Knowledge, Acceptance, and Use of Traditional, Complementary, and Alternative Medicine Among Peruvian Medical Students: Insights from a Multicenter Cross-Sectional Study

Knowledge, Acceptance, and Use of Traditional, Complementary, and Alternative Medicine Among Peruvian Medical Students: Insights from a Multicenter Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Knowledge, Acceptance, and Use of Traditional, Complementary, and Alternative Medicine Among Peruvian Medical Students: Insights from a Multicenter Cross-Sectional Study Leonardo J. Uribe-Cavero, Angie Diaz-Mejía, Ayleen A. Torres-Sánchez, and 23 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8340724/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Traditional, Complementary, and Alternative Medicine (T&CM) is widely used in Peru, especially in Andean and Amazonian regions. However, its place in medical curricula remains limited. Objective To evaluate knowledge, acceptance, and use of T&CM among Peruvian medical students through a multicenter survey and to identify factors associated with these outcomes. Methods We conducted a multicenter cross-sectional study (March–June 2025) in 15 medical schools located in the coast, highlands, and rainforest regions. A random sample of 855 students completed a validated questionnaire. Data were analyzed using descriptive statistics and Poisson regression with robust variance. Results Median age was 22 years; 59.2% were women. Nearly all students (95.9%) reported knowledge of at least one T&CM modality; 65.3% expressed acceptance and 75.7% reported use. Acceptance was higher among women (aPR = 1.24; 95% CI: 1.12–1.37), students speaking a native language (aPR = 1.14; 95% CI: 1.02–1.26), and those with prior training (aPR = 1.18; 95% CI: 1.07–1.30). Similar factors were associated with use: female sex (aPR = 1.29; 95% CI: 1.18–1.41), native language (aPR = 1.16; 95% CI: 1.05–1.28), and training (aPR = 1.21; 95% CI: 1.10–1.33). Students with higher acceptance were more likely to use T&CM (aPR = 1.71; 95% CI: 1.52–1.92). Most students were willing to receive training (88.3%) and favored integration of T&CM into practice (87.3%), though fewer supported recognition as a specialty (44.9%). Conclusions This multicenter study shows high awareness but lower acceptance and use of T&CM among Peruvian medical students. Gender, cultural background, and training strongly influence attitudes. Findings highlight the demand for standardized, evidence-based curricular integration to prepare culturally competent physicians. Traditional Medicine Complementary Therapies Health Knowledge Attitudes Practice Students Medical Education Medical Culture Peru Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Highlights • High awareness of T&CM among Peruvian medical students (95.9%). • Acceptance and use lower than knowledge, influenced by sex and culture. • Prior training boosts both acceptance (aPR = 1.18) and use (aPR = 1.21). • Acceptance strongly predicts T&CM use (aPR = 1.71). • Most students support T&CM integration into medical practice (87.3%). 1. Introduction Traditional, Complementary, and Alternative Medicine (T&CM) constitutes an integral part of global health systems, deeply rooted in cultural and historical practices. The World Health Organization (WHO) estimates that over 170 Member States utilize T&CM, and its 2014–2023 Traditional Medicine Strategy emphasizes integrating these practices into health systems safely, effectively, and evidence-based ( 1 ). In developed countries, surveys indicate that 40–70% of the population have used some form of T&CM ( 2 , 3 ). Reported prevalence is even higher in low- and middle-income regions, particularly in Latin America and Africa ( 4 ). In Peru, T&CM practices such as medicinal plant use, ritual plant baths, and other ancestral rites form part of both cultural identity and everyday healthcare, especially in Andean and Amazonian regions ( 5 – 7 ). Ethnobotanical studies have documented hundreds of plant species used for healing across Northern Peru, highlighting the prevalence and persistence of traditional healing knowledge in rural and indigenous communities ( 8 ). Furthermore, during the COVID-19 pandemic, anecdotal and media reports suggest a marked resurgence in community reliance on ancestral practices, underscoring both gaps in formal medical infrastructure and enduring cultural trust in traditional medicine ( 9 , 10 ). Medical students occupy a pivotal position in this context as future healthcare providers who will inevitably encounter patients using T&CM alongside conventional medicine. Evidence from multiple countries shows that students generally report favorable attitudes toward T&CM but demonstrate heterogeneous knowledge levels, often shaped by prior exposure through formal education ( 11 ). In Bangladesh, for example, although most students believed in the efficacy of T&CM, medical students reported significantly lower knowledge levels compared to their non-medical peers, despite nearly 80% expressing interest in formal training ( 12 ). Similarly, in Malaysia, approximately 75% of students supported integrating T&CM into the medical curriculum, yet many felt underprepared to address its clinical applications ( 13 ). Collectively, these findings highlight the need for structured educational approaches to ensure future physicians can critically appraise and safely integrate T&CM into clinical decision-making. Despite its widespread use and cultural importance, T&CM remains insufficiently incorporated into medical education in Peru and elsewhere. Understanding current levels of knowledge, acceptance, use, and perception among medical students is essential to identify educational deficits and inform intercultural strategies that promote safe, holistic, and culturally appropriate healthcare. Therefore, this study aims to assess knowledge, acceptance, and use of T&CM among Peruvian medical students, to uncover educational gaps and recommend curricular interventions that respond to cultural and patient care realities. 2. Methods 2.1. Study Design We conducted a multicenter, cross-sectional observational study using a structured survey. The study adhered to the recommendations of the “Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE) statement for observational studies ( 14 ). 2.2. Setting The study was conducted in the academic setting of 15 medical schools in Peru between March and June 2025. For analytical purposes, institutions were classified according to the three traditional natural regions of Peru—Coast (Costa), Highlands (Sierra), and Rainforest (Selva)—as recognized in Peruvian geographic and environmental literature (e.g., SINIA – Ministerio del Ambiente) ( sinia.minam.gob.pe ), and in national cartographic and statistical frameworks (IGN / INEI) ( inei.gob.pe ). Universities in the Costa region included Universidad Nacional del Santa (Chimbote), Universidad de San Martín de Porres – Chiclayo campus (Chiclayo), Universidad Nacional Pedro Ruiz Gallo (Lambayeque), Universidad Nacional de Piura (Piura), Universidad Científica del Sur (Lima), Universidad Ricardo Palma (Lima), Universidad de San Martín de Porres – Lima campus (Lima), and Universidad Nacional San Luis Gonzaga (Ica). The Sierra region comprised Universidad Nacional del Centro del Perú (Huancayo), Universidad Nacional de San Cristóbal de Huamanga (Ayacucho), Universidad Nacional de San Agustín de Arequipa (Arequipa), Universidad Católica Santa María (Arequipa), Universidad Nacional del Altiplano (Puno), and Universidad Privada de Tacna (Tacna). The Selva region included Universidad Nacional de Ucayali (Pucallpa). 2.3. Participants 2.3.1. Inclusion criteria : Undergraduate medical students enrolled between the first and sixth academic year. Age ≥ 18 years. Active enrollment at one of the participating universities. Provision of written informed consent. 2.3.2. Exclusion criteria : Refusal to provide informed consent. Having completed less than one academic semester. Enrollment outside the specified academic years. 2.4. Sample Size and Sampling A simple random sampling method was applied within each university to ensure representativeness. The sample size was calculated using the formula for proportions with finite population correction, considering a total population of 11,180 students. The parameters were as follows: expected proportion (p) = 80% (based on previous studies on knowledge and attitudes toward T&CM [10]), confidence level = 97% (Z = 2.17), and margin of error = 3%. A higher confidence level and a narrower margin of error were selected to increase the precision of the estimates, given the expected heterogeneity across subgroups of students by region, university, gender, and prior exposure to T&CM. With these parameters, the minimum sample size was 779 students. However, anticipating potential nonresponse and incomplete questionnaires, we increased the sample size by approximately 10%, reaching 855 students to maintain statistical power and precision in subgroup analyses. A detailed flow diagram illustrating the selection of participants at each stage of the study is presented in Fig. 1 . 2.5. Data Collection The sampling frame consisted of official enrollment lists of medical students provided by the academic offices of each participating medical school. Within each institution, students were selected using simple random sampling generated through a computer-based random number algorithm to ensure unbiased participant selection. Data were collected using a self-administered online questionnaire created in Google Forms and distributed in person by trained local investigators. 2.6. Questionnaire The questionnaire was adapted from a previously validated instrument originally developed for physicians in Peru ( 15 ). Content validity was assessed through expert review by specialists in T&CM, who evaluated the clarity, relevance, and representativeness of the items. A pilot study with 30 medical students was then conducted to assess item clarity, comprehension, and completion time. The pilot yielded a Cronbach’s alpha of 0.80, demonstrating good internal consistency. Data from the pilot phase were excluded from the final analysis. The complete questionnaire is available in Supplementary Material 1 . 2.7. Study Variables The questionnaire included four sections: sociodemographic characteristics, knowledge of T&CM, acceptance, and use. Full operational definitions are provided in Supplementary Table 1. 2.7.1. Sociodemographic characteristics This section collected age, sex, place of origin and birth, spoken languages, self-identified ethnicity, type of university, academic phase, and prior coursework related to T&CM. 2.7.2. Knowledge of T&CM Participants indicated whether they recognized commonly used traditional (e.g., medicinal plants, egg cleansing) and complementary/alternative modalities (e.g., acupuncture, yoga). Three conceptual questions assessed understanding of basic T&CM definitions. A participant was classified as having knowledge if they recognized at least one traditional and one complementary/alternative modality. Participants passed the conceptual evaluation if they answered correctly at least two of the three conceptual questions. Only the five modalities with the highest recognition will be reported. 2.7.3. Acceptance of T&CM Acceptance referred to willingness to consider a modality for personal use. Participants were classified as accepting T&CM if they endorsed at least one traditional and one complementary/alternative modality. 2.7.4. Use of T&CM Use reflected lifetime personal experience with any T&CM modality. Participants were classified as users if they reported using at least one traditional and one complementary/alternative modality. 2.8. Statistical Analysis Categorical variables were summarized as frequencies and percentages, while continuous variables were summarized as medians and interquartile ranges (IQR). Normality was evaluated using the Kolmogorov–Smirnov test given the large sample size. For the bivariate analysis, Chi-square or Fisher’s exact tests were used for categorical variables, and the Mann–Whitney U test for continuous variables. Variables with a p-value < 0.20 in the bivariate analysis, along with those considered clinically or theoretically relevant, were included in the multivariable analysis. Poisson regression models with robust variance were fitted to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). A p-value < 0.05 was considered statistically significant. All analyses were performed using Stata v17. 2.9. Ethical Considerations The study protocol was approved by the Ethics Committee of Universidad de San Martín de Porres (IRB No. 00003251), and permission to conduct the survey was obtained from each participating university. The study was conducted in accordance with the principles of the Declaration of Helsinki. Participation was voluntary, anonymous, and confidential. Electronic informed consent was obtained through the online questionnaire, which was administered in person during data collection. 3. Results 3.1. Sociodemographic Profile of Participants A total of 855 medical students participated in the study, with a median age of 22 years (IQR: 20–24). Of the total, 59.2% (n = 506) were women and 40.8% (n = 349) were men. Most participants were enrolled in private universities (74.6%, n = 638), whereas 25.4% (n = 217) studied in public institutions. Regarding the academic stage, 33.1% (n = 283) were in the basic sciences phase, while 66.9% (n = 572) were in the clinical-surgical phase. Additionally, 67.4% (n = 576) came from provinces, 16.4% (n = 140) reported knowledge of a native language, and 39.5% (n = 338) had taken a course related to T&CM. 3.2. Knowledge, Acceptance, and Use of T&CM Overall, 95.9% (n = 820) of students reported knowledge of at least one T&CM modality, 65.3% (n = 558) expressed acceptance, and 75.7% (n = 647) reported having used at least one modality. Acceptance was significantly higher among women compared with men (71.3% vs. 56.4%, p < 0.001), students with knowledge of a native language (74.3% vs. 63.5%, p = 0.012), and those who had taken a related course (74.0% vs. 59.6%, p < 0.001). Similarly, use of T&CM was more frequent among women (81.9% vs. 66.8%, p < 0.001) and students with knowledge of a native language (84.3% vs. 74.0%, p = 0.007). Knowledge was slightly higher among students who had passed the conceptual evaluation (98.1% vs. 94.7%, p = 0.01) and those who had attended a related course (98.2% vs. 94.3%, p = 0.002). Full descriptive details are presented in Table 1 . Table 1 Characteristics of participants and their association with knowledge, acceptance, and use of T&CM Characteristic (n = 855) Total n (%) Knowledge n (%) p Acceptance n (%) p Use n (%) p Age, median [IQR] 855 (100) Yes: 820 (95.9) 22, [20–24] 0.93 Yes: 558 (65.3) 22, [20–24] < 0.001 Yes: 647 (75.7) 22, [20–24] 0.15 No: 35 (4.1) 22, [20-23.5] Yes: 297 (34.7) 21, [20–23] Yes: 208 (24.3) 22, [20–24] Sex Male 349 (40.8) Yes: 333 (95.4) 0.54 Yes: 197 (56.4) < 0.001 Yes: 233 (66.8) < 0.001 No: 16 (4.6) No: 152 (43.6) No: 116 (33.2) Female 506 (59.2) Yes: 487 (96.2) Yes: 361 (71.3) Yes: 414 (81.8) No: 19 (3.8) No:145 (28.7) No: 92 (18.2) Type of university Public 217 (25.4) Yes: 212 (97.7) 0.12 Yes: 126 (58.1) 0.01 Yes: 164 (75.6) 0.96 No: 5 (2.3) No: 91 (41.9) No: 53 (24.4) Private 638 (74.6) Yes: 608 (95.3) Yes: 432 (67.7) Yes: 483 (75.7) No: 30 (4.7) No: 206 (32.3) No: 155 (24.3) Academic stage Basic sciences 283 (33.1) Yes: 275 (97.2) 0.18 Yes: 186 (65.7) 0.84 Yes: 224 (79.2) 0.09 No: 8 (2.8) No: 97 (34.3) No: 54 (20.8) Clinical-surgical 572 (66.9) Yes: 545 (95.3) Yes: 372 (65.0) Yes: 423 (73.9) No: 27 (4.7) No: 200 (35.0) No: 149 (26.1) Place of origin Lima 279 (32.6) Yes: 267 (95.7) 0.83 Yes: 187 (67.0) 0.45 Yes: 209 (74.9) 0.71 No: 12 (4.3) No: 92 (33.0) No: 70 (25.1) Province 576 (67.4) Yes: 553 (96.0) Yes: 371 (64.4) Yes: 438 (76.0) No: 23 (4.0) No: 205 (35.6) No: 138 (24.0) Has taken any course related to T&CM No 517 (60.5) Yes: 488 (94.4) 0.08 Yes: 308 (59.6) < 0.001 Yes: 381 (73.7) 0.09 No: 29 (5.6) No: 209 (40.4) No: 136 (26.3) Yes 338 (39.5) Yes: 332 (98.2) Yes: 250 (74.0) Yes: 266 (78.7) No: 6 (1.8) No: 88 (26.0) No: 72 (21.3) Knowledge of a native language No 715 (83.6) Yes: 683 (95.5) 0.20 Yes: 454 (63.5) 0.01 Yes: 529 (74.0) < 0.01 No: 32 (4.5) No: 261 (36.5) No: 186 (26.0) Yes 140 (16.4) Yes: 137 (97.9) Yes: 104 (74.3) Yes: 118 (84.3) No: 3 (2.1) No: 36 (25.7) No: 22 (15.7) Evaluation of T&CM concepts Failed 543 (63.5) Yes: 514 (94.7) 0.01 Yes: 348 (64.1) 0.34 Yes: 402 (74.0) 0.14 No: 29 (5.3) No: 195 (35.9) No: 141 (26.0) Passed 312 (36.5) Yes: 306 (98.1) Yes: 210 (67.3) Yes: 245 (78.5) No: 6 (1.9) No: 102 (32.7) No: 67 (21.5) 3.3. Knowledge, Acceptance, and Use of Specific T&CM Modalities Figures 2 and 3 summarize students’ knowledge, acceptance, and use of individual T&CM modalities. Among traditional medicine practices, medicinal plant use showed the highest awareness (96.7%) and was also the most accepted (60.0%) and used (96.7%). Egg cleansing (“pasada de huevo”) also demonstrated high familiarity (89.6%) and considerable use (55.6%), though acceptance was more moderate (42.0%). In contrast, traditional bone setting showed the lowest levels of awareness (61.6%), acceptance (15.4%), and use (18.6%). Ritual practices such as guinea pig cleansing (“sobada de cuy”) showed similarly low acceptance (18.1%) and use (15.8%) despite moderate knowledge (71.0%). Among alternative and complementary modalities, yoga showed the highest awareness (85.6%) and acceptance (49.1%), and was the most widely used (67.0%). Music therapy also displayed substantial acceptance (37.3%) and moderate use (23.3%) despite a slightly lower level of knowledge (73.0%). Conversely, acupuncture presented a notable discrepancy between relatively high knowledge (76.6%) and very low use (9.6%), paired with low acceptance (26.9%). Functional foods and nutraceuticals (knowledge 66.2%, acceptance 28.2%, use 35.7%) and aromatherapy (knowledge 66.0%, acceptance 31.2%, use 21.4%) showed moderate awareness with variable levels of acceptance and use. Overall, these findings highlight a substantial gap between knowledge and personal use across most modalities. T&CM: Traditional, Complementary, and Alternative Medicine *For each method, the bars represent the proportion of participants who indicated (i) having knowledge of the method, (ii) accepting its use in healthcare, and (iii) having personally used it. CAM: Complementary and Alternative Medicine *For each method, the bars represent the proportion of participants who indicated (i) having knowledge of the method, (ii) accepting its use in healthcare, and (iii) having personally used it. 3.4. Association Analyses of Knowledge, Acceptance, and Use of T&CM Bivariate analyses showed a strong association between knowledge and both acceptance (χ² = 68.6, p < 0.001) and use (χ² = 113.5, p < 0.001) of T&CM. Acceptance was also positively associated with use (χ² = 152.4, p < 0.001), with an adjusted prevalence ratio of 1.71 (95% CI: 1.52–1.92; p < 0.001). Multivariable models for the associations between knowledge and acceptance, as well as knowledge and use, could not be estimated due to complete separation in the contingency tables. This occurred because all students reporting knowledge of T&CM also reported both acceptance and use of these modalities (Table 2) . Table 2 Bivariate and multivariable association between Knowledge, Acceptance, and Use of T&CM (n = 855). Exposure → Outcome χ² (p-value) Adjusted PR (95% CI) p-value Knowledge → Acceptance 68.6 (< 0.001) Not estimable† — Knowledge → Use 113.5 (< 0.001) Not estimable† — Acceptance → Use 152.4 (< 0.001) 1.71 (1.52–1.92) < 0.001 PR = prevalence ratio; CI = 95% confidence interval. †Adjusted PRs were estimated using Poisson regression with robust variance, controlling for age, sex, type of university, academic phase, province of origin, native language, and whether the student passed the conceptual evaluation. “Not estimable” indicates complete separation in the contingency table, leading to perfect prediction and preventing reliable estimation of the association. 3.5. Factors Associated with Knowledge, Acceptance, and Use Adjusted analyses are presented in Table 3 . Knowledge of T&CM was significantly higher among students who had attended a related course (aPR = 1.05; 95% CI: 1.02–1.08; p = 0.002) and those who passed the conceptual evaluation (aPR = 1.03; 95% CI: 1.01–1.06; p = 0.01). Acceptance of T&CM was greater in women (aPR = 1.24; 95% CI: 1.12–1.37; p < 0.001), students with knowledge of a native language (aPR = 1.14; 95% CI: 1.02–1.26; p = 0.02), and those who had attended a related course (aPR = 1.18; 95% CI: 1.07–1.30; p = 0.001). Older age was associated with slightly lower acceptance (aPR = 0.96; 95% CI: 0.94–0.99; p = 0.004). Use of T&CM was more frequent among women (aPR = 1.29; 95% CI: 1.18–1.41; p < 0.001), students with knowledge of a native language (aPR = 1.16; 95% CI: 1.05–1.28; p = 0.004), and those who had attended a related course (aPR = 1.21; 95% CI: 1.10–1.33; p < 0.001). No significant associations were observed for university type, academic stage, or geographic origin across any of the outcomes. Detailed estimates for all variables are provided in Table 3 . Table 3 Factors associated with Knowledge, Acceptance, and Use of T&CM (n = 855) Variable Adjusted PR (95% CI) Knowledge p Adjusted PR (95% CI) Acceptance p Adjusted PR (95% CI) Use P Age (years) 1.00 (1.00–1.01) 0.34 0.96 (0.94–0.99) 0.004 0.99 (0.98–1.01) 0.31 Sex (female vs male) 1.01 (0.98–1.04) 0.50 1.22 (1.10–1.36) < 0.001 1.23 (1.13–1.34) < 0.001 University type (private vs public) 0.97 (0.94–1.01) 0.12 1.09 (0.95–1.24) 0.23 0.97 (0.88–1.07) 0.53 Academic phase (clinical vs basic) 0.97 (0.94–1.00) 0.05 1.00 (0.88–1.13) 0.99 0.93 (0.86–1.02) 0.11 Place of origin (province vs Lima) 1.00 (0.97–1.04) 0.89 1.02 (0.92–1.14) 0.73 1.01 (0.93–1.10) 0.77 Knows native language (Yes vs No) 1.01 (0.98–1.04) 0.42 1.15 (1.02–1.29) 0.02 1.12 (1.03–1.22) 0.01 Passed conceptual evaluation (Yes vs No) 1.03 (1.01–1.06) 0.01 1.02 (0.93–1.13) 0.68 1.05 (0.97–1.13) 0.21 Attended related course (Yes vs No) 1.05 (1.02–1.08) 0.002 1.24 (1.13–1.37) < 0.001 1.07 (0.99–1.16) 0.09 PR = prevalence ratio; CI = 95% confidence interval. Adjusted prevalence ratios were estimated using Poisson regression with robust variance. All models were adjusted for age, sex, university type, academic phase, place of origin, native language, passing the conceptual evaluation, and attending a related course 3.6. Exposure and Environment Related to T&CM Figure 4 shows students’ exposure to and engagement with T&CM in their environment. Fewer than half of the participants (47.6%, n = 409) reported knowing whether T&CM was practiced in their district. Regarding academic influence, 34.7% (n = 297) indicated that an instructor not associated with the T&CM course had discussed T&CM with them. Family exposure was more common, with 64.5% (n = 551) reporting conversations about T&CM with relatives. Additionally, 73.6% (n = 629) expressed interest in actively seeking information about T&CM. Importantly, most students (89.9%, n = 769) reported not being informed about the acceptance of T&CM by national or international organizations of recognized scientific credibility, while only 10.1% (n = 86) indicated being aware of such institutional positions. T&CM: Traditional, Complementary, and Alternative Medicine 3.7. Perceptions of T&CM Figure 5 illustrates students’ perceptions toward T&CM. The vast majority had a positive view of physicians practicing T&CM (83.9%, n = 792) and reported willingness to recommend or advise patients to access T&CM treatments in their future practice (81.1%, n = 694). Similarly, 88.3% (n = 755) of students expressed willingness to receive training related to T&CM. Fewer students supported formal recognition of T&CM as a medical specialty (44.9%, n = 382), though 75.5% (n = 642) would consider encouraging a patient to continue using T&CM if aware of its use. Finally, most participants (87.3%, n = 746) agreed that integrating T&CM approaches into modern medical practice is appropriate. 4. Discussion 4.1. Main Findings This multicenter study revealed that nearly all Peruvian medical students were familiar with at least one modality of T&CM, although acceptance and use were considerably lower. The strong associations between knowledge, acceptance, and use suggest that awareness alone does not necessarily translate into endorsement or clinical integration. Furthermore, the inability to model some associations due to near-complete overlap between knowledge and subsequent acceptance and use highlights the pervasive exposure of medical students to T&CM in non-academic contexts. 4.2. Comparison with Previous Literature Our findings align with international studies showing that medical students frequently report high awareness of T&CM but exhibit variable levels of acceptance and use. For instance, a study among Malaysian pharmacy students found that 57.8% were currently using CAM while 77.6% had used it previously; additionally, a majority believed that CAM knowledge is necessary for a well-rounded professional ( 12 ). In contrast, studies in Ghana have shown that about 59.0% of medical students had ever used CAM, and around 75% favored its introduction in the medical curriculum, reflecting good acceptance though not always matched with institutional recognition ( 16 ). Interestingly, while our study found that nearly 88% of students expressed willingness to receive training in T&CM, only 45% supported its recognition as a medical specialty. This divergence between personal acceptance and institutional endorsement resembles findings from South Africa, where a study of medical schools showed that although many institutions cover TCAM, it is often in a tokenistic manner and without strong curricular commitment ( 17 ). Similarly, research in the UK indicates that while medical students are positively disposed to CAM education and perceive it as useful for future practice, fewer support CAM being fully professionalized or integrated as a specialty without stronger evidence ( 18 ). 4.3. Discrepancies in Knowledge, Acceptance, and Use of Specific T&CM Modalities Our study revealed notable gaps between medical students’ knowledge, acceptance, and use of specific T&CM modalities. Practices such as egg cleansing and medicinal plant use were widely recognized (89.6% and 83.3%), but acceptance and actual use were lower. Conversely, huesería showed moderate awareness (61.6%) but high acceptance (84.3%), suggesting cultural perception and perceived efficacy influence attitudes beyond mere familiarity. Among complementary modalities, yoga and phytotherapy had high awareness (67.8% and 82.5%), yet usage remained limited, especially for acupuncture (9.6%). These patterns align with international evidence showing that medical students often hold positive attitudes toward T&CM but have variable knowledge and practical experience ( 16 ). These discrepancies highlight the importance of integrating structured T&CM education into medical curricula to improve students’ understanding, cultural competence, and ability to guide patients safely ( 19 ). 4.4. Determinants of Knowledge, Acceptance, and Use Our findings that female students reported greater acceptance and use of T&CM than their male counterparts are consistent with multiple studies worldwide. Research in Turkey and Saudi Arabia has shown that women tend to have more positive attitudes toward CAM and are more likely to use these therapies themselves, possibly reflecting gender differences in health-seeking behavior and openness to holistic care approaches ( 20 , 21 ). Cultural background also appears to play a significant role. In our study, students with knowledge of a native language—likely reflecting stronger cultural ties—reported greater acceptance and use of T&CM. Similar findings have been reported in Bangladesh and Sierra Leone, where family and community transmission of traditional practices was strongly associated with both knowledge and personal use of CAM, underscoring the importance of cultural continuity in shaping attitudes toward these modalities ( 11 , 22 ). Educational exposure emerged as another consistent determinant. We observed that students who had taken a T&CM-related course reported higher knowledge, acceptance, and use. Evidence from pre- and post-intervention studies in Saudi Arabia and curriculum evaluations in Europe demonstrates that structured CAM education improves factual knowledge, enhances confidence in discussing CAM with patients, and fosters more favorable attitudes toward its integration into medical practice ( 21 , 23 ). Overall, our results, together with existing evidence, indicate that gender, cultural ties, and formal education are the primary determinants of knowledge, acceptance, and use of T&CM, whereas institutional and demographic characteristics play a lesser role. 4.5. Exposure and Perceptions In our study, many students reported limited awareness of whether T&CM modalities are practiced in their own districts, moderate exposure through external instructors and family discussions, and strong interest in seeking more information. These findings resonate with previous research showing that medical students often rely more on informal sources (media, friends/relatives) than formal education for exposure to CAM, yet they maintain generally positive perceptions toward its use. For example, in a cross-sectional study at King Saud bin Abdulaziz University, a majority of students (≈ 60–70%) reported awareness of CAM modalities, considered many as effective, and acquired information mostly from media, books, friends/relatives, while very few had formal CAM training ( 24 ). In another study from Bangladesh, around 80% of medical and non-medical students expressed interest in receiving education about CAM, even though knowledge differed by modality and source of information ( 11 ). Similarly, a pre- and post-course survey in Saudi Arabia showed that exposure to a dedicated CAM course significantly improved perceptions regarding efficacy, personal use, advising patients, and the inclusion of CAM in medical curricula ( 23 ). These patterns mirror our finding that while informal exposure is common, formal academic engagement and curricular exposure lag behind, yet student perceptions are favorable and demand for training is high. 4.6. Educational implications Our findings, along with recent evidence from Peru and other regions, highlight the urgent need to strengthen the formal integration of T&CM into undergraduate medical curricula. A recent national review found that only 31.9% of Peruvian medical schools included dedicated TCM courses, most of them elective, with substantial variability in topics covered, teaching methods, and evaluation strategies ( 25 ). This aligns with international reports indicating limited or inconsistent curricular exposure to T&CM despite students’ expressed interest in training and generally positive attitudes toward its use ( 10 ). A scoping review analyzing CAM education across multiple countries concluded that structured, evidence-based curricular interventions improve students’ factual knowledge, confidence in discussing CAM with patients, and attitudes toward its integration into modern practice ( 26 ). Similarly, a critical review of medical student attitudes toward CAM emphasized that early, standardized exposure reduces misconceptions and promotes a more balanced perspective regarding risks, benefits, and ethical considerations ( 10 ). In Latin America, studies have reported that interest in learning about T&CM often surpasses actual curricular opportunities ( 27 ). For example, Colombian medical students cited both cultural relevance and patient demand as motivations for formal training, yet also highlighted the absence of standardized modules or faculty expertise as barriers ( 28 ). Similarly, a multimodal CAM curriculum implemented at the University of California, Irvine, which included lectures, online assignments, and interactive components, significantly improved medical students’ familiarity with CAM modalities, perceptions of safety and efficacy, and willingness to recommend CAM treatments ( 29 ). Furthermore, initiatives involving medical students in curriculum development have shown positive effects on engagement and attitudes toward CAM education, underscoring the value of well-designed educational interventions in shaping clinical perspectives ( 30 ). Therefore, integrating T&CM as mandatory components in medical curricula, rather than elective courses, appears crucial. Curricular reforms should ensure minimum standardized content, practical training opportunities, and ethical guidelines for clinical use. Furthermore, faculty development programs are essential to equip educators with the necessary expertise for supervising and evaluating CAM education effectively. Without addressing both curricular structure and educator preparedness, efforts to integrate T&CM risk remaining fragmented and unsustainable ( 31 ). 5. Strengths and Limitations This study has several important strengths. It represents the first multicenter investigation in Peru and one of the few in Latin America assessing knowledge, acceptance, and use of T&CM among medical students. By including 855 participants from 15 universities across three geographic regions and both public and private institutions, the study reflects the sociocultural and educational diversity of a multicultural country such as Peru, where ancestral traditions and modern medical training coexist. The questionnaire underwent internal validation through expert review and pilot testing, demonstrating good internal consistency (Cronbach’s α = 0.80). Moreover, the use of random sampling, a large sample size exceeding power requirement, and adherence to STROBE guidelines reinforce the methodological robustness and transparency of the findings. Nevertheless, some limitations should be acknowledged. The cross-sectional design precludes causal inference between sociodemographic factors and T&CM outcomes. The reliance on self-reported data may introduce recall and social desirability biases, potentially leading to over- or underestimation of attitudes and practices. The complete separation observed in contingency tables restricted multivariable modeling for some associations, limiting exploration of potential confounders. Furthermore, although the study included institutions from diverse regions, findings may not be fully generalizable to other Latin American countries, given cultural and curricular differences. Finally, unmeasured factors such as socioeconomic background, religiosity, or previous family exposure to T&CM may have influenced students’ perceptions but were not assessed in this study. Despite these limitations, this research provides robust baseline evidence for future longitudinal and interventional studies and offers valuable insights to guide the integration of T&CM education into medical curricula in Peru and other multicultural contexts across Latin America. 6. Conclusion This multicenter study showed that nearly all Peruvian medical students were familiar with at least one T&CM modality, although acceptance and use were lower and varied by specific technique or method. Female students, those with knowledge of a native language, and those who had received T&CM-related education reported higher acceptance and usage. Despite widespread interest in receiving formal training, curricular exposure remains limited and inconsistent. These findings underscore the need for structured, evidence-based integration of T&CM into medical curricula to enhance cultural competence, practical knowledge, and the ability to safely guide patients. Declarations Acknowledgments: None Declaration of conflicting interest: The authors declare no conflicts of interest regarding this study. Funding statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contributions: L.J.U.-C.: Study design, execution, data analysis and interpretation, manuscript drafting. A.D.-M., A.A.T.-S., Z.M.-C., N.S.-T., K.A.M.-S., J.N.N.-C., E.C.-C., Y.M.M.-T., O.N.V.-G., J.S.Q.-G., P.R.D.-A., A.J.V.-U., D.S., O.C.B.-S., L.P.Á., C.M.-O., I.S.S., A.D.V.-R.-T., C.P.L., X.C.B.-C., E.P.-C., Z.T.H.L., L.R.S.S.: Data collection, contribution to analysis and interpretation, critical review of content. M.V.-L and J.H.-R.: Overall supervision, methodological guidance, and critical manuscript review as senior author. Ethical approval and informed consent statements: The study protocol was approved by the Ethics Committee of Universidad de San Martín de Porres (IRB No. 00003251), Lima, Perú and permission to conduct the survey was obtained from each participating university. The study was conducted in accordance with the principles of the Declaration of Helsinki. Participation was voluntary, anonymous, and confidential. 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01:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8340724/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8340724/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103050104,"identity":"8aa3d6ec-4416-44e6-b361-c8fb04e478bd","added_by":"auto","created_at":"2026-02-20 07:48:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33607,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of Participant Selection for the Study\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8340724/v1/2d719b4a1b50271709d7e8b5.png"},{"id":103002379,"identity":"7b471b49-2734-4524-90d5-de89ba94bbb5","added_by":"auto","created_at":"2026-02-19 14:07:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":33772,"visible":true,"origin":"","legend":"\u003cp\u003eKnowledge, acceptance, and use of the five T\u0026amp;CM methods most frequently reported as known by the students*.\u003c/p\u003e\n\u003cp\u003eT\u0026amp;CM: Traditional, Complementary, and Alternative Medicine\u003c/p\u003e\n\u003cp\u003e*For each method, the bars represent the proportion of participants who indicated (i) having knowledge of the method, (ii) accepting its use in healthcare, and (iii) having personally used it.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8340724/v1/b7922ce41ca160c625334bb8.png"},{"id":103049985,"identity":"5df654d5-6bc0-47c0-a84e-de6ad487b8dc","added_by":"auto","created_at":"2026-02-20 07:47:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":30794,"visible":true,"origin":"","legend":"\u003cp\u003eKnowledge, acceptance, and use of the five CAM methods most frequently reported as known by the students*\u003c/p\u003e\n\u003cp\u003eCAM: Complementary and Alternative Medicine\u003c/p\u003e\n\u003cp\u003e*For each method, the bars represent the proportion of participants who indicated (i) having knowledge of the method, (ii) accepting its use in healthcare, and (iii) having personally used it.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8340724/v1/871a30b750f9a7824c4726fa.png"},{"id":103050319,"identity":"3b3a2be6-f83d-4b64-9e0d-bf127cc1298d","added_by":"auto","created_at":"2026-02-20 07:49:27","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":29373,"visible":true,"origin":"","legend":"\u003cp\u003eExposure to and Environment Surrounding T\u0026amp;CM Among Medical Students\u003c/p\u003e\n\u003cp\u003eT\u0026amp;CM: Traditional, Complementary, and Alternative Medicine\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8340724/v1/00d984034f5c99e00000720c.png"},{"id":103050074,"identity":"744f4c43-3d7b-47bd-81af-2de754af8937","added_by":"auto","created_at":"2026-02-20 07:47:59","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":36173,"visible":true,"origin":"","legend":"\u003cp\u003ePerceptions of T\u0026amp;CM Among Medical Students\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eT\u0026amp;CM:\u003c/strong\u003e Traditional, Complementary, and Alternative Medicine\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8340724/v1/463bcb9c7cc1add9bc359695.png"},{"id":107545683,"identity":"1bf98239-0e0f-4caf-888a-b92cbf5e2f28","added_by":"auto","created_at":"2026-04-22 13:12:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":880352,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8340724/v1/f2a43956-5ad6-428a-a188-e0b2def7ec2b.pdf"},{"id":103002383,"identity":"7d1145a3-8ce8-44ac-b9bf-79d29ad515a1","added_by":"auto","created_at":"2026-02-19 14:07:41","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":23545,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-8340724/v1/445fa20a5dd33846bc127d84.docx"},{"id":103002384,"identity":"aeeccc7f-0815-4be3-9a63-47485f2e59c3","added_by":"auto","created_at":"2026-02-19 14:07:42","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":3051673,"visible":true,"origin":"","legend":"","description":"","filename":"bmcquessionaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-8340724/v1/fc5ba8af9fe1ebb89b80a200.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eKnowledge, Acceptance, and Use of Traditional, Complementary, and Alternative Medicine Among Peruvian Medical Students: Insights from a Multicenter Cross-Sectional Study\u003c/p\u003e","fulltext":[{"header":"Highlights","content":"\u003cp\u003e\u0026bull; High awareness of T\u0026amp;CM among Peruvian medical students (95.9%).\u003c/p\u003e\u003cp\u003e\u0026bull; Acceptance and use lower than knowledge, influenced by sex and culture.\u003c/p\u003e\u003cp\u003e\u0026bull; Prior training boosts both acceptance (aPR\u0026thinsp;=\u0026thinsp;1.18) and use (aPR\u0026thinsp;=\u0026thinsp;1.21).\u003c/p\u003e\u003cp\u003e\u0026bull; Acceptance strongly predicts T\u0026amp;CM use (aPR\u0026thinsp;=\u0026thinsp;1.71).\u003c/p\u003e\u003cp\u003e\u0026bull; Most students support T\u0026amp;CM integration into medical practice (87.3%).\u003c/p\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eTraditional, Complementary, and Alternative Medicine (T\u0026amp;CM) constitutes an integral part of global health systems, deeply rooted in cultural and historical practices. The World Health Organization (WHO) estimates that over 170 Member States utilize T\u0026amp;CM, and its 2014\u0026ndash;2023 Traditional Medicine Strategy emphasizes integrating these practices into health systems safely, effectively, and evidence-based (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In developed countries, surveys indicate that 40\u0026ndash;70% of the population have used some form of T\u0026amp;CM (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Reported prevalence is even higher in low- and middle-income regions, particularly in Latin America and Africa (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Peru, T\u0026amp;CM practices such as medicinal plant use, ritual plant baths, and other ancestral rites form part of both cultural identity and everyday healthcare, especially in Andean and Amazonian regions (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Ethnobotanical studies have documented hundreds of plant species used for healing across Northern Peru, highlighting the prevalence and persistence of traditional healing knowledge in rural and indigenous communities (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Furthermore, during the COVID-19 pandemic, anecdotal and media reports suggest a marked resurgence in community reliance on ancestral practices, underscoring both gaps in formal medical infrastructure and enduring cultural trust in traditional medicine (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMedical students occupy a pivotal position in this context as future healthcare providers who will inevitably encounter patients using T\u0026amp;CM alongside conventional medicine. Evidence from multiple countries shows that students generally report favorable attitudes toward T\u0026amp;CM but demonstrate heterogeneous knowledge levels, often shaped by prior exposure through formal education (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In Bangladesh, for example, although most students believed in the efficacy of T\u0026amp;CM, medical students reported significantly lower knowledge levels compared to their non-medical peers, despite nearly 80% expressing interest in formal training (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Similarly, in Malaysia, approximately 75% of students supported integrating T\u0026amp;CM into the medical curriculum, yet many felt underprepared to address its clinical applications (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Collectively, these findings highlight the need for structured educational approaches to ensure future physicians can critically appraise and safely integrate T\u0026amp;CM into clinical decision-making.\u003c/p\u003e \u003cp\u003eDespite its widespread use and cultural importance, T\u0026amp;CM remains insufficiently incorporated into medical education in Peru and elsewhere. Understanding current levels of knowledge, acceptance, use, and perception among medical students is essential to identify educational deficits and inform intercultural strategies that promote safe, holistic, and culturally appropriate healthcare. Therefore, this study aims to assess knowledge, acceptance, and use of T\u0026amp;CM among Peruvian medical students, to uncover educational gaps and recommend curricular interventions that respond to cultural and patient care realities.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design\u003c/h2\u003e \u003cp\u003eWe conducted a multicenter, cross-sectional observational study using a structured survey. The study adhered to the recommendations of the \u0026ldquo;Strengthening the Reporting of Observational Studies in Epidemiology\u0026rdquo; (STROBE) statement for observational studies (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Setting\u003c/h2\u003e \u003cp\u003eThe study was conducted in the academic setting of 15 medical schools in Peru between March and June 2025. For analytical purposes, institutions were classified according to the three traditional natural regions of Peru\u0026mdash;Coast (Costa), Highlands (Sierra), and Rainforest (Selva)\u0026mdash;as recognized in Peruvian geographic and environmental literature (e.g., SINIA \u0026ndash; Ministerio del Ambiente) (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003esinia.minam.gob.pe\u003c/span\u003e), and in national cartographic and statistical frameworks (IGN / INEI) (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003einei.gob.pe\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUniversities in the Costa region included Universidad Nacional del Santa (Chimbote), Universidad de San Mart\u0026iacute;n de Porres \u0026ndash; Chiclayo campus (Chiclayo), Universidad Nacional Pedro Ruiz Gallo (Lambayeque), Universidad Nacional de Piura (Piura), Universidad Cient\u0026iacute;fica del Sur (Lima), Universidad Ricardo Palma (Lima), Universidad de San Mart\u0026iacute;n de Porres \u0026ndash; Lima campus (Lima), and Universidad Nacional San Luis Gonzaga (Ica). The Sierra region comprised Universidad Nacional del Centro del Per\u0026uacute; (Huancayo), Universidad Nacional de San Crist\u0026oacute;bal de Huamanga (Ayacucho), Universidad Nacional de San Agust\u0026iacute;n de Arequipa (Arequipa), Universidad Cat\u0026oacute;lica Santa Mar\u0026iacute;a (Arequipa), Universidad Nacional del Altiplano (Puno), and Universidad Privada de Tacna (Tacna). The Selva region included Universidad Nacional de Ucayali (Pucallpa).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Participants\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1. \u003cb\u003eInclusion criteria\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eUndergraduate medical students enrolled between the first and sixth academic year.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;18 years.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eActive enrollment at one of the participating universities.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProvision of written informed consent.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2. \u003cb\u003eExclusion criteria\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eRefusal to provide informed consent.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHaving completed less than one academic semester.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEnrollment outside the specified academic years.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Sample Size and Sampling\u003c/h2\u003e \u003cp\u003eA simple random sampling method was applied within each university to ensure representativeness. The sample size was calculated using the formula for proportions with finite population correction, considering a total population of 11,180 students. The parameters were as follows: expected proportion (p)\u0026thinsp;=\u0026thinsp;80% (based on previous studies on knowledge and attitudes toward T\u0026amp;CM [10]), confidence level\u0026thinsp;=\u0026thinsp;97% (Z\u0026thinsp;=\u0026thinsp;2.17), and margin of error\u0026thinsp;=\u0026thinsp;3%. A higher confidence level and a narrower margin of error were selected to increase the precision of the estimates, given the expected heterogeneity across subgroups of students by region, university, gender, and prior exposure to T\u0026amp;CM.\u003c/p\u003e \u003cp\u003eWith these parameters, the minimum sample size was 779 students. However, anticipating potential nonresponse and incomplete questionnaires, we increased the sample size by approximately 10%, reaching 855 students to maintain statistical power and precision in subgroup analyses. A detailed flow diagram illustrating the selection of participants at each stage of the study is presented in \u003cb\u003eFig.\u0026nbsp;1\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Data Collection\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe sampling frame consisted of official enrollment lists of medical students provided by the academic offices of each participating medical school. Within each institution, students were selected using simple random sampling generated through a computer-based random number algorithm to ensure unbiased participant selection. Data were collected using a self-administered online questionnaire created in Google Forms and distributed in person by trained local investigators.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Questionnaire\u003c/h2\u003e \u003cp\u003eThe questionnaire was adapted from a previously validated instrument originally developed for physicians in Peru (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Content validity was assessed through expert review by specialists in T\u0026amp;CM, who evaluated the clarity, relevance, and representativeness of the items. A pilot study with 30 medical students was then conducted to assess item clarity, comprehension, and completion time. The pilot yielded a Cronbach\u0026rsquo;s alpha of 0.80, demonstrating good internal consistency. Data from the pilot phase were excluded from the final analysis. The complete questionnaire is available in \u003cb\u003eSupplementary Material 1\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.7. Study Variables\u003c/h2\u003e \u003cp\u003eThe questionnaire included four sections: sociodemographic characteristics, knowledge of T\u0026amp;CM, acceptance, and use. Full operational definitions are provided in Supplementary Table\u0026nbsp;1.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.7.1. Sociodemographic characteristics\u003c/h2\u003e \u003cp\u003eThis section collected age, sex, place of origin and birth, spoken languages, self-identified ethnicity, type of university, academic phase, and prior coursework related to T\u0026amp;CM.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.7.2. Knowledge of T\u0026amp;CM\u003c/h2\u003e \u003cp\u003eParticipants indicated whether they recognized commonly used traditional (e.g., medicinal plants, egg cleansing) and complementary/alternative modalities (e.g., acupuncture, yoga). Three conceptual questions assessed understanding of basic T\u0026amp;CM definitions. A participant was classified as having knowledge if they recognized at least one traditional and one complementary/alternative modality.\u003c/p\u003e \u003cp\u003eParticipants passed the conceptual evaluation if they answered correctly at least two of the three conceptual questions. Only the five modalities with the highest recognition will be reported.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e2.7.3. Acceptance of T\u0026amp;CM\u003c/h2\u003e \u003cp\u003eAcceptance referred to willingness to consider a modality for personal use. Participants were classified as accepting T\u0026amp;CM if they endorsed at least one traditional and one complementary/alternative modality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e2.7.4. Use of T\u0026amp;CM\u003c/h2\u003e \u003cp\u003eUse reflected lifetime personal experience with any T\u0026amp;CM modality. Participants were classified as users if they reported using at least one traditional and one complementary/alternative modality.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e2.8. Statistical Analysis\u003c/h2\u003e \u003cp\u003eCategorical variables were summarized as frequencies and percentages, while continuous variables were summarized as medians and interquartile ranges (IQR). Normality was evaluated using the Kolmogorov\u0026ndash;Smirnov test given the large sample size.\u003c/p\u003e \u003cp\u003eFor the bivariate analysis, Chi-square or Fisher\u0026rsquo;s exact tests were used for categorical variables, and the Mann\u0026ndash;Whitney U test for continuous variables. Variables with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.20 in the bivariate analysis, along with those considered clinically or theoretically relevant, were included in the multivariable analysis.\u003c/p\u003e \u003cp\u003ePoisson regression models with robust variance were fitted to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All analyses were performed using Stata v17.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e2.9. Ethical Considerations\u003c/h2\u003e \u003cp\u003eThe study protocol was approved by the Ethics Committee of Universidad de San Mart\u0026iacute;n de Porres (IRB No. 00003251), and permission to conduct the survey was obtained from each participating university. The study was conducted in accordance with the principles of the Declaration of Helsinki. Participation was voluntary, anonymous, and confidential. Electronic informed consent was obtained through the online questionnaire, which was administered in person during data collection.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Sociodemographic Profile of Participants\u003c/h2\u003e \u003cp\u003eA total of 855 medical students participated in the study, with a median age of 22 years (IQR: 20\u0026ndash;24). Of the total, 59.2% (n\u0026thinsp;=\u0026thinsp;506) were women and 40.8% (n\u0026thinsp;=\u0026thinsp;349) were men. Most participants were enrolled in private universities (74.6%, n\u0026thinsp;=\u0026thinsp;638), whereas 25.4% (n\u0026thinsp;=\u0026thinsp;217) studied in public institutions. Regarding the academic stage, 33.1% (n\u0026thinsp;=\u0026thinsp;283) were in the basic sciences phase, while 66.9% (n\u0026thinsp;=\u0026thinsp;572) were in the clinical-surgical phase. Additionally, 67.4% (n\u0026thinsp;=\u0026thinsp;576) came from provinces, 16.4% (n\u0026thinsp;=\u0026thinsp;140) reported knowledge of a native language, and 39.5% (n\u0026thinsp;=\u0026thinsp;338) had taken a course related to T\u0026amp;CM.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Knowledge, Acceptance, and Use of T\u0026amp;CM\u003c/h2\u003e \u003cp\u003eOverall, 95.9% (n\u0026thinsp;=\u0026thinsp;820) of students reported knowledge of at least one T\u0026amp;CM modality, 65.3% (n\u0026thinsp;=\u0026thinsp;558) expressed acceptance, and 75.7% (n\u0026thinsp;=\u0026thinsp;647) reported having used at least one modality.\u003c/p\u003e \u003cp\u003eAcceptance was significantly higher among women compared with men (71.3% vs. 56.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), students with knowledge of a native language (74.3% vs. 63.5%, p\u0026thinsp;=\u0026thinsp;0.012), and those who had taken a related course (74.0% vs. 59.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, use of T\u0026amp;CM was more frequent among women (81.9% vs. 66.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and students with knowledge of a native language (84.3% vs. 74.0%, p\u0026thinsp;=\u0026thinsp;0.007).\u003c/p\u003e \u003cp\u003eKnowledge was slightly higher among students who had passed the conceptual evaluation (98.1% vs. 94.7%, p\u0026thinsp;=\u0026thinsp;0.01) and those who had attended a related course (98.2% vs. 94.3%, p\u0026thinsp;=\u0026thinsp;0.002). Full descriptive details are presented in \u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of participants and their association with knowledge, acceptance, and use of T\u0026amp;CM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic (n\u0026thinsp;=\u0026thinsp;855)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKnowledge n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcceptance n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUse n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAge, median [IQR]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e855 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 820 (95.9)\u003c/p\u003e \u003cp\u003e22, [20\u0026ndash;24]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 558 (65.3)\u003c/p\u003e \u003cp\u003e22, [20\u0026ndash;24]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 647 (75.7)\u003c/p\u003e \u003cp\u003e22, [20\u0026ndash;24]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 35 (4.1)\u003c/p\u003e \u003cp\u003e22, [20-23.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 297 (34.7) \u003c/p\u003e \u003cp\u003e21, [20\u0026ndash;23]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 208 (24.3) \u003c/p\u003e \u003cp\u003e22, [20\u0026ndash;24]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e349 (40.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 333 (95.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 197 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 233 (66.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 16 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 152 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 116 (33.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e506 (59.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 487 (96.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 361 (71.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 414 (81.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 19 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo:145 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 92 (18.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of university\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePublic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e217 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 212 (97.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 126 (58.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 164 (75.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 5 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 91 (41.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 53 (24.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePrivate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e638 (74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 608 (95.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 432 (67.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 483 (75.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 30 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 206 (32.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 155 (24.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcademic stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eBasic sciences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e283 (33.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 275 (97.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 186 (65.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 224 (79.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 8 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 97 (34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 54 (20.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eClinical-surgical\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e572 (66.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 545 (95.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 372 (65.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 423 (73.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 27 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 200 (35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 149 (26.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of origin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLima\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e279 (32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 267 (95.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 187 (67.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 209 (74.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 12 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 92 (33.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 70 (25.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eProvince\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e576 (67.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 553 (96.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 371 (64.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 438 (76.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 23 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 205 (35.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 138 (24.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHas taken any course related to T\u0026amp;CM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e517 (60.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 488 (94.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 308 (59.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 381 (73.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 29 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 209 (40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 136 (26.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e338 (39.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 332 (98.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 250 (74.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 266 (78.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 6 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 88 (26.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 72 (21.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of a native language\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e715 (83.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 683 (95.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 454 (63.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 529 (74.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 32 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 261 (36.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 186 (26.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e140 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 137 (97.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 104 (74.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 118 (84.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 3 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 36 (25.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 22 (15.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEvaluation of T\u0026amp;CM concepts\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFailed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e543 (63.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 514 (94.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 348 (64.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 402 (74.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 29 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 195 (35.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 141 (26.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePassed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e312 (36.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes: 306 (98.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes: 210 (67.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes: 245 (78.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo: 6 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo: 102 (32.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo: 67 (21.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Knowledge, Acceptance, and Use of Specific T\u0026amp;CM Modalities\u003c/h2\u003e \u003cp\u003eFigures 2 and 3 summarize students\u0026rsquo; knowledge, acceptance, and use of individual T\u0026amp;CM modalities. Among traditional medicine practices, medicinal plant use showed the highest awareness (96.7%) and was also the most accepted (60.0%) and used (96.7%). Egg cleansing (\u0026ldquo;pasada de huevo\u0026rdquo;) also demonstrated high familiarity (89.6%) and considerable use (55.6%), though acceptance was more moderate (42.0%). In contrast, traditional bone setting showed the lowest levels of awareness (61.6%), acceptance (15.4%), and use (18.6%). Ritual practices such as guinea pig cleansing (\u0026ldquo;sobada de cuy\u0026rdquo;) showed similarly low acceptance (18.1%) and use (15.8%) despite moderate knowledge (71.0%).\u003c/p\u003e \u003cp\u003eAmong alternative and complementary modalities, yoga showed the highest awareness (85.6%) and acceptance (49.1%), and was the most widely used (67.0%). Music therapy also displayed substantial acceptance (37.3%) and moderate use (23.3%) despite a slightly lower level of knowledge (73.0%). Conversely, acupuncture presented a notable discrepancy between relatively high knowledge (76.6%) and very low use (9.6%), paired with low acceptance (26.9%). Functional foods and nutraceuticals (knowledge 66.2%, acceptance 28.2%, use 35.7%) and aromatherapy (knowledge 66.0%, acceptance 31.2%, use 21.4%) showed moderate awareness with variable levels of acceptance and use.\u003c/p\u003e \u003cp\u003eOverall, these findings highlight a substantial gap between knowledge and personal use across most modalities.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eT\u0026amp;CM: Traditional, Complementary, and Alternative Medicine\u003c/p\u003e \u003cp\u003e*For each method, the bars represent the proportion of participants who indicated (i) having knowledge of the method, (ii) accepting its use in healthcare, and (iii) having personally used it.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCAM: Complementary and Alternative Medicine\u003c/p\u003e \u003cp\u003e*For each method, the bars represent the proportion of participants who indicated (i) having knowledge of the method, (ii) accepting its use in healthcare, and (iii) having personally used it.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Association Analyses of Knowledge, Acceptance, and Use of T\u0026amp;CM\u003c/h2\u003e \u003cp\u003eBivariate analyses showed a strong association between knowledge and both acceptance (χ\u0026sup2; = 68.6, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and use (χ\u0026sup2; = 113.5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) of T\u0026amp;CM. Acceptance was also positively associated with use (χ\u0026sup2; = 152.4, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with an adjusted prevalence ratio of 1.71 (95% CI: 1.52\u0026ndash;1.92; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eMultivariable models for the associations between knowledge and acceptance, as well as knowledge and use, could not be estimated due to complete separation in the contingency tables. This occurred because all students reporting knowledge of T\u0026amp;CM also reported both acceptance and use of these modalities \u003cb\u003e(Table\u0026nbsp;2)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate and multivariable association between Knowledge, Acceptance, and Use of T\u0026amp;CM (n\u0026thinsp;=\u0026thinsp;855).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExposure \u0026rarr; Outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ\u0026sup2; (p-value)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdjusted PR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge \u0026rarr; Acceptance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.6 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot estimable\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge \u0026rarr; Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113.5 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot estimable\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptance \u0026rarr; Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152.4 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71 (1.52\u0026ndash;1.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003ePR\u0026thinsp;=\u0026thinsp;prevalence ratio; CI\u0026thinsp;=\u0026thinsp;95% confidence interval.\u003c/p\u003e \u003cp\u003e\u0026dagger;Adjusted PRs were estimated using Poisson regression with robust variance, controlling for age, sex, type of university, academic phase, province of origin, native language, and whether the student passed the conceptual evaluation. \u0026ldquo;Not estimable\u0026rdquo; indicates complete separation in the contingency table, leading to perfect prediction and preventing reliable estimation of the association.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Factors Associated with Knowledge, Acceptance, and Use\u003c/h2\u003e \u003cp\u003eAdjusted analyses are presented in \u003cb\u003eTable\u0026nbsp;3\u003c/b\u003e. Knowledge of T\u0026amp;CM was significantly higher among students who had attended a related course (aPR\u0026thinsp;=\u0026thinsp;1.05; 95% CI: 1.02\u0026ndash;1.08; p\u0026thinsp;=\u0026thinsp;0.002) and those who passed the conceptual evaluation (aPR\u0026thinsp;=\u0026thinsp;1.03; 95% CI: 1.01\u0026ndash;1.06; p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eAcceptance of T\u0026amp;CM was greater in women (aPR\u0026thinsp;=\u0026thinsp;1.24; 95% CI: 1.12\u0026ndash;1.37; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), students with knowledge of a native language (aPR\u0026thinsp;=\u0026thinsp;1.14; 95% CI: 1.02\u0026ndash;1.26; p\u0026thinsp;=\u0026thinsp;0.02), and those who had attended a related course (aPR\u0026thinsp;=\u0026thinsp;1.18; 95% CI: 1.07\u0026ndash;1.30; p\u0026thinsp;=\u0026thinsp;0.001). Older age was associated with slightly lower acceptance (aPR\u0026thinsp;=\u0026thinsp;0.96; 95% CI: 0.94\u0026ndash;0.99; p\u0026thinsp;=\u0026thinsp;0.004).\u003c/p\u003e \u003cp\u003eUse of T\u0026amp;CM was more frequent among women (aPR\u0026thinsp;=\u0026thinsp;1.29; 95% CI: 1.18\u0026ndash;1.41; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), students with knowledge of a native language (aPR\u0026thinsp;=\u0026thinsp;1.16; 95% CI: 1.05\u0026ndash;1.28; p\u0026thinsp;=\u0026thinsp;0.004), and those who had attended a related course (aPR\u0026thinsp;=\u0026thinsp;1.21; 95% CI: 1.10\u0026ndash;1.33; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eNo significant associations were observed for university type, academic stage, or geographic origin across any of the outcomes. Detailed estimates for all variables are provided in \u003cb\u003eTable\u0026nbsp;3\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with Knowledge, Acceptance, and Use of T\u0026amp;CM (n\u0026thinsp;=\u0026thinsp;855)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted PR (95% CI) Knowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted PR (95% CI) Acceptance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted PR (95% CI) Use\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00 (1.00\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.96 (0.94\u0026ndash;0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.99 (0.98\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (female vs male)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.01 (0.98\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.22 (1.10\u0026ndash;1.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.23 (1.13\u0026ndash;1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity type (private vs public)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.97 (0.94\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.09 (0.95\u0026ndash;1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.97 (0.88\u0026ndash;1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic phase (clinical vs basic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.97 (0.94\u0026ndash;1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00 (0.88\u0026ndash;1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.93 (0.86\u0026ndash;1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlace of origin (province vs Lima)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.97\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02 (0.92\u0026ndash;1.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.01 (0.93\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnows native language (Yes vs No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.01 (0.98\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.15 (1.02\u0026ndash;1.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.12 (1.03\u0026ndash;1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePassed conceptual evaluation (Yes vs No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.03 (1.01\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02 (0.93\u0026ndash;1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.05 (0.97\u0026ndash;1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttended related course (Yes vs No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.05 (1.02\u0026ndash;1.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.24 (1.13\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.07 (0.99\u0026ndash;1.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003ePR\u0026thinsp;=\u0026thinsp;prevalence ratio; CI\u0026thinsp;=\u0026thinsp;95% confidence interval.\u003c/p\u003e \u003cp\u003eAdjusted prevalence ratios were estimated using Poisson regression with robust variance.\u003c/p\u003e \u003cp\u003eAll models were adjusted for age, sex, university type, academic phase, place of origin, native language, passing the conceptual evaluation, and attending a related course\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e3.6. Exposure and Environment Related to T\u0026amp;CM\u003c/h2\u003e \u003cp\u003eFigure 4 shows students\u0026rsquo; exposure to and engagement with T\u0026amp;CM in their environment. Fewer than half of the participants (47.6%, n\u0026thinsp;=\u0026thinsp;409) reported knowing whether T\u0026amp;CM was practiced in their district. Regarding academic influence, 34.7% (n\u0026thinsp;=\u0026thinsp;297) indicated that an instructor not associated with the T\u0026amp;CM course had discussed T\u0026amp;CM with them. Family exposure was more common, with 64.5% (n\u0026thinsp;=\u0026thinsp;551) reporting conversations about T\u0026amp;CM with relatives. Additionally, 73.6% (n\u0026thinsp;=\u0026thinsp;629) expressed interest in actively seeking information about T\u0026amp;CM.\u003c/p\u003e \u003cp\u003eImportantly, most students (89.9%, n\u0026thinsp;=\u0026thinsp;769) reported not being informed about the acceptance of T\u0026amp;CM by national or international organizations of recognized scientific credibility, while only 10.1% (n\u0026thinsp;=\u0026thinsp;86) indicated being aware of such institutional positions.\u003c/p\u003e \u003cp\u003eT\u0026amp;CM: Traditional, Complementary, and Alternative Medicine\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e3.7. Perceptions of T\u0026amp;CM\u003c/h2\u003e \u003cp\u003eFigure 5 illustrates students\u0026rsquo; perceptions toward T\u0026amp;CM. The vast majority had a positive view of physicians practicing T\u0026amp;CM (83.9%, n\u0026thinsp;=\u0026thinsp;792) and reported willingness to recommend or advise patients to access T\u0026amp;CM treatments in their future practice (81.1%, n\u0026thinsp;=\u0026thinsp;694). Similarly, 88.3% (n\u0026thinsp;=\u0026thinsp;755) of students expressed willingness to receive training related to T\u0026amp;CM. Fewer students supported formal recognition of T\u0026amp;CM as a medical specialty (44.9%, n\u0026thinsp;=\u0026thinsp;382), though 75.5% (n\u0026thinsp;=\u0026thinsp;642) would consider encouraging a patient to continue using T\u0026amp;CM if aware of its use. Finally, most participants (87.3%, n\u0026thinsp;=\u0026thinsp;746) agreed that integrating T\u0026amp;CM approaches into modern medical practice is appropriate.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Main Findings\u003c/h2\u003e \u003cp\u003eThis multicenter study revealed that nearly all Peruvian medical students were familiar with at least one modality of T\u0026amp;CM, although acceptance and use were considerably lower. The strong associations between knowledge, acceptance, and use suggest that awareness alone does not necessarily translate into endorsement or clinical integration. Furthermore, the inability to model some associations due to near-complete overlap between knowledge and subsequent acceptance and use highlights the pervasive exposure of medical students to T\u0026amp;CM in non-academic contexts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Comparison with Previous Literature\u003c/h2\u003e \u003cp\u003eOur findings align with international studies showing that medical students frequently report high awareness of T\u0026amp;CM but exhibit variable levels of acceptance and use. For instance, a study among Malaysian pharmacy students found that 57.8% were currently using CAM while 77.6% had used it previously; additionally, a majority believed that CAM knowledge is necessary for a well-rounded professional (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In contrast, studies in Ghana have shown that about 59.0% of medical students had ever used CAM, and around 75% favored its introduction in the medical curriculum, reflecting good acceptance though not always matched with institutional recognition (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInterestingly, while our study found that nearly 88% of students expressed willingness to receive training in T\u0026amp;CM, only 45% supported its recognition as a medical specialty. This divergence between personal acceptance and institutional endorsement resembles findings from South Africa, where a study of medical schools showed that although many institutions cover TCAM, it is often in a tokenistic manner and without strong curricular commitment (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Similarly, research in the UK indicates that while medical students are positively disposed to CAM education and perceive it as useful for future practice, fewer support CAM being fully professionalized or integrated as a specialty without stronger evidence (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Discrepancies in Knowledge, Acceptance, and Use of Specific T\u0026amp;CM Modalities\u003c/h2\u003e \u003cp\u003eOur study revealed notable gaps between medical students\u0026rsquo; knowledge, acceptance, and use of specific T\u0026amp;CM modalities. Practices such as egg cleansing and medicinal plant use were widely recognized (89.6% and 83.3%), but acceptance and actual use were lower. Conversely, hueser\u0026iacute;a showed moderate awareness (61.6%) but high acceptance (84.3%), suggesting cultural perception and perceived efficacy influence attitudes beyond mere familiarity.\u003c/p\u003e \u003cp\u003eAmong complementary modalities, yoga and phytotherapy had high awareness (67.8% and 82.5%), yet usage remained limited, especially for acupuncture (9.6%). These patterns align with international evidence showing that medical students often hold positive attitudes toward T\u0026amp;CM but have variable knowledge and practical experience (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These discrepancies highlight the importance of integrating structured T\u0026amp;CM education into medical curricula to improve students\u0026rsquo; understanding, cultural competence, and ability to guide patients safely (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec30\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Determinants of Knowledge, Acceptance, and Use\u003c/h2\u003e \u003cp\u003eOur findings that female students reported greater acceptance and use of T\u0026amp;CM than their male counterparts are consistent with multiple studies worldwide. Research in Turkey and Saudi Arabia has shown that women tend to have more positive attitudes toward CAM and are more likely to use these therapies themselves, possibly reflecting gender differences in health-seeking behavior and openness to holistic care approaches (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCultural background also appears to play a significant role. In our study, students with knowledge of a native language\u0026mdash;likely reflecting stronger cultural ties\u0026mdash;reported greater acceptance and use of T\u0026amp;CM. Similar findings have been reported in Bangladesh and Sierra Leone, where family and community transmission of traditional practices was strongly associated with both knowledge and personal use of CAM, underscoring the importance of cultural continuity in shaping attitudes toward these modalities (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEducational exposure emerged as another consistent determinant. We observed that students who had taken a T\u0026amp;CM-related course reported higher knowledge, acceptance, and use. Evidence from pre- and post-intervention studies in Saudi Arabia and curriculum evaluations in Europe demonstrates that structured CAM education improves factual knowledge, enhances confidence in discussing CAM with patients, and fosters more favorable attitudes toward its integration into medical practice (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOverall, our results, together with existing evidence, indicate that gender, cultural ties, and formal education are the primary determinants of knowledge, acceptance, and use of T\u0026amp;CM, whereas institutional and demographic characteristics play a lesser role.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003e4.5. Exposure and Perceptions\u003c/h2\u003e \u003cp\u003eIn our study, many students reported limited awareness of whether T\u0026amp;CM modalities are practiced in their own districts, moderate exposure through external instructors and family discussions, and strong interest in seeking more information. These findings resonate with previous research showing that medical students often rely more on informal sources (media, friends/relatives) than formal education for exposure to CAM, yet they maintain generally positive perceptions toward its use. For example, in a cross-sectional study at King Saud bin Abdulaziz University, a majority of students (\u0026asymp;\u0026thinsp;60\u0026ndash;70%) reported awareness of CAM modalities, considered many as effective, and acquired information mostly from media, books, friends/relatives, while very few had formal CAM training (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn another study from Bangladesh, around 80% of medical and non-medical students expressed interest in receiving education about CAM, even though knowledge differed by modality and source of information (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Similarly, a pre- and post-course survey in Saudi Arabia showed that exposure to a dedicated CAM course significantly improved perceptions regarding efficacy, personal use, advising patients, and the inclusion of CAM in medical curricula (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). These patterns mirror our finding that while informal exposure is common, formal academic engagement and curricular exposure lag behind, yet student perceptions are favorable and demand for training is high.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003e4.6. Educational implications\u003c/h2\u003e \u003cp\u003eOur findings, along with recent evidence from Peru and other regions, highlight the urgent need to strengthen the formal integration of T\u0026amp;CM into undergraduate medical curricula. A recent national review found that only 31.9% of Peruvian medical schools included dedicated TCM courses, most of them elective, with substantial variability in topics covered, teaching methods, and evaluation strategies (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This aligns with international reports indicating limited or inconsistent curricular exposure to T\u0026amp;CM despite students\u0026rsquo; expressed interest in training and generally positive attitudes toward its use (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA scoping review analyzing CAM education across multiple countries concluded that structured, evidence-based curricular interventions improve students\u0026rsquo; factual knowledge, confidence in discussing CAM with patients, and attitudes toward its integration into modern practice (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Similarly, a critical review of medical student attitudes toward CAM emphasized that early, standardized exposure reduces misconceptions and promotes a more balanced perspective regarding risks, benefits, and ethical considerations (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Latin America, studies have reported that interest in learning about T\u0026amp;CM often surpasses actual curricular opportunities (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). For example, Colombian medical students cited both cultural relevance and patient demand as motivations for formal training, yet also highlighted the absence of standardized modules or faculty expertise as barriers (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Similarly, a multimodal CAM curriculum implemented at the University of California, Irvine, which included lectures, online assignments, and interactive components, significantly improved medical students\u0026rsquo; familiarity with CAM modalities, perceptions of safety and efficacy, and willingness to recommend CAM treatments (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Furthermore, initiatives involving medical students in curriculum development have shown positive effects on engagement and attitudes toward CAM education, underscoring the value of well-designed educational interventions in shaping clinical perspectives (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, integrating T\u0026amp;CM as mandatory components in medical curricula, rather than elective courses, appears crucial. Curricular reforms should ensure minimum standardized content, practical training opportunities, and ethical guidelines for clinical use. Furthermore, faculty development programs are essential to equip educators with the necessary expertise for supervising and evaluating CAM education effectively. Without addressing both curricular structure and educator preparedness, efforts to integrate T\u0026amp;CM risk remaining fragmented and unsustainable (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Strengths and Limitations","content":"\u003cp\u003eThis study has several important strengths. It represents the first multicenter investigation in Peru and one of the few in Latin America assessing knowledge, acceptance, and use of T\u0026amp;CM among medical students. By including 855 participants from 15 universities across three geographic regions and both public and private institutions, the study reflects the sociocultural and educational diversity of a multicultural country such as Peru, where ancestral traditions and modern medical training coexist. The questionnaire underwent internal validation through expert review and pilot testing, demonstrating good internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.80). Moreover, the use of random sampling, a large sample size exceeding power requirement, and adherence to STROBE guidelines reinforce the methodological robustness and transparency of the findings.\u003c/p\u003e \u003cp\u003eNevertheless, some limitations should be acknowledged. The cross-sectional design precludes causal inference between sociodemographic factors and T\u0026amp;CM outcomes. The reliance on self-reported data may introduce recall and social desirability biases, potentially leading to over- or underestimation of attitudes and practices. The complete separation observed in contingency tables restricted multivariable modeling for some associations, limiting exploration of potential confounders. Furthermore, although the study included institutions from diverse regions, findings may not be fully generalizable to other Latin American countries, given cultural and curricular differences. Finally, unmeasured factors such as socioeconomic background, religiosity, or previous family exposure to T\u0026amp;CM may have influenced students\u0026rsquo; perceptions but were not assessed in this study.\u003c/p\u003e \u003cp\u003eDespite these limitations, this research provides robust baseline evidence for future longitudinal and interventional studies and offers valuable insights to guide the integration of T\u0026amp;CM education into medical curricula in Peru and other multicultural contexts across Latin America.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThis multicenter study showed that nearly all Peruvian medical students were familiar with at least one T\u0026amp;CM modality, although acceptance and use were lower and varied by specific technique or method. Female students, those with knowledge of a native language, and those who had received T\u0026amp;CM-related education reported higher acceptance and usage. Despite widespread interest in receiving formal training, curricular exposure remains limited and inconsistent. These findings underscore the need for structured, evidence-based integration of T\u0026amp;CM into medical curricula to enhance cultural competence, practical knowledge, and the ability to safely guide patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interest:\u003c/strong\u003e The authors declare no conflicts of interest regarding this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement:\u003c/strong\u003e This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eL.J.U.-C.: Study design, execution, data analysis and interpretation, manuscript drafting.\u003c/p\u003e\n\u003cp\u003eA.D.-M., A.A.T.-S., Z.M.-C., N.S.-T., K.A.M.-S., J.N.N.-C., E.C.-C., Y.M.M.-T., O.N.V.-G., J.S.Q.-G., P.R.D.-A., A.J.V.-U., D.S., O.C.B.-S., L.P.\u0026Aacute;., C.M.-O., I.S.S., A.D.V.-R.-T., C.P.L., X.C.B.-C., E.P.-C., Z.T.H.L., L.R.S.S.: Data collection, contribution to analysis and interpretation, critical review of content.\u003c/p\u003e\n\u003cp\u003eM.V.-L and J.H.-R.: Overall supervision, methodological guidance, and critical manuscript review as senior author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and informed consent statements:\u003c/strong\u003e The study protocol was approved by the Ethics Committee of Universidad de San Mart\u0026iacute;n de Porres (IRB No. 00003251), Lima, Per\u0026uacute; and permission to conduct the survey was obtained from each participating university. The study was conducted in accordance with the principles of the Declaration of Helsinki. Participation was voluntary, anonymous, and confidential. Electronic informed consent was obtained through the online questionnaire, which was administered in person during data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003enot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOrganization WH, WHO Traditional Medicine Strategy. : 2014\u0026ndash;2023. Strategy / Report. 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Revista espa\u0026ntilde;ola de salud p\u0026uacute;blica. 2008;82:251\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVillar L\u0026oacute;pez M, Ballinas Sueldo Y, Soto Franco JN, Medina Tejada N. Knowledge, acceptance and use of traditional, alternative and/or complementary medicine among medical doctors from the Social Health Insurance. Peruvian Journal of Integrative Medicine. 2016;1(2):55\u0026ndash;63. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hdl.handle.net/20.500.12959/3988\u003c/span\u003e\u003cspan address=\"https://hdl.handle.net/20.500.12959/3988\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmeade EPK, Amalba A, Helegbe GK, Mohammed BS. Medical students' knowledge and attitude towards complementary and alternative medicine \u0026ndash; A survey in Ghana. J Traditional Complement Med. 2016;6(3):230\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChitindingu E, George G, Gow J. A review of the integration of traditional, complementary and alternative medicine into the curriculum of South African medical schools. BMC Med Educ. 2014;14(1):40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlaherty G, Fitzgibbon J, Cantillon P. Attitudes of medical students toward the practice and teaching of integrative medicine. J Integr Med. 2015;13(6):412\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuartey NK, Ma PHX, Chung VCH, Griffiths SM. Complementary and Alternative Medicine Education for Medical Profession: Systematic Review. Evidence-Based Complement Altern Med. 2012;2012:1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkan H, Izbirak G, Kaspar E\u0026Ccedil;, Kaya \u0026Ccedil;A, Aydin S, Demircan N, et al. 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J Complement Integr Med. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoliman MS, Bilszta J. Teaching complementary and alternative medicine in undergraduate medical education: a scoping review. Int J Med Educ. 2021;12:140\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoylan PM, Murzello A, Parmar J, Chow NK. Integration of Latin American Complementary and Alternative Medicine Topics Into a Doctor of Pharmacy Curriculum and Survey of Student Attitudes and Behaviors. J Med Educ Curric Dev. 2020;7:238212052090412.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePimentel J, Sarmiento I, Zuluaga G, Andersson N. What motivates medical students to learn about traditional medicine? A qualitative study of cultural safety in Colombia. Int J Med Educ. 2020;11:120\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarag C, Caines LC, Wu H, Sun M, Guerrera MP. Familiarity with Complementary and Alternative Medicine: A Multimodal Curriculum in Medical Education. Integr Med Rep. 2022;1(1):101\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZurkinden E, Dubois J, Rodondi P-Y, Huber BM. Involving Medical Students in the Curriculum Development of Traditional, Complementary and Integrative Medicine: An Exploratory Qualitative Study. J Med Educ Curric Dev. 2025;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuzm\u0026aacute;n-Rosas SC, Kleiche-Dray M, Zolla C, Suaste-G\u0026oacute;mez E. The Exclusion of Indigenous Traditional Knowledge in the Higher Education: The Case of Traditional Medicine and the Mexican Medical Education. Creative Educ. 2015;06(09):867\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Traditional Medicine, Complementary Therapies, Health Knowledge, Attitudes, Practice, Students, Medical, Education, Medical, Culture, Peru","lastPublishedDoi":"10.21203/rs.3.rs-8340724/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8340724/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTraditional, Complementary, and Alternative Medicine (T\u0026amp;CM) is widely used in Peru, especially in Andean and Amazonian regions. However, its place in medical curricula remains limited.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo evaluate knowledge, acceptance, and use of T\u0026amp;CM among Peruvian medical students through a multicenter survey and to identify factors associated with these outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe conducted a multicenter cross-sectional study (March\u0026ndash;June 2025) in 15 medical schools located in the coast, highlands, and rainforest regions. A random sample of 855 students completed a validated questionnaire. Data were analyzed using descriptive statistics and Poisson regression with robust variance.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMedian age was 22 years; 59.2% were women. Nearly all students (95.9%) reported knowledge of at least one T\u0026amp;CM modality; 65.3% expressed acceptance and 75.7% reported use. Acceptance was higher among women (aPR\u0026thinsp;=\u0026thinsp;1.24; 95% CI: 1.12\u0026ndash;1.37), students speaking a native language (aPR\u0026thinsp;=\u0026thinsp;1.14; 95% CI: 1.02\u0026ndash;1.26), and those with prior training (aPR\u0026thinsp;=\u0026thinsp;1.18; 95% CI: 1.07\u0026ndash;1.30). Similar factors were associated with use: female sex (aPR\u0026thinsp;=\u0026thinsp;1.29; 95% CI: 1.18\u0026ndash;1.41), native language (aPR\u0026thinsp;=\u0026thinsp;1.16; 95% CI: 1.05\u0026ndash;1.28), and training (aPR\u0026thinsp;=\u0026thinsp;1.21; 95% CI: 1.10\u0026ndash;1.33). Students with higher acceptance were more likely to use T\u0026amp;CM (aPR\u0026thinsp;=\u0026thinsp;1.71; 95% CI: 1.52\u0026ndash;1.92). Most students were willing to receive training (88.3%) and favored integration of T\u0026amp;CM into practice (87.3%), though fewer supported recognition as a specialty (44.9%).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis multicenter study shows high awareness but lower acceptance and use of T\u0026amp;CM among Peruvian medical students. Gender, cultural background, and training strongly influence attitudes. Findings highlight the demand for standardized, evidence-based curricular integration to prepare culturally competent physicians.\u003c/p\u003e","manuscriptTitle":"Knowledge, Acceptance, and Use of Traditional, Complementary, and Alternative Medicine Among Peruvian Medical Students: Insights from a Multicenter Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-19 14:07:36","doi":"10.21203/rs.3.rs-8340724/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"175e050c-4051-4bb4-aa04-2e3622396659","owner":[],"postedDate":"February 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T13:11:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-19 14:07:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8340724","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8340724","identity":"rs-8340724","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}