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

2. 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

3. INTRODUCTION

4. 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.

5. Page 5 Methodology Online survey. 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 27 th ) 29,094 email invitations were sent out on October 4 th inviting Members to participate in the survey A reminder email 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.

6. 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.

7. 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.

8. EXECUTIVE SUMMARY

9. 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.

10. 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.

11. 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.

12. 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

13. DETAILED FINDINGS

14. 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.

15. 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 2 4445344442224 3 to 5 65766457566712 6 to 7 909189 9192918989 92 9184 Mean score 6.5 6.4 6.5 6.46.5 6.66.56.4 “ 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)

16. 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%

17. 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 – 1011 - 20 More than 20 Very Important (6 or 7) Somewhat Important (3 to 5) Not Important (1 or 2) 1 to 2 4041442549313442443837423018 3 to 5 5655536949635955535957556859 6 to 7 443626733363223 Mean score 3.0 2.93.52.83.33.22.9 3.03.12.93.14.1 “ 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)

18. 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.

19. 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 8584888785879177 The spine is of central importance to the practice of chiropractic 727369 73837867 The spine is of central importance to the public identity of chiropractic 66 6467736963 The nervous system is of central importance to the public identity of chiropractic 60 616460556754 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 )

20. Page 20 Total (%) Country of Current Practice (%)Years in Active Practice (%) USCan.Reg. Eur.Unreg. Eur.Aus./NZRest of world5 or less6 – 1011 - 20>20 The nervous system is of central importance to the practice of chiropractic 85868085898788868984 The spine is of central importance to the practice of chiropractic 72 73 77758467747277 The spine is of central importance to the public identity of chiropractic 66 69677370786365 72 The nervous system is of central importance to the public identity of chiropractic 6061564766606462635859 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 )

21. 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 5453605354 64656163 General public’s view of the profession 2526212428252919161714 Chiropractic’s view of the profession 21 1923182117 192223 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…?

22. 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.

23. 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

24. 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 55 535848535968575662 Primary health care: broad scope 3635393342383323273623 Specialist care 91089 98916815 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 scope4142374440454234395947256820 Specialist care 30 32303121293734112119618 No clear perception26252823263026 2427 531953 Primary health care: broad scope33333433335379 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

25. 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

26. 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 888790 87808988 768276 Complementary & Alternative 121310 13201112 241824 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 – 10 11 - 20>20 Complementary & Alternative898796918886899182969192 8885 Mainstream 111349121411918498881215 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

27. 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

28. 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…

29. 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.

30. 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… 7737585965603022-47-34 Gap

31. 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 8381888482808780857659806975 Non-drug / non-surgical health care 8280898681808480837974917881 Management of spinal problems & their impact on general health 7574787375837475 73 787588 Management of neuromusculoskeletal conditions & their impact on general health 72717768747867787276 71 85 Primary health care 67657667 706863667667787364 Management of vertebral subluxation & its impact on general health 6564706863747652665551746967 Management of back & neck pain & their impact on general health 6059625561715664596166655778 Management of neuromusculoskeletal conditions 60 595860705468596469545766 Management of spinal problems 60 565859705764596063595766 Management of vertebral subluxation 565558605467 46574740625755 Management of back & neck pain 4748454448664254474859484556 % S aying 6 – 7 % S aying 6 – 7 (on a 1-7 scale from Does Not Describe at All to Describes Perfectly )

32. 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 81 848681678084828085668461 Management of spinal problems 6059646061535565605671577148 Non-drug / non-surgical health care 45434947444544 454446534438 Management of neuromusculoskeletal conditions 3837423739373841402935 2934 Management of back & neck pain & their impact on general health 30 273827262833312625162722 Management of spinal problems & their impact on general health 1718161917221423181317111712 Management of neuromusculoskeletal conditions & their impact on general health 13 141512221216149101289 Management of vertebral subluxation 981481017911107911613 Wellness care 66666767653624 Management of vertebral subluxation & its impact on general health 55645957633625 Primary health care 23112631236563 % S aying 6 – 7 % S aying 6 – 7 (on a 1-7 scale from Does Not Describe at All to Describes Perfectly )

33. 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.

34. 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

35. 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 – 5960+ Group A Group BUSCan. Reg. Eur. Unreg. Eur. Aus./ NZ Rest of world Ability to get patient back to work / daily activities 8483888085918285848689847992 Patient-centered care 84 878584888385 8483778277 Spinal care expertise 77 747881777576798382 86 Issues of ethics, professional behaviour & trust 77 787577877680787471 7679 Hands-on care 7675777576827775767378797778 Quick recovery from pain & disability 7574786878857278757778767184 Ability to manage pain 7271756574836676717276687082 Ability to manage back pain 7170726373856575697282757289 Ability to diagnose the cause of symptoms 6867726469846273677376706981 Level of education / training 68 71696778667167717273 79 Practice model that does not involve drugs / surgery 656469676368 62666155665868 Attitudes of the media 62 6461646265636751595363 Preventative care 5958626456646257605349595465 The profession's different model of health 59 616357616554615242615261 Attitudes of government & health authorities 58 575957635761596048534669 Third party funding for care 55 524857645363595223292832 Attitudes of other health care professionals 54 556052505158545751494861 % 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

36. 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 848286898673 Patient-centered care 84 86818581 Spinal care expertise 777874857868 Issues of ethics, professional behaviour & trust 77 76817871 Hands-on care 767577 76 Quick recovery from pain & disability 757377817763 Ability to manage pain 726974787456 Ability to manage back pain 717069827357 Ability to diagnose the cause of symptoms 686473757052 Level of education / training 686671737058 A practice model that does not involve drugs or surgery 65 626468 Attitudes of the media 62 636450 Preventative care 595565535957 The profession's different model of health 595863565961 Attitudes of government & health authorities 585759626043 Third party funding for care 555356595737 Attitudes of other health care professionals 545255595638 % S aying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important ) Influencing Factors on Public Perceptions - Profiled

37. 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%

38. 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.

39. 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 87 86889088868789 858988 Manual procedures (adjusting, mobilization, manipulation, soft tissue, etc.) 74 777574 7376747679767387 Specialized knowledge & education 6768646269746668657375 73 Non-drug / non-surgical approach 6261686362646364635955725559 Availability of third party funding 5859565460645864635522273031 Diagnostic ability 5554585155684959536269636166 Exercise / rehabilitation 38 403938453347384140303449 Lifestyle counseling / advice 3635393337433541363332462254 Nutritional support / advice 27 312527412436292214201429 Factor Influence When Seeking Chiropractic Care - Profiled % S aying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important )

40. 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 8790 86848987 Manual procedures (adjusting, mobilization, manipulation, soft tissue, etc.) 74788672707974 Specialized knowledge & education 67 7268647466 Non-drug / non-surgical approach 62636861626462 Availability of third party funding 58 5661566158 Diagnostic ability 55 6257515954 Exercise / rehabilitation 38 4941354238 Lifestyle counseling / advice 36345836 4235 Nutritional support / advice 27244930263027 Factor Influence When Seeking Chiropractic Care - Profiled % S aying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important )

41. 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.

42. 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 – 1011 - 20>20 No clear perception49464964494546584877567247494654 Specialist care3133322031413610191351532343526 Primary heath care: focused scope 20211916191418313210391221181920 Primary heath care: broad scope ***-***1% -* *-** For comparison: Chiropractors believe 26% of the general public does not have a clear perception of the profession.

43. 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 ?

44. 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.

45. 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 67726642676678696847 A competitor within health care delivery 55535649575032535539 Non-drug / non-surgical health care 47504736484644553743 The management of spinal problems 42444230404157544942 The management of neuromusculoskeletal conditions 32333223332231352527 The management of back & neck pain & their impact on general health 142112614 1916129 The management of neuromusculoskeletal conditions & their impact on general health 71074857735 The management of spinal problems & their impact on general health 710637512985 The management of vertebral subluxation 777675111037 Wellness care 3333323316 The management of vertebral subluxation & its impact on general health 3333333215 Primary health care 1111135252 % S aying 6 – 7 (on a 1-7 scale from Does Not Describe Their Perception at All to Describes It Perfectly )

46. 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.

47. 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.

48. 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 – 10 11 - 20>20 Medical doctors' perceptions about the safety of chiropractic health care 8988958891899388 938690899088 Medical doctors' perceptions about the effectiveness of chiropractic health care 868491858886 84 868388868783 Medical doctors' knowledge & understanding of the standards for chiropractic education & practice 858392838784 878488 87828584 Attitudes & behaviours of chiropractors 8382878283 888382948583 82 Attitudes & behaviours of medical doctors 797784777978818477 7882788074 Chiropractors' perceptions about the safety of medical health care 64636663666559605863606664 62 Chiropractors' perceptions about the effectiveness of medical health care 60596559626057585658676459 58 Influence, attitudes and behaviours of third party payers 60 5965625541384956 586064 Financial barriers to referring patients for chiropractic health care 6061585962 615245485058596064 Chiropractors' knowledge and understanding of the standards for medical education and practice 565462546056466053527260555651 % S aying 6 – 7 % S aying 6 – 7 (on a 1-7 scale from Not at all Important to Very Important )

49. APPENDIX: Respondent Profile

50. Page 50 Respondent Profile Total (%) Gender Male79 Female21 Age Under 3527 35 – 5968 60+5 Average40 Country of Graduating Institution US86 Canada6 Europe3 Australia / New Zealand3 Rest of the world2 Years Since Graduation 5 or less26 6 – 1018 11 – 2028 More than 2028 Average13 Base: Total sample (n=3689)

51. 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 – 1017 11 – 2028 More than 2026 Average13 Current Role in Chiropractic Clinical practice91 Administration / Education / Research6 Retired1 Other2 Base: Total sample (n=3689)

52. Page 52 Respondent Profile (cont’d) % saying… USCanadaEuropeAustralia / New ZealandRest of the world US9442122 Canada289111 Regulated Europe1265742 Unregulated Europe112445 Australia / New Zealand132839 Rest of the world116421 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?