditional Chinese Medicine’. The percentage of Indian students using Ayurvedic medicine was much lower (40.8%). The only group regarding CAM as a strong part of their tradition was the group of Chinese students; (v2=23.632, p=0.001). For students from a ‘White background’ CAM was not at all a part of their tradition. This trend was not significant because of the small number of White students. In quantitative terms Indian and Pakistani students speaking Gujarati and Hindi tended to use more CAM, especially Ayurvedic medicine than students speaking Punjabi or Urdu. Although the Indian and Pakistani groups represent a large number of students, the student number in the different categories is too small to allow a statistically significant differentiation. No difference was observed in the use of CAM between students who consider English or another language as their mother tongue. Plants, herbal medical products and natural remedies One hundred fifty-three students (58%) mentioned at least one plant, product or remedy they used; 105 students (39.8%) responded positively to the question about ‘plants, products, remedies you know’. More
Ethnicity Asian or Asian British (71.77%)
Black or Black British (9.80%) White (9.41%)
a Nine missing of a total of 264 questionnaires
Mixed I do not wish to give the information Other Total
Indian Pakistani Chinese Other Asian background African Other Black background British Other White background
n
Percentage
99 32 31 21 21 4 15 9 8 3 12 255a
38.82 12.55 12.16 8.24 8.24 1.57 5.88 3.53 3.14 1.18 4.71 100.00
123
16
Pharm World Sci (2006) 28:13–18
Percent [%]
30 26,8
Table 3 The use of and knowledge about specific medicinal plants and herbal medical products (excluded are HMPs with less than five answers in both categories)
25,0 25,0
25
19,6
20
14,3
15 10
12,5
10,7 3,6
5
2,7
1,8
at he M ed ra py ic A a yu l h T C ve er M di ba lis c m m H om edc i A eop ne cu a B pun thy ac h ctu F r R low e ef le ers A cu xol p og C res y Id h iro su o no pr re tk ac no tic w O th th e e gr r ou p
ro m A
Use of MPs or HMPs over the last months
Knowledge about MPs or HMPs
Camomile Ginseng Echinacea Ginkgo Green tea Peppermint Turmeric Aloe vera Evening primrose oil Fish oil Ginger tea Tea tree oil Indian Chai Lavender Garlic St John’s Wort Valerian Arnica
22 16 15 15 15 10 10 9 9 9 9 8 5 5 3 3 3 2
10 16 15 17 4 10 4 5 7 3 4 6 1 6 8 30 9 9
1,8
0
Fig. 1 Types of CAM reported by ULSOP students Table 2 Types of CAM in the various ethnic groups Ethnicity (number of CAM users)
Ayurvedic medicine
Traditional Chinese Medicine
Other CAM
Indian (n=49) Pakistani (n=10) Chinese (n=17) Other Asian (n=6) White (n=10) Black (n=9) Mixed (n=5) Total
20 2 – – – – – 22
8 – 12 2 1 1 1 25
42 13 13 8 16 12 8 112
than 90% of the plants and preparations mentioned could be identified (Table 3) based on the popular names using dictionaries and the internet. Of course, a definite botanical identification was not possible. The answers to both questions (i.e. the one on knowledge and the one on use) were similar. Most students mentioned single herbal remedies and mixed herbal remedies (e.g. mixture turmeric powder and honey; honey and milk). A large number of phytomedicines commonly used in Europe were mentioned (see Discussion). Two mineral remedies (sodium fluoride, glucosamine sulphate), complex mixtures and remedies with an explicit complementary use (e.g. Bach flower: rescue remedy) were also reported. Many plants and preparations from the students’ cultural background were mentioned in interviews. Chinese students mentioned plants such as Huang Qi (Astragalus sp.) used as a tonic or Niu Huang Jie Du Pian, a preparation containing five ingredients: e.g. Angelicae radix and Rhei rhizomae used for constipation. Commonly known among Indian students were medicinal preparations containing ginger (9 records) and turmeric (10 records) for colds, coughs and bacterial infections and Chyawanprash, a type of jam consisting of 37 different plants or plant extracts and used as a daily health supplement. Apart from medicine from their cultural backgrounds further types of CAM used by the interviewees were aromatherapy and
123
Plant names
8,0
Western herbalism. The use of essential oils has a place in all of the interviewees’ cultures (Chinese, Indian, African) and is a major component of all traditional healing principles. Psychological problems were the group of illnesses most frequently mentioned, other important groups of remedies include ones for cold and flu, for gastrointestinal disorders and skin problems. General assessment of CAM by students at ULSOP Sixty percent stated that they were very interested in complementary and alternative medicine (Table 4). This interest was not associated with gender, ethnicity or year of study. Forty-two percent of all students were uncertain whether plants and natural products were good or poor health products, but another 46% considered them to be good to excellent health care products (see Table 4). Most students regard these products as necessary and do not want them to be banned but promoted widely (Table 4). There was a desire for a distribution of these remedies by the NHS (National Health System) in more than 32%, and a further 43% of the students would agree with this spread by the NHS (Table 4). Often students obtain their knowledge about the use of traditional medicine in their families especially from their grandparents and other older people in their community. The use in a family was described by a Chinese student ‘‘It is a very common practice in a Chinese family. Usually we consume the Chinese medicine daily through our diet. Say, we boil sugar (sugar cane) with ginger as dessert during winter and
Pharm World Sci (2006) 28:13–18
17
Table 4 Student responses to selected statements on a scale from 1 to 7 (in percent)
Part of my tradition (1)–Not part of my tradition (7) Of interest to me as a pharmacy student (1)–Of no interest to me (7) Excellent health care products (1)–Poor health care products (7) Natural remedies have few side effects (1)–Natural remedies have many side effects (7) These remedies should be banned (1)–These remedies should be promoted widely (7) These products should be available through the NHS (1)–These products should not be available through the NHS (7)
1
2
11.8 29.9
13.8 16.5 30.3 11.1
17.3 11.5
6.9
11.5 28.1
41.5 10.0
1.5
11.1
11.5 16.5
35.6 14.2
6.9
2.3 16.5
believe it can help improve circulation. We will drink traditional medicine in soup for keeping the Qi-balance in our body.’’ (ID 159) Cultural change also affects this student population and while the elder generation may still have a strong link to such traditional forms of treatment, the generation studying pharmacy often has little or no interest and/or knowledge: • Grandparents encourage their use. My parents and I never or nearly never use such products probably because of the lack of information available. (ID 189) • Herbal medical products are not widely used as other natural remedies such herbal teas are. People in the country are used to collect herbs and then boil them and drink the juice. But this is not common in young people. (ID 18) Majority of the students strongly agree with the statement ‘health care professionals should be aware of natural remedies’. Others classified some traditional products as products of high quality and good products suitable for a wider distribution in the population but pointed out the pharmacists’ knowledge of these products is currently lacking or insufficient to counsel patients. Discussion This study is a pilot study and to our knowledge it is the first to focus on the impact of cultural identity and ethnicity on pharmacists’ knowledge about and use of CAM. The study highlights the important role various forms of CAM plays in a population of young and presumably mostly healthy students. It focuses on the students in one large ethnically diverse School of Pharmacy, and studies in various other settings are currently ongoing [12]. The knowledge about traditional medicines is passed on in the families. Grandparents and most of the
3
1.5
4
5 8.3 8.4
4.2
20.3 18.0
15.7 19.5
24.1 12.3
6
7
10.2 22.0 3.8 5.0
No. of answers
Missing answers
100% 254 100% 261
9 3
0.4
100% 260
4
4.2
100% 261
3
21.8 31.8
100% 261
3
100% 261
3
7.3
4.6
parents of the students grew up in other countries, in another environment and during another time where no other remedies were available while most of the students grew up in the UK and adopted a UK lifestyle. Interestingly, British Chinese students almost unanimously reported to rely on TCM and it seems that TCM in this group has a greater importance as an indicator of ethnic identity than Ayurvedic medicine has for British Indians and Pakistanis. Also, Chinese medicine shops are relatively abundant in London while Ayurvedic, Arabic or African medicine shops are much more difficult to locate. The most popular species mentioned in the questionnaire are all remedies very much embedded in European herbal traditions [e.g. echinacea, camomile, but also ginkgo (of course, of Chinese origin) and ginseng], a fact which may be explained by the students’ expectation that they are better known in the context of UK pharmacy and the wide marketing such products have experienced. The ethnographic approach sheds additional light on this matter. The use of medicinal plants common in European herbalism or phytotherapy shows the impact of the UK lifestyle on students’ life with influences from the media and current scientific thought (e.g. ID 3 on Ginkgo and Blueberry extract: ‘I read about the use in a newspaper’, ID 5: Ginkgo: ‘I heard about the use in lectures’). The reaction and assessment of the quality and safety of CAM by pharmacy students does not only give an insight into their opinion and what they have learned at the School of Pharmacy but also an insight on how pharmacists will deal with CAM in the future. Reports about contamination and severe adverse effects are often published in newspapers, TV and medical journals [13] and clearly raise students’ awareness and general concern. If the data are analysed by year of study it becomes apparent that students in years 1 and 2 considered CAM to be safe, unproblematic and as products having few side effects. Contrary to this students in years 3 and 4 tended to see CAM as more
123
18
dangerous, more problematic and as having side effects. A clear difference between first/second and third/ fourth year students regarding the question on natural remedies having few/many side effects was proved (v2=7.457, p=0.024). This association may in part be explained by the students’ timetable. The main lectures at ULSOP in phytotherapy/pharmacovigilance of HMPs take place in the second term of the second year. It can be assumed that the view of students in year 1 and 2 concerning safety topics may have been similar to the views in the general population whereas 3rd and 4th year students, being sensitised in the lectures at the School, showed a greater concern for safety issues of natural remedies. Perhaps the views of students in years 3 and 4 are more representative of pharmacists on this topic. Conclusions This study does not only highlight that students of pharmacy at ULSOP have in their majority a considerable interest in this topic, but that they commonly use CAM. Pharmacists (especially community pharmacists) are in an ideal position to monitor and support the safe use of CAM products. There might be an important gap between what people do as part of their responsibilities as health care providers and the traditions they have been brought up with. This study provides a telling example of how health care providers harbour beliefs about healing which may not be commensurate with the general biomedical model. As pointed out by Dogra et al. [14], the teaching of ‘cultural diversity’ in medical schools is already a part of the curriculum but needs to be developed further. Similarly, this topic needs to be addressed by other schools of pharmacy. However, here we show that this diversity is not the only one which needs to be looked at focusing on patients’ cultural diversity, but also on the cultural diversity of the health care providers. Further research on the use of traditional and other herbal remedies (as well as other forms of what is generally termed CAM in the UK) by health care professionals and most notably by the numerous ethnic groups in urban Britain [12, 15]. and increased efforts for educating pharmacists and other health care professionals [13] on these topic will be essential to ensure that the whole UK population ‘has access to medicine of their choice’ [16].
123
Pharm World Sci (2006) 28:13–18
Acknowledgements We are grateful to all students who gave their time and participated in the survey as well as to all course leaders for allowing us to do this project during normal teaching time. This project received no external funding and the authors have no conflicts of interest to declare.
References 1. Zollman C, Vickers A. ABC of complementary medicine. Users and practitioners of complementary medicine. Brit Med J 1999; 319:836–383 2. Thomas KJ, Fall M, Nicholl J, Williams B. Methodological study to investigate the feasibility of conducting a population-based survey of the use of complementary health care. SCHARR: University of Sheffield; 1993 3. Harris P, Rees R. The prevalence of complementary and alternative medicine use among the general population: a systematic review of the literature. Complement Ther Med 2000; 8:88–96 4. Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complement Ther Med 2001; 9:2–11 5. Ernst E, White A. The BBC survey of complementary medicine use in the UK. Complement Ther Med 2000; 8:32–36 6. Barnes J. Pharmacovigilance of herbal medicines. Drug Safety 2003; 26:829–851 7. Kayne SB (2002) Complementary therapies for pharmacists. Pharmaceutical Press, p. 6–7. ISBN 0-85369-430-3. 8. Clarke DB, Doel MA, Segrott J. No alternative? The regulation and professionalization of complementary and alternative medicine in the United Kingdom. Health Place 2004; 10:329–338 9. House of Lords Select Committee on Science and Technology (2000) Session 1999–2000, 6th report. Complementary and alternative medicine. The Stationery Office, London 10. Leonti M, Sticher O, Heinrich M. Antiquity of medicinal plant usage in two Macro-Mayan Ethnic Groups. J Ethnopharmacol 2003; 88:119–124 11. Sesselberg T, Wilson KM, Gray NJ, Klein JD. Adolescents’ knowledge of and beliefs about complementary and alternative medicine: a qualitative study. J Adolesc Health 2003; 32:126 12. Sandhu DS, Heinrich M. The use of health foods, spices and other botanicals with the Sikh community in London. Phytother Res 2005; 19: 633–642 13. Ernst E. Toxic heavy metals and undeclared drugs in Asian herbal medicines. Tr Pharmacol Sci 2002; 23:136–139 14. Dogra N, Connin S, Gill P, Spencer J, Turner M. Teaching of cultural diversity in medical schools in the United Kingdom and Republic of Ireland: cross sectional questionnaire survey. Brit Med J 2005; 330:403–404 15. Heinrich, M (2005) Challenges and threats to interdisciplinary medicinal plant research. In: Zahora, Yaniv editor. Handbook of medicinal plants. Haworth Press, Binghampton, New York, USA, p. 447–464. ISBN-13: 978-156022-994-0 16. Barnes J. Meeting the impact of the Traditional Herbal Medicinal Products Directive. Complement Ther Med 2003; 11:129–131
