Consultation on Identity Quantitative Research Findings December 7, 2004

Table of Contents Page INTRODUCTION 3 Background & Objectives 4 Methodology 5 Definitions 6 Reporting Perspective 7 EXECUTIVE SUMMARY 8 DETAILED FINDINGS 13 APPENDIX – Respondent Profile 49

INTRODUCTION

Background & Objectives Within chiropractic, there has been continuing controversy concerning the identity of the profession, widespread international growth of chiropractic education and practice, and more diversity of the practice settings and services offered. The World Federation of Chiropractic (WFC) has been asked by its Members’ national associations worldwide, to carry out an international consultation on the most appropriate public identity for the profession within health care. The purpose of the study is to understand attitudes and perceptions towards the profession. The survey will be used as a tool to help define the organization’s positioning strategy.

Methodology Online survey. 3,689 completes were obtained. A list of Members’ email addresses was provided to Northstar Members were sent an email notifying them of the survey one week in advance of the survey launch (September 27th) 29,094 email invitations were sent out on October 4th inviting Members to participate in the survey A reminder email was sent out on October 11th to Members who had not yet completed the survey The survey closed on October 24th 3,689 completes were obtained. Questionnaire was approximately 15 minutes in length. Data has been weighted to reflect the true distribution of chiropractors in the participating countries.

Definitions For the purposes of this study, the following terms were defined for respondents as follows: Primary Health Care: Focused Scope Direct access; focused scope of practice; may have overall responsibility for patient and coordination of care within scope of practice. Example: dentist, optometrist. Primary Health Care: Broad Scope Direct access; broad scope of practice; overall responsibility for patient and coordination of care. Example: Family MD/GP, internist. Specialist Care: Primary care and specialist training; focused scope of practice; practice on referral. Example: orthopaedic surgeon, radiologist. Mainstream: Services which are part of the core health delivery system. Complementary & Alternative: Services accepted by many of the public but that are not part of the core health delivery system.

Reporting Perspective Data has been tested for statistical significance, which is indicated in the report as follows: = Statistically higher / lower between groups = Directionally higher / lower between groups A sample of 3,689 is accurate within a statistical tolerance level of +/- 1.6 percentage points, 19 times out of 20.

EXECUTIVE SUMMARY

Executive Summary There is general consensus among chiropractors that it is important for a profession to have a clear public identity. That said, most agree that the chiropractic profession suffers from an unclear identity and position within health care today. When it comes to communicating with the general public to promote the use of chiropractic services, just over one-half (54%) of chiropractors believe that the chiropractors’ view of the profession and the general public’s view of the profession are equally as important to represent. This underscores the importance of understanding how chiropractors think the profession should be viewed and how they think it is actually viewed.

Executive Summary (cont’d) There is significant discrepancy in the way chiropractors believe the profession should be perceived by the general public and medical doctors and the way they think the profession is actually perceived. While the vast majority of chiropractors believe the profession should be considered primary health care with focused (55%) or broad (36%) scope, in actuality, most believe that both the general public and medical doctors alike, have no clear perception of the profession or perceive the profession as offering specialist care. Similarly, while most chiropractors (88%) believe the profession and its services should be perceived as mainstream (or core to the health delivery system), there is agreement that the profession is not viewed this way by the public at large or by medical doctors, instead it is viewed as being complementary and alternative. Further, while the vast majority of chiropractors believe the practice of chiropractic should be perceived as wellness care and / or non-drug, non-surgical health care, the general sense is that the profession is perceived by the general public as the management of back and neck pain and to a slightly less extent, the management of spinal problems.

Executive Summary (cont’d) Most chiropractors (62%) strongly agree with the policy statement opposing the use of prescription drugs in the practice of chiropractic. In fact, positioning the profession as non-drug, non-surgical heath care is viewed as being integral to how the profession should be perceived by the general public.

Executive Summary (cont’d) The lack of clarity surrounding the identity of the profession has also likely been fed by: Limited public awareness regarding the education of chiropractors. Recent newsworthy events that have called into question the ethics & professional conduct of some members of the profession. There is agreement that this has impacted the level of public confidence in chiropractic health care & that the issues of ethics, professional behaviour and trust is very important for the profession’s positioning within the heath care system. Issues of ethics, professional behaviour & trust (along with the ability to get patients back to their daily routine, patient-centered care and spinal care expertise) are viewed as being very important in shaping perceptions of the profession. Furthermore, there is consensus that medical doctors’ perceptions about the safety of chiropractic care is very important for building greater mutual respect and cooperation between the two professions. 1 2

DETAILED FINDINGS

Importance for a Profession to Have a Clear Public Identity There is almost universal agreement that it is important for a profession to have a clear public identity. “It is Important for a Profession to Have a Clear Public Identity” (1 to 7 Scale from Strongly Disagree to Strongly Agree) Strongly Agree (6&7) 90% Mean Score: 6.5 Base: Total sample (n=3689) Q1a. To begin, please indicate the extent to which you agree or disagree with the following statements. Please use the 7-point scale below where 1 means strongly disagree and 7 means strongly agree.

Importance for a Profession to Have a Clear Public Identity - Profiled “It is Important for a Profession to Have a Clear Public Identity” (1 to 7 Scale from Strongly Disagree to Strongly Agree) Total (%) Gender (%) Age (%) School Philosophy (%) Country of Graduating Institution (%) Rating Men Women <35 35 – 59 60+ Group A Group B US Can. Europe Aus./NZ Rest of world 1 to 2 4 5 3 2 3 to 5 6 7 12 6 to 7 90 91 89 92 84 Mean score 6.5 6.4 6.6 Base: Total sample (n=3689) Q1a. To begin, please indicate the extent to which you agree or disagree with the following statements. Please use the 7-point scale below where 1 means strongly disagree and 7 means strongly agree.

Clarity of the Profession’s Identity However, most chiropractors in our sample don’t believe the chiropractic profession has a clear public identity today. “The Chiropractic Profession Has a Clear Public Identity” (1 to 7 Scale from Strongly Disagree to Strongly Agree) Strongly Disagree (1&2) 40% Strongly Agree (6&7) 4% Mean Score: 3.0 Base: Total sample (n=3689) Q1b. To begin, please indicate the extent to which you agree or disagree with the following statements. Please use the 7-point scale below, where 1 means strongly disagree and 7 means strongly agree.

Clarity of the Profession’s Identity - Profiled “The Chiropractic Profession Has a Clear Public Identity” (1 to 7 Scale from Strongly Disagree to Strongly Agree) Country of Current Practice (%) Years in Practice (%) Importance of a Clear Identity (%) Rating Total (%) US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world 5 or less 6 – 10 11 - 20 More than 20 Very Important (6 or 7) Somewhat Important (3 to 5) Not Important (1 or 2) 1 to 2 40 41 44 25 49 31 34 42 38 37 30 18 3 to 5 56 55 53 69 63 59 57 68 6 to 7 4 3 6 2 7 23 Mean score 3.0 2.9 3.5 2.8 3.3 3.2 3.1 4.1 Base: Total sample (n=3689) Q1b. To begin, please indicate the extent to which you agree or disagree with the following statements. Please use the 7-point scale below, where 1 means strongly disagree and 7 means strongly agree.

Area of Central Importance in Practice & Public Identity While the nervous system is viewed as being fundamental to the practice of chiropractic (more so than the spine), it is viewed as being less important when it comes to framing the profession’s identity. % Rating Level of Agreement a 6 – 7 (on a 1-7 scale from Strongly Disagree to Strongly Agree) The nervous system is of central importance to the practice of chiropractic The spine is of central importance to the practice of chiropractic The spine is of central importance to the public identity of chiropractic The nervous system is of central importance to the public identity of chiropractic Base: Total sample (n=3689) Q9. Please indicate the extent to which you agree or disagree with the following statements. Please use the 7-point scale below, where 1 means strongly disagree and 7 means strongly agree.

Area of Central Importance in Practice & Public Identity - Profiled % Rating Level of Agreement a 6 – 7 (on a 1-7 scale from Strongly Disagree to Strongly Agree) Total (%) Gender (%) Age (%) School Philosophy (%) Men Women <35 35 – 59 60+ Group A Group B The nervous system is of central importance to the practice of chiropractic 85 84 88 87 91 77 The spine is of central importance to the practice of chiropractic 72 73 69 83 78 67 The spine is of central importance to the public identity of chiropractic 66 64 63 The nervous system is of central importance to the public identity of chiropractic 60 61 55 54 Base: Total sample (n=3689) Q9. Please indicate the extent to which you agree or disagree with the following statements. Please use the 7-point scale below, where 1 means strongly disagree and 7 means strongly agree.

Area of Central Importance in Practice & Public Identity - Profiled % Rating Level of Agreement a 6 – 7 (on a 1-7 scale from Strongly Disagree to Strongly Agree) Total (%) Country of Current Practice (%) Years in Active Practice (%) US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world 5 or less 6 – 10 11 - 20 >20 The nervous system is of central importance to the practice of chiropractic 85 86 80 89 87 88 84 The spine is of central importance to the practice of chiropractic 72 73 77 75 67 74 The spine is of central importance to the public identity of chiropractic 66 69 70 78 63 65 The nervous system is of central importance to the public identity of chiropractic 60 61 56 47 64 62 58 59 Base: Total sample (n=3689) Q9. Please indicate the extent to which you agree or disagree with the following statements. Please use the 7-point scale below, where 1 means strongly disagree and 7 means strongly agree.

Country of Current Practice (%) Preferred Emphasis When Promoting Use of Services to the General Public Most feel that when it comes to promoting the use of chiropractic services to the general public, both the chiropractic’s and the general public’s views, are equally as important to emphasize. This highlights the importance of understanding how doctors of chiropractic would like the profession perceived by the public as well as how they think it is being perceived today. Total (%) Gender (%) School Philosophy (%) Country of Current Practice (%) Men Women Group A Group B US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world Both views are equally important 54 53 60 64 65 61 63 General public’s view of the profession 25 26 21 24 28 29 19 16 17 14 Chiropractic’s view of the profession 23 18 22 Base: Total sample (n=3689) Q8. When communicating with the general public to promote the use of chiropractic services, which view do you think should receive more emphasis…?

There is considerable discrepancy between how chiropractors feel the profession should be perceived by the general public and how they think it is actually being perceived.

Perceptions of How the General Public Perceives the Chiropractic Profession Most chiropractors (91%) think the profession should be perceived by the general public as a form of primary health care with a focused (55%) or broad (36%) scope. However, only four-in-ten (44%) believe this is how the profession is actually perceived by the general public. The Chiropractor’s Perspective How the Profession Should Be Perceived by the Public How the Profession is Currently Perceived by the Public Base: Total sample (n=3689) Q2. Using the definitions provided below, do you think the chiropractic profession is currently perceived by the general public in your country as offering primary health care: focused scope, primary health care: broad scope, or specialist care? Q3. Again, using the definitions provided, do you think the chiropractic profession should be perceived by the general public in your country as offering primary health care: focused scope, primary health care: broad scope, or specialist care?

Perceptions of How the Public Perceives the Chiropractic Profession - Profiled The Chiropractor’s Perspective How the Profession Should Be Perceived by the Public Gender (%) School Philosophy (%) Country of Current Practice (%) Total Men Women Group A Group B US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world Primary heath care: focused scope 55 53 58 48 59 68 57 56 62 Primary health care: broad scope 36 35 39 33 42 38 23 27 Specialist care 9 10 8 16 15 How the Profession is Currently Perceived by the Public Gender (%) Age (%) School Philosophy (%) Country of Current Practice (%) Total Men Women <35 35 – 59 60+ Group A Group B US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world Primary heath care: focused scope 41 42 37 44 40 45 34 39 59 47 25 68 20 Specialist care 30 32 31 21 29 11 19 6 18 No clear perception 26 28 23 24 27 53 Primary health care: broad scope 3 4 5 7 9 Base: Total sample (n=3689) Q2. Using the definitions provided below, do you think the chiropractic profession is currently perceived by the general public in your country as offering primary health care: focused scope, primary health care: broad scope, or specialist care? Q3. Again, using the definitions provided, do you think the chiropractic profession should be perceived by the general public in your country as offering primary health care: focused scope, primary health care: broad scope, or specialist care?

Perceptions of How the General Public Perceives the Chiropractic Profession While the vast majority feel that the chiropractic profession and its services should be perceived by the general public as mainstream, a near equal proportion feel that in actuality, it is being perceived as a form of complementary & alternative health care. The Chiropractor’s Perspective How the Profession & Its Services Should Be Perceived by the Public How the Profession & Services are Currently Perceived by the Public Base: Total sample (n=3689) Q4. Using the definitions appearing below, do you think the chiropractic profession and its services are currently perceived by the general public in your country as mainstream or complementary and alternative? Q5. Again, using the definitions provided, do you think the chiropractic profession and its services should be perceived by the general public in your country as mainstream or complementary and alternative?

The Chiropractor’s Perspective Perceptions of How the Public Perceives the Chiropractic Profession - Profiled The Chiropractor’s Perspective How the Profession & Its Services Should Be Perceived by the Public Total (%) Gender (%) Age (%) Country of Current Practice (%) Men Women <35 35 – 59 60+ US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world Mainstream 88 87 90 80 89 76 82 Complementary & Alternative 12 13 10 20 11 24 18 How the Profession & Services are Currently Perceived by the Public Gender (%) Age (%) Country of Current Practice (%) Years in Active Practice (%) Total Men Women <35 35 – 59 60+ US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world 5 or less 6 – 10 11 - 20 >20 Complementary & Alternative 89 87 96 91 88 86 82 92 85 Mainstream 11 13 4 9 12 14 18 8 15 Base: Total sample (n=3689) Q4. Using the definitions appearing below, do you think the chiropractic profession and its services are currently perceived by the general public in your country as mainstream or complementary and alternative? Q5. Again, using the definitions provided, do you think the chiropractic profession and its services should be perceived by the general public in your country as mainstream or complementary and alternative?

Agreement with Policy Opposing Use of Prescription Drugs The majority (62%), strongly support the policy opposing the use of prescription drugs in the practice of chiropractic. Agreement with Policy Opposing Use of Prescription Drugs Total Gender Men Women Country of Current Practice US Canada Regulated Europe Unregulated Europe 79% Australia / New Zealand Rest of world School Philosophy Group A Group B Years in Practice 5 or less 6 – 10 11 – 20 > 20 Base: Total sample (n=3689) Q17. Since 1999, the World Federation of Chiropractic has had a policy statement opposing any use of prescription drugs in the practice of chiropractic. In that policy the WFC resolves that “for reasons of chiropractic principle, patient welfare and interdisciplinary cooperation, the practice of chiropractic does not include the use of prescription drugs”.  To what extent do you agree with this policy? Do you …

In fact, the non-drug, non-surgical mandate of chiropractic is viewed as being ‘cornerstone’ to the profession’s identity. However…

While most would like chiropractic to be perceived as wellness care and / or non-drug, non-surgical health care, many believe chiropractic health care is more commonly perceived by the general public as the management of neck & back pain and to a lesser extent, the management of spinal problems.

Perceptions of How the General Public Perceives the Chiropractic Profession % Saying 6 – 7 (on a 1-7 scale from Does Not Describe at All to Describes Perfectly) How Chiropractic Profession… Should Be Perceived by the General Public is Currently Perceived by the General Public Gap Wellness care Non-drug / non-surgical health care Management of spinal problems & their impact on general health Management of neuromusculoskeletal conditions & their impact on general health Primary health care Management of vertebral subluxation & its impact on general health Management of back & neck pain & their impact on general health Management of neuromusculoskeletal conditions Management of spinal problems Management of vertebral subluxation Management of back & neck pain 77 37 58 59 65 60 30 22 - 47 -34 Base: Total sample (n=3689) Q6. Please indicate how well each of the following statements describes how chiropractic health care is currently perceived by the general public in your country. Please use the 7-point scale below, where 1 means does not describe public perception at all and 7 means describes it perfectly. Q7. Please indicate how well each of the following statements describes how you would like chiropractic health care to be perceived by the general public in your country. Again, please use the 7-point scale below, where 1 means does not describe what I would like at all and 7 means describes what I would like perfectly.

Country of Current Practice (%) Perceptions of How the Public Perceives the Chiropractic Profession - Profiled % Saying 6 – 7 (on a 1-7 scale from Does Not Describe at All to Describes Perfectly) How chiropractic profession SHOULD BE perceived… Total (%) Gender (%) Age (%) School Philosophy (%) Country of Current Practice (%) Men Women <35 35 – 59 60+ Group A Group B US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world Wellness care 83 81 88 84 82 80 87 85 76 59 69 75 Non-drug / non-surgical health care 89 86 79 74 91 78 Management of spinal problems & their impact on general health 73 Management of neuromusculoskeletal conditions & their impact on general health 72 71 77 68 67 Primary health care 65 70 63 66 64 Management of vertebral subluxation & its impact on general health 52 55 51 Management of back & neck pain & their impact on general health 60 62 61 56 57 Management of neuromusculoskeletal conditions 58 54 Management of spinal problems Management of vertebral subluxation 46 47 40 Management of back & neck pain 48 45 44 42 Base: Total sample (n=3689) Q7. Please indicate how well each of the following statements describes how you would like chiropractic health care to be perceived by the general public in your country. Again, please use the 7-point scale below, where 1 means does not describe what I would like at all and 7 means describes what I would like perfectly.

General Public’s Perceptions of Chiropractic Health Care - Profiled % Saying 6 – 7 (on a 1-7 scale from Does Not Describe at All to Describes Perfectly) How chiropractic profession IS CURRENTLY perceived… Total (%) Gender (%) Age (%) School Philosophy (%) Country of Current Practice (%) Men Women <35 35 – 59 60+ Group A Group B US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world Management of back & neck pain 81 84 86 67 80 82 85 66 61 Management of spinal problems 60 59 64 53 55 65 56 71 57 48 Non-drug / non-surgical health care 45 43 49 47 44 46 38 Management of neuromusculoskeletal conditions 37 42 39 41 40 29 35 34 Management of back & neck pain & their impact on general health 30 27 26 28 33 31 25 16 22 Management of spinal problems & their impact on general health 17 18 19 14 23 13 11 12 Management of neuromusculoskeletal conditions & their impact on general health 15 9 10 8 Management of vertebral subluxation 7 6 Wellness care 5 3 2 4 Management of vertebral subluxation & its impact on general health Primary health care 1 Base: Total sample (n=3689) Q6. Please indicate how well each of the following statements describes how chiropractic health care is currently perceived by the general public in your country. Please use the 7-point scale below, where 1 means does not describe public perception at all and 7 means describes it perfectly.

From the chiropractor’s perspective, the ability to get a patient back to their regular routine and the fact that chiropractic health care delivers patient-centered care and spinal care expertise are key in helping shape the general public’s perceptions of the profession. Additionally, issues of ethics, behaviour & trust play an important role in influencing public opinion.

Influencing Factors on Public Perceptions % Saying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important) Ability to get the patient back to work / daily activities Patient-centered care Spinal care expertise Issues of ethics, professional behaviour & trust Hands-on care Quick recovery from pain & disability Ability to manage pain Ability to manage back pain Ability to diagnose the cause of symptoms Level of education / training A practice model that does not involve drugs or surgery Attitudes of the media Preventative care The profession's different model of health Attitudes of government & health authorities Third party funding for care Attitudes of other health care professionals Base: Total sample (n=3689) Q11. In your opinion, how important are each of the following in shaping the general public’s perception of the chiropractic profession? Please use the 7-point scale below, where 1 means not at all important and 7 means very important.

Influencing Factors on Public Perceptions - Profiled % Saying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important) Total (%) Gender (%) Age (%) School Philosophy (%) Country of Current Practice (%) Men Women <35 35 – 59 60+ Group A Group B US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world Ability to get patient back to work / daily activities 84 83 88 80 85 91 82 86 89 79 92 Patient-centered care 87 77 Spinal care expertise 74 78 81 75 76 Issues of ethics, professional behaviour & trust 71 Hands-on care 73 Quick recovery from pain & disability 68 72 Ability to manage pain 65 66 70 Ability to manage back pain 63 69 Ability to diagnose the cause of symptoms 67 64 62 Level of education / training Practice model that does not involve drugs / surgery 61 55 58 Attitudes of the media 51 59 53 Preventative care 56 57 60 49 54 The profession's different model of health 52 42 Attitudes of government & health authorities 48 46 Third party funding for care 23 29 28 32 Attitudes of other health care professionals 50 Base: Total sample (n=3689) Q11. In your opinion, how important are each of the following in shaping the general public’s perception of the chiropractic profession? Please use the 7-point scale below, where 1 means not at all important and 7 means very important.

Influencing Factors on Public Perceptions - Profiled % Saying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important) Total (%) Desired Perception of Profession (%) Desired Perception of Profession & Services (%) Focused scope Broad scope Specialist Mainstream Complementary & Alternative Ability to get the patient back to work/ daily activities 84 82 86 89 73 Patient-centered care 81 85 Spinal care expertise 77 78 74 68 Issues of ethics, professional behaviour & trust 76 71 Hands-on care 75 Quick recovery from pain & disability 63 Ability to manage pain 72 69 56 Ability to manage back pain 70 57 Ability to diagnose the cause of symptoms 64 52 Level of education / training 66 58 A practice model that does not involve drugs or surgery 65 62 Attitudes of the media 50 Preventative care 59 55 53 The profession's different model of health 61 Attitudes of government & health authorities 60 43 Third party funding for care 37 Attitudes of other health care professionals 54 38 Base: Total sample (n=3689) Q11. In your opinion, how important are each of the following in shaping the general public’s perception of the chiropractic profession? Please use the 7-point scale below, where 1 means not at all important and 7 means very important.

Professional Conduct & Standards In fact, there is consensus among chiropractors that public confidence has been impacted by newsworthy events that have called into question the conduct of some members of the profession. Most also believe that the public at large is not aware of the level of education of chiropractors. % Saying Strongly or Somewhat Agree Concerns with respect to the ethics and professional conduct of some members of the profession have a significant impact on the level of public confidence in chiropractic health care The general public has confidence in the quality of care provided by chiropractors The general public is aware of the level of education of chiropractors Higher among… Those practicing in regulated Europe – 84%; 60+ years – 72% Those practicing in a school outside of the US – 28%; Those who have been practicing for 11+ years – 24%; 35+ years – 22% Base: Total sample (n=3689) Q12. Please indicate whether you strongly agree, somewhat agree, somewhat disagree or strongly disagree with the following statements:

Factor Influence When Seeking Chiropractic Care From a chiropractor’s perspective, reputation for effectiveness, manual procedures and specialized knowledge and education are most important to patients seeking chiropractic health care. % Saying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important) Reputation for effectiveness Manual procedures (adjusting, mobilization, manipulation, soft tissue, etc.) Specialized knowledge & education Non-drug / non-surgical approach Availability of third party funding Diagnostic ability Exercise/ rehabilitation Lifestyle counseling / advice Nutritional support / advice Base: Total sample (n=3689) Q10. Patients seek chiropractic care for different reasons. In your opinion, how important are each of the following attributes of chiropractic health care to patients? Please use the 7-point scale below, where this time, 1 means not at all important and 7 means very important.

Factor Influence When Seeking Chiropractic Care - Profiled % Saying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important) Total (%) Gender (%) Age (%) School Philosophy (%) Country of Current Practice (%) Men Women <35 35 – 59 60+ Group A Group B US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world Reputation for effectiveness 87 86 88 90 89 85 Manual procedures (adjusting, mobilization, manipulation, soft tissue, etc.) 74 77 75 73 76 79 Specialized knowledge & education 67 68 64 62 69 66 65 Non-drug / non-surgical approach 61 63 59 55 72 Availability of third party funding 58 56 54 60 22 27 30 31 Diagnostic ability 51 49 53 Exercise / rehabilitation 38 40 39 45 33 47 41 34 Lifestyle counseling / advice 36 35 37 43 32 46 Nutritional support / advice 25 24 29 14 20 Base: Total sample (n=3689) Q10. Patients seek chiropractic care for different reasons. In your opinion, how important are each of the following attributes of chiropractic health care to patients? Please use the 7-point scale below, where this time, 1 means not at all important and 7 means very important.

Factor Influence When Seeking Chiropractic Care - Profiled % Saying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important) Total (%) Desired Perception of Profession (%) Perception of Profession & Services (%) Focused scope Broad scope Specialist No clear perception Mainstream Complementary & Alternative Reputation for effectiveness 87 90 86 84 89 Manual procedures (adjusting, mobilization, manipulation, soft tissue, etc.) 74 78 72 70 79 Specialized knowledge & education 67 68 64 66 Non-drug / non-surgical approach 62 63 61 Availability of third party funding 58 56 Diagnostic ability 55 57 51 59 54 Exercise / rehabilitation 38 49 41 35 42 Lifestyle counseling / advice 36 34 Nutritional support / advice 27 24 30 26 Base: Total sample (n=3689) Q10. Patients seek chiropractic care for different reasons. In your opinion, how important are each of the following attributes of chiropractic health care to patients? Please use the 7-point scale below, where this time 1 means not at all important and 7 means very important.

Up until now, we have focused on perceived perceptions of the general public. We will now turn our attention to how chiropractors believe the profession is perceived by medical doctors.

Perceptions of How Chiropractic is Perceived by Medical Doctors It appears that chiropractors believe the fuzziness surrounding the identity of their profession is even greater among medical doctors than the public at large, with one-half of chiropractors believing medical doctors have no clear perception of the profession. For comparison: Chiropractors believe 26% of the general public does not have a clear perception of the profession. Total (%) Age (%) School Philosophy (%) Country of Current Practice (%) Years in Active Practice (%) <35 35 – 59 60+ Group A Group B US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world 5 or less 6 – 10 11 - 20 >20 No clear perception 49 46 64 45 58 48 77 56 72 47 54 Specialist care 31 33 32 20 41 36 10 19 13 5 15 34 35 26 Primary heath care: focused scope 21 16 14 18 39 12 Primary heath care: broad scope * - 1% * Less than 0.5% Base: Total sample (n=3689) Q14. Using the definitions provided below, do you think the chiropractic profession is currently perceived by medical doctors as offering primary health care: focused scope, primary health care: broad scope, or specialist care?

Perceptions of How Chiropractic is Perceived by Medical Doctors Consistent with how chiropractors think the general public perceives the profession, most chiropractors believe medical doctors perceive chiropractic care as complementary & alternative rather than mainstream. Base: Total sample (n=3689) Q15. Again, using the definitions provided below, do you think the chiropractic profession and its services are currently perceived by medical doctors as mainstream or complementary and alternative?

Perceptions of How Chiropractic is Perceived by Medical Doctors The general perspective among chiropractors is that medical doctors perceive chiropractic care as the management of back and neck pain first and foremost. There is also a perception that some medical doctors (55%) see chiropractic as a competitor within the health care system. % Saying 6 – 7 (on a 1-7 scale from Does Not Describe Their Perception at All to Describes It Perfectly) The management of back & neck pain A competitor within health care delivery Non-drug / non-surgical health care The management of spinal problems The management of neuromusculoskeletal conditions The management of back & neck pain & their impact on general health The management of neuromusculoskeletal conditions & their impact on general health The management of spinal problems & their impact on general health The management of vertebral subluxation Wellness care The management of vertebral subluxation & its impact on general health Primary health care Base: Total sample (n=3689) Q13. Please indicate how well each of the following statements describes how you believe chiropractic health care is currently perceived by medical doctors. Please use the 7-point scale below, where 1 means does not describe their perception at all and 7 means describes it perfectly.

Perceptions of How Chiropractic is Perceived by MDs - Profiled % Saying 6 – 7 (on a 1-7 scale from Does Not Describe Their Perception at All to Describes It Perfectly) Total (%) Age (%) Country of Current Practice (%) <35 35 – 59 60+ US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world The management of back & neck pain 67 72 66 42 78 69 68 47 A competitor within health care delivery 55 53 56 49 57 50 32 39 Non-drug / non-surgical health care 36 48 46 44 37 43 The management of spinal problems 30 40 41 54 The management of neuromusculoskeletal conditions 33 23 22 31 35 25 27 The management of back & neck pain & their impact on general health 14 21 12 6 19 16 9 The management of neuromusculoskeletal conditions & their impact on general health 7 10 4 8 5 3 The management of spinal problems & their impact on general health The management of vertebral subluxation 11 Wellness care 2 1 The management of vertebral subluxation & its impact on general health Primary health care Base: Total sample (n=3689) Q13. Please indicate how well each of the following statements describes how you believe chiropractic health care is currently perceived by medical doctors. Please use the 7-point scale below, where 1 means does not describe their perception at all and 7 means describes it perfectly.

In recent years there has been a call for greater mutual cooperation and respect between chiropractic and medical doctors in the interest of patients. Earlier we discussed the importance of ethics, professional conduct & trust in shaping the identity of the profession. Medical doctors’ perceptions surrounding the safety of chiropractic care and the standards for education & practice are also key in building stronger inter-professional relations.

Importance for Building Inter-Professional Relations % Saying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important) Medical doctors' perceptions about the safety of chiropractic health care Medical doctors' perceptions about the effectiveness of chiropractic health care Medical doctors' knowledge & understanding of the standards for chiropractic education & practice Attitudes & behaviours of chiropractors Attitudes & behaviours of medical doctors Chiropractors' perceptions about the safety of medical health care Chiropractors' perceptions about the effectiveness of medical health care Influence, attitudes & behaviours of third party payers Financial barriers to referring patients for chiropractic health care Chiropractors' knowledge & understanding of the standards for medical education and practice Base: Total sample (n=3689) Q16. ….In your opinion, how important are each of the following with respect to inter-professional relations? Please use the 7-point scale below, where 1 means not at all important and 7 means very important.

Importance for Building Inter-Professional Relations % Saying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important) Gender (%) School Philosophy Country of Current Practice (%) Years in Practice (%) Total (%) Men Women Group A Group B US Can. Reg. Eur. Unreg. Eur. Aus./NZ Rest of world 5 or less 6 – 10 11 - 20 >20 Medical doctors' perceptions about the safety of chiropractic health care 89 88 95 91 93 86 90 Medical doctors' perceptions about the effectiveness of chiropractic health care 84 85 83 87 Medical doctors' knowledge & understanding of the standards for chiropractic education & practice 92 82 Attitudes & behaviours of chiropractors 94 Attitudes & behaviours of medical doctors 79 77 78 81 80 74 Chiropractors' perceptions about the safety of medical health care 64 63 66 65 59 60 58 62 Chiropractors' perceptions about the effectiveness of medical health care 57 56 67 Influence, attitudes and behaviours of third party payers 55 41 38 49 Financial barriers to referring patients for chiropractic health care 61 52 45 48 50 Chiropractors' knowledge and understanding of the standards for medical education and practice 54 46 53 72 51 Base: Total sample (n=3689) Q16. Independent studies in various countries have called for greater mutual cooperation and respect between chiropractic and medical doctors in the interest of patients. In your opinion, how important are each of the following with respect to inter-professional relations? Please use the 7-point scale below where 1 means not at all important and 7 means very important.

APPENDIX: Respondent Profile

Respondent Profile Gender Age Country of Graduating Institution Total (%) Gender Male 79 Female 21 Age Under 35 27 35 – 59 68 60+ 5 Average 40 Country of Graduating Institution US 86 Canada 6 Europe 3 Australia / New Zealand Rest of the world 2 Years Since Graduation 5 or less 26 6 – 10 18 11 – 20 28 More than 20 13 Base: Total sample (n=3689)

Respondent Profile (cont’d) Total (%) Country of Current Practice US 82 Canada 7 Europe 6 Australia / New Zealand 3 Rest of the world 2 Years in Active Practice 5 or less 29 6 – 10 17 11 – 20 28 More than 20 26 Average 13 Current Role in Chiropractic Clinical practice 91 Administration / Education / Research Retired 1 Other Base: Total sample (n=3689)

Respondent Profile (cont’d) Country of Graduating Institution % saying… US Canada Europe Australia / New Zealand Rest of the world 94 4 2 1 22 89 Regulated Europe 65 7 42 Unregulated Europe 24 5 3 83 9 6 21 Country of Current Practice Base: Total sample (n=3689) Q20. Which institution did you graduate from? Q23. What country do you currently practice in?