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An intervention and program evaluation to determine the effectiveness of public health reforms on primary prevention practices by chiropractic interns
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Content
An Intervention And Program Evaluation To Determine The Effectiveness Of Public
Health Reforms On Primary Prevention Practices By Chiropractic Interns
Copyright 2004
by
Gary Alan Globe
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(EPIDEMIOLOGY)
August 2004
Gary Alan Globe
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UMI Number: 3145202
Copyright 2004 by
Globe, Gary Alan
All rights reserved.
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Dedication
fo r Denise,
the queen o f our forest
and the love o f my life.
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Acknowledgments
Few efforts of this dimension are accomplished alone and certainly this
endeavor was no exception. There are several people that I not only must
acknowledge, but must thank from the bottom of my heart for making this
dissertation possible. First and foremost, I must thank best friend and soul mate, my
wife Denise Globe, MS, DC, Ph.D. Without her constant encouragement, support
and guidance this dissertation would never have been started, completed or one tenth
as good a final product. Whenever I felt like giving up, she was always there to
encourage me to continue on. Whenever I was frustrated and confused, she would
help me to understand. She is the brightest, kindest, most ethical, and most hard
working person I know. She is also the best wife, mother, and daughter that God has
ever created. God said that it was not good for man to be alone and that is why He
made his last and greatest creation, woman. This woman has been the source of joy
and meaning in my life. Thank you for this and all that is good in my life.
The next two people need an apology as well as an acknowledgment; my two
beautiful, wonderful and special daughters, Jaime and Shauna, who bravely
sacrificed some of their precious time with me during the years while I was working
towards the completion of this degree. Thank you both for your help, in you own
unique ways, in making this dream a reality. I love you both and you have my word
that I will never, ever, ever do anything like this again. And by the way, I’m
reclaiming my spot back on the couch where we can all snuggle together once again.
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Next, I want to thank my parents, Ruth and Herb Globe, who not only gave
me life and love, but the self-confidence to accomplish my dreams. Throughout my
life my parents have exemplified the meaning of honesty, goodness and hard work. I
want them to always know that they have been great parents, that I love and respect
them, and that I appreciate their love and all the personal sacrifices that they made in
helping me to grow to be the person that I am as well as achieve so much success in
my life. I love you both and thank you.
Another critical person in the quest to achieving this goal was Dr. Michael
Birozy, who’s moral support was only exceeded by his willingness to frequently
stand in for me whenever I had to run over to the University to take a class or have a
meeting with one of my committee members. Michael Birozy is the gold standard of
integrity, ethics and unyielding loyalty. I am honored to be able to call him my
friend. Mike, I will never forget you for this, thank you from the bottom of my heart.
I also want to thank Dr. Carl Cleveland III, President of Cleveland
Chiropractic College, for providing financial support in helping to make this dream a
reality. My deep appreciation also goes to Dr. Miriam Kahan, Academic Dean of
Cleveland Chiropractic College, for her moral support, particularly during the
process of writing the dissertation. Lastly, I want to thank my committee members,
Dr. Stanly Azen, Dr. Thomas Valente, and Dr. Michael Nichol, for there advice and
guidance throughout the process of completing the program and the dissertation. To
all of you, once again, thank you. I owe you all a very deep debt of gratitude.
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Table of Contents
DEDICATION..................................................................................................................................................................ii
ACKNOW LEDGEMENTS......................................................................................................................................... iii
LIST OF TABLES AND FIGURES...................................................................................................................... viii
ABSTRACT.......................................................................................................................................................................x
CHAPTER ONE: A LITERATURE REVIEW OF HISTORICAL AND CURRENT
DETERMINANTS OF PREVENTIVE HEALTH SERVICES TRAINING IN CHIROPRACTIC
COLLEGES........................................................................................................................................................................1
Intro duc tio n.............................................................................................................................................................1
The Increasing U tilization of N on-A llopathic Ca r e ..........................................................................4
The Emergence of Chiropractic...................................................................................................................... 5
The R oad to An Expanded R ole in Preventive Care............................................................................15
The Origins of Preventive Care: D evelopment of a M odel Public Health
Curriculum..............................................................................................................................................................31
The N eed for Preventive Services............................................................................................................... 34
Comm unity Partnerships for Improved H ealth....................................................................................36
Healthy People 2010: A V iew of our N atio n’s He alth...................................................................... 37
Incidence and Prevalence of D iseases: The Potential for Chiropractic Im p a c t...............39
Tobacco U se......................................................................................................................................................... 40
Physical A ctivity.................................................................................................................................................41
Nutrition and Weight Control.......................................................................................................................... 43
A ccess to Quality Health Care Services - Clinical Preventive Care...................................................46
Arthritis, Osteoporosis, and Chronic Back C onditions........................................................................... 50
Arthritis..................................................................................................................................................................52
Osteoporosis..........................................................................................................................................................53
Chronic Back Conditions..................................................................................................................................53
Diabetes.................................................................................................................................................................. 55
Theories a nd M ethods that Influence Provider B ehavior Ch ang e...........................................57
Continuing Education.........................................................................................................................................58
Academic Detailing.................................................................... 59
Physician Reminders, Audits, and Feedback..............................................................................................59
Evidence-Based Guidelines.............................................................................................................................. 60
Consensus Development Panels......................................................................................................................61
Economic Incentives.......................................................................................................................................... 62
Choosing An Effective Appro ac h.................................................................................................................62
Conclusions and Future Research A g e n d a............................................................................................ 65
CHAPTER TWO: IMPROVING PREVENTIVE HEALTH SERVICES TRAINING IN
CHIROPRACTIC COLLEGES: A PILOT IMPACT EVALUATION OF THE INTRODUCTION
OF A MODEL PUBLIC HEALTH CURRICULUM..........................................................................................69
A rticle Ab st r a c t ..................................................................................................................................................70
Introduction........................................................................................................................................................... 72
The Need for Preventive Services in the United States........................................................................... 72
Development o f a M odel Public Health Curriculum................................................................................ 74
M eth o d s.....................................................................................................................................................................75
Re su lt s....................................................................................................................................................................... 78
D iscussio n..................................................................................................................................................................81
Co nclusio n............................................................................................................................................................... 82
v
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CHAPTER THREE: IMPROVING PREVENTIVE HEALTH SERVICES TRAINING IN
CHIROPRACTIC COLLEGES: A FEASIBILITY STUDY TO INTRODUCE A BRIEF,
CLINICALLY RELEVANT, SMOKING CESSATION TRAINING PRO G RA M ................................. 86
A. Specific Ai m s ..................................................................................................................................................... 86
B. B ac k g r o u n d...................................................................................................................................................... 89
B .l Significance o f Problem ...........................................................................................................................89
B .2 Utilization o f Complementary and Alternative Medicine (CAM): Chiropractic Focus on
Preventive Care...................................................................................................................................................89
B .3 Limitations in Chiropractic Public Health Training.........................................................................92
B 4. Selecting the Appropriate Healthy People 2010 O bjective............................................................93
B 5. Evidence for Smoking Cessation Interventions.................................................................................96
C Preliminary St u d ie s.......................................................................................................................................98
C .l Pilot Study Evaluating Initial Model Curriculum............................................................................. 98
C.2 Preliminary Study Results Evaluating Initial M odel Curriculum...............................................100
C.3 Pilot Study o f A Chiropractic Preventive Health Survey............................................................. 102
C.4 Results o f Pilot Chiropractic Preventive Health Survey................................................................104
D. M ethods............................................................................................................................................................. 107
D .l Specific Aim 1: To develop a clinically relevant, intern-level, health promotion
intervention specifically targeting an increase in recommendations for tobacco cessation 107
D.1.1 Intervention Design: Conceptual Framework.................................................................................... 107
D.1.2 Intervention Design: Model Application............................................................................................108
D.1.3 Development of Intervention Educational Materials........................................................................ 110
D .2 Specific Aim 2: Conduct a program intervention in a population o f chiropractic
interns, during their clinical training, aimed at increasing the frequency o f smoking
cessation recommendations to patients....................................................................................................... 112
D.2.1 Research Design.................................................................................................................................... 112
D.2.2 Study Implementation.......................................................................................................................... 112
D.2.2.1 Clinical Faculty In-Service and Training..................................................................................112
D.2,2.2 Intern-level Educational Program Intervention........................................................................ 113
D.3 Specific Aim 3: Evaluate the program impact on the frequency o f smoking cessation
recommendations at the intern provider level........................................................................................... 117
D.3.1 Formative Measurements.................................................................................................................. 117
D.3.2 Process Measurement and Program Monitoring...............................................................................119
D.3.3 Outcomes Measurement....................................................................................................................... 121
D.3.3.1 Primary Outcome - Change in Smoking Cessation Recommendation Behavior.................121
D.3.3.2 Secondary Outcome - Change in Smoking Cessation Self-Efficacy.................................... 125
D.3.3.3 Tertiary Outcome - Change in Intention to Screen and/or Refer for Smoking Cessation
Counseling.................................................................................................................................................. 125
D.4 Sample Size Calculations....................................................................................................................... 129
D.4.1 Primary Outcome Measure Power Estimate...................................................................................... 129
D.4.2 Secondary & Tertiary Outcome Measure Power Estimate...............................................................129
D.5 Sample Selection.......................................................................................................................................130
D.6 Analysis Plan.............................................................................................................................................. 130
D.6.1 Primary Outcome - Change in Smoking Cessation Recommendation Behavior......................... 130
D.6.1.1 Secondary Analysis: Impact on Patient Outcomes................................................................... 131
D.2 Secondary Outcome - Change in Smoking Cessation Self-Efficacy................................................ 132
D.3 Tertiary Outcome - Change in Intention to Screen or Refer for Normative Health Promotion
Services..............................................................................................................................................................132
D.4 Regression models:.................................................................................................................................. 133
BIBLIOGRAPHY......................................................................................................................................................... 136
APPENDIX 1: PREVENTIVE HEALTH SU R V E Y ........................................................................................158
vi
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APPENDIX 2: CHIROPRACTIC PREVENTIVE HEALTH SURVEY RESPONSE
FREQ UENCIES.......................................................................................................................................................... 167
A PPENDIX 3: SMOKING CESSATION COUNSELING FLOW SHEET...............................................177
A PPENDIX 4: ADDED TOBACCO USE TO VITAL SIGNS SECTION OF PHYSICAL
EX AM INATIO N......................................................................................................................................................... 174
APPENDIX 5: PATIENT BROCHURE.............................................................................................................. 175
A PPENDIX 6: PILOT STUDY CHART ABSTRACTION INSTRUM ENT........................................... 177
APPENDIX 7: PILOT STUDY TABLES - INTERN PCS RECOM M ENDATIONS.......................... 182
APPENDIX 7: SMOKING CESSATION INTERVENTION AND PROGRAM EVALUATION
STUDY M A T R IX .......................................................................................................................................................191
APPENDIX 8: PILOT STUDY CURRICULUM CHANGE M A T R IX .....................................................192
APPENDIX 9: INTERN SMOKING CESSATION COUNSELING GUIDEBOOK.............................194
vii
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List of Tables and Figures
T a b l e 1: C h ie f C o m p l a in t s of C h ir o p r a c t ic P a t ie n t s ................................................................................... 18
T a b l e 2: E t io l o g y o f P a t ie n t C o n d it io n s ............................................................................................................20
T a b l e 3: P r e v e n t iv e H e a l t h Se r v ic e s P r o v id e d b y C h ir o p r a c t o r s .................................................... 23
T a b l e 4: M .D . v e r s u s C h ir o p r a c t o r 's V iew s o n P r e v e n t iv e H e a l t h T r a in in g ...............................23
T a b l e 5: S o u r c e s o f P r e v e n t iv e H e a l t h T r a in in g b y C h ir o p r a c t o r s.................................................24
T a b l e 6: C h ir o p r a c t ic Su r v e y o n P r im a r y C o m p l a in t s a n d C o n c u r r e n t C o n d it io n s ............. 25
T a b l e 7: C h ir o p r a c t ic M a n a g e m e n t o f C o n d it io n s .......................................................................................26
T a b l e 8: H e a l t h P e o p le 2010 Focus A r e a s ...........................................................................................................38
T a b l e 9: Se l e c t e d H e a l t h y P e o p l e 2010 O b je c t iv e s R e g a r d in g T o b a c c o U s e ...............................40
T a b l e 10: Se l e c t e d H e a l t h y P e o p l e 2 0 1 0 O b je c t iv e s Re g a r d in g P h y s ic a l A c t iv it y ............... 43
T a b l e 11: Se l e c t e d H e a l t h y P e o p l e 2010 O b je c t iv e s R e g a r d in g D ie t A n d N u t r it io n .............45
T a b l e 12: Se l e c t e d H e a l t h y P e o p l e 2010 O b je c t iv e s R e g a r d in g C l in ic a l P r e v e n t iv e
C a r e ................................................................................................................................................................................47
T a b l e 13: O s t e o p o r o s is St a t is t ic s, U n it e d S t a t e s, 1995............................................................................. 53
T a b l e 14: Se l e c t e d H e a l t h y P e o p l e 2010 O b je c t iv e s R e g a r d in g A r t h r it is , O st e o p o r o s is,
a n d C h r o n ic B a c k P a i n .......................................................................................................................................55
T a b l e 15: Se l e c t e d H e a l t h y P e o p l e 2010 O b je c t iv e s R e g a r d in g D ia b e t e s ..................................... 57
T a b l e 16: P a t ie n t D e m o g r a p h ic s a n d R is k F a c t o r s .......................................................................................78
T a b l e 17: P r o p o r t io n o f P a t ie n t s N e e d in g P r e v e n t iv e H e a l t h Se r v ic e s
R e c o m m e n d a t io n s..................................................................................................................................................80
T a b l e 18: U .S . P r e v e n t iv e Se r v ic e s T a s k F o r c e (U S P S T F ): C o u n s e l in g T o P r e v e n t
T o b a c c o U s e a n d T o b a c c o -C a u s e d D is e a s e ............................................................................................96
T a b l e 19: P r o p o r t io n o f P a t ie n t s N e e d in g P r e v e n t iv e H e a l t h Se r v ic e s
R e c o m m e n d a t io n s ................................................................................................................................................100
T a b l e 20: S u m m a r y o f E ff ic a c y a n d In t e n t io n S c o r e s .............................................................................106
T a b l e 21: M o d e l P u b l ic H e a l t h C u r r ic u l u m P il o t St u d y P r o g r a m E v a l u a t io n ..................... 110
T a b l e 22: S m o k in g C e s s a t io n In t e r v e n t io n S t r a t e g ie s f o r In t e r n T r a in in g a n d
T r a n s t h e o r e t ic a l M o d e l C h a n g e St a g e s ............................................................................................ I l l
viii
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T a b l e 2 3 : Sm o k in g C e s s a t io n In t e r v e n t io n a n d P r o g r a m E v a l u a t io n St u d y - S t u d y
E d u c a t io n a l P r o g r a m T o o l s ....................................................................................................................... 115
T a b l e 2 4 : Sm o k in g C e s s a t io n In t e r v e n t io n a n d P r o g r a m E v a l u a t io n S t u d y - Su m m a r y
o f M e a s u r e m e n t In s t r u m e n t s...................................................................................................................... 126
F ig u r e 1: U sin g A B e h a v io r a l M o d e l T o D e s ig n T h e P r o g r a m In t e r v e n t io n .............................109
ix
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ABSTRACT
Contemporaneously with the growth in alternative care utilization among
United States consumers, chiropractic researchers and educators have begun to
embrace a greater role for chiropractors in providing a broader array of preventive
health services. This emerging potential for expanding the role of chiropractors
warrants further investigation and is the impetus for an extensive literature review to
identify the determinants associated with chiropractic training relevant to improving
the delivery of preventive health service delivery.
Chiropractic researchers have recently attempted to update the public health
curriculum that is offered in chiropractic colleges to include a greater focus on health
promotion and clinical preventive services. In an effort to study the outcome of this
effort, a retrospective pilot study was performed to evaluate the frequency of clinical
preventive health recommendations made by interns during their clinical training. A
standardized data abstraction tool was developed to collect data from clinic charts
that would establish a patient’s need for any one of nine preventive health services
which could be provided by chiropractic interns. Of the 408 charts examined (204
each from treatment and comparison groups) on a random sample of patients
presenting for care in the college outpatient clinic, there were only four documented
instances (1.0%) of recommendations for any of the nine preventive health service
categories measured.
It is clear from this preliminary pilot study that there is a strong need to build
on the initial efforts of the public health reform movement by moving toward a more
x
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clinically relevant preventive services model of training. The development and
assessment of a clinically appropriate training module, designed to influence the
preventive health practice behaviors of chiropractic interns, is clearly needed. A
grant proposal has been developed to determine the feasibility and impact of a
clinically relevant intervention designed to increase the frequency of preventive care
recommendations among chiropractic interns.
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Chapter One: A Literature Review Of Historical And Current Determinants Of
Preventive Health Services Training In Chiropractic Colleges
Introduction
A nexus has recently developed between the growth in alternative care utilization in
the United States and the opportunity to further enhance the nation’s health. Over
the past decade, research has confirmed that chiropractic patient encounters comprise
a notable percentage of alternative care visits, with alternative practitioner visits
actually outnumbering medical physician visits annually.67,68,2 6 4
Contemporaneously with this growth in alternative care utilization, researchers and
educators, both internal and external to the chiropractic profession, have begun to
embrace a greater role for chiropractic in providing orthodox preventive health
services.96,99'101,1 0 3 -1 0 5 This emerging potential for expanding the role of
chiropractors in providing orthodox preventative health services warrants further
investigation. The opportunity to have a direct epidemiological impact on the
delivery of primary, secondary, and tertiary prevention services sparks a scientific
interest in better understanding what factors would facilitate development of this
burgeoning opportunity for chiropractors in this transformational health care
environment. This then, is the impetus, perhaps the imperative, for new
investigation, to better characterize the potential for health enhancing opportunities
and ultimately, to assist in the successful development and nurturing of this potential.
It is standing at this crossroad, where one can see the purpose for this dissertation.
1
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Organizations involved in federally sponsored, national health promotion guidelines,
with decades of experience in leading, organizing, and directing the nation’s path
towards improved health state that “community partnerships, particularly when they
reach out to nontraditional partners, can be among the most effective tools for
improving health in communities”. This acknowledgment is clearly an invitation
for chiropractors, with their historic roots as a conservative, holistic health care
provider, to join other public health minded individuals and groups in meeting the
national goals as set out by Healthy People 2010. The nascent opportunity to enlist
the broader participation of this nation’s chiropractors, a 60,000 strong and growing
profession of practitioners, could certainly assist in reaching the nation’s goals for
health promotion and disease prevention over the next decade and beyond.
With the growth of U.S. consumer’s strong interest in procuring complementary and
alternative health care to facilitate optimization of their health, chiropractors would
certainly be well positioned to assist patients in broadly achieving these goals, but
only if there exists interest and willingness among providers and the appropriate
level and type of effective training in preventive health services. The extent to which
chiropractic education currently trains students to provide a broad array of orthodox
preventive health services and the barriers to improving the breadth and impact of
this training needs to be understood.
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Two recent developments suggest a growing interest among chiropractors in
pursuing a greater role in providing health promotion and disease prevention
services. First, recent studies in the chiropractic literature identify a cohort of
chiropractic researchers that are making the case for chiropractors to embrace a
broader role in serving the nation’s preventive health needs. Additionally, to
facilitate greater chiropractic impact, recent efforts by a cadre of chiropractic
researchers, chiropractic educators, and interested stakeholders from the public
health community have attempted to update the public health curriculum that is
offered in United States chiropractic colleges (a model public health curriculum) to
include a greater focus on health promotion and disease prevention. The outcomes
of these efforts have yet to be studied and are the focus of this dissertation’s pilot
study.
What are appropriate interventions suitable for chiropractic practice? The literature
review will next turn to evaluating potential epidemiological targets where
chiropractors could provide health promotion and disease prevention services.
Applicable focus areas and target objectives from Healthy People 2010 will be
reviewed.
Academic medicine research clearly points out that for meaningful attitude,
knowledge and skill development to occur, the learning must be reinforced in a
clinically relevant environment. While the chiropractic model public health
3
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curriculum is certainly a positive development, it is not clear that this didactically
based curricular change alone will achieve the level of contemplated practitioner
impact desired. It is likely that there will be an additional need to build on this initial
reform within chiropractic by moving toward a more clinically orientated health
promotion and clinical preventive services model of training. To date, there exists
no research that has moved forward in this direction and thus, leads us to the need for
further investigation. The development and assessment of a clinically appropriate
training module, designed to positively and synergistically influence the preventive
health practice behaviors of chiropractic interns, is clearly identified and urgently
needed. To facilitate consideration of an appropriate interventional approach,
previously studied methods aimed at enhancing health provider preventive service
behaviors will be reviewed.
The Increasing Utilization of Non-Allopathic Care
The level of appropriate utilization of preventive health services in the United States
949
remains disappointingly low. Clearly, any additional public health assistance in
this effort would be welcomed from the standpoint of improving the nation’s health,
thus minimizing the human and financial impact of clinically advanced, preventable
disease. A large contingency of chiropractic healthcare providers currently remains
largely on the sidelines in the effort to improve national levels of primary prevention
of disease and the attending human and financial costs associated with this disease
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burden. But there are emerging indications that individuals and groups within this
cohort that are attempting to move the profession forward.
The demand generally for non-allopathic services, of which chiropractic is a
segment, has steadily increased over the past decade. Annually, one third of all
Americans utilize an alternative form of practitioner, such as a homeopath,
acupuncturist, or a chiropractor, all of which accounts for more total visits annually
than all medical visits combined.6 7 There are currently, in the United States alone,
over 60,000 licensed chiropractors and this number is expected to rise to over
100,000 by the year 2010. Ranking as the largest alternative and complementary
health profession in the United States, chiropractors annually care for one out of
every three individuals who suffer with low back pain which translates into 160
million clinical encounters and a total annual expenditure of $4 billion.5 4 ’5 9 ’6 1 > 2 2 7
The Emergence of Chiropractic
Chiropractors have fought a tenacious battle for acceptance since the inception of
chiropractic just over 100 years ago. Throughout this almost century log battle,
chiropractic’s nemesis has been, for the most part, the medical profession. The first
state to license chiropractors was Kansas in 1913. It took almost 60 years for the last
state to grant licensure (Louisiana in 1974). This more than half-century delay in
fully granting licensure throughout the United States was accomplished by a very
successful strategy structured by organized medicine “to contain and eliminate
5
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Q -5
chiropractic”. Federal recognition of chiropractic practice was finally achieved
during the 1970’s when the government began providing chiropractic coverage under
Medicare, Medicaid, and Workers’ Compensation. It was also during this period that
Council on Chiropractic Education (CCE) was approved as the federal accrediting
agency for chiropractic colleges. In the past decade, for the first time in the history
of the profession, federal research dollars, through the auspices of the National
Institutes of Health, have been dispersed for the purposes of chiropractic research.1 5
Not only has chiropractic fought external conflicts, which has undermined it’s
growth and threatened its very existence, but there has been a significant amount of
tension internally. This internal strife has been particularly focused over the
controversy surrounding ‘chiropractic philosophy’ and the resultant variability
(schism) in practitioner practice scope and specific attributes of practice. This
professional in-fighting has resulted in much conflict within the profession and
contributed to a diminution in the rapidity of growth and professional acceptance.
The first chiropractic treatment was first performed, circa 1895, by D. D. Palmer in
Davenport Iowa.2 5 6 This intervention reportedly ‘cured’ the deafness of the first
chiropractic patient and thus, it has been anecdotally reported, allowed him to “hear
1 O D O
the wagons on the street”. Besides bonesetting , Palmer was influenced by other
healing approaches, generally rejected by medical physicians. One such healing
approach was magnetic healing1 8 8 , which was based on Anton Mesmer’s theory of
6
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the flow of healing energy. Palmer transformed this theory into the concept of “Life
Force” which originates in a “Universal Intelligence” and is expressed in the human
as an “Innate Intelligence” that facilitates all healing from the “Universal
1 8 8
Intelligence” and indeed, if optimized, can prevent disease itself. This paradigm
for body’s ability to heal itself was analogous in some ways to the later medical
model of homeostasis with the attendant recognition of the body’s inborn
physiological capacity to heal itself, particularly when the body is not overwhelmed
by physical damage or severe disease manifestations. Chiropractors recognized and
embraced, at a time when it was questionable whether medicine helped more people
than it hurt, this concept that the body could heal itself from some ailments without
invasive nostrums or cures. Clearly, many controversies today surrounding patient’s
questions and concerns about natural versus invasive treatment choices as well as the
more recent phenomenon of proactively searching for strategies that improve their
overall wellness continue to this day.
Palmer’s miracle cures were warmly received by a sizeable segment of the
population that was well acquainted with the limitations of medical care (and it’s
external cause of disease theory) at the time and had already begun to embrace such
‘alternative’ approaches as homeopathy, Christian Science, and herbal medicine.2 6 0
Palmer, a product of this environment, was an apt and prolific spokesman against the
‘dangers’ of the armamentarium of the medical profession at this pre-antibiotic
period such as lances, tincture, leeches, plasters, and other procedures. Palmer
7
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expounded upon the risks of medical interventions that, at the time, more than
occasionally led to not only no cure, but increased morbidity or the death of it’s
recipients.2 6 0 in this early period of competition for patients, the conflict between
medical doctors and chiropractors was not so apparent. In fact, Palmer drew upon
the personal teachings of many of his medical mentors1 8 8 , and a large proportion of
early graduates from the Palmer college of chiropractic were in fact medical
1 &R
doctors. Much of the later animus towards chiropractic from the other health
professions reflected political and economic issues rather than the philosophical
disparities in approach to delivering health care. This antipathy carried over to the
scientific research community and starved the chiropractic profession of research
dollars for over half of the 20th century.
D.D. Palmer’s ideas developed into a set of beliefs that were termed “chiropractic
philosophy”. This model of health centrally posited that a significant determinant of
the health of human beings was the proper functioning of the nervous system. The
primary impediment to this proper functioning was the presence of the manipulable
spinal articular dysfunction, also know as the subluxation.9 1 In tandem with this
first axiom of chiropractic was another central premise of “chiropractic philosophy”
which held that the body possesses inherent recuperative abilities that assist in the
restoration and maintenance of health. These tenets still form the basic paradigm
that is embraced by the preponderance of practitioners within the chiropractic
profession today, over a century after D.D. Palmer’s first chiropractic adjustment.
8
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Palmer chiropractic belief system can be understood scientifically as comprising two
components; (1) the untestable model, comprised of the three major components;
“Life Force, “Universal Intelligence” and “Innate Intelligence”, and (2) a testable
principle. The untestable model was a belief that healing energy emanated from a
“Universal Intelligence”. This “Universal Intelligence” controls the body’s “Innate
Intelligence” by directing “Life Force” through the nervous system.2 3 0 This
metaphysical approach facilitated a way for chiropractor’s to conceptionalize the
mechanism responsible for the body’s ability to heal itself. As described earlier, this
approach was a precursor to medicine’s holistic use of a model, such as homeostasis,
and the consequent physiological understanding and acceptance of the body’s
inherent ability to heal. The testable principle, the structurally manipulable
subluxation, is more easily defined operationally, and thus is amenable to scientific
inquiry and evaluation. The patient’s health status is determined by the presence of a
specific mechanical spinal lesion (the subluxation) that can be removed via a
chiropractic adjustment and thus restore abnormal physiologic functioning or, better
yet, prevent abnormal physiologic functioning that would prospectively lead to
disease (chiropractic’s version of primary prevention).
While reductionist and mechanistic methodologies have led to spectacular advances
in medicine, such as antibiotics and emergency medical procedures, they have been
somewhat less effective in alleviating the chronic diseases of man.1 6 3 Neither the
testable chiropractic principle nor the medical paradigm centered on reductionism
9
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explains the great questions of the meaning of life or provides insight into the
processes that reside beyond what is measurable or understandable. The problem for
chiropractic acceptance over the past century, and it’s lack of contribution to the
development in science and health related research, has been the continued
intertwining and promotion, particularly among certain factions of chiropractors, of
the testable principle with a vitalistic, holistic but untestable paradigm. Some
chiropractors continue to embrace an anti-reductionist, and consequently an anti
science, anti-medicine, belief system and this has slowed the process of development
of clinical chiropractic practices and countervailed attempts to widen chiropractic’s
definition of primary prevention to include normative health promotion and disease
47
prevention practices.
D.D. Palmer’s concept of “Innate Intelligence” and the spinal “bone out of place”
subluxation complex that was responsible, was controversial from it’s inception not
i OQ
only among medical professionals, but among many other chiropractic educators.
This conflict was mirrored by a division within the profession between ‘straights’,
representing a minority of the profession1 6 1 , who emphasized innate intelligence, the
subluxation, and the minimalist idea that this was the solution for all of disease, and
the ‘mixers’ who generally embraced conventional medicine and a greater range of
accepted scientific interventions and generally held a narrower and more reserved
™ 117 178
assertion for range of chiropractic’s beneficial effects in health. ’ ’
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Taken to the extreme, this ‘straight’ chiropractic paradigm, if solely relied upon, will
fail to correctly make the proper risk-benefit determination regarding the choice for
patient care and intervention.4 7 As a helpful example, it is normative in the United
States to expect that if a patient presents with a bacterial bone infection
(osteomyeleitis) that the need for antibiotic therapy will be recognized. While the
chiropractic perspective attempts to balance the benefit versus the risk of medical
clinical interventions, in this type of health care scenario, an alternative, holistic
approach would carry the risk of bone deformity at a minimum as well as run the risk
of death related to systemic infection. This is clearly not reasonable or socially
acceptable to the majority of Americans. Therefore it is the imperative responsibility
that all practitioners, alternative, complementary, or otherwise utilize a mechanistic
approach when the patient’s presenting signs and symptoms dictate that a natural
approach would be insufficient.1 4 6 Yet there continues to exist a small contingency
o f ‘straight’ oriented ‘philosophy-based’ chiropractors that promote their
professional services as strictly an alternative, rather than complementary or
collaborative approach to health care, and these vocal minority advocates within the
profession continue to have some effect of clouding the boundaries and timing of
appropriate medical referral. This type of health promotion practice, among some
chiropractors, continues to restrain fuller integration of chiropractic into the
mainstream of integrated health care. These Palmer influenced, ‘philosophy-based’
chiropractors mistake the population’s continued and growing enthusiasm for
complementary health care as approval of their conception of chiropractic as a
11
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substitution to medical health care. Yet, the reality is that the majority of
chiropractors see themselves as musculoskeletal specialists (mixer’s)1 7 5 1 7 4 , focusing
on the treatment of functional, reversible mechanical conditions, with the majority of
patients agreeing, utilizing complementary approaches to enhance their health,
particularly for neck and back problems, while continuing to seek usual and
customary medical care for the wider breadth of systemic problems. Patients
transition from a complementary to an alternative approach when medicine fails,
particularly with respect to chronic systemic and chronic degenerative disease, and
desperately seek support and relief from an alternative provider. It is at this
intersection where patients may find satisfaction with a highly patient-centered,
compassionate, hands-on alternative care practitioner who provides a plausible,
holistic answer to a problem that medicine finds difficult to define, provide hope, or
ameliorate. It is here where having the vitalistic approach allows the alternative
practitioner the ability to continue with an intervention where the reductionistic,
mechanistic medical based provider must halt secondary to a lack of scientific
evidence for clinical solutions. It is in these grey areas, crossing the boundary of
evidence-based practice where medicine holds no hope, that chiropractors and other
alternative provide patients with hope. Fortunately, the mainstream of contemporary
chiropractors recognizes that adherence to dogmatic, uncritical, and untestable
doctrines for all patient clinical complaints, along with anti-medical practices, such
as communicating a negative image of allopathic medicine to their patients, is
counterproductive to the best interests of overall patient care and health status as well
12
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as the profession’s current standing, future growth and further shift into the nation’s
integrated health delivery system.
Today, chiropractors continue to be a somewhat fractious group with regard to their
differing philosophy of the scope of chiropractic care. While most of the
chiropractic profession conceives of and promotes itself as a wellness profession
comprised of eclectic preventive health, portal of entry, providers primarily directed
the treatment of musculoskeletal conditions, a minority among the profession
continue to foster broader health promotion and disease prevention effects
exclusively through chiropractic assessment and correction of spinal dysfunction
(subluxation).2 1 0 ’ 2 0 9
While there is no evidence of a comprehensive survey of chiropractor’s
philosophical beliefs, there is data on preferences for the scope of practice.1 6 6 A
survey of 6000 chiropractors in current practice reports that 93% treat spinal related
problems and greater than 67% reported including supportive care techniques such as
exercise and nutritional counseling.1 6 6 Although data indicates that that these
chiropractic treatments are primarily acquired secondary to the onset of
musculoskeletal complaints, much of the chiropractic profession does view the
outcomes of care, to varying extents, as having a more holistic physiological effect
towards wellness and disease prevention. As described earlier, one of the major
barriers to the greater implementation of orthodox preventive health services on the
part of a chiropractors has been the more extreme belief, within a segment of the
13
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chiropractic profession, that the removal of subluxations is the primary prevention
for all disease and that orthodox preventive health services, such nutrition, tobacco,
and obesity counseling are part of a different system of health (medicine) fitting with
the medical model of disease and intervention. Although many within the field of
chiropractic have begun to embrace a broader conception and definition of health
promotion and intervention, this segment of the chiropractic profession remains
focused on a model of health promotion and prevention primarily accomplished by
increasing awareness of the existence and correction of spinal misalignments.1 3 ,1 0 0 ,
173,209,2 1 0 An even smaller percentage of chiropractors actually hold that they have
no other responsibility or role in the health or prevention of disease in the patient
1 9S
except for the correction of spinal misalignments. The nervous system impact of
these spinal misalignments (subluxations) remains, for this small cohort of ‘straight’
chiropractors, primary over other factors such as poor nutrition, stress, trauma,
fatigue, environmental stressors and sedentary lifestyles that may contribute to
diminishing resistance and fostering physical disharmony.
The debate continues among chiropractic camps whether the profession should
specialize solely as portal of entry providers focusing on spinal care, or promoters of
1 A fl 1
general health and wellness. ’ After nearly one century of struggling to achieve
mainstream status among the league of health care providers, controversy
surrounding the future role of chiropractors and their scope of practice remains
undecided. Some practitioners and educators within the profession remain
14
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steadfastly adherent to the founder’s precepts of an absolute alternative to medicine
while the majority seeks to provide a complementary and collaborative role
alongside medicine.
The Road to An Expanded Role in Preventive Care
The literature reveals some within the chiropractic profession who argue that
chiropractic education, when compared to medical education, does not provide the
necessary training for graduates to serve as primary care providers.1 7 5 One study has
demonstrated that more than 50% of a medical resident’s duties are occupied with
issues unrelated to immediate patient care, such as charting in medical records.1 3 0 A
important study by the New Zealand Commission of Inquiry, assessing chiropractic
basic science education throughout North America, found that it was comparable to
medical basic science education.1 7 7 Interestingly, physician assistant education is
very similar to a compressed version of medical school and is similar in may respects
1 9 1
to chiropractic education. Research additionally demonstrates that physician
assistants as well as nurse practitioners perform similarly, and occasionally superior
1 O T
to physicians on a number of quality care measures. Empirically, then, it is
reasonable to suggest that chiropractic training could or should minimally provide
the same level of training, and thus allow for the delivery of primary preventive care,
as these other ancillary programs have been able to successfully accomplish.
15
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Within the allopathic medical paradigm, health promotion is encompassed by a
broader but somewhat overlapping set of targets for prevention activities, including
(1) primary prevention screenings for known diseases, (2) obesity, smoking, drug
prevention programs, (3) dietary and nutritional counseling and education (4)
psychological counseling and stress reduction, (5) injury prevention, etc. The
significance of health promotion in the prevention of diseases, that currently affects
contemporary society, has become increasingly recognized.2 4 2 Within the context of
health promotion, population health education continues to provide an important
preventive strategy. Clearly, the leading causes of mortality such as coronary heart
disease and cancer lend themselves well to health education interventions.
Allopathic physician involvement with health promotion and disease prevention,
unlike their chiropractic counterparts, holds as essential the control of diseases,
particularly where behavioral risk factors are etiologically important. Yet, even in
light of this belief, physician involvement with health promotion is generally
perceived as less than optimal.1 1 6 Research indicates that a significant portion of the
deaths in the United States could be prevented or postponed using known
'jA'y
interventions. There is sufficient evidence to support that even very brief health
promotion messages from a doctor can impact patient health behaviors.7 5 Due to the
generally long-term associations between chiropractors and their patients, and that
chiropractic treatment normatively requires several follow-up visits for maximum
16
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affect, the chiropractic profession occupies an excellent position to provide repeated
health promotion messages aimed at impacting a change in patient health behaviors.
Over the past two decades, the status of chiropractors has, in many respects, grown
in the broader public’s perception so as to become a conventional rather than an
alternative supplier of musculoskeletal health care services. Survey research leaves
little doubt that the majority of patients who visit chiropractors are likely to be
satisfied with the their care.5,35,46,211,213’2 5 7 When compared to conventional
approaches to care for low back pain, patients report a comparative three-fold
satisfaction rate increase with chiropractic care.48,1 2 2 Patients access chiropractors
primarily for the treatment of various musculoskeletal complaints (see table 1).
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Table 1: Chief Complaints of Chiropractic
Patients1 6 6
Condition Percent
Low back/pelvis 25.6%
Neck 19.3%
Headache or facial 13.3%
Mid-back 11.8%
Lower extremity 9.4%
Upper extremity 8.6%
Other non-musculoskeletal conditions 5.3%
Chest 3.7%
Abdominal 2.9%
Total 100%
A national telephone survey, conducted in the early 1990s, of the United States adult
population reported that 7 percent of persons had used a chiropractor in the prior
year.6 8 A follow-up study verified that this number is increasing as approximately
11 percent of the population visited a doctor of chiropractic in 1997.6 8 In 1990,
consumers purchased a total of $13.7 billion dollars in alternative therapy services
(of which chiropractic is a component).6 8 Of this total outlay, 10.3 billion was paid
directly by the consumer. These statistics are quite revealing in light of the fact that
/"O
the expenses for all U.S. hospital visits were $12.8 billion in the same year. The
follow-up survey data (1997) verifies that the expenditures for alternative therapies
reached $21.2 billion with the number of alternative care visits reaching 629 million
compared to all primary care allopathic encounters of 386 million.6 7 This study
further details that the number of individuals in the United States who see an
alternative care provider reached 83 million (42.1%) with the total percentage of the
population using chiropractic (in 1997) reaching 11 percent.6 7
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Another nationwide phone survey in 1997 found that Americans embrace alternative
care (chiropractic, acupuncture, massage, etc.) with 42% of adults reporting that they
would pay more in order to have access to alternative care and 67% believing that
availability of alternative care is important when choosing a health plan.1 4 1
Interestingly, 40% of the adults surveyed said their attitudes toward alternative care
have become more positive in the last 5 years because they have learned more about
it or have had a favorable response with it.1 4 1 Finally, 74% of those surveyed
reported that they are using alternative care along with traditional health care.1 4 1
A more recent nationally representative household telephone survey (n=2055)
studied the “patterns and perceptions of care for treatment of back and neck pain”.2 6 4
The main outcome measure was the use of complementary therapies in the last year
to treat the back or neck. The results indicated that 37% of those surveyed reported
seeing a conventional provider, while 54% had used complementary treatments2 6 4 .
Specifically, 18% had reported seeing a chiropractor.2 6 4 Conventional providers
were rated as “very helpful” by 27% of users while chiropractors were rated “very
helpful” by 61% of users 2 6 4 One-third of all visits to complementary providers were
made to treat back or neck pain, more that for any other medical condition.2 6 4 Table
2 below reviews a national survey on the etiology of chiropractic patients’
conditions.1 6 6
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Table 2: Etiology of Patient Conditions1 6 6
Patient Condition Percent
Activities of daily living 18.9%
Motor vehicle accidents 14.2%
Overuse/repetitive stress 12.9%
Work 10.9%
Sports/exercise/recreation 9.5%
Wellness/preventive care 9.3%
Emotional stressors 7.9%
Environment/dietary stressors 6.3%
Acute illness 5.1%
Chronic illness 4.5%
Other 0.5%
Total 100%
Contemporaneously with the growing acceptance of chiropractic within the
integrated health delivery system is the continued lack of clarity of what it means to
be a primary care practitioner. This certainly has implications for access in an
environment that is being rapidly penetrated by managed care. As customary within
the chiropractic profession there is division within the two philosophical camps, each
articulating their ideology. One argues that chiropractors are not primary care
providers but rather portal of entry specialists in musculoskeletal conditions.1 7 4 The
other position attempts to persuade us that chiropractors are primary health care
30
providers. This is tenuously explained by pointing our that some definitions of
primary care include attributes that chiropractors, it can be argued, fulfill to some
extent, such as emphasizing “the linkage between community (public) health and the
individual patient diagnosis and treatment”.9 9 Although chiropractic colleges
generally train chiropractors to differentiate between, and care for a variety of
clinical conditions, an unrestricted title of primary care provider does not indicate
20
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to the public sector that some chiropractors may or may not offer conventional
recommendations for garden variety health indications such as vaccination and
normative preventive health screening recommendations. Some researchers within
chiropractic have articulated concerns regarding chiropractic college’s general lack
of student training in (1) evidence-based prevention and health promotion methods,
(2) how to provide health education to patients, and (3) a significant lack of
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interdisciplinary collaboration with public health professionals. The American
Chiropractic Association (ACA) has issued a comprehensive statement on primary
care that was intended to clarify the chiropractor’s role in this regard. The ACA has
articulated the position that chiropractors should be viewed as a direct access, first
contact provider for neuromusculoskeletal health indications.6 4
The determination of scope of practice, including whether to function in the role as a
primary care provider, will be a critical issue for the continued growth of the
chiropractic profession, particularly with regard to access to patients and
reimbursement within an increasing managed care environment. There is limited
data describing practicing chiropractor’s beliefs regarding scope of practice and
specifically their ability to offer primary care and primary prevention services. One
1995 survey of a small sample of chiropractors, with a marginally acceptable
response rate (n = 492, response rate = 65.3%) revealed that, while chiropractors
exhibit some clinical characteristics related to primary care, there was a strong need
to increase the delivery of non-musculoskeletal preventive health services.1 0 4
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Chiropractors reported that they checked blood pressure on all of their patients only
34.9% of the time, performed a complete physical examination on only 29% of all
patients, and took a complete health history on 71.3% of all patients seen.1 0 4 The
survey revealed that 78.1 percent of chiropractors reported that they had referred a
patient to a medical or osteopathic physician within the last three months.1 0 4 The
survey also summarized practitioner’s beliefs in whether all chiropractors should
receive training in preventive services and whether they had counseled a patient in
the last three months (see table 3). Table 4 reveals how some of these opinions
compare to primary care physicians. Chiropractic preventive counseling was
reported as statistically significantly lower than other primary care physicians.
Although there were also statistically significant differences reported between the
chiropractic and non-specialist medical providers, the differences were reported in
varying directions and were not reported by individual preventive service category.
Further analysis of the dataset offered a breakdown of where surveyed chiropractors
received their training in various preventive health services (see Table 5). The
results of this survey clearly supports that; (1) some orthodox prevention-related
training is occurring in chiropractic colleges, (2) chiropractors have an interest in
learning more about preventive health services, (3) the level of clinical
recommendations from chiropractors is far below their medical primary care
providers counterparts.
22
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Table 3: Preventive Health Services Provided by Chiropractors
(selected services)1 0 4 _______ _____ _____ _________________
All D.C.’s should
discuss (%)
Discussed with
a patient in the
last 3 months
(% )
Lifting techniques 78.0 64.0
Postural education 76.4 59.8
Fitness exercise! 69.3 68.1
Injury prevention! 68.3 54.2
Ergonomics 59.6 49.6
Stress management! 59.6 59.0
Cancer detection! 54.5 32.9
Sm oking! 53.5 52.7
Hypertension control! 53.5 51.9
W eight loss programs! 38.2 55.8
Immunization! - pro 39.4 42.9
Immunization! - con 49.6 42.9
| Recommended in Health People 2000
Table 4: M.D. versus Chiropractor's Views on Preventive Health Training
104, 215
D.C..: Training
should prepare for
counseling (n =
492) (%)
Primary care
M.D.: Training
should prepare for
counseling (n = 66)
(%)
Non-specialist
M.D.: Training
should prepare for
counseling (n = 46)
(% )
Hypertension control 54 99 56
Cancer detection 55 97 46
Smoking 54 94 70
Weight loss programs 38 86 52
Immunization 36 85 24
Fitness exercise 69 80 54
Stress management 60 74 52
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Table 5: Sources of Preventive Health Training by Chiropractors1 0 5
Chiropractic
College (%) Elsewhere (%) Either (%)
Lifting techniques 59.3 42.7 86.7
Postural education 70.7 28.3 86.5
Fitness exercise 34.5 59.1 82.0
Nutritional supplements 43.3 55.7 75.3
Injury preventionf 46.3 44.1 68.3
Ergonomics 29.7 48.0 64.7
Hypertension control! 42.3 31.5 64.3
Stress management! 30.3 46.1 65.2
Sexually transmitted diseasef 47.2 25.2 62.2
Sm okingf 38.6 31.9 60.8
Cancer detection! 48.0 24.0 60.6
A ID S! 16.3 49.0 59.8
A lcohol! 32.3 32.1 56.4
W eight loss programs! 18.5 41.5 56.0
Drug abuse! 29.3 33.7 53.3
Immunization
Pro 33.5 21.1 46.3
pro and con 28.5 16.9 41.5
Con 43.5 30.1 40.4
fU .S . Preventive Services Task Force and Healthy People 2000 recommended.
Chiropractors report encountering and managing patients not only with primary
musculoskeletal disorders but with other conditions that fit within many of the focus
areas and target objectives promoted by national public health initiatives such as
Healthy People 2010 (see tables 6 and 7).
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Table 6: Chiropractic Survey on Primary Complaints and Concurrent
Conditions1 6 6
R outinely Seen________________ Often Seen Som etim es Seen___
Spinal subluxation/iomt T T , .
j _ J Headaches
dysfunction
Scoliosis!
Osteoarthritis/degenerative
joint diseasef
Bursitis or synovitis
Hypolordosis of cervical or
lumbar spinef
Carpal or tarsal tunnel syndrome
Extremity subluxation/joint
dysfunction
Fibromyalgia
Muscular strain/tear High Blood Pressure!
Sprain of any joint Allergies
Intervertebral disc syndromef Obesity!
Myofascitis! TMJ syndrome
Osteoporosis!/osteomalacia
Congen./developmental anomaly
(spinal)
Vertebral facet syndrome! Menstual disorder
Radiculitis or radiculopathy! Dizziness/vertigo
Tendinitis/tensosynovitis Thoracic outlet syndrome!
Hyerlordosis or cervical or
lumbar spine
Asthma, emphysema or COPD
Peripheral neuritis or Congen./develop. Anomaly
neuralgia! (extraspinal)
Kyphosis of thoracic spine! Loss of equilibrium/vertigo
Nutritional disorders
Systemic/rheumatoid arthritis!
Upper respiratory or ear
infections
Diabetes!
Spinal canal stenosis!
Viral infection
f Conditions that are targets for Healthy People 2010 interventions.
Source data from National Board o f Chiropractic Examiners Job Analysis o f Chiropractic1 6 6
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Table 7: Chiropractic Management of Conditions1 6 6
Percent of
respondents who
did not treat the
majority of cases
during the
previous year.
Percent of
respondents who
solely m anaged
the majority of
cases during the
previous year.
Percent of
respondents who
co-managed the
majority of cases
during the
previous year.
Intervertebral disc syndrome 1.1 70.2 28.7
Peripheral neuritis or neuralgia 3.2 70.1 26.7
Carpal or tarsal tunnel syndrome
2.5 65.5 32.0
Fibromyalgia 3.0 47.8 49.2
TMJ syndrome 5.0 47.7 47.3
Nutritional disorders 12.0 45.3 42.7
Loss o f equilibrium/vertigo (due to
neurological conditions) 7.0 37.9 55.1
Osteoporosis/osteomalacia 10.3 35.5 54.2
Spinal canal stenosis 8.7 32.5 58.7
Dizziness/vertigo (due to inner ear
conditions) 9.2 30.3 60.5
Upper respiratory or ear infection
10.6 30.3 59.1
Obesity 26.0 25.1 48.9
Systemic/rheumatoid arthritis or gout
12.9 19.2 68.0
Eating disorders 35.3 17.5 47.2
High blood pressure 23.4 7.8 68.8
Diabetes 38.6 4.2 57.2
Source data from National Board o f Chiropractic Examiners Job Analysis o f Chiropractic
Besides definitional issues of primary care, chiropractic training, and provider
willingness, there are other potential barriers to chiropractors providing primary care
preventive health services such as financial, professional, and legal scope of
Q 9
practice. Regarding individual state scope of practice laws, a systematic review
demonstrated that there are minimal restrictions that would impact chiropractors
from providing the majority of primary care preventive health services.9 2 The
majority of restrictions center around prohibitions in prescribing medication,
performing surgery, and providing obstetrical services.9 2
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There have been many studies that have attempted to access the frequency with
which referrals move between chiropractors and medical physicians.1 6 ’I04,166,2 1 2 It is
very important that chiropractors are able to refer without interprofessional conflict
issues as the outcome of screening for disease frequently requires further follow-up
with medical testing. For example, a diabetic patient presents to a chiropractor with
peripheral neuropathy and pain masked as a primary neuromuscular complaint.
Ultimately, in the public health interest, we would want the chiropractor to refer the
patient for a diabetic work-up while co-managing the musculoskeletal component of
the patient’s complaint. Co-management is possible through mutual acceptance and
willingness to accept referral and collaborate on care. Any dampening of an open
referral pattern might diminish the likelihood of the chiropractor making a timely
referral. Some have hypothesized that those chiropractors who have developed the
most efficient networks with medical physicians are more likely to restrict their
practices to musculoskeletal indications.9 2 But what is not discussed is whether these
chiropractors, who have established firm collaborative networks with medical
physicians, are making greater efforts to screen for primary care health problems.
While barriers have historically pervaded these professional interactions, particularly
before physicians were professionally enjoined from the prohibition of associating
with chiropractors, current studies reveal that there is a significant amount of
referral activities extending in both directions.2 6 1 Evidence supports that the
majority of chiropractors report referring some of their patients to medical physicians
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(upwards of 93%) and a significant proportion report receiving referrals from
medical physicians (upwards of 77%)1 6 ’1 0 4 ’166,2 1 2 . Some authors have hypothesized
that while chiropractors may be referring to medical physicians for primary and other
medical conditions, medical physicians are primarily referring to chiropractors for
indications related to musculoskeletal complaints.9 2
Barriers secondary to the increased growth in numbers and penetration of managed
care organizations (also know as Health Maintenance Organizations or HMOs) could
potentially limit the access of patients to chiropractors as primary care providers.
Survey data indicates that approximately 70% of chiropractors are working with an
HMO and many are working with more than one organization.1 6 6 Additionally,
many HMOs have instituted point of service plans (POS plans) secondary to patient
1 97 •
or legal pressure. While POS plans allow patients to access providers (medical
and chiropractic) directly outside of their regular HMO care providers, evidence
exists that the majority of patients do not utilize this option and remain “in-
9 1
network”. Studies reveal that HMO’s provide minimal revenue (10% to 14%) and
account for even a smaller number of patient encounters for chiropractors.94,162,1 6 6
It is conceivable that some managed care plans might attempt to utilize chiropractors
as primary care providers if there existed evidence of a cost-savings. Although
medical research and education are heavily subsidized through billions of taxpayer
dollars, these differential subsidies arguably do little for alternative and
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complementary providers, such as chiropractors, in their quest to increase the breadth
of clinical services.
Another factor potentially limiting the scope of chiropractic services is the practice
of many insurance plans (indemnity, government-sponsored, and managed care) to
only reimburse for neuromusculoskeletal diagnoses. This serves as a disincentive for
chiropractors to provide primary care health prevention services. There is currently
no information that elucidates how and to what extent third party reimbursement
systems functions to restrict the scope of practice for chiropractors but claims data
indicate that 85% to 90% of reimbursement to chiropractors is for diagnoses related
to neuromusculoskeletal complaints and thus it appears fairly clear that a minimum
1 0 9
of other primary care services are currently reimbursed.
Patient self-selection to chiropractors for neuromusculoskeletal disorders also
potentially serves as barrier to increasing primary care and prevention services.3 0 ,6 0 ,
8 9 ’2 5 7 While patients report significantly higher satisfaction rates for low back care
with chiropractors rather than medical providers, there exist no data on their
experiences with general primary care prevention services.4 6 A survey of rural
chiropractors (in geographical locations that have diminished medical physician
presence) reports an increased utilization of chiropractors as first-contact providers.
The authors speculate that this might be an indication that patients are utilizing
chiropractors for primary care.3 4 There is no other data to corroborate this
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hypothesis and there are generally very few chiropractors practicing in rural areas so
it remains difficult to assess whether there is indeed an increased substitution in
patient procurement of primary care services under these less than common
circumstances.9 2 Generally, while patient data suggests that patients favorably
perceive chiropractors as neuromuscularskeletal experts they do not substitute
chiropractic care for primary medical care.5 1 Clearly, more recent data demonstrates
that a surprisingly increased number of Americans (roughly 1/3 of all individuals in
the U.S. annually) are visiting non-conventional practitioners, such as a chiropractor,
homeopath, acupuncturist, etc., more frequently than their medical physicians68.
Much speculation surrounds this explanation for this phenomenon. Some have
posited that Americans want to assume a more involved role in their health,
particularly as it relates to health promotion and disease prevention.9 2
Many chiropractors work in multi-disciplinary health groups, many provide services
in governmental health care systems such as Medicaid and Medicare (10% of
rrl
chiropractic revenues), many are members of 3 party payor systems such as
preferred provider organizations and private indemnity insurance plans (80% - 85%
of worker’s have chiropractic benefits) and health maintenance organizations (40%
1 t 8
of worker’s have chiropractic coverage). Many continue to prefer a private
practice environment while collaborating through interdisciplinary referral. The
increasing breadth and frequency of the delivery of chiropractic care offers an
opportunity for public health oriented individuals to tap into this practitioner base
30
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and increase its contribution towards efforts in improving the public’s health through
the delivery primary prevention services.
Within the past 10 years, articles have begun appearing in the literature that identify
a small but growing reform movement within the chiropractic profession that seeks
to change chiropractic public health education to include a role in the provision
orthodox clinical preventive health services.65,92,96,1 0 3 It is not clear that
chiropractors are trained to provide the range of services that patients may require.
Clearly, if chiropractic education does not include a clinical training focus on
screening for primary prevention of disease, and does not make this instruction
clinically relevant during the chiropractic student’s training during patient care, then
it will be less likely that chiropractors will provide these services in professional
practice.9 6 The potential for chiropractic students to learn the necessary attitudes,
knowledge and practices (KAP) associated with clinical preventive services is
obtainable but the chiropractic educators must embrace a construct that reforms
public health education and emphasizes the need for chiropractic students to provide
orthodox health promotion and clinical preventive services.
The Origins of Preventive Care: Development of a Model Public Health
Curriculum
Nationally, chiropractic practice is licensed in each state. Internationally,
chiropractic has achieved licensure in more than 30 countries.1 6 6 There are currently
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16 accredited chiropractic colleges in the United States4 7 averaging 4 years in length
and 4,400 to 5,220 hours of instruction divided between basic (average of 25-30
percent) and clinical sciences that are generally comparable to medical training47.
The major discrepancy between chiropractic and medical education revolves around
the emphasis on manual techniques in chiropractic colleges and the addition of the
three year residency for physicians. Another discrepancy of interest is the number of
hours of public health instruction, with chiropractic colleges averaging 70 hours and
medical schools averaging 289 hours of instruction.4 7
The chiropractic colleges throughout the United States have recently implemented a
model public health curriculum in the hopes of directing greater focus in the training
of chiropractic students on health promotion and disease prevention.1 9 5 Preliminary
studies previously demonstrated that chiropractors were frequently failing to make
and follow through with recommendations regarding preventive health services such
10 7
as weight loss and exercise. It was believed that one factor responsible for this
rather poor behavioral outcome was the lack of a modem public health curriculum
that emphasized clinical preventive services. In response to this conundmm, a
consortium chiropractic faculty and administrator as well as other interested health
stakeholders, representing a broad spectrum of health care disciplines, acquired
funding to study the current public health programs offered in chiropractic colleges.
Their goal was to make recommendations for curricular improvements through a
model public health course of study.1 0 7 These model curriculum efforts were aimed
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at addressing goals promulgated by Healthy People 2010 regarding education of the
health professions, particularly with respect to increasing the proportion of medical
professional training schools whose basic curriculum for health care providers
includes the core competencies in health promotion and disease prevention. The
impact of implementation of this model public health curriculum on clinical
preventive services has yet to be studied.1 9 1
A full review of all chiropractic college catalogs revealed a continued focus on topics
such as microbiology and sewage treatment rather than those with more clinically
relevant application to preventive health services.9 6 The overall consensus reached
by reform advocates was that current chiropractic college instruction, both in topical
focus and teaching methodology, was inadequate in light of the current patient
preferences and healthcare marketplace.1 0 7 Didactic lecture format, where the focus
was on memorization of facts (an approach reflecting a relatively low level of
cognitive abstraction and learning) was the primary pedagogical approach.2 7 This
was posited as having a decidedly inhibiting effect on the practical utilization and
implementation of this information in a clinical setting. Rare was any evidence, in
chiropractic course catalogs, of learning environments where clinical preventive
services skills were actually practiced in a hands-on format and rarer still was
evidence of integrating and applying clinical preventive care skills during patient-
base clinical training.9 6 While chiropractic students are trained to progress from
didactic classroom experiences to acquisition of clinical skills in a ‘student clinic’
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format and then to actual ambulatory and practice-based clinical training, emphasis
on preventive health services is not part of this progression in training.
A portion of this limitation in focus on clinical preventive services is secondary to
the difficulties associated historically with the development and acceptance of
chiropractic by the medical profession. Leaders within the chiropractic profession
have typically guarded reopening of the of state acts which granted licensure status
to chiropractors as they fear that any efforts to change any portion of the acts,
including curricular modernization would open all elements of the licensure acts to
scrutiny and change, including scope of practice components. The necessities of
articulating exact hours and courses of instruction in insuring licensing for graduates
at the state level and accreditation nationally continue to drive curricular decisions
within the chiropractic training programs and stand now as an actual impediment to
change and modernization of curricula.
The Need for Preventive Services
Over the past 20 years the health goals for the nation have been articulated in the
form of nationally participative initiatives, ultimately leading to the current iteration
of Healthy People 2010. This resource, representing the work of thousands of
contributors, serves as a compendium of health goals, targeting behavioral factors
and other interventions, through the health professions, the general population, and
other stakeholders interested in health promotion, disease prevention, and healthy
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lifestyles. Areas of continued opportunities for improving the nation’s health,
operating under the dual goals of extending quality and quantity of life and
reconciling disparities in health outcomes, are cataloged in 28 specific objectives.
Operationally, this roadmap challenges providers to embrace and deliver prevention
services, asks neighborhoods and commerce to underwrite and carry out health
promotion activities in educational venues, sites of employment, and beyond. It
directs researchers to new avenues of study. But the documents highest calling is for
all Americans to recognize their role in collaborating in normative and innovative
9 49
interventions in achieving the target outcomes. This health improvement initiative
operates under the paradigm that health, on an individual basis, cannot be fully
optimized without addressing community health behaviors and their underlying
9 49
beliefs and attitudes.
While significant progress has been made in some areas of the nation’s health, other
problems, such as diabetes, and various chronic diseases remain difficult
challenges.2 4 2 The mortality statistics regarding tobacco remain quite grim as well.
With 440,000 deaths each year, tobacco use is the single largest cause of preventable
premature mortality in the United States”.1 5 6 Related indicators influencing many
chronic diseases such as obesity and sedentary lifestyle have continued to increase or
remain unsuitably high, with obesity up 50% in the past twenty years and avoidance
of physical exercise during non-working time periods at almost 40% in the adult
population.2 4 2 Research indicates that while 87% of family physicians agree with a
35
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minimum of one area of guidelines recommended by the US Preventive Services
Task Force, these physicians only implement 20% to 60% of the total recommended
preventive services.1 1 6
Community Partnerships for Improved Health
The Healthy People 2010 manuscript was created to continue the roadmap for
improving the Nation’s health during this first decade of the new millennium. The
two primary goals of the Healthy People 2010 framework are to (1) increase quantity
and quality of years lived, and (2) remove the differences in quantity and quality of
years lived among various populations groups, such as the poor, or certain
242
ethnicities. This document serves to promote greater resources and effort towards
disease prevention and wellness through the implementation of health promotion
9 4 9
activities that span the lives of Americans.
The Healthy People 2010 goals and objectives has served as a magna carta for local,
state, and national planning needs for developing health promotion and disease
prevention interventions for the past two decades. This prescription for improving
the nation’s health contemplates a cooperative strategy among disparate
constituencies from government leaders to educators to members of the business
community. This diversity in membership is thought to enhance the effectiveness of
reaching articulated goals by including all interested stakeholders.2 4 2
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Healthy People 2010: A View of our Nation’s Health
While the lifespan of Americans has increased significantly in the past century (47.3
years in 1900 versus 77 years in 2000, our nation still lags behind many other
countries in this category. As seen in quantity of years of life, quality of life can be
effected significantly among different population groups such as people who earn the
lowest family income per household who report poorer health status at a rate of 5-
fold compared to those in the top tier of household income.2 4 2 Race and ethnicity is
another grouping that identifies health disparities among Americans. Latino-
Americans have a 2-fold increase risk of death secondary to diabetes and have
increased rates of obesity, hypertension, and low birth weight newborns compared to
Caucasians of non-Hispanic origin.
Data continue to reveal the disparities between race and education 2 4 2 Population
groups with low education and income obtainment are associated with increased
rates of mortality and morbidities such as heart disease, obesity, low birth weight
newborns, and diabetes. These disparities have been increasing during the past 30
years. These outcomes are related to various etiological factors such as (1) a
diminished level of access to health services and other health promotion and disease
prevention programs and (2) diminished education obtainment leading to a lowered
knowledge base regarding health prevention and health promoting activities that
decrease mother and infant health status.
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Disparities in education divide along racial and ethnic boundaries with large
differences seen in outcomes such as adult and infant mortality. For example, among
Americans aged 25 to 64, we see a doubling in the death rates for those people with
less that 12 years of education versus those whose education exceeds 13 years.
Additionally, the rate of infant death is twice as high in infants whose mothers split
along the above mentioned educational divide. Similar disparities are seen relative
to other factors such as the level of physical function and geographic living location.
These types of environmental and behavioral disparities drive nearly 70 percent of
the reduced life expectancy outcomes among Americans which is why a planned
approach to influencing these changeable attributes of health is so vitally important.
The Healthy People 2010 roadmap for improving the Nation’s health is divided into
28 focus areas (see table 8) that are linked to 467 objectives. The document also
specifies top level health issues, called ‘Leading Health Indicators’, of which
physical activity and overweight and obesity top the list. These leading indicators
take into consideration a target value formula that contemplates health impact for
effort expended as well as looking for targets that are amenable to health promotion
and disease prevention interventions.
Table 8: Health People 2010 Focus Areas
242
1. Access to Quality Health Services
2. Arthritis, Osteoporosis, and Chronic Back Conditions
3. Cancer
4. Chronic Kidney Disease
5. Diabetes
6. Disability and Secondary Conditions
7. Educational and Community-Based Programs
8. Environmental Health
9. Family Planning
10. Food Safety
11. Health Communication
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Table 9: Health People 2010 Focus Areas continued
12. Heart Disease and Stroke______________________________________
13. H IV__________________________________________________________
14. Immunization and Infectious Diseases__________________________
15. Injury and Violence Prevention_________________________________
16. Maternal, Infant, and Child Health______________________________
17. M edical Product Safety________________________________________
18. Mental Health and Mental Disorders____________________________
19. Nutrition and Overweight______________________________________
20. Occupational Safety and Health________________________________
21. Oral Health___________________________________________________
22. Physical Activity and Fitness___________________________________
23. Public Health Infrastructure____________________________________
24. Respiratory Diseases__________________________________________
25. Sexually Transmitted Diseases_________________________________
26. Substance Abuse______________________________________________
21. Tobacco Use__________________________________________________
28. V ision and Hearing____________________________________________
Incidence and Prevalence of Diseases: The Potential for Chiropractic Impact
Many of the focus areas are immediately and highly relevant to chiropractic practice.
Chiropractors are demonstrably well-matched to developing an important position in
providing health promotion and disease prevention services in their communities.
As documented earlier, many chiropractors already provide community wellness
information at the individual patient level or through public wellness classes.1 0 4 ,1 0 6 ,
2°9,2 1 0 The majority of chiropractors currently counsel their patients about diet,
exercise, and lifestyle modifications in an effort to encourage wellness among their
patient base.106,209,2 1 0 By adopting basic screening procedures, utilizing
standardized patient education resources, and expanding into other Health People
2010 focus area targets, such as tobacco use, diabetes, physical activity, overweight,
nutrition, and clinical preventive services, chiropractors could have a significant
impact on the nation’s health and serve as a model health care provider for wellness,
health promotion and disease prevention.
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Tobacco Use
The mortality statistics regarding tobacco use are quite grim. With 440,000 deaths
each year, tobacco use is the single largest cause of preventable premature mortality
in the United States”.1 Much is know about the specific deleterious health effects
related to tobacco use, with directs links established to chronic lung disease, heart
disease, and many types of cancer. In addition to the human costs associated with
smoking related deaths, there is also the matter of the 100 billion dollars spent
annually in the U.S. that results in an enormous financial burden as well as presents
an opportunity cost for pursuing other pressing health care needs.2
Preventing initiation of tobacco use, assisting individuals in quitting are major goals
articulated within the Health People 2010 objectives. Many modes of intervention
have been established as effective including community-based intervention programs
and media interventions. Listed below (table 9 ), are selected Healthy People 2010
physical activity objectives that fit easily within the chiropractic scope of practice
and are supported by a cohort of chiropractors as conditions they generally believe
should be part of their overall care approach.
Table 9: Selected Healthy People 2010 Objectives Regarding Tobacco Use1
Objective Number/Statement
Baseline
Data
Target 2010
Outcome
“27-la. Reduce tobacco use by adults. Cigarette smoking.” 24% 12%
“27-5. Increase smoking cessation attempts by adult smokers.” 41% 75%
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Physical Activity
Physical activity levels have been shown to be an influential predictor of health
status with all participants benefiting from increased activity. Data form 1997 reveal
that just 15 percent of the U.S. adult population reached target physical activity
levels, with 1999 adolescent data showing that only 65% reached target level.2 4 3
Adequate physical activity levels have been demonstrated to have a protective effect
on the risks of acquiring or dying from such diseases as diabetes, heart disease, and
hypertension2 . People who are physically active generally outlive people who are
not with the.same disparities in physical functioning and its ramification on
independent living and overall quality of life.32,123,135'137,176,187,2 1 7 People with bone
and joint health issues, such as arthritis, osteoporosis, and chronic back pain are also
- 5 '7 1 7 1 7 0 1
positively affected by engaging in regular physical activity. ’
Disparities in health, a major concern of Healthy People 2010, exist between
population groups, and physical activity is no exception with Latinos and Americans
of African decent demonstrating lower physical activity levels than Caucasians.
Physical activity levels are amenable to interventional approaches such as promoting
participation in these activities in schools, which has declined generally, and with
increasing awareness among primary care providers in making physical activity
recommendations to the populations they serve. Increases in sedentary lifestyle has
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the additional detrimental outcome of facilitating weight gain among Americans,
leading to complicating factors related to overweight and obesity.
The risk of developing many diseases, such as heart disease, osteoporosis, and
arthritis, is lowered significantly through regular exercise.11 9 ,2 4 9 ’2 5 0 This is
170 9Tfi 940
particularly true in the elderly. ’ ’ Chiropractors frequently recommend
exercise as part of their normative care plans for their older patients as well as
generally educate patients to adopt exercise as part of a wellness paradigm.128,1 5 3
Chiropractors are well positioned to influence their communities on a wider scope by
participating with other community health leaders in promoting this health behavior.
Listed below (table 10), are selected Healthy People 2010 physical activity
objectives that fit easily within the chiropractic scope of practice and are supported
by a cohort of chiropractors as conditions they generally believe should be part of
their overall care approach.
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Table 10: Selected Healthy People 2010 Objectives Regarding Physical Activity1
Objective Number/Statement
Baseline
Data
Target 2010
Outcome
“22-1. Reduce the proportion o f adults who engage in no
leisure-time physical activity.”
40% 20%
“22-2. Increase the proportion o f adults who engage regularly,
preferably daily, in moderate physical activity for at least 30
minutes per day.”
15% 30%
“22-3. Increase the proportion o f adults who engage in vigorous
physical activity that promotes the development and
maintenance o f cardiorespiratory fitness 3 or more days per
week for 20 or more minutes per occasion.”
23% 30%
“22-4. Increase the proportion o f adults who perform physical
activities that enhance and maintain muscular strength and
endurance.”
18% 30%
“22-5. Increase the proportion o f adults who perform physical
activities that enhance and maintain flexibility.”
30% 43%
“22-6. Increase the proportion o f adolescents who engage in
moderate physical activity for at least 30 minutes on 5 or more
o f the previous 7 days.”
27% 35%
22-7. Increase the proportion o f adolescents who engage in
vigorous physical activity that promotes cardiorespiratory
fitness 3 or more days per week for 20 or more minutes per
occasion.
65% 85%
“22-11. Increase the proportion o f adolescents who view
television 2 or fewer hours on a school day.”
57% 75%
“22-14a. Increase the proportion o f trips made by walking.”
Children & Adolescents (age 5-15)
31% 50%
“22-14b. Increase the proportion o f trips made by walking.”
Adults (ages > 1 8 )
17% 25%
“22-15a. Increase the proportion o f trips made by bicycling.”
Children & Adolescents (age 5-15)
2.4% 5%
“22-15a. Increase the proportion o f trips made by bicycling.”
Adults (ages > 1 8 )
.6% 2%
Nutrition and Weight Control
The primary aim of promoting proper nutrition and ideal weight is to reduce the
human and financial tolls secondary to the burden of preventable chronic diseases,
Ofj
and early morbidity. Dietary factors are linked with 40% of the primary causes (4
of 10) of mortality in the nation, specifically coronary heart disease, cancer (but not
all types), stroke, and type 2 diabetes.1 6 8 Not only are these factors related to health
outcomes but they consequently drive attendant increased societal financial and
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labor productivity costs, $200 billion annually, associated with these disease states.7 9
Additionally, over 25 million elderly (and post-menopausal) Americans suffer the
debilitating effects of osteoporosis, the effects of which are know to be mitigated via
proper nutrition and dietary approaches.1 7 2
The prevalence of overweight and obesity in Americans (55%) has increased
7 8 1 "34
dramatically (see figure 6). ’ Body mass index (BMI) is standardly used to assess
and compare weight status in individuals that is comprised by a formula using both
height and weight data. BMI less than 25 is associated with normal weight, while
individuals with scores above this number are categorized as overweight (up to but
not including 30) or obese (30 and above). By these boundaries, adult Americans as
well as children (> 6 years) have seen a dramatic increase in obesity.78,2 4 0 Obesity,
like a sedentary lifestyle, has enormous ramifications for increased risks for
preventable mortality as well as preventable morbidities such as hypertension, type 2
diabetes, heart disease (coronary), and other acute and chronic diseases. The
financial impact secondary to obesity has been estimated at $99 billion (1997
data).2 6 3
Again, disparities for risk factors associated with obesity abound in U.S.
subpopulations such as Latinos and African-Americans. Differences in rates of
obesity are seen across not only race and ethnic boundaries but across age groups
and genders.
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There are many opportunities to begin addressing risk factors associated with
increased weight beyond school based nutrition education programs (which continue
to need addressing as well) and chiropractors could easily participate in many of
these interventions. Adult health promotion activities, such as screening, awareness,
and prevention programs, are needed as even successful weight reduction programs
are frequently subject to full reversal within 5 years.1 7 8 Portal of entry and primary
care providers can have a large impact on overweight and obesity through the
provision of preventive assessment and intervention as they are viewed by patients as
knowledgeable sources of health information.2
Listed below (table 11), are selected Healthy People 2010 diet and nutrition
objectives that fit easily within the chiropractic scope of practice and are again
supported by a cohort of chiropractors as conditions they generally believe should be
part of their overall care approach.
Table 11: Selected Healthy People 2010 Objectives Regarding Diet And
Nutrition1
Objective Number/Statement
Baseline
Data
Target 2010
Outcome
“19-1. Increase the proportion o f adults who are at a healthy
weight.”
42% 60%
“19-2. Reduce the proportion o f adults who are obese.” 23% 15%
“19-3 a. Reduce the proportion o f children and adolescents who
are overweight or obese. Children 6 - 11 years.”
11% 5%
“19-3b. Reduce the proportion o f children and adolescents who
are overweight or obese. Adolescents aged 12 -19 years.”
11% 5%
“19-17. Increase the proportion o f physician office visits made
by patients with a diagnosis o f cardiovascular disease, diabetes,
or hyperlipidemia that include counseling or education related to
diet and nutrition.”
42% 75%
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Access to Quality Health Care Services - Clinical Preventive Care
There are several other focus areas that are relevant to primary portal of care
providers. The focus area on Access to Quality Health Services includes clinical
preventive services (along with three other components; primary care, emergency
services, and long-term and rehabilitative care).
Clinical Preventive Services (CPS) represent a significantly beneficial approach to
preventing mortality and morbidity (primary prevention) through the early detection
and treatment (secondary prevention) particularly at the initial, asymptomatic stage.
The primary resource for recommended CPS is the U.S. Preventive Services Task
Force Guide to Clinical Preventive Services which describes various evidence-based
preventive activities that are indicated for use.2 4 8 There are many barriers to
Americans participating more actively in primary prevention such as access, lack of
financial resources, absence of a regular care provider, and skepticism regarding
some types of CPS.92,108,1 2 6 For example, Latinos rank highest (40%) of groups
without health insurance which translates into a lack of regular or ongoing care and
diminished access to clinical preventive services.1 6 7
Unlike Pap tests, many effective health promotion and disease preventing
interventions are not reimbursable events for health care providers.2 6 2 This creates
various barriers to the routine providing of other valuable services such as tobacco
cessation counseling.1 There have also been some concern about the difficulty for
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educators and providers to stay abreast of health promotion program revisions
949
contained in the Healthy People guidelines , as well as the concern of the
burdensome nature of clinical guidelines related to health promotion in busy clinical
practice.2 4 6 Various methods have been developed to overcome these practice based
barriers but there is currently a paucity of national data on the provision of these
preventive care interventions. In fact, the authors of Healthy People 2010 have not
been able to include this issue as an objective and have alternatively made
i v t q ') 'J A 7 - 3 7 O /tO
recommendations for further improved collection of data and inquiry. ’
Listed below (table 12), are selected Healthy People 2010 clinical preventive care
objectives that are contemplated to fit within the chiropractic scope of practice and
are again supported by a cohort of chiropractors as important and necessary in
practice.
Table 12: Selected Healthy People 2010 Objectives Regarding Clinical
Preventive Care2 4 2
Objective Number/Statement
Baseline
Data
Target 2010
Outcome
“1-3. Increase the proportion o f persons appropriately
counseled about health behaviors.”
N o Data N /A
“1-4. Increase the proportion o f persons who have a specific
source o f ongoing care.”
N o Data N o Data
“1-5. Increase the proportion o f persons with a usual primary
care provider.”
77% 85%
“1-7. (Developmental) Increase the proportion o f schools o f
medicine, schools o f nursing, and other health professional
training schools whose basic curriculum for health care
providers includes the core competencies in health promotion
and disease prevention.”
N o Data N o Data
“1-9. Reduce hospitalization rates for three ambulatory-care
sensitive conditions— pediatric asthma, uncontrolled
diabetes, and immunization-preventable pneumonia and
influenza.”
N o Data N o Data
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Significant deficiencies continue to exist in the provision of clinical preventive
services aimed at changing health behaviors related to preventable morbidities,
particularly those related to sedentary lifestyle and nutritional habits.1 5 5 Evidence
points to socioeconomic factors as contributory in determining whether physicians
deliver CPS to their patients.2 3 4 Studies demonstrate that when physicians engage in
counseling of short duration this can be an effective strategy to reducing the impact
on certain undesirable health behaviors, although others, such as increasing activity
levels, have been less fruitful.74,110,2 4 8
The deficiency of not having a regular provider or source for health care has a
dampening effect on the acquisition of preventive health services.71,1 6 5 Again,
Latinos fair the worst of all groups categorized by race when it comes to having
access to care (28% of Latinos from Mexico versus 15% of adults irrespective of
race).
Primary health care services which are delivered in a consistent, and thorough
manner, can reduce the degree of specific illness morbidity. Healthy People 2010
targets three diseases that are frequently seen in a primary care setting (asthma,
diabetes, and pneumonia/influenza) that, in the absence of preventive activities, can
frequently result in hospitalization. The Healthy People 2010 objective aims to
utilize a PHS targeted approach so as to minimize the illness severity associated with
these conditions. Again, there exist significant differences in frequency of
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hospitalization for these diseases by racial groups with Blacks and Latinos
demonstrating elevated relative risks compared to Caucasians.
As reported earlier, chiropractors do see patients, such as diabetics, in practice and
co-manage these patients with medical physicians. A point of clarification though is
necessary at this juncture. Frequently, patients who present to chiropractors for
neuromusculoskeletal (NMS) complaints will frequently exhibit signs, symptoms, or
previous diagnoses of other co-morbidities. The data surveyed by the National
Board of Chiropractic Examiners does not inform us whether these co-morbidities
are a focus of the chiropractic intervention or just present during the treatment of
NMS conditions. While we await data clarifying this issue, an overall impression of
other studies regarding chiropractors’ and patients’ perceptions of what chiropractors
treat argues for the case that these ‘co-managed’ conditions are not the focus of most
chiropractors’ interventions. Yet, the opportunity remains to support health
promotion and disease prevention programs related to these conditions. For
example, chiropractors are seeing diabetic patients and could easily participate in
screening, awareness campaigns as well as reinforce prevention messages to these
patients. Clearly the same opportunities present themselves with respect to other
major causes of morbidity and mortality such as tobacco use. Again, chiropractors
could easily serve as a needed addition to the team of providers that could be
educated to increase the breadth of contact and scope of these interventions within
the communities they serve.
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Arthritis, Osteoporosis, and Chronic Back Conditions
We are entering an era when increasing numbers of Americans are surpassing 65
years of age, with the trend continuing into the foreseeable future. As individuals
continue to live ever increasing lifespans, the quality of these senior years of life
become an ever increasing health care factor for consideration. Maintaining
functionality is also a goal for this senior population. Loss of function is one of the
primary sources for diminished levels of reported quality of life. Musculoskeletal
problems due to osteoporosis, recurrent or longstanding low back pain and both
osteoarthritis and rheumatoid arthritis are primarily responsible for the lowered
public health status and overall reported life quality in this cohort.
Data indicate that a significant proportion of Americans remain in the work force
•3Q
well into their late sixties secondary to demographic factors. Clearly any limitation
in physical functioning will have an adverse impact in their successfully remaining
gainfully employed. There exist viable programs, targeted at maintaining improved
physical functioning, that could circumvent much of the disability and limitations
caused by arthritis, osteoarthritis, chronic back pain. Conditions, such as arthritis,
impacts over 20% of all adults and is the primary source of disability (total figure of
3%) in Americans.3 9 Evidence of chiropractic effectiveness with low back pain in
this cohort has been well established.6 7 ’6 8 ’1 1 5 ’2 0 3 ’ 4 1 ’4 3 ’1 0 9 ’1 4 3 ’ 6 7 ’6 8 ’1 1 5 ’2 0 3 Guidelines
introduced by the American Geriatric Society reinforce their approval of drugless
interventions, including chiropractic treatment, as safe and cost-effective.7
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The literature refers to a “Compression of Morbidity Paradigm”8 3 which looks at
disability as a cumulative concept and orients interested stakeholders in the public’s
health to seek ways to delay the onset of morbidities, particularly in the presence of
an increasing elderly population cohort. This effort is not without economic
motivation as well for it has been estimated that a diminution of age-specific
disability that reaches 1.5% annually would delay the insolvency of Medicare by at
least 70 years.2 2 0 The literature clearly demonstrates strong evidence that morbidity
is being compressed56,81,2 2 0 and this effect is not exclusive to Caucasians, as
minority populations appear to be moving in the same direction. This is an
enormously helpful finding as it directs researchers towards fulfilling one the two
major goals of Health People 2010, that of removing disparities in health between
subpopulations (racial groups). While the full explanation of etiology of these
improvements in disability remains unclear, health improvements including
decreases in disability, medical utilization, and self-reported pain have been verified
(some changes as large as 10% annually during the intervention period) by large
randomized clinical trials involving geriatric patient cohorts.8 4 '86,149,2 0 2 This delay in
disability, through the use of primary prevention health promotion services, has
significant economic impact implications, not only on our increasingly elderly
o i one
population, but on the financial solvency of the Medicare system. ’ Clearly this
point is not lost by the Health Care Financing Administration (HCFA), which
oversees Medicare, as they have funded a design project based on a 2001 Rand
evidence-based review of the impact of health promotion in the elderly.2 0 2 It is
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evident that HCFA has become of aware of the problem with Medicare’s paradigm
remaining limited in it’s function to merely functioning as a health insurer rather
than also systematically promoting healthy behaviors and offering financial
incentives to encourage provider participation in delivering disease prevention
208
programs.
Arthritis
The financial and productivity costs associated with arthritis are quite large. Data in
1992 demonstrated that arthritis accounted for 65 billion in total outlays, about a
quarter of which is related to costs associated with health care. To get an idea of
how large this number is, this total represented 1.1% of the GDP (gross domestic
product) in the United States and was comprised of millions of doctor’s visits, % of a
million hospitalizations and 4 million hospital days annually. 43,45,2 6 6 Although the
majority of individuals who suffer with arthritis are in an employable age cohort,
data indicates that they have a statistically lower employment rate.38,109,144,2 4 1
Analysis of the population indicates an aging of the United States population, so it is
clear that the burden of this disease will become more profound in the coming
decades.2 9 With these estimates in mind, it is predicted that 18% of the U.S.
population, almost 60 million individuals will be burdened with this disease and this
will directly contribute to the almost 4% of individuals who will suffer significant
activity restrictions.39,109,1 4 3
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Osteoporosis
Osteoporosis is a disease that affects many Americans (see table 13) and involves
loss of bone density which leads to fractures, disability and, in the case of 25% of
individuals older than 50 years suffering a hip fracture, death with one year.2 0 4
Another 50% will require ambulatory assistance.2 0 4 Annually, there are
approximately 1.5 million fractures secondary to this disease resulting in health care
expenditures exceeding $13 billion (each year).2 0 4
Table 13: Osteoporosis Staitistics, United States, 19952 0 4 .
Men Women
Osteoporosis (decrease in bone
mass or density that increases
the risk o f fracture)
Age > 50 3% to 6% 13% to 18%
Absolute total 1 to 2 million 4 to 6 million
Osteopenia (loss in bone mass
that is less severe than
osteoporosis)
Age > 50 28% to 47% 37% to 50%
Chronic Back Conditions
Annually, pain arising from the back is reported in up to 45% of all individuals in the
United States.10,23,87,88,2 3 3 During the course of a lifetime, up to 85% of all
individuals will suffer from this malady.10,23,87,88,2 3 3 Frequently, individuals have
back pain that exceeds 3 months in duration (chronic low back pain) or have repeat
episodes of this pain which causes a decrement in activity level, physical limitations,
and disability. Nationally, back pain ranks first among causes of physical
restrictions in individuals less than 45 years of age, second in causes of primary care
encounters, fifth for causes of hospitalization and is the third leading cause of
9, 126, 194
surgery.
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Latinos are significantly affected by chronic low back, ranking second most frequent
among this racial group for prevalence as well as cause of physical limitations with
respect to activity. Lower educational attainment and lower income levels are
predictive of increased rates of this arthritis and the accompanying physical
limitations.9,38,92,143,1 4 4 Generally, excess body weight has been identified as a
potential variable exacerbating the development of non-rheumatoid bony arthritis.7 3
Many programs, aimed at changing patient behavior, have been successful and
decreasing the effect of arthritis, osteoporosis, and chronic low back pain on physical
limitations as well costs of care.133,148,151,158’159,200,2 5 4 Unfortunately, only a very
limited number of the potentially affected cohort are being reached by these
interventions.
Listed below (table 14), are selected the Healthy People 2010 arthritis, oseoporosis,
and chronic back pain objectives that are well suited within the chiropractic scope of
practice and are again supported by a cohort of chiropractors as important and
necessary in practice.
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Table 14: Selected Healthy People 2010 Objectives Regarding Arthritis,
Osteoporosis, and Chronic Back Pain2 4 2 ______
Objective Number/Statement
Baseline
Data
Target 2010
Outcome
“2-1. (Developmental) Increase the mean number of days
without severe pain among adults who have chronic joint symptoms.”
No Data No Data
“2-2. Reduce the proportion of adults with chronic joint
symptoms who experience a limitation in activity due to arthritis.”
27%* 21%*
“2-3. Reduce the proportion of all adults with chronic joint
symptoms who have difficulty in performing two or more
personal care activities, thereby preserving independence.”
2.0%* 1.4%*
“2-5. Increase the employment rate among adults with arthritis
in the working-aged population.”
67%** 78%**
“2-7. (Developmental) Increase the proportion of adults who
have seen a health care provider for their chronic joint
symptoms.”
No Data No Data
“2-8. (Developmental) Increase the proportion of persons with
arthritis who have had effective, evidence-based arthritis
education as an integral part of the management of their
condition.”
No Data No Data
“2-9. Reduce the proportion of adults with osteoporosis.” 10% 8%
“2-10. Reduce the proportion of adults who are hospitalized
for vertebral fractures associated with osteoporosis.”
17.5f 14.0f
“2-11. Reduce activity limitation due to chronic back conditions.”
3 2 tt 2 5 ft
* Adults >18 years
**Adults aged 18 to 64 years with arthritis
■(Hospitalizations per 10,000 adults aged 65 years and older,
f f Adults per 1,000 population aged 18 years and older.
Diabetes
Individuals with diabetes are normally a target for a variety of interventional
approaches including, but not limited to, the medical use of insulin, and behavioral
interventions such as improved levels of physical activity and nutrition. The latter
two factors are amenable to program interventions offered through a variety of health
care settings including chiropractors’ offices, although these interventions have been
relatively weak regarding changing health behaviors.42,50,1 2 9 Nationally, the
incidence of type 2 diabetes (adult onset) and it’s accompanying complications
continues to increase5 0 with a current total of 10.5 million individuals and another
5.5 million that remain unaware of their disease.33,44,1 2 9 Nationally, diabetes is
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directly responsible annually for 57,000 amputations, 20,000 cases of blindness, and
28,000 cases of kidney disease that require dialysis with total expenditures exceeding
100 billion3,44, m . Sadly, all these sequella occur in the face of widely available and
effective secondary and tertiary intervention programs.6,31,62,6 3 ’66,98,132,147,229,2 5 3
It is anticipated that the national incidence of diabetes will continue to increase into
the foreseeable future, and even more so for certain high-risk groups such as the
poor, the elderly and racial groups such as Latinos and Blacks. Disparities in the
incidence of diabetes among these two racial groups is significant, with Latinos and
Blacks having an increased relative risk of developing diabetes (and all the attending
complications such as amputations, renal disease, etc.) in their communities relative
to their white counterparts.7 7 Reduced access to intervention programs is also
frequently a complicating factor for certain racial groups as well as the elderly and
the poor.
Listed below (table 15), are selected the Healthy People 2010 objectives related to
diabetes that are contemplated to be within the chiropractic scope of practice and are
again supported by a cohort of chiropractors as important to recognize and co-
manage in practice.
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Table 15: Selected Healthy People 2010 Objectives Regarding Diabetes2 4 2
Objective Number/Statement Baseline Data
Target 2010
Outcome
“5-1. Increase the proportion o f persons with diabetes
who receive formal diabetes education.”
45% 60%
“5-2. Prevent diabetes.” 3.5 new cases/1000
pop.
2.5 new cases/1000
pop.
“5-4. Increase the proportion o f adults with diabetes
whose condition has been diagnosed.”
68% 80%
“5-5. Reduce the diabetes death rate.” 75/100,000 pop 45/100,000 pop.
“5-6. Reduce diabetes-related deaths among persons
with diabetes.”
8.8 deaths/1,000 7.8 deaths/1000
“5-7. Reduce deaths from cardiovascular disease in
persons with diabetes.”
343 deaths/100,000 309 deaths/100,000
“5-8. Decrease the proportion o f pregnant women with
gestational diabetes.”
N o Data N o Data
“5-9. Reduce the frequency o f foot ulcers in persons
with diabetes.”
N o Data No Data
“5-10. Reduce the rate o f lower extremity amputations
in persons with diabetes.”
4.1 lower extremity
amp./1000
1.8 lower extremity
amp ./1000
“5-11. (Developmental) Increase the proportion o f
persons with diabetes who obtain an annual urinary
microalbumin measurement.”
N o Data N o Data
“5-12. Increase the proportion o f adults with diabetes
who have a glycosylated hemoglobin measurement at
least once a year.”
24% 50%
“5-13. Increase the proportion o f adults with diabetes
who have an annual dilated eye examination.”
47% 75%
“5-14. Increase the proportion o f adults with diabetes
who have at least an annual foot examination.”
55% 75%
“5-15. Increase the proportion o f persons with diabetes
who have at least an annual dental examination.”
58% 75%
“5-16. Increase the proportion o f adults with diabetes
who take aspirin at least 15 times per month.”
20% 30%
“5-17. Increase the proportion o f adults with diabetes
who perform self-blood-glucose-monitoring at least
once daily.”
42% 60%
Theories and Methods that Influence Provider Behavior Change
Experience suggests that a didactic public health program alone will not be effective
in producing the desired preventive service behaviors. Therefore, to reinforce
classroom learning with clinically relevant experiences, what interventions would be
effective during later clinical internship training? During the clinical training stage
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interns begin to model independent practitioner attitudes. It would be helpful to
briefly review the strategies and the associated theoretical models that have been
used with active practitioners that may have applicability to interventions directed
towards the clinical internship phase of chiropractic training.
Valente outlines several theories that are helpful in the design of programs
contemplated for health improvement and promotion; (1) Diffusion of
Innovations2 0 5 , (2) Hierarchy of Effects1 5 7 , (3) Stages of Change and the
Transtheoretical Model1 9 7 , (4) Theory of Reasoned Action4: (5) Social Learning
Theory1 7 and (6) Health Belief Model1 9 (HBM). These theories have been
previously described throughout the literature in much detail.2 0 5 ,1 5 ’1 9 7 ’1 5 7 ’ 1 9 7 A ,i7,i9
The literature describing interventions aimed at improving physician performance
has have also been thoroughly reviewed and summarized elsewhere.2 2 There exist
several interventions which demonstrate varying degrees of effectiveness in
changing clinical practice behaviors among physicians.
Continuing Education
Continuing education programs have been contemplated as effective via elements of
learning theory.2 2 1 The literature provides some evidence that physicians, who are
considering or in the process of changing behavior, will attend continuing education
venues to evaluate/compare the validity and reliability of their behavior and
learning.2 0 1 This includes both ongoing clinical behaviors as well as new
information and innovations. Post-graduate and continuing education as well as
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printed materials generally utilize relatively passive means of changing behavior
strategies and have shown little evidence of effectiveness.58,8 2 When these passive
strategies are combined with corroborating strategies to boost outcomes, the results
have been inconsistent with the added difficulty of sorting out individual
interventional impacts.
Academic Detailing
Academic detailing is a one-on-one direct encounter between practiced-based
physicians and distinctively trained individuals to exchange specified clinical
behaviors. This approach was adapted from the “detailing” work performed by
employees of pharmaceutical organizations to practicing physicians. Academic
detailing is frequently performed by leaders in the field or noteworthy peers 2 2 5 This
approach springs from theories such as the diffusion of innovation.2 0 5 Academic
detailing appears to yield beneficial results but requires an extraordinary degree of
human and financial capital.2 3 8
Physician Reminders, Audits, and Feedback
Also emerging from behavior and learning theory are reminders, audits and
feedback, which aim to sway medical provider activities by the use of an external
223 8 11
source prompt. Theories that have been used to explain health behaviors ’ such
as the social cognitive theory 1 7 and the health belief model 48,150,2 0 7 argue that
alteration in health behavior, at the individual level, is primarily influenced by an
individual’s locus of perceptions and aspirations. Physician behaviors can be shaped
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or modified by internal and external influences. The social cognitive theory and the
health belief model both suggest that normative behavior feedback to physicians,
guideline compliance prompts, and administratively enforced policies are valuable in
influencing physician habits and performance. Studies also indicate that reminders
or physician prompts exhibit the most consistent evidence of reliable behavior
outcomes although an absence of data on issues such as long-term behavior change
and physician dissonance with reminder content (lack of agreement), indicates that
the full-story regarding when reminders work has yet to be written.14,1 2 0 While
audit and feedback strategies provide a great degree of flexibility in design and
dissemination of health behavior interventions, studies indicate that their impact is
minimal.
Evidence-Based Guidelines
Guidelines that originate from best-evidence research are driven theoretically by
cognitive theory. While not without some benefit, in the context of a multifaceted
approach, research has well delineated that knowledge of guidelines is not sufficient
to significantly effect physician behavior. Guidelines have been widely developed to
positively affect physician performance yet they have been of limited use and impact
to date with respect to chiropractors. Initiatives targeted at implementing physician
practice guidelines have met frequently with minimal results.1 2 4 Extrapolating to
chiropractors, these practitioners are exposed to many influences during and
subsequent to their training that can impact behaviors that influence philosophies of
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health care approach, including chiropractic faculty, various affiliations with
chiropractic technique organizations, management consultants, seminars and other
private practitioners.
During clinical training, faculty inculcate standards of normative practice behaviors
through the use of clinical instruction, mentorship, and observation. Clinical faculty
repetitively assess and hopefully ingrain core clinical competencies with regard to
knowledge, attitudes, and skills.5 5 Subsequent to licensure, graduates are exposed to
a updated evidence-based clinical guidelines aimed at impacting practice behavior.
Physician performance indicators suggest that guidelines are an important strategy
but not sufficient to produce behavior change as a solitary intervention.9 7 Other
investigators have reviewed the literature and concluded that, with respect to the
adoption of practice guidelines, factors such as (1) the qualities of the guidelines, (2)
the individuality of the practitioner, (3) issues related to the health care location,
practice rules and policies, (4) practitioner economic incentives, and (5) individual
patient dynamics are most influential.5 7
Consensus Development Panels
The literature provides previous reviews of the findings of multiple evaluations of
9 0 S
National Institutes of Health (NIH) consensus development conferences. These
evaluations, aimed at determining whether recommendations to adopt or not adopt a
medical practice or behavior, as recommended by consensus panel findings, were
very limited in their impact. The main limitations found were that only some
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providers of health care in a particular specialty are aware of the consensus panel
finding and, of this subpopulation of providers, only some follow the
recommendation in practice.2 0 5
Economic Incentives
In 1776, Adam Smith, a Scottish political economist and philosopher provided a
model that specified greed as being the invisible hand that lies at the core of an
• • ')'77
individuals capitalistic raison d'etre. ’ Theory, emanating specifically from
health economists, support this contention that individual behavior is as aimed
toward achieving the highest level of monetary realization.2 8 The influence of
economic incentives on physician behavior has been the least studied strategy. This
has been primarily due to research design issues as well as the obvious ethical
concerns. A few trials, though, have documented that economic-based interventions
do work. Trials that have successfully utilized this intervention strategy were aim at
improving preventive services delivery such as childhood vaccination rates and an
increase in geriatric influenza vaccination rates.7 2 ,1 3 1 One trial concluded that this
strategy plus feedback was unsuccessful in elevating the frequency of breast cancer
screening among females older than age fifty U1.
Choosing An Effective Approach
Physician characteristics, such as ethics and beliefs, are believed to be positively
associated with practice behaviors. Many outside influences impact chiropractor
and chiropractic student behaviors. Chiropractors, and particularly chiropractic
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students, are frequently influenced by external seminars, particularly practice
management seminars that are run by practice management consultants who
frequently role-model and advocate behaviors that are often dissonant with those of
faculty and the institution’s educational goals. The effect of these influences on
practitioner behaviors, motivating capital profits and minimizing patient encounter
time, can produce a barrier to developing a broader student interest and participation
in providing additional, and frequently non-reimbursed services, such as preventive
health services. Chiropractic students frequently attend practice management
seminars where they are told that to be successful, they need to operate their
practices efficiently (and not by providing services for which they are not
reimbursement). Occasionally, seminar speakers and management consultants in the
private sector advocate strong views against patients utilizing medical care and
actually promote ‘straight’ chiropractors to use various fear tactics in discouraging
patients from utilizing medical care, advocating chiropractic spinal manipulation as
the only necessary health promotion and disease prevention service suitable for
practice. Chiropractors and physicians are both motivated by multifactorial
influences such as patients, community, and health care insurance stakeholders.
They both must strive to achieve an equilibrium among these competing demands
for accountability.
Some health practitioners remain more cognitively open to improving the quality and
appropriateness of their services while others resist any quality assurance or
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improvement initiatives. These initiatives can range from counseling a mother and
child on bicycle helmet safety to more effectively diagnosing serious patient
conditions.
The transtheoretical model delineates stages of change as an important factor
influencing behavior change. 196,1 9 7 This theory has shown encouraging evidence of
validity in several health research studies.1 9 8 This research indicates though that an
effective model includes multiple approaches that utilize optimal intervention
methods at each particular stage along the change continuum, thus facilitating the
improved health behavior change outcome at each stage. For example, preliminary
stage interventions are best targeted with educational strategies while reminders
should be directed towards stages occurring later in the change continuum.
The studies on effectiveness of physician focused health behavior change strategies
lead one to several conclusions; (1) while clinical guidelines are useful to the
overarching purpose of improving outcomes, they are not effective by themselves as
a change inducing strategy, (2) a few hours or days of education relative to years of
training is useless, (3) using several strategies is better than using only one, (4)
reminders have demonstrated the most effectiveness, but have been researched in
environments where generalizability is called into question, and (5) implementation
strategies and methods aimed at changing physician behaviors and improving health
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care outcomes should (a) stay focused on evidence-based theory and (b) implement
numerous interventional strategies.
Conclusions and Future Research Agenda
Over the past decade, there has been the significant discovery concerning Americans
increasing their utilization of complementary and alternative care interventions to
promote wellness and preventive disease and disability. The evidence supports that
people continue to increase this utilization even in the absence of third party
reimbursement coverage - they are willing to pay out of pocket to feel better and/or
stay well. This literature review has highlighted the growth of chiropractic as it has
matured from a complete alternative to medical care to a more complementary form
of health care and have identified the opportunities and barriers to the continued
growth in their scope of preventative activities by chiropractors. Chiropractic
researcher’s and educators, aware of the nation’s goals, as disseminated Health and
Human Services sponsored documents such as Healthy People 2000 and 2010, have
begun to lead the profession in an effort to expand their chiropractic paradigm of
wellness to include orthodox preventive health services. They have taken the first
steps by reviewing the status of public health training in chiropractic colleges and
then creating a model public health education program. They have distributed this
program to all chiropractic colleges in the United States and have presented the
model program at a major chiropractic association (Association of Chiropractic
Colleges) conference to encourage adoption o f the model into the curriculum at each
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of the 16 chiropractic colleges across the nation. The impact of this effort, to
facilitate the increase in practitioner impact in delivering health promotion and
disease prevention services, has yet to be evaluated at any level.
Rising with the enormous growth of alternative care use, there have been manifold
changes in the United States regarding the delivery of health services. Greater public
accountability has driven health school educators, throughout the medical and allied
health professions, to reexamine their curricula to insure the inclusion of PHS.2 5 5
This pattern of change substantiates the recognition of the important connection
between the objectives and goals of the public health system and the goal of
delivering superior health services. " ’ Recently, within medical education
research, there has been a movement towards developing teaching cases, based on a
core set of competencies1 4 5 , that are clinically relevant, problem- and community
population-based (revolved around a fictitious or real patient case history and
presentation) and presenting these cases during medical training.12,46,48,4 9 ’69,70,142,
154 , 164, 179 , 181 , 182,190 j^ese teaching methods, that fill a perceived need for
integrating curriculum towards community-based population focused prevention,
frequently embrace an adaptable instructional approach, such as small group
discussion, to enhance flexibility of the learning environment. Study of the
effectiveness of this approach in student learning has demonstrated significant
1 s n o 'X 'y —
improvements in medical student skills in population-based prevention. ’ There
is no evidence of any chiropractic studies that have investigated this type of
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clinically relevant approach to student learning of preventive service delivery. Nor is
there any evidence in the chiropractic literature of any similar assessment of theories,
methods, and strategies for altering practice behaviors such those reviewed earlier
involving medical providers. Clearly the need for research in all these areas is quite
enormous.
An assessment of the impact of the change in the public health curriculum is urgently
needed as a first step. As such, a pilot is contemplated to assess the change pre- and
post- model curriculum dissemination to determine whether there has been any
impact on chiropractic intern health promotion behaviors and care provided to
patients during their clinical training. The literature clearly identifies the limitations
associated with didactic coursework absent clinically relevant learning, experiences,
or reinforcement. Empirical evidence, strongly suggests that the efforts to
didactically influence health promotion behaviors at one of the chiropractic colleges
(Cleveland Chiropractic College, Los Angeles) has suffered from this limitation. A
pilot study is planned to yield a metric that will assist in characterizing whether the
dissemination of the model public health curriculum has been a success or failure in
changing behaviors to increase a broader delivery of health promotion and clinical
preventive services.
It is highly likely that an intervention, that would assist in making the provision of
clinical preventive services more clinically relevant and meaningful, will be
required. A study will be proposed, in the form of a grant, to deliver an intervention
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targeting a specific population need identified by the pilot study that is also
congruent with the chiropractic paradigm of health.
The nation’s goals, as set forth in Healthy People 2010 and particularly related to
chiropractic practice, have been reviewed. Chiropractors maintain the potential to
impact areas of great societal interest from the morbidity of tobacco use to the
limitation of disability, particularly in the elderly population.
The significance of this dissertation rests on a growing confluence of consumer,
alternative practitioner, public health researcher, and government payer interest in
improving the nation’s health for both humanistic reasons and capital expenditure
benefits. The direction of this research agenda is driven by the real opportunities for
making a significant impact on the health status of Americans, ultimately assisting in
the financial stability of the Medicare system, by increasing the effectiveness of
methods aimed at improving disease and disability prevention advocacy behaviors
by this second largest professional organization of ‘primary care’ providers in the
United States.
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Chapter Two: Improving Preventive Health Services Training in Chiropractic
Colleges: A Pilot Impact Evaluation of the Introduction of a Model Public
Health Curriculum
Gary A. Globe, MBA, DC
Associate Academic Dean
Acting Director of Research
Cleveland Chiropractic College, Los Angeles
Stanley P. Azen, Ph.D.
Professor & Director of Biometry Division
Keck School of Medicine
University of Southern California
Thomas Valente, Ph.D.
Associate Professor and Masters In Public Health Program Director
Institute For Prevention Research
Keck School of Medicine
University of Southern California
Michael B. Nichol, Ph.D.
Associate Professor and Department Chairman
Pharmaceutical Economics & Policy
School of Pharmacy
University of Southern California
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Article Abstract
Background: Recent efforts have been made by chiropractic researchers, educators,
and interested stakeholders from the public health community to update the public
health curriculum provided by chiropractic colleges to include a greater focus on
health promotion and disease prevention. This updated curriculum was aimed at
increasing the provision of clinical preventive services by field practitioners.
Objective: To investigate the impact of the model public curriculum, implemented
by one of the U.S. chiropractic colleges, on chiropractic interns during their
outpatient clinical internship.
Design and Setting: A retrospective pilot study was performed to evaluate the
frequency of nine patient clinical preventive health recommendations made by
interns, during their clinical training. The frequency of recommendations by interns
completing their public health coursework after dissemination of the model
curriculum was compared with those completing their coursework during the time
frame immediately proceeding dissemination. A standardized data abstraction tool
was developed to collect data from clinic charts that would establish a patient’s need
for any one of nine preventive health services which could be provided by
chiropractic interns.
Results: Of the 408 charts examined (204 each from treatment and comparison
groups) on a random sample of patients presenting for care in the college outpatient
clinic, there were only four documented instances (1.0%) of recommendations for
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any o f the nine preventive health service categories. Two recommendations
occurred in the pre-curriculum change period. One event involved the student intern
sending the patient out for blood cholesterol testing. Follow-up for this one event
was documented in the chart. The second recommendation was for a cervical cancer
screening in which a pap smear was recommended. There was no evidence of
follow-up for this event documented in the chart. The two recommendations that
occurred in the post-curriculum change period were for blood pressure screening.
There was no documentation in the chart for either of these two patients which
reflected whether or not they had followed-up with the initial recommendation.
Conclusion: The results of this pilot study indicate that there has been no observable
impact on intern behaviors toward educating patients in preventive health services
since the dissemination of the model public health curriculum at one of the
chiropractic colleges in the United States. The sampling of every fifth clinic patient
chart achieved a representative, and demographically comparable cohort of clinic
patients in the pre- and post-curriculum change groups. The impact of this reform in
public health education may have been limited by its minimal focus on clinical
preventive services and by a focus on didactic rather than a clinically relevant
learning exposure.
Key Indexing Terms: Clinical Preventive Services; Preventive Health Services;
Public Health; Chiropractic; Curriculum
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Introduction
In recent years a nexus has developed between the growth in alternative care
utilization in the United States and the opportunity to further enhance the nation’s
health. Over the past decade, research has confirmed that chiropractic patient
encounters comprise a notable percentage of alternative care visits, with alternative
practitioner visits actually outnumbering medical physician visits annually67,68,2 6 4 .
Contemporaneously with this growth in alternative care utilization, researchers and
educators, both internal and external to the chiropractic profession, have begun to
embrace a greater role for chiropractors in providing ‘orthodox’ preventive health
services, such as recommendations for avoidance of sedentary lifestyle behaviors and
obesity, counseling on proper diet and nutrition, encouragement in stopping
smoking, and cancer screening.96,99~ 1 0 1 ’1 0 3 -1 0 5 phis emerging potential for expanding
the role of chiropractors in providing orthodox preventative health services warrants
greater attention and further investigation.
The Need for Preventive Services in the United States
Over the past 20 years the health goals for the nation have been articulated in the
form of nationally participative initiatives, ultimately leading to the current iteration
of Healthy People 2010. This resource, representing the work of thousands of
contributors, serves as a compendium of health goals, targeting behavioral factors
and other interventions, through the health professions, the general population, and
other stakeholders interested in health promotion, disease prevention, and healthy
lifestyles. Areas of continued opportunities for improving the nation’s health,
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operating under the dual goals of extending quality/quantity of life and reconciling
disparities in health outcomes, are cataloged in 28 specific objectives. Operationally,
this roadmap challenges providers to embrace and deliver prevention services, asks
neighborhoods and commerce to carry and underwrite health promotion activities in
educational venues, site of employment, and beyond. It directs researchers to new
avenues of study. But the documents highest calling is for all Americans to recognize
their role in collaborating in normative and innovative interventions in achieving the
242
target outcomes.
While significant progress has been made in some areas of the nation’s health, other
problems, such as various chronic diseases remain difficult challenges. Related
indicators influencing many chronic diseases such as obesity and sedentary lifestyle
have continued to increase or remain unsuitably high, with obesity up 50% in the
past twenty years and avoidance of physical exercise during non-working time
periods at almost 40% in the adult population.2 4 2 Increases in sedentary lifestyle has
the additional detrimental outcome of facilitating weight gain among Americans,
leading to complicating factors related to overweight and obesity. The risk of
developing many diseases, such as heart disease, osteoporosis, and arthritis, is
lowered significantly through regular exercise.119,249,2 5 0 This is particularly true in
1*7/1 ' j i r O /IQ
the elderly. ’ ’ Physical activity levels are amenable to interventional
approaches by primary care providers. Chiropractors frequently recommend
exercise as part of their normative care plans for their patients as well as generally
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educate patients to adopt exercise as part of a wellness paradigm.128,1 5 3
Chiropractors are well positioned to influence their communities on a wider scope by
participating with other community health leaders in promoting healthy behaviors.
Development of a Model Public Health Curriculum
In November of 1998, the Chiropractic Health Care Section of the American Public
Health Association (APHA) formed the Public Health Curriculum Task Force with
the goal of improving the quality of public health training for chiropractic students.
One year later, based on the report of a task force of interdisciplinary researchers, the
Chiropractic Health Care Section of APHA disseminated to all chiropractic colleges
a detailed list of topics and resources (developed by the Task Force with input from
all faculty teaching public health in U.S. chiropractic colleges) for inclusion in their
public health courses. By June of 2001, a “Model Course for Public Health
Education in Chiropractic Colleges” users guide was distributed to all chiropractic
colleges in the United States. In September of 2001, Cleveland Chiropractic
College, Los Angeles implemented the model curriculum into their public health
coursework.
The goal of this new curriculum was to change the focus of the subject matter that
was presented to chiropractors at chiropractic colleges during didactic coursework.
Chiropractic catalog reviews, conducted by the Public Health Curriculum Task Force
had revealed that traditional public health education in chiropractic colleges
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generally placed a decided focus on topics such as microbiology, sewage treatment,
potable water, pasteurization, etc. Clearly these topics were not particularly relevant
to contemporary clinical chiropractic practice and topics with greater relevance to
health promotion and clinical preventative services, such as physical exercise, safe
lifting, weight loss strategies, and smoking cessation were not as common.
The outcomes of these efforts to update the public health curriculum provided by
chiropractic colleges to include a greater focus on health promotion and disease
prevention have yet to be studied and are the focus of this retrospective pilot study.
Methods
To evaluate the impact of the dissemination of the model public curriculum, a
retrospective pilot study was performed to evaluate the frequency of patient clinical
preventive health recommendations made by interns, during their clinical training,
who were exposed and not exposed to the revised curriculum.
A standardized data abstraction form was developed, which was used for both the
pre- and post-curricular change chart reviews. The primary purpose of this tool was
to collect factors from each chart that would establish the need for preventive health
services which could be provided by chiropractic interns (tobacco cessation, physical
activity, obesity, nutrition, hypertension, reduction in dietary fat intake, blood
cholesterol levels, and recommendations for receipt of screening for cervical, breast,
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and colorectal cancer). Guidelines from the U.S. Preventive Services Task Force’s
Guide to Clinical Preventive Services2 4 8 were used to operationally define when a
patient was a candidate for a preventive health service recommendation. A
preliminary review of patient charts was conducted to determine which data fields
(contained within patient health history forms, printed examinations forms, patient
narrative condition summaries, and progress notes) could be consistently abstracted.
Information included patient gender, age, family history of cancer, family history of
diabetes, family history of heart disease, history of blood cholesterol testing, blood
pressure measurement, self-report of performing monthly breast exams, date of last
mammogram, history of surgery of the cervix/uterus, date of last pap smear,
screening of colorectal cancer in the past year, weight, height (to calculate body mass
index), current smoking status, number of packs smoked, participation in physical
activity, and dietary information. Other factors that might be associated with intern
behavior, including intern gender, were also included in the chart abstraction tool.
The chart abstraction form also collected evidence of documented preventive health
service recommendations, the date it was made, and whether or not there was
evidence that the recommendation was followed-up upon (by the intern and the
patient).
A series of 204 charts were abstracted for both the exposed and the unexposed
groups. The initial chart selected for each group was the first new patient for the
identified semester. Subsequently every fifth chart was abstracted. If the chart was
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missing, the next chart in the file number sequence was abstracted and so forth, with
the next selected chart at the originally prescribed interval. For example, if chart
number 25000 was not able to be located, then 25001 would be reviewed. The next
chart abstracted would be 25005. This process was repeated for both the exposed
and unexposed groups. A trial run of 10 chart abstractions were reviewed and
checked for accuracy and revealed good agreement with the investigator. An in-
depth interview was performed to answer questions and review procedures.
Thereafter, the charts were abstracted over the period of one month without the
direct involvement of the investigator. The abstracted charts were delivered to the
investigator who entered the data into the statistics program SPSS, version 12.0. A
ten percent data entry check was performed to insure data entry accuracy.
Frequency distributions of the characteristics of patients included in the pre- and
post- chart abstractions and the proportion of patients identified as needing
preventive health services for each of the nine categories was determined. Next the
proportion of those patients who needed preventive health services and received
health promotion counseling by their intern was determined. The difference in
receipt of preventive health services counseling documented on pre-curriculum
charts was, wherever possible, compared to those documented on post-curriculum
charts using the Chi-square statistical test.
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Results
Over sixty percent of the interns were male in both groups. In the baseline group the
mean age was 39.4 (sd 15.2), 45% were male, 30% had a documented family history
of cancer, 24% had a documented family history of diabetes, and 33% had a
documented family history of heart disease. In the follow-up group the mean age
was 38.8 (sd 14.0), 50% were male, 34% had a documented family history of cancer,
28% had a documented family history of diabetes, and 25% had a documented
family history of heart disease. There were no statistically significant differences in
demographic and family history characteristics between the patients included in the
pre-curriculum and post-curriculum groups (see table 16).
Table 16: Patient Demographics and Risk Factors
Pre-curriculum
Change Group
Post-curriculum
Change Group P-value
N 204 204
Intern gender*
Male (%) 125(61.3%) 141(69.1%) N/A
Female (%) 79(38.7%) 63(30.9%)
Patient age in years (SD) 39.4(15.2) 38.8(14.0) 0.68
Patient gender
Male (%) 92(45.1%) 102(50%)
Female (%) 112(54.9%) 102(50%) 0.32
Family history of cancer (%) 61(29.9%) 69(33.8%) 0.27
Family history of diabetes (%) 69(33.8%) 57(27.9%) 0.17
Family history of heart disease (%)
68(33.3%) 51(25.0%) 0.07
* The unit of analysis is the patient, these proportions include more then one observation per intern.
In the pre-curriculum chart abstraction nearly all of the patients had a demonstrated
need for at least one type of preventive health services recommendation.
Specifically, of the total number of patient files abstracted during the pre-
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curriculum change period, 36.3% needed cholesterol screening, 2.0% needed
hypertension management, 11.3% needed breast cancer screening, 25% needed
colorectal cancer screening, 24.5% needed cervical cancer screening, 41.6% needed
obesity counseling, 12.7% needed tobacco cessation, 70.1% needed physical activity
counseling, 96.6% needed dietary counseling of the total cohort (either no dietary
information was available or evidence of need for low-fat dietary recommendations
was evident) (Table 17). Similarly, in the post-curriculum chart abstraction nearly
all of the patients had a demonstrated need for at least one type of preventive health
services recommendation. Specifically of the total number of patient files abstracted
during the post-curriculum period 36.8% needed cholesterol screening, 3.4% needed
hypertension management, 9.8% needed breast cancer screening, 22.5% needed
colorectal cancer screening, 28.9% needed cervical cancer screening, 43.6% needed
obesity counseling, 24.5% needed tobacco cessation counseling, 89.2% needed
physical activity counseling, 98.5% needed dietary counseling (either no dietary
information was available or evidence of need for low-fat dietary recommendations
was evident) (Table 2). The need for recommendations for changes in physical
activity (p = 0.00) and smoking cessation (p = 0.009) increased significantly between
the pre- and post-curriculum change periods. There was a trend of decreasing
documentation of dietary information in the charts between the pre- and post
curriculum change periods, although this difference was marginally statistically
significant (p = 0.05).
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Table 17: Proportion of Patients Needing Preventive Health Services
Recommendations
% Pre-curriculum
change group needing
recommendations
(n=204)
% Post-curriculum
change group needing
recommendations
(n=204)
Cholesterol Screening 36.3 36.8
Hypertension management 2.0 3.4
Breast cancer screening 11.3 9.8
Colorectal cancer screening 25.0 22.5
Cervical cancer screening 24.5 28.9
Obesity counseling 41.6 43.6
Tobacco cessation counseling 12.7 24.5*
Physical activity counseling 70.1 89.2*
Dietary counseling 96.6 98.5
*Statistically significant difference.
Of the 408 charts examined there were only four documented instances (1.0%) of
recommendations for any of the nine preventive health service categories. Two
recommendations occurred in the pre-curriculum change period. One event involved
the student intern sending the patient out for blood cholesterol testing. Follow-up for
this one event was documented in the chart. The second recommendation was for a
cervical cancer screening in which a pap smear was recommended. There was no
evidence of follow-up for this event documented in the chart. The two
recommendations that occurred in the post-curriculum change period were for blood
pressure screening. Two patients who were identified as having high diastolic or
systolic blood pressure during their clinic visit and had no previous history of
medical management for hypertension were referred out for medical management of
high blood pressure. There was no documentation in the chart for either of these two
patients which reflected whether or not they had followed-up with the initial
recommendation.
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Discussion
The results of this pilot study indicate that there has been no observable impact on
intern behaviors toward educating patients in preventive health services since the
dissemination of the model public health curriculum at one of the chiropractic
colleges in the United States.
One explanation for the minimal impact may be the minimal amount of the time
devoted to screening and clinical preventive services in the curriculum. The model
public health curriculum is designed to be offered as a 45 hour course that only
allocates a total of six hours of didactic coursework devoted to specific health
promotion concepts. Of these six hours, three individual hours cover smoking,
physical activity, and substance abuse respectively. One additional hour is divided
between three topics; stress reduction, weight management, and injury prevention.
The last two hours are devoted to topics regarding populations with special needs.
Since a normal chiropractic training has 4400 to 5500 contact hourse, the public
health curriculum is less than 1% of the overall training.
Another potential explanation for the lack of change in student intern behaviors
could be the issue of program fidelity (was the model curriculum disseminated and
were the core content areas implemented as intended). The Academic Dean verified
that indeed the model public health curriculum syllabus documentation was given to
the course instructor. A comparison of the CCCLA public health syllabi and course
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notes with the Model Public Health curriculum indicated that the topics articulated in
the Model Curriculum were covered by the instructor and this was subsequently
confirmed verbally by the instructor as well. Thus, the curriculum appears to have
been disseminated and core subject areas implemented as intended.
Another possible limitation to this pilot study is the possibility that interns were
providing the recommendations but not charting these conversations nor
documenting recommendations. A focus group was held during clinic rounds with
interns who were exposed to the model curriculum. These interns, upon prompting,
remembered covering topics related to clinical preventive health screening in their
public health coursework, but they had clearly not internalized that they were
responsible for assessing for these types of needs in their patients. While there was
no philosophical objection voiced to patient’s utilizing this method of prevention,
there had been no understanding developed or responsibility assumed by interns to
provide services other than those related to finding and adjusting subluxations.
Conclusion
The majority of chiropractors see themselves as musculoskeletal specialists, focusing
on the treatment of functional, reversible mechanical conditions.1 7 4 The majority of
chiropractic patients appear to agree, utilizing chiropractic as a complementary
and/or alternative approach to medicine (CAM) that enhances their musculoskeletal
health, while continuing to seek usual and customary medical care for the wider
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breadth of systemic problems.1 7 4 Some patients transition from a strictly medical to
a complementary and occasionally a complete alternative care approach, particularly
when medicine fails to provide help for a chronic health problem. It is at this
boundary, where medicine becomes less articulate, that some patients find
satisfaction with a complementary or alternative health care practitioner who can
offer a compassionate, hands-on answer.
Chiropractic colleges normatively train chiropractors to differentiate between, and
care for, a variety of clinical conditions, although this training is frequently limited to
a didactic learning environment. While chiropractors exhibit some clinical
characteristics related to primary care, there is evidence that suggests that there is a
strong need to increase the delivery of non-musculoskeletal preventive health
services.1 0 4 A 1995 survey reported that chiropractors checked blood pressure on all
of their patients only 34.9% of the time, performed a complete physical examination
on only 29% of all patients, and a took a complete health history on 71.3% of all
patients seen.1 0 4 The author concluded from this survey that; (l)some orthodox
prevention-related training is occurring in chiropractic colleges, (2) chiropractors
have an interest in learning more about preventive health services, and (3) the level
of clinical recommendations from chiropractors is far below their medical primary
care providers counterparts.
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Part of this underperformance may also be explained by the continued practice of
some chiropractors who emphasize the detection and removal of subluxations as the
sole method of primary prevention, leaving the recommendation of ‘orthodox”
i i -I r ir v | n n O f\Q T I O
clinical preventive services to other (allopathic) health care providers. ’
While patients may be willing to transfer care to a CAM provider when medicine
fails to provide relief for a specific condition, it does not necessarily follow that
patients are willing to forego the balance of other evidence-based clinical preventive
services aimed at preventing diseases such as prostate, breast, and ovarian cancer for
subluxation care. Just as patients are frequently frustrated by allopathic omission in
discussing chiropractic options for musculoskeletal conditions, it would seem a
reasonable corollary that patients would expect an informed choice regarding health
prevention from their chiropractors. It is also unclear how chiropractors will assume
a role such as primary care provider if they do not consistently educate their patients,
when appropriate, regarding standard clinical preventive services. Researchers
within chiropractic have echoed similar concerns regarding chiropractic colleges’
general lack of emphasis on student training in (1) evidence-based prevention and
health promotion methods, (2) how to provide health education to patients, and (3)
the significant lack of interdisciplinary collaboration with public health
professionals.1 0 2
At the time of the development of the model public health curriculum, chiropractic
proponents for health reform in public health education voiced their concerns in
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proposing a traditional lecture class in public health. These types of learning
environments, which are segregated from clinical experience, run the risk of being
limited in their clinical relevance. These public health reformers expressed their
reservations and concerns that a traditional lecture format alone would not
adequately prepare graduates to practice health promotion and provide clinical
preventive services. It seems likely that while the changes to the chiropractic public
health curriculum was a useful preliminary step, the ability of chiropractors to
provide enhanced public health services will require additional training to reinforce
these concepts in a clinically relevant learning environment in order to impact
chiropractic interns’ preventive health service behaviors.
Healthy People 2010 opines that “Community partnerships, particularly when they
reach out to nontraditional partners, can be among the most effective tools for
747
improving health in communities”. This is clearly an invitation for chiropractors,
with their historic roots as conservative, holistic health care providers, to make an
impact by participating in organized efforts associated with meeting national goals as
set out by Healthy People 2010. While Healthy People 2010 calls for practitioners
and other interested stakeholders to assist in improving the nation’s health through
evidence-based interventions that work, it remains to be seen if the nation’s
chiropractic educators will step up to the task of preparing graduates to take an active
role in engaging in these types of clinical prevention health screenings and
interventions.
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Chapter Three: Improving Preventive Health Services Training in Chiropractic
Colleges: A Feasibility Study to Introduce a Brief, Clinically Relevant, Smoking
Cessation Training Program
A. Specific Aims
Improving the nation’s health is of primary importance in this current health care
environment of increased costs. Many of the most significant causes of mortality are
associated with behavioral risk factors such as smoking, obesity and sedentary
lifestyle. National plans for improving the Nation’s health, such as those articulated
in Healthy People 2010, call for health care providers and workers and other
interested community stakeholders to seek methods of addressing major focus areas
and objectives aimed at improving current health indicators. Recently, with the
increased utilization of alternative and complementary medicine within the United
States, chiropractors have emerged as a potential, but as yet, relatively untapped
resource in the battle to improve the health status of Americans through the
recommendation of normative preventive care services such as smoking cessation
and cholesterol and cancer screening. Chiropractic educators and researchers have
taken steps to begin a shift in the educational focus of chiropractors and chiropractic
training by increasing focus on preventive health recommendations during didactic
coursework. To date, no clinically relevant training has been reported in the area of
normative clinically preventable disease recommendations. This proposal describes
a study to determine the feasibility and impact of a clinically relevant intervention
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designed to increase the frequency of preventive care recommendations among
chiropractic interns.
There are three specific aims this study will accomplish:
Specific Aim #1: To develop a clinically relevant, intem-level, health promotion
intervention specifically targeting an increase in recommendations for tobacco
cessation.
Specific Aim #2: To conduct a program intervention in a population of chiropractic
interns, during their clinical training, aimed at increasing the frequency of
recommendations to patients for smoking cessation.
Specific Aim #3: To evaluate the program impact on the frequency of smoking
cessation recommendations at the intern provider level.
Preliminary data indicates a need for increased smoking cessation recommendations
among the providers targeted by this intervention. The public health importance of
tobacco cessation and the attending anti-smoking messages are congruent with
chiropractic principles of emphasizing a drug-free approach to health and healthy
lifestyle. Additionally, it is the responsibility of chiropractors who see patients in a
primary care setting to inform patients of the important health risks related to
tobacco and to encourage cessation. Finally, it is important that chiropractic interns
expand their training focus from one disproportionately centered on the treatment of
musculoskeletal conditions to a broader set of health promotion indications, thus
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increasing self-efficacy and fostering appropriate attitudes towards making
recommendations on a wider range of prevention measures within the communities
these interns will ultimately serve. Smoking cessation, as the target for the health
promotion intervention, is feasible within the constraints of the packed clinical
curriculum as a first step in expanding the health promotion recommendation
competencies beyond ones related to conditions quite familiar to chiropractors, such
as the recommendations related to obesity.
As the clinical training component of chiropractic education is rather compressed
(normally 2 semesters), with interns under sizable stress to complete their clinical
requirements, the initial feasibility of addressing all possible preventive health
indications is rather unrealistic. It is for this reason that a highly focused, clinically
and population-based relevant intervention is preferably. We believe that this study
will greatly expand our knowledge related to the efficacy and effectiveness of this
type of clinical intervention in changing intern attitudes, self-efficacy and practice
behaviors. Understanding how to change intern practice behavior by reinforcing the
role perception, attitudes, and self-efficacy skills related to preventive health
behaviors is fundamental to improving a much broader set of preventive health
recommendation behaviors.
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B. Background
B .l Significance of Problem
The mortality statistics regarding tobacco use are quite grim. With 440,000 deaths
each year, tobacco use is the single largest cause of preventable premature mortality
in the United States”.1 5 6 In addition to the human costs associated with smoking
related deaths, there is also the matter of the 100 billion dollars spent annually in the
U.S. that results in an enormous financial burden as well as presents an opportunity
cost for pursuing other pressing health care needs.2 4 5 While medical providers
readily acknowledge the significance of smoking cessation as a fundamental issue in
disease prevention, a limited number of these physicians report the necessary
1 j } 1 1 Q £
confidence in their skills in assisting patients with quitting their smoking habit. ’
214, 251,259
B.2 Utilization of Complementary and Alternative Medicine (CAM):
Chiropractic Focus on Preventive Care
Interestingly, while some Americans continue to engage in unhealthy behaviors,
such as tobacco use, that lead to serious preventable morbidity and mortality over the
past decade there has been increasing utilization of complementary and alternative
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care interventions aimed at promoting improved health and preventing disease. A
significant proportion of these encounters are utilized for chiropractic services.
Chiropractic researchers and educators, understanding the opportunity to contribute
to Healthy People 2000 and 2010 goals and objectives, have begun to lead the
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profession in an effort to expand the chiropractic paradigm of wellness, customarily
focused on musculoskeletal complaints, to include normative preventive health
services. As a first step to move the profession towards greater preventive health
care service awareness, a model public health education curriculum guideline was
developed and distributed to U.S. chiropractic colleges.1 0 7 As discussed later in this
grant proposal, these efforts, while a necessary preliminary step, have yet to result in
an impact on clinical behaviors. The literature clearly explains the limitations
associated the low yield associated with didactic coursework absent the
£ ■ Q O ’! 1
reinforcement of a clinically relevant learning environment. ’ ’ That is why a
clinically relevant intervention is proposed, taking place during chiropractic clinical
internship, to further address barriers to improved frequency of provide preventive
care service recommendations, and specifically smoking cessation counseling.
Clearly, the potential for encouraging the diffusion of normative health promotion
and disease prevention behaviors to this nation’s 60,000 chiropractors makes this
group a high priority target for educational intervention. The nascent opportunity to
move this profession towards a greater public health role within the integrated health
delivery system would certainly assist other public health stakeholders in reaching
our nation’s 2010 and those that reside beyond.
Rising with the enormous growth of alternative care utilization in the United States
has been transformative changes in the health care delivery system. Greater public
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accountability has driven health school educators, throughout the medical and allied
health professions, to reexamine their curricula to insure the inclusion of preventive
255
health services . This pattern of change recognizes of the important connection
between the objectives and goals of the public health system and the goal of
delivering superior health services.2 4 '26,2 5 8 The literature informs us of a survey of
preventive medicine educators in U. S. medical schools, which illustrated that fewer
than 60% of the educator respondents held the expectation that their students should
be knowledgeable about the delivery of population-based health care and only a very
small proportion of these educators evaluated their students in this competency.9 0
In the meantime, the chiropractic colleges throughout the United States have
distributed a model public health curriculum in the hopes of directing greater focus
in the training of chiropractic students on health promotion and disease
prevention.1 9 5 Preliminary assessment had revealed that chiropractors were
frequently failing to make and follow through with recommendations regarding
preventive health services such as weight loss and exercise.1 0 7 It was believed that
one factor responsible for this rather poor behavioral outcome was the lack of a
modem public health curriculum that emphasized clinical preventive services. In
response to this concern, a consortium of interested health stakeholders, led by a
consensus panel of researchers, representing a broad spectrum of health care
disciplines, chiropractic faculty and administrators received funding to study the
current public health programs offered in chiropractic colleges and make
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recommendations for curricular improvements through a model public health course
1 0 7
of study. These model curriculum efforts mirrored goals addressed in Healthy
People 2010 regarding education of the health professions, particularly aims to
increase the proportion of medical professional training schools whose basic
curriculum for health care providers includes the core competencies in health
promotion and disease prevention.2 4 2
B.3 Limitations in Chiropractic Public Health Training
The overall consensus reached by these reform advocates was that current
chiropractic college instruction, both in topical focus and teaching methodology, was
inadequate in light of the current patient preferences and healthcare marketplace.1 0 7
Didactic lecture format, where the focus is on memorization of facts (an approach
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reflecting a relatively low level of cognitive abstraction and learning) was the
primary pedagogical approach. This was determined as having a decidedly
inhibiting effect on the practical utilization and implementation of this information in
a clinical setting. Rare was any evidence, in chiropractic course catalogs, of learning
environments where clinical preventive service (CPS) skills were actually practiced
in a ‘hands on format’ and rarer still was evidence of integrating and applying these
CPS skills during patient-base clinical training.9 6 While chiropractic students are
trained to progress from didactic classroom experiences to acquisition of clinical
skills in a ‘student clinic’ format to actual ambulatory and practice-based clinical
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training, emphasis on preventive health services is not part of this progression in
training.
Recently, medical education research has responded with a movement towards
developing cases that are clinically relevant1 4 5 , and presenting these cases during
medical training.1 2 ’4 8 ’4 9 ’6 9 ’7 0 ’1 4 2 ’1 5 4 ’1 6 4 ’1 7 9 ’1 8 1 ’1 8 2 ’1 9 0 These teaching methods
integrate curriculum towards a community-based population focused prevention,
frequently embrace an adaptable instructional approaches, such as small group
discussion, to enhance flexibility of the learning environment. Study of the
effectiveness of this approach in student learning has demonstrated significant
improvements in medical student skills in population-based prevention. ’ There
is no evidence of any chiropractic studies that have investigated this type of
clinically relevant approach to improving student cognitive, affective, and behavioral
skills toward the practice of clinical preventive care service delivery.
B4. Selecting the Appropriate Healthy People 2010 Objective
Many of the focus areas outlined in Healthy People 2010 are immediately and highly
relevant to chiropractic practice. Chiropractors are demonstrably well-matched to
developing an important position in providing health promotion and disease
prevention services in their communities. Many chiropractors already provide
community wellness information at the individual patient level or through public
wellness classes.104,106,209,2 1 0 Additionally, many chiropractors report that they
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currently counsel their patients about diet, exercise, and lifestyle modifications in an
effort to encourage wellness among their patient base.106 ,2 0 9 ’2 1 0 By adopting other
normative clinical preventive service screening procedures targeted in Healthy
People 2010 focus areas, such as smoking cessation, chiropractors could have a
significantly broader impact on the nation’s health and serve as a model health care
provider for wellness, health promotion and disease prevention.
Chiropractic interns are under a great deal of pressure to complete their clinical
requirements during their two semester internship. The initial semester is based out
of the outpatient health center located within the chiropractic college where the
interns encounter ambulatory patients seeking help primarily for musculoskeletal
complaints. During this first semester of clinical training they also must
concurrently enroll in 16 additional units of didactic coursework. For some interns
who manage to have completed their requirements ahead of schedule, there is the
highly coveted opportunity to spend a proportion of their final semester at an
external internship site with an affiliated field practitioner. Given the already
intensive demands and comparatively brief proportion of the training that occurs in
the clinic, it would be unwise to implement a pilot intervention that was too far-
reaching and demanding of time and intern cooperation. This is supported by the
one report of an intervention in a chiropractic training program. In that study, the
investigator attempted to deliver a clinically relevant intervention to clinic interns,
but this was abruptly terminated by the investigator when interns protested the an
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excessive burden of three additional didactic hours of coursework per week.9 6
Therefore the feasibility of addressing all possible preventive health indications is
rather unrealistic. It is for this reason that a highly focus, clinically relevant
intervention is preferable. It is also important to choose an intervention that exhibits
a ‘good fit’ with chiropractor attitudes and practice patterns. A smoking cessation
program was selected as the program intervention for several reasons. The public
health importance of tobacco cessation and the attending anti-smoking messages are
congruent with chiropractic principles of emphasizing a drug-free approach to health
and healthy lifestyle. Additionally, it is the responsibility of chiropractors, who see
patients in a primary care setting, to inform patients of the important health risks
related to tobacco and to encourage cessation. Finally, it is important that
chiropractic interns expand their training focus from one disproportionately centered
on the treatment of musculoskeletal related conditions to a broader set of health
promotion indications, thus increasing self-efficacy and fostering appropriate
attitudes towards making recommendations on a wider range of prevention measures
within the communities these interns will ultimately serve. Smoking cessation as the
target for the health promotion intervention is both feasible within the constraints of
the packed clinical curriculum and as a first step in expanding the health promotion
recommendation competencies beyond traditional chiropractic clinical targets.
The evidence is actually quite good that any brief counseling on the part of a health
care provider is “effective in increasing the proportion of smokers who successfully
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quit smoking and remain abstinent after 1 year” (See table 18).2 4 7 It is clear from
the recommendations of the U.S Preventive Services Task Force recommendations
that if providers counsel their patients regarding smoking cessation, there is a
consistent and predictably consequent impact on patient behaviors.
Table 18: U.S. Preventive Services Task Force (USPSTF): Counseling To
Prevent Tobacco Use and Tobacco-Caused Disease2 4 7
Recommendation
Statement
“The USPSTF strongly recommends that clinicians screen all adults
for tobacco use and provide tobacco cessation interventions for those
who use tobacco products.”
Rating Recommendation A*
Rationale “The USPSTF found good evidence that brief smoking cessation
interventions, including screening, brief behavioral counseling (less
than 3 minutes).................. are effective in increasing the proportion of
smokers who successfully quit smoking and remain abstinent after 1
year. Although most smoking cessation trials do not provide direct
evidence of health benefits, the USPSTF found good evidence that
smoking cessation lowers the risk for heart disease, stroke, and lung
disease. The USPSTF concluded that there is good indirect evidence
that even small increases in the quit rates from tobacco cessation
counseling would produce important health benefits, and that the
benefits of counseling interventions substantially outweigh any
potential harms.”
‘A’*
Rating
Definition
“The USPSTF strongly recommends that clinicians provide [the
service] to eligible patients. The USPSTF found good** evidence that
[the service] improves important health outcomes and concludes that
benefits substantially outweigh harms.”
‘Good’** Evidence
Definition
“Evidence includes consistent results from well-designed, well-
conducted studies in representative populations that directly assess
effects on health outcomes.”
B5. Evidence for Smoking Cessation Interventions
There is little doubt regarding the recognition among medical providers of the
significance of smoking cessation as a fundamental tool in disease prevention, yet a
limited number of these physicians report confidence in their skills at assisting
1ST l Ofi Old. 0S1 OSQ
patients in quitting their smoking habit. ’ ’ ’ ’ Various factors have been
identified in explaining the minimal physician activity towards smoking cessation
including an absence of counseling skills, limited awareness of the significant
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impact of their efforts on patient quitting behaviors, and the lack of patient education
materials to assist them and their patients in this disease prevention behavior.1 8 ,1 8 3 ,
185, 186, 251,259
A literature review of tobacco use evidence-based recommendations1 1 4 supports the
efficacy of interventions to diminish the use of tobacco.40,76,95,113,139,140,216,218,219,
226,228,236,239,2 4 4 “Multicomponent clinical programs that included a provider
reminder system plus a provider education program, with or without patient self-help
cessation materials” was “strongly recommended”.1 1 4 The authors also concluded
that the following actions steps demonstrated statistically significant improvements
in cessation rates: (1) “implementing a tobacco-user identification system”, (2)
“providing physician education training to promote provider intervention”, (3)
utilizing “prompts and reminders”.1 1 4 Supporting these recommendations are those
of the U.S. Preventive Services Task Force (USPSTF), discussed above, which
recommends as effective “Brief tobacco cessation counseling interventions (3
minutes or less)” and which has been demonstrated to decrease overall tobacco use
rates.2 4 7 Furthermore, several studies, including one funded by the National Cancer
Institute, demonstrated that other health care providers, such as dentists, “can be as
effective as physicians in influencing patients to quit smoking”.1 6 0
Previous research confirms that in “as little as two hours”1 6 0 interns can develop the
necessary skills to help patients quit smoking. Additionally, the training can be
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“conducted by general faculty members and does not necessitate experts in smoking
cessation counseling”.1 6 0
C Preliminary Studies
C .l Pilot Study Evaluating Initial Model Curriculum
To evaluate the impact of the dissemination of the model public curriculum at
Cleveland Chiropractic College, Los Angeles, a retrospective pilot study was
performed to evaluate the frequency of patient clinical preventive health
recommendations made by interns, during their clinical training, who completed
their public health coursework after dissemination of the model curriculum versus
those completing their coursework during the time frame immediately proceeding
dissemination of the revised curriculum. The pilot study necessitated two,
independent sample, cross-sectional data abstraction periods as the interns from the
baseline abstraction period had subsequently graduated by the time the post
curriculum change abstraction period occurred.
Pre- and post model public health curriculum dissemination dates were determined
using the May, 2001 distribution date of the “Model Course for Public Health
Education in Chiropractic Colleges” (see appendix 7 for modal public health
curriculum development and dissemination dates). The initial task force meetings to
develop the revised public health curriculum were held in September of 1998. The
pre-curriculum sample was abstracted from 204 charts of 93 interns with initial
examination dates prior to September 1st, 1998. In September of 2001, the first class
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at Cleveland Chiropractic College, Los Angeles that would be affected by any
change in the public health curriculum was exposed. This class began their clinical
training as interns in January, 2003. The following class to receive the curriculum
was used to establish the date for the post-curriculum change abstraction to allow
greater time for dissemination and implementation of the revised public health
curriculum. Therefore the post-curriculum data abstraction was carried out on 204
charts o f 78 interns with initial examination dates of May 5th, 2003 and later.
The frequency of nine patient clinical preventive health recommendations were
assessed. A standardized data abstraction tool was developed to collect data from
clinic charts that would establish a patient’s need for any one of these nine
preventive health services which could be provided by chiropractic interns. The
primary purpose of this tool was to collect factors from each chart that would
establish the need for preventive health services which could be provided by
chiropractic interns (tobacco cessation, physical activity, obesity, nutrition,
hypertension, reduction in dietary fat intake, blood cholesterol levels, and
recommendations for receipt of screening for cervical, breast, and colorectal cancer).
The chart abstraction form also collected evidence of documented preventive health
service recommendations, the date of recommendation, and whether or not there was
evidence that the recommendation was followed-up upon (by the intern and the
patient).
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C.2 Preliminary Study Results Evaluating Initial Model Curriculum
There were no statistically significant differences in demographic and family history
characteristics between the patients included in the pre-curriculum and post
curriculum groups. In both the pre-curriculum and post-curriculum groups nearly all
of the patients had a demonstrated need for at least one type of preventive health
services recommendation (see table 19).
Table 19: Proportion of Patients Needing Preventive Health Services
Recommendations
% Pre-curriculum
change group needing
recommendations
(n=204)
% Post-curriculum
change group needing
recommendations
(n=204) p-value
Cholesterol Screening 36.3 36.8 0.9182
Hypertension management 2.0 3.4 0.3591
Breast cancer screening 11.3 9.8 0.6286
Colorectal cancer screening 25.0 22.5 0.4873
Cervical cancer screening 24.5 28.9 0.2617
Obesity counseling 41.6 43.6 0.6888
Tobacco cessation counseling 12.7 24.5 0.0022
Physical activity counseling 70.1 89.2 0.0000
Dietary counseling 96.6 98.5 0.0218
Patient age in years (SD) 39.4(15.2) 38.8(14.0) 0.68
Patient gender
Male (%) 92(45.1%) 102(50%)
Female (%) 112(54.9%) 102(59%) 0.32
Family history of cancer (%) 61(29.9%) 69(33.8%) 0.27
Family history of diabetes (%) 69(33.8%) 57(27.9%) 0.17
Family history of heart disease (%) 68(33.3%) 51(25.0%) 0.07
Of the 408 charts examined (204 pre-, 204 post-curriculum change) there were only
four (2 pre, and 2 post) documented instances (1.0%) of recommendations for any of
the nine preventive health service categories. The results of this pilot study indicate
that there was no observable impact on intern behaviors toward educating patients in
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preventive health services since the dissemination of the model public health
curriculum at one of the chiropractic colleges in the United States.
One cause of the lack of change in student intern behaviors may be the lack of
emphasis on clinical preventive services, even with the model public health
curriculum. Only three individual hours are devoted to smoking, physical activity,
and substance abuse respectively. One additional hour is divided between three
topics; stress reduction, weight management, and injury prevention. The last two
hours are devoted to topics regarding populations with special needs. This six hours
of focus on health promotion and disease prevention occurs in the context of a
professional curriculum that normal spans 4400 to 5500 contact hours.
Interns are extensively trained to document all patient communications in a formal
progress note that contains the subjective complain, objective findings, clinical
assessment, and updated treatment plan. Students are required to chart
recommendations for home therapy including instructions for modalities such as heat
and cold, modification of activities of daily living as well as strengthening and
stretching exercises. Interns are even required to document the patient’s scheduled
follow-up visit in the progress note for each encounter. Documentation is required
for treatment encounters as well as telephone follow-up calls to monitor patient
response and progress. If communications about clinical preventive services were
occurring during clinical encounters, it would appear very unlikely that almost none
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of these (except for four) would have any associated supportive documentation. To
qualitatively assess whether preventive care behaviors were occurring but not being
documented, a focus group was held with 20 interns immediately after the post
curriculum data abstraction period. The principle investigator reviewed the findings
of the pilot study and questioned students about their practices related to clinical
preventive services. The interns admitted that they were preoccupied with (1)
developing their skills in treating musculoskeletal conditions and (2) fulfilling their
clinical requirements for graduation and were not providing other clinical preventive
service recommendations.
The results also indicate that the most notable increase in need for preventive health
recommendations within the chiropractic college health center population was that
for smoking cessation counseling, with a nearly 100 percent increase during the pilot
study interval. Besides the fact that accrediting bodies require health promotion
competences5 5 , these data clearly support evidence in the literature of a need to
develop effective, clinically relevant program interventions to increase the frequency
of preventive care services among chiropractic interns.1 0 4
C.3 Pilot Study of A Chiropractic Preventive Health Survey
The purpose of this study was to obtain a preliminary look at the feasibility of
completion and distribution of responses of a Chiropractic Preventive Health survey
which will be used as an assessment tool in the intervention.
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Previous research has shown that provider behaviors are related to intern
characteristics (such as age and gender), knowledge of preventive care, prior
preventive care beliefs, and self-efficacy. Intention to refer to a medical doctor or to
provide clinical preventive services is also an important measure of any curricular
program targeting chiropractic provider clinical behaviors. A pilot survey
questionnaire was developed to preliminarily explore intern characteristics and self-
reported behaviors. Demographic items included; 1) age, 2) gender, 3) ethnicity, 4)
marital status, 5) number of children, 6) trimester enrolled in, 7) highest pre
chiropractic degree held, 8) employment history, 9) source of usual primary care.
Five questions assessed attitudes and beliefs towards preventive health; four
questions assessed attitudes influencing choice of profession; six questions assessed
perceptions of chiropractic’s role in health promotion; twelve questions assessed
intention to provide normative preventive care services (PCS) and nine assessed
intention to refer for PCS; four questions assessed self-efficacy for smoking
cessation counseling; and 14 questions assessed knowledge of indications for PCS.
(see appendix 1) This survey was administered to 20, 8th trimester students,
currently enrolled in their first semester of a two semester internship, at Cleveland
Chiropractic College as a pilot test to review question design, burden, and question
scale variability.
Frequency distributions were calculated for every item. The Likert scales, originally
entered into the database as 1 (lowest of the construct) to 5 (highest of the construct)
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were converted for analysis purposes to a range of 0 (lowest of the construct) to 100
(highest of the construct). Next, mean scale scores for Self-Efficacy and Intention to
Screen or Refer were calculated by computing the arithmetic means of the items that
were theoretically associated with the scale. For instance, four items were
theoretically associated with the Self-Efficacy Scale. The mean of the four items
was calculated to determine the Self-Efficacy Scale. The knowledge score was
calculated by summing the number of correct responses out of total 14 possible. The
score was calculated by dividing the sum by 14 and multiplying by 100.
C.4 Results of Pilot Chiropractic Preventive Health Survey
All 20 students completed the questionnaire. One student had missing data, where
one entire page was inadvertently skipped. The questionnaire was completed in 15
minutes, on average. Frequency distributions of all questions were completed (see
appendix 1). Respondents ranged in age from 21 - 35. The majority (40%) were
Asian, while 25% identified themselves as Hispanic or Latino, and 20% as White.
Half were bom in the United States. More than half, 55% had never been married
and most (85%) did not have any children. Fifty-five percent had a Bachelor’s
degree and 80% reported that Chiropractic was their first career. The interns
predominantly used either Chiropractors (45%) or Medical Doctors (40%) as their
primary care providers.
The frequency distributions for most items were distributed across the range of the
five point Likert scale (1 = strongly disagree to 5 - strongly agree). Self-Efficacy
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and Intention Scores are presented in Table 20 (C2). The mean knowledge score was
71%. The assignment of items to scales was assessed by a preliminary factor
analysis. However, due to the small sample size a stable factor structure could not be
determined.
Assessment of the responses to the pilot data resulted in a reduction of the number of
items in the survey. Review of these deleted items revealed that they either did not
match the conceptual model or had ceiling effects. Also, the Intention to Screen or
Refer questions were separated into different items initially (i.e., “Do you intend to
screen high cholesterol” was a separate item than “Do you intend to refer to an
medical doctor for high cholesterol screening”). After reviewing the distribution of
responses to these questions it became clear that some students planned to refer
while others planned to provide the health promotion activity themselves. This is
consistent with the scope of chiropractic practice. For intention questions for which
the actual activity would not be within the scope of practice only the intent to refer
form of the question will be included (such as PAP or mammogram).
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Table 20: Summary of Efficacy and Intention Scores
Self-Efficacy Scores* Mean± SD
I have the skills necessary to help my patients quit smoking. 38.8 22.2
I have the confidence that I can help my patients quit smoking. 46.3 27.2
Overall, I feel very comfortable with how to recognize when
patients require regular preventive health recommendations. 82.5 14.3
Overall, I feel very comfortable discussing regular preventive
health recommendations with patients. 90.8 12.4
Mean Self-Efficacy Scoref 79.9 7.9
Intention Scores** Mean± SD
SmokingJJ
Smoking: DC intends to screen 90.0 15.0
Smoking: DC intends to refer to MD 76.3 15.1
Cholesterol:}: j
Cholesterol: DC intends to screen 52.5 30.3
Cholesterol: DC intends to refer to MD 82.5 25.8
Blood
PressureJJ
BP: DC intends to screen 91.3 14.7
BP: DC intends to refer to M D 87.5 15.2
Breast
Cancerft
Breast cancer: DC intends to screen 23.8 27.5
Breast cancer: DC intends to refer to MD 93.8 13.8
P A P ft
PAP: DC intends to screen 12.5 25.0
PAP: DC intends to refer to M D 98.8 5.6
Colorectal
C A ff
Colorectal CA: DC intends to screen 12.5 23.7
Colorectal CA: DC intends to refer to MD 98.8 5.6
Obesity % %
Obesity: DC intends to screen 88.8 15.1
Obesity: DC intends to refer to MD 51.3 29.8
Sedentary! t
Sedentary: DC intends to screen 90.0 12.6
Sedentary: intends to refer to MD 37.5 29.8
D ietf J
Diet: DC intends to screen 84.4 13.2
Diet: intends to refer to MD 39.3 31.6
Mean Intention ScoreJ 64.2 12.9
* Survey revision includes all original self-efficacy items.
tM ean o f four items (0 lowest self-efficacy to 100 highest self-efficacy).
**Survey revision combines PCS recommendations into intention to screen and/or refer to
MD for each PCS indication.
t Mean o f eighteen items (0 lowest intent to 100 highest intent).
The two items in this category will be combined into one question for the revised questionnaire
(e.g. the DC intends to screen or refer to an M D for cholesterol screening).
t t The two items in this category will be reduced to one question for the revised questionnaire asking
only if the DC intends to refer to an M D (e.g. the DC plans to refer the patient to an M D for colorectal
cancer screening).
± Computed on a 0 lowest to 100 highest scale.
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D. Methods
Overall, three specific aims will be accomplished. These aims are to:
(1) To develop a clinically relevant, intern-level, health promotion
intervention specifically targeting an increase in recommendations for
tobacco cessation.
(2) Conduct a program intervention in a population of chiropractic interns,
during their clinical training, aimed at increasing the frequency of intern
recommendations for smoking cessation to patients.
(3) Evaluate the program impact on the frequency of smoking cessation
recommendations at the intern provider level.
D .l Specific Aim 1: To develop a clinically relevant, intern-level, health
promotion intervention specifically targeting an increase in recommendations
for tohacco cessation.
D.1.1 Intervention Design: Conceptual Framework
The transtheoretical model delineates stages of change as an important factor
influencing behavior change. 196,1 9 7 This theory has shown encouraging evidence of
validity in several health research studies.1 9 8 This research indicates though that an
effective model includes multiple approaches that utilize optimal intervention
methods at each particular stage along the change continuum, thus facilitating the
improved health behavior change outcome at each stage. For example, those interns
at a preliminary stage, precontemplative or contemplative are best targeted with
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educational strategies while reminders should be directed towards stages occurring
later in the change continuum, such as the action stage. The transtheoretical model
of change has been successfully utilized in smoking cessation studies as well as other
behavior change intervention targets.152,199,2 0 6 To help facilitate emphasis and
targeting of intervention program components, as well as measure post-intervention
stage change outcomes, intern stage of change will be identified through the use of a
short series of questions incorporated into pre and post-intervention surveys.
D.1.2 Intervention Design: Model Application
A brief example, using the transtheorectical model of behavior change, is instructive
to see how the model can be useful in guiding the design of an intervention. Imagine
that we want to change the behavior of individuals so that they consistently use a
condom when engaging in sex for purposes other than reproduction. The
precontemplative stage would refer to individuals who had never heard of a condom.
The contemplative stage would apply to an individual who knew what a condom was
but perhaps needed to investigate the idea more, such as by considering which one to
purchase, where and how to make a purchase, and was still considering whether they
would actually use one even if purchased. The preparation stage would apply to an
individual who decided to have purchased a condom so that it would be available for
use. The action stage would describe an individual who was engaging in the desired
behavior, using a condom. The main issue occurring during the maintenance stage is
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the need to insure that behavior change continues on a consistent basis. It is
important for an investigator to insure that they have addressed the necessary stages
of change in their intervention otherwise the program impact will likely be
insufficient to achieve the desired behavior change. Figure 1 below summarizes how
all stages of the transtheoretical model will be addressed by the proposed program
intervention.
Figure 1: Using A Behavioral Model To Design The Program Intervention
Precontemplation Contemplation Preparation Action Maintenance
Basic Science
Training
+ r J
Intern
Predisposing
characteristics
Didactic
Courses:
- \ Public Health m
’ ’'PCS Knowledge
+
Prior Beliefs
I
PSC Intensions
Intervention as
| cue to action g
Self-efficacy
training
Intention to
screen for PCS
diseases g
Intern makes
smoking
cessation
recommendations
Clinician Prompts
!® +
Chart
Reminders
This model can be used to address the reasons why the didactic program used in the
introduction of the Model Public Health Curriculum was not successful in altering
the intern referral/health promotion behaviors. As can be seen in table 21 below, the
didactic program only addressed the process of change between the
precomtemplative and contemplative stage of the model with processes between
other stages not addressed by the Model Public Health Curriculum. This study
proposes to include activities which will address the processes of change between all
five stages of the model.
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Table 21: Model Public Health Curriculum Pilot Study Program Evaluation
Strategies
Stage of Adoption/Implementation
Pre-
contemplative Contemplative Preparation Action
Main
tenance
Change in
Didactice
Coursework
(Consciousness
Raising)
D.1.3 Development of Intervention Educational Materials
There exists an enormous amount of smoking cessation educational training
resources that are readily available and easily adaptable for the purposes of the
intervention. These materials were available at no cost and were adapted for
chiropractic intern use from three sources; (1) the World Federation of Chiropractic
smoking cessation campaign website, (2) the Office of the Surgeon General
website1 8 4 which contains numerous resources for consumer and clinicians, and (3)
Treating Tobacco Use and Dependence (“A Public Health Service-sponsored
Clinical Practice Guideline, ... a partnership among Federal Government and
nonprofit organizations comprised of the Agency for Healthcare Research and
Quality; Centers for Disease Control and Prevention; National Cancer Institute;
National Heart, Lung, and Blood Institute; National Institute on Drug Abuse; Robert
Wood Johnson Foundation; and University of Wisconsin Medical School’s Center
for Tobacco Research and Intervention”)1 8 4 . These resources were utilized in
developing the educational intervention including anti-smoking campaign posters, a
slide presentation information, a smoking cessation education handbook for interns
and clinicians, and a patient brochure. Previous research has indicated the
importance of keeping the training session simple and avoiding the use of excessive
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didactic instructional materials and this intervention has been designed to incorporate
this previously proven methodology1 6 0 .
Previous research has established specific smoking cessation interventional strategies
that are effective at each stage of change. In table 22 below, the educational
interventions utilized in this grant are listed with the standard intervention
approaches for the five stages of the transtheortical model.
Table 22: Smoking Cessation Intervention Strategies for Intern Training and
Transtheoretical Model Change Stages1 6 0 ______________________________
_________________ Stage o f Adoption/Implementation_________________
Strategies (Materials Precontem- Contem- Prep- Main-
for Interns)____________ plation plation aration Action tenance
Resource and
Referral List
(Educational
Handbook and
Patient Brochure)
Information About
Provider
Effectiveness (Slide
presentation and
educational
handbook)
Materials for
Patients
(Patient brochure)
V
Materials to
Identify Smokers
(Prompt in exam
form and Smoking
Cessation Counseling
Flowchart)
t/
Skill Training
Workshop for
Provider (Slide
presentation and role-
modeling workshop)
t/ ✓ /
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D.2 Specific Aim 2: Conduct a program intervention in a population of
chiropractic interns, during their clinical training, aimed at increasing the
frequency of smoking cessation recommendations to patients.
D.2.1 Research Design
The proposed intervention is a controlled, pre-post, experimental (panel) study,
consisting of a clinically relevant, educational program intervention with two waves
of data collection per study arm. The experimental arm will be conducted at the Los
Angeles Campus of Cleveland Chiropractic College and the control group, used to
detect history effects (such as occurrences in the external environment that may have
impacted smoking cessation recommendations), will be located in Kansas City (sister
campus to Los Angeles). Unlike the introduction of the Model Public Health
Curriculum, which clearly did not address all change stages, the proposed
intervention addresses all stages of change identified by the Transtheoretical Model.
D.2.2 Study Implementation
D.2.2.I Clinical Faculty In-Service and Training
One month prior to the intern-level educational intervention, the principal
investigator will present an extended in-service, including details of the program
intervention, the rationale, all program materials and any additional training
information requested by the clinical faculty. This extended in-service has been
authorized by the department chairman, and will appraise the clinical faculty of the
educational intervention and the program goals. The department chairman, has
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acknowledged his full support for the program intervention and will encourage
continued faculty support during the intervention period.
D.2.2.2 Intern-level Educational Program Intervention
Mandatory attendance at weekly Grand Rounds meetings is required of all clinic
interns. These Grand Rounds meetings, normally one and a half hours in length, are
designed to present relevant cases of interest, distinguished guest speakers and other
integrative seminar topics. The primary investigator, Gary Globe, MBA, DC, is a
frequent lecturer at these meetings. Dr. Globe will present the smoking cessation
intervention program. Dr. Globe is an experienced and skilled lecturer, capable of
delivering the educational program. Dr. Globe will be recognized by students as
having legitimate authority to expect their interest and cooperation secondary to (1)
their prior experiences with him during Grand Round lectures as well as other
courses (2) his recognized clinical expertise (3) and the institutional positions he
holds. Using Dr. Globe to deliver the intervention will help insure that the
interventional message and expectations are effective.
During the Grand Rounds session the smoking cessation program intervention
educational program will be presented and will include the following components;
(1) a 10-minute PowerPoint presentation that introduces factual information related
to smoking mortality and the relevance of smoking cessation to chiropractic practice,
(2) introduction of the World Federation of Chiropractic produced anti-smoking
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brochures and posters with reinforcement of relevance to intern clinical behaviors
through exposure to the expert referent group’s recommendations, (3) a smoking
cessation education handbook for interns (and clinicians) that reinforces numbers 1
and 2 above and presents strategies for use during the smoking cessation counseling
and (4) introduction of the patient smoking cessation contact protocol including the
use of the Smoking Cessation Counseling Flowchart, (5) a 10-minute videotape
demonstration of two effective counseling exchanges (one vignette of an interaction
with a motivated patient and one vignette with an unmotivated patient), followed by
a 20-minute group discussion to answer questions and assess (focus group format)
intern understanding of program aim and materials. This initial session will be
followed two weeks later by a series of small group sessions to discuss intem’s
preliminary attempts to counsel patients and to role-model/workshop with interns to
address any concerns regarding self-efficacy in counseling patients.
The education intervention is designed to address all intern behavior change stages.
Table 23 below presents the behavior stages and the associated programmatic
interventions.
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Table 23: Smoking Cessation Intervention and Program Evaluation Study -
Study Educational Program Tools______________________________ _____
Timepoint
Stage of Adoption/Implementation Program
Tool(s) Precontemplative Contemplative Preparation Action M aintenance
Pre
program
Knowledge of
Smoking PCS
Public
Health
Didactic
Course
Prior Beliefs &
Intentions
Applied to
PCS
N/A
Self-
Efficacy
N/A
Smoking
PCS
Screening
&
Referral
N/A
Continued
PCS
Screening
&
Referral
N/A
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Table 25: Smoking Cessation Intervention and Program Evaluation Study -
Study Educational Program Tools continued_____________________ ____
Timepoint
Stage of Adoption/Implementation Program
Tool(s) Precontemplative Contemplative Preparation Action M aintenance
Smoking
Cessation
Program
Intervention
Knowledge of
Smoking PCS
Slide
Presentation
On
Smoking
Prior Beliefs &
Intentions
Applied to
PCS
Presentation
ofWFC
Brochure &
Posters
Self-
Efficacy
Video
Vignettes
&
Role-
Modeling
Workshops
Smoking
PCS
Screening
&
Referral
Smoking
Question on
Exam Vital
Signs
Section
Prompt
Continued
PCS
Screening
&
Referral
Smoking
Cessation
Counseling
Flowsheet
Reminder
&
Ed.
Handbook
Timepoint
Stage of Adoption/Implementation Program
Tool(s) Precontemplative Contemplative Preparation Action Maintenance
Data
Collection
Period
&
Program
Monitoring
(Mns 1-4)
Knowledge of
Smoking PCS
Prior Beliefs &
Intentions
Applied to
PCS
Self-
Efficacy
Role-
modeling
workshops
&
Clinician
Prompts
Smoking
PCS
Screening
&
Referral
Continued
PCS
Screening
&
Referral
Review
Smoking
Cessation
Counseling
Flowsheet
Reminders
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Table 26: Smoking Cessation Intervention and Program Evaluation Study -
Study Educational Program Tools continued__________________________
Timepoint
Stage of Adoption/Implementation Program
Tool(s) Precontemplative Contemplative Preparation Action Maintenance
End of
Data
Collection
Period
Knowledge of
Smoking PCS
N/A
Prior Beliefs &
Intentions
Applied to
PCS
N/A
Self-
Efficacy
N/A
Smoking
PCS
Screening
&
Referral
N/A
D.3 Specific Aim 3: Evaluate the program impact on the frequency of smoking
cessation recommendations at the intern provider level.
D.3.1 Formative Measurements
This study will employ qualitative evaluation methods to support the interpretation
of the primary outcome measurement. Two focus group discussions (FGD) will be
conducted to qualitatively assess student beliefs, attitudes, cognitive skills and self-
efficacy related to providing smoking cessation counseling as well as other clinical
preventive services. Each FGD session will include 8 tolO intern participants and
will use a standardized moderator’s guide. Both FGD sessions will be held at the
Los Angeles campus (the experimental arm), one immediately prior to the
educational program intervention and one held again post-program. During the pre
intervention focus group, intern input will also be elicited regarding the proposed
intervention educational materials.
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This focus group discussion session will inform the finalization of the development
of the survey to collect information on the secondary and tertiary outcomes, (self-
efficacy and intention to recommend smoking cessation). Other explanatory
covariates surveyed will be intern demographics, knowledge of and attitudes towards
preventive care, prior preventive care beliefs, and stage of change. Previous research
has shown that provider behaviors are related to intern characteristics (such as age
and gender), knowledge of and attitudes towards preventive care, prior preventive
care beliefs, and self-efficacy. Intention to refer or treatment is also an important
measure of any curricular program targeting provider clinical behaviors. Fourteen
knowledge question, related to the timing of clinical preventive services, were
derived from the U.S. Preventive Task Force clinical preventive services guidelines.
Prior belief questions focus on intern philosophy of health related to natural methods
of heeling as well as personal preferences for preventive health care. The self-
efficacy questions assess general readiness to provide clinical preventive services as
well as specific readiness to counsel patients on smoking cessation. This Self-
efficacy and Intention survey (SI survey) will be administered to all interns in the
experimental arm at pre-and post-intervention timepoints. This SI survey has been
preliminarily pilot (Chiropractic Student Preventive Health Survey) tested to review
question design, burden, and question scale variability (see appendix 2). The post
study focus group discussion session will qualitatively evaluate the interns’
perceptions of the program intervention and program materials as well as
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improvement in intentions and self-efficacy related to providing smoking cessation
counseling.
D.3.2 Process Measurement and Program Monitoring
This study will employ process evaluation methods to insure the adequacy of
program exposure and reinforcement. During the pre-study baseline chart
abstraction period (before the program intervention is delivered) new patients will be
questioned by supervising clinicians to verify whether preventive service
recommendations were made by the intern, particularly smoking cessation
counseling. Chiropractic accreditation standards require that supervising clinicians
must directly observe a significant proportion of clinical encounters. Clinicians
normally review with patients their care plans and progress during these regularly
observed clinical encounters. Clinicians will be instructed to enquire about any
preventive care recommendations that were made to the patient by the intern. The
clinician will then review the progress notes to confirm whether any intern
recommendations or counseling were noted in the chart. If recommendations were
made or counseling was provided but not documented, the clinician will require the
intern to document the communication in the chart.
To insure that interns are reminded to counsel all patients who currently smoke, the
new patient registration clerk will be trained to identify these patients by reviewing
the patient history form section where this data is recorded. The new patient
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registration clerk will then insert a Smoking Cessation Counseling Flowsheet (see
appendix 3) into the chart so that interns are prompted to discuss smoking cessation
with these patients. The principal investigator in Los Angeles will review all new
patient charts each day throughout the study period to insure that the new patient
registration clerk is compliant with the study protocol. Additionally, the new patient
physical examination form will be changed to include a smoking status question
prompt in the box where the interns normally records the patient’s vital signs (see
appendix 4).
Through the use of the Smoking Cessation Counseling Flowsheet (see appendix 3),
interns will be reminded of the steps to follow in counseling patients to consider
smoking cessation and will be prompted to dispense a brochure on smoking
cessation to patients (see appendix 5). Interns will be trained and required to
document patient actions on the initial and subsequent visits including whether the
(1) patient is not interested in quitting smoking at the time of the visit, (2) patient
refused smoking cessation counseling attempts, (3) patient reports that s/he will
attempt to quit smoking, (4) patient is seeking additional help with smoking
cessation with another health care provider, or (5) patient reports that s/he has
discontinued smoking.
Interns are normally divided into four separate, small group discussion sections that
meet weekly to review clinical cases. A follow-up session will be held with each of
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these small group sections two weeks after the presentation of the intern education
intervention. The principal investigator will evaluate initial intern perceptions and
intern perceived effectiveness of the program training, assess intern patient
counseling progress, and problem-solve issues/barriers related to self-efficacy. The
principal investigator will workshop and role-play with interns during this session to
enhance intern counseling skills.
D.3.3 Outcomes Measurement
D.3.3.1 Prim ary Outcome - Change in Smoking Cessation Recommendation
Behavior
The primary methodology for assessing impact of the intervention on increasing
preventive health services recommendations will be through the use of a data
abstraction instrument (chart review) tool to assess the pre- and post-intervention
rates of recommendations by chiropractic interns (see appendix 6).
D.3.3.1.1 Chart Abstraction
Chiropractic interns are required, by State and National licensing agencies, to
examine a minimum of 20 different patients during their clinical internship training
program. A chart (data source documentation for this study) is maintained for each
patient with extensive self-reported patient data as well as physical examination,
imaging and clinical laboratory examination reports, progress notes, outside patient
records, and a three to five page narrative report for each patient the intern examines.
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Related to this intervention, charts of smokers will also contain a Smoking Cessation
Counseling Flowsheet (see appendix 3) that requires the intern to document whether
they recommended smoking cessation advice, a brochure or further information.
To obtain a pre-study baseline of recommendation frequency, all new patient charts
for the semester prior to the program intervention, will be reviewed utilizing a data
abstraction instrument (see appendix 6). This instrument has been previously
successfully utilized in the preliminary study. The new patient physical examination
will be modified, immediately prior to the baseline period initial start date, to include
(1) a simple yes or no question regarding the patient’s current use of tobacco and (2)
if the intern counseled the patient regarding smoking cessation (appendix 4). This
procedure is intended to increase the likelihood that any pre-intervention smoking
cessation counseling is documented in the chart. Interns will not be advised of the
planned intervention during this baseline period.
The initial chart selected for the baseline period will be the first new patient
presenting for treatment at the beginning o f this immediately preceding semester.
Immediately after the program intervention, which will be held during the first week
of the semester following the baseline period, all new patient charts will be reviewed
for the remaining 14 weeks of (the 15 week) semester, thus constituting the post
intervention period.
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A research assistant will be extensively trained to perform the chart abstractions.
This methodology was successfully utilized in the preliminary study. Prior to the
initiation of the study, the research assistant will perform chart abstractions on ten
charts and these will be reviewed and checked for accuracy by the principal
investigator. An in-depth interview will be performed to answer questions and
review procedures. The principle investigator will continue training the research
assistant until 95% agreement can be achieved on the overall abstraction data (and
100% agreement on the primary outcome of smoking cessation counseling) can be
achieved on 10 consecutive charts. Thereafter, the pre-intervention charts will be
abstracted until all new patient charts have been reviewed. Periodic review of chart
abstractions accuracy will be conducted for every 25th chart completed. Post
intervention (study period) charts will be abstracted four weeks after the completion
of the new patient examination. This will insure the necessary time for the intern to
have provided and recorded the initial smoking cessation counseling as well any
counseling or reported patient responses to the intervention on subsequent visits.
The principal investigator will assess completed chart abstractions to monitor early
program impact. Periodic review of chart abstractions accuracy will be conducted
again for every 25th chart completed. The control arm site (Kansas City) will follow
the same methodology but will perform chart reviews on 20% of the new patient
visits.
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The chart abstraction instruments will be delivered to the principle investigator who
will supervise the input of data into the statistics program SPSS, version 12.0 by a
research assistant. A ten percent data entry check will be performed to insure data
entry accuracy.
Other preventive health recommendations will also be abstracted for the purposes of
a secondary analysis that will assess whether there was any ‘carry-over’ effect of the
smoking cessation intervention on recommendations for other preventive care
services. The other preventive care service recommendations abstracted are; (1)
blood pressure screening, (2) screening for colorectal cancer, (3) routine screening
for breast cancer, (4) routine screening for cervical cancer, (5) screening for obesity,
(6), high blood cholesterol screening, (7) counseling patients on physical activity,
and (8) counseling to limit dietary intake of fat.
Chart abstractions will commence at the control site in Kansas City with the
initiation of the intervention program at the Los Angeles site. The new patient
physical examination form will modified so that it duplicates the changes made to
the Los Angeles site exam during the pre-intervention period. This will facilitate
confirmation of documentation of smoking cessation counseling provided at the
control site during the period of the intervention conducted in Los Angeles.
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D.3.3.2 Secondary Outcome - Change in Smoking Cessation Self-Efficacy
The SI survey instrument, discussed previously in section D.3.1, contains four
questions related to intern perception of self-efficacy related to smoking cessation
counseling, and will be analyzed for pre- post-intervention changes.
D.3.3.3 Tertiary Outcome - Change in Intention to Screen and/or Refer for
Smoking Cessation Counseling
The SI survey instrument also contains nine questions establishing intern intention to
screen for and provide smoking cessation counseling and/or refer the patient to a
physician for this purpose. The survey will be analyzed for pre- post-intervention
changes. Table 24 below presents the behavior stages, the associated programmatic
interventions and the proposed measurement instruments.
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Table 24: Smoking Cessation Intervention and Program Evaluation Study -
Summary of Measurement Instruments______________________ ________
Time
point
Stage of Adoption/Implementation
Program
Tool(s)
Measurement
Instrument Precontem
plative
Contem
plative
Prep
aration Action
M ain
tenance
Pre
program
Knowledge of
Smoking PCS
Public
Health
Didactic
Course
SI Survey:
Knowledge
Score
Prior
Beliefs &
Intentions
Applied to
PCS
N/A
SI Survey:
Intention Score
Self-
Effi
cacy
N/A
SI Survey:
Self-Efficacy
Score
Smoking
PCS
Screen
ing &
Referral
N/A
Retrospective
Chart
Abstraction
(prior 4 mns.)
Con
tinued
PCS
Screen
ing
&
Referral
N/A N/A
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Table 28: Smoking Cessation Intervention and Program Evaluation Study -
Summary of Measurement Instruments continued______________________
Time
point
Stage of Adoption/Implementation
Program
Tool(s)
Measurement
Instrument Precontem
plative
Contem
plative
Prep
aration Action
M ain
tenance
Smoking
Cessation
Program
Inter
vention
Knowledge of
Smoking PCS
Slide
Presen
tation On
Smoking
N/A
Prior
Beliefs &
Intentions
Applied to
PCS
Present
ation of
WFC
Brochure
& Posters
N/A
Self-
Effi
cacy
Video
Vignettes
&
Role-
Modeling
Workshop
N/A
Smoking
PCS
Screen
ing &
Referral
Smoking
Question
on Exam
Vital
Signs
Section
Prompt
N/A
Continu
ed PCS
Screeni
ng
&
Referral
Smoking
Cessation
Coun
seling
Flowsheet
Reminder
&
Ed.
Handbook
N/A
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Table 29: Smoking Cessation Intervention and Program Evaluation Study -
Summary of Measurement Instruments continued ________________
Time
point
Stage of Adoption/Implementation
Program
Tool(s)
Measurement
Instrument
Precontem
plative
Contem
plative
Prep
aration Action
M ain
tenance
Begin
Data
Collection
Period
&
Program
Monitor
ing
(Mns 1-4)
Knowledge of
Smoking PCS
Prior
Beliefs &
Intentions
Applied to
PCS
Self-
Effi
cacy
Role-
modeling
workshop
s
&
Clinician
Prompts
Smoking
PCS
Screen
ing &
Referral
Con
tinued
PCS
Screen
ing
&
Referral
Review
Smoking
Cessation
Coun
seling
Flowsheet
Reminder
Study Period
Chart
Abstraction
Timepoint
Stage of Adoption/Implementation
Program
Tool(s)
Measurement
Instrument
Precontem
plative
Contem
plative
Prep
aration Action
Main
tenance
End of
Data
Collection
Period
Knowledge of
Smoking PCS
N/A
SI Survey:
Knowledge
Score
Prior
Beliefs &
Intentions
Applied to
PCS
N/A
SI Survey:
Intention Score
Self-
Effi
cacy
N/A
SI Survey:
Self-Efficacy
Score
Smoking
PCS
Screen
ing &
Referral
N/A
Chart
Abstraction:
Change in
Proportion of
Recommen
dations
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D.4 Sample Size Calculations
D.4.1 Primary Outcome Measure Power Estimate
The number of interns currently ranges between approximately 70 to 80 students.
Previous literature indicates that, for multimodal interventions that include patient
education, provider reminders, and provider education, provider advice to quit
increased by 22 percentage points1 1 4 . A sample size of 70 students (assuming 100%
participation in the intervention, with alpha = .05; beta = 80%) will have the power
to identify a .621 probability that the proportion of recommendations in the post-test
will be greater than the proportion of recommendations in the pre-test for each intern
(nQuery Advisor 2.0).
D.4.2 Secondary & Tertiary Outcome Measure Power Estimate
Means and standard deviations of the Self-Efficacy and Intention scales from the
pilot study of the questionnaire were used to assess the minimal point difference that
could be measured in the secondary and tertiary outcomes, based on the sample size
estimate from the primary outcome (proportional change in intern
recommendations). A sample size of 70 in will have 80% power to detect a
difference in the mean Self-Efficacy score of 2.5 points (the difference between
mean pre-implementation Self-Efficacy score and mean post-implementation score)
assuming that the common standard deviation is 7.93 using a paired t-test with a
0.050 one-sided significance level. Similarly this sample size will have 80% power
to detect a difference in means of four-points (the difference between mean pre-
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implementation Intention score and mean post-implementation score) assuming that
the common standard deviation is 12.91 using a paired sample t-test with a 0.050
one-sided significance level.
D.5 Sample Selection
Both study groups will use convenience samples of all interns who are in the clinical
training segment of their education at each respective campus. Gary Globe, MBA,
DC, Ph.D[cand.], the principal investigator co-directs the outpatient training Health
Center at the Los Angeles campus of Cleveland Chiropractic college. He also holds
the positions of Associate Academic Dean, Acting Research Director, and directs the
educational performance and assessment activities for the clinical training program.
Mark Pfefer, MS, DC is the Research Director for the Kansas City campus and will
be coordinating the research study at this site.
D.6 Analysis Plan
D.6.1 Primary Outcome - Change in Smoking Cessation Recommendation
Behavior
Data will be collected at the patient level but the unit of analysis will be at the intern
level. Frequency distributions of the characteristics of patients included in the pre-
and post- intervention chart abstractions will be determined. The proportion of
patients per intern identified as needing preventive health services for smoking
cessation will be determined. Next the proportion of those patients per intern who
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reported current smoking will be determined. The difference in the proportion of
documented smoking cessation counseling events per intern documented in pre
intervention charts will be compared to the proportion documented in the post
intervention charts using a Wilcoxon rank-sum test. A review of 20% of the new
patient charts in the Kansas City delayed entry control arm during the Los Angeles
campus intervention study period will be performed to detect differences between
groups attributable to the program intervention.
D.6.1.1 Secondary Analysis: Impact on Patient Outcomes
Although the specific aims of this grant are primarily directed at assessing the intern
as the unit of analysis with respect to proportional change in a specific preventive
health behavior as well as change in the determinants (self-efficacy and intention) of
this behavior, a secondary analysis will be performed to measure change in patient
behavior secondary to the intern’s interventional actions. Although the primary
interest of this grant is the exploration of methods to improve the preventive health
recommendations of chiropractic interns, it is important to attempt to measure the
clinical impact and meaningfulness of these changes in intern behaviors. The
Smoking Cessation Counseling Flowsheet will be used by the Intern to document
study related data including patients’ responses to the smoking cessation
recommendations. Interns will be instructed to continue to elicit patient feedback
including whether they have contemplated making an attempt to quit, have sought
additional help with smoking cessation with another health care provider and
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whether the patient reports the they have discontinued smoking. Calculations will
be performed to determine the proportion of patients per intern who have (1)
attempted to quit, (2) have sought additional help with smoking cessation with
another health care provider and (3) report that they have discontinued smoking.
D.2 Secondary Outcome - Change in Smoking Cessation Self-Efficacy
Pre- and post-qualitative survey measurements of the change in self-efficacy
associated with smoking cessation counseling (Self-Efficacy Scale) will be analyzed
to detect differences secondary to the intervention program. The Self-Efficacy Scale
consists of four questions, with Likert scale response choices, that measure student
perception of self-efficacy. First, the Likert responses will be transformed from 1-5
(strongly disagree to strongly agree) to 0 to 100. Then the average of the four
questions will be calculated to create the Self-Efficacy Scale score. The scale will
range from 0 (lowest Self-Efficiacy) to 100 (highest Self-Efficacy). The Self-
Efficacy Scale will be analyzed for pre- and post-intervention means and standard
deviations. A paired t-test will be used to analyze statistically significance
differences in this scale pre- and post-intervention.
D.3 Tertiary Outcome - Change in Intention to Screen or Refer for Normative
Health Promotion Services
Pre- and post qualitative survey measurements of the change in intern intention to
screen or refer for health promotion/disease prevention counseling (Intention to
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Screen/Refer Scale) will be analyzed to detect differences secondary to the
intervention program. The Intention to Screen/Refer Scale consists of nine
questions, related to common preventive health screening targets, with Likert scale
response choices. First, the Likert responses will be transformed from 1-5 (strongly
disagree to strongly agree) to 0 to 100. Then the average of the nine questions will
be calculated to create the Intention to Screen/Refer Scale score. The scale will
range from 0 (lowest Intention to Screen/Refer) to 100 (highest Intention to
Screen/Refer). The Intention to Screen/Refer Scale will be analyzed for pre- and
post-intervention means and standard deviations. A paired t-test will be used to
analyze statistically significance differences pre- and post-intervention.
D.4 Regression models:
Regression models will be used to assess characteristics associated with changes in
intern counseling behavior.
Based on the preliminary study, we do not expect many of the pre-intervention chart
abstractions to include documentation of counseling interventions. If at least 10% of
the charts contain evidence of documented counseling for PCS we will assess the
baseline rates of counseling and the baseline characteristics.
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Baseline Rate of Smoking Cessation Counseling - demographics + baseline
preventive health beliefs + baseline self-efficacy + baseline intention to refer/screen
+ baseline knowledge
Next, we will assess the association of baseline intern characteristics with the
changes in the intern’s rate of smoking cessation counseling. This analysis will help
to identify interns who are more likely to be impacted.
Change in Rate of Smoking Cessation Counseling = demographics + baseline
preventive health beliefs + baseline self-efficacy + baseline intention to refer/screen
+ baseline knowledge
Finally, we will assess the association between changes in counseling
recommendations and changes in intern self-efficacy and intention after
implementation of the program:
Change in Rate of Smoking Cessation Counseling = demographics + change in
preventive health beliefs + change in intention to refer/screen + change in self-
efficacy + change in knowledge
Lagged Analysis
Regression analysis using change scores will be supplemented by a lagged analysis.
First, a correlation analysis will be performed to look for evidence of regression to
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the mean between baseline and follow-up scores for preventive health beliefs,
intention to refer/screen, self-efficacy and knowledge in both experimental and
control groups. Strong correlations between baseline and follow-up indicate
regression to the mean, which can occur with measurements that occur at multiple
timepoints, indicate a need to use lagged analysis. Lagged analysis assesses will
then be performed to assess the association between baseline scores with (how well
they predict) follow-up scores (Rate of Smoking Cessation Counseling), controlling
for other intern characteristics.
Rate of Smoking Cessation Counseling at Follow-up = rate of smoking cessation
counseling at baseline + demographics + change in preventive health beliefs +
change in intention to refer/screen + change in self-efficacy + change in knowledge
These analyses will be repeated for the overall change in the rate of PCS counseling
for all nine categories (including smoking cessation) as the dependent variable.
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Appendix 1: Preventive Health Survey
We would like to get some information about your chiropractic philosophy o f health toward patient
care which includes your beliefs, attitudes and intentions to practice health promotion and disease
prevention. Please take your time and complete this survey to the best o f your ability. Thank you for
your feedback.
Intern Demographics
1. What is your gender?
0 1 0 Male
020 Female
2. What is your age? _______
3. Which one or more o f the following would you say is your race? Mark all that apply.
01 □ White
020 Hispanic or Latino
030 Black or African American
040 Asian
050 Native Hawaiian or Other Pacific Islander
060 American Indian, Alaska Native
070 Other_________________________________
4. Are you:
010 Married
020 Divorced
030 Widowed
040 Separated
050 Never married
060 A member o f an unmarried couple
5. How many children do you have?
Number o f children
000 None
6. Some individuals have significant work experience in other disciplines or professions. Do you
consider Chiropractic your;
01D First Career
020 Second Career
030 Third Career
158
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7. Are you currently:
01D Full-time student only; not working
02D Employed part-time (<20 hours/week)
0 3 0 Employed full-time (>20 hours/week)
8. W ho do you go to for your primary care?
0 1 0 Chiropractor
02D M edical Doctor
0 3 0 Acupuncturist
0 4 0 Naturopath
050 Homeopath
060 Self-care only
070 Other
080 DC & MD
9. I regularly counsel patients on smoking cessation
010 Yes, I have been for MORE then 6 months
020 Yes, I have been for LESS than 6 months
030 N o, but I am planning to start within the next 30 days
040 N o, but I intend to start in the next 6 months
050 No, and I do NOT intend to start with in the next 6 months
Intern Beliefs
10. Before entering chiropractic college, I had experiences with complementary and alternative
forms o f healing (including chiropractic) which have influenced m y orientation towards
preventive health.
□ o i EH 02 C H o 3 E H 04 E H o 5
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
11. In reference to my philosophy towards preventive health; chiropractic philosophy courses taught
in chiropractic college have been the primary influence and source o f my beliefs and attitudes.
□ d Q ( ) 2 EHo3 EHo4 EHo5
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
12. In reference to m y philosophy towards preventive health; speakers, seminars and/or other
individuals outside o f the chiropractic college have been the primary influence and source o f my
beliefs and attitudes about preventive health.
□ o i □ ( ) 2 E H o 3 E H o 4
strongly somewhat undecided somewhat
disagree disagree agree
159
EH 0 5
strongly
agree
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13. I regularly see or, when appropriate, intend on regularly seeing a chiropractor or other alternative
care provider for any and all preventive health services.
□ o t O o 2 CD03 O o 4 O o 5
strongly somewhat vmdecided somewhat strongly
disagree disagree agree agree
14. I regularly see or, when appropriate, intend on regularly seeing a physician for some preventive
health services such as cholesterol and cancer screening tests.
□01 CD02 D o 3 D o 4 O o s
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
15. I have chosen chiropractic as a profession because o f the potential for financial reward and
financial security.
□ o i CD 02 C D 03 C D o4 C D o5
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
16. I have chosen chiropractic as a profession because o f a personal chiropractic experience.
□ o i CD 02 CD 03 CDo4 CDo5
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
17. I have chosen chiropractic as a profession because I will enjoy a high degree o f professional
status.
□ o i C D o2 CDo3 C D 04 CD 05
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
18. I have chosen chiropractic as a profession because it centers its therapeutic strategies on natural
and holistic approaches to health promotion and disease prevention.
□ o i CD 02 CD03 EDo4 C D 05
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
19. Chiropractors should recognize their responsibility to inform patients o f health care options
available from medical providers for conditions, including preventive care, that are frequently
responsive to allopathic intervention.
□ o i CD 02 CD 03 C D 04 CD 0 5
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
160
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20. Chiropractors are a neuromusculoskeletal specialist portal o f entry provider and therefore do not
need to concern themselves with making recommendations regarding preventive health
screening.
□01
strongly
disagree
□ 0 2
somewhat
disagree
□ 0 3
undecided
□ 0 4
somewhat
agree
□ 0 5
strongly
agree
21. Counseling my patients about smoking is personally important to me as a health care provider.
□01
strongly
disagree
□ 0 2
somewhat
disagree
□ 0 3
undecided
□ 0 4
somewhat
agree
□ 0 5
strongly
agree
22. It is not within the chiropractic philosophy o f health prevention for chiropractors to screen or
recommend treatment for smoking cessation.
□ 0 1
strongly
disagree
In tern Self-E fficacy
□ 0 2
somewhat
disagree
□ 0 3
undecided
□ 0 4
somewhat
agree
□ 0 5
strongly
agree
23. I have the skills necessary to help my patients quit smoking..
25.
□01
strongly
disagree
□ 0 2
somewhat
disagree
□ 0 3
undecided
□ 0 4
somewhat
agree
24. I have the confidence that I can help my patients quit smoking.
□ 0 1
strongly
disagree
□ 0 2
somewhat
disagree
□ 0 3
undecided
□ 0 4
somewhat
agree
□ 0 5
strongly
agree
□ 0 5
strongly
agree
Overall, I feel very comfortable with how to recognize when patients require regular preventive
health recommendations.
□01
strongly
disagree
□ 0 2
somewhat
disagree
□ 0 3
undecided
□ 0 4
somewhat
agree
□ 0 5
strongly
agree
26. Overall, I feel very comfortable discussing regular preventive health recommendations with
patients.
□01
strongly
disagree
□ 0 2
somewhat
disagree
□ 0 3
undecided
□ 0 4
somewhat
agree
□ 0 5
strongly
agree
161
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Intentions to Make Specific Preventive Health Recommendations
27. I intend on counseling patients for smoking cessation and/or recommending patients see their
m edical doctors for smoking cessation treatment options.
□ o i EH 02 EH 03 EH 04 D o s
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
28. W hen indicated, I intend on screening patients m yself for elevated cholesterol levels and/or
referring patients to see their medical doctor for cholesterol screening.
□ o i EH 02 EH 03 EH 04 D o s
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
29. I intend on measuring the blood pressure o f all patients during initial examination and/or
recommending patients see their medical doctors for blood pressure screening.
□ o i EH 02 EH 03 EH 04 D o s
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
30. W hen indicated, I intend on recommending patients see their medical doctors for breast cancer
screening.
□ o i EH 02 EH 03 EH 04 D o s
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
31. When indicated, I intend on recommending patients see their medical doctors for cervical cancer
(PAP) screening.
□ o i EH 02 E H o 3 EH 04 EH 05
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
32. When indicated, I intend on recommending patients see their medical doctors for colorectal
cancer screening.
□ o i EH 0 2 E H 0 3 EH 0 4 EH 0 5
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
33. I intend on counseling overweight and obese patients and/or I intend on recommending patients
see their medical doctors or other professionals for weight reduction or exercise prescription.
□ o i EH 02 E H o 3 EH 04 EH 05
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
162
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34. I intend on providing exercise counseling to patients who report sedentary lifestyle
characteristics and/or I intend on recommending patients see their medical doctors for sedentary
lifestyle issues.
□ 0 1 EH 02 d o 3 D o 4 D o s
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
35. I intend on providing dietary counseling to patients who report unhealthy eating habits and/or I
intend on recommending patients see their m edical doctors for dietary counseling.
□ o i D o2 D o3 D o4 D o5
strongly somewhat undecided somewhat strongly
disagree disagree agree agree
Preventive Health Knowledge Questions
36. Periodic screening for high blood cholesterol is recommended for men ages:
01 □ A ll ages above 18 years.
02 □ 35 to 65 years.
03 □ 55 to 75 years.
04 □ Periodic screening for high blood cholesterol is not recommended men.
37. Periodic screening for high blood cholesterol is recommended for women ages .
01 □ All ages above 18 years.
02 □ 45 to 65 years.
03 □ 55 to 75 years.
04 □ Periodic screening for high blood cholesterol is not recommended for women.
38. Screening for hypertension is recommended for:
01 □ A ll adults.
02 □ A ll children.
03 □ All children and adults.
04 □ Screening for hypertension is generally not recommended.
39. Routine screening for breast cancer is recommended for women aged
01 □ 45-65
02 □ 30-65
03 □ 30-75
04 □ 50-69
05 □ routine screening for breast cancer is not recommended.
163
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40. For the appropriate age group, routine screening for breast cancer should occur
01 □ Every 1 to 2 years
02 □ Every 3 to 5 years
03 □ Every 5 years
04 □ Every 10 years
05 □ There is no appropriate frequency o f screening as routine screening is not recommended
Routine screening for breast cancer can be performed with
01 □ Mammography alone
02 □ Mammography plus annual clinical breast examination
03 □ Clinical breast examination without ever having mammography
04 □ Blood tests for cancer markers
05 □ There is no appropriate frequency o f screening as routine screening is not recommended
Screening for colorectal cancer is recommended for
01 □ Men aged 50 and older
02 □ Women age 50 and older
03 □ All persons aged 50 and older
04 □ A ll persons aged 65 and older
05 □ Screening for colorectal cancer is not recommended
43. Recommended screening tests for colorectal cancer is/are
01 D a . annual fecal occult blood testing
02 □ b. annual blood tests
03 □ c. sigmoidoscopy
04 □ a or c or both a and c
05 □ Screening for colorectal cancer is not recommended
164
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44. Routine screening for cervical cancer with Papanicolaou testing is recommended for all women
who:
01 □ a. have been sexually active
02 □ b. have a cervix
03 □ c. older than 18 years
04 □ both a & b
05 □ Routine screening for cervical cancer with PAP testing is not recommended
45. Screening for obesity is accomplished by
01 D a . observing the patient to see if they look overweight
02 □ b. asking the patient if they are overweight
03 □ c. measuring the patient’s weight
04 □ d. measuring the patient’s height
05 □ both c and d
46. Screening for obesity is recommended for.
01 □ patients over the age o f 5
02 □ patient over the age o f 18
03 □ patients over the age o f 40
04 □ patient over the age o f 65
05 □ all patients
47. Tobacco cessation counseling on a regular basis is recommended for
01 □ all patients who use tobacco products
02 □ all patients who smoke cigarettes only
03 □ adults who use tobacco products
04 □ patients who smoke more than 1 pack o f cigarettes per day
05 □ tobacco cessation counseling is not recommended as patients normally do not want to
quit.
165
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48. Counseling patients to incorporate regular physical activity into their daily routines is
recommended to prevent morbidity and/or mortality related to:
01 □ coronary heart disease
02 □ hypertension
03 □ obesity & diabetes
04 □ all o f the above
05 □ counseling patients to incorporate regular physical activity is not recommended
49. Nutritional counseling in adults and children over age 2 is recommended to encourage
01 □ limitation o f dietary intake o f fat (especially saturated fat) and cholesterol.
02 □ maintenance o f caloric balance in their diet.
03 □ emphasis on foods containing fiber (i.e., fruits, vegetables, grain products).
04 □ all o f the above.
05 □ counseling patients on nutrition is not recommended.
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Appendix 2: Chiropractic Preventive Health Survey Response Frequencies
Pilot Study Intern Demographics (n^ZO)_________________________________
Variable Category Frequency Percent
G ender(n=20) Male 15 75
Female 5 25
A ge (n=20) 20-25 4 20
26-30 9 45
31-35 7 35
Ethnicity (n=20) White 4 20
Hispanic or Latino 5 25
Black or African American 0 0
Asian 8 40
Native Hawaiian or Other Pacific Islander 1 5
American Indian, Alaska Native 0 0
Other 2 10
Marital Status (n=20) Married 6 30
Divorced 0 0
Widowed 0 0
Separated 0 0
Never Married 11 55
A member o f an unmarried couple 3 15
Number o f Children 17 85
(n=20) None
1 2 10
2 1 5
Chiropractic Career
(n=20) First 16 80
Second 4 20
Third 0 0
Employment Status 18 90
(n=19 Full-time student only; not working
Employed part-time (<20 hours/week) 1 5
Employed part-time (>20 hours/week) 0 0
Primary Care Provider
(n=20) Chiropractor 9 45
Medical Doctor 8 40
Acupuncturist 0 0
Naturopath 0 0
Homeopath 0 0
Self-care only 0 0
Other 1 5
Chiropractor and M edical Doctor 2 10
167
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Pilot Study Intern Beliefs (n=20)
Variable C ategory Frequency Percent
Before entering chiropractic college, I had
experiences with complementary and
alternative forms o f healing (including
chiropractic) which have influenced my
orientation towards preventive health. Strongly Disagree 2 10
Somewhat Disagree 2 10
Undecided 4 20
Somewhat Agree 7 35
Strongly Agree 5 25
In reference to my philosophy towards
preventive health; chiropractic philosophy
courses taught in chiropractic college have
been the primary influence and source o f my
beliefs and attitudes. Strongly Disagree 1 5
Somewhat Disagree 5 25
Undecided 1 5
Somewhat Agree 9 45
Strongly Agree 4 20
In reference to my philosophy towards
preventive health; speakers, seminars and/or
other individuals outside o f the chiropractic
college have been the primary influence and
source o f my beliefs and attitudes about
preventive health. Strongly Disagree 0 0
Somewhat Disagree 2 10
Undecided 2 10
Somewhat Agree 12 60
Strongly Agree 4 20
I regularly see or, when appropriate, intend
on regularly seeing a chiropractor or other
alternative care provider for any and all
preventive health services. Strongly Disagree 0 0
Somewhat Disagree 2 10
Undecided 2 10
Somewhat Agree 5 25
Strongly Agree 11 55
I regularly see or, when appropriate, intend
on regularly seeing a physician for some
preventive health services such as
cholesterol and cancer screening tests. Strongly Disagree 0 0
Somewhat Disagree 2 10
Undecided 4 20
Somewhat Agree 11 55
Strongly Agree 3 15
168
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Pilot Study I n te r n Beliefs Continued (n=20)
V ariable C ategory Frequency Percent
I have chosen chiropractic as a profession
because o f the potential for financial reward
and financial security. Strongly Disagree 3 15
Somewhat Disagree 5 25
Undecided 1 5
Somewhat Agree 6 30
Strongly Agree 5 25
I have chosen chiropractic as a profession
because o f a personal chiropractic
experience. Strongly Disagree 2 10
Somewhat Disagree 3 15
Undecided 1 5
Somewhat Agree 5 25
Strongly Agree 9 45
I have chosen chiropractic as a profession
because I will enjoy a high degree o f
professional status. Strongly Disagree 2 10
Somewhat Disagree 2 10
Undecided 3 15
Somewhat Agree 7 35
Strongly Agree 6 30
I have chosen chiropractic as a profession
because it centers its therapeutic strategies
on natural and holistic approaches to health
promotion and disease prevention. Strongly Disagree 0 0
Somewhat Disagree 1 5
Undecided 1 5
Somewhat Agree 7 35
Strongly Agree 11 55
Chiropractors should recognize their
responsibility to inform patients o f health
care options available from medical
providers for conditions, including
preventive care, that are frequently
responsive to allopathic intervention. Strongly Disagree 1 5
Somewhat Disagree 0 0
Undecided 0 0
Somewhat Agree 8 40
Strongly Agree 10 50
169
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Pilot Study Intern Beliefs Continued (m=20)
Variable Category Frequency Percent
Chiropractors are a neuromusculoskeletal
specialist portal o f entry provider and
therefore do not need to concern themselves
with making recommendations regarding
preventive health screening. Strongly Disagree 12 60
Somewhat Disagree 6 30
Undecided 0 0
Somewhat Agree 1 5
Strongly Agree 0 0
Counseling my patients about smoking is
personally important to me as a health care
provider. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 1 5
Somewhat Agree 13 65
Strongly Agree 6 30
It is not within the chiropractic philosophy
o f health prevention for chiropractors to
screen or recommend treatment for smoking
cessation. Strongly Disagree 7 35
Somewhat Disagree 5 25
Undecided 3 15
Somewhat Agree 5 25
Strongly Agree 0 0
Pilot Study Intern Self-efficacy
V ariable Category Frequency Percent
I have the skills necessary to help my
patients quit smoking. (n=20) Strongly Disagree 2 10
Somewhat Disagree 8 40
Undecided 7 35
Somewhat Agree 3 15
Strongly Agree 0 0
I have the confidence that I can help my
patients quit smoking. (n=20) Strongly Disagree 2 10
Somewhat Disagree 6 30
Undecided 6 30
Somewhat Agree 5 25
Strongly Agree 1 5
170
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Pilot Study Intern Self-efficacy Continued
Variable Category Frequency Percent
Overall, I feel very comfortable with how to
recognize when patients require regular
preventive health recommendations. (n=20) Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 1 5
Somewhat Agree 12 60
Strongly Agree 7 35
Overall, I feel very comfortable discussing
regular preventive health recommendations
with patients. (n=20) Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 0 0
Somewhat Agree 7 35
Strongly Agree
Intention to Screen, Intension to refer* (n=20)
12 60
Variable Category Frequency Percent
I intend on questioning patients regarding
their smoking habits. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 1 5
Somewhat Agree 6 30
Strongly Agree 13 65
When indicated, I intend on recommending
patients see their medical doctors for other
smoking cessation treatment options. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 3 15
Somewhat Agree 13 65
Strongly Agree 4 20
When indicated, I intend on screening
patients m yself for high cholesterol. Strongly Disagree 3 15
Somewhat Disagree 5 25
Undecided 3 15
Somewhat Agree 5 25
Strongly Agree 4 20
*The intention to screen and intention to refer questions were separate items initially as they appear in
this table. They were subsequently m odified to reflect responses obtained from the initial survey.
Most items were merged into one question that measured intention to screen and/or refer. The
exceptions were breast, colorectal and uterine (PAP test) screening where only the intention to refer to
a medical provider was retained.
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Intention to Screen, Intension to refer Continued* (n=20)
V ariab le Category Frequency Percent
W hen indicated, I intend on recommending
patients see their medical doctors for
cholesterol screening. Strongly Disagree 0 0
Somewhat Disagree 2 10
Undecided 2 10
Somewhat Agree 4 20
Strongly Agree 12 60
I intend on measuring the blood pressure o f
all patients during initial examinations. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 1 5
Somewhat Agree 5 25
Strongly Agree 14 70
When indicated, I intend on recommending
patients see their medical doctors for
treatment related to elevated blood pressure. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 1 5
Somewhat Agree 8 40
Strongly Agree 11 55
When indicated, I intend on screening
patients m yself for breast cancer. Strongly Disagree 10 50
Somewhat Disagree 3 15
Undecided 5 25
Somewhat Agree 2 10
Strongly Agree 0 0
When indicated, I intend on recommending
patients see their medical doctors for breast
cancer screening. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 1 5
Somewhat Agree 3 15
Strongly Agree 16 80
*The intention to screen and intention to refer questions were separate items initially as they appear in
this table. They were subsequently modified to reflect responses obtained from the initial survey.
Most items were merged into one question that measured intention to screen and/or refer. The
exceptions were breast, colorectal and uterine (PAP test) screening where only the intention to refer to
a medical provider was retained.
172
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Intention to Screen, Intension to refer Continued* (m=20)
Variable C ategory Frequency Percent
When indicated, I intend on screening
patients m yself for cervical cancer (PAP
smears). Strongly Disagree 15 75
Somewhat Disagree 2 10
Undecided 1 5
Somewhat Agree 2 10
Strongly Agree 0 0
When indicated, I intend on recommending
patients see their medical doctors for
cervical cancer screening. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 0 0
Somewhat Agree 1 5
Strongly Agree 19 95
When indicated, I intend on screening
patients m yself for colorectal cancer. Strongly Disagree 15 75
Somewhat Disagree 1 5
Undecided 3 15
Somewhat Agree 1 5
Strongly Agree 0 0
When indicated, I intend on recommending
patients see their medical doctors for
colorectal cancer screening. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 0 0
Somewhat Agree 1 5
Strongly Agree 19 95
I intend on counseling overweight and obese
patients on weight reducing dietary and
exercise approaches. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 1 5
Somewhat Agree 7 35
Strongly Agree 12 60
*The intention to screen and intention to refer questions were separate items initially as they appear in
this table. They were subsequently modified to reflect responses obtained from the initial survey.
Most items were merged into one question that measured intention to screen and/or refer. The
exceptions were breast, colorectal and uterine (PAP test) screening where only the intention to refer to
a medical provider was retained.
173
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Intention to Screen, Intension to refer Continued* (n=20)
V ariable Category Frequency Percent
W hen indicated, I intend on recommending
patients see their medical doctors or other
professionals for weight reduction or
exercise prescription. Strongly Disagree 2 10
Somewhat Disagree 5 25
Undecided 5 25
Somewhat Agree 6 30
Strongly Agree 2 10
I intend on providing exercise counseling to
patients who report sedentary lifestyle
characteristics. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 0 0
Somewhat Agree 8 40
Strongly Agree 12 60
I intend on recommending patients see their
medical doctors for sedentary lifestyle
issues. Strongly Disagree 4 20
Somewhat Disagree 8 40
Undecided 3 15
Somewhat Agree 4 20
Strongly Agree 1 5
I intend on providing dietary counseling t
patients who report unhealthy eating habits. Strongly Disagree 0 0
Somewhat Disagree 0 0
Undecided 1 5
Somewhat Agree 6 40
Strongly Agree 11 55
I intend on recommending patients who
report unhealthy eating habits see their
medical doctors. Strongly Disagree 4 20
Somewhat Disagree 5 25
Undecided 5 25
Somewhat Agree 4 20
Strongly Agree 2 10
*The intention to screen and intention to refer questions were separate items initially as they appear in
this table. They were subsequently modified to reflect responses obtained from the initial survey.
Most items were merged into one question that measured intention to screen and/or refer. The
exceptions were breast, colorectal and uterine (PAP test) screening where only the intention to refer to
a medical provider was retained.
174
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Preventive Health Knowledge Questions
Variable n C ategory Frequency Percent
Periodic screening for high blood
cholesterol is recommended for men ages: 19* Correct
Incorrect
10
9
52.6
47.4
Periodic screening for high blood
cholesterol is recommended for women
ages: 19* Correct
Incorrect
10
9
52.6
47.4
Screening for hypertension is recommended
for: 19* Correct
Incorrect
9
10
47.4
52.6
Routine screening for breast cancer is
recommended for women aged: 19* Correct
Incorrect
0
19
0
95
For the appropriate age group, routine
screening for breast cancer should occur: 20 Correct
Incorrect
19
1
0
95
Routine screening for breast cancer can be
performed with: 20 Correct
Incorrect
18
2
90
10
Screening for colorectal cancer is
recommended for: 20 Correct
Incorrect
17
3
85
15
Recommended screening tests for colorectal
cancer is/are: 20 Correct
Incorrect
16
4
80
20
Routine screening for cervical cancer with
Papanicolaou testing is recommended for all
women who: 20 Correct
Incorrect
10
10
50
50
Screening for obesity is accomplished by: 20 Correct
Incorrect
16
4
80
20
Screening for obesity is recommended for: 20 Correct
Incorrect
14
6
70
30
* One subject omitted a page on the survey.
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Preventive Health Knowledge Questions Continued
Variable n C ategory Frequency Percent
Tobacco cessation counseling on a regular
basis is recommended for: 20 Correct 16 80
Incorrect 4 20
Counseling patients to incorporate regular
physical activity into their daily routines is
recommended to: 20 Correct 19 95
Incorrect 1 5
Nutritional counseling in adults and children
over age 2 is recommended to encourage:** 20 Correct 20 100
Incorrect 0 0
** The correct answer for this question was inadvertently left on the survey.
176
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Appendix 3: Smoking Cessation Counseling Flowsheet
Smoking Cessation Intervention Program
YOUR PATIENT HAS REPORTED THAT THEY ARE A CIGARETTE SMOKER.
Ask your patient about their smoking behavior during the new patient initial visit and
subsequent visits and document their answers on this chart form:
Ask your patent:
□Do you want to quit smoking?
Provide advice and offer resources.
□ Advise patients of potential dangers to them (review Intern Smoking Cessation
Counseling Guidebook) and offer the patient a brochure.
Identify returning patients who want help.
On subsequent visits inquire of your patients whether they are still using tobacco
products and, if so, whether they would like to quit now. Document the date of the
visit and use the following response codes below:
Patient Response to Smoking Cessation Approaches.
1 Patient is not interested in quitting smoking at this time.
2 Patient refuses smoking cessation counseling attempts.
3 Patient will attempt to quit smoking.
4 Patient seeking additional help with smoking cessation with another health care
provider.
5 Patient reports that they have discontinued smoking.
/ / / / / /
I n i t i a l V is it Response Code Date of Visit Response Code Date o f Visit Response Code
/ / / / / /
Date o f Visit Response Code Date of Visit Response Code Date of Visit Response Code
/ / / / / /
Date of Visit Response Code Date of Visit Response Code Date of Visit Response Code
/ / / / / /
Date of Visit Response Code Date o f Visit Response Code Date o f Visit Response Code
Intern’s Name:_____________ Date:_______ Patient File N o.:__________
Smoking Cessation Counseling Flowsheet
Cleveland Chiropractic College Clinic Los Angeles • 590 North Vermont • Los Angeles, California 90004
111
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Appendix 4: Added Tobacco Use to Vital Signs Section of Physical Examination
Vital Signs
P ulse________ / min □ regular □ irregular
R esp.________ /m in Oral Tem p._________°F
B.P. sitting (mmHg) L _____ / _____ R _/ ____
Patient Reports Current Tobacco Use: Yes No (circle one)
Advised Patient to Quit Smoking: Yes No (circle one)
178
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Appendix 5: Patient Brochure
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Appendix 6: Pilot Study Chart Abstraction Instrument
1. Pilot study group: □ Pre □ Post
(arm) 01 02
2. C hart A bstraction #:
(obs)
3. P atient’s file #
(id)
4. Intern gender:
(intsex)
5. Gender:
(ptsex)
□ M ale □ Fem ale
01 02
□ M ale □ Fem ale
01 02
6. A g e :________
(age)
7. Fam ily history o f cancer:
(fam hxca)
□ Yes □ N o □ M issing
01 02 03
8. Fam ily history o f diabetes:
(fam hxdb)
□ Yes □ N o □ M issing
01 02 03
9. Fam ily history o f heart disease:
(fam hxhd)
□ Y es □ N o □ M issing
01 02 03
10. Currently smokes cigarettes:
(cursm oke)
01 □ N ever
02 □ O ccasionally
03 □ M issing
11. N um ber o f packs/day:
(packday)
01 □ none
0 2 □ < ‘ / 2
03 □ 1
04 □ l'A
05 □ 2
06 □ 2'A
07 □ 3
08 □ G reater than 3
09 □ M issing
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F em a le only. I f ob servation is m ale, th en skip to item # 1 5 .
12. D ate o f last PAP test:
(p ap d ate)
/ _________
M onth Year
01 □ < 12 months
02 □ > 1 year < 2 years
03 □ > 2 year < 3 years
04 □ > 3 year < 4 years
05 □ > 4 year < 5 years
06 □ > 5 years
07 □ Patient does not rem em ber
08 D N ever had a PA P test
09 □ M issing
1 0 D N /A, docum entation o f hysterectom y
13. Perform s m onthly breast exams:
(chksbrst)
□ Yes □ N o □ M issing
01 02 03
14. D ate o f last m am m ogram :
(m am date)
/ _______
M onth Y ear
01 □ < 12 m onths
02 □ > 1 year < 2 years
03 □ > 2 year < 3 years
04 □ > 3 year < 4 years
05 □ > 4 year < 5 years
06 □ > 5 years
07 □ Patient does not rem em ber
08 □ N ever had a m am m ogram
09 □ M issing
15. H istory o f cervix/uterine surgery:
(utsurghx)
□ Y es □ N o □ M issing
01 02 03
16. Blood pressure m easurem ent taken
(bptaken)
□ Y es D N o
01 02
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17. B lood pressure reading was:
(bpread)
01 □ N o rm a l (< or =140/90) (systolic/diastolic)
02 □ M ildly elevated (140/90 - 159/99; confirm w ithin 2 m onths)
03 □ M oderately elevated (160/100 - 179/109; refer w ithin 1 month)
04 □ Severely elevated (180/110 - 209/119; refer w ithin 1 week)
05 □ V ery severe (> or =210/120; im m ediate referral)
06 □ M issing
18. D ate o f H istory/Physical E x a m in a tio n :_____ / ______/ _____
(exam date)
19. W e i g h t : ________ pounds □ M issing
(w eight)
20. H e i g h t : _____ inches □ M issing ( ’ ____ “ )
(height)
21. B M I . ______ (calculate from Q20 and Q 2 1) □ M issing D ata
(bm i)
22. Physical activity:
(activity)
01 □ N o reported regular physical activity/exercise program (no frequency or
intensity).
02 □ Regular physical activity/exercise reported.
23. Intern elicited/docum ented sufficiently detailed dietary inform ation.
(diethab)
□ Yes □ No
01 02
24. Patient reported (intern recorded) sufficient details to establish that they are attem pting to
m aintain a low fat diet.
(lowfat)
□ Yes □ N o □ N ot applicable
01 02 03
T ob acco cessation cou n selin g recom m en d ation
25. D id the intern docum ent an initial recom m endation regarding tobacco cessation counseling
recom m endation?
(sm ok erec)
□ Y es □ No
01 02
26. Did the intern docum ent that they offered the patient a brochure regarding tobacco cessation
counseling recom m endation?
(b roch u re)
□ Yes □ No
01 02
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27. D id the intern docum ent follow up on their initial recom m endation regarding tobacco cessation
counseling recom m endation?
(sm okefu)
□ Yes □ No □ Patient did not return
01 02 03
28. D id the intern docum ent that the patient initiated an action step regarding tobacco cessation
counseling recom m endation?
(sm okeact)
□ Yes □ No □ Patient did not return
01 02 03
H igh blood cholesterol screening
29. The patient’s history/exam ination docum entation reveals testing for cholesterol w ithin the past
two to three years.
(cholscrn)
□ Yes □ No
01 02
30. D id the intern docum ent an initial recom m endation regarding high blood cholesterol screening?
(hbcrec)
□ Yes □ No
01 02
Blood pressure screening
31. P atient’s blood pressure m easurem ent was docum ented as norm al?
(bpnorm )
□ Yes □ N o □ D ata M issing
01 02 03
35. P atient’s blood pressure m easurem ent was docum ented as under m edication/m edical
m anagem ent?
(bpm dm an)
□ Yes □ N o □ D ata M issing
01 02 03
32. Did the intern docum ent an initial recom m endation about the p atien t’s elevated blood pressure
screening results?
(bprec)
□ Yes □ No
01 02
Screening for colorectal cancer
33. The patient’s history/exam ination docum entation revealed testing for colorectal cancer w ithin the
past year.
(prrecsrn)
□ Yes D N o
01 02
184
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34. D id the intern document an initial recommendation regarding screening for colorectal cancer?
(rectrec)
□ Yes □ No
01 02
S creen in g for ob esity
35. D id the intern document an initial recommendation regarding weight reduction?
(obeserec)
□ Yes D N o
01 02
C o u n selin g patients on ph ysical activity
36. Did the intern document an initial recommendation regarding counseling the patient on physical
activity?
(phyexrec)
□ Yes □ No
01 02
C o u n selin g to lim it d ietary intake o f fat
37. Did the intern document an initial recommendation regarding counseling adult or parent/child to
limit dietary intake o f fat?
(d ietrec)
□ Yes □ No
01 02
F em ale ad u lt only.
R o u tin e screen in g for b reast can cer
38. Did the intern document an initial recommendation regarding routine screening for breast cancer?
(b rstrec)
□ Yes □ No
01 02
R ou tin e screen in g for cervical can cer
39. Did the intern document an initial recommendation regarding routine screening for cervical
cancer?
(cervrec)
□ Yes D N o
01 02
185
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Appendix 7: Pilot Study Tables - Intern PCS Recommendations
Table 24: Pilot Study High Blood Cholesterol Screening; Males ages 35 to 65
Pre
curriculum
Change
Group
(n=40)
Post
curriculum
Change
Group
(n=45) P-value
Patient’s chart reveals
history of testing for
cholesterol.
yes 0 (0.0%) 0
no 40 (100%) 45 (100%) N/S*
Intern made
recommendation for
cholesterol testing.
yes 1 (2.5%) 0
no 39(97.5%) 45 (100%) N/S*
Intern followed up on
cholesterol recommendation
yes 1 0
no 0 0
n 1 0 N/S*
Intern document action
step/testing initiated by
patient
yes 1 0
no 0 0
n 1 0 N/S*
*U nable to calculate secon dary to c e lls w ith frequ en cies o f < 5.
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Table 25: Pilot Study High Blood Cholesterol Screening:
Fem ale ages 45 to 65____________________ ____________
Pre
curriculum
Change
Group
(n=34)
Post
curriculum
Change
Group
(n=30) P-value
Patient’s history and/or
examination reveals testing
for cholesterol.
yes 0 0
no 34(100%) 30 (100%) N/S*
Intern made
recommendation for
cholesterol testing.
yes 0 0
no 34(100%) 30 (100%) N/S*
Intern followed up on
cholesterol recommendation
yes 0 0
no 0 0
n 0 0 N/S*
Intern document action
step/testing initiated by
patient
yes 0 0
no 0 0 N/S*
n 0 0
*U nable to calculate secondary to c e lls w ith frequ en cies o f < 5.
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Table 26: Pilot Study Blood Pressure Screening
Pre
curriculum
Change
Group
(n=204)
Post
curriculum
Change
Group
(n=204) P-value
Blood Pressure Taken (%)
Yes 202(99.0%) 204(100%)
No 2(1.0%) 0 N/S*
Blood Pressure Normal (%)
Yes 195(95.6%) 197(96.6%)
No 8(3.9%) 7(3.4%)
Missing 1(0.5%) 0 N/S*
If blood pressure is not
normal is it medically
managed?
yes 4 (2.0%) 0(0.0%)
no 4 (2.0%) 7(3.4%) N/S*
Blood pressure control
recommendation
yes 0 2(28.6%)
no 4 5(71.4%) N/S*
Follow-up on blood pressure
recommendation
no n/a 0
Patient did not return for
F/U n/a 2 N/S*
*U nable to calcu late secon d ary to em p ty cells.
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Table 27: Pilot Study Breast Cancer Screening; All Females
Pre Post- 1
curriculum curriculum
Change Change
Group Group
(n=112) (n=102) P-value
Performs monthly breast exam
(%)
Yes 33(29.5%) 26(25.5%)
No 73(65.2%) 71(69.6%)
missing 6(2.7%) 5(4.9%) 0.79
Patients who answered no to
monthly breast exam advised
regarding breast cancer
screening
yes 0 0
no 79 76 N/S*
Time since last mammogram
(%)
< 12 months 9(8.0%) 1(1.0%)
> 1 year < 2 years 16(14.3%) 21(20.6%)
> 2 year < 3 years! 1(0.9%) 4(3.9%)
> 3 year < 4 years! 1(0.9%) 3(2.9%)
> 4 year < 5 years | 0(0.0%) 0(0.0%)
> 5 yearsf 1(0.9%) 3(2.9%)
never had a mammogramf 50(44.6%) 32(31.40%)
missing! 34(30.4%) 38(37.3%) N/S*
|Recommendation for routine
screening for breast cancer
(patient was age 50 to 69
years with history of last
mammogram date older than 2
years)
Yes 0(0.0%) 0(0.0%)
No 17(100%) 18(100%)
Groupn 17 18 N/S*
*U nable to calcu late secondary to em pty cells,
j U sed in calculation o f recom m endation for P A P exam
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Table 28: Pilot Study Breast Cancer Screening; Female Subjects
Age 50 to 69)_____________ ___________ ____________
Pre
curriculum
Change
Group
(n=27)
Post
curriculum
Change
Group
_ (5.~2_1)___ P-value
Time since last mammogram
(%)
<12 months 4(14.8%) 1(4.8%)
> 1 year < 2 years 8(29.6%) 5(23.8%)
> 2 year < 3 years 0(0.0%) 0(0.0%)
> 3 year < 4 years 0(0.0%) 1(4.8%)
> 4 year < 5 years 0(0.0%) 0(0.0%)
> 5 years 0(0.0%) 1(4.8%)
never had a mammogram 4(14.8%) 4(19.0%)
missing 11(40.7%) 9(42.9%) N/S*
Intern made recommendation
regarding routine screening
for breast cancer
Yes 0(0.0%) 0(0.0%)
No 23(100%) 20(100%) N/S*
*U n ab le to calculate secondary to em p ty cells.
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Table 29: Pilot Study Colorectal Cancer Screening
Pre
curriculum
Change
Group
Post
curriculum
Change
Group P-value
Age > 50
Yes
No
52(25.5%)
152(74.5%)
46(22.5%)
158(77.5%) NS
Intern made
recommendation regarding
routine screening for
colorectal cancer
Yes
No
0(0.0%)
52(100%)
0(0.0%)
46(100%) N/S*
*Unable to calculate secondary to empty cells.
Table 30: Pilot Study Cervical Cancer Screening
Pre
curriculum
Change
Group
(n=H2)
Post
curriculum
Change
Group
(n=102) P-value
Time since last PAP test (%)
< 12 months
> 1 year < 2 years
> 2 year < 3 yearsf
> 3 year < 4 yearsf
> 4 year < 5 yearsf
> 5 yearsf
never had a PAP testf
missingf
N/A,hysterectomy
36(32.1)
24(21.4)
2(1.8%)
1(0.9%)
0(0%)
5(4.5%)
8(7.1%)
34(30.4%)
2(1.8%)
19(18.6%)
23(22.5%)
6(5.9%)
5(4.9%)
(0%)
4(3.9%)
11(10.8%)
33(32.4%)
1(1.0%) NS*
Recommended PAP examf
yes
no
n
1(2%)
49 (98%)
50
0
59(100%)
59 NS*
*Unable to calculate secondary to empty cells,
f Used in calculation of recommendation for PAP exam
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Table 31: Pilot Study Obesity Screening
Pre-
curriculum
Change
Group
(n=204)
Post
curriculum
Change
Group
(n=204) P-value
BMIf
Normal Range (%)
Overweight (%)
Obesity (%)
(Missing 40 obs)
100(54.1%)
60(32.4%)
25(13.5%)
94(51.4%)
57(31.1%)
32(17.5%)
0.57
Recommendation for weight
reduction if overweight or
obese
yes
no
0
85(100%)
0
89(100%)
N/S*
*Unable to calculate secondary to empty cells.
t Normal weight = 18.5-24.9; overweight = 25-29.9; obesity = BMI >30 (National Heart, Lung, and Blood
Institute)
Table 32: Pilot Study Tobacco Use Screening
Pre
curriculum
Change
Group
Post
curriculum
Change
Group
P-value
Currently smokes cigarettes 26(12.7%) 50(24.5%) 0.009
(%)
Recommended smoking
cessation
yes 0 0
no 26(100%) 50(100%) NS*
*Unable to calculate secondary to empty cells.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Table 33: Pilot Study Physical Exercise Screening
Pre
curriculum
Change
Group
(n-204)
Post
curriculum
Change
Group
(n=2Q4)
P-value
Patient reports engaging in
regular physical activity (%)
Yes 59(29.2%) 22(10.8%)
No 143(70.8%) 182(89.2%)
missing 2 0 0.000
Of those patient’s who
reported not exercising
regularly, intern
recommended regular
physical exercise
Yes 0 0
No 143 (100%) 182(100%) N/A*
*U n ab le to calcu late secondary to em p ty cells.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Table 34: Pilot Study Dietary Fat Intake Screening
Pre-
curriculum
Change
Group
(n=204)
Post
curriculum
Change
Group
(n=204)
P-value
Intern elicited detail dietary
information
yes
no
missing
13 (6.4%)
189(93.6%)
2
5(2.5%)
199(97.5%)
0 .05
Patient observes low fat diet
yes
no
n
5(38.5%)
8(61.5%)
13
3(60%)
2(40%)
5 N/A*
Intern made
recommendation regarding
dietary fat intake
yes
no
0
8(100%)
0
2(100%) N/A*
*U nab le to calculate secon dary to c e lls w ith frequ en cies o f < 5.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Appendix 7: Smoking Cessation Intervention and Program Evaluation Study
Matrix
12/1/04 -12/31/05
J F M A M J J A s o N D
Conduct baseline
chart reviews X
Begin data entry X X X X X X
Pre-study Focus
Group X
Develop Survey X
Develop Educational
Materials X
Pilot test survey X
Administer baseline
survey X
Conduct smoking
cessation program
intervention X
Begin chart reviews
(both study arms) X X X X
Conduct role-
modeling workshops X
M onitor program X X X X
Administer post
study survey X
Conduct post-study
FGD X
Complete chart
reviews X
Begin Data Analysis
X
M anuscript
preparation X
195
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Appendix 8: Pilot Study Curriculum Change Matrix
November, 1998: Chiropractic Health Care Section of APHA formed the Public
Health Curriculum Task Force with the goal of improving the quality of public
health training for chiropractic students.
November, 1999: Based on the report of the Task Force, the Chiropractic Health
Care Section of APHA disseminated to all chiropractic colleges the detailed list of
topics and resources (developed by the Task Force with input from all faculty
teaching public health in U.S. chiropractic colleges) for inclusion in their public
health courses.
M arch, 2001: Association of Chiropractic Colleges (ACC) held a session on the
public health content to interested chiropractic college faculty.
June, 2001: A Model Course for Public Health Education in Chiropractic Colleges
users guide distributed to all U.S. chiropractic colleges June, 2001.
P re/P o st
D a ta
C ollection
T rim ester D ates__________ T im elin e__________________ C lass________________ T im ep oin ts
Summer,
1998
5 /1 9 9 8 -
8/1998
Pre
curriculum
change data
collection
period
Fall, 1998 9 /1 9 9 8 -
12/1998
Curriculum Task force
group meets to develop
revised public health
curriculum
Spring, 1999 1/1999 —
4/1999
Summer,
1999
5/1999 -
8/1999
Fall, 1999 9/1999 -
12/1999
Public health
topics/resources dist.
Spring, 2000 1 /2 0 0 0 -
4/2000
Summer,
2000
5/2000 -
8/2000
Fall, 2000 9/2000 -
12/2000
Spring, 2001 1/2001 -
4/2001
ACC session - Model
Public Health Curriculum
Review by CCCLA
Academic Dean and
distributed to public
health course instructors.
196
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Trimester Dates Timeline Class Pre/Post
D ata
Collection
Timepoints
Summer
2001
5/2001 -
8/2001
User guide distributed -
Implementation o f Model
Public Health Curriculum
Fall, 2001 9/2001 -
12/2001
First Class exposed
to Model Public
Health Curriculum
Spring, 2002 1/2002 -
4/2002
Summer,
2002
5/2002 -
8/2002
Fall, 2002 9/2002 -
12/2002
Spring, 2003 1/2003 -
4/2003
Interns who were
exposed to M odel
Public Health
Curriculum begin
clinical internship
training
Summer,
2003
5/2003 -
8/2003
Interns who were
exposed to M odel
Public Health
Curriculum
complete clinical
internship training
Pre
curriculum
change data
collection
period
Pre-curriculum change period will abstract charts with initial examination dates prior
to 9/1/98.
Post curriculum change abstraction dates will have initial examination dates older
than 5/1/03.
197
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Appendix 9: Intern Smoking Cessation Counseling Guidebook
Introduction
In support of the World Federation of Chiropractic (WFC) campaign to reduce
smoking, the clinic will be implementing a smoking cessation intervention for all
patients who report current smoking. The WFC represents 80 national associations
of chiropractors and is a non-governmental organization (NGO) in official relations
with the World Health Organization (WHO), strongly supports WHO’s public health
campaign to reduce smoking and other tobacco use. The WHO campaign is called
the Tobacco Free Initiative, and is a priority cabinet level project. WHO estimates
that the global tobacco pandemic, which caused four million deaths in 2002, will kill
ten million people a year by 2030. And every tobacco-related death is preventable.
The WFC supports the Tobacco Free Initiative because of the well-established
devastating impact of tobacco use on health, the congruency of this public health
issue with the drug-free and healthy living principles of chiropractic health care, and
the WFC’s duty and desire to support the policies of WHO.
Why all interns and chiropractors should support this public health campaign
Public health importance. First of all, tobacco use produces extensive avoidable
morbidity and mortality. Next, the prolonged time between exposure to tobacco use
and nicotine addiction, and then later disease and death, causes people to
underestimate the problem. Finally, many people are not alert to the dangers of
second-hand smoke (SHS).
Congruency with chiropractic principles. This is a natural public health issue for
chiropractors, given chiropractic principles, which include a drug-free approach to
life and health promotion.
Significance fo r chiropractic patients. Apart from general health issues, the
majority of chiropractic patients present with spinal pain syndromes and there is a
documented relationship between smoking and low-back pain. Many patients will
be unaware of the dangers of SHS to their families. For example, children exposed to
SHS are 50% more likely to suffer longterm damage to their lungs and to encounter
breathing problems such as asthma.
Duty as primary healthcare practitioner. As members of the primary healthcare
team, chiropractors have a duty to alert patients to major public health concerns that
may have an impact on them and their families.
More Important Smoking Facts
• Unless they quit, up to half of all smokers will die from their smoking, most
of them before their 70th birthday and only after years of suffering from a
reduced quality of life.
• Major smoking related causes of death are heart disease, stroke and cancer.
Cigarette smokers are twice as likely to develop Alzheimer’s Disease.
• Quitting reduces the risk of stroke and heart attack. After 12 months of not
smoking your excess risk of heart disease is down to almost half of that of a
198
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
smoker. Fifteen years after stopping, this risk is almost the same as for a
nonsmoker.
• Quitting reduces the risk of lung cancer if the disease is not already present.
After 10 years the risk is halved.
• There are early benefits. Within two months of quitting, the blood flow to
the hands and feet improves.
• The risk of death form heart attack increases dramatically with age for
women who smoke and take the contraceptive pill.
• Smoking rates among both men and women are going down to North
America. Rates for men are almost halved in the past 50 years; 73% of men
and 77% of women do not smoke.
• In epidemiological studies on men and women, there is evidence of a
relationship between smoking and low-back pain.
• There is evidence of a relationship between smoking and changes in
anatomical structures in the lower back.
Steps for interns with each patient who identifies that they are a smoker.
A sk patient history questions.
Ask the following questions during every new patient initial consultation, and
document answers in the case record:
□ Do you want to quit smoking?
Identify returning patients who want help.
On subsequent visits inquire of all patients previously identified as tobacco smokers
whether they are still smoking and, if so, whether they would like to quit now. Their
reply will be your guide in recommending the appropriate clinical intervention,
which can range from simple counseling to expert referral.
Provide advice and offer resources.
Advise patients of potential dangers to them and their families and offer the patient a
brochure that contains further information and resources the patient contact.
Document the date of the visit the for smoking cessation intervention form. Use the
following response codes below:
Patient Response to Smoking Cessation Approaches.
1 Patient is not interested in quitting smoking at this time.
2 Patient refuses smoking cessation counseling attempts.
3 Patient will attempt to quit smoking.
4 Patient seeking additional help with smoking cessation with another health care provider.
5 Patient reports that they have discontinued smoking.
199
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Smoking Cessation Intervention Program
YOUR PATIENT HAS REPORTED THAT THEY ARE A CIGARETTE SMOKER.
Ask your patient about their smoking behavior during the new patient initial visit and
subsequent visits and document their answers on this chart form:
A sk your patent:
□ Do you want to quit smoking?
Provide advice and offer resources.
□ Advise patients of potential dangers to them (review Intern Smoking Cessation
Counseling Guidebook) and offer the patient a brochure.
Identify returning patients who want help.
On subsequent visits inquire of your patients whether they are still using tobacco
products and, if so, whether they would like to quit now. Document the date of the
visit and use the following response codes below:
Patient Response to Smoking Cessation Approaches.
1 Patient is not interested in quitting smoking at this time.
2 Patient refuses smoking cessation counseling attempts.
3 Patient will attempt to quit smoking.
4 Patient seeking additional help with smoking cessation with another health care
provider.
5 Patient reports that they have discontinued smoking.
Initial Visit
Date of V isit
Date of Visit
Date of Visit
Response Code
Response Code
Response Code
Response Code
Date of Visit
Date ofVisit
Date ofVisit
_ / _ 7_
Date ofVisit
Response Code
Response Code
Response Code
Response Code
Date ofVisit
Date ofVisit
Date ofVisit
_ J _ C _
Date ofVisit
Response Code
Response Code
Response Code
Response Code
Intern’s Name:______________ Date:_______ Patient File N o.:__________
Smoking Cessation Counseling Flowsheet
Cleveland Chiropractic College Clinic Los Angeles 9 590 North Vermont • Los Angeles, California 90004
200
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On the clinic physical examination, the vital sign box has been changed to facilitate
identifying all tobacco users. The new patient registration clerk will insert a
Smoking Cessation Intervention Program form for you to chart (see above).
Vital Signs
Pulse / min □ regular □ irregular
Resp. / min Oral Temp. °F
B.P. sitting (mmHg) L / R /
Patient Reports Current Tobacco Use: Yes No (circle one)
Advised Patient to Quit Smoking: Yes No (circle one)
Smoking Cessation Counseling Strategies
Advise— Strongly urge all tobacco users to quit
A ction
; In a clear, strong, and
; p erso n a lized m anner,
i urge every tobacco user
| to quit.
Assess—Determine willingness to make a quit attem pt
i Action Strategies for Implementation
■ A sk every tob acco user
i i f h e or she is w illin g to
! m ake a quit attem pt at
] this tim e (e.g ., w ithin the
| n ext tw o w eek s).
201
A sse ss patient's w illin g n ess to quit:
• I f the patient is w illin g to m ak e a quit attem pt at this
tim e, p rovide assistance.
Strategies for Im plem entation
A d v ice sh ould be:
:
• C lear— "I think it is im portant for y o u to quit sm ok in g j
n o w and I can help you." "Cutting d ow n w h ile you are i
ill is n ot enough."
• Strong— "As your intern, I n eed y o u to k n o w that
quitting sm ok in g is the m o st im portant thing you can
do to protect your h ealth n o w and in the future. I w ill
h elp you."
• P erson alized— T ie to b a cco u se to current health/
illn ess, and/or its so cia l and ec o n o m ic costs,
m otivation level/read in ess to quit, and/or the im pact o f j
tob acco u se on children and others in the h ousehold .
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Assist— Aid the patient in quitting
; Action ; Strategies for Implementation
: H elp th e patient w ith a j A patient's preparations for quitting:
j quit p lan .
P rovid e practical
co u n selin g (problem
solving/trainin g).
P rovide intra-treatment
social support.
H elp patient obtain
extra-treatm ent social
support.
Set a quit date— id eally, the quit date sh ould b e w ithin
2 w eeks.
Tell fam ily, friends, and cow ork ers about quitting and
request understanding and support.
A nticipate ch allen ges to plann ed quit attem pt,
particularly during th e critical first fe w w eek s. T hese
in clu d e n icotin e w ithd raw al sym ptom s.
R em ove tob acco products from you r environm ent.
Prior to quitting, avoid sm o k in g in p laces w h ere you
sp en d a lot o f tim e (e.g ., w ork , h om e, car).
A bstinence— T otal ab stin en ce is essen tial. "Not even a
sin g le p u ff after th e quit date."
P ast quit experience— R e v ie w past quit attem pts
in clu d in g id en tification o f w h at h elp ed during the quit
attem pt and w hat factors contributed to relapse.
A n ticipate triggers or challenges in upcom ing
attem pt— D isc u ss ch allen ges/triggers and h o w patient
w ill su cc essfu lly o v erco m e them .
A lcohol— B e ca u se alcoh ol can cau se relapse, the
patient should con sid er lim itin g/ab stain in g from
alcoh ol w h ile quitting.
P rovide a supportive clin ica l environm ent w h ile
en couraging the patient in h is or h er quit attempt. "I am
availab le to a ssist you."
H elp patient d ev elo p so cia l support for h is or her quit
attem pt in h is or her en viron m en ts ou tsid e o f treatment.
"Ask your spouse/partner, friends, and cow orkers to
support you in you r quit attem p t."
Provide Brochure.
B rochure — G ive the patient a sm oking brochure.
202
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Common elements of practical counseling
......
j P ractical counseling i E xam ples
(problem-solving/skills
training) treatm ent
com ponent
R ecognize danger j
j situations— Id en tify
even ts, internal states, or j
activities that increase j
the risk o f sm oking or !
relapse. j
i
-
j
• L earning to anticipate and avoid tem ptation.
• A cc o m p lish in g life sty le ch an ges that reduce stress,
im prove q u ality o f life, or produce pleasure.
• A n y sm ok in g (ev en a sin g le p u ff) increases the
lik elih o o d o f fu ll relapse.
• W ithdraw al ty p ic a lly p eak s w ithin 1-3 w ee k s after
quitting.
« W ithdraw al sym p tom s in clu d e n egative m ood , urges to j
sm oke, and d ifficu lty concentrating.
• T he ad dictive nature o f m oking.
Sample Initial Statement to Patient
“I notice that you are a cigarette smoker. Smoking is harmful to your health. In many
cases, the hannful effects of smoking can be reversed. As part of your health care
provider team, I must advise you to stop smoking. If you are interested, I have a
brochure here that lists of some resources for stopping smoking available to you.
Intern Responses to Patients’ Concerns
Patient: I am under a lot of stress, and smoking relaxes me.
Response: Your body and brain have become accustomed to the drug effects of
nicotine, so you naturally feel more relaxed when you get the nicotine you have
come to depend on. But nicotine is also a stimulant that temporarily raises heart rate,
blood pressure, and adrenaline levels. After a few weeks of not smoking, most ex-
smokers feel less nervous.
; D evelop coping skills—
; Identify and practice
i cop in g or problem -
; solvin g skills. T yp ically,
j these skills are intended
1 to cop e w ith danger
1 situations.
P rovide basic
' information— P rovide
; b asic inform ation about
; sm oking and su ccessfu l
j quitting.
N eg a tiv e affect.
B ein g around other sm okers.
D rinking alcoh ol.
E xp erien cin g urges.
B e in g under tim e pressure.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Patient: Smoking stimulates me and helps me to be more effective in my work.
Response: Difficulty in concentrating can be a symptom of nicotine withdrawal, but
it is a short-term effect. Over time, the body and brain function more efficiently
when you don’t smoke, because carbon monoxide from cigarettes is displaced by
oxygen in the bloodstream.
Patient: I have already cut down my smoking to a safe level.
Response: Cutting down is a good first step toward stopping. But smoking at any
level increases the risk of illness. And some smokers who cut back inhale more often
and more deeply, thus maintaining nicotine dependence. It is best to stop smoking
completely.
Patient: I only smoke safe, low-tar/low-nicotine cigarettes.
Response: Low-tar cigarettes still contain harmful substances. Many smokers inhale
more often or more deeply and thus maintain their nicotine levels. Carbon monoxide
intake often increases with a switch to low-tar cigarettes.
Patient: I don’t have the willpower to give up smoking.
Response: It can be hard for some people to give up smoking, but for others it is
much easier than they expect. More than 3 million Americans stop every year. It may
take more than one attempt for you to succeed, and you may need to try different
methods of stopping. I will give you all the support I can.
Patient: I wish everyone would mind their business about my smoking.
Response: It must be hard to feel like people are nagging you about your smoking. I
do not want to add to this. However, I feel as your physician I have a responsibility
to help you stay well. I also would like to be able to provide help and support. Is
there anything I can do to help?
The contents o f this reference guideline is abstracted from several sources:
In developing its CAT campaign and associated materials, the WFC has relied upon the work and
recommendations o f its Health-for-All Committee, which is named after the mission o f WHO and
assists the WFC in a number o f collaborative projects with WHO.
Treating Tobacco Use and Dependence: Agency fo r Healthcare Research and Quality
Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Quick Reference
Guide for Clinicians. Rockville, MD: U.S. Department o f Health and Human Services. Public Health
Service. October 2000.
204
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Asset Metadata
Creator
Globe, Gary Alan
(author)
Core Title
An intervention and program evaluation to determine the effectiveness of public health reforms on primary prevention practices by chiropractic interns
School
Graduate School
Degree
Doctor of Philosophy
Degree Program
Epidemiology
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
health sciences, public health,OAI-PMH Harvest
Language
English
Contributor
Digitized by ProQuest
(provenance)
Advisor
Azen, Stanley (
committee chair
), Nichol, Michael (
committee member
), Valente, Thomas (
committee member
)
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