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The effectiveness of teaching complementary and alternative medicine based on the components of theory of planned behavior on nutrition students: multicenter research study

Mohammad reza mahmoodi, sara shafian, manizhe shaban alinaghizade.

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Received 2022 Dec 11; Accepted 2023 Apr 7; Collection date 2023.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Safe and beneficial use of complementary and alternative medicine (CAM) modalities results from integrating CAM education into curricula and increasing CAM knowledge. We sought how much teaching CAM procedures in a virtual environment can influence the components of the theory of planned behavior (TPB), including knowledge, attitude, behavioral intention, and behavior of nutrition students.

This cross-sectional descriptive-analytic study was conducted on 162 undergraduate nutrition students were selected through convenience sampling based on inclusion criteria in 2021–2022. Data were collected through a validated researcher-made CAM questionnaire that was designed based on TPB questionnaire that consisted of four constructs (knowledge, attitude, behavioral intention, and behavior). The content validity index and content validity ratio of the questionnaire were evaluated.

Our results revealed that students who significantly scored the highest scores in attitude, behavioral intention, and behavior constructs were the students who claimed that “teaching two credits of CAM for nutrition students is not enough” ( p . value =  < 0.001, < 0.001, and 0.005, respectively). In addition, these students used treatment methods of CAM for themselves, suggested treatment methods of CAM to others, and followed the recommendations of the CAM specialists (for three pairwise comparisons: p . value =  < 0.001, < 0.001, and < 0.001, respectively). The attitude could predict 70% of behavioral intention. However, attitude and behavioral intention could predict 90% of behavior.

Attitude was the most critical determinant influencing behavioral intention and behavior. CAM teaching using evidence-based CAM-ITM principles with a succinct, concerted, and collaborative curriculum, integration of CAM into continuing education, and integration of educational CAM programs continuously for several years into the academic curriculum in the actual setting influence the success of the educational CAM program.

Keywords: Complementary and alternative medicine, Effectiveness of teaching, Theory of planned behavior

Introduction

Complementary and alternative medicine (CAM) modalities are entirely favorite in Iran, among which Iranian Traditional Medicine (ITM) and Acupuncture are the most used. As an eastern country, Iran needs to communicate with East Asian countries to institute academic relations on ITM [ 1 ]. The results of a survey revealed that CAM is the most widely used in three East Asian countries such as Japan (76%), South Korea (75%), and Malaysia (56%) [ 2 ].

The CAM integration in conventional healthcare services enhances the capacity of holistic services and results in filling therapeutic gaps in available healthcare procedures, treating the patient, and increasing healthcare choices [ 3 ]. Regarding the extensive use of CAM, practitioners and health system managers should pay more attention to CAM modalities. Thereby, the supervision and training of traditional practitioners and nutritionists are critical [ 4 ]. Regulation of academic standards and the development of consistent curricula for CAM will help students proficiently provide safe and efficient CAM therapies [ 5 ]. Safe and beneficial use of CAM modalities results from integrating CAM education practices into curricula and increasing knowledge of CAM modalities [ 6 ]. Integration of CAM training into the medical curriculum remarkably influences the attitude of medical students toward CAM. The capability of communicating with patients about safe and confident CAM use is the primary motivation of medical students in CAM learning [ 7 ]. The knowledge of the students regarding ITM and CAM was low. The student’s attitude toward the integration of ITM and CAM into their curriculum was positive. The majority of the students had not passed any courses on ITM. Therefore, university policymakers should provide diverse training courses on ITM and CAM to increase students' knowledge [ 8 ].

Results of some studies revealed that pharmacy, medical, and nursing students had positive attitudes and perceptions toward CAM therapies, despite poor knowledge regarding CAM modalities [ 9 – 12 ]. All students agreed and supported the integration of CAM education into the medical education curriculum due to its importance concerning the doctor-patient encounter and advising patients regarding safe and beneficial CAM use [ 11 – 14 ]. On the other hand, people of some communities were very interested in CAM practices and had good knowledge, but their attitude towards CAM was low [ 15 ]. Familiarization and acclimatization of health professionals with ITM and CAM as an inseparable part of Iran's heritage can help them select the best remedy options for their patients. Hence, authorities have been suggested including ITM and CAM into the medical education curricula of medical and some paramedical students as a two-credit course for implementation [ 16 ].

Nutrition students commonly must have desirable knowledge and attitudes toward CAM as adjuvant therapy to treat patients under diet therapies to have proficiency and competency in counseling patients regarding the interaction between diet and CAM therapies. Hence, due to the lack of research studies regarding the effectiveness of CAM education on nutrition students, we sought how much teaching CAM procedures in a virtual environment can influence the components of the theory of planned behavior (TPB) including their knowledge, attitude, behavioral intention, and behavior of nutrition students.

Materials and methods

Participants eligibility, sampling and study design.

This cross-sectional descriptive-analytic study was conducted on 162 undergraduate nutrition students were selected through convenience sampling based on inclusion criteria in 2021–2022 from 13 universities. Sixty four nutrition students aged 22–25 years old from Kerman University of Medical Sciences and 98 nutrition students from 12 other universities of medical sciences enrolled in this study. The inclusion criteria were 1) nutrition students who have passed two-credit CAM in a virtual environment supported through the Virtual University that cover teaching medical and some paramedical students from summer 2021 in Iran; 2) willingness to participate in the study; and 3) ability to understand the educational content and participate in the study; the exclusion criterion was 1) unwillingness to continue cooperation due to any reason. Some of nutrition students refused to cooperate due to a lack of motivation. Indifference in presenting the opinion to change the imposed educational curriculum is also one of the other reasons for not cooperating in the study. Data was collected through a validated researcher-made CAM questionnaire. Before the start of the study, the purpose of the project and the concealment of the information was explained to them. After getting permission and coordinating with the nutrition students, the questionnaires were sent through Email to every student in a routine manner. The students completed the questionnaires and referred them to the researchers. To maximize the internal validity of the study data and prevent information bias, we decided that all nutrition students who have taken this course in a certain period in a virtual setting will be assessed. The method of choosing participants was convenience sampling which is a specific type of non-probability sampling method that relies on data collection from University students who are conveniently available to participate in the study. Therefore, the goal was to include all nutrition students from medical sciences universities in the country who were willing to cooperate with our study.

Careful administration of the study was done by the original executor from the Kerman University of Medical Sciences. Monitoring of the good implementation of the study was done by selected supervisors from the National Agency for Strategic Research in Medical Education. The Research Ethics Committee of the National Agency for Strategic Research in Medical Education approved the protocol (Approval ID: IR.NASRME.REC.1400.455). This project was funded by the National Agency for Strategic Research in Medical Education; Tehran, Iran (Grant No. 4000432).

Designing of CAM questionnaire and questionnaire validation

The structured researcher-made CAM questionnaire was designed based on the TPB questionnaire that consisted of educational variables, knowledge queries, and the TPB constructs. The modified CAM-TPB constructs of the structured questionnaire were designed based on a modified 5-point Likert scale which consisted of 34 items in 4 subscales under the following titles: knowledge (10 items), attitude (11 items), behavioral intention (7 items), and behavior (6 items). Knowledge means the theoretical or practical understanding acquired through education and teaching. However, attitude is defined as an individual's favorable or unfavorable evaluation of a determined behavior. On the other hand, we designed four two-level queries for attitude construct to better interpret the data of four constructs. Therefore, these four two-level queries for attitude were selected as part of the statistical analysis of the data. A 5-point Likert scale with 1–5 coding was used for the knowledge construct: very much = 5, much = 4, Intermediate = 3, low = 2, and none = 1. On the Likert scale, strongly disagree = 1 and strongly agree = 5 was used for the attitude construct. On the Likert scale of behavioral intention, very low probability = 1 and very high probability = 5; and on the Likert scale of behavior, never = 1 and always = 5.

Five experts familiar with medical education and nutrition determined the face and content validities. The content validity index (CVI) and content validity ratio (CVR) of the CAM-TPB questionnaire were evaluated. The CVI was calculated at 0.98 for the overall scale. The reliability was calculated by measuring the internal consistency and test–retest method (12-day interval). Only 51 students out of 64 students who freely entered the study from Kerman University of Medical Sciences agreed to participate in the validation of the questionnaire. To measure internal consistency, Cronbach's alpha coefficient was calculated for 51 samples. The Intra Class Correlation (ICC) was calculated. The range of Cronbach's alpha coefficient for the four constructs was 0.847–0.943.

Statistical analysis

Data were analyzed using IBM SPSS Statistics software, version 22.0. Significance was assumed at P  < 0.05. The normal distribution of variables was examined by the Kolmogorov–Smirnov test. The Chi-square test was used to determine the relationship between the gender variable and three different levels (favorable, relatively favorable, and unfavorable) of four constructs. In Table 2 , to avoidance of confusion and a more precise interpretation of collected data, the lower tertile of the whole score of each construct is considered unfavorable. The middle tertile of the whole score of each construct is considered relatively favorable. The upper tertile of the whole score of each structure is considered desirable. Therefore, overall score grouping was based on unfavorable, relatively favorable, and favorable. The Chi-square test was used to determine the relationship between gender variable and two-level queries of attitude construct. Independent t-test analyzed the mean differences of four constructs (knowledge, attitude, behavioral intention, and behavior) scores between the pairwise comparisons of the attitude construct. The Pearson correlation coefficient was calculated to examine the relationship between the mean scores of four constructs. Linear regression analysis was used to predict the value of a variable (the dependent variable) based on the values of the other variables. At first, the behavioral intention was the dependent variable, and knowledge and attitude were the independent variables. In the second step, behavior was the dependent variable, and knowledge, attitude, and behavioral intention were the independent variables.

Frequencies a of total scores grouping b for four constructs (knowledge, attitude, behavioral intention, and behavior) between two genders.

a Chi-Square test analyzed the differences between total scores grouping for four constructs (knowledge, attitude, behavioral intention, and behavior) based on two genders

b Whole score grouping was based on unfavorable, relatively favorable, and favorable. The lower third of the whole score of each construct is considered unfavorable. The middle third of the whole score of each construct is considered relatively favorable. The upper third of the whole score of each structure is considered desirable.

The mean (± SD) age of male students was 22.64 ± 1.53 years and for female students was 22.32 ± 1.30 (34% males and 66% females).

The Chi-Square test analyzed the differences between frequencies of responses to the pairwise comparisons of the attitude construct based on two genders (Table 1 ). The percentage of students that responded to the phrase “two credits of the CAM course were adequate for teaching nutrition students” did not differ by gender, X 2 (1, N  = 162) = 2.158, p  = 0.171. The percentage of “nutrition students that used CAM modalities for themselves” did not differ by gender, X 2 (1, N  = 162) = 0.004, p  = 1.000. The percentage of “nutrition students that recommended CAM modalities to others” did not differ by gender, X 2 (1, N  = 162) = 0.344, p  = 0.613. The percentage of “nutrition students that would follow the recommendation of a CAM specialist” did not differ by gender, X 2 (1, N  = 162) = 0.848, p  = 0.376.

Frequencies a of the pairwise comparisons b of the attitude c based on two genders.

a Chi-Square test analyzed the differences between the pairwise comparisons of the attitude construct based on two genders

b Pairwise comparisons generally are methods for comparing entities in pairs to judge which of each entity is preferred or has a greater amount of some quantitative property, or whether or not the two entities are identical

c Two-level queries of attitude such as 1) Are two credits of the CAM course adequate for teaching students? 2) Have you ever used CAM modalities for yourself? 3) Have you ever recommended CAM modalities to others? 4) If a CAM specialist recommends one of the modalities, would you use it?

The Chi-Square test also analyzed the differences between whole scores grouping (unfavorable, relatively favorable, and favorable) for four constructs (knowledge, attitude, behavioral intention, and behavior) based on two genders (Table 2 ). The percentage of whole scores grouping did not differ by gender for knowledge construct, X 2 (2, N  = 162) = 4.814, p  = 0.090; attitude construct, X 2 (2, N  = 162) = 0.995, p  = 0.608; behavioral intention, X 2 (2, N  = 162) = 0.349, p  = 0.840; behavior, X 2 (2, N  = 162) = 0.656, p  = 0.720 (Table 2 ).

There was a significant difference between the total score of knowledge in the two genders ( p . value = 0.031). However, there were no significant differences between both gender groups in total scores of attitude, behavioral intention, and behavior (Table 3 ).

Mean ± SD a of total scores of four constructs (knowledge, attitude, behavioral intention, and behavior) between two genders.

a Independent t-test analyzed the differences (Mean ± SD) of total scores of four constructs (knowledge, attitude, behavioral intention, and behavior) between two genders

Table 4 indicated that students who claimed “two credits of the CAM course were not adequate for teaching” earned significantly more scores in attitude, behavioral intention, and behavior ( p . value =  < 0.001, < 0.001, and 0.005, respectively). The students who claimed that they “used CAM modalities for themselves” earned significantly more scores in attitude, behavioral intention, and behavior ( p . value =  < 0.001, < 0.001, and < 0.001, respectively). The students who claimed that they “recommended CAM modalities to others” earned significantly more scores in knowledge, attitude, behavioral intention, and behavior ( p . value = 0.003, < 0.001, < 0.001, and < 0.001, respectively). The students who claimed that they “would follow the recommendation of a CAM specialist” earned significantly more scores in knowledge, attitude, behavioral intention, and behavior ( p . value = 0.001, < 0.001, < 0.001, and < 0.001, respectively) (Table 4 ).

Mean ± SD a four constructs (knowledge, attitude, behavioral intention, and behavior) scores between the pairwise comparisons b of the attitude c .

a Independent t-test analyzed the differences (Mean ± SD) of four constructs (knowledge, attitude, behavioral intention, and behavior) scores between the pairwise comparisons of the attitude construct

The Pearson correlation coefficient between attitude and behavioral intention as well as between attitude and behavior were strong ( r  = 0.764, p  < 0.001; r  = 0.762, p  < 0.001). The Pearson correlation coefficient between behavioral intention and behavior was strong ( r  = 0.862, p  < 0.001) (Table 5 ).

Pearson correlation coefficients for the relationship between mean scores of four constructs.

Table 6 revealed that the association between the behavioral intention and predictors of knowledge and attitude in the model is statistically significant. However, attitude contributes the most to the variability in behavioral intention. The higher the R 2  value, the better the model fits our data.

Linear regression analysis for predicting behavioral intention from knowledge and attitude based on theory of planned behavior.

a Dependent variables: Behavioral intention; Predictors: Knowledge and attitude

Table 7 revealed that the association between the behavior and predictors of attitude and behavioral intention in the model is statistically significant. The p-value for knowledge was higher than 0.05, which indicated that there was not enough evidence to conclude that knowledge related to the behavior. However, behavioral intention contributes the most to the variability in the behavior. The higher the R 2  value, the better the model fits our data.

Linear regression analysis for predicting behavior from knowledge, attitude, and behavioral intention based on theory of planned behavior.

a Dependent variables: Behavior; Predictors: Knowledge, attitude, and behavioral intention

Nutrition students customarily must have favorable knowledge and attitudes toward CAM as an adjuvant therapy to treat patients under therapeutic diets to have expertise and competency in counseling patients regarding the interaction between diet and CAM therapies. Hence, we sought how much teaching CAM procedures in a virtual environment can influence the components of the TPB including knowledge, attitude, behavioral intention, and behavior of nutrition students. Our results revealed that there was no difference in gender between the pairwise comparisons of the attitude construct (Yes/No). Furthermore, the percentage of whole scores grouping did not differ by gender for knowledge, attitude, behavioral intention, and behavior constructs. The students who significantly scored the highest scores in attitude, behavioral intention, and behavior constructs were the students who claimed that teaching two credits of CAM for nutrition students is not enough. In addition, these students used treatment methods of CAM for themselves, suggested treatment methods of CAM to others, and followed the recommendations of the CAM specialists.

Results of some studies revealed that pharmacy, medical, and nursing students had positive attitudes and perceptions toward CAM therapies, despite poor knowledge concerning CAM modalities [ 8 – 12 ]. Therefore, university policymakers should provide diverse training courses on ITM and CAM to increase student’s knowledge [ 8 ]. The data also suggested a significant association between familiarity with CAM and gender [ 9 ]. In this regard, we revealed that there was a significant difference between the total score of knowledge in the two genders.

We used adjusted R square to compare models that had different numbers of predictors to choose the correct model. It appears the second model is the best. Attitude could predict 70% of behavioral intention. However, attitude and behavioral intention could predict 90% of behavior. Therefore, attitude is the most critical determinant influencing behavioral intention and behavior.

In this context, a question is raised as that why in most of the studies [ 6 – 8 , 11 – 15 ], all students agreed and supported the integration of CAM education into the medical education curriculum; nonetheless, despite poor knowledge regarding CAM modalities, the majority of students had positive attitudes and perceptions about CAM usage. Therefore, the reasons for the gap between students’ knowledge and attitude must be determined. The findings indicate that integration of CAM into the nursing curriculum and continuing education/training in CAM is necessary to prepare future nurses [ 11 ]. It proved that the lack of trained professionals, inaccessibility of credentialed providers, lack of staff pedagogy, lack of appropriate guidelines, and lack of reliable and scientific evidence regarding CAM were the most apperceived obstacles to CAM execution [ 11 , 17 ]. One of the weaknesses of CAM education-included curricula was how to strengthen students' knowledge [ 18 ]. The solution to this weakness that is educational CAM programs should be integrated continuously for several years into the educational curriculum to increase students' knowledge and performance [ 19 ]. The timing of the CAM curriculum near graduation, students' investigation of several CAM modalities through deep studying, and student interaction with society CAM providers are features of the curriculum that make the curriculum prosperous and unforgettable [ 20 ]. Figure  1 illustrates the crucial barriers and limitations to obstacle CAM education-included curricula; and solutions and opportunities which can eliminate these barriers. CAM education-included curriculum influences the knowledge and attitude of students concerning CAM and advises patients concerning CAM use, and the practice of CAM therapies in the future [ 20 ]. Most students were uncertain about the effectiveness of herbs in promoting good health. The students claimed that obstacles to their CAM knowledge were insufficient education, a lack of scientific evidence, and a lack of trained professionals and education. Most students requested CAM educational courses regarding CAM therapies with nutrition professors being ranked highest as the providers of this education [ 21 ]. Medical educators must be efficiently capable of teaching CAM using evidence-based medicine principles with a concise, interactive curriculum. This procedure has a good impetus for medical educators and a useful influence on medical students' willingness to gain new knowledge regarding CAM [ 22 ]. Training of holistic nurses and practitioners depend on CAM integration study into medical curricula and the practice of the CAM therapies to promote their knowledge. They demonstrated the effectiveness of CAM education for the remarkable development in the preparation of holistic practitioners and nurses [ 23 ]. The majority of the students agreed that CAM therapy could integrate with modern medicine to achieve better consequences. The knowledge of CAM is important since many patients still prefer this module of treatment [ 24 ]. Therefore, the CAM integration in conventional healthcare services, familiarization and acclimatization of health professionals with ITM and CAM, the supervision and training of traditional practitioners and nutritionists, increase proficiency and competency in counseling patients regarding the interaction between diet and CAM therapies, regulation of academic standards, and the development of consistent curricula for CAM can enhance the capacity of holistic healthcare services.

Major barriers and limitations to obstacle CAM education-included curricula; and solutions and opportunities which can eliminate these barriers

Strengths and limitations

The most important strength of this study is the implementation of this research in nutrition students and their behavior rationalization through the most effective educational model. One of the limitations of this study is the non-participation of all nutrition students in the present study. Two critical reasons were unwillingness to participate in the study for personal reasons and failure to teach this course to nutrition students in some universities of medical sciences in the country.

Conclusions

We concluded that the prerequisite for obtaining expertise and competency in counseling patients regarding the integration between diet and CAM therapies is to have desirable knowledge and attitudes toward CAM. The attitude could predict 70% of behavioral intention. The attitude and behavioral intention together could predict 90% of behavior. Therefore, the attitude was the most important determinant influencing behavioral intention and behavior. Teaching CAM using evidence-based CAM-ITM principles with a succinct, concerted, and collaborative curriculum and integration of educational CAM programs continuously for several years into the academic curriculum influence the success of the educational CAM program. The removing obstacles on the way to knowledge increase such as the lack of trained professionals, inaccessibility of credentialed providers, and lack of reliable and scientific evidence regarding CAM.

Acknowledgements

The authors are grateful to the National Agency for Strategic Research in Medical Education in this study. The authors are also grateful to nutrition students that contributed in this study.

Authors’ contributions

MRM contributed to the conception of the original idea, conducting the study design, analysis and interpretation of the data, drafting and revising the draft, approval of the final version of the manuscript, and agreeing to all aspects of the work. SS is the consultant of the study and agreed to all aspects of the work. MSA contributed to the conception of the primary study, the acquisition of questionnaire data, and agreeing to all aspects of the work.

This project was funded by the National Agency for Strategic Research in Medical Education; Tehran, Iran (Grant No. 4000432).

Availability of data and materials

The data that support the findings of this study are available from the corresponding author, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available.

Declarations

Ethics approval and consent to participate.

The Research Ethics Committee of the National Agency for Strategic Research in Medical Education approved the protocol (Approval ID: IR.NASRME.REC.1400.455). All methods were performed in accordance with relevant guidelines and regulations. Before completing the Complementary and Alternative Medicine Questionnaire, informed consent was obtained from all nutrition students included in the study.

C onsent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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Contributor Information

Mohammad Reza Mahmoodi, Email: [email protected], Email: [email protected].

Sara Shafian, Email: [email protected].

Manizhe Shaban Alinaghizade, Email: [email protected].

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A critical integrative review of complementary medicine education research: key issues and empirical gaps

• Alastair C. Gray   ORCID: orcid.org/0000-0003-4520-4560 1 , 2 , 3 , 6 ,
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BMC Complementary and Alternative Medicine volume  19 , Article number:  73 ( 2019 ) Cite this article

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Complementary Medicine (CM) continues to thrive across many countries. Closely related to the continuing popularity of CM has been an increased number of enrolments at CM education institutions across the public and private tertiary sectors. Despite the popularity of CM across the globe and growth in CM education/education providers, to date, there has been no critical review of peer-reviewed research examining CM education undertaken. In direct response to this important gap, this paper reports the first critical review of contemporary literature examining CM education research.

A review was undertaken of research to identify empirical research papers reporting on CM education published between 2005 and 17. The search was conducted in May 2017 and included the search of PubMed and EBSCO (CINAHL, MEDLINE, AMED) for search terms embracing CM and education. Identified studies were evaluated using the STROBE, SRQP and MMAT appraisal tools.

From 9496 identified papers, 18 met the review inclusion criteria (English language, original empirical research data, reporting on the prevalence or nature of the education of CM practitioners), and highlighted four broad issues: CM education provision; the development of educational competencies to develop clinical skills and standards; the application of new educational theory, methods and technology in CM; and future challenges facing CM education. This critical integrative review highlights two key issues of interest and significance for CM educational institutions, CM regulators and researchers, and points to number of significant gaps in this area of research. There is very sporadic coverage of research in CM education. The clear absence of the robust and mature research regarding educational technology and e-learning taking place in medical and or allied health education research is notably absent within CM educational research.

Despite the high levels of CM use in the community, and the thriving nature of CM educational institutions globally, the current evidence evaluating the procedures, effectiveness and outcomes of CM education remains limited on a number of fronts. There is an urgent need to establish a strategic research agenda around this important aspect of health care education with the overarching goal to ensure a well-educated and effective health care workforce.

Peer Review reports

The practice, uptake and economics of Complementary Medicine (CM) - a range of therapies, products and approaches to health and illness not traditionally associated with the medical profession or medical curriculum [ 1 ] - continues to thrive in many countries [ 2 , 3 , 4 , 5 , 6 , 7 ] and concurrently the enrolments at CM education institutions have steadily increased [ 8 , 9 ]. CM education institutions providing training and qualifications including naturopathy, nutritional medicine, homeopathy, acupuncture, massage therapy and herbal medicine are located across both the public and private tertiary sector in many regions, Australia [ 10 ], USA [ 11 ], UK [ 12 ], Asia [ 13 ]. The professionalization of the CM education sector appears to be evolving with continuing professional education, education standards, levels of foundational medical science and higher levels of qualifications emerging in recent years [ 14 , 15 , 16 , 17 , 18 ].

These education institutions face innumerable challenges. These include preparing CM graduates to function as health professionals in a contemporary health system when they apply predominantly traditional principles and concepts [ 19 , 20 ]. Another challenge is training students in inter-professional care when the focus during training is often on mastering a traditional technique or philosophy [ 21 ]. Further challenges involve providing education about evidence-based healthcare when the focus during training is often on learning and applying traditional evidence - defined here as evidence with a long and coherent history of use, well documented in monographs such as materia medica and other texts, mainly inductive in nature, and passed on orally over many generations [ 22 ]. This is pertinent in a field that has 700 Cochrane systematic reviews yet one where traditional evidence and knowledge is also highly regarded. Further, providing education on patient-centred care [ 23 ], supporting non-traditional students [ 24 , 25 ] and also gaining funding for and providing education related to perceived non-credible CM modalities in conventional tertiary education settings are challenges [ 26 ]. In addition, challenges continue to arise for education leaders both within and beyond CM regarding technological advances and the consequences for students, educators and institutions [ 27 , 28 , 29 ]. New developments in healthcare such as e-health/tele-health [ 30 ] and a growth in interest in the pedagogy and andragogy of online learning [ 31 , 32 ] in general, present challenges for educational institutions, professional associations and regulators. Alongside these general educational challenges, faculty resistance to change, the digital divide between students, and between students and faculty, and online readiness for study has been a focus of recent research and discourse in health education [ 33 , 34 , 35 , 36 ]. More broadly, beyond CM-specific education, tertiary students are increasingly engaging with technology in both their personal and study lives [ 37 , 38 ] and technology-based learning and teaching in higher education is becoming almost a presumed proposition in many undergraduate courses [ 39 , 40 ]. CM education is not exempt from such circumstances and there is a necessity for future research on this topic.

In direct contrast to research related to CM practitioner education, there are numerous studies investigating the degree of, and attitudes to CM in conventional medical training [ 41 , 42 , 43 ], in biomedical education [ 44 ], midwifery [ 45 ], pharmacy [ 46 , 47 , 48 ] and in nursing training [ 44 , 49 , 50 , 51 , 52 ]. Paradoxically, much of the research regarding CM education relates to its importance and application in nursing education [ 53 ], or the experience of integrating naturopathy into nursing educational programs [ 54 ], the education of physicians about their patients and CM [ 55 ], or addressing the obstacles to success in the implementing of change in science delivery in nursing [ 56 ].

The growing CM workforce requires training appropriate to performing evidence-informed, co-ordinated and inter-professional care within the broader health system and developing the evidence-base on this topic will not only aid the CM field but also provide potential insights for health/medical education more broadly [ 57 ]. The development of a robust evidence-base on this topic requires a clear understanding of the current landscape. Unfortunately, there has been no critical review of the peer-reviewed research examining CM education to date. In direct response to this important research gap, this paper reports the first critical review of contemporary literature examining a number of key issues across the CM education field.

The aim of this critical integrative review [ 58 ] was to review all published original research found in peer-reviewed literature examining education within higher educational institutions that provide training for CM professionals.

A database search was undertaken to identify original peer-reviewed literature published from 2005 to 2017 reporting on issues relating to CM education. This date range was chosen to reflect contemporary issues and ensure findings were as pertinent to current practice and policy as possible.

Search strategy

The search was conducted in May 2017 and included the systematic search of PubMed and EBSCO (CINAHL, MEDLINE, AMED). MESH terms and keywords from related papers were explored to guide the process of selecting search terms, and the process was further refined after referral to a related 2014 review [ 59 ]. The first stage was conducted in PubMed. Search A - The search terms embracing CM included, Complementary Therapies, Complementary Medicine, Homeopathy, Naturopathy, Herbal Medicine, Acupuncture, Acupuncture Therapy, Medicine, Chinese Traditional, Massage, Therapy, Soft Tissue, Integrative Medicine, Medicine, Traditional, Holistic Health, Osteopathic Medicine, Manipulation, Chiropractic, Musculoskeletal Manipulations, Physical Therapy Modalities. Filter 2005–2017. ( n  = 258,099). Search B - The search terms embracing education included, education, learning, curriculum, teaching, health occupation students, eLearning, E-Learning, online learning, educational technologies, blended learning. Filter 2005–2017. ( n  = 906,575). A + B Combined ( n = 38,441). Stage 2 was conducted in EBSCO. The same search terms used in PubMed when entered into EBSCO provided millions of hits, education ( n  = 160 + M) hits, Complementary Therapies ( n  = 629,674) hits and too many potential papers to work. Including ‘eLearning’ and ‘e-learning’ was manageable but these two terms with ‘learning technologies’ made it impossible to proceed. In the process, a review was located which had used similar terms but a different strategy, Milanes 2014 systematic review, Is a blended learning approach effective for learning in allied health clinicians? Because of the enormous number of hits using the EBSCO database, and based on this article a revised search method was undertaken for the EBSCO search. Search C - EBSCO Search terms, 1. Online learning OR blended learning or web-based learning, 2. e-learning OR elearning, 3. education* OR curriculum* OR teaching* OR learn*, 4. Combine all (1–3) with AND 5. Complementary Therapies*, 6. Search 4 AND 5 ( n  = 637), 7 Limit to articles from 2005 ( n  = 567 (with duplicates removed)). Search D - This process was completed again searching on the slightly different terminology. Search terms, 1. Online learning OR blended learning or web-based learning, 2. e-learning OR elearning, 3. education* OR curriculum* OR teaching* OR learn*, 4. Combine all (1–3) with AND, 5. Complementary Medicine*, 6. Search 4 AND 5 = 1203, 7. Limit to articles from 2005 = ( n  = 1013 (with duplicates removed)). Stage 3 (Milanes Refined) PubMed. Search E - The search terms Health occupation students OR educational technologies OR teaching OR curriculum AND complementary therapies, filter to last 10 years. Search results = ( n  = 8439). Totals: Search C – n  = 567, Search D – n  = 1013, Search E – n  = 8439. Total Papers n  = 10,019. Duplicates removed n  = 523. Grand Total 9496. Manual searching of reference lists of identified papers was also conducted to ensure as full coverage of literature as possible.

Inclusion and exclusion criteria

Papers written in English, presenting original empirical research data, related to courses where graduates receive a qualification in a CM to a standard accepted by those professions and reporting on the prevalence or nature of the education of CM practitioners in some way were included in the review. Papers reporting conference presentations, or studies relating to how pharmacy, nursing or registered medical professionals are educated regarding their patient behaviours or looking to how they accumulate CPD points in short term CM topics were excluded.

Search outcomes

The combined (Complementary Therapies n  = 420,476 and Education n  = 102,024) search results ( n  = 9927) were imported into Endnote. Of these, 9895 papers were excluded via title and abstract due to not meeting the inclusion criteria, and all identified duplicates ( n  = 280) were excluded leaving 32 papers. Upon reviewing full papers an additional 26 articles were excluded due to their focus on just allied health and / or only learning technologies with no CM focus; leaving 6 papers. A total of 12 additional papers were identified for review following manual searches. In total, 18 papers were identified for this review. The process undertaken for this review is presented in Fig. 1 .

Literature Review Methodology and Selection Process flowchart for articles reporting education and CM (PRISMA Guidelines)

Critical analysis of included papers

Our critical literature appraisal employed three analytical tools, STROBE [ 60 , 61 ], SRQR [ 62 ] and MMAT [ 63 ]. Papers were evaluated for quality and the findings are collated in Table 1 .

Of 9927 identified papers, 18 papers met the review inclusion criteria. An overall synopsis of all papers included in the review incorporated preliminary categorical analysis is outlined in Table  2 . The identified studies were conducted in Australia ( n  = 7), the US ( n  = 5), Norway ( n  = 2) and one each from Canada, Taiwan, Israel and India. The research designs reported in the reviewed literature varied widely with quantitative, qualitative and mixed methodologies reported. The quantitative studies selected for review utilized a number of survey design approaches and attracted samples of between 10 and 246 individual participants. The qualitative studies identified employed survey methods [1, 2, 8–14, 18] as well as interviews [1, 6, 11, 15, 16], open essays [2] and focus groups [17]. The spread, focus and identification of themes and topics by CM therapy is represented in Table 2 . The naturopathic profession has received most attention from researchers within the international CM education landscape, followed by acupuncture. There are three studies on homeopathy, two studies of chiropractic, and one each of osteopathy, herbal medicine, ayurveda and massage. Six of the included studies focus on a specific class inside of a CM college [1–4, 7, 17], four on academics in CM institutions [6, 12, 16], four studies surveyed members of professional associations [5, 10, 17], and four surveyed College directors [8, 9, 13, 18]. Thematic categorization of the included papers identified four substantive topic areas: (1) CM education provision, (2) the development of educational competencies to develop clinical skills and standards, (3) the application of existing and new educational theory, methods and technology in CM, and (4) future challenges facing CM education.

CM education provision

The review identified three papers that reported a simple description of educational provision in an area of CM. One study compared naturopathy and chiropractic curricular in Australia. Course structures and subject unit descriptions for accredited naturopathic courses were examined from websites where they existed and in some instances short follow-up interviews were conducted. This study reported the percentage of curriculum devoted to medical sciences and clinical training whereby it was found that on average, chiropractic courses allocated 45.9% of their curricula to medical sciences, whereas university-based naturopathy courses allocated 26.2% to medical science and non-university naturopathy courses allocated 23.1% [ 64 ]. Another study reported on the scope of education provision in homeopathy and examined the preponderance of accredited full-time and part-time courses and accredited and non-accredited courses in Europe. This cross-sectional survey of 85 homeopathy education providers found an average of 47 enrolled students and 142 graduates in these generally small schools. Course duration lasted on average 3.6 years part-time, less than half had entry requirements, provided any medical science education or required students to obtain medical science tuition elsewhere. Average teaching hours at surveyed schools were 992 overall, with 555 h devoted to didactic homeopathy study, while the rest focused on clinical training [ 65 ]. A similar 2009 study focused on the demographics, satisfaction, challenges and expectations of homeopathy students, teachers and school administrators in North America. The study consisted of three separate surveys targeted at homeopathy students, faculty and school directors consisting of 40 questions with a 91.5% completion rate [ 66 ]. It was found that there were 29 homeopathy schools, with 250 teachers and 1080 students currently enrolled in the United States. Programs varied considerably in length; however the average program (670 h) was barely sufficient to meet the minimum standards for homeopathic certification. Homeopathy teachers tend to be older than both homeopathy students or practitioners. The average age of students is 54.3 years old. Although the vast majority of students are female (90%) and practitioners are female (75%), males are much more common as teachers (43.5%) and school directors (45%). As with homeopathy students, practitioners, and teachers, homeopathy school directors are nearly all Caucasian (85%). An important conclusion was that education in homeopathy in the United States has largely remained stagnant in the last 10 years. Although many new schools have been formed, many have closed. It was not speculated as to the cause.

The development of educational competencies to develop clinical skills and standards

Eight papers from the review focused on improving education and clinical skills in CM. One study reporting findings from 43 education providers of naturopathy and western herbal medicine in Australia found educational standards varied widely, including unsustainable variations in award types, contact hours, clinical education, length of courses and course content with some practitioners unlikely to be trained to professional standards. This study found a need for better integration of complementary care with mainstream healthcare necessitating education to rise to the level of a bachelor degree [ 67 ]. The development or application of learning competencies was a focus of these eight papers. Competencies and competency models refer to how the knowledge, skills, and abilities required by these standards are structured. In a study focussing on the skills, knowledge, attributes and competencies of homeopaths and homeopathy education provision, telephone interviews with 17 educators from different schools in 10 European countries were conducted [ 68 ]. This qualitative study used constant/simultaneous comparison and analysis to develop categories and properties of educational needs and theoretical constructs and to describe behaviour and social processes and showed educators define a competent homeopath as a professional able to help patients in the best way possible. It was found that course providers and teachers required the competency to be student-centred, and students and homeopaths to be patient-centred [ 68 ]. In an Australian study, CM practitioners were reported as having a low level of confidence in identifying clients requiring referral to registered health practitioners, despite the reported high frequency of educational training in, and use of, Western and CM diagnostic techniques [ 69 ].

Two identified papers focused on teaching aspects of practitioner communication skills and the integration of complementary and conventional medicine in CM schools. Using a pre-course ‘semi-structured questionnaire’ plus surveys after an educational intervention, 62 students in Israel reported on how the communication gap with conventional physicians and CM practitioners could be improved [ 70 ]. This study found that CM practitioners perceived themselves as better equipped to communicate with conventional health care practitioners when critical thinking, patient-centered care, and communicating skills were emphasized in their course of undergraduate study [ 70 ]. In addition, a Canadian study published findings derived from 28 directors of colleges of CM. The author reported that student’s ability to understand research findings, to rely on high quality research and to engage in continuing education was important in communicating with conventional care providers [ 71 ].

Meanwhile, the need for schools to adopt research literacy and evidence based practice competencies was the focus of three papers. One study that examined the attitudes towards research and scholarly activity of 202 faculty academics in an Australian CM college reported low confidence in undertaking research [ 72 ]. Respondents in this Australian study perceived research as important to their personal professional goals (86.0%) although confidence in being able to undertake research was less common (56.5%). The perceived importance of publication of research to the respondents’ personal professional goals was also notably high (80.0%) although confidence in their own ability to produce research publications was lower (52.9%) [ 72 ]. Another study conducted in the US examined the approaches of 9 CM colleges to develop evidence-informed skills and knowledge with the aim of developing both students and faculty to critically appraise evidence and then employ that evidence to guide clinical practice [ 73 ]. This study found that in developing the framework for their educational programs, educational institutions used strategies that were viewed critical for success, including making them multifaceted and unique to their specific institutional needs. It was found that these strategies, in conjunction with existing instructional approaches, were of practical use in other CM and non-CM academic environments where administrators were considering the introduction of research literacy and EBP competencies into their curricula. Training programs and workshops were found to be the most useful way to train faculty in evidence based medicine and research literacy [ 74 ]. Finally, one reviewed paper reported on the educational competencies and institutional teaching strategies that had been developed and implemented to enhance research literacy at all nine R25-funded CM institutions in the US [ 73 ]. This study found that while each institution designed approaches suitable for its own research culture, the guiding principles were similar across all, and the need to develop evidence-informed skills and knowledge was important to help students and faculty to critically appraise evidence and then use that evidence to guide their clinical practice. The strategies adopted by these institutions included a need for course content to be conducive to reinforcing EBM competencies using spiral learning strategies, and that faculty were willing to learn and teach EBM skills [ 73 ].

Application of existing and new educational theory, methods and technology in CM

The changing role of the trainer/lecturer in didactic and clinical subjects, the application of existing and new educational theory and problem-based learning within the context of CM curricula in bachelor and medical college programs, as well as the growing use of learning technologies was highlighted by six papers included in the review. In one study three educational interventions testing new teaching methods were introduced in an ayurveda program [ 75 ]. The instructional methods that were evaluated were an integrative module on cardiovascular physiology, case-stimulated learning and classroom small group discussion with findings showing the development of testable integrative teaching methods is possible in the context of Ayurveda education [ 75 ]. In contrast, findings from an educational intervention, the implementation of an objective structured clinical examination (OSCE) model as well as a patient-centered training approach within traditional Chinese medicine (TCM) practitioner education in one Taiwanese medical school, found this examination approach effective in evaluating, teaching, and certifying TCM clinical competencies to improve the quality of TCM practices. In this study the training program subjects included TCM internal medicine, TCM genecology, TCM paediatrics, TCM dietetics, acupuncture, TCM orthopaedics, and traumatology [ 76 ].

When it comes to resources and the use of technologies, Wardle’s 2014 study used focus groups with current and recent students of 4-year naturopathic degree programs in Australia to ascertain how they interact with clinical teaching materials, and their perceptions and attitudes towards teaching materials in naturopathic education. This study described a desire among naturopathy students for existing curriculum to focus on evidence-based approaches and information that both supported and was critical of traditional naturopathic practices. These students remained largely ambivalent about new teaching technologies and preferred that these develop organically as an evolution from printed materials, rather than depart dramatically and radically from these previously established materials [ 17 ]. CM student’s preferred learning methods are often based on levels of computer skills and experience, their current use of computers as an educational tool, and attitudes regarding the role of computers in medical education according to a cross sectional survey study from a 27-item questionnaire distributed to 1–4-year Osteopathic medical students in the US [ 77 ]. One ethnographic study based on interviews conducted in the Australian university system with Naturopathic Faculty found an openness to the utilization of a number of technologies for flexible learning, including wikis, podcasts and synchronous audio-based online interactions [ 78 ]. In contrast, another study in the US found acupuncture, chiropractic, and massage therapy faculty lacked awareness of the capabilities of online education and the elements of good online learning and described a perception that what they taught could not be taught online because of its hands-on kinaesthetic requirements such as palpation [ 79 ].

Future challenges facing CM education

Lastly, one paper included in our review identified some of the challenges ahead for the Australian naturopathic profession including naturopathic education, the changing student body in naturopathic education, naturopathic student expectations, and the growing tension between traditional and scientific evidence [ 80 ]. This study, involving semi-structured interviews with 20 naturopaths, found that participants articulated a paradox whereby on the one hand, they supported the teaching of increased levels of biomedical sciences in naturopathic education, yet also complained of the trend of contemporary naturopathic education to “become more scientific” – a trend they attributed to their desire for the discipline to be “accepted in the university sector”. The participants claimed that such a development would be undertaken at the expense of the philosophical underpinnings of the profession. The authors found the continued development of minimum standards of practice and education that value traditional naturopathic principles and philosophies in tandem with the development of appropriate regulatory regimes, was vital in ensuring continued ethical and effective clinical practice.

Quality of papers

Based on the STROBE reporting guidelines [ 60 ] the quantitative papers included in this study, while rich in design, descriptive data and discussion of results exhibited a broad weakness in stating clear objectives. In addition, statements and acknowledgement of bias were mostly absent. Other elements commonly missing from these papers were descriptions of statistical methods and generalisability leaving a general impression of low quality among the included papers. Based on the SRQR [ 62 ] tool for evaluating qualitative studies, all selected papers omitted a discussion on the qualitative approach and research paradigm used. A description of researcher characteristics and reflexivity, and techniques to enhance trustworthiness and credibility of data analysis were mostly missing. In addition, potential sources of influence or perceived influence on study conduct and conclusions and how these were managed were also under-reported across this collected literature. In addition, a lack of reporting on sources of funding and other support, the role of funders in data collection, interpretation, and write-up were other weaknesses identified. The application of the MMAT critical appraisal tool for the mixed methods studies [ 63 ] in this instance found all papers used, included and reported appropriate sources of data relevant to answer the research question, took into account the context in data analysis, used appropriate sampling to answer the research question, and integrated qualitative and quantitative data and/or results. On the other hand, only some papers applied features of the tool such as data analysis relevant to answer the research question, and only a few reported on complete outcome data, or dropout rate, reported on recruitment minimizing bias and appropriate follow-up, used appropriate randomization, appropriate measurement, sample representative of the population, or appropriate measurement. No papers reported on the reflexivity of researchers, nor concealment allocation, and only a few reported on the mixed method design relevant to answer the research questions, integrated the mixed qualitative and quantitative data and results nor took into consideration any limitations associated with this integration, leaving an overall impression of poor quality.

This critical integrative review highlights two key issues and large current empirical gaps. Firstly, given the growing popularity of CM and as a consequence the growth in CM education, there is very sporadic coverage of research in the CM education field. Across the 18 included papers, research from 7 countries is represented with 4 of those countries having only one identified relevant paper. In addition, the quantity and quality of available evidence invariably relates to disparate, random and unrelated parts of CM education philosophy and practice. Our review findings highlight that much of the research is now relatively dated [ 81 ]. In addition, there is extreme diversity in the represented professions and ultimately the quality of papers. Many papers were excluded due to inconsistencies between title, abstract and findings [ 82 ]. Some papers were relevant but not published in peer reviewed journals and thus excluded; highlighting how in a maturing field there is a need to publish in both professional industry journals and the peer reviewed literature. One such example was the result of a survey of ‘profession-wide’ educational acupuncture institutions in the US as well as an extensive literature review, subject matter expert interviews, community discussions, strategic planning, analysis, and evaluation, that called for the development of educational competencies [ 83 ]. Others examples were the Survey on Inter-institutional and Interprofessional Relationships of Accredited Complementary and Alternative Medicine Schools and Consortium of Academic Health Centers for Integrative Medicine Programs [ 84 ], the National Education Dialogue to Advance Integrated Health Care: Creating Common Ground [ 84 ], the Project for Inter- Institutional Education Relationships [ 85 ]: Examples of Real Life Inter-Institutional Collaborations [ 84 ], and the Credentialing Licensed Acupuncture and Oriental Medicine Professionals for Practice in Healthcare Organizations: An Overview and Guidance for Hospital Administrators, Acupuncturists and Educators [ 84 ].

Our review identified that whilst educational standards and practices were considered within original research articles related to CM, this was mostly as part of the contextual discussion of findings of related but not directly relevant CM research. This pattern was observed both in the grey literature [ 86 , 87 ] and peer-reviewed publications [ 8 , 15 , 54 , 67 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 ]. One striking example of research emphasizing information related to CM education but collected in other settings, is by Wardle and colleagues in which practicing naturopaths were interviewed regarding multiple issues including the public misconception of the role of naturopathic medicine, the devaluation of naturopathic philosophy as a core component of naturopathic practice, the pressure to move towards an evidence-based medicine model focused on product prescription, as well as naturopathic education. In this paper, much of the data collected related to CM education but came from a broader research question and sample than research which focuses specifically on education and relevant stakeholders. Similarly, in Steel’s 2011 article, 12 naturopaths in current clinical practice were interviewed on the sources of information used in clinical practice, and the participants’ perceptions of these sources. This elicited comments about naturopathic education as well as concluding comments by the authors in relation to naturopathic education [ 89 ].

Another major finding from this review is that the robust and mature research exploring educational technology and e-learning that is taking place in medical and or allied health (nursing, midwifery, pharmacy) education research is clearly absent within the CM educational research field. Research within conventional medical and allied health education has explored the value of educational technology in place of traditional face-to-face delivery or within clinical training [ 100 , 101 ]. Moreover, there is also now substantial research examining the culture change for stakeholders in medical and allied health education, with qualitative research drawing on the results of surveys reporting of student and staff characteristics for developing faculty, or reporting on digital literacy and other academic processes as a consequence of e-learning [ 102 , 103 ]. In addition, many case studies of educational interventions have been published using some aspect of e-learning in medical or health services training [ 104 ]. Finally there are many original research papers examining the challenges facing medical education due to the clear trends of changing student behaviour, often as a result of the use of learning technologies [ 105 , 106 , 107 ]. Further, there are numerous studies exploring more effective delivery methods, and the development of critical thinking [ 108 , 109 ]. None of these areas of research relating to learning technologies have being reported nor evaluated in CM at present. This highlights that there is a significant discourse relating to andragogy and learning technologies taking place in arenas not too distant from CM education but not within CM practitioner education itself. These findings also highlight that most of the research on CM education is in non-CM environments or in arenas possibly similar to CM, such as nursing or Integrative Medicine but not CM.

Consequences

As identified in this review, the current evidence evaluating the procedures, effectiveness and outcomes of CM education remains limited in many significant areas despite the high levels of use of CM in the community and the thriving nature of CM educational institutions globally. As a result, there are a number of challenges previously described by commentators [ 8 ] which impact on the growth and sustainability of CM education. In particular, the ongoing absence of strategy in CM education research ensures a gap in the available knowledge and contributes to uncertainty for CM education leaders, policy makers and other health professionals as to the needs of employers and the market [ 8 ]. Furthermore, our review reveals the current empirical data regarding CM education as affording only a limited, superficial understanding of contemporary CM education highlighting the sporadic spread and apparent scarcity of research in this field. Our research suggests that possibly practitioners and users of CM for so long out of mainstream health care activity in Western societies [ 3 , 110 , 111 ] hold unique values attitudes to health [ 79 ]. In addition, it possibly suggests that there is in general a slower adoption of technology, and a stronger culture of resistance to change [ 78 ]. Yet it also points to a selective use of technologies as there is growing evidence of innumerable CM consultations taking place online [ 112 , 113 ]. This relatively low amount of empirical data pertaining to CM research in general may also be explained by the fact that there are few research active CM academics [ 8 ] and this is underpinned by a lack of perceived relevance of research in CM educational entities that are for the most part more technical colleges with academics often focused on technical and clinical expertise rather than empirical research activities [ 72 ].

Research opportunities and directions

The findings of this review highlight that there are significant gaps in the existing research examining CM education. There is a need to establish a strategic research agenda in this field. To effectively address these gaps it is important that future research build on a strong understanding of the unique educational environment of CM courses, colleges and universities. A key foundational step to developing a better understanding of the effectiveness of CM education is to more clearly identify current CM educational provision. Building upon a health services research approach, future research is required which examines the characteristics, attitudes, preferences, experiences and motivations of modern CM students. There is an urgent need to understand CM educational institutions geographical location, enrolment patterns, andragogy, their size and scope as well as international similarities and differences. This is particularly important given the as yet largely unexplored and potentially unique characteristics of CM educational institutions and their similarities or differences with other health services education (nursing, pharmacy), the potential size of the CM education market and the numbers of graduates entering CM professions. Alongside this, a closer examination of the use and reliance on technologies, faculty attitudes to technologies and change, the demographics, psychographics and the values of faculty at CM colleges is needed. Moving forward there is a need to understand how changing educational trends relate to CM, if CM educational settings are distinct because of their unique student body, the difference between training CM practitioners and training people about the use of CM, the broad and differing landscape of CM education provision across the world, to what degree are CM educational institutions influenced by the broader trends taking place in education globally? CM education is not immune or separate from the changes taking place in education globally (Massive Open Online Courses (MOOCs), flipped classrooms, constructivist education theories and the implementation of problem based learning [ 114 , 115 , 116 , 117 , 118 , 119 ] and this points the way forward for CM education research. Such an examination of CM education must also include the cultural diversity of education provision, local regulations and nuances. A broader knowledge of how health services education informs CM education, the degree to which research and evidence in health services education can be scaled to CM education [ 120 ], and how the foundational sciences are taught in CM institutions is also required. It might be beneficial for Colleges to explore strategies to develop faculty in areas such as e-learning technologies, research literacy and evidence-based practice skills, and students in health literacy and information literacy. For this, faculty and administrative champions are needed, as are early adopters and change-leaders. More needs to be known about the sheer breadth of educational provision in CM internationally, the range of award options with courses currently available at undergraduate, and postgraduate level, the relationship between prerequisites, the content of the program and the graduate outcome, as well as pathways include promoting CM-related courses in higher education generally, such as meditation, or somatics. General education courses to benefit all students and entry requirements and education prior to CM training, which may improve science literacy, publication productivity, professional standards. In addition more needs to be known about the financial drivers of for profit private equity educational institutions in the CM field.

Limitations

These findings can be contextualised within identifiable limitations. Searching literature related to CM can be challenging due to the lack of a consistent international definition. Further, there are many relevant studies, papers and commentaries that are not peer-reviewed and fell outside the scope of this review. There were 12 papers in this review that were identified through manual searching. This possibly highlights that despite research being conducted in this area, papers may not be published in journals which are indexed in commonly searched research databases. Whether this is due to a perception amongst CM-specific or health professional education journals that research in CM education falls outside of their relative scope and prefer to focus on clinical questions or the researchers are not targeting these other journals is not clear. Moreover, the application of three critical appraisal tools created challenges of inclusion and exclusion related to quality. In the case of the SRQR and MMAT, these guidelines were written for pure qualitative and mixed methods research, yet the papers in this review were published in public health and education journals. As such, the structure and content of the included qualitative and mixed methods articles may have been modified to suit the journal style guide and intended audience and the reporting guidelines may have been compromised as a result. For this reason, the low score for some of these articles may be due to reporting omissions of necessity rather than true gaps in methodology. Another limitation identified is that conducting research that crosses national borders comparisons become challenging. There are quite different standards for entry level and practice even between the various professions from country to country. The findings of the article reflect a symptom of wider issues and general statements are necessarily hesitant in this context. Nevertheless, where possible these limitations have been mitigated through attending to systematic review best practice, and as a consequence the relevance and value of the findings presented here for contemporary healthcare education provision should not be minimised.

Despite the high rates of CM use worldwide and growing interest in CM education, only a sporadic and under-developed body of original research has examined relevant issues to date and there is a need for both a growth in research activity and a clear coordinated research agenda in this important topic area. The significance of growing such a research program around the broad topic of CM education is essential to ensuring an adequately trained and educated CM workforce capable of realising an important role in the broader, coordinated and inter-professional health care system.

Abbreviations

Complementary Medicine

Evidence Based Medicine

Human Research Ethics Committee

Mixed Methods Appraisal Tool

Massive Open Online Course

Objective Structured Clinical Examination

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Standards for Reporting Qualitative Research

Strengthening the Reporting of Observational Studies in Epidemiology

Traditional Chinese Medicine

United States

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Acknowledgements

The research on which this paper is based was conducted as part of the authors PhD at the Faculty of Health University of Technology Sydney, and part of a broader research piece exploring CM education in the US and Australia. We are grateful to the Endeavour College of Natural Health and National University of Natural medicine for their time and commitment to the research in their profession.

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AG conceptualised the analysis and the paper, undertook the analysis. JA and AS assisted with interpretation of the findings of the analysis. All authors contributed to drafting and finalising the manuscript.

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Gray, A.C., Steel, A. & Adams, J. A critical integrative review of complementary medicine education research: key issues and empirical gaps. BMC Complement Altern Med 19 , 73 (2019). https://doi.org/10.1186/s12906-019-2466-z

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Received : 14 February 2018

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Published : 20 March 2019

DOI : https://doi.org/10.1186/s12906-019-2466-z

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