Racial and Ethnic Representation Among Complementary and Integrative Health Program Graduates

Abstract

Background:

Use of complementary and integrative health care (CIH) varies across racial and ethnic groups in the United States. Lack of racial and ethnic diversity among CIH providers may hinder access to CIH for underrepresented groups. This study aimed to (1) document racial and ethnic representation in licensed CIH professions (chiropractic, acupuncture, traditional East Asian medicine, naturopathic medicine, direct-entry midwifery, and massage therapy), non-licensed CIH professions, and conventional health care; (2) compare diversity in these professions with the U.S. population; and (3) examine changes in CIH diversity in recent years.

Methods:

We conducted a repeated cross-sectional study design with the 2011–2022 Integrated Postsecondary Education Data System to examine race and ethnicity among graduates in licensed CIH professions, compared with non-licensed CIH professions and conventional health care. Our sample included 53,393 programs representing 3,524,494 individuals. We examined the proportion of graduates from each racial and ethnic group, compared results with the U.S. population, and graphically explored changes between 2011 and 2022.

Results:

Inclusion or exclusion of massage therapy influenced interpretations across all questions. With massage therapy, licensed CIH professions appeared more diverse, with a higher proportion of Latino and Black graduates. Without massage therapy, diversity in licensed CIH professions was similar or slightly reduced compared with non-licensed CIH professions and conventional health care. Notable differences emerged among licensed CIH professions: acupuncture and East Asian medicine had larger proportions of Asian graduates than other CIH programs and the U.S. population. Racial and ethnic diversity in CIH increased modestly between 2011 and 2022.

Discussion:

While professions such as massage therapy, acupuncture, and traditional East Asian medicine have greater diversity, a disparity persists between the racial and ethnic composition of licensed CIH professions and the diversity of the overall U.S. population.

Introduction

Understanding racial and ethnic identity among health care providers is imperative to addressing health care disparities in the United States.¹ Patient–provider concordance, which refers to the alignment of demographic or personal characteristics such as race, ethnicity, or language between patients and health care providers, can improve communication and trust between patients and providers.^2
–4 Some patients feel more comfortable and understood when interacting with providers who share their backgrounds.⁴ Patient–provider racial concordance has been linked to improved patient satisfaction, a greater sense of partnership, and perceived supportiveness.² Concordance may also mitigate the effects of implicit bias in health care settings, as providers who share cultural backgrounds with their patients may be less likely to hold prejudiced attitudes.⁵ Particularly for patients from racially and ethnically marginalized backgrounds, having a health care provider of a similar background predicts improvements in patient experiences with care,^6,7 including greater patient involvement in decision-making,⁷ patient adherence to medication⁸ and screening recommendations,⁹ and improved pain outcomes.¹⁰

Research about conventional health care providers has often shown a misalignment between the provider population and the general population^11

–15; Salsberg and colleagues focused on four racial and ethnic groups and found that for physicians, White individuals (62%) were overrepresented, while Black (5.2%), Native American (0.1%), and Hispanic individuals (6.9%) were underrepresented, compared with their proportions in the U.S. population.¹¹ However, a gap in the literature exists concerning a frequently used domain of the U.S. health care system—complementary and integrative health care (CIH).^16
–18

CIH is an umbrella concept that encompasses many professions and approaches, including natural products such as medicinal plants, mind/body practices such as yoga and Tai Chi, and manual therapies, among others.^19
–21 CIH emphasizes wellness and prevention,^19,20,22,23 and CIH disciplines include practices other than standard biomedical practices as a complement to, or integrated with, conventional treatments.²⁰ Of particular relevance for scientific research and health care policy are the licensed CIH professions. Five such professions for which licensure is available in at least some U.S. states are acupuncture and East Asian medicine, chiropractic, direct entry midwifery, massage therapy, and naturopathic medicine.²⁴

Over one third of Americans use at least one type of CIH.^16,17 CIH usage has increased in recent years.¹⁷ A growing body of evidence demonstrates the efficacy and effectiveness of CIH treatments for many health issues.²¹ Guidelines recommend CIH as an alternative to opioid treatments for pain.^25,26 Nearly three quarters of older CIH users stated that CIH improves their health,¹⁶ and individuals from certain racial and ethnic groups were more likely to report benefits. American Indian and Alaska Native patients and Black patients were more likely to perceive better health, reduced stress, and improved control over their health because of CIH.¹⁶ The expanding evidence base for the effectiveness and benefits of CIH makes equitable access increasingly important.

There are differences in CIH use by patient’s race and ethnicity that point to concerning disparities, although the patterns vary depending on how researchers operationalize CIH and racial and ethnic categories.^16,17 One population-based study that defined CIH broadly, to include a range of therapies (e.g., acupuncture, chiropractic, naturopathy) and care practices (e.g., nonvitamin and nonmineral dietary supplements, yoga, meditation), and focused analysis on three large racial and ethnic groups, found that White Americans were more likely to use CIH than Hispanic and Black Americans.¹⁷ An exception was that yoga use increased notably for Latino and Black respondents in the most recent time period.¹⁷ Another U.S. population study parsed types of CIH and racial and ethnic groups in detail and found more complex patterns of CIH use.¹⁶ American Indian and Alaska Native adults were more likely than other groups to use traditional healing and herbal supplements; Asian adults were more likely to use yoga and Tai Chi.¹⁶ Black and Latino adults were less likely to report using two or more types of CIH than other racial and ethnic groups, and they were less likely to use treatments such as acupuncture and chiropractic relative to White adults.¹⁶ In short, differences in CIH use by race and ethnicity are nuanced, but some U.S. communities, in particular Black and Latino communities, have less access to CIH.

Diversity in the provider pool is one determinant of access to care.¹ Existing evidence suggests a lack of racial and ethnic diversity among CIH professionals. As one measure, 58% of the U.S. population identifies as White Non-Hispanic.²⁷ Yet, the proportion of CIH professionals who are White is higher, according to professional associations and testing agency data; 85% of chiropractors are White,²⁸ as are 85% of midwives (direct-entry and nurse midwives),²⁹ 69% of acupuncturists and/or traditional East Asian medicine practitioners,³⁰ 61% of naturopathic doctors,³¹ and 61% of massage therapists.³²

Through articles and policy statements, CIH educational leaders have observed that the lack of racial and ethnic diversity in their professions negatively impacts patient access to care, with authors specifically noting overrepresentation of White CIH professionals and lower representation of Black professionals and, specifically in chiropractic, of Latino, Asian, and Native American professionals.^33,34 Importantly, current and recent CIH training graduates represent the future of the professions, yet no peer-reviewed research to date has measured racial and ethnic diversity for educational programs across all five licensed CIH professions.

The primary objective of the research described herein is to address this research gap. Our research questions were: (1) How has racial and ethnic representation varied across the licensed CIH professions, and how has it compared with other (non-licensed) CIH professions and with conventional health care professions? (2) How does racial and ethnic representation in the licensed CIH professions compare with the U.S. population? (3) How has racial and ethnic representation in licensed CIH professions changed in recent years?

Materials and Methods

Data

We conducted a repeated cross-sectional study design with the 2011–2022 Integrated Postsecondary Education Data System (IPEDS)³⁵ to examine race and ethnicity among graduates in licensed CIH professions, compared with non-licensed CIH professions and conventional health care. IPEDS is a survey system that institutions of higher learning (universities, colleges, and vocational and technical institutions) that participate in federal student financial aid programs must complete. Institutions collect completion data annually during the fall, referring to completions from the previous academic year. By utilizing IPEDS completion data files from 2011 through 2022, we used 12 waves in total.

Variables

Training programs

We used 6-digit classification of instructional programs (CIP) codes to identify CIH and other health care training programs (Supplementary Table S1). We separated CIH training programs into two groups. First, we focused on CIH professions for which licensure or a similar registration is available in the United States: chiropractic, acupuncture, traditional East Asian medicine, naturopathic medicine, direct entry midwifery, and massage therapy.²⁴ Because massage therapy programs were far more numerous and tended to obscure results for the other five groups, some analysis excluded massage therapy programs. Also, we have referred here to five licensed CIH professions, but CIP codes separate acupuncture from traditional East Asian medicine (referred to in the CIP codes as Traditional Chinese/Asian Medicine and Chinese Herbology). Thus, our profession-specific analyses show six program types. Second, we examined 18 non-licensed CIH professions and modalities, including homeopathy, ayurveda, and yoga. We also examined four conventional health care professions: registered nurse, medical doctor, osteopathic medicine/osteopathy, and physical therapy.

Race/ethnicity of graduates

IPEDS completion data included information on the number of students completing awards/degrees. Moving forward, we refer to these individuals as graduates; we have quantified them overall and within the following racial and ethnic categories: Hispanic/Latino, American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, two or more races, and race and ethnicity unknown (operational definitions are shown in Supplementary Table S2). Institutions were instructed to report race for non-Hispanic/Latino individuals only, making the race and ethnicity categories mutually exclusive.

Analysis

We calculated the number of degree programs per profession. We then determined the total number of graduates who completed degree programs for our four professional categories: licensed CIH professions with massage therapy, licensed CIH professions without massage therapy, other (non-licensed) CIH programs, and conventional medical programs.

To answer research question 1, describing racial and ethnic representation across licensed CIH professions and in comparison to non-licensed professions and conventional health care, we identified the overall proportion, taking the sum total of graduates from each racial or ethnic category and dividing it by the number of graduates. The denominator for the proportion calculations included all graduates in a specific program that year; some subgroups of graduates were not listed in these analyses, such as undocumented graduates, because it was beyond the scope of our study, so proportions do not sum to 100.

To answer research question 2, comparing racial and ethnic representation in licensed CIH professions with the overall U.S. population, we compared the proportions for specific racial and ethnic groups in each CIH profession with weighted percentages of U.S. adults aged 20–35 years, an age range representative of higher education students that encompasses the typical student age for CIH training institutions.^36
–38 Those estimates came from 2019 American Communities Survey data as estimated by Salsberg and colleagues.¹¹ Two-sided z-tests and a significance level of 0.05 were used to examine statistically significant differences.

To answer research question 3, describing changes over time in the diversity of CIH training programs, we first determined the average programmatic-level proportion of graduates from racial and ethnic categories. Then, we graphed proportions of graduates in licensed CIH professions across the 12 years of data.

Data analysis was conducted using SAS (Release 9.4; SAS Institute Inc., Cary, NC). This secondary data analysis study was determined to not be human subjects research by RAND’s Human Subjects Protection Committee, which is equivalent to an institutional review board. IPEDS data are publicly available at nces.ed.gov/ipeds/.

Results

Analytic sample

The 12 waves of IPEDS completion data included 3,493,637 observations (programs). After excluding n = 3,440,244 programs with CIP codes not related to our professional categories of focus, an analytic sample of n = 53,393 programs remained. This included n = 11,264 programs in the licensed CIH professions, n = 1545 programs from other (non-licensed) CIH professions, and n = 40,584 conventional health care comparison programs. For some analyses of the licensed CIH professions, we excluded massage therapy (n = 9743), leaving a subsample of n = 1521 programs.

Description of sample

Of the six types of academic programs included in the licensed CIH professions category, massage therapy was by far the most numerous (n = 9743), and all other professions had fewer than 900 programs in the sample (Table 1).

Table 1.

Degree Programs in Licensed Complementary and Integrative Health, Non-Licensed Complementary and Integrative Health, and Conventional Health care Professions, 2011–2022

Degree programs	n	%
Programs in licensed CIH professions, all 12 waves
Doctor of chiropractic	195	1.7
Acupuncture	877	7.8
Traditional East Asian medicine	245	2.2
Naturopathic medicine	81	0.7
Direct-entry midwifery	123	1.1
Massage therapy	9743	86.5
Total	11,264	100
Other CIH professions
Alternative and complementary medicine and medical systems, general	147	9.5
Homeopathic medicine/homeopathy	10	0.7
Ayurvedic medicine/Ayurveda	65	4.2
Holistic health	344	22.3
Alternative and complementary medicine and medical systems, other	159	10.3
Alternative and complementary medical support services, other	56	3.6
Asian bodywork therapy	90	5.8
Somatic bodywork	72	4.7
Somatic bodywork and related therapeutic services, other	46	3.0
Movement therapy and movement education	121	7.8
Yoga teacher training/yoga therapy	128	8.3
Hypnotherapy/hypnotherapist	41	2.7
Movement and mind–body therapies and education, other	57	3.7
Aromatherapy	12	0.8
Herbalism/Herbalist	102	6.6
Polarity therapy	54	3.5
Reiki	17	1.1
Energy and biologically based therapies, other	24	1.6
Total	1545	100
Conventional health care
Registered nurse	34,455	84.9
Medical doctor	1743	4.3
Osteopathic medicine/osteopathy	265	0.7
Physical therapy	4121	10.2
Total	40,584	100

CIH, complementary and integrative health care.

Among the 18 non-licensed CIH programs included, the most numerous was Holistic Health (n = 344), described in IPEDS as focusing on “interconnectedness of physical, psychological, social, spiritual, and environmental well-being, and that integrates aspects of Eastern and Western medicine to promote, maintain, and optimize wellness.”³⁹ Among the four conventional health care programs, the most numerous was registered nursing (n = 34,455).

Question 1, overall racial and ethnic distribution in licensed CIH professions

A total of n = 3,524,494 individual graduates were included in our analyses (Table 2). In programs for licensed CIH professions, including massage therapy, there were n = 280,183 graduates. The largest proportion identified as White, followed by Hispanic or Latino and then Black or African American, Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander. Supplementary Table S3 shows estimates for each racial and ethnic group across program types using both the overall average and the average proportion approaches.

Table 2.

Graduates Completing Licensed CIH, Other CIH and Conventional Health Care Programs, 2011–2022

Degree program	Graduates	%
Licensed CIH professions (include massage therapy)	Graduates (total = 280,183)
Hispanic/Latino	48,252	17.2
American Indian or Alaska Native	2038	0.7
Asian	19,165	6.8
Black or African American	34,140	12.2
Native Hawaiian or Other Pacific Islander	1317	0.5
White	148,563	53.0
Two or more races	7444	2.7
Race and ethnicity unknown	14,967	5.3
Licensed CIH professions (exclude massage therapy)	Graduates (total n = 59,354)
Hispanic/Latino	4631	7.8
American Indian or Alaska Native	362	0.6
Asian	8195	13.8
Black or African American	2418	4.1
Native Hawaiian or Other Pacific Islander	365	0.6
White	36,296	61.2
Two or more races	1319	2.2
Race and ethnicity unknown	2859	4.8
Other (non-licensed) CIH professions	Graduates (total n = 20,867)
Hispanic/Latino	2233	10.7
American Indian or Alaska Native	187	0.9
Asian	1030	4.9
Black or African American	1957	9.4
Native Hawaiian or Other Pacific Islander	107	0.5
White	13,088	62.7
Two or more races	739	3.5
Race and ethnicity unknown	1279	6.1
Conventional health care professions	Graduates (total n = 3,223,444)
Hispanic/Latino	364,184	11.3
American Indian or Alaska Native	17,002	0.5
Asian	230,581	7.2
Black or African American	320,020	9.9
Native Hawaiian or Other Pacific Islander	9138	0.3
White	2,018,773	62.6
Two or more races	69,441	2.2
Race and ethnicity unknown	162,815	5.1

Total graduates: n = 3,524,494. Percentages represent overall proportion of graduates within each professional group that identify with specific racial or ethnic category. Percentages do not sum to 100 because denominator includes some groups, such as undocumented graduates, who were not included in these analyses.

Comparison to other CIH professions and conventional health care

Relative to licensed CIH professions (excluding massage therapy), the non-licensed CIH professions and conventional health care professions had slightly more White, Latino, and Black graduates, fewer Asian graduates, and similar proportions (within 1 percentage point) of American Indian or Alaska Native and Native Hawaiian or Pacific Islander graduates (Table 2).

Question 2, comparison within the licensed CIH professions and comparison to U.S. population

There were many instances where the proportions of graduates from specific racial and ethnic categories were significantly higher or lower than the U.S. population aged 20–35 years (Table 3). Some groups, including Hispanic/Latino graduates and Black/African American graduates, had lower representation in most licensed CIH professions. Native Hawaiian or other Pacific Islander graduates and White graduates had higher representation in many. For American Indian or Alaska Native graduates and Asian graduates, we observed a mix of higher, comparable, and lower representation.

Table 3.

Proportion of Graduates from Licensed CIH Professions by Race and Ethnicity Compared with Overall U.S. Population, 2011–2022

	Hispanic/ Latino	American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White
Overall U.S. population, 20–35 years	21.3	0.7	6.5	13.7	0.2	54.5
CIH graduates
Doctor of chiropractic	8.0^{* L}	0.6	6.3	4.8^{* L}	0.4^{* H}	69.5^{* H}
Acupuncture	7.4^{* L}	0.6^{* L}	26.0^{* H}	2.7^{* L}	0.9^{* H}	48.5^{* L}
Traditional East Asian medicine	5.9^{* L}	0.7	18.0^{* H}	3.7^{* L}	0.2	63.0^{* H}
Naturopathic medicine	10.9^{* L}	0.6	7.1	6.0^{* L}	1.2^{* H}	59.4^{* H}
Direct-entry midwifery	5.0^{* L}	1.0	1.0^{* L}	5.3^{* L}	0.3	75.6^{* H}
Massage therapy	19.8^{* L}	0.8^{* H}	5.0^{* L}	14.4^{* H}	0.4^{* H}	50.8^{* L}

p < 0.05 for two-sided z-tests comparing with overall U.S. population age 20–35 years from American Communities Survey, as noted in first row, estimated and reported by Salsberg and colleagues.¹¹

Percentage here is significantly lower than in the U.S. population.

Percentage here is significantly higher than in the U.S. population.

Question 3, changes over time

Figure 1 depicts changes over time in the average proportions of graduates from racial and ethnic groups by year from 2011 to 2022 for licensed CIH professions (excluding massage therapy), other CIH professions, and conventional health care. Across all three categories, the proportion of graduates who were White was higher than other groups but decreased over time. In the licensed CIH professions, Asian graduates were consistently the second most populous group, and the third largest group, Hispanic/Latino graduates, steadily increased in size over time. Supplementary Figure S1 shows changes over time, including the massage therapy programs.

FIG. 1.

Proportion of graduates from licensed CIH, other CIH, and conventional health care programs by race and ethnicity, 2011–2022. Licensed CIH category excludes massage therapy. Proportions represent average proportion of graduates from each racial and ethnic group for a given year. CIH, complementary and integrative health care.

Discussion

This is, to our knowledge, the first study to examine racial and ethnic diversity in a national census of graduates completing training programs in licensed CIH professions. Using administrative data from 2011 through 2022, two overarching findings emerged. First, licensed CIH programs were diverse when the numerous massage therapy programs were included, that is, more Latino graduates, more Black graduates, and relatively fewer White graduates, compared with conventional care. However, when massage therapy was excluded, diversity in licensed CIH professions was similar, if not reduced, compared with non-licensed CIH professions and conventional health care.

Second, within licensed CIH professions, racial and ethnic representation varied greatly from one profession to the next. Direct entry midwifery and chiropractic programs had the largest proportion of White graduates, acupuncture and traditional East Asian medicine had the largest proportions of Asian graduates, and massage therapy had the largest proportion of Hispanic Latino, American Indian or Alaska Native, and Black graduates.

We observed modest improvements in diversity between 2011 and 2022, including a subtle increase in the proportion of Latino graduates and a decrease in White graduates within the licensed CIH professions (excluding massage therapy). This mirrored reports that younger cohorts of CIH providers are more diverse than older cohorts. For instance, chiropractors under age 30 are more diverse than their over-30 counterparts.²⁸ Yet, as earlier research found with the medical doctor workforce,^11

–15 we find that the current CIH workforce still does not reflect the broader U.S. population.

While the licensed CIH professions have a shared history of functioning outside the conventional health care system,^19,24 they are distinct professions. Opinions vary about whether some professions should be considered part of CIH or part of conventional health care, as has been noted for chiropractic⁴⁰ as well as direct-entry midwifery.²⁴ Furthermore, these professions have different histories, cultural ties, educational requirements, and employment opportunities, which may affect which individuals enter these fields. For instance, chiropractic was developed in the midwestern United States in the late 19th century⁴¹; in contrast, acupuncture and traditional East Asian medicine originated centuries ago in China and were adapted and practiced in other East Asian countries.^42
–44 Familial experiences with these approaches may inform students’ interests in traditional East Asian medicine and acupuncture.⁴⁴ Professions differ in educational requirements and later employment opportunities, too. Obtaining a massage therapy degree requires less time and fewer years of higher education than obtaining degrees in the other licensed CIH professions,²⁴ and massage therapy has been promoted as a flexible career option, accommodating full-time or part-time work.⁴⁵

Diversity among providers may be viewed as a concern for patient access, but it is also an issue of equitable access to good quality employment. While student loan debt^46,47 and burnout^48,49 are noted issues, careers in CIH offer rewarding work characterized by high job satisfaction and autonomy.^50

–55 Like in conventional medical professions,¹¹ the lack of racial and ethnic diversity in CIH jobs can be viewed as a manifestation of structural racism, which limits access among underrepresented groups to safe, rewarding, well-paid work.^55,56 The lack of diversity in CIH may also relate to the low perceived status of CIH professions. For instance, chiropractic was historically described as a marginal profession whose professionals came from the lower social class groups.⁵⁷ This status may have made CIH professions appear riskier or less appealing to some prospective students.

Higher education literature suggests that disparities in student retention and success are rooted in policies that require systemic changes.^58
–60 Increasing diversity among students is challenging for CIH and conventional medicine alike.^12,33,61 Recommended strategies include informing K-12 students about the professions to increase awareness.⁶² CIH institution leaders can establish more supportive social networks and financial support for trainees⁶² and offer faculty professional development to reduce implicit bias.⁵⁹ Cultural change at the institution may be necessary. Educational institutions in North America, including those in CIH, are grounded in an individualist approach common to those of White European background; a collectivist approach may be more appropriate for a broader group of students.^59,63 CIH faculty can apply antiracist and anticolonial frameworks to their teaching, research, and practice to better understand and address structural inequities.⁶⁰ Efforts to diversify health care professions are complicated by the recent elimination of affirmative action as a tool in admissions⁶⁴ and by cuts to diversity, equity, and inclusion programs at higher education institutions.⁶⁵

It is important to consider and help mitigate deeper structural inequities, including disparities by race and ethnicity and by social class in the quality of available K-12 education and in resources (i.e., tutoring programs, test preparation) to support higher education success.⁶¹ On the financial side, addressing student loan debt is key. Naturopathic medicine graduates, for example, have an unusually high debt-to-income ratio^46,47; this may make those training programs untenable for some prospective students.

Strengths, Limitations, and Areas for Future Research

This study has notable strengths. In describing racial and ethnic representation across CIH and other professions, this study fills a gap in the scientific literature. We used 12 years of IPEDS administrative data, which included 53,393 institution-specific graduating cohorts with 3,524,494 total graduates. Because IPEDS is effectively a census of graduates rather than a selected sample, we are not limited by selection bias. In addition to information about licensed CIH professions, we offer descriptive information about non-licensed CIH professions, which are less frequently examined in the scientific literature, and we provide comparable information about conventional health care professions.

However, this study has methodological limitations. IPEDS completion data were at the programmatic level; while it was possible to calculate the number of graduates for racial and ethnic subgroups, it was not possible to further analyze those groups by variables like age or family socioeconomic status.

We observed few notable changes in representation among Native Hawaiian or other Pacific Islander graduates as well as American Indian or Alaska Native graduates, but this is likely because we studied groups as a percentage of the overall graduate population, and their numbers were relatively small. Future research should examine trends for these groups in greater detail. Notably, American Indian and Alaska Native adults are among the communities most likely to use CIH.⁶⁶

The present study used a simple approach to describe diversity in the professions. Rather than taking a dichotomous approach to assessing diversity, like comparing the number of White professionals with the number of professionals from all other racial and ethnic identities grouped together,⁶⁷ we described proportions for all groups. This approach maintained meaningful information about variations across groups and professions. Sophisticated metrics exist for assessing racial and ethnic distribution in a population, including metrics for diversity and polarization⁶⁸; future studies should explore which measures may further advance understandings about diversity in CIH.

Racial and ethnic representation is a central issue in access to equitable care and equitable jobs. However, future studies should examine other aspects of diversity among CIH providers, including gender, nationality, immigration status, family socioeconomic status, and sexual orientation. More research should be conducted to understand what draws students into different CIH professions and how those decision-making processes could relate to racialized identities. Qualitative or mixed methods research could, for instance, help elucidate why certain groups, such as Black or African American graduates, are overrepresented in massage therapy programs yet not in other types of CIH programs. Furthermore, while we included 24 CIH training programs, data were not available for all types of CIH, including Indigenous healing. Traditional and Indigenous medicine and healing disciplines may be taught within communities and families rather than in academic institutions^69,70; thus those practitioners would not be represented in this study. Future studies should consider characteristics and experiences among professionals and students of those areas of expertise.^71,72

IPEDS is considered a comprehensive source of information about higher education graduates³⁵; institutions that participate in federal student aid programs are required to submit information to this system, and the response rate on the IPEDS survey is estimated to be over 99%.⁷³ While we are not aware of any CIH institutions that do not participate in this system, there could be institutions that do not and thus would not have been represented in this study.

We categorized individuals based on the CIH degree they completed. However, a single CIH provider may offer multiple types of CIH care. A naturopathic doctor, for instance, could also offer homeopathy services.⁷⁴ Access to modalities of CIH care is more complex than access to a professional with a specific degree.

Future research should consider other determinants of health care access, such as financial access and affordability.¹ In the United States, the cost to a patient for health care, including CIH, depends on whether a patient has health insurance, who the insurer is, and the type of plan.⁷⁵ Eight percent of Americans are uninsured.⁷⁶ Among those with health insurance, coverage for CIH services can range from none to partial to complete coverage.⁷⁷ Coverage for CIH in state Medicaid plans, which are public insurance plans that serve lower-income Americans, is limited.^78,79 Some patients pay out of pocket for CIH and other types of health care,⁷⁵ an option that requires sufficient financial means. Notably, among U.S. adults (excluding those age 65 and above, as they are typically covered through Medicare⁷⁵), patients who are Latino, Black, American Indian, or Alaska Native or Native Hawaiian or Other Pacific Islander are more likely to be uninsured or to use Medicaid, relative to White and Asian American patients.⁷⁶ Thus, patients from communities who find less representation among CIH providers may also face greater financial challenges in accessing CIH care.

The research questions addressed and the specific methodological decisions applied in this study reflect the context of the United States, and they may not be generalizable to other contexts. Racial and ethnic categories are social constructs^80,81; their meanings differ across settings, particularly from one country to another.^82,83 Similarly, our categorization of providers as licensed or non-licensed reflects the U.S. context.²⁴ Thus, the findings may have less applicability in other contexts. However, the characteristics of the CIH workforce and the degree to which those characteristics align, or not, with the broader population is a more universal question. Future research should explore this issue in the context of other countries.

Conclusion

Our analysis of 12 years of administrative data of U.S. training graduates showed that overall, licensed CIH professions need to be more racially and ethnically diverse to be able to better represent the U.S. population and to provide optimal access and quality of care to patients from underserved populations. Professions such as massage therapy, acupuncture, and traditional East Asian medicine had more diversity than chiropractic, direct entry midwifery, and naturopathic medicine. Notably, licensed CIH professions had similar racial and ethnic representation when compared with non-licensed CIH professions and with conventional health care. Diversity appears to be improving but only modestly. These findings suggest that ongoing diversity efforts at CIH institutions should be strengthened.

Footnotes

Authors’ Contributions

M.D.W.: Conceptualization, methodology, validation, and writing—original draft. N.M.: Investigation and writing—review and editing. P.M.H.: Conceptualization and methodology. I.D.C.: Supervision. M.M.: Writing—review and editing. R.B.: Writing—review and editing. B.K.: Writing—review and editing. J.M.: Software and validation. T.K.: Project administration.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Research reported in this publication was supported by the National Center for Complementary & Integrative Health of the National Institutes of Health under Award Number U24AT012549 through the RAND REACH Center.

Supplementary Material

Supplementary Figure S1

Supplementary Table S1

Supplementary Table S2

Supplementary Table S3

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