Table 4.
Study characteristics and attitudes regarding regulation of traditional and complementary medicine professions
| First author year | Country (jurisdiction, if limited) | Study design | Stakeholder population | Sample N | T&CM profession/s examined | Main findings |
|---|---|---|---|---|---|---|
| Consumers ( n = 8) | ||||||
| El-Olemy 2014 [102] | Egypt (Tanta, Gharbiya governorate) | Quantitative Cross-sectional self-administered, supervised questionnaire survey | Students (University School of Education) | 187 | Traditional and complementary medicine |
95.2% agreed that regulating practices was essential, 1.6% disagreed, 3.2% were uncertain Respondents with previous knowledge of T&CM (n = 146) were significantly more positive towards T&CM regulation (p = 0.002) 95.2% agreed that T&CM practices should be available and easily accessible, 92.0% agreed that integration of T&CM practices into health care improves patient care |
| Emslie 2002 [76] | Scotland (Grampian) | Quantitative. Population-based postal questionnaire survey | Residents | 424 | Acupuncture, aromatherapy, chiropractic, herbalism, homeopathy, hypnotherapy, osteopathy, reflexology |
90% agreed that a register of approved therapists was essential/desirable (61% essential, 29% desirable), 1% agreed it was unnecessary, 8% gave no opinion 44% of 82 participants indicated concern about the registration of therapists 65% indicated concern about practitioner qualifications |
| Evans 2008 [83] | New Zealand (Gisborne) | Quantitative. Population-based face to face questionnaire survey | Inpatients of a provincial hospital | 92 | Acupuncture, antioxidants, aromatherapy, Bach flower remedies, Bowen, chiropractic, colour therapy, detoxification programs, dietary therapy, electro/biomagnetic therapy, herbal therapies, homeopathy, hypnotherapy, imagery/visualisation, iridology, massage (Romi Romi), naturopathy, osteopathy, reflexology, relaxation techniques, Rongoā Māori, shark cartilage, spiritual healing, vitamins, yoga |
78% agreed T&CM should be regulated, e.g. like pharmaceutical drugs, a consultation with a qualified person first before purchasing medicines Reasons for supporting regulation were that medicines could be dangerous, treatment may not be safe, regulation may give consumers more access to information about products, and give better informed choice Reasons for opposing regulation were loss of freedom of choice, losing control over one's own health, and would probably make treatment too expensive |
| Lin 2005 (Section 9, Hill) [52] (Summarised in [105]) | Australia (Melbourne) | Qualitative Focus groups | Consumers within a metropolitan area | 24 | Western herbal medicine, naturopathy |
The majority of participants indicted there should be some form of regulation Because consumers place a great deal of trust in practitioners, and are often vulnerable, several participants indicated practitioners should have a qualification (implying an approved qualification) and that they should be regulated Those agreeing with regulation said it was needed to raise the standard of practitioners, ensure consistency of care, and stop unethical practice Regulation implied recognition of practices Some were aware that regulation did not ensure quality care, but thought that it was important for consumers to know that a practitioner had undertaken a minimum standard of training Concerns included the ability of professional associations to investigate complaints against their members, the possibility that poor practitioners could leave (or be forced to leave) one association only to join another, and the need for a body to hear complaints A few though regulation would not improve practitioner quality, and may inhibit them from trying new treatments, that an intuitive approach might be lost if practitioners were required to be registered, and that registration might restrict what they could practise. It was believed that regulation would not address the critical issue of practitioner communication skills |
| Taylor 2003 [91] | New Zealand (Wanganui) | Quantitative Print-based questionnaire survey | Consecutive patients of general practitioners at three general practices | 104 | Acupuncture, aromatherapy, chiropractic, hypnosis, Rongoā Māori |
71.1% agreed regulation of T&CM practices should be on a par with orthodox medicine Patients indicated T&CM was sometimes, usually, or always safe 64.4% agreed there could be side-effects, and the majority were aware that there could be interactions with orthodox medicine |
| Xue 2005 [93] | Australia (Melbourne) | Quantitative Print-based questionnaire survey. Convenience sampling | Members of the public in three localities, predominantly Asian and Caucasian | 575 | Chinese medicine |
76.3% agreed the practice should be regulated the same as Western medicine 67.7% agreed the practice should be more rigorously regulated 20.9% agreed registration improved public confidence in the practice as a health care option 18.7% agreed registration protected the public from unqualified service 37.9% agreed they would contact the registration board about service provision concerns 78.2% were aware statutory practitioner registration was recently introduced 29.9% agreed they only see a registered practitioner 80.8% agreed they would see a non-registered practitioner |
| Zhang 2006 [94] | Australia | Quantitative. Population-based random digit dialled telephone survey | Representative proportions of households in all states and territories | 1067 | Chinese medicine (Chinese herbal medicine, acupuncture) |
86.4% agreed with the government regulation of acupuncture practitioners 86.0% agreed that mandatory registration of acupuncture practitioners provided for greater public safety and confidence in acupuncture 85.0% agreed with the government regulation of Chinese herbal medicine practitioners 82.7% agreed that mandatory registration of Chinese herbal medicine practitioners provided for greater public safety in Chinese herbal medicine |
| Zhang 2008 [79] | Australia (Victoria) | Quantitative Cross-sectional population-based random digit dialled telephone survey | Households in eight geographical regions | 2526 | Indian herbal medicine (Ayurveda), traditional Chinese herbal medicine, naturopathy, Western herbal medicine |
89.6% agreed practitioners should be statutorily regulated (as for medical practitioners), 4.8% disagreed, 5.5% were unsure/did not answer 46.6% of herbal medicine users agreed they were aware of the potential risks of herbal medicine |
| Traditional and complementary medicine practitioners (n = 19) | ||||||
| Bensoussan 2004 [73] | Australia | Quantitative. National postal questionnaire survey | Naturopaths, Western herbal medicine practitioners, homeopaths, nutritionists | 795 | Western herbal medicine, naturopathy |
More positive than negative changes were indicated to result from government regulation for: professional status (78.6%), practice standards (73.0%), education standards (72.7%), access to research infrastructure (58.4%), post-graduate education (59.5%), access to scheduled herbs/products (55.2%), quality of herbal medicines/products (46.5%), and establishing occupational boundaries (41.3%) Uncertainty was indicated regarding the impact of regulation on practitioner income (56.1%), litigation (54.0%), patient costs (51.2%) and freedom of practice (37.6%) Negative impacts were indicated to be more likely in the area of medical influence on practice (44.3%) 44% indicated their training poorly prepared them for inter-professional communication, 22% indicated they were poorly prepared in the area of clinical training |
| Boon 2004 [53] | Canada (Toronto, Ontario) | Qualitative Focus groups | Acupuncture/traditional Chinese medicine practitioners, homeopaths, naturopaths | 20 | Acupuncture/traditional Chinese medicine, homeopathy, naturopathy |
Statutory regulation was identified as the goal of the professionalisation All practitioners stated their group was pursuing statutory regulation Most, but not all, felt this was an important goal for their occupation Many considered regulation would result in some form of monopoly for their practice Regulation would prevent the co-optation of their skills and knowledge, allow the achievement of social closure by establishing education and qualifications standards that would prevent co-optation by those outside the profession Attempts at closure were hampered by lack of internal cohesion, and disagreement over the content and form of education and practice standards, particularly for homeopathy and acupuncture/traditional Chinese medicine professions Fragmentation was partially due to the intra-professional diversity of practices and philosophies Some feared a loss of freedom to practise due to regulation In T&CM finding a place within the health care system, the public was one of their biggest allies Some homeopaths and naturopaths recast their work as possibly harmful in order to be eligible for regulation |
| Braun 2013 [74] | Australia | Quantitative Online questionnaire survey | Naturopaths, Western herbal medicine practitioners | 479 | Western herbal medicine, naturopathy |
85% agreed practitioners should be formally registered to safeguard the public, 8% disagreed, 8% were unsure Responses indicated possible benefits of regulation were increased public safety, protection from inadequately trained practitioners within and outside their profession, increased practice standards, increased confidence and credibility of the profession and its broader integration into the health care system Some (n = 9) who agreed with regulation did not agree that public safety was the main issue, stating that being a member of a professional association was the same as registration so formal registration was not necessary Others (n = 9) expressed concern that practitioners outside their profession could regulate their profession if formal registration occurred |
| Canaway 2009 [71] | Australia (Melbourne) | Qualitative Semi-structured interviews Snowball sampling | Naturopaths (senior practitioners mostly in leadership roles) | 7 | Naturopathy |
Registration was necessary to safeguard the public, raise education standards in line with public expectations, ensure transparent complaints handling, guard against unscrupulous practitioners, maintain professional and ethical standards, provide guarantees regarding practitioner education, improve relationships with medical professionals, provide access to hospitals, protect the interests of the profession such as misappropriation of practice, could promote professional unity, and limit the proliferation of profit-oriented private colleges Regulation was also necessary because it was not the job of the professional associations Potential positive impacts were increased status, legitimacy and acceptance particularly by the medical profession, opening the way for medicare rebates, accessing restricted herbs, aiding the removal of incompetent practitioners, gaining a greater share of the health care market, establishing higher minimum education standards and greater consistency in the quality and length of training Registration was unnecessary because natural therapies were safe when offered by trained practitioners, a registered profession is not necessarily a safe profession, current complaints handling was adequate, protection of title did not prevent unsafe practitioners from using different titles, it inappropriately defined the profession as unsafe, it only conferred status and bolstered self-esteem which is not its purpose, other T&CM registered professions disliked it, current self-regulation was working with most practitioners being members of professional associations which monitored standards so there was little to gain Potential negative impacts were restrictions to practice, loss of freedom to practise, standardisation of practice, could attract different types of people to the profession motivated by status, increased professional indemnity costs and registration fees that would be passed onto clients, not all practitioners may be eligible for registration which would be negative for them, uncertainty of who the profession would be answerable to, greater emphasis on scientific aspect of education and less on the holistic approach, erosion of naturopathic philosophy, and closure of colleges unable to meet the new standards |
| Cottingham 2015 [96] | New Zealand | Quantitative Online questionnaire survey. Convenience sampling | Naturopaths and herbal medicine practitioners | 107 | Herbal medicine, naturopathy |
62% supported statutory registration, 18% were opposed.a 82% supported registration, 75% of which were in favour of statutory registration and 25% supported voluntary registration |
| Cottingham 2017 [97] | New Zealand | Quantitative Online questionnaire survey. Convenience sampling | Homeopaths | 47 | Homeopathy |
51% supported statutory registration.a 87% favoured registration, of which 59% supported statutory registration |
| Cottingham 2018 [82] | New Zealand | Quantitative Online questionnaire survey. Convenience sampling | Registered massage therapists | 104 | Massage |
56% supported statutory registration.a 93% supported registration, of which 67% supported statutory registration, 31% supported voluntary registration, 1% preferred other registration types (not-specified) |
| Ericksen-Pereira 2020 [55] | South Africa | Qualitative Emailed unstructured (open-ended) survey or face to face unstructured interviews | Naturopaths | 21 | Naturopathy |
Registration was important to all participants because it allowed them to use the title of naturopath and practise legally Challenges of registration created impediments to establishing viable practices, including being deregistered when failing to pay on time, bureaucracy requiring further application fees and increased annual re-registering fees, the need to register within the first six months of graduating or undergo a competency assessment requiring a fee, annual registration fees regardless of whether graduates were in a financial position to establish a practice, costs of registration (around 20% of the average salary of a new graduate), being prevented from sharing clinic space or working in interdisciplinary practices with registered practitioners such as medical doctors which prevented integrative practices |
| Flatt 2013 [71] | New Zealand | Quantitative Postal questionnaire survey | Naturopaths and Western herbal medicine practitioners | 120 | Western herbal medicine, naturopathy |
Over 60% agreed that change of regulatory status would have positive effects on professional status, professional relationships, integrative practice, potential health subsidies, practitioner competence, and practice and education standards Over 50% agreed that change of regulatory status would have positive effects on professional equity, shared care, conduct and discipline and continuing education Almost 60% disagreed that regulatory change would have a positive effect on association fees Just under 50% felt there would be negative effects on freedom of practice Around 50% were uncertain about the effects on income, litigation, research access, biomedical influence and career prospects There was little agreement on the impact on occupational boundaries, access and quality of medicines, patient numbers, patient well-being, and patient access |
| Gyasi 2017 [56] | Ghana (Ashanti Region) | Qualitative In-depth interviews | Traditional healers | 7 | Traditional healing |
Despite being available, most practitioners were not registered and practised without any regulatory oversight Most registered practitioners were located in urban areas, where there was greater competition and need to uphold ethical and quality standards Registered practitioners thought registration was important to assure consumers of the quality of medicines sold and for the preparation of herbal prescriptions Reasons for not registering include difficulties such as having to travel to town to register, the time and cost involved, the complexity and stress, and the lack of information about how to register Non-registered practitioners were ready to register given the opportunity |
| Ijaz 2015 [50] | Canada (Ontario) | Qualitative Online and postal questionnaire survey analysis of open-ended question | Chinese medicine practitioners, homeopaths, naturopaths | 688 | Acupuncture/Chinese medicine, homeopathy, naturopathy |
The majority supported regulation but 33% of Chinese medicine practitioners, 44% of homeopaths and 48% of naturopaths were concerned about regulation Concerns related to the way regulation was being implemented, and whether the regulating body overseeing the implementation was representative of the profession A number were concerned about unwanted financial and administrative burdens on practitioners, and costs being passed onto patients Concerns regarding regulation were that regulation would reduce or restrict practice scopes, or would not expand adequately to allow for diagnostic rights and biomedical testing, inter-occupational overlapping practice scopes, co-optation of practice, including co-optation from other T&CM professions (e.g. between homeopaths and naturopaths), inappropriate or unfair registration standards, e.g. how regulation would assess practitioner qualifications, grandparenting provisions, and language proficiency requirements, some practitioners may be inappropriately excluded from registration, and that regulatory changes threatened underlying paradigmatic foundations of practice Several were concerned that practice would become 'medicalized', and that regulators did not adequately take into account the 'culture and tradition' of practices Some considered that training of some practitioners was inadequate Some stated that enforcing standards would likely improve quality of patient care by raising practitioner level of treatment, and increased biomedical training would improve competency and enhance credibility A few felt there should be no grandparenting, rather, there should be an exam in order to have a legal license A small number were concerned about the use of public safety messages to increase regulatory control over low-risk activities |
| Malhotra 2020 [57] | Australia | Qualitative Semi-structured telephone interviews | Naturopaths | 20 | Naturopathy |
A primary barrier to implementing integrated care models was the lack of acknowledgment from conventional medical practitioners Conventional doctors often had concerns regarding the efficacy of naturopathic treatments The current self-regulation model and absence of statutory regulation was seen as a barrier to legitimising the profession The lack of a well-defined curriculum and standard training competencies framework was considered a barrier to being acknowledged by conventional medical practitioners as a legitimate profession |
| Morin 2017 [88] | Canada (Quebec) | Quantitative Postal questionnaire survey | Osteopaths | 297 | Osteopathy |
62% would be moderately/greatly influenced by government regulation and the establishment of university-based programs, 38% would not be very influenced/influenced by regulation Practitioners indicated regulation would promote collaboration, 97.2% agreeing that collaborating with physicians was slightly/quite/very important |
| Parker 2013 [78] | Canada (Ontario) | Quantitative Cross-sectional online questionnaire survey | Homeopaths | 329 | Homeopathy |
Most supported regulation (mean agreement score 3.9 (SD 1.2), 5 point Likert scale, n = 273) Most felt regulation would: improve credibility with the public (4.3 (SD 1.0), n = 275) and other health care professionals (4.1 (SD 1.1), n = 274), benefit the public (4.0 (SD 1.2), n = 275), improve quality of patient care (3.8 (SD 1.2), n = 275), and benefit homeopaths (3.6 (SD1.3), n = 273) There was less certainty regarding the impact on practice (2.9 (1.4), n = 270) 70% intended to apply for registration but 35.9% appeared ineligible due to not meeting educational or grandparenting requirements Those that appeared both eligible and ineligible for registration generally supported regulation Those potentially ineligible were older, had been practising for longer, were more likely to work in a home based office, appeared to spend less time with patients on initial visit, and were less likely to hold a college/university degree |
| Smith 2015 [58] | New Zealand | Qualitative Semi-structured interviews | Massage educators, therapists, and students | 20 | Massage |
Practitioners supported both government regulation and regulation by the professional association. Some were opposed to compulsory statutory regulation Regulation was viewed as a useful step to move the profession towards legitimation and professional recognition Both statutory and self-regulation were identified as mechanisms to control practice, establish a scope of practice, achieve recognition, access government funding, achieve consistency, facilitate professionalism, and establish standard education levels Practitioners stressed the need for clear scopes of practice Education required a cohesive set of standards across education providers Issues regarding regulation were cost, being valued as a profession, government regulation would establish standards of education, professional association has standards and rules Some thought degree level education should be the benchmark, others thought there was room for both diploma and degree levels as long as scopes were clear |
| Steel 2020 [60] | Australia (Queensland) | Qualitative Semi-structured interviews | Complementary medicine practitioners specialising in maternity care (acupuncturists, doulas, chiropractors, massage therapists, naturopaths, osteopaths) | 23 | Acupuncture, chiropractic, doula, massage, naturopathy, osteopathy |
Regulation was needed to gain increased respect from other professions and because of concerns about unethical financial practice such as profiteering by practitioners Education standards were a concern for some participants due to a lack of consistency across institutions and qualifications Education standards was also perceived by some practitioners to impact the ability of other health professions to work alongside them, some practitioners perceiving that inconsistency in training created a negative perception of their profession among conventional providers Often there was disagreement about the impact of regulation, however there was agreement from both regulated and unregulated professions that regulation was tied to improved training standards Regulation was not always viewed favourably by participants due to the perception of practice limits being imposed Some suggested the absence of regulation created difficulties in referring peers to appropriate colleges of education |
| Tsai 2008 [92] | Taiwan (Taipei) | Quantitative Print-based cross-sectional questionnaire survey | Folk medicine practitioners | 400 | Ba guan, gua sha, reflexology, tuina |
Around one half of all respondents agreed that statutory regulation was necessary for all practices 64%-85% agreed credentialling of folk medicine practitioners was necessary 65%-82% agreed practitioners should receive formal education/training Support for regulation: 56.9% of city versus 50.8% of country ba guan practitioners (p = 0.26) 52.8%/42.1% city/country gua sha practitioners (p = 0.04) 53.8%/42.7% city/country reflexology practitioners (p = 0.04) 58.4%/58.5% city/country tuina practitioners (p = 1.0) Opposition to regulation: 43.1%/49.2% city/country ba guan practitioners (p = 0.26) 47.2%/57.9% city/country gua sha practitioners (p = 0.04) 46.2%/57.3% city/country reflexology practitioners (p = 0.04) 41.6%/41.5% of city/country tuina practitioners (p = 1.0) |
| Wardle 2013 [69] | Australia (Darling Downs) | Qualitative Semi-structured interviews | Naturopaths | 20 | Naturopathy |
Regulation was considered positive by all but one practitioner Regulation was seen by many practitioners as the solution to many of the problems of the profession The primary reason for supporting regulation was to rid the profession of unethical, bogus, or fraudulent individuals who were practising without the required qualifications Regulation would overcome the challenges of increasing external influences, internal division/fragmentation, professional acceptance, problems in education of practitioners, and co-optation by undertrained/fraudulent/practitioners that devalued the profession |
| Yu 2015 [100] | Korea | Quantitative Email, postal and print-based questionnaire survey | Acupuncturists, alternative therapists, chiropractors, clinical art therapists, feet massage therapists, laughter therapists, Qi gong therapists and trainees of traditional Chinese medicine | 62 | Acupuncture, alternative medicine, chiropractic, clinical art, feet massage, laughter, Qi gong, trainees of traditional Chinese medicine |
Across all provider groups, medical and T&CM professionals, 32.8% agreed legislation to govern providers was preferable, 25.0% agreed with qualifications/accreditation, 13.6% agreed with making/evaluating standards 48.4% agreed that a college/university qualification was necessary for gaining qualifications, 22.6% agreed with taking and passing a government administered examination 53.3% agreed legislation and national control for management of qualifications was preferable, 29.0% agreed that a national examination was preferable |
| Conventional medicine practitioners (n = 23) | ||||||
| Al Mansour 2015 [95] | Saudi Arabia (Majmaah City) | Quantitative Cross-sectional Print-based questionnaire survey | Medical students | 65 | Complementary and alternative medicine | Prior to T&CM training 38.5% agreed the unavailability of credentialled practitioners was a barrier to their use in Western medical settings, increasing to 70.8% following training (p = 0.0006) |
| Barnes 2018 [61] | New Zealand | Qualitative Semi-structured telephone interviews | Practising community pharmacists | 27 | Complementary medicine |
Regulation of practitioners such as herbalists and naturopaths was important, although there were mixed views about whether governance should be statutory or self-regulation Some suggested that access to certain medicinal plant preparations should only be through registered CMs practitioners, such as herbalists Some framed the need for regulation in terms of providing recognition and validation of practitioner expertise |
| Cavaco 2017 [72] | Portugal (Lisbon and Porto) | Qualitative Semi-structured interviews | Community pharmacists | 6 | Homeopathic dispensing by pharmacists/non-pharmacists |
There were no restrictions regarding dispensing homeopathic medicines in pharmacies Participants commonly mentioned the need for regulation of homeopathic practitioners, particularly in relation to dispensing by non-pharmacists Improved legislation would benefit prescribers, increase legal protection, and improve social recognition |
| Chaterji 2007 [81] | USA (Washington) | Quantitative Print-based questionnaire survey | Medical students | 266 | Acupuncture, aromatherapy, biofeedback, chiropractic, herbal medicine, homeopathy, hypnosis/guided imagery, magnets, massage, meditation, music, nutritional supplements, prayer/spiritual healing, rolfing, therapeutic touch | 71.8% agreed that the lack of credentialled providers was a barrier to the use of practices in Western medical settings |
| Cohen 2005 [101] | Australia | Quantitative. National postal questionnaire survey | General practitioners | 579 | Acupuncture, aromatherapy, Chinese herbal medicine, chiropractic, herbal medicine, homeopathy, hypnosis, massage, meditation, naturopathy, osteopathy, reflexology, spiritual healing (e.g. reiki), vitamin and mineral therapy, yoga |
The practices that required regulation were chiropractic (88% agreed), acupuncture (87%), Chinese herbal medicine (80%), hypnosis (79%), herbal medicine (77%), naturopathy (73%), osteopathy (72%), homeopathy (66%), vitamin and mineral therapy (66%), yoga (49%), meditation (44%), spiritual healing (e.g. reiki) (36%), aromatherapy (34%), massage (33%), and reflexology (28%) The practices that government should not regulate were: yoga (49% agreed), meditation (44%), spiritual healing eg. reiki (36%), aromatherapy (34%), massage (33%), reflexology (28%), vitamin and mineral therapy (18%), homeopathy (13%), naturopathy (11%), osteopathy (10%), hypnosis (9%), herbal medicine (8%), Chinese herbal medicine (7%), acupuncture (6%), and chiropractic (4%) Areas of greatest concern were incorrect/inadequate/delayed diagnosis, interactions between complementary medicines and pharmaceuticals, and patients not disclosing T&CM use to their doctors Some commented that complementary therapies caused no harm in the hands of appropriately trained practitioners Many GPs indicated that therapies that did not involve medicines (such as yoga, meditation, and spiritual healing) did not require regulation, whereas others that had potential to delay diagnosis or interact with conventional medication (such as herbal medicine or naturopathy) should be regulated Some suggested self-regulation (e.g. industry accreditation) was more appropriate for some therapies than government regulation |
| Dooley 2010 [75] | Australia (Gold Coast, Melbourne, and Wagga Wagga) | Quantitative. Postal, online, and print-based questionnaire survey | Pharmacy assistants | 107 | Western herbal medicine, naturopathy | 75% strongly agreed/agreed naturopaths should be formally registered to safeguard the public, 2% disagreed, 22% were unsure |
| Flower 2015 [62] | UK | Qualitative Semi-structured face to face and telephone interviews | General practitioners | 15 | Herbal medicine |
Practitioner regulation and proper quality control procedures were key factors that were required before herbal treatments could be recommended Many were open to the use of herbal medicines when conventional treatment had failed Concerns were expressed about the lack of quality assurance of herbal products, potential adulteration with pharmaceuticals, and possible interactions between herbs and drugs The training, lack of regulation or licensing, and the level of medical knowledge of herbal practitioners, were additional sources of uncertainty |
| Hall 2000 [103] | Australia (Perth) | Quantitative Cross-sectional postal questionnaire survey | General practitioners | 282 | Acupuncture, aromatherapy, herbal medicine, homeopathy, hypnosis, massage, naturopathy, meditation, spinal manipulation, yoga |
32.2% did not favour referral to practitioners citing lack of government regulation and training standards GPs were most likely to refer patients to acupuncture (75.0% of respondents), massage (62.0%), meditation (53.0%), and yoga (42.0%) Fewer than 8% would refer patients to aromatherapy, herbal medicine, homeopathy, or naturopathy |
| Harris 2006 [84] | USA (Minnesota) | Quantitative Print-based questionnaire survey | College of Pharmacy faculty department members, and pharmacy students | 94 | Acupuncture, aromatherapy, bioelectromagnetic therapies, biofeedback, chiropractic, herbal medicine, homeopathy, hypnosis/guided imagery, massage, music, nutritional supplements, prayer/spiritual healing, meditation, rolfing, therapeutic/healing touch |
58% of faculty members and 80% of students (p = 0.074) agreed the unavailability of credentialled providers was a barrier to the use of T&CM practices 74% of faculty members and 53% of students indicated chiropractic a mainstream health care practice 53% of students indicated nutritional supplements mainstream practice No other practice achieved > 50% agreement on being a mainstream practice |
| James 2020 [59] | Sierra Leone (Freetown in Western Area, Bo district in Southern Region, Kenema district in Eastern Region, Bombali district in Northern Region) | Qualitative Semi-structured interviews | Doctors, nurses, and community health officers | 15 | Traditional and complementary medicine |
The prerequisites for health care integration included training of T&CM practitioners on what diseases to treat and what to refer, regulation of practices, and public education to seek care from licensed practitioners only T&CM practitioners should be adequately educated in basic medical training Collaboration with some T&CM practices, such as herbal medicine, which were perceived to cause serious adverse effects, should not be permitted |
| Jarvis 2015 [61] | England (Liverpool and Manchester) | Qualitative Semi-structured telephone interviews | General practitioners | 19 | Complementary and alternative medicine |
Practitioners should be professionally regulated GPs were significant concerned about herbal remedies (e.g. causing interactions with pharmaceuticals) Having greater confidence in the robustness of practitioner training and regulatory procedures enables GPs to have greater confidence in endorsing practices and referring patients to practitioners |
| Langworthyb 2000 [85] | Netherlands | Quantitative Postal questionnaire survey | Osteopaths, manual therapists, physiotherapists | 227 | Chiropractic |
59% of osteopaths (n = 49), 24% of manual therapists (n = 46), and 15% of physiotherapists (n = 132) agreed chiropractors should be 'politically recognized' through statutory registration 13% of manual therapists and 3% of physiotherapists agreed chiropractors should not be 'politically recognized' through statutory registration 67% of manual therapists agreed chiropractic was in competition with manual therapy 22% of osteopaths agreed chiropractic was in competition with osteopathy 19% of physiotherapists agreed chiropractic was in competition with physiotherapy |
| Livingston 2010 [86] | Australia (Sydney) | Quantitative Postal questionnaire survey | General practitioners | 288 | Herbal medicine, naturopathy |
91% strongly supported a national register for naturopaths and herbalists, requiring qualifications for listed members to be licensed 84.0% agreed that herbal therapies should be regulated in the same way as pharmaceuticals, 7.3% disagreed |
| Montbriand 2000 [87] | Canada (Saskatchewan) | Quantitative Postal questionnaire survey | Nurses, pharmacists, physicians | 153 | Alternative therapies |
Across all three professional groups 69% agreed with regulation, 10% did not, 21% were undecided 82% of pharmacists (n = 49) agreed T&CM should be regulated or have government controls, 10% did not agree, 8% did not know Pharmacists were alarmed at the number of herbal and homeopathic products entering the market without standards, regulations and proper labelling 69% of physicians (n = 52) agreed T&CM should be regulated or have government controls, 15% did not agree, 15% did not know Physicians felt practices with potentially harmful side-effects should be regulated, but were concerned about the impracticality of controls and whether effective regulation was possible 56% of nurses (n = 52) agreed T&CM should be regulated or have government controls, 6% did not agree, 38% did not know Nurses focussed comments on practitioners, expressing the need for self- or government regulation and certification to practice |
| Morin 2017 [88] | Canada (Quebec) | Quantitative Postal questionnaire survey | Physicians | 266 | Osteopathy |
Physicians supported the regulation of osteopathy and indicated it would promote collaboration 72% would be greatly/moderately influenced by government regulation and the establishment of university-based programs, 28% would not be influenced/very influenced by regulation Physicians indicated regulation would promote collaboration, 85.3% agreeing that collaborating with osteopaths was slightly/quite/very important |
| Poreddi 2016 [104] | India (Bangalore) | Quantitative Cross-sectional Print-based questionnaire survey | Student nurses | 122 | Acupuncture, Ayurveda, aromatherapy, biofeedback, chiropractic, herbal medicine, homeopathy, hypnosis, naturopathy, reflexology, spiritual healing | 81.1% agreed that the unavailability of credentialled providers was a barrier to the use of T&CM, 18.9% did not agree |
| Poynton 2006 [98] | New Zealand | Quantitative. Nationwide cross-sectional postal questionnaire survey | General practitioners | 300 | Acupuncture, aromatherapy, traditional Chinese medicine, chiropractic, herbal medicine, homeopathy, hypnosis, traditional Māori medicine, naturopathy, osteopathy, traditional Pacific Island medicine, reflexology, spiritual healing |
Less than 12.3% of GPs referred patients to aromatherapy, herbal medicine, naturopathy and traditional Chinese medicine, traditional Māori medicine, and traditional Pacific Island medicine, compared to greater than 70.0% referral rate to acupuncture, chiropractic, and osteopathy The most common reasons for not referring patients were lack of evidence (88%, n = 264), lack of regulation (78%, n = 234), and financial cost to patients (50.3%, n = 151) Other reasons for non-referral include concerns about exploitation of vulnerable patients and the risk of adverse effects or harm |
| Price 2004 [89] | UK | Quantitative. Population-based postal questionnaire survey | Members of the British Medical Acupuncture Society (including general practitioners (75% of respondents), hospital doctors and other health professionals) | 1112 | Acupuncture | 56% favoured of some form of regulatory governing body for practitioners, 27% were undecided |
| Semple 2006 [90] | Australia (South Australia, Queensland, and Victoria) | Quantitative Postal questionnaire survey | Practising pharmacists | 211 | Complementary and alternative medicine practices dispensing vitamins and minerals, flower remedies, herbal products and other dietary supplements, homeopathic products, tissue salts | Pharmacists agreed the current level of regulation of practitioners was a barrier to information provision about T&CM to consumers. One way of overcoming this was indicated to be better regulation of practitioners |
| Taylor 2003 [91] | New Zealand (Wanganui) | Quantitative Postal questionnaire survey | General practitioners | 25 | Acupuncture, aromatherapy, chiropractic, colour therapy, homeopathy, hypnosis, iridology, reflexology, Rongoā Māori |
84% indicated they would like to see better regulation of therapies 96% indicated concern about the safety of therapies |
| Tiralongo 2010 [99] | Australia | Quantitative. National postal questionnaire survey | Community, hospital, consultant, industry, academia, public service, and army pharmacists | 583 | Herbal medicine, naturopathy | 92% strongly agreed/agreed that practitioners should be formally registered to safeguard the public, 3% disagreed/strongly disagreed, 5% were unsure |
| Wardle 2018 [51] | Australia (Non-metropolitan New South Wales) | Qualitative. Population-based online and postal questionnaire survey analysis of open-ended question | General practitioners | 152 | Complementary medicine |
Risk was a major theme in many of the responses, with both direct (e.g. drug-herb interaction, adverse events), and indirect risks (e.g. delayed diagnosis, exploitation) identified Most held that risks were maximised due to the variability of standards, practices and treatments which was related in large part to the regulatory vacuum Practitioner or product variability or potential monopolisation of care by providers were highlighted as major issues that increased potential risks to patients. For many GPs, it was this risk, rather than risk of ineffective therapies, which was of most concern Both supporters and detractors of T&CM were concerned about the lack of regulation Providers practised in a regulatory vacuum and were considered to be practising without any regulatory oversight and therefore without restrictions |
| Yuc 2015 [100] | Korea | Quantitative Email, postal and print-based questionnaire survey | Doctors, nurses, Oriental (Korean) medical doctors as medical professionals | 19 | Acupuncture, alternative medicine, chiropractic, clinical art, feet massage, laughter, Qi gong, trainees of traditional Chinese medicine |
Across all provider groups, medical and T&CM professionals, 32.8% agreed legislation to govern providers was preferable, 25.0% agreed with qualifications/accreditation, 13.6% agreed with making/evaluating standards 31.6% agreed government administered examinations were the most important for gaining T&CM qualifications, 15.8% agreed that qualifications from a certified institute, e.g. college/university was preferable 29.4% agreed a national examination for managing qualifications was preferable, 23.6% agreed with legislation and national control as the preferred option |
| Professional associations (n = 6) | ||||||
| Clarke 2004 [54] | UK | Qualitative. Document analysis |
T&CM professional associations representing aromatherapy, Chinese herbal medicine, chiropractic, crystal healing, feng shui, 'lay' homeopathy, medical homeopathy, osteopathy and radionics |
9 | Aromatherapy, Chinese herbal medicine, chiropractic, crystal healing, feng shui, 'lay' homeopathy, medical homeopathy, osteopathy, radionics |
Most associations promoted the need for tighter regulation Professionalisation strategies were necessary to eliminate unprofessional conduct, ensure autonomy of practice and promote legitimacy of practitioners The Chinese herbalists associations and chiropractic associations were most concerned with professionalisation The Chinese herbalists associations were committed to statutory self-regulation arguing this was the best option to ensure professional recognition, establish protection of title and give authority to use scheduled herbs Leaving regulation unaddressed would risked imposition of government controls Regulation provided greater protection for patients, increased credibility, raised the visibility of herbal medicine and protected practice autonomy Challenges to regulation was gaining consensus between associations Concerns included dilution of philosophical traditions and practice standardisation |
| Gilmour 2002 [63] | Canada (Ontario) | Qualitative. Unstructured interviews | Leaders in the professions of acupuncture/traditional Chinese medicine, homeopathy, and naturopathy | 24 | Acupuncture/traditional Chinese medicine, homeopathy, naturopathy |
Statutory self-regulation was seen as key to full professionalisation by all groups. They desired the protection of statutory regulation which included status and legitimacy, acknowledgement of skills and qualifications, potential integration into the health care system, restricted use of designated titles to registered members, acceptance of practices by private insurers, provision of a defined scope of practice, to assure consumers of the quality of training and protection against those who did not meet the standards All groups expressed the hope that regulation would lead to the establishment and enforcement of standards of practice but were unable to accomplish this due to internal disagreements, division, lack of cohesion, and intra-professional competition, all of which hindered regulation attempts Only the naturopaths saw the need for appropriate research to support the push for regulation, the two remaining groups were content to rely on historical evidence |
| Kelner 2004 [67] | Canada (Ontario) | Qualitative Semi-structured interviews, and published policy material | Directors or presidents of conventional professional associations of medicine, nursing, physiotherapy, clinical nutrition and public health, and federal/provincial statutory governing bodies of the professions of clinical nutrition, medicine, nursing, physiotherapy, and public health | 10 | Acupuncture/traditional Chinese medicine, chiropractic, homeopathy, naturopathy, reiki |
Most were unsympathetic to the professionalisation of T&CM groups Achieving statutory self-regulation was important for professionalisation but had to be earned. There was a reluctance to encourage T&CM groups to gain regulation They argued that unless therapies had a body of knowledge based on scientific evidence and a method of delivering care in an objective, standardised way, it was unsafe to allow practitioners to treat patients Higher standards of evidence were essential to gain formal recognition and a place in the health care system In order for T&CM practitioners to be credentialled, their therapies and practices would need to be evidence-based Nursing representatives more often emphasised the need for public safety and protection as a rationale for regulating T&CM providers, rather than a need for evidence Allied health professions felt strongly that regulation should not be granted until there was scientific evidence that therapies were safe and effective and scopes of practice were suitable Regulation would promote referrals, especially from the nursing profession The issue of scope of practice evoked tensions and concerns about maintaining jurisdictional boundaries and protecting turf Leaders proposed several ways to block or control integration; co-optation, physicians as gatekeepers, and opposing government funding for T&CM |
| Kelner 2006 [68] | Canada (Ontario) | Qualitative Semi-structured interviews, and documentary material | Leaders in the professions of chiropractic and homeopathy | 16 | Chiropractic, homeopathy |
Common professionalisation strategies were used by both professions, i.e. improving education quality, raising practice standards, developing research capacity, and increasing group cohesion There was insufficient support from government for professionalisation efforts Achieving statutory self-regulation motivated chiropractors to pursue professionalisation strategies Regulation gave authority to enforce practice standards and monitor ethical misconduct, but did not improve professional harmony As an unregulated profession, homeopathy had scarce resources, and greater difficulty in maintaining clinical standards and sanctioning unethical practitioners because of inadequate monitoring. They also had greater internal division which impeded professionalisation efforts Some homeopathy leaders believed regulation would promote cohesion and raise practice standards |
| Lin 2005 (Section 6, McCabe) [52] (Summarised in [105]) | Australia | Quantitative Postal questionnaire survey | T&CM professional associations of naturopathy and Western herbal medicine | 11 | Western herbal medicine, naturopathy |
36% of associations supported statutory regulation, 36% supported the existing self-regulatory model, 27% wanted stronger regulation (unspecified) 64% of associations were negative about the existing self-regulatory model, in part because it had not produced a national, consistent, or effective regulatory system The need to protect the professions and practices was seen as strong motivators by supporters and opposers of statutory regulation There was no uniform minimum standard of education, and concerns about inadequately trained or incompetent practitioners Some supporters of statutory regulation argued that this status, and with it raised standard of education, was essential to gain access to currently scheduled natural medicines Others believed statutory regulation could introduce unacceptable restrictions on practice, and care should be taken that the regulatory effect on education, particularly increasing medicalisation of naturopathy, did not diminish the founding philosophies There was potential for conflict of interest if professional associations were linked with private education providers, whose commercial interests might not be served by the requirement to raise standards of education |
| Welshd 2004 [70] | Canada (Ontario) | Qualitative Semi-structured interviews | T&CM senior leaders of the associations of traditional Chinese medicine/acupuncture, homeopathy, and naturopathy | 24 | Acupuncture/traditional Chinese medicine, homeopathy, naturopathy |
Strategies employed to achieve statutory self-regulation were improving education and practice standards, engaging in peer-reviewed research, and increasing group cohesion The inclusion of medical science was considered the basis of distinguishing between 'science' and 'non-science' and who should practise and who should not. All groups attempted to demarcate knowledge claims from competitors, and they all engaged in boundary work. The diversity of knowledge claims made uniform standards difficult to achieve Leaders looked forward to the raised minimum education standards that regulation would impose but differing educational standards between homeopathy schools impeded the setting of uniform standards. High standards were seen as important to protect the public Some saw the need for more clinical and peer-reviewed research to support regulation claims but debated what research was required Challenges included no intra-professional agreement on the best standards to follow, which knowledges to codify or what kind of research should be conducted Some considered encouraging more cohesion through conflict resolution to successfully deal with government and achieve regulatory status |
| Education providers (n = 2) | ||||||
| Lin 2005 (Section 5, McCabe) [52] (Summarised in [80]) | Australia | Quantitative Postal questionnaire survey | Education providers of undergraduate and post-graduate courses | 19 | Western herbal medicine, naturopathy |
Overall 53% preferred statutory regulation of practitioners 64% of private providers (n = 14) supported government involvement in regulation, 36% supported statutory regulation, 28.5% supported co-regulation, 7% supported continued self-regulation 100% of universities (n = 5) supported statutory regulation A degree level of education was essential 'for the good of the profession’, and to provide university pathways, though only 45% of providers supported a bachelor's degree as the minimum requirement A major concern of private providers was that moving courses into the university sector might result in a loss of traditional holistic philosophies and perspectives There was about ongoing conflict within the professions over regulation and education Major concerns were lack of agreement on the most appropriate model of regulation and minimum educational standards, the commercialisation of education resulting in lowered standards, lack of democratic processes and transparent policies in some professional associations, and the need for standards to be set by an independent body |
| Welshd 2004 [70] | Canada (Ontario) | Qualitative Semi-structured interviews | T&CM senior leaders of the major schools of traditional Chinese medicine/acupuncture, homeopathy, and naturopathy | 24 | Acupuncture/traditional Chinese medicine, homeopathy, naturopathy |
Strategies employed to achieve statutory self-regulation were improving education and practice standards, engaging in peer-reviewed research, and increasing group cohesion The inclusion of medical science was considered the basis of distinguishing between 'science' and 'non-science' and who should practise and who should not. All groups attempted to demarcate knowledge claims from competitors, and they all engaged in boundary work. The diversity of knowledge claims made uniform standards difficult to achieve Leaders looked forward to the raised minimum education standards that regulation would impose but differing educational standards between homeopathy schools impeded the setting of uniform standards. High standards were seen as important to protect the public Some saw the need for more clinical and peer-reviewed research to support regulation claims but debated what research was required Challenges included no intra-professional agreement on the best standards to follow, which knowledges to codify or what kind of research should be conducted Some considered encouraging more cohesion through conflict resolution to successfully deal with government and achieve regulatory status |
| Policy-makers (n = 2) | ||||||
| Kelly 2005 [65] | Canada (Alberta, British Columbia) | Qualitative Semi-structured interviews | Regional health policy-makers | 10 | Acupuncture, chiropractic, herbal medicine, homeopathy, hypnosis, massage |
Policy-makers held a positive view for the integration of T&CM at the clinical and primary care levels of practice Public safety was an important concern Policy-makers supported the movement towards integrative health services, but emphasised that the issues of evidence-based T&CM research, standards of accreditation and training for T&CM practitioners, as well as the issue of who pays, needed to be addressed to ensure the improved health and well-being of the public CAM credibility and the potential for integration suffered from a lack of evidence demonstrating beneficial outcomes More rigorous training and licensing of T&CM practitioners would contribute positively to movement towards integration Poor and uneven accreditation of T&CM practitioners was a significant barrier More thorough and consistent accreditation procedures for T&CM practitioners would increase legitimacy in the eyes of the conventional healthcare system, the government and the general public Some identified the need for medical training in the T&CM curricula and viewed this step as the 'point of real leverage' for T&CM integration A few felt that integration was hampered by potential boundary disputes between conventional and T&CM practitioners |
| Kelner 2004 [66] | Canada (Ontario) | Qualitative Semi-structured interviews | Federal, provincial, and municipal government health department officials | 10 | Acupuncture/traditional Chinese medicine, chiropractic, homeopathy, naturopathy, reiki |
Most comments were focussed on acupuncture/traditional Chinese medicine, chiropractic, and naturopathy The role of the state was to fulfil their mandate to protect the public while responding to consumer demand for T&CM services Statutory self-regulation was regarded as a mechanism for ensuring public safety, creating accountability for practitioners Regulation was regarded as a bargain that confers legitimacy, social inclusion, and socioeconomic status in exchange for constraints that protected the public interest Most said they could foresee a legitimate place for T&CM groups within the health care system, but it was essential to establish evidence of effectiveness and safety, standards of training, credentialling, effective control over practice, and clear accountability Practitioners would achieve better acceptance from conventional medicine and government if they had scientific evidence of efficacy and safety Governments hesitated to endorse the 'legitimation' of T&CM due to concerns about the costs of health care that they feared T&CM groups would make demands on. Cost of health care was seen as a barrier to integrating T&CM into mainstream medicine A clear and appropriate scope of practice was essential for T&CM groups to gain a 'legitimate' place in the system. An example was naturopathy with a broad scope that overlaps with other specialities, making it difficult to achieve social closure and hampered efforts to make jurisdictional claims. It could also infringe on the practices of medical professionals and hinder legitimation and integration of T&CM Disorganisation, internal conflicts and tensions, and fragmentation of some T&CM groups made engagement with government difficult and hampered integration into the health care system |
a This percentage has been calculated by the first author using raw data supplied in the published article
b Physiotherapists, manual therapists and osteopaths were considered conventional medical practitioners in the country of research
c Oriental medical doctors were considered conventional medicine professionals in the country of research
d This study examined both professional association and education provider stakeholders