Prevalence of Traditional,Complementary,and Integrative Medicine Training,Its Different Practices,and Associated Sociodemographic Factors: A Study with Brazilian Nurses

Abstract

Objective:

To analyze the prevalence of nurses trained in traditional, complementary, and integrative medicine (TCIM), the different practices, and associated sociodemographic factors.

Methods:

This quantitative, cross-sectional study was implemented online in Brazil from June 2021 to January 2022 among 1,154 nurses using a questionnaire comprising open- and closed-ended questions. The Stata IC software, version 16.0, was used in the statistical analysis. The dependent variable was training in TCIM, and the prevalence of different TCIM practices was also investigated. The independent variables included sociodemographic information. Descriptive and inferential statistical tests were performed. This study was approved by the Institutional Review Board at the Federal University of Rio Grande do Sul and was developed according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) initiative.

Results:

The prevalence of TCIM training was 43.50%. Most participants were women (89.49%), Brazilian (99.65%), aged 39.71 on average (SD = 10.37), and had an income of up to four times the minimum wage (52.43%). The prevalence of professionals implementing TCIM in their practice among those with training was 64.60%. They reported working up to 2 h a week (36.96%) in primary health care settings (33.40%) and providing individual consultations (78.0%). After the adjusted analysis, TCIM training appeared significantly associated with age (p < 0.001), the region where the workplace is located (p < 0.001), and income (p < 0.001). Auriculotherapy (59.96%) stood out among the TCIM practices in which nurses were trained.

Conclusions:

Almost half of the nurses working in Brazil have training in TCIM and sociodemographic factors such as age, region of work, and income are significantly associated with this training.

Introduction

The World Health Organization (WHO) defines traditional, complementary, and integrative medicine (TCIM) as a broad set of practices, knowledge, and products grouped together because they do not fit within the scope of conventional medicine.¹ In Brazil, the acronym TCIM, also synonymous with complementary and alternative medicine (CAM), is known as Práticas Integrativas e Complementares em Saúde (PICS) [Integrative and Complementary Health Practices], which the Brazilian Ministry of Health regulated in 2006 through the National Policy on Integrative and Complementary Practices (PNPIC in Portuguese).^2,3 As TCIM is the acronym recognized by the WHO, it was adopted here to encompass the PICS in Brazil and CAM employed elsewhere.

The population in Brazil and worldwide has become increasingly interested in TCIM. Studies show that 32.3%–33.2% of adults in the United States and 21%–50% of adults in Europe use this resource. In comparison, even higher percentages are found in Saudi Arabia and South Korea, 68% and 74.8%, respectively.⁴ These practices have also been increasingly adopted in Iran, mainly due to the prevalence of diseases and crises.⁵ The prevalence of TCIM in Brazil was 5.2%, with acupuncture, homeopathy, herbal medicine, and yoga among the most frequently adopted.³

A relevant aspect regarding the increased use of TCIM is that patients often fail to report its use to health workers due to fear of disapproval.⁶ However, not reporting the use of TCIM imposes a risk to patients, given potential side effects and interactions with conventional treatments.⁷

Nurses are the largest group of health care workers worldwide⁸ and are essential in providing care. Hence, considering the increased adoption of TCIM practices, nurses must acquire knowledge and training to provide guidance and advise patients to promote health and prevent diseases.^4,5

Nurses’ attitudes toward TCIM are influenced by their academic training, knowledge, and work context.⁵ The training of Brazilian nurses in TCIM emerges from the need to heed the population’s needs. There is a contingent of 705,629 nurses registered in regional councils and a significant demand for nurses capable of integrating allopathic health care approaches with TCIM.⁹

Countries including New Zealand, Australia, Iran, and the United States have conducted studies on the knowledge and training of health workers on TCIM; however, few Brazilian studies investigate these aspects in this population.^4,5,10,11 Despite the high interaction of nurses with patients, the literature shows their incipient knowledge of TCIM.^4,5,10,11

The profile of Brazilian nurses working with TCIM is unknown. Hence, considering the increased relevance of TCIM in contemporary health care practices and understanding the prominent role of nurses in health care delivery, this study’s objective is to analyze the prevalence of TCIM training among nurses, its different practices, and associated sociodemographic factors.

Material and Methods

Study design and participants

This study’s procedures complied with all ethical guidelines proposed by the Brazilian Research Ethics Council (CONEP) and the Declaration of Helsinki. It was approved by the Institutional Review Board (Opinion No. CAAE:43306921.6.0000.5347) and followed the recommendations provided by the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE).¹² All participants signed an informed consent form.

This quantitative, cross-sectional study was implemented online through a questionnaire developed by the research team using the LimeSurvey tool. The questionnaire, containing open- and closed-ended questions, underwent peer review and pilot testing. It comprised 52 questions, 17 of which were to be answered by all nurses in the sample and 34 questions specifically directed to those reporting some training in TCIM.

The sample size was determined according to the criteria proposed by Hill and Hill.¹³ The formula was applied considering a total population of 582,197 Brazilian nurses; the minimum number required was 384 participants.⁹ Eligibility criteria were (1) having a nursing degree, (2) being able to read and understand Portuguese, and (3) having access to an electronic device. A total of 1,154 nurses participated in the study.

Recruitment

The study was disseminated online through emails and social media. A digital PDF leaflet containing a link and QR code to access the survey was emailed to Conselho Federal de Enfermagem [Federal Nursing Council - COFEN] and State Nursing Councils. A brief synopsis of this study was published in news format on major national websites. The questionnaire remained available from June 2021 to January 2022, and no financial rewards were offered.

Research variables and instrument

This study’s dependent variable was training in TCIM. The prevalence of different TCIM practices was also investigated. The independent variables were sex, age group quartiles, self-reported race, nationality, city of birth, marital status, children/no children, number of children, time since graduation, religion/no religion, income (times the minimum wage, which was approximately US$200.00 in the study period), the macroregion where the workplace is located, time since graduation (in months), and registration/no registration with the Brazilian Nursing Council.

Statistical method

Stata IC software, version 16.0, was used. Potential associations between training in TCIM and the independent variables were verified through Pearson’s chi-square or Fisher’s exact test when values were equal to or lower than five in the contingency table cell. The linear trend p test measured the ordinal categorical variables.

Prevalence ratios (PRs) were the effect measures verified using Poisson regression with robust adjustment for variance, with precision assessed by 95% confidence intervals (95% CI); the Wald test was performed to see whether the PR was significant.^14

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All variables were included in the adjusted analysis, and a three-level hierarchical causality model was created.¹⁴ The adjusted analysis was performed using the backward variable selection method. First, all variables from the distal block were included. The model was adjusted removing the variables with the highest p-value one by one until only the variables that obtained a p-value of ≤0.20 in the Wald test remained. The intermediate-level variables were then inserted, and the model was adjusted with the distal block variables. The variables from the proximal block were included, and new adjustments were made. A significance level <5% was adopted for all analyses in two-tailed tests. PRs were considered null when the unit value 1.0 was present in the 95% CI.

Results

Participant demographics

A total of 1,154 nurses participated in the study. Most participants were women (89.49%), Brazilian (99.65%), and on average 39.71 years old (SD = 10.37 years). They declared themselves Caucasian (72.65%), were born in the southern region of Brazil (45.06%), had some form of religion (87%), were married (41.28%), and had children (56.93%) (Table 1).

Table 1.

Distribution of the Participants’ Sociodemographic Profile

	n	%
Age	1,069
21–32	294	27.50%
33–39	286	26.75%
40–46	243	22.73%
47–73	246	23.01%
Sex	1,151
Female	1.030	89.49%
Male	121	10.51%
Nationality	1,151
Brazilian	1.147	99.65%
Foreign	4	0.35%
Region of birth	1,143
Southeast	408	35.70%
South	515	45.06%
Northeast	145	12.69%
Midwest	46	4.02%
North	29	2.54%
Marital status	1,153
Married	476	41.28%
Single	309	26.80%
Stable union/cohabitating/dating	245	21.25%
Divorced/separated	107	9.28%
Widowed	16	1.39%
Children	1,154
Yes	657	56.93%
No	497	43.07%
No. of children	652
1	308	47.24%
2	272	41.72%
3	60	9.20%
4	12	1.84%
Race	1,148
Caucasian	834	72.65%
Mixed race	245	21.34%
Afro-descendent	50	4.36%
Asian	18	1.57%
Indigenous	1	0.09%
Religion	1,154	100%
Yes	1.004	87%
No	150	13%
Time since graduation	1,151
Up to 12 months	74	6.43%
Between 13 and 36 months	108	9.38%
Between 37 and 60 months	126	10.95%
Between 61 and 120 months	171	14.86%
Between 121 and 180 months	187	16.25%
Between 181 and 240 months	149	12.95%
More than 241 months	336	29.19%
Region where workplace is located	1,151
Southeast	430	37.36%
South	534	46.39%
Northeast	115	9.99%
Midwest	53	4.60%
North	19	1.65%
Income	1,150
Up to 2 times the minimum salary	156	13.57%
Between 3 and 4 times the minimum salary	447	38.87%
Between 5 and 6 times the minimum salary	282	24.52%
Between 7 and 8 times the minimum salary	152	13.22%
More than 9 times the minimum salary	113	9.82%

TCIM training and practice

The prevalence of TCIM training was 43.50% (n = 502), and most had completed their first training course by 2017 (54.42%). Expenditure on TCIM training was approximately US$189.00 per year (61.77%).

The prevalence of individuals implementing TCIM in their practice was 64.60%. Working up to 2 h a week (36.96%), in primary health care (PHC) settings (33.40%), and providing individual care (78.00%) were the most frequent (Table 2).

Table 2.

Distribution of the Profile of Participants with Training in TCIM

	N	%
Completion of the first TCIM course	498
Between 1980 and 2011	126	25.30%
Between 2012 and 2017	145	29.12%
Between 2018 and 2019	141	28.31%
Between 2020 and 2022	86	17.27%
Average annual spending on TCIM training	429
Up to R$ 500.00	165	38.46%
From R$ 500.01 to R$1,000.00	100	23.31%
From R$ 500.01 to R$1,000.00	101	23.54%
Above R$ 3,000.01	63	14.69%
Implement TCIM practices in the working routine	500	100%
Yes	323	64.60%
No	177	35.40%
Weekly hours implementing TCIM	322
1–2 h	119	36.96%
3–4 h	79	24.53%
5–10 h	57	17.70%
11–20 h	31	9.63%
21–30 h	14	4.35%
Above 30 h	22	6.83%
Working setting where TCIM is implemented (multiple choice question)
Primary health care (UBS. ESF)	167	33.00%
Private service or private practice	120	24.00%
Itinerant provider	53	10.60%
Voluntary outpatient clinic	32	6.00%
Outpatient clinic located in a public university	25	5.00%
Inpatient unit in a public hospital	23	4.60%
Outpatient clinic in a public hospital	19	3.80%
Outpatient clinic in a public university	10	2.00%
Inpatient unit in a private hospital	6	1.20%
Outpatient clinic in a public hospital	3	0.60%

TCIM, traditional, complementary, and integrative medicine.

Auriculotherapy (59.96%), laying on of hands (37.45%), aromatherapy (29.28%), and acupuncture (27.49%) were the four most prevalent TCIM practices in which the participants were trained. Also noteworthy is the breadth of training in TCIM undertaken by nurses, with a total of 30 TCIM and nurses often having more than one training course (Table 3).

Table 3.

Prevalence of Different TCIM Practices (n = 502; Multiple-Choice Question)

	n	%
Auriculotherapy	301	59.96%
Laying on of hands	188	37.45%
Aromatherapy	147	29.28%
Acupuncture	138	27.49%
Cupping therapy	128	25.50%
Flower therapy	118	23.51%
Moxibustion	109	21.71%
Phytotherapy	92	18.33%
Meditation	88	17.53%
Foot reflexology	85	16.93%
Chromotherapy	81	16.14%
Traditional medicine	77	15.34%
Shantala	61	12.15%
Ozone therapy	42	8.37%
Biodanza or dance	30	5.98%
Community therapy	29	5.78%
Music therapy	28	5.58%
Family constellation	25	4.98%
Ayurveda	24	4.78%
Homeopathy	21	4.18%
Geotherapy	20	3.98%
Bioenergetics	19	3.78%
Art therapy	19	3.78%
Hypnotherapy	17	3.39%
Osteopathy and chiropractic	16	3.19%
Naturopathy	13	2.59%
Orthomolecular	12	2.39%
Anthroposophy	10	1.99%
Thermalism	8	1.59%
Apitherapy	1	0.20%

TCIM, traditional, complementary, and integrative medicine.

Nine out of 10 (94.01%) participants reported that having TCIM training was important or very important for their professional practice, 74.55% noted important changes at work, and 97.60% observed positive impacts. The participants also reported that TCIM resulted in greater autonomy as nurses (88.20%) (Table 4).

Table 4.

Nurses’ Perceptions and TCIM Practice

	N	%
Importance of TCIM for professional life?	501	100%
Very important	370	73.85%
Important	101	20.16%
Little important	24	4.79%
Changed nothing	6	1.20%
Positive repercussions of TCIM training and practice	501	100%
Yes	489	97.60%
No	12	2.40%
The implementation of TCIM resulted in important changes in your practice as a nurse	499	100%
Yes	372	74.55%
No	127	25.45%
Greater autonomy as a nurse	500	100%
Yes	441	88.20%
No	59	11.80%
Greater autonomy for patients	500	100%
Yes	484	96.80%
No	16	3.20%

TCIM, traditional, complementary, and integrative medicine.

TCIM training was significantly associated with age (p < 0.001), place of birth (p = 0.002), marital status (p = 0.013), number of children (p = 0.029), the region where the workplace is located (p < 0.001), income (p < 0.001), and time since graduation (p < 0.001).

Regarding age, individuals between 40 and 46 years were 52% more likely to have TCIM training than nurses between 21 and 32 (PR: 1.52; 95% CI: 1.24–1.86; p < 0.001). Likewise, nurses between 47 and 73 were 67% more likely to have TCIM training than those between 21 and 32 (PR: 1.67; 95% CI: 1.37–2.03; p < 0.001).

Those born in the Midwest were 1.75 times more likely to have attended a TCIM course than nurses born in the Southeast (PR: 1.75; 95% CI: 1.39–2.20; p < 0.001). Similarly, those working in the Northeast and Midwest were, respectively, 1.38 (PR: 1.38; 95% CI: 1.12–1.71; p < 0.001) and 2.25 times more likely (PR: 2.25; 95% CI: 1.90–2.66; p < 0.001) to have attended a TCIM course than those in the Southeast.

Nurses who were divorced/separated (PR: 1.32; 95% CI: 1.09–1.60; p = 0.005) and those with two children (PR: 1.32; 95% CI: 1.10–1.58; p = 0.017) were 32% more likely to have TCIM training than married nurses or those with one child.

The probability of having attended a TCIM course increased linearly with increased income. The participants with higher incomes (more than nine times the minimum wage) were 80% more likely to obtain training than those receiving up to two times the minimum wage (PR: 1.80; 95% CI: 1.36–2.37; p < 0.001). The participants who had graduated between 121 and 180 months and more than 241 months before were, respectively, 50% (PR: 1.50; 95% CI: 1.03–2.17; p = 0.0132) and 64% (PR: 1.64; 95% CI: 1.15–2.34; p = 0.0132) more likely to have obtained TCIM training than nurses who graduated 12 months ago or less than 12 months ago (Table 5).

Table 5.

Sociodemographic Factors Associated with Training in TCIM

	No TCIM training[n (%)]	TCIM training[n (%)]	p-Value^a	Raw analysis
	No TCIM training[n (%)]	TCIM training[n (%)]	p-Value^a	Wald p-value^d	PR (95% CI)
Age
21–32 yo	196 (66.67%)	98 (33.33%)	p < 0.001^b	p < 0.001	1
33–39 yo	177 (61.89%)	109 (38.11%)			1.14 (0.92–1.42)
40–46 yo	120 (49.38%)	123 (50.62%)			1.52 (1.24–1.86)
47–73 yo	109 (44.31%)	137 (55.69%)			1.67 (1.37–2.03)
Sex
Female	584 (56.70%)	446 (43.30%)	p = 0.781	p = 0.780	1
Male	67 (55.37%)	54 (44.63%)	p = 0.781	p = 0.780	1.03 (083–1.27)
Nationality
Brazilian	647 (56.41%)	500 (43.59%)	p = 0.637^c	p = 0.521	1
Foreign	03 (75%)	01 (25%)	p = 0.637^c	p = 0.521	0.57 (0.10–3.13)
Region of birth
Southeast	246 (60.29%)	162 (39.71%)	p = 0.002	p = 0.002	1
South	293 (56.89%)	222 (43.11%)			1.09 (0.93–1.27)
Northeast	77 (53.10%)	68 (46.90%)			1.81 (0.96–1.46)
North	14 (48.28%)	15 (51.72%)			1.30 (090–1.89)
Midwest	14 (30.43%)	32 (69.57%)			1.75 (1.39–2.20)
Marital status
Casado	268 (56.30%)	208 (43.70%)	p = 0.013	p = 0.005	1
Divorced/separated	45 (42.06%)	62 (57.94%)			1.32 (1.09–1.60)
Single	191 (61.81%)	118 (38.19%)			0.87 (0.73–1.04)
Stable union	138 (56.33%)	107 (43.67%)			1.0 (0.84–1.19)
Widowed	9 (56.25%)	7 (43.75%)			1.0 (0.57–1.76)
Children
No	292 (58.75%)	205 (41.25%)	p = 0.179	p = 0.18	1
Yes	360 (54.79%)	297 (45.21%)	p = 0.179	p = 0.18	1.10 (0.96–1.25)
No. of children
1	186 (60.39%)	122 (39.61%)	p = 0.029^b	p = 0.017	1
2	130 (47.79%)	142 (52.21%)			1.32 (1.10–1.58)
3	34 (56.67%)	26 (43.33%)			1.09 (0.79–1.51)
4	5 (41.67%)	7 (58.33%)			1.47 (0.89–2.42)
Race
Caucasian	475 (56.95%)	359 (43.05%)	p = 0.093^c	p < 0.001	1
Asian	11 (61.11%)	7 (38.89%)			0.90 (0.51–1.62)
Indigenous	0	1 (100%)			2.32 (2.14–2.51)
Afro-descendant	35 (75%)	15 (30%)			0.69 (0.45–1.07)
Mixed race	127 (51.84%)	118 (48.16%)			1.12 (0.96–1.30)
Religion
No	86 (57.33%)	64 (42.67%)	p = 0.820	p = 0.830	1
Yes	566 (56.37%)	438 (43.63%)	p = 0.820	p = 0.830	1.02 (0.84–1.25)
Region where the workplace is located
Southeast	268 (62.33%)	162 (37.67%)	p < 0.001	p < 0.001	1
South	310 (58.05%)	224 (41.95%)			1.11 (0.95–1.30)
Northeast	55 (47.83%)	60 (52.17%)			1.38 (1.12–1.71)
North	10 (52.63%)	9 (47.37%)			1.25 (0.77–2.05)
Midwest	8 (15.09%)	45 (84.91%)			2.25 (1.90–2.66)
Income
Up to 2 times the MW	106 (67.95%)	50 (32.05%)	p < 0.001^b	p < 0.001	1
Between 3 and 4 times the MW	268 (59.96%)	179 (40.04%)			1.25 (0.97–1.61)
Between 5 and 6 times the MW	156 (55.32%)	126 (44.68%)			1.39 (0.07–1.81)
Between 7 and 8 times the MW	72 (47.37%)	80 (52.63%)			1.64 (1.25–2.16)
More than 9 times the MW	48 (42.48%)	65 (57.52%)			1.80 (1.36–2.37)
Time since graduation
Up to 12 months	51 (68.92%)	23 (31.08%)	p < 0.001^b	p = 0.0132	1
Between 13 and 36 months	68 (62.96%)	40 (37.04%)			1.19 (0.78–1.81)
Between 37 and 60 months	82 (65.08%)	44 (34.92%)			1.12 (0.74–1.70)
Between 61 and 120 months	100 (58.48%)	71 (41.52%)			1.33 (0.91–1.96)
Between 121 and 180 months	100 (53.48%)	87 (46.52%)			1.50 (1.03–2.17)
Between 181 and 240 months	84 (56.38%)	65 (43.62%)			1.40 (0.95–2.06)
More than 241 months	165 (49.11%)	171 (50.89%)			1.64 (1.15–2.34)

Pearson’s chi-square.

p-Value for linear trend.

Fisher’s exact test.

Wald’s test.

TCIM, traditional, complementary, and integrative medicine; CI, confidence interval; PR, prevalence ratio.

Table 6 presents the variables that remained in the final model obtained in the adjusted analysis. The association remained significant for age, region in which the workplace is located, and income.

Table 6.

Final Model of Adjusted Prevalence Ratios (95% CI) for Sociodemographic Factors Associated with Training in TCIM

Level	Variable	Adjusted PR	Adjusted 95% CI	Adjusted Wald p-value
I	Age^a
	21–32 yo	1	—	p < 0.001
	33–39 yo	1.16	0.93–1.45
	40–46 yo	1.56	1.27–1.92
	47–73 yo	1.66	1.34–2.06
II	Region where the workplace is located^a
	Southeast	1	—	p < 0.001
	South	1.24	1.05–1.46
	Northeast	1.6	1.29–1.98
	North	1.22	0.76–1.96
	Midwest	2.32	1.93–2.79
	Income^a
	Up to 2 times the MW	1	—	p = 0.043
	Between 3 and 4 times the MW	1.98	0.92–1.56
	Between 5 and 6 times the MW	1.27	0.96–1.67
	Between 7 and 8 times the MW	1.45	1.09–1.92
	More than 9 times the MW	1.28	0.94–1.73

Level I: Distal: age, place of birth, nationality, race, sex, children, marital status.

Level II: Intermediate: the region where the workplace is located, income, and number of children.

Level III: Proximal: registration in Nursing Council and time since graduation.

The other variables obtained a p-value in Wald’s test below 0.20 and were removed from the adjusted model.

TCIM, traditional, complementary, and integrative medicine; CI, confidence interval; PR, prevalence ratio.

Discussion

Most participants were women, which reflects a trend in the profession worldwide.⁸ Such a tendency of women working in this field is related to the history of nursing, which began with women dedicated to charity, with religious ties, and performing lay work without pay.¹⁸ Thus, despite nurses composing more than half of the global health workforce, this historical burden seems to perpetuate, resulting in the devaluation of the nursing profession, evidenced by salary disparities and low professional status, raising a necessary discussion about gender inequality.¹⁹

The poor remuneration of nursing workers became evident during the COVID-19 pandemic.²⁰ This situation still prevails in several countries, as studies conducted in Taiwan and the United States show.^21,22 Thus, as verified here, it is crucial to understand the influence of adequate salaries on the qualification and probability of nursing workers obtaining TCIM training.

One study addressing nurse educators in the United States found that, during the undergraduate program, most acknowledged the role played by TCIM; however, few programs provided guidance or information regarding the role of nurses in adopting TCIM practices.²³ One study was performed in Australia to identify weaknesses in TCIM courses. Its results indicate that nurses pointed out that many TCIM practitioners were not registered, suggesting that these professionals lacked credentials and adequate experience.²⁴ The global scenario aligns with the Brazilian context, considering TCIM practices lack regulations and are not fully integrated into nursing practices, restricting training possibilities among health professionals.

However, despite the adversities in obtaining a TCIM qualification, most of the participants with training considered it relevant for their professional practice, reporting positive repercussions and significant changes at work. This finding corroborates the literature, in which health care workers identify TCIM as a way to address gaps in biomedical care, providing an opportunity for health care institutions to maintain a competitive advantage and improve their reputation as a leading service in advancing comprehensive care.²⁵ Furthermore, there is evidence that integrating these practices promotes the patients’ quality of life and well-being; health workers note that integrating TCIM with allopathic care is beneficial despite the barriers to its implementation.^26,27

Having knowledge, familiarity, or implementing TCIM influences nurses’ autonomy. Improving professional skills through TCIM training is a possibility nurses can benefit from. Hence, nurses should take the lead by disseminating these practices and highlighting their benefits and associated risks.¹¹ Such an opportunity enables nurses to play a leading role in disseminating comprehensive care, stripping away the biomedical culture rooted in exclusively allopathic training and expanding the autonomy of nurses in different work settings. A systematic review performed in 2022 found that TCIM has beneficial effects on health-related quality of life and well-being in diverse patient populations, with most studies reporting positive impacts on one or more aspects of quality of life.²⁶

PHC was the primary setting where nurses implemented TCIM practices. This finding is consistent with data from the Brazilian government, as TCIM is most frequently provided at PHC services, which is the level accounting for 90% of the consultations in the public health system.²⁸ The PHC level is the entry door to the Brazilian unified health system, and for this reason, it is a privileged locus for implementing these practices. However, some barriers remain to the implementation of these practices at other levels of complexity. A recent study listed some obstacles including lack of experience, familiarity, and knowledge.²⁷

Similar to the context found in other countries, auriculotherapy, laying on of hands, aromatherapy, and acupuncture are the most prevalent practices performed by trained nurses in Brazil.^1,8 Acupuncture is one of the most widely known practices worldwide; 80% of the 129 WHO member countries recognize it as a therapeutic intervention.¹ Recent studies in Brazil and abroad show that TCIM interventions are implemented to meet various therapeutic objectives (e.g., hypertension, chronic and acute pain, side effects of oncological treatments, anxiety), with acupuncture and auriculotherapy being the leading practices.^29

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Acupuncture and auriculotherapy should be considered nursing specialties with potential patient benefits and a favorable cost–benefit for health institutions. It is worth noting that some gaps persist, despite COFEN having regulated the activity of acupuncture in 2008, considering it a nursing specialty in the Brazilian territory.³³

A significant association was found between older nurses and a greater probability of having attended a TCIM training program. However, an inverse result was found when we exclusively addressed the nurses who currently implement TCIM practices to treat patients with hypertension, with younger nurses being more likely to have attended a TCIM training program.²⁹

A continent-spanning country such as Brazil presents a vast environmental and cultural diversity. Hence, being born or working in a particular region may contribute to the probability of attending a TCIM course. The Midwest, comprising the states of Goiás, Mato Grosso, Mato Grosso do Sul, and the Federal District, which hosts the Brazilian capital, Brasília, stood out in this aspect. Furthermore, Mato Grosso, the state hosting the State University of Mato Grosso, will host the first Indigenous Intercultural Nursing Program in the world, highlighting the relevance of the nursing field to connect and cooperate with traditional indigenous medicines in the Brazilian context.³⁴

The higher the participants’ income, the more likely they were to attend a TCIM training program. Therefore, a lack of financial resources is a barrier for nurses to expand their training and implement TCIM practices in health care settings.^4,10,27 Such a notion is reinforced by the few governmental incentives provided in Brazil for this field; hence, nurses must rely on self-financing to obtain a TCIM specialization.^29,35

Conclusions

This pioneering study conducted in Brazil shows that nurses have TCIM training and sociodemographic factors such as age, the region of the workplace, and income are significantly associated with having attended a TCIM training program. Hence, these factors should be considered when investigating the issues related to TCIM qualification among nursing workers. Nurses implement TCIM practices in different health care settings, and having knowledge, familiarity, or using TCIM influences their autonomy. Finally, although some participants failed to answer some of the questions, which resulted in missing information, data analysis was not compromised.

Footnotes

Acknowledgment

The authors would like to thank the National Council for Scientific and Technological Development (CNPq) for financing this project.

Authors’ Contributions

D.R.P.: Conceptualization (supporting), data curation (lead), writing—review and editing (lead), and writing—original draft (lead). D.D.: Conceptualization (lead), data curation (equal), writing—review and editing (equal), and writing—original draft (supporting). K.A.d.S.: Writing—original draft (equal), data curation, and investigation (equal). A.M.S.: Writing—original draft (equal), data curation, and investigation (equal). Y.G.: Writing—review and editing (equal). T.M.M.D.d.A.B.: Writing—review and editing (equal).

Author Disclosure Statement

The authors have no competing financial interests to disclose.

Funding Information

Financial support was provided by the National Council for Scientific and Technological Development (CNPq) - 404534/2021-0.

Supplementary Material

Supplementary Data S1

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