Journal of Chiropractic Education 2018 (Mar 6) [Epub] ~ FULL TEXT
Katie E. de Luca, BAppSci (Ex and Sp Sci), MChiro, PhD, Jordan A. Gliedt, DC, Matthew Fernandez, BSpSc, MChiro, PhD, Greg Kawchuk, DC, PhD, and Michael S. Swain, BChiroSc, MChiro, MPhil
Chiropractic Academy for Research Leadership
24 Salmon Circuit,
South West Rocks,
New South Wales 2431, Australia;
OBJECTIVE: To evaluate Australian and New Zealand chiropractic students' opinions regarding the identity, role setting, and future of chiropractic practice
METHODS: An online, cross-sectional survey was administered to chiropractic students in all chiropractic programs in Australia and New Zealand. The survey explored student viewpoints about the identity, role/scope, setting, and future of chiropractic practice as it relates to chiropractic education and health promotion. Associations between the number of years in the program, highest degree preceding chiropractic education, institution, and opinion summary scores were evaluated by multivariate analysis of variance tests.
RESULTS: A total of 347 chiropractic students participated in the study. For identity, most students (51.3%) hold strongly to the traditional chiropractic theory but also agree (94.5%) it is important that chiropractors are educated in evidence-based practice. The main predictor of student viewpoints was a student's chiropractic institution (Pillai's trace =.638, F[16, 1368] = 16.237, p < .001). Chiropractic institution explained over 50% of the variance around student opinions about role/scope of practice and approximately 25% for identity and future practice.
CONCLUSIONS: Chiropractic students in Australia and New Zealand seem to hold both traditional and mainstream viewpoints toward chiropractic practice. However, students from different chiropractic institutions have divergent opinions about the identity, role, setting, and future of chiropractic practice, which is most strongly predicted by the institution. Chiropractic education may be a potential determinant of chiropractic professional identity, raising concerns about heterogeneity between chiropractic schools.
KEYWORDS: Attitude; Chiropractic; Cross-Sectional Studies; Students; Surveys and Questionnaires
From the FULL TEXT Article:
Chiropractic has been described as a profession at a
crossroads between mainstream and alternative medicine. 
There has been an increasing amount of evidence
suggesting valuable metrics associated with chiropractic
care, [2, 3] and chiropractic has been included in several
evidence-based guidelines. [4–8] As a primary care physician,
chiropractors are involved in the diagnosis and management
of spine and musculoskeletal conditions and are at
the forefront in educating the community on the importance
of health promotion and injury prevention.
A complicating factor inhibiting the chiropractic
profession from fully progressing into a mainstream health
profession may be the presence of differing ideological
approaches to care and a perceived inability of the
profession to act as a unified group. [9, 10] As health care
has evolved toward shared decision-making and integrative
care teams, it is important that the chiropractic
profession has a clear understanding of its path toward
establishing itself as a fully accepted, competent, and
contributing member of the health care team. Gaining a
more discernible understanding of the viewpoints within
the chiropractic profession may provide a greater appreciation
of the commonalities and mutual goals that exist
between them.  Importantly, a unified profession is
essential to the personal and social well-being of both an
individual and the community at large.
Chiropractic students are the future of the chiropractic
profession and make up a considerable portion (about
33%) of the chiropractic field.  Australian chiropractors
study at university for a minimum of 5 years and are
included in the Australian national registration scheme for
health practitioners.  The study of chiropractic students
therefore provides insight into current opinions and may
relate to future practitioner ideologies and practice
patterns. Two recent studies have investigated North
American–based chiropractic students' opinions relating
to chiropractic's identity, role, and future. [13, 14] These
studies suggest cognitive dissonance, particularly regarding
traditional chiropractic theories and evidence-based practice.
To the authors' knowledge, no such studies have
involved chiropractic students enrolled in chiropractic
programs in Australia and New Zealand. Hence, the aim
of this study was to evaluate Australian and New Zealand
chiropractic students' opinions regarding the identity, role,
setting, and future of chiropractic practice.
Ethical review for this study was approved on by the
Human Research Ethics Committee (Medical Sciences) of
Macquarie University, Australia.
Study Design and Setting
A Web-based cross-sectional survey of Australian and
New Zealand chiropractic students was conducted between
August and October 2016. The head of research at each
institution with a chiropractic program in Australia and
New Zealand were invited, via e-mail, to administer
recruitment information for the study at their respective
All 5 eligible institutions participated in this
Central Queensland University,
New Zealand Chiropractic College, and
Participant recruitment involved the head of research or
their designated faculty representative posting an electronic
recruitment flyer on the institution's learning management
system to notify potentially eligible chiropractic
students of the study. In addition, each head of research or
representative forwarded an initial e-mail invitation to
potentially eligible participants at their respective institution,
with 2 subsequent reminder e-mail invitations
forwarded at 2 and 6 weeks. The total study period per
institution was 8 weeks. The flyer and e-mail invitations
contained a link to the Web-based survey. To incentivize
participation, 2 $40 iTunes gift cards were promoted to be
given away via lottery to randomly selected participants
once the survey was closed.
Study data were collected and managed using REDCap
software version 5.4.2 (Vanderbilt University, Nashville,
TN) electronic data capture tools hosted at Macquarie
University.  REDCap (Research Electronic Data Capture)
is a secure, Web-based application designed to
support data capture for research studies.
Participants and Eligibility Criteria
Students who were then enrolled in a bachelor or
master of chiropractic degree program at an eligible
institution (Central Queensland University, Macquarie
University, Murdoch University, New Zealand Chiropractic
College, and RMIT University–Melbourne) at the time
of this study were eligible for participation.
The survey was modified from the 23–item questionnaire
used by Gliedt et al  to study chiropractic student
opinions in North America. The survey's original core
statements (11 Likert response items and 4 nominal
response items) about identity, role/scope, and setting
were duplicated in the current survey, with additional
items pertaining to future practice as it relates to public
health education initiatives. Demographic items were
modified to fit the regional context; for example, the local
professional associations were contextualized to Australia
and New Zealand. In total, the survey instrument
consisted of 31 items. The first 8 items were structured to
solicit demographic information, such as participants' age,
sex, current enrollment status, education, and degrees
achieved prior to enrollment as well as student chiropractic
organization affiliations. The remaining 23 survey items
explored participants' opinions concerning chiropractic's
identity, role, scope, setting, and future practice.
Variables and Measurements
Chiropractic students' responses to statements about
the identity, role and scope, setting, and future of
chiropractic practice were summarized using construct
scales that ranged from 0 = progressive/mainstream
viewpoint to 100 = traditional/alternative viewpoint.
Progressive/mainstream viewpoints were operationally
defined as aligning with currently orthodox scientific
views, whereas traditional/alternative viewpoints could be
considered unorthodox to current evidence-based care and
guidelines.  Summary scores were based on a total of 16
statements that required a response on a 5–point Likert
scale: 0 = strongly agree, 1 = agree, 2 = neutral, 3 = disagree, and 4 = strongly disagree.
The construct score for
identity was based on the average response to 4 statements:
(1) it is important for chiropractors to be educated in evidence-based practice,
(2) contemporary and evolving scientific evidence is more important than traditional chiropractic principles,
(3) it is appropriate to allow for updating and enrichment of chiropractic theories based on current scientific advancements, and
(4) it is important for chiropractors to hold strongly to the traditional chiropractic theory that adjusting the spine corrects "dis-ease."
Item 4 was reverse coded so that a positive opinion would
be reflected by a higher summary score. The construct
score for role/scope was based on the average response to 4
(1) the chiropractic profession should expand
its scope of practice to include prescribing medication,
with appropriate advanced training;
(2) the primary
purpose of the chiropractic examination is to detect
(3) emphasis of chiropractic care
is to eliminate vertebral subluxations; and
care should consist of the chiropractic adjustment only.
Items 2 to 4 were reverse coded so that a positive opinion
would be reflected by a higher summary score. The
construct score for setting was based on the average
response to 3 statements:
(1) the public health care setting
(hospitals and local health districts) are appropriate
settings for chiropractic health care,
(2) inclusion of
clinical chiropractic training internships in integrative
medical settings is important to the progression of the
chiropractic profession, and
3) chiropractic practitioners
should maintain a primary care (direct access) status.
construct score for future practice was based on the
average response to 4 statements about involvement in
public health education initiatives:
(1) chiropractic care
should include screening for smoking;
(2) chiropractic care
should include healthy lifestyle advice and screening for
poor nutrition, weight management, and body mass index
(3) chiropractic care should include screening for
hazardous alcohol consumption; and
(4) chiropractic care
should include healthy lifestyle advice and screening for
All summary scores were transformed
to fall within a 0- to 100–point scale of opinion.
Data were collated, cleaned, and inspected, and
descriptive statistics were generated for all variables. Only
participants with completed questionnaires were included
in the analyses. Participant characteristics were stratified
by institution, highest entry degree, and year in chiropractic
program. Descriptive analyses for each item were
reported as frequency distributions, including those items
utilizing a 5–point Likert scale. Summary score distributions
were illustrated via box plots.
Statistically significant differences between factors
(institution, highest entry degree, and year in program)
and response summary scores (identity, role, setting, and
future) were tested using multivariate analysis of variance
(MANOVA). Prior to conducting the MANOVAs, a series
of Pearson correlations were performed between the
dependent scores to test the MANOVA assumption that
the dependent variables would be correlated with each
other in the moderate range.  To satisfy the assumption of
homoscedasticity, equality of covariance matrices was
constructed and checked, estimating the covariances
among the dependent variables split across the test groups.
We reported Pillai's trace for the F test, which is robust to
violations of MANOVA assumptions. 
As follow-up tests to the MANOVAs, a series of 1–way
analysis of variance (ANOVA) tests were conducted to test
for differences between institutions based on individual
response summary scores: identity, role, setting, and
future. A series of post hoc analyses were performed using
Fisher's least significant difference (LSD) test to examine
mean differences and effect size of differences across the 5
chiropractic institutions for student opinions on identity,
role, setting, and future. All analyses were conducted using
SPSS Statistics for Windows version 24.0 (IBM Corp,
Armonk, NY). Graphical output of data was plotted using
SigmaPlot version 12.3 (Systat Software, Inc, San Jose,
A total of 347 participants (53.3% female) completed
the survey. The ages of participants were 18 to 25 years
(63.4%), 26 to 35 years (24.2%), 36 to 45 years (8.4%), 46
to 55 years (3.2%), and .55 years (0.9%). The New
Zealand Chiropractic College had the highest student
response rate per institution (students completing the
online survey) at 45.7%, followed by Central Queensland
University at 34.0%, RMIT University–Melbourne at
13.8%, Macquarie University at 13.6%, and Murdoch
University at 7.8%. From a total of 1,853 enrolled
chiropractic students across the 5 institutions, 18.7%
completed the survey. Table 1 reports the number of
chiropractic students who participated by institution, year
of enrollment, and highest academic achievement prior to
entering a chiropractic degree program. Approximately
one-third (34.3%) of the participants were not a member
of a professional association. The other two-thirds
reported being members of local chiropractic associations:
the Chiropractors' Association of Australia (CAA)
(29.1%), the New Zealand Chiropractors' Association
(NZCA) (15%), Chiropractic Australia (CA) (5.5%), CA
and CAA (13.5%), CA and NZCA (0.3%), CAA and
NZCA (1.4%), and CA, CAA, and NZCA (0.9%).
Students feel adequately represented (70.4%) when they
hold a professional association membership compared to
students who are not a member of a professional
association (82.2%). Chiropractic students that responded
typically had completed a subject in evidence-based
practice (85.3%) and were interested in higher-degree
Description of Survey Responses
Table 2 reports the distributions of participant responses
to statements about the identity, role/scope, setting, and
future of chiropractic practice. For identity, 75.2% of
participants responded that chiropractors should be
considered allied health care practitioners and 24.8%
complementary/alternative health care practitioners. Responses
for the most appropriate practice paradigm for the
chiropractic profession were nonsurgical spine and musculoskeletal
care experts (44.7%), detection and correction
of subluxation only (28.5%), nervous system experts
(15.6%), spine care only (0.9%), and other (10.4%).
Regarding setting, students believe that the most appropriate
setting for chiropractic health care was in integrative
settings with other health care disciplines, including
allopathic medicine (81.3%), followed by alone or with
other chiropractors without integration with any other
health care disciplines (13.5%) and integrative settings
with alternative medicine practitioners only (5.2%). All
(100%) participants believe that chiropractic research is
important and believe that the primary focus of future
research should be physiological mechanisms of chiropractic
adjustments (63.1%), followed by outcomes/costeffectiveness
of chiropractic care (25.1%) and outcomes/
cost-effectiveness of integrative care models (11.8%).
Figure 1 illustrates the distribution of participant response
summary scores to statements about identity, role/scope,
setting, and future.
Primary Analyses: Effect of Enrollment Status,
Level of Education and Institution on Students' Opinions
There was a meaningful pattern of correlations
observed among response summary scores to statements
about identity, role/scope, setting, and future scores,
suggesting the appropriateness of conducting 1–way
MANOVA tests (Table 3) to test the hypotheses that
there would be 1 or more significant differences between
study factors: (1) enrollment status, (2) level of education
at entry to chiropractic program, (3) chiropractic institution
and outcomes: response summary scores (identity,
role/scope, setting, and future). Student enrollment status
was not significant as a predictor of student opinion
summary scores (Pillai's trace = 0.057, F[16, 1368] = 1.234,
p = .234). Level of education at entry into a chiropractic
education program was a statistically significant predictor
of summary scores (Pillai's trace = 0.124, F[12, 1026] =
3.682, p , .001). For the model, the effect size (partial etasquared)
was 0.041, suggesting that 4% of the variance in
the summary scores was accounted for by level of
education on entry to program. Chiropractic institution
was statistically significant and the strongest predictor of
summary scores (Pillai's trace = 0.638, F[16, 1368] =
16.237, p , .001). The multivariate effect size was
estimated at 0.16, which implies that 16.0% of the variance
around the summary scores was accounted for by
chiropractic institution. Figure 2 illustrates the mean
scores and 95% confidence intervals for the 3 general
Secondary and Post Hoc Analyses:
Effect of Institution on Students' Opinions
All ANOVAs that tested the effects of chiropractic
institution were statistically significant, with effects sizes
ranging from 15% for setting to 56% for role/scope (Table 4). A series of post hoc analyses (Fisher's LSD) were
performed to examine individual mean difference comparisons
across all 5 chiropractic institutions and the 4
dependent summary scores. There was a trend across
institutions for responses to all summary scores (Figure 2),
with the most pronounced mean differences between
institutions B and D. The largest mean differences were
associated with the role/scope scores, accompanied by very
large effect sizes  as indicated by Cohen's d values greater
than 1.2 (Table 5).
In our study, chiropractic students in Australia and
New Zealand had progressive viewpoints about the
identity, setting, and future practice of chiropractic but
not the role/scope of chiropractic. Student opinions tended
to be internally conflicting, where both alterative and
mainstream viewpoints coexist. A chiropractic student's
institution was the strongest predictor of their viewpoint
about chiropractic identity, role/scope, setting, and future,
albeit the level of internal contradiction in viewpoints
varies between individuals from different chiropractic
institutions. Between chiropractic institutions, there were
divergent viewpoints among students that were most
pronounced for opinions about the role/scope of chiropractic.
Across several institutions, the effect size of the
differences in student opinions was very large (based on
Cohen's d), and the reasons for this are currently unclear.
Most Australian and New Zealand chiropractic students
in this sample support the notion that subluxations
cause and that adjustments prevent "dis-ease." Furthermore,
the primary purpose of the chiropractic examination
and intervention was to identify and correct subluxations.
Both viewpoints are aligned with traditional and unorthodox
tenets of the chiropractic profession. The majority of
chiropractic students also responded that learning concepts
in evidence-based practice is important, and new and
emerging science is preferred over traditional chiropractic
theories. Moreover, chiropractic students responded that
they wanted to be part of integrative, mainstream health
care. Strong contradictory opinions such as these are also
reported in large samples of chiropractic students from
North America [13, 14] and may be explained by factors
inherent to chiropractic students or their training. As
noted by Gliedt et al,  contrary viewpoints may be
interpreted as cognitive dissonance, where internal inconsistencies
in opinion are explained by a want or a need to
justify historical theories of the chiropractic profession. A
unique finding in the current study was that these internal
inconsistencies were variable among students from different
chiropractic institutions and that factors such as
chiropractic institution and level of education before
chiropractic study could explain much of the variance
around a chiropractic student's opinion. While philosophical differences between chiropractic institutions have
previously been noted,  the current study provides the
first data toward a link between institution and student
opinion. Our study clearly highlights this association;
however, further research is needed to investigate if this
link infers a causal relationship.
Chiropractic education as a potential determinant of
chiropractic professional identity is theoretically normalized
via a process of accreditation that assesses graduate
competencies and educational standards  to produce
graduates who focus on the diagnosis and treatment of
spine and musculoskeletal disorders.  The extent to which
chiropractic institutions in Australia and New Zealand
teach traditional chiropractic theories is currently unclear,
but this may vary greatly according to institutional
position and values. [22, 23] The transmission of norms,
values, and beliefs conveyed in the classroom and the
learning environments (eg, clinical internships) may
explain the large differences in opinions found between
students from different chiropractic institutions in the
current study. Our findings raise new concerns over the
legitimacy and effectiveness of the accreditation process,
whereby education and competency standards  may fail
to definitively rule on the role of traditional knowledge in
chiropractic curriculum. Our results also may suggest a
lack capacity within the accreditation frameworks to
quantify education content not covered by the accreditation
standards, which may be addressed by accreditors
formally evaluating student beliefs in addition to academic
The most consistent viewpoints among chiropractic
students were the settings most appropriate for chiropractic
practice. Over three-quarters of respondents believed
that an integrative setting is appropriate for chiropractic
care, with two-thirds in favor of public health care settings
such as hospitals and local health districts. Notwithstanding,
Australian chiropractors currently service the community
in private clinical practice settings, frequently
alongside another chiropractors (57%) or massage therapists
(30%).  While over half of Australian chiropractors
refer patients to general practitioners, seldom do they work
in the same practice as other health providers. Results
from the Australian Chiropractic Research Network reveal
that chiropractors infrequently work alongside psychologists
(12%), physiotherapists (9%), exercise physiologists
(6%), and general practitioners (6%).  Therefore, student
opinions and, potentially, expectations as they relate to
chiropractic setting do not currently align with the reality
of clinical practice. Regarding future practice, most
chiropractic students strongly agreed that care should
include preventive (wellness) care for nonspecific chronic
conditions. However, they were less strongly opinionated
about the role of chiropractic care in screening for physical
inactivity, poor nutrition, smoking, and hazardous alcohol
consumption. This again suggests the possibility of
disparate viewpoints with practice reality given that recent
nationally representative data on chiropractic clinical
management suggests that Australian chiropractors often
discuss physical activity (85%), diet/nutrition (51%), and
smoking/drugs/alcohol (25%) with patients.25 This may
suggest that there is room for improvement within
chiropractic educational programs to better engage students
as conduits for public health education initiatives
and potentially to manage expectations for future clinical
practice.  The fact that most students advocate future
practice in integrative and public health settings may
simply reflect the current accreditation requirements or
best practice for clinical internships and case-mix loads.
In Australia and New Zealand, chiropractic is a
registered health care profession that falls under the allied
health banner,  with an estimated 16% of the population
using chiropractic care most frequently for musculoskeletal
complaints.  Respondents tended to identify chiropractors
as allied health care practitioners (75%), most
appropriately positioned as nonsurgical spine and musculoskeletal
care experts (45%). This finding supports a
recent commentary on the identity of chiropractors in
which authors suggest that chiropractors internally accept
the public view that they are in fact specialists for spine
and musculoskeletal disorders.  Nonetheless, several
chiropractic students in the region did not hold identity
views that align with either the national legislative
frameworks or community demand, and opinions did not
appear to change with increasing year level of study for
students in the current sample. Added to this, 1 in 5
respondents oppose the view that chiropractic care should
be integrated with other health care disciplines, including
medicine. Musculoskeletal conditions (low back and neck
pain) remain among the highest cause of disability burden
in society globally.  The majority of people who pursue or
seek chiropractic care do so for musculoskeletal and spinal
complaints, yet the presumption that chiropractors provide
primarily a service that society wants and needs [21, 30]
may be challenged if student opinions found in this study
match those of graduate chiropractors. Incongruous
expectations between student's/chiropractor's views and
society's wants/needs may explain professional issues
associated with limited cultural authority and integration
into mainstream health in the region to date. Whether
Australian and New Zealand student and graduate
opinions correlate or student opinion remains congruent
over time is currently unclear and an area for future
Study Strengths and Limitations
The current study provides unique insights into
chiropractic student opinion from different institutions in
Australia and New Zealand. We were expecting dissimilar
student opinions to those of North American chiropractic
students given that chiropractic training is exclusively
university based in Australia. Our study is the first to
provide data that suggest that chiropractic institution may
indeed explain student opinion. On this, we adopted a
stepwise analytical approach to minimize the possibility of
incorrectly rejecting a true null hypothesis as it relates to
between-school differences in opinion (inflating the type I
error rate).  We used a preexisting survey instrument  to
allow for comparability of findings with North America
and future studies from other regions using the same tool.
However, we acknowledge that the psychometric properties
of these questions or the validity of summary scores
are currently unclear. Despite the strengths, our study was
limited by low response rate, with 1 in 5 students
answering the online survey, which is comparable to the
same North American study.  Given this, we have
interpreted these results with caution based on poor
representativeness and generalizability. Inherent to crosssectional
study designs is the inability to determine the
direction of associations or to imply causal inference. It
may be that other factors beyond those studied here are
predictive of local student viewpoints, and these remain an
area for future research.
Divergent viewpoints about the identity, scope, and
future of chiropractic practice exist in our sample of
Australian and New Zealand chiropractic students. The
problem of conflicting professional identity is well reported
in the chiropractic literature.  The lack of a unified voice
not only demoralizes chiropractors and chiropractic
students it also may limit public acceptance of chiropractic
and hinder the public from utilizing evidence-based care
for common musculoskeletal pain.  Our results provide a
strong motivation for chiropractic institutions, along with
local accreditation agencies (Council on Chiropractic
Education Australia), to review their procedures for
evaluating student applicants, program curriculum, and
accreditation standards in order to ameliorate the disparity
that exists in student opinion and therefore create
consistency in the delivery of mainstream vs traditional
models of chiropractic health care
Chiropractic students in Australia and New Zealand
simultaneously encompasses mainstream, orthodox, and
potentially scientific views as well as traditional, unorthodox
and potentially pseudoscientific opinions about
chiropractic. A possible explanation for conflicting viewpoints
may be factors associated with a student's
chiropractic program of study. Indeed, viewpoints vary
most when considering educational programs where there
are internally conflicting and internally consisted opinions.
What remains unclear is whether there is a causal
relationship between institution and student opinion.
Future prospective studies are now required that evaluate
whether student opinions change over time and whether
student opinion is moderated by additional education or
experience gained in the field.
We would like to thank those faculty members at each
chiropractic program in Australia and New Zealand who
assisted the investigators with dissemination of survey
invitations and notifications to eligible participants.
FUNDING AND CONFLICTS OF INTEREST
This research received no specific grant from any
funding agency in the public, commercial, or not-forprofit
sectors. The authors declare that there are no
conflicts of interest.
About the Authors
Katie de Luca is in private practice and a member of
Chiropractic Academy for Research Leadership (24 Salmon
Circuit, South West Rocks, New South Wales 2431, Australia;
email@example.com). Jordan Gliedt is with the College of
Chiropractic, Logan University (1851 Schoettler Road,
Chesterfield, Missouri 63017; firstname.lastname@example.org).
Matthew Fernandez is in private practice and a member of
the Chiropractic Academy for Research Leadership (103,169
Victoria Road, Drummoyne, New South Wales 2047,
Australia; email@example.com). Greg Kawchuk
is a professor in the Department of Physical Therapy, Faculty
of Rehabilitation Medicine, University of Alberta (Corbett
Hall, 8205 114 Street NW, Edmonton, Alberta T6G 2G4,
Canada; firstname.lastname@example.org). Michael Swain is in the
Department of Chiropractic, Faculty of Science and Engineering,
Macquarie University, and a member of the
Chiropractic Academy for Research Leadership (Balaclava
Road, Macquarie University, New South Wales 2109,
Australia; email@example.com). Address correspondence
to Katie de Luca, 24 Salmon Circuit, South West
Rocks, New South Wales 2431, Australia; chirokatie@live.
com.au. This article was received September 19, 2017, revised
October 25, 2017 and accepted December 8, 2017.
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