Exploring Criteria for the Translation of Traditional Knowledge Within Contemporary Clinical Practice,Research,Policy,and Education: A Stakeholder Forum

Abstract

Background:

The 2018 Declaration of Astana identifies traditional knowledge (TK) as one of the drivers for strengthening primary health care systems through the use of technology (traditional medicines) and knowledge and capacity building (traditional practitioners). While TK underpins both traditional practice and the use of traditional medicines, facilitating the use of TK in contemporary health care systems has been difficult to achieve. The aim of this study was to identify key factors related to the translation of TK into contemporary settings to help establish tools to support the knowledge translation process.

Methods:

This study used World Café methodology to collect the observations, ideas, and perspectives of experts who use TK in their practice. These experts (n = 9) were from a variety of contexts, including clinical practice, research, education, policy, and consumer advocacy, participated in the 1-day event. Data were collected into NVivo 12 software and analyzed using inductive-deductive thematic analysis.

Results:

Thematic analysis identified five themes: the need to define the elements required for critical evaluation of sources of TK as evidence, the importance of applying a tradition-centric lens when translating TK for contemporary use, the need to bridge gaps between TK and its contemporary applications, the value of critically evaluating the TK translation process itself, and the recognition of traditions as living systems. Taken together, the themes showed holistic interpretation of the translation process that incorporates critical analysis of the TK itself and accountable, transparent, and ethical processes of translation that consider safety, socioeconomical and intellectual property impacts of TK in contemporary use.

Conclusions:

Stakeholders identified TK as a valid and important source of evidence that should guide practice in a range of contemporary settings (e.g., policy and clinical practice), and outlined important consideration for critiquing, evaluating, communicating, and using TK within these settings.

Introduction

The 2018 Declaration of Astana acknowledges the importance of the role of traditional medicine knowledge and practice in driving the success of primary health care and the achievement of universal health coverage.¹ This acknowledgment reinforces ongoing efforts—led by the World Health Organization—to strengthen regulation and facilitate the integration of traditional medicine systems (TMSs) within broader health systems.² A TMS is a system of health care that encompasses a range of knowledge, skills, and practices that are based on theories, beliefs, and experiences indigenous to a specific culture and drawn upon to maintain health and prevent, diagnose, improve, and treat physical and mental illness.³

Traditional knowledge (TK) is knowledge that originates from or is central to the historical practice of a TMS. Traditional medicine practitioners, treatments, and therapies are relied upon by a substantial proportion of the global population.² Individuals who seek to apply TK in contemporary domains face complex challenges, including intellectual property issues, language barriers, and the need to account for differences between the time or context from which the TK originates and its modern-day application.^4,5 While TK is already employed in a variety of contemporary domains,^6

–9 there is little evidence that those using it take into account implementation science (IS) and its growing emphasis on rigorous, robust knowledge translation methodology.¹⁰

IS is the study of methods to promote the systematic uptake of evidence-based practices into routine practice, with the aim of improving the quality and effectiveness of health services.¹¹ As this definition suggests, IS focuses on improving uptake of research findings into clinical practice settings, from primary care to tertiary hospital environments.¹² Knowledge translation is the core feature of IS, encompassing the exchange, synthesis, and ethically sound application of knowledge to accelerate the benefits of research.¹³ As IS developed in response to biomedicine's call for evidence-based practice, it is unsurprising that it privileges research findings over other forms of knowledge.

In the decades since evidence-based practice was first described,¹⁴ IS has also matured. Scholars have described frameworks for modeling “knowledge-to-action” as spanning three generations of thinking:¹⁵ (1) First-generation thinking considers evidence use through a linear model from production to use; from researcher to end-users whereby it is incorporated into policy or practice; (2) Second-generation thinking accounts for relationship models when planning for evidence use, emphasizing evidence sharing, partnership development, and stakeholder networks; (3) Third-generation thinking also referred to as “knowledge mobilization”:¹⁶ incorporates a systems approach that recognizes diffusion and dissemination as shaped, embedded, and organized through complex systems involving multiple agent interactions.

This complex systems-based thinking of knowledge mobilization is reflected in contemporary IS frameworks, such as the Exploration–Preparation–Implementation–Sustainment (EPIS) framework,¹⁷ and Ward's Framework for Knowledge Mobilizers.¹⁸

The application of IS to TMS has to date been limited.¹⁰ Recent traditional, complementary, and integrative health scholarship has focused on progressing IS within the context of TMS¹⁹ and, while commendable, these efforts largely focus on applying IS's biomedical lens to TMs' knowledge and practice.²⁰ Yet, TMSs differ from biomedicine in several ways, including that concepts of health and healing are deeply embedded in and derive from historical culture and practice, and reflect principles of complexity theory and systems thinking.^21
–23

Thus, IS third-generation thinking that recognizes this complexity may better support the systematic translation of TK. Importantly, to facilitate its application to TMS, IS must embrace “knowledge equity”—where the embedded expertise (of both patient and clinician) and other forms of nonresearch knowledge (including that arising from prescience practices and observations) are accepted as valid knowledge although requiring further rigorous investigation. This need for knowledge equity requires that the imperative for quality evidence that assures the community have access to safe and effective treatments must be balanced against the therapeutic potential of treatments identified and applied based on TK, particularly given TMS users may already be exposed to inequities in countries with culturally embedded TK and poorly funded conventional health systems.^24,25

Given the widespread use of TK, there is a need to adapt IS to better support the contemporary use and integration of TMS. Embracing knowledge equity and developing strategies and frameworks to support the meaningful translation of TK become an issue of social justice and a means to better address inequality in health outcomes.⁴

Alongside recent and ongoing efforts to understand the application of IS within the context of TMS,^19,20,26 a clear conceptual model and practical guide of how IS may be adapted to facilitate TK translation is underdeveloped. This study builds on a systematic review of studies that examined, adapted, and applied TK in contemporary domains. The review found numerous examples of attempts by scholars to translate TK in practice but few examples of the application of systematic methods. To address this gap, a forum with stakeholders who use TK was facilitated, to consider the criterion that may be employed to support the translation of TK into contemporary contexts.

Materials and Methods

Aim

This study brought together stakeholders from five contexts (practice, research, policy, education, and consumer advocacy) to discuss factors that shape the translation of TK into contemporary health systems. The aim of the forum was to explore elements, which may be used to establish criteria and guidelines that support the appropriate selection, evaluation, and application of TK as evidence.

Design and setting

A descriptive qualitative design was applied in the form of a stakeholder discussion forum. The face-to-face forum was held onsite at the University of Technology Sydney, Australia, on May 3, 2022. A follow-up online session was also held through Zoom video conferencing to secure the views of one participant who was unable to contribute in-person due to Covid-related travel disruptions.

Participants and recruitment

Purposive sampling was used to identify prospective participants—opinion leaders from across Australia with recognized experience using TK and with expertise in one or more of four domains—clinical practice, research, education, and policy. E-mail invitations were sent to experts from traditional medicine professional associations, research, policy, and education institutions. Snowballing method was employed, asking invitees to recommend someone with similar expertise if they were unable to participate themselves.

In total, nine individuals provided consent, participating as individuals and in some cases representing their organizations. The participants included the following: clinical practice (n = 2), research (n = 2), education (n = 3), policy (n = 2), and consumer advocacy (n = 1). Their expertise spanned most of the common TMSs in Australia, including naturopathy, Western herbal medicine, Ayurveda, homeopathy, and Chinese medicine.²⁷ The professional backgrounds of research team members who facilitated the forum covered the disciplines of naturopathy, nursing, public health, health education/pedagogy, sociology, and preclinical science.

Data collection

Data collection took place during the 5-h forum, conducted using the World Café methodology.²⁸ The World Café methodology involves separating participants into small groups for discussion rounds on various aspects of the research topic, after which discussion outcomes are shared among the whole group for feedback and integration of ideas. Research participants were split into two groups, each with two researchers facilitating discussion, for four rounds of discussion separated by short breaks. Notes were taken by at least two people from each group. These were then summarized by a fifth researcher for group feedback.

The discussion topics selected for each of the four discussion rounds were informed by a literature review,²⁹ which mapped the criteria that had been used to select, appraise, or apply TK in published research against an adaptation of the four-phase EPIS (Exploration, Preparation, Implementation, and Sustainment) implementation framework.¹⁷ This previous review found that TK has primarily been used in the Exploration phase of implementation with little evidence of its use in the other three phases. It also found that TK users validated TK with other scientific or traditional evidence sources or assessed factors that may influence translation of knowledge across settings when they were selecting, evaluating, or applying TK.

The discussion rounds were structured using the four phases of the EPIS framework. Participants were asked to identify and discuss factors relating to the translation of TK in each phase. Hardcopy materials were provided as a template with examples of the findings from the review to stimulate discussion points; however, participants were informed to use these examples as a guide only and to focus on sharing their own expertise. The templates also provided a structure for field notes (Supplementary File S1). The follow-up video-conferencing session held with one additional participant followed the same core process in a 2-h discussion with three researchers in attendance.

All data were collected in written form during the discussion sessions, and no recordings were made. After the whole-group feedback that concluded the discussion forum, participants were also invited to revise the initial data synthesis for clarity and integrity of interpretation, and to participate in manuscript editing as coauthors. All participants agreed the final study findings reflected their meanings and perspectives.

Field notes were transcribed and imported into NVivo 12 qualitative analysis software. Data were then synthesized using the Braun and Clark method of thematic analysis.³⁰ Codes and themes were derived using an inductive approach, then deductively mapped against the EPIS framework phases. The generation of initial codes and themes was undertaken by one researcher, with input from all coauthors and participants provided at the stages of reviewing and defining the themes. All coauthors were involved in producing the final article report.

Ethics approval

Ethical approval for the study was granted by the University of Technology Sydney Human Research Ethics Committee, approval number ETH21-6443.

Findings

The analysis identified five themes: (1) the characteristics required for critical evaluation of sources of TK and evidence; (2) the importance of applying a tradition-centric lens when translating TK; (3) the need to address gaps between TMS practice and modern practices when translating TK into the contemporary context; (4) the value of critically evaluating the process of translation to contemporary contexts; and (5) the recognition of TMS as living systems.

Critical evaluation of sources of TK and evidence

Participants asserted that the sources from which TK or evidence is drawn should be critically evaluated to determine whether the knowledge is suitable for translation and use in contemporary contexts. They recommended that TK translation be applied pragmatically, as some approaches to evaluating knowledge or evidence may not always be appropriate or accessible to the situation at hand. Participants identified four key factors to consider when critically evaluating TK sources: authenticity, triangulation, trustworthiness, and safety. They also emphasized the need for reporting guidelines to support research efforts evaluating TK translation and implementation. Details of the participants' recommendations arising from this theme are presented in Table 1.

Table 1.

Elements Identified by Participants Regarding the Critical Evaluation of Sources of Traditional Evidence

Element	Description
Authenticity of knowledge	Evidence should be traceable to a TK source, and the translation of TK should be reported with transparency about its source and undertaken with authenticity to the TMS from which it originates. Evidence can be inauthentically presented as TK when it has in fact been influenced and adapted in a manner inconsistent with the TMS, or by parties external to the TMS (e.g., for commercial reasons).
Triangulation of evidence	The quality and reliability of TK may be tested through triangulation with other sources of evidence. Such sources encompass traditional texts from other TMS, contemporary scientific studies (including in vitro and in vivo research), and expert opinions including anecdotal evidence from experienced practitioners. Triangulation between sources within the same TMS can also be useful, as TK may be widely dispersed rather than collated in one source. Participants reported differing views regarding whether it is appropriate to employ scientific principles in triangulation and evaluation of TK. There was, however, consensus that the quantity of evidence and relevance of different sources to the TMS philosophy and contemporary context should be considered.
Trustworthiness of evidence source	It is important to evaluate and report on the trustworthiness of a source of TK. TMS and their professions may have different views on what constitutes trustworthiness. Examples of features of trustworthiness can include consensus from experts and experienced clinicians (collective rather than individual opinions), the persistence of knowledge over time and transmission through generations, the perceived authority of the author of the source and their scope of practice/jurisdiction, and the reasoning or rationale behind the knowledge.
Safety of knowledge in contemporary context	TK has strengths and weaknesses regarding safety of use. Historical use of TK over long periods of time presents strength and is often used as a proxy for safety. However, critical attention to safety is still important as some TK may fail to meet contemporary standards of safety, have previously unknown harms revealed through new evidence, or become unsafe as contextual factors change with time (e.g., emergence of pharmaceutical use and polypharmacy may carry risk of unknown drug or treatment interactions).
The role of critical research and transparent reporting	Formal research, academic and educational engagement with TMS practices that have otherwise been neglected in contemporary research may support the critique required for sustained implementation of TK. Reporting guidelines for TK research could ensure appropriate maintenance and evolution of TMS by encouraging accountability to the TMS and transparency in translation while adapting to contemporary expectations around evidence.

TK, traditional knowledge; TMS, traditional medicine system.

Translating from TK: applying a tradition-centric lens

Participants suggested that a tradition-centric lens should be applied by individuals undertaking TK translation, to ensure that the integrity of the TK being translated is maintained and any adaptations are appropriate to the contemporary practice and evolution of the TMS. This means those doing the translation adopt the “way of knowing” or worldview that is embedded within the philosophical roots of the TMS from which the TK is drawn. Participants suggested that this approach should include maintaining the alignment of the translated TK with the core tenets of the TMS. For instance, where the TMS has at its core a patient-centered philosophy, participants highlighted the need to use explicitly person-centered methods when applying the TK.

Participants also emphasized the need to adopt ethical approaches to intellectual property, knowledge custodianship, and any potential sociocultural impacts of TK use. The tradition-centric lens described by participants also included careful attention to the communication and framing of TK when it is shared—to ensure that an appropriate balance is found between contemporary biomedical perspectives and the different ways of knowing and expressing health concepts and practices.

They also suggested translation of TK from traditional sources should carefully consider the accuracy of interpretation, to account for factors that may affect the translation of evidence across languages, time periods, cultures, etc. Participants recommended that stakeholders with expertise in the TMS (e.g., practitioners or knowledge custodians) be central to the translation process, to ensure a full understanding of the TMS context. Table 2 reports a more detailed description of the components identified through this theme.

Table 2.

Elements Identified by Participants Regarding Translating from Traditional Knowledge: A Tradition-Centric Lens

Element	Description
Alignment with the core characteristics of the tradition	The process of translating knowledge from TK sources requires identification of the core characteristics of the TMS, or the intervention/practice as it relates to the TMS. The translation process needs to assess whether the TK is being implemented in a manner true to the TMs' core characteristics. Philosophical roots are often more important for fidelity than specific products or practices. As the core characteristics of TMS can be complex, translation requires a complex approach and a comprehensive range of tools.
Patient-centric translation for patient-centric traditions	TMSs tend to be characteristically holistic and use individualized, patient-centric approaches to care. The outcomes of TK translation therefore need to be patient centric to retain the core characteristics of the TMS. This can be challenging as modern approaches to health care and health systems are not often individualized, creating mismatches between TMS and contemporary context. Collaboration with patients and other end-users throughout the process of knowledge translation, including dissemination of relevant TK to patients or patient advocacy organizations, could promote patient-centric outcomes by identifying unmet needs and sociological factors that could affect or be affected by implementation.
Ethical approaches to intellectual property and sociocultural impacts of use	Use of TK requires consideration of the ethics surrounding intellectual property rights and potential sociocultural impacts. This is due to complexities surrounding some TMS, relating to historical and ongoing colonialism, exploitation, and other forms of knowledge appropriation. Fashions and trends surrounding the use of some TK can have negative or positive social impacts on custodians of TK and those at the source of traditional medicine resource production. Collaboration and liaison with custodians of TK may be necessary in some traditions, particularly where practice of the TMS has been adopted in locations beyond its native locality. This highlights the importance of considering when it is appropriate to use a specific source of TK and when it is not.
Tradition-centric communication and framing in knowledge sharing	The language, terminology, and conceptual framing used to share TK or communicate TK translation should reflect and respect the philosophy and core traits of the TMS. While including contemporary biomedical perspectives may be beneficial and pragmatic, it is not sustaining for TMS to use such perspectives as the default frame of reference. Different ways of knowing have a place in TK translation, and different languages may be required for different audiences. The challenge here is that biomedical terminology has become the common tongue of medicine and health care.
Accuracy of interpretation	Knowledge translation from traditional medicine sources should consider the accuracy of interpretation and account for factors affecting the translation of knowledge across languages, time periods, cultures, and different contexts. It is important to ensure an accurate understanding of what is meant by the source, as closely as possible within the temporal limits of TK.

TK, traditional knowledge; TMS, traditional medicine system.

Translating into the contemporary context: bridge building across the gap

Participants recommended TK translators consider various practical and philosophical factors (Table 3) as essential to bridging the gap between TK and contemporary context. They argued for a comprehensive, systematic approach that draws connections between contemporary needs and the opportunities presented by TK. To achieve this, participants suggested that TK translation should be intentional and based on an assessment of whether the TK can potentially address unmet needs of the consumer/patient population or other relevant stakeholders. However, participants also highlighted the need for all translating TK to consider sociocultural aspects of the contemporary and traditional contexts before TK is applied to determine alignment or mismatch between traditional evidence and contemporary context.

Table 3.

Elements Identified by Participants Regarding Translating into the Contemporary Context: Bridge Building Across the Gap

Element	Description
Intentional translation and response to the sociological landscape	TK translation must be intentional rather than based in convenience. It should begin with identification of unmet needs among the consumer/patient population or other relevant stakeholders, and assessment of whether the TK can potentially address those needs. Use of traditional medicine is typically consumer driven and individualized in clinical practice, and as such calls for patient-centric codesign throughout the process of translation, implementation, and evaluation. This codesign involves accountability for the potential risks and benefits for the TMS, and for consumers or other stakeholders in the contemporary context. Cultural and sociological impacts such as affordability, accessibility, and respect for patient/consumer choice should be considered.
Transferability of evidence: appropriateness to the contemporary context	Successful TK translation into contemporary settings relies on selecting, evaluating, adapting, and implementing TK in a manner appropriate to the contemporary context. Sociocultural aspects of contemporary context should be considered to determine alignment or mismatch between TK and contemporary context. This applies in terms of both what the population and contemporary setting needs from the TK, and what the TK implementation requires of the contemporary sociological context. Transferability of TK to contemporary lifestyles, family and community structures, cultural values, changes in biological and pathophysiological factors, geographical location, patient acceptance, and modern quality of care standards all need to be considered.
Availability and accessibility of traditional resources in the contemporary context	When translating TK, it is essential to examine whether the contemporary context can provide safe, reliable, ethical, and sustainable access to the resources required for implementation (e.g., herbal medicine plant materials or manual therapy tools). This may include investigating local and global availability of raw and manufactured materials, social acceptability, cultural suitability, economic accessibility, policy and regulatory limitations, and the impact of climate change. Modifications to materials or their preparation may be necessary.
Accountability in translation	Accountability is facilitated by transparency in the process of implementation (e.g., where TK was sourced, how it was adapted), and by considering potential risks and benefits to end-users, the TMS (impact of modifications on practice), wider community and natural environment. While it is essential for TK translation to be informed by consumer needs and behaviors, translation that is led by TK experts and TMS practitioners can promote maintenance of safety and efficacy in application. Challenges are presented by pressure from competing interests in the different sectors that shape use, interest, and acceptance (i.e., corporate/commercial industry, TMS profession, consumers, academia, education, policy).
Relative advantage of traditional or contemporary approaches	It is important to identify whether a genuine need for TK implementation exists by assessing whether there is relative advantage over existing contemporary interventions or practices. This relative advantage may change over time or differ across contemporary contexts (e.g., changes to the availability or accessibility of resources, to the health and disease landscape, or patient preferences and values). There may be opportunities for TK implementation in some emerging areas of convergence with modern medicine.
Importance of foundational assessment for successful translation	The foundational stages of exploring and preparing TK for translation, adaptation and implementation can be complex. However, if these earlier stages are executed well, implementation and sustainment are likely to be more successful. For example, without clear definitions and accurate translation of TK, it may be difficult to measure or evaluate whether translation has retained the core characteristics and philosophical roots of the TMS, while conversely, codification during the preparation of TK would provide measurable evaluation outcomes.

TK, traditional knowledge; TMS, traditional medicine system.

As an extension of this point, the importance of accounting for the availability and accessibility of traditional resources (e.g., materials for medicines) in the contemporary context before proceeding with implementation was highlighted. Participants further emphasized the need for accountability in TK translation, whereby those undertaking the translation ensure transparency in the implementation process (e.g., where TK was sourced, how it has been adapted), and consider potential risks and benefits to end-users, the TMS (impact of modifications on practice), wider community, and natural environment.

Participants also described the importance of identifying a genuine need for implementation of the TK before undertaking an intervention, including assessment of whether there is relative advantage over the existing contemporary interventions or practices. With these challenges and priorities in mind, participants acknowledged that the foundational stages of exploring, selecting, and preparing TK for translation, adaptation, and implementation can be complex, but if these early steps are well executed, successful implementation and sustainment are more likely.

Critical evaluation of translation to contemporary context

Applying critical evaluation not only to the source of TK but also to the process and outcomes of translating, adapting, and implementing TK (outlined in Table 4) was also seen by participants as essential. They considered that evaluation should apply to any practices, products, education and curricula, research methods, and policy that engage with TK. To retain the integrity of the philosophical roots and core characteristics of the TMS, participants recommended that evaluation use contemporary resources but apply these from the comprehensive/holistic perspective of the tradition, as well as assess concordance with the TMS.

Table 4.

Elements Identified by Participants Regarding the Critical Evaluation of Translation to Contemporary Context

Element	Description
Traditional perspective, contemporary tools	Evaluation of TK translation and implementation should use contemporary resources and apply them from the comprehensive/holistic perspective of the TMS. It should assess concordance with the TMS to retain the integrity of the TMs' philosophical roots and core characteristics. This includes accounting for individualized patient care. Such an approach could promote appropriate evolution without loss to the TMS and assist in addressing the challenges of communicating different ways of knowing with external stakeholders. TMS experts should be consulted about appropriate evaluation if not already involved in the translation and implementation.
Evaluation at point of use	Evaluation of TK translation and implementation should be undertaken by or with end-users and other stakeholders who are present at the point of use, and who have expertise regarding the TMS (e.g., practitioners of the tradition). Evaluation should also include feedback from patients and other consumers. Employment of reflective and reflexive practice at the point of use could enable such evaluation.
Transparency of evaluation and evolution	As with appraisal of traditional sources, transparency of process and interpretation is important when evaluating adaptations, implementation and outcomes of translated TK in the contemporary context. As practice, education, research and policy shape the evolution of TMS, integrity to the TMS can be upheld through comprehensive, systematic and transparent evaluation in these areas, even in cases of differing interpretations. Contemporary resources such as internet technology can support such transparency by providing avenues for accessible reporting.
Integrity of traditional resources in contemporary context	Many factors could potentially impact the quality or efficacy of traditional resources present in contemporary contexts (e.g., growing conditions may change the phytochemical profile of herbs, nontraditional solvents used in medicine making may substantially alter the phytochemical profile of the finished medicine, or manufacturing standards may impact the delivered dose of an acupuncture intervention). These factors should be, where possible, identified, examined, and used to inform adaptations such as changes to dose or preparation methods as required.

TK, traditional knowledge; TMS, traditional medicine system.

Participants argued that evaluation should be undertaken by or with end-users and other stakeholders who are present at the point of use and who have expertise regarding the tradition in question (e.g., practitioners of the tradition), while also including feedback from patients and other consumers. As with other phases in the implementation process, participants suggested that transparency of process and interpretation is important when evaluating adaptations, implementation, and outcomes of translated evidence. However, they also described the need to identify and examine factors that could potentially impact the quality or efficacy of available traditional resources, before making adaptations.

Traditions are living systems

Participants acknowledged that TK and TMS practices have often undergone many evolutionary adaptations over time, in response to changing needs, environments, and contexts (as presented in Table 5). To sustain the relevance of TK over time, participants suggested that it was problematic to seek to maintain TK as rigid and unchanging—instead knowledge must intentionally evolve through living practice. Participants argued that in some TMSs there is a need for further codification, to define how TK is used in practise and is philosophically rooted in the present time.

Table 5.

Elements Identified by Participants Regarding Traditions Are Living Systems

Elements	Description
Codification: defining the systems of living traditions	TMS can be shaped by a variety of influences over time, leading to a lack of consistency in terminology and definition. Thus, there is an unmet need for codification within some traditions to provide definition around how they are practiced and philosophically rooted in the present time. Codification can provide clear understandings of where boundaries, definitions, limits, and professional identity lie to guide context-appropriate, tradition-centric adaptations, implementation, and evaluation. Codification may also help determine what is considered best practice of a TMS in the contemporary context. The complex and individualized nature of TMS practice makes the codification process challenging. Expert consensus may assist in identifying the core principles suitable to meet the complex requirements of TMS codification and evaluation. International and national professional organizations, educational institutions, and industry may have a role in jointly facilitating codification.
Critique of TK is necessary to evolve as living traditions	Critical evaluation of TK is essential to determine which knowledge and practices are both authentically aligned with the philosophical roots of the TMS and appropriate for the contemporary context. Because TMSs are living systems that undergo adaptation over time, ongoing evaluation is required as part of the TMs' evolution. Appropriate and successful evolution of a TMS can be shaped by a dual approach of critically unpicking TK and navigating its adaptation. This is challenging as TMS can often be perceived as static and sometimes face taboos against critique.
Evolution of practice, retention of tradition	TMS are not static and must evolve to maintain relevance in contemporary contexts. Evolution ensures the roots, philosophy, and core characteristics of the TMS are retained as embodied principles, while practices associated with the TMS may undergo adaptation in response to changing needs or new evidence. Evolution may involve novel implementation of traditional practices or philosophies (e.g., use of herbal medicine in COVID-19; application of Vis medicatrix naturae in Green Prescribing, or adaptation of acupuncture point prescriptions in response to contemporary knowledge of neuroanatomy). Fidelity to the philosophical roots in applied practice of TK is often considered more important than fidelity to the specifics of traditional practices. These principles of evolution apply to both implementation and deimplementation of TK. Evolution should be led by the tradition itself rather than by commercial interests to ensure integrity to the TMS.
Pragmatic translation to achieve balance between tradition and contemporary context	Translation requires a pragmatic and transparent approach to appropriately bridge TK with the contemporary context. This means seeking a balance between retention of the core characteristics of the TMS, adaptation to the contemporary context, and maintenance of the effectiveness or utility of the translated knowledge. The methods used to seek and achieve balance in translation. Guidance from TK experts is important to determine the level of adaptation acceptable within the TMS to maintain efficacy and safety, while engagement and codesign with patients and community can assist in determining how much adaptation is required to meet end-user needs.
Empirical testing and peer-to-peer knowledge sharing	Empirical testing through clinical experience and peer-to-peer knowledge sharing is a characteristic of TMS, historically shaping the development and evolution of TMS as living systems. There is a need for effective ways for TK stakeholders, particularly clinicians, to share knowledge gained from their clinical experience. Professional associations, educational and academic institutions, and special interest groups may have a role in facilitating this knowledge mobilization. Established academic channels for knowledge dissemination—such as published case studies—can be a barrier to TMS knowledge sharing as the process of producing such a case study can influence how the clinician practices.

TK, traditional knowledge; TMS, traditional medicine system.

In viewing TMSs as living systems that are subject to adaptation over time, participants also suggested that successful evolution of a TMS can be shaped by a dual approach—of critically unpicking TK and navigating its adaptation. Participants explained TMSs as always evolving to maintain their relevance in contemporary contexts. They also stressed how such evolution can and should ensure the roots, philosophy, and core characteristics of the TMS are preserved as embodied principles, while practices associated with the TMS may undergo adaptation in response to changing needs or new evidence.

With these tensions in mind, participants argued that knowledge translation requires a pragmatic, transparent approach to appropriately bridge TK with the contemporary context. Specifically, they understood this means seeking a balance across the retention of core traditional characteristics, adaptation to the contemporary context, and maintenance of the effectiveness or utility of the TK. Participants also identified empirical testing—through clinical experience and peer-to-peer knowledge sharing—as an important feature that has historically shaped the development and evolution of TMS as living systems. As such, participants described a need for effective ways for TK stakeholders, particularly clinicians, to share knowledge gained from experience.

Discussion

This study represents the first direct, explicit examination of the challenges, opportunities, and considerations involved in translating knowledge from TMSs to contemporary service delivery, education, research, and policy contexts, from the perspective of stakeholders. It represents a contribution to the global study of public health and primary care in light of the 2018 Declaration of Astana and its call to apply knowledge, including TK, to strengthen primary care service delivery and improve health outcomes.¹

There is potential for alignment of TMS with global public health priorities and for TMS to contribute to addressing public health challenges, including the need for person-centered and prevention-focused health systems.^31,32 For this potential to be realized, TK translation or implementation must be sensitive to the TMS from which the TK arises. Key findings discussed below build on the findings of earlier research²⁹ or fill some gaps in the existing evidence base.

The complexity of critical evaluation of TK

These study findings describe the need for TK sources to be critically evaluated as part of the knowledge translation process. However, the findings also suggest that evaluating TK has some additional and unique considerations that generally do not apply to the critical evaluation of scientific evidence, or apply to the same extent.

Criteria for evaluating TK sources proposed in this study—such as authenticity, triangulation, and fidelity—are already applied to scientific evidence through peer review. While the peer-review process is positioned as the foundation of the scientific critical process, it is still criticized as an imperfect method for appraisal,³³ and in response the scientific community has developed reporting guidelines, critical appraisal tools, and journal editorial guidelines to strengthen the quality of knowledge generated from science. This means that critical elements affecting evidence quality are addressed during knowledge generation and dissemination. This reduces, but does not erase, the need for the end-user to critically appraise peer-reviewed published research to the same degree.

In contrast, in the absence of a similar level of academic infrastructure, TK end-users are themselves required to undertake most if not all critical appraisal of TK sources. Further, they are asked to do so in the absence of systematic guidelines to inform such appraisal. This may explain why previous research shows limited critical evaluation of TK before its application to contemporary clinic, research, policy, or education contexts.²⁹ The findings of this study offer a first important step toward the development of critical evaluation guidelines for TK. Future research should build on this work.

TMS as living traditions and the implications for IS

Participants in this study emphasized the importance of engaging in TK translation and implementation with an explicit recognition of TMS as living, evolving traditions. This concept of “living traditions” is somewhat fraught across many TMS professions. For instance, researchers and practitioners of Chinese medicine describe tensions between pre 1950s “classical” Chinese medicine and the more recent “Traditional” Chinese Medicine, with the former seen as a historically diverse collection of practices while the latter positioned as a modernized version influenced by postcultural revolution nationalist politics.^34,35

Similarly, boundary tensions have been identified between nature cure and naturopathy,^36,37 and among “mixers” and “straight” practitioners of chiropractic.³⁸ Insights reported through this study provide practical guidance to navigate these challenges. These insights can build upon the existing important work undertaken to advance TK use through application of cutting edge research methods such as adapting critical appraisal tools to assess scientific research on TK-based diagnosis methods,³⁹ or developing techniques to make TK diagnostic practices replicable using modern statistical approaches.⁴⁰

Similarly, it can support front-line implementation activities such as operationalizing TK use through digital health technologies.⁴¹ The results of this study may provide the necessary foundations to systematically guide such cutting edge research, as well as supporting efforts of TM professions working to codify their TK^42
–44 and guidance on how codified knowledge can be systematically applied in TMS knowledge translation.^45,46

Centering the TMS in the translation and implementation of TK

This study's findings highlight the importance of centering, that is, giving primacy to or paying due regard to, the philosophies and principles of the TMS from which the TK originates when undertaking TK translation. While this has been referred to in previous studies regarding IS,^10,12 this study provides empirical support for the need for researchers/practitioners to prioritize this centering process. The findings on how best to achieve this centering of the TMS raise familiar public health issues such as knowledge sovereignty and intellectual property,⁴⁷ and patient-centered health service design and delivery.⁴⁸

Participants also identified retaining the core philosophies and principles of the TMS as requiring TK users to balance being relevant to the target audience with remaining sensitive to the TMS. The complexity of such a challenge may be addressed by embracing knowledge mobilization frameworks¹⁰ and principles such as knowledge equity,⁴ while also learning from the theoretical and practical skills in health literacy, patient education, and health promotion fields.⁴⁹ While there is some evidence that TMS practitioners may engage with some or all of these fields,^32,50 they may not always possess the required breadth and depth of expertise to address the challenge of TMS-centered TK translation and implementation. Researcher–practitioner partnerships may be one means to help address these challenges.

Criteria for translation

These findings may help direct the translation of TK into contemporary domains—a critical gap identified through the systematic review²⁹—providing the basis for developing criteria or guidelines for future TK translation. For instance, the concept of “relative advantage”—to select and apply the most appropriate treatment for an individual patient based on the best available evidence—is relevant to the foundational aim of evidence-based practice. It requires those translating TK to access information that compares the effectiveness of TMS against other non-TMS treatments (specifically, biomedicine treatments).

Unfortunately, comparative effectiveness research remains an underused clinical trial design in TMS,⁵¹ and this would need to change for “relative advantage” criteria to be applied to support TK use. The study participants described opportunities for synergism—to expand the concept of relative advantage beyond comparing the TMS with standard care, to consider the potential for cumulative effectiveness when TMS and standard care are used together.

Furthermore, participants proposed extending the concept of relative advantage, to recognize and value the contributions of TMS knowledge of health and disease, to improve outcomes in other areas of health. Examples are the emerging scientific understanding of the “gut–brain connection,” which has been long understood and reflected in naturopath TK and practice,²³ and the correlation between the spinal innervation of organs and Traditional Chinese Medicine acupoint relationships to the same organs.⁵²

The participants also highlighted intentionality as a useful criterion for assessing TK translation. This picks up on issues identified in the previous review,²⁹ namely, that often insufficient attention is given to the process of translating TK, at least based on the details provided in the described methodologies of studies investigating TMS practices or interventions.

Novel insights into evaluating TK translation and implementation

The findings of this study address a gap, identified in the earlier systematic review, which the process of evaluating TK translation and implementation remains largely overlooked.²⁹ Participants recommended evaluation of TK translation and implementation at the point of use. However, this requires a level of research literacy, which may or may not be present among TK end-users or other individuals affected by their TK use.

Efforts to use the purpose-built E-BASE instrument to map systematically the evidence-based practice behaviors of TM practitioners^53
–55 have identified variability in self-reported evidence-based practice attitudes and behaviors across TM professions. However, this research did not test practitioner competence in reflexivity or process appraisal; a practice identified by participants in this study as important to TK translation. While the need for reflexivity and appraisal skills are not limited to TMS,^56,57 they are central to the proposed approach to evaluating TK translation and implementation identified through the study.

Limitations

This study produces novel findings to advance the public health and IS scholarship of TMS. However the generalizability and transferability of findings may be limited by the domestic focus of the sample. While participants were engaged from across all major contemporary domains (practice, education, research, policy, advocacy), the perspectives of participants related principally to the Australian context. The policy and researcher participants each brought a global perspective on TK translation from their respective domains, whereas clinical, education, and consumer participants tended to focus on local experiences (e.g., the impact on clinical practice of regulations and policies applied by Australia's medicines and therapeutic goods regulators). However, it is also important to acknowledge that—in line with third-generation thinking¹⁵—implementation is most effective when conducted at a local level.

While the foundational work of this study may be expanded to include international perspectives, future implementation and translation efforts will always be context specific; that is, requiring an understanding of the local regulatory, education, research, and/or practice contexts. Equally, while there is no definitive guide for determining the ideal number of participants for World Café method,⁵⁸ it is possible that additional participants may have resulted in different perspectives. For this reason, testing the results from this study through an international Delphi study or similar consensus methodology may further refine and strengthen the transferability of the findings.

Future work and opportunities

This study provides grounding for further work in two main areas: the design of guidelines for implementing the translation of TK into contemporary practice; and consideration of strategies to strengthen collaborations across disciplines and professions that use TK.

The elements of TK translation identified through this study may be used to design purpose-built framework(s) and guideline(s) for translation, implementation, and evaluation of TK within a range of practice settings. For example, a framework that guides the translation of TK for use in education settings might articulate where and how TK is taught, implemented, and evaluated within clinical and preclinical professional training where relevant.

These elements may also assist with the development of criteria for critiquing and reporting TK use in research (e.g., checklist for studies that use TK), or for translating and implementing TK in policy on regulation of medicines or practitioners. Such work needs to happen in parallel with the critical work underway to develop clinical practice guidelines for TMS such as Traditional Chinese Medicine.²⁶

Greater collaboration across practice, education, research, and policy is needed to help bridge the current science–policy gap. This might involve designing TK coding systems and consistent language that are understood by all professions,^43,44 and providing infrastructure such as networks that allow collaborations within contexts where TK is used, including dissemination of relevant information to patients and patient advocacy groups in line with the patient-centered needs identified by the study participants. This study could form the basis of codifying TK and bringing together networks that allow closer collaboration for translating TK into all applicable contemporary domains.

Furthermore, and in line with the complexity of “third-generation thinking,”¹⁵ there is a need for future research to examine the shared challenges and opportunities associated with translating both scientific knowledge and TK into TMS clinical practice. The barriers and facilitators to clinician's use of scientific evidence have been studied for a range of TMS professions, including Traditional Chinese Medicine,⁵⁹ naturopathy,^8,60 chiropractic,^61,62 and osteopathy,^63,64 but similar research investigating clinician's application of TK is somewhat limited.^7,8,50 The translation of these two types of knowledge into real-world contexts must be conducted independently but also with consideration of each other to allow IS researchers and knowledge mobilizers to support TK users to integrate diverse knowledge sources into modern settings.

Conclusion

This study highlighted the need for clear, transparent, and appropriate implementation of TK into contemporary contexts. TK implementation should be based on trustworthy and safe traditional practices and knowledge that has been evaluated by an expert in the relevant TMS. Implementation should also be intentional, ethical, and explicitly aligned with TMS. It should also address an identified need in a contemporary context, consider the end-user (e.g., patient), the socioeconomic impact and tools of implementation. TK should be codified, critiqued using appropriate tools, and evaluated using empirical testing and pragmatic translation tools that preserve the integrity of the TK throughout its implementation and continued evolution in contemporary context(s).

Footnotes

Authors' Contributions

A.S. contributed to conceptualization, methodology, formal analysis, investigation, writing—original draft, writing—review and editing, visualization, supervision, project administration, funding acquisition. H.F. carried out methodology, formal analysis, investigation, data curation, writing—original draft, writing—review and editing, visualization, project administration. A.B. performed formal analysis, investigation, writing—original draft, writing—review and editing, visualization. J.W. contributed to conceptualization, methodology, formal analysis, investigation, writing—review and editing, funding acquisition. H.B., A.-L.C., G.C., K.D., P.G., R.R., J.H., N.S., and I.B. performed formal analysis, investigation, writing—review and editing. J.A. assisted with conceptualization, methodology, formal analysis, investigation, writing—original draft, writing—review and editing, visualization, funding acquisition.

Author Disclosure Statement

The authors declare no conflicts of interest.

Funding Information

This study was funded by the National Centre for Naturopathic Medicine, Southern Cross University, which receives funding from the Blackmores Foundation. Blackmores Foundation had no influence on the research design, conduct, or reporting of the study, nor any influence on the writing or publication of this article.

Supplementary Material

Supplementary File S1

References

World Health Organization. Declaration of Astana (Global Conference on Primary Health Care). World Health Organization: Kazakhstan; 2018.

World Health Organization. WHO Traditional Medicine Strategy 2014–2023. World Health Organization: Geneva, Switzerland; 2013.

World Health Organization. Traditional, Complementary and Integrative Medicine. 2022. Available from: https://www.who.int/health-topics/traditional-complementary-and-integrative-medicine#tab=tab_1 [Last accessed: July 18, 2022].

Twarog

, Kapoor

Protecting and Promoting Traditional Knowledge: Systems, National Experiences and International Dimensions. United Nations; 2004. Available from: https://www.international-arbitration-attorney.com/wp-content/uploads/ditcted10_en.pdf [Last accessed: July 18, 2022].

Zemplén GÁ. Trajectories and Challenges of Translating Traditional Chinese Medicine. In: Controversies in the Contemporary World. ( Scarafile

, Fabris

. eds.) John Benjamins B.V., 2019; pp. 105–126.

Harvie

, Steel

, Wardle

. Traditional Chinese medicine self-care and lifestyle medicine outside of Asia: A systematic literature review. J Altern Complement Med, 2019; 25(8):789–808.

Steel

, Adams

. The interface between tradition and science: Naturopaths' perspectives of modern practice. J Altern Complement Med, 2011; 17(10):967–972.

Steel

, Peng

, Gray

, et al. The role and influence of traditional and scientific knowledge in naturopathic education: A qualitative study. J Altern Complement Med, 2019; 25(2):196–201; doi: 10.1089/acm.2018.0293

Wardle

, Seely

The Challenges of Traditional, Complementary and Integrative Medicine Research: A Practitioner Perspective. In: Traditional, Complementary and Integrative Medicine: An International Reader. ( Adams

. ed.) Palgrave MacMillan: New York; 2007; pp. 266–282.

10.

Adams

, Steel

, Reid

A Holistic Approach to Implementation Science (IS): Broadening the IS Gaze to Traditional, Complementary and Integrative Medicine. In: Public Health and Health Services Research in Traditional, Complementary and Integrative Health Care: International Perspectives. ( Adams

, Broom

, Sibbritt

, et al. eds.) World Scientific: London, 2019; pp. 99–117.

11.

Eccles

, Mittman

. Welcome to implementation science. Implement Sci, 2006; 1(1):1–3.

12.

Steel

, Rapport

, Adams

. Towards an implementation science of complementary health care: Some initial considerations for guiding safe, effective clinical decision-making. Adv Integr Med, 2018; 5(1):5–8; doi: 10.1016/j.aimed.2018.02.002

13.

White

KM.

The Science of Translation and Major Frameworks. In: Translation of Evidence into Nursing and Health Care Practice. ( White

, Dudley-Brown

. eds.) Springer: New York; 2012; pp. 23–48.

14.

Sackett

, Rosenberg

, Gray

, et al. Evidence based medicine: What it is and what it isn't. BMJ, 1996; 312(7023):71–72.

15.

Best

, Holmes

. Systems thinking, knowledge and action: Towards better models and methods. Evid Policy, 2010; 6(2):145–159.

16.

Boaz

, Nutley

Using Evidence. In: What Works Now?: Evidence-Informed Policy and Practice. ( Boaz

, Davies

, Fraser

, et al. eds.) Policy Press: Bristol; 2019; pp. 251–274.

17.

Movsisyan

, Arnold

, Evans

, et al. Adapting evidence-informed complex population health interventions for new contexts: A systematic review of guidance. Implement Sci, 2019; 14(1):1–20.

18.

Ward

Why, whose, what and how? A framework for knowledge mobilisers. Evid Policy, 2017; 13(3):477–497.

19.

Taylor

, Dusek

, Elwy

. Moving integrative health research from effectiveness to widespread dissemination. J Altern Complement Med, 2021; 27(S1):S1–S6.

20.

Clark

, Edwards

, Murray

, et al. Implementation science methodologies for complementary integrative health research. J Altern Complement Med, 2021; 27(S1):S7–S13.

21.

Graham

, Steel

, Wardle

. Primary health care case management through the lens of complexity: An exploratory study of naturopathic practice using complexity science principles. BMC Complement Med Ther, 2022; 22(1):107; doi: 10.1186/s12906-022-03585-2

22.

Graham

, Steel

, Wardle

. The converging paradigms of holism and complexity: An exploration of naturopathic clinical case management using complexity science principles. J Eval Clin Pract, 2022:1–20.

23.

Steel

, Goldenberg

, Hawrelak

, et al. Integrative physiology and traditional naturopathic practice: Results of an international observational study. Integr Med Res, 2020; 9(4):100424; doi: 10.1016/j.imr.2020.100424

24.

James

, Wardle

, Steel

, et al. Traditional, complementary and alternative medicine use in Sub-Saharan Africa: A systematic review. BMJ Global Health, 2018; 3(5):e000895.

25.

Suswardany

, Sibbritt

, Supardi

, et al. A critical review of traditional medicine and traditional healer use for malaria and among people in malaria-endemic areas: Contemporary research in low to middle-income Asia-Pacific countries. Malar J, 2015; 14:1–9.

26.

Chung

VCH

, Ho

, Lao

, et al. Implementation science in traditional, complementary and integrative medicine: An overview of experiences from China and the United States. Phytomedicine, 2023; 109:154591; doi: 10.1016/j.phymed.2022.154591

27.

Reid

, Steel

, Wardle

, et al. Complementary medicine use by the Australian population: A critical mixed studies systematic review of utilisation, perceptions and factors associated with use. BMC Complement Altern Med, 2016; 16(1):1–23.

28.

Löhr

, Weinhardt

, Sieber

. The “World Café” as a participatory method for collecting qualitative data. Int J Qual Meth, 2020; 19:1–15; doi: 10.1177/1609406920916976

29.

Foley

, Bugarcic

, Adams

, et al. A systematic review of criteria for the selection, evaluation and application of traditional knowledge in contemporary health practice, education, research and policy. Health Inf Lib (under review).

30.

Clarke

, Braun

, Hayfield

Thematic Analysis. In: Qualitative Psychology: A Practical Guide to Research Methods. ( Smith

. ed.) Sage Publications Ltd.: London; 2015; p. 248.

31.

Foley

, Steel

. The nexus between patient-centered care and complementary medicine: Allies in the era of chronic disease?. J Altern Complement Med, 2017; 23(3):158–163.

32.

Steel

, Lloyd

. Community education and health promotion activities of naturopathic practitioners: Results of an international cross-sectional survey. BMC Complement Med Ther, 2021; 21:1–14.

33.

Mahoney

MJ.

Publication prejudices: An experimental study of confirmatory bias in the peer review system. Cognit Ther Res, 1977; 1(2):161–175.

34.

Buck

Acupuncture and Chinese Medicine: Roots of Modern Practice. Singing Dragon: Philadelphia, London; 2014.

35.

Fruehauf

Science, politics and the making of TCM: Chinese medicine in crisis. J Chin Med, 1999; 6(61):6–14.

36.

Boon

Canadian naturopathic practitioners: Holistic and scientific world views. Soc Sci Med, 1998; 46(9):1213–1225.

37.

Wardle

, Adams

, Lui

C-W

, et al. Current challenges and future directions for naturopathic medicine in Australia: A qualitative examination of perceptions and experiences from grassroots practice. BMC Complement Altern Med, 2013; 13(1):15; doi: 10.1186/1472-6882-13-15

38.

Simpson

, Young

. Vitalism in contemporary chiropractic: A help or a hinderance?. Chiropr Man Therap, 2020; 28(1):1–20.

39.

LTF

, Chung

VCH

, Wong

CHL

, et al. Evaluating traditional Chinese medicine diagnostic instruments for functional dyspepsia: A systematic review on measurement properties. Integr Med Res, 2021; 10(3):100713; doi: 10.1016/j.imr.2020.100713

40.

, Zhang

, Xu

, et al. Latent tree analysis for the identification and differentiation of evidence-based Traditional Chinese Medicine diagnostic patterns: A primer for clinicians. Phytomedicine, 2022; 106:154392; doi: 10.1016/j.phymed.2022.154392

41.

, Xu

, Zhang

, et al. Quantification of prevalence, clinical characteristics, co-existence, and geographic variations of traditional Chinese medicine diagnostic patterns via latent tree analysis-based differentiation rules among functional dyspepsia patients. Chin Med, 2022; 17(1):101; doi: 10.1186/s13020-022-00656-x

42.

Lloyd

, Steel

, Wardle

, (eds). Naturopathy: Practice, Effectiveness, Costs, Safety. World Naturopathic Federation: Toronto, Ontario; 2021.

43.

Phillips

RB.

The Global Advance of Chiropractic: The World Federation of Chiropractic, 1988–2013. World Federation of Chiropractic: London; 2013.

44.

Reddy

, Fan

. Incorporation of complementary and traditional medicine in ICD-11. BMC Med Inform Decis Mak, 2021; 21(6):1–9.

45.

May

, Lu

, Xue

CCL

. Collections of traditional Chinese medical literature as resources for systematic searches. J Altern Complement Med, 2012; 18(12):1101–1107; doi: 10.1089/acm.2011.0587

46.

May

, Zhang

, Lu

, et al. The systematic assessment of traditional evidence from the premodern Chinese medical literature: A text-mining approach. J Altern Complement Med, 2014; 20(12):937–942; doi: 10.1089/acm.2013.0372

47.

World Health Organization. Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property. World Health Organization: France; 2011.

48.

World Health Organization. WHO Global Strategy on People-Centred and Integrated Health Services: Interim Report. World Health Organization: Geneva; 2015.

49.

Van den Broucke

Health literacy: A critical concept for public health. Arch Public Health, 2014; 72(1):1–2.

50.

Steel

, Leach

, Brosnan

, et al. Naturopaths' mobilisation of knowledge and information in clinical practice: An international cross-sectional survey. BMC Med Ther, 2021; 21(1):205; doi: 10.1186/s12906-021-03383-2

51.

Schloss

, McIntyre

, Steel

, et al. Lessons from outside and within: Exploring advancements in methodology for naturopathic medicine clinical research. J Altern Complement Med, 2019; 25(2):135–140.

52.

da Silva

MAH.

A neurosegmental perspective of the classical back Shu points. Med Acupunct, 2010; 22(4):257–264.

53.

Snow

, Leach

, Clare

. Attitudes, skill and use of evidence-based practice among US Western herbal medicine providers: A national survey. J Complement Integr Med, 2017; 14(1):20150101.

54.

Leach

, Shaw

, Austin

, et al. Attitudes, skills, and use of evidence-based practice: A cross-sectional survey of Swedish osteopaths. Int J Osteopath Med, 2020; 38:41–49; doi: 10.1016/j.ijosm.2020.10.006

55.

Leach

, Gillham

. Are complementary medicine practitioners implementing evidence based practice?. Complement Ther Med, 2011; 19(3):128–136; doi: 10.1016/j.ctim.2011.04.002

56.

Landy

, Cameron

, Au

, et al. Educational Strategies to Enhance Reflexivity Among Clinicians and Health Professional Students: A Scoping Study. Freie Universität Berlin: Berlin; 2016.

57.

Davies

, Powell

, Rushmer

Healthcare Professionals' Views on Clinician Engagement in Quality Improvement: A Literature Review. The Health Foundation: London; 2007.

58.

Schiele

, Krummaker

, Hoffmann

, et al. The “research world café” as method of scientific enquiry: Combining rigor with relevance and speed. J Bus Res, 2022; 140:280–296; doi: 10.1016/j.jbusres.2021.10.075

59.

Wong

CHL

, Tse

JVH

, Nilsen

, et al. Barriers and facilitators to promoting evidence uptake in Chinese medicine: A qualitative study in Hong Kong. BMC Complement Med Ther, 2021; 21(1):200; doi: 10.1186/s12906-021-03372-5

60.

Leach

, Aucoin

, Cooley

. Canadian naturopathic doctor engagement, preparedness, and perceptions of evidence-based practice: A national cross-sectional study. J Integr Complement Med, 2022; 28(12):955–964.

61.

Leach

, Palmgren

, Thomson

, et al. Skills, attitudes and uptake of evidence-based practice: A cross-sectional study of chiropractors in the Swedish Chiropractic Association. Chiropr Man Therap, 2021; 29(1):1–12.

62.

Albisser

, Schweinhardt

, Bussières

, et al. Self-reported attitudes, skills and use of evidence-based practice among Swiss chiropractors: A national survey. Chiropr Man Ther, 2022; 30(1):59.

63.

Sundberg

, Leach

, Thomson

, et al. Attitudes, skills and use of evidence-based practice among UK osteopaths: A national cross-sectional survey. BMC Musculoskelet Disord, 2018; 19(1):1–10.

64.

Cerritelli

, Iacopini

, Galli

, et al. Evidence-based practice among Italian osteopaths: A national cross-sectional survey. BMC Complement Med Ther, 2021; 21:1–10.

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