Profile of the complementary and alternative medicine workforce across Australia, New Zealand, Canada, United States and United Kingdom

Complementary Therapies in Medicine (2013) 21, 364—378

Available online at www.sciencedirect.com

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Profile of the complementary and alternative medicine workforce across Australia, New Zealand, Canada, United States and United Kingdom Matthew J. Leach ∗ School of Nursing & Midwifery, University of South Australia, North Terrace, Adelaide, South Australia 5000, Australia Available online 23 May 2013

KEYWORDS Census; Complementary and alternative medicine; Health services; Workforce

Summary Background: Despite the expressed demand for complementary and alternative medicine (CAM) services in developed countries, little is known about the CAM workforce in terms of supply and composition. Objective: To describe the CAM workforce across five developed countries to better inform health workforce and health services planning, and perchance, inform debate on future public health and primary care policy. Methods: Data from the Australian, New Zealand, Canadian, UK and US Censuses of population were interrogated for information pertaining to the size and characteristics of the CAM workforce. This was supplemented by other population-level workforce data where available. Results: The quality and availability of population-level data on the CAM workforce vary substantially across nations. Of the nine CAM disciplines explored, massage therapy consistently comprised the largest portion of the CAM workforce, followed closely by chiropractic. Disciplines in shortest supply were homoeopathy in Australia, traditional Chinese medicine in New Zealand, and naturopathy in the US. Across the broader CAM workforce, practitioners were typically female, aged ≥40 years, worked within a primary care setting, held a vocational or higher education level qualification, worked full-time, and earned <$1000 gross per week. Conclusions: This work has helped shape current understandings of the CAM workforce. In doing so, it will help to inform the training and continuing education needs of the evolving CAM workforce, and further, ensure the provision of a competent CAM workforce to service the needs of consumers. Addressing the many limitations of existing data sources will assist in meeting these needs. © 2013 Elsevier Ltd. All rights reserved.

Introduction Complementary and alternative medicine (CAM) represents a diverse range of health-related therapies and interven-

∗

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tions that are largely considered to be outside the realm of Western medicine. Consumer interest in complementary and alternative medicines and CAM services has increased over the past decade. Recent data indicate that a large proportion of the population of developed countries,1 including Australia (52—69% of those surveyed),2,3 Canada (59—60%),4 the United States (62%),5 Singapore (76%)6 and Japan (50%),7

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Profile of the CAM workforce have used CAM at least once over a twelve-month period. Over the same period of time, close to twelve percent of Canadian adults,8 sixteen percent of US adults,9 twenty-six percent of English adults,10 and twenty-three11 to forty-four percent of Australians3 had consulted a CAM practitioner, with massage being the most commonly used service. Even though a comparatively greater proportion of the population of developed countries visit Western medical practitioners (i.e. >77%) than CAM practitioners,12,13 there is surprisingly little difference in the total number and cost of visits between groups, at least in Australia. For instance, in 2005, Australian adults made an estimated 69.2 million visits to CAM practitioners, at an estimated cost of AU$1.73 billion. In the same year, there were approximately 68.9 million consults with Western medical practitioners, at a total cost of AU$1.6 billion.3 In the US, the out-of pocket costs for CAM services are far less than Western medical care. In 2007, US adults made 354.2 million visits to CAM practitioners, at an estimated out-of-pocket cost of US$11.9 billion14 ; the out-of-pocket cost of Western physician services in the same year was $US46.8 billion.15 These data provide clear evidence of expressed demand for CAM services in developed countries, which is not too dissimilar from the expressed demand for Western medical services. There are several explanations for the increasing use of complementary medicines and CAM services across the globe.2,9 Earlier studies have suggested that consumer dissatisfaction with Western medicine may be a leading reason for CAM use1 ; however, more recent reports indicate that an aspiration for active health-care participation, greater disease chronicity and severity, holistic health-care beliefs, and an increase in health-awareness behaviour are more likely to be associated with CAM use.16—18 These transformations in consumer attitude and health behaviour have paralleled changes in the way many CAM specialties practice.19 This suggests that complementary medicines and CAM services are addressing unmet needs in health care. Despite the increasing demand and need for CAM services in developed countries, little is known about the CAM workforce in terms of supply and composition; and apart from a few workforce surveys, which are hampered by narrow scope, limited data, poor response rates, and/or moderatesized convenience samples,20—23 little has been published in the public domain. Without knowledge of the composition of the CAM workforce, it is difficult to (1) understand the diversity and characteristics of the CAM workforce, (2) meet the training and continuing education needs of the evolving CAM workforce, and (3) ensure the provision of a competent CAM workforce to service the needs of consumers. In recognising these concerns, this article describes the CAM workforce across five developed countries in order to better inform health workforce and health services planning, and perchance, inform debate on future public health and primary care policy.

Methods Geographical regions were limited to organisation for economic cooperation and development (OECD) countries as the increasing demand for CAM is largely reported in these developed nations. Of these countries, only those that provided publicly accessible census data on the CAM workforce

365 were considered. Five countries were selected: Australia, New Zealand, Canada, United Kingdom and the United States. The CAM workforce was defined as any health service not considered a core component of Western medicine, nursing or allied health,24 and delivered in any industry of employment. This included, but was not limited to, system-based therapies (e.g. naturopathy, herbal medicine, traditional Chinese medicine [TCM], acupuncture, homoeopathy) and manipulative therapies (e.g. chiropractic, osteopathy and massage therapy). Diagnostic techniques (e.g. iridology, kinesiology) were excluded. Census data were acquisitioned by request where possible (e.g. Australia and New Zealand), and where requests for data were not feasible or cost-prohibitive (e.g. UK, US and Canada), data were sourced from the websites of each census administrator. Data from the 2006 Australian Bureau of Statistics Census of Population and Housing, 2006 Statistics New Zealand Census of Population and Dwellings, 2006 Statistics Canada Census of Population, 2001 UK Office for National Statistics Census, and the 2000 US Census Bureau Census of Population and Housing were interrogated for information pertaining to the size of the CAM workforce, as well as key characteristics of the workforce, such as age, sex, primary discipline, highest level of education attained, industry of employment, hours worked per week, and gross weekly income. These five population censuses were selected as they employed similar study methods, used comparable survey items, and provided highquality data that were highly representative of each national population (Table 1). Where possible, census information was supplemented by workforce data reported by other pertinent sources where the publication date closely approximated the census date of the selected country. While more recent censuses have been conducted across four of the five selected countries (i.e. Australia, Canada, UK and US), detailed occupation data were not publicly available from any of these censuses during the conduct of the project. Available data were analysed descriptively using frequencies and percentages. Workforce populations were converted to patient-provider ratios to allow for international comparisons. General/family practitioner population data were included as a point of reference only.

Results Quality of CAM workforce data The Australian and New Zealand Census of population provided the most comprehensive population-level data on the CAM workforce; although, data were only available for seven distinct CAM disciplines (Table 1). The Canadian Census of population provided data for most fields of interest, but only for chiropractors and general practitioners. Data for all other CAM occupations were reported in aggregate form with other non-CAM occupations and were not useful for occupation-specific workforce planning. US population census data were limited, with data available for only few fields of interest for chiropractors and massage therapists; data for most fields had to be sourced from workforce surveys. Data for all other occupations were reported in aggregate form

366

Table 1

Quality of CAM workforce data derived from population censuses.

Census

Year conducted

Description of Census

Data available

Notes

Australian Bureau of Statistics Census of Population and Housing

2006

The Australian census is a self-administered questionnaire comprising 60 closed/free text questions. It is administered nationally to every home in Australia, every 5 years. In 2006, the Australian census achieved a response rate of 97%.

Detailed occupation data from the 2011 census were not available as at 30th Sep 2012.

Statistics Canada Census of Population

2006

Statistics New Zealand Census of Population and Dwellings

2006

The Canadian census is a self-administered questionnaire, which is distributed in two main forms. The short form comprises 8 closed/free text questions, and is distributed to 80% of the Canadian population. The long form comprises 61 closed/free text questions, and is distributed to 20% of the population. The census is administered nationally to every home in Canada, every 5 years. In 2006, the Canadian census achieved a response rate of 97%. The New Zealand (NZ) census is a self-administered questionnaire comprising 47 closed/free text questions. It is administered nationally to every home in NZ, every 5 years. In 2006, the NZ census achieved a response rate of 98%.

- Reports demographic data (i.e. gender, age, highest qualification held, hours worked per week in all jobs, gross weekly income, industry of employment) for each of the following primary occupations: osteopath, chiropractor, naturopath, homoeopath, acupuncturist, traditional Chinese medicine practitioner, massage therapist and general medical practitioner. - Data for herbalists, aromatherapists, iridologists and reflexologists are reported in aggregate form (under ‘natural remedy consultant’) and cannot be separated. - Reports demographic data (i.e. gender, age, highest qualification held, hours of paid work per week in all jobs, gross annual income, industry of employment) for each of the following primary occupations: chiropractors and general practitioners. - Data for other professional occupations (e.g. naturopath, osteopath, podiatrist and orthoptist) are reported in aggregate form and cannot be separated.

UK Office for National Statistics (OFN) Census

2001

The next census is scheduled for 2013

Detailed occupation data from the 2011 census were not available as at 30th Sep 2012.

M.J. Leach

The UK census is a self-administered questionnaire comprising 44 closed/free text questions. It is administered nationally to every home in England and Wales, every 10 years. In 2001, the UK census achieved a response rate of 98%.

- Reports demographic data (i.e. gender, age, highest qualification held, hours worked per week in all jobs, gross annual income, industry of employment) for each of the following primary occupations: osteopath, naturopath, herbalist, homoeopath, acupuncturist, traditional Chinese medicine practitioner, massage therapist, general practitioner and other CAM provider. - Data for ‘therapists not elsewhere classified’ (i.e. acupuncturist, dietician, masseur, orthoptist, osteopath and psychotherapist) are reported in aggregate form and cannot be separated. - Does not report income or qualification data for occupation groups.

Detailed occupation data from the 2011 census were not available as at 30th Sep 2012.

US Census Bureau Census of Population and Housing

2000

The US census is a self-administered questionnaire, which is distributed in two main forms. The short form comprises 7 closed/free text questions, and is distributed to 100% of the US population. The long form comprises 53 closed/free text questions, and is distributed to 17% of the population. The census is administered nationally to every home in the US, every 10 years. In 2001, the US census achieved a response rate of 67%.

- Reports demographic data (i.e. gender, age and gross annual income) for the following primary occupations: chiropractors and massage therapists. - Data for general practitioners are aggregated with physicians and surgeons and cannot be separated. - Data for CAM practitioners are aggregated with ‘other health diagnosing and treating practitioners’ (i.e. acupuncturist, naturopath, hypnotherapist) and ‘other healthcare practitioners and technical workers’ (i.e. traditional Chinese herbalist, podiatrist) and cannot be separated.

Detailed occupation data from the 2010 census were not publicly available as at 30th Sep 2012.

Profile of the CAM workforce

367 with other non-CAM occupations and thus, were not useful for occupation-specific workforce planning. Data derived from the UK census were insufficient for the purposes of CAM workforce planning due to the way data were coded and aggregated; subsequently, all UK data had to be sourced from workforce surveys. Population-level data for the herbal medicine workforce could not be sourced for any country.

Size of the CAM workforce The collective CAM workforce was relatively smaller than the general practitioner workforce in Australia (19,401 vs. 29,920) and New Zealand (3495 vs. 4011) in 2006, but comparatively larger in the US (189,855 vs. 86,848) in 2000 (Table 2). The most prevalent CAM occupation, which had the greatest number of providers per head of population, was massage therapy; this was followed by ‘other’ CAM disciplines and naturopathy in Australia and New Zealand, and by chiropractic and osteopathy in the US. Disciplines in shortest supply were homoeopathy in Australia, traditional Chinese medicine in New Zealand, and naturopathy in the US. Apart from massage therapy and acupuncture, and chiropractic in Australia, Canada and the US, provider-population ratios for each discipline were generally inconsistent across countries.

Gender composition The gender composition of each CAM discipline was largely consistent across countries where data were available (Table 3). Chiropractic in all countries but the UK, and osteopathy in the US, were clearly male dominant, with a male to female ratio of at least 2.1 to 1. Traditional Chinese medicine was only slightly dominated by males, with a minimum male to female ratio of 1.4 to 1; not dissimilar to general practice, where male to female ratios ranged between 1.5 and 1.7. Female dominance was particularly evident for occupations such as massage therapy, naturopathy and homoeopathy, where there were at least three female practitioners to every male. The ratio of males to females in osteopathy (in Australia and New Zealand) and acupuncture was almost 1 to 1.

Age distribution The distribution of practitioners across the three age groups, for each CAM discipline, was similar between countries (Table 4). Across the nine CAM disciplines, 35—55 percent of practitioners were aged under 40 years, and less than 15 percent were aged 60 years or older. Approximately twothirds of practitioners of acupuncture, traditional Chinese medicine, naturopathy and other CAM disciplines were aged 40 years or over; which is comparable to general practice. Homoeopathy was the oldest workforce, with more than 79% of practitioners aged ≥40 years. For massage therapy and chiropractic, the distribution of practitioners aged <40 years and ≥40 years was similar. Osteopathy demonstrated variable distribution across countries; in Australia, close to 68% of osteopaths were <40 years of age, compared to the US, where around two thirds of clinicians were aged ≥40 years;

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M.J. Leach

for New Zealand, the proportion of practitioners aged <40 years and ≥40 years was similar.

Educational attainment Most practitioners of chiropractic, osteopathy and acupuncture held a Bachelor degree or postgraduate degree as their highest level of education, which was comparable to general practice (Table 5). For traditional Chinese medicine practitioners, close to half possessed a Bachelor

Table 2

degree qualification. Massage therapists and other CAM practitioners reported the lowest level of education, with most holding a qualification no higher than a Diploma or Advanced Diploma. Over half of naturopaths held as their highest qualification a Diploma, Advanced Diploma or Bachelor degree. Most homoeopathic practitioners also possessed a Diploma, Advanced Diploma or Bachelor degree qualification, though proportions did vary across countries, with 53% of New Zealand homoeopaths holding a Bachelor degree, compared to 37% of Australian homoeopaths. By contrast, New Zealand had a greater proportion of CAM

Number of CAM and general practitioners by country, across all industries of employment.

Chiropractors

Osteopaths

Massage therapists

Naturopaths

TCM practitioners

Homoeopaths

Acupuncturists

Other CAM practitioners

All CAM practitionersk

a

Australia Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd

Population

PPR

2488 6660 255 2024e 50,330 777 NA 312 3161f 48,678g 8191 NA 1272 NA 72,940 2982 NA 435 NA 3679h 483 NA 42 NA NA 238 NA 102 NA NA 946 NA 252 NA 14,228i 3296 NA 825 NA NA 19,401 6660 3495 5185 189,855

1:7980 1:4747 1:15,796 1:29,206 1:5464 1:25,554 NA 1:12,910 1:18,701 1:5781 1:2424 NA 1:3167 NA 1:3858 1:6658 NA 1:9260 NA 1:76,494 1:41,108 NA 1:95,904 NA NA 1:83,426 NA 1:39,490 NA NA 1:20,989 NA 1:15,984 NA 1:19,779 1:6024 NA 1:4882 NA NA 1:1023 1:4747 1:1153 1:11,400 1:1482

Profile of the CAM workforce

369

Table 2 (Continued)

Australiaa Canadab New Zealandc United Kingdom United Statesd

General medical practitioner

Population

PPR

29,920 42,605 4011 28,802l 86,848j

1:664 1:737 1:1004 1:2052 1:3240

NA, data not available; PPR, provider-population ratio. a Based on 2006 Australian population data25 and data from the 2006 Australian population census.26 b Based on 2006 Canadian population data27 and data from the 2006 Canadian population census.28 c Based on 2006 New Zealand population data29 and data from the 2006 New Zealand population census.30 d Based on 2000 US population data31 and data from the 2000 US population census.32 e Based on 2004 UK population data33 and data reported by the 2004 UK General Chiropractic Council.34 f Based on 2001 UK population data33 and data reported by the 2001 UK General Osteopathic Council.35 g Based on 2003 data reported by Magen, Ward and Corp.36 h Based on 2000 data reported by Hough, Dower and O.Neill.23 i Based on 2000 data reported by the US National Acupuncture Foundation.37 j Based on 2000 data reported by Salsberg and Forte.38 k Defined as the sum of all chiropractors, osteopaths, massage therapists, naturopaths, TCM practitioners, homoeopaths, acupuncturists and other CAM practitioners, where data are reported. l Based on 2001 data for England only, reported by Office for National Statistics.46

Table 3

Number of CAM and general practitioners by gender.

Chiropractors

Osteopaths

Massage therapists

Naturopaths

TCM practitioners

Homoeopaths

Acupuncturists

a

Australia Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom

n (%) males

Male to female ratio

1675 (67.3) 4660 (70.0) 177 (69.4) 1113 (55.0)e 39,311 (78.1) 401 (51.6) NA 165 (52.9) 1644 (52.0)f 36,211 (74.0)g 2041 (24.9) NA 195 (15.3) NA 13,739 (18.8) 626 (21.0) NA 66 (15.2) NA NA 284 (58.8) NA 24 (57.1) NA NA 58 (24.4) NA 12 (11.8) NA NA 475 (50.2) NA 135 (53.6) NA

2.1:1.0 2.3:1.0 2.3:1.0 1.2:1.0 3.6:1.0 1.1:1.0 NA 1.1:1.0 1.1:1.0 2.9:1.0 1.0:3.0 NA 1.0:5.5 NA 1.0:4.3 1.0:3.8 NA 1.0:5.6 NA NA 1.4:1.0 NA 1.6:1.0 NA NA 1.0:3.1 NA 1.0:7.3 NA NA 1.0:1.0 NA 1.2:1.0 NA

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M.J. Leach

Table 3 (Continued)

Other CAM practitioners

All CAM practitionersh

General medical practitioners

United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd Australiaa Canadab New Zealandc United Kingdom United Statesd

n (%) males

Male to female ratio

NA 820 (24.9) NA 162 (19.6) NA NA 6380 (32.9) 4660 (70.0) 936 (26.8) 2757 (53.2) 89,261 (47.0) 18,783 (62.8) 26,405 (61.5) 2382 (48.8) NA NA

NA 1.0:3.0 NA 1.0:4.1 NA NA 1.0:2.0 2.3:1.0 1.0:2.7 1.1:1.0 1.0:1.1 1.7:1.0 1.6:1.0 1.5:1.0 NA NA

NA, data not available. a Based on data from the 2006 Australian population census.26 b Based on data from the 2006 Canadian population census.28 c Based on data from the 2006 New Zealand population census.30 d Based on data from the 2000 US population census.32 e Based on data from 2004 UK General Chiropractic Council survey.34 f Based on data from the 2001 UK General Osteopathic Council survey.35 g Based on 2003 data reported by Magen, Ward and Corp.36 h Defined as the sum of all chiropractors, osteopaths, massage therapists, naturopaths, TCM practitioners, homoeopaths, acupuncturists and other CAM practitioners, where data are reported.

Table 4

Number of CAM and general practitioners by age.

Chiropractors

Osteopaths

Massage therapists

Naturopaths

TCM prac.

Australiaa Canadab,c New Zealandd United Kingdome United Statesf Australiaa Canada New Zealandd United Kingdom United Statesf,g Australiaa Canada New Zealandd United Kingdom United Statesf Australiaa Canada New Zealandd United Kingdom United States Australiaa Canada New Zealandd United Kingdom United States

<40 years n (%)

40—59 years n (%)

≥60 years n (%)

Not stated n (%)

Total n (%)

1335 (53.7) 2330 (35.0) 108 (42.4) 1103 (54.5) 23,284 (46.3) 527 (67.8) NA 147 (47.1) NA 18,716 (38.3) 4013 (49.0) NA 567 (44.5) NA 33,195 (45.5) 1208 (40.5) NA 114 (26.2) NA NA 133 (27.5) NA 9 (21.4) NA NA

960 (38.6) 3445 (51.7) 129 (50.6) 739 (36.5) 24,021 (47.7) 217 (27.9) NA 138 (44.2) NA 25,313 (51.8) 3778 (46.1) NA 627 (49.3) NA 33,268 (45.6) 1532 (51.4) NA 264 (60.7) NA NA 305 (63.1) NA 24 (57.1) NA NA

193 (7.8) 885 (13.3) 18 (7.1) 55 (2.7) 3023 (6.0) 33 (4.3) NA 27 (8.7) NA 4838 (9.9) 400 (4.9) NA 78 (6.1) NA 2575 (3.5) 242 (8.1) NA 54 (12.4) NA NA 45 (9.3) NA 6 (14.3) NA NA

0 (0.0) 0 (0.0) 0 (0.0) 127 (6.3) 0 (0.0) 0 (0.0) NA 0 (0.0) NA 0 (0.0) 0 (0.0) NA 0 (0.0) NA 3902 (5.3) 0 (0.0) NA 3 (0.7) NA NA 0 (0.0) NA 3 (7.1) NA NA

2488 (100) 6660 (100) 255 (100) 2024 (100) 50,328 (100) 777 (100) NA 312 (100) NA 48,867 (100) 8191 (100) NA 1272 (100) NA 72,940 (100) 2982 (100) NA 435 (100) NA NA 483 (100) NA 42 (100) NA NA

Profile of the CAM workforce

371

Table 4 (Continued)

Homoeopaths

Acupuncturists

Other CAM practitioners

All CAM practitionersh

General medical prac.

Australiaa Canada New Zealandd United Kingdom United States Australiaa Canada New Zealandd United Kingdom United States Australiaa Canada New Zealandd United Kingdom United States Australiaa Canadab New Zealandd United Kingdom United States Australiaa Canadab New Zealandd United Kingdom United States

<40 years n (%)

40—59 years n (%)

≥60 years n (%)

Not stated n (%)

Total n (%)

31 (13.0) NA 21 (20.6) NA NA 338 (35.7) NA 81 (32.1) NA NA 1152 (35.0) NA 225 (27.3) NA NA 8737 (45.0) 2330 (35.0) 1272 (36.4) 1103 (54.5) 56,479 (36.8) 9137 (30.5) 8450 (19.7) 1083 (22.2) NA NA

175 (73.5) NA 72 (70.6) NA NA 537 (56.8) NA 153 (60.7) NA NA 1760 (53.4) NA 501 (60.7) NA NA 9264 (47.8) 3445 (51.7) 1908 (54.6) 739 (36.5) 82,602 (53.8) 16,487 (55.1) 22,535 (52.5) 2511 (51.4) NA NA

32 (13.5) NA 9 (8.8) NA NA 71 (7.5) NA 15 (6.0) NA NA 384 (11.7) NA 96 (11.6) NA NA 1400 (7.2) 885 (13.3) 303 (8.7) 55 (2.7) 10,436 (6.8) 4296 (14.4) 11,920 (27.8) 417 (8.5) NA NA

0 (0.0) NA 0 (0.0) NA NA 0 (0.0) NA 3 (1.2) NA NA 0 (0.0) NA 3 (0.4) NA NA 0 (0.0) 0 (0.0) 12 (0.3) 127 (6.3) 3902 (2.5) 0 (0.0) 0 (0.0) 871 (17.8) NA NA

238 (100) NA 102 (100) NA NA 946 (100) NA 252 (100) NA NA 3296 (100) NA 825 (100) NA NA 19,401 (100) 6660 (100) 3495 (100) 2024 (100) 153,419 (100) 29,920 (100) 42,905 (100) 0 (0.0) NA NA

NA, data not available; Prac., practitioner. a Based on data from the 2006 Australian population census.26 b Based on data from the 2006 Canadian population census.28 c Data reported in age groups <40 years, 40—59 years and ≥60 years represent data for the following age groups: 20—34 years, 35—54 years and ≥55 years, respectively. d Based on data from the 2006 New Zealand population census.30 e Based on data from 2004 UK General Chiropractic Council survey (GCC 2004). Data reported in age groups <40 years, 40—59 years and ≥60 years represent data for the following age groups: 20—40 years, 41—60 years and ≥61 years, respectively. f Based on data from the 2000 US population census.32 g Based on 2003 data reported by Magen, Ward and Corp.36 h Defined as the sum of all chiropractors, osteopaths, massage therapists, naturopaths, TCM practitioners, homoeopaths, acupuncturists and other CAM practitioners, where data are reported.

practitioners (relative to Australia and Canada where data were available) reporting high school or certificate qualification as their highest level of education, including more than 26% of massage therapists, naturopaths, traditional Chinese medicine practitioners and other CAM practitioners.

Hours worked Over one-half of chiropractors, osteopaths, traditional Chinese medicine practitioners and ‘other’ New Zealand CAM practitioners, and near half of acupuncturists, worked fulltime (≥35 h/week), compared to approximately two-thirds of general practitioners (Table 6). In the fields of naturopathy and homoeopathy, more than 56% of practitioners worked part-time (<35 h/week). Massage therapists and ‘other’ Australian CAM practitioners worked relatively fewer

hours than the remaining CAM disciplines, with 38—40% of these therapists working 1—16 h per week.

Weekly income More than 85% of practitioners of massage therapy, naturopathy, traditional Chinese medicine, homoeopathy, acupuncture and ‘other’ CAM disciplines earned less than $1000 gross per week (in each country’s respective currency) (Table 7). In the fields of chiropractic and osteopathy, close to half of clinicians reported a gross weekly income of ≥$1000. Very few practitioners earned $2000 or more per week, apart from chiropractic, where 16—34% of practitioners fell into this income bracket. This is in contrast to general practitioners, where 42—55% earned ≥$2000 per week. With the exception of chiropractic in the US, where relatively more practitioners earned ≥$2000 per week, there were no

372

Table 5

Highest level of education attained for CAM and general practitioners.# High school or certificate

Chiropractors

Osteopaths

Massage therapists

Naturopaths

TCM prac.

Homoeopaths

Acupuncturists

Other CAM practitioners

All CAM practitionersd

General medical prac.

a

Australia Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc

Bachelor degree

n (%)

Diploma or advanced diploma n (%)

Postgrad. degree

No qualif. or not stated

Total

n (%)

Graduate diploma or certificate n (%)

n (%)

n (%)

n (%)

66 (2.6) 65 (1.0) 9 (3.6) 9 (1.2) NA 21 (6.7) 2261 (27.6) NA 489 (38.4) 300 (10.1) NA 114 (26.2) 43 (8.9) NA 15 (35.7) 0 (0.0) NA 6 (5.8) 31 (3.2) NA 42 (16.7) 1027 (31.2) NA 288 (34.9) 1476 (8.6) 65 (1.0) 984 (28.2) 305 (1.1) 80 (0.2) 96 (2.0)

119 (4.8) 470 (7.1) 3 (1.2) 89 (11.5) NA 99 (31.7) 4030 (49.2) NA 459 (36.1) 1272 (42.7) NA 162 (37.2) 77 (15.9) NA 3 (7.1) 123 (51.7) NA 24 (23.5) 208 (22.0) NA 15 (6.0) 1031 (31.3) NA 228 (27.6) 6949 (40.5) 470 (7.1) 993 (28.4) 125 (0.4) 315 (0.7) 27 (0.6)

1129 (45.4) 2835 (42.6)

61 (2.5) 960 (14.4)

1023 (41.1) 2320 (34.8) 60 (23.5) 340 (43.8) NA 108 (34.6) 101 (1.2) NA 45 (3.5) 80 (2.7) NA 30 (6.9) 80 (16.6) NA 0 (0.0) 12 (5.0) NA 15 (14.7) 129 (13.6) NA 36 (14.3) 142 (4.3) NA 81 (9.8) 1907 (11.1) 2320 (34.8) 375 (10.7) 5818 (19.4) 7480 (17.4) 2598 (53.2)

90 (3.6) 10 (0.2) 3 (1.2) 20 (2.6) NA 3 (1.0) 615 (7.5) NA 108 (8.5) 216 (7.2) NA 30 (6.9) 42 (8.7) NA 3 (7.1) 12 (5.0) NA 3 (2.9) 57 (6.0) NA 12 (4.8) 329 (9.9) NA 60 (7.3) 1381 (8.1) 10 (0.2) 222 (6.4) 1507 (5.0) 40 (0.1) 874 (17.9)

2488 (100) 6660 (100) 255 (100) 777 (100) NA 312 (100) 8191 (100) NA 1272 (100) 2982 (100) NA 435 (100) 483 (100) NA 42 (100) 238 (100) NA 102 (100) 946 (100) NA 252 (100) 3296 (100) NA 825 (100) 19,401 (100) 6660 (100) 3495 (100) 29,920 (100) 42,905 (100) 4882 (100)

180 (70.6) 304 (39.1) NA

15 (1.9) NA 81 (26.0)

1075 (13.1) NA

109 (1.3) NA 171 (13.4)

1042 (34.9) NA

72 (2.4) NA 99 (22.8)

234 (48.4) NA

7 (1.5) NA 21 (50.0)

88 (37.0) NA

3 (1.3) NA 54 (52.9)

506 (53.5) NA

15 (1.6) NA 147 (58.3)

605 (18.4) NA

162 (4.9) NA 168 (20.4)

4983 (29.1) 2835 (42.6)

444 (2.6) 960 (14.4)

921 (26.4) 21,585 (72.1) 580 (1.9) 34,800 (81.1) 190 (0.4) 1287 (26.4)

M.J. Leach

NA, data not available; Prac., practitioner. # Highest level of education data for the listed CAM disciplines was not available for the US or UK. a Based on data from the 2006 Australian population census.26 b Based on data from the 2006 Canadian population census.28 c Based on data from the 2006 New Zealand population census.30 d Defined as the sum of all chiropractors, osteopaths, massage therapists, naturopaths, TCM practitioners, homoeopaths, acupuncturists and other CAM practitioners, where data are reported.

Number of hours worked per week by CAM and general practitioners.#

Chiropractors

Osteopaths

Massage therapists

Naturopaths

TCM prac.

Homoeopaths

Acupuncturists

Other CAM practitioners

All CAM practitionerse

General medical prac.

Australiaa Canadab,d New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab,d New Zealandc

0h n (%)

1—16 h n (%)

17—34 h n (%)

≥35 h n (%)

Not stated n (%)

Total n (%)

62 (2.5) 160 (2.4) 0 (0.0) 28 (3.6) NA 0 (0.0) 309 (3.8) NA 0 (0.0) 100 (3.4) NA 0 (0.0) 14 (2.9) NA 0 (0.0) 12 (5.0) NA 0 (0.0) 17 (1.8) NA 0 (0.0) 151 (4.6) NA 0 (0.0) 693 (3.6) 160 (2.4) 0 (0.0) 1100 (3.7) 1475 (3.4) 0 (0.0)

246 (9.9) 420 (6.3) 9 (3.5) 90 (11.6) NA 33 (10.6) 3102 (37.9) NA 486 (38.2) 737 (24.7) NA 114 (26.2) 61 (12.6) NA 9 (21.4) 83 (34.9) NA 30 (29.4) 167 (17.7) NA 39 (15.5) 1320 (40.0) NA 147 (17.8) 5806 (29.9) 420 (6.3) 867 (24.8) 1871 (6.3) 1675 (3.9) 240 (4.9)

787 (31.6) 2710 (40.7) 78 (30.6) 188 (24.2) NA 90 (28.9) 2660 (32.5) NA 405 (31.8) 946 (31.7) NA 141 (32.4) 123 (25.5) NA 6 (14.3) 79 (33.2) NA 33 (32.4) 290 (30.7) NA 69 (27.4) 898 ((27.2) NA 204 (24.7) 5971 (30.8) 2710 (40.7) 1026 (29.4) 5222 (17.5) 7305 (17.0) 756 (15.5)

1354 (54.4) 3340 (50.2) 156 (61.2) 453 (58.3) NA 174 (55.8) 1932 (23.6) NA 315 (24.8) 1134 (38.0) NA 156 (35.9) 274 (56.7) NA 24 (57.1) 54 (22.7) NA 39 (38.2) 458 (48.4) NA 129 ((51.2) 836 (25.4) NA 444 (53.8) 6495 (33.5) 3340 (50.2) 1437 (41.1) 21,300 (71.2) 32,080 (74.8) 2805 (57.5)

39 (1.6) 30 (0.5) 12 (4.7) 18 (2.3) NA 15 (4.8) 188 (2.3) NA 66 (5.2) 65 (2.2) NA 24 (5.5) 11 (2.3) NA 3 (7.1) 10 (4.2) NA 0 (0.0) 14 (1.5) NA 15 (6.0) 91 (2.8) NA 30 ((3.6) 436 (2.3) 30 (0.5) 165 (4.7) 427 (1.4) 370 (0.9) 1081 (22.1)

2488 (100) 6660 (100) 255 (100) 777 (100) NA 312 (100) 8191 (100) NA 1272 (100) 2982 (100) NA 435 (100) 483 (100) NA 42 (100) 238 (100) NA 102 (100) 946 (100) NA 252 (100) 3296 (100) NA 825 (100) 19,401 (100) 6660 (100) 3495 (100) 29,920 (100) 42,905 (100) 4882 (100)

Profile of the CAM workforce

Table 6

NA, data not available; Prac., practitioner. # Data on number of hours worked for the listed CAM disciplines was not available for the US or UK. a Based on data from the 2006 Australian population census.26 b Based on data from the 2006 Canadian population census.28 c Based on data from the 2006 New Zealand population census.30 d Data reported under 1—16 h, 17—34 h and ≥35 h represent data for the following groups: 1—19 h, 20—39 h and ≥40 h, respectively. e Defined as the sum of all chiropractors, osteopaths, massage therapists, naturopaths, TCM practitioners, homoeopaths, acupuncturists and other CAM practitioners, where data are reported.

373

374 Table 7

M.J. Leach Average gross weekly income for CAM and general practitioners, in each country’s respective currency.#

Chiropractors

Osteopaths

Massage therapists

Naturopaths

TCM prac.

Homoeopaths

Acupuncturists

Other CAM practitioners

All CAM practitionerse

General medical prac.

Australiaa New Zealandb United Statesc,d Australiaa New Zealandb United Statesc Australiaa New Zealandb United Statesc,d Australiaa New Zealandb United Statesc Australiaa New Zealandb United Statesc Australiaa New Zealandb United Statesc Australiaa New Zealandb United Statesc Australiaa New Zealandb United Statesc Australiaa New Zealandb United Statesc Australiaa New Zealandb United Statesc

$0—999 n (%)

$1000—1999 n (%)

≥$2000 n (%)

Not stated n (%)

Total n (%)

1038 (41.7) 99 (38.8) 24,318 (48.3) 356 (45.8) 171 (54.8) NA 7621 (93.0) 1209 (95.0) 66,407 (91.0) 2614 (87.7) 372 (85.5) NA 412 (85.3) 39 (92.9) NA 210 (88.2) 93 (91.2) NA 808 (85.4) 228 (90.5) NA 2980 (90.4) 726 (88.0) NA 16,039 (82.7) 2937 (84.0) 90,725 (73.6) 2944 (9.8) 525 (10.8) NA

1023 (41.1) 96 (37.7) 8826 (17.5) 336 (43.2) 117 (37.5) NA 402 (4.9) 36 (2.8) 1952 (2.7) 288 (9.7) 33 (7.6) NA 47 (9.7) 0 (0.0) NA 18 (7.6) 9 (8.8) NA 102 (10.8) 18 (7.1) NA 219 (6.6) 84 (10.2) NA 2435 (12.6) 393 (11.2) 10,778 (8.7) 10,071 (33.7) 1383 (28.3) NA

390 (15.7) 57 (22.4) 17,153 (34.1) 62 (8.0) 21 (6.7) NA 31 (0.4) 9 (0.7) 677 (0.9) 44 (1.5) 6 (1.4) NA 9 (1.9) 0 (0.0) NA 3 ((1.3) 0 (0.0) NA 15 (1.6) 0 (0.0) NA 38 (1.2) 0 (0.0) NA 592 (3.1) 93 (2.7) 17,830 (14.5) 16,567 (55.4) 2064 (42.3) NA

37 (1.5) 3 (1.2) 33 (0.1) 23 (3.0) 3 (1.0) NA 137 (1.7) 18 (1.4) 3904 (5.4) 36 (1.2) 24 (5.5) NA 15 (3.1) 3 (7.1) NA 7 (2.9) 0 (0.0) NA 21 (2.2) 6 (2.4) NA 59 (1.8) 15 (1.8) NA 335 (1.7) 72 (2.1) 3937 (3.2) 338 (1.1) 910 (18.6) NA

2488 (100) 255 (100) 50,330 (100) 777 (100) 312 (100) NA 8191 (100) 1272 (100) 72,940 (100) 2982 (100) 435 (100) NA 483 (100) 42 (100) NA 238 (100) 102 (100) NA 946 (100) 252 (100) NA 3296 (100) 825 (100) NA 19,401 (100) 3495 (100) 123,270 (100) 29,920 (100) 4882 (100) NA

NA, data not available; Prac., practitioner. # Data on average weekly income for the listed CAM disciplines was not available for Canada or the UK. a Based on data from the 2006 Australian population census.26 b Based on data from the 2006 New Zealand population census.30 c Based on data from the 2000 US population census.32 d Data reported under $0—999, $1000—1999 and ≥$2000 represent data for the following income brackets: $0—961, $962—1442 and ≥$1443, respectively. e Defined as the sum of all chiropractors, osteopaths, massage therapists, naturopaths, TCM practitioners, homoeopaths, acupuncturists and other CAM practitioners, where data are reported.

distinct differences in average gross weekly income between countries, across each of the CAM disciplines.

naturopathy, traditional Chinese medicine, homoeopathy and other CAM disciplines were employed.

Discussion Industry of employment The majority of CAM practitioners were employed in medical and other health care services (Table 8). Employment in this industry was particularly high (>80%) for chiropractors, osteopaths and acupuncturists. Very few CAM practitioners worked in hospitals (≤2.1% for all disciplines, excluding other CAM practitioners in New Zealand), residential care facilities (≤2.4%) or social assistance services (≤6.2%). Employment in ‘other’ industries was also very low for most countries, except for New Zealand, where close to one third of practitioners in the fields of massage therapy,

This is the first known study to describe the complementary and alternative medicine workforce across multiple English-speaking countries. This work indicates that across the combined CAM workforce (for the disciplines and OECD countries where data were available), practitioners were most likely to be female, aged 40 years or older, working within a medical or health care service, holding a vocational or higher education level qualification, working full-time, and earning less than $1000 gross per week. Massage therapists, which comprised the largest portion of the CAM workforce, were generally younger, held the lowest level of

Industry of employment for CAM and general practitioners.#

Chiropractors

Osteopaths

Massage therapists

Naturopaths

TCM prac.

Homoeopaths

Acupuncturists

Other CAM practitioners

All CAM practitionersd

General medical prac.

Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc Australiaa Canadab New Zealandc

Medical & other health care service n (%) 2421 (97.3) 6555 (98.4) 237 (92.9) 759 (97.7) NA 261 (83.7) 6881 (84.0) NA 600 (50.0) 2116 (71.0) NA 216 (49.7) 418 (86.5) NA 27 (64.3) 203 (85.3) NA 63 (61.8) 905 (95.7) NA 210 (83.3) 2289 (69.4) NA 297 (36.0) 15,992 (82.4) 6555 (98.4) 1911 (54.7) 22,531 (75.3) 30,570 (71.3) 2955 (60.5)

Social assistance service n (%)

Other heath/social service n (%)

Other industry

Not stated

n (%)

Residential care service n (%)

n (%)

n (%)

0 (0.0) 10 (0.2) 0 (0.0) 0 (0.0) NA 0 (0.0) 23 (0.3) NA 24 (1.9) 6 (0.2) NA 9 (2.1) 0 (0.0) NA 0 (0.0) 0 (0.0) NA 0 (0.0) 0 (0.0) NA 3 (1.2) 68 (2.1) NA 117 (14.2) 97 (0.5) 10 (0.2) 153 (4.4) 5597 (18.7) 12,050 (28.1) 546 (11.2)

0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) NA 0 (0.0) 49 (0.6) NA 3 (0.2) 6 (0.2) NA 3 (0.7) 0 (0.0) NA 0 (0.0) 0 (0.0) NA 0 (0.0) 0 (0.0) NA 0 (0.0) 78 (2.4) NA 15 (1.8) 133 (0.7) 0 (0.0) 21 (0.6) 26 (0.1) 285 (0.7) 18 (0.4)

9 (0.4) 10 (0.2) 0 (0.0) 3 (0.4) NA 0 (0.0) 66 (0.8) NA 9 (0.7) 29 (1.0) NA 12 (2.8) 0 (0.0) NA 0 (0.0) 0 (0.0) NA 3 (2.9) 0 (0.0) NA 0 (0.0) 101 (3.1) NA 51 (6.2) 208 (1.1) 10 (0.2) 75 (2.2) 93 (0.3) 0 (0.0) 27 (0.6)

19 (0.8) 0 (0.0) 3 (1.2) 6 (0.8) NA 3 (1.0) 247 (3.0) NA 0 (0.0) 115 (3.9) NA 0 (0.0) 29 (6.0) NA 0 (0.0) 11 (4.6) NA 0 (0.0) 4 (0.4) NA 0 (0.0) 238 (7.2) NA 0 (0.0) 669 (3.5) 0 (0.0) 6 (0.2) 452 (1.5) 0 (0.0) 0 (0.0)

26 (1.1) 75 (1.1) 15 (5.9) 9 (1.2) NA 30 (9.6) 861 (10.5) NA 522 (41.0) 677 (22.7) NA 156 (35.9) 33 (6.8) NA 12 (28.6) 14 (5.9) NA 33 (32.4) 32 (3.4) NA 27 (10.7) 448 (13.6) NA 303 (36.7) 2100 (10.8) 75 (1.1) 1098 (31.4) 1124 (3.8) 0 (0.0) 369 (7.6)

13 (0.5) 10 (0.2) 0 (0.0) 0 (0.0) NA 18 (5.8) 64 (0.8) NA 114 (9.0) 33 (1.1) NA 39 (9.0) 3 (0.6) NA 3 (7.1) 10 (4.2) NA 3 (2.9) 5 (0.5) NA 12 (4.8) 74 (2.2) NA 42 (5.1) 202 (1.0) 10 (0.2) 231 (6.6) 97 (0.3) 0 (0.0) 967 (19.8)

Hospital

Profile of the CAM workforce

Table 8

NA, data not available; Prac.: practitioner. # Data on industry of employment for the listed CAM disciplines was not available for the US or UK. a Based on data from the 2006 Australian population census.26 b Based on data from the 2006 Canadian population census.28 c Based on data from the 2006 New Zealand population census.30 d Defined as the sum of all chiropractors, osteopaths, massage therapists, naturopaths, TCM practitioners, homoeopaths, acupuncturists and other CAM practitioners, where data are reported.

375

376 education, worked the least number of hours and earned the lowest income relative to other disciplines. By contrast, chiropractors and osteopaths held the highest level of education, worked the longest hours and earned the highest income, compared with most other CAM disciplines. The CAM workforce collectively contained a high proportion of female practitioners relative to male practitioners (i.e. 54% vs. 46%). This is not dissimilar to the pattern observed within the mainstream health workforce across four of the five included countries, where more than seventy-one percent of practitioners were female.25,28,29,32 The proportion of females in female-dominant occupations (i.e. >60% female) was also similar between the CAM and mainstream health workforce (at least in Australia and New Zealand). For instance, for the female-dominant disciplines of massage therapy, naturopathy and homoeopathy, more than seventy-nine percent of practitioners were female; likewise, across the female-dominant professions of nursing, physiotherapy, dietetics, social work, speech therapy and occupational therapy, more than 80% of clinicians were female.39 For the fields of chiropractic, osteopathy, TCM and acupuncture, which collectively comprise seventy-four percent male practitioners, this was similar to the fields of dentistry, optometry and general practice, where approximately 58% of practitioners were male.25 Further research may help in understanding the reasons for these gender differences across CAM disciplines. Many fields of CAM, such as acupuncture, naturopathy, TCM and homoeopathy, were characterised by an older workforce. This is consistent with the age profile of many mainstream health occupations, namely dentistry, nursing and general practice.25,28,29,32 Several factors may explain the older age profile of these CAM disciplines: it is probable that the older age profile reflects the high number of mature-age students entering CAM courses or programs40 ; it also may be indicative of high rates of retention in these disciplines.39 These same factors may also explain the relatively younger age profile of massage therapists and chiropractors across the selected countries, as well as osteopaths in Australia. It is difficult to determine how this older workforce and/or potentially low retention rates will impact on the future supply of CAM practitioners without first understanding CAM workforce demand; unfortunately, this work has yet to be done. Three occupations (i.e. chiropractic, osteopathy and acupuncture) demonstrated a higher level of education relative to other CAM disciplines. This may be because each of these occupations are statutory regulated (including acupuncture and TCM in Australia), and as such, minimum training requirements for board certification or registration are clearly stipulated. On the other hand, no assurance can be given that these qualifications are related to these CAM discipline areas; it is possible that the high levels of education could, in some cases, be related to other fields or prior occupations. For most of the other CAM occupations, the highest qualification held was a Diploma or Advanced Diploma (with the exception of homoeopathy in New Zealand, for which most practitioners held a Bachelor degree). Several reasons can be given for the relatively lower education level of these disciplines. First, neither of these occupations is statutory regulated (at least in Australia and New Zealand

M.J. Leach where data were available). Second, membership of pertinent Australian/New Zealand CAM professional associations only requires a Diploma/Advanced Diploma as a minimum training requirement. Third, Bachelor degrees for many of these disciplines have only emerged recently.41 Given that these conditions are likely to vary across countries, it is probable that the highest qualifications held by CAM practitioners in other countries will vary. It also infers that changes in the regulation of CAM disciplines (i.e. introduction of licensing or statutory regulation) may drive improvements in the education level of practitioners. Most CAM practitioners in Australia, Canada and New Zealand had worked full-time (≥35 h a week) in the year of the population census (i.e. 2006). The disciplines that largely comprised a part-time workforce, such as naturopathy, homoeopathy and massage therapy, were also female-dominant occupations. This is not surprising as female practitioners work on average fewer hours per week than their male counterparts; one reason being to care for younger children.42,43 The older age profile of naturopathy and homoeopathy also may have contributed to the higher proportion of practitioners working part-time in these fields.42 The association between increasing female participation in the workforce, an ageing workforce, and the rising number of medical practitioners working part-time, lends support to these assertions.42 Much of the CAM workforce earned less than $1000 gross per week. Practitioners earning equal to or greater than $1000 per week (i.e. chiropractors and osteopaths) were typically in male-dominant occupations, held a highereducation qualification, and worked full-time. While each of these factors is likely to contribute to the higher weekly income of these disciplines, another consideration is the duration of the patient consultation. Relative to other CAM disciplines (e.g. naturopathy, herbalism, acupuncture and massage therapy), which typically provide consultations of 40—60 min duration,10,44 chiropractic and osteopathic consultations are generally of shorter length, often less than 20 min duration; similar to Western physicians.44 This potentially allows for greater patient throughput, and hence, higher turnover. Complementary and alternative medicine services in Australia and New Zealand, and possibly Canada, were largely delivered through primary care settings. Very few services were provided through secondary or tertiary health care settings, such as hospitals and residential care facilities. Given that patients attending CAM services are in many cases self-referred,10,44 CAM practitioners may be for many consumers the first point of contact with the health care system, and in such cases, may be the patient’s primary care provider. There are concerns, however, that the low level of education of some practitioners, as well as the absence of appropriate regulatory and quality standards for practice for some CAM disciplines,45 could mean that some clinicians may not have the necessary competencies to deliver appropriate and effective primary care. Tighter regulation of several CAM disciplines, including the stipulation of minimum training requirements, may help to safeguard those consumers who choose to use CAM practitioners as primary care providers. While this work has provided some insights into the broader CAM workforce, it has highlighted two major issues

Profile of the CAM workforce with using census data for the assessment of CAM workforce supply, and more generally, health workforce planning. The first issue is that few data sources provide comprehensive low-level data on the characteristics of the CAM workforce, with the exception of the Australian Bureau of Statistics Census of Population and Housing and Statistics New Zealand Census of Population and Dwellings. As illustrated in Table 1, most sources only capture limited data on age, gender and income, with few reporting on hours worked, highest qualification held, and industry of employment. The second issue relates to the paucity of data for each distinct discipline area, particularly herbalism. This may be attributed in part to the way CAM disciplines are categorised, with each country utilising different occupational classification systems to code occupations; despite each census questionnaire recording occupation in free-text form. As a result, many data sources had grouped distinct CAM disciplines (e.g. herbalists) with often unrelated occupations (e.g. podiatry); such data is unlikely to be of any use to either discipline. Similarly, many data providers collapsed data from multiple CAM occupations into broader, often meaningless categories (e.g. other healthcare practitioners), which has little value in health workforce planning. Even though census data from each of the selected countries is trustworthy, reliable and highly representative of each nation’s population, the data quality issues aforementioned limit the conclusions that can be made about the CAM workforce across these countries. Furthermore, because much of the US and UK data were derived from sources other than the census, it is possible that methodological differences between data sources could contribute in part to the differences observed between countries. These data quality issues draw attention to the need for more comprehensive data on the CAM workforce, including specific details on each distinct CAM discipline. Further exploration of the CAM workforce beyond the five selected countries is also recommended, as distinct cultural, political and social differences between countries are likely to have a notable impact on the profile of the CAM workforce. Many of these issues could be addressed through the implementation of a comprehensive CAM workforce survey, or by revising the way CAM disciplines are coded and reported in population censuses. This work is a call for that research.

Conclusion This work has broadened understanding of the CAM workforce across Australia, Canada, New Zealand, United Kingdom and United States. One insight gained from this work was the notable differences between disciplines in income, hours worked and education level. Whilst differences in the former may be attributed to the gender profile of the discipline and the duration of the patient consultation, the latter is expected to be driven by disparate regulatory and training requirements across disciplines. The implementation of tighter regulation is one strategy that may help to raise the education level of many CAM practitioners, and in so doing, ensure the provision of a competent CAM workforce to service the needs of consumers; it may also serve to safeguard consumers who use CAM practitioners as primary care providers. Although the quality of available

377 data somewhat limits the conclusions that can be made, it does emphasise the need for better quality data on the CAM workforce, including the provision of comprehensive data on each distinct CAM discipline; it also highlights the need for greater understanding of CAM workforce demand in order to better inform the training and continuing education needs of the evolving CAM workforce.

Conflict of interest statement None declared.

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