Attitudes toward chiropractic page 2

mation of attitudes, referral practices, and impressions toward chiropractic assessment and treatment (content validity).16 The pretest participants also commented on the clarity and comprehensiveness of the questionnaire.
Questionnaire Administration
We identified all 764 surgeons who were members of the Canadian Orthopedic Association as of August 2005 by acquiring a mailing list from this organization. From July 2006 to June 2007, we administered a 43-question survey to a sample of 500 Canadian orthopedic surgeons. In September 2006, we purchased contact information for all 24,172 American orthopedic surgeons listed with a private physician roster (available at: www.dr-411.com) and from July 2007 to June 2008, we administered the same survey to a sample of 500 American orthopedic surgeons. Both samples were selected using a computer based random number generator. We administered surveys by fax, and all surgeons’ offices were telephoned before sending a survey to confirm their presence and fax number. Participants were provided with a disclosure letter detailing the intent of the survey and explicit instructions that, should they choose not to complete the survey, they could check a box on the cover page indicating that they did not wish to participate and fax it back to our attention. At 4 and 8 weeks following the initial mailing, we again faxed the questionnaire to all nonresponders who
had not indicated that they did not wish to participate. We telephoned each office that received a third (final) survey before faxing in an effort to encourage completion of the instrument, which has been shown to increase response rates.17 The McMaster University Research Ethics Board
approved the study. Twenty-three survey questions requested demographic data from respondents and queried their knowledge of chiropractic
and referral practices for chiropractic care. The survey also included 20-items that asked respondents to indicate their attitudes toward chiropractic—the chiropractic attitude questionnaire (CAQ). Each of the 20 questions comprising the CAQ was graded on a 5-point Likert scale, from 0 to 4. The responses were then summed to arrive at a total score ranging from 0 (most negative attitude toward chiropractic) to 80 (most positive attitude toward chiropractic). The approximation to the normal distribution was confirmed with a Kolmogorov-Smirnov test (P_0.62) and examination of probability plots. The internal consistency of the CAQ, using all 487 respondents, was 0.92 (Cronbach alpha). The last item of the CAQ asked about the
respondent’s general attitude toward chiropractic. The Spearman correlation between responses to that question and the total CAQ score (excluding that question) was 0.86 (P _ 0.01), indicating preliminary evidence of the construct validity of the CAQ.
Statistical Analysis
We generated frequencies for all collected data, and checked for differences in responses across items between Canadian and American surgeons with the t test and _2 test. Two of us (J.W.B., J.J.) reviewed written comments independently and in duplicate in order to establish common themes and resolved discrepancies by discussion. We hypothesized, a priori, the following associations of respondents’ attitudes toward chiropractic: (1) older surgeons would hold more negative attitudes; (2) among chiropractic colleges, there exists a range in teaching philosophy, from institutions
(“straight” colleges) that maintain a literal interpretation of the theories of D. D. Palmer, the founder of chiropractic, to colleges that attempt to consolidate medical and chiropractic approaches to health care. Some straight colleges promote the belief that malpositioned (subluxated) spinal vertebrae may interfere with the nervous system, thereby obstructing the body’s own natural- or innate-healing power, and that patients should reject drugs, surgery, and other allopathic medical procedures in favor of chiropractic for their primary health care.18 The United States has 18 chiropractic colleges that span this philosophical spectrum.19 Canada has only one English-language chiropractic college, the Canadian Memorial Chiropractic College, which promotes an evidence-based approach to the role of chiropractic in healthcare with a focus on treatment of neuromusculoskeletal disorders.20 Approximately 80% of Canadian chiropractors are graduates of Canadian Memorial Chiropractic College.21 Greater standardization
in chiropractic education among Canadian chiropractors, consistent with a philosophy that may be more in keeping with allopathic medicine, would result in improved attitudes toward chiropractic among Canadian surgeons; (3) more critical attitudes if respondents spent a higher percentage of their practice conducting independent medical examinations; (4) more positive attitudes if their practice was restricted to adults; (5) spine surgeons would
hold more favorable attitudes; (6) greater self-professed knowledge of chiropractic would be associated with more favorable opinions; and (7) surgeons endorsing patient feedback, a relationship with a specific chiropractor, the scientific literature, personal treatment experience, or feedback from family and friends as sources of information regarding chiropractic would hold more positive attitudes. These variables were entered into a generalized linear model. The dependent variable, attitude toward chiropractic, was defined as the aggregate score of the CAQ. We calculated that we would require at least 240 completed surveys in order to ensure that our regression model was reliable (10 respondents for each independent variable considered).22 All comparisons were 2-tailed and a variable was considered statistically significant if it had a P _ 0.05 in the final multivariable model. We report the unstandardized regression coefficient and 95% confidence interval for each significant variable in the analysis. The value of the unstandardized regression coefficient represents the change in response score on the CAQ. We plotted residuals from the regression analyses to
ensure that their distributions were reasonably normal. Multicollinearity was deemed concerning if the variance inflation factor for any independent variable was greater than 5.23 We performed all analyses using SPSS 15.0 statistical software (SPSS Inc., Chicago, IL).
Results
Characteristics of Respondents
Surgeons returned 680 of 1000 surveys, a response rate of 68%; 193 respondents returned the cover page only and indicated that they did not wish to participate in the survey. 487 surgeons returned completed surveys, a completed response rate of 49%. Demographic characteristics varied significantly by country of practice (Canada or the United States) for a number of variables (Table 1). Most respondents were male (94.0%) and 45.8% had been in practice for more than 20 years. The majority of respondents (96.7%) indicated that they had at least some knowledge of chiropractic, and 82.7% were at least somewhat comfortable discussing chiropractic

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