Practice and research in Australian massage therapy: a national workforce survey.

BACKGROUND: Massage is the largest complementary medicine profession in Australia, in terms of public utilisation, practitioner distribution, and number of practitioners, and is being increasingly integrated into the Australian health care system. However, despite the increasing importance of massage therapists in Australian health care delivery, or the increased practice and education obligations this may entail, there has been little exploration of practice, research, and education characteristics of the Australian massage therapist workforce.
PURPOSE: To identify practice, research, and education characteristics among the Australian massage therapist workforce. SETTINGS: The Australian massage therapy profession. PARTICIPANTS: 301 randomly selected members of the Association of Massage Therapists (Australia). RESEARCH
DESIGN: A 15-item, cross-sectional telephone survey. MAIN OUTCOMES MEASURES: Massage therapists' demographic information, practice characteristics, and education and research characteristics.
RESULTS: Most respondents (73.8%) worked 20 hours per week or less practising massage, nearly half of all respondents (46.8%) treated fewer than 10 massage clients per week, and over three-quarters (81.7%) of respondents were self-employed. Massage therapy was the sole source of income for just over half (55.0%) of the study respondents. Only 5.7% of respondents earned over the average wage ($50,000) through their massage activities. Nearly half of all respondents (43.3%) reported regularly exceeding their continuing professional education (CPE) quota mandated by their professional association. However, 21.1% reported struggling to achieve their CPE quota each year. Over one-third of respondents (35.6%) were not interested in acquiring further CPE points beyond minimum requirements. Respondents were significantly more likely to have an active approach to research if they had higher income (p = .015). Multivariate analysis showed factors associated with access to CPE to be the only significant predictors for increased CPE.
CONCLUSIONS: The massage profession in Australia remains largely part-time and practitioners earn less than the average Australian wage. The factors that underlie research and education involvement appear to be highly individualised and, therefore, policies targeting specific groups may be arbitrary and ineffective.

INTRODUCTION

Massage therapy is among the most commonly used forms of complementary and alternative medicine in Australia, with high utilisation amongst the Australian public( and relatively high levels of support and referral from conventional medical providers.( Massage therapists are a major provider of health services in Australia, with Australian Bureau of Statistics census data in 2006 indicating there are 8,199 persons who report massage therapy as their primary source of income in Australia.;( This number is expected to reach over 17,000 by 2017.( However, this may underestimate practitioner numbers. Many practitioners may not derive their primary income from massage and, although there is likely to be some overlap relating to dual memberships, professional associations purporting to represent massage therapists represent over 15,000 practitioners, though this could also reflect some massage therapists retaining their association memberships even when they are not actively practising.( Massage therapists outnumber both chiropractors and naturopaths as the largest professional group providing CAM therapies in Australia.(

Though data on specific number of type of massage consultations are lacking, the utilisation of massage therapists by the Australian general public appears to be high, with 20% of Australians reporting consultations with a massage therapist in the previous 12 months.( There also appears to be high utilisation of massage therapists for specific clinical scenarios. For example, over one-third of Australian women (34.1%) seek the services of a massage therapist for pregnancy-related health conditions,( and nearly half (44.1%) of older Australian women report using massage therapists for treatment of back pain.(

In addition to high practitioner numbers and high utilisation by the public, there are also significant levels of support amongst Australian GPs for further incorporation of massage therapy into primary health care. A national survey of Australian GPs in 2005 found that 17% of respondents had already received some formal training in massage and remedial therapies and 11% of the GPs used these therapies in their clinical practice.( This research also found that 35% of the GP sample expressed an interest in further training in this area, and 29% of GPs who had not practised these therapies would consider doing so if appropriate. Additionally, approximately half of the GPs in this study thought it would be appropriate for GPs to practise massage, remedial, and tactile therapies and for Medicare (the Australian government public health insurer) to pay for massage therapy.(

In contrast to many other CAM practitioner groups, massage therapists are not generally considered to be primary health care providers in most jurisdictions( and tend to focus treatment on a specific range of musculoskeletal conditions,( leading to an adjunctive rather than competitive role with conventional health care providers. Additionally, although classified and categorised as CAM, there may be little difference between the users of conventional medicine and those of massage therapy, far less than is observed in other CAM disciplines. For example, Robinson et al.( found that holistic health care beliefs amongst users of massage therapy in Australia were not significantly different from non-users of CAM, and that massage users were more likely to use massage therapy for specific health issues as opposed to the treatment or maintenance of general health problems.

Another area which is receiving increased attention is the engagement of clinicians with clinical research and the evidence base for their therapies. ( Engagement with research and evidence may be particularly relevant to CAM practices, which have recently drawn criticism for a perceived lack of both evidence-base and commitment to critical evidence-based practice.( Developing and sustaining research capacity amongst CAM practitioner groups is integral not only to developing appropriate tools for clinical and policy decision-making in CAM but as an essential tool for the development of modern CAM professions.( The importance of research in advancing the therapeutic massage communities has been highlighted,( as has the potential for increased engagement with research and evidence-based medicine to improve clinical outcomes in massage therapy.( Further research has also identified massage therapists’ clinical skills as positively affected when the massage therapist is certain of the evidence-base of their treatments.( However, there has been little research to date exploring the level of engagement of the massage community with research, and the small amount of research that has been done has shown low levels of engagement with research in clinical practice among massage therapists. A Canadian study found that neither chiropractors nor massage therapists engaged substantially with research, though massage therapists were less engaged than chiropractors.( Another Canadian study found that, while overall perceptions of research were positive among massage therapists, research literacy was low and research utilisation remained limited amongst this provider group.( Other research also suggests massage therapists do at least recognise increased engagement by clinicians with research as imperative to advancing their profession.(

Despite the significant therapeutic footprint of massage practitioners in Australia, no peer-reviewed published studies have explored the Australian massage therapy workforce in detail or the research practices of Australian massage therapists. Additionally, the research of massage practice overseas may not be directly transferable to the Australian massage practitioner community due to variations in practice patterns across countries. This study provides the first step in addressing this research gap by investigating practice and research characteristics among the Australian massage therapist workforce.

METHODS

A cross-sectional telephone survey of 301 randomly selected practising massage therapists who were accredited with the Association of Massage Therapists (AMT) was conducted in the second half of 2010. At the time of the survey the total membership of AMT was 1,538, so this survey represents a random sample comprising nearly one-fifth of the total membership. There is little discernible difference between AMT and most other massage associations in terms of qualifications for membership or functional role in Australia; however, one significant difference is that AMT has pursued enforcement of continuing education for two decades at the time of the survey, whereas this function was still not undertaken by some associations at the time of writing. Of the massage therapists contacted, there were 115 refusals to participate, giving a total of 416 massage therapists contacted to reach the target of 301 (response rate of 72.4%). The 15-item survey instrument contained questions relating to massage therapists’ demographic information (gender, age), practice characteristics (hours and locations worked, practice type, number of clients per week, income derived from massage therapy, percentage of income derived from massage therapy, amount of business from insurers and referrals, time in practice), and education and research characteristics (type of massage qualification, exposure to massage research, continuing education), and consisted of multiple choice and multiple response close-ended questions, with an open-response final question (see Appendix A). The survey instrument was developed in conjunction with a major Australian massage association (AMT) to help identify a practice, research and education profile of the Australian massage therapy profession.

Survey questionnaire data were analysed using descriptive statistics via frequency distributions and cross-tabulations. Characteristics (demographic and practice) of massage therapists who took an active (regularly accessing research and peer-reviewed research articles online or through other means through their own volition) or passive (not reading research at all or only reading it when provided by the association) approach to research were compared using chi-square tests. Significance was set at the p < .05 level. All analyses were conducted using the software program SPSS v19. The open-ended questions did not provide enough data for meaningful qualitative analysis. The study received ethical approval from the Association of Massage Therapists.

RESULTS

The results of the workforce survey are outlined in Table 1. Approximately two-thirds (67%, n = 202) of respondents were female, closely matching the gender profile of the Australian massage therapy profession more broadly (which was 71% female at the time of data collection).( The majority of respondents (58%, n = 174) had been in practice for more than five years, with nearly one-third of respondents (30%, n = 30) having practised massage for more than 10 years. Most respondents worked part-time, with 14.6% (n = 44) working a full-time load of more than 30 hours per week as a massage therapist. Over three-quarters (81.7%, n = 246) of respondents were self-employed, whilst fewer than 5% (n = 12) reported practising massage on a volunteer base or as a ‘hobby’. The vast majority of respondents (98%, n = 295) were trained in Australia, and nearly half of respondents (43.5%, n = 131) had a qualification that pre-dated the development of national competency standards (rolled out in 2002).

Table 1

Massage Workforce Survey Results

Factors		Frequency (percent)
Gender (n=301)	Male	99 (32.8%)
	Female	202 (67.2%)
Income (n=265)	Less than $5,000 pa	73 (27.6%)
	$5,001–$20,000 pa	88 (33.2%)
	$20,001–$40,000 pa	78 (29.4%)
	$40,001–$60,000 pa	21 (7.9%)
	More than $60,001 pa	5 (1.9%)
Percentage of clients claiming through a private health insurer as total (n=301)	0%–10%	65 (21.6%)
	11%–30%	22 (8.3%)
	31%–50%	38 (14.3%)
	51%–70%	49 (16.3%)
	More than 70%	82 (30.9%)
	Unsure	6 (2.0%)
Percentage of income derived from massage therapy (n = 300)	0%–10%	43 (14.3%)
	11%–30%	39 (13.0%)
	31%–50%	39 (13.0%)
	51%–70%	7 (2.3%)
	71%–90%	5 (1.7%)
	More than 90%	165 (55.0%)
Percentage of clientele referred by other health professionals (n = 301)	0%–10%	221 (73.4%)
	11%–30%	37 (12.3%)
	31%–50%	23 (7.6%)
	51%–70%	7 (2.3%)
	>70%	13 (4.3%)
Hours many hours per week do you work as a massage therapist? (n = 301)	0–5	60 (19.9%)
	6–10	67 (22.3%)
	11–20	79 (26.2%)
	21–30	51 (16.9%)
	More than 30	44 (14.6%)
Massage sole source of Income? (n = 300)	Yes	165 (55.0%)
	No	135 (45.0%)
Number of clients seen per week (n = 301)	0–5	65 (21.6%)
	6–10	76 (25.2%)
	11–20	81 (26.9%)
	More than 20	79 (26.2%)
Massage Qualifications (n = 301)	HLT Diploma	164 (54.5%)
	Pre-HLT Diploma	131 (43.5%)
	Overseas trained	6 (2.0%)
Are they registered for sales tax? (n=300)	Yes	55 (18.3%)
	No	245 (81.7%)
Type of Practice (n=301)	Commercial clinic	144 (47.8%)
	Mobile – home visits	30 (10.0%)
	Mobile – corporate seated	5 (1.7%)
	Home-based clinic	97 (32.2%)
	Other (spa, gym)	25 (8.3%)
CPE (n = 289)	I struggle to maintain	61 (21.1%)
	I do just what I need	103 (35.6%)
	I exceed my quota	125 (43.3%)
Exposure to massage therapy research (n = 300)	Never read any published research	4 (1.3%)
	Haven’t read any research since graduating	9 (3.0%)
	Read research when it is published in professional association newsletter/journal	169 (56.1%)
	Regularly access research articles elsewhere	118 (39.2%)

Massage therapy was the sole source of income for just over half (55.0%, n = 165) of the study respondents. Over one-quarter (27.6%, n = 73) earned less than $5,000 per annum through their massage services, less than the amount to file a tax income return in Australia. Only 5.7% (n = 15) of respondents earned over $50,000 through their massage activities. In Australia, therapists must register for sales tax collection if their annual pre-expenses income is more than $75,000. Only 18.3% (n = 55) of respondents had registered for sales tax collection and were required to charge goods and services tax, indicating that over four-fifths of respondents had turnover (i.e., pre-expenses income) in their business of less than $75,000 per year. Nearly half of all respondents (46.8%, n = 141) treated fewer than 10 massage clients per week. Nearly three-quarters of respondents (73.4%, n = 221) reported receiving less than 10% of their clients via referral. Nearly one-third (30.9%, n = 82) of respondents reported that a substantial majority (over 70%) of their patients claimed their treatment through a private health insurer. But a slightly smaller portion, 21.6% (n = 65) contrastingly reported that less than 10% of their clients claimed their treatment through private health insurance

Nearly half of all respondents (43.3%, n = 125) reported regularly exceeding their continuing professional education (CPE) quota mandated by their professional association (in this case AMT). However, 21.1% (n = 61) reported struggling to achieve their CPE quota each year. Over one-third of respondents (35.6%, n = 103) reported undertaking an adequate level of CPE to achieve their quota, and were not interested in acquiring further CPE points beyond such minimum requirements. Most of the massage therapists surveyed (56.1%, n = 169) relied on research dissemination provided by their professional association (in this case AMT, via its newsletter and journal) in order to remain informed about updates in massage therapy. However, a significant number of respondents (39.2%, n = 118) adopted a more active role in research by also accessing articles online and in other journals.

Univariate analysis was performed to explore which factors were associated with massage therapists taking an active or passive approach to research. Table 2 shows a comparison between massage therapists who take an active approach to research (those who actively sought out research online and in journals) and those who took a passive approach (relied on the association to disseminate, or did not do any research activity). Only income and continuing professional education were significantly associated with an active approach to research amongst massage therapists. Respondents were significantly more likely to have an active approach to research if they had higher income (p = .015), though there was no significant association between higher numbers of clients treated or number of hours worked with research engagement. There was also a significant association with approach to continuing professional education, with those who reported being able to easily exceed their CPE quota being significantly more likely to have an active approach to research than those who undertook only what they were mandated to undertake to achieve their CPE quota, or who found it difficult to reach their CPE quota (p = .004).

Table 2

Demographic and Practice Characteristics Associated with Passive and Active Approaches to Research by Massage Therapists in Australia

		Approach to Massage Research
Factors		Passive (%)	Active (%)	P value
Gender	Male	58.2	41.8	0.536
	Female	61.9	38.1
Income	Less than $5,000 pa	69.9	30.1	0.015
	$5,001–$20,000 pa	62.5	37.5
	$20,001–$40,000 pa	52.6	47.4
	$40,001–$60,000 pa	38.1	61.9
	More than $60,001 pa	20.0	80.0
Percentage of private health insurance clients as total	0%–10%	66.2	33.8	0.576
	11%–30%	54.5	45.5
	31%–50%	65.8	34.2
	51%–70%	63.3	36.7
	More than 70%	55.8	44.2
Percentage of income derived from massage therapy	0%–10%	62.5	37.5	0.928
	11%–30%	59.0	41.0
	31%–50%	68.4	31.6
	51%–70%	57.1	42.9
	More than 70%	60.0	40.0
Percentage of clientele referred by other health professionals	0%–10%	62.3	37.7	0.348
	11%–30%	62.2	37.8
	31%–50%	43.5	56.5
	51%–70%	42.9	57.1
	>70%	69.2	30.8
Hours per week worked	0–5	68.3	31.7	0.271
	6–10	62.1	37.9
	11–20	64.2	35.8
	21–30	52.1	47.9
	More than 30	51.1	48.9
Massage sole source of Income?	Yes	58.8	41.2	0.461
	No	63.0	37.0
Number of clients seen per week	0–5	65.2	34.8	0.670
	6–10	59.2	40.8
	11–20	63.0	37.0
	More than 20	55.8	44.2
Massage Qualifications	HLT Diploma	59.8	40.2	0.910
	Pre-HLT	61.5	38.5
	Overseas trained	66.7	33.3
GST registered?	Yes	61.8	38.2	0.829
	No	60.2	39.8
Type of Practice	Commercial clinic	60.4	39.6	0.792
	Mobile – home visits	66.7	33.3
	Mobile – corporate seated	80.0	20.0
	Home-based clinic	59.8	40.2
	Other	54.2	45.8
CPE	I struggle to maintain	65.6	34.4	0.004
	I do just what I need	69.9	30.1
	I exceed my quota	49.2	50.8
Years of experience as massage therapist	0–2	60.9	39.1	0.865
	3–5	57.6	42.4
	6–10	64.2	35.8
	More than 10	59.6	40.4

Table 3 shows the result of multiple logistic regression modelling to determine the most important predictive factors for massage therapists taking an active approach to research. This modelling shows that the only factor that predicted an active approach to research among massage therapists was CPE, with those who exceeded their quotas easily more likely to adopt an active approach to research than those who struggled to achieve the quota or could not access CPE. Those who exceeded their quotas easily were 3.28 times (95% CI: 1.70, 6.33) more likely to develop an active approach to research than those who reported doing ‘just what they needed’. Those who struggled to achieve their CPE quota each year were 1.90 times (95% CI: 0.91, 3.95) more likely to be active in their approach to research than those who preferred to do ‘just enough’.

Table 3

Predictive Factors for Taking an Active Approach to Research Among Australian Massage Therapists

Factor		Odds Ratio	95% CI
Participation in CPE?	Exceed my quotas easily	3.28	1.70, 6.33
	Struggle to achieve/can’t access	1.90	0.91, 3.95
	Do just as much as I need to	1.00	─

DISCUSSION

Despite attracting an increasing role in Australian primary care,( our study shows that massage therapy in Australia remains a nascent profession, with most massage therapists working part-time and earning below the national average wage, even where most practitioners report massage therapy as the sole or major source of their income. The predominantly part-time nature of the massage workforce identified in our study is consistent with data which show similar trends in other CAM professions, and make precise and accurate determination of the ‘real-world’ therapeutic footprint of massage difficult, even when practitioner numbers and distribution are known.( A more detailed investigation of the role of massage therapists in the Australian health care setting could offer valuable insights for policy and health care decision-makers in efforts to provide safe, effective, and coordinated health services responsive to consumer demand and need.

Our study suggests that the factors influencing massage therapists to engage in research are highly individualised. Apart from CPE (which is probably both a predictor for and a product of an active approach to research), no other predictive factors could be identified for massage therapists in this study taking an active role in engaging with research evidence. These findings may also be indicative of deeper issues for massage therapists in Australia. Those who do ‘as much as they need to and little more’ are clearly a simplistic proxy for passive research, but access to CPE resources would appear to be an issue for massage therapists in Australia. Access to education materials may also be an issue in the massage profession, with some practitioners not reaching CPE quota due to a possible lack of CPE opportunities, rather than a lack of interest. For example, massage therapists who struggled to achieve their CPE quota each year are still 1.90 times (95% CI: 0.91, 3.95) more likely to be active in their approach to engaging with research evidence than those who actively chose to undertake enough (but no more) CPE to reach their quota. This could suggest that there is an unmet need in Australian massage practice for more accessible forms of informing practitioners about latest clinical and professional research. This problem does not appear to be unique to massage therapy; a lack of independent CPE activities has also been identified by other CAM practitioners, such as naturopaths, as a major limiting factor in their attempts to remain updated in their research activities.( Further research exploring possible interventions that increase the accessibility of CPE for massage therapists, as well as effective information on evidence and clinical health care delivery to practitioners, may be warranted to help address these deficiencies. One method of improving CAM practitioner access to research may be to extend information resources for conventional health care practitioners regarding a broader range of health practitioners, such as massage therapists, who currently practise beyond the public health system. As it stands, most research related to practice requires paid or institutional subscription for full text access, placing a significant barrier to translation of research into practice and resulting in ad-hoc, rather than systematic, access to information sources.

Additionally, type or level of education did not appear to be associated with massage therapists adopting an active or passive approach to engaging with research evidence for their clinical practice. There were no differences in approach to engaging with research literature and information between those massage therapists in this study who were trained under formal national competency standards through the Health Training Package or those whose training pre-dated this regulation and may have been less formal. This suggests that, while increasing the level of massage therapist training is often promoted as a way to improve research literacy and research engagement in the profession,( increasing standards of training alone may not be enough to improve research literacy and application amongst massage therapists, and may have no effect if further upstream factors (such as increasing the level and accessibility of CPE materials) are not addressed. This finding is consistent with that identified for other CAM professions in Australia suggesting that, although education may have a role in improving research literacy and engagement with research evidence in some professions, it is not, in-and-of itself, a guarantee of improving such engagement among CAM professions.( Supporting the culture of research within the massage profession through active engagement across research, practice, and policy communities, and supporting individual practitioner access to research resources may be more effective ways of facilitating increased research engagement than education alone.

The finding from our study that massage therapists reporting higher income levels were more likely to have an active approach to reading research literature is significantly associated with an active research approach amongst massage therapists also raises interesting questions. Given that over 90% of the massage therapists surveyed earn less than the average Australian annual wage of $50,408, encouraging more active approaches across the profession may be a simple method of improving the economic sustainability of massage practice in Australia. However, it should also be acknowledged that many massage therapists practise part-time or as part of other business ventures, and income drawn solely through massage may be a poor proxy for total practitioner income.

However, income alone was not a predictive factor for an active research approach. This may be due to a possible relationship between income and CPE (i.e., CPE expenses would be more easily afforded by those on higher incomes) and the effect of income on CPE affordability and access would be particularly pronounced in a profession in which 94.3% of the population earns less than the national average wage. However, the association of increased research engagement with higher income amongst massage therapists may also be indicative of increased professionalisation of those practitioners on higher incomes. Increased research engagement has been linked to improved professional and clinical outcomes,( and it is possible that more active research engagement is flowing on into better professional outcomes for massage therapists. Further research examining the impact of research engagement on professional and clinical outcomes in massage therapy is warranted to uncover the impact and importance of research for both patient and practitioner communities.

Although the sample in this study was limited to one professional association, this association does have national representation, and the limited demographic data available from the Australian Bureau of Statistics suggest that the sample is broadly representative of the Australian massage therapy profession.( Nevertheless, the fact that this sample is limited to one of the multiple professional associations that represent massage therapists in Australia should be considered in generalising the study’s results to the broader Australian massage therapist population. Other limitations of the study, in common with other studies that utilise questionnaires, include the use of self-reported data and possible recall bias inherent in retrospective collection of data. Self-selection of respondents may also have resulted in some level of response bias.

CONCLUSION

Despite high levels of public utilisation and support, the massage therapy profession in Australia remains nascent, with most practitioners working part-time and earning less than the national average wage. The factors that underlie active research engagement by massage therapists appear to be highly individualised. Rather than focusing on improving education standards as the sole mechanism to improve standards in massage practice, a broader agenda including upstream factors, such as more active collaboration between researchers, clinicians, and policy-makers and improving access to professional development resources, may provide a more effective way of promoting and facilitating professional development within the massage profession.