Background
Complementary and Alternative medicine (CAM) refers to a large group of healthcare practices that are not part of a country’s own conventional medicine and are not integrated into mainstream healthcare of a country [
1]. CAM therapies follow a holistic model of health with the practitioner-client relationship being an important element of practice [
2]. This group of therapies employ interventions/techniques that promote the innate healing ability of the body while retaining a core focus on individuality, holism, education and disease prevention [
3]. The growing use of CAM across the globe [
4] can be attributed to many factors, including but not limited to, the move towards holistic well-being, the recognition of the limitations associated with conventional medicine and the increasing discourse on the important contribution of CAM [
5]. As the popularity of CAM has increased, so has the level of scrutiny about the evidence underpinning its effectiveness [
6]; resulting in calls for increased research and an appraisal of the evidence [
7,
8]. There is a view amongst the scientific community that CAM, unlike conventional medicine, is not underpinned by rigorous research [
9], and this has resulted in calls for increased research and a balanced appraisal of the evidence in order to improve confidence in the CAM industry [
7].
Parallel to the calls for more CAM research is the increasing recognition of the numerous barriers to conducting rigorous research in CAM [
8]. Furthermore, translation of evidence into practice in CAM continues to face challenges [
10‐
15] that result in persistent knowledge and practice gaps [
16]. While the existence of these issues in CAM research and practice are recognised, there is no single instrument that adequately measures the barriers to the conduct of research and the application of research evidence in CAM. While some measures are available that explore the barriers to the utilisation of research in practice, such as the “Barriers to Research Utilization Scale” (BARRIERS) [
17] and the “Evidence-Based practice Attitude and utilization SurvEy” (EBASE) [
18], these tools do not address barriers pertinent to both the
conduct of CAM research and the
application of research evidence in CAM practice. The former is important, as the identification of barriers to the
conduct of research is the necessary first step towards improving the quality of research in CAM [
19]; identifying the barriers to the
application of research is a necessary second step to ensuring that the findings of such research are utilised in clinical practice.
One factor possibly contributing to the slow uptake of evidence-based practice (EBP) in CAM may be that the barriers to the conduct of research and the application of research evidence in CAM are not well understood, or alternatively, have not been adequately measured. This highlights the need for an instrument that can identify the barriers to the conduct as well as the application of research in CAM. Identifying these obstacles to CAM research conduct / application will set the path to establishing a stronger research culture, building a quality evidence base, and improving the uptake of the best available evidence in CAM practice.
This research presents the third and final stage of a multi-method project designed to develop an instrument to measure the barriers to the conduct and application of research in CAM. Stage one of the project was a systematic review, the purpose of which was to synthesise the evidence pertaining to the barriers to the conduct and application of research in CAM [
20]. The barriers that were unique to the
conduct of research were captured within one of two categories: “capacity” and “culture”. “Capacity” referred to barriers in the areas of access, competency and bias. Access related to funding, training, and skills; bias related to the inherent negative perceptions about CAM research; and competency referred to the skills, knowledge, experiences and research education of the CAM practitioner in terms of conducting research. Barriers identified within the “culture” category were broadly classified as values and complex systems. Values related to inherent practices, reluctance to engage with mainstream research, historical perspectives, and an educational model that places little emphasis on research evidence. Complex systems referred to the complexity underpinning CAM research, the inability to undertake blinding and/or use placebo controls, and the limited generalisability of findings.
The barriers to the application of research were similarly captured within the categories of “capacity” and “culture”. Under “capacity” were barriers pertaining to access, competency and bias. Access related to limited resources, limited quality evidence and insufficient skills. Competency referred to the limited research skills of a practitioner and the inability to interpret and impart results. Within the sub-category of bias were negative perceptions of research, historical viewpoints leading to the antithesis of EBP in CAM, the lack of incentives in CAM research and lack of time. The category of “culture” captured a number of barriers relating to beliefs, lack of interest in research and infrequent use of bibliographic databases. All of these barriers to the conduct and application of research in CAM provided the necessary framework for a provisional survey instrument. Statements to be included in the provisional survey instrument were developed using a nominal group technique.
Stage two of the research project involved conducting a nominal group technique (NGT) [
21]. The NGT brought together the findings from the systematic review, as well as the expertise of local CAM providers and researchers, to develop a preliminary list of statements for a pilot survey instrument. The experts were selected using purposive sampling; this ensured that participants with pertinent expertise and personal attributes were selected [
22]. The nominal group technique consisted of 7 stages [
21]: In stages 1 and 2 (welcome and deliberations), an A3 document containing a list of all barriers generated from the stage 1 systematic review were handed to the participants. Adjacent to these barriers were 72 examples of potential statements that reflected these barriers. This included 44 statements relating to the barriers to the conduct of research in CAM, and 28 statements relating to the barriers to the application of research in CAM. Each participant individually considered the issues to be deliberated. For stages 3 and 4 (generation of ideas/themes and discussions), each participant disclosed the results of their deliberations. The group discussed that it had understood the items that were put forward, and that all participants agreed that each of the statements were relevant barriers to the field of CAM. Attention was then directed towards the wording of the statements, of which some statements underwent minor editorial changes. In stages 5 and 6 (evaluation and consensus), ideas were evaluated; participants agreed upon ideas; and the list of 72 examples of potential statements presented in stage 2 evolved into 36 statements. For stage 7 (data refinement), the developed ideas were reworded and rearranged, and key constructs for themes that were suggested by the NGT participants were taken into consideration in the design of the preliminary survey instrument.
The outcome of the NGT was the development of a preliminary survey instrument consisting of 30 statements, with the conduct section of the instrument consisting of 16 statements, and the application section of the instrument comprising 14 statements. This instrument was referred to as “BarrierS To the Application and Conduct of rEsearch (oBSTACLES)”. This preliminary instrument was later refined and validated through a Delphi study involving international experts in CAM. This manuscript reports the findings from this Delphi study.
Aim
The aim of this study was to refine and validate a preliminary survey instrument for measuring the barriers to the conduct and application of research in complementary and alternative medicine.
Discussion
Despite the increasing focus on CAM to prove its evidence-base, and growing recognition of the numerous barriers to the conduct and application of research within CAM, there has not been a single instrument that has adequately captured and measured these barriers to date. Therefore, the extent to which stakeholders of CAM are impacted by barriers to the conduct AND application of research is largely unknown. While there are generic instruments that explore CAM stakeholder’s perspectives of issues such as EBP, these instruments do not capture the range of barriers impacting through the EBP continuum (generation – access – application of research evidence). Therefore, the aim of this research was to refine and validate a dedicated instrument (oBSTACLES instrument) for measuring the barriers to the conduct and application of research in CAM.
Using the Delphi method, the panel of international experts in CAM agreed that myriad barriers exist to the conduct and application of research in CAM. The views of the experts are congruent with and supported by contemporary literature [
20]. For example, the expert panel concurred that time was an important barrier to research application, and this was consistent with previous reports [
10,
12,
13,
49,
50]. Also supported by previous literature was the view that access to funding was a critical barrier to research conduct [
51‐
56]. Furthermore, the panel of international experts did not reject any statement that had formed the preliminary oBSTACLES instrument (which were developed from the systematic review and NGT). This highlights the consistency of, and consensus amongst, experts on the recognition of myriad barriers encountered when engaging with research.
The resultant output of this research is the oBSTACLES instrument. This self-administered questionnaire comprises 40 items, divided into three parts: Part A (barriers to the conduct of research in CAM; 18 statements), Part B (barriers to the application of research in CAM; 14 statements) and Part C (demographic details; 8 items). All items in parts A and B used a Likert scale response format. The oBSTACLES instrument has familiarity with other survey instruments, such as EBASE and the BARRIERS scale. The BARRIERS [
17] scale, for instance, sets out to measure the factors that hinder the
application of nursing research, taking into account the researcher, the organisation, and the innovation. EBASE [
18], on the other hand, although related to CAM, investigates the factors impacting the clinical
application of evidence-based practice, such as practitioner attitude, skills and training. However, where the oBSTACLES instrument differs from these two instruments is its focus on measuring the barriers to both the
conduct and
application of research in CAM. This is important, as these barriers may occur throughout the EBP continuum (generation – access – application of research evidence). It is important to capture these barriers throughout the continuum as previous research indicates that access to research alone is not sufficient [
57] when promoting EBP; the focus should also be on the application of research [
58]. Without such overt focus across the EBP continuum, evidence-practice gaps will continue to persist [
59].
The oBSTACLES instrument also acknowledges that effective engagement with CAM research requires a contribution from more than one stakeholder [
60]. In fact, the instrument draws attention to the influential role of at least six different stakeholder groups that impact EBP implementation, including researchers, educators, funders, editors/publishers, practitioners and industry (i.e. professional associations). Therefore, the data generated from using the oBSTACLES instrument may shed light on the development of strategies that are more targeted and meaningful to specific stakeholder groups, which in turn, may assist in breaking down barriers to the conduct and application of research in CAM.
As with any research, there are some limitations to this study. First, given the nature of the Delphi study methodology, there were three distinct rounds. This “stop-start-stop” process did not allow for free-flowing exchange of ideas and discussions [
61]. However, the use of Delphi study methodology as means of gaining consensus on a given topic [
62] is well recognised and commonly used in survey development. Second, despite considerable efforts to ensure wide-spread representation across the globe, participants from Asia and Europe were under-represented. Acquiring equal numbers of CAM practitioners and researchers also could not be controlled due to the voluntary nature of the Delphi recruitment process. As this research brought together an international sample of CAM experts from multiple geographical locations, the impact of under-representation was minimised. Third, anonymity due to privacy and confidentiality reasons may have led to a paucity of accountability [
63]. Prior to the commencement of the Delphi study, the research team did request all participants to actively and openly contribute to the research. Even though this research provides evidence of consensus on the barriers to the conduct and application of research in CAM, as it used a Delphi study methodology, the findings are considered expert opinion only. Notwithstanding, as this Delphi study included CAM experts from across several other countries, the research arguably captured broad and diverse perspectives and experiences. Furthermore, as the oBSTACLES instrument has its foundation in a systematic review of the literature as well as a nominal group technique, the impact of these limitations has been minimized. Lastly, even though the oBSTACLES instrument may have potential application to areas other than CAM (such as medicine, nursing and allied health), further psychometric testing of the oBSTACLES instrument would be required.
Conclusion
While there has been widespread recognition of the barriers that confront CAM stakeholders when engaging with research, there has been limited research that has systematically identified and measured what these barriers are across the EBP continuum. This research, by bringing together CAM experts from across the globe, has generated a series of evidence-informed statements, in the form of a survey instrument, to identify, measure and evaluate barriers to the conduct and application of research in CAM. The outcome of this research was the development of the BarrierS to the Application and Conduct of rEsearch (the oBSTACLES instrument) in CAM - a bespoke instrument that can measure and quantify barriers to both the conduct and the application of research in CAM.
Implications for practice
The oBSTACLES instrument is a simple, easy to use instrument, which is evidence-informed as it has been developed in a methodological manner and underpinned by rigorous research processes (the systematic review, the nominal group technique and the Delphi study). It builds on existing tools such as EBASE and the BARRIERS scale, while addressing their limitations. This instrument can be applied across a range of different practice settings spanning the spectrum of CAM disciplines. As the oBSTACLES instrument measures and quantifies barriers to the conduct and application of research in CAM, it will assist in the development of targeted enabling strategies to overcome these barriers. By doing so, the oBSTACLES instrument provides opportunities to address entrenched barriers that confront CAM stakeholders when engaging with research.
Implications for research
While the development process for the oBSTACLES instrument was underpinned by a systematic and rigorous methodology, formal psychometric testing remains to be undertaken. Areas of future research include establishing reliability, validity and utility of the oBSTACLES instrument, as well as formal testing with other health professional groups (such as nursing and allied health). With increasing focus on not just the generation of evidence but also on the implementation and evaluation of evidence in health care, the oBSTACLES instrument provides ideal opportunities for future research to examine, measure and understand those barriers that exist not in isolation but across the evidence-based continuum. In turn, the instrument may help to determine what enabling strategies may work best for whom and under what contexts.