Phillip Cottingham, ND, BHSC, Grad Dip HSC, PG Dip HSc1*, Jon Adams, PhD2, Ram Vempati, PhD1, Jill Dunn, MHSC, BHSc (Comp Med); Dip. Natural Therapeutics, Dip. Herb Med; RGON (non-practising)1, David Sibbritt, PhD2
1Wellpark College of Natural Therapies, Auckland, New Zealand
2Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), University of Technology, Sydney, Australia
Background
Massage therapy is widely recognized as offering many health benefits, with a growing number of studies finding it has value in stress management, pain reduction, and overcoming physical limitations. However, there are few studies of massage therapists practices and perceptions in New Zealand and internationally. This paper reports the findings from the first national survey examining the characteristics, perceptions, and experiences of New Zealand-based massage therapists on a range of aspects related to their role and practices.
Purpose
This study sought to ascertain the characteristics, experiences, and perceptions of massage therapists in New Zealand, particularly in the aspects of: integration of health care; attitudes and practices related to research; and evidence and attitudes to registration.
Setting
Massage practice in New Zealand (nationwide survey).
Participants
Members of Massage New Zealand (a massage practitioners association).
Research Design
Massage practitioners were surveyed online, using a 65-part questionnaire, on a range of characteristics of their practices and their attitudes to research, integration, and registration. Statistical analysis was performed using STATA. Statistical significance was set at 0.05.
Main Outcome Measures
Four hundred massage therapists (MTs) were invited to participate and 115 responded, providing a response rate of 29%. MTs valued research (95%) and perceived that it had an impact for their practices (88%). Significant correlations were found for research value and: mean case-load (p = .009) and level of academic qualification (p = .004). The majority of MTs (79%) supported integration with conventional practitioners, and 83% referred clients to general practitioners, with 75% receiving referrals from general practitioners. Ninety-three percent of MTs supported registration, with 67% of those supporting statutory registration.
Conclusion
Massage practitioners perceive that they make a significant contribution to health care, but area of practice, such as research, and referral and integration into mainstream health care require more in-depth investigation.
KEYWORDS: massage, health care survey, perception, practices, integrative medicine, referral, government regulation
Massage therapy (MT) is one of the most popular forms of complementary and integrative medicine (CIM) with the general public.(1–7) The perceived health benefits for MT users include: emotional well-being and reduced physical limitation;(8) pain reduction;(9) stress reduction; enhancing sleep; injury repair and enhancing recovery from injury.(10)
A number of studies of MTs have been conducted worldwide, investigating MTs practice characteristics and perceptions of aspects related to their practices (see Table 1). Some studies have focused on the therapeutic encounter and how MTs approach the treatment of patients and conditions(11,12) and others have investigated MTs’ perceptions and practice characteristics.(13–15)
Table 1 Comparison of International Studies of Massage Therapists
The practice of MT in NZ is regulated, under a voluntary registration system by Massage New Zealand (MNZ), the only professional body in NZ that regulates MTs.(16) At the time of the survey reported here, MNZ had 400 members.(17)
To date, there has only been one New Zealand (NZ) study of the practices of MTs, investigating: MTs’ profiles; a range of practice characteristics and referral patterns; modalities used; conditions treated; and a selection of professional issues. This work, conducted in 2008, provides early descriptive data regarding MTs’ practice across NZ.(14)
A 2013 study has shown that, in 2006, Australian MTs comprised the largest number of CIM providers per head of population (1:2,424). Comparatively, in 2006, NZ had one MT for every 3,167 people.(18)
MTs’ attitudes and perceptions of the value of regulation and registration have been investigated in a number of studies in NZ,(19,20) Australia,(21,22) and Canada.(23) Findings from these studies illustrate the importance of understanding practitioner perceptions and practices to inform the emergent professions of CIM, such as MT,(24,25) an issue highlighted by the NZ Ministerial Advisory Committee (of CIM) in its identification of the need for “quality, unbiased information on the safety and efficacy of CIM modalities, and for further work to be done to identify and address consumers’ needs for information about the practice of CIM in New Zealand”.(26)
Inspired by the other international studies and the Ministerial Advisory Committee’s recommendation, researchers from two colleges delivering massage education developed a survey to collect data on CIM practitioners’ perceptions and practices in NZ. This paper reports the findings from this survey.
A comprehensive literature search identified only one paper(14) on CIM practitioner attitudes and perspectives in NZ. The importance of understanding evidence for CIM practice(27) led to the development of a survey investigating perceptions and practices among CIM practitioners. This paper reports findings from this survey with regards to MTs’ characteristics, experiences, and perceptions in NZ and makes comparison with similar studies in NZ and internationally.
A largely quantitative online survey was administered to a range of practitioners (including MTs, naturopaths, herbalists, and homeopaths) in NZ, examining their characteristics, perceptions, and experiences relating to a range of key practice-related issues, such as use of evidence in MT practices and integration with other health care practitioners. Using an online platform (via Survey Monkey), the survey included seven domains: demographic practitioner data; practice and referral characteristics; academic qualifications; perceptions and experiences regarding research; integration; registration, and alignment to the NZ health strategy.(28)
A convenience sampling approach was utilized. MTs were recruited through Massage New Zealand (MNZ), the NZ professional body for MTs with a membership (at the time of the survey) of 400. (At the time of the survey there were approximately 1,400 MTs in NZ.(29) However, MNZ is the only organization that registers MTs in NZ; therefore, it was selected for collection of data.) A similar approach has been employed by another survey of MTs in NZ.(28) The total dissemination of the survey was to 1,067 CIM practitioners. This paper reports on the data obtained from MTs only.
Ethics approval was granted by the NZ Ministry of Health National Ethics Advisory Northern A Committee(30) and, for ongoing analysis, the ethics committee of the University of Technology Sydney, Australia.(31) Informed consent was implied by participation, per the NZ national ethics committee guidelines.(30) Participants were invited to complete the survey via letters that were sent to prospective participants by their respective associations. The raw data were then downloaded by the survey team onto spreadsheets.
Descriptive analysis was conducted (using Excel software) and included frequencies, percentages, means, and standard deviations, where applicable. Bivariate associations between categorical variables used a chi-square test, with a Student’s t test being applied to test mean differences across categorical variables. Statistical analyses were conducted using Stata® software. Statistical significance was indicated by a p value of < .05.
One hundred and fifteen MTs responded to the questionnaire (representing 29% of MNZ membership at the time of the survey). Respondents consisted of 86% females and 14% males, which closely related to the gender make up of MNZ membership at the time of the survey (80% female, 20% male). Forty-one percent of respondents were aged less than 45, with 42% aged between 45 and 54, and 18% aged 55 or older. The base level of qualifications for majority of MTs (64%) was diploma or advanced diploma. Some respondents did hold higher qualifications, with 9% holding a post-graduate degree.
MTs’ practices were located mostly in cities (58%), with 31% in towns and 11% rurally. Fifty percent of MTs utilized professional rooms, with 32% utilizing their own homes and 10% consulting via mobile practices, either going to the client’s workplace or homes. Most MTs practised part-time (61%), with 36% full-time and 3% practising occasionally. Mean practitioner hours per week were 18.6 (n = 106, SD = 10.6), with 47% practising over 20 hours per week. Massage therapy consultations were an average duration of 68 minutes for the initial visit and 58 minutes for follow-up consultations. Average total caseloads per month were 45.6 (SD = 37.0), with median caseloads per month being 39 comprising 11.4 (SD = 16.1) new clients per month and 35.3 (SD = 28.8) follow-up clients per month. On average, 4.7 hours per week (n = 37, SD = 3.7) were spent in training (massage therapy professional development). Most other mean massage therapy-related hours per week were spent in teaching faculty (n = 18, mean 10.5, SD 9.1) followed by practice-related tasks (mean = 4.7; SD = 7.0).
The majority of MTs (95%) perceived research as having value for their practice, with 88% stating that it impacts (highly or moderately) on their practice. Table 2 depicts the associations between practitioner characteristics and research value and research utilization. A significant inverse association (p = .009) was found between mean case-load and the value placed on research. Those practitioners who considered research as having value for their practice spent an average of 17.9 (SD = 10.3) hours in clinical practice, compared to the 28.8 (SD = 7.6) hours spent in clinical practice by those MTs who perceived research as having no value for their practice. Another significant association was found between academic qualification and value placed on research (p = .004), with those who hold a certificate or diploma more likely to value research. No significant associations were found between research impact (on MTs’ practice) and years of experience, practice hours per week, training hours per week or average caseload per month.
Table 2 The Association Between Massage Practitioner Characteristics and Aspects of Research
While 46% of respondents reported having the skills to interpret research within their clinical environment, only 15% reported having the skills to conduct research. Sixty-seven percent of the MTs reported that they did not keep up-to-date with research findings. Evidence from research was sourced by the MTs from: association journals (64%); web articles (54%); health-specific magazines (45%); news articles (45%); online scientific journals (34%); association meetings (21%); peer reviewed journals (21%); newsletter from manufacturers (17%); and international conferences (12%). The reasons given by MTs for not having skills to interpret research were: insufficient time (52%); insufficient skills in reading research papers (20%); financial restraints (7%); no access to databases (7%); and the view that it is not important to MTs’ practices (7%).
Ninety-three percent of MTs supported registration for massage therapy (n = 97). Of the MTs who supported registration, 67% supported statutory registration, 31% supported voluntary registration, with 1% supporting other types (non-specified). No association was found between MTs’ support for registration and practitioner age (p = .291), level of academic qualification (p = .755) or years of experience in MT (p = .142) (see Table 3).
Table 3 The Association Between Massage Practitioner Characteristics and Aspects of Regulation and Funding
A combination of private (insurance) and government subsidies for funding MTs’ practice was favoured by the MTs (67%), with only 3% of the respondents preferring government subsidies alone.
The majority of MTs were supportive of integrating their own clinical patient care with a range of conventional care practitioners (CCPs) including with GPs (81%), specialists (78%), and physiotherapists (81%). Eighty-three percent of the MTs surveyed currently referred patients to CCPs. Two percent of MTs’ mean annual caseloads were referred to CCPs and 2% (of mean annual caseloads) were received from CCPs. MTs’ average number of referrals (per annum) of patients to CCPs were as follows: GPs (6.5); specialists (6.7); physiotherapists (8.1); midwives (11.7); nurses (13.5); dietitians (6.7); and clinical psychologists (8.5). A significant positive association was found between MTs’ referral to GPs and MTs’ average caseload per month (p = .025), with those reporting smaller caseloads per annum being less likely to refer to a GP. No other significant associations were found between referrals to CCPs and MTs’ characteristics, practices or perceptions (see Tables 4–8). The main reported reasons for referral to CCPs by MTs were : for conditions outside the MTs’ scope of practice (83%); for medical diagnosis of condition (68%); for conditions more suited to other treatments (67%); where warning signs indicate further investigation (63%); to gain clearance or rule out contraindication for CIM treatment (62%); for conditions too severe for the MTs to deal with (56%); and for conditions MTs training did not cover (53%). Seventy-four percent of referrals to CCPs were conducted through word of mouth, with 21% by referral letter, 20% by e-mail, and 15% by telephone.
Table 4 The Association Between Practitioner Characteristics and Referrals Made Between Massage Practitioners and GPs
Table 5 The Association Between Practitioner Characteristics and Referrals Made From Massage Practitioners to Specialists
Table 6 The Association Between Practitioner Characteristics and Referrals Made Between Massage Practitioners and Physiotherapists
Table 7 The Association Between Practitioner Characteristics and Referrals Made Between Massage Practitioners and Midwives
Table 8 The Association Between Practitioner Characteristics and Referrals Made Between Massage Practitioners and Clinical Psychologists
Seventy-five percent of MTs reported receiving referral from CCPs. The average number of referrals received from CCPs per annum by the MTs were: GPs (5.6); specialists (9.6); physiotherapists (8.4); midwives (8.9); nurses (13.3); dietitians (18.2); and clinical psychologists (12.6). Seventy percent of referrals from CCPs were conducted through word of mouth, with 14% by referral letter, 13% by telephone, and 12% by e-mail. No significant associations were found between referrals from CCPs and MTs characteristics, practices or perceptions (see Tables 4–8).
The perceptions of MTs with regard to ways in which they contribute to NZ Ministry of Health-published public health objectives(28) included: increasing physical activity (83%); improving nutrition (68%); reducing smoking (41%); reducing obesity (39%); reducing the incidence and the impact of cardiovascular disease (32%).
Most MTs in our study were not in full-time practice, which suggests that MTs’ practices may not be their sole source of income. This is similar to other studies in NZ and internationally. Whilst many of these previous studies may not be as nationally representative of the MT profession examined, they provide useful comparisons with our study findings. A small (n = 66) postal survey of MTs in NZ(14) found that 57.6% had massage therapy as a sole source of income. Similarly, an Australian study of 301 randomly selected MTs belonging to the Australian Association of Massage Therapists (AMT) (19.5% of total membership) found that nearly half of MTs surveyed had fewer than 10 clients per week (n = 141), and for only 55% (n = 165), massage therapy was the sole source of income.(13) However, it must be noted that AMT is not the only association representing MTs in Australia; members of Massage and Myotherapy Australia, which is the largest association representing MTs across that country, were not sampled in this recent Australian study. A sub-group analysis of a small US study of the characteristics of four CIM professions found that most MTs had between 10 and 17 hours of direct patient contact per week.(12) Comparative modality analyses in the same study (MTs, acupuncturists, naturopaths, and chiropractors) also found that MTs had fewer contact hours per week than the other two professions.(32) It would be informative to the massage therapy profession and massage therapy educators in New Zealand to examine more deeply the reasons why MTs appear to have fewer hours of contact with patients compared to other health professionals.
The inverse correlation between MTs’ perceptions of the value that research has for practice and MTs caseload as found in our study may be partly the result of the amount of time the practitioners have to read and apply research, with those in busier practices perhaps having less time to read published research findings. It is also possible that many MTs feel that individualization of treatment leaves little space for applying researched information.(15,23) Nevertheless, there are implications of this lack of interest in research among MTs. One study in British Columbia identified that a lack of research had an impact on the acceptance of MTs’ role in health care by other health professionals.(33) These findings are also reflected in a survey of MTs in Saskatchewan, where research was perceived by MTs as adding credibility to their profession.(34) Further, Baskwill and Dore(35) found that lack of access to sources of researched information is likely to be contributing to MTs understanding of the role of researched information in massage practice. Another Canadian study showed that there is still a perceived need for more research training in MTs education.(36) Furthermore, in Canada, an investigation of the development of research understanding amongst MT students (through the use of case studies) found that, alongside the growth of research into MT and body work, competency requirements in MTs’ research literacy (by the Canadian massage practice regulatory body) have also grown. This study concludes that the use of case studies in MTs’ education is an important step in the process of developing research understanding among the ranks of the profession.(37) In the UK, a qualitative study showed that development of EBP was linked with education (both formal and professional development), as well as access to database information.(38)
While the MTs in our study viewed research as valuable and providing information that validated some of their practices, this was not reflected in their perception of its impact on practice. The lack of impact of research in MTs’ practices was also found in a study of Australian MTs,(13) which indicated that MTs gain most of their researched information passively through continuing professional education (CPE), a finding that was not reflected in our study, which found no association between the various forms of CPE MTs undertake and their perception of the value of research, or the impact of research on MTs’ practice. However, our study did show a significant association between academic qualifications and the value placed on research, although there was still a perceived lack of guidance in research methods and development of protocols, indicating the need for more CPE in these areas. The Australian workforce study of MTs found that the majority of MTs surveyed regularly read research articles,(13) but the source of those articles is not identified, as it was in our study. The lack of evidence about the role of research within massage therapy practices indicates a potential role for massage therapy educators to educate massage therapy students in the importance of sourcing information from primary research in peer-reviewed journal articles in the development of an evidence-based practice. Another Australian study of MTs found that those reporting higher income levels from their massage practice were more likely to engage with research.(13) However, the authors conclude that neither MTs’ income nor education were found to be the only determinants of engagement with research, and MTs may need to create collaborative networks with researchers and policy makers to enhance their practice.
A study of MTs’ educators in the United States(39) found that research literacy was not a high competency desired for MT educators’ colleagues (48.1% for colleagues working in a clinical setting, and 38.9% for their own personal therapist). A contrasting study in the US, found that some MTs have responded well to being involved in research studies (as participants), including randomized controlled trials,(40) and MTs are potentially well disposed to being involved in practitioner-generated research, such as case report studies.(41) There is certainly potential in collaboration between massage therapy educators and researchers in NZ to create an agenda that allows MTs to develop into researchers, or at least active providers of interventions in research studies.(42) Such an agenda could include explorations into: how the therapeutic relationship between MTs and their clients is facilitated in practice; the role and value of educational approaches in massage therapy in enhancing MTs skill and aptitudes in clinical practice settings; and how to collect and utilize data within a massage therapy clinical practice.
Statutory registration (SR) was favoured by most MTs in our study (56% of total respondents). In NZ, Smith(19) found mixed views on statutory regulation amongst NZ MTs, but concluded that it is an important step in professionalization of MTs. Just over half (50.6%) of MTs in NZ surveyed by Massage NZ (Inc.) agreed that the association should work towards SR of MTs.(20) As yet MNZ has not stated explicitly that it will pursue statutory registration.(16) The support for a combination and private funding for massage therapy found in our study may reflect the lack of funding support that MTs in NZ experience.(20)
In Australia,(43) there is a similar regulatory situation, with voluntary registers being established with a 50% positive response to the Australian Massage Therapy Association survey question about whether Australian MTs should be statutory registered and funded.(21)
A Canadian study(23) found that SR is perceived by MTs to be linked with evidence-based practice, good business practice, and education curricula that include these approaches. This study also found that MTs in Canada felt challenged through practising outside the publicly funded health system. Future studies of MTs in NZ could explore the MTs perspectives of how funding affects their ability to practise massage therapy successfully.
In Europe, massage therapy is regulated in 20 countries, with 16 of those having European Union registration, by far the greatest span of countries that recognize massage therapy. In several of the European countries, massage therapy is also government funded (wholly or partially).(44)
These studies show that, while SR remains a goal for MTs, there is limited progress towards such regulation worldwide, with only a few countries having SR.(14) Potentially regulation could assist with the integration of MT into mainstream health care.
The study finding support MTs desire to be integrated with mainstream health care and show some slight progress in terms of referral between MTs and CCPs in NZ. Progress in integration of MT with conventional care in NZ has been linked to the lack of research into MT effectiveness.(45) This may be the reason that the findings in our study indicate that, although MTs in NZ support integration of MTs with other CCPs, annual referrals to and from CCPs are not frequent. However, most MTs did refer patients and received referrals from CCPs. A previous NZ study found similar patterns of referral to and from CCPs in MTs’ practices.(14) Meanwhile, an Australian massage therapy workforce study identified MTs as receiving less than 10% of their average annual caseload from referral.(13) In Singapore, 86% of CIM practitioners (with MTs being the predominant modality studied – 50%), referred to CCPs and 74% received referrals from CCPs. Unfortunately, annual referral numbers were not reported in this Singaporean study.(46) A UK study(47) found that 20% of GPs referred to MTs. But again, referral numbers were not reported. Another study in London found that, among CCPs, non-GPs were more likely to refer to MTs,(48) a result similar to that from our study, where only 7% of average annual referrals were from GPs. Similarly, in NZ, CCPs referrals are 1% of total caseload of naturopathic/herbalists.(49) Although many international studies have investigated referral patterns and attitudes among CCPs and CIM practitioners, no data are available internationally on MTs’ method of referral to CCPs or how MTs receive referrals from CCPs. Given that our findings show that most referrals to CCPs occur informally (74% by word of mouth), this important information about integrative patient care seems to have been neglected by researchers, despite implications for patient safety and continuity of care. There is scope for more in-depth investigation of integrative practices between MTs and CCPs.
The convenience sampling employed in our study means that only those practitioners who were members of the voluntary register held by MNZ were recruited for participation. This will have excluded MTs who choose not be registered with MNZ, indicating that any conclusions arising from this study may only be reasonably applied to MTs registered with MNZ, or similar bodies internationally. Nevertheless the response rate of 32% is not dissimilar to other health workforce studies of this kind,(50) particularly those where data have been collected electronically. Another possible limitation of our study is that the information from MTs is self-reported, leading to potential recall bias in the results, a comment made in other similar surveys of MTs.(51,52)
There is an apparent integration of MT in NZ in terms of referrals and relationships with CCPs. However, research engagement may present an obstacle to further development of full integration of MT with the mainstream NZ health care system.
Several key areas, including MTs’ attitudes and incorporation of researched information into practice, the need for statutory registration of MTs, and how massage therapy could be integrated into mainstream health care, require further investigation in order to contribute to a greater understanding of the role and nature of MTs’ practice in the NZ health care system.
The authors would like to acknowledge the comments made by the anonymous reviewer and editor, which significantly improved the focus of this article.
The authors declare there are no conflicts of interest.
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INTERNATIONAL JOURNAL OF THERAPEUTIC MASSAGE AND BODYWORK, VOLUME 11, NUMBER 2, June 2018