This research can help discover previous knowledge and understanding among the students outside the chiropractic environment. The research will help to find out how much understanding the students already have about the chiropractic. The study can help organising promotion events with students as well as other aspects of the general public. To the authors’ knowledge, there have not been similar studies done in the United Kingdom. This research will be conducted by pen-and-paper questionnaire given to students of University of South Wales during lectures. The sample participants were chosen to be from courses that have not previously collaborated with chiropractic course or chiropractic clinic at the university premise. The reason for this sample was to gain information outside the chiropractic environment. This sample was to relate to larger population, to allow more diverse answers, to gain additional knowledge for those outside the chiropractic environment making it more applicable to the real world.
2. Literature Review
Chiropractic is defined by the World Health Organisation as “A health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. There is an emphasis on manual techniques, including joint adjustment and/or manipulation, with a particular focus on subluxations.”(World Health Organisation, 2005). According to research done in Sweden (Leboeuf-Yde et. al., 1997), Denmark (Hartvigsen et al., 2012) and Netherlands (Rubinstein et al., 2000) patients seek chiropractic care mostly for low back, back and neck pain complaints. In the United Kingdom chiropractors feel that mechanical conditions of the musculoskeletal system are treated effectively by chiropractic treatment with the focus on the spine. Chiropractors in the United Kingdom believe that patients with visceral/organic conditions can also benefit from the chiropractic treatment (Pollentier and Lnagworthy, 2007). These studies were conducted by asking the chiropractors what kind of conditions they treat and benefits they have gained.
There have not been many studies exploring what public sees chiropractic being best suitable for. In Australia (Brown et al., 2013) study found that majority seek chiropractic care for musculoskeletal conditions, main complains being low back and neck pain. This goes in line with the studies done on chiropractors and what chiropractors are treating most. (Leboeuf-Yde et. al., 1997), (Hartvigsen et al., 2012), (Rubinstein et al., 2000) (Pollentier and Lnagworthy, 2007). The study by Brown et al. (2013) also found that even though General Practitioner keeps their place as first point of contact for different musculoskeletal conditions, chiropractors are gaining more and more knowledge and patient base in the public eye as a complementary and alternative medicine for the musculoskeletal complaints.
2.2 Chiropractic as part of complementary and alternative medicine
Chiropractic and other Complementary and Alternative Medicine (CAM) practices have been getting more and more popular worldwide over the past decade (Su and Li, 2011). In the United Kingdom, the 12-month prevalence for all-CAM use by adults was 26% on 2005 (Harris et al., 2012) compared to 10% on 2001 (Thomas and Coleman, 2010). This shows significant growth in the CAM use. In the United Kingdom, there are new universities starting to offer chiropractic degree and number of registered chiropractors grow each year (GCC, 2018). This shows that the profession is growing in the United Kingdom which makes the need to understand the public view of the profession more important. Understanding the public perception of the chiropractic and the need the public have for the treatment are important aspects of the growth of the profession (Schneider, Murphy and Hartvigsen, 2016).
In the United Kingdom chiropractic has ninth highest lifetime prevalence and tenth highest 12-month prevalence of use out of CAM therapies (Thomas, Coleman and Nicholl, 2010). Chiropractic came after massage therapy, aromatherapy, acupuncture, relaxation, osteopathy, herbal medicine and reflexology. Chiropractic was one of the most commonly utilised CAM therapy for low back pain in pregnancy (Wand et al., 2005). The prevalence of chiropractic use among general population varies. The prevalence use in the United States was estimated to be 5.2% of the population in 2008 ( Zodet and Stevans, 2012) and in 16.1% of the population in 2005 (Xue et al., 2008). To Authors knowledge there is no similar data from United Kingdom.
2.3 Chiropractic and the general public
Survey of the general public from Australia (Brown et al., 2013) found that lack of knowledge about chiropractic and concerns about safety are the main reasons for not utilising chiropractic services. Unawareness of the scientific evidence and lack of knowledge of the scope of chiropractic practice were found to be concerns in the study of nurse practitioner and physician assistant students’ attitudes and knowledge of chiropractic (Browden et al., 2016). This is in line with the study done in Australian public and also what Wong et al (2013) concluded on study in which participants were medical students. Both of these studies were done in the United States and to authors knowledge, there has not been done similar studies exploring the public views of chiropractic in the United Kingdom.
General medical practitioner is chosen to be the first contact most often with respect to therapy for musculoskeletal complaints (Brown et al., 2013). This burdens their workload when there could be other, maybe even more, suitable professions to take some of the workload. In 2007 musculoskeletal conditions accounted for 12.1% of all general practitioner consultations in the United Kingdom (Jordan et al., 2007)
2.4 University students and back pain
Low back and neck pain is common in adolescence and university students. Study done in Thailand shows that 31% of the students reported new onset of low back pain during their undergraduate degree and 31% of those to reported the pain to be persistent (Kanchanomai et al., 2011a). 1-year incidence of getting neck pain among undergraduate students varies a lot in different studies. Grimby-Ekman, Andersson and Hagberd (2009) found one-year prevalence for neck pain to be 15% on undergraduate students in Sweden. Kanchanomai et al (2011b) reported 46% of undergraduate students to develop neck pain during one year follow up study in university at the United States. According to these studies it is likely that in the study sample there will be participants who are experiencing or have experienced low back or neck pain while being at the university or before starting the course.
2.5 Research aim
The research is seeking answers to following questions: What areas the participants see most suitable for chiropractic care? Is there association between previous chiropractic visit and what areas the participant see most suitable for chiropractic care? Is there association between satisfaction of chiroprac
tic care received and considering seeking chiropractic care in the future? These questions will be best answered by conducting quantitative research with pen-and-paper questionnaire handed in for students during a lecture that they would normally have on their curriculum. Inclusion criteria are set for participants that they are enrolled students at the University of South Wales, they are fluent in English and they consent to be part of the research study. Exclusion criteria are not understanding English, not being enrolled student at the University of South Wales, being from course that has previously collaborated with chiropractic degree or outpatient clinic and not consenting to take part of the research. 3. Methodology
This research utilised a descriptive quantitative design gathering data via questionnaire survey. The questionnaire included short explanation of the study and that taking part for the study is completely voluntary for the participants. The subjects were allowed to withdraw to any point before handing in the questionnaire as the questionnaires didn’t have any identifying markers and were completely anonymous so removing after this point would have been impossible. Refusal of consent to participate in the study was assumed by returning a blank questionnaire paper. The study was approved by the University of South Wales Research Ethics committee.
The pen-and-paper questionnaire (Appendix 1) was constructed for this research. It had 9 questions and consisted of 3 parts. Questions on the questionnaire were adapted and constructed from questionnaire utilised in Chiropractic in Australia: A survey of the General Public study done by Brown et al. (2013). First three questions were demographic and educational questions to identify what year of study the participants are in, how old are they are and what is the highest level of education they have achieved so far. This was collected to describe the sample population. The second part included three questions which were used to identify who the participants would consult for musculoskeletal complaint, who they have consulted previously and what musculoskeletal complaints they see appropriate for chiropractic care and one question about their awareness of the outpatient chiropractic clinic at the university premises and if they had visited the clinic. The third part included two questions only for those who had previously seen chiropractor asking how satisfied they were with the care they had received, and the second question was used to see if they would consider seeing chiropractor in the future. The questions were multiple-choice questions with possibility to choose multiple answers.
Before giving the questionnaire to the study participants the questionnaire was piloted, reviewed and tested by final year chiropractic students. Feedback on questions, presentation and grammar was implemented after the pilot test of the study. This resulted to changes to the age ranges to make them better represent the student population, changes on wording of some the questions and correcting some minor grammar issues.
Participants for the study were chosen to be enrolled University of South Wales students. They were chosen to be from modules that have not previously collaborated with the chiropractic degree or the chiropractic clinic and were filling to participate in the study. The questionnaire was handed in during a lecture that was part of their course and which they were expected to attend. This way the research utilised opportunity sampling of those students who attended the specific lecture where the questionnaires were handed in for them to be filled in.
The data were entered into IBM SPSS Statistics, version 24, for analysing. Statistical significance was set to 5%. Descriptive statistics, frequencies, were recorded for who the participants would visit first if they developed a muscle or joint complaint, which areas the participants saw most suitable for the different body areas and awareness of the outpatient chiropractic clinic at the university premises. Those who answered to the last two questions were identified and recorded as participants previously visited chiropractor. Chi-square test of association was performed to see association between those who have previously seen chiropractor and how suitable they saw chiropractic being for back pain. Chi-square test was also performed to see if there were association between how satisfied the participants were with the care they had previously received and if they would see a chiropractor in the future. 4. Results
160 questionnaires were printed and given for distribution. 45 questionnaires were returned with 37 of these completed. 8 questionnaires were returned unanswered. This makes overall completion rate to 0.62% and completion rate out of the questionnaires received to 82.2%. Demographics of the population are presented in table 1.
Response frequencies to question about which partitioner the participant would first visit if they developed musculoskeletal complaint are represented in table 2. Twenty-four (64.95%) of the participants would first visit general medical practitioner if they developed a muscle or joint complaint, four (10.8%) would go to chiropractor, two would go to massage therapist and physiotherapist (5.4%) and five (13.5%) participants answered none/I don’t know to this question.
In total of 11 (29.7%) of the 37 participants answered to question about their satisfaction of chiropractic care they have received previously and 6 (54%) of the 11 answered “not applicable”. Two (5.4%) of the participants answered that they were satisfied with the care they had received. Respectively two (5.4%) answered that they were not satisfied with the care they had received. One (2.2%) answered “I don’t know”.
A chi-square test was performed to see if there was association between the satisfaction the participant had with previously received chiropractic care and how likely they were to see chiropractor in future. The results were x^2(6)=12.1, p=0.06. The result was not statistically significant and it was concluded that there is no association between satisfaction for chiropractic care, and if the patient would consult chiropractor in the future. However, standardised residual showed significant correlation between not being satisfied with the chiropractic care received and not consulting chiropractor in the future. Other standardised residuals didn’t show significant results.
Response frequencies for areas that the participants consider suitable for chiropractic care are presented in table 3. Twenty-four (70.6%) of the participants see chiropractic being suitable for low and middle back and neck pain. Thirty-one (91.2%) participants sees chiropractic suitable for low back pain and twenty-eight (82.4%) for middle back pain and twenty-five (73.5%) for neck pain. Other suitable areas participants thought to be: shoulder, 23 participants (67.6%); hips, 13 participants (38.2%); and knees 11 participants (32.4%).
A chi-square test was performed to examine the association between having received chiropractic care before and how suitable the participants see low back, middle back and neck being for chiropractic care. The relation between these variables was not significant. X^2(1)=2.525, p=0.112. Therefore it was concluded that there isn’t statistically significant association between having received chiropractic care before and how suitable the patients see low back, middle back and neck being for chiropractic care.
A chi-square test was performed to examine if there is a relationship between visiting chiroprac
tor before and how suitable the participants see just low back or neck being for chiropractic treatment. The relation between these variables was not significant; Low back: X^2(1)= 3.005, p= 0.083 and neck X^2(1)=0.014, p=0.906. Therefore it was concluded that there is not statistically significant association between having visited chiropractor before and how suitable the participant see low back or neck being for chiropractic care.
A chi-square test was performed to analyse the association between having received chiropractic care before, and how suitable the participants see middle back being for chiropractic care. There was significant association between these variables. X^2(1)=6.181, p=0.013 So it was concluded that there is statistically significant association between those who had received chiropractic care before and seeing middle back being suitable for chiropractic care. Standardised residuals didn’t show significant differences in 5% statistical significance but they showed that there is weak association on those having previously received chiropractic care seeing middle back less likely to be suitable for chiropractic care.
Twenty-nine (78.4%) of the participants weren’t aware that there is outpatient chiropractic clinic at the university premises and eight (21.6%) responded that they were not aware of the clinic. Only one (2.7%) of the participants responded being visited the clinic. A chi-square test was performed to examine the correlation between visiting chiropractor before and being aware of the chiropractic clinic at the university premises. There was not statistical significant relation between these variables X^2(6)=3.186, p=0.203. Therefore it was concluded that there is not association between having visited chiropractor care before and being more aware of the clinic at the university premises. 5. Discussion
This research assessed the knowledge of the chiropractic among students at the University of South Wales. The research was implemented to determine which areas the students thought to be most suitable for the chiropractic care. In addition the research was used to investigate if there is a difference between those who had previously received chiropractic care and those who had not. We expected those who had previously seen chiropractor be more open to different areas that chiropractor can treat, and select most of the options on question number six asking about the suitable areas for chiropractic care. Low back, middle back and neck options were expected to be chosen to be suitable for chiropractic care by most of the participants. This would represent previous study conducted by Brown et al. (2013) indicating that neck and back pain can benefit from chiropractic treatment. There was also expected to be positive association between satisfaction and seeing chiropractor in the future. The research utilised a pen-and-paper questionnaire given to students at the University of South Wales. The tests performed on the data showed some statistical significance, but most of the statistical analysis results were non-significant. This is most likely due to a limited sample size, and a low response rate amongst the small sample.
5.1 Satisfaction with chiropractic care
Total of 11 participants answered the question about their satisfaction of chiropractic care they had previously received. However, only one person answered having previously seen chiropractor in the question number five: “In the past, have you consulted any of the following? (you can select more than one)”. This is why the authors suggest removal of this question on future studies utilising the questionnaire as it clearly caused confusion among the participants, and did not collect the data it was intended to do. It was assumed on the data analysis that everyone who answered to the two last questions had previously received chiropractic care. This assumption was made even though six out of the 11 answered “not applicable” to question about the satisfaction of the care they had received. Choosing “not applicable” can have multiple reasons and one of them could be that they hadn’t actually visited a chiropractor previously and ignored the requests to only answer the last two questions if they have previously seen chiropractor. However, it could also mean they weren’t sure how they felt about the treatment they had received, or they had just started the treatment. These are just speculations as the questionnaire didn’t ask reasons for the answers by the participants. How the questionnaire is set up should probably be made more clear in future studies, an addition of a researcher present at the beginning to the questionnaire to answer any questions the participant may have to prevent confusion for the overall questionnaire.
Even thought there wasn’t statistically significant association between satisfaction of the chiropractic care received and if the participant would seek chiropractic care in the future, there was correlation between not being satisfied with chiropractic care received previously and not consulting chiropractor in the future. This is expected result. This research showed, however, significantly lower satisfaction rate than research studies exploring satisfaction rates of chiropractic have done previously. Gaumer (2005) reported 83% to be “satisfied or better” with the care they had received. Haneline (2006) determined satisfaction level of 94%. In our study the satisfaction rate was 5.4% if including everyone who answered the question about satisfaction. If those who answered “not applicable” is excluded the satisfaction rate is 40% which is still lower than in the previous studies. This is most likely due to small sample size, 11 on overall question and only 5 on answering “satisfied” or “not satisfied. It can also be due that in this study the targeted sample population wasn’t chiropractic patients at the chiropractic practices but instead the participants were targeted to be populations that are not in the chiropractic environment. The participants were targeted to be students from modules that had not previously collaborated with the chiropractic degree or outpatient chiropractic clinic. This can make it more likely that the study population had more of those who have not been satisfied with the care they have received.
5.2 Practitioner the participant would first visit
The result was as expected that the most of the participants would first visit general medical practitioner if they developed a muscle or joint complaint. Chiropractor received the second highest number of answers (10.8%). This is slightly higher than expected as chiropractic has not been the highest utilised CAM practice in previous studies (Thomas, Coleman and Nicholl, 2010). However, the responding rate for other practitioners than general medical practitioner was significantly lower. Due to the small sample size of the study these variances are more prone to happen and cause statistical error. This can explain the higher percentage of answers to chiropractic compared to massage therapist and physiotherapist.
5.3 Areas the participants see most suitable for chiropractic care
The most of the participants thought back (low back, middle back and neck) being the most suitable for chiropractic. This goes along the study done for Australian population (Brown et al., 2013) and is similar to the scope of practice in United Kingdom (Pollentier and Langworthy 2007). Low back was considered being the most suitable for the chiropractic care by those who have not seen chiropractor and by those who had. There was similar trend on neck being suitable for chiropractic care. The study didn’t find significant differences between those who had visited chiropractic before and those who had in terms of seeing low back and neck suitable for chiropractic care.< /p>
Interestingly, those who had received chiropractic care previously were less likely to see middle back being suitable for chiropractic treatment compared to those who had not receive chiropractic care in the past. When writing the questionnaire middle back was used instead of thoracic spine because it was expected that middle back would be more clear to the participants than using the correct anatomical name thoracic. The results were unexpected as thoracic manipulation has been found to be useful for neck pain complaints (Lau, Wing Chiu and Lam, 2011), (Westerhuis, 2005). Thoracic manipulation is also often used in conjunction with low back manipulation for treatment of the low back pain (Leboeuf-Yde et al., 1997). This shows that those who had seek chiropractic care were likely to have received thoracic manipulation even if they didn’t complain upper back pain.
5.4 Awareness of the chiropractic clinic at the university
Most of the students weren’t aware that there is outpatient chiropractic clinic at the university premises and only one out of 37 had visited this clinic. The university students get the treatments at 50% discount at the clinic, so it’s not considered being expensive. Research done by Kanchanomai et al. (2011a, 2011b) and Grimby-Ekman, Andersson and Hagberg (2009) show that undergraduate university students are likely to develop low back and neck pain during their studies. The chiropractic clinic could be beneficial in helping these students to relieve the pain they are having and decrease the risk of the pain becoming chronic, lasting more than 6 months. A link between low back pain in adolescence and adulthood was determined in the study by Hestbaek et al. (2006). This why it would be important to decrease the pain the students are having from early on of its course to prevent chronicity and the pain following to adulthood.
5.2 Limitations
A major flaw of this research was its small sample size and low response rate. The small sample size can affect the results and make it bias for wrong interruptions (Faber and Fonseca, 2014), (Dochtermann and Jenkins, 2010). The small sample size also makes the results to less likely represent a larger population of students. This is why, when interpreting the results, it should be kept in mind not to generalise the results and be aware of the small sample size of this study. Because the target population was students it cannot be assumed that the results will represent other aspects of the general population.
The questionnaire used was utilised first time in this study. The result analysing showed that the question number five asking “In the past, have you consulted any of the following? (you can select more than one)” gave contradictory results to the responses from other questions. This why it was chosen to be excluded from the data analysis and removal of this question in the future studies should be considered. The last two questions were only meant to be answered by those who had previously receive chiropractic care. However, six out of 11 answered “not applicable” to this question. This could mean that they have not received chiropractic care previously and misinterpret the instructions. This is why the authors recommend making this clear in the future studies.
A pilot study could have helped to tackle some of the limitations and bring to light, before conducting the research survey, the necessary changes that would have needed to be made. This could have made the study to show more significant results. The study only included students from degrees that had not previously collaborated with the chiropractic degree or the outpatient chiropractic clinic. It would maybe be beneficial to include students who have been contacted or collaborated with the clinic previously. This another student population could be used for comparison.
This study can be viewed as a pilot study if intended to do similar study in the future. The authors would recommend modifying the questionnaire by removing question 6 and making it more clear that only those who have previously sought chiropractic care should answer to questions about satisfaction and if they would consider seeking chiropractic care in the future.
6. Conclusion
The participants saw back including low back, middle back and neck being the most suitable for chiropractic care. This is in line with the scope of chiropractic practice and previous studies showing that the students are aware what chiropractic can treat (Pollentier and Langworthy 2007). Statistically significant finding of this study was that there is association between having previously sought chiropractic care and seeing middle back pain suitable for chiropractic care. There was not statistically significant results on other aspects of the research questions due to the small sample size of this study.
Only one of the participants had visited the outpatient chiropractic clinic at the university premises and eight out of 37 were aware of the clinic. In the future this knowledge can be used to possibly market the clinic better to students and make them aware it is in their use with discounted prices if they develop musculoskeletal pain. Knowing what conditions they see most suitable for chiropractic care helps to identify how to advertise the clinic for the students.