Measurements of traditional Chinese medicine health literacy regarding chronic pain: A scoping review

Measurements of traditional Chinese medicine health literacy regarding chronic pain: A scoping review | 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 Measurements of traditional Chinese medicine health literacy regarding chronic pain: A scoping review Zhiyi Qian, Grace Wang, Marcus Henning, Yan Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3355534/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Chronic pain is a prevalent health condition that imposes a significant burden on the global health system. Health literacy is a determinant of the quality of pain management which directly impacts public and individual health. However, the existing health literacy measurements have predominantly focused on medical models stemmed from Western culture and the knowledge of Indigenous and other non-Western health models has largely been neglected. This review scopes refereed health literacy publications with regards to traditional Chinese medicine and chronic pain to explore and identify 1) the conceptual basis underlying the development of Traditional Chinese medicine health literacy (TCM-HL) in this area, and 2) measurement tools used in this area and their associated psychometric qualities. Twenty-eight were assessed and the results showed that most studies’ conceptual basis was unable to cover three key health literacy aspects defined by the World Health Organization (access, understand, and apply). Furthermore, the identified health literacy measurement tools generally lacked rigorous psychometric evaluation. Future studies should focus on exploring a comprehensive model that encompasses various health models and develop measurement tools with more culturally representative psychometric assessments. health literacy measurement traditional Chinese medicine chronic pain psychometric evaluation Figures Figure 1 Introduction Chronic pain, such as knee osteoarthritis and lumbar disc herniation, has been defined as pain that persists for an extended period (i.e., at least three months or longer) and lasts longer than the expected recovery time (1). Chronic pain has high prevalence among older adults and places a significant burden on the health system globally (2,3). Chronic pain can negatively affect persons’ daily function, job opportunities, psychological wellbeing, and quality of life (4-6). Also, the recurring pain increases the chance of medication misuse which may cause addictive or other adverse medical issues (7). Extensive clinical efforts have been made to remediate individuals with chronic pain, including conventional methods (e.g., various types of analgesics or surgery), as well as complementary and alternative medicine (e.g., Chinese medicine or meditation) (8,9). In addition, self-management, regarded as a critical skill for achieving better health outcomes in populations with chronic pain, is addressed in both clinical and community settings (10). Health literacy (HL) is a concept initially proposed in the 1970s for western medicine (11) and has been widely accepted as one of the most influential determinants for both individual and public health (12). According to the World Health Organization (13), health literacy significantly contributes to an individual’s capacity to improve their lifestyle and health status, which includes basic skills such as reading pamphlets and making appointments, and advanced abilities related to acquiring, understanding, and utilizing health information or services to make constructive health-related decisions (14). Evidence suggests that health literacy is associated with the ability to manage pain and to improve health outcomes (15). For example, a person with a low level of health literacy is likely to have less knowledge about medication and pain, behave poorly in regulating self-management, and, thus, suffer a higher intensity of pain. When applied in the context of public health, the level of health literacy can be used as an evidence-based index to appraise and optimize health information, health services or health education programs, ultimately contributing to better health outcomes (16,17). Health literacy measurements with proven reliability and validity can help practitioners evaluate patients’ health-related knowledge and skill levels as well as identifying vulnerable populations (18). At present, the most commonly used objective measurement tools of chronic pain management are the Newest Vital Sign (NVS) (19), the Rapid Estimate of Adult Literacy in Medicine (REALM) (20) and its revised versions (REALM- Short Form or REALM-Revised), and the Short Test of Functional HL in Adults (S-TOFHLA). There are also subjective tools such as the Single Item Literacy Screener (SILS) (21), Subjective Numeracy Scale (22), Brief HL Screen (BHLS) (23), and Chew et al.’s brief screener (24). All these tools were developed based on Nutbeam’s (25) three-level model of health literacy and primarily focus on the functional level (i.e., basic reading and writing skills to be able to understand and use health information). Further developmental work is needed to capture the more advanced aspects of health literacy, such as the ability to assess the validity of health claims. In countries or regions with a strong Chinese cultural influence (i.e., Mainland China, Hongkong, Taiwan, Malaysia, Singapore), both traditional Chinese medicine (TCM) treatments (acupuncture, acupressure, massage, moxibustion, herbs, etc.) and western medicine treatments are used in the remediation of chronic pain. People who are accustomed to multiple health systems may hold different expectations and criteria when making health-related decisions. Their perceptions and understanding of intervention options influence the choice and effectiveness of treatment. For example, patients born and living in a country with the preference for western medicine tend to rely on biomedical options (i.e., physiotherapy, opioid medications, and surgery) to treat chronic pain. Conversely, those familiar with dual or multiple medical systems need to decide which system they should utilise, western medicine, TCM, or both. This decision-making process often results in various treatment options each with their own therapeutic benefits and side-effects. Therefore, a comprehensive understanding of culturally specific health literacy is crucial for accurately and inclusively assessing health literacy accurately and inclusively in these groups (26,27). Failure to do so may result in barriers to health promotion and disease prevention may occur (28). Being aware of the importance of TCM-HL, the Chinese government has published a guideline that consists of 66 items pertaining to the preservation of knowledge believed to be beneficial to the general population in 2012 (29). Several questionnaires have since been developed and applied in different regional groups (30-32). Similar to the WHO definition of health literacy, the TCM-HL is defined as the ability of individuals to gain access to, understand and apply TCM-related information to promote and maintain good health (33). Gaining access to TCM-related information refers to the ability to maintain the integrity of TCM, promoting therapeutic understanding, and ensuring patients can access professional health service providers. Understanding TCM-related information refers to individuals’ reading comprehension and numeracy skills which can help them understand health information more optimally. Applying TCM-related information to promote and maintain good health refers to the ability to choose an appropriate self-care method, determine the necessity of seeking professional help, and make positive medical decisions to navigate the dual-medical system. However, a preliminary literature search revealed that a dearth of research has been conducted in the area of TCM-HL in clinical contexts, especially in reference to chronic pain. Questions related to individuals’ access to pain management information or services, knowledge of chronic pain, or ability to self-manage pain and other related issues have been ambiguously investigated. This scoping review aims to expand and more systematically explore this initial literature search by addressing the following questions: what is the conceptual basis underlying the development of health literacy in TCM with respect to chronic pain? What are the TCM-HL measurement tools being used in reference to chronic pain research and practice, and what are their associated psychometric qualities? Methods This review follows the methodological approach recommended by Arksey and O’Malley (34). They recommend that researchers specify the research question, identify relevant literature, summarize, synthesize, and report the results. The systematic search was conducted according to the JBI PRISMA extension for scoping reviews checklist (35). Eligibility criteria Inclusion criteria: Population: Chinese population, including those from mainland China, Hongkong and Taiwan Research aims: TCM, pain and HL are mentioned; Articles should contain at least one aspect of HL (e.g., access to health information or service, understanding of process, diagnosis or treatment, or applying health information or service); and Articles should mention how HL has been evaluated Language: simplified or traditional Chinese, or English Publication date: no limit-March 2023 Article type: peer reviewed empirical (original research) articles Exclusion criteria: Review article (meta, systematic, scoping), grey literature, commentary, opinion, editorial, book, chapter, thesis, or conference abstract; Articles have no description on how TCM HL was measured; No exact TCM contents can be extracted from the measurements being applied; Chronic pain without persistent attacks (e.g., angina pectoris caused by coronary heart disease, dysmenorrhea); and Full text not available. Search strategy We conducted search with five databases: two simplified Chinese (SC) databases (Wanfang and CNKI), one traditional Chinese (TC) database (Airiti Library), and two English databases (PubMed and CINAHL). Search terms were categorized according to three groups: Group 1 consisted of terms related to TCM, including different expressions of TCM and various treatments. Group 2 comprised of terms related to HL, including different expressions of HL and related themes. Group 3 contained different expressions of pain. Search results should include at least one term from each group (using Boolean Operator ‘OR’ between terms in the same group and ‘AND’ between different groups). As the topic included TCM as major variable of interest, we chose three language search strategies to cover populations who were most likely familiar with or interested in TCM. The Chinese and English search terms were conducted and refined by authors and two librarians to generate more partially related terms of HL such as ‘behavior’ or ‘preference’, and using both British and US English spelling variations such as ‘behaviour’ and ‘behaviour’ to cover more materials for analysis. Group 1 terms were generated in Chinese and then translated to English. The terms in Groups 2 and 3 were generated in English and then translated to Chinese. The traditional Chinese terms were translated from simplified characters, while the English terms were not the same as Chinese terms as some Chinese terms had different expressions in English such as ‘ re fu ’ translates to ‘hot pack’ or ‘hot compress’, or some English terms have different expressions in Chinese such as ‘health concept’ translates to ‘ jian kang guan nian ’ or ‘ bao jian guan nian ’ or ‘ jian kang li nian ’ or ‘ bao jian li nian ’. Selection of sources of evidence The database search was conducted by the first author, followed by title and abstract screening. Full text screening was conducted by all authors. Articles written in Chinese were checked by the YC and GW, who are also native Chinese speakers, and discussed with MAH, a native English speaker. The included articles needed to achieve consensus between authors according to the inclusion and exclusion criteria. Data charting process and synthesis of results All authors discussed and reached an agreement on which information should be extracted and summarised. Table 1 consists of summarized information such as setting (community health centre, tertiary hospital, or clinic), types of pain, research designs, or participant details, and synthesized information including what were considered and assessed as TCM-HL, key items used in the measure, the quality of measurements, and which elements of health literacy (access, understanding or applying) have been explored. Results Selection of source of evidence The first search phase generated 4409 simplified Chinese articles, 247 traditional Chinese articles, and 1613 English articles. After deleting duplications, 5594 articles remained. At the title screening stage, 5106 articles were excluded as their titles were not related to TCM or CAM (complementary and alternative medicine) HL regarding pain. At the abstract screening stage, 296 articles were excluded as their abstracts revealed no content related to TCM HL regarding pain. At the full text screening stage, 166 articles were excluded as there were no measurement or description detail related to TCM HL regarding pain. Twenty-five simplified Chinese articles, one traditional Chinese article, and two English articles were included for the final review. The PRISMA-ScR flow diagram is shown in Figure 1. [Insert Figure 1 here] Measurement tools in reference to TCM health literacy and chronic pain The publication years of selected articles ranged from 2007 to 2022. Three studies were conducted in Taiwan (46,59,63), while others originated from mainland China. The majority of the studies (16 out of 28, 57%) were conducted in tertiary hospitals and the remaining studies were coordinated in either community hospitals or private clinics (59,63) (see Table 1). Various disease types and research methods were included in the articles. The most commonly studied disease was osteoarthritis (OA, N = 11), nine of which were knee osteoarthritis (KOA). There were nine articles concentrating on waist pain, one focusing on lower back pain (LBP), three focusing on lumbar disc herniation, one related to waist and leg, and four articles investigated pain associated with joint pain in the neck, shoulder, waist, and leg. Five articles studied osteoporosis, among which two focused specifically on osteoporosis and three mentioned osteoporosis along with other chronic pain diseases. Arthritis rehabilitation and general TCM knowledge (including pain items) were studied in three articles, respectively. Two articles focused on rheumatoid arthritis and one article studied soft tissue injury. The most commonly employed research designs were cross-sectional study (n=12) and randomized controlled trials (RCT, n=11). Three studies used quasi-experimental methods and two used a Delphi method (see Table 1). Psychometric quality of measurement tools There was a scarcity of item details presented in articles and only a few of them reported reliability and validity measures. Among the 28 included articles, seven described psychometric evaluation and 21 (six cross-sectional, three quasi-experimental and 11 RCTs) did not present any psychometric details, resulting in difficulties in appraising their evidence quality. Cronbach's α was the most frequently used statistical method to measure reliability and item internal consistency of the questionnaires. One article (43) described its reliability with a statement of ‘internal consistency’, but it was not clear which method they used (e.g., Cronbach's α or split-half, test-retest). To reflect the validity of the measurements, content validity was the most commonly used description (N = 5). Two Delphi studies (57,61) reported expert authority coefficients and coordination coefficients. One cross-sectional study (50) presented the content validity index (CVI) to show acceptable content validity, and another article mentioned face validity by experts but no further details were presented (59). Commonly used exploratory factor analysis measures, such as KMO (Kaiser-Meyer-Olkin) and Bartlett, were used in one article (49) to show acceptable construct validity (see Table II). Most articles stated increases in scores after health education with ambiguous item and psychometric details (39,46, etc.). TCM-HL conceptual basis and application in chronic pain area As seen in Table II, the reviewed measurement tools had different conceptual bases underlying health literacy as a concept. Only one article (63) covered all three aspects of the WHO HL framework (as aforementioned) referring to: apply (how health literacy can be applied in clinical and community settings), understand (how health literacy is understood in populations) and access (how health literacy information can be accessed). The remaining twenty-seven articles conceptualized and measured TCM-HL in one or two of these aspects. Twenty-four out of 28 studies mentioned the ‘apply’ construct with or without other facets (43,57, etc.), among which 20 focused only on the ‘apply’ facet (58,60, etc.). The most frequently adopted method to measure the ‘apply’ facet occurred when comparing participants’ scores on knowledge mastery level of certain diseases before and after health education. For example, Li (39) reported that participants’ knowledge mastery scores (diet, exercise, TCM method, health awareness, emotion) increased after TCM nursing intervention. Six articles explored the ‘understand’ facet by investigating patients’ perception of acupuncture sensation (46) or misunderstanding of hot compress therapy (37). Only three articles (51,57,63) included the facet of ‘access’ facet by exploring how people engaged in self-management and employing TCM health education information. Therefore, the conceptual basis of current studies was not conclusive which might cause inaccurate assessment results and neglect meaningful perspective. Discussion Our findings indicated that the conceptual basis of existing measures of TCM-HL regarding chronic pain fails to correspond to all three facets of the WHO’s definition, which is the ability to gain access, understand and apply health information or service to maintain healthy conditions ( 13 ). Only a few papers clarified the definition or conceptual model of the TCM-HL before developing a measurement tool. The majority of these tools only explored one or two facets of health literacy and none of the reviewed tools measured the ‘apply’ facet regarding people’s ability to navigate the dual medical system ( 64 ). The psychometric quality of measurement tools was often difficult to discern. However, a few studies have shown some evidence of reliability and validity (43,49, etc.), while most of the included articles failed to conduct proper psychometric assessments (44,54, etc.). This lack of rigorous transparency makes the assessment of measurement tools difficult and the statement of results less defensible. A lack of emphasis on a comprehensive conceptual model for TCM-HL or limited cultural adaptation of tools that were developed in the western medical system may have contributed to the design and development of unsatisfactory measurement tools ( 26 ). In the current review, only one measurement tool ( 63 ) captured all three aspects of the WHO HL framework, but details regarding the item domains were limited. For example, to assess the ‘understand’ facet, only a single item was used to measure the percentage of believing the effectiveness of Chinese medicine treatments among rural older adults with chronic musculoskeletal pain in Taiwan. However, this single item could only reflect patients’ subjective opinions and was not able to accurately measure the targeted ability level because only a few validated items were being used. Furthermore, in most of the reviewed articles, the coverage of health literacy was limited to the mastery level of TCM preservation knowledge. TCM health literacy is usually evaluated with a supplementary measurement tool to attest the secondary benefit of health education during treatments. It is also important to note that practitioners and researchers also contribute to the instilment of health literacy level, which inevitably contributes to beneficial pain management resulting in good health outcome ( 15 ). Multiple factors have contributed to the findings when researching the efficacy of TCM health literacy in the remediation of chronic pain. Firstly, practitioners in China could be a key agent in promoting TCM health literacy. However, they are not trained health educators and their primary task is providing healthcare due to the large numbers of patients waiting for immediate diagnosis and prescription ( 65 ). Secondly, researchers are instrumental in developing valid and reliable measurement tools. However, they haven’t managed to do so because developing effective treatments/cures are prioritized in the clinical context instead of exploring ways to understand and promote patients’ health literacy skills. Thirdly, the large population in China means that there is a huge variation in people’s health literacy levels and this poses challenges to the healthcare system. Both health education and healthcare systems should be involved to promote the population’s health literacy levels and self-management skills as relying on practitioners’ one-sided healthcare (TCM or western medicine) is not sufficient. However, this could be difficult to achieve due to limited resources. The purpose of developing health literacy is to improve patients’ communication and self-care skills as well as optimizing the medical system ( 66 , 67 ), therefore, more emphasis should be put on catering to patients’ needs when considering long-term population health. The Chinese government has realized the importance of HL by publishing the official TCM-HL questionnaire ( 30 ), while the ongoing covid crisis further highlighted the importance of health literacy and self-management skills. The exploration of TCM health literacy in the chronic pain area can contribute to both individuals and the health system by promoting self-management and more equitable distribution of health resources. For example, the misunderstanding of the use of a hot compress might influence a patient’s medical decision by overusing it in an inappropriate manner or totally rejecting this treatment even if it is a cost-effective method. There are several limitations associated with this review. One is related to the development of search terms. Although efforts were made to cover all available articles in the area, it is possible that some studies were missed due to different pain-related expressions or conditions which were not directly related to pain but have measured health literacy. Another issue is related to the exclusion process, given that all reviewed studies were focussed on Chinese populations in mainland China, Hong Kong, and Taiwan. The results might be more comprehensive and applicable if include other regions with Chinese cultural backgrounds were investigated. The strength of the study is providing a clear view of current conceptual basis of TCM-HL and existing measurement tools, which can be a foundation for developing more culturally-specific assessment models and methods. Future studies could further explore how TCM health literacy could benefit public health. For the Chinese population or other TCM consumers, focus can be put on developing more comprehensive measurement tools to accurately assess TCM health literacy level and conducting related health education programmes. In addition, conducting more robust research in the area could provide more evidence on how TCM health literacy could contribute to better population health outcomes. Take chronic pain for example, population with higher TCM health literacy level will have better abilities in regards of obtaining related information, understanding essential knowledge, applying appropriate methods, and navigating between different medical systems, which benefit both individual pain management and public health. Conclusion Current research reflects some deficiencies regarding how Traditional Chinese medicine health literacy has been studied in the field of chronic pain. These deficiencies include the underestimation of its importance, the ambiguous nature when defining concepts, and the overabundance of low-quality measurements. It is proposed that future research should focus on exploring the development of clearer definitions, advancing more comprehensive conceptual frameworks, and actively engaging in the design and implementation of high-quality, psychometrically robust assessment tools. Abbreviations BHLS: Brief Health Literacy Screen CAM: complementary and alternative medicine CVI: content validity index HL: health literacy KMO: Kaiser-Meyer-Olkin KOA: knee osteoarthritis LBP: lower back pain NVS: Newest Vital Sign OA: osteoarthritis RCT: randomized controlled trials REALM : Rapid Estimate of Adult Literacy in Medicine SC: simplified Chinese SILS: Single Item Literacy Screener S-TOFHLA : Short Test of Functional HL in Adults TC: traditional Chinese TCM: traditional Chinese medicine Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials All data generated or analysed during this study are derived from journal articles available in the following public databases: PubMed https://pubmed.ncbi.nlm.nih.gov CINAHL https://www.ebsco.com/products/research-databases/cinahl-database CNKI https://www.cnki.net Wanfang https://www.wanfangdata.com.cn Airiti Library https://www.airitilibrary.com Competing interests The authors declare that they have no competing interests. Funding None Authors' contributions ZQ conducted the initial literature searching and screening and wrote the first draft of the manuscript. GW and YC conducted the full text screening of Chinese articles. MH conducted the full text screening of English articles. All authors participated in literature analysis, manuscript writing and scientific discussion. Acknowledgements The authors acknowledge librarian Joanna Feng for the suggestions of searching terms. References Apkarian AV, Baliki MN, Geha PY. Towards a theory of chronic pain. Prog Neurobiol. 2009;87(2):81–97. Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789–858. Institute of Medicine. 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Application of health management intervention guided by traditional Chinese medicine syndrome differentiation in patients with knee osteoarthritis. J Qiqihar Med Coll. 2020;41(17):2242–4. Chen C, Yan J. Study on the cognition and satisfaction of middle-aged and elderly population regarding acupuncture treatment for soft tissue injuries. J Welf Technol Service Manage. 2021;9(1):21–36. Lan Z, Wang J, Huang Q, Chen L. Observation of the impact of PDCA-guided health education on patients' cognition, attitudes, and behaviors regarding knee osteoarthritis treated with Zhuang Yao Nijiu therapy. China Med Innov. 2021;18(14):171–4. Niu Y, Wang C, Wang X. Application of the PDCA-based knee osteoarthritis health education evaluation standard. Integr Traditional Chin Western Nurs. 2021;7(4):8. Fei J. Application of health education in acupuncture treatment of rheumatoid arthritis. Special Health. 2021;13:201. Liu CT, Wu BY, Chen YH, Tsai MY. Pain experiences and coping strategies in rural older adults with chronic musculoskeletal pain in mountainous areas of Taiwan. Pain Manage Nurs. 2022;23(4):524–31. Qian ZY, Wang GY, Henning MA, Chen Y. Understanding health literacy from a TCM perspective. J Integr Med. 2023;21(3):215–20. Li X, Krumholz HM, Yip W, Cheng KK, Maeseneer JD, Meng QY, Mossialos E, Li C, Lu JP, Su M, Zhang QL, Xu DR, Li LM, Normand ST, Peto R, Li J, Wang ZW, Yan WB, Gao RL, Chunharas S, Gao X, Guerra R, Ji HJ, Ke Y, Pan ZG, Wu XP, Xiao SY, Xie XY, Zhang YJ, Zhu J, Zhu SZ, Hu SS. Quality of primary health care in China: Challenges and recommendations. The Lancet. 2020;395(10239):1802–12. Lawrence W. Advancing health literacy: Building health communication from the patient side. J Communication Healthc. 2008;1(2):182–19. Parnell TA, Stichler JF, Barton AJ, Loan LA, Boyle DK, Allen PE. A concept analysis of health literacy. Nurs Forum. 2019;54(3):315–27. Tables Table 1 Information of included articles Author, Year, Setting Type of pain Research design, participant details HL focus Key items used in the measure Quality of the measure Elements of HL Feng et.al., 2007 (36) community centre waist and limb chronic pain RCT (n= 68), 50~78 yrs., and 42% female mastery level of self-preservation knowledge No items shown but a mastery score was presented. not validated Apply Liang et.al., 2008 (37) tertiary hospital neck, shoulder, waist, and leg pain Cross-sectional (n=100), 16~74 yrs., and 42% female awareness of hot compress Items measure how patients understand the usage, placement and effect of hot compress. not validated Understand Huang et. al., 2009 (38) tertiary hospital lumbar intervertebral disc herniation RCT (n=68), 43~73 yrs., and 44% female mastery level of diet, exercise, TCM method, health awareness and emotion knowledge No items shown but mastery scores were presented. not validated Apply Li, 2010 (39) tertiary hospital osteoporosis RCT (n=112), 60~97 yrs., and 44% female mastery level of diet, TCM method, health awareness and emotion knowledge No items shown but mastery scores were presented. not validated Apply Sun et.al., 2011 (40) community centre osteoporosis; neck, shoulder, waist, and leg pain; arthritic rehabilitation cross-sectional (n=391), 45~59 yrs., and 50% female mastery level of disease-related TCM preservation or treatment knowledge No items shown but mastery scores were presented. Cronbach's α Apply Cao, & Qiu, 2011 (41) tertiary hospital knee osteoarthritis RCT (n=60) mastery level of KOA knowledge No items shown but a mastery score was presented. not validated Apply Li, 2012 (42) community centre rheumatoid arthritis quasi-experimental (n=105), 50±16 yrs., and 76% female mastery level of TCM and western medicine nursing knowledge No items shown but a mastery score was presented. not validated Apply Yue, & Yang, 2012 (43) community centre general TCM knowledge (including pain items) cross-sectional (n=208), 47% 30~40 yrs. mastery level of basic concepts, Chinese medicine knowledge, diet and diagnosis terms, attitude towards TCM knowledge, and TCM healthcare-seeking behaviour Items measures community nurses’ understanding of TCM treatments, perceptions of TCM, and TCM experience for pain management. internal consistency face validity Understand Apply Guan, 2013 (44) tertiary hospital lumbar disc protrusion RCT (n=70), 43~73 yrs., and 44% female mastery level of TCM preservation method No items shown but a mastery score was presented. not validated Apply Yang, & Chen, 2013 (45) community centre osteoarthritis cross-sectional (n=388), 41~72 yrs., and 54% female mastery level of basic knowledge and osteoarthritis-related risks Practise the horse-riding squat as an exercise for OA. not validated Apply Chen et.al., 2015 (46) tertiary hospital low back pain cross-sectional (n=101), 22~74 yrs., and 76% female understand level of treatment sensation Items measure patients understanding of sensations during the acupuncture treatment. not validated Understand Zheng et.al., 2015 (47) tertiary hospital knee osteoarthritis cross-sectional (n=148), 88% female TCM treatments selection rate One item shows patients’ or practitioners’ choice of TCM treatments. not validated Apply Yuan, 2015 (48) community centre osteoporosis; neck, shoulder, waist, and leg pain; arthritic rehabilitation quasi-experimental (n=399), 60~78 yrs., and 43% female mastery level of TCM dietary guidance and disease-related TCM preservation or treatment knowledge No items shown but mastery scores were presented. not validated Apply Jin, & Qiu, 2015 (49) community centre general TCM knowledge and attitude (including pain items) cross-sectional (n=1726), 47.24±15.28 yrs., and 65% female awareness and utilization of TCM health service Items measure residents’ perspectives towards TCM health service. Cronbach's α KMO Bartlett Understand Zheng et.al., 2017 (50) tertiary hospital general TCM knowledge and attitude (including pain items) cross-sectional (n=218) problems of the clinical application of TCM nursing therapies No items shown but a mastery score was presented. Cronbach's α content validity: CVI apply He et.al., 2017 (51) community centre knee osteoarthritis cross-sectional (n=1000), 40~82 yrs., and 55% female know, believe and perform rate of TCM fumigation sources of health information No items shown but rates were presented. One item measures choice of information sources. not validated Access Apply Liu, 2017 (52) tertiary hospital lumbar intervertebral disc herniation RCT (n=40), 36~70 yrs., and 30% female mastery level of diet, TCM method, health awareness and emotion knowledge No items shown but mastery scores were presented. not validated Apply Zen et.al., 2017 (53) tertiary hospital osteoporosis RCT (n=86), 56~81 yrs., and 33% female mastery level of osteoporosis knowledge No items shown but a mastery score was presented. not validated Apply Pang et.al., 2019 (54) community centre knee osteoarthritis RCT (n=60), 38~64 yrs., and 73% female mastery level of disease and self-care knowledge No items shown but a mastery score was presented. not validated Apply Li et.al., 2019 (55) Tertiary hospital knee osteoarthritis cross-sectional (n=162), 18~80+ yrs., and 61% female mastery level of KOA diagnosis and treatment knowledge mastery level of physical exercise knowledge KOA can be treated by TCM methods. Practise the horse-riding squat as an exercise for KOA. not validated Apply Zha, 2019 (56) community centre Osteoporosis; neck, shoulder, waist, and leg pain; arthritis; rehabilitation quasi-experimental (n=56), 61~77 yrs., and 46% female mastery level of general TCM preservation knowledge and disease-related TCM preservation knowledge No items shown but mastery scores were presented. not validated Apply Zeng, et.al., 2020 (57) tertiary hospital knee osteoarthritis Delphi (n=71), and 47% female importance level of mastering knowledge of preventing exogenous and preserving methods sources of self-management and TCM health information Items related to knowledge of preventing and self-managing disease and sources of health education information are assessed by experts. content validity Access Apply Hu, 2020 (58) tertiary hospital knee osteoarthritis RCT (n=76), 45~80 yrs., and 61% female Implementation rate of diet, precaution and exercise No items shown but rates were presented. not validated Apply Chen, & Yan, 2021 (59) clinic soft tissue injury cross-sectional (n=254), 45~75+ yrs., and 65.2% female awareness of the procedure of acupuncture Items measure understanding of preparations before treatments, what may happen during and after treatments, prevention of uncomfortable feeling during treatments. Cronbach's α content validity (no data) Understand Lan, et.al., 2021 (60) tertiary hospital knee osteoarthritis RCT (n=86), 55~83 yrs., and 56% female mastery level of KOA and Zhuang herb mud moxibustion knowledge No items shown but mastery scores were presented. not validated Apply Niu et. al., 2021 (61) tertiary hospital knee osteoarthritis Delphi (n=15), 30~50 yrs. mastery level of TCM method, differentiation and diet, post-discharge preservation knowledge No items shown but mastery scores were presented. face validity Apply Fei, 2021 (62) tertiary hospital rheumatoid arthritis RCT (n=62), 39~76 yrs., and 39% female mastery level of health knowledge No items shown but a mastery score was presented. not validated Apply Liu et.al., 2022 (63) clinic chronic musculoskeletal (MSK) pain cross-sectional (n=55), 65~90+ yrs., and 69.1% female awareness of Chinese medicine source of health information; Chinese medicine treatments were believed to be benefit; Chinese medicine treatments for coping with MSK not validated Access Understand Apply Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3355534","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":242572738,"identity":"af75402e-257f-4b0e-8a73-0e81c8f3c9ac","order_by":0,"name":"Zhiyi Qian","email":"","orcid":"","institution":"University of Auckland","correspondingAuthor":false,"prefix":"","firstName":"Zhiyi","middleName":"","lastName":"Qian","suffix":""},{"id":242572739,"identity":"19e7fe08-c46f-4aca-b9d7-002d74ded71d","order_by":1,"name":"Grace Wang","email":"","orcid":"","institution":"University of Southern Queensland","correspondingAuthor":false,"prefix":"","firstName":"Grace","middleName":"","lastName":"Wang","suffix":""},{"id":242572740,"identity":"c7b9676b-2e4f-45d2-8429-10719bb26c4e","order_by":2,"name":"Marcus Henning","email":"","orcid":"","institution":"University of Auckland","correspondingAuthor":false,"prefix":"","firstName":"Marcus","middleName":"","lastName":"Henning","suffix":""},{"id":242572741,"identity":"e8d4f7ce-fe7e-44b0-b31c-c8ef020ad46b","order_by":3,"name":"Yan Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIie3RMUvDQBTA8XcE6hLaNTfpR3glkKn0s/QRcApByCIImulcrFnjt0gRpOOTDFlOumasi1OGZhE66SWrnNTN4f5wd8Px48EdgMv1XxM5wGw8r8zOpxKZDyf+hSCfSrB5YzhuF2nY6Hlf4jKdsvd+ENtbO9HpSqz1ZRbpJJQVxpnkSRgIPbETTtATqqYXTiKxR48qhgiE8u1k1w3ki56LbiB3hpx9GhLYSTtOYaoCM6XC2hB/mIJWItsOX9cqprL9yGSJDT3VfhaQWlnJdJfM90e1pKKIN/3D9Q09NvebQ6/sL3bBPz7CM8s+A+A8/+XS5XK5XGPf0UFZ+kuKcmgAAAAASUVORK5CYII=","orcid":"","institution":"University of Auckland","correspondingAuthor":true,"prefix":"","firstName":"Yan","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2023-09-14 13:14:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3355534/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3355534/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":45376997,"identity":"a39daa88-4ed5-43c5-89b5-277575330d7d","added_by":"auto","created_at":"2023-10-28 17:33:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30114,"visible":true,"origin":"","legend":"\u003cp\u003eSearches and screening flow according to PRISMA-ScR\u003c/p\u003e","description":"","filename":"Figure11.png","url":"https://assets-eu.researchsquare.com/files/rs-3355534/v1/ec4b08646911a559482cf7b8.png"},{"id":45377788,"identity":"d185d25e-a01a-4232-9b1e-5a3b9c4e4d84","added_by":"auto","created_at":"2023-10-28 17:41:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":374087,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3355534/v1/7e358fb2-0541-43bd-913a-fddebe1e484f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Measurements of traditional Chinese medicine health literacy regarding chronic pain: A scoping review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic pain, such as knee osteoarthritis and lumbar disc herniation, has been defined as pain that persists for an extended period (i.e., at least three months or longer) and lasts longer than the expected recovery time (1). Chronic pain has high prevalence among older adults and places a significant burden on the health system globally (2,3). Chronic pain can negatively affect persons\u0026rsquo; daily function, job opportunities, psychological wellbeing, and quality of life (4-6). Also, the recurring pain increases the chance of medication misuse which may cause addictive or other adverse medical issues (7). Extensive clinical efforts have been made to remediate individuals with chronic pain, including conventional methods (e.g., various types of analgesics or surgery), as well as complementary and alternative medicine (e.g., Chinese medicine or meditation) (8,9). In addition, self-management, regarded as a critical skill for achieving better health outcomes in populations with chronic pain, is addressed in both clinical and community settings (10).\u003c/p\u003e\n\u003cp\u003eHealth literacy (HL) is a concept initially proposed in the 1970s for western medicine (11) and has been widely accepted as one of the most influential determinants for both individual and public health (12). According to the World Health Organization (13), health literacy significantly contributes to an individual\u0026rsquo;s capacity to improve their lifestyle and health status, which includes basic skills such as reading pamphlets and making appointments, and advanced abilities related to acquiring, understanding, and utilizing health information or services to make constructive health-related decisions (14). Evidence suggests that health literacy is associated with the ability to manage pain and to improve health outcomes (15). For example, a person with a low level of health literacy is likely to have less knowledge about medication and pain, behave poorly in regulating self-management, and, thus, suffer a higher intensity of pain.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen applied in the context of public health, the level of health literacy can be used as an evidence-based index to appraise and optimize health information, health services or health education programs, ultimately contributing to better health outcomes (16,17). Health literacy measurements with proven reliability and validity can help practitioners evaluate patients\u0026rsquo; health-related knowledge and skill levels as well as identifying vulnerable populations (18). At present, the most commonly used objective measurement tools of chronic pain management are the Newest Vital Sign (NVS) (19), the Rapid Estimate of Adult Literacy in Medicine (REALM) (20) and its revised versions (REALM- Short Form or REALM-Revised), and the Short Test of Functional HL in Adults (S-TOFHLA). There are also subjective tools such as the Single Item Literacy Screener (SILS) (21), Subjective Numeracy Scale (22), Brief HL Screen (BHLS) (23), and Chew et al.\u0026rsquo;s brief screener (24). All these tools were developed based on Nutbeam\u0026rsquo;s (25) three-level model of health literacy and primarily focus on the functional level (i.e., basic reading and writing skills to be able to understand and use health information). Further developmental work is needed to capture the more advanced aspects of health literacy, such as the ability to assess the validity of health claims.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn countries or regions with a strong Chinese cultural influence (i.e., Mainland China, Hongkong, Taiwan, Malaysia, Singapore), both traditional Chinese medicine (TCM) treatments (acupuncture, acupressure, massage, moxibustion, herbs, etc.) and western medicine treatments are used in the remediation of chronic pain. People who are accustomed to multiple health systems may hold different expectations and criteria when making health-related decisions. Their perceptions and understanding of intervention options influence the choice and effectiveness of treatment. For example, patients born and living in a country with the preference for western medicine tend to rely on biomedical options (i.e., physiotherapy, opioid medications, and surgery) to treat chronic pain. Conversely, those familiar with dual or multiple medical systems need to decide which system they should utilise, western medicine, TCM, or both. This decision-making process often results in various treatment options each with their own therapeutic benefits and side-effects. Therefore, a comprehensive understanding of culturally specific health literacy is crucial for accurately and inclusively assessing health literacy accurately and inclusively in these groups (26,27). Failure to do so may result in barriers to health promotion and disease prevention may occur (28).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeing aware of the importance of TCM-HL, the Chinese government has published a guideline that consists of 66 items pertaining to the preservation of knowledge believed to be beneficial to the general population in 2012 (29). Several questionnaires have since been developed and applied in different regional groups (30-32). Similar to the WHO definition of health literacy, the TCM-HL is defined as the ability of individuals to gain access to, understand and apply TCM-related information to promote and maintain good health (33). Gaining access to TCM-related information refers to the ability to maintain the integrity of TCM, promoting therapeutic understanding, and ensuring patients can access professional health service providers. Understanding TCM-related information refers to individuals\u0026rsquo; reading comprehension and numeracy skills which can help them understand health information more optimally. Applying TCM-related information to promote and maintain good health refers to the ability to choose an appropriate self-care method, determine the necessity of seeking professional help, and make positive medical decisions to navigate the dual-medical system.\u003c/p\u003e\n\u003cp\u003eHowever, a preliminary literature search revealed that a dearth of research has been conducted in the area of TCM-HL in clinical contexts, especially in reference to chronic pain. Questions related to individuals\u0026rsquo; access to pain management information or services, knowledge of chronic pain, or ability to self-manage pain and other related issues have been ambiguously investigated. This scoping review aims to expand and more systematically explore this initial literature search by addressing the following questions:\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003ewhat is the conceptual basis underlying the development of health literacy in TCM with respect to chronic pain?\u003c/li\u003e\n \u003cli\u003eWhat are the TCM-HL measurement tools being used in reference to chronic pain research and practice, and what are their associated psychometric qualities?\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Methods","content":"\u003cp\u003eThis review follows the methodological approach recommended by Arksey and O\u0026rsquo;Malley (34). They recommend that researchers specify the research question, identify relevant literature, summarize, synthesize, and report the results. The systematic search was conducted according to the JBI PRISMA extension for scoping reviews checklist (35).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria:\u003c/p\u003e\n\u003cp\u003ePopulation: Chinese population, including those from mainland China, Hongkong and Taiwan\u003c/p\u003e\n\u003cp\u003eResearch aims:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTCM, pain and HL are mentioned;\u003c/li\u003e\n \u003cli\u003eArticles should contain at least one aspect of HL (e.g., access to health information or service, understanding of process, diagnosis or treatment, or applying health information or service); and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eArticles should mention how HL has been evaluated\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eLanguage: simplified or traditional Chinese, or English\u003c/p\u003e\n\u003cp\u003ePublication date: no limit-March 2023\u003c/p\u003e\n\u003cp\u003eArticle type: peer reviewed empirical (original research) articles\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExclusion criteria:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eReview article (meta, systematic, scoping), grey literature, commentary, opinion, editorial, book, chapter, thesis, or conference abstract;\u003c/li\u003e\n \u003cli\u003eArticles have no description on how TCM HL was measured;\u003c/li\u003e\n \u003cli\u003eNo exact TCM contents can be extracted from the measurements being applied;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eChronic pain without persistent attacks (e.g., angina pectoris caused by coronary heart disease, dysmenorrhea); and\u003c/li\u003e\n \u003cli\u003eFull text not available.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eSearch strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted search with five databases: two simplified Chinese (SC) databases (Wanfang and CNKI), one traditional Chinese (TC) database (Airiti Library), and two English databases (PubMed and CINAHL).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSearch terms were categorized according to three groups: Group 1 consisted of terms related to TCM, including different expressions of TCM and various treatments. Group 2 comprised of terms related to HL, including different expressions of HL and related themes. Group 3 contained different expressions of pain. Search results should include at least one term from each group (using Boolean Operator \u0026lsquo;OR\u0026rsquo; between terms in the same group and \u0026lsquo;AND\u0026rsquo; between different groups).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs the topic included TCM as major variable of interest, we chose three language search strategies to cover populations who were most likely familiar with or interested in TCM. The Chinese and English search terms were conducted and refined by authors and two librarians to generate more partially related terms of HL such as \u0026lsquo;behavior\u0026rsquo; or \u0026lsquo;preference\u0026rsquo;, and using both British and US English spelling variations such as \u0026lsquo;behaviour\u0026rsquo; and \u0026lsquo;behaviour\u0026rsquo; to cover more materials for analysis. Group 1 terms were generated in Chinese and then translated to English. The terms in Groups 2 and 3 were generated in English and then translated to Chinese. The traditional Chinese terms were translated from simplified characters, while the English terms were not the same as Chinese terms as some Chinese terms had different expressions in English such as \u0026lsquo;\u003cem\u003ere fu\u003c/em\u003e\u0026rsquo; translates to \u0026lsquo;hot pack\u0026rsquo; or \u0026lsquo;hot compress\u0026rsquo;, or some English terms have different expressions in Chinese such as \u0026lsquo;health concept\u0026rsquo; translates to \u0026lsquo;\u003cem\u003ejian kang guan nian\u003c/em\u003e\u0026rsquo; or \u0026lsquo;\u003cem\u003ebao jian guan nian\u003c/em\u003e\u0026rsquo; or \u0026lsquo;\u003cem\u003ejian kang li nian\u003c/em\u003e\u0026rsquo; or \u0026lsquo;\u003cem\u003ebao jian li nian\u003c/em\u003e\u0026rsquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelection of sources of evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe database search was conducted by the first author, followed by title and abstract screening. Full text screening was conducted by all authors. Articles written in Chinese were checked by the YC and GW, who are also native Chinese speakers, and discussed with MAH, a native English speaker. The included articles needed to achieve consensus between authors according to the inclusion and exclusion criteria.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData charting process and synthesis of results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors discussed and reached an agreement on which information should be extracted and summarised. Table 1 consists of summarized information such as setting (community health centre, tertiary hospital, or clinic), types of pain, research designs, or participant details, and synthesized information including what were considered and assessed as TCM-HL, key items used in the measure, the quality of measurements, and which elements of health literacy (access, understanding or applying) have been explored.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSelection of source of evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first search phase generated 4409 simplified Chinese articles, 247 traditional Chinese articles, and 1613 English articles. After deleting duplications, 5594 articles remained. At the title screening stage, 5106 articles were excluded as their titles were not related to TCM or CAM (complementary and alternative medicine) HL regarding pain. At the abstract screening stage, 296 articles were excluded as their abstracts revealed no content related to TCM HL regarding pain. At the full text screening stage, 166 articles were excluded as there were no measurement or description detail related to TCM HL regarding pain. Twenty-five simplified Chinese articles, one traditional Chinese article, and two English articles were included for the final review. The PRISMA-ScR flow diagram is shown in Figure 1.\u003c/p\u003e\n\u003cp\u003e[Insert Figure 1 here]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasurement tools in reference to TCM health literacy and chronic pain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe publication years of selected articles ranged from 2007 to 2022. Three studies were conducted in Taiwan (46,59,63), while others originated from mainland China. The majority of the studies (16 out of 28, 57%) were conducted in tertiary hospitals and the remaining studies were coordinated in either community hospitals or private clinics (59,63) (see Table 1).\u003c/p\u003e\n\u003cp\u003eVarious disease types and research methods were included in the articles. The most commonly studied disease was osteoarthritis (OA, N = 11), nine of which were knee osteoarthritis (KOA). There were nine articles concentrating on waist pain, one focusing on lower back pain (LBP), three focusing on lumbar disc herniation, one related to waist and leg, and four articles investigated pain associated with joint pain in the neck, shoulder, waist, and leg. Five articles studied osteoporosis, among which two focused specifically on osteoporosis and three mentioned osteoporosis along with other chronic pain diseases. Arthritis rehabilitation and general TCM knowledge (including pain items) were studied in three articles, respectively. Two articles focused on rheumatoid arthritis and one article studied soft tissue injury. The most commonly employed research designs were cross-sectional study (n=12) and randomized controlled trials (RCT, n=11). Three studies used quasi-experimental methods and two used a Delphi method (see Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychometric quality of measurement tools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was a scarcity of item details presented in articles and only a few of them reported reliability and validity measures. Among the 28 included articles, seven described psychometric evaluation and 21 (six cross-sectional, three quasi-experimental and 11 RCTs) did not present any psychometric details, resulting in difficulties in appraising their evidence quality. Cronbach\u0026apos;s \u0026alpha; was the most frequently used statistical method to measure reliability and item internal consistency of the questionnaires. One article (43) described its reliability with a statement of \u0026lsquo;internal consistency\u0026rsquo;, but it was not clear which method they used (e.g., Cronbach\u0026apos;s \u0026alpha; or split-half, test-retest). To reflect the validity of the measurements, content validity was the most commonly used description (N = 5). Two Delphi studies (57,61) reported expert authority coefficients and coordination coefficients. One cross-sectional study (50) presented the content validity index (CVI) to show acceptable content validity, and another article mentioned face validity by experts but no further details were presented (59). Commonly used exploratory factor analysis measures, such as KMO (Kaiser-Meyer-Olkin) and Bartlett, were used in one article (49) to show acceptable construct validity (see Table II). Most articles stated increases in scores after health education with ambiguous item and psychometric details (39,46, etc.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTCM-HL conceptual basis and application in chronic pain area\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs seen in Table II, the reviewed measurement tools had different conceptual bases underlying health literacy as a concept. Only one article (63) covered all three aspects of the WHO HL framework (as aforementioned) referring to: apply (how health literacy can be applied in clinical and community settings), understand (how health literacy is understood in populations) and access (how health literacy information can be accessed). The remaining twenty-seven articles conceptualized and measured TCM-HL in one or two of these aspects. Twenty-four out of 28 studies mentioned the \u0026lsquo;apply\u0026rsquo; construct with or without other facets (43,57, etc.), among which 20 focused only on the \u0026lsquo;apply\u0026rsquo; facet (58,60, etc.). The most frequently adopted method to measure the \u0026lsquo;apply\u0026rsquo; facet occurred when comparing participants\u0026rsquo; scores on knowledge mastery level of certain diseases before and after health education. For example, Li (39) reported that participants\u0026rsquo; knowledge mastery scores (diet, exercise, TCM method, health awareness, emotion) increased after TCM nursing intervention. Six articles explored the \u0026lsquo;understand\u0026rsquo; facet by investigating patients\u0026rsquo; perception of acupuncture sensation (46) or misunderstanding of hot compress therapy (37). Only three articles (51,57,63) included the facet of \u0026lsquo;access\u0026rsquo; facet by exploring how people engaged in self-management and employing TCM health education information. Therefore, the conceptual basis of current studies was not conclusive which might cause inaccurate assessment results and neglect meaningful perspective.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings indicated that the conceptual basis of existing measures of TCM-HL regarding chronic pain fails to correspond to all three facets of the WHO\u0026rsquo;s definition, which is the ability to gain access, understand and apply health information or service to maintain healthy conditions (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Only a few papers clarified the definition or conceptual model of the TCM-HL before developing a measurement tool. The majority of these tools only explored one or two facets of health literacy and none of the reviewed tools measured the \u0026lsquo;apply\u0026rsquo; facet regarding people\u0026rsquo;s ability to navigate the dual medical system (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). The psychometric quality of measurement tools was often difficult to discern. However, a few studies have shown some evidence of reliability and validity (43,49, etc.), while most of the included articles failed to conduct proper psychometric assessments (44,54, etc.). This lack of rigorous transparency makes the assessment of measurement tools difficult and the statement of results less defensible. A lack of emphasis on a comprehensive conceptual model for TCM-HL or limited cultural adaptation of tools that were developed in the western medical system may have contributed to the design and development of unsatisfactory measurement tools (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current review, only one measurement tool (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) captured all three aspects of the WHO HL framework, but details regarding the item domains were limited. For example, to assess the \u0026lsquo;understand\u0026rsquo; facet, only a single item was used to measure the percentage of believing the effectiveness of Chinese medicine treatments among rural older adults with chronic musculoskeletal pain in Taiwan. However, this single item could only reflect patients\u0026rsquo; subjective opinions and was not able to accurately measure the targeted ability level because only a few validated items were being used. Furthermore, in most of the reviewed articles, the coverage of health literacy was limited to the mastery level of TCM preservation knowledge. TCM health literacy is usually evaluated with a supplementary measurement tool to attest the secondary benefit of health education during treatments. It is also important to note that practitioners and researchers also contribute to the instilment of health literacy level, which inevitably contributes to beneficial pain management resulting in good health outcome (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMultiple factors have contributed to the findings when researching the efficacy of TCM health literacy in the remediation of chronic pain. Firstly, practitioners in China could be a key agent in promoting TCM health literacy. However, they are not trained health educators and their primary task is providing healthcare due to the large numbers of patients waiting for immediate diagnosis and prescription (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). Secondly, researchers are instrumental in developing valid and reliable measurement tools. However, they haven\u0026rsquo;t managed to do so because developing effective treatments/cures are prioritized in the clinical context instead of exploring ways to understand and promote patients\u0026rsquo; health literacy skills. Thirdly, the large population in China means that there is a huge variation in people\u0026rsquo;s health literacy levels and this poses challenges to the healthcare system. Both health education and healthcare systems should be involved to promote the population\u0026rsquo;s health literacy levels and self-management skills as relying on practitioners\u0026rsquo; one-sided healthcare (TCM or western medicine) is not sufficient. However, this could be difficult to achieve due to limited resources. The purpose of developing health literacy is to improve patients\u0026rsquo; communication and self-care skills as well as optimizing the medical system (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e), therefore, more emphasis should be put on catering to patients\u0026rsquo; needs when considering long-term population health. The Chinese government has realized the importance of HL by publishing the official TCM-HL questionnaire (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), while the ongoing covid crisis further highlighted the importance of health literacy and self-management skills. The exploration of TCM health literacy in the chronic pain area can contribute to both individuals and the health system by promoting self-management and more equitable distribution of health resources. For example, the misunderstanding of the use of a hot compress might influence a patient\u0026rsquo;s medical decision by overusing it in an inappropriate manner or totally rejecting this treatment even if it is a cost-effective method.\u003c/p\u003e \u003cp\u003eThere are several limitations associated with this review. One is related to the development of search terms. Although efforts were made to cover all available articles in the area, it is possible that some studies were missed due to different pain-related expressions or conditions which were not directly related to pain but have measured health literacy. Another issue is related to the exclusion process, given that all reviewed studies were focussed on Chinese populations in mainland China, Hong Kong, and Taiwan. The results might be more comprehensive and applicable if include other regions with Chinese cultural backgrounds were investigated. The strength of the study is providing a clear view of current conceptual basis of TCM-HL and existing measurement tools, which can be a foundation for developing more culturally-specific assessment models and methods.\u003c/p\u003e \u003cp\u003eFuture studies could further explore how TCM health literacy could benefit public health. For the Chinese population or other TCM consumers, focus can be put on developing more comprehensive measurement tools to accurately assess TCM health literacy level and conducting related health education programmes. In addition, conducting more robust research in the area could provide more evidence on how TCM health literacy could contribute to better population health outcomes. Take chronic pain for example, population with higher TCM health literacy level will have better abilities in regards of obtaining related information, understanding essential knowledge, applying appropriate methods, and navigating between different medical systems, which benefit both individual pain management and public health.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCurrent research reflects some deficiencies regarding how Traditional Chinese medicine health literacy has been studied in the field of chronic pain. These deficiencies include the underestimation of its importance, the ambiguous nature when defining concepts, and the overabundance of low-quality measurements. It is proposed that future research should focus on exploring the development of clearer definitions, advancing more comprehensive conceptual frameworks, and actively engaging in the design and implementation of high-quality, psychometrically robust assessment tools.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBHLS: Brief Health Literacy Screen\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCAM: complementary and alternative medicine\u003c/p\u003e\n\u003cp\u003eCVI: content validity index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHL: health literacy\u003c/p\u003e\n\u003cp\u003eKMO: Kaiser-Meyer-Olkin\u003c/p\u003e\n\u003cp\u003eKOA: knee osteoarthritis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLBP: lower back pain\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNVS: Newest Vital Sign\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOA: osteoarthritis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRCT: randomized controlled trials\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eREALM : Rapid Estimate of Adult Literacy in Medicine\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSC: simplified Chinese\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSILS: Single Item Literacy Screener\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eS-TOFHLA : Short Test of Functional HL in Adults\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTC: traditional Chinese\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTCM: traditional Chinese medicine\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are derived from journal articles available in the following public databases:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePubMed https://pubmed.ncbi.nlm.nih.gov\u003c/p\u003e\n\u003cp\u003eCINAHL https://www.ebsco.com/products/research-databases/cinahl-database\u003c/p\u003e\n\u003cp\u003eCNKI https://www.cnki.net\u003c/p\u003e\n\u003cp\u003eWanfang https://www.wanfangdata.com.cn\u003c/p\u003e\n\u003cp\u003eAiriti Library https://www.airitilibrary.com\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZQ conducted the initial literature searching and screening and wrote the first draft of the manuscript. GW and YC conducted the full text screening of Chinese articles. MH conducted the full text screening of English articles. All authors participated in literature analysis, manuscript writing and scientific discussion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge librarian Joanna Feng for the suggestions of searching terms.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eApkarian AV, Baliki MN, Geha PY. Towards a theory of chronic pain. Prog Neurobiol. 2009;87(2):81\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDisease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990\u0026ndash;2017: A systematic analysis for the Global Burden of Disease Study 2017. 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Int J Soc Res Methodol. 2005;8(1):19\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EL, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, Lewin S, Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriaty J, Clifford T, Tun\u0026ccedil;alp \u0026Ouml;, Straus S. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med. 2018;169(7):467\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng X, Zeng L, Mo Y, Zheng X. Traditional Chinese medicine nursing intervention for community patients with chronic lumbar and leg pain. Hebei Traditional Chinese Medicine. 2007;29(6):554\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang L, Guo W, Zhen Y, Duan L, Shi N, He W, Wang X. 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Observation of the effects of implementing traditional Chinese medicine health education pathway on patients with knee osteoarthritis. Nurs Res (Late Edition). 2011;5:1370\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Z. Integrated traditional Chinese and Western nursing intervention for community rheumatoid arthritis patients. Int Med Health Guidance News. 2012;18(19):2902\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYue S, Yang X. Survey and analysis of traditional Chinese nursing knowledge, attitudes, and behaviors among community nurses. Nurs Res (Late Edition). 2012;26(3):798\u0026ndash;801.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuan J. Traditional Chinese medicine nursing and daily health care for lumbar disc herniation. North Pharm. 2013;10(12):150\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang W, Chen G. Survey and analysis of osteoarthritis awareness among community middle-aged and elderly people. Massage and Rehabilitation Medicine. 2013;4(9):204\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen LC, Cheng LJ, Zhang Y, He X, Knaggs RD. Acupuncture or low frequency infrared treatment for low back pain in Chinese patients: A discrete choice experiment. PLoS ONE. 2015;10(5):e012691.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng S, Xu J, Huang S, He F, Ding C. Analysis of the current situation of medical treatment and treatment of 148 patients with knee osteoarthritis in a Class A hospital. Chin J Disease Control Prev. 2015;19(1):91\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan X. Analysis of the cognition of traditional Chinese medicine health knowledge and the effect of intervention among community elderly residents. Chin J Traditional Med Manage. 2015;1:117\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJin A, Qiu X. Survey and analysis on the recognition and utilization of traditional Chinese medicine services in Hangzhou residents' communities. China Rural Health Service Administration. 2015;9:1202\u0026ndash;120.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng J, Zhang L, Lin J, Wei L, Xu Y, Liu J, Li S, Liu Y, Yang Y, Ni C. Survey and analysis of the clinical application status of traditional Chinese nursing techniques in Grade A tertiary Chinese hospital. Chin Practical Nurs. 2017;33(31):2457.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe D, Zhao X, Dong Q. Investigation of cognition on traditional Chinese medicine intervention for knee osteoarthritis in community elderly. Massage and Rehabilitation Medicine. 2017;8(7):59\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu X. Effect of traditional Chinese medicine nursing intervention on patients with lumbar disc herniation. China Health Care \u0026amp; Nutrition. 2017;27(8):189.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeng D, Wang G, Guo X. Application study of traditional Chinese medicine characteristics health education combined with warm acupuncture in patients with osteoporosis. Front Med Health. 2017;7(18):156\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePang L, Chen X, Zhang G. Effect of traditional Chinese medicine syndrome differentiation nursing combined with routine nursing on knee osteoarthritis patients. Snake J 2019;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, Zhao Y, Chen Y. Survey of awareness of knee osteoarthritis in middle-aged and young people. Chin Med Med Res. 2019;25(20):84\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZha B. Analysis of the cognition and intervention effect of traditional Chinese medicine health knowledge among community elderly residents. Health Cultures 2019;83\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeng L, Yang W, Liang G, Xiao X, Luo M, Chen H, Guo D, Pan J, Han Y, Huang H, Zhao J, Zhao D, Liang W, Liu J. Expert questionnaire and analysis of lifestyle intervention and traditional Chinese medicine health management in knee osteoarthritis population. World Science and Technology-Modernization of Traditional Chinese Medicine and Materia Medica 2020;22(9):3311\u0026ndash;3317.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu X. Application of health management intervention guided by traditional Chinese medicine syndrome differentiation in patients with knee osteoarthritis. J Qiqihar Med Coll. 2020;41(17):2242\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen C, Yan J. Study on the cognition and satisfaction of middle-aged and elderly population regarding acupuncture treatment for soft tissue injuries. J Welf Technol Service Manage. 2021;9(1):21\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLan Z, Wang J, Huang Q, Chen L. Observation of the impact of PDCA-guided health education on patients' cognition, attitudes, and behaviors regarding knee osteoarthritis treated with Zhuang Yao Nijiu therapy. China Med Innov. 2021;18(14):171\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiu Y, Wang C, Wang X. Application of the PDCA-based knee osteoarthritis health education evaluation standard. Integr Traditional Chin Western Nurs. 2021;7(4):8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFei J. Application of health education in acupuncture treatment of rheumatoid arthritis. Special Health. 2021;13:201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu CT, Wu BY, Chen YH, Tsai MY. Pain experiences and coping strategies in rural older adults with chronic musculoskeletal pain in mountainous areas of Taiwan. Pain Manage Nurs. 2022;23(4):524\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQian ZY, Wang GY, Henning MA, Chen Y. Understanding health literacy from a TCM perspective. J Integr Med. 2023;21(3):215\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi X, Krumholz HM, Yip W, Cheng KK, Maeseneer JD, Meng QY, Mossialos E, Li C, Lu JP, Su M, Zhang QL, Xu DR, Li LM, Normand ST, Peto R, Li J, Wang ZW, Yan WB, Gao RL, Chunharas S, Gao X, Guerra R, Ji HJ, Ke Y, Pan ZG, Wu XP, Xiao SY, Xie XY, Zhang YJ, Zhu J, Zhu SZ, Hu SS. Quality of primary health care in China: Challenges and recommendations. The Lancet. 2020;395(10239):1802\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawrence W. Advancing health literacy: Building health communication from the patient side. J Communication Healthc. 2008;1(2):182\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParnell TA, Stichler JF, Barton AJ, Loan LA, Boyle DK, Allen PE. A concept analysis of health literacy. Nurs Forum. 2019;54(3):315\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Information of included articles\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"926\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor, Year, Setting\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of pain\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResearch design, participant details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHL focus\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey items used in the measure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality of the measure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eElements of HL\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eFeng et.al., 2007 (36)\u003c/p\u003e\n \u003cp\u003ecommunity centre\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003ewaist and limb chronic pain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n= 68), 50~78 yrs., and 42% female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of self-preservation knowledge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but a mastery score was presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eLiang et.al., 2008 (37)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eneck, shoulder, waist, and leg pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eCross-sectional (n=100), 16~74 yrs., and 42% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003eawareness of hot compress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eItems measure how patients understand the usage, placement and effect of hot compress.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eUnderstand\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eHuang et. al., 2009 (38)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003elumbar intervertebral disc herniation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n=68), 43~73 yrs., and 44% female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of diet, exercise, TCM method, health awareness and emotion knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but mastery scores were presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eLi, 2010 (39)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eosteoporosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n=112), 60~97 yrs., and 44% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of diet, TCM method, health awareness and emotion knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but mastery scores were presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eSun et.al., 2011 (40)\u003c/p\u003e\n \u003cp\u003ecommunity centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eosteoporosis; neck, shoulder, waist, and leg pain; arthritic rehabilitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=391), 45~59 yrs., and 50% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of disease-related TCM preservation or treatment knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but mastery scores were presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eCronbach\u0026apos;s\u0026nbsp;\u0026alpha;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eCao, \u0026amp; Qiu, 2011 (41)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eknee osteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n=60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of KOA knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but a mastery score was presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eLi, 2012 (42)\u003c/p\u003e\n \u003cp\u003ecommunity centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003erheumatoid arthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003equasi-experimental (n=105), 50\u0026plusmn;16 yrs., and 76% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of TCM and western medicine nursing knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but a mastery score was presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eYue, \u0026amp; Yang, 2012 (43)\u003c/p\u003e\n \u003cp\u003ecommunity centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003egeneral TCM knowledge (including pain items)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=208), 47% 30~40 yrs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of basic concepts, Chinese medicine knowledge, diet and diagnosis terms, attitude towards TCM knowledge, and TCM healthcare-seeking behaviour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eItems measures community nurses\u0026rsquo; understanding of TCM treatments, perceptions of TCM, and TCM experience for pain management.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003einternal consistency\u003cbr\u003e\u0026nbsp;face validity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eUnderstand\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eGuan, 2013 (44)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003elumbar disc protrusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n=70), 43~73 yrs., and 44% female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of TCM preservation method\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but a mastery score was presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eYang, \u0026amp; Chen, 2013 (45)\u003c/p\u003e\n \u003cp\u003ecommunity centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eosteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=388), 41~72 yrs., and 54% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of basic knowledge and osteoarthritis-related risks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003ePractise the horse-riding squat as an exercise for OA.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eChen et.al., 2015 (46)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003elow back pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=101), 22~74 yrs., and 76% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003eunderstand level of treatment sensation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eItems measure patients understanding of sensations during the acupuncture treatment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eUnderstand\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eZheng et.al., 2015 (47)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eknee osteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=148), 88% female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003eTCM treatments selection rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eOne item shows patients\u0026rsquo; or practitioners\u0026rsquo; choice of TCM treatments.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eYuan, 2015 (48)\u003c/p\u003e\n \u003cp\u003ecommunity centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eosteoporosis; neck, shoulder, waist, and leg pain; arthritic rehabilitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003equasi-experimental (n=399), 60~78 yrs., and 43% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of TCM dietary guidance and disease-related TCM preservation or treatment knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but mastery scores were presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eJin, \u0026amp; Qiu, 2015 (49)\u003c/p\u003e\n \u003cp\u003ecommunity centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003egeneral TCM knowledge and attitude (including pain items)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=1726), 47.24\u0026plusmn;15.28 yrs., and 65% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003eawareness and utilization of TCM health service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eItems measure residents\u0026rsquo; perspectives towards TCM health service.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eCronbach\u0026apos;s\u0026nbsp;\u0026alpha;\u003c/p\u003e\n \u003cp\u003eKMO\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBartlett\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eUnderstand\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eZheng et.al., 2017 (50)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003egeneral TCM knowledge and attitude (including pain items)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=218)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003eproblems of the clinical application of TCM nursing therapies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but a mastery score was presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eCronbach\u0026apos;s \u0026alpha;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003econtent validity: CVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eapply\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eHe et.al., 2017 (51)\u003c/p\u003e\n \u003cp\u003ecommunity centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eknee osteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=1000), 40~82 yrs., and 55% female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003eknow, believe and perform rate of TCM fumigation\u003c/p\u003e\n \u003cp\u003esources of health information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but rates were presented.\u003c/p\u003e\n \u003cp\u003eOne item measures choice of information sources.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eAccess\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eLiu, 2017 (52)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003elumbar intervertebral disc herniation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n=40), 36~70 yrs., and 30% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of diet, TCM method, health awareness and emotion knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but mastery scores were presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eZen et.al., 2017 (53)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eosteoporosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n=86), 56~81 yrs., and 33% female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of osteoporosis knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but a mastery score was presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003ePang et.al., 2019 (54)\u003c/p\u003e\n \u003cp\u003ecommunity centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eknee osteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n=60), 38~64 yrs., and 73% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of disease and self-care knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but a mastery score was presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eLi et.al., 2019 (55)\u003c/p\u003e\n \u003cp\u003eTertiary hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eknee osteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=162), 18~80+ yrs., and 61% female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of KOA diagnosis and treatment knowledge\u003c/p\u003e\n \u003cp\u003emastery level of physical exercise knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eKOA can be treated by TCM methods.\u003c/p\u003e\n \u003cp\u003ePractise the horse-riding squat as an exercise for KOA.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eZha, 2019 (56)\u003c/p\u003e\n \u003cp\u003ecommunity centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eOsteoporosis; neck, shoulder, waist, and leg pain; arthritis; rehabilitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003equasi-experimental (n=56), 61~77 yrs., and 46% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of general TCM preservation knowledge and disease-related TCM preservation knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but mastery scores were presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eZeng, et.al., 2020 (57)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eknee osteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eDelphi (n=71), and 47% female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003eimportance level of mastering knowledge of preventing exogenous and preserving methods\u003c/p\u003e\n \u003cp\u003esources of self-management and TCM health information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eItems related to knowledge of preventing and self-managing disease and sources of health education information are assessed by experts.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003econtent validity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eAccess\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eApply \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eHu, 2020 (58)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eknee osteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n=76), 45~80 yrs., and 61% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003eImplementation rate of diet, precaution and exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but rates were presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eChen, \u0026amp; Yan, 2021 (59)\u003c/p\u003e\n \u003cp\u003eclinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003esoft tissue injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=254), 45~75+ yrs., and 65.2% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003eawareness of the procedure of acupuncture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eItems measure understanding of preparations before treatments, what may happen during and after treatments, prevention of uncomfortable feeling during treatments. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eCronbach\u0026apos;s \u0026alpha; \u0026nbsp;\u003cbr\u003e\u0026nbsp;content validity (no data)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eUnderstand\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eLan, et.al., 2021 (60)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eknee osteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n=86), 55~83 yrs., and 56% female\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of KOA and Zhuang herb mud moxibustion knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but mastery scores were presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eNiu et. al., 2021 (61)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003eknee osteoarthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eDelphi (n=15), 30~50 yrs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of TCM method, differentiation and diet, post-discharge preservation knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but mastery scores were presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eface validity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eFei, 2021 (62)\u003c/p\u003e\n \u003cp\u003etertiary hospital\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003erheumatoid arthritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003eRCT (n=62), 39~76 yrs., and 39% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003emastery level of health knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eNo items shown but a mastery score was presented.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.23110151187905%\" valign=\"top\"\u003e\n \u003cp\u003eLiu et.al., 2022 (63)\u003c/p\u003e\n \u003cp\u003eclinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.151187904967603%\" valign=\"top\"\u003e\n \u003cp\u003echronic musculoskeletal (MSK) pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.282937365010799%\" valign=\"top\"\u003e\n \u003cp\u003ecross-sectional (n=55), 65~90+ yrs., and 69.1% female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.51403887688985%\" valign=\"top\"\u003e\n \u003cp\u003eawareness of Chinese medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003esource of health information; Chinese medicine treatments were believed to be benefit; Chinese medicine treatments for coping with MSK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003enot validated\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.1274298056155505%\" valign=\"top\"\u003e\n \u003cp\u003eAccess\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUnderstand\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eApply\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"health literacy, measurement, traditional Chinese medicine, chronic pain, psychometric evaluation","lastPublishedDoi":"10.21203/rs.3.rs-3355534/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3355534/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eChronic pain is a prevalent health condition that imposes a significant burden on the global health system. Health literacy is a determinant of the quality of pain management which directly impacts public and individual health. However, the existing health literacy measurements have predominantly focused on medical models stemmed from Western culture and the knowledge of Indigenous and other non-Western health models has largely been neglected. This review scopes refereed health literacy publications with regards to traditional Chinese medicine and chronic pain to explore and identify 1) the conceptual basis underlying the development of Traditional Chinese medicine health literacy (TCM-HL) in this area, and 2) measurement tools used in this area and their associated psychometric qualities. Twenty-eight were assessed and the results showed that most studies\u0026rsquo; conceptual basis was unable to cover three key health literacy aspects defined by the World Health Organization (access, understand, and apply). Furthermore, the identified health literacy measurement tools generally lacked rigorous psychometric evaluation. Future studies should focus on exploring a comprehensive model that encompasses various health models and develop measurement tools with more culturally representative psychometric assessments.\u003c/p\u003e","manuscriptTitle":"Measurements of traditional Chinese medicine health literacy regarding chronic pain: A scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-28 17:33:45","doi":"10.21203/rs.3.rs-3355534/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-06T09:55:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-31T19:54:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30608951664633506546465700886310097350","date":"2024-07-31T18:37:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1279429948060750933493695239301294148","date":"2024-07-30T12:51:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306510855373608250103487349817640551595","date":"2024-07-01T19:13:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-11T10:01:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b9e5a22b-feb5-45f6-8f74-80f9584893d5_SNPRID","date":"2024-02-29T14:15:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-08T17:35:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-08T09:46:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-10-24T17:18:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-10-24T17:17:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Complementary Medicine and Therapies","date":"2023-09-14T13:06:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2c1cfef-d973-44e0-bbf1-24f140aa43a4","owner":[],"postedDate":"October 28th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-11-02T18:23:15+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-28 17:33:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3355534","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3355534","identity":"rs-3355534","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}