Working conditions in complementary and integrative healthcare professions

Abstract

Objective:

The study aimed to describe working conditions among complementary and integrative healthcare (CIH) providers, specifically acupuncturists, chiropractors, massage therapists, midwives, and naturopathic doctors.

Methods:

We used cross-sectional Occupational Information Network data (2013-2021) for 5 CIH occupations. We examined means and 95% confidence intervals [CIs] for 10 variables that represented positive conditions, ergonomic demands, psychosocial demands, and schedule demands. We compared CIH to conventional healthcare and non-healthcare occupations.

Results:

CIH occupations had relatively high degrees of positive conditions, moderate degrees of psychosocial demands, and moderate hours/scheduling. Massage therapists, chiropractors, and acupuncturists reported more ergonomic hazards (e.g., 1-5 scale where 5=highest, mean bending/twisting frequency for chiropractors=3.43 [95% CI: 3.80-4.05], compared to 2.17 for midwives [CI: 1.97-2.36] and 1.96 for managers [CI: 1.42-2.51]).

Conclusions:

CIH occupations generally had healthy working conditions, although ergonomic hazards were prominent.

INTRODUCTION

Working conditions are known to impact workers’ physical and mental health.^1,2 The impacts can be positive; for instance, jobs that offer workers the freedom to make decisions and exercise leadership can be health enhancing.^3-5 At the same time, some occupational exposures negatively impact health. Ergonomic hazards, like frequent twisting, bending and awkward or repetitive movements can lead to musculoskeletal injuries.^6,7 Psychosocial hazards like long hours (i.e., over 50 hours/week), high time pressure, and interpersonal conflict may lead to burnout, cardiovascular and mental health problems.^1,4,8

Among healthcare workers like doctors and nurses, there is a well-documented burnout problem.^9-13 Stress, physical hazards, isolation, low job satisfaction and burnout have been widely reported among medical doctors and nurses,^9-11,13 and it is likely that the clinician burnout crisis⁹ worsened during the COVID-19 pandemic.¹⁴ In the case of healthcare providers, unhealthy working conditions affect not just the health and wellbeing of workers themselves, but also of patients.¹⁵

Working conditions among conventional healthcare providers have been documented in the literature.^9-11,13,15 A far less studied group of providers are complementary and integrative health (CIH) providers. As the name implies, CIH may involve treatments provided to complement or be integrated with conventional medical care. The National Institute for Complementary and Integrative Health notes that CIH care may include physical approaches like manual therapies and acupuncture, psychological and mind-body approaches like meditation and yoga, as well as nutritional and natural product approaches like dietary plants and herbs.¹⁶ CIH care is considered key within the “whole health” approach promoted by the National Academies of Sciences and the Veterans Health Administration.^17-20 We focus here on CIH professions for which licensure is possible in the United States: acupuncturists, chiropractors, midwives (specifically, non-nurse midwives such as direct entry midwives and certified professional midwives), massage therapists, and naturopathic doctors.²¹

CIH represents a sizeable workforce. While estimates vary, licensed CIH professions in the US include well over 200,000 professionals, among them approximately 33,000 acupuncturists,²² 77,000 chiropractors,²³ 16,000 midwives (certified nurse midwives, certified professional midwives, and certified midwives),^24,25 over 90,000 massage therapists (not including those who are self-employed),²⁶ and 6,000 naturopathic physicians.²⁷ Further, CIH care is increasingly popular in the US, with significant growth in receipt of acupuncture, massage and naturopathic care²⁸ as well as midwife maternity care.^29,30 More than one third of Americans utilize some form of CIH care, broadly defined.^31-33 Given the growth in these professions, it is increasingly important to understand conditions in CIH jobs and whether these professionals experience the challenging working conditions reported for conventional healthcare.

There is a small body of peer-reviewed empirical literature on working conditions in CIH, with far more studies focusing on chiropractic than other CIH professions. Positive aspects of working in CIH professions have been noted. For instance, high job satisfaction and positive interactions with patients have been reported for chiropractors,³⁴ massage therapists,³⁵ midwives,³⁶ and naturopathic doctors.³⁷ Negative working conditions in CIH professions were reported as well, including high stress and moderate burnout among practicing chiropractors,³⁸ chiropractic students³⁹ and massage therapists.⁴⁰ Attrition concerns have been raised for chiropractors⁴¹ and Chinese Medicine providers⁴² (this group includes Chinese Medicine providers with specialties of general practice, acupuncture or bone-setting, also called TuiNa, a practice similar to physical medicine and chiropractic.⁴³). Both chiropractors³⁴ and massage therapists^35,44 have reported concerns about how the public perceives their jobs. Workplace bullying has been reported among midwifery students.⁴⁵ Notably, ergonomic concerns have been reported for massage therapists,⁴⁶ chiropractic students,⁴⁷ and practicing chiropractors;⁴⁸ 40% of chiropractors have been injured on the job, particularly while performing manipulation (67%) and most commonly in their wrist, hand and/or fingers (43%).⁴⁸

Thus, evidence to date has suggested a mix of positive aspects and occupational health concerns. However, no comprehensive descriptive study has examined working conditions across licensed CIH professions in the US. Prior work focused on individual CIH professions but did not encompass or compare among a full range of licensed CIH professions. In addition, while studies from non-US healthcare systems and work environments were informative,^35,42,37,45 due to differences in scope and practice norms, research specific to CIH workforce characteristics in the US will have more direct applications for policy domestically. Similarly, qualitative studies^35,36 and studies of students, ^39,45,47 while useful, have not allowed for quantitative comparisons across currently working professionals.

The present study aimed to fill this gap in the literature by quantitatively describing working conditions for CIH professions licensed in the US. We leveraged existing data from the Occupational Information Network (O*NET)⁴⁹ to, first, describe the degree to which professionals in the licensed CIH professions, specifically, acupuncturists, chiropractors, massage therapists, midwives, and naturopathic doctors, were potentially exposed to specific healthy and unhealthy working conditions. Second, we explored how their self-reported exposure compared to that of conventional healthcare providers. We considered 7 diverse conventional healthcare occupations, including physician and nursing occupations as well as physical therapists and home health aids. To put CIH working conditions in the context of the broader population, we also compared to the 2 most common occupations in the US, managers and retail salespeople.

METHODS

Design and Dataset

To describe working conditions for CIH professionals, we used a cross-sectional approach with publicly available data from O*NET. O*NET is a data source sponsored by the US Department of Labor/Employment and Training Administration by funding to the North Carolina Department of Commerce. O*NET provides detailed occupation information for many purposes.⁴⁹ Researchers have evaluated O*NET^50,51 and frequently used it to study the impact of working conditions on health.^7,52,53 The O*NET database includes what are labeled work context topics; these characterize the interpersonal, physical and structural work environment for nearly 1,000 occupations. Here we have used the term working conditions, which encompass work environment and how work activities are organized,⁵⁴ to refer to O*NET’s work context information.

O*NET sample and respondents:

The O*NET Data Collection Program uses two data collection approaches. First, in their establishment method, the program uses a two-stage sampling design that includes, first, a random sample of businesses that have employees in the occupations under study, and second, a random sample of workers in occupations. Then data is collected directly from those workers, referred to as incumbents. The second method is the occupational expert method, wherein data is collected from someone who worked in the occupation for at least one year, had at least five years as either an incumbent supervisor or trainer, and had this experience within the past 6 months. O*NET employs the occupational expert method for some instances to improve data collection efficiency and reduce burden, and may use it with many emerging occupations for which employment data are not available.⁵⁵ Data are collected via questionnaire; respondents can select online or paper copy, English or Spanish, and respondents receive cash incentives.⁵⁵

Table 1 shows the sample size, source (incumbent versus expert), and year of last data update. Supplemental Table 1 provides additional background information about the occupations, including the occupation code, annual wages and general education requirement.

Table 1.

Sample size, source and year of most recent update for complementary and integrative health occupations and other occupations in the Occupation Information Network (O*NET) database

Occupation	Sample size	O*NET respondent type	Year of most recent update
CIH professions
Acupuncturists	16	Incumbent	2020
Chiropractors	19	Incumbent	2013
Massage therapists	26	Expert	2021
Midwives	22	Incumbent	2021
Naturopathic physicians	25	Expert	2021
Conventional healthcare professions
Family medicine physicians	21	Incumbent	2020
General internal medicine physicians	22	Incumbent	2021
Home health aides	42	Incumbent	2014
Nurse practitioners	23	Expert	2021
Physical therapists	25	Incumbent	2020
Physician assistants	37	Expert	2021
Registered nurses	34	Incumbent	2021
Other common occupations
General and operations managers	22	Incumbent	2023
Retail salespersons	30	Incumbent	2018

Abbreviations: CIH=Complementary and Integrative Health. Notes: Maximum sample size is listed here. Sample size for specific variables/items may be lower. For instance, for chiropractors, many variables had a sample of n=19, but freedom to make decisions, bending or twisting and time pressure had sample size of n=18. Year refers to when the Occupational Information Network (O*NET) Work Context information was last updated. Other pieces of information in O*NET about this occupation may have been updated more recently. “Incumbent” refers to respondents who were currently employed in occupation, “Expert” refers to respondents who were previously held the position.

CIH and comparison professions:

The primary aim of this study was to describe working conditions for the 5 licensed CIH professions. O*NET reports specific occupation codes and corresponding working conditions information for 4 of the 5 professions: acupuncturists, chiropractors, massage therapists and naturopathic physicians. For the fifth, midwifery, O*NET has 2 relevant codes: one entitled nurse midwives, and the second, which we used, entitled simply midwives. The latter group encompasses direct-entry midwives, certified professional midwives and lay midwives; as this group of professionals is not required to have a degree in nursing, a conventional healthcare profession,²⁴ we considered it better aligned with CIH.

As shown in Table 1, working conditions data were collected from incumbents for acupuncturists, chiropractors and midwives, while the data were collected from experts for massage therapists and naturopathic physicians. Table 1 lists the sample size for each occupation, which, among CIH professions, ranged from 16 (acupuncturists) to 26 (massage therapists). Table 1 also shows the year when working conditions information for that profession was most recently updated. O*NET updates its dataset regularly, which means that data for different topics and for different occupations were collected at distinct points in time. With the exception of chiropractors, for whom data were last updated in 2013, working conditions data for the other CIH professions were updated in 2020 or 2021.

The second aim of this study was to identify similarities and differences in working conditions facing CIH and non-CIH professions, given the well-documented unhealthy working conditions, high burnout and turnover among conventional, non-CIH health professionals.^9-11,15 Thus, for comparison, we examined the same working conditions information for common non-CIH health professions: family medicine physicians, general internal medicine physicians, physical therapists, registered nurses, physician assistants, nurse practitioners, and home health aides. We also aimed to understand how working conditions in CIH compared to conditions for workers more generally, not only healthcare workers. Because both groups are in the health sector and involve providing patient care, CIH and non-CIH healthcare jobs may have many similar working conditions, while there may be meaningful differences between CIH and professions outside the health sector. ⁵⁶ For this reason, we also examined two of the most common occupations in the US: retail salespersons and generation and operations managers. Table 1 shows sample size, source and year for O*NET data for those comparison occupations.

Variables

O*NET includes data for over 50 working conditions;⁵⁵ we focused on 10 variables that represent health-relevant conditions, including positive conditions as well as potentially harmful ergonomic, psychosocial and schedule conditions. Specifically, for positive working conditions, we examined the degree of freedom to make decisions and coordinating or leading others, in line with evidence that greater control and opportunities for leadership predict better cardiovascular and mental health.^3-5 For ergonomic conditions, we examined the amount of time spent doing repetitive motions, bending and twisting the body, sitting and standing, which are behaviors that can cause musculoskeletal injury and related comorbidities.^6,7 For psychosocial demands, we examined frequency of dealing with unpleasant or angry people and time pressure, in line with evidence that interpersonal conflict and high time demands at work predict worse physical and mental health.^1,8 For schedule, we examined the duration of a typical work week (whether less than, equal to or more than 40 hours per week) and regularity of work schedule (regular, irregular or seasonal), given the negative health effects of working long hours⁴ and of night and/or rotating shifts.⁵⁷

The wording and response scale for each item is shown in Table 2. All items except the schedule items collected responses with a 5-point Likert scale where 1 represented no exposure and 5 represented the highest or most frequent degree of exposure. The two schedule variables had a 3-point, ordinal-level response; for duration of work week, 1 referred to less than 40, 2 referred to 40 and 3 referred to more than 40 hours per week. For work schedules, 1 referred to regular schedule, 2 referred to irregular, and 3 referred to seasonal.

Table 2.

Working conditions variables from O*NET

Domain	O*NET variable	O*NET item wording
Positive working conditions	Freedom to make decisions	How much decision-making freedom, without supervision, does the job offer? (Range: 1 to 5, where 1=No freedom, 3=Limited freedom and 5=A lot of freedom)
	Coordinating or lead	How important is it to coordinate or lead others in accomplishing work activities in this job? (Range: 1 to 5, where 1=Not important at all, 3=Important and 5=Extremely important)
Ergonomic demands	Repetitive motions	How much does this job require making repetitive motions? (Range: 1 to 5, where 1=Never, 3=About half the time, and 5=Continually or almost continually)
	Bending and twisting body	How much does this job require bending or twisting your body? (Range: 1 to 5, where 1=Never, 3 = About half the time, and 5=Continually or almost continually)
	Sitting	How much does this job require sitting? (Range: 1 to 5, where 1=Never, 3=About half the time and 5=Continually or almost continually)
	Spend time standing	How much does this job require standing? (Range: 1 to 5, where 1=Never, 3=About half the time and 5=Continually or almost continually)
Psychosocial demands	Deal with unpleasant or angry people	How frequently does the worker have to deal with unpleasant, angry, or discourteous individuals as part of the job requirements? (Range: 1 to 5;1=Never, 3=Once a month or more but not every week and 5=Every day)
	Time pressure	How often does this job require the worker to meet strict deadlines? (Range: 1 to 5, 1=Never, 3=Once a month or more but not every week and 5=Every day)
Schedule demands	Hours per week (Duration of typical work week)	Number of hours typically worked in one week (Range: 1 to 3, where 1=Less than 40 hours, 2=40 hours and 3=More than 40 hours)
	Schedule irregularity (Work schedules)	How regular are the work schedules for this job? (Range: 1 to 3, where 1=Regular, 2=Irregular and 3=Seasonal)

Analysis

Descriptive data:

O*NET data are made available publicly (www.onetcenter.org) at the occupational level only. For the work context/working conditions information collected from incumbents, O*NET provides mean scores and 95% confidence intervals (CIs) for incumbent-based data. These estimates are weighted for establishment and employee respondent factors (e.g., non-response, under-coverage and the complex sampling design). For information collected from experts, O*NET does not conduct weighting. Expert-based data have mean estimates but not 95% CIs.

We compared mean scores and, where available, 95% CIs for working conditions estimates for the 5 CIH occupations and the 9 comparison occupations. We interpreted and described scores in CIH occupations and comparison occupations by comparing average scores to the corresponding response choice. To understand where working conditions differed statistically significantly across occupations, we identified instances where there was no overlap in the CIs. We focused our comparisons on the 5 CIH occupations and referred to the other occupations for additional context. We used a horizontal bar graph to illustrate and examine a subset of working conditions that varied notably across the 14 occupations.

We conducted data cleaning and analysis in StataMP 18; we created the graph in Excel. Our study was determined to be exempt from further review by the RAND Human Subjects Protection Committee.

RESULTS

The sample of occupations from O*NET represented information from n=108 CIH professionals, n=204 other healthcare professionals and n=52 other common professionals (salespersons and managers), including incumbents and experts. Here we have described selected means and 95% CIs (note that CIs are only available for some occupations). We have noted differences across the CIH professions as well as prominent differences between CIH professions, conventional healthcare professions and non-healthcare occupations (retail salespersons and general and operations managers) All means and CIs are shown in Table 3; specific ergonomic and psychosocial variables are highlighted in Figure 1.

Table 3.

Working conditions scores for complementary and integrative healthcare professions and conventional healthcare professions

	Positive conditions Mean (95% CI) n		Ergonomic demands Mean (95% CI) n				Psychosocial demands Mean (95% CI) n		Schedule demands Mean (95% CI) n
Occupation	Freedom to make decisions	Coordinate or lead	Repetitive motions	Bending or twisting	Sitting	Standing	Deal with unpleasant or angry people	Time pressure	Hours per week	Schedule irregularity
Complementary and Integrative Healthcare
Acupuncturists	4.45 (3.64, 5.00) n=16	2.91 (1.43, 3.48) n=16	3.63 (2.36, 4.89) n=16	3.42 (2.30, 4.54) n=16	2.23 (1.83, 2.63) n=16	3.77 (3.37, 4.18) n=16	2.87 (1.72, 4.03) n=16	3.71 (2.46, 4.96) n=16	2.27 (1.65, 2.89) n=16	1.23 (1.00, 1.64) n=16
Chiropractors	4.96 (4.90, 5.00) n=18	3.37 (2.60, 4.14) n=19	3.7 (2.99, 4.42) n=19	3.43 (2.80, 4.05) n=18	2.51 (2.00, 3.03) n=19	3.55 (2.98, 4.12) n=19	2.70 (2.22, 3.18) n=19	3.58 (2.60, 4.56) n=18	2.00 (1.54, 2.46) n=19	1.0 n=19
Massage therapists	4.54 n=26	1.73 n=26	4.35 n=26	3.96 n=26	2.04 n=26	4.23 n=26	2.19 n=26	2.28 n=25	1.27 n=26	1.54 n=26
Midwives	4.54 (4.23, 4.84) n=22	3.70 (3.09, 4.31) n=22	1.74 (1.38, 2.11) n=22	2.17 (1.97, 2.36) n=22	3.30 (2.78, 3.83) n=22	2.54 (2.23, 2.85) n=22	2.69 (2.21, 3.16) n=22	2.80 (2.29, 3.31) n=22	2.20 (1.73, 2.66) n=22	1.61 (1.45, 1.78) n=22
Naturopathic physicians	4.68 n=25	3.16 n=25	3.63 (2.36, 4.89) n=16	1.72 n=25	3.83 n=24	2.25 n=24	2.87 (1.72, 4.03) n=16	3.88 n=25	2.32 n=25	1.08 n=25
Conventional Healthcare
Family medicine physicians	4.98 (4.94, 5.00) n=21	4.29 (3.96, 4.62) n=21	1.50 (1.00, 2.07) n=21	1.51 (1.26, 1.77) n=21	3.05 (2.39, 3.70) n=21	2.92 (2.27, 3.57) n=21	3.64 (3.15, 4.14) n=20	4.72 (4.33, 5.00) n=21	2.1 (1.82, 2.38) n=21	1.00 n=21
General internal medicine physicians	4.84 (4.59, 5.00) n=21	3.72 (2.83, 4.60) n=21	2.36 (1.66, 3.07) n=21	2.00 (1.66, 2.34) n=22	2.92 (2.48, 3.35) n=22	3.14 (2.71, 3.56) n=22	3.30 (2.75, 3.85) n=21	4.08 (3.41, 4.76) n=22	2.45 (1.93, 2.97) n=22	1.21 (1.00, 1.47) n=22
Home health aides	3.47 (2.83, 4.11) n=42	3.76 (3.27, 4.25) n=41	3.24 (2.64, 3.84) n=42	3.54 (3.01, 4.07) n=42	2.22 (1.82, 2.62) n=42	3.61 (3.04, 4.18) n=42	2.96 (2.43, 3.49) n=41	3.43 (2.84, 4.02) n=40	1.79 (1.45, 2.13) n=42	1.10 (1.00, 1.22) n=42
Nurse practitioners	4.70 n=23	4.09 n=23	2.73 n=22	2.48 n=23	2.83 n=23	3.13 n=23	3.52 n=23	4.09 n=23	2.52 n=23	1.09 n=23
Physical therapists	4.75 (4.43, 5.00) n=25	4.29 (3.64, 4.93) n=25	3.04 (2.45, 3.63) n=25	3.08 (2.57, 3.60) n=25	2.34 (2.08, 2.60) n=25	3.80 (3.52, 4.08) n=24	3.75 (3.22, 4.27) n=25	4.24 (3.65, 4.83) n=25	1.77 (1.42, 2.11) n=25	1.12 (1.00, 1.27) n=25
Physician assistants	4.73 n=37	4.03 n=37	2.49 n=37	2.00 n=37	3.19 n=37	3.33 n=36	3.89 n=36	4.35 n=37	2.62 n=37	1.19 n=37
Registered nurses	4.10 (3.53, 4.68) n=34	4.44 (4.08, 4.80) n=34	2.65 (1.96, 3.34) n=33	2.70 (1.89, 3.51) n=33	2.93 (2.42, 3.44) n=34	3.01 (2.08, 3.94) n=34	4.14 (3.77, 4.51) n=33	3.99 (3.58, 4.40) n=32	2.16 (1.84, 2.49) n=34	1.13 (1.00, 1.29) n=34
Other common occupations
Retail salespersons	3.43 (2.8, 4.06) n=30	3.61 (2.91, 4.31) n=30	2.12 (1.81, 2.43) n=29	2.76 (2.06, 3.46) n=30	2.14 (1.55, 2.73) n=30	4.07 (3.5, 4.64) n=30	3.88 (3.41, 4.34) n=30	3.42 (2.96, 3.89) n=29	1.85 (1.31, 2.4) n=29	1.15 (1.00, 1.35) n=30
General and operations managers	4.81 (4.56, 5.00) n=22	4.48 (4.15, 4.80) n=22	2.42 (1.82, 3.03) n=22	1.96 (1.42, 2.51) n=22	3.09 (2.46, 3.71) n=22	2.90 (2.36, 3.45) n=22	3.24 (2.89, 3.59) n=22	4.08 (3.49, 4.68) n=22	2.70 (2.43, 2.96) n=22	1.16 (1.00, 1.39) n=22

Score range: For positive conditions and for ergonomic, psychosocial and schedule demands, 1 referred to no exposure, 5 referred to the highest frequency of exposure. For hours per week, 1=< 40 hours, 2=40 hours, 3=>40 hours. For schedule irregularity, 1=Regular, 2=Irregular, 3=Seasonal.

CI: Confidence Interval. N refers to sample size from Occupational Information Network (O*NET) data.

Figure 1. Frequency of ergonomic and psychosocial demands for complementary and integrative healthcare, conventional healthcare and other common occupations.

Scores were based on Occupational Information Network (O*NET) data. These graphs visualize the two domains for which there were prominent differences between CIH and other professions.

Positive working conditions:

Most CIH professionals had substantial freedom to make decisions on the job. Mean scores among CIH occupations were all in the “some freedom” to “a lot of freedom” range, from 4.45 (acupuncturists) to 4.96 (chiropractors). Scores were comparable to scores for the non-CIH professions except for home health aids and retail salespersons, which scored considerably lower (mean of 3.47 for home health aids and 3.43 for retail salespersons) and were significantly lower (no overlap in 95% CIs) than decision-making freedom among chiropractors and midwives.

Coordinating or leading others in CIH occupations ranged from a low of fairly important (mean 1.73) among massage therapists to very important (mean 3.70) for midwives. In comparing CIH occupations to the comparison occupations, midwives scored similarly (scores within a tenth of a point) to home health aids and retail salesperson, but for the other CIH professions, coordinating and leading others held less importance compared to other occupations.

Ergonomic demands:

Midwives and naturopathic doctors engaged in repetitive motions less than half the time (mean scores 1.74 and 2.04 respectively), while acupuncturists, chiropractors and massage therapists spent more than half their time doing repetitive motions (mean scores 3.63, 3.70 and 4.35 respectively). Further, scores for the latter three occupations were higher than the other comparison occupations, although the differences did not reach statistical significance. See Figure 1 for graphic illustration of the differences in bending/twisting and repetitive motion.

In terms of frequency of bending and twisting, naturopathic physicians and midwives engaged in these less than half the time (mean scores 1.72 and 2.17, respectively), compared to half the time or more among acupuncturists, chiropractors and massage therapists. Some of the differences in bending and twisting scores reached statistical significance (e.g., 95% CI for chiropractors has no overlap with the 95% CI for midwives). In comparison with other occupations, massage therapists (mean 3.96) bend and twist more frequently than all the comparison occupations. Following closely, acupuncturists and chiropractors (mean scores: 3.42 and 3.43, respectively) bend and twist more frequently than all the other occupations studied except for home health aids (mean 3.54).

For frequency of sitting, scores among CIH occupations ranged from less than half the time for massage therapy (mean 2.04) to more than half the time for naturopathic medicine (mean 3.83). For occupations with CI data available, midwives reported sitting significantly more (mean 3.30) than acupuncturists (mean 2.23). Sitting frequency in CIH occupations had a similar range compared to other occupations. Scores for frequency of standing showed the inverse pattern. Naturopathic physicians reported standing less than half the time (mean 2.25) while massage therapists reported standing more than half the time (mean 4.23). Midwives stood significantly less often (mean 2.54) compared to both acupuncturists (mean 3.77) and chiropractors (mean 3.55). Relative to other occupations, some conventional healthcare jobs like physical therapist (mean 3.80), or retail salespersons (mean 4.01) reported standing as often as acupuncturists and massage therapists. At the same time, other occupations reported less frequent standing, like family medicine (mean 2.92) or in the non-healthcare sector, managers (mean 2.90).

Psychosocial demands:

Frequency of dealing with “unpleasant, angry or discourteous individuals” in CIH occupations ranged from once a year or more for massage therapists (mean 2.19) to once a month for acupuncturists (mean 2.87). The other comparison occupations experienced this more frequently; for instance, at the high end, registered nurses reported dealing with unpleasant people once a week (mean 4.14).

Among CIH professions, time pressure, or requirements to meet strict deadlines, ranged from once a year or more but not every month in massage therapy (mean 2.28), to, on the high end, chiropractors, acupuncturists, and naturopathic physicians, who reported strict deadlines once a week or more (means 3.58, 3.71, 3.88). Time pressure in CIH was generally lower than other healthcare jobs (e.g., at the high end, family medicine physicians reported strict deadlines every day, or mean score 4.72), and CIH occupations experience time pressure comparable to home health aids (mean 3.42) and managers (mean 4.08). See Figure 1 for a graphic illustration of the differences in dealing with unpleasant or angry people and time pressure.

Schedule demands:

Massage therapists reported working less than 40 hours per week (mean score 1, where 1 indicates less than 40 hours), while all other CIH occupations reported roughly 40 hours per week. Most of the comparison occupations also reported working approximately 40 hours per week (responses near 2), although scores for physician assistants and nurse practitioners rounded closer to the greater than 40 hours per week values (mean scores 2.62 and 2.52, respectively), as did general and operations managers (mean 2.70).

Lastly, chiropractors, naturopathic physicians and acupuncturists reported fairly regular schedules (means of 1.0, 1.08 and 1.23, respectively), while massage therapists and midwives tended toward irregular schedules (means of 1.54 and 1.61, respectively). All of the comparison occupations reported regular schedules.

Supplemental Table 1 lists median wages and typical education requirements across these professions. Median annual wages varied, with home health aids and retail workers on the lower end, while most licensed CIH professions, registered nurses, physical therapists, and managers fell in the middle tier/range. Physicians and physician assistants had relatively higher wages. Educational requirement scores tended to align with these wage distributions; however, moderately-paid licensed CIH professions had high educational requirements (i.e., required a graduate degree) that were similar to higher-paying conventional medical professions.

DISCUSSION

We leveraged secondary data to describe working conditions across 5 licensed CIH professions in the US: acupuncturists, chiropractors, massage therapists, midwives, and naturopathic doctors. Overall, CIH professionals generally experienced healthy working conditions and comparable or lower levels of psychosocial hazards and unhealthy schedules relative to non-CIH and other occupations. One important exception was the higher degree of ergonomic exposures in acupuncture, chiropractic and massage therapy.

This has been the first study, to our knowledge, to quantitatively describe working conditions across licensed CIH professions. CIH in the US is growing in terms of the number of professionals⁴⁹ and in its popularity among patients,^28-30 and as the field grows, more CIH professionals and patients can be impacted by healthy and unhealthy working conditions and their sequelae. Our finding of only low to moderate psychosocial hazards and generally reasonable schedule structures is a positive sign for this growing field. However, as noted below, these are complex issues that can vary over time and across settings.

Our findings about ergonomic demands in acupuncture, chiropractic and massage therapy aligned with previous studies in many respects. For instance, prior research identified ergonomic risks among chiropractic students⁴⁷ and practicing chiropractors.^48,58 A study of working conditions among massage therapists posited that physical demands contribute to burnout and attrition in that profession.⁴⁰ Furthermore, moderate to high levels of stress and burnout have been reported among chiropractic students³⁹ and practicing chiropractors,⁵⁸ and we observed moderate psychosocial stressors (i.e., time pressure) among chiropractors – lower than most conventional healthcare providers, but higher than midwives and massage therapists.

Limitations and areas for future research

This study had multiple limitations. O*NET data are not available at the individual level, only at the occupation level, and no demographic or other individual information is available for individuals who provided data. This limited our analyses to only general descriptive statistics and meant that we could not share results stratified by sociodemographic or other variables. We could only obtain confidence intervals (CIs) for occupations where incumbent data were used, further limiting analyses. Some O*NET estimates, including psychosocial conditions among healthcare providers, may have inadequate validity.⁵⁰ In addition, while there were benefits to studying working conditions at the occupation rather than individual level, like avoiding individual variation in perceptions of conditions,⁵⁹ there were also disadvantages. Some health-relevant working conditions may vary too much from one individual to the next to be studied effectively at the occupation level. Even within a profession, there can be widely distinct work settings; for instance, some chiropractors have solo practices and own their own businesses, while others may work as part of a large healthcare organization.^60,61 Solo practices could bring more independence as well as additional stresses; this study cannot capture those distinctions.

Relative to conventional healthcare, CIH professions occupy similar roles within the healthcare system,¹⁶ and we found similarities among these 5 CIH professions in terms of their working conditions– low to moderate psychosocial conditions, limited hazards from scheduling/hours, but concerns around ergonomics for professions doing manual therapy. In spite of the commonalities across CIH professions, opinions vary among scholars and among practitioners as to whether these 5 professions, especially midwifery^62,63 and chiropractic,^64-66 should be categorized as part of CIH. These questions are further complicated by the fact that professional roles can vary across countries and healthcare systems.^24,62,63,67 Classification of these professions, even if not universally agreed upon, helps scientists and practitioners understand “the nature and peculiarities” of these professions, and for the purposes of this study, the ways that CIH professions may differ from their conventional counterparts.⁶⁸ Notably, we focused on 5 licensed CIH professions, but future research should examine other increasingly utilized CIH professions, such as ayurvedic doctors, mind-body therapists, yoga teachers, herbalists and others.

A central element of this study was comparing working conditions in CIH to conditions in conventional healthcare. This approach helped us put potentially abstract working conditions scores into a known context. Yet, it may not be optimal to compare CIH professions to professions such as medicine and nursing that are experiencing burnout crises.^9-11,13 We found that psychosocial conditions like time pressure were moderate in CIH relative to conventional medicine, but the fact that we were comparing CIH to highly stressful jobs could obscure psychosocial challenges in CIH. Our inclusion of retail salespersons and general and operations managers partly addressed this, but the limitations of making comparisons remain. Many CIH practitioners are solo-proprieters^22,23 and thus shoulder the burden of running a business in addition to other responsibilities; these circumstances could bring distinct psychosocial stressors and health hazards^69,70 that would not be captured in the O*NET data used here. Future research should examine the impact of working conditions in CIH on providers and patient care.

The 10 working conditions that we examined may relate to health in a more complex way than a simple linear positive or negative effect. The experience of these conditions can vary based on the characteristics of the individual worker and their environment. For instance, we referred to freedom to make decisions and degree of coordinating or leading others as positive conditions, in line with literature on job control and opportunities for growth,^3,5 but some workers may experience negative health effects as a result.⁷¹

We described, in a supplemental table, typical pay and educational requirements in the occupations that we examined. Notably, some CIH occupations had high educational requirements but moderate pay. This relates to reports of high student loan burden among CIH professionals including naturopathic doctors, acupuncturists and chiropractors.^72-74 High student loan burden is not, strictly speaking, an occupational demand or hazard, but it can negatively impact workers’ mental health and wellbeing⁷⁵ and merits consideration in connection to working conditions and job quality.

Future studies should examine other sociodemographic characteristics among CIH professionals, such as race, ethnicity and gender and their intersections with working conditions. Race, ethnicity and gender are social constructs associated with occupational and other exposures.^76,77 They can indicate underlying structures like gender norms, sexism and racism that affect who has access to which professions.^1,78,79 While each CIH profession has distinct sociodemographic characteristics, typically the professions do not align with the diversity of the US population.⁸⁰ Taking as examples the two most numerous licensed CIH professions, chiropractic and massage therapy, the chiropractic workforce is predominately White (70%)⁸⁰ and also predominately men (67%).²³ In contrast, massage therapy has higher proportions of Latino, Black, American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander professionals relative to the US population⁸⁰ and it is predominately women (75%).⁸¹ Sociographic characteristics can also point to moderating factors that increase health risks from certain working conditions. For instance, we observed high physical demands in massage therapy, and the majority of massage therapists are women. Women healthcare workers may experience higher physical demands at home relative to their male counterparts, in addition to high physical demands at work,⁸² compounding their risk of musculoskeletal problems. As practitioners explore ways to mitigate occupational exposures,⁴⁶ these broader social contexts should also be taken into account.

The working conditions examined here continue to evolve, including for CIH professions. For instance, we observed low to moderate frequency of dealing with angry people among CIH professions, but violence against a variety of health care providers may be on the rise.^83,84 As their professions become further integrated into larger healthcare systems, CIH providers may be more subject to this hazard.^20,61 In addition, while the acupuncturist, massage therapist, midwife and naturopathic physician data were all from 2020 or 2021, the chiropractic data came from 2013, meaning those results would not reflect working conditions that have changed noticeably in the past decade.

Further, there are many health-relevant working conditions that are not captured in O*NET and would be important for CIH. Interpersonal dynamics and interactions with other professions, including perceived discrimination, may be particularly important in CIH, evidenced in prior research by concerns among chiropractors³⁴ and massage therapists^35,44 about how others view their professions. CIH professions have historically functioned outside of the conventional healthcare system, but are increasingly being integrated into multidisciplinary healthcare systems and working alongside conventional healthcare providers such as the Veterans Health Administration.^17,20,61 While a positive development overall, this could mean that some CIH providers are now interfacing with other professionals who may not understand their training and skills. We also did not have information about sexual harassment on the job. Prior research with massage therapists and female chiropractors found they were vulnerable to sexual harassment, in part because their job involves providing manual therapy.^85,86

Policy implications

The World Health Organization (WHO)/International Labour Organization (ILO)’s 2022 report, “Caring for those who care,” underscored the importance of conducting a basic assessment of occupational hazards facing health workers, listing it as the first essential function of any health worker occupational health program.⁸⁷ The present study is the first to collectively examine occupational health issues among licensed CIH providers, focusing on the US.

Working conditions are modifiable.^88,89 Given the ergonomic risks we identified facing acupuncturists, chiropractors and massage therapists, interventions should be explored to reduce those hazards. For instance, additional training can be offered to prevent common problems, like a strength building program for chiropractic and other CIH students to prevent musculoskeletal injuries.⁹⁰ Stretching programs could also be helpful,⁹¹ as well as social support and mentorship to CIH trainees.⁹² Clinical care approaches can also be modified; one mainstream medical study reduced clinician burnout by redistributing tasks between medical assistants and clinicians.⁹³ Research on massage therapists suggests that if management is supportive of provider self-care, the workplace safety culture is improved.⁴⁶ WHO offers a free online toolkit for reducing common hazards affecting health workers, including occupational stress, harassment and injuries.⁹⁴ Many of these interventions focus on changes that practitioners need to implement. Per the hierarchy of controls model, the most effective occupation safety and health interventions eliminate or remove workers from hazards, rather than relying on workers to implement controls.⁹⁵ Future research should examine higher level interventions to reduce exposure to musculoskeletal and psychosocial demands among CIH providers. The continued growth and popularity of these professions urges greater attention from occupational health to these issues.

LEARNING OUTCOMES.

• Readers will evaluate why working conditions for complementary and integrative healthcare providers merit study

• Readers will identify at least one unhealthy working condition to which complementary and integrative healthcare providers are disproportionately affected

• Researchers will analyze O*NET data as a source of information for working conditions among healthcare providers

Data availability:

Data used for this study are publicly available at https://www.onetonline.org/