Multinational Survey of Chiropractic Patients:
Reasons For Seeking CareThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Can Chiropr Assoc 2008 (Aug); 52 (3): 175–184 ~ FULL TEXT
Charles Blum, DC, Gary Globe, MBA, DC, PhD, Lisa Terre, PhD,
Timothy A. Mirtz, DC, PhD(c), CHES, Leon Greene, PhD, Denise Globe, DC, MHSA, PhD
Sacro Occipital Technique Organization - USAINTRODUCTION: This study explores the extent to which consumers seek wellness care when choosing chiropractors whose practice methods are known to include periodic evaluative and interventional methods to maintain wellness and prevent illness.
METHODS: Using an international convenience sample of Sacro-Occipital Technique (SOT) practitioners, 1316 consecutive patients attending 27 different chiropractic clinics in the USA, Europe and Australia completed a one-page survey on intake to assess reason for seeking care. A forced choice response was obtained characterizing the patient's reason for seeking chiropractic care.
RESULTS: More than 40% of chiropractic patient visits were initiated for the purposes of health enhancement and/or disease prevention.
CONCLUSION: Although prudence dictates great caution when generalizing from this study, if confirmed by subsequent research among other similar cohorts, the present results may lend support to continued arguments of consumer demand for a more comprehensive paradigm of chiropractic care, beyond routine musculoskeletal complaints, that conceptualizes the systemic, nonspecific effects of the chiropractic encounter in much broader terms.
From the Full-Text Article:
Introduction
In the emerging health care arena, the topic of wellness care has generated considerable interest. Consumers are seeking, alongside of conventional medical options, improved ways to prevent the onset of chronic diseases and even the common effects of aging by increasing their use of complementary and alternative (CAM) approaches to promoting health and preventing illness. [1, 2]
With regard to non-allopathic services, chiropractic is among the most commonly used modality. [3–5] Although prevalence estimates vary, it has been suggested that each year in the U.S. there may be more total visits to CAM providers (including homeopaths, acupuncturists, and chiropractors) than to more traditional primary care physicians. [2] Moreover, CAM use is predicted to rise with increasing third party reimbursement and managed care coverage. [5, 6] Research focused on patient motivations for seeking CAM suggest that this trend is not primarily rooted in patient dissatisfaction with conventional care but, instead, rests on more complex considerations including a “philosophical congruence” with alternative practitioners emphasizing a holistic approach to wellness. [5–7] Indeed, the growing popularity of wellness care has been described as a fundamental change in the “healthcare paradigm”8 that may reflect a “tipping point” [9] in the evolution from a purely biomedical to a more holistic, biopsychosocial perspective [10] that is reverberating throughout the healthcare system, affecting both allopathic as well as complementary and alternative (CAM) providers. [3]
Recently, chiropractic has expanded its longstanding spinal wellness emphasis by disseminating a widely adopted Model Course for Public Health Education in Chiropractic Colleges12 as well as specifying health promotion and wellness as key chiropractic competencies. [13] In support of these developments, Hawk and colleagues [3, 4] have advocated promoting “wellness concepts” in chiropractic student training, emphasizing national health targets (such as those found in Healthy People 201014) and evidence-based-practices for health promotion and disease prevention. [3, 4]
The recent formal inclusion of public health preventive measures within the scope of chiropractic practice has raised concerns about chiropractic’s evolving public identity and the potential public acceptance of chiropractors as wellness providers. For instance, the World Federation of Chiropractic’s Identity Consultation Task Force, in its 2005 final report, [15] emphasized the urgent need for a clear public identity in chiropractic. Indeed, in terms of public perception, chiropractic has long been synonymous with spinal manipulation and is characterized as “manual healing” (not “alternative systems”) in NC-CAM’s taxonomy. [3] Without a better understanding of the public’s willingness to seek out wellness care from chiropractic providers, the preparation of chiropractors as wellness providers may be a case of the cart leading the horse.
The World Federation of Chiropractic’s “Consultation on Identity” found that only 6% of patients seek wellness care from chiropractic providers.16 However, the fact that a minority of patients currently seek wellness care from chiropractic providers may have more to do with consumers’ current understanding of actual chiropractors’ scope of practice than with the acceptability of chiropractors as wellness practitioners. Indeed, practicing chiropractors currently differ substantially on whether they provide one therapeutic modality or a “complete system of healing.” [3]
Accordingly, as a first step effort, the present study explored the extent to which consumers seek wellness care when the provider is known to offer complementary approaches beyond standard manipulation to alleviate patient symptoms and enhance patient feelings of wellness. [18] Based on studies indicating that patients seek chiropractic care primarily for musculoskeletal complaints such as neck and low back pain, [17] the present study examined wellness preferences of patients visiting an international convenience sample of Sacro-Occipital Technique (SOT) practitioners utilizing a broad palate of holistic methods.
Discussion:
Using an international convenience sample, this study attempted to identify patients’ specific wellness preferences when seeking chiropractic care from a cohort of chiropractors where wellness care is affirmatively promoted. Findings indicate, overall, more than 40% of patients seeking care reported doing so for the purpose of “optimizing health” or “preventing illness” (including the prevention and/or early intervention of potential risk factors). These findings differ from a previous World Federation of Chiropractic survey, which indicated less than 5– 10% of patients seeking care for non-musculoskeletal conditions. Indeed, the rates of patient-initiated wellness visits in this convenience sample of wellness promoting chiropractors is notable when compared to previous estimates indicating lower consumer demand for chiropractic wellness care. [16, 17] One obvious explanation for the outcomes may be related to these patients’ awareness that their chiropractors actually offer care other than solely for pain reduction for musculoskeletal conditions such as low back pain. Sacro-Occipital Technique practitioners are trained to utilize a system of complex diagnostic and treatment procedures focused upon systemic as well as neuromusculosketal complaints. SOT practitioners educate patients on the value of periodic (1–2 times per year) examination/wellness check-ups to assess patient’s overall/ systemic health status by evaluating the spine and nervous system through various mechanical and reflex techniques. Treatment recommendations are then individualized based upon the findings and typically involve short-term, outcome-based interventions supported by modification in patient lifestyles, diet, exercise, nutrition, and other modifying behavioral and psychosocial factors.
Furthermore, the SOT model of care does not advocate the unethical use of long-term, pre-paid maintenance treatment programs developed outside of the normative parameters of clinical indicators. While the authors clearly believe that the frequency of maintenance/supportive care should ethically be left strictly to individual patient preferences, this tendentious aspect of chiropractic preventive care is clearly beyond the focus of this paper.
Based on the public’s (and their chiropractors’) current perceptions of chiropractic as primarily an NMS specialty, 19,16 the typical consumer responding to prior surveys may not have been aware of the possibility that preventive/ wellness care is a chiropractic option and therefore would have been less likely to express a desire for this type of care. By contrast, patients in this cohort of SOT practitioners, where preventive/wellness approaches to health are emphasized in their practices (and presumably transmitted through patient social and informal referral networks), appeared to report higher rates of wellness seeking preferences. This phenomenon might have important implications for those chiropractic educators and policy-makers who also continue to advocate a primary healthcare role for chiropractors, particularly emphasizing wellness/preventive care. A profession that does not regularly offer their patients primary care services nor educate their patients as to their capabilities to serve as a primary care provider will certainly find it challenging to alter patient attitudes and behaviors in this regard.
Consistent with the broader literature on gender differences in health attitudes and practices,20–25 women in the present sample were more likely to express interest in wellness, prevention, and self-care compared to men, who were somewhat more prone to favor illness care, which was most evident in the responses from the European sample. Although explanations for these well-documented gender differences are complex and remain a focus of active research efforts, there are some empirical hints in the broader literature that women’s socialization experiences may sensitize them to identify incipient somatic symptoms, and facilitate help-seeking sooner than their male counterparts. By contrast, traditional male socialization tends to reward risk-taking and a projected image of strength, which often involves problem denial (especially at sub threshold levels of severity such as those associated with emerging health problems) and a reluctance to seek help. [20–25] These socialization patterns have direct implications for women’s greater propensity to seek out health information and to utilize primary prevention and early detection efforts. [26, 27] However, our findings also resonate with extant research suggesting that, despite well-documented gender differences, within group variability also exists in men and women’s health beliefs and practices, [28] highlighting the need to continue efforts at unpacking the construct of gender with an eye toward better tailoring of public health promotion messages. [22] This need for more relevant public health communications is especially pressing given that the health behaviors of most adults still fall far short of public health recommendations [29] and that these modifiable risk factors significantly impact national health care costs. [30]
Interestingly, the geographic differences noted herein are also consistent with the burgeoning literature highlighting the importance of sociocultural and ethnic factors in shaping symptom perceptions and motivations for seeking health care. Although very little research has focused specifically on chiropractic, numerous longitudinal and cross-sectional studies have documented regional variability in lifestyle, symptom perception, illness behavior, general health care utilization, and health outcomes as a function of complex combinations of sociocultural, ethnic, and other local influences. [31–33] Hence, in addition to being compatible with results from the broader health care literature, our findings on regional variability provide a preliminary foundation on which to build subsequent research on consumer motivations for seeking chiropractic care specifically.
Although international in scope, our convenience sample of SOT practitioners certainly introduced selection bias, thereby reducing the generalizability of the results. The point was to demonstrate whether the previously reported low rates of demand for wellness care were a function of lack of interest on the part of patients or, perhaps, a lack of understanding on the part of previous chiropractic patients and their doctors that wellness/ preventive care was an option. The absence of information on patient ethnicity, socioeconomic status, and other potentially relevant background characteristics (which was not collected in the present study) may have also constrained our ability to examine some potentially important influences on patient care preferences. Moreover, the self-reported nature of responses may have been influenced by a variety of potential response biases (including social desirability and other demand characteristics). In addition, the cross sectional nature of the data certainly precludes any inferences about causality.
Further study should include more controlled research that systematically examines chiropractic preferences, perhaps utilizing an expanded survey administered in a variety of chiropractic settings (beyond SOT) where wellness/ preventive care is normatively, ethically practiced, including questions targeting patient interest in receiving wellness/preventive care from their chiropractors.
Conclusion:
This study was an attempt to determine patients’ specific wellness preferences when seeking chiropractic care. Based on an international convenience sample of Sacro- Occipital technique (SOT) practitioners utilizing a broad palate of holistic methods, more than 40% of patients agreeing to participate in this study self-reported a preference for care targeted at health enhancement and/or disease prevention. Although generalizations from these preliminary data cannot be made, the findings from this study suggest there may be a sector of chiropractic patients who seek out a more comprehensive paradigm of chiropractic care that conceptualizes health broadly, beyond the simple absence of disease or disability. [34] Indeed, the Final Report of the Identity Consultation Task Force of the World Federation of Chiropractic includes the following foundational statement: “A patient-centered and biopsychosocial approach, emphasizing the mind/ body relationship in health, the self-healing powers of the individual, individual responsibility for health, and encouraging patient independence” (page ii). [15] In order for chiropractors to optimally serve their patients, there appears to be a need for greater clarity and more well-developed understanding of actual consumers’ health care preferences. While the research literature indicates that there is a substantial demand for complementary and alternative care in the United States, [1, 2, 35] further research is warranted to evaluate how chiropractors may ethically and productively serve various subpopulations who exhibit a preference for including access to some chiropractic wellness approaches to health promotion and disease prevention.
Appendix: Patient Health Preference Categories*
Behavior
Definition
Wellness Activity undertaken by a person, who believes himself to be healthy, for the purpose of attaining a greater level of health. Preventive Health Activity, undertaken by a person, who perceives himself to be healthy, for the purpose of preventing illness or detecting it in an asymptomatic state. At-risk Activity undertaken by a person, who believes himself to be healthy, but at greater risk of developing a specific health condition, for the purpose of preventing that condition or detecting it in an asymptomatic state. Illness Activity undertaken by a person, who perceives himself to be ill, to define the state of his health and discover a suitable remedy. Sick Role Activity undertaken by a person, who considers himself to be ill, for the purposes of getting well. It includes receiving treatments, involves few dependent behaviors, and leads to some degree of neglect of ones’ usual duties. Self Care Activity undertaken by a person, who considers himself to be ill, for the purpose of getting well. It includes minimal reliance on therapists, involves a few dependent behaviors, and leads to little neglect of one’s duties.
*Handbook of Clinical Chiropractic Care, 2005: Jones and Barlett Publishers, Sudbury, MA. www.jbpub.com, Reprinted with permission
Form Sent to Participating SOT Clinicians
Health Behaviors [1, 2]
Wellness behavior — Are you here today because although you feel healthy you want to even have a greater level of health?
Preventive health behavior — Are you here today because although you feel healthy you want to help prevent an illness or possible injury?
At-risk behavior — Are you here today because although you feel healthy you have a tendency to be at risk for injuring yourself and want to prevent that from happening?
Sick role Behavior — Are you here today because you are injured or ill and want help so that you will feel better, without having to do any home therapies or modifying activities out of this office?
Self role Behavior — Are you here today because you are injured or ill and want help so that you will feel better, and want to have home therapies and activities that I can do to help myself outside this office? [2]
It is questionable whether one can “motivate someone sufficiently to affect their lifestyle behaviors which play a large role in many of today’s disease states.” [2] If effective health promotion is based upon the person’s willingness to change for something better and wellness is a behavior, then understanding various health behaviors will help gain insight into the types of patients and what they are seeking in a chiropractor’s office. [2]
As chiropractors “acknowledge that patients may present with various health behaviors the clinical encounter will become more exacting as well as educational. The knowledge of such behaviors will aid in identifying patients to help meet their unique individual needs.” [2]
Few if any studies have been performed in the chiropractic profession evaluating patients’ health behaviors relating to their reason for seeking chiropractic care. While it might not seem all that important to a typical practitioner it is essential for those in the research and epidemiological community to understand the thought processes of a typical chiropractic patient. This pilot study will help gain insight and greater understanding into the nature of the presenting health behavior of patients in a sacro occipital technique (SOT) chiropractic office.
1. Green LW, Kreuter MW
Health Promotion Planning
Mayfield Publishing Company, Mountain View, CA. 1999
2. Mirtz TA
Health Promotions in Clinical Practice in Handbook of Clinical Chiropractic Care
(Wyatt LH) 2nd edition, Jones and Bartlett Publishers: Sudbury, MA, 2005: 8–9
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