Barriers and facilitators to chiropractic pediatric practice

Dr Tylah Strauss, M.Tech Chiropractic, MHSc: Homoeopathy, MSc MSK Pediatric Health
Jeju-do, South Korea

Dr Aurélie M Marchand, MChiro, MScAPP, MMEd
Senior Lecturer, Health Sciences University
Bournemouth, England, United Kingdom

Tylah Strauss , Corresponding Author
strausstylah17@gmail.com
33 Globaledureo, 145 beongil, Daejeongeup, seogwiposi, 63644, Jeju-do, South Korea

ABSTRACT
Objective: To investigate the perceptions and experiences of South African chiropractors, with a special interest in the pediatric population, and to explore any barriers and/or facilitators experienced in their practices when caring for pediatric patients. Methods: Semi-structured interviews with purposive sampling were used to identify South African chiropractors with a declared interest in pediatrics. Eight participants were included in the study and data saturation was reached. The online private interviews utilized a semi-structured approach: collecting demographics, practice-based questions, followed by a ‘grand tour’ question and probing questions. The interviews were transcribed verbatim and then analysed according to the six phases of reflexive thematic analysis, whereby recurring themes were extracted from the data for interpretation. Results: This study identified new findings about the South African pediatric chiropractic profession. Four major themes were identified: chiropractors, parents and/or caregivers, healthcare professionals, and advertising and public awareness. The findings showed that most factors were considered as both facilitators and barriers and that, depending on how a practitioner utilized them, they could be dynamic and moldable. Findings suggest that increasing knowledge and awareness of pediatric chiropractic to other healthcare professionals and the public, establishing and building interprofessional relationships, and integrating into public healthcare would be useful. Conclusion: The findings show that barriers experienced may be manipulated into facilitators and that facilitators can be enhanced. These findings could assist practitioners, professional bodies, and institutions in addressing perceived barriers and developing pediatric practices.

Introduction
Chiropractic is sought out by parents for managing a variety of pediatric musculoskeletal and non-musculoskeletal conditions worldwide.^1-3 In this area of practice, current patterns identify a female predominance holding additional pediatric qualifications.^1,4,5 Referral patterns show variation including healthcare professionals (HCPs), family and/or word of mouth.^1,6 Adverse effects are rare and normally mild and temporary; however, further research is warranted.^7-9 Best practice recommendations¹⁰ noted barriers and facilitators to chiropractic pediatric practice: patient communication, establishing trust with parents/caregivers, having cultural/religious/gender sensitivity, and developing interprofessional relationships. In adult chiropractic populations, finances, outcome expectations, lack of awareness, accessibility and knowledge were additional factors.¹¹ Other pediatric healthcare professions identified parental educational status, cultural and parental participation in physiotherapy¹², parental participation, trust, interprofessional collaboration, technology, policy, and education in nursing^13,14, and financial or lack of knowledge in multi-disciplinary practice.¹⁵

There is sparse literature exploring the South African context, with grey literature reporting a high volume of pediatric patients,^16,17 and chiropractors not holding an additional pediatric qualification due to lack of available and/or affordable opportunities.^16-18 But otherwise similar practice patterns to global chiropractic pediatric practice. African countries are typically low- to middle-income earning with their own cultural and context-specific issues having a unique impact on healthcare.¹⁹ Pediatric chiropractic is currently developing in South Africa (SA) with practitioner lack of confidence and knowledge, collegial support, undergraduate education, parental satisfaction, patient-doctor communication,¹⁸ knowledge and awareness from other HCPs, and interprofessional relationships¹⁷ identified as barriers in the grey literature.

The National Health Insurance (NHI) will be progressively implemented over 2024-2028 in SA. The NHI aims to become a single source of healthcare funds from which the government can purchase services from HCPs in both the public and private sectors.²⁰ However, chiropractic’s stake in the NHI has yet to be confirmed, further highlighting the need for higher-quality evidence in pediatric chiropractic.

This study aimed to address a gap by investigating facilitators and barriers in a South African context, answering the research question: What are the barriers and facilitators encountered by South African pediatric chiropractors when caring for this population?

Methods
Design
An explorative, qualitative design,²¹ grounded theory model,²² and constructivist paradigm²³ were chosen for this study. The standards for reporting qualitative research (SRQR) were utilized in the development and reporting of this study.²⁴

Researcher characteristics
The researcher is a chiropractor with previous interview-based qualitative research experience. All South African chiropractors with a pediatric special interest were invited to participate; it was attempted to include an equal number of participants from both South African universities where a Chiropractic Masters is offered to limit introduction bias. Assumptions prior to data collection, were that barriers and facilitators would be separate factors.

Context
Healthcare is regulated by the National Department of Health (NDoH), which consists of six health professional councils, with the Allied Health Professions Council of South Africa (AHPCSA) regulating chiropractors.²⁵ Chiropractic is delivered privately or via student learning clinics and is not considered an integral part of pediatric healthcare. Upon their application to the AHPCSA, chiropractors may elect to provide free services to the community in safe houses, a child service agency where abandoned or surrendered children are given to the state for care.²⁶

In June 2024, there were 953 chiropractors registered with the AHPCSA.²⁷ The voluntary pediatric chiropractic association (Pediatric Chiropractic South Africa (PCSA)²⁸ held 167 PCSA members or 17.5% of the whole chiropractor population.

Sampling
Purposive sampling was used to identify participants based on their declared interest in pediatrics.²⁹ All members of PCSA were invited to participate, as well as chiropractors with a declared special interest in pediatrics.

Ethical considerations
Ethics approval was granted from the AECC University College Ethics Panel (AECC Ethics Approval Number: SOC - 0823 - 04). Participants gave informed consent to their data being processed, confidentiality was maintained and data was stored securely.

Data collection and analysis
A focus group (n=3) and pilot study (n=1) were conducted to ensure the validity and reliability of the interview guide (see Appendix A). Recruitment of potential participants was open between December 2023 and March 2024. A total of 174 potential participants were contacted, and follow-up reminders were sent. Sixteen expressed an interest in participating: One did not meet the inclusion criteria; six agreed to participate. After reminders, a further nine chiropractors responded, with two being included, two cancelling due to emergencies, and five no longer being available. In total, eight participants were interviewed. Data saturation was reached at the sixth interview, confirming data saturation.^30,31

Semi-structured online interviews were recorded and transcribed as private meetings on Microsoft Teams (Microsoft Corp, Redmond, WA, USA); interviews were anonymised during transcription. To increase the credibility of data, reflective notes were made during the interviews and research process³², data saturation was achieved³³, the six-phase process of reflexive thematic analysis was followed³⁴, and the interpretation was reviewed with another researcher to ensure accurate and reasonable interpretation.

Results
The mean age of participants was 34, ranging from 25 to 45. Six were female. They collectively held 66 years of experience (mean: 8.25, range: 1-20). They furthered their knowledge and/or skills by reading literature (n=7), attending seminars (n=5), enrolling in courses (n=5), searching journal databases (n=2), membership to PCSA (n=2), colleague interaction (n=1), and mentorships (n=1).

The anticipated themes of barriers and facilitators identified in the literature, did not emerge from the data, instead the reports of the participants showed blurred distinctions: “...I suppose a barrier and a facilitator [are] really just opposite sides of the same coin...”. The results are therefore presented per themes instead of barriers and facilitators. A total of four themes on chiropractors, parents/caregivers, other HCPs, and advertising and public awareness emerged, with thirteen interrelated subthemes. Figure 1.1 shows the relationships between the themes and subthemes.

Figure 1.1 Barriers and facilitators to chiropractic pediatric practice

Discussion
The barriers and facilitators identified in SA chiropractic pediatric practice were chiropractors, parents or caregivers, HCPs, and advertising and public awareness. Participants reported barriers, which could be adapted and turned into facilitators. Some were consistent throughout a practitioner’s career, such as regulations and restrictions, while others changed over time, such as advancing years of experience resulting in increased confidence.

On the theme of the chiropractor, the female predominance observed is aligned with previous local^16-18 and overseas^1,2 findings. Factors such as historical gender dominance or preference for child-carer therapeutic alliance³⁴ could be at play.

The subtheme of education and practice information was similar to the methods of furthering knowledge and/or skills, through journal reading and attending conferences and seminars,³⁵ previously identified locally. The lack of availability and high costs of attending conferences and seminars were also reported.^16-18 This lack of availability in pediatric training could also be due to the relatively new establishment of post-graduate chiropractic speciality programs.⁸ Approximately a quarter of overseas pediatric chiropractors report additional formal training^1,36 and half of the participants in this study held additional pediatric training. Participants commended the advancements in post-graduate education yet felt that education could be improved in their undergraduate training.

Another sub-theme was the increased consultation time (for in-depth examination and patient education) needed, similarly to a local study.¹⁸ Additionally, participants emphasized the importance of having a healthy work-life balance to protect from burnout by reducing working hours.³⁷

The subtheme of confidence showed a bell-shaped curve in the development of confidence: recent graduates spend time on upskilling themselves whilst building a client base. They had time to see patients, yet due to a lack of confidence or experience or clientele, they did not. With increasing years of practice, the amount of time spent seeing patients rose. A plateau was reached mid-career when decisions relating to work-life balance were made. Thereafter, a progressive decline in clinical time was observed with advancing age. Towards the end of their careers, practitioners felt most equipped in terms of clinical experience to see patients but were less likely to see them due to decreased clinical time. It is proposed that mentorship at this stage could be most beneficial to recent graduates wanting to pursue pediatrics and to the overall profession.

The subtheme lack of confidence was reported as the biggest barrier for recent graduates. They did not rate themselves as highly competent at managing this population,¹⁷ and would avoid treating this population due to lack of confidence;¹⁶ which may result from a lack of knowledge and formal specialization in this area.¹⁷ This was mitigated by corresponding with experienced pediatric colleagues. Another novel finding influencing confidence was skepticism and critique from parents. Some participants perceived this as ongoing critique of themselves and by extension, the chiropractic profession. They emphasized the need for mental toughness and thorough individualized education for the parents/caregivers to dispel concerns.

For the sub-theme environment, the expense of chiropractic care is not currently covered by the South African healthcare system. This financial barrier could limit chiropractic access to patients or prevent it all together. A SA chiropractor may need to consider the general affluence in an area when setting up. Additionally, Australian chiropractors reported location influencing pediatric chiropractic practice. When practising in remote and rural areas with limited healthcare, chiropractors may have to “extend” themselves to pediatrics to meet the needs of their population.³⁸

Another subtheme identified was pediatric chiropractic as a sub-speciality. If applied, this could become a barrier and a facilitator in the future: generalist chiropractors would be barred from caring for this population without additional education, hence becoming a barrier. A facilitator of specialization would be that of formalized education being made accessible to the profession, which would produce more confident and competent pediatric chiropractors. Education standards expect all qualified chiropractors to complete a simple pediatric assessment^10,39 and refer out where applicable.^1,39 Despite this, most participants felt disappointed in their undergraduate training. However, those with undergraduate pediatric exposure reported it as a facilitator to pediatric practice with increased confidence, competency, and igniting their passion for this population. This perceived educational need could be explored further by educational providers in SA. Currently, varied postgraduate pediatric chiropractic qualifications are offered in the United States;^40,41 United Kingdom;^42,43 South Africa,⁴⁴ and Australia.⁴⁵ Developing this in SA could lead to improved health outcomes for pediatrics and increased recognition for additional training.

For the theme parents and caregivers, chiropractors reported becoming increasingly responsible for their education about the condition when parents were less educated. This finding is similar to those in India, where unrealistic treatment expectations from less educated parents complicated interactions and served as barriers to effective management.¹² South African chiropractors, however, reported spending more time educating all parents of pediatric patients compared to adult patients, not only those with lower educational backgrounds. Furthermore, low-income families had a low adherence to treatment,¹² most likely due to the associated costs of repeated chiropractic visits.¹⁸ Indeed, less affluent caregivers only utilized chiropractic when affordable and prioritised pediatricians instead, whereas higher incomes were facilitators to accessing pediatric chiropractic care.

In the cultural subtheme for parents/caregivers, HCPs needing to adapt and individualize management plans that ensure cultural acceptability.⁴⁶ For instance, in this study, a participant explained the importance of being culturally sensitive to the practice of baby-wearing on the mother’s back, yet still providing medical advice around the concerns of hip dysplasia prevention. Therefore, not considering the parents’ cultural beliefs can lead to decreased treatment compliance,¹² and act as a cultural barrier. Participants reported having adaptable and individualized management plans to ensure cultural acceptability, as previously reported.⁴⁶ Furthermore, in some South African cultures, a lack of awareness about pediatric chiropractic care may also lead caregivers to overlook it in healthcare in favor of culturally acceptable treatment methods. Indeed, a lack of awareness around pediatric chiropractic was reported by chiropractors with most parents/caregivers not including it as part of their child’s HC. This is similar to other countries with limited use of chiropractic pediatrics.

Parent/caregiver education was utilized to address mistrust and concerns surrounding chiropractic care. Trust between practitioners and family members, as well as active family participation, positively influences a child’s healthcare.¹⁴ Participants reported that once trust was gained, it assisted in dispelling skepticism, encouraged word-of-mouth referrals and led to successful patient management.

Under the theme of HCPs, a lack of openness to engaging and co-managing with chiropractors was reported from most HCPs and pediatricians. The exception was the midwifery profession,⁴⁷ and those who had a personal experience with chiropractic, who were more willing to engage and develop professional relationships.

The limited knowledge and awareness of pediatric chiropractic by other HCPs, may be affected by the currently limited evidence supporting it, which was a subtheme barrier to interprofessional relationships. The safety concern of pediatric chiropractic was also most prominently reported in the interviews and compounded by the lack of evidence. Indeed, the current evidence in Australia⁴⁸ and other systematic reviews,^7,8 indicated no or inconclusive evidence over the efficacy of manual therapy in the pediatric population. Additionally, these reviews were critiqued on methodological flaws and the validity of their conclusions.⁴⁹ The scientific climate calls for more robust scientific evidence,⁴⁸ with funding and research required to produce higher-level studies both locally and globally.

Under the subtheme of interprofessional referral and co-management, current overseas referral patterns primarily show referrals from family and/or “word of mouth”,^1,50,51 with some reporting rare interprofessional communication, or informing pediatric HCPs,^35,50 and a general trend of referrals to other HCPs rather than from.^8,52 In this study, most pediatric patients came from word of mouth, with pediatric HCPs having little or no knowledge of pediatric chiropractic. In Switzerland, where chiropractic is a government-recognized healthcare profession, chiropractors report receiving significant referrals from other HCPs,⁵³ showing how government policy may impact interprofessional relationships. When HCPs are knowledgeable of each other’s scope, co-management is more effective.^{10,17,47,54,55} Interprofessional practices involving chiropractors are at the early stages⁵⁴ with many barriers including professional mistrust, lack of interprofessional education, professional license and regulation, funding, policies and support being strongly in place. Improving awareness and understanding of chiropractic pediatrics among other HCPs was recognized as essential by participants.

In the last theme of public awareness and regulation, chiropractors felt that the public had limited access to the profession due to current healthcare policies not including chiropractic. Indeed, legislation plays a role as a financial and scope of practice barrier,⁶ and promoting pediatric chiropractic at a public level can increase the exposure of students and chiropractors to this population in South Africa.¹⁸ When considering private healthcare routes, barriers were encountered through medical aid schemes, public and private funds being often depleted quickly.

Under the subtheme of marketing, social media can be a barrier to marketing due to public confusion.³⁸ However, in a South African context, the proper utilization of this tool could be beneficial by increasing awareness of pediatric chiropractic, educating the public and increasing the number of potential patients. Marketing guidelines for the profession have been identified as a barrier to awareness of pediatric chiropractic.¹² In this study, participants confirmed this barrier and highlighted the usefulness of social media. Strategies to further the public awareness that do not infringe on current guidelines should be investigated.

Limitations
The results may not be representative of the entire South African chiropractic profession, should be interpreted with caution and not generalized to the entire population. The sampling method was open to self-sampling and non-response biases. Despite the methodology employed, difficulties in interpreting questions or forgetting a noteworthy incident, might have impacted the data collected. The interviewer had some prior experience in qualitative interviews, which may be considered a limitation. Due to the pediatric chiropractic profession in South Africa being small, two participants were known to the interviewer.

Future recommendations from this study include further pediatric chiropractic undergraduate and postgraduate education being available and accessible to ensure practitioners are capable and confident in pediatric management. Mentorship opportunities in private pediatric chiropractic practice, and further research in the specific South African context would also be beneficial.

Conclusion
The South African pediatric chiropractic profession has commonalities and differences with chiropractic pediatric worldwide. Specific South African barriers and facilitators included the clinical environment in terms of the chiropractors, other HCPs, the financial and cultural factors concerning the caregivers, and the advertising and public awareness of the profession. The participants experienced many barriers, however barriers could be adapted and turned into facilitators. Some barriers/facilitators were consistent throughout a practitioners’ career (e.g.: regulations and restrictions); some changed with time (e.g.: advancing years of experience resulting in increased confidence). These findings may be useful to support the future development practitioners, the professional bodies that represent them, and the institutions that educate them.

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