Introduction

Chiropractors in Aotearoa, New Zealand are one of several registered and regulated health professional groups. They predominately operate privately and work in the community at a primary-healthcare level, working “hands on,” alone or in association with other chiropractors and other health professionals, each of whom have their own philosophical view of health, education, ongoing training and, if regulated, operate from a defined scope of practice.

Clients generally pay privately as chiropractors are not integrated into accessing public health funding. However, some clients are eligible for Accident Compensation Corporation (ACC) funding if their physical health injury has occurred by way of accident and some private insurance companies also will cover chiropractic care to an extent.

The NZCA will celebrate 100 years of chiropractic practice in 2022 and the past provides a light to the future. Chiropractors, in New Zealand, have had to operate within a colonial English-led health environment in which they had little control as to where they can operate, limited access to public funding, and sparse public sector support for education, research, clinical development, and few options for the public to access payment for services (e.g. private health insurance or ACC).¹

Chiropractors in New Zealand have an interesting history. First, the profession was legally recognised in 1960 under their own Chiropractic Act. The Commission of Inquiry into Chiropractic in New Zealand 1979 found chiropractors to be safe, scientific and led to them being able to access ACC funding on behalf of clients.² This development led chiropractors to have their own health licensing authority, the Chiropractic Board. This entity operates under the Health Practitioners Competency Assurance Act (HPCAA) 2003. It has the responsibility to protect the health and safety of the public and to ensure that all chiropractors are registered, are competent to practice, undergo compulsory annual continuing education and receive an annual practicing certificate to practice.

Chiropractors have their own scope of practice in New Zealand. It focuses on the spinal framework influencing the nervous system and affecting the overall health and well-being of the individual. Chiropractors focus on assessment of conditions related to the spine and extremities, leading to diagnosis, prevention, rehabilitation, and management of conditions as well as promotion of education to support clients in managing their health and wellbeing.

Chiropractors have also established their own New Zealand Chiropractors’ Association (NZCA), a professional association that provides a voice for registered chiropractors and to support the development and ongoing education of the profession. The NZCA, in conjunction with a grant from the Hamblin Trust, has funded this research. As a professional body, it is independent; however, NZCA also has links with other professional chiropractic bodies internationally including the World Federation of Chiropractic, the peak international body representing chiropractic. It also has links with the New Zealand College of Chiropractic (NZCC). This college provides tertiary education of chiropractors, which involves at least 5 years of tertiary education. Once completed, graduates are required to meet competency standards prescribed by the Chiropractic Board to ensure the health and safety of the public. Overseas trained chiropractors are also assessed by the Chiropractic Board to determine whether they are competent to practice within New Zealand.

New Zealand’s health system has special responsibilities to Māori, the indigenous population in Aotearoa. Prior to contact with first settlers, the Maori had created their own tikanga or values and principles to promote and protect their health since the arrival of non-Māori in the late 17^th and early 18^th century. Māori as tangata whenua (indigenous population) have engaged with settlers and have been in constant negotiation with them for health funding, access, and participation in the delivery of health and related services so that they can meet their needs as individuals, members of family, whanau, hapu and iwi.³

To provide public health and related services, registered health practitioners are now required to take recognition of Te Tiriti o Waitangi, consult with Māori regarding health matters and improve health outcomes for tangata whenua. Māori have their own holistic view of health and treatment modalities and support holistic approaches to health recognizing the importance of physical, mental, family and spiritual wellbeing linked to their connection with their whenua (land), the natural and spiritual environments they inhabit and have kaitiaki or guardianship responsibilities, to care for current and future generations.⁴ This view of health is increasingly being recognised and incorporated in the philosophies and health practices of other health professionals, including chiropractors.

New Zealand’s health services are now in a process of structural change with new arrangements to begin in 2022 that have a greater focus on public health, prevention, and early intervention. These proposed changes now provide an opportunity for different health perspectives, health providers and health practitioners to blend or work together and for boundaries to be renegotiated as to where different health practitioners can practice, are entitled to access public-health funding, and be involved in the design and delivery of different health services for different communities, populations and clients with complex mobility and health-related issues.

This survey is timely with the initiative by Māori and New Zealanders to refocus on the importance of public health, prevention and early detection of health issues and teaching and empowering individuals, families, and communities to maintain their health and wellness and their connections to the natural and spiritual environments.

Methods

Participants were recruited online between June 26, 2019, and July 10^th, 2019. Flybuy points were offered as a koha (gift) for participation which is normal practice in Aotearoa, New Zealand. A total of 1,002 respondents aged 18 and older participated and this survey was weighted to the 2013 New Zealand national census, to align with expected data regarding age, gender, ethnicity, and region to provide a whole picture of the country. A mixed-methods methodology, was used and the results obtained from both approaches are reported.

Results

There were 1,002 respondents aged 18 and older. Response rate was 23.7%. There was an even spread of gender and age groups. Most of the sample were comprised of European (78%), followed by Asian (11%), and Māori (5%). The location of the highest responses was Auckland (33%), Wellington (11%), and Canterbury (13%) areas of concentration of the New Zealand population. The rest of the demographic groups were too small to report.

Most participants in the sample were more likely familiar with GPs and dentists as healthcare providers, yet 31% of the participants knew about chiropractic care. Older participants (65+), mainly male, and those who have never been to a chiropractor were less likely to know about chiropractors. The ethnic group who knew the least about chiropractic care were Asians. The groups that were less likely to view chiropractors as safe were older New Zealanders and those who have never attended a session with a chiropractor. Two reasons reported in this sample among those with low association with chiropractor care were effectiveness (34%) and safety (32%).

For the most part, there was a positive perception of chiropractic care. Overall, 65% of New Zealanders who went to a chiropractor were satisfied. Fifty percent of the participants sampled agreed that chiropractic care was effective in the management of neuromusculoskeletal and spinal conditions and 45% agreed it’s a beneficial part of mainstream health services. The main reasons New Zealanders would consider chiropractic care were based upon a positive previous experience and chiropractors’ expertise. Seventy-six percent of those who would choose chiropractic care as their first choice had visited a chiropractor in the last year.

Some of the positive endorsements from participants were as follows:

My chiropractor listens to me and provides explanations which help me after my appointment’

‘Because they look for the cause of pain rather than suppression of symptom’

Seventy-six percent of participants had visited a chiropractor for back pain, 69% of the sample visited a chiropractor for alignment of the spine and 68% of the sample for neck pain. Half of the sample would seek a chiropractor as their first choice for back pain, neuromusculoskeletal (NMSK) or spinal conditions. One man described his chiropractic care:

‘I had back pain for over 10 years and a chiropractor was my last resort. I wish I had gone sooner as I was always told by health professionals that chiropractors were charlatans. This could not be further from the truth. They fixed more than just my back. They realigned my spine and various other ailments. GPs and physios were useless! (Male, 50-64).’

More narratives of satisfied patients described how chiropractors listen, explain, and provide a plan and advice for future well-being:

'He fixed my sore knee in one treatment, and it has been fine since. He explained why I had hurt it and gave me tips to make sure it was ok in the future. He also gave me supplements for the spike in my blood sugar and explained why the spike had happened. The supplements have worked. My chiropractor listens to me and provides explanations which help me after my appointment. And;

My chiropractor is cheaper than my doctor and more successful at keeping me healthy. He treated the cause and gave me ongoing advice on how to alleviate myself and prevent further injury.’

Chiropractors were also described as providing care for the cause of the issue:

‘Because they look for the cause of pain rather than suppression of symptoms. They identified and dealt with the cause of the problem very efficiently.’

Others reported that chiropractors look at the body as a whole.

‘Can assist with most areas of unwellness and pain in the body. Advise on healthy lifestyle.’

Some of the reasons why certain groups (mainly female and/or identify as NZ European) of New Zealanders would not consider chiropractic care included the belief that treatment of chiropractors was not supported by empirical research, cost of treatment was expensive, and some viewed the treatment as harsh, and they didn’t know enough about chiropractors to consider going to one. Some of the commentaries reflected these reasons:

‘Are harsher on the body- I have had more effective pain relief from cranial osteopathy’ (Female 50-64 years of age)

'I was advised several years ago by an orthopaedic surgeon not to visit a chiropractor for my back pain.’ (Female, 50-64 years of age)

Participants who were 65 years of age and older who would not consider going to a chiropractor for back pain due to a bad experience and they felt that they may risk of doing more harm than good. Some responded that they were concerned about the training/expertise or medical qualifications. For example,

Because in the past I have suffered pain after a visit to a chiropractor (Female 65+ years of age)

I do not believe they have sufficient training or are knowledgeable’ (Male 65+)

Only a quarter of this sample of people of Aotearoa New Zealand viewed chiropractors as a primary healthcare provider or were licensed to take or refer people for x-rays. However, 6 out of 10 participants (68%) knew that chiropractors were registered with Accident Compensation Corporation (ACC) which provided some financial compensation for no fault accident claims. There were also low levels of knowledge about whether chiropractors could provide care in hospitals. Three in 10 participants agreed that chiropractors could provide care within hospitals, while 2 out of 10 participants disagreed. Half of the sample of New Zealanders were unsure.

Discussion

Literature Review

Research in public perceptions of chiropractic care was sparse internationally; however, findings were similar across studies. Weeks and colleagues explored public perceptions of chiropractors in a national survey in the USA. A large sample of 5,422 were included and results reported that those who were most likely to seek a chiropractor at the time of this survey, were female, white, married, and employed. Sixty-one percent surveyed viewed chiropractic intervention as effective in manipulating the neck and back to alleviate pain. Sixty-one percent of this sample trusted the chiropractors for neck and spine adjustments and 52% deemed chiropractors as ‘trustworthy.’ A quarter of the sample described chiropractors as ‘dangerous.’ The more people went to chiropractors, themore their view of effectiveness and trustworthiness increased and perceptions of chiropractors as ‘dangerous’ decreased. Furthermore, the more chiropractors in an area, the higher the likelihood that they were viewed in a positive light.⁵

Another study reported data from a sample of 1,414 respondents from the general population in the USA. Participants who were self-funded (as opposed to using insurance to pay) had higher expectations of a chiropractor compared with to a medical doctor. If people believed that both chiropractors and medical doctors were equally skilled in alleviating back pain, participants would prefer a medical doctor. A potential barrier reported was that some insurance companies did not cover chiropractic care or insurances that did honor such care had more limitations for chiropractic services regarding the number of appointments and how much was covered, compared to insurance coverage for conventional medical doctors. Insurance companies, therefore, influence consumers’ choice of care in United States.⁶ Another US research study reported that 45% agreed that insurance companies discriminated against chiropractors. However, the study only included 1 section of the state of Connecticut (USA), comprised of only 500 people. This sample was largely white females. Forty percent of the sample had at least 1 person in the household to have been to a chiropractor. Seventy-eight percent believed chiropractors were effective, 89% were satisfied with their treatment, 72% believed that the cost was reasonable, and 72% would go again. There were, however, many methodological limitations to this study. First, the study employed a phone survey, interviews were only conducted in English, the demographic profile interviewed were not of mixed ethnicity, it was not a nationwide sample and didn’t include all income groups, and the sample was biased to those more affluent.⁷

Another USA study was significantly larger (N= 5,442), sampling across the whole country and reporting a cross-cultural demography of ethnicities, a range of age groups, and different levels of socio-economic backgrounds. The methodology included contacting participants by website, mail, landline, and cell phone to contact participants. Results identified that only 12% of the sample had been to a chiropractor within the last 5 years and 14% attended a session within the last 12 months. Half of those who had been to a chiropractor had a positive view, finding the treatment effective. Those in the sample who were 35 years and older, were more likely to visit a chiropractor. Caucasians went to a chiropractor significantly more than African Americans or Hispanics. Some of the barriers identified were lack of knowledge of chiropractic care and they were unsure if their insurance covered chiropractic treatment. Forty-three percent reported that treatment was expensive and 44% stated too many visits were barriers to continue chiropractic care.⁸ Both American studies, despite major differences in the methodologies and decades apart, continued to report similar findings.

An Australian study closer to New Zealand sampled 757 respondents, reporting that 39% of the sample had been to a chiropractor. Seventy-six percent of respondents were satisfied or highly satisfied with chiropractor care. There were no significant differences in the responses amongst those surveyed irrespective of income, age and gender. However, when controlling for income and gender, respondents aged 45 years or more sought chiropractic care compared to those younger. Reasons for not going to a chiropractor included expense, lack of knowledge about chiropractors, low numbers of referrals from doctors to chiropractors, a preference of another health professional (primarily physiotherapists) and concerns about the safety and effectiveness of a chiropractor.⁹

A later study also explored perceptions of patients who actively go to a chiropractor. The sample comprised of mostly females, aged between 45- 64 years old and those earning a good salary. Decisions to seek treatment from a chiropractor were influenced by the following factors: age, gender, knowledge of chiropractic services, cost of consultation and location and access to payment for service provided. Seventy percent visited a chiropractor due to their own personal beliefs about chiropractor’s effectiveness Most of the reasons to attend chiropractic services were for musculoskeletal issues. Ninety-six percent went to a chiropractor for overall well-being and physical health maintenance. Ninety-seven percent would go back to a chiropractor. Overall, their findings concluded that people who went to chiropractors had adequate knowledge about chiropractors and what assistance they can offer. Individuals who visited a chiropractor were satisfied and they had similar beliefs and philosophy about well-being to chiropractic care.¹⁰

Overview

All of this highlights that little is known about chiropractic care amongst the general population on an international level. The findings also suggested specific groups of people were drawn to chiropractic care. In this study, we explored similar queries regarding chiropractor care in Aotearoa New Zealand.

Our study addresses a gap in national research in Aotearoa New Zealand, providing information on New Zealanders’ perceptions of chiropractic care in Aotearoa New Zealand, and comparing any similar findings with previous studies overseas.

The NZCA commissioned and funded (with assistance from the Hamblin Trust) this research and contracted Colmar Brunton, an independent market research company to investigate New Zealanders’ perceptions of chiropractors and chiropractic care. Information was sought to identify when members of the public would see a chiropractor, for what reasons, their knowledge and barriers that impede seeking help from this health professional group and their experiences of use of this professional health care.

Overall, chiropractors were seen as being professional and knowledgeable. Sixty-five percent of New Zealanders’ were satisfied with their chiropractor’s service. The findings that 50% of the sample agreed that chiropractic care is effective in the management of neuromusculoskeletal (NMSK) and spinal conditions was consistent with other studies reporting perceptions of chiropractic care.^5,9

In order to improve perceptions of chiropractic care in Aotearoa New Zealand, one could provide education using social media, including its wide availability of options (e.g. ACC providers, insurance providers). In this study, only 31% had some knowledge about chiropractors, yet another study reported that 42% had little knowledge of chiropractors before attending their services.¹⁰ However, members of the public continued to go to a chiropractor once they had experienced effective treatment. Our results support these findings, too. Seventy-six percent of the New Zealand sample who selected chiropractic care as their first choice had also visited a chiropractor within the last year. Likewise, 97% of those who had visited a chiropractor regularly would return for future treatment.¹⁰

Some participants suggested that some of the terminology used by chiropractors could be more ‘user friendly’ by changing, for example, ‘manipulation’ to ‘adjustments.’ This is important given that language used in healthcare settings is linked to health literacy.¹¹ Less technical jargon employed by the profession may also reduce a perception of chiropractors as being ‘dangerous or painful,’ but research is warranted.

The results of this study not only provided a baseline in which research could be replicated within Aotearoa New Zealand, but offered insight into some of the barriers which have prevented a portion of people potentially benefitting from chiropractic care. This knowledge is timely with the onset of COVID with lockdowns in Aotearoa New Zealand (mainly Auckland) which have imposed further barriers for chiropractors to offer their care. This study was conducted before the global pandemic which makes the findings more pertinent. With lockdown, forcing more people to work at home in Aotearoa New Zealand due to COVID- 19, ACC has seen an increase in the number of New Zealanders seeking help from poor posture and back pain and repetitive strain injuries from time spent on digital tools and working in spaces not designed for office work.¹²

New Zealand is like other countries globally as it addresses the impact of COVID-19 and its effects on health practitioners, client’s access to services and public health requirements to be met and of course changes depending upon different alert levels. New Zealand initially adopted an elimination strategy to eradicate COVID- 19 and now manages the Delta and Omicron variants of the virus.

The different lockdowns that New Zealanders’ have experienced since 2020 have also impacted on the work of chiropractors significantly, who have had restricted ability to offer a service to their clients as a “face to face” and “hands on service”. Initially not recognised as primary “essential” health personnel, this has affected their income, relationship with clients and their ability to offer health care to those in their communities who seek their services. This has particularly hit hard with those living in Auckland during 2020 and 2021 which highlights the urgency to provide the public with knowledge on the potential benefits of chiropractic care and its impact on health and well-being during these unprecedented times.

Strengths and Limitations

The strengths of this study were that compared to other studies, sample size was relatively large. Despite methodology issues, it also involved a mixed-methods approach using qualitative information which provided further clarity to the quantitative research. In addition, this is the first large study conducted by chiropractors as a professional group in Aotearoa New Zealand who want to improve the public image and outreach to the communities.

Limitations of the study are that recruitment was conducted online and therefore comprised participants that had a digital tool and internet data to be able to participate. A generous koha may have also motivated certain participates to engage in the survey. Most respondents were from Auckland followed by Wellington and Canterbury which highly populated areas and may have more chiropractors accessible. This also meant the study did not include a large sample of people living in rural areas who are often involved in industries such as farming, agriculture, forestry, and different recreational activities as sport, hunting fishing and so forth, which can have heavy demands on the physical body and neuromuscular issues. In addition, poorer populations with fewer resources and options to go to a chiropractor may also suffer more effects from ageing, poor diet, stress, and lifestyle changes.

The demographics were not compared between gender, age, or ethnicity in the study in comparison with some of the variables. There was equal distribution with gender and age, but there wasn’t any comparison on the data. It was difficult to compare ethnicity when the sample was primarily European.

Conclusion

Chiropractors were viewed in a positive light; yet more people could further benefit from their services if the general population knew more about what chiropractors provided and reduced any stigma regarding them being under qualified. In addition, specific groups should be targeted such as Asians, males, and older people to further promote chiropractic care. On top of barriers such as lack of knowledge or public health funding for services, the COVID restrictions have put further barriers on the potential to enhance the opportunities for chiropractors to attract potential patients.