Attitudes, beliefs and knowledge regarding medical cannabis among healthcare students in Cyprus: A cross-sectional descriptive correlational study

doi:10.21203/rs.3.rs-2225819/v1

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Attitudes, beliefs and knowledge regarding medical cannabis among healthcare students in Cyprus: A cross-sectional descriptive correlational study

https://doi.org/10.21203/rs.3.rs-2225819/v1

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Background: Although the international research-based literature from the last two decades seems to favour medical cannabis (MC) use, there is a lack of evidence concerning healthcare students’ education on MC in Cyprus and across the world. Therefore, this study explored Cyprus healthcare students’ attitudes, beliefs and knowledge regarding MC use. We paid special attention to differences across specific sociodemographic (gender, age and religion status) and educational (level, year and study field) characteristics.

Methods: A descriptive cross-sectional study with internal comparisons was performed from November 2019 to March 2020. All active undergraduate/postgraduate healthcare students (N= 900) studying in public and private universities in Cyprus were eligible to participate (final sample involved N = 819, response rate = 91%). To collect the data, we used the Attitudes, Beliefs and Knowledge towards Medical Cannabis Questionnaire (MCQ) questionnaire. To analyse the data, we employed the Pearson chi-square test for group differences, in addition to assessing descriptive and inferential statistics.

Results: Healthcare students had a generally positive attitude towards MC. Statistically significant differences were observed between genders and in terms of beliefs/risk associated with using MC, with males being likelier to believe that there are significant mental-health benefits associated with using ΜC (x²= 8.06, OR: 0.6, 95% CI: 0.49–0.89) and females being likelier to believe that using MC poses serious physical (x²= 23.00, OR: 1.6, 95% CI: 1.35–2.0, p < .001) and mental-health (x²= 13.06, OR: 1.4, 95% CI: 1.2–1.81) risks. Moreover, healthcare students who received specific (formal) education about MC during their study/training, they were more prepared to answer patient/client questions about ΜC (x²= 17.27, df = 1, p < .001). In addition, the participants who received formal education had more friends (x²=12.69, df=1, p <.001) or family member who uses/has used MC (x²=4.03, df=1, p <.05).

Conclusions: This study provides useful information for curriculum development, educational changes and policy decisions related to cannabis use for medical purposes in Cyprus. The results show that the majority of healthcare students in Cyprus are in favour of MC use. However, the participants reported a dearth of knowledge and recommended additional evidence-based research and education to enhance their knowledge of MC use. Therefore, we recommend the implementation of formal education about MC in healthcare students in Cyprus during their study and clinical training. Furthermore, it is important to add MC-related theoretical and clinical/laboratory courses during studies and clinical practice.

Cyprus

healthcare students

attitudes

beliefs

knowledge

medical cannabis

The term cannabis refers to pharmacologic agents derived from plants belonging to the Cannabis genus [1]. Cannabidiol (CBD), a cannabis compound, is associated with multiple therapeutic benefits [2]. According to international studies conducted over the last two decades, medical cannabis (MC) can be an effective medical treatment [3] to manage the symptoms of chronic pain, anxiety and severe and terminal illnesses and can be used as an alternative treatment [2, 4] for patients who have not responded to conventional medical interventions [5].

Healthcare providers have the authority to recommend non-pharmaceutical CBD products for therapeutic purposes in compliance with state law [6]. As future healthcare professionals, healthcare students will play a significant role in patient care, handling patients who will be legally allowed to use MC. Over the past few years, scholars have observed gaps in healthcare students’ education on MC [5, 7–20] in relation to such issues as MC use, its dosing, delivery methods, misuse, adverse reactions and dependence, among other issues of concern [9–12, 17–20].

However, few studies have been published concerning healthcare students’ knowledge, attitudes and beliefs regarding MC. The vast majority of such studies have been performed in countries where MC has been legalised. Moreover, there is a lack of information on MC use in countries where it is not authorised [16].

In Cyprus, cannabis was legalised for medical use at the beginning of 2019 [2]. The legislation focused on promoting production quality and substance provision [17]. More specifically, it describes licensing procedures, safety measures and good production practices [17]. Further details on this legislation in the Republic of Cyprus have been reported in our previous article [17]. However, the legalisation of cannabis in Cyprus has raised serious individual and public health concerns [17], especially when it comes to healthcare students and healthcare professionals, as they are expected to effectively manage MC-related issues during their clinical practice [17].

Aim

There is a lack of evidence on healthcare students’ attitudes, knowledge and beliefs regarding MC in Cyprus and across the world. Therefore, our study explored Cyprus healthcare students’ attitudes, beliefs and knowledge regarding MC use. We paid special attention to differences across specific sociodemographic (gender, age and religion status) and educational (level, year and study field) characteristics.

Search strategy

A descriptive cross-sectional study with internal comparisons was performed from November 2019 to March 2020. All active undergraduate/postgraduate healthcare students (N = 900) studying in public (n = 350) and private universities (n = 550) in Cyprus were eligible to participate (final sample involved N = 819, response rate = 91%), regardless of age, gender and nationality.

Sample and data collection

The collection of data took place in the students’ classrooms. The final sample involved in the present study was 819 (response rate of 91%) healthcare students. More specifically, the sample consisted of nursing students (n = 253), physiotherapy students (n = 275), speech therapy students (n = 112), and pharmacist and occupational therapist students (n = 179).

Among non-participants (n = 81), 64 were students who were absent on the day of the survey, 13 students were present but refused to participate and 4 students were excluded from analysis due to missing/incomplete data. Participation in the study was voluntary and anonymous to guarantee confidentiality. Questionnaires and consent forms were distributed to healthcare students at the beginning of a lecture. Then, after a short briefing on the study’s aim and procedures, the healthcare students who wished to participate could place their filled-in questionnaires in sealed envelopes in a collection box located outside the lecture room.

Our study was approved by the National Bioethics Committee (Ref. No 2019.01.155) and the research committee of each university involved in the research.

Instruments

The Attitudes, Beliefs and Knowledge towards Medical Cannabis Questionnaire (MCQ) was used for data collection [15, 21]. The questionnaire was developed for cross-national studies on MC education among healthcare professionals and students [13, 14, 17–23]. Thirteen items of the MCQ assessed attitudes and beliefs towards MC/ cannabis (e.g. benefits, risks, effectiveness). 18 items assessed beliefs and knowledge about the effectiveness of MC on medical conditions, while two items assessed beliefs and attitudes regarding MC education. Educational training-related attitudes towards MC were assessed by two items with predefined answers. One item assessed participant’s attitudes towards formal and informal sources of information on MC. A section with demographic (age, gender, origin, family), educational (year of studies, academic status, expertise), personal background (religion, work experience) and cannabis/MC-related behaviors variables was included in the data collection instrument. The MCQ has a high level of internal consistency (Cronbach’s alpha values ranging from 0.767 to 0.831) [15, 21].

The MCQ was translated into Greek by Sokratous et al. [17]. The scale was translated from English into Greek by two independent translators familiar with Cypriot culture. The new Greek version of the instrument was compared with the previous one to generate a single reconciled version, which was then translated back into English. The final version of the instrument was pretested in a pilot study with 100 students to assess its readability and general comprehensibility. The metric properties of the scale were also tested in our previous study [17]. In this previous study, we used the MCQ to examine attitudes, beliefs and knowledge regarding MC among Greek Cypriot nursing students findings showed that the MCQ exhibited a high level of internal consistency (Cronbach’s alpha values ranging from 0.75 to 0.85) [17].

The data collection instrument also included a section with variables on demographic characteristics (age, gender, religion, origin, family status and employment status), educational level (years of study, highest degree completed, field of expertise and years of work experience), and cannabis- and MC-related behaviours.

Statistical analysis

Descriptive statistics were calculated for the sociodemographic characteristics and the MCQ items and were expressed, as appropriate, as frequencies, mean values and standard deviations. Responses to the ordinal MCQ variables were grouped into the following three categories: (a) agree/effective, (b) disagree/ineffective and (c) do not know. Differences between the groups were assessed according to gender, age, religion, family status and years of work experience using the Pearson chi-square test. Multivariable backward stepwise logistic regression analysis after adjusting for sociodemographic characteristics was applied to confirm our results. For data analysis, SPSS (version 25.0) statistical software was used. The significance level was set at α = 0.05.

Sociodemographic characteristics of healthcare students

The final sample population consisted of 819 healthcare students. In total, 560 (68.4%) participants were male, and 259 (31.6%) were female. The mean age of the participants was 21.48 years (SD: 4.07; range: 17–50 years). The vast majority of the healthcare students were of Cypriot origin (n = 564, 68.9%), 168 (20.6%) were Greek and 87 (10.5%) were foreigners. In addition, most participants were Christian Orthodox (n = 744, 90.1%), while the rest reported other religions (n = 75, 9.2%). Concerning employment status, the vast majority of the participants were unemployed (n = 545, 66.4%). Most of the participants were third-year (n = 236, 28.7%) and fourth-year (n = 212, 25.9%) students. Finally, 767 (93.6%) participants were undergraduate students, 27 (3.3%) were master’s students, 15 (1.8%) were MD students, eight were PhD students and two (0.3%) were other postgraduate-level students. Most participants were physiotherapy students (n = 275, 33.7%), while 253 were nursing students (30.8%), 112 were speech-therapy students (13.6%) and 179 (21.9%) were in other study fields, such as occupational therapy and pharmacy, among others (Table 1).

Table 1

Socio-demographic characteristics of healthcare students (n = 819)
Variables	n (%)
Mean age = 21.48 (Range 17–50years / SD = 4.07)
Gender
Female	560(68.4)
Male	259(31.6)
Religious
Christian Orthodox	744(90.8)
Other	75(9.2)
Degree of loyalty
Not religious	102(12.5)
Somewhat religious	327(39.9)
Religious / Very religious	390(47.6)
Mother born
Cyprus	564(68.9)
Greece	168(20.6)
Other	87(10.5)
Family status
Single	369(44.9)
Other	450(54.8)
Current employment status
Full-time / Part-time employed	274(33.5)
Unemployed	545(66.5)
Academic status
Undergraduate degree (BA, BS)	767(93.6)
Master degree (MA, MS)	27(3.3)
MD	15(1.8)
PhD	8(1.0)
Other post graduate level degree	2(0.3)
Year of study
First	173(21.1)
Second	161(19.7)
Third	236(28.7)
Fourth	212(25.9)
More	37(4.6)
Field of study
Nursing	253(30.8)
Physiotherapist	275(33.7)
Speech therapy	112(13.6)
Other (eg. Occupational therapist, pharmacist etc)	179(21.9)

Health-related behaviours linked to cannabis and MC among healthcare students, friends and relatives

The vast majority of the participants (n = 786, 96%) had never used prescribed MC, 20 (2.4%) rarely used prescribed MC for personal purposes and 15 (01.8%) used prescribed MC on a daily or monthly basis for personal purposes. Moreover, 628 participants (76.7%) had never used cannabis for recreational purposes, 122 participants (14.9%) used recreational marijuana rarely, 35 (4.3%) students used recreational marijuana on a monthly basis, 18 (2.2%) students used recreational cannabis weekly and 14 (1.7%) participants used recreational marijuana on a weekly basis. Furthermore, 83 (10.1%) participants had a family member who used or had used MC, while 112 (13.7%) participants had a family member who used or had used recreational marijuana on a daily or weekly basis. In addition, 154 (18.8%) participants had a friend or friends who used or had used MC, while 401 participants (48.9%) had a friend or friends who used or had used recreational marijuana on a daily or weekly basis.

Healthcare students’ attitudes and beliefs regarding cannabis and MC

The vast majority of the participants believed that health and healthcare professionals should have formal training related to MC before recommending it to patients (n = 770, 94%). Moreover, many of the participants (n = 676, 82.5%) believed that educational training in MC use should be integrated into the practice and clinical practice requirements of nurses. At the same time, most participants believed that educational training in MC must be integrated into academic programmes for health and welfare professionals (n = 774, 94.5%). Furthermore, the participants stated that the medical professionals who prescribe MC should have ongoing contact with their patients/clients (n = 794, 96.9%). Moreover, 84.9% (n = 696) of the participants noted that they would recommend MC to their clients, and 8 out of 10 participants supported the idea that physicians should recommend cannabis for medical therapy (n = 675, 82.4%). Most participants supported that marijuana should not be legalised for recreational use (n = 459, 66%), and the vast majority of the participants believed that cannabis can be addictive (n = 730, 89.1%). Furthermore, 585 (71.4%) participants reported that using marijuana poses serious physical-health risks, while 605 (73.7%) participants stated that cannabis poses significant mental-health risks. Finally, 9 out of 10 participants agreed that additional research on MC should be encouraged (n = 768, 93.8%).

Healthcare students’ attitudes and beliefs regarding formal MC education

The majority of the healthcare students (n = 694, 84.7%) reported that they had never received any formal education on MC during study and clinical practise. Additionally, 414 (50.5%) believed that healthcare students should receive formal education about MC laws and regulations during study.

Healthcare students’ sources of information on MC

Concerning of students’ sources of information on MC, the most frequently reported sources of information were medical literature (n = 446, 54.5%), classroom lectures (n = 299, 36.5%) and experiences with patients/clients (n = 289, 35.3%), while, much fewer students stated as the main source of information about MC, the personal use of medicinal cannabis (n = 58, 7.1%) and by cannabis dispensary owners/workers (n = 53, 6.5%)

Attitudes, beliefs and knowledge regarding MC in terms of healthcare students’ sociodemographic characteristics

Gender

Gender had a statistically significant positive effect on the participants’ attitudes and beliefs regarding MC. Female participants (vs. male participants) expressed in strong percentages their positive preference for using classroom lectures as the main resource on MC (76.5% vs. 23.5%, p < .001), while male participants (vs. female participants) preferred the personal use of recreational cannabis (24.7% vs. 10.9%, p < .001) (Table 2). Moreover, compared to female participants, male participants more frequently reported having a family member (13.1% vs. 8.8%, p = .039) and a friend(s) (28.2% vs. 14.3%, p < .001) who used or had used MC. Furthermore, male participants (vs. female participants) more frequently reported having a friend(s) who used or had used recreational cannabis daily or weekly (65.6% vs. 41.2%, p < .001). Moreover, male participants (vs. female participants) expressed in strong percentages that they would recommend MC to their patients (88.0% vs. 83.2%, p = .046); they also believed that physicians should recommend cannabis for medical therapy (87.6% vs. 80.2%, p = .005) and that cannabis should be legalised for recreational use (56.8% vs. 38.4%, p < .001), while more female participants (vs. male participants) believed that using cannabis can be addictive (91.5% vs. 85.9%, p = .02). Furthermore, male students believed that they were prepared to answer MC-related questions by patients and clients, while female students believed that students should receive formal education on MC as well as MC laws and regulations (p < .05). Male participants (vs. female participants) reported more frequently that they had used prescribed MC or recreational cannabis for personal purposes (56.8% vs. 38.4%, p < .05) (Table 3).

Table 2

Association between source of information about medicinal cannabis individual and academic characteristics
	Classroom lectures			Personal use of recreational cannabis				Personal use of medical cannabis			Cannabis dispensary owners/workers		Medical literature			Friends / Family use of recreational cannabis
Which sources of information do you use?	%(n)	P		%(n)			P	%(n)	P		%(n)	P	%(n)		P	%(n)		P
Gender		< 0.01					< 0.01	NSS				0.01	NSS			NSS
Female	76.5(228)			10.9(61)							5.0(28)
Male	23.5(70)			24.7(64)							9.7(25)
Age			0.019	NSS				NSS					NSS			NSS
18–20	37.1(144)										5.7(22)	0.014
21–22	41.3(104)										4.4(11)
> 23	28.2(51)										11.0(20)
Religion		0.041			< 0.01			NSS				< 0.01	NSS				< 0.001
Christian orthodox	37.4(279)			13.0(97)							5.7(41)					15.8(118)
Other	26.7(20)			37.7(125)							23.1(12)					29.3(22)
Graduate status		0.048		NSS				NSS			NSS		NSS				0.01
Undergraduate	37.4(285)															18(137)
Other	26.9(14)															5.2(3)
Field of study	NSS					< 0.01				0.022	NSS		NSS			NSS
Nursing				13 (33)				8.3(21)
Physiotherapist				22(61)				9.7(27)
Speech therapy				3.6(4)				2.7(3)
Other				15.1(27)				3.9(7)
Year of study	NSS					0.015		NSS			NSS			0.017		NSS
First				11.6(20)									48.3(83)
Second				13.8(22)									13.8(73)
Third				17(39)									17(39)
Fourth				19.5(41)									59.5(123)
Fifth or more				0									43.2(16)
NNS: Non statistically significant

Table 2

Association between source of information about medicinal cannabis and individual and academic characteristics (Continued)
	University policy		Other sources			Clinical practice setting			Other students			Experiences with patients/clients
Which sources of information do you use?	%(n)	P	%(n)		P	%(n)		P	%(n)		P	%(n)	P
Religion	NSS			0.046		NSS			NSS			NSS
Christian orthodox			13.3(99)
Other			21.3(16)
Graduate status	NSS		NSS				0.037			0.006		NSS
Undergraduate						20.1(153)			23.1(175)
Other						8.6(5)			5.2(3)
Field of study		0.003	NSS				< 0.001				0.019		< 0.001
Nursing	10.7(27)					32(81)			26.6(67)			46.2(117)
Physiotherapist	4(11)					11.9(33)			24.5(68)			31(86)
Speech therapy	3.6(4)					20.5(21)			12.7(14)			26.8(30)
Other	15.1(27)					11.7(21)			16.3(29)			31.3(56)
NNS: Non statistically significant

Regarding gender positions on MC benefits, both males and females believed that MC provides significant benefits to physical and mental health. Regarding physical health, female participants expressed a slightly stronger agreement than male participants (of approximately one percentage point), but the difference was not statistically significant (x² = 1.121, OR: 0.9, 95% CI: 0.6–1.41, p = .728). Concerning mental health benefits, male compared to female participants, more male participants agreed that there are significant benefits to using medical marijuana (x² = 8.06, OR: 0.6, 95% CI: 0.49–0.89, p < .05). At the same time, both genders believed that marijuana use can pose serious risks to physical and mental health, with female participants agreeing more frequently than males in both cases (physical health: x² = 23.0, OR: 1.6, 95% CI: 1.35–2.0, p < .001; mental health: x² = 13.06, OR: 1.44, 95% CI: 1.2–1.81, p < .001) (Table 4).

Table 3. Socio‑demographic characteristics about MC attitudes, beliefs, and knowledge of healthcare students

		Gender
		Female %(n)			Male %(n)		Total			P value
++Do you have a family member who uses/had used medical cannabis?		8.8(49)			13.1(34)		10.1(83)			0.039
++Do you have friend(s) who uses/had used medical cannabis?		14.3(80)			28.2(73)		18.3(150)			0.000
++Do you have friend(s) who uses/had used recreational cannabis daily or weekly?		41.2(230)			65.6(170)		48.8(400)			0.000
+Would you recommend medical cannabis for your patients?		83.2(466)			88.0(228)		84.5(692)			0.046
+Do you believe that physicians should recommend cannabis as medical therapy?		80.2(449)			87.6(226)		82.4(675)			0.005
+Do you believe that there are significant mental health benefits using medical marijuana?		76.3(427)			84.9(220)		79(647)			0.003
+Do you believe that cannabis should be legalized for recreational use?		38.4(213)			56.8(147)		44(360)			0.000
+Do you believe that cannabis can be addictive?		91.1(510)			85.9(220)		89.1 (730)			0.020
			Age
			18-20 years old %(n)			21-22 years old %(n)		>23 years old %(n)			P value
++Do you have a family member who uses/had used recreational cannabis daily or weekly?			11.3(44)			10.7(27)		23.0(41)			0.000
++Do you have a friend(s) who uses/had used medical cannabis?			12.6(49)			19.4(49)		31.5(56)			0.000
++Do you have a friend(s) who uses/had used recreational cannabis daily or weekly?			45.1(175)			46.0(116)		61.8(110)			0.001
+Do you believe that cannabis can poses physical health risks?			77.6(301)			65.1(164)		67.6(121)			0.001
+Do you believe that cannabis can poses mental health risks?			79.9(310)			67.9(171)		69.3(124)			0.001
*Would you recommend medical cannabis for your patients?			37.6(41)			42.2(46)		20.2(22)			0.002
*I am prepared to answer patient/client questions about medical marijuana			46(120)			29.5(77)		24.5(64)			0.025
+ The table presents the n and % of participants who answered that they ‘agree’ ++ The table presents the n and % of participants who answered ‘yes’ *Τhe participants who had received formal education about Medical Cannabis
Table 3. Socio‑demographic characteristics about MC attitudes, beliefs, and knowledge of healthcare students(continued)
	Religion								p value
	Christian orthodox			Other
+Do you believe that marijuana should be legalized for recreational use?	42.9(319)			91.1(41)					0.036
+Do you believe that marijuana can be addictive?	90.3(672)			77.3(58)					0.016
+Do you believe that using marijuana can poses serious physical health risks?	73.3(546)			54.1(40)					0.001
+Do you believe that using marijuana can poses serious mental health risks?	74.8(557)			64(48)					0.046
++Do you have a family member who uses/has used recreational cannabis daily or weekly?	12.8(95)			23.0(17)					0.016
++Do you have a friend(s) who uses/has used recreational cannabis daily or weekly?	46.2(344)			77.0(57)					0.000
++Would you recommend medical cannabis for your patients?	83.9(626)			93.3(70)					0.017
+ The table presents the n and % of participants who answered that they ‘agree’ ++ The table presents the n and % of participants who answered ‘yes’

Table 4: Differences between gender and beliefs about benefits/risk using MC


			Physical health					Mental health
There are significant benefits using medical marijuana	Total		X²	OR (95%CI)	P	Total		X²	OR (95%CI)	P
	n	%				n	%

Male			1.121	0.9(0.60-1.41)	0.728			8.06	0.6(0.49-0.89)	0.005
Disagree	36	13.9				39	15.1
Agree	223	86.1				220	84.9
Female
Disagree	83	14.8				133	13.8
Agree	477	85.2				427	76.2
Using marijuana poses serious risks
Using marijuana poses serious risks
Male			23.00	1.6(1.35-2.0)	<0.001			13.06	1.4(1.20-1.81)	<0.001
Disagree	102	39.4				88	34
Agree	157	60.6				171	66
Female
Disagree	130	23.3				124	22.1
Agree	430	76.8				436	77.9

Age

In terms of age, the participants were divided into three age groups. Τhe first group was between 18–20 years old, second was 21–22 years old and the third group was over 23 years old. Almost the half of the participants of the second group aged 21–22 years old, reported that their main information source about MC was classroom lectures (41.3%) compared to the others 2 groups age (vs. 37.1% and 28.5%, p = .019 first and third, respectively). On the contrary, the third group age over 23 years old declared that their main source information was cannabis dispensary owners and workers compared to students who were between the ages of 18–20 (first group) and 21–22(second group), 11.0% vs. 5.7% and 4.4%, p = .014, respectively. (Table 2).

Furthermore, the oldest age group (those over 23 years old) reported doubles percentages scores of having a family member who used or had used cannabis for recreational reasons daily of weekly (23.0%) compared with the other group of age [vs. (11.3%, 18–20 years old) and (10.7%, 21–22 years old) p < .001]. The same group reported higher percentages scores of having more friend(s) who used or had used cannabis for recreational reasons daily of weekly (61.8%) compared with the other two age groups [vs. (45.1%, 18–20 years old) and (46%, 21–22 years old) p < .001]. Additionally, the students over 23 years old had a friend(s) who used or had used MC (31.5%) reported doubles percentages scores compared with the other two age groups [vs. (12.6%,18-20years old) and (19.4%, 21–22 years old) p < .001]. (Table 3).

Moreover, statistically significant differences were observed in whether they believed that the use of MC could poses health risk. Specifically, the ages group between18-20 years reported the highest scores (77.6%) compared with the other ages years groups that MC poses physical health risk (vs 65.1%, 21–22 years old, and 76.6%, ≥ 23 years old)] or mental health risk [79.9% vs. (67.9%, 21–22 years old and 69.3%, ≥ 23 years old, p = .001). (Table 3).

Religious status

In terms of religion, Christian Orthodox participants (vs non-Christian Orthodox participants) used classroom lectures as their main source of information (37.4% vs. 26.7%, p = .041), while participants who were non-Christian Orthodox (nondenominational /atheist and Muslim) (vs. Cristian Orthodox) reported relying on personal experience in using MC for recreational cannabis as their main source of information (37.7% vs. 13%, p < .05) (Table 2). Moreover, non-Christian Orthodox participants (vs Christian Orthodox participants) expressed a positive position on cannabis legalisation for recreational use (91.1% vs. 42.9%, p = .036), while 9 out of 10 Christian Orthodox participants (vs non-Christian Orthodox participants) claimed that cannabis can be addictive (90.3% vs. 77.3%, p = .001). Of the Christian Orthodox participants, 73.3% reported that cannabis can pose serious physical-health risks and 74.8% reported that cannabis can pose serious mental-health risks, while non-Christian Orthodox participants exhibited lower percentages (p < .005). Non-Christian Orthodox participants (vs Christian Orthodox participants) more frequently reported having a family member (p = .016) or a friend(s) (p < .000) who used or had used recreational cannabis daily or weekly. Finally, non-Christian Orthodox participants agreed that they would recommend MC to their patients (p = .017) (Table 3).

Furthermore, over 80% of the nondenominational and atheist participants considered MC use to be acceptable for specific medical conditions, such as arthritis, cachexia, nausea and / or vomiting due to cancer treatment, chronic pain, fibromyalgia, glaucoma, inflammatory bowel disease, insomnia / sleeping disorders, multiple sclerosis, Parkinson’s disease, persistent muscle spasm, epilepsy and terminal illness

Educational characteristics

Level of study

Regarding educational characteristics, statistically significant differences were observed between undergraduate students (vs postgraduate), who reported classroom lectures as their main information source on MC (37.4%, vs 26.9%, p < .05), compares with postgraduates students which were the main source of information MC the cannabis dispensary owners/workers (23.1% vs 5.2%, p < .05). (Table 2).

Furthermore, postgraduate (vs undergraduate) students believed that there are significant mental-health benefits associated with MC use (94.8% vs 84.8%, p < .05), while postgraduate (vs undergraduate) stated that they would recommend MC to their patients (93.1% vs 84.1%, p <. p < .05). Finally, undergraduate students (vs. postgraduate) believed that using cannabis can poses serious physical-health risks (71.4% vs. 60.3%, p = .038) (Table 5, Part A).

Table 5: Academic characteristics about MC attitudes, beliefs, and knowledge of healthcare students

Part (a)		Graduate status
		Undergraduate %(n)			Other %(n)		P Value
+Do you believe that there are significant mental health benefits using medical marijuana?		84.8(647)			94.8(55)		0.033
+Do you believe that using marijuana can poses serious physical health risks?		72.4(551)			60.3(35)		0.038
++Would you recommend medical cannabis for your patients?		84.1(642)			93.1(54)		0.042
Part (b)	Field of study
	Nursing %(n)		Physiotherapist %(n)	Speech therapy %(n)		Other %(n)		P Value
+Do you believe that there are significant mental health benefits using medical marijuana?	76.7(194)		85.6(237)	76.8(86)		73.2(131)		0.008
+Do you believe that marijuana should be legalized for recreational use?	43.7(110)		55.6(153)	32.7(36)		34.1(61)		0.000
+Do you believe that marijuana can be addictive?	92.4(232)		82.6(228)	97.3(109)		91.1(163)		0.000
+Do you believe that using marijuana can poses serious physical health risks?	80.6(204)		60.0(165)	83.0(93)		69.3(124)		0.000
+Do you believe that using marijuana can poses serious mental health risks?	81.0(205)		64.4(177)	86.6(97)		70.4(126)		0.000
++Do you have friend(s) who uses/had used medical cannabis?	13.8(35)		25.3(70)	11.6(13)		20.5(36)		0.001
++Do you have friend(s) who uses/had used recreational cannabis daily or weekly?	41.9(106)		58.8(163)	34.8(39)		52.8(93)		0.000
+ The table presents the n and % of participants who answered that they ‘agree’ ++ The table presents the n and % of participants who answered ‘yes’

Part (c)	Year of study
	First %(n)	Second %(n)	Third %(n)	Fourth %(n)	Fifth or more %(n)	P Value
+Do you believe that there are significant mental health benefits using medical cannabis?	66.9(115)	81.3(130)	83.8(192)	81.9(172)	73.0(27)	0.000
++Do you have friends who uses/ has used medical cannabis?	11.0(19)	17.5(28)	10.5(47)	21.5(45)	29.7(11)	0.023
+Would you recommend medical cannabis for your patients?	76.7(132)	86.9(139)	88.2(202)	86.7(182)	78.4(29)	0.012
+Do you believe that physicians should recommend cannabis as medical therapy?	70.3(121)	88.8(142)	85.5(195)	84.8(178)	78.4(29)	0.000
+Do you believe that educational training for medical cannabis must be integrated into the academic programs of the health and welfare professionals?	88.4(152)	95.6(153)	87.3(200)	93.8(197)	81.1(30)	0.005
+Do you believe that marijuana should be legalized for recreational use?	30.6(52)	44.3(70)	55.0(126)	42.6(89)	45.9(17)	0.000
+Do you believe that using marijuana can poses serious mental health risks?	80.8(139)	76.7(122)	76.3(174)	65.2(132)	70.3(26)	0.007

+ The table presents the n and % of participants who answered that they ‘agree’

++ The table presents the n and % of participants who answered ‘yes’

Study field

Furthermore, nursing students reported that the main information sources on MC were clinical practice (32%) and experiences with patients/clients compared (46.2%) with other departments faculties’ healthcare students and this was statistically significant (p < .05). Meanwhile, physiotherapy students (9.7%) used their personal experiences with MC or recreational cannabis (22%) as their main source of information (p < .05) (Table 2). Furthermore, compared with others departments faculties’ healthcare students, physiotherapy students believed more strongly that there are significant mental-health benefits to using MC (85.6%, p = .008); they also supported the idea that cannabis should be legalised for recreational use (55.6%, p < .001). On the other hand, almost all speech therapy students believed more than the others healthcare students that cannabis can be addictive (97.3%, p < .001) and that cannabis use can pose serious physical- or mental-health risks (86.6%, p < .001). Physiotherapy students reported the highest scores compared with students study in other faculties that having a friend(s) who used or had used MC or recreational cannabis daily or weekly (58.8%, p < .001), (Table 5, Part B).

Year of study

Concerning the year of study, third-year students reported that their main information source was medical literature (59.5%, p < .05), while fourth-year students reported that their main information source was personal experience with recreational cannabis (19.5%, p < .05) (Table 2). Furthermore, fourth-year students believed that there are significant mental-health benefits to using MC (81.9%, p < .001). At the same time, students in their fifth and upper years reported having a friend(s) who used or had used MC (29.7%, p = .023), they also claimed that they would recommend MC to their patients (78.4%, p = .012). Third-year students stated that cannabis should be legalised for recreational use (55%, p < .001). Second-year students believed that physicians should recommend cannabis for medical therapy (88.8%, p < .001) and that educational training in MC must be integrated into the academic programmes of health and welfare professionals (95.6%, p = .005). Thus, first-year students believed that using cannabis can pose serious mental-health risks (80.8%, p = .007). These data are presented in Table 5.

Differences between formal education about MC and health care students' individual, academic characteristics, attitudes, beliefs and knowledge

With regard of healthcare students (n = 819) who had received any formal education about MC, only a small number 15.2% (n = 126) of the participants received formal education about MC in their curricula/clinical settings. In terms of students’ individual characteristics, male participants had received more formal education on MC (n = 53, 20.3%) than female participants (n = 74, 13.2%) (x² = 6.93, df = 1, p = .008).

Similarly, a statistically significant difference was also observed among 21–22 years old (n = 55, 21.8%), who reported the highest percentage scores of receiving formal education in their curricula/clinical settings compared to participants aged 18–22 years (n = 11.8, 46%) and those aged over 23 years (n = 25, 13.9%) (x² = 12.43, df = 2, p = .002).

Moreover, the healthcare students who had friend(s) (24.7%) or family member (22.9%) who uses/has used MC had received more formal education compared with those (13.2%, x² = 12.69, df = 1, p < .001) who had no friends friend(s) or family member (14.5%) who uses/has used MC (x² = 4.03, df = 1, p < .005).

Concerning the educational characteristics, the fourth-year study students reported that they had received formal education than students in other years (n = 44, 19.3%) (x² = 19.32, df = 4, p = .001). Physiotherapy students reported higher percentages of receiving formal education in their curricula/clinical settings than nursing students (n = 39, 15.5%), speech therapy students (n = 3, 1.8%) and those studying in others faculties (n = 40, 22.5%) (x² = 22.94, df = 3, p < .001).

Furthermore, students with 1–5 years of work experience had received more formal education on MC (n = 49, 23.9%) compared with other students with more than five years of experience (n = 5, 16.1%) or those without any experience (n = 71, 12.2%) (x² = 15.98, df = 2, p < .001).

Moreover, 258 (31.5%) participants considered themselves academically prepared to answer patient/client questions on MC; from them 60 (23.3%) students had received formal education related on MC, compared with those who were not prepared to answer patient/client questions on MC. Finally, only 20 (9%) participants had received formal education related on MC (x² = 17.27, df = 3, p < .001). (Table 6).

Table 6: Differences between formal education about MC and health care students' individual, academic characteristics, attitudes, beliefs and knowledge


Received any formal education about medical marijuana	Yes		No		Χ²	DF	P
	Total		Total
	N	%	N	%

Gender					6.93	1	0.008
Male	53	20.3	207	79.7
Female	73	13.2	486	86.8
Age					12.43	2	0.002
18-20	46	11.8	341	88.2
21-22	55	21.8	197	78.2
<23	25	13.9	155	86.1
Religious					0.03	1	0.860
Other	12	16	63	84
Christian Orthodox	114	15.4	629	83.4
Which year are you studying?					19.32	4	0.001
1^st year	10	5.8	163	94.2
2^ed year	25	16.1	135	83.9
3^th year	41	17.8	195	82.2
4^th year	44	19.3	168	78.7
5^th year and more	6	16.2	31	83.8
What is your field of study					22.94	3	<0.001
Nursing	39	15.5	213	84.5
Physiotherapists	44	15.9	233	84.1
Speech therapy	3	2.7	109	97.3
Other	40	22.5	138	77.5
Past years of work experience					15.98	2	<0.001
no previous experience	71	12.2	512	87.8
1-5 years	49	23.9	156	76.1
>5 years	6	19.3	25	80.7
I am prepared to answer patient/client questions about medical marijuana					17.27	1	<0.001
Agree	60	23.3	198	76.7
Disagree	20	9	201	91
Neutral	45	13.4	290	86.6
Ι would recommend MC for my patients					0.68	1	0.421
Agree	109	15.7	586	84.3
Disagree	16	12.9	108	87.1
Physicians should recommend marijuana as a medical therapy					0.44	1	0.507
Agree	19	13.4	569	84.4
Disagree	105	15.6	123	86.6

Table 6: Differences between formal education about MC and health care students' individual, academic characteristics, attitudes, beliefs and knowledge (continued)

Received any formal education about medical marijuana	Yes		No		Χ²	DF	P
	Total		Total
	N	%	N	%

There are significant physical health benefits using medical marijuana					1.25	1	0.262
No	14	11.6	104	88.1
Yes	111	15.9	588	84.1
There are significant mental health benefits using medical marijuana					0.02	1	0.926
No	26	15.2	145	84.8
Yes	99	15.3	547	84.7
Educational training for medical marijuana must be integrated into the academic programs of the health and welfare professions.					1.40	1	0.235
No	15	20	60	80
Yes	110	18.8	632	85.2
Educational training in the use of medical marijuana should be integrated into the practice / clinical practice requirements of students in health and social care professions					0.16	1	0.745
No	23	16.1	120	83.9
Yes	101	15.0	572	85.0
Health and welfare professionals should have formal training on the medical marijuana before recommending it to someone who is being treated					0.95	1	0.329
No	10	20	40	80
Yes	114	14.9	652	85.1
Marijuana should be legalized					0.10	1	0.745
No	62	13.7	391	86.3
Yes	62	17.3	297	82.7
Do you have a family member who uses/has used recreational marijuana daily or weekly?					1.25	1	0.263
No	104	14.8	599	85.2
Yes	21	18.9	90	81.1
Do you have a family member who uses/has used medical marijuana?					4.03	1	0.045
No	106	14.5	625	85.5
Yes	19	22.9	64	77.1
Do you have a friend who uses/has used medical marijuana					12.69	1	<0.001
No	87	13.2	573	86.8
Yes	38	24.7	116	75.3
Do you have a friend who uses/has used medical marijuana for recreational marijuana daily or weekly?					0.79	1	0.374
No	59	14.3	355	85.7
Yes	66	16.5	334	83.5
Marijuana can be addictive					0.37	1	0.543
No	15	82.6	71	82.6
Yes	109	15.1	620	85

To the best of our knowledge, the present study is the first to describe university healthcare students’ attitudes, beliefs and knowledge regarding MC in Cyprus. Given the relatively high response rate and census sampling, it is possible to generalise our findings to the entire healthcare student population in Cyprus.

In our study, we examined specific sociodemographic characteristics of the participants (gender, age and religion status), as well as and specific educational characteristic (level, year and field of study) compared with their attitudes, beliefs and knowledge regarding MC use. Therefore, the study contributes more evidence to the existing literature. Our results showed that gender had a statistically significant positive effect on the participants’ attitudes and beliefs regarding MC. More specifically, our results revealed that male participants used cannabis for recreational purposes more frequently while being more concerned about the mental-health benefits of using MC than female participants. This finding may highlight the link between the personal experience of cannabis use and its perceived benefits to mental health during student life [20]. In terms of the link between gender and MC-related attitudes and knowledge, previous studies have shown contradictory results [5, 24]. Evidence from international research supports a higher frequency of cannabis use among male rather than female healthcare students [2, 6, 16, 17]. These results have been associated with sociocultural explanations, including factors related to gender roles, and with biological and psychological patterns [17]. Sokratous et al. [17] found that females have more knowledge of MC benefits and more positive attitudes towards the need for formal MC-related education. According to previous studies, male students use cannabis more frequently than female students, which may be related to the fact that male participants’ knowledge and beliefs are based on their personal experiences [17, 18, 25]. Our results showed that, at the same time, both genders believe that marijuana use can pose and mental serious risks to physical health; while females presented higher percentages on the scale than males in mental and physical serious risks on health. In the Sokratous et al. [17, 18], in similar researches studies on nursing population in Cyprus, supported that the above may be related to the fact that females achieve higher grades more frequently than males, while females are more engaged with the study curricula and consequently, tend to express their opinions more freely about improvements in the curriculum [18].

Ιn addition, the results of our study concerning attitudes, beliefs and knowledge regarding MC in terms of healthcare students’ age showed statistical significance. Almost the half of the participants of the group aged 21–22 years old reported that their main information source about MC was classroom lectures or clinical practice compared to the others groups of aged. On the contrary, the third group age over 23 years old declared that their main source information was cannabis dispensary owners and workers compared to students who were between the ages of 18–20 (first group) and 21–22(second group). The above result may be related to the new curriculum development, educational changes and policy decisions related to cannabis use for medical purposes in Cyprus in the latest 2 years.

Furthermore, in our results the oldest age group (those over 23 years old) students reported doubles percentages scores of having a family member and friend(s) who used or had used cannabis for recreational reasons daily of weekly compared with the other group of age. Additionally, the students over 23 years old had a friend(s) who used or had used MC reported doubles percentages scores compared with the other two age groups. The above may explain the fact that third group age students over 23 years old declared that their main source information was cannabis dispensary owners and workers.

Our results showed that religion marked a statistically significant difference, with the non-Christian Orthodox participants being likelier than those of other religions to recommend MC to their patients. Ιn the literature, religiosity refers to participation in an organised religion and has been identified as a factor linked to substance use prevention and treatment [15]. However, little attention has been paid to the association between religiosity and university healthcare students and their MC knowledge, attitudes and beliefs [24].

Furthermore, in our study the vast majority of the participants support MC use. The main findings of our study showed that Cypriot healthcare students reported possessing moderate knowledge regarding the risks and benefits of patients’ MC use. The participants considered themselves academically prepared to answer patient/client questions on MC; from them 60 (23.3%) students had received formal education related on MC, compared with those who were not prepared to answer patient/client questions on MC.

Although that, the results showed that, a number of participants considered themselves academically prepared to answer patient/client questions on MC and reported satisfactory confidence when discussing MC benefits for specific disorders with their patients. Specially, a high percentage number of participants believed MC use was considered acceptable for the patients with Alzheimer’s disease, Arthritis, Cachexia, nausea and / or vomiting due to cancer treatment, chronic pain, eating disorders, fibromyalgia, glaucoma, insomnia or other sleeping disorders, mental health disorders, multiple sclerosis, nausea, Parkinson’s disease, persistent muscle spasm, epilepsy and terminal illness. At the same time, they didn’t believe that MC can be useful for AIDS of HIV. Previous studies in similar population in Cyprus, are in contract with these results [17, 18]. More specific, previous studies in nursing students [17] and in nurses and midwifes [18] have shown lack of knowledge on MC benefits and less confidence on discussion about MC. Furthermore, in this study, we observe a strong association between participants who would recommend MC to their patients assumed that physicians would recommend MC as a medical therapy.

Previous research evidences from the literature have shown that health practitioners have insufficient theoretical and clinical knowledge of MC use and its benefits [5, 26]. At the same time, although scientific evidence remains scarce, participants acknowledged that the therapeutic potential of cannabis may be explained by the fact that they personally know people who use cannabis and thus may be aware of such positive effects [18]. These findings highlight the significant need for curricula designed to inform students about MC use in order for students to be adequately prepared to work with patients who may use this substance [27]. The participants who believed that there are significant physical-health benefits to using MC and that educational training in the use of MC should be integrated into the practice and clinical practice requirements of students in health and social care were likelier to recommend MC to their patients.

Furthermore, in our study, the healthcare students who reported that health and welfare professionals should have formal training in MC before recommending it to someone who is being treated were likelier to recommend MC to their patients. These results supported by the other research evidence from national and international literature, which highlighted the necessity of providing MC formal education among healthcare professionals [10, 28].

Additionally, in terms of departments’ faculties the healthcare students in the physiotherapy departments most frequently agreed with the notion of MC benefits in their clinical practice. These results may be explained by the fact that in physiotherapy departments, MC-related courses are offered more often compared to other study fields (e.g. nursing) during healthcare studies in the public and private universities of Cyprus [5, 17]. It could be hypothesised that students may be more willing to express their attitudes towards cannabis when relevant topics are openly discussed during classes. These findings highlight the need for curricula designed to inform students about the use of cannabis in order for students to be adequately prepared to work with patients who may use MC.

Ιn conclusion, this study provides useful information for curriculum development, educational changes and policy decisions related to cannabis use for medical purposes in Cyprus. The results show that the majority of healthcare students in Cyprus are in favour of MC use. However, the participants reported a dearth of knowledge and recommended additional evidence-based research and education to enhance their knowledge of MC use. Therefore, we recommend the implementation of formal education about MC in healthcare students in Cyprus during their study and clinical training. Furthermore, it is important to add MC-related theoretical and clinical/laboratory courses during studies and clinical practice.

However, this finding needs to be investigated further. Additional limitations of our study include a lack of triangulation with qualitative data and a possible underestimation of the actual frequency of positive attitudes towards MC. More importantly, the cross-sectional nature of the study does not permit any inference regarding the direction of the observed association between MC use and healthcare students’ attitudes, beliefs and knowledge. Nevertheless, in our study, the large sample and the use of an appropriate and robust instrument allowed for a more accurate estimation of healthcare students’ attitudes, beliefs and knowledge regarding MC use.

M C

Medical Cannabis

MCQ

Medical Cannabis Questionnaire

CBD

Cannabidiol

Ethics approval and consent to participate

Our study was approved by the National Bioethics Committee (Ref. No 2019.01.155). Additionally, the study was approved by universities research committees. All methods were carried out in accordance with the relevant guidelines and regulations of the aforementioned committees. The participants were informed about the purpose of the study and the data collection procedures prior to providing their consent. All participants agreed to participate and informed consent was obtained from all subjects and/or their legal guardians. Participation in the study was voluntary and anonymous in order to guarantee confidentiality. The collection of data took place in the students’ classrooms. Questionnaires and consent forms were distributed to healthcare students at the beginning of a lecture. Then, after a short briefing on the study’s aim and procedures, the healthcare students who wished to participate could place their filled-in questionnaires in sealed envelopes in a collection box located outside the lecture room.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analyzed during the present study are not publicly available because the authors are currently working on them in order to prepare the final version of this manuscript. However, they are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The present study was partially funded by the Cyprus University of Technology (internal funding code=319).

Authors’ contributions

The present study was jointly designed by all of the authors. Each author made substantial contributions to the conception, design, analysis, and interpretation of the data; was involved in drafting and/or critically revising the manuscript for important intellectual content; and gave final approval for the version to be published.

Acknowledgements

We would like to thank all of the healthcare students who participated in this study. We would also like to acknowledge the field workers who contributed to the collection of the data.

Research involving human embryos, gametes, and stem cells

Not applicable. (The present study involved data collection but did not involve experiments that used human embryos or gametes, human

Embryonic stem cells or related materials, or clinical applications of stem cells.

The present study strictly followed the rules and guidelines of the aforementioned committees).

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No competing interests reported.

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Attitudes, beliefs and knowledge regarding medical cannabis among healthcare students in Cyprus: A cross-sectional descriptive correlational study

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Abstract

Background

Aim

Methods

Search strategy

Sample and data collection

Instruments

Statistical analysis

Results

Sociodemographic characteristics of healthcare students

Health-related behaviours linked to cannabis and MC among healthcare students, friends and relatives

Healthcare students’ attitudes and beliefs regarding cannabis and MC

Healthcare students’ attitudes and beliefs regarding formal MC education

Healthcare students’ sources of information on MC

Attitudes, beliefs and knowledge regarding MC in terms of healthcare students’ sociodemographic characteristics

Gender

Age

Religious status

Educational characteristics

Level of study

Study field

Year of study

Discussion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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