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Social Science & Medicine 59 (2004) 13071313

Medicine in a multi-cultural society: the effect of cultural

background on beliefs about medications
Robert Hornea,*, L!da Graupnera, Susie Frosta, John Weinmanb, Siobhan
Melanie Wrightc, Matthew Hankinsa
a

Centre for Health Care Research, Faculty of Health, University of Brighton, Falmer Campus, Brighton BN1 9PH, UK
Division of Psychiatry and Psychology, Guys, Kings and St Thomas School of Medicine, 5th Floor, Thomas Guy House,
Guys Campus, London SE1 9RT, UK
c
UK School of Pharmacy and Biomolecular Sciences, University of Brighton, BN1 9PH, UK

Abstract
This exploratory, cross-sectional study examined the effect of self-reported cultural background on beliefs about
medicines (modern pharmaceuticals) and perceptions of personal sensitivity to the adverse effects of taking medication.
Using a validated questionnaire, beliefs about pharmaceutical medication were compared between 500 UK
undergraduate students who identied themselves as having an Asian or European cultural background. There was
a signicant association between cultural background and beliefs about the benets and dangers of medicines. Students
who self-reported to have an Asian cultural background expressed more negative views about medication than those
who reported a European cultural background. Students with an Asian cultural background were signicantly more
likely to perceive medicines as being intrinsically harmful, addictive substances that should be avoided. They were
signicantly less likely to endorse the benets of modern medication. There was no signicant relationship between
cultural background and perceptions of personal sensitivity to medication effects or belief about how doctors use
medication. In the total sample, past and present experience of taking medication was associated with a more positive
orientation to medicines in general. Students who considered themselves to have a European cultural background had
signicantly more experience with prescribed medication than those who selected an Asian cultural background. The
relationship between cultural background and beliefs about medicines in general was maintained after controlling for
potential confounding variables, including chosen degree course, experience of taking prescribed medication, age, and
gender. The identication of differences in beliefs about medication, between two specic cultural groups, suggests the
need for a greater understanding of the effects of cultural background on medicine-usage with potential implications for
the conduct of prescribing-related consultations and for the provision of patient information on medication.
r 2004 Elsevier Ltd. All rights reserved.
Keywords: Beliefs; Culture; Ethnicity; Medicines; Perceptions; UK

Introduction
Ethnicity and ethnic grouping rest on the cultural
differentiation of individuals and on the creation of
*Corresponding author. Health Psychology, Pharmacy Practice School of Pharmacy, University of Brighton, Biomed
Sciences, Cockroft Building, Lewes Road, Brighton BN2 4GJ,
UK. Tel.: +44-1273-642098; fax: +44-1273-679333.
E-mail address: r.horne@brighton.ac.uk (R. Horne).

social bonds between those who share a common

culture (Rex, 1993). Culture is the collective noun for
the conventional patterns of thought and behaviour,
including value beliefs and rules of conduct, which
distinguish a particular social group and that are learned
rather than inherited (Tattersall, 1995) and which are
transmitted through the most fundamental dimensions
of culture: food, language and kinship relations
(Jovchelovitch & Gervais, 1999). Ethnic or cultural
differences may have a powerful inuence on many

0277-9536/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2004.01.009

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R. Horne et al. / Social Science & Medicine 59 (2004) 13071313

aspects of peoples lives including those relating to

health (Helman, 1990).
The emergence of culture and ethnicity as important
concepts in health research owes much to social
scientists who have observed and documented beliefs
and behaviours that appear to be characteristic of
particular cultural groups. For example, explanatory
models, which are lay theories about the causes and
mechanisms of disease and illness, are held by individuals but are strongly inuenced by culture (Kleinman,
1980).
Cultural differences in health beliefs and behaviour
may affect health-care utilisation. For example, one
study found that cultural background was a signicant
predictor of undergoing screening for breast and
cervical cancer, even after controlling for potential
mediating factors, such as education, family history of
breast or cervical cancer, and knowing someone with
either disease (Tang, Solomon, Yeh, & Worden, 1999).
Young Asian women were less likely than young
Caucasian women to opt for screening, which could be
explained by differences in the cultural barriers to
screening, with Asian women reporting greater
sexual modesty and less overall utilisation of Western
health care.
As well as lay models of illness, there is increasing
interest in representations of treatment, particularly
medication (Horne, 1997). The prescription of a
medicine is the most common medical intervention in
developed countries. There has been much interest in
peoples views about medication and how these might
inuence demand for prescriptions (Britten, 1994) and
adherence to medication (Horne, & Weinman, 1999).
Over the last decade or so, a number of interview-based
studies have elicited lay representations of medicines (see
Horne, 1997, for a review). Studies conducted in the UK
(Britten, 1994; Morgan & Watkins, 1988; Berry,
Gillie, & Banbury, 1995), USA (Clinthorne, 1986;
Cochran & Gitlin, 1988; Cohen, 1983; Conrad, 1985)
and Europe (Fallsberg, 1991) have identied
common themes or notions about medication (such as
the danger of long-term effects, addiction, and the
over-prescribing of medicines by doctors). Principal
components analysis has shown that common beliefs
about medicines in general can be grouped under
certain core themes, such as notions about the intrinsic
nature of medicines and their capacity for harm or
benet, and ideas about the degree to which they are
overused by doctors (Horne, 1997). Recent research
suggests that these constructs seem to be particularly
useful in distinguishing peoples orientation towards
medicines in general. Many people have fairly negative
perceptions of modern medicines, which are often
associated with the notion that the chemical/unnatural
origins of medicines are dangerous and that
complementary treatments are more natural and

therefore safer (Horne, & Weinman, 1999; Lam, 2001).

Such general perceptions may inuence treatment
preferences, pathways to care, and adherence to
medication (Horne, 2000).
Research suggests that notions of modern medicines
may be incorporated into the explanatory models
adopted by particular cultural groups (Greenhalgh,
Helman, & Chowdhury, 1998; Kruse, Rampmaier,
Ullrich, & Weber, 1994; Morgan, 1983; Robbins &
Kirmayer, 1991). It has also been suggested that
attitudes to particular classes of treatment may differ
across socio-demographic and cultural groups (Lim,
Shwartz, & Lo, 1994; Pachter, 1994). This notion
appears plausible and the recent development of
validated questionnaire-based methods of assessing
beliefs about medicines (Horne, Weinman, & Hankins,
1999) provides an opportunity to augment existing
qualitative research by assessing the effects of cultural
background on beliefs about medicines using quantitative methodologies.
Recent research suggests that people differ not just in
their beliefs about the nature and uses of medicines, but
also in the degree to which they perceive themselves to
be sensitive or susceptible to the potential adverse effects
of medication. As might be expected, people who view
themselves as being particularly sensitive to the adverse
effects of medication are more likely to perceive
medicines as intrinsically harmful poisons that are
over-prescribed by doctors (Horne, 1997). We have only
recently begun to study perceived sensitivity to medication and as yet we know little about the origins of these
beliefs. However, we suspect that they are likely to arise
from more general perceptions of self and hardiness
(Leventhal et al., 1997; Low, 1999; Wang, 1999) and
from past experiences (of self and others) as well as from
beliefs about the nature of medicines. We would
therefore anticipate that notions of personal sensitivity
might be less strongly inuenced by ethnicity or cultural
norms than beliefs about the intrinsic nature of classes
of treatments.
The aim of the present study was to explore
interactions between cultural group and two aspects of
beliefs about medication among university students:
perceptions of medicines in general and beliefs about
personal sensitivity to the potential adverse effects of
medicines. Because ethnic minority members are not an
undifferentiated group, and many social and cultural
factors differentiate between ethnic groups (Sissons
Joshi, 1998), we focused our research on two broad
cultural groupings, and compared beliefs about medicines in general and perceptions of personal sensitivity to
adverse effects between students who identied themselves as having an Asian or European cultural background.
Our hypothesis was that views about prescribed
medicines would differ between Asian and European

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R. Horne et al. / Social Science & Medicine 59 (2004) 13071313

students, but notions of personal sensitivity would not

be inuenced by cultural background.

Method
Study design and sampling strategy
An exploratory cross-sectional study in which a
sample of 600 UK undergraduate students were asked
to complete questionnaires assessing beliefs about
medicines in general, perceptions of personal sensitivity
to the potential adverse effects of medication, past and
present experience of taking medication, and demographic characteristics. Beliefs about medicines were
compared between undergraduate students who identied themselves as having an Asian or European cultural
background, whilst controlling for experience of taking
medication (past and present) and choice of degree
course. All participants in this study had also taken part
in an earlier study, reported by Horne, Frost, Hankins,
and Wright (2001).

Measures
Demographic characteristics
Participants were asked to provide information on
their age, gender, degree course, year of study, and
cultural background. Participants were asked to select
their cultural origin from the following list: Afro
Caribbean, African, Asian, European, or other.
The Beliefs about Medicines Questionnaire (Horne et al.,
1999)
Participants beliefs about medicines in general were
assessed using the Beliefs about Medication Questionnaire (BMQ) General scale, which comprises two 4-item
sub-scales. The General-Harm scale assesses individuals
beliefs about the intrinsic properties of medicines and
the degree to which medicines in general are perceived to
be harmful, addictive poisons, which should not be
taken for long periods of time. Items in the scale include:
People who take medicines should stop their treatment for
a while every now and again, Most medicines are
addictive, Medicines can do more harm than good, and
All medicines are poisons. The General-Overuse scale
assesses beliefs about the way in which medicines are
used and the extent to which individuals perceive that
medicines are over-prescribed by doctors. Items in the
scale include: Doctors use too many medicines, Doctors
place too much trust on medicines, Natural remedies are
safer than medicines and If doctors had more time with
patients they would prescribe fewer medicines. The

1309

internal reliabilities for the original 4-item Harm and

Overuse scales were less than satisfactory (harm: a
0:54; overuse: a 0:64), However, the internal reliability
for both scales improved signicantly when the item,
Natural remedies are safer than medicines was transferred from the Overuse scale to the Harm scale, and
when the item All medicines are poisons was excluded
from the Harm scale. The alpha values for the revised 4item Harm scale and 3-item Overuse scale were Harm:
a 0:62; and Overuse: a 0:72: Four additional statements were added to the BMQ-General, to assess
individuals beliefs about the potential benets of
medicines. These were: Without medicines doctors would
be less able to cure people, Medicines help many people to
live better lives, Medicines help many people to live longer,
and In most cases the benefits of medicines outweigh the
risks. These items constituted the General-Benet scale,
which was found to have acceptable internal reliability
(a 0:62).
Assigning scores to medication beliefs
Respondents indicate their degree of agreement with
each individual statement about medicines on a 5-point
Likert scale, ranging from 1 (strongly disagree) to 5
(strongly agree). Scores obtained for the individual items
are summed to give a scale score. Total scores for the
Harm and Benet scales ranged from 4 to 20 for each
scale, and for the Overuse scale from 3 to 15, with higher
scores indicating stronger beliefs in the concepts
represented by the scale.
The Sensitive Soma scale (Diefenbach, Leventhal &
Leventhal, personal communication)
The Sensitive Soma scale assesses perceptions of
personal sensitivity to the potential adverse effects of
medication. The scale comprises ve items, which assess
perceived intrinsic sensitivity to the adverse effects of
medication, e.g., My body is very sensitive to medicines,
My body over-reacts to medicines. Responses to the
individual items are scored on a 5-point Likert scale
ranging from 1 (strongly disagree) to 5 (strongly agree).
Scores on the ve individual items are summed to
give a total Sensitive Soma scale score from 5 to 25,
where high scores indicate a high perceived sensitivity to
the potential adverse effects of medication. The
internal reliability of this scale was high (Cronbach
alpha=0.79).
Procedure
Permission to invite students to take part in the study
was obtained from relevant members of academic staff
(course leaders and tutors). Students were approached at
the start of a core lecture and invited to take part in the

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R. Horne et al. / Social Science & Medicine 59 (2004) 13071313

study. Those who agreed were then given 15 min to

complete the study questionnaire before the lecture
began.

to be entered into the nal analysis (response

rate 83%).
Description of participants

Statistical analysis
Statistical analysis was carried out with the SPSS for
Windows statistical software package. Independent
samples t-tests were performed to investigate the effect
of gender and experience of prescribed medication on
medication beliefs. The effect of cultural background on
beliefs about medicines was assessed in Asian and
European students. Due to the signicant association
between cultural background, choice of course, and
experience of prescribed medication, a regression
analysis was used to partial out the effects of chosen
course, experience of medicines, as well as age and
gender.

Details of the demographic characteristics of the

sample are shown in Table 1. As Afro-Caribbean,
African, and other ethnic categories together accounted
for only 9% of the overall sample, statistical analyses
investigating the effect of cultural group on medication
beliefs included only the Asian (n=83) and European
(n=417) origin groups. The total sample was 52% male
and 48% female, and the mean age was 23.9 years
(SD=6.5). A higher percentage of students who selfreported an Asian origin were studying science degrees,
compared to students reporting a European origin. A
greater number of students who reported a European
origin had current (26.1%) and past (49.9%) experience
of taking medicine, compared to students who reported
an Asian origin (14.5% and 37.3%, respectively).

Results
Effect of gender on medication beliefs
Incomplete
or
spoiled
questionnaires
were
excluded, leaving a total of 500 completed
questionnaires from students who identied themselves
as having Asian or European cultural backgrounds,

Independent samples t-tests revealed a signicant

association between gender and general harm beliefs,
with male students being more likely to believe that

Table 1
Sample characteristics for total sample, European students, and Asian students
Total (n 500)

European (n 417)

Asian (n 83)

Age (years)
Mean
SD
Range

23.9
6.5
1754

24.2
6.9
1754

22.0
2.8
1832

Gender
Male
Female

258
242

(51.6%)
(48.4%)

216
201

(51.8%)
(48.2%)

42
41

(50.6%)
(49.4%)

Coursea
Pharmacy
Mechanical engineering
Accounting and nance
Social policy and administration
Humanities

124
102
110
94
68

(24.9%)
(20.5%)
(22.1%)
(18.9%)
(13.7%)

84
88
85
90
68

(20.2%)
(21.2%)
(20.5%)
(21.7%)
(16.4%)

40
14
25
4
0

(48.2%)
(16.9%)
(30.1%)
(4.9 %)

Year of studyb
One
Two
Three

123
174
112

(42.7%)
(34.9%)
(22.4%)

183
139
94

(44.0%)
(33.4%)
(22.6%)

30
35
18

(36.1%)
(42.2%)
(21.7%)

Experience of taking medication

Current or in the recent past
Neither current nor recent past

248
252

(29.6%)
(50.4%)

214
203

(51.3%)
(48.7%)

34
49

(41.0%)
(59.0%)

a
b

n 498 (two missing data points in the European group).

n 499 (one missing data point in the European group).

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medicines in general are potentially harmful, addictive

substances: respectively M (SD)=2.79 (0.6), M
(SD)=2.62 (0.7), t 2:8; df=498, po0:01: Male and
female participants did not differ signicantly in their
beliefs whether doctors overuse medication, respectively,
M (SD)=3.29 0.8, M (SD)=3.42 (0.8), t 1:85;
df=498, ns, beliefs in the general benets of taking
medicine, respectively, M (SD)=4.0 (0.5), M
(SD)=3.93 (0.6), t 0:63; df=498, ns, or in perceived
sensitivity to medicines, respectively, M (SD)=2.41
(0.6), M (SD)=2.38 (0.7), t 0:53; df=489, ns.

The effect of previous experience of prescribed medication

on medication beliefs
Independent samples t-tests were performed to assess
the effect of previous experience of prescribed medication on medication beliefs (see Table 2). Among all
students (n 500), those who had recent past, or
present experience of taking prescribed medication were
less likely to believe that medicines in general are
harmful, and were more likely to believe in the general

Table 2
Mean (SD) scores for beliefs about medicines for students with
and without current, or recent previous, experience of
prescribed medication
Variable

Yes (n 121)

No (n 379)

Currently taking prescribed medication

General harm
2.56 (0.68)
2.75
General overuse 3.27 (0.8)
3.39
General benet
4.05 (0.52)
3.92
Sensitive soma
2.44 (0.59)
2.39

Variable

Yes (n 239)

2.79
1.50
2.38
0.89

(0.67)
(0.76)
(0.54)
(0.61)

No (n 261)

Previously taken prescribed medication

General harm
2.62 (0.68)
2.79
General overuse 3.31 (0.77)
3.40
General benet
4.03 (0.53)
3.88
Sensitive soma
2.38 (0.61)
2.41

(0.67)
(0.77)
(0.53)
(0.59)

t (df=498)

t (df=498)
2.78
1.32
2.97
0.55

 po0:05;  po0:01:

1311

benets of taking medicines, compared to students who

did not have experience of prescribed medication. There
was no relationship between past and present experience
of taking medication and the belief that doctors overprescribe medication, or perceived sensitivity to the
adverse effects of taking medication.
The effect of cultural background on medication beliefs,
controlling for gender, experience and chosen course
Cultural origin was strongly associated with choice of
course, w2 49:3; df=4, po0:001; and having been
prescribed a medicine in the past, w2 4:4; df=1,
po0:05; and in the present, w2 5:1; df=1, po0:05:
Students who self-reported an Asian origin were
signicantly less likely than those reporting a European
origin to be taking a prescribed medication at the
time of the study (Asian, n 12 (14.5%), European: n
109 (26.1%), w2 df 1 5:1; po0:05), and were
signicantly less likely to have been prescribed medication during the previous year study (Asian n 31
(37.3%), European n 208 (49.9%), w2 df 1 4:4;
po0:05).
To examine the effect of cultural background on
medication beliefs, multiple linear regression was used to
partial out the effects of degree course, experience of
medicines, gender, and age. The adjusted means quoted
in Table 3 refer to the regressed variables. As
hypothesised, cultural background had a clear inuence
on medication beliefs but had no effect on personal
sensitivity to medication. Participants who self-reported
an Asian origin had a more negative view about
medicines in general than those who reported a
European origin. Table 3 shows that the former had
signicantly higher mean scores on the Harm scale,
indicating stronger beliefs in the notion that medicines in
general are harmful, addictive poisons which should not
be taken for long periods of time. They also had
signicantly lower scores on the Benet scale, indicating
less agreement with the idea that medicines in general
have primarily benecial effects upon health. The effect
size (d) for each signicant difference (Cohen, 1969)
suggests that the signicant differences between cultural
groups on beliefs about medicines were non-trivial.

Table 3
Adjusted mean (SD) scores for beliefs about medicinesa for Asian and European undergraduate students
Variable

Asian (n 83)

European (n 417)

t (df=498)

p (two-tailed)

Effect size (d)

General harm
General overuse
General benet
Sensitive soma

2.90
3.47
3.70
2.37

2.54
3.35
3.99
2.27

5.47
1.39
4.97
1.29

o0.001
>0.05
o0.001
>0.05

0.7

0.6

(0.50)
(0.71)
(0.50)
(0.61)

(0.55)
(0.74)
(0.49)
(0.64)

Scores are adjusted for course, age, sex, and experience of medication.

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Discussion
This study quanties the effect of cultural background
on medication beliefs. The ndings suggest that there is
a strong association between cultural background and
beliefs about medicines in general, even when controlling for potentially confounding variables, such as
chosen degree course, experience of taking medicines,
and gender.
Cultural background inuenced students views about
the intrinsic nature of allopathic medicines (potential for
benet and harm) but not their views about whether
medicines are overused by doctors, or their beliefs about
personal sensitivity to the adverse effects of medication.
Students who identied themselves as Asian in origin
were more likely than students with a European origin
to perceive medicines as intrinsically harmful. These
ndings support previous research, which found that
students who identied themselves as Asian were
generally less satised with Western medical care
compared with Western students (Armstrong &
Swartzman, 1999).
Students who reported themselves as Asian in origin
did not perceive themselves to be more sensitive to the
potential adverse effects of medication and were no
more likely to have experienced adverse effects from
medication than their European-origin counterparts.
The effects of culture on beliefs about medicines are very
specic: the differences appear to be in beliefs about the
intrinsic properties of medicinestheir capacity for
harm and benetrather then the way in which they
are prescribed by doctors, or beliefs about personal
sensitivity to adverse effects.
It is relevant that Asian-origin respondents had
signicantly less experience with prescribed medication
than their European-origin counterparts. In the total
student sample, current and previous experience of
taking medication was associated with a more positive
orientation to medicines in general. Similar ndings
have been reported in the literature relating to attitudes
towards benzodiazepine tranquillisers, with users reporting more favourable attitudes towards these drugs
than non-users (Clinthorne, 1986; Mansbridge & Fisher,
1984). However, the clear differences in beliefs about
medicines between the two groups of participants could
not be accounted for by differential experience of taking
medication.
In this study no distinction was made between SouthEast Asian (e.g. Vietnam, Taiwan) and Indian or
Pakistani Asian. The notion of Asian cultural group in
this study thus encompasses a range of separate cultures
and explanatory systems. However, the many different
Asian cultures are associated with explanatory models
and attitudes to illness which are different to Western
biomedicine and which may predispose against it
(Khajuria & Thomas, 1992; Pachter et al., 2002; Uba,

1992). This simple, exploratory study sheds little light on

why students reporting an Asian origin had a more
negative orientation to medication. However, it is
interesting that the traditional Hindu Ayuvedic system
of medicine emphasises herbal remedies (Schechtman &
Gordon, 1994), and the belief that modern pharmaceutical medicine carries the risk of dependence has been
noted in rural communities in Pakistan (Hunte &
Sultana, 1992). It is noteworthy that the majority of
respondents who specied their cultural origin to be
Asian would have been naturalised UK residents. It is
therefore possible that culture-related attitudes have
been passed on from parents or grandparents. Culturerelated differences in medication beliefs may be even
stronger for older members of the community.
Cultural differences in health and treatment beliefs
may have important implications for discussions about
medication between patients and health care practitioners and shared decisions about prescribing. Future
research needs to further explore the issues surrounding
culture and perceptions of treatment, such as the
possible role of cultural background on beliefs about,
and adherence to, medication prescribed for specic
illnesses. In this study we addressed the effects of
cultural background on beliefs about medicines; we did
not investigate the effects of intra-cultural diversity in
beliefs and practices. We recognise that variables such as
acculturation, generation, household composition or
religion may also create as much variability in beliefs
and behaviour. Our preliminary ndings justify further
research to improve our understanding of the impact of
cultural background on preference for medical treatments and how this knowledge might be used to improve
the delivery of care.

Acknowledgements
We would like to thank Cara Davis, Research
Assistant at the Centre for Health Care Research,
University of Brighton, for help in the preparation of
this paper.

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