C onsultation on I dentity December 7, 2004 Quantitative Research Findings

Page 2 Table of Contents Page INTRODUCTION 3 Background & Objectives 4 Methodology 5 Definitions 6 Reporting Perspective 7 EXECUTIVE SUMMARY 8 DETAILED FINDINGS 13 APPENDIX APPENDIX – Respondent Profile 49

INTRODUCTION

Page 4 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. international consultation on the most appropriate public identity for the profession 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. attitudes and perceptions towards the profession. The purpose of the study is to understand attitudes and perceptions towards the profession. tool to help define the organization’s positioning The survey will be used as a tool to help define the organization’s positioning strategy.

Page 5 Methodology Online survey. A list of Members’ addresses was provided to Northstar Members were sent an notifying them of the survey one week in advance of the survey launch (September 27 th ) 29,094 invitations were sent out on October 4 th inviting Members to participate in the survey A reminder was sent out on October 11 th to Members who had not yet completed the survey The survey closed on October 24 th 3,689 completes 3,689 completes were obtained. 15 minutes Questionnaire was approximately 15 minutes in length. Data has been weighted Data has been weighted to reflect the true distribution of chiropractors in the participating countries.

Page 6 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.

Page 7 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

Page 9 Executive Summary important for a profession to have a clear public identity. There is general consensus among chiropractors that it is important for a profession to have a clear public identity. suffers from an unclear identity and position within health care today. That said, most agree that the chiropractic profession suffers from an unclear identity and position within health care today. chiropractors’ view of the profession and the general public’s view of the profession are equally as important to 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. think the profession should be viewedthink it is actually viewed. This underscores the importance of understanding how chiropractors think the profession should be viewed and how they think it is actually viewed.

Page 10 Executive Summary (cont’d) significant discrepancyshould be actually perceived. 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. primary health care no clear perception specialist care. 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. should be perceived as mainstream complementary and alternative. 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. wellness care non-drug, non-surgical health care, management of back and neck painspinal problems. 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.

Page 11 Executive Summary (cont’d) strongly agree with the policy statement opposing the use of prescription drugs Most chiropractors (62%) strongly agree with the policy statement opposing the use of prescription drugs in the practice of chiropractic. integral to how the profession should be perceived 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.

Page 12 Executive Summary (cont’d) The lack of clarity surrounding the identity of the profession has also likely been fed by: Limited public awarenesseducation Limited public awareness regarding the education of chiropractors. ethics & professional conduct of some members of the profession. Recent newsworthy events that have called into question the ethics & professional conduct of some members of the profession. impacted the level of public confidence 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 get patients back to their daily routine, patient-centered care and spinal care expertise) 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. safety of chiropractic caregreater mutual respect and cooperation 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

Page 14 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. Strongly Agree (6&7) 90% Mean Score: 6.5 “ I t is I mportant for a P rofession to H ave a C lear P ublic I dentity” (1 to 7 Scale from Strongly Disagree to Strongly Agree) 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.

Page 15 Importance for a Profession to Have a Clear Public Identity - Profiled 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. Total (%) Gender (%)Age (%)School Philosophy (%)Country of Graduating Institution (%) Rating MenWomen<3535 – 5960+Group AGroup BUSCan.Europe Aus./ NZ Rest of world 1 to to to Mean score “ I t is I mportant for a P rofession to H ave a C lear P ublic I dentity” (1 to 7 Scale from Strongly Disagree to Strongly Agree)

Page 16 Clarity of the Profession’s Identity However, most chiropractors in our sample don’t believe the chiropractic profession has a clear public identity today. “ T he C hiropractic P rofession H as a C lear P ublic I dentity” (1 to 7 Scale from Strongly Disagree to Strongly Agree) 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. Strongly Disagree (1&2) 40% Strongly Agree (6&7) 4%

Page 17 Clarity of the Profession’s Identity - Profiled 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. Country of Current Practice (%)Years in Practice (%)Importance of a Clear Identity (%) Rating Total (%)USCan. Reg. Eur. Unreg. Eur. Aus./ NZ Rest of world 5 or less6 – More than 20 Very Important (6 or 7) Somewhat Important (3 to 5) Not Important (1 or 2) 1 to to to Mean score “ T he C hiropractic P rofession H as a C lear P ublic I dentity” (1 to 7 Scale from Strongly Disagree to Strongly Agree)

Page 18 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. 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 % R ating L evel of A greement a 6 – 7 (on a 1-7 scale from Strongly Disagree to Strongly Agree ) 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.

Page 19 Total (%) Gender (%)Age (%)School Philosophy (%) MenWomen<3535 – 5960+Group AGroup B 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 Area of Central Importance in Practice & Public Identity - Profiled 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. % R ating L evel of A greement a 6 – 7 (on a 1-7 scale from Strongly Disagree to Strongly Agree )

Page 20 Total (%) Country of Current Practice (%)Years in Active Practice (%) USCan.Reg. Eur.Unreg. Eur.Aus./NZRest of world5 or less6 – >20 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 Area of Central Importance in Practice & Public Identity - Profiled 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. % R ating L evel of A greement a 6 – 7 (on a 1-7 scale from Strongly Disagree to Strongly Agree )

Page 21 Total (%) Gender (%)School Philosophy (%)Country of Current Practice (%) MenWomenGroup AGroup BUSCan.Reg. Eur.Unreg. Eur.Aus./NZRest of world Both views are equally important General public’s view of the profession Chiropractic’s view of the profession 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. 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…?

considerable discrepancy should be actually being perceived. 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.

Page 23 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. 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 ? T he Chiropractor’s P erspective H ow the P rofession Should B e P erceived by the P ublic H ow the P rofession is Currently P erceived by the P ublic

Page 24 Perceptions of How the Public Perceives the Chiropractic Profession - Profiled 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 ? Gender (%)School Philosophy (%)Country of Current Practice (%) TotalMenWomenGroup AGroup BUSCan.Reg. Eur.Unreg. Eur.Aus./NZRest of world Primary heath care: focused scope Primary health care: broad scope Specialist care Gender (%)Age (%)School Philosophy (%)Country of Current Practice (%) TotalMenWomen<3535 – 5960+Group AGroup BUSCan. Reg. Eur. Unreg. Eur. Aus./ NZ Rest of world Primary heath care: focused scope Specialist care No clear perception Primary health care: broad scope T he Chiropractor’s P erspective H ow the P rofession Should B e P erceived by the P ublic H ow the P rofession is Currently P erceived by the P ublic

Page 25 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. 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 ? T he Chiropractor’s P erspective H ow the P rofession & I ts S ervices Should B e P erceived by the P ublic H ow the P rofession & S ervices are Currently P erceived by the P ublic

Page 26 Perceptions of How the Public Perceives the Chiropractic Profession - Profiled 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 ? Total (%) Gender (%)Age (%)Country of Current Practice (%) MenWomen<3535 – 5960+USCan.Reg. Eur.Unreg. Eur.Aus./NZRest of world Mainstream Complementary & Alternative Gender (%)Age (%)Country of Current Practice (%)Years in Active Practice (%) TotalMenWomen<3535 – 5960+USCan. Reg. Eur. Unreg. Eur. Aus. /NZ Rest of world 5 or less 6 – >20 Complementary & Alternative Mainstream T he Chiropractor’s P erspective H ow the P rofession & I ts S ervices Should B e P erceived by the P ublic H ow the P rofession & S ervices are Currently P erceived by the P ublic

Page 27 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. 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 … A greement with P olicy O pposing U se of P rescription D rugs 79% Total Gender Rest of world Australia / New Zealand Unregulated Europe Canada US Country of Current Practice Women Men School Philosophy Group B Group A 11 – 20 6 – 10 5 or less Years in Practice > 20 Regulated Europe

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

would likewellness care and / or non-drug, non-surgical health care, While most would like chiropractic to be perceived as wellness care and / or non-drug, non-surgical health care, general public as the management of neck & back pain management of spinal problems 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.

Page 30 Perceptions of How the General Public Perceives the Chiropractic Profession % S aying 6 – 7 % S aying 6 – 7 (on a 1-7 scale from Does Not Describe at All to Describes Perfectly ) 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 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. Should Be Should Be Perceived by the General Public Currently is Currently Perceived by the General Public How Chiropractic Profession… Gap

Page 31 Perceptions of How the Public Perceives the Chiropractic Profession - Profiled 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. SHOULD BE How chiropractic profession SHOULD BE perceived… Total (%) Gender (%)Age (%)School Philosophy (%)Country of Current Practice (%) MenWomen<3535 – 5960+Group AGroup BUSCan. Reg. Eur. Unreg. Eur. Aus./ NZ Rest of world 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 % S aying 6 – 7 % S aying 6 – 7 (on a 1-7 scale from Does Not Describe at All to Describes Perfectly )

Page 32 General Public’s Perceptions of Chiropractic Health Care - Profiled 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. How chiropractic profession IS CURRENTLY IS CURRENTLY perceived… Total (%) Gender (%)Age (%)School Philosophy (%)Country of Current Practice (%) MenWomen<3535 – 5960+Group AGroup BUSCan. Reg. Eur. Unreg. Eur. Aus./ NZ Rest of world Management of back & neck pain Management of spinal problems Non-drug / non-surgical health care Management of neuromusculoskeletal conditions Management of back & neck pain & their impact on general health Management of spinal problems & their impact on general health Management of neuromusculoskeletal conditions & their impact on general health Management of vertebral subluxation Wellness care Management of vertebral subluxation & its impact on general health Primary health care % S aying 6 – 7 % S aying 6 – 7 (on a 1-7 scale from Does Not Describe at All to Describes Perfectly )

ability to get a patient back to their regular routine patient-centered care spinal care expertise 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. ethics, behaviourtrust Additionally, issues of ethics, behaviour & trust play an important role in influencing public opinion.

Page 34 Influencing Factors on Public Perceptions 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. % S aying 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

Page 35 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. Total (%) Gender (%)Age (%)School Philosophy (%) Country of Current Practice (%) MenWomen<3535 – Group A Group BUSCan. Reg. Eur. Unreg. Eur. Aus./ NZ Rest of world Ability to get 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 Practice model that does not involve drugs / 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 % S aying 6 – 7 % S aying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important ) Influencing Factors on Public Perceptions - Profiled

Page 36 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. Total (%) Desired Perception of Profession (%)Desired Perception of Profession & Services (%) Focused scopeBroad scopeSpecialistMainstreamComplementary & Alternative 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 % S aying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important ) Influencing Factors on Public Perceptions - Profiled

Page 37 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. 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 % S aying S trongly or S omewhat A gree Base: Total sample (n=3689) Q12. Please indicate whether you strongly agree, somewhat agree, somewhat disagree or strongly disagree with the following statements: Higher among… Those practicing in a school outside of the US – 28%; Those who have been practicing for 11+ years – 24%; 35+ years – 22% Those practicing in regulated Europe – 84%; 60+ years – 72%

Page 38 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. % S aying 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.

Page 39 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. Total (%) Gender (%)Age (%)School Philosophy (%)Country of Current Practice (%) MenWomen<3535 – 5960+Group AGroup BUSCan. Reg. Eur. Unreg. Eur. Aus./ NZ Rest of world 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 Factor Influence When Seeking Chiropractic Care - Profiled % S aying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important )

Page 40 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. Total (%) Desired Perception of Profession (%)Perception of Profession & Services (%) Focused scopeBroad scopeSpecialistNo clear perceptionMainstreamComplementary & Alternative 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 Factor Influence When Seeking Chiropractic Care - Profiled % S aying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important )

profession is perceived by medical doctors. 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.

Page 42 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. * 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 ? Total (%) Age (%)School Philosophy (%)Country of Current Practice (%)Years in Active Practice (%) <3535 – 5960+Group AGroup BUSCan. Reg. Eur. Unreg. Eur. Aus./ NZ Rest of world 5 or less6 – >20 No clear perception Specialist care Primary heath care: focused scope Primary heath care: broad scope ***-***1% -* *-** For comparison: Chiropractors believe 26% of the general public does not have a clear perception of the profession.

Page 43 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 ?

Page 44 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. % S aying 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.

Page 45 Perceptions of How Chiropractic is Perceived by MDs - Profiled 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. Total (%) Age (%)Country of Current Practice (%) <3535 – 5960+USCan. Reg. Eur. Unreg. Eur. Aus./ NZ Rest of world 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 % S aying 6 – 7 (on a 1-7 scale from Does Not Describe Their Perception at All to 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. safety standards for education & practicekey in building stronger inter-professional relations. 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.

Page 47 Importance for Building Inter-Professional Relations % S aying 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.

Page 48 Importance for Building Inter-Professional Relations 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. Gender (%)School PhilosophyCountry of Current Practice (%)Years in Practice (%) Total (%)MenWomenGroup AGroup BUS Ca n. Reg. Eur. Unreg. Eur. Aus./ NZ Rest of world 5 or less 6 – >20 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 and behaviours of third party payers Financial barriers to referring patients for chiropractic health care Chiropractors' knowledge and understanding of the standards for medical education and practice % S aying 6 – 7 % S aying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important )

APPENDIX: Respondent Profile

Page 50 Respondent Profile Total (%) Gender Male79 Female21 Age Under – Average40 Country of Graduating Institution US86 Canada6 Europe3 Australia / New Zealand3 Rest of the world2 Years Since Graduation 5 or less26 6 – – 2028 More than 2028 Average13 Base: Total sample (n=3689)

Page 51 Respondent Profile (cont’d) Total (%) Country of Current Practice US82 Canada7 Europe6 Australia / New Zealand3 Rest of the world2 Years in Active Practice 5 or less29 6 – – 2028 More than 2026 Average13 Current Role in Chiropractic Clinical practice91 Administration / Education / Research6 Retired1 Other2 Base: Total sample (n=3689)

Page 52 Respondent Profile (cont’d) % saying… USCanadaEuropeAustralia / New ZealandRest of the world US Canada Regulated Europe Unregulated Europe Australia / New Zealand Rest of the world C ountry of C urrent P ractice C ountry of G raduating I nstitution Base: Total sample (n=3689) Q20. Which institution did you graduate from? Q23. What country do you currently practice in?