J Clinical Chiro Pediatrics 2014 (Nov); 14 (3): 1167–1171 ~ FULL TEXT
By Ida Marie Navrud, DC, Joyce Miller, BSc, DC, DABCO, PhD,
Maja Eidsmo Bjørnli, DC, Cathrine Hjelle Feier, DC, Tale Haugse, DC
Private practice, Norway
Introduction: Chiropractic is a common parental choice as a therapeutic intervention for numerous pediatric conditions. No studies investigating parent satisfaction with pediatric chiropractic care have been published to date.
Method: All infants aged 0-36 weeks and presenting to a chiropractic teaching clinic on the south coast of England between January 2011 and October 2013 were eligible for inclusion. Parents completed questionnaires, which rated their own and their infant’s characteristics prior to, and at the end of, a course of chiropractic care. Non-parametric tests were used to analyze before and after care scores.
Results: A total of 395 results were collected in this study. Satisfaction scores of 10/10 (“completely satisfied”) were reported by 75.1% (n=295) of the parents. There was a significant
improvement in parental distress (Median=5.0 before care, Median=2.0 after care, Z=-13.7, p<.001, r =-.49)
and infants’ sleep quality (Median=5.0 before care, Median=3.0 after care, Z=-10.5, p<.001, r =-.38). Satisfaction scores were found to have a small correlation with sleep quality (rs =-.21) after care, as well as a moderate correlation with distress (rs =-.31) and improvement scores (rs =.42), p<.01.
Conclusion: The parents in this study appear to be satisfied with the care their infant received. However, the satisfaction scores and improvement scores are only moderately correlated, which indicates that there are other factors influencing the level of satisfaction.
MeSH terms: chiropractic, complementary therapies, infants, pediatrics
Key words: pediatric, satisfaction, parent, chiropractic, complementary alternative medicine
From the Full-Text Article:
Satisfaction with chiropractic care for pediatric patients is
currently an unexplored area in the literature. Measuring
outcomes of care is essential in evidence-based healthcare,
and satisfaction is a key concept in assessing patients’ perception
of care. Studies of satisfaction can be useful in determining
how well patients’ hopes and expectations are met
when they receive a form of treatment. [1, 2] There is substantial
agreement in the literature about satisfaction measures
being valid in assessing quality of care. They allow patients
to express their personal evaluation of health care services
and practitioners. [3-7]
The concept of satisfaction is difficult to grasp, and even
harder to define. The literature does not provide one clear
definition, but some general components can be identified.
It is often an emotional or cognitive response; pertaining to
a particular focus or goal. [8, 9] Satisfaction has been described
as the fulfillment of expectations, needs, or desires. 
and Arnetz investigated parent satisfaction with hospital
care for the pediatric patient. They found that parents were
most satisfied with staff attitudes, care processes, and medical
treatment. Accessibility and staff work environment received
the lowest satisfaction scores.  It has been suggested
that patient satisfaction is dependent on the patient feeling
empowered, in control of one’s life, and the establishment
of an empathetic therapeutic relationship. Hope, communication,
respect, and trust were the four main themes associated
with the therapeutic relationship.  Good Communication
stands out as a consistent determinant of overall
satisfaction in several studies. [1, 6, 11-16]
However, in the care of the pediatric patient, the patient has
no say in the matter, only the parent or guardian. Hence,
satisfaction may take on a unique character in this domain.
We hypothesize that parents might be most satisfied with
improvement in the child’s condition. A survey was developed
to test this theory, and investigate parental rating of
satisfaction and other factors in patient care.
A cohort of parents presenting their infant to a chiropractic
teaching clinic, located on the south coast of England, were
followed through the course of care for their infant. All infants
between the age of one day up to 36 weeks who presented between January 2011 and October 2013 were eligible
for inclusion if the parents had completed both pre- and
post-treatment questionnaires. No further exclusion criteria
were used. A total of 395 valid results were collected and
analyzed for this study.
Data were collected using two, practitioner-administered,
questionnaires. The first was done prior to initiation of care,
and the second on the day of discharge. In the first questionnaire,
parents were asked to rate their level of distress
due to the infant’s behavior. These metrics were measured
using a 10-point scale, with 1 being the most positive (e.g.
not at all distressed) and 10 being the most negative response
(e.g. extremely distressed). The parents were asked
to indicate the numerical value that best represented their
perception of the questions asked. On the day of discharge,
the parents were asked the same questions using the same
methods. In addition, they were asked to rate the degree of
improvement in their infant’s condition, and their satisfaction
with the care received. The scale ranged from 1 (not at
all) to 10 (completely better). Data on age, gender, number
of treatments, and time frame of treatment (in weeks) were
All statistical analyses were conducted in IBM SPSS Statistics
20.  Measures of central tendency were calculated.
Kolmogorov-Smirnov and Shapiro-Wilks tests were used to
test the data for normality. Non-parametric tests were used
as the data were not normally distributed, but also to account
for the ordinal nature of the majority of the data. The
Mann-Whitney U test was performed to assess for differences
between two independent groups. Wilcoxon’s signedrank
test was used to compare scores before and after care.
Spearman’s rank correlation coefficient (Spearman’s rho)
was calculated to assess the relationship between variables.
According to Cohen, a correlation coefficient of 0.1-0.3 is
defined as small, moderate if 0.3-0.5, and high if greater
than 0.5. 
The Anglo European College of Chiropractic (AECC) ethics
panel approved the study, and data from all patients were
A summary of the sample characteristics can be found in
Table 1. The sample consisted of 11.8% (n=47) more males
than females. Mann-Whitney U tests were performed to
assess for differences between genders, but no significant
differences were detected.
The main reasons for presenting to the clinic were
“difficulty feeding” (18.1%) and
“check up” (12.7%).
Reasons mentioned under “other” included:
“birth trauma” (5.1%)
“will not lie supine with comfort” (5.3%)
“cannot turn head equally” (5.1%)
“positional head deformity” (3.8%)
“axial musculoskeletal” (2.5%) and
Characteristics of the pediatric population in the sample (N=395)
Participating parents were asked to rate their level of distress
on a 1-10 scale, with 1 being “not at all” and 10 being
“extremely distressed”, before and after care (Table 2). Distress
scores of 5 and below were reported by 56.0% before
care, and 92.6% after care. This was further investigated
through a Wilcoxon signed-rank test, and there was a significant
decrease in distress from before care (Median=5.0)
to after care (Median=2.0), Z=-13.7, p<.001, r =-.49.
Distribution of scores regarding distress, sleep quality, improvement, and satisfaction
Sleep quality before and after care was assessed on a 1-10
scale, with 1 representing “sleeps deeply and restfully most
of the time” and 10 representing “restless, difficult to settle
or stay asleep or does not sleep deeply.” Scores of 5 or lower
were reported by 50.6% before care, and 78.6% after care.
Wilcoxon’s signed-rank test revealed a significant improvement
in sleep scores from before care (Median=5.0) to after
care (Median=3.0), Z=-10.5, p<.001, r =-.38.
The amount of over-all improvement was investigated
through a 1-10 scale, where 1 represented “infant’s condition
is worsened” and 10 represented “completely better.”
The lowest score reported was 2, indicating “no change,”
and 8.7% reported scores of 5 and lower. Scores from 8 to 10
(indicating good or total recovery) were reported by 69.1%.
Parents were also asked to rate their level of satisfaction
with the care on a scale from 1-10, with 1 being “not at all”
and 10 being “completely satisfied.” Scores below 7 were reported
by 1.3%, and a total of 75.1% responded that they
were completely satisfied (Table 2).
All correlations between improvement, satisfaction, distress
after care, and sleep quality after care were statistically
significant at the .01 level (Table 3). The positive correlations
indicate that high scores in one group are associated
with high scores in the other group, and that low scores in one group are associated with low scores in the other
group. The negative correlations, however, indicate that
high scores in one group are associated with low scores in
the other group. Distress and sleep quality scores are better
the lower they are, whereas satisfaction and improvement
scores are better the higher they are.
Correlation coefficients (Spearman’s rho) between improvement,
satisfaction, distress after care, and sleep quality after care
The Spearman’s rho revealed a small negative correlation
between satisfaction and sleep quality after care (-.21). A
moderate positive correlation was found between satisfaction
and improvement scores (.42). Moderate negative
correlations were found between improvement and sleep quality after care (-.37), between improvement and distress
after care (-.39), as well as between satisfaction and distress
after care (-.31). Furthermore, a high positive correlation
was revealed between distress after care and sleep quality
after care (.53).
The parents in this study reported high levels of satisfaction,
and improvement of the presenting condition. Parents
reported a decrease in their distress levels, and an improvement
in the infant’s sleep quality after an episode of care.
For example, lower levels of parental distress correlate with
higher parental satisfaction. Analysis of the data revealed
a moderate positive correlation between satisfaction and
improvement scores. A moderate negative correlation was
found between satisfaction scores and parents’ level of distress.
Satisfaction and sleep quality after care demonstrated a small negative correlation. This is suggestive of high improvement
scores, improved sleep quality, and lower levels
of parental distress being associated with high levels of
satisfaction (Table 4). However, these correlations were not
strong enough to account for the high satisfaction levels reported
in this study. This suggests that other factors, not investigated
in this study must influence parent satisfaction.
The literature suggests that satisfaction is a multidimensional
concept, and thus other possible factors should be
investigated. Suggestions of such factors include practitioner’s
communication skills and interpersonal manner, time
spent with the patient, and time allowed for questions. In
addition, sociodemographics and treatment cost could play
a role. [14, 15] It should be noted that parents pay for care at this
clinic, whereas medical care is free in the UK.
Variables with high positive correlations with each other
According to Jackson et al., satisfaction levels obtained at
the end of the treatment course provide more information
on treatment success than those obtained early in the course
of treatment.  Satisfaction scores obtained early on are
thought to provide an evaluation of factors such as the clinician,
the clinic, and patient-practitioner interaction. Clinical
outcome and satisfaction have been found to be positively
linked.  However, a study by Williams et al. suggests that
high satisfaction rates do not necessarily mean high quality
of care; it could also be that no situations leading to dissatisfaction
were encountered.  It appears that while efficacious
therapeutic techniques are important, other variables
may have a greater impact on reported satisfaction. These
include communication, practitioner’s technical skills and
interpersonal manner, time spent with practitioner, accessibility
and availability of services, and the financial aspects
through the course of treatment. [8, 15, 19-21]
While satisfaction studies can be an effective tool in gathering
patients’ perceptions of health care environments, they
are challenging to execute. Satisfaction is a multidimensional concept, making it difficult to measure accurately. 
Satisfaction studies have been criticized for demonstrating
a lack of standardization, low reliability, and uncertain
validity of results due to generally high reported satisfaction
levels and lack of variability in responses. This caused
Haggerty to question whether satisfaction is a flawed way
of evaluating practice performance.  It has been suggested
that dissatisfaction might be a more valuable concept.
Negative findings will give feedback of areas requiring improvement,
and it is thought to give a greater understanding
of what patients expect from their treatment. [2, 5, 21]
The questionnaires utilized in this study were presented to
the parents in the treatment room, and placed in the chart
upon completion. Interviewer-administered questionnaires
tend to yield responses in a socially desirable direction. 
The parents might have felt embarrassed to give a low
score, which may have resulted in unrealistically high satisfaction
scores. The validity of a survey depends on subjects’
honesty in their responses.  Additionally, some evidence
suggests that non-responders tend to be less satisfied than
An unknown number of pediatric patients seen at the clinic
may never have been included in this study. There can be
various reasons for this; their practitioner did not provide
the questionnaire for completion, the parents were not willing
to submit it, or the patient never returned to complete
the care regime. One can only speculate if these outstanding
responses, which leave an unfilled gap in the results, could
be due to dissatisfaction regarding their experience. Handling
paper questionnaires versus electronic is a time and
resource consuming process. The data were entered manually,
which is associated with data entry errors, although
10% were checked for accuracy. It also results in very slow
feedback, thus delaying the actions on problems identified. 
Although no studies have been published on the topic of
parent satisfaction with chiropractic pediatric care, a pilot
study was carried out at a private clinic in France in 2012.
This was a much smaller study than the one carried out at
the UK clinic, but the results were similar, showing high
levels of satisfaction with care. 
This study showed that parents generally were very satisfied
with chiropractic care of their child. Correlations between
high satisfaction and improvement of the infant’s
presenting complaint, improved sleep quality, and lower
levels of parental distress were observed. As these correlations
were not strong enough to account for the high satisfaction
levels reported, additional research is needed to
identify other factors influencing parent satisfaction with pediatric chiropractic care.
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