A Survey of Acupuncture Chinese Herbal Medicine Students to Identify Barriers to Teaching and Motivations to Study Acupuncture Research

Abstract

Background:

While acupuncture use and research publications are growing in the United States, we know little about acupuncture and chinese herbal medicine (ACHM) students’ beliefs and behaviors regarding acupuncture research.

Purpose:

This project aims to identify barriers to teaching acupuncture research and opportunities to engage and excite students to study acupuncture research. To our knowledge, a national survey of acupuncture students’ research interests has not been completed previously.

Methods:

A cross-sectional survey of 32 closed and 6 open-ended questions was administered once through SurveyMonkey^© to ACHM students in the United States. Analysis techniques include simple tabulations with confidence intervals for central tendency, along with selected correlations between variables.

Results:

We received responses from students at 36 different schools, with 16 schools not represented. The total number of student respondents recorded was 467. We found heterogeneity in many of the attitude and behavior response sets, highlighting the diversity of students’ viewpoints. Many students were comfortable with their level of research skills. Attitudes toward the importance of research for the ACHM profession were often correlated with each other, with demographics suggesting that the background and demographics of the students may be related to their attitudes towards research education. These relationships can help tailor ways to address specific subpopulations of acupuncture students and students interested in studying acupuncture research.

Discussion:

The authors are ACHM educators and researchers who offer data-based suggestions to potentially improve students’ appreciation of the importance of research to ACHM.

INTRODUCTION

The rationale for performing this survey of acupuncture and chinese herbal medicine (ACHM) students was to identify barriers to teaching acupuncture research and opportunities to engage and excite students to study acupuncture research. To our knowledge, a national survey of acupuncture students’ research interests has not been completed previously. Understanding students’ barriers to learning relevant research and developing research skills is the next step in reducing those barriers. Reducing barriers may increase student interest in the topic of research, and interest is a powerful motivation to energize learning,¹ leading to deeper processing, feelings of enjoyment, and understanding.²

BACKGROUND

The National Center for Complementary and Integrative Health awarded a series of R25 grants to complementary and integrative health (CIH) institutions³ starting in 2001 through the Complementary and Alternative Medicine Practitioner Research Education Project Grant Partnership. The goal of these awards was to increase the quality and quantity of education research, especially evidence-informed practice (EIP), in CIH institutions. These grants involved a partnership between a CIH and a research-intensive institution, with the long-term goal of encouraging the integration of research into clinical practice.

These grants funded projects to assess the research skills of CIH students at three ACHM schools in the United States. One such project was the survey completed at the Pacific College of Health and Science (formerly named Pacific College of Oriental Medicine), upon which this current project’s survey is based.⁴ Other surveys were completed at the New England School of Acupuncture and the Oregon College of Oriental Medicine.⁵ These were surveys of students at different stages of their ACHM programs assessing student perspectives about research and self-assessed research skills. These surveys were completed between 2006 and 2012.

Findings from these studies included: (1) students recognized the importance of research, especially to the public, the medical profession, and insurance companies; and (2) students’ interest in and perceived value of research declined over the 3–4 years of these academic degree programs.^5,6 This trend has also been reported with chiropractic students.⁶ A possible reason for this decrease in student interest as CIH programs progress is that students may become increasingly aware of the differences between clinical practice and the standardized treatment approaches used in randomized controlled trials.⁶ However, in recent years, medical research that reflects real-world practice (e.g., pragmatic clinical trials) and whole-person health concepts has become more common and accepted.^7,8 Thus, it is possible that such student perceptions may have changed.

The Accreditation Commission for Acupuncture and Herbal Medicine (ACAHM) sets standards for research and EIP education. Master’s degree competencies include the ability to find, assess, and use biomedical research as part of a treatment plan, and doctoral degree competencies include the ability to discuss biomedical theories and assess relevant information from a wide variety of sources.⁹ Doctoral degree programs (of which there are 31 in the United States) usually have dedicated research courses. Programs that grant only master’s degrees (of which there are 68 in the United States) may or may not have a dedicated research course.¹⁰

The authors of this study identified two primary gaps in our current knowledge base. First, these surveys mentioned above were conducted over a decade ago, and in that time, the average age of ACHM students decreased, with more students choosing ACHM as their first career. Furthermore, the number of ACHM students actively studying has decreased by 25%.¹¹ With these demographic changes, there is reason to believe that current ACHM students’ perspectives about research may differ from those found previously. Do ACHM students still find less value in research as programs progress?⁴ A second gap is that no nationwide survey has been undertaken to assess ACHM student perspectives toward research. Having national data improves the applicability of our results to ACHM schools in the United States.

This survey is part of a larger project aimed at improving the teaching of research in ACHM programs. To that end, the authors surveyed subject matter experts and stakeholders to create a model research curriculum. The report of that survey and the curriculum are currently under review for publication. The authors recognize that students are stakeholders in this conversation.

Purpose and Aim

This survey sought to answer the following questions: What are ACHM students’ skills, knowledge, and attitudes towards evidence-based medicine, research in general, and acupuncture research in particular? Are there any student characteristics (age, career history, educational attainment, etc.) that are related to the students’ perceptions? Our goal in asking these questions was to identify barriers to teaching acupuncture research and provide insight into possible opportunities to engage and excite students to study acupuncture research.

METHODS

Study Design

The study design was a cross-sectional survey of 32 closed and 6 open-ended questions administered once through SurveyMonkey^© (please see Supplementary Appendix SA2: Student Survey).

Part 1 of the survey asked demographic questions. These questions were multiple choice with an option for “other” and space to explain. Data collected included gender, age, previous education, years of ACHM schooling, degree program, ethnic background, English as a second language, current employment, annual income, and research experience.

Part 2 questions were designed to understand survey participants’ interest in research in general, ACHM research in particular, and beliefs concerning ACHM and CIH research. Most of these questions allowed participants to use a slide bar to indicate their agreement/disagreement with statements. Rather than offering preset category responses, the use of a slider scale allows us to collect interval data, capturing an array of responses.¹²

The Study Population

The study population was ACHM students enrolled in accredited programs in the United States. In April 2021, we obtained a list of the 56 ACHM schools accredited in the United States by the ACAHM.¹³ We searched each program’s website for program directors and contact information.

Schools were excluded if they were not accredited by the ACAHM. All master’s and doctoral students from the 56 accredited schools were eligible to be included in this study if they were over 18 years of age.

The total possible number of eligible students at the time the survey was planned (Fall 2020) was 6508 students.¹⁰ We aimed to reach all eligible enrolled students without sampling restrictions. The authors pretested the questionnaire by taking the survey.

Further details on the time of the survey administration itself are included in Supplementary Appendix SA3.

Data was analyzed using the SPSS data analysis platform (IBM Corp. Released 2012; IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY). Simple tabulations with confidence intervals for central tendency were included. We also considered a few relationships between respondents’ demographics and reported attitudes or behaviors, as well as relationships with the belief that acupuncture is more a science than an art, using Spearman chi-square correlations. We performed data cleaning, tabulations, and graphic representations of responses. Open-ended questions were collected and read for themes and will be reported in a later publication.

RESULTS

We received responses from students at 36 different schools, with 16 schools not represented. Total number of student respondents recorded was 467, but 17 of these attempts did not record consent, reported that they were not students but graduates, and one respondent was studying in a Chinese rather than a US school; these cases were dropped from the final analysis, leaving a total sample of 445. There are approximately 6508 students currently enrolled in US ACHM academic programs. Therefore, the survey response rate was approximately 7%.

Table 1 displays the demographic characteristics of our sample. To estimate how representative our sample is, the far right column of Table 1 lists the known same categories for all acupuncture students in this country according to the accrediting body (ACAHM). Note that these data were collected during the COVID-19 pandemic, which may have influenced the income potential for some respondents. Students most often identified as white, female, native English-speaking, and in their mid-30s to early 50s. The most commonly reported annual income category is $40,000–$54,999.

Table 1.

Demographics of Our Sample

Race	% reporting (n)	Compared with other acupuncture students
White	61.1 (272)	42.3
Black	2.9 (13)	4.6 (241)
American Indian or Alaska Native	2.7 (12)	0.57 (30)
Asian	26.5 (118)	39.7 (2079)
Hispanic	8.1 (36)	8.0 (417)
Native Hawaiian or Pacific Islander	0.9 (4)	0.40 (21)
Resident Alien	0.4 (2)	NA
Race/ethnicity unknown	1.3 (6)	NA
Other (write in most common responses were Irish [n = 4], Jewish [n = 2])	4.5 (20)	NA
Is English a second language for you?
Yes	25.8 (115)	10% of US students CCD
No	73.5 (327)	NA
Currently employed
No	37.8 (168)	NA
Yes	61.6 (274)	NA
Age
18–22	0.7 (3)	NA
23–27	8.5 (38)	NA
28–32	15.5 (69)	NA
33–37	13.9 (62)	NA
38–42	14.2 (63)	NA
43–47	14.8 (66)	NA
48–52	12.8 (57)	NA
53–57	9.4 (42)	NA
58–62	5.8 (26)	NA
63–67	2.5 (11)	NA
68–72	1.1 (5)	NA
Income
$0	8.1 (36)	NA
$1–$9999	12.4 (55)	NA
$10,000–$24,999	13.7 (61)	NA
$25,000–$39,999	9.7 (43)	NA
$40,000–$54,999	10.6 (47)	NA
$55,000–$69,999	9.2 (41)	NA
$70,000–$84,999	7.6 (34)	NA
$85,000–$99,999	3.6 (16)	NA
$100,000–$114,999	2.9 (13)	NA
$115,000–$129,999	1.3 (6)	NA
$130,000–144,999	1.8 (8)	NA
$145,000–$159,999	1.8 (8)	NA
$160,000–$174,999	0.4 (2)	NA
$175,000 or more	4.7 (21)	NA
I prefer not to say	10.8 (48)	NA
Gender		From ACACHM report: compared with survey US acupuncture students
Female	73 (322)	78.6 (4581)
Male	17 (76)	22.5 (1328)
Nonbinary	3 (14)	NA
Queer	Less than 1% (1)	NA
Other (genderfluid, questioning, etc.)	Less than 1% (1)	NA
Prefer not to say	Less than 1% (3)	NA
No answer	5.2 (23)	NA

Multiple responses were allowed for the race and gender categories for accurate recording. The far right column lists the same categories for all acupuncture students in this country according to the Accreditation Commission for Acupuncture and Herbal Medicine (ACACHM) to show how representative our respondents are of ACHM students in the United States. The percentage of students who report English as a second language is compared with the same figure from the US Department of Education, National Center for Education Statistics, Common Core of Data (CCD).

NA, not available.

Table 2 offers detail on respondents’ research and educational background, including years in ACHM school and other ACHM and non-ACHM education. A mere 1% had not completed a bachelor’s degree, and many had a master’s (35%) or a doctorate degree (18%). Most (66%) were in their first few years of school and reported having some research experience (57.3%). This experience most frequently occurred during undergraduate or graduate educational experiences, with fewer reporting experiences from employment (17.6%). Number reporting is noted as n=.

Table 2.

Educational Background of Our Sample

	% reporting (n=)
Highest degree you currently hold?
Incomplete undergraduate	Less than 1% (1)
Associates	Less than 1% (4)
Bachelors	46 (199)
Masters	35 (157)
Doctorate	18 (79)
No Answer	Less than 1% (5)
How many years have you been a student at your EAM school
Less than 1 year	27.4 (122)
1 year but less than 2	20.4 (91)
2 years but less than 3	20.9 (93)
3 years but less than 4	13.7 (61)
4 years but less than 5	9.4 (35)
5 or more years	7.9 (35)
Currently on medical leave	Less than 1% (1)
Do you have research experience?
No	42.5 (189)
Yes	57.3 (255)
No answer	Less than 1% (1)
If you have research experience, where did you receive it?
While completing undergraduate degree	31 (137)
While completing graduate degree	28 (126)
Volunteer	4.5 (20)
Employment	17.6 (78)
Other
If your research experience comes from employment, what was your role?
Research assistant	12.1 (54)
Study coordinator	4.7 (21)
Health care practitioner	11.2 (50)
Measured key clinical outcome(s)	1.6 (7)
Assessed adverse events	1.1 (5)
Basic scientist (animal or laboratory-related)	4.9 (22)
Clinical researcher (clinical trials, etc.)	4.9 (22)
Data manager or statistician	6.5 (29)
Other (nonmedical research work is most common)	5.1 (23)

n = is noted as number reporting.

Figure 1 consists of frequency polygons, a graph that shows the count of respondents’ perspectives on the questions for each of the attitude and behavior questions. The higher the frequency, the more respondents endorsed that particular perspective. They demonstrate the rich heterogeneity in respondents’ attitudes toward research in general, EAM research in particular, and their beliefs concerning ACHM and CIH research. Subjects were asked to rate their level of agreement from lack of agreement (0) to complete agreement (100) for each of the statements shown in the legend of the figure. The first (A) mostly skews to the right, indicating a general comfort in using research skills such as finding articles and understanding sources of bias. The second (B) and third (C) tell the story of respondents’ attitudes toward their research education, and the shape of the figures shows more respondents feeling unsure or even negative about their program. The fourth (D) tells us of a generally positive attitude toward research and its applications to increasing patient referrals and strengthening the knowledge base of ACHM. Yet more doubt enters in the fifth (E) set of responses as students consider research’s importance in ACHM in particular; here, we see many students reporting that biomedical research may not be relevant to the practice of ACHM. The sixth (F) tells us that many students are interested in continuing with research for themselves and the profession. Of note, the 2nd, 3rd, 5th, and 6th sets of responses show many students who are unsure or ambivalent. Overall, the mean of responses in all cases was about 50%, indicating that in this sample, most of the respondents scored at the midpoint or positive toward research and its applications to ACHM; fewer students were negative.

FIG. 1.

Students’ attitudes and behaviors concerning ACHM research and research activities. ACHM, acupuncture and herbal medicine.

We also considered whether attitudes correlated with students’ previous research experience, age, or belief that acupuncture is more a science than an art, using Pearson’s or Spearman’s rho correlations as appropriate.¹⁴ The correlation table (FIG. 2) displays these correlations labeled from lightest to darkest: negligible correlation (p < 0.00–0.30), low correlation (0.30–0.50), moderate correlation (0.50–0.70), or high correlation (0.70–0.90). The correlation analysis found that self-reported previous research experience was positively related to questions of comfort in identifying well-designed research and reading scientific literature. Students’ age was positively related to their desire to engage in EAM research after graduation, belief that the scientific method (gathering empirical and measurable evidence) is compatible with the basic principles of EAM, and comfort in identifying well-designed research. The degree currently held was not related to any of the attitude or behavioral questions. What degree program the respondent was currently engaged in was negligibly correlated with a few of the attitude questions. We also considered whether exposure to acupuncture training was related to attitudes and behaviors. The number of years students had been in their program and previous degrees were not related to attitudes or behavior.

FIG. 2.

Correlation table of students’ demographics with attitudes and behaviors.

The belief that acupuncture is more of a science than an art was positively associated with all but one of the attitude questions (row 30, correlation table), but not to respondents’ age, year in program, or degree being sought. That is, those who saw acupuncture to be more of a science than an art tended to have a supportive attitude toward biomedical research education in the ACHM curriculum, saw the importance of biomedical literature applied to patient care, and felt that biomedical research supported the profession in the eyes of patients and other health care providers. None of the behavior questions (such as comfort using the web to find research) were associated with the belief that acupuncture is more of a science than an art, nor was self-reported previous research experience.

DISCUSSION

Most of our students report comfort in searching the research literature, applying their research skills. Most students did not support increasing research training either earlier in the program or throughout the curriculum. Still, most students believed that research education should be part of their ACHM program and that their schools should apply for external research funding. The greater the respondents’ experience with research, the more they agreed that research education is a necessary part of ACHM education. A strong majority see the importance of biomedical research in shaping public perception, increasing insurance reimbursements, and improving biomedical referrals to acupuncturists. A majority of students felt biomedical research was useful to their clinical practice, that their quality of patient care is improved when they assess the outcomes of their treatments and use this knowledge to decide on future treatments, and that the scientific method is compatible with the principles of ACHM. Finally, students reported interest in engaging in research after graduation and felt that CIH practitioners would benefit from a strong foundation of training in research methodology and outcomes. While most students supported these ideas, a large number were indifferent/unsure or did not agree. This can be seen in the figures with a large spike in the middle. This significant number leaves room for improvement in acupuncture research education as more and better quality research education may improve students’ interest in research.

Our data align with similar studies undertaken at ACHM and CIH institutions^4–6 that showed CIH students recognize the importance of research and that students’ research skills improved after taking EIP courses. These studies also showed that students’ interest and perceived value of research declined as they progressed through the degree programs. Our sample did not show this trend, possibly because most students completing the survey were in the first two years of their ACHM degree program. Notably, we had a few students completing the survey in the later stages of their degree programs (years 3 onward), possibly suggesting a disinterest in research among these students.

We also considered if the question, “Is acupuncture more of an art than a science?” correlated with other attitude and behavioral questions. The authors together have over 85 years of experience in ACHM research and teaching research methods to acupuncture students. We hypothesized that this belief may drive acceptance or rejection of the importance of research education. While correlation does not show causation, we did find a consistent trend in the correlations that the belief that acupuncture is more of an art was negatively correlated with positive attitudes toward research education and application. Another way to understand this relationship is that students who think acupuncture is more a science than an art are more likely to see the need for scientific evidence to be applied to patient care and inclusion of research in their own education. Interestingly, we found that responses to this question of art versus science were not correlated with previous research experience or any of the behavioral questions, such as comfort searching the science literature. This suggests that there may be at least two ways to increase students’ interest in research. One is to address students’ attitudes through education about ACHM science and methods, and the second is to build students’ confidence in performing research behaviors. Past research has shown that ACHM master’s degree students’ self-reported research behaviors and attitudes can increase after a 14-week, 3-h-per-week, face-to-face Evidenced Informed Practice course.¹⁵

Suggested remediation for the attitude that acupuncture is more than an art can include giving students more evidence and experience that acupuncture is a science and/or can be studied scientifically. Specific research education tasks could include first (1) showing students a broader view of “science,” and that different medical systems use different worldviews that carry along with them different ways of doing science. Study design should be determined by what question the investigator is interested in. While biomedicine may privilege controlled study designs and mechanistic biological explanations, other study designs exist that can be more appropriate for certain study questions. (2) Employ a greater focus on research designs that are in line with the real-world practice and required treatment or clinical material students need to know to pass their board exams for licensure; for example, case study designs that require rich clinical information and observational studies that were popularly used historically in the development of Chinese Medicine on which ACHM is based.¹⁶ (3) More examples of controlled studies that do not lose the “art” part, that is, the importance of practitioner engagement with Chinese medicine theory, such as the recent machine learning studies that show predictability from Chinese medicine diagnoses,¹⁷ and pragmatic clinical trials that allow for the inclusion of a naturalistic context of treatment and reflect real-world practice.¹⁸ (4) Research curricula should include data showing that acupuncture research has led to increased government and private insurance reimbursements and increased acceptance by biomedical practitioners as a motivator for student learning. Students can consider questions such as how ACHM research has affected policy and the biomedical science world and the acceptance of acupuncture by biomedicine (such as mechanistic studies). (5) Another motivator is to emphasize that good clinicians are engaged in the research process every time they enter a treatment room by asking, “What is the best treatment for my patient?” and afterward, “What was the result of my treatment?” Clinically relevant research should be included that shows acupuncture’s effectiveness in treating a variety of conditions. A list of specific research topics educators could include can be found in Supplementary Appendix SA1.

The authors recently published a related survey of subject matter experts and stakeholders considering ways to improve acupuncture research education, which resulted in the development of a model research curriculum that mirrors the above topics and more.¹⁹ Curriculum changes are possible and can be well received by students.²⁰

Limitations

Although our survey response rate of 7% was low, it is similar to other national web surveys with response rates of 8%,²¹ 11%, and higher.²² A clear weakness of our data originates from our lack of access to the population. We could not directly reach out to ACHM students in accredited programs because no national list of ACHM students exists, and student names are protected by the Family Educational Rights and Privacy Act. Additionally, the ACHM profession does not have a publicly available list of directors of ACHM programs. There was no mechanism to ensure the people we identified would send the survey to their students, and a few programs said they would require approval of the survey from their own institutional review boards and declined to make that request. To better understand the research needs and perspectives of students at ACHM schools, communication that supports the collection of informative data needs to be established and supported by all stakeholders.

In the interest of confidentiality and with special consideration for our vulnerable population of students, we collected no identifiers. This made it impossible to check for duplicate entries.

Our sample demographics resemble those of other known samples in many ways. Some differences that we might expect include our sample having a higher percentage of people who spoke English as a second language ([25.8%] versus the national average for students which is 10%).

A limitation of the survey structure was the lack of a “no response” option on attitude and behavior questions. While including a “no response” option can reduce noise in data from questions that respondents may not feel clearly about,²³ in our case, we were asking about the respondents’ own behaviors and attitudes. Still, respondents might have endorsed the scale’s midpoint to indicate indifference, uncertainty, or no opinion, and we cannot determine the intended sentiment. But the data does not indicate that as for all questions there is a range of sentiment and experience in our sample.

Future research will combine the data from this student survey with our survey results of ACHM subject matter experts and stakeholders with the goal of improving research curricula and creating a model curriculum that can be adopted by all acupuncture programs. We are also conducting a qualitative analysis of the open fields collected in this student survey, which builds on previous work concerning the importance and value of thinking about a medical system’s worldview.²⁴

CONCLUSION

We found great heterogeneity in the attitudes of ACHM students toward research, suggesting that educators could use a diversity of rationales and methods to help students engage with the material. A discussion of the importance of medical worldview is important to place early and often in the curriculum to encourage students to visit and revisit their attitudes toward different ways of thinking about health and medicine.

AUTHORS’ CONTRIBUTIONS

All authors were involved in the conceptualization of the project. L.C. designed the survey tool and completed the data management and analysis with input from the other authors. All authors were involved in the article development and conclusions.

AUTHOR DISCLOSURE STATEMENT

No competing financial interests exist.

FUNDING INFORMATION

No funding was received for this review.