PONE-D-25-02800Evaluation of an Evidence-Based Practice Continuing Education Course for Canadian Naturopathic DoctorsPLOS ONE

Dear Dr. Cooley,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 28 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following financial disclosure: 

This project was awarded a competitive grant from the Canadian CAM Research Fund (CCRF).  

Please state what role the funders took in the study.  If the funders had no role, please state: ""The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."" 

If this statement is not correct you must amend it as needed. 

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

3. In the online submission form, you indicated that data cannot be shared publicly because this was not approved by the research ethics board or included in the participant informed consent form. Data requests can be made to the corresponding author maucoin@ccnm.edu and will be reviewer by the Research Ethics Board. 

All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information.

This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval.

4. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: PONE-D-25-02800 "Evaluation of an Evidence-Based Practice Continuing Education Course for Canadian Naturopathic Doctors".

Comments to the Authors

Thank you for your work on this manuscript. This research will add to the literature in a number of different areas. The manuscript is well-written and meets the journal’s publication criteria.

Originality

This is an original piece of work that can add to the literature in the context of designing courses that focus on evidence-based practice (EBP) in the context of continuing education for naturopathic doctors.

Introduction

Relevant background information and a rationale for the study are provided. Study aims are clearly stated.

Methods

The Methods section is clearly organised and provides relevant information under each section. Study measures are clearly described. Detailed information of the analysis process is provided.

Results

The results are clearly outlined and answer the research aims. The Tables and Figure support the results.

Discussion

The main findings of the study are discussed, and some links are made to earlier research that is applicable. Study limitations and strengths are discussed. Conclusions are supported by the data. Future research directions are discussed.

Suggested edit

1. Instead of using the term ‘complementary and alternative medicine,’ consider using the term ‘traditional, complementary, and integrative medicine (TCIM).’

Reviewer #2: I am pleased to recommend the acceptance of this manuscript for publication in your esteemed journal. The study provides a comprehensive analysis of the trends and changes in the utilization of Traditional Korean Medicine (TKM) from 2013 to 2022, offering valuable insights into the structural and functional transformations within TKM.

The key findings, including the significant increase in inpatient services of TKM hospitals and medical expenses, as well as the diversification of diagnostic and treatment methods, highlight the evolving nature of TKM. These observations are crucial for understanding the current landscape of TKM and its integration into the broader healthcare system.

While the study acknowledges some limitations, its contributions to the field are substantial. The call for future research to include all TKM-related data and to examine sociocultural and clinical factors influencing TKM utilization is well-justified. Such comprehensive studies are essential for policymakers, healthcare providers, and researchers aiming to promote the effective integration of TKM and improve public health outcomes in Korea.

Overall, the manuscript is well-structured, and the conclusions are supported by the data presented. I believe that this study will contribute significantly to the ongoing discussions about the role of traditional medicine in modern healthcare systems.

Thank you for the opportunity to review this manuscript.

Reviewer #3: This is a simple and well written manuscript describing the evaluation and outcomes of evaluation of an EBP continuing education course for naturopathic doctors in Canada. It highlights a gap in that evaluation of EBP training for NDs may not have previously been performed, whereas it has for doctors of medicine. My comments are minor and based on questions arising while reading the manuscript - that if addressed may lead to future readers having fewer questions about what and why.

Introduction:

If possible, add a little more context.

What is the level of education of ND in Canada?

What is the extent of research skills learnt currently during ND training and in training over the past 20 years?

Only licensed practitioners were eligible - but what is the eligibility criteria for licensing?

How many licensed Canadian NDs are there? (this is also relevant later when interpreting the success of recruitment and reach of the course.

Methods

Please add the institutions through which the course was developed delivered. It came as a surprise in the Discussion that the course was for fee paying practitioners. I assume then that it was delivered via the Canadian College of Naturopathic Medicine. Was this the first time the course was run or just the first time it was evaluated?

Lines 157-163. Would it work better to have the second sentence first and edit the first sentence to fit. As it is, I'm reading this as: EBASE as been used to assess changes - but only for chiropractic and nursing. But it has been administered to a far broader group of disciplines. This was confusing and had me going back to re-read the paragraph from 144 explaining EBASE. Is the difference that it is mostly used as a one off point in time measure - whereas it has been used on multiple occasions with nurses and chiros to measure change over time?

From line 164, notes that EBASE has self-report bias, so a 16 question quiz was administered. It reads as though this quiz was instead of EBASE. It's only at line 191 that it is clear that both are used. Suggest adding to the Fig 1 flow chart to include of the various recruitment and data collection steps AND time points, i.e.name the assessment tools and when administered e.g. week 0, w1, follow-up etc. Also, later, make sure use of 'w' for week is explained (lines 286-289).

One line describing qualitative data analysis is insufficient and the Results do not appear to be Braun and Clarke style thematic analysis - but more like a structured Framework analysis approach.

Results

Does the geographical local match distribution of NDs in Canada? i.e. are there very few in the provinces other than the most populous Ontario and BC?

Quebec has high population. Was lack of attendance from there due to language or other reasons? This should be noted. (This perhaps for Discussion)

Table 4. This does not look like an output from Braun and Clark style thematic analysis. It appears to be a very simple, structured framework analysis based on the evaluation questions where the 'themes' might be better labeled as 'Course element' - or some such.

Why is there nothing on most and least helpful resources in the table? Not likely an accidental omission - but without anything in the box it raises the question that it could be accidental. Suggest adding something in the empty boxes, even if only "evaluation questions did not elicit this data".

Discussion

While course enrolment does seem high given the short time of advertising, without knowing the number of licenced NDs, saying it is high is subjective. As suggested earlier, provide number of licenced NDs as denominator on which to judge success of recruitment. Can you explain the low number of participants from other provinces?

The Discussion expands on and contextualizes Results, but it doesn't reflect upon what this evaluation contributes to the field, it is lacking in direction to others who may wish to establish a similar course or evaluate something similar. Is there more published elsewhere on how the course was designed and developed? It's said that the codesign was a strength, but this is fairly meaningless when What is included on that in the intro/methods is cursory. e.g. at lines 75-76 I expected references 19,20,21 to be citing publications that described how the course was created - but they do not.

As the authors have not described how much research training is on offer to NDs in training, it's not possible to judge the importance or utility of this training.

I think the Discussion could condense some of what is currently included and reflect on why or how increased EBP knowledge and skill is helpful to the naturopathic profession, why others perhaps ought to pursue this, and on relevance to naturopaths or other T&CM practitioners in Canada or elsewhere.

Conclusion

The conclusion is appropriate given the current discussion. If suggestions made to strengthen the description of the course creation and Discussion are taken up, the conclusion should be edited accordingly.

The supplementary material is really useful.

Thank you.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: PLOSONE.docx

Attachment

Submitted filename: Reviewer report.docx

Evaluation of an Evidence-Based Practice Continuing Education Course for Canadian Naturopathic Doctors

PONE-D-25-02800R1

Dear Dr. Cooley,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Jenny Wilkinson, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: