Intercultural dissemination of complementary and alternative medicine: unveiling the intentions of foreign students in China to share traditional medicine culture cross-border

Abstract

Background

Complementary and Alternative Medicine (CAM), including Traditional Chinese Medicine (TCM), is gaining global recognition. The cross-border exchange of knowledge, particularly regarding the cultural aspects of various medical systems, has become more important than ever for fostering integrative medicine and inclusive health care. This study investigates the factors influencing international students’ intentions to share TCM culture across borders, using the Theory of Planned Behaviour (TPB) as a framework.

Methods

A TCM Culture Sharing Scale was developed based on the TPB model through expert consultation, Delphi surveys, and psychometric evaluations, followed by a pilot survey. A cross-sectional survey was conducted among international students studying in Mainland China. Logistic regression models were used to examine the influence of attitudes (ATT), subjective norms (SN), perceived behavioural control (PBC), and various sociodemographic factors on international students’ intentions to share TCM culture with people from their home countries.

Results

Of the 1,438 valid responses, ATT (OR = 1.306, 95% CI: 1.202–1.419, P < 0.001) and PBC (OR = 1.554, 95% CI: 1.437–1.682, P < 0.001) significantly predicted international students’ intentions to share TCM culture with people from their home countries, while SN was not significant. Male students, atheists, and those with prior TCM experiences were more likely to share TCM culture. Students pursing their doctorate degree or from Europe showed lower odds of sharing. The multivariable model demonstrated strong predictive power (AUC = 0.933).

Conclusion

This study highlights the importance of ATT and PBC in shaping international students’ intentions to share TCM culture across borders and suggests that fostering positive attitudes and empowering students through resources and experiential learning can enhance cross-border dissemination of TCM culture. Aligned with broader efforts to establish more integrative and inclusive healthcare systems, this study provides insights into enhancing the global dissemination of CAM, emphasizing its cultural foundations. Future research should expand to longitudinal and qualitative approaches for broader and deeper insights into CAM culture sharing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-025-05200-6.

Introduction

Background

The integration of complementary and alternative medicine (CAM) into mainstream healthcare systems demands a paradigm shift in both the dissemination of knowledge and its acceptance across various medical frameworks. Medical systems, such as Ayurveda, Homeopathy, Naturopathy, and Traditional Chinese Medicine (TCM), encompass comprehensive philosophies and approaches to diagnosing and treating diseases. As integrative medicine [1–3] and integrated care [4, 5] gain momentum, exchanges of CAM knowledge become increasingly vital to creating healthcare services and models that are diverse, adaptable, and synergistic. By aligning traditional practices with modern medical standards, this global exchange enhances therapeutic options and fosters more holistic patient care.

Lupton (2012) [6] suggested that medicine has cultural aspects, which can present significant challenges in comprehending or harmonizing medical practices from diverse countries and regions, particularly in reconciling the differences between Western and Eastern medicine [7]. According to Lupton (2012) [6] and other social scientists [8], culture, more broadly, could be understood as the conglomeration of meanings, discourses, technologies and practices that accumulate around medicine, specifically “a set of values, beliefs, and norms that direct the thinking and decision making in medicine” [8].It has been widely acknowledged by socio-cultural research that culture matters in understanding, delivering and experiencing medical practices and services, especially in a cross-cultural context [9]. Therefore, it is crucial to prioritize culture, rather than simply considering it as a backdrop, when examining medicine systems as well as their flows and dynamics.

A wide consensus is that TCM, a China-originated, time-honoured, distinct healthcare system characterized by unique concepts, substances, and methodologies, is a profound repository of Chinese cultural heritage [7]. It rooted in traditional Chinese philosophies such as “balance” and “holism”, embodying a comprehensive framework of values, beliefs, norms, and principles that intricately guide people’s understanding of health and health-related decision-making processes [10].

TCM has served as a cornerstone for health maintenance, disease prevention, and treatment among the Chinese populace for millennia, and recently has recognized as a pivotal player in the fight against pandemics such as COVID-19 [10, 11]. In the last three decades, China has been committed to promoting TCM globally, focusing on improving its standards of diagnosis, treatment, and evaluation, increasing its export volume of materials and services, and establishing the legal status of TCM in other countries [12, 13]. However, efforts have predominantly emphasized TCM as a medical technology or service, without much highlighting its cultural properties. Culturally specific theories, values, beliefs, norms, and principles that form the foundation of TCM often present as opaque and elusive to those beyond its cultural milieu, thereby inhibiting its widespread adoption and integration into diverse cultural contexts [14]. Language barriers, as well as political dynamics and ideological diversity, further compound these obstacles, impeding the international community’s complete comprehension of TCM culture [15]. Currently, while the majority of empirical studies have focused on the knowledge and attitudes of individuals from diverse backgrounds towards TCM and their intentions of or behaviours in using it [12, 16, 17], there is a lack of research specifically examining people’s views on the cultural aspect of TCM and their significance in the global dissemination and promotion of TCM.

International student mobility, a result of the trend toward globalization as well as a driver of globalization itself, has captured the attention of scholars across multiple disciplines and topics [18], particularly in education [19], psychology [20], and socio-cultural studies [21]. As the “TCM going abroad” national strategy advances, which has been deeply integrated into cross-border initiatives such as “One Belt, One Road” as well as international education programs, Chinese scholars have recently started to examine TCM education and promotion through the lens of international students who receive education in China [22–24]. For instance, Qiu (2007) [7] investigated opinions about TCM courses and learning among undergraduate international students majoring in conventional medicine at a university in China. Zhu et al. (2022) [24] suggested that in addition to providing medical knowledge and practical demonstrations, a comprehensive approach that incorporates cultural elements into TCM course should be considered to improve the learning experience for international students.

Despite the extensive research on the knowledge, attitudes, and practices of TCM among foreign students and adults [25, 26], there is a lack of research focusing on the role and perspectives of higher-education foreign students in a cross-national or cross-cultural context to promote TCM culture. Specifically, there is a need to understand their willingness or intentions to share and disseminate TCM culture in their home countries. While international students studying in China have the opportunity to gain experiential understanding and appreciation of TCM culture, their potential role as ambassadors for sharing and promoting TCM culture has not been fully understood.

Theoretical foundation

The Theory of Planned Behaviour (TPB), proposed by Ajzen (1991) [27], is a useful framework for analysing and predicting social behaviour. According to TPB, the intention to perform a behaviour (BI) is influenced by the person’s attitude that reflects the person’s expectations or beliefs about the behaviour (ATT), subjective norms that refers to perceived expectations from important people or social pressure to perform the behaviour (SN), and perceived behavioural control (PBC) that relates to the individual's perceived ability and capability to perform the behaviour [27]. Picture illustrates TPB conceptual model (Fig. 1). TPB has been used in multi-cultural settings to understand how different cultures form or characterise sharing behaviours such as knowledge sharing and information sharing [28, 29]. However, there are no published studies that employed TPB to investigate knowledge or information sharing in cross-cultural or cross-national settings in relation to medicines and medical culture.

Fig. 1.

The conceptual model of the Theory of Planned Behaviour (TPB). It provides illustration of the Theory of Planned Behaviour model, detailing theoretically how attitudes, subjective norms, and perceived behavioural control influence behavioural intentions and behaviours

Objectives and hypotheses

The purpose of this study is to investigate international students’ intentions to share TCM culture with people from their home countries while studying in China, using the TBP framework. We examined how the three constructs of the TPB (ATT, SN, and PBC) predict international students’ intentions to share TCM culture across borders. We developed the following hypotheses (Fig. 2).

Fig. 2.

Hypotheses of the study. It presents the hypothesized relationships between attitudes, subjective norms, perceived behavioural control, and the intention to share TCM culture

• H1: Attitudes towards sharing TCM culture with people from their home countries will predict international students’ intentions to do so.

• H2: Subjective norms regarding sharing TCM culture with people from their home countries will predict international students’ intentions to do so.

• H3: Perceived behavioural control over sharing TCM culture with people from their home countries will predict international students’ intentions to do so.

Materials and methods

Development of measurement

To measure the three constructs of the TPB (ATT, SN, and PBC) in relation to international students’ behavioural intentions (BI) to share TCM culture with people from their home countries, we developed a TCM Culture Sharing ATT-SN-PBC Scale via a multi-step approach. For generating items, we conducted a comprehensive review of existing literature primarily on knowledge and information sharing [30], TCM culture [31, 32], TPB-based questionnaires [33, 34], as well as their intersections, including sources in both English and Chinese (primary databases: PubMed, Embase, Web of Science, CNKI, VIP and Wanfang). In addition, two focus group sessions were conducted with international students (n = 6 per session) using a series of open-ended questions, which helped to explore more attitudinal, normative and control beliefs influencing the target behaviour. The initial item pool was presented in Additional File 1. Each construct includes a series of questions on a five-point scale, where “1” indicated the most negative view (i.e., strongly disagree) while “5” meant the most favourable view (i.e., strongly agree).

For refining and validating items, expert consultation (n = 4, one expert specialized in TCM culture, one in scale development, one in statistical analysis, and one in international education), two-round Delphi survey (n = 20), cognitive interviews with international students (n = 7), and psychometric properties evaluation with a pilot study in Zhejiang Chinese Medical University (n = 160, based on the commonly used rule that sample size should be at least 10 times the number of items [35]) were conducted.

The final version of the TCM Culture Sharing ATT-SN-PBC Scale is presented in Table 1, along with the results of reliability and validity tests, primarily using Cronbach’s alpha analysis and confirmatory factor analysis (CFA) [36]. The 12-item TCM Culture Sharing ATT-SN-PBC Scale (with 4 items for ATT [score range: 4–20], 3 for SN [score range: 3–15], and 5 for PBC [score range:5–25]) demonstrated high reliability and validity.

Table 1.

Final Version of the TCM Culture Sharing ATT-SN-PBC Scale with Reliability and Validity Test Results

Constructs	Item			Item To Total Correlation	Revised Item To Total Correlation (Item to the rest)	Cronbach's α Coefficient After Deletion	Factor Loading	Average Variance Extracted (AVE)	Composite Reliability (CR)
ATT	ATT1: I think sharing TCM culture with people from my home country will be beneficial to the overall development of my home country			0.784**	0.779	0.958	0.916	0.7846	0.9357
	ATT2: I think sharing TCM culture with people from my home country will promote the health of people in my home country			0.799**	0.786	0.958	0.916
	ATT3: I think sharing TCM culture with people from my home country will be well received			0.775**	0.804	0.957	0.856
	ATT4: I think I will benefit by sharing TCM culture			0.814**	0.825	0.957	0.853
SN	SN1: Most people who are important in my social network (e.g., family, friends, colleague, etc.) support me in sharing TCM culture with people from my country			0.783**	0.824	0.957	0.932	0.7834	0.9153
	SN2: Most people who are important in my social network (e.g. family, friends, colleague, etc.) think I should share TCM culture with people from my country			0.798**	0.848	0.956	0.920
	SN3: Most people who are important in my social network (e.g. family, friends, colleague, etc.) often share TCM culture with people from my country			0.690**	0.746	0.959	0.797
PBC	PBC1: I can make use of every opportunity to share TCM culture with people from my home country			0.809**	0.844	0.956	0.894	0.7372	0.9334
	PBC2: I can overcome any difficulties in sharing TCM culture with people from my home country			0.778**	0.814	0.957	0.830
	PBC3: I can make publications focusing on TCM culture for people from my home country			0.773**	0.806	0.957	0.890
	PBC4: I can explain TCM culture to others from my home country			0.810**	0.801	0.957	0.861
	PBC5: I can use some platforms and channels to share TCM culture with people from my home country			0.760**	0.769	0.958	0.815
Chi-Square	df	Chi-Square/df	IFI	TLI		CFI		RMR
128.569	51	2.521	0.960	0.948		0.960		0.048

(link texts: The final version of the TCM Culture Sharing ATT-SN-PBC Scale is presented in Table 1, along with the results of reliability and validity tests, primarily using Cronbach's alpha analysis and confirmatory factor analysis (CFA))

Note:*p < 0.05,**p < 0.01

A single item, “I intend to share Traditional Chinese Medicine (TCM) culture with people from my home country” with a 5-Point Likert Scale (1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly Agree), was used to measure the behavioural intention. For the purpose of predicting BI using ATT, SN, and PBC, BI was dichotomized for analysis, with responses of 1–3 classified as “no intention” and 4–5 as “having an intention”, facilitating more straightforward predictive modelling.

Study design and participants

A cross-sectional study was conducted among international students across various universities in Mainland China. This study was ethically approved by Ethics Committee of Zhejiang Chinese Medical University (No.20230525–4).

Data collection

We collected data through a questionnaire survey, which included a question about the intention to share TCM culture, the TCM Culture Sharing ATT-SN-PBC Scale, as well as other questions to collect demographic information (age, gender, degree pursued, major, religion, continent of origin, and Chinese roots [whether having ancestral or familial ties to China, e.g., having Chinese parents, grandparents, or other relatives, or having a cultural or ethnic connection to China]), Chinese language proficiency, length of stay in China, experiences with TCM, and health status. To ensure inclusivity and avoid limiting gender categories to binary options (male/female), additional options including “other” and “prefer not to say” were provided for the gender question.

To facilitate the collection of high-quality data, we sought formal support from the International Cooperation and Exchange Offices (ICEOs) of universities with existing contacts and employed a snowball sampling strategy of requesting assistance from the contacted universities to reach more universities. We requested their assistance in facilitating an online survey targeting international students. The ICEOs of universities that were successfully reached and willing to cooperate in this study shared the survey link or its QR code with their international students at school, who were then encouraged to voluntarily participate and provide informed consent. The online survey platform used for data collection ensured anonymity and confidentiality of responses to encourage honest and open feedback from the participants. The survey respondents were assured that their participation would not have any impact on their academic standing or other aspects of their university life. Additionally, participants were encouraged to share the questionnaire link with their friends and family members who may also be suitable candidates for the survey. The survey commenced on 5 January 2024 and continued for two weeks. The questionnaire, developed specifically for this study and presented in Additional File 2, took participants approximately 10–15 min to complete.

Data analysis

The normality of the distribution of continuous variables in the dataset was assessed by observing Q-Q plots, which showed that all continuous variables (age, length of stay in China, ATT scores, SN scores, PBC scores, and BI scores) included in this study were almost satisfied with the assumption of normality (for all variables, the points roughly follow a straight 45-degree line on the Q-Q plots). Descriptive analyses were carried out on all study variables. Continuous outcome variables that did not achieve a normal distribution were dichotomized into binary categorical variables via median split [37, 38]. Collinearity statistics showed that each independent variable had variance inflation factor (VIF) coefficients less than 5.0, indicating the absence of multicollinearity issues in Additional File 3.

Univariable and multivariable logistic regression models were employed to analyse how the primary independent variables, i.e., ATT, SN and PBC, affect the international students’ BI to share TCM culture with people from their home countries, as BI was dichotomized into binary categorical variable (1–3 classified as “no intention” and 4–5 as “having an intention”). In the multivariable modelling process, we intentionally introduced covariates, controlling for potential confounders that included socio-demographic characteristics, Chinese language proficiency, length of stay in China, experiences with TCM, as well as health status. The Receiver Operating Characteristic (ROC) curve and the area under the ROC curve (AUC), providing insights into the model’s ability to discriminate between classes, were employed in this study to evaluate the performance of the final model and primary variables in predicting international students’ BI in sharing TCM culture across borders. Statistical significance was defined as a P-value less than 0.05. All analytical procedures were executed using IBM SPSS Statistics (version 22.0).

Results

We received a total of 1,511 responses, of which 1,438 were deemed valid and included in the analysis (Fig. 3). Six participants who selected “other” or “prefer not to say” for gender were excluded from the final analysis due to the small sample size, which was insufficient for meaningful statistical evaluation. To maintain the integrity and relevance of the study findings, thirty-three participants were excluded from the final analysis due to reporting an age below 15, which was likely too young to be a university student in China, or providing invalid age responses. In addition, a few of participants with a reported length of stay in China exceeding ten years were excluded to ensure the focus remained on international students actively engaged in cross-cultural exchange, as extended stays may indicate substantial assimilation or a shift in resident status, potentially affecting study outcomes.

Fig. 3.

Flowchart of the study population. It outlines the process of participant recruitment and sample finalization for analyses

Among the included participants (n = 1,438), 987 responses came from universities located in eastern China, 400 from universities in central and western regions, while 51 responses could not be attributed to specific universities. Additionally, 696 responses were from students attending TCM-specialized universities, representing 13 out of the 31 universities identified in the study. At the time of the survey, there were 24 TCM-specialized universities in Mainland China. Table 2 displays the basic characteristics of our sample, which had a mean age of 24.85 years (SD = 6.16). The gender distribution was almost equal, with 50.42% females and 49.58% males. In terms of their academic backgrounds, 29.55% were major in TCM, 21.63% were studying in western medicine programs, and 48.82% were in non-medical majors. Most respondents were pursuing a bachelor’s degree (64.05%), followed by 21.21% in master’s programs, and smaller percentages in PhD and other degree programs. Religiously, the group was diverse, with the largest proportions identified as Muslim (38.94%) and Christian (23.09%), while 19.89% followed Buddhism. The majority of respondents came from Asia (69.12%), with significant representation from Africa (25.31%). A notable 70.79% had no Chinese roots, and 48.82% had previously experienced TCM, while 51.18% had not. The mean length of stay in China was one and half years, and 92.84% reported good health.

Table 2.

Sample characteristics

Characteristics	Overall (N = 1438)
Age, mean ± SD	24.85 ± 6.16
Gender, N (%)
Female	725(50.42)
Male	713(49.58)
Degree pursued, N (%)
Bachelor	921(64.05)
Master	305(21.21)
PhD	67(4.66)
Others	145(10.08)
Major, N (%)
Traditional Chinese medicine	425(29.55)
Western medicine	311(21.63)
Non-medical	702(48.82)
Religion, N (%)
Christianity	332(23.09)
Islam	560(38.94)
Buddhism	286(19.89)
Hinduism	107(7.44)
Atheism	55(3.82)
Other	98(6.82)
Continent, N (%)
Asia	994(69.12)
Europe	51(3.55)
Africa	364(25.31)
America	22(1.53)
Oceania	7(0.49)
Chinese roots, N (%)
Having Chinese roots	317(22.04)
No Chinese roots	1018(70.79)
Not sure	103(7.16)
Chinese language level, N (%)
Little	322(22.39)
Elementary	324(22.53)
Intermediate	475(33.03)
Advanced	212(14.74)
Native	105(7.3)
Length of stay in China (month), mean ± SD	16.82 ± 20.90
Having experiences with TCM, N (%)
Yes	702(48.82)
No	736(51.18)
Health status, N (%)
Good	1335(92.84)
Not good	35(2.43)
Unsure	68(4.73)
Attitude, mean ± SD	16.16 ± 3.44
Subjective Norms, mean ± SD	11.36 ± 2.90
Perceived Behavioural Control, mean ± SD	19.07 ± 4.63
Behavioural Intention, N (%)
Yes (4,5)	1001(69.96)
No (1–3)	437(30.04)

(Link texts: Table 2 displays the basic characteristics of our sample, which had a mean age of 24.85 years (SD = 6.16).)

Table 3 displays regressions exploring the factors influencing international students’ behavioural intentions of sharing TCM culture with people from their own countries. After controlling for confounding factors, the multivariable regression analyses showed that ATT and PBC were significant predictors of international students’ intention to share TCM culture with people from their home countries. Specifically, ATT had an adjusted odds ratio (OR) of 1.306 (95% CI: 1.202–1.419, p < 0.001), and PBC had an adjusted OR of 1.554 (95% CI: 1.437–1.682, p < 0.001), indicating their strong positive influence. However, SN was not a significant predictor.

Table 3.

Regressions exploring the factors influencing international students’ behavioural intentions of sharing TCM culture

Outcome	Unadjusted model		Adjusted model
INTENTION (0-No/1-Yes)	Crude OR (95% CI)	P value	Adjusted OR (95% CI)	P value
Attitude (ATT)	1.753 (1.653 ~ 1.860)	<.001	1.306 (1.202 ~ 1.419)	<.001
Subjective Norms (SN)	1.842 (1.721 ~ 1.972)	<.001	1.021 (0.918 ~ 1.135)	0.702
Perceived Behavioural Control (PBC)	1.795 (1.683 ~ 1.914)	<.001	1.554 (1.437 ~ 1.682)	<.001
Age	1.030 (1.009 ~ 1.051)	0.004	1.027 (0.989 ~ 1.066)	0.170
Gender
Female	1.000 (Reference)		1.000 (Reference)
Male	1.166 (0.931 ~ 1.460)	0.181	1.637 (1.138 ~ 2.355)	0.008
Degree pursued
Bachelor	1.000 (Reference)		1.000 (Reference)
Master	1.156 (0.866 ~ 1.544)	0.324	1.039 (0.621 ~ 1.738)	0.885
PhD	0.827 (0.490 ~ 1.396)	0.477	0.346 (0.134 ~ 0.894)	0.028
Others	0.750 (0.520 ~ 1.082)	0.124	0.729 (0.402 ~ 1.321)	0.298
Major
Traditional Chinese Medicine	1.000 (Reference)		1.000 (Reference)
Western medicine	2.104 (1.439 ~ 3.075)	<.001	1.208 (0.591 ~ 2.470)	0.604
Non-medical	0.566 (0.435 ~ 0.736)	<.001	1.179 (0.688 ~ 2.021)	0.549
Religion
Christianity	1.000 (Reference)		1.000 (Reference)
Islam	1.108 (0.829 ~ 1.482)	0.487	0.887 (0.513 ~ 1.533)	0.667
Buddhism	1.446 (1.018 ~ 2.053)	0.039	0.720 (0.357 ~ 1.452)	0.358
Hinduism	0.977 (0.616 ~ 1.550)	0.922	0.886 (0.379 ~ 2.073)	0.781
Atheism	0.802 (0.445 ~ 1.447)	0.464	2.985 (1.010 ~ 8.820)	0.048
Other	1.528 (0.914 ~ 2.554)	0.106	1.336 (0.550 ~ 3.242)	0.522
Continent
Asia	1.000 (Reference)		1.000 (Reference)
Europe	0.232 (0.129 ~ 0.416)	<.001	0.198 (0.065 ~ 0.609)	0.005
Africa	0.803 (0.620 ~ 1.041)	0.098	0.657 (0.384 ~ 1.125)	0.126
America	1.327 (0.485 ~ 3.631)	0.582	0.788 (0.140 ~ 4.456)	0.788
Oceania	0.976 (0.188 ~ 5.057)	0.976	3.588 (0.447 ~ 28.805)	0.229
Chinese roots
Have Chinese roots	1.000 (Reference)		1.000 (Reference)
No Chinese roots	0.627 (0.468 ~ 0.840)	0.002	1.140 (0.628 ~ 2.071)	0.667
Not sure	0.581 (0.358 ~ 0.943)	0.028	1.088 (0.496 ~ 2.385)	0.833
Chinese language level
Little	1.000 (Reference)		1.000 (Reference)
Elementary	0.901 (0.648 ~ 1.253)	0.536	1.042 (0.626 ~ 1.736)	0.873
Intermediate	0.904 (0.667 ~ 1.224)	0.513	0.878 (0.530 ~ 1.456)	0.615
Advanced	1.459 (0.983 ~ 2.167)	0.061	0.741 (0.376 ~ 1.460)	0.387
Native	1.802 (1.057 ~ 3.071)	0.030	0.635 (0.254 ~ 1.587)	0.331
Length of stay in China	0.995 (0.990 ~ 1.000)	0.062	1.042 (0.626 ~ 1.736)	0.635
Having experiences with TCM
Yes	1.000 (Reference)		1.000 (Reference)
No	0.327 (0.258 ~ 0.416)	<.001	0.571 (0.376 ~ 0.865)	0.008
Health status
Good	1.000 (Reference)		1.000 (Reference)
Not good	0.727 (0.362 ~ 1.457)	0.368	0.635 (0.223 ~ 1.804)	0.394
Unsure	0.840 (0.501 ~ 1.407)	0.508	0.879 (0.405 ~ 1.906)	0.743

(Link texts: Table 3 displays regressions exploring the factors influencing international students’ behavioural intentions of sharing TCM culture with people from their own countries)

Meanwhile, gender and degree pursued also played a role, with males being more likely to share TCM culture than females (adjusted OR: 1.637, 95% CI: 1.138–2.355, p = 0.008), and PhD students showing significantly lower odds compared to bachelor’s students (adjusted OR: 0.346, 95% CI: 0.134–0.894, p = 0.028). Atheism had a significant positive effect on TCM culture sharing intention, as atheists were significantly more likely to share TCM culture compared to Christians (the reference group) (adjusted OR: 2.985, 95% CI: 1.010–8.820, p = 0.048). European students were less likely to share TCM culture compared to their Asian counterparts (the reference group) (adjusted OR: 0.198, 95% CI: 0.065–0.609, p = 0.005). Additionally, students without previous experiences of TCM were significantly less inclined to share TCM culture across borders (adjusted OR: 0.571, 95% CI: 0.376–0.865, p = 0.008). In multiple regression analysis, variables like major and Chinese language proficiency level showed no significant influence after adjustment.

The multiple regression model’s ability to predict international students’ intentions to share TCM culture across borders was evaluated by drawing ROCs and calculating corresponding AUC scores (Fig. 4). The AUC scores for ATT (0.874), SN (0.866), and PBC (0.924) indicated strong predictive capabilities of each variable, with PBC showing the highest predictive power and SN with the lowest predictive power. The combined AUC for the entire model was 0.933, indicating that the inclusion of multiple variables significantly improves the model’s performance. This high AUC value suggested the entire model had excellent accuracy in distinguishing between individuals who intended to share TCM culture and those who did not.

Fig. 4.

ROC and AUC. It displays the ROC curve and AUC values, evaluating the predictive power of the model in distinguishing intentional students’ intentions to share TCM culture with people from their home countries

Discussion

Using the classic TPB framework, this study investigated the predictors of the BI of international students in China to share TCM culture with individuals from their home countries and found that ATT and PBC significantly influenced sharing intentions, while subjective norms did not emerge as a strong predictor. Furthermore, demographic factors such as gender, degree pursued, continent of origin, religious affiliation, and previous experiences with TCM were also found to influence the intention to share TCM culture across borders.

The noteworthy positive correlation between ATT and BI corroborates existing literature on information and knowledge sharing, such as [39] that synthesized substantial evidence affirming that the TPB framework can effectively predict knowledge-sharing behaviour and particularly illustrated that favourable attitudes toward information sharing significantly influence individuals’ intentions to engage in such behaviours. In our context, TCM culture can be seen as a valuable repository of knowledge that individuals could be motivated to share, as it possesses the potential to transform perceptions of health, influence health-related behaviours, and thereby alter overall health outcomes [32]. Thus, when international students recognize that disseminating TCM culture can yield tangible benefits for individuals within their home countries or for themselves personally, they are more likely to appreciate and express a desire to share the cultural elements of TCM. Moreover, there is a discernible evolution in global attitudes towards health and wellness, with an increasing number of individuals gravitating towards holistic and alternative therapies [40]. This paradigm shift across various regions has fostered a more favourable reception of alternative medicines, such as TCM, and its philosophical or cultural foundations, thereby promoting people’s attitudes towards the sharing of alternative medicine cultures.

According to this study, international students in China who felt empowered and confident in their ability to share TCM culture were much more likely to have the intention to do so. Feng et al. (2021) [41] investigated people’s knowledge-sharing behaviours in social Q&A platforms and suggested that the theoretical model of planned behaviour has strong explanatory power for people’s willingness to share knowledge, particularly emphasizing that self-efficacy have a significant positive effect. In our contexts, PBC may particularly address the barriers that individuals may perceive in cross-cultural contexts. For instance, international students might face language barriers or uncertainty about the reception of TCM culture in their home countries. Many CAM systems, such as TCM and Ayurvedic, are deeply tied to cultural traditions, which means their adoption by and integration with other healthcare systems can be culturally complex, depending on whether individuals feel competent and comfortable sharing CAM culture in an appropriate and sensitive manner.

This study noticed the weak influence of SN on international students’ intention in sharing TCM culture, which was consistent with many previous studies concerned about influential factors of people’s behavioural intention. According to La Barbera and Ajzen [42], relatively weak relation between SN and BI were frequently observed in TPB studies. Particularly, a systematic review and meta-analysis conducted by Nguyen, Nham et al. [39] suggested that, compared to other two constructs, SN had a minor influence on people’s intention of sharing knowledge. In TPB, SN tends to be a stronger predictor when there is clear and consistent social consensus regarding the behaviours, which is probably often lacking in TCM culture-sharing settings. The lack of clear, unified social pressure may reduce the impact of SN on intention. CAM systems often originate from specific cultural contexts (e.g., Ayurveda from India, TCM from China) [43], and in a cross-cultural or cross-border setting, the relevance of subjective norms to the intention of sharing these medicines may weaken due to cultural differences. Healthcare providers or international students studying in a new country may not feel that their home culture’s norms around CAM apply in the new context, or they may find that the local culture does not have clear norms around CAM integration. In these cross-cultural situations, subjective norms become less influential, probably because they are not yet well-defined or relevant across cultural boundaries.

This study also found other significant factors potentially influencing the international students’ intention of sharing TCM culture. Our study revealed gender differences in sharing intentions, with male students showing a stronger inclination to promote TCM culture across borders. Even though without a medicine culture perspective, some previous studies have consistent observation [10, 13, 44–46]. In many cultures, men may be more encouraged to engage in behaviours that involve social risk, such as promoting unfamiliar cultural practices, which could translate into more confidence or willingness to share cultural practices [47]. The observation that European students have a relatively low intention of sharing TCM culture across borders suggested that in exotic medicine culture-sharing settings, individuals’ sharing behaviours may be influenced by national culture or local medicine culture, as House et al. (2004) [48] suggested nations could be classified into cultural groups based on cultural similarities as these may affects perception and behaviours. In addition, we noticed that PhD students were less likely to share TCM compared to bachelor’s students. This is probably due to that PhD students may perceive their roles more critically, being more focused on specific academic aspects and possibly less inclined towards promoting cultural concepts or practices. Furthermore, a notable correlation was found between TCM experiences and the intention to share TCM culture. International students who have first-hand experience with TCM may directly perceive its benefits, which can in turn foster a greater inclination towards sharing TCM culture.

Practical implications

With the rising global interest in holistic health and integrated care, sharing culture-related knowledge and understandings of CAM—such as Ayurveda, Homeopathy, Naturopathy and TCM—can bridge medical practices, promoting a more inclusive healthcare model. In the trend, as the study suggests, enhancing foreign people’s ATT towards medicine culture-sharing, enhancing their PBC on the behaviours and creating positive medical experiences could enhance their intention to share the exotic medicine culture in home nations. Particularly, providing necessary resources, inclusive platforms, institutional support as well as experiential training can empower foreign people to share CAM cultures confidently and effectively across borders, which may facilitate their intentions to share. Moreover, facilitating opportunities for foreign people to experience CAM first hand may substantially bolster their intention to engage in CAM culture sharing activities.

Strengths and limitations of the study

By applying TPB and investigating how attitudes, subjective norms, and perceived behavioural control influence medical culture sharing across borders, the study provides a structured and predictive model for understanding TCM culture dissemination across borders, which has not been specifically studied yet. Understanding the complexity of cultural sharing within international student populations could significantly contribute to fostering global health communication and the promotion of diverse cultural practices, particularly in the context of traditional medicine like TCM. With a focus on cross-cultural and cross-border medicine culture sharing, the study provides insights of the sharing of CAM across diverse healthcare systems and cultural contexts. This cross-border perspective allows for a better understanding of the unique challenges and opportunities in adapting CAM practices internationally, offering further insights into how to promote the global exchange of CAM knowledge and practices for constructing more integrative or inclusive healthcare systems.

Methodologically, the study employed a rigorous multi-step approach to develop and validate the TCM Culture Sharing ATT-SN-PBC Scale, ensuring the constructs were tailored specifically to the target population. In addition, the study leveraged both formal institutional support from universities and a snowball sampling strategy to maximize reach among the target population of international students in China, which allowed for a large, diverse sample size, ensuring a broad representation of perspectives across different regions, educational levels, and backgrounds.

However, it is important to acknowledge the limitations of our study. Primarily, focusing on the intention of international students in China to share TCM culture cross-border, our study included a majority of responses from universities in eastern China, with fewer responses from central and western regions, which may limit the generalizability of the findings to universities across all of China, to international students from diverse educational, cultural or socio-economic backgrounds, or to the sharing cultural dimensions of other CAM. Specifically, while the sample included a culturally and geographically diverse group of international students, with the majority originating from Asia (69.12%) and Africa (25.31%), which aligns with the continent-level origin of international students studying in China from 2018 to 2022 (according to unpublished data provided by our contacts at the Ministry of Education of China), this study lied in the absence of precise, stratified analysis based on participants’ home-country healthcare systems or economic classifications that may influence international students’ intentions and behaviours to share TCM culture cross-border. While we estimated, based on the World Bank’s 2024 income classifications across continents and communication with participating institutions, that most students likely came from low- and middle-income countries, this estimation was not quantitatively accounted for in the analysis.

Additionally, although we took a comprehensive approach to gender information collection, six individuals who identified their gender as “other” were excluded from the final analysis due to the small sample size, which was insufficient for meaningful statistical analysis. While it was necessary to ensure statistical reliability, excluding underrepresented groups could be controversial, highlighting the need for larger, more diverse samples in future research. Moreover, the reliance on self-reported data introduces the possibility of bias, as students’ perceptions, intentions, and experiences may not perfectly align with their actual behaviours. Further, the cross-sectional design may restrict our ability to establish causal relationships between focused variables.

Future research should aim to utilize a longitudinal design to track changes in sharing intentions over time, helping establish causal relationships between predicted variables and actual behaviours. It would also be beneficial to design the future studies with inclusivity in mind, expanding the participant base to include international students with more diverse backgrounds, from more universities in China or those with experiences in other CAM to enhance the external validity of the findings. Further research could incorporate more granular, country-level analyses to better capture how structural and cultural factors interact to shape the global dissemination of traditional medicine culture. Moreover, qualitative approaches—such as in-depth interviews or ethnographic studies—could provide rich insights into the underlying motivations, barriers, and facilitators of cultural sharing among international students. Researchers could also explore other influential factors on sharing intentions, such as social media and digital platforms, as these channels may play significant roles in information or knowledge sharing across borders in the modern society.

Conclusion

Based on TPB model, this study highlights the significant roles of ATT and PBC in shaping international students’ intentions to share TCM culture cross-border, with SN having a weaker influence, and provides a model of predicting international students’ intentions to share TCM culture across borders. The findings suggest that fostering positive attitudes and empowering individuals through education and resources can effectively promote cross-border CAM culture sharing, potentially advancing the global trend toward integrative medicine and inclusive healthcare systems. Future research should explore other CAM systems and utilize longitudinal and qualitative methods to further examine medicine culture sharing across borders, contributing to the development of more integrative and conclusive global healthcare systems.

Abbreviations

ATT

Behavioural Attitude

AUC

Area under the ROC Curve

BI

Behavioural Intention

CAM

Complementary and Alternative Medicine

ICEOs

International Cooperation and Exchange Offices

OR

Odds Ratio

PBC

Perceived Behavioural Control

ROC

Receiver Operating Characteristic Curve

SN

Subjective norms

TCM

Traditional Chinese Medicine

TPB

Theory of Planned Behaviour

VIF

Variance Inflation Factor

Authors’ contributions

JNW: Data curation, Investigation, Methodology, Resources, Validation, Writing – original draft, Writing – review and editing DG: Formal analysis, Investigation, Methodology, Software, Validation, Visualization, Writing – review and editing YP: Formal analysis, Investigation, Methodology, Software, Validation, Visualization, Writing – review and editing JZ: Formal analysis, Investigation, Methodology, Software, Validation, Visualization YX: Methodology, Writing – review and editing ZHZ: Formal analysis, Investigation, Methodology, Software, Validation, Visualization YZW: Formal analysis, Investigation, Methodology, Software, Validation, Visualization AC: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review and editing.

Funding

This work was supported by the following funding sources:

– GK2022 Basic Research Funding—2023 University-Level Research Project: Research on the International Communication of Traditional Chinese Medicine Culture among International Students in China Based on the Theory of Planned Behaviour (No. 702213A12613), funded by Zhejiang Chinese Medical University, awarded to An Chen and Jingna Wang.

– Special Project of Social Science Planning in Zhejiang Province (No. 24FNSQ021YB), funded by the Zhejiang Federation of Humanities and Social Sciences, awarded to Jingna Wang.

– Zhejiang Province Higher Education “14th Five-Year Plan” Graduate Teaching Reform Project (No. 701100G00821), funded by the Zhejiang Provincial Department of Education, awarded to An Chen and Jingna Wang.

The funders had no involvement in the study design, data collection, data analysis, interpretation of results, manuscript preparation, or the decision to submit the work for publication.

Data availability

The dataset generated and analysed for this study is not publicly available due to the restrictions claimed in the document of the research permission and ethical approval. But the data are available from the ethics committee of Zhejiang Chinese Medical University for researchers who meet the criteria for access to confidential data. To request access to the data, please contact the corresponding author AC.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Zhejiang Chinese Medical University (No.20230525–4). This non-medical study involves human participants (i.e., international students in China), and it follows the principles and guidelines defined in the Declaration of Helsinki. Informed consent in a written form was obtained from all participants prior to their involvement in the study.

Consent for publication

Permission for publication was obtained from all participants through a consent form, ensuring their data would be published in an anonymous manner. The consent process adhered to ethical guidelines, protecting the confidentiality and privacy of all individuals involved.

Competing interests

The authors declare no competing interests.