Clinical Chiropractic 2009 (Mar); 12 (1): 11–22 ~ FULL TEXT
Patricia Carlton, Ian Johnson and Christina Cunliffe
McTimoney College of Chiropractic,
Kimber Road, Abingdon,
Oxon OX14 1BZ, United Kingdom
The attitudes and opinions of parents or guardians as the main decision-makers in their children's health care are likely to play an important role in determining whether or not children receive chiropractic care. The aim of this study was to determine the factors likely to influence parents or guardians when seeking chiropractic care for their children.
An anonymous questionnaire was sent via the head teachers of 8 primary schools in a typical UK county to the parents/guardians of children aged 5–11 who were attending the schools.
Of 987 questionnaires distributed, 259 were returned with 175 eligible for inclusion within the study (26% response rate). Healthcare choices for children were mostly made by mothers. Parents/guardians who already used complementary medicine (CAM), including chiropractic, were most likely to use chiropractic care for their children. Users of CAM were more likely to have a friend or family member in a healthcare profession than non-users of CAM. The family physician exerted considerable influence on the parent/guardian's decision to use chiropractic care for their children.
The results indicate that mothers are the main decision-makers when chiropractic care is chosen for a child and they are mostly influenced by the family physician and friends. This information could help inform campaigns aimed at dissemination of information about the practice and scope of paediatric chiropractic care.
From the Full-Text Article:
Chiropractic has long been grouped in the category of complementary and alternative medicine (CAM) along with therapies such as acupuncture, osteopathy, homeopathy and naturopathy. Use of CAM is increasing in Europe and the USA.  and  Research into the use of CAM for children  has indicated that in Europe, 25–50% of adults were CAM users as were 20–30% of children. Whilst other studies have found the percentage of child CAM users to be closer to 10–15%, [4–7]chiropractic can still account for approximately 36% of all CAM use.  and 
Children present to CAM practitioners mostly with respiratory, ear, nose and throat problems, followed by musculoskeletal problems.  Of these conditions, otitis media, asthma, allergies and infantile colic are common childhood complaints.7 Positive effects of CAM on well-being have been proposed, such as the reduced crying seen after spinal manipulation of children diagnosed with colic,  which has been viewed as having a likely positive impact on the parent–child relationship rather than a direct effect on colic.  Similarly, whilst chiropractic has been reported to have little direct effect on lung function and hyper-responsiveness in paediatric patients with asthma, treated children rate their quality of life substantially higher and their asthma severity substantially lower.  and 
Given that approximately one third of children who use CAM receive chiropractic care, there is a case for the profession to promote the benefits of chiropractic care for children. This can only be done rationally if it is underpinned by knowledge of how responsible adults make the decision to seek chiropractic care for children. The aim of this study is to determine the factors influencing the decision of parents or guardians to seek chiropractic care for their children.
The overall response rate for this survey was 26% for a sample size of 987. According to Bennekon  this response rate is likely to have produced representative survey data since, after taking into account the size of the population, the segmentation analysis desired, the degree of variance and the tolerance for error, a survey response rate of 25% for a population of 1000 is calculated to give approximately 95% certainty with ±5% accuracy.
Ninety-four percent of respondents, who considered themselves the main person responsible for healthcare decisions, were mothers. This is similar to the findings of other researchers, who all suggest that the mother is the parent who invests most in their child's health care. , ,  and 
Use of CAM and chiropractic
Most respondents identified at least one member of the family that had used some form of CAM; 50% of those CAM users were mothers and most of the children who had used CAM had parents that were also CAM users. These results reflect those found by Pitetti  and Nyiendo  who suggested that the main users of CAM are women and that, if they are also caregivers to children, then those children are also more likely to use CAM. A positive association has also been reported between social class and health, as an individual with a higher level of education may have greater knowledge or better access or exposure to information. 
In the current study, as with an earlier one by Madsen,  no relationship was found between the total household income and the use of CAM for their children, though this contrasts with a number of other studies which suggest that tertiary level education and higher family income are linked to the choice to use CAM. [17–22] Almost all the respondents in the current study were over the age of 30 and many were educated to degree level or above. Leboeuf et al. state that education is a strong determinant of social class, which in turn has a positive association with health.  They also state that health-related behaviour, attitudes and outcomes are governed by educational attainment such that the better educated have better access to information resulting in better awareness, and more efficient use, of available health services. Since children are generally dependent on their parents, it is likely that they are influenced by the experiences and opportunities of their parents and in particular the mother. Indeed, Case et al. have suggested that the educational level of the mother is more significant than that of the father in terms of health care because the mother is the main health care investor. 
Factors affecting use of chiropractic
There appear to be a number of factors that distinguish CAM users, including health awareness, making good food choices, monitoring consumption of preservatives and caffeine as well as taking regular exercise, and dissatisfaction with orthodox medicine and its responses medical profile.  However, in many studies the factor most likely to encourage respondents to seek chiropractic care for their children was positive feedback from a family member or friend. ,  and  The results of the current study indicate that the physician exercises considerable influence when parents/guardians are making healthcare decisions for their children, which may reflect the relatively new position of chiropractors as regulated healthcare professionals in the UK healthcare scene. As part of a wider study of CAM in the UK, White  reported that over 50% of UK family physicians felt that chiropractic should be available on the NHS. In line with this, most respondents in the current study said availability of chiropractic on the NHS would encourage them to choose it. Despite this, family physicians continue to display a low rate for referral to CAM, including chiropractic, and it has been suggested that this may be because family physicians want more quality published research on effectiveness, or because of they worry about the cost incurred by their patients when using CAM as a form of private health care.  The latter concern contrasts with the results of the current study where only 39% ranked cost as a factor that would discourage them from using CAM. This might indicate a mismatch between the family physician's perceptions about the affordability of CAM and those of their patients.
The second most influential factor affection a parent/guardian's decision to choose chiropractic care for their children was the opinion of friends and family. The importance of personal referrals is central to most practice-building guides and appears to be in line with the personal experience of chiropractors. ,  and 
The third most influential factor was the school or practice nurse. This may reflect the trend for the school nurse to take over many roles previously carried out by others, such as health visitors. 
Level of knowledge
The majority of respondents knew little or nothing about chiropractic and its suitability for primary school-aged children. As a result, they felt they could not make an informed choice about this form of health care. This lack of knowledge was reflected by the 72% of respondents who indicated that they did not know if chiropractic was appropriate for children. This result indicates that some adults who have chosen chiropractic care for themselves have not investigated the appropriateness of chiropractic care for their children. The reasons for this remain obscure; nevertheless, more information about chiropractic for children clearly needs to be made available to, and accessible by, parents and guardians and, if a target group of adults were to be selected on the basis of the current study, they would be mothers and family physicians.
The main reason given by parents/guardians for not choosing chiropractic care for their primary school-aged children was lack of knowledge. A campaign to disseminate information about the practice and scope of chiropractic care is clearly required to make parents/guardians aware of this healthcare option that is available for their children. Any targeted approach to such a campaign should be guided by the finding that the key parental decision-maker in this case is usually the mother, who in turn is heavily influenced by the opinions of friends and the family physician in the UK.