Introduction
Established surveys have explored chiropractic students' opinions on their chiropractic identity, role/scope, setting, and future of practice. These areas, along with the worldview of chiropractors, have a long history of challenges internally and externally.1–7 These challenges range from attempts to contain and eliminate the profession, to the restricting scope of practice with children, and to the impact of chiropractic philosophy on the profession and its education. Students of chiropractic have been previously surveyed to ascertain their opinions and beliefs.8–11
An initial assessment, conducted in 1 North American chiropractic teaching institution with 664 students and published in 2012, entailed a 44-item questionnaire. The survey investigated “Demographics and Experience”, “Attitude of Future Career Characteristics” and “Chiropractic Philosophical Beliefs”.8 This study was used as a pilot and modified for a 2015 survey that obtained participation of 1247 students from 12 of the 19 accredited North American chiropractic colleges between November 2013 and April 2014. This 2015 study, with 23 items, aimed to investigate chiropractic student opinions about evidence-based practice, chiropractic identity, role/scope of practice and future practice.9 The creation of this survey have been challenged by Senzon (2022) due to the 2015 questions being new and not systematically or objectively developed. The authors comment on (page 6) how the majority of students “would like to see an emphasis on correction of vertebral subluxation in chiropractic practice” and also consider “it is important to learn about evidence based-practice.”9 Their reflection on these two perspectives note that they “may seem contradictory, suggesting cognitive dissonance”.
As no similar studies were identified investigating these concepts in Australian and New Zealand chiropractic programs, further research was conducted.10 This study was based on the 2015 survey and data was collected between August and October 2016. At that time 5 Australian and New Zealand programs had eligible students to participate – Central Queensland University, Macquarie University, Murdoch University, New Zealand College of Chiropractic, and RMIT University. This study modified the 2015 survey instrument (p116), using the “original core statements (11 Likert response items and 4 nominal response items) about identity, role/scope, and setting, with additional items pertaining to future practice as it relates to public health education initiatives”, resulting in 31 items.10 They obtained an 18.7% response rate with 347 participants. These authors created “construct scales” to summarise respondents' statements on a scale from 0 = progressive/mainstream viewpoint to 100 = traditional/alternative viewpoint. No references were provided evidencing the use of this scale, so it is assumed it is a novel creation by expert opinion of the authors in this instance. Quantifying themes using the framework of the construct scales outlined may have utility; however, this utility needs further exploration relative to the precision of terms used in the survey and the accuracy or potential bias within the framing of the questions.
The concept of chiropractic professional identity has been explored through a series of articles by Glucina et al,12,13 resulting in the recent development and validation of a Chiropractic Professional Identity Embodiment Scale (CPIES).14 Numerous items within this scale reflect items previously used by both de Luca et al and Gliedt et al in their surveys and discussions.
The concept of cognitive dissonance, undefined in Gliedt et al 2015, is considered by de Luca et al 2018 “where internal inconsistencies in opinion are explained by a want or a need to justify historical theories of the chiropractic profession.”10 These authors found that chiropractic institution and level of education before chiropractic study explained the majority of the differences in participants (chiropractic student) opinion.10 A 2021 paper completed a secondary analysis on “chiropractic students' cognitive dissonance to statements about professional identity, role, setting and future.”11 This data came from the 2015 North American and 2018 Australia and New Zealand research papers, along with unpublished European data presented at the World Federation of Chiropractic Congress in Berlin, 2019. The authors define cognitive dissonance as being “exhibited when one possesses multiple paradoxical beliefs, or when an individual's behavior is inconsistent or conflicting with their beliefs.”11
These studies use varying definitions of cognitive dissonance, some relating to chiropractic theories and some relating to behaviors and beliefs. There is considerable room for interpretation on this term, and the discussion is framed around the authors interpretation of the respondents’ beliefs. Mifsud and Smut note that beliefs form an ontological framework, that may consist of overlapping beliefs with functional utility, resulting in a generalized worldview.15 The question whether the participants exhibited cognitive dissonance could be further explored by adding an enquiry about their personal beliefs, or worldview. To address this, a construct of “worldview” was added to the current modified survey entailing four questions attempting to explore the respondent’s worldview relating to health. Variants of two of these questions now make up part of the Glucina et als CPIES.14 The aim of this pilot study was to test an updated survey instrument used with chiropractic students in order to reduce bias, streamline public health initiative questions, assess internal consistency, and add 4 items regarding participants worldview.
Methods
Ethical approval was obtained from the Human Research Ethics Committee (approval number 2021/040).
Study Design and Setting.
A web based opportunistic pilot survey and feedback focus group of first year chiropractic students at one Council of Chiropractic Education Australasia accredited institution was conducted in May 2021. On completion, the participants were invited to an online (Zoom Communications, Inc) based feedback focus group to be conducted at a convenient time for those interested.16 No financial incentives were offered. The survey was constructed and administered from the Qualtrics Survey platform.
Participants and Eligibility Criteria
First-year chiropractic students enrolled in the chiropractic program were eligible for participation. The head of research was engaged to facilitate distribution of the survey invitation. Two follow-up emails were sent over the next two weeks.
Survey Instrument
The survey was modified by a research team of 3 scholars with survey research experience from the 31-item questionnaire used by de Luca et al10 to reduce bias, streamline public health initiative questions, assess internal consistency, and add 4 items regarding participants worldview. Following 3 meetings to discuss and develop the survey, the result entailed 28 items available to answer and continued the Australia/New Zealand focus of the 2018 survey. Six demographic items solicited age, gender, highest level of education prior to enrollment in chiropractic studies, other healthcare qualifications, institutional enrollment, and student membership of professional associations. The following 22 survey items explored participants' opinions relating to chiropractic identity, role/scope, setting, future practice, and their worldview.
Variables and Measurements
Following the same expert opinion method of de Luca et al,10 a series of construct scales were created from summaries of participants answers. These tallied scores on questions relating to chiropractic identity, role/scope, setting, future practice, and their worldview. The prior method was followed using a scale ranging from “0 = progressive/mainstream viewpoint to 100 = traditional/alternative viewpoint in which 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.”10 This study sought to reduce bias in language and aimed to provide unique data on the respondents’ worldview for analysis alongside the 4 other constructs.
Following the methodology of de Luca et al,10 summary scores were formulated from the 18 Likert-scale questions. However, an additional option of “No opinion/don't know” was added for Likert scale question. Therefore: 0 = strongly agree; 1 = agree; 2 = neutral; 3 = disagree; 4 = strongly disagree; 5 = No opinion/don't know. The construct score for identity was based on the average response to four statements1: it is important for chiropractors to hold strongly to the traditional chiropractic theory that adjusting the spine corrects ‘‘dis-ease’’2; it is important for chiropractors to be educated in evidence-based practice3; contemporary and evolving scientific evidence is more important than traditional chiropractic principles4; it is appropriate to allow for updating and enrichment of chiropractic theories based on current scientific advancements. Item 1 was reverse coded so that a positive opinion would be reflected by a higher summary score. Within this construct score for identity the same question was asked in reverse order to minimize respondent error and ascertain an insight into internal consistency17 of the participants answers i.e.: “Question 12: traditional chiropractic principles are more important than contemporary and evolving scientific evidence” versus “Question 21: contemporary and evolving scientific evidence is more important than traditional chiropractic principles”.
The construct score for role/scope was based on the average response to 4 statements1: the main emphasis of chiropractic care is to eliminate vertebral subluxations/vertebral subluxation complexes (this added “main” and “/vertebral subluxation complexes” to the question relative to the prior survey)2; the chiropractic profession should expand its scope of practice to include prescribing pharmaceutical medication, with appropriate advanced training (this added pharmaceutical)3; the primary purpose of the chiropractic examination is to detect vertebral subluxations4; chiropractic education prepares students for the care of infants and children. Previously4 was “chiropractic care should consist of the chiropractic adjustment only”. This was removed as it reflects the same answer as items1 and3 stated here and is addressed in Question 26 ranking interventions used by chiropractors. Chiropractic care of infants and children was added as a scope of practice question, particularly pertinent in Australia since the 2019 Safer Care Victoria review.7 Items 1 and 3 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 three statements1: inclusion of clinical chiropractic training internships in integrative medical settings is important to the progression of the chiropractic profession2; chiropractors should maintain a primary contact (direct contact with the public, no referral required) status3; inclusion of post-graduate practice in integrative medical settings with other health professionals is important to the progression of the chiropractic profession.
For this construct, item2 changed “chiropractic practitioners” to “chiropractors”; “primary care” to “primary contact”; “direct access” changed to “direct contact with the public, no referral required”. Item3 had said the “public health care setting (hospitals and local health districts) are appropriate settings for chiropractic health care”; the updated version makes specific time references as post-graduate and specified “with other health professionals.”
The construct score for future practice was based on the average response to 2 statements about dividing the profession into 2 subgroups and public health initiative advice1: it is appropriate the chiropractic profession distinguish and promote two subgroups: one that has subluxation as a practical clinical concept and one that considers subluxation of only historical note2; chiropractic education prepares students to provide health promotion advice (nutrition, weight management, alcohol, smoking cessation, physical inactivity etc). These firstly asked the participant to reflect their perspective on dividing the profession and secondly combined four health initiatives statements from the 2018 survey into 1.
The construct score for worldview was based on the average response to 4 statements1: in chiropractic philosophy, there is no difference between disease and dis-ease2; all truth and knowledge emerge from scientific methods and investigation3; health is a state when there is no disease present4; the way a person thinks has no influence on their physical disease. All summary scores were transformed to fall within a 0-to-100-point scale.
Following the survey, a feedback focus group consisting of 3 students (7.89% of respondents) discussed eight specific questions1: did you understand all the questions2; did you have any concerns with any of the questions3; were there any concepts you did not understand/struggled with4; did you find any concept too simple or too complex5; was the time allowed sufficient6; did you find the survey platform/website easy to use7; were you able to rank the final 3 questions effectively8; Did you have any suggestions about the survey? An opportunity for open discussion was also provided.
Statistical Methods
Data were imported from Qualtrics, cleaned, inspected and descriptive statistics were derived for all appropriate variables. Only participants who completed questionnaires to the end of the Likert scales (89% completed, including up to question 25 of 28) were included in the analysis to allow for construct creation.
Descriptive analysis for each item within each construct score were reported as frequency distributions across the 5-point Likert scale, along with the “no opinion/don't know” option.
Summary construct scores were illustrated using box plots. The 2 questions testing the same underlying identity construct of traditional principles versus contemporary evidence (Question 12 and 21) were assessed for internal consistency with Cronbach‘s alpha18 and Spearman-Brown coefficient.19,20 Cronbach’s alpha ranges from 0 to 1 with values above 0.7 usually considered acceptable, however for scales with only two items values are typically lower.18 Spearman-Brown coefficient is a better estimate of short scales20 such as 2 question constructs. Pearson's correlation for construct independence was calculated for the worldview construct against the other four constructs. The mean difference between educational level and worldview summary score was calculated via Hochberg analysis.
Results
Analyses: Internal consistency.
This analysis showed a Cronbach's alpha of 0.417, suggesting a modest internal consistency between the 2 questions and a Spearman-Brown score of 0.417 confirms the modest internal consistency between those two questions.
Demographic data.
A total of 38 participants (55.3% female) completed the demographic and Likert scale questions, providing the data for construct score creation. With the pilot cohort consisting of 75 students, this is a response rate of 50.7% completing the survey. A total of 35 completed the additional three ordering priority questions (Q26, Q27, Q28). The participants ranged in age from 18 to 37 years for an average of 22 years and the mode age being 19 years. Prior education entailed high school for 9 students, a diploma for 20 students, and a bachelor's degree for 9 students. Over two-thirds (68.4%) of participants were members of a chiropractic association.
Description of Survey Responses
Relating to the most appropriate practice paradigm, 44.7% responded for a general healthcare focus, 39.5% responded for a traditional subluxation focus, 7.9% responded for a musculoskeletal care focus, and 7.9% responded as unsure or other focus (Table 1).
Table 2 reports the distributions of participants responses to statements about identity, role/scope, setting, future practice and worldview. Relating to the identity construct, 94.8% of respondents agreed it is important for chiropractors to be educated in evidence-based practice. A majority (Q12 52.4% and Q21 68.4%) agreed that contemporary and evolving scientific evidence was more important than traditional principles; however, over a quarter of respondents were either neutral or had no opinion/didn‘t know. There was agreement for 84.2% that it is important for chiropractors to hold strongly to the traditional chiropractic theory that adjusting the spine corrects “dis-ease”, and a 94.7% agreement that it is appropriate to allow for updating and enrichment of chiropractic theories based on current scientific advancements. When considering the role/scope construct, 91.6% agreed that the main emphasis of chiropractic care is to eliminate vertebral subluxations/vertebral subluxation complexes. Concerning pharmaceuticals, the majority disagreed (57.9%) that the chiropractic profession should expand its scope of practice to include prescribing pharmaceutical medication, with appropriate advanced training. However almost a fifth (18.4%) were neutral on this point, with another 18.4% agreeing with the statement. Over three quarters (78.9%) agreed that the primary purpose of the chiropractic examination is to detect vertebral subluxations. When asked whether their chiropractic education prepares students for the care of infants and children, 68.4% agreed. Interestingly 29% were either neutral or didn’t know if this was so. Questions relating to the setting construct indicated a majority agreeing with primary contact status (73.8%), supporting inclusion of clinical chiropractic training internships in integrative medical settings as important to the progression of the chiropractic profession (57.9%), and (65.7%) agreeing with the inclusion of post-graduate practice in integrative medical settings with other health professionals as important to the progression of the chiropractic profession. Alongside this majority, a third (34.2%) of respondents to the internships in medical setting were either neutral or had no opinion/didn’t know if this was important to the progression of the chiropractic profession. For the future practice construct, respondents were asked if it is appropriate the chiropractic profession distinguish and promote 2 subgroups: 1 that has subluxation as a practical clinical concept and 1 that considers subluxation of only historical note. This question had varied responses: 34.2% disagreed, 26.3% agreed 26.3% had no opinion/didn't know and 13.2% were neutral. A majority (81.6%) agreed that chiropractic education prepares students to provide health promotion advice. The worldview construct explored aspects of chiropractic philosophy and individual health beliefs. The majority (94.8%) agreed that there is a difference between disease and dis-ease. A majority (84.2%) disagreed that the way a person thinks has no influence on a physical disease. Similarly, a majority (57.9%) disagreed that health is a state when there is no disease present; however, 29% agreed with this statement. Finally, the statement that “all truth and knowledge emerge from scientific methods and investigation” elicited a balanced spread of responses: 39.5% disagreed, 36.9% agreed, and 23.7% were neutral.
The answers to the ranking questions relating to chiropractic interventions, settings, and future research focus were completed by 35 participants (46.7% response rate).
The most frequent answers by respondents when ranking the most to least important interventions as used by chiropractors were: 1 chiropractic adjustment; 2 manipulation; 3 mobilization; 4 and 5 equally were rehabilitation and health promotion advice; 6 soft tissue therapy; and 7 appropriate supplements (Table 3).
The responses for the most appropriate setting for chiropractic health care indicated first were integrative settings with other health care disciplines including medical practitioners; followed by solo practice or with other chiropractors; then integrative settings with allied health practitioners; and finally with integrative settings with complementary medicine practitioners only.
The ranking of importance of areas for chiropractic researchers to focus on was firstly on the validity of the construct of vertebral subluxation, followed physiological mechanisms of chiropractic adjustments, then outcomes/cost-effectiveness of chiropractic care, and finally on outcomes/cost-effectiveness of integrative care models.
Analyses: Effect of level of education on students' opinions
Correlation analysis between construct scores demonstrated weak to moderate correlations (Table 4). The weak correlation of the worldview construct suggests this construct provides a unique output and addresses a non-strongly related component to the survey data.
Summary scores for each construct are illustrated in Figure 1 below. This distribution for Identity, Role/Scope, Setting, and Future Practice are similar to those produced by de Luca et al,10
The mean difference between educational level and worldview summary score via Hochberg analysis is shown in Table 5. For worldview the High School mean was 81.25, the Diploma mean was 73.13, and the Bachelors was 62.5. This is on the 100-point scale where 0 relates to “progressive/mainstream” and 100 relates to “traditional/alternative”.
The feedback focus group did not result in any substantive change to the survey.
Discussion
The objective of this research was to pilot an updated survey instrument in chiropractic students. The modifications to questions to reduce bias resulted in data congruence for construct scores with previous studies. The pilot survey demonstrated internal consistency. Public health initiatives were streamlined from four questions into one. The addition of the worldview construct added unique data to the survey.
This pilot survey was successful in attaining a good response rate of 50.7%. This was higher than the 18.7% rate of the Australian and New Zealand 2018 survey and 16.7% rate of the North American 2015 survey.9,10 The process used for participant engagement was successful, however as it was in 1 program only, it is unknown if the response rate will be as high for a broader survey using the instrument.
The respondent‘s internal congruence was assessed by asking the same question in reverse order (Question 12 and Question 21), which showed a majority (Q12 52.4% and Q21 68.4%) agreement that contemporary and evolving scientific evidence was more important than traditional principles. This demonstrated modest internal consistency with Cronbach’s alpha of 0.417 and confirmed with a Spearman-Brown coefficient of 0.417. However, over a quarter of respondents were either neutral or had no opinion/didn't know. This provides evidence the respondents were consistent with their interpretation of the question and their answers. This majority reflects the 94.8% of respondents agreeing they should be educated in evidence-based practice. Like previous surveys, a majority agreed that chiropractors should hold strongly to the traditional theory that adjusting the spine corrects “dis-ease”, and that it is appropriate to allow for updating and enrichment of chiropractic theories based on current scientific advancement. Uniquely, this survey reported a 94.8% majority agreement that there is a difference between disease and dis-ease. This term has often been inappropriately conflated4,21–23 and this pilot provides data on student perspectives of this term.
When considering a distinguishing of 2 subgroups within the chiropractic profession, where one used subluxation as a practical clinical concept and one considering subluxation of historical note only, a broad spread of opinions were reported. One third agree, a quarter disagreed, a quarter had no opinion/didn't know, and 13% were neutral. This may reflect the level of exposure of the first year students to the practical and political discussion surrounding this issue. Findings from Glucina et al suggest that up to 86% of chiropractors consider the vertebral subluxation approach in their practice; however, the authors also note that simplicity of self-categorisation of practice sub-types may not be as differentiated as thought previously.24 Surveying of senior students and early graduates would further enlighten this topic, as would qualitative exploration of these concepts with respondents.
The majority of first year students disagreed with the expansion of practice scope to include prescribing pharmaceutical medication. However, 18.4% were neutral on this question, and 18.4% agreed with the statement. Given the reflection of most respondents around the focus of chiropractic care being the elimination of vertebral subluxation/vertebral subluxation complexes, this may demonstrate a dissonance in understanding or perspective on a broader scope of chiropractic practice by the first year students. This may be further explored with senior students and early graduate opinions.
A majority agreed that their chiropractic education prepares them for the care of infants and children. With the challenges that have emerged in the Australasian region over the past decade2,7,25 this is an area that requires continued vigilance from educators and regulators to ensure appropriate education and scope of practice facilitating the freedom of choice for families to access chiropractic care.
First year students were supportive of primary contact status, along with agreement of chiropractic training internships in integrative medical settings and the inclusion of chiropractors in post-graduate integrative medical settings with other health professionals. This model has been enacted in areas of Europe26,27 and North America28,29 and, although not so extensively in the Australasian region, it may be an area for the profession to research and engage with.
When considering the construct scores, the general distribution of the box plots showed consistency with the 2018 construct score distribution. This indicates the modifications made to the 2018 survey questions and used in this pilot survey maintained reasonable alignment while reducing potential bias and decreasing the number of questions asked. Importantly, the correlation analysis when adding the worldview construct demonstrated weak to moderate correlation, which suggest this construct provides a unique output and addresses a non-strongly related component to the survey data. This analysis may be further explored in a larger survey.
The worldview construct explored aspects of chiropractic philosophy and individual health beliefs. The majority (94.8%) agreed that there is a difference between disease and dis-ease. This statement reflects an understanding of traditional chiropractic philosophy, where Stephenson stated “disease is a term used by physicians for sickness….dis-ease is a term used in Chiropractic meaning not having ease…is indicative of the body being minus something that should be restored”.30 A majority (84.2%) disagreed that the way a person thinks has no influence on a physical disease. This reflects much of the published literature over the past decades that dispute a Cartesian dualism perspective on health and consider that the way someone thinks has an impact on their physical state.31,32 Similarly, a majority (57.9%) disagreed that health is a state when there is not disease present; however, 29% agreed with this statement. Finally, the statement that “all truth and knowledge emerge from scientific methods and investigation” elicited a balanced spread of responses – 39.5% disagreed, 36.9% agreed, and 23.7% were neutral. This broad range of opinion may reflect deeper philosophical and practical debates in society about the scope, authority, and limitations of the scientific method.33 It may be considered that although the scientific method has strengths in establishing accurate understandings about the natural world, it is provisional, evolving and influenced by societal values and broader worldviews.34–36
The analysis of education on worldview did not show statistically significant differences. For worldview the High School mean was 81.25, the Diploma mean was 73.13, and the Bachelors was 62.5. This is on the 100-point scale where 0 relates to “progressive/mainstream” and 100 relates to “traditional/alternative”. Although none reach a significant level (0.05) it is interesting to note the difference between scores of those with a high school level to diploma (8.1 points on the 100-point scale) to bachelor’s degree (18.8 points); along with the 10-point difference between diploma and bachelors’ qualifications. Further exploration of this with larger data sets may give a deeper understanding of this relationship.
Strengths and Limitations
This was a pilot study surveying chiropractic student’s identity, role, setting, future and worldview. A strength relates to the use of, and updating of, prior survey questions and methodology. This has seen the generation of data, particularly the construct scores, with similar distributions to prior data. This may allow for further comparisons of data sets when used over a larger population. Limitations of the study were that only one cohort from one year level in one institution was surveyed, and the use of an opportunistic sampling process. A strength of the pilot study is the use of a feedback group to gain perspective on subjects’ participation, which did not lead to any substantive change to the survey. The pilot survey was able to reduce bias, streamline public health initiative questions, assess internal consistency, and add 4 items regarding participants worldview
Conclusion
The modifications to questions to reduce bias resulted in data congruence for construct scores with previous studies. The pilot survey demonstrated internal consistency. Public health initiatives were streamlined from four questions into one. The addition of the worldview construct added unique data to the survey. Future research should consider respondents from both early and final stage students and include opinions from early stage graduates.
Funding statement
No funding was received for this study
Conflicts of Interest declaration
No conflicts of interest were reported.
Author contributions
MD conceived the project, MD, PO, SM contributed to the design and implementation of the research, MD produced the analysis and manuscript, MD, PO, and EE reviewed the manuscript.
ACKNOWLEDGEMENT
This article is dedicated to the memory of my coauthor and supervisor, Emeritus Professor Stephen Myers, whose invaluable guidance and support were critical to this work. His insightful contributions and encouragement profoundly shaped this project. Sadly, Emeritus Professor Myers passed away before the publication of this article, and it is with deep respect that we honor his legacy here and remember his generosity, wisdom, and humor.