Master's thesis of Science: Patient-centred outcomes of a community chiropractic clinic serving disadvantaged people

Patient-Centred Outcomes of a Community Chiropractic Clinic Serving Disadvantaged People

A thesis submitted in fulfilment of the requirements for the degree of Master of Science

Dan Michael Marthick-Hone

Bachelor of Health Sciences (Chiropractic), RMIT University

Master of Clinical Chiropractic, RMIT University

School of Health and Biomedical Sciences

College of Science, Engineering and Health

RMIT University

May 2020

Declaration

I certify that except where due acknowledgement has been made, the work is that of

the author alone; the work has not been submitted previously, in whole or in part, to qualify

for any other academic award; the content of the thesis is the result of work which has been

carried out since the official commencement date of the approved research program; any

editorial work, paid or unpaid, carried out by a third party is acknowledged; and, ethics

procedures and guidelines have been followed.

I acknowledge the support I have received for my research through the provision of

Australian Government Research Training Program Scholarship.

Candidate’s Name: Dan Marthick-Hone

Date: 14 May 2020

Acknowledgements

The writing of this thesis has truly been an epic journey for me, certainly regarding

both personal and professional development. Like most who embark upon the journey that

is higher degree research it has come with ups and downs. I know that I would not have

made it this far without the support of my friends, family and colleagues. I have the utmost

appreciation for their support and help throughout this process.

I would first like to acknowledge RMIT University for its continued support

throughout this project, particularly Prof. Regina Crameri who aided in navigating some

difficult situations. I would like to acknowledge RMIT University for providing me with a full

scholarship throughout my candidature. I would also like to acknowledge the Australian

Chiropractors Association (formerly Chiropractic Association of Australia) for providing me

with stipend scholarship. These scholarships allowed me to maintain my focus throughout

my candidature without financial stress. Thank-you.

I acknowledge the unpaid editing work undertaken throughout my candidature.

Thank-you to my unofficial editor and very special friend, Pauline Dingli. You are the

loveliest person and I am so pleased to know you. Thank-you so much for your ever-so-keen

editing skills and support throughout my writing process. Your keen eye and amazing

administrative skills are the best I know!

I am tremendously grateful to my supervisory team for their continued support

throughout my candidature. Dr. Barbara Polus and Dr. Charlotte Paterson had the idea for

this project many years ago and I am truly proud to have been able to bring this important

work to fruition. Thank-you Barb, you have been the most amazing supervisor I could have

asked for and I am glad to be able to call you my friend. Thank-you to Dr. Dein Vindigni for

his continued positivity, even when times were tough you always managed to stay the

course and keep me on track. Dein, you are one of the kindest men I know. I am truly

privileged and grateful to know you and to have had you as a mentor for many years. To

Prof. Gerard Kennedy, thank-you for your expertise and guidance throughout this process, it

has been of extreme help. I have enjoyed getting to know you throughout this process. All

the best for the new job in Ballarat! Finally, to my unofficial supervisor, Aunty Kerrie Doyle.

Although you may not think so, Aunty, your help, whether it be a five-minute chat here and

there, has been extremely helpful! You are a true gem and I have loved being able to learn

from you. All the best in Sydney!

To Mum and Dad, thank-you for raising me to be the man I am today. You have

instilled in me the importance of hard work, dedication and perseverance. I hope I have

made you proud. To my brother, Owen and my lovely sister-in-law, Mykaela, you have made

me a proud uncle and brought me happiness and love while completing this course.

To my colleagues at RMIT University, Sandra, Frank, Emilio, Jen, Sam, Keith, Serena,

Bruce, Mick, Nereo, Rikki, Bec and the lovely Georgie, thank-you for brightening my day

whenever we have been working together. You are all amazing and I am lucky to have such

a great bunch of supportive co-workers.

To my dearest friends. I love you all. To Jess, thanks for being my bestie, always

having my back and always being there to listen to me complain, you’re the greatest. To my

RMIT buddy, Julie, you have no idea how much I have loved getting to know you as I

embarked on this journey. Your experience and counsel have been so helpful. You have

helped me navigate some of the most difficult times throughout this process and have

always offered sound advice and support. To Lochie, thank-you for helping me unwind at

iii

the end of most days and always being up for a game or two of Overwatch! Thank-you to

my other friends, Sam and Lachy, Clare and Taryn.

Thank-you to my study buddies Nic and Gemma. I loved our time getting work done

in Building 10. You have both helped to keep me motivated and I am so happy to call you my

friends.

Thank-you to those who wrote and sang the music I have listened to for many hours

while writing. To those who I was lucky enough to see live throughout this course: Charley

Pride, Kris Kristofferson, Willie Nelson, Bill Anderson, Jeannie Seely, Adam Harvey and Beccy

Cole, thanks for giving me something to look forward to.

Thank-you to my loving husband, Jono. You have been there through thick and thin,

have always been there to listen and never complained. You are my rock. We both

experienced some major lows and highs while I have been doing this course and it is great

to know that we will always be there for each other. Love you.

Finally, and most importantly, thank-you to The Wellington for your

cooperation and help throughout the data collection process, and to all the participants

involved in this project. Your patience and participation have been much appreciated.

List of Tables

Table 1 Summary of PROMs…………………………………………………………………………………….24

Table 2 Inclusion and Exclusion Criteria for Clients who Completed PROMS…………….45

Table 3 Measure Yourself Medical Outcome Profile Activity Nominated by Clients….61

Table 4 Patient Enablement Instrument Responses…………………………………………………66

Table 5 Themes and Codes……………………………………………………………………………………...67

Table 6 Interview Participant Pseudonyms…………………………………………………………..….68

Table 7 Summary of First Theme………………………………………………………………………………80

Table 8 Summary of Second Theme……………………………………………………………………..….90

Table 9 Summary of Third Theme…………………………………………………………………………..101

Table 10 Summary of Fourth Theme………………………………………………………………..………107

Table 11 Summary of Fifth Theme……………………………………………………………………………115

List of Figures

Figure 1 Components of Patient-Centred Care as described by Kitson et al. …………….18

Figure 2 Bronfenbrenner’s Ecological Systems Model……………………………………………….33

Figure 3 Measure Yourself Medical Outcome Profile Scores at Baseline and

Follow-Up…………………………………………………………………………………..…………..…..59

Figure 4 Location of Primary Symptom……………………..………………………………………………62

Figure 5 Chronicity of Primary Symptom……………………………………………………………………63

Figure 6 European Quality of Life Five Domain Five Level Index Scores at Baseline and

Follow-up…………………………………………………………………………………………………….65

Figure 7 A client receiving treatment at The Wellington.……………….….………………………75

Figure 8 Chiropractic students at The Wellington………………………………………………………95

List of Abbreviations

ADL Activities of Daily Living

AIHW Australian Institute of Health and Wellbeing

EQ-5D-3L European Quality of Life Five Domain Three Level Health Questionnaire

EQ-5D-5L European Quality of Life Five Domain Five Level Health Questionnaire

EQVAS European Quality of Life Visual Analogue Scale

CAM Complementary and Alternative Medicine

MSK Musculoskeletal

MYMOP Measure Yourself Medical Outcome Profile

PCC Patient-Centred Care

PEI Patient Enablement Instrument

PGI Patient Generated Index

PROMs Patient-Reported Outcome Measures

RCT Randomised Controlled Trial

SMT Spinal Manipulative Therapy

TT Therapeutic Touch

TW The Wellington

W-BQ12 12-Item Wellbeing Questionnaire

WSR Whole Systems Research

vii

Declaration ................................................................................................................................................................. i

Acknowledgements...............................................................................................................................................ii

List of Tables ............................................................................................................................................................ v

List of Figures ........................................................................................................................................................ vi

List of Abbreviations ......................................................................................................................................... vii

Table of Contents ............................................................................................................................................... viii

Abstract ......................................................................................................................................................................1

Chapter 1: Synopsis ..............................................................................................................................................4

Background 4

Methods 5

Patient-Reported Outcome Measures.................................................................................................6

Interviews ........................................................................................................................................................8

Results 10

Patient-Reported Outcome Measure Data ..................................................................................... 10

Interview Findings .................................................................................................................................... 11

Discussion 13

Conclusion 15

Chapter 2: Introduction ................................................................................................................................... 16

Patient-Centred Care 16

Patient-Centred Care and Outcomes in Allied Health and Complementary and Alternative Medicine Therapies 20

Measuring Patient-Centred And Reported Outcomes 22

A Qualitative Assessment for Disadvantaged Communities 32

Patient-Reported Outcomes in Disadvantaged Communities 35

Summary and Gaps within the Literature 38

Study Aim of the Thesis .......................................................................................................................... 39

Chapter 3: Methodology .................................................................................................................................. 41

Introduction 41

Location, Recruitment and Demographics .................................................................................... 41

Participants .................................................................................................................................................. 43

Inclusion and Exclusion Criteria .................................................................................................... 44

Instruments and Materials 46

Patient-Reported Outcome Measures.............................................................................................. 46

Measure Your Medical Outcome Profile..................................................................................... 47

viii

European Quality of Life Five Domain Five Level Health Questionnaire ................... 48

Patient Enablement Instrument .................................................................................................... 49

50 Data Analysis

Measure Yourself Medical Outcome Profile and European Quality of Life Five Domain Five Level Health Questionnaire ...................................................................................... 50

Patient Enablement Instrument ......................................................................................................... 51

51 Qualitative Methods

Interviews and Observation ................................................................................................................. 55

Qualitative Data Analysis ....................................................................................................................... 56

Chapter 4: Results ............................................................................................................................................... 58

58 Data Collected

Demographic Data ..................................................................................................................................... 58

58 Patient-Reported Outcome Measure Data

Measure Yourself Medial Outcome Profile .................................................................................... 58

The European Quality of Life Five Domain Five Level Health Questionnaire .............. 63

Patient Enablement Instrument ......................................................................................................... 65

66 Interview Data

Theme 1: A Patient-Centred Approach for Clients (Microsystem) ................................... 68

Code 1: The Client Experience of Chiropractic at The Wellington ................................ 69

Summary of The Client Experience at The Wellington .................................................. 72

Code 2: Client Treatment Protocol at The Wellington ........................................................ 72

Summary of Client Treatment Protocol at The Wellington .......................................... 75

Code 3: The Wellington as a Setting ............................................................................................. 76

Summary of The Wellington as a Setting .............................................................................. 79

Summary of A Patient-Centred Approach for Clients................................................. 80

Theme 2: Clients are Complex (Mesosystem) ............................................................................. 80

Code 1: Benefits and Reasons for Attending Chiropractic at The Wellington ......... 80

Summary of Benefits and Reasons for Attending Chiropractic at The Wellington ................................................................................................................................................................... 84

Code 2: Impact of Health Problems on Clients’ Lives .......................................................... 84

Summary of Impact of Health Problems on Clients’ Lives ............................................ 87

Code 3: Chronicity and Multiple Conditions ............................................................................ 87

Summary of Chronicity and Multiple Conditions .............................................................. 89

Summary of Clients are Complex ......................................................................................... 90

Theme 3: Trust (Exosystem) ............................................................................................................... 90

Code 1: Relationships .......................................................................................................................... 91

Summary of Relationships ........................................................................................................... 95

Code 2: Student Delivery of Chiropractic Care at the Wellington.................................. 95

Summary of Student Delivery of Chiropractic Care at The Wellington .................. 97

Code 3: Client Experience with External Healthcare Providers ..................................... 98

Summary of Client Experience with External Healthcare Providers.................... 101

Summary of Trust ..................................................................................................................... 101

Theme 4: The Cost of Being Disadvantaged (Macrosystem) ............................................. 101

Code 1: Client Experience with Medication ........................................................................... 102

Summary of Client Experience with Medication ............................................................ 103

Code 2: Financial Barriers Impair Access to Chiropractic Care ................................... 104

Summary of Financial Barriers Impair Access to Chiropractic Care .................... 106

Summary of The Cost of Being Disadvantaged ........................................................... 107

Theme 5: Looking to the Future (Chronosystem) .................................................................. 107

Code 1: The Wellington as a Setting Over Time .................................................................. 107

Summary of The Wellington as a Setting Over Time .................................................... 112

Code 2: Future of Clients and Their Healthcare Needs .................................................... 112

Summary of Future of Clients and Their Healthcare Needs ..................................... 114

Summary of Looking to The Future ................................................................................. 115

Chapter 5: Discussion/Conclusion .......................................................................................................... 116

Prominent Findings 116

Chronic Disease and Comorbidity .................................................................................................. 117

Health and Wellbeing ........................................................................................................................... 118

Enablement ................................................................................................................................................ 122

Physical Mobility and Function ........................................................................................................ 126

Limitations 128

Recommendations for Future Research 129

Conclusion 129

Bibliography ....................................................................................................................................................... 132

Appendices .......................................................................................................................................................... 155

Appendix A: Ethics Approval (Page 1 of 2) 155

Appendix A: Ethics Approval (Page 2 of 2) 156

Appendix B: Recruitment Flyer 157

Appendix C: Measure Yourself Medical Outcome Profile (MYMOP) 158

Appendix D: European Quality of Live Five Domain Five Level Health Questionnaire (EQ-5D-5L) (Page 1 of 3) 159

Appendix D: European Quality of Live Five Domain Five Level Health Questionnaire (EQ-5D-5L) (Page 2 of 3) 160

Appendix D: European Quality of Live Five Domain Five Level Health Questionnaire (EQ-5D-5L) (Page 3 of 3) 161

Appendix E: Interview Schedule (Clients) (Page 1 of 2) 162

Appendix E: Interview Schedule (Clients) (Page 2 of 2) 163

Appendix E: Interview Schedule (All Other Interview Groups) (Page 1 of 2) 164

Appendix E: Interview Schedule (All Other Interview Groups) (Page 2 of 2) 165

Abstract

Introduction: Patient-centred outcomes have been studied for several decades through the

use of patient-reported outcome measures (PROMs) for a number of different conditions

and therapies, including chiropractic. Yet investigation into patient-centred outcomes of

those living with disadvantage and how these outcomes may differ to the general

population is lacking. This is likely due to chiropractic being a mostly privatised service

within Australia, with those experiencing disadvantage typically not having access to this

type of care due to financial barriers. However, some universities within Australia offer

outreach clinics where students can offer their services to those living with disadvantage.

Aim: A mixed-methods observational study was used to investigate the patient-centred

outcomes of clients attending a community student chiropractic clinic and how this setting

may influence the patient-centred outcomes of the clients attending.

Methods: Three PROMs were chosen to investigate these outcomes. They were the

Measure Yourself Medical Outcome Profile (MYMOP), the European Five Domain Five Level

Quality of Life Questionnaire (EQ-5D-5L) and the Patient Enablement Instrument (PEI).

These measures were completed by clients attending the community clinic for chiropractic

care. Paired sample t-tests were used to compare baseline and follow-up scores for

normally distributed data and Wilcoxon signed-rank tests were used where data were not

normally distributed. Semi-structured interviews were also conducted with clients receiving

chiropractic care, the chiropractic students, their clinical supervisors and the staff that assist

in running the clinic. These interviews were conducted so that those involved in the clinic

could offer insight as to what outcomes were important to patients and what may have

influenced those outcomes. Interview data were analysed using thematic analysis and codes

and themes were formed using Bronfenbrenner’s ecological systems theory.

Results: A total of 37 participants were recruited at baseline and 17 at follow-up. 71.97% of

participants nominated their primary complaint to be chronic. Health and wellbeing scores

for the EQ-5D-5L 100-point visual analogue scale (EQVAS) were significantly lower than

those reported in the population normative data for South Australia. Significant change was

noted in general health and wellbeing for the MYMOP, pain and disability for the EQ-5D-5L

and index scores for the EQ-5D-5L, indicating improved health and wellbeing. Greater than

50% of all participants experienced higher levels of enablement as a result of attending the

clinic according to findings from the PEI. A total of 12 participants agreed to be interviewed.

Five themes were developed from the interview data. Those themes were 1) A Patient-

Centred Approach for Clients at The Wellington, 2) Clients are Complex, 3) Trust, 4) The Cost

of Being Disadvantaged and 5) Looking to the Future. A pattern emerging from these

themes was that clients often related their lived experience to their health problems. It was

suggested that these clients experience significant disability as a result of their conditions

and that attending this clinic offered benefits beyond that of the improvement of pain and

disability.

Conclusion: Those living with disadvantage suffer from higher rates of chronic conditions

and multimorbidities. Little work has been done to investigate how this cohort experience

patient-centred care and what their outcomes might be. This study showed that as a result

of a short course of treatment clients experienced better levels of health and wellbeing and

decreased levels of pain and disability. Interview data suggest that this may be due to a

combination of therapy, setting and relationships formed within that setting. These findings

indicate that those who experience disadvantage may receive significant benefit by

attending community centres that offer chiropractic care, suggesting that services such as

these should be made more widely available to those less fortunate.

Chapter 1: Synopsis

Background

Patient-centred care (PCC) and the outcomes associated with that care have been

investigated for a number of years with the aim of improving patient care and cost-

effectiveness of interventions (Bauman et al., 2003; Delaney, 2018; Trenaman et al., 2017).

This is usually achieved by using what are known as patient-reported outcome measures

(PROMs) (Nelson et al., 2015). These PROMs allow a unique assessment of patients’

individual outcomes, health and wellbeing and quality of life. Patient-reported outcome

measures can be either disease-specific or more generic, with the goal of measuring

outcomes that are of importance to the patient completing them. Patient-reported

outcome measures have been used in a number of studies, investigating a wide variety of

interventions as well as conditions. They have been used to assess treatment modalities

including traditional Chinese medicine (acupuncture) (Paterson et al., 2010), chiropractic

(Alcantara et al., 2018), physiotherapy (Fennelly et al., 2018), spinal surgery (Austevoll et al.,

2019) and numerous other interventions. The utilisation of these measures for specific

conditions is also quite common with studies using PROMs investigating outcomes for

conditions such as chronic low back pain (Koc, 2018), mental health disorders (Kendrick et

al., 2016), lumbar scoliosis (Goz et al., 2017) and numerous other conditions. While these

measures have been widely utilised in a number of different studies, little investigation has

reported on: outcomes for those who experience disadvantage (lower socioeconomic

status, physical and mental disability or a combination) in their lives; why these outcomes

are important; and what factors might influence these outcomes.

The literature also reports that those who live with, or experience disadvantage,

suffer from higher rates of chronic conditions and comorbidities (Katikireddi et al., 2017;

Roberts et al., 2015; Stringhini et al., 2017). Specifically in relation to chronic low back pain,

there is a strong association between its prevalence and socioeconomic status, both in high-

income and low-income countries alike (Hartvigsen et al., 2018). It is also known that the

management for chronic low back pain such as surgery and opioid prescription is typically

ineffective for this condition (Hartvigsen et al., 2018). This poses a problem for those who

live with disadvantage and do not have ready access to healthcare such as allied health,

complementary and alternative medicine (CAM) that is typically privatised and inaccessible

due to financial barriers. Alongside higher rates of chronic conditions and comorbidities,

those from lower socioeconomic backgrounds may also experience discrimination from

healthcare practitioners potentially leading to avoidance behaviours when seeking

healthcare (Moscoso-Porras & Alvarado, 2018; Stepanikova & Oates, 2017). These findings

suggest that careful consideration must be taken when caring for individuals suffering from

disadvantage as their clinical presentations are likely to be complicated by personal and

medical histories.

The literature review within this thesis examines the importance of PCC and the

outcomes associated with this care. It also discusses the usage of different PROMs and what

the most appropriate method for investigating the outcomes of those living with

disadvantage might be.

Methods

This study aimed to investigate the outcomes of a cohort of clients who attended an

RMIT University student chiropractic clinic located within a community organisation known

as The Wellington (TW) and what impact this service and setting had upon these outcomes.

All of the clients who attend TW experience disadvantage to some degree and are

encouraged to meet and interact with other members of the community in a welcoming

drop-in atmosphere (The Wellington, 2020). This study involved a mixed-methods

observational study that utilised a combination of PROMs, semi-structured interviews and

non-participant observation. This research design was based on an emerging framework of

research known as Whole Systems Research (WSR) (Ijaz et al., 2019). This framework was

deemed suitable for this investigation as it integrates the use of quantitative research

techniques with qualitative research techniques. The reason for this combined approach

was to identify as many contributing factors as possible that might be associated with the

outcomes for participants involved in the study. Data collection took place from February

2019 until December 2019 with approval from RMIT’s Human Research Ethics Committee

(Approval Number 21684).

Patient-Reported Outcome Measures

A total of three PROMs were chosen for use in this investigation. They were chosen

for their reliability, validity and ability to detect change across time. The first PROM chosen

was called the Measure Yourself Medical Outcome Profile (MYMOP). The MYMOP was

developed with the aim of allowing the respondent to nominate symptoms of their primary

health complaint and an activity in their day-to-day lives impacted upon because of that

symptom (Paterson, 1996). This is important, as it allows for the respondent to choose

symptoms and an activity that is specifically important to them, rather than choosing from a

list of options. The MYMOP has been used in a number of studies in the past. Some of these

include investigating the outcomes of patients receiving hip arthroplasty (Kassam et al.,

2018), traditional Chinese medicine for long-term conditions (Paterson et al., 2010) and in

patients suffering from acute exacerbations of chronic bronchitis (Paterson et al., 2000).

Due to the MYMOP’s usefulness in measuring change in chronic conditions and its

measurement of patient-specific individual outcomes, it was deemed appropriate for use in

this study.

The second PROM chosen for this study was known as the European Quality of Life

Five Domain Five Level Health Questionnaire (EQ-5D-5L). The EQ-5D-5L is a health-related

quality of life outcome measure that asks the respondent to nominate on a five level scale

how good or bad their health is pertaining to five different domains of health (Herdman et

al., 2011). These domains are “Mobility”, “Personal Care”, “Usual Activities”, “Pain and

Discomfort” and “Anxiety and Depression”. Accompanying these domains is also a 100-point

visual analogue scale known as the EQVAS. The EQVAS asked the respondent to nominate

on this scale how good or bad their health had been that day. The EQ-5D-5L has been used

in a number of studies investigating outcomes of patients with chronic conditions (Sakthong

et al., 2015), knee osteoarthritis, chronic osteoarthritis, low back pain or cancer pain (Rejas

& Albertos, 2017) and to determine the cost-effectiveness of care received (Bilbao et al.,

2018). The EQ-5D-5L was chosen over the first version (EQ-5D-3L) due to its higher

sensitivity to change (Janssen et al., 2008). It was also chosen as an appropriate adjunct to

the MYMOP. Because responses from the MYMOP are individual, based on nominated

symptoms and activities, it was deemed important to have a tool that measured outcomes

that were the same for all participants.

The third measure was the Patient Enablement Instrument (PEI). The PEI is a PROM

that measures the enablement of patients as a result of attending a health service (Howie et

al., 1997). Enablement is considered as empowerment of the patient and their ability to

comprehend, understand and cope with their particular illness or condition (Howie et al.,

1998). The PEI asks the respondent six questions pertaining to their consultations over the

past weeks or months. The PEI has been used within the literature to assess the enablement

of patients suffering from chronic musculoskeletal (MSK) pain (Enthoven et al., 2019). It has

been suggested that practitioner empathy is an important factor in order to enable patients,

in both high and low-socioeconomic areas. As this was an observational study, it was

important to include a PROM that asked respondents questions regarding outcomes that

pertained specifically to the treatment they received as opposed to external factors.

The MYMOP and EQ-5D-5L were administered to all clients at baseline who agreed

to participate in the study. Follow-up took place at two weeks or after a total of four

treatments with the student chiropractors, whichever came first. At follow-up the MYMOP

and EQ-5D-5L were again administered, this time along with the PEI.

All data from the MYMOP and EQ-5D-5L were analysed using paired-sample t-tests

where data were normally distributed and where data were not normally distributed

Wilcoxon signed-rank tests were used. All other data were described descriptively.

Interviews

The other component of this study was to interview those involved at TW. This

included. clients, student chiropractors, chiropractic supervisors and staff of TW. The reason

groups aside from the clients were interviewed, was to assist in determining what

components of care were important to clients, how these outcomes benefited clients, what

other factors may have influenced client outcomes and to what extent TW as a setting may

have influenced these outcomes. Interviews were semi-structured in their design and pre-

determined probes were utilised where necessary. Thematic analysis was used to analyse

interview data and a constant comparative approach was used throughout (Braun & Clarke,

2012; Glaser, 1965). Non-participant observation was used as a way to gain a deeper

understanding from interview findings. This non-participant observation was conducted to

establish the sense of setting and to describe the different interaction that took place in the

common area/ waiting room between those at TW who sought chiropractic care and to

allow for a deeper understanding of other qualitative and quantitative findings. Interviews

were conducted until data saturation was achieved.

To minimise bias when reporting interview findings, an appropriate theory was

selected for the development of codes and themes. This theory was developed by

Bronfenbrenner and is known as ecological systems theory (Bronfenbrenner, 1979). Initially

this theory was quite often used in studies investigating childhood development. However,

in recent years, the theory’s use has been expanded to a number of studies including those

investigating Indigenous populations (Doyle et al., 2017) and in promoting sustainability of

community-based healthcare (Patrick et al., 2011). Because Bronfenbrenner’s ecological

systems theory has been used in studies that involved disadvantaged populations as well as

community-based healthcare settings, it was deemed as an appropriate theory to apply to

this study’s interview findings.

Bronfenbrenner’s ecological systems theory states that the development of any

individual is influenced by five systems that comprise the individual ecosystem. These five

systems are described as: (1) the microsystem, a person’s immediate settings that they

participate in; (2) the mesosystem, this is a collection of microsystems within a person’s life

that influence each other; (3) the exosystem, external settings that the individual is not

involved in but is influenced by; (4) the macrosystem, the overarching influence of a

society’s beliefs, religions, laws and morals; and (5) the chronosystem, how the passage of

time may influence a person’s life, either past, present or future (Bronfenbrenner, 1979).

Results

This study had a total of 37 clients complete PROMs at baseline. Follow-up was

possible with 17 of these clients. Of those 37 clients, a total of 16 were male and 21 were

female. The average age of clients in this study was 52 years.

Patient-Reported Outcome Measure Data

Significant change was detected between baseline and follow-up scores of the

MYMOP profile scores. When comparing baseline MYMOP profile scores with those of a

previous study conducted in another RMIT teaching clinic that serves the general

population, there was a statistically significant difference between scores (Polus et al.,

2011). It was found that at baseline, a total of 72% participants reported attending TW for a

problem that was chronic in nature and 75.7% of clients stated that they were not currently

taking any medication to assist with their primary symptom. More than half of clients in this

study stated that avoiding medication usage for their symptoms was of some importance to

them.

Data from the EQ-5D-5L showed significant change between baseline and follow-up

for the domain of “Pain and Discomfort”. Similarly, significant change was noted in baseline

and follow-up EQ-5D-5L index scores. All other domains and the EQVAS showed no

significant change between baseline and follow-up. When comparing EQVAS baseline scores

from this study with population normative data from a South Australian population, a

statistically significant difference was noted between scores (McCaffrey et al., 2016).

Seventeen participants completed the PEI at follow-up. While not all clients who

completed the PEI experienced improved scores pertaining to enablement, the majority did.

Interview Findings

Interviews were conducted with a total of 12 participants, including a mixture of

clients, chiropractic students, chiropractic supervisors and staff at TW. From the interview

findings codes were developed using Bronfenbrenner’s ecological systems theory

(Bronfenbrenner, 1979). A total of five themes were developed, each having relation to one

of Bronfenbrenner’s five systems.

The first theme was titled A Patient-Centred Approach for Clients and was developed

in relation to what is known as the microsystem. This theme was comprised of codes that

were related to how clients experienced chiropractic care at TW, how they were treated at

TW and how TW acted as the primary setting for this study. Findings suggest that clients

attending TW for chiropractic care experienced benefits beyond just the improvement of

pain and disability. Clients discussed how they had found the clinic offered hope for their

future and that they felt their mental health had improved as a result of attending. It was

also reported that clients who attended the chiropractic clinic at TW experienced PCC from

the students who treated and cared for them. The Wellington was found to be important for

the clients who attended setting. Consistent with what appeared on the TW’s website, that

it encouraged meeting and interacting with others who attend, interview participants also

discussed how TW as a setting provided a source of community and an opportunity to

simply chat with someone.

The second theme was established using Bronfenbrenner’s mesosystem. This second

theme was titled Clients are Complex and was generated from codes pertaining to benefits

and reasons that clients attend TW, the impact that clients’ health problems had upon them

and how the clients experienced chronic conditions and comorbidities. Findings under this

theme indicated that clients valued the improvement of their condition and when this was

not possible, maintaining their current levels of function. Clients placed great value in being

able to improve their physical mobility and function as it meant they were able to continue

participating in their daily activities. It was also reported that in some cases clients’ health

problems had significant impact upon their lives. There was general acceptability of this by

clients and they discussed how this meant that they needed to plan their day-to-day lives

and their future living around their complaints. Consistent with findings from the PROMs,

interviewees reported that clients live with chronic conditions, often with comorbidities. It

was found that the clients attending TW have complex personal and medical histories.

The third theme was titled Trust and was based upon what Bronfenbrenner

described as the exosystem. This theme was produced from codes surrounding the

relationships clients formed with those at TW, students and their delivery of care and

clients’ experience with external healthcare providers. Interview respondents discussed how

important trust was as a key component of forming and maintaining genuine relationships

with the clients at TW. Clients described how they appreciated the care they received at TW

and how they particularly valued students who were genuine in their approach to caring for

clients. Clients described how they perceived the care they received at TW as being separate

from other healthcare workers, although they acknowledged how they work together in

serving the betterment of their health as their common goal. It was, however, reported by

one client that they had experienced discrimination from other healthcare providers

external to TW in the past.

The fourth theme was titled The Cost of Being Disadvantaged and was formed using

Bronfenbrenner’s macrosystem. This theme was constructed by codes surrounding clients’

experience with medication and the financial barriers they faced when trying to access

primary healthcare such as chiropractic at TW. Similar to the findings from the PROMs, all

clients reported that they preferred to avoid taking medication for their complaint, primarily

because they did not find their usage too effective in managing their symptoms for an

extended period of time. Clients also reported some frustration that services like TW were

not more widely available. They described that healthcare such as chiropractic should be

available to a wider population, regardless of income status.

The final theme was titled Looking to the Future and was generated using what

Bronfenbrenner described as the chronosystem. This theme comprised codes that described

how TW was an important setting for those who live within the local community, how it acts

as a place that addresses their healthcare needs and how the clients were hopeful regarding

the future of their health conditions. Also, that they planned to continue using TW as a place

to address these needs.

Discussion

The literature suggests that those who experience disadvantage have higher rates of

chronic conditions and comorbidities when compared with the general population

(Chamberlain et al., 2020). This study’s findings aligned with the literature, as a vast majority

of the clients nominated having had their primary symptom (as nominated on the MYMOP)

for greater than three months in duration. This was also iterated in the interview findings

with all clients interviewed expressing how they lived with and managed their chronic

conditions.

Data from the MYMOP indicated that many of the clients preferred to avoid using

medication as a means to treat their symptoms. This is not congruent with the literature,

which suggests that it is common for people experiencing chronic MSK conditions to also

have long-term opioid prescriptions to manage their pain (Ashaye et al., 2018). Interview

findings from client participants suggested that the reason for this low rate of medication

usage among the clients at TW was because they found the usage of pain medication to be

ineffective in the management of their symptoms. Of those who did use medication for the

management of symptoms, the majority found it to be of some importance to them that

they reduce their medication usage where possible.

Data from the MYMOP and EQ-5D-5L indicated that clients experienced a statistically

significant improvement in their health and wellbeing after a short course of treatment at

TW. The literature suggests that those with complex care needs require a combination of

both healthcare and social care (Kuluski et al., 2017), and the outcomes of interviews at TW

were congruent with these findings. The social aspects of attending TW were clearly of great

importance to clients, with some clients even suggesting that this social interaction

improved their mental health and gave them hope for the future.

Study comparisons indicated that clients of TW experienced significantly poorer

levels of health and wellbeing when compared to MYMOP scores from another RMIT

University teaching clinic (Polus et al., 2011) and, when comparing EQVAS scores to

population normative data for the South Australian Population (McCaffrey et al., 2016). The

average age of participants in TW study was over the age of 50 and this may, in part,

account for the poorer levels of health and wellbeing described by clients at TW as those

who are older and experience disadvantage are reported to typically experience higher rates

of chronic back pain (González-Chica et al., 2018).

Another pertinent finding of this study was that favourable levels of enablement

were experienced by the clients who attended TW, as captured by the PEI. The literature

suggests that those who experience disadvantage also tend to have decreased levels of

enablement (Mercer et al., 2012). The findings of favourable levels of enablement are

positive and were iterated by the interview data. Clients expressed that as a result of their

treatments they were better able to manage their conditions even when students were

absent from the clinic. It was also reported that clients valued being given home exercise

and advice for when their conditions had acute exacerbations and they had to wait until

their next consultation.

Clients described the importance of improved or maintained levels of physical

mobility and function. It was reported that as a result of their care at TW they were better

able to complete their individual daily tasks. The social components of attending TW and

being able to receive care simultaneously were particularly important for the health of the

clients of TW, with the literature suggesting links between those who experience social

isolation and disadvantage, and having decreased levels of physical mobility, particularly in

older adults (Shankar et al., 2017). This suggests that the social components of attending TW

may be, in part, responsible for these findings.

Conclusion

It was reported that clients who attended TW for chiropractic care experienced PCC

from their student chiropractors. Those who did attend were typically older and

experienced chronic conditions, sometimes with multiple comorbidities compounding their

primary health concern. The presentation of clients at TW was that of individuals with

complex personal and medical histories. Outcomes of importance to those who attended for

chiropractic included improvement in physical mobility, function and enablement, and

having a space where genuine relationships were formed. The findings of this study suggest

that TW as a setting is a key contributing factor for those who attend for care. Those

interviewed all stated how they think that this type of service should be made more widely

available for members of the community, regardless of their status.

Chapter 2: Introduction

Patient-Centred Care

Patient-centred care (PCC) is a concept in healthcare that takes into consideration

both health outcomes and treatment options that are important to the patient as an

individual. This model of care employs educated and shared decision making for both the

patient and the practitioner, which should complement evidence-based care and best

decision making. Patient-centred care has been described as important in all healthcare

disciplines including biomedical healthcare approaches (Kinmonth et al., 1998) as well as

allied health and complementary and alternative medicines (CAM) therapies. All forms of

healthcare should have the patient`s best interest in mind (Verhoef et al., 2002). However,

little research has been conducted to specifically investigate how PCC might be experienced

by people from diverse demographic backgrounds and the outcomes associated with PCC.

Most studies in this area typically utilise either private or general healthcare practices to

source their participants (Paterson et al., 2010; Rööst et al., 2015), which may not create an

accurate snapshot of those living with disadvantage (lacking basic resources, living

conditions, access to healthcare and education), marginalisation (members of the

community who find themselves isolated from socially meaningful groups) or low

socioeconomic status (low-income individuals). This review of the literature aimed to

investigate the ways in which PCC, and its outcomes, can be appropriately measured and

how patient-centred outcomes might best be measured in populations that experience

disadvantage and/or marginalisation in some way.

Varying definitions of PCC appear in the literature, including the most important

factors when attempting to measure PCC and its outcomes in the general populations. Little

et al. (Little et al., 2001) described PCC using an observational study to investigate patient

preferences for patient-centred approaches to care. In this study Little suggested that in

order of importance, the main components in a patient-centred approach included

communication, partnership, health promotion, and, to a lesser extent, examination and

medication prescription (Little et al., 2001). The data for Little’s study were patient-

generated, and it is important to appreciate that PCC is inherently driven by the patient’s

own desired outcomes. Kitson et al.’s (2013) findings differed from those of Little et al.’s and

suggested that PCC is comprised of three main components. These components are: (1)

patient participation and involvement; (2) the practitioner-patient relationship; and (3) the

context in which the healthcare is delivered (Kitson et al., 2013) (Figure 1). While there are

some differences between these findings, they both highlight the importance of the

relationship between patient and practitioner. Similar to Kitson et al.’s findings, another

review was conducted in 2017 with the aim of defining the themes of PCC. Clarke et al.

reported six themes relating to PCC (Clarke et al., 2017). Those themes were very similar to

those that Kitson et al. outlined in their review, with some overlap. The six themes consisted

of the following: (1) engaging the patient as a whole; (2) the importance of emotional

recognition and appropriate responses to those emotions; (3) the therapeutic alliance

between patient and practitioner; (4) promotion of information exchange; (5) shared

decision making; and (6) patient enablement.

Figure 1: Components of Patient-Centred Care as described by Kitson et al.

While the practitioner-patient relationship is important, other substantial factors

constitute and contribute to PCC and patient outcomes. Empathy, enablement, and time

spent with the patient are important factors in providing PCC. A study conducted by (Mercer

& Reilly, 2004), in the United Kingdom, suggested that its participants most valued the time

their practitioners spent with them, as well as how genuinely empathetic the practitioner

was. An earlier study, by Mercer (Mercer et al., 2002) within the same hospital, described

the practitioner`s empathy as another important aspect of PCC. Another study investigated

what the requirements for PCC were (Ogden et al., 2017). This study included participants

who were clinicians, patients, and carers of patients with one or more chronic illness(es).

The findings of this study were presented as a conceptual map that outlined the

requirements of PCC. The study identified 13 components required for PCC and divided

these into three main groups. These groups were: firstly, health system, policy and

management; secondly, career spanning education and training; and thirdly, humanity and

partnership. These findings indicated that PCC involves certain aspects that go beyond the

relationship between the patient and practitioner and that PCC is a multifaceted process.

As the healthcare system shifts to a more patient-centred approach, a need to

measure the outcomes of this approach has arisen. This has been carried out by using what

has come to be known as patient-reported outcome measures (PROMs). These are

measures that are typically completed by the patient only and encompass components of

health and outcomes that are considered important to the patient (Deshpande et al., 2011).

These outcomes can be self-elected or standardised, depending on the PROM and the

clinical intervention being used. Patient-reported outcome measures can give insight into

patient outcomes that clinical measures might not include. These can include aspects such

as quality of life, patient satisfaction, impact on daily activities of living (ADLs), health status

and wellbeing (Meadows, 2011). This means that when selecting appropriate PROMs, the

specific outcomes of the patient being measured need to be considered. Patient-reported

outcome measures can either be generic or disease-specific (Calvert & Freemantle, 2003)

and should be chosen in a way that does not overburden the patient completing them.

Patient-reported outcome measures can be used to measure more subjective aspects of a

patient’s presentation as well as outcomes such as pain, wellbeing and ability to participate

in activities of daily living (ADLs) (Fries, 1983a, 1983b). Patient-reported outcome measures

are able to measure change across time and because they are subjective, outcomes will

inherently be influenced by sociodemographic factors (Bausewein et al., 2011; Gilbody et

al., 2003). A systematic review of the literature found that the implementation of routine

PROMs in cancer patients led to better communication between practitioners and their

patients and higher levels of patient satisfaction (Chen et al., 2013). However, this review

found poor or non-existent evidence to suggest that this implementation led to any change

in patient management or their health outcomes. Another systematic review conducted in

2017 aimed to assess PROMs in clinical practice and the measurement of pain (Holmes et

al., 2017). While the studies used in this review were of poor quality and were

heterogeneous, it was found that PROMs were useful in the decision-making process of

patient care, tracking a course of treatment and that PROMs may influence the practitioner-

patient relationship, differing from Chen et al.’s findings.

Patient-Centred Care and Outcomes in Allied Health and Complementary

and Alternative Medicine Therapies

Several studies have assessed patient-centred outcomes of care in allied health and

CAM therapies clinical research and in practitioners measuring treatment outcomes for

patients. Within the last few decades the usage of PROMs in professions such as

physiotherapy has increased as a way of tailoring treatments to the patient’s specific needs

(Kyte et al., 2015). A systematic review conducted in 2018 aimed to determine the patient-

centred outcomes of people receiving physiotherapy for musculoskeletal (MSK) conditions

(Fennelly et al., 2018). This review found the main outcomes captured by the utilisation of

PROMs in patients receiving physiotherapeutic care for MSK conditions were patient

satisfaction, quality of life, pain levels and patient’s functional status. This review indicated

that within this field of healthcare and in clinical settings, these measures were being

utilised to enhance individual patient outcomes. A preliminary study investigating the

utilisation by Australian chiropractors of PROMs in patients experiencing low back pain

yielded similar findings (Clohesy & Schneiders, 2018). This survey found that 72.5% of its

respondents utilised PROMs when treating patients with low back pain. One particular case

study tracked the outcomes of an elite basketballer with patellar tendinopathy receiving

chiropractic treatment by using a combination of clinical measures in conjunction with a

PROM known as the Measure Yourself Medical Outcome Profile (MYMOP) (Jarosz, 2010).

This study demonstrated that chiropractic treatment enabled the individual to manage their

chronic patellar tendinopathy whilst being able to continue to train at an elite level, catering

to the patient’s goals of treatment.

Some studies in the areas of allied health and CAM therapy focus on the patient’s

perception of how patient-centred the care they received was rather than their outcomes. A

study conducted by (Orrock, 2016), using a mixed-methods approach of quantitative surveys

and semi-structured interviews, was able to demonstrate that participants perceived

osteopathic treatment as “patient-centered”, “tailored to their context” and “holistic”.

Studies regarding patient-centredness in physiotherapy have also been conducted, with one

study investigating patients who received physiotherapy for chronic low back pain (Cooper

et al., 2008) suggesting that there are six main components of PCC that patients find

important. These six key themes for PCC in physiotherapy were as follows: (1)

communication; (2) individual care; (3) decision-making; (4) information; (5) the

physiotherapist; and (6) organisation of care. The key themes in this study are very similar to

those reported by (Clarke et al., 2017; Kitson et al., 2013). Another investigation into the

patient-centredness of physiotherapy by (Cruz et al., 2012) focused mainly on the

practitioner and their interaction with the patient. The findings of this study suggested that

patient health outcomes are improved when a patient-centred approach is employed by the

practitioner (Cruz et al., 2012).

There has also been some investigation into the relationship between PCC and

patient outcomes. A study conducted in a Canadian hospital explored the relationship

between patient outcomes and PCC and the extent to which nurses provided this care

(Poochikian-Sarkissian et al., 2010). This investigation found moderate use of PCC according

to the nurses and patients included in the study. A moderate correlation was found

between aspects of PCC and patient outcomes of self-care and satisfaction of care. A study

conducted in Western Australian student chiropractic clinics in 2019 aimed to assess

chiropractic student use of person-centred care and what effects this care had on MSK pain

(Stomski et al., 2019). This investigation was undertaken across four teaching clinics, two of

which were outreach clinics. Patients were asked to complete several PROMs measuring

empathy of their practitioners and their MSK pain outcomes. The study found that the

patients attending these student chiropractic clinics had very positive reactions to the

majority of the students’ person-centred care. Although these students lacked clinical

experience, they were still able to deliver care in a person-centred approach that was

appreciated by the patients. However, because this investigation’s data set were skewed, an

inferential analysis was not possible. The investigators were unable to determine if the

clinically significant outcomes related to their pain were solely attributed to the PCC

received.

Measuring Patient-Centred And Reported Outcomes

Measuring patient-centred outcomes is not a simple task and can be difficult to

achieve if using only a single PROM. Some authors have suggested that the best approach

for measuring patient-centred outcomes within complex and multifaceted interventions

should employ a mixed-methods approach. This can be achieved by using a combination of

quantitative PROMs to complement qualitative methods such as semi-structured interviews,

focus groups and observations (Paterson & Britten, 2000). This type of research design has

been referred to as Whole Systems Research (WSR) (Verhoef, Lewith, et al., 2005). Verhoef

et al. suggested that WSR is an appropriate way of assessing allied health and CAM

therapies because these therapeutic approaches tend to be considered holistic in their

approach to patient care. Whole Systems Research was defined by Ritenbaugh et al. as the

“…investigation of both the process and the outcomes of complex healthcare interventions”

(Ritenbaugh et al., 2003, p. 33). This includes investigating all aspects of care that might

influence the patient outcome including the setting in which care is delivered, the patients,

their practitioners and any other factors that might influence outcomes of care. Verhoef et

al. suggested that this combined approach of WSR is useful for understanding important

factors associated with therapies such as allied health and CAM, including when caring for

those with chronic conditions. With a shift towards “fit-for-purpose” methodological

approaches (Loudon et al., 2015), WSR strikes a balance between research design and

therapeutic paradigm particularly in areas of allied health and CAM (Ijaz et al., 2019). A

scoping review of the literature was conducted in 2019 assessing advances made in WSR

over recent years (Ijaz et al., 2019). This review found that although WSR is an emerging

research discipline, it is patient-centred in its focus. As a result, it offers appropriate

methods of designing investigations to assess the encompassing effectiveness of complex

clinical interventions and personalised care (see Table 1 for a summary of PROMs discussed

in this section).

Table 1: Summary of PROMs.

Author/s Summary Outcome Measure

MYMOP Paterson et al.

Allows the respondent to nominate one or two symptoms caused by their primary complaint and one activity that is affected by symptom one. This measure also asks the respondent to rate their health and wellbeing over the past week, whether they are taking medication for their primary symptom and how important avoiding or reducing medication is to them.

PGI Ruta et al. This is a personalised PROM that allows the respondent to nominate any five areas related to their quality of life and attach a numerical score to them.

EQ-5D-3L The EuroQol Research Foundation This PROM measures five different domains of quality of life. Each domain is then measured on a three-level scale. This measure also utilises a 100-point visual analogue scale for respondents to rate their overall health.

EQ-5D-5L The EuroQol Research Foundation This PROM is a variation of the EQ-5D-3L, except instead of rating domains on a three-level scale, respondents have an additional two options, making it a five-level scale. These additional levels were added to reduce floor and ceiling effects.

PEI Howie et al. This PROM is a six-item questionnaire that asks the respondent to reflect upon the quality of their consultation.

In a study conducted by Paterson and Britten in 2003 (Paterson & Britten, 2003),

PROMs were completed by participants, alongside semi-structured interviews, in an attempt

to determine how well the outcome measures captured the participants’ perceived effects

and benefits of treatment. Their findings suggested that there were whole person benefits

to the intervention, not captured by the outcome measures which were more readily

captured in the interview data. Some of these benefits included increased energy levels and

changes in the participants’ personal social identity. Had these interviews not been

conducted and adjunct data not collected, then these “extra” benefits would not have been

realised or captured by the quantitative outcome measures alone. The interview data

assisted Paterson and Britten to determine what was being captured, what was being

captured well, and what was being completely missed by the measures. It has also been

further discussed that there might also be incidental placebo effects to complex

interventions such as acupuncture and other allied health and CAM therapies that may not

be tied to any specific theoretical underpinning (Paterson & Dieppe, 2005).

When measuring patient-centred outcomes it is important to consider all aspects of

that care. Verhoef argues that the whole is more important than any individual aspect of

care and that the research design should attempt to capture all aspects of care associated

with the effectiveness of an intervention whether it is allied health, CAM or conventional

medicine. (M. Verhoef et al., 2006). This approach led to the development of PROMs as a

way of investigating what are often individual outcomes of care which may be ignored or

missed by disease-specific outcome measures. Paterson designed and began evaluating an

outcome measure known as the Measure Yourself Medical Outcome Profile (MYMOP)

(Paterson, 1996). The MYMOP was designed as a PROM that allows the patient to specify

symptoms of their primary health complaint, an ADL that is affected by these symptoms and

to rate their feeling of general wellbeing over the past week. Because the patient is able to

nominate their symptoms, it means the MYMOP can be used as a somewhat disease-specific

measure while still maintaining some generic aspects by measuring wellbeing. The MYMOP

was later amended to include a question regarding patient medication in 2000 (Paterson &

Britten, 2000). The same year Paterson released her study investigating the MYMOP as an

outcome measure, other researchers (Ruta & Garratt, 1996) brought the MYMOP into

scrutiny. They suggested that the MYMOP’s reliability needed to be verified and that it was

unsupported by the evidence and undermined basic psychometric theory. In 2004 Paterson

et al. attempted to evaluate the MYMOP for reliability. However, they argued that because

the MYMOP measures in-person change over a period of time, that responsiveness to

change was a better measure to use than reliability (Paterson, 2004). This study also showed

that the MYMOP is in fact sensitive to change with minimal risk of ceiling and floor effects.

This was based on earlier work conducted by (Guyatt et al., 1993).

Despite this criticism, the MYMOP has been used in a number of patient-reported

outcome studies including a cohort suffering chronic bronchitis (Paterson & Britten, 2000),

patients attending Chinese medicine (including acupuncture) clinics (Cassidy, 1998a, 1998b;

Paterson et al., 2010), massage therapy interventions (Paterson et al., 2008) and more

recently in a study investigating reduction of pain and medication prescription in a military

population utilising acupuncture (P. Crawford et al., 2017). In 2011 the MYMOP was used

alongside another patient-centred outcome measure known as the 12-Item Wellbeing

Questionnaire (W-BQ12) by (Polus et al., 2011), to evaluate the benefits of receiving

chiropractic care in patients attending a student teaching clinic. The results of this study

found that both outcome measures used demonstrated statistically and clinically significant

sensitivity to change and that both measures appeared to be useful in assessing what

chiropractic patients perceived as well-being. In 2019 Ishaque et al. completed a critical

appraisal of the MYMOP and its different variations. The findings of this study indicated that

the MYMOP was unable to measure episodic conditions, had high levels of floor effect and

was inaccurate at measuring changes in medication. It did however, show good content

validity, responsiveness to change, and the ability to measure acute conditions (of less than

four weeks). The authors stated that there was a need for outcome measures such as the

MYMOP that were consistent with a more personalised and patient-centred approach to

medicine.

A translation and validation study of the MYMOP was conducted in Germany and

found again that the MYMOP had strong construct validity as well as responsiveness to

change (Hermann et al., 2014). This iterates that it can detect when there is improvement or

no change in a patient’s symptoms. This study measured the MYMOP’s construct validity

against that of another PROM known as the European Quality of Life Five Domain Five Level

Health Questionnaire (EQ-5D-5L) and it was found to be higher than anticipated, based on

Paterson’s 1996 study. The conclusion of Hermann et al.’s study was that because the

MYMOP is a one-page measure and is easy for patients to complete, it could also be a useful

PROM in assisting with the betterment of PCC within the German healthcare system.

Because PROMs are patient generated, they are considered inherently subjective.

While this is the case, some PROMs are better equipped at capturing patient-centred

outcomes than others. The Patient Generated Index (PGI) is a good example of this. Similar

to the MYMOP, the PGI is a PROM that measures the outcomes of the respondent’s five

most important areas relating to their quality of life (Ruta et al., 1994). This tool has been

used to measure outcomes in conditions such as ankylosing spondylitis (Haywood et al.,

2003) and response shift in post-stroke patients (Ahmed et al., 2005). A study conducted by

(Mayo et al., 2017) compared the PGI to a number of generic and disease-specific outcome

measures and patient responses across four different conditions. The conditions in the

study included multiple sclerosis, advanced cancer, human immunodeficiency virus positive

and post-stroke. The results of this study showed that the PGI, as a PROM had lower ratings

overall for health-related quality of life. It was suggested that the reason for this was

because the PGI allowed the patient to elect areas in their life that were affected by their

health condition. When given the ability to do this, the patients tended to elect more

negative areas as opposed to positive areas. The study revealed that the PGI was useful in

determining treatment options for patients as the measure captured unique information

that was missed in the standardised generic measures. This again highlights the value of

PROMs that allow their respondents to nominate outcomes that are of importance to them.

The cost-benefit of any intervention can be important in policy and funding decisions

within health systems. One particular outcome measure, named the European Quality of

Life Five Domain Three Level Health Questionnaire (EQ-5D-3L) has demonstrated some

success in assessing cost-effectiveness of interventions. The EQ-5D-3L measures five

different domains of health on a three-level scale and includes a 100 point “thermometer”

visual analogue scale for health. Van Exel et al. used a pre-existing framework to estimate

quality-adjusted life years for the cost effectiveness of post-stroke patients (Van Exel et al.,

2004) and in doing so, also assisted in confirming the EQ-5D-3L’s validity. A similar

publication by (Solberg et al., 2005) attempted to determine how the EQ-5D-3L might

provide cost utility data in relation to patients undergoing low back surgery. This study

suggested that the EQ-5D-3L was valid, reliable and sensitive to change and drew the

conclusion that it could also provide cost-utility data, although this was not fully explained.

The EQ-5D-3L was also included in Paterson’s 2004 study (Paterson, 2004) alongside

the MYMOP and Dartmouth COOP/WONCA charts outcome measure in an assessment of

the patient-centred outcomes of participants receiving acupuncture as an intervention.

Paterson claimed that all patient-centred outcome measures should “…encompass the aims,

values and treatment effects that are prioritised by individuals, and should enable each

individual to provide an unambiguous assessment of change over time” (p. 871). Though this

study found the EQ-5D-3L demonstrated the least sensitivity within the study, it is

nonetheless important to remember that the EQ-5D-3L was designed to complement other

outcome measures and to be used in conjunction with them (Brooks, 1996). Studies have

found the EQ-5D-3L to have problems with ceiling effects where high numbers of

participants were nominating the maximum scores on the EQ-5D-3L and as a result of this

had a low sensitivity to change (Kaarlola et al., 2004; Sullivan et al., 2005; Wang et al., 2005).

In an effort to increase the EQ-5D-3L’s sensitivity to change, the EuroQol Group decided to

make some changes to the existing measure and to add an additional two levels in which

participants could score their health outcomes within each of the five domains. This

updated outcome measure became known as the European Quality of Life Five Domain Five

Level Questionnaire (EQ-5D-5L). Since this change there have been several studies

comparing the three-level EQ-5D to the five-level version with results suggesting that the

addition of these two levels was responsible for a decrease in ceiling effect (Agborsangaya

et al., 2014; Scalone et al., 2013; Selivanova et al., 2018).

Testing the psychometric properties of the EQ-5D-5L in patients with scoliosis,

(Cheung et al., 2016) found the measure to be both valid and reliable as well as sensitive to

change when aiming to assess the health related quality of life in their participants.

Following this, a study investigated the psychometric properties of the EQ-5D-5L in patients

with hip or knee osteoarthritis (Bilbao et al., 2018). Similar to Cheung et al.’s study, the

findings also supported the validity, reliability and sensitivity to change of the EQ-5D-5L. This

indicates that similarly to the MYMOP, the EQ-5D-5L may be a useful PROM and aid in PCC.

The EQ-5D-5L has also been shown to have good validity and reliability when measuring

certain chronic conditions such as type II diabetes (McClure et al., 2018), rectal cancer

(Huang et al., 2018), cardiovascular disease (Dyer et al., 2010) as well as health related

quality of life across a number of different conditions including osteoarthritis and

rheumatism (Ascef et al., 2017). Given the success in measuring these chronic conditions

with a good level of reliability and validity, the EQ-5D-5L may be suitable for other

conditions that are of a chronic nature. A systematic review of the literature was conducted

in 2015 to investigate the EQ-5D-5L’s ability to detect meaningful change in the health

status so that it might be used in clinical research and more economic evaluation of

interventions (Payakachat et al., 2015). This review found that nearly all conditions within

the review had some responsiveness to change. It was found that 25 conditions (45%) had

at least some responsiveness. The remaining 48% had a mixed response to change (28

conditions) and only four conditions (7%) showed no change when being assessed by the

EQ-5D-5L. This review recommended that when utilising the EQ-5D-5L, it is best used in

conjunction with other condition-specific outcome measures to allow for a broader

interpretation of findings.

While PCC is a multifaceted approach, so too are the outcomes as a result of this

care. Enablement as an outcome of PCC has been linked to the patient’s perception of their

practitioner’s empathy (MacPherson et al., 2003). Enablement of the patient has been

linked to both the quality of the patient-practitioner encounter as well as the patient`s

outcome (Howie et al., 1997; Hudon et al., 2011). (Howie et al., 1998) described enablement

as a primary care outcome which can be measured as a reflection of care with the Patient

Enablement Instrument (PEI). Another investigation involving cancer patients, reported

similar findings (Kvåle & Bondevik, 2008). Their study found that participants valued having

their practitioners listen to them, believe them, and respect them as adults. A recent study

in 2018, investigated patients’ lived experiences through a lens of enablement in a primary

care setting with nurse practitioners. This study found that efficient use of time by the

practitioner, holistic approaches to care and the relationship building between the patient

and practitioner to be of importance to the patient’s health outcomes (Frost et al., 2018).

This highlights that the outcomes being measured need to be consistent with those that the

patient has nominated as important, in order to be truly patient centred. Kinmoth et al.’s

randomised controlled trial (RCT) suggested that while not losing sight of the patient`s

disease and presentation as an important consideration, it is equally important to focus on

their unique and personalised experience of their illness (Kinmonth et al., 1998).

The Patient Enablement Instrument allows for a patient to reflect on a course of

treatment over a period of weeks and/or months and measures how the interaction with

the practitioner and the care received has better enabled them to take charge of their

health. In 2019 a validation study was conducted in patients with chronic musculoskeletal

conditions using the PEI to determine the content validity, construct validity and internal

consistency of the measure (Enthoven et al., 2019). The investigation found that the PEI was

inadequate at measuring change, but that it had both fair construct validity and content

validity as well as fair internal consistency. This instrument may also be useful in assessing

patients from a range of socioeconomic backgrounds. An investigation was conducted to

discern the influencing factors of enablement in those living in areas of both high and low

socioeconomic deprivation (Mercer et al., 2012). The study used the PEI as a dependent

variable for their multivariate analysis and found that in both affluent and deprived areas,

empathy was a key factor in the enablement of patients. It was found that with scores of

low empathy, maximal patient enablement was not possible.

Overall, the literature suggests that different outcome measures have different

strengths, and that a combination of measures can lead to more robust findings. A study

conducted by (Paterson et al., 2010) investigated the outcomes of traditional Chinese

medicine acupuncture in patients with chronic conditions. This study found that the EQ-5D-

3L, MYMOP and PEI demonstrated that they were responsive to change, easy to administer

and acceptable to both staff administering them and participants. In this study the PROMs

were completed by participants of varying socioeconomic backgrounds within United

Kingdom National Health Scheme’s (NHS) acupuncture clinics. These measures were able to

provide a combination of robust qualitative and quantitative data (Paterson et al., 2010).

The qualitative data within Paterson’s study were collected by adding an additional open

question to the MYMOP that asked the participants what was most important to them when

reflecting upon their acupuncture treatment. A combination of these outcomes, used in

combination with qualitative research techniques such as semi-structured interviews, focus

groups and observations would allow the researcher to investigate complex interventions

and conditions like chronic pain in an holistic manner (Verhoef et al., 2002; M. Verhoef et

al., 2006).

A Qualitative Assessment for Disadvantaged Communities

Qualitative research methods are an appropriate way of investigating human social

practices and human experience. They can also be valuable in helping to interpret

quantitative findings (Silverman, 2016). Bronfenbrenner’s ecological systems theory offers a

framework for beginning to assess the outcomes and development for disadvantaged

populations (Bronfenbrenner, 1979). This framework describes the development of a person

as being influenced and impacted by the systems in which they participate. There are five

systems described by Bronfenbrenner, and they range from the immediate, for example

inside the home, to broader constructs such as societal values, traditions, beliefs and even

time.

Bronfenbrenner’s ecological systems theory allows for a deep exploration into the

different influences within a person’s environment that might impact their own personal

development or choices. These influences were described by Bronfenbrenner throughout all

five systems of his theory (Bronfenbrenner, 1979). These systems are known as the

microsystem, mesosystem, exosystem, macrosystem and chronosystem. Together, these

systems form what Bronfenbrenner refers to as the individual’s ecosystem, all components

of which will influence a person’s development throughout their lives (Figure 2).

Figure 2: Bronfenbrenner’s Ecological Systems Model. Adapted from (Shelton, 2018).

The microsystem is described as the developing person’s immediate settings in which

they interact. Bronfenbrenner described his systems in relation to children and their

development (Bronfenbrenner, 1979). He gave examples of the microsystem of a child being

in their home, pre-school, or other settings in which they are directly involved. Other

examples of microsystems could include grandparents’ homes, places of worship or a

friend’s house that they spend time at.

The second system is known as the mesosystem. The mesosystem is comprised of the

multiple microsystems in which an individual takes part. For microsystems to form a

mesosystem they must directly affect one another. An example of this, in the context of a

child would be how the lessons they learn at school might influence their behaviours at

home. It could also be something as simple as receiving homework to complete at home. If

a child participates in school sporting activities and is injured, this may influence their ability

to participate in activities that take place within their other settings.

The exosystem is the third system in Bronfenbrenner’s theory. The exosystem is a link

between two settings where the individual is only a participant in one, but the second

setting directly influences the first. For example, a child’s parent may have to work late in

their job due to some unforeseen circumstances. This means that the parent might not be

home in time to prepare a family meal, which can directly influence the dynamics of the

child’s home as a microsystem.

The fourth system is known as the macrosystem. This system is described as the

overarching influence of a society’s culture, laws, religions, policies, values and beliefs.

These are all factors that an individual is likely not to be directly involved in but is directly

influenced by. An example of this might be a government’s policy surrounding childcare

subsidies. Without such subsidies it might mean the child’s parents could not afford for

them to attend childcare and instead they may be required to stay with another relative

while the parent works.

The fifth system in Bronfenbrenner’s ecological systems theory is known as the

chronosystem. This system is defined by overall change across the life of the individual. This

may be on a personal level, dealing with stress, or it may be broader and encompass family

structure, changes in employment or socioeconomic status. This system is important as time

will influence the other four systems.

Initially, Bronfenbrenner’s work was mainly focused on human development,

particularly that of the child. However, his ecological systems theory has been used within

the literature to assist in the analysis of qualitative studies investigating a range of

populations including the patient-centred outcomes of women who suffer from depression-

like symptoms as well as socioeconomic deprivation (Poleshuck et al., 2019), minority

students experiencing hardship throughout the course of their study (B. F. Crawford et al.,

2019), retention rates of students in schools located in rural, regional or disadvantaged

areas (J. M. Allen et al., 2018) and common challenges faced when teaching Indigenous

history within Australian and New Zealand schooling systems (Manning, 2017).

Bronfenbrenner’s theory offers a framework to understand and support a wide range of

complex themes.

Patient-Reported Outcomes in Disadvantaged Communities

Disadvantage in communities leads to increased rates of chronic medical conditions

(Schanzer et al., 2007), from increased rates of renal disease (Garcia-Garcia & Jha, 2015; Ritte et al.,

2020), cardiovascular disease (Diez-Roux et al., 1999; Winkleby et al., 1992), pneumonia (Goss et al.,

2003) and musculoskeletal conditions (Brett et al., 2014). A prevalence study, conducted by (Barnett

et al., 2012), included nearly one third of Scotland’s population and used digital medical records of

314 primary care facilities throughout the country. Through this method of data collection, the

researchers were able to extract data that were representative of the entire population. This study

suggested that those living in areas of lower income showed higher levels of multimorbidity at

earlier ages compared to their counterparts living in more affluent areas. Interestingly, those with

mental health as a comorbidity, also showed higher levels of multimorbidity with higher rates in

areas of lower socioeconomic status. A study by Payne et al. argued that physical multimorbidity is

something that can also lead to higher levels of unplanned hospital admissions, made even worse by

coexisting mental health conditions and lower socioeconomic status (Payne et al., 2013). Payne’s

study suggested that further research was recommended, to determine if these admissions could be

managed, or even prevented, by primary care services. With similar findings, a longitudinal study

known as the Twenty-07 Study (Katikireddi et al., 2017) followed participants from 1987 to 2007 and

tracked their risk factors for multimorbidity, how many medical conditions they suffered (2+

indicating multimorbidity) as well as socioeconomic determinants. The findings of this study also

indicated that participants with lower socioeconomic status displayed higher levels of

multimorbidity at increased rates across the 20-year time frame of the study.

Socioeconomic status can also have an impact upon other areas of health. A systematic

review investigating the association between socioeconomic status and health determinants in

lower-middle-income-countries was conducted by (L. Allen et al., 2017). This review focused on diet,

exercise levels and alcohol and tobacco usage in relation to socioeconomic status. The findings of

this review showed that those in lower socioeconomic brackets had higher usage levels of tobacco

and alcohol and consumed less fish, fruit and vegetables in their diet when compared with those

from higher socioeconomic backgrounds. All of these factors can increase the risk of complicated

health issues such as chronic liver disease (Seitz et al., 2018), lung cancers (Miranda-Filho et al.,

2019) and heart disease (Micha et al., 2017).

People living with chronic pain and conditions may require, or prefer, a more patient-

centred approach to their healthcare than a clinical one. A mixed-methods study investigating the

facilitators and barriers to living with spinal cord injury found that patients preferred a more patient-

oriented approach when being cared for by their practitioner (Widerström-Noga et al., 2017). This

study found several barriers that presented to patients living with spinal cord injury. The first major

barrier was that of communication between patient and practitioner regarding their health problem.

The other main barrier was that not enough information was provided to them regarding their pain

and treatment options. Communication between the patient and practitioner is considered to be a

key component within PCC (Kitson et al., 2013; Little et al., 2001). There has been some suggestion

that patient-practitioner communication can even have some effect on patient pain levels (Mistiaen

et al., 2016). While the Widerström-Noga et al. study found there were some positive facilitators to

living with chronic pain after a spinal cord injury, the identified barriers involved the importance of

patient-practitioner communication. This may indicate that communication is particularly important

when dealing with or treating patients with chronic pain.

Within the literature, PROMs have been used to describe the outcomes of patients living

with chronic disease and musculoskeletal conditions such as diabetes (Reid et al., 2010), chronic

bronchitis (Paterson & Britten, 2000), macular degeneration (Mitchell & Bradley, 2001) and other

chronic and long lasting conditions (Paterson et al., 2010). These studies focused on patient

outcomes other than pain, as chronic pain conditions are those which are long lasting in nature and

typically do not respond well to intervention (Nicholas et al., 2019). Paterson et al. used a

combination of objective and patient generated outcomes to measure the effectiveness of

acupuncture, with results demonstrating that these outcome measures were both feasible and

acceptable to its participants (Paterson et al., 2010). This study indicated that those living with

chronic/long term conditions valued being listened to as individuals, as well as receiving advice from

their practitioners. The study also showed high levels of responsiveness to change but was limited by

its lower than anticipated response rates. In 2010 Reid et al. assessed participants with type II

diabetes (Reid et al., 2010) and used two patient generated outcome measures, the Short Form 36

(SF-36) health questionnaire (Ware Jr & Sherbourne, 1992) and the W-BQ12 (Bradley, 2000), in

conjunction with measuring the level of HbA1c in the participant’s blood before and after

intervention, to evaluate different types of aerobic exercise and their effects on wellbeing and

HbA1c levels. The study showed only a partial relationship between participant wellbeing and HbA1c

levels within the blood. This study contained no qualitative measurement and it is possible that the

inclusion of qualitative feedback could have helped explain the lack of an association between the

two measures used as recommended by (Verhoef et al., 2002) and (Paterson et al., 2009). In the

bronchitis study (Paterson & Britten, 2000) three patient generated outcome measures were used to

evaluate the patient-centred outcomes of acute exacerbations of chronic bronchitis. The outcome

measures used in this study were the MYMOP, EQ-5D and the Medical Outcome Study health

related questionnaire (Tarlov et al., 1989). Paterson suggested that in order to have higher rates of

completion, a patient generated outcome measure should be both responsive and valid. Within this

study, the MYMOP was shown to be the most responsive of the measures.

Summary and Gaps within the Literature

Patient-reported outcomes have been used in various studies assessing chronic health

conditions. The use of these measures in people who suffer from chronic conditions suggests a

starting point for assessing disadvantaged and marginalised populations, as these groups of people

often experience higher rates of chronic conditions and poorer health related quality of life (Mielck

et al., 2014). A combination of outcome measures, that incorporate quantitative and qualitative

research techniques, may help us to better understand what patient-centred outcomes are most

important to this group of people. As Paterson (Paterson et al., 2009; Paterson & Britten, 2003) and

Verhoef (Verhoef et al., 2002; Verhoef, Lewith, et al., 2005; Verhoef, Mulkins, et al., 2005; M.

Verhoef et al., 2006) have suggested, a combination of both quantitative and qualitative methods,

with an appropriate theoretical underpinning should be the first step in assessing any group of

people for their patient-centred outcomes. There is, however, a gap in the literature that details

how patient-centred outcomes might be experienced differently by those who are suffering from

marginalisation or disadvantage.

Patient-centred care is becoming a corner-stone of modern healthcare (Delaney, 2018).

With this shift, it has become important to measure outcomes of patients as a result of this type of

care. This is more commonly achieved with the use of PROMs such as those previously mentioned

within this literature review. However, PROMs or other clinical measures can be limiting in what

data they capture, particularly in therapies that are complex and holistic in their approach to patient

management (M. J. Verhoef et al., 2006). Because of this, the utilisation of PROMs alone may miss

certain outcomes and aspects of care that are specifically important to the patient (Paterson &

Britten, 2000). This has led to the development of a research framework known as Whole Systems

Research that utilises a mixed-methods approach to investigate patient outcomes of complex

interventions including allied health and complementary and alternative medicine (Ijaz et al., 2019).

Patient-reported outcome measures like the MYMOP and EQ-5D-5L have been shown to be useful

when measuring changes in outcomes of those living with chronic conditions (Agborsangaya et al.,

2014; Paterson & Britten, 2003; Paterson et al., 2000; Rejas & Albertos, 2017; Sakthong et al., 2015;

van Amstel et al., 2018) and the literature states that disadvantaged populations experience higher

rates of chronic conditions and multimorbidities (Chamberlain et al., 2020). A combination of these

PROMs with qualitative research techniques and a suitable framework may be an appropriate way of

measuring outcomes of disadvantaged patients who utilise therapies such as allied health and CAM.

Bronfenbrenner’s ecological systems theory may also be an appropriate framework for this as the

five systems he outlines are focused on the individual and the settings, relationships and

development that takes place within those systems (Bronfenbrenner, 1979).

Study Aim of the Thesis

This project used a combination of PROMs in conjunction with semi-structured interviews to

investigate the outcomes of those living with disadvantage who attended a chiropractic clinic within

a community organisation. The other aim of this study was to investigate what impact the setting in

which this chiropractic care was delivered may have had on the outcomes of those attending. The

PROMs selected for this study were the MYMOP, EQ-5D-5L and PEI and Bronfenbrenner’s ecological

systems theory was used in the analysis of qualitative findings (Bronfenbrenner, 1979). This

combination of quantitative and qualitative research techniques was chosen based on

recommendations surrounding WSR (Ijaz et al., 2019).

Chapter 3: Methodology

Introduction

This research project was a mixed-methods observational study that aimed to describe

whole person, patient-centred experiences and outcomes of chiropractic care that was

delivered to people experiencing disadvantage within a free student-staffed healthcare

clinic. The project invited new or existing clients, who presented with a new complaint to an

RMIT University (Melbourne, Australia) chiropractic community clinic located within The

Wellington (TW) to participate in the study. The Wellington is located in the Melbourne

suburb of Collingwood and offers a wide variety of allied health and complementary

therapies, including chiropractic, traditional Chinese medicine (TCM), myotherapy and

osteopathy. All clients who attend TW are considered to be marginalised or disadvantaged

in some way, with all clients being required to possess a Health Care Card, or when this is

not possible, judgement is made by the staff at TW to enable clients to use the clinic’s

services. It was not the aim of this project to gather data pertaining to the specifics of its

participants’ levels of marginalisation or disadvantage. However, age and sex of participants

were collected through one of the study’s PROMs (the Measure Yourself Medical Outcome

Profile). Ethics approval for this study was granted by RMIT University’s Human Research

Ethics Committee (HREC) (Approval Number 21684) (Appendix A).

Location, Recruitment and Demographics

The Wellington was located at 215 Wellington Street, Collingwood, Victoria, Australia.

The location of this clinic was later moved, during the data collection period, in September

of 2019, to level 1 of the Melbourne Polytechnic building. This new location is only a few

hundred metres away from the old location. This new facility is now located at 20 Otter

Street, Collingwood, Victoria, Australia. The Wellington was first established in 2004 and

historically operated from St. Joseph’s Church and then later St. Martin’s Community

Church. The Wellington offers a place of community, inclusion and friendship in a

welcoming atmosphere that aims to offer support and assistance to those suffering from

disadvantage, marginalisation and social and cultural isolation within the community and

acts as a drop-in centre for these populations (The Wellington, 2020). The Wellington has

numerous partnerships with community organisations and institutions including local

universities (that offer allied health, complementary and alternative medicine (CAM)

therapies), hospitals, churches, and the City of Yarra Council. When the clinic operated at St

Martin’s it would transform during clinic days into an open plan clinical setting with

curtained partitions for client privacy. The pews were placed against the back wall to allow

room for the chiropractic interns to place six to eight portable tables along the walls for

treatment. These tables would then be partitioned to allow for client privacy. This clinical

space was utilised by the different clinical services offered within TW throughout the week

on different days. The RMIT chiropractic interns were all within their final years of

completing their degree (fourth or fifth year). The shifts that students attended were on a

rotational basis and the chiropractic clinic was open on Wednesday and Friday afternoons

from 1:30pm – 4:00pm. This meant that continuity of care with the same practitioner was

sometimes difficult to maintain for the client.

When TW moved physical location, there were some changes to the allocation of space

for students. The new location offered more space for TW and this allowed for eight

treatment rooms to be permanently established, each with their own individual treatment

tables, chairs and desks. These eight treatment rooms each included doors and frosted

glass, to allow for client privacy during consultations.

Participants for this study were all recruited from within TW. All new attendees of the

chiropractic clinics at TW were initially informed of the study via the welcoming

receptionists and a flyer that contained basic information regarding the study was at the

reception desk for clients to read if they wanted to learn more about the research project

(see Appendix B). If a client of the clinic was interested in participating in the study the

receptionists would provide them with a client information sheet that detailed the study

and what participation involved or, if the client requested, introduced the potential

participant to the researcher who was in attendance whenever the chiropractic clinic was

operating. Before any data were collected from the participants, informed written consent

was obtained using the patient information and consent form that was made available to

clients at the reception desk and approved by RMIT’s Human Research Ethics Committee.

This informed consent was required from all participants who wished to partake in the

study.

Participants

This study contained three participant groups, with the main focus being clients who

attended the RMIT student chiropractic clinic located at TW. Participant groups were as

follows:

• Clients attending the chiropractic clinic at TW;

• Fourth and fifth year RMIT chiropractic interns who were treating clients at TW;

as well as their clinical supervisors;

• Staff of TW (manager and receptionist).

All participants in this study were over the age of 18 years with the ability to give

informed written consent.

Inclusion and Exclusion Criteria

The inclusion criteria for clients (Table 2) in this study who completed PROMs included

anyone presenting with a self-elected complaint. The participants were all either new to the

clinic or existing clients of the clinic who presented with a new complaint that required

assessment. The reason clients were either new or existing clients with a new complaint,

was to minimise external factors that might contribute to, or influence, the improvement of

the condition (particularly if it was already being treated elsewhere). Clients who were

already having this primary complaint treated elsewhere were not eligible for participation,

as this may have increased the difficultly in discerning which intervention may have been

responsible for their outcomes. Throughout the course of the study participants were also

asked to disclose if they had received any secondary treatment from any of the other

services offered within TW clinic. This was performed at collection of follow up data. This

was to minimise any external factors that might have interfered with participant outcomes.

If participants did receive treatment from elsewhere during their chiropractic treatment

schedule, they were omitted from further follow-up data collection. If a participant’s

condition required referral to a medical practitioner, they were omitted from the study. All

participants were required to sign a written participant information and consent form

before any data were collected.

Table 2: inclusion/exclusion criteria for clients who completed PROMs.

Inclusion Criteria New clients presenting to the RMIT student chiropractic clinic at TW.

Exclusion Criteria A client who had a new complaint but was already having this managed externally to TW regardless of healthcare provider. A participant of the study who disclosed they received care from another provider at TW, or externally (Chinese medicine, myotherapy, osteopathy, general practitioner, physiotherapist or other healthcare professional).

An existing chiropractic client at TW who had a new complaint that had not been assessed or treated by the students interning at TW. Conversely, someone who had been a client of TW chiropractic clinic but had returned after a six-month + absence and required a full review before treatment commenced. Over the age of 18 with the ability to give informed consent to participate in the study.

Under the age of 18, unable to provide informed consent or unable to read and understand the participant information and consent forms.

Any client participants who fulfilled these inclusion criteria were followed over a course

of treatment. Once consent was obtained, they were asked to complete a set of outcome

measures at baseline and after two weeks or four treatments, whichever came first.

Treatment was delivered by RMIT University chiropractic interns in their fourth or fifth

(final) year of study. Participants presented with a wide variety of conditions and each

received a combination of treatment modalities to form an individual treatment plan for

each client, depending on their diagnoses.

The inclusion criteria for clients who were interviewed were: (1) over the age of 18; (2)

able to give informed written consent; and, (3) that they had been a patient of the RMIT

chiropractic clinic at TW in the past. The inclusion criteria were initially the same as clients

completing outcome measures. However, due to unforeseen changes that took place during

the data collection period (i.e. change in location of TW and uncertainty as to when data

collection may resume) it was deemed necessary to expand these inclusion criteria to any

client who had received treatment at TW. This was to ensure interviews with clients were

obtained in a timely manner.

The inclusion criteria for chiropractic interns, the clinical supervisor, the manager and

staff/volunteers of TW was simply that they were either on placement at TW clinic or were

staff/volunteers at TW and were physically present at the time when the chiropractic clinic

was operating.

Instruments and Materials

Patient-Reported Outcome Measures

The patient-reported outcome measures used in this study were chosen for their

brevity; validity; reliability; and their responsiveness to change. They were also chosen

based on their previous use in the literature when assessing similar groups of participants

experiencing chronic medical conditions (Ahmed et al., 2005; Mitchell & Bradley, 2001;

Paterson et al., 2000; Paterson et al., 2010; Reid et al., 2010; Solberg et al., 2005).

A total of three health and well-being outcome measures were selected for their

suitability to be administered to the participants who received chiropractic care. These

measures were:

• The Measure Yourself Medical Outcome Profile (MYMOP)

• The European Quality of Life Five Domain Five Level Health Questionnaire (EQ-

5D-5L)

• The Patient Enablement instrument (PEI)

The outcome measures were all administered by the same researcher to ensure

consistency of delivery to all participants in completing outcome measures. The MYMOP

and EQ-5D-5L were administered at baseline. At follow-up the same two outcome measures

were administered along with the PEI.

Measure Your Medical Outcome Profile

The MYMOP asks the participant four questions relating to their symptoms, an activity

affected by their symptoms and their wellbeing (see Appendix C). These questions are

scored on a scale from 0-6. The first question asks the participant to nominate one symptom

related to their primary complaint and to rate how “good” or “bad” it has been within the

past week, with 0 being the best it could be and 6 being the worst it could be. The second

question of the MYMOP asks the participant to nominate a second symptom related to their

primary complaint. If there is no second symptom, the participant can leave this section

blank. If not left blank this second symptom is again rated on a scale of 0-6. The third

question asks the participant to nominate an “Activity” which is an activity of daily living

that has been directly affected or impacted upon by “Symptom 1”. The fourth question asks

the client to rate their general feeling of “Wellbeing” for the past week out of a scale of 0-6.

The scoring for these four questions can be added together and the average score is known

as the “MYMOP Profile Score”. This score is considered an overall score of health and

wellbeing for the participant.

The MYMOP also asks the participant to rate the chronicity of symptom 1. This is rated

from 0-4 weeks, 4-12 weeks, 3 months-1 year, 1-5 years or greater than 5 years.

Additionally, the participant is asked to indicate if they are taking medication for their health

problem. If answered yes, the participant is asked to indicate if reducing medication usage is

important to them. If answered no, the participant is asked if avoiding medication for their

problem is important. The MYMOP did not require permission to be reproduced and used.

European Quality of Life Five Domain Five Level Health Questionnaire

The EQ-5D-5L is a health-related quality of life outcome measure that utilises

questions from five domains of health and uses a “thermometer” visual analogue scale to

measure the overall general health and wellbeing of the client (see Appendix D). There are

two different variations of the EQ-5D available and the one selected for this project was the

EQ-5D-5L. The EQ-5D-5L was an expansion of the pre-existing EQ-5D-3L created to decrease

the ceiling effect of the measure (Agborsangaya et al., 2014). This means that for each

domain of health there are five “levels”, or options, of severity for the participant to choose

from. This allows for a decrease in ceiling effect and a higher sensitivity to change. The five

domains of health in the EQ-5D are “Mobility”, “Personal Care”, “Usual Activities”, “Pain and

Discomfort” and “Anxiety and Depression”. For each of these five domains there are five

options to choose from. Once completed, the scores from the EQ-5D-5L can be translated

into a profile score and then an index score. A profile score is the combination of the level

values nominated within the five different domains of the EQ-5D-5L. These scores can then

be turned into an index value that is a representation of all five domain scores as a single

number. An index score of 1 represents full health while a score of 0 is the equivalent of

being worse than dead. Index scores are generated from societal value sets. For this study,

value sets from the United Kingdom were used to generate index scores. Value sets from

the United Kingdom were used as no value set exists for the Australian population and

because the National Health Scheme in the United Kingdom is relatively similar to that of

Australia’s healthcare system. This decision was based on data from the Australian Institute

of Health and Welfare (AIHW, 2019).

The EQ-5D-5L has been used in a number of studies assessing quality of life for those

living with chronic medical conditions. A catalogue of EQ-5D scores was created as a result

of a systematic review and provides a comprehensive list of scores in chronic disease (Van

Wilder et al., 2019). This list of assessed conditions varies widely and includes scores for

diseases of the musculoskeletal (MSK) system and connective tissues. The EQ-5D-5L has also

shown potential in determining cost-effectiveness of interventions (Nolan et al., 2016). The

EQ-5D-5L has demonstrated good levels of reliability and validity (Bilbao et al., 2018). This

study has been registered with the EuroQol Research Foundation and permission was

granted to reproduce and use the EQ-5D-5L in this study.

Patient Enablement Instrument

The Patient Enablement Instrument (PEI) is designed to reflect client enablement (see

Appendix E). This outcome assesses the level of enablement the participant experiences

throughout their individual treatment process. Enablement is the ability of the patient to

make informed decisions based around their own health and its management. The PEI has

been used in studies that have assessed enablement for both complementary and

alternative medicine (CAM) therapies (MacPherson et al., 2003; Mercer et al., 2002;

Paterson et al., 2010) and primary care (Frances et al., 2015; Frost et al., 2018; Howie et al.,

1998; Rööst et al., 2015). A correlation between practitioner empathy and enablement has

been shown in a study by Howie (Howie et al., 1998). The PEI is also easy to administer and

has demonstrated appropriate levels of acceptability for participants and practitioners alike

(Paterson et al., 2010). The PEI has also shown high levels of reliability (Rööst et al., 2015)

and validity (Åkesson et al., 2018).

The Patient Enablement Instrument is a short questionnaire that consists of six

questions:

“As a result of your visit to the Doctor today do you feel you are:

1. able to cope with life;

2. able to understand your illness;

3. able to cope with your illness;

4. able to keep yourself healthy;

5. confident about your health;

6. able to help yourself.”

These six questions are answered on a scale of “much better/more, better/more, about

the same, less, or not applicable”. Responses are then graded on a 3-point scale with “about

the same”, “less” and “not applicable” scoring 0, “better/more” scoring 1 and “much

better/more” scoring a 2. The PEI can be used post treatment to gauge enablement and in

the context of this study, this is how the PEI was used. The PEI itself does not require

permission to use and is a public access outcome measure.

Data Analysis

All data were initially entered into a spread sheet prior to being imported into the

statistical analysis package. Quantitative data were analysed using SPSS software package

(IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM

Corp).

Measure Yourself Medical Outcome Profile and European Quality of Life Five

Domain Five Level Health Questionnaire

Data for these measures were first assessed for normality using the Shapiro-Wilk

test. A paired-samples t-test or non-parametric equivalent Wilcoxon Signed-Rank test was

used to determine statistically significant change between baseline and follow-up scores.

Level of significance was set at p < 0.05.

Patient Enablement Instrument

The Patient Enablement Instrument was only administered at follow-up. Inferential

statistical analysis was therefore not conducted. However, a statistical descriptive analysis

was performed.

Qualitative Methods

Chiropractic utilises a wide range of treatment modalities in order to affect an

individualised treatment for the client and their presenting musculoskeletal (MSK)

complaint. The modalities used by the RMIT chiropractic interns at TW included a varying

combination of spinal manipulative therapy (SMT) which utilises a high velocity low

amplitude thrust to manipulate joints of the body (Maigne & Vautravers, 2003) , soft tissue

therapies (STT) (Weerapong et al., 2005), hand-held adjusting instruments such as an

activator (Gemmell & Jacobson, 1995) and mechanical wedges (blocks). These mechanically

assisted instruments are often used as an alternative treatment method for SMT as they can

provide a low-force method of spinal mobilisation. This care was delivered under the

supervision of an Australian Health Practitioner Regulation Agency (Ahpra) registered

chiropractor (Ahpra, 2020).

Randomised control trials (RCTs) have long been considered the gold standard for

assessing any one intervention and its outcome. However, an RCT may not be the most

appropriate way to assess a whole systems approach such as those utilised by many

complementary and alternative medicine and allied health therapies (Cassidy, 1994;

Verhoef, Lewith, et al., 2005). Because of this complexity, an RCT method may be too

limiting for a study design that is aiming to investigate a model of care in its entirety,

including the patient-centred benefits of this model of care, in a particular setting. Verhoef

(M. Verhoef et al., 2006) suggests that in order to best assess the patient-centred outcomes

of CAM and allied health therapies, there should be a primary analysis of appropriate

patient-centred outcomes, followed by a secondary analysis of qualitative data including

interview transcripts, focus groups or other qualitative methods. Ritenbaugh et al described

the study of complex CAM interventions as Whole Systems Research (WSR) (Ritenbaugh et

al., 2003). The Whole Systems Research approach was designed to capture not only the

process of the intervention, but also its outcomes. Ritenbaugh acknowledged that

throughout the lived experiences of clients receiving CAM therapies there is also a

multifaceted set of interactions that take place beyond the delivery of the intervention

(Ritenbaugh et al., 2003) and that these interactions also need to be captured if the entire

experience is to be explored. Paterson agreed with this approach (Paterson et al., 2009)

suggesting that an initial collection of outcome measure data in conjunction with qualitative

research methods was the most appropriate way to evaluate these kinds of complex

interventions, therapies and experiences. For this reason, data collection was conducted

using a combination of patient-reported outcome measures (PROMs), non-participant

observation and semi-structured interviews.

Interviews were conducted with clients who had received care recently at TW

(regardless of if they were a new patient or had a new complaint), the chiropractic interns

delivering care, their supervisor, volunteers and staff at TW, as well as the manager. Non-

participant observation was conducted in the main waiting room of TW only, was

descriptive of interactions taking place and were non-identifying to those involved.

The outcome measures that were used in this study did not ask the questions of how

important client-practitioner relationships were to the participant or the importance of the

setting in which their care was delivered. The interview schedule and non-participant

observation provided a unique way to capture this experience without any interference to

the care being delivered. Although treatment with the chiropractic interns was kept private

and not observed, interactions were observed where the interns entered the waiting area

and took their clients to the treatment room. The researcher did not take notes during the

observation process. This was to ensure the researcher did not interfere with the

participants being observed. Field notes were written down by the researcher, in private,

once observations were complete. Observational data such as this are useful when trying to

provide a “thick description” of the experience or phenomenon that is being described

(Hammersley & Atkinson, 1995). Outcome measures, in general, are limited to the questions

that they ask. If a participant finds an aspect of their care to be important to them, and that

question isn’t assessed in the outcome measures, then that information may be potentially

lost (Devlin & Appleby, 2010). That is why the interview schedule was designed in such a

way as to capture as many aspects of the client experience at TW that the measures may

have missed.

Qualitative data were collected via semi-structured interviews. These semi-structured

interviews were conducted with participants who received chiropractic care from the

interns, as well as the chiropractic interns themselves, their supervisors and the staff of TW

who managed the patient schedule and running of the chiropractic clinic. Interviews were

all conducted and transcribed by the researcher. When necessary, pre-determined probes

were used to elicit elaboration on what the participant was discussing. Interviews were

conducted until data saturation was achieved, or until there were no more participants in a

group (for instance, there were only three supervising clinicians and therefore only three

interviews could be conducted with this group). Because the main objective of this study

was to describe the experience of those attending TW, a wide range of participants were

approached to be interviewed. This was implemented to best describe the entire experience

of TW as a setting, from multiple angles and not just from the perspective of an individual

client.

Urie Bronfenbrenner’s ecological systems theory was used to analyse interview and

observational data. Bronfenbrenner’s theory stipulates that the development of the person

is formed by the multitude of different stimuli in the ecosystem they participate in

(Bronfenbrenner, 1979). This project focused on a particular setting, TW, and the different

systems, relationships, roles and interactions that took place within this unique setting. The

non-participant observation allowed for a description of this setting and the interaction

taking place within it. Data were analysed throughout the process of its collection and a

constant comparative approach was applied throughout the process (Glaser, 1965). In the

instance of this study, TW was considered the main setting of importance in relation to this

study as it was where clients received their treatment.

Bronfenbrenner’s theory discusses the importance of a setting and its impact on the

development of the people within it. Bronfenbrenner’s theory proposes that if a setting has

indirect links to other settings of power, then this can directly influence the potential of

development of the person involved in those settings. An example of this might be TW’s

links with RMIT University or the education students receive at the university. These are

arguably settings of power that provide resources to the clients of TW and are responsive to

their needs. Bronfenbrenner’s theory describes how the more indirect links a setting such as

this might have, the greater the developmental potential (Bronfenbrenner, 1979). The

Wellington is a prime example of this, offering a multitude of opportunities such as

healthcare, food drops and social groups for the clients who attend.

Interviews and Observation

All semi-structured interviews were audio recorded, conducted and transcribed by the

researcher. This was to maintain consistency throughout the interview process and to assist

in the analysis of the data. Interview length varied and this was due to having separate

interview schedules (one for clients and one for students, clinical supervisors and staff at

TW). All interviews were transcribed verbatim by the researcher. The semi-structured

interview schedules used all open-ended questions, with the intention of participants

expressing what was most important to them and their perspective on the TW. A number of

pre-determined probes were used in conjunction with each major question to ascertain as

rich data as possible and follow up questions were used when it was thought a participant

had more to say on a matter (please see Appendix 5 for interview schedules).

The Wellington operates five days per week, offering a wide range of CAM therapies

depending on the day. Chiropractic is offered by RMIT students, under supervision, on

Wednesday and Friday afternoons from 1:30pm – 4:00pm. After moving to the new location

on Otter Street, chiropractic was then only offered on Wednesdays. During these times non-

participant observation was undertaken by the researcher. Observation aimed to be

conducted for a length of one to two hours at a time. The goal of this observation was to

capture the experience of the individuals attending TW, as well as the different interactions

taking place. Another goal was to observe all interactions, not just those between the clients

receiving chiropractic care from the chiropractic interns, but also interactions with other

clients and the staff who greeted clients of TW when they first arrived. Observation only

took place at the entrance to TW and in the client waiting area. Observation notes were

non-identifying and subjective regarding the interactions that took place. This was to add

context to the interview data. No observation took place within the treatment room, to

ensure client and practitioner privacy when discussing private and sensitive information.

Because observation was not possible across all interactions, interview data were used to

explore these relationships. It has been documented that the client-practitioner relationship

is an important aspect of patient-centred care (Little et al., 2001; Mulkins & Verhoef, 2004)

and it was deemed important to capture this through both the semi-structured interviews

as well as non-participant observations.

Qualitative Data Analysis

A thematic analysis was utilised in conjunction with Bronfenbrenner’s theory of

developmental ecology. The six step approach to thematic analysis outlined by Braun and

Clarke (Braun & Clarke, 2012) was used to approach analysis of the interview data. This

approach initially has the researcher familiarise themselves with the data set. In this

instance it meant gaining a level of familiarity with the interview transcripts. This was

achieved by having the same researcher conduct the interviews, transcribe the interviews

and then read through the transcripts without taking any notes. The next step was to read

through the transcripts and generate initial codes. This involved reading through the

transcripts while annotating and interpreting what the participant was saying in relation to

Bronfenbrenner’s ecological systems theory. Thirdly, these initial codes were collapsed into

broader codes. The fourth step in this process was to review themes that were arising.

Themes were determined by significance to Bronfenbrenner’s ecological systems theory.

Themes chosen were related to the five systems Bronfenbrenner described as comprising an

individual’s ecosystem. These systems are known as the microsystem, mesosystem,

exosystem, macrosystem and chronosystem.

Once codes were generated from the transcripts, they were named and then placed into

relevant themes that reflected the fives systems in Bronfenbrenner’s ecological systems

theory. Step five of Braun and Clarke’s approach was to reassess the codes and themes to

ensure that they had been placed appropriately and in line with Bronfenbrenner’s theory

and were accurately represented (Bronfenbrenner, 1979).

In the next chapter, the results of this methodology will be presented in a format that

discusses findings of both PROMs used and the findings of the semi-structured interviews.

Chapter 4: Results

Data Collected

Data collection took place between February 2019 and December 2019. This was

continuous, except for a brief period in September 2019, when the clinic was required to

close while it moved locations. This study had a total of 49 participants, including interview

participants. A total of 37 participants completed outcome measures at baseline with a

follow-up percentage of 45% (17 participants). Twelve participants agreed to be interviewed

for this study. Of those twelve, four were clients of the clinic, three were chiropractic interns

who treat clients at the clinic, three were clinical supervisors who supervised the treating

students and two were staff members of TW.

Demographic Data

Of the 37 participants who completed outcome measures, 43.2% were male (16

males, 21 females). The mean age and standard deviation of participants in this study was

calculated in years for male participants (52 ± 16.1) and for female participants (52 ± 17.5).

Of the 17 follow-up participants, six were male and 11 were female. Mean and standard

deviation of age was calculated for both male (54 ± 14.9) and female (60 ± 15.9) participants

who completed follow-up.

Patient-Reported Outcome Measure Data

Measure Yourself Medial Outcome Profile

The mean MYMOP profile score and standard deviation was (3.75 ± 1.4) for baseline

participants (n=37). Of those who did not complete follow-up, there were 10 males and 10

females. The mean and standard deviation baseline MYMOP profile scores for those who

did not complete follow-up were (3.56 ± 1.62) (n=20).

Of those who completed follow-up for the MYMOP, 11 were female and 6 were

male. A paired-samples t-test was used to determine whether there was a statistically

significant mean difference between baseline and follow-up MYMOP profile scores. Data

were normally distributed, as assessed by Shapiro-Wilk test (p > .05) and there were no

outliers in the data. Data are forthwith referred to as mean ± standard deviation. For those

who completed follow-up there was a statistically significant difference between baseline

(3.94 ± 1.22) and follow up (3.2 ± 1), (t(16)=2.84), (p = 0.012) (Figure 3).

Figure 3: Measure Yourself Medical Outcome Profile Scores at Baseline and Follow-up. The box represents 95% C.I.; solid lines within the boxes are median values; X refers to mean values; whiskers refer to maximum and minimum values.

The baseline data of MYMOP scores were compared with average baseline MYMOP

scores from a study that included participants attending another RMIT University student

chiropractic clinic that served the general population (Polus et al., 2011). Two participants in

the current study had profile scores that indicated their symptoms had little or no effect on

their health and wellbeing and as such were removed for this comparison. A one-sample t-

test was used to determine whether there was a statistically significant difference between

this study’s baseline profile scores (3.95 ± 1.2) and those of Polus et al.’s study (3.4 ± 1).

There was a statistically significant difference between baseline MYMOP profile scores

(t(34)=2.6), (p = 0.012).

The Measure Yourself Outcome Profile asked clients to nominate an activity that was

being affected by their primary symptom. All responses were individual and are listed below

(Table 3). These can be defined as groups such as physical mobility, leisure activities or study

and work activities.

Table 3: MYMOP Activity Nominated by Clients

MYMOP Activity MYMOP Activity

Client Number 1 2 3 4 5 6 7 8 9 Client Number 20 21 22 23 24 25 26 27 28 Walking Getting out of bed Walking Chewing From work Carrying bag Washing Study Sleep

10 11 12 13 Walking long distances Can't work in a job University project Getting out of bed Mopping/vacuuming Catching public transport Gardening Bending to clean Washing dishes/cleaning up Walking Gym work/sport Bending forward Walking 29 30 31 32

33 34 35 36 37 Picking up my child Walking Standing Moving heavy items on trolley Holding Working out Boxing Chewing Leaving the house

Sitting long periods Walking Picking vegetables Reading Driving Work duties

14 15 16 17 18 19

Responses from the MYMOP were used to code what region of their body the

client’s primary symptom was affecting. The most common region was that of “More than 1

body region” with a total of nine participants (24.3%) nominating this option. The second

most common region was “Neck” with five participants nominating this as the region of

primary complaint. The third most common regions were “Head”, “Shoulder”, “Upper Back”

and “Lower Limb”. These four regions were equal with four participants in each category

that they experienced two symptoms that were associated with their primary complaint. Of those

who completed follow-up a total of 67% had two symptoms associated with their primary complaint.

(see Figure 4). Of the clients who completed baseline data collection, a total of 28 (75.6%) stated

Figure 4: Location of Primary Symptom – bars indicate frequency of clients’ reported

Location of Primary Symptom

Head

Neck

Shoulder

Hips

Upper Back

Lower Back

Upper Limb

Lower Limb

More Than 1 Region

Location of Primary Symptom

location of primary symptom.

A total of 27 clients nominated their primary symptom as chronic, having lived with

this symptom for three months or longer (72%). Of those who completed follow-up a total

of 70% nominated having had their primary symptom for more than three months. A total

of 28 (75.7%) participants were not taking medication at the time the MYMOP was

completed and 22 (67.5%) stated that avoiding taking medication or reduction in medication

for their primary complaint was either “A bit important” or “Very important” to them (see

Figure 5).

Chronicity of Primary Symptom

0-4 weeks

4-12 weeks

3 months - 1 year

1 - 5 years

5+ years

Chronicity of Primary Symptom

Figure 5: Chronicity of Primary Symptom – bars indicate frequency of reported chronicity of primary symptom.

The European Quality of Life Five Domain Five Level Health Questionnaire

Baseline scores from the EQ-5D-5L 100-point visual analogue scale (EQVAS) were

compared with population normative data in South Australia (McCaffrey et al., 2016). A one-

sample t-test was used to determine if there was a statistically significant difference

between this study’s EQVAS scores (59.57 ± 22.24) and McCaffrey et al.’s (78.55 ± 15.71).

There was a statistically significant difference between baseline EQVAS scores (t(36)= -5.19),

(p = 0.0005).

A paired-samples t-test was used to determine if there was a statistically significant

difference between baseline TW EQVAS scores (51.17 ± 19.36) and follow-up (58.58 ±

19.14). Data were normally distributed, as assessed by Shapiro-Wilk test (p > 0.05). No

statistically significant change occurred between baseline and follow-up (t(16)= -1.93), (p =

0.71).

The assumption of normality for the five domains of the EQ-5D-5L was not satisfied

for any of the domains, as assessed by Shapiro-Wilk test (p < 0.05). Wilcoxon signed-rank

tests showed no significant differences between baseline and follow-up for the EQ-5D-5L

domains of “Mobility” (p= 0.589), “Personal Care” (p = 0.414), “Usual Activities” (p= 0.314)

and “Anxiety and Depression” (p= 0.608. However, a statistically significant change was

noted for the domain of pain and discomfort (p = 0.014).

Baseline EQ-5D-5L profile scores were used to calculate index values which is a single

number that reflects how good or bad a respondent’s health was. These index scores are

based on value sets provided by the EuroQol Research Foundation and are only available for

some countries (EuroQol Research Foundation, 2020). A value set for Australia is not

currently available and so the value set for the United Kingdom was used instead to

determine index scores for this study. The United Kingdom value sets were used to

determine this study’s index scores due it its close similarity of health and vitality according

to the Australian Institute of Health and Welfare (AIHW, 2019). A paired-samples t-test was

used to determine if there was a statistically significant change between baseline (0.48 ±

0.27) and follow-up (0.57 ± 0.30) EQ-5D-5L index scores. Data were normally distributed, as

assessed by Shapiro-Wilk test (p > 0.05). There was a statistically significant change noted in

baseline and follow-up EQ-5D-5L index score (t(16)= -2.3), (p = 0.033) (See Figure 6).

Figure 6: European Quality of Life Five Domain Five Level Index Scores at baseline and follow-up. The box represents 95% C.I.; solid lines within the boxes are median values; X refers to mean values; whiskers refer to maximum and minimum values.

Patient Enablement Instrument

The Patient Enablement Instrument was completed by all participants at follow-up (6.47 ±

3.3). A total of 29.4% participants said they were “Much better/more” able to cope with their lives

while 35.3% stated they were “Better/more” able. A total of 35.3% and 47.1% of clients felt they

were “Much better/more” and “Better/more” able to understand their illness, respectively. A total

of 41.2% and 41.2% found they were either “Much better/more” or “More/better” able to cope with

their illness as a result of attending the chiropractic clinic at TW, respectively. A total of 23.5%

participants were “Much better/more” able to keep healthy while 35.3% of participants were

“Better/more” able to keep healthy. When asked to nominate if they felt more confident in their

health 35.3% of participants nominated that they were “Much better/more” confident, while 35.3%

of clients felt “Better/more” confident about their health. Finally, 35.3% of participants and 52.9%

found they were “Much better/more” and “Better/more” able to help themselves as a result of

attending the clinic in previous weeks/months (see Table 4).

Table 4: Patient Enablement Instrument Responses (n= 17)

Question Much better/more Better/more n (%) Same or less n (%)

n (%)

5 (29.4) 6 (35.3) 6 (35.3) Able to cope with

life

Able to understand 6 (35.3) 8 (47.1) 3 (17.6)

your illness

Able to cope with 7 (41.2) 7 (41.2) 3 (17.6)

your illness

4 (23.5) 6 (35.3) 7 (41.2) Able to keep healthy

6 (35.3) 6 (35.3) 5 (29.4) Confident about

your health

Able to help yourself 6 (35.3) 9 (52.9) 2 (11.8)

Interview Data

A total of 12 interviews were conducted. These interviews ranged from 10 minutes

to 1 hour and varied in length depending on which question schedule was used (client

interview schedule or schedule used for everyone else). Data were coded and placed into

themes that were formed using Bronfenbrenner’s ecological systems theory

(Bronfenbrenner, 1979). Given that the aim of this project was to investigate and describe

TW as the main setting and the people who influenced the clients’ outcomes within this

setting, the majority of codes fell under the first two themes of Bronfenbrenner’s theory:

the microsystem and mesosystem (see Table 5).

Table 5: Themes and Codes

Theme 3 Exosystem Trust

Theme 2 Mesosystem Clients are Complex Theme 5 Chronosystem Looking to the Future

Theme 4 Macrosystem The Cost of Being Disadvantaged

Codes Relationships

Codes Client experience with medication Codes The Wellington as a setting over time

Theme 1 Microsystem A Patient- Centred Approach for Clients Codes The Client experience of chiropractic at The Wellington

Codes Benefits and reasons for attending chiropractic at The Wellington Impact of health problem on clients’ lives

Client treatment protocol at The Wellington Financial stress impairs access to chiropractic care Future of clients and their healthcare needs

The Wellington as a Setting

Chronicity and multiple conditions

Student delivery of chiropractic care at The Wellington Client experience with external healthcare providers

Pseudonyms were assigned for all interview participants (see Table 6).

Table 6: Interview Participant Pseudonyms

Participant Number 1 2 3 4 5 6 7 8 9 10 11 Pseudonym Norman (Client) Charles (Client) Lisa (Client) Robert (Client) Lauren (Student) Dawn (Student) David (Student) Fernando (Supervisor) Ethan (Supervisor) Susan (Supervisor) Nicole (TW Staff)

12 Brittany (TW Staff)

Interview Group Client Client Client Client Chiropractic Student Chiropractic Student Chiropractic Student Chiropractic Supervisor Chiropractic Supervisor Chiropractic Supervisor The Wellington Staff Member The Wellington Staff Member

Theme 1: A Patient-Centred Approach for Clients (Microsystem)

This theme was generated from codes where the individual participants spoke about

their microsystems specifically (as described in the Methodology). This included comments

from all participant groups including the clients of TW, the treating chiropractic students,

their supervising clinicians and the staff of TW. Within this theme, codes represented the

microsystems of the clients at TW and what contributing factors within this setting may

have influenced the experiences of the clients. A microsystem is a setting that an individual

participates in and one that influences their development. In this theme the main

microsystem focused on was TW. This theme was named A Patient-Centred Approach for

Clients.

Code 1: The Client Experience of Chiropractic at The Wellington

This code was devised from statements regarding the clients and their experiences

at TW, specifically surrounding the chiropractic clinic and the care they received. Because

this code was synthesised from comments that related to chiropractic at TW, it was placed

under the first theme “Internal contributing factors”.

Norman (Client) reported that he gave feedback to students pertaining to whether

or not he felt their treatment was helpful and that it was an important part of their

placement in order for the student to gain experience.

“I think it’s a lot of experience thing, with just, feedback from the clients with how

well their work’s going.”

When asked about client reactions to the clinic, Nicole, a staff member of TW mentioned

that clients will give feedback about the clinic and that most of the feedback received is

positive regarding the care being delivered at TW.

“Uhm, um. I s’pose it took me a little while to realise how much. Er I get a lot of

feedback from clients about the effectiveness of the treatment [clears throat] and

yeah just, you know, what a difference it makes to their lives.”

Charles (Client) reported that he did not mind seeing multiple practitioners each week and

that in previous experiences with hospitals it was more common to see multiple

practitioners for the same issue.

“So, over, if you’re in hospital for five days, right? You might be actually seeing, like,

10 people. So, for me, like, this is, this is nothing.”

Student chiropractors felt that the clients were grateful and appreciative of the care

they were receiving at TW. Lauren (Student) said,

“I feel like they’re people who really appreciate the time we spend with them.”

This was iterated in the interview with David (Student) who mentioned that in his

experience clients were more appreciative of the care that they received, more than in

other clinics that the student had worked in previously.

“Uhm, but you know everyone’s so lovely and really appreciative of the work that you

do. That’s definitely one thing that you notice more in the community clinic. Their

appreciation. For sure.”

Norman (Client) mentioned that he found the optimism from the students to be a positive

influence on him and that it made the client more optimistic regarding himself.

“And it’s, so. It's good to be around them and it’s been really good to be around these

young uni students with all their optimism for the future, because it just sort of gives

you a bit of optimism yourself. Yeah.”

It was mentioned by Lisa (Client) that she had had good experiences with multiple students

and that different students brought different approaches to their treatment.

“They’re all very, they’ve all got different styles and I find, there was a couple I had

that was sports medicine. I find them really good.”

Susan (Supervisor) felt that she felt she was making a really positive impact upon the

lives of those who were being treated at the chiropractic clinic at TW. Susan (Supervisor)

stated,

“…actually making a difference to someone’s life who, who wouldn’t have, in general

any access to joy, or little and to be a part of that.”

Lauren (Student) reflected upon her time at TW and spoke about how some clients may be

looking for more than just physical treatment. That they might be looking for more of a

connection, or someone to listen to them and care.

“I feel like they are looking, a lot of them anyway, not all of them, but, are looking for

a bit of connection, or someone who cares and, uhm, yeah, I fou-I found that to sort

of be the main kind of, I’ve lost the word [laughs]. Uhm, theme to the treatments.”

Lisa (Client) discussed her experience at the clinic, how the therapy she received helped her

and how she got along well with those involved in the clinic’s operation.

“Uhm, well I need the therapy, like it helps my body. But I could, it just, the

management and people and, and the, and people from RMIT are all lovely…”

Some clients did discuss how in the past they had some adverse reactions to the

treatment delivered at TW. Robert (Client) recalled a time when a student performed a new

treatment and left him in significant pain for some time afterwards. He said,

“…he put his neck, his knee, in the middle of me back and I, and I was in real trouble

for near on a month.”

Robert (Client) said that because of incidences like the one he experienced, it was of great

importance for students to read their notes while treating their patients. Robert (Client)

continued,

“And this is why I say it’s important to read the notes.”

Norman (Client) reported that when he first started attending, he had some setbacks with

the therapy. However, he said that he had not had an adverse reaction to treatment in

some time.

“Ah, just sometimes, someone that’s not thinking will sort of, do something wrong

and make you feel worse [laughs]. But it doesn’t happen very often, or, it doesn’t

happen as often now, because my problem’s not as bad as it was. But, uhm, in the

early days of coming here it was, if they got it wrong it was really sending me

backwards, a bit. But yeah, things are pretty good now. I haven’t found a bad

therapist for quite a long time.”

Summary of The Client Experience at The Wellington

As a consequence of attending TW clients expressed that they did not only receive

improvement of their physical ailments but also received other benefits such as becoming

more connected due to the community atmosphere. Additionally, clients stated that they

offered feedback to their student practitioners. Clients reported having experienced some

adverse reactions during their time attending the clinic. However, they understood that

they were attending a teaching clinic and received appropriate care to recover.

Code 2: Client Treatment Protocol at The Wellington

This code was developed by compiling comments that related to how clients

received their care while attending TW. Because this code was directly related to TW as a

setting, it was placed under Theme 1, which correlates to what Bronfenbrenner described as

the microsystem (Bronfenbrenner, 1979).

It was reported that treatment methods for clients might change depending on how

they presented to the clinic. Norman (Client) stated,

“Yeah, so, you can definitely tell that they’re thinking about what’s going on. Cos,

usually they’ll pick out something that’s wrong with me that even I wasn’t aware of.

You know?”

Ethan (Supervisor) also iterated that clients’ treatment methods sometimes changed

depending on their response to particular treatment styles.

“Uhm, you know, I, we try to tackle it from different angles, as being, you know,

when I’m trying to pass on some advice to the students to suggest, you know, maybe

we try a different exercise or perhaps we try a different treatment next time and see

if we can get some better results.”

Robert (Client) described how he was treated at the clinic and that the communication

between the student practitioner and client prevented him from feeling as though he was

just a number.

“I tell em what my problems are and if they aren’t manipulating strong enough, or

they’re not hitting the right spots, I tell them and they’re appreciative of any

feedback they get and I think they need that feedback because otherwise you’re just

treating people like lining up at a, at a queue in Centrelink, you’re just a number.”

This sort of patient-centred approach to treatment was also mentioned by the students

delivering care at TW. Lauren (Student) stated,

“Uhm, well. Generally, but not always, generally the patients coming in there tend to

have, you know, more than one complaint that’s been signed off at some point. So,

you’re treating multiple areas and kind of treating the whole person, as such.”

Listening and being an outlet for clients to voice their concerns was something also

mentioned by the students,

“…I know we’re not sort of, counsellors, per se, sort of thing. But them just, sort of,

venting, uhm, can help them, uhm, I’ve had a few that sort of talk about the stress

and then they get into the treatment and they just relax and that’s probably the best

outcome.”

This was also something recognised by Susan (Supervisor), one of the clinical supervisors,

who discussed how it is important to make meaningful connection with the clients.

“Uhm, and you can’t have, uhm, relationships with them if you are, uhm, very

structured and, uhm, uhm, go through motions. You’ve actually gotta step back and

connect. It slow, it slows your world down. That’s my feeling.”

Students and their clinical supervisors reported that they believed clients would

typically respond better to treatment methods that were gentler, such as soft tissue therapy

(massage), as opposed to what may be considered as a rougher approach, such as spinal

manipulative therapy. Susan (Supervisor) stated that this may have been due to previous

lived traumas of the clients receiving the treatment.

“Yeah. So, there seems to be, yeah, and I don’t know what that is. Whether there’s

sense of trauma associated with that manipulation. Even if it’s not a traumatic,

physically traumatic experience. It seems to be a negative.”

David (Student) stated that the main types of therapy used were those of soft tissue therapy

and hand-held adjusting devices like the activator.

“Uhm, I would say that generally consisted, you know, of your general soft tissue,

activator treatment…”

Of the four clients interviewed, all four reported they were treated with these lower force

techniques. However, Lisa (Client) reported she found better results when being treated

with spinal manipulative therapy as opposed to the hand-held adjusting tool. She stated,

“… I was doing just adjuster and it was just, it, it feels good, but just, just doesn’t, you

feel not aligned or just, I don’t know…”

Figure 7: A client receiving treatment at The Wellington. (Written informed consent was sought and received by those in this photograph for its reproduction and use). Summary of Client Treatment Protocol at The Wellington

Interview findings suggested that students used a patient-centred approach when

treating clients at TW. This was identified in comments made by clients, student

practitioners and clinical supervisors alike. It was also found that clients preferred a lower-

force approach to treatment involving home-exercise and advice, hand-held adjusting and

soft tissue therapies.

Code 3: The Wellington as a Setting

This code was developed by comments made by all interview groups on the topic of

TW. These comments included a wide variety of aspects surrounding TW including other

services that were offered; as well as perspectives from different interview groups that

assisted in describing TW as a setting. This code is the last of three that makes up the first

theme of A Patient-Centred Approach for Clients and is related to Bronfenbrenner’s

microsystem (Bronfenbrenner, 1979).

Many of the individuals interviewed stated the importance of TW for those in the

community who attended and used its services. Norman (Client) discussed how his own

experience and observation of others at TW showed the services were needed.

“I see what it does for me and see what it does for other people. So, I think it’s a

charity worth looking after, really.”

Lisa (Client) recalled how she came to TW and her reasons for staying were due to

relationships formed at TW,

“…then eventually I came here and I liked it and the people sort of relaxed and the

people that run it are great. So ... I kept coming.”

The sense of community gained was something mentioned by Robert (Client). He mentioned

that as a result of attending TW it had aided in his mental health.

“I know mental health’s - a lot of old blokes like myself think it’s a bit of a wank, but

the mental health issue is having someone to talk to and the community environment

was really helpful.”

Impressions of students were similar to those of others interviewed. Lauren (Student) stated

that it was a pleasant environment to work in and that it offered a necessary service to

those in the community who need it.

“First impressions, I really like it. Uhm, I think it’s a really good, a really nice place and

a really good initiative for, you know, helping people in need.”

Fernando (Supervisor) discussed how TW is an environment of respect and that it offers

many services to the community.

“I found it, actually, quite good. The, uhm, the staff were in control of the

environment, uhm, there was a good vibe to the place, there was food, there was

activity, uhm, and it, I found it a very respectful environment.”

Ethan (Supervisor) mentioned that clients of the clinic would often attend TW regardless of

whether or not they were being treated, indicating that the other services, or social

interaction, are all of importance to the clients.

“You know, they, they’ll, easily every week, I’ll see the same faces coming through

the door. Uhm, whether or not they’re receiving treatment is, is irrelevant. They’re

still here.”

Social interaction for those living in social isolation was something reported by

Nicole (TW Staff) at TW. She said,

“I just find, you know, another thing that we deal with here is social isolation and,

you know, people are chronically, you know, have chronic pain, yeah they might just

stay at home all day and not leave. So, yeah, it’s the little steps, even if they are

coming into the clinic to, you know, have a treatment; that, in itself, could be, you

know, has other positive benefits to the clients along the way.”

Nicole (TW Staff) also mentioned how it was important to manage the expectations of

clients attending TW for the first time and offered some hope that they might see some

benefit as a result of attending.

“I don’t make promises when they’re coming in but just encourage people to think

that the treatment they’re getting can actually have some positive impact in their life

that you know it can increase their mobility, which, you know means that they can,

you know, pick their kids up from school, that that can, you know, get to Centrelink if

they need.“

Charles (Client) mentioned how it was important to have expectations met regarding his

condition as it allowed him to better plan for his future.

“As a chronic asthmatic, I have a lot of experience with dealing with sort of, you

know, like the medical sort of side of things. Uhm, I, as I said like, they gave me a

plan and I was like “Okay, let me just follow this plan”. Right? And then, the plan they

gave me, nothing seemed unreasonable.”

It was mentioned by Susan (Supervisor) that the environment at TW allowed for real

and meaningful connection between the people who attended and worked there,

“…my first impressions was, uhm, it was a little bit like a community family. Family

away from family. Uhm, ah, very holistic environment that the environment enabled

people to have a sense of connection with others.”

While most comments regarding social interaction were positive, Lisa (Client) found there to

be some difficulty when she first attended the clinic. She recalled how the other clients

were a little apprehensive to have someone new at the clinic. While this was the case, the

interviewed client reported that she settled in well and subsequently got along with clients,

staff and students alike.

“…The people I now talk to weren’t, it was like ‘Who is this?’ their turf and it was like

looked a bit, felt a bit rough to me. But after a while I sort of integrated. Uhm, yeah it

was good, yeah, they were all, the staff are great and the, the uhm, chiros were

great…”

Robert (Client), who had received care in the past but was not currently receiving care at

TW, still attended for social reasons, and felt that his attendance was a way of giving back to

TW as well as to the students at the clinic. Robert (Client) stated,

“I pop in as much as I can. Uhm, but unless you’re fully back engaged with the

treatment and things like that, you sort of feel a little bit out of the loop and I don’t

wanna be like one of these parasites that line up here for lunch or, you know? Free

fuckin’ food. I think you’ve gotta put something back. You know? And ah, but no. I’m

looking forward to big-time getting back into it. Yeah.”

Summary of The Wellington as a Setting

The Wellington was identified as an important service for the community. It offered

a place for individuals within the community to congregate and form meaningful and

genuine relationships with others, helping battle social isolation some clients may

experience. It was also identified as an important learning experience for students who

treated clients at TW.

Summary of A Patient-Centred Approach for Clients

Table 7: Summary of First Theme

Microsystem Code 1: The Client Experience at The Wellington

Code 2: Client Treatment Protocol at The Wellington

Code 3: The Wellington as a Setting

Findings There are additional benefits as a result of attending. Students and clients learn from each other. Students use a patient-centred approach which is appreciated by clients. Meaningful and genuine relationships are formed at TW. The Wellington is important to clients as a source of community. Students find the experience of working at TW valuable.

Theme 2: Clients are Complex (Mesosystem)

Theme two was named Clients are Complex and was based on the second system

outlined in Bronfenbrenner’s ecological systems theory (Bronfenbrenner, 1979). This system

is known as the mesosystem which is a collection of microsystems that can influence each

other and as a result, the development of an individual. For this reason, the codes

generated within this theme all related to the clients’ different settings and how they might

influence each other in some way. While most codes in this theme were made of comments

from a collection of interview groups, some were only made from comments made by

clients, as some questions were specifically related to the clients’ personal experiences.

Code 1: Benefits and Reasons for Attending Chiropractic at The Wellington

This code was made from comments made by clients describing some of the benefits

they received by attending TW and how that helped them engage with activities they might

not have been able to otherwise participate in.

Clients discussed how improvement and maintenance of function and physical

mobility was of importance to them. Norman (Client) reported that after being in a motor

vehicle accident he was able to continue to return to work as a result of his attendance at

TW.

“Uhm, so, yeah, I’ve just been coming here for treatment ever since and at least,

uhm, the last couple years I’ve been back at work most of the time.”

Charles (Client) spoke about the importance of physical mobility to him and that his

attendance at the clinic had helped to keep him on his feet.

“Oh, yeah! Well, basically, like, to be honest, like, if I wasn’t, sort of, getting

treatment here, like, I’d probably be in a wheelchair, to be honest.”

When Lisa (Client) was asked what her goals were for attending the clinic, she mentioned

that she wanted to maintain her current state and hoped that the treatment would improve

her condition in the future.

“Well, just keep maintaining it or maybe eventually it might get a little bit better.”

Robert (Client) recalled when he used to receive treatment and the benefit that he gained

from it. He described how the regular treatment he received kept him active and off the

couch.

“It does give me the, the flexibility that if I was lazy and just resided to sitting on the

couch eating chips watching the midday movie, well, I wouldn’t be here anyway. So,

yeah, it’s been very, very beneficial. Very, very, beneficial. As I say, I’ve missed it for

the last six months, I really have.”

Some clients mentioned personal reasons where the treatment they received had enabled

them to do things that mattered to them. Norman (Client) spoke about how he had been

able to ride his bicycle again,

“Well, it’s made me more mobile again and able to just function in some sort of a

normal way. Uhm, I'm always going to have a few problems. Uhm, when I first put

my back out, if I stood off a step I could feel the bones crunch and then, uh, most of

that’s gone now although I had a big heavy backpack on my back today, riding on a

bicycle and it’s the first time I’ve sort of, of felt that sort of sensation in a long time

[laughs].”

Lisa (Client) spoke about how, as a result of her treatment, she was able to pat her cat;

something she was unable to do when her condition was untreated.

“‘Cos I couldn’t actually give it like, uhm, uhm, what do you call it, motor, fine motor

skill, sort of, massage or something. So, I used to just basically pat it with my

forearm. Now I’m actually able to give it an actual full on massage, I can give it at

least five minutes at least five or seven and like I can do a little bit of, like not chiro,

but a bit of massage on the cat. So, I think that’s really good.”

Interview participants reported that consistency of care was important in

maintaining their different conditions and in turn maintaining their ability to participate in

their activities of daily living. Participants also expressed that their home exercises played a

significant role in their maintenance. Lisa (Client) spoke about how the maintenance care

and home exercises were important to her,

“…I realised it’s not gonna go away, it’s about maintenance and just keeping it - I've

done a lot of exercises, like they’ve given me a lot of exercises to do and, sort of

thing. And they’ve really helped.”

Charles (Client) also described how important the exercises that are given to him were in

maintaining and improving his condition.

“The actual treating session, that’s only actually half the work. There’s a lot of work

that you’ve gotta do at home. In terms of like, just stretching other sort of, like,

exercises you gotta do, cos like, the thing is that sometimes when you have, like uhh,

some sort of, you know, exacerbation of like, you know, an inflammation or things

along those lines, you might lose a bit of, you know, structural strength and things

like that.”

Charles (Client) also reported that education of the patient was of importance,

“…like just sort of the structural function of like how your legs and everything else

sort of works and stuff like that and how like, it’s funny like, you know, like, it’s the

song, you know, ‘Leg bones connected to the...’ you know, but it’s, you know what I

mean? You really do start to listen to things and how things sort of work and

whatever, right?”

Brittany (TW Staff) reported a high retention rate of patients and that a high number

would return for consecutive treatment.

“Uhm, I think if I was to do percentages in terms of returns, I think, 90% of our clients

are returned.”

However, some RMIT supervising staff expressed concerns that there may have been a

dependence on chiropractic treatment. That in some cases this may have actually been of

detriment to the client and may feed into aspects of chronic pain. Susan (Supervisor) stated,

“Ha, uhm, good or bad, uhm, certainly, uhm, it’s good, uhm, for nurturing and, and

connection the client has with society. Uhm, but, uhm, whether that has a positive or

negative impact on their, ah, ah, presentation of pain, uhm and whether it actually

increases chronic pain, I’m not really sure.”

Ethan (Supervisor) also expressed concerns that there might have been some clients

attending the clinic who were not receiving benefit from the treatment but would continue

to attend regardless.

“But I can see from the, uhm, notes from the files, ah, from the interactions that I’m

having with the students and how they feel that the patient is travelling. Uhm, yeah

there are quite, ah, I’d say maybe two or three that come to mind, uhm, which don’t

look like they’re progressing.”

Summary of Benefits and Reasons for Attending Chiropractic at The Wellington

The maintenance or improvement of physical mobility and function in order to complete

activities was found to be of importance to clients. These findings were individual to each patient.

Clients continued to return to TW at high rates according to staff. It was reported that not all clients

may have received improvement in their presenting health problems, according to their patient files.

Code 2: Impact of Health Problems on Clients’ Lives

This code was generated from comments made specifically regarding the clients’

health problems and their reasons for attending TW. This may have included what their

health problem was and how it affected their activities of daily living.

All clients discussed how their health condition was debilitating and how it impacted

upon their ability to participate in their daily activities of living. Norman (Client) spoke about

how it could interfere with his ability to work in a job as his low back pain would flare up

when completing tasks in his job,

“…every time I go and work, it plays up.”

Charles (Client) reported that, as a result of his condition and comorbidities he had to move

into a residence that was more accessible to his physical mobility requirements,

“…sometimes a few issues with the foot and whatever and I think if I was just in

somewhere now where I did have to go up and stairs now, it would just completely

change the way you actually organise your daily life.”

Charles (Client) also reflected on when he was homeless and that the harsh conditions

homeless citizens can face can make their health worse. Charles (Client) said,

“So, imagine if you’re sleeping out somewhere. Oh, sometimes you can get like, you

know a reasonable amount of sleep in a night. Sometimes you can’t. Cos things

happen, right? Then you gotta try and catch up on sleep during the day and if it’s

raining, well then mate, you’ve gotta find somewhere to lie down. Do you know what

I mean? It’s like it’s, there’s all these little like, little factors that sort of go on, you

know what I mean?”

Lisa (Client) also discussed how in the past when her condition was at its worst she would

have to modify how she undertook her daily activities.

“Like, I’d just have to moderate what I did and just, I just had to sort of start not

having handbags and using bags that go over me and really just extremely moderate,

modify my body.”

Robert (Client) also expressed how his condition had affected his daily activities, mentioning

that it had impacted upon his ability to get out of bed in the morning.

“That’s ah, that’s difficult. Uhm, getting out of bed’s been difficult.”

And how it has affected his sex life,

“Well I can’t have the parallel pogo [slapping noise] too well. That’s ah, that’s

difficult.”

Norman (Client) also discussed how, as a result of his treatment he had been able to

future-plan and deal with his problem. When asked if the treatment had changed the way

he felt about his problem. His response was,

“Oh, absolutely! Cos, when it first happened, I thought I was stuffed. I honestly

thought I’d never work again.”

Charles (Client) discussed how his problem forced him to find housing that would

accommodate him in later years, as his condition had the potential to deteriorate,

“…for example: my shower at home. That’s big enough for a wheelchair maybe. So,

like even later on in life, if I had some mobility issues or whatever like that, no

problems, mate.”

Lisa (Client) recalled a time she filled in to work for a friend and how it served as a reality

check that she needed to avoid strenuous work due to her condition.

“…I did it for one day and I, I know why I’m not doing simple things. I really pushed

myself and I could make coffee and I sold pies and I thought, I did it, and I thought ‘I

could, I just, I can’t kid myself I can’t do physical things like that’.”

Summary of Impact of Health Problems on Clients’ Lives

Clients discussed how their individual health problems impaired their ability to

participate in their daily activities. Clients also discussed how in certain circumstances they

needed to plan for the future, as their health conditions were chronic. One client was aware

of the consequences of their condition and had to make preparations surrounding work

related activities.

Code 3: Chronicity and Multiple Conditions

This code was created from comments made regarding clients’ chronic conditions as

well as comorbidities that they might have presented with. Because these conditions were

chronic, it was expected they would have impact upon all settings in which the clients

participated. Therefore, this code was considered appropriate for this theme.

It was reported by Charles (Client) that because of his chronic condition he had

developed a dependency on the medical system as he required frequent medical attention

for his chronic asthma.

“No. As I said, anything before then was just asthma related. So, I’ve had like, 40

hospital admissions for asthma.”

Charles (Client) also spoke about how he had to accept the fact that his condition was

chronic and not likely to improve any time soon,

“…as I said, you’ve just gotta realise that this is gonna be a long-term adjustment and

then you just gotta build your life around that.”

Lisa (Client) also spoke about how her condition was chronic in nature and that the

improvement she had experienced was incremental and her hope was to see her condition

improve bit by bit.

“I think that, you know, it’s just a, you know, uhm, just increments of change and,

and betterment. Like uh, well it’s available, it’s got like probably 40% better than it

originally was. So, you know, there’s no reason it can’t get like 5% here, 5% there

maybe, I don’t know.”

Lisa (Client) also acknowledged the complexity of her condition,

“Well mine’s sort of complex in a sense I’ve got different parts to deal with.”

Students reported that quite a few clients presented with complex and complicated

health complaints, including mental health conditions. Lauren (Student) recalled how clients

could present to the clinic with not just physical but also mental health conditions,

“Ah, physically and mentally, you know, a lot of things going on in their life and/or

their bodies that make their treatment in some ways, a bit more challenging…”

Dawn (Student) also spoke about how her time at TW made her realise that clients

presented with multiple conditions and that they could interact and impact on each other.

“It’s definitely given me an appreciation of various conditions, that it’s not just one

condition, it’s all multifactorial and how lots of factors actually interact to cause a

certain, uhm, presentation to arise.”

David (Student) iterated that clients could present with comorbidities that allowed for some

unusual patient presentations at the clinic.

“Uhm, I would say that’s generally it, you know, some of the... some of the patients,

or not some of them, a few of them, had some complicated cases, with being many

different regions that they had, you know, difficulty, or pathology.”

David (Student) reported that the high rates of comorbidity in clients may have been due to

the older demographic of patients that presented to the clinic for treatment,

“…I was booked in to see more older individuals at The Wellington clinic, where in

comparison to my, the Uni Hill clinic, I don’t really see THAT many old people. So, I

guess it’s somewhat expected that they’re gonna have more regions of pathology…”

Mental health conditions were something mentioned by the supervisors as well as

TW staff. Nicole (TW Staff) reported that TW had a lot of clients who presented with mental

health conditions.

“We deal with a lot of people with mental health issues, so uhm, you know, off-meds

schizophrenics, or, uhm, is it’s a day-to-day reality for me.”

Fernando (Supervisor) discussed how some clients would present with complex personal

and medical health histories that could sometimes remain unknown.

“We don’t know the history of a lot of these people and the students don’t delve into

whether there’s been abuse, or whatever else.”

Summary of Chronicity and Multiple Conditions

Clients reported having chronic conditions. Supervisors, students and clinical

supervisors reported that some clients presented with not only physical conditions but also

mental health problems. It was also reported that clients might present with more than one

condition and that they sometimes had complex medical and personal health histories.

Summary of Clients are Complex

Table 8: Summary of Second Theme

Mesosystem Code 1: Benefits and Reasons for Attending The Wellington

Code 2: Impact of Health Problems on Clients’ Lives

Findings Clients attend the chiropractic clinic for the reasons of maintenance and improvement of physical mobility and function. Clients’ health problems impact upon their daily activity and in some cases, they plan for the future as a result.

Code 3: Chronicity and Multiple Conditions Clients present to TW with chronic

conditions, sometimes with multiple conditions and complex histories.

Theme 3: Trust (Exosystem)

This theme was developed from codes relating to RMIT’s influence at TW. The RMIT,

as a university, was considered an external setting in which clients did not participate. While

RMIT had an agreement with TW to provide a service to its clients and influence their lives,

the clients did not actively participate in the university as a setting. Without the agreement

between the university and TW there would be no chiropractic clinic located at TW and this

would directly influence client access to care. These codes were formed from comments

including those of the students as well as the supervisors of the chiropractic clinic. This

theme is known as the exosystem within Bronfenbrenner’s ecological systems theory

(Bronfenbrenner, 1979). The exosystem consists of external settings an individual is not

directly involved in but continues to be influenced by. This theme was named Trust.

Code 1: Relationships

The relationships between clients, students, staff and supervisors would not be

possible without the agreement in place between RMIT and TW. Therefore, this code was

comprised of comments surrounding these relationships. This code was placed under the

third theme, as it related specifically to relationships formed at TW as a result of this

agreement.

The most frequently reported relationship was between client and student. These

relationships were overwhelmingly positive and this was reflected in interviews with both

clients of TW as well as the chiropractic students who treated them. Robert (Client)

mentioned that it could take time for these relationships to form and that as students

learned more about the client and their conditions, they began to include and introduce

different treatment plans for the client.

“In the early days it was like, oh shit, what have we got here? But as, as the students,

uhm, the more they get to know you, the more they want to experiment or try and

get to the bottom of what’s wrong with you. ‘Oh, how bout we try this?’ mmm.”

Lisa (Client) reinforced this point and reported that her relationships with the students as

well as staff at TW had been positive ones.

“Uhm, yeah it was good, yeah, they were all, the staff are great and the, the uhm,

chiros were great…”

Where students may have been inexperienced, clients reported that they were

understanding and they realised that it might take time for some students to develop the

necessary skills to deliver the best treatment they could. Charles (Client) stated,

“…I’ve been doing it for a long time and I understand that, uhm, you know, some of

the students, ah they’re a little bit greener than others. Some, but some of them are

like, you know, they understand the technical side, but they’re still working on their,

sort of, patient treatment side.”

Robert (Client) mentioned that he got on well with students and that they were quite

likeable.

“So, it’s been really good. Not just for the treatment side of things, but also the kids

that the, uhm, the students, ah, are affable, they’re, they’re talkative.”

When asked how well she got on with her student practitioners, Lisa (Client) gave a very

similar answer, that the students were quite easy to get along with and that individually,

they each had their own strengths.

“Yeah, well they’re really, they’re really affable and they’re really helpful and they’re

really friendly and, you know, I try to give credit where it’s due, I say ‘Oh, you know,

you’re good at what you do’, if, if, you know that sort of thing and, uhm, I find them

all quite good at their own little way”.`

Other relationships included those between students, their clinical supervisors and

how that impacted upon the clients at TW. Susan (Supervisor) reported that sometimes

intervening in a client’s consultation became necessary. This intervention usually led to a

positive outcome for the clients and for the students as it could build trust within these

relationships. Susan (Supervisor) recalled,

“So, for example where a client just wanted to get treated but we had, uhm, the need

to actually review that client by taking a, a particular history; or further examination

and the client would be frustrated with that and so, stepping in and being able to

facilitate that, uhm, but that always then led to, uhm, the client, uhm, connection

afterwards. Such that they would be on their way in and drop by and say ‘Hello’ and

on their way out and drop by and say ‘Hello’. Yeah. That’s generally how it went.”

Relationships were also formed between the supervisors and the staff who ran TW. Susan

(Supervisor) reported that the relationships formed between staff of TW and RMIT

supervising staff were built on trust and understanding. Susan (Supervisor) said,

“Uhm, uhm, ongoing outside relationships, obviously not with patients. Uhm, but

relationships with, uhm, the staff that ran the centre, The Wellington. Uhm,

understanding the environment more, uhm, through those relationships, that’s

mainly the relationships that I, I made.”

When discussing his relationship with the staff at TW, Ethan (Supervisor) mentioned that

there was an element of trust between the two and that this came as a result of TW staff

knowing the clients on a deeper level.

“So, I trust them implicitly in, in how they know the patients. So, uhm, they do get to

see them on, on a daily basis, as opposed to a weekly basis.”

Relationships between the staff of TW and their clients were also something

discussed frequently by both groups. Nicole (TW Staff) discussed the importance of building

good rapport within this community of people, as well as the importance of trust. Nicole

(TW Staff) mentioned that the clients typically were not quick to trust, due to their previous

lived experiences and that the services being offered needed to be genuine, otherwise

clients would not return.

“Uhm, but no, the rapport thing is very important ‘cos, I mean there’s a lot of, yeah,

mistrust into a lot of organisations and a lot of people have to deal with government

bureaucracy a lot of the time. So, to think that we’re actually here, offering a service;

that we’re not, you know, trying to, it’s not a fiscal reality, it, it’s actually outcome

related.”

Brittany (TW Staff) also discussed the importance of trust and genuine connection with the

clients of TW and that the trust was mutual between the two groups. “Connection. And, I

suppose it, kind of, you become a point where they say, ‘I can trust her...’ uhm, you know

‘...life is not so bad.’ You know what I mean? When you feel isolated? Uhm, life is really hard.

Cos you think ‘Oh, can I depend on her? Who can I trust? Who could I speak to? Who I can

ask a favour from?’”

Figure 8: Chiropractic students at The Wellington. (Written informed consent was sought and received by those in this photograph for its reproduction and use).

Summary of Relationships

Relationships were formed between all of those involved with the operation of the

chiropractic clinic. Trust was identified as an important component of relationships between

clients and others at the clinic. There was some speculation from interviewees that this

might have been due to previous lived experiences of the clients who attend TW.

Code 2: Student Delivery of Chiropractic Care at the Wellington

This code was synthesised from comments made by participants regarding the

delivery of chiropractic care by students and the way in which this type of care was

delivered. These comments were all related to events, relationships and interactions that

took place as a result of RMIT and TW’s agreement to offer chiropractic to the clients of TW

and the education that students receive at RMIT University.

Norman (Client) reported that he preferred some students over others, stating,

“I found that some of them are just really good at what they do, and it’s always been

beneficial with these particular people and then I find that there is some students

that, sort of, more just, go through the steps.”

While he mentioned that some students might have simply been going through the

motions, he also noted that others made appropriate clinical decisions for their clients.

Norman (Client) also stated,

“…you can see that they’re thinking about what they’re doing and they’re making

good choices.”

All clients that were interviewed were happy with the services provided by students.

However, clients clearly had a preference towards some students over others. Robert

(Client) discussed the need for students to put genuine effort and care into the delivery of

their treatment and patient interaction by saying,

“But some students had taken the extra time to delve more into the biomechanics of

the body and mate, those are the students I found that would excel. In this field. If

you just going through the motions, you’re just doing your theory and practical and

getting your little tick that says ‘doctor’ and if you don’t have your heart in it, you’re

full of shit.”

In general, the relationships formed between the clients and their student

practitioners were meaningful ones, even though they were only formed over short periods

of time due to student rotation in and out of the clinic. Robert (Client) stated,

“…It’s hard to build up a relationship… because I’ve only, maybe only get em twice.

Uhm, but then the two weeks, or three weeks maybe that you have the same

student, they’re good, terrific.”

It appeared that the clients understood the circumstance in which their care was being

delivered and who was delivering their care. Robert (Client) expressed that he understood

that the students could not always be available and that their placement at TW was only

temporary. Lisa (Client) mentioned,

“They’re coming for their daily, their placement here and then they go to another

clinic or they do something else. They graduate or whatever they do. Hehe that’s

cool.”

It was reported that clients somewhat relied on the care delivered by the students and

missed that care while the students were on a break, over the Christmas period, for

example. Lisa (Client) mentioned,

“…every time you have a break over that time and I had not therapy I was like, it was

murder for that 6 weeks…”

Summary of Student Delivery of Chiropractic Care at The Wellington

Clients acknowledged that they did prefer some students over others. However, they

stated how they were happy with the care they received from all students. Clients preferred

students who were genuine in their approach to treatment and communication and

preferred to be treated as an individual and not a number. Clients made bonds with their

student practitioners over short periods of time and were understanding that students

needed to move on for various reasons.

Code 3: Client Experience with External Healthcare Providers

Clients were asked about their experience with external healthcare providers and

how their interactions with these providers may have influenced their attendance at the

chiropractic clinic. This code was developed from those interactions as these external

providers were considered to be in a setting in which the RMIT students and staff did not

participate but were influenced by those interactions.

Some clients expressed a distrust of certain medical doctors. They felt as though

their medical doctors had a prejudice that the client was only there to gain something.

Norman (Client) expressed this within his interview.

“I think you go and see one of them if you wanna get on a pension or something.

‘Yeah I’m nuts doctor! I will just keep applying and I’ll learn the right answers that

you wanna hear and I’ll, you know. I can sit on the dole!’”

Lisa (Client) found that her doctor was surprised to learn that she was attending a

chiropractor.

“Like I've told GP’s how good it is. Sometimes they’re not as, as, as friendly with the

chiros as - but I’ve just always felt how good it is. Cos, I, I only see my GP not that

often I just, look I just go to, uhm, osteopath at The Wellington and, and, chiro, sorry.

And, uhm, yeah, so, yeah he just sort of hehehe he’s sort of amazed. Cos I think

they’re a bit old school sometimes some of them.”

Lisa (Client) also discussed how she had found some doctors more accepting than others of

treatments that were an alternative to medication.

“But then I went to another doctor that was like - that's the one that was trying to

give, give me the, the medical like, uhm, the Norspan and the ad, ad, what did I say

before? This uhm, Endone. And she just said, I said ‘Oh’, about natural therapies. She

just, she just no, she just said ‘I don’t do anything like natural therapy. I only do,

have, like basically chemicals. I don’t...’. So, she wasn’t really for it, but she knew that

I believed in it. Uhm, and then I went to a Jewish doctor in, it’s nearly Elwood, in the

mid, the [inaudible] clinic. And he’s lovely. He knows, I mean, he’s got like, he does

acupuncture and different things.”

Robert (Client) stated that his doctor accepted that he was attending the chiropractor as

well,

“Uhm, they’re, they’re happy with it, as long as I’m happy. If I get the benefit out of

it, even if it’s just a small token.”

Norman (Client) spoke about how he tended to avoid talking to doctors about his

chiropractic treatment as in the past he has found them to be disinterested.

“They’re not interested. So, I just don’t tell them about it. I mean, I have told them.

But I don’t discuss it with them. They just look at you like ‘Ah yeah, yeah, oh do you

want a pension?’ [laughs]. You know what I mean? So, I just don’t talk to them about

it. Yeah.”

Norman (Client) also discussed how he tended to have more conversations with the

chiropractic students regarding his own health than with his doctor.

"Oh, everything about my physical being with my treatments here is all discussed

with them. With the students and, uhm, none of it with the doctor at all.”

Charles (Client) spoke about how while the chiropractic students and his medical

practitioners didn`t exactly work together, they still worked towards a common goal.

“So, the way I look at it, it’s just, uhm, it’s, it’s, it’s part of like a, just, an overall

structure. So, you can’t really, I can’t really completely separate the asthma from,

whatever. You know what I mean? Because, they do impact on each other, right?”

Lisa (Client) discussed how in the past she had received some treatment from her doctor for

her musculoskeletal problem and how she found the treatment she received to only have

short term benefits.

“I’ve had scans. He’s pretty, he’s pretty good. Uhm, he, he knows about my condition.

Uhm, he’s actually given me some LASER at points in time, which didn’t, doesn’t

really, it, it, it’s alright in the moment but doesn’t really last long.”

Robert (Client) reported that his medical practitioners did work together with the

chiropractic students, in a limited capacity. Robert (Client) spoke about how if a student

recommended imaging, then the doctor would write a referral for this.

“Yes. Separate. Nah, it’s separate. It’s completely separate. Separate. I mean here, I

might say ‘Oh, I’ve got a problem with my back’, tell them what the student might

recommend, he then gives me a referral, I get the x-ray done, the student sees the x-

ray, shows the supervising doctor: ‘Alright, well I suggest you then do this, this and

this course of treatment’. So, they’re working well that way.”

100

Summary of Client Experience with External Healthcare Providers

Some clients reported having experienced discrimination from external healthcare

providers such as general practitioners. Most clients viewed the care they received

externally to be separate to that received at TW, although they served a common goal. The

chiropractic students treating clients at TW did maintain a link to the broader healthcare

system for clients when managing their health complaints.

Summary of Trust

Table 9: Summary of Third Theme

Findings

Exosystem Code 1: Relationships

Code 2: Student Delivery of Chiropractic Care at The Wellington

Code 3: Client Experience with External Healthcare Providers

Trust was an important factor for clients when forming relationships with the chiropractic students. Clients appreciate the care received, and they appreciate when students are genuine in their approach. Clients view the care they receive at TW as separate. Students maintain a relationship with the broader healthcare system.

Theme 4: The Cost of Being Disadvantaged (Macrosystem)

This theme was formed from comments surrounding matters that were influenced

by societal beliefs, political systems, policy, culture and traditions. Particularly, the focus of

this theme was that of clients’ experience with medication; as prescription of medication

was typically influenced by guidelines, policy and procedure. The other focus of this theme

was on the comments made surrounding financial pressure and how this could impact upon

the clients’ access to healthcare, such as chiropractic. This theme was reflective of what

Bronfenbrenner described as the macrosystem (Bronfenbrenner, 1979). This theme was

titled The Cost of Being Disadvantaged.

101

Code 1: Client Experience with Medication

This code was generated from responses regarding the clients’ medication usage.

Norman (Client) reported that he took some medications, out of necessity. He stated

that his usage of medication was as prescribed and that it helped him function within

society.

“But now since I’m on anti-depressants, uhm, and my social anxiety’s largely gone

away, uhm, I find it a lot easier, just to be part of society.”

Norman (Client) also discussed how he did not particularly like taking medication but took

his current medication as it worked for him.

“I take and, ah, I don’t like taking pills, I don’t even take painkillers, you know. I don’t

take anything for headaches. I just really don’t get into pills. But this one seems to

work so I stick with it.”

Charles (Client) also discussed how he preferred to avoid medication for his musculoskeletal

problems as they were not much help. Charles (Client) stated,

“Well, you know, you just gotta find ways to deal with things, you know? Cos, as I

said, if you don’t, if you just sort of think ‘Oh, I’ll just use a pill or whatever...’ well, no,

no, no, a pill is, a pill ain’t gonna... a pill ain’t gonna do much, mate. It really isn’t, you

know? Honestly, I would do, even now, even in a bad day, I would try and do at least

10 minutes of stretching a day.”

Lisa (Client) discussed how the use of constant painkillers were not helpful for her condition

either. She said,

“So, and it and I got on a really heavy one called Endone, I think, at one point and it

was like, you take two or three and you’re sleeping for 12 hours and you get up and

you go back to sleep. I just kept on going to the chiropractor.” `

102

She mentioned that the medication she was taking did not have lasting relief for her

condition.

“I did have a trial with, uhm, a doctor put me on some, ahh, like patches, Norspan

patches but they didn’t, they just took the edge off the pain. It was consistently

pulsing, uhm, just pulsing.”

Lisa (Client) said she would take medication in the period when students were on their

break. She said,

“No, I was just gonna say, Lyrica is the only medication, over the, over the time

someone said ‘Oh, what about Lyrica?’ and my doc, I asked my doctor over the break

and I did have it last, like the six-week trough over Christmas. The Lyrica is the only

medication, it’s like a pain medication for this, even though it’s not a pain

medication. That’s the only medication I will have on the break.”

Robert (Client) discussed how he had taken quite a few different medications. However, not

for his musculoskeletal conditions.

“Oh, I’ve had a lot, yeah. Just mainly due to the heart and that things, but yeah. So,

but nothing to do with the body, it’s mainly because of the heart and the cancers, I’ve

been on a lot of medication. Hence why I, you know, I’ve put the belly on, because it

retains fluid and I feel like shit. Because I’m on all this medication. You know? Uhm,

don’t go for a walk because it’s hot? Oh, get fucked. Fuck!”

Summary of Client Experience with Medication

Clients stated that they preferred to not take medication for their health conditions.

Clients found that for their MSK conditions, medication was not as useful at reducing pain

levels as the care they received at TW. Clients stated how they would use medication to

manage their other conditions such as heart disease and chronic asthma.

103

Code 2: Financial Barriers Impair Access to Chiropractic Care

This code was generated from comments made surrounding financial constraints

and how they might impact upon the clients’ access to healthcare such as chiropractic.

Again, government policy and privatisation of some parts of the health system means that

this can make it difficult to have access to types of care such as chiropractic that exist

predominantly within the private sector.

Norman (Client) discussed the difficulties he had faced as an immigrant and not

being able to obtain access to healthcare. He mentioned that because he was unable to

access welfare he had to continue to work, even with back pain. He said,

“Uhm, and well, not being able to get any government assistance is a case of, I can’t

really work because my back keeps playing up on me. But I have to [laughs]. Because,

you know, there’s not much choice in the matter, you know.”

Charles (Client) spoke about how he accessed certain types of healthcare and how he had to

rely on government-run facilities to receive care like physiotherapy and podiatry.

“Cos, a uhm, there’s a clinic that’s up around, uhm, just near Queen Victoria Market.

Sort of, sort of similar to this, except it’s, you know, it’s more, more like a government

facility. Uhm, but they also deal with a lot of people who are, sort of, you know, on

the edge of just, sort of, society and whatever. And so, yeah, I sort of, have seen

physio as well there. Sometimes podiatry is there, but mainly physio there, as well.”

Lisa (Client) also required government assistance. During her interview, she discussed how

she required help from the council to manage the cleanliness of her home as she was

unable to do so due to her condition.

104

“Like just things would accumulate and then the councilwoman would come every

few months and then sorted all that out and put things in piles and then I’d get rid of

stuff, or whatever. So, that sort of thing. But before I’d be like, I could just be on top

of moving. But I just do what I can and what I can’t do, I leave now. I don’t think, I’m,

not gonna stress myself out about it.”

Robert (Client) described how he felt access to this type of healthcare was important for

everyone and not just the wealthy. He said,

“Uhm, and uhm, it just offers such a wonderful, wonderful opportunity for people to

get the treatment. Because if you’ve got money, you get the best lawyers, you get

the best healthcare. But if you’ve got jack shit, you get fuck all.”

Dawn (Student) iterated this point in her interview as well by saying,

“Uhm, but, sort of, being able to, sort of help and make a difference and give them a

treatment that they deserve. Uhm, just because they’re unfortunate in their

circumstances or anything like that, uhm, shouldn’t be withheld.”

Nicole (TW Staff) discussed how the clients who attend chiropractic services do not

have any other way of accessing this type of healthcare by saying,

“That they couldn’t effectively get treatment in any other way, uhm, that, you know,

the... pretty much yeah. None of our clients have, you know, a private health

insurance, uhm, yeah from my understanding the, yeah, they couldn’t get a referral

from their GP to, you know, get a subsidised, uhm, treatment.”

105

Brittany (TW Staff) reflected on how the students and clinical supervisors continue to

provide this service, making the point that it is needed.

“That these people have, yeah, the clinicians and the supervisors and the fact that

they’re actually coming back really indicates to me that A: it’s needed and B: uhm,

you know, uhm it should be, I think, available for more people.”

David (Student) spoke about how this type of therapy was something new to a lot of clients

and that this may be due to their socioeconomic status. David (Student) said,

“I believe they, they benefit from potentially a new therapy that they never really

tried before. A lot of the people I found had been to the medical route and they sort

of just come to the, you know obviously, low-socioeconomic factors are influenced

here, you know, but they don’t naturally tend to go to a chiropractor, uhm, yeah.”

Charles (Client) discussed how he had experienced issues in the past in gaining access to

financial assistance as a result of his health condition. He said,

“Cos, in the, uhm, in the early ‘90s I used to be with the Commonwealth

Rehabilitation Service and ah, they tried to get me on the pension and the

government was just like... Cos, they have all these points criterias, right?”

Summary of Financial Barriers Impair Access to Chiropractic Care

Clients discussed how financial cost was a barrier to accessing healthcare services

that are predominantly privatised such as chiropractic. Clients spoke of the value they gain

from being able to attend TW and other free or subsidised healthcare services. It was

reported by all participant groups how they felt services like those offered at TW should be

available to all, regardless of the cost involved.

106

Summary of The Cost of Being Disadvantaged

Table 10: Summary of Fourth Theme

Macrosystem Findings

Code 1: Client Experience with Medication Clients avoid medication usage for the

Code 2: Financial Barriers Impair Access to Chiropractic Care

health conditions as they find them to be ineffective. Financial cost acts as a barrier to healthcare for clients. Healthcare services such as those at The Wellington should be available to everyone.

Theme 5: Looking to the Future (Chronosystem)

This theme was developed from comments used to describe change over time taking

place at TW, the future of TW and comments made regarding the future of the clients at the

clinic and their health problems. This theme comprised comments made from all interview

groups. This theme represents the system Bronfenbrenner described as the chronosystem

(Bronfenbrenner, 1994). The chronosystem is the influence of time on an individual’s life;

this can be past, present or future and can include changes in terms of living situations,

personal life, employment and any other aspects of a person’s life that can change across

time. This theme was named Looking to the Future.

Code 1: The Wellington as a Setting Over Time

This code was generated from comments surrounding how TW had changed over

time. Because TW changed location throughout data collection it meant that some

participants were interviewed prior to the move and some were interviewed afterwards. All

students and staff of TW were interviewed prior to the move, two of the client participants

were interviewed before the change in location and two after the move. All supervising

clinicians were interviewed after the move.

107

When asked about the future, Norman (Client) discussed how he felt there was

going to be a positive change at TW once it changed location. This client spoke about how

he had participated in some volunteer work at TW and how he felt his job was done now

that the move was going to happen. Norman (Client) said,

“Well this place is doing alright. It’s got its own premises coming up. So, uhm, that

makes me feel good for just some sort of achievement that I’ve been fighting so

many people over the years to make sure The Wellington was alright that, uhm, I feel

really good about that. Uhm, although I do feel that once The Wellington moves, I

feel like my job’s done. And The Wellington will be safe.”

Norman (Client) continued to talk about his future involvement at TW and how he hoped he

could attend just as a client, saying he’d been told to spend some time on himself.

Continuing, Norman (Client) said,

“Uhm, although I do feel that once The Wellington moves, I feel like my job’s done.

And The Wellington will be safe. With any luck. And ah, I’m sort of just at a point

where it’s time to start a new venture, I think. And, ah, it would be nice to come to

The Wellington to be a client.”

When asked if he had anything to add during his interview, Robert (Client) spoke about how

he hoped the service would continue. He spoke about how good the service was as a

resource within the community and as a positive learning experience for the students who

participate in placement at TW. Robert (Client) said,

“You know and that’s a real big concern and I just want The Wellington to, to be

around and see me out, it might only be 10 years but I want them to still be here. You

108

know, and providing students with a pathway to get everything we can to help them

become better, or, or really exemplary practitioners. Cos that helps the community.

You know? It really does. So, the better quality of student that we get here, and we

can all help them to have the practical, the better it is for the whole of the

community.”

Robert (Client) also spoke about how he hoped there would be continued support into the

future, from the government as well. He said,

“Fantastic, it’s a great community service, I wish it to continue and to be viable and

uhm, and not to continue to be worrying about financial stability. I think if the

community would, in particular, if the Greens wanna save climate change and global

warming and this bullshit. Well how ‘bout hitting your fucking kick and helping real

community people and, and uh, like what the RMIT does here with all the facilities on

offer.”

Students also expressed their hopes for TW-RMIT agreement to continue into the future

and that they hoped this type of placement to be available on a permanent basis. David

(Student) stated,

“Loved it. Loved it. Wish I could do it, I, I hope RMIT have it permanently, I think they

should have it on at least once a week forever. Just like Uni Hill. In my opinion. It’s a

great experience.”

109

Staff at TW were also positive regarding the future of TW. However, they did express

concern regarding the future for the clients. During her interview, Nicole (TW Staff) said that

TW was ready for expansion. She said,

“Uhm, I worry about the future of the clients. Uhm the future here I think will be

interesting, I think we’re ready to, yeah, take it to the next level. So, we’re running off

a model system that’s been running for fifteen years out of here. And, yeah, I think

that’s long enough to have learnt, yeah, we’ve built up what we’re doing, we know

what we’re doing and it’s ready to take it to the next level to, you know, whether that

is to make us more, more corporate in a way.”

Nicole (TW Staff) continued to speak about her confidence in the future for TW and how she

hoped for a new space that would be customised for their needs. This became a reality after

the move that took place. Nicole (TW Staff) stated,

“So, we have, uhm, yeah. More confidence in the future because of certain, yeah

financial things in place to, yeah to have, uhm yeah, maybe a building that is, yeah

customised for us that, you know, would make everything run, run smoother, better,

to, you know.”

Nicole (TW Staff) elaborated and explained how more time and space would allow for more

services to be delivered to those who need it. She said,

“Yeah. To me it’s really just, yeah. Expanding on services that we really have. Now,

not really re-inventing the wheel, but just, yeah, finding the time and the space to do

more, for more people.”

110

Brittany (TW Staff) was also confident in a future for TW. Brittany (TW Staff), like Nicole (TW

Staff) stated the need for planning. She said,

“Uhm, there is a future. There is future. It just is, I think, planning becomes pivotal.

You gotta be logistically sound and financially, uhm, structured.”

Brittany (TW Staff) continued to explain how this future planning would carry with it a

financial burden by continuing to say,

“Just as, I suppose, to maintain the overheads whether it’s your rent, rent and

ongoing cost and wages and, cos nobody’s gonna work for free. You’ve got, you’ve

got bills to pay and food to put on the table as well. Uhm, yeah so, I think, uhm, it’s

gotta be logistically planned and coordinated.”

Students spoke about changes they would like to see within the clinic at TW.

Responses from students regarding change were minimal, while some students could not

think of any necessary changes. Lauren (Student) said,

“Uhm, so, I can’t think of anything off the top of my head that I would wanna change

there.” She did however, say that she would like free parking when at TW.

Lauren (Student) said,

“The only possible complaint I could think of is parking and that’s totally irrelevant.

So, [laughs].”

Dawn (Student) said she would like more times available to be able to work at TW and that

she would like simpler forms for her paperwork. She said,

111

“Probably, often more times. Uhm, Cos it, sort of, it’s a really good clinic to go to,

uhm it’s easy to get to, access wise. Uhm, public transport. Uhm, probably just, sort

of simplifying that review form [laughs].”

David (Student) expressed some concern for hygiene standards while at TW and that he

hoped in the future these would improve. David (Student) said,

“Yeah well like, you, I would, I would have liked more emphasis on, like, I know it’s

tough though but like, I’d like more hygiene in, uh, hygiene products, whether it be

like, I know they have like your gels there, which is good, but maybe just more towels

and maybe some pillows, like that you can change per person, I think that’s

something that could help. Uhm, but I thought everything else was great.”

Summary of The Wellington as a Setting Over Time

Clients reported how they relied on TW and that they hope for it to continue as a

community service for years to come. It was stated that the change in location was seen as a

positive for clients and staff described how the move would allow for an expansion of

services such as the chiropractic offered there. Students only offered minimal responses

regarding change they wanted to see at TW, such as better hygiene practices and free

parking.

Code 2: Future of Clients and Their Healthcare Needs

This code was generated from the response clients gave when asked how the future

was looking for them and their health problem.

112

When asked how the future was looking for them Charles (Client) offered a positive

outlook. He discussed how he was aware of his health problems and what to expect in the

future. He also spoke about how it did not get him down. Charles (Client) said,

“Oh, as I said, for me, things are relatively steady. Right? Uhm, you know, as I said,

for me, I’m just, sort of, I, cos, I, from an asthma point of view, of course I take things

day-by-day. Cos, I have asthma every day. And everything else, I just sort of, like, you

know, as I said, if I get a few setbacks, I don’t sort of, like, I don’t get depressed about

it.”

Charles (Client) continued to explain his understanding of the health problems that affected

him and that he realised there would be good times and bad times. Charles (Client)

continued by saying,

“Because I realised that sometimes those things are going to happen and there are

gonna be periods where you’re gonna have, like, an okay run. Do you know what I

mean? So, you just have to, sort of re-adjust to what’s sort of, going on.”

Lisa (Client) spoke about acceptance of her condition and she understood that it might

never improve to the capacity where it was back to normal. However, Lisa (Client) did

express she was comfortable with her current state. She said,

“Oh well I, I got to a point where I, I’m, I feel quite positive about the future but I just,

I, I’m not expecting to do what I used to do but I’m, I’m, I’m comfortable with where

I’m at.”

Lisa (Client) continued to explain how she had accepted that she could no longer participate

in activities she used to and that she maintained a positive outlook. Lisa (Client) said,

113

“I’ve come to terms with not doing you know, lots of manual labour, artwork or stuff

that I would have enjoyed doing sort I just, I, I’m alright I’ve got a good mindset.

Generally, I’m pretty positive.”

Robert (Client) spoke as to how he hoped to get back into regular treatment. He explained

that since a recent surgery he had been unable to receive treatment at TW. Robert (Client)

still felt as though returning to regular treatment would be a step on the road to recovery

for him. Robert (Client) said,

“If I get back, well, health-wise not too good. But we’ll get there. But If I can get back

into having treatment here in say the next, I’m hoping next 6 weeks. Then, then I’ll

feel as if I’m on the road to recovery.”

Robert (Client) continued by explaining that if he could recover from his more serious health

concerns he would then be able to focus on his musculoskeletal complaints and improve. He

continued by saying,

“I’ll feel like I’m back to normal and these problems with, with the body I can deal

with that. But the heart and the cancer, I can’t. You know, I, they keep putting little

hurdles up and I gotta keep jumpin’ em. You know?”

Summary of Future of Clients and Their Healthcare Needs

Clients stated that they were positive regarding the future of their health conditions.

It was expressed by clients how they understood their chronic conditions may never resolve.

However, they were determined to continue seeking care as they found value in

maintaining the current state of their condition or at least maintaining current levels so that

their condition did not deteriorate.

114

Summary of Looking to The Future

Table 11: Summary of Fifth Theme

Chronosystem Code 1: The Wellington as a Setting Over Time and Looking to the Future

Code 2: Future of Clients and Their Healthcare Needs

Findings The Wellington is an important setting for the community and for their healthcare needs. Clients were hopeful for the future of their conditions and planned to continue managing their healthcare complaints at TW.

115

Chapter 5: Discussion/Conclusion

Prominent Findings

This study aimed to investigate the patient-centred outcomes of those living with

disadvantage who attended a student chiropractic clinic located within a community

organisation known as The Wellington (TW). The study also aimed to investigate what

influence TW as a setting may have had in influencing these outcomes. This was performed

using a mixed-methods approach similar to the research design known as Whole Systems

Research (WSR) (Ijaz et al., 2019). Data were collected from clients attending TW using three

outcome measures, the Measure Yourself Medical Outcome Profile (MYMOP), European

Quality of Life Five Domain Five Level Health Questionnaire (EQ-5D-5L) and the Patient

Enablement Instrument (PEI). Qualitative research techniques were also used to gather data

from the clients, the staff at TW, chiropractic students and their clinical supervisors.

Bronfenbrenner’s ecological systems theory allowed for themes to be developed in a way

that explored the client’s experience and outcomes as well as other influencing factors such

as TW as a setting and other external influences (Bronfenbrenner, 1979).

Prominent findings of this investigation indicated that clients who attended TW for

chiropractic care experienced high rates of chronicity related to their health problems and

improved levels of health and wellbeing and pain and discomfort after only a short schedule

of care at the clinic. Clients also experienced improved levels of enablement regarding their

health issues as a result of attending the clinic. Interview data revealed that outcomes of

care that clients found important to them were improvement and maintenance of physical

mobility and function and mental health and wellbeing. It was also reported that meaningful

relationships of trust were formed at TW. This suggests that the outcomes that clients

116

experienced may be due to a combination of therapy, the setting in which care is delivered

and the relationships and bonds that are formed within that setting.

Chronic Disease and Comorbidity

It is well documented within the literature that those who experience disadvantage

also have higher associated rates of chronic conditions and comorbidities (Chamberlain et

al., 2020). This investigation revealed similar findings. Data from the MYMOP showed that

over 70% of clients’ primary symptoms were chronic. While the MYMOP does not directly

ask the client to list their medical conditions, interview data suggested that many of the

clients at TW do experience chronic conditions and comorbidities concomitant with their

musculoskeletal (MSK) conditions. Interviews with students and clinical supervisors

indicated that the clients at TW often presented with complex medical histories in addition

to their primary reason for attending the chiropractic clinic. The literature suggests that

older people and those with a lower household income have higher rates of chronic

conditions and multimorbidity (three chronic diseases or more) (Roberts et al., 2015). All

clients attending TW experienced disadvantage to some degree in their lives and the

majority of those who participated in this study were over the age of 50. The age of clients

and the disadvantage they experienced could account for the high rates of chronic

conditions experienced by those who attended the chiropractic clinic at TW.

Globally, neck and low back pain are ranked fourth as the leading causes of

disability-adjusted life years (DALYs) (Hurwitz et al., 2018). The MYMOP asked the client to

nominate up to two symptoms associated with their health problem that most affected

them. These responses were coded into different regions of the body that were affected.

The most commonly coded body region of clients’ reported symptoms was that their

117

symptom affected more than one body region with the second most common area and

condition being that of neck pain. Symptoms affecting the low back only accounted for 8.1%

of clients. However, 88% of clients were coded as having a symptom affecting more than

one body region, with some of these areas being the low back. When including those who

had a symptom affecting more than one body area, including the low back, 29.7% of

baseline participants experienced symptoms affecting their low back region.

It is common for patients experiencing chronic MSK conditions to have long-term

prescriptions of opioids and over prescription of these opioids is common (Ashaye et al.,

2018). Opioid over prescription for chronic non-cancer pain has become commonplace in

recent years, despite guidelines recommending otherwise (Volkow & McLellan, 2016). The

study at TW revealed that only 24.3% of clients were taking any form of medication to treat

their presenting MSK symptoms. Compared with other studies, this figure is considerably

low. One investigation found that in 76.9% of cases where patients experienced chronic low

back pain, they had long-term prescriptions of opioids (Shmagel et al., 2018). Measure

Yourself Medical Outcome Profile data indicated that the majority of clients attending TW

also preferred to avoid medication when possible and if they were taking medication

responded that reducing usage was of importance to them. Interview findings under theme

four (The Cost of Being Disadvantaged) suggested that clients preferred to avoid medication

to treat their symptoms primarily because they found the medications to be ineffective at

treating their symptoms.

Health and Wellbeing

Data from Patient Reported Outcome Measures (PROMs) and interviews indicated

that those attending TW for chiropractic care experienced improved levels of both health

118

and wellbeing after short treatment schedules of four visits or two weeks’ care. The

literature suggests that when caring for those who have complex care needs, that a

combination of healthcare and social care is more appropriate than purely traditional

healthcare services that focus mainly on the condition and symptoms of the patient (Kuluski

et al., 2017). Interview data collected from clients in this investigation indicated within the

first theme (A Patient-Centred Approach for Clients) that because the chiropractic clinic was

embedded within TW it allowed for more social interaction between clients, practitioners,

staff and supervisors. Observational data suggested that this social interaction took place

before and after the clients’ appointments and interviews reported that meaningful

relationships were formed during the clients’ appointments. The domain for “Anxiety and

Depression” in the EQ-5D-5L showed no statistically significant improvement between

baseline and follow-up. The clients in this study experienced high rates of chronic conditions

and the literature suggests that those who experience chronic conditions also have much

higher rates of mental health disorders (Rayner et al., 2016). It may be unreasonable to

assume that after such a short treatment schedule to see significant change regarding

mental health. However, clients stated in their interviews that they found attending the

chiropractic clinic at TW to be beneficial for their mental health and that it may have offered

hope for their future. The lack of significance in the EQ-5D-5L domain of “Anxiety and

Depression” may be accounted for in other outcomes of the PROMs used in the study.

Measure Yourself Medical Outcome Profile scores that measure overall health and

wellbeing of the client showed significant improvement, as did index scores from the EQ-5D-

5L. It is possible that follow-up times were too short to show significant change in the

“Anxiety and Depression” domain. It is important to acknowledge that mental health and

wellbeing can be considered as two different constructs and while the scores for “Anxiety

119

and Depression” did not improve, wellbeing scores did demonstrate positive changes. This

might indicate that as a result of care, clients were better able to cope with their chronic

conditions. Another factor that may account for interview responses regarding improved

mental health might be that clients who were interviewed did not complete PROMs as they

were clients who had been visiting the clinic at TW for longer periods of time.

The profile score of the MYMOP can be used as an indicator of general health and

wellbeing of the respondent. Measure Yourself Medical Outcome Profile baseline scores

were compared with another study conducted in an RMIT University chiropractic teaching

clinic (Polus et al., 2011). Baseline profile scores at TW were 3.95 while those in the 2011

study were 3.4. This indicates that those attending TW experienced poorer levels of general

health and wellbeing. This may have been due to the older age of clients attending TW

(Brett et al., 2014; Prince et al., 2015), as the 2011 study had a more even distribution

between age groups (Brett et al., 2014; Prince et al., 2015). Another factor that could

account for these higher baseline profile scores could be the disadvantage status of those

attending TW, as TW chiropractic clinic only saw clients who were experiencing

disadvantage.

Baseline scores from the clients’ EQ-5D-5L Visual Analogue Scale (EQVAS) were also

compared with population normative data of the South Australian population (McCaffrey et

al., 2016). It was found that there was a highly statistically significant difference between

McCaffrey et al.’s study and the study conducted at TW. Those attending the clinic at TW

reported much lower scores on the EQVAS that measures how good or bad the

respondent’s health is on that day. These significantly lower scores from the EQVAS

indicated that those attending TW for chiropractic care had poorer levels of health when

120

compared to the population normative data of the South Australian population. Interview

data may have assisted in interpreting these findings. Under the second theme (Clients are

Complex), clients and their student practitioners discussed how the clients experienced

chronic conditions as well as associated comorbidities that impacted upon their health.

Clients described how their condition could have impacted upon their ability to participate

in activities that were of importance to them. Prevalence of chronic MSK conditions such as

chronic back pain increase with age and in groups experiencing disadvantage (González-

Chica et al., 2018). González-Chica et al.’s investigation found that lower socio-economic

groups, ex-smokers, veterans and people of Indigenous backgrounds all experience higher

rates of chronic back pain as opposed to the general population. The older age,

disadvantage and high rates of chronicity experienced by clients attending the TW for care

may account for why this population experienced poorer levels of baseline health and

wellbeing.

Improvement in health and wellbeing may also be related to the phenomenon

known as therapeutic touch (TT). Within nursing literature TT is defined as a modality that

employs the use of the hands for the conscious effort of benefit for the patient (Daley, 1997;

Meehan, 1998). While the exact mechanism of TT is unknown, the literature reports some

positive effect on patient outcomes. A study investigating the effects of TT on adults

experiencing back pain in a neurological ward found that PROM scores of the intervention

group showed a significant improvement when compared with a control group (Mueller et

al., 2019). In a similar study, investigators added a “preparatory phase” to massage therapy,

where the physician applied TT to the affected area of chronic low back pain patients. This

study found that patients who experienced this “preparatory phase” in addition to their

massage therapy, experienced significant improvement in pain compared to a control

121

group, as recorded by PROMs (Zangrando et al., 2017). Another study investigated the

effects of TT on patients with cancer. This study reported that cancer patients who received

TT had improvements in health status (Tabatabaee et al., 2016). While it was not the aim of

this study to investigate the impact of TT on clients attending the clinic at TW, it is still

important to acknowledge this as a possible contributing factor when accounting for

improvements in PROM scores of health and wellbeing.

Enablement

Patient enablement is closely related to empowerment of the patient, which has

been defined as their understanding and ability to cope with their condition (Hudon et al.,

2011). Enablement can also be an important outcome of patient-centred care PCC (Howie et

al., 1998). Those living with multiple chronic conditions, regardless of whether they live in

socioeconomically affluent or deprived areas, tend to have considerably reduced

enablement. Emotional distress can further negatively impact upon the enablement scores,

particularly in those living in more deprived areas (Mercer et al., 2012). This study at TW

found that favourable levels of client enablement were captured by the Patient Enablement

Instrument in all six areas. This was again reflected within the interview data under the third

theme (Trust), where participants from all groups stated how they found genuine

relationships were formed between the student practitioners and their clients. Clients

discussed how they liked to give feedback to their practitioners and that they found them

“affable” indicating that their relationships were built on trust and understanding and that

they felt enabled enough to let students know how they felt their treatment was working

for them. The majority of clients described that the most improvement occurred in the PEI

category of “being able to help yourself”, with 88.2% of clients reporting improvement in

this area as a result of the care they received. This was again a finding in the interview data,

122

with clients discussing how they found the home exercise and advice they received from the

students to be useful in managing their conditions. In particular, when the students were

absent from TW during holiday breaks. Other notably high areas of enablement for clients

included being “able to understand your illness” and being “able to cope with your illness”,

with 82.3% of clients seeing some form of improvement in both areas. This suggests that

communication between the students and clients is of importance as they were more able

to understand their illness as a result of attending the chiropractic clinic. The importance of

practitioner-patient communication is well documented within the literature and an

important component of patient enablement (Ruberton et al., 2016). Studies have shown

that practitioner empathy, communication and managing patient expectations in a positive

manner can have significant, albeit small, effects on pain (Mistiaen et al., 2016). Empathy is

another important component of PCC and enablement of the patient. When practitioners

display empathy in their consultation it can result in the patient feeling relief, satisfaction

and trust with their practitioner. When empathy is lacking in the consultation it can result in

feelings of frustration and disappointment from the patient (Derksen et al., 2017). Managing

expectations is another aspect of care that client interviewees found to be of importance.

They discussed in their interviews how knowing what their condition was and how long it

may take to improve as being an important component when coping with their illness.

There were similar findings regarding managing expectations in the clients attending TW. A

staff member of TW discussed how for new clients they aimed to manage their expectations

for their first visit to avoid any surprises to the client that might upset them. Charles, a

client, discussed how he found it important for his expectations to be met as this allowed

him to better plan for the future. This led him to find suitable housing for the future for

when he expected his mobility at home to decrease.

123

The formation of genuine relationships is an aspect of PCC that is valued by the

patient (Hahn et al., 2017). A study investigating Australian chiropractic student attitudes

towards PCC was conducted in 2019 using an online survey and the outcome measure

known as the Patient-Practitioner-Outcome-Scale (PPOS) (Hammerich et al., 2019). This

study included responses from seven chiropractic education programs across the world with

a total of 1,858 respondents from student chiropractors throughout different year levels. It

was found that chiropractic student attitudes towards patient treatment leant towards a

patient-centred approach. It has also been documented within the literature that the

patient-practitioner relationship is an important aspect of PCC as it allows for

communication and, in turn, enablement for the patient (Kitson et al., 2013). Interview data

with clients at TW indicated that a patient-centred approach was of importance to them.

For example, client Robert discussed how he found authentic relationships to be an

important part of feeling as though he was not just being treated as a number. Similarly,

Susan, one of the clinical supervisors, stated how in order to form these meaningful

relationships that, “You’ve actually gotta step back and connect.” These comments suggest

that there is a tendency for students treating at TW to employ patient-centred aspects of

care, certainly in the aspect of patient-practitioner relationships. Interview findings and

observational data suggest that TW provided a unique setting for these relationships to

form and that they are not just limited to client-practitioner. Relationships between staff,

student, supervisors and other clients all appeared to be positive and allowed for a

welcoming atmosphere at TW.

Perceived discrimination from healthcare providers can occur in a number of

different groups including those living with disability, those with racially diverse

backgrounds and those of lower socioeconomic status (Moscoso-Porras & Alvarado, 2018;

124

Stepanikova & Oates, 2017). One study investigated reasons for discrimination amongst a

multiethnic sample of individuals and found that discrimination can occur for a number of

reasons including race or language barriers, factors related to the provider delivering care,

for example, dismissive attitudes of staff and finally, systemic factors that included income

status affecting an individual’s ability to access care (D’Anna et al., 2018). Another

investigation found discrimination to be a variable when explaining the link between

socioeconomic disadvantage and health (Fuller-Rowell et al., 2018). Interviews with clients

at TW indicated that some had experienced a certain level of discrimination when visiting

other healthcare providers. One client stated this was due to their previous medical

histories and that they found the attitude from staff was discriminatory as a result. Clients

revealed that they preferred to manage health issues by seeing student chiropractors at TW

rather than consult their general practitioner. It is important to note that not all clients had

experienced discrimination from their other healthcare providers in the past and that all

respondents stated they would seek medical care for their other health concerns if

necessary. Most clients discussed how the care they received at TW was mostly separate

from care they received elsewhere. However, they found that the care they received at TW

and elsewhere were complementary as they shared a common goal of maintaining their

health. Norman, a client, spoke about how he avoided his general practitioner unless

necessary because of previously experienced discrimination. This kind of avoidance

behaviour has also been documented in Australians living with disability and comorbidities.

A recent investigation found that while governments have policies and procedures in place,

some people living with disability and comorbidities still continue to experience

discrimination from their healthcare providers and as a result can resort to avoidance

behaviours (Temple et al., 2018). The clinic at TW may offer an important gathering space

125

without discrimination where clients can receive judgment-free healthcare.

Under the third theme (Trust), interview participants discussed how their access to

healthcare services like chiropractic was difficult for them due to financial constraints. The

literature suggests that people may avoid or delay access to healthcare based on factors

such as cost, even when insured (Smith et al., 2018). Interview findings under theme four

(The Cost of Being Disadvantaged) suggest that those attending TW for healthcare reasons

do so because access to privatised services including chiropractic are not available or

affordable in other settings. Clients discussed how they felt this type of care should be

available to everyone regardless of their income. This was reinforced by staff member

Nicole who discussed how the clients would have no access to this type of care elsewhere.

This is important to note as the literature states that chiropractic can have a significant

impact on physical functioning and health related quality of life in conditions such as chronic

low back and neck pain (Hays et al., 2019). The existing opportunity for those attending TW

to receive care from the RMIT chiropractic students removed the financial barrier to

receiving care for their MSK complaints and better enabled them to manage their health

problems without the financial repercussions.

Physical Mobility and Function

Social isolation and loneliness have been linked to a decrease in physical mobility,

particularly gait speed, in older adults and these effects are amplified with increased

socioeconomic disadvantage (Shankar et al., 2017). Emerging from the interview data,

clients discussed how they experienced improved physical mobility and function to

participate in their activities of daily living. Client Charles recalled how important it was for

him as it allowed him to complete basic tasks like going to the grocery store. However, the

126

domain of “Mobility” in the EQ-5D-5L did not show any significant change pre- and post-

exposure to chiropractic care, nor did the domain of “Anxiety and Depression”. This may be

due to the short follow-up period used in this study. It may also have been because clients

who participated in interviews were not new clients and had been attending chiropractic at

TW for a longer period. Interview participants did, however, discuss the importance of the

social aspects they experienced as a result of attending TW. It was noted amongst those not

participating in the study that many clients of TW attended for reasons other than to receive

care at the chiropractic clinic as such. Clients discussed how they had formed friendships as

a result of attending TW and that it also opened up opportunities for them to socialise

outside of this setting. These outcomes indicate that because TW offered both a social space

and a place to receive care, that the two aspects complemented each other.

Activities of daily living become more difficult to participate in within older

populations who experience widespread and intense pain levels (Dueñas et al., 2019). The

Measure Yourself Medical Outcome Profile had all participants nominate an activity that

was important to them and was being affected by their primary symptom. Nearly all

responses were related to either mobility or other activities that were important to the

client. Mobility, specifically being able to ambulate and transfer, are considered important

physical ADLs (Mlinac & Feng, 2016). The activity of simply “walking” was the most

nominated activity by clients. The improvement of mobility was a key finding in the

interview data and should be considered as an important outcome to the clients attending

TW. Measure Yourself Medical Outcome Profile scores saw significant improvement at

follow-up for the clients in this study. While this change in score is not directly related to the

activity nominated by the client, it might be reasonable that these scores did not improve

alongside other aspects of the MYMOP such as wellbeing and symptom severity levels. The

127

EQ-5D-5L domain for “Mobility” saw no significant change, which may be consistent with

this assumption. An explanation for this may also be the short follow-up time with clients.

There may not have been enough time between the initial consultation and follow-up to

detect a significant change in the EQ-5D-5L domain of “Mobility”. Despite this, interview

findings under the fifth theme (Looking to the Future) suggested that all clients were

hopeful regarding the future of their health pertaining to their primary reason for attending

TW.

Limitations

This study had several limitations. Follow-up with clients only occurred after a short

timeframe and there was no further follow-up. This makes it difficult to determine if the

benefits of attending the clinic are long-lasting or only temporary, although interview data

suggests that benefits are long-lasting to some extent. It is important not to speculate that

benefits experienced by clients were a direct result of chiropractic treatment. This was an

observational study as distinct from an interventional study. Other factors may have

influenced these outcomes such as natural history of a condition, acute exacerbations of a

chronic condition or the influence of TT, as mentioned previously. There may have been

some unavoidable inherent bias by respondents as there could have been an expectation to

provide favourable responses in a setting they clearly appreciated, depended upon and

where they felt welcomed. Another limitation is that client interviewees were not new

clients to the clinic, interview findings suggest they were long-standing clients who

continued to return to the clinic due to the benefit they personally received. This may

account for some discrepancies between the quantitative and qualitative findings. However,

128

this did allow for a deeper exploration into the aspects of care, such as a sense of

community and the setting, as these clients had greater opportunity to experience this.

Recommendations for Future Research

It was found throughout the course of data collection that those who attend TW

were often a transient population. This meant that many clients did not return for

subsequent visits and were unable to complete follow-up outcome measures as a result.

Future research should therefore allow more time for data collection to take place. In order

to increase sample size and data collection, it is also recommended that the inclusion

criteria be expanded. In this instance TW offered other services such as osteopathy and

traditional Chinese medicine. To include clients who used these services would have

resulted in a larger data sample. Similarly, if there are other settings that offer comparable

services to those in need it would, where possible, be advisable to include them in data

collection. This would allow for a comparison between settings and to see if outcomes may

differ as a result. This study was only able to obtain interviews from existing clients at TW

and while they were able to provide rich answers, it would also be valuable to see how new

clients experience TW and to see if these responses differed.

Conclusion

The findings of this investigation indicated that TW as a setting, and the chiropractic

clinic operating within it, provides a nurturing space for those living in disadvantage to

experience meaningful physical and psychosocial health outcomes. The research design

used in this study was based on WSR (Ritenbaugh et al., 2003) and consisted of utilising a

combination of PROMs and qualitative research techniques. This allowed for a suitable way

to examine the outcomes of those attending TW. The use of Bronfenbrenner’s ecological

129

systems theory enabled an appropriate analysis of interview data as health outcomes are

quite often dependent on factors such as social, community and cultural contexts

(Bronfenbrenner, 1979). Outcomes important to the clients of TW varied on an individual

basis, although analysis assisted in identifying codes and themes surrounding these

outcomes. Genuine relationships with their practitioners, the maintenance and

improvement of their symptoms and benefits associated with mental health were all

outcomes that were identified as important to the client. Patient-reported outcome

measure data supported these findings, with improved scores of wellbeing noted in MYMOP

scores and in the EQ-5D-5L index scores. A key component of enablement requires a healthy

therapeutic relationship between the practitioner and patient (Mercer et al., 2008). Given

the high level of enablement experienced by clients of TW, as demonstrated by PEI scores, it

is reasonable to assume that the genuine relationships experienced by interview

participants are also occurring between new clients to the clinic and their student

practitioners. These outcomes are consistent with the literature regarding intended benefits

of PCC and outcomes that matter to the patient (Ocloo et al., 2020; Ogden et al., 2017). The

Wellington provided a setting in which these relationships could form, even when the client

was not there for the purpose of treatment. Data from the PROM indicated that the clients

attending TW were older and experienced high rates of chronic conditions. This is consistent

with the literature that older people experience higher rates of chronic conditions (Blyth &

Noguchi, 2017). Outcomes related to PROM data indicated that improved levels of health

and wellbeing were also experienced by those attending TW for chiropractic.

Patient-centred care has been linked with improved outcomes for patients

(Poochikian-Sarkissian et al., 2010) and has been defined within the literature as having

three main components. These components consist of: the relationship between the

130

practitioner and patient; allowing the patient to be a part of the decision making process

surrounding their healthcare and treatment; and the setting in which the care is delivered

(Kitson et al., 2013). This study’s findings demonstrate that these three components exist at

the chiropractic clinic located at TW. Patient Enablement Instrument scores suggest that as

a result of their care clients feel more enabled. Interview data suggest that student

practitioners try different approaches to care and that they allow clients to have input as to

what modalities of treatment are chosen based on personal preferences. These positive

enablement scores and interview findings surrounding the relationships between student

practitioners and clients also suggest that the therapeutic relationships formed between

them are genuine and built on trust.

Finally, TW as a setting provides a gathering space which enables clients to interact

in a supportive, welcoming setting as an integral part of the treatment they receive. Beyond

the reported improvements in physical mobility and reduction in pain it also enables the

development of friendships and nurtures a sense of belonging and community. All of the

groups interviewed as part of this study expressed how important TW is as a place for those

experiencing disadvantage as it offers a safe space with many resources, including

chiropractic care. In the words of many of The Wellington`s clients, “This type of care should

be available to everyone regardless of their income.”

131

Bibliography

Agborsangaya, C. B., Lahtinen, M., Cooke, T., & Johnson, J. A. (2014). Comparing the EQ-5D

3L and 5L: measurement properties and association with chronic conditions and

multimorbidity in the general population. Health and Quality of Life Outcomes, 12(1),

74.

Ahmed, S., Mayo, N. E., Wood-Dauphinee, S., Hanley, J. A., & Cohen, S. R. (2005). Using the

patient generated index to evaluate response shift post-stroke. Quality of Life

Research, 14(10), 2247-2257.

Ahpra. (2020, 2020). Regulating Australia's chiropractic practitioners. Retrieved from

https://www.chiropracticboard.gov.au/

AIHW. (2019, 10/09/2019). International comparison of welfare data. Retrieved from

https://www.aihw.gov.au/reports/australias-welfare/international-comparisons-of-

welfare-data

Åkesson, K., Ekvall Hansson, E., Sundén, A., & Stigmar, K. (2018). The patient enablement

instrument – a validation study. Osteoarthritis and Cartilage, 26, S275-S276.

doi:https://doi.org/10.1016/j.joca.2018.02.559

Alcantara, J., Nazarenko, A. L., Ohm, J., & Alcantara, J. (2018). The Use of the Patient

Reported Outcomes Measurement Information System and the RAND VSQ9 to

Measure the Quality of Life and Visit-Specific Satisfaction of Pregnant Patients Under

Chiropractic Care Utilizing the Webster Technique. The Journal of Alternative and

Complementary Medicine, 24(1), 90-98.

Allen, J. M., Wright, S., Cranston, N., Watson, J., Beswick, K., & Hay, I. (2018). Raising levels

of school student engagement and retention in rural, regional and disadvantaged

areas: is it a lost cause? International Journal of Inclusive Education, 22(4), 409-425.

132

Allen, L., Williams, J., Townsend, N., Mikkelsen, B., Roberts, N., Foster, C., &

Wickramasinghe, K. (2017). Socioeconomic status and non-communicable disease

behavioural risk factors in low-income and lower-middle-income countries: a

systematic review. The Lancet Global Health, 5(3), e277-e289.

Ascef, B. d. O., Haddad, J. P. A., Álvares, J., Guerra Junior, A. A., Costa, E. A., Acurcio, F. d. A.,

. . . Soeiro, O. M. (2017). Health-related quality of life of patients of Brazilian primary

health care. Revista de saude publica, 51, 22s.

Ashaye, T., Hounsome, N., Carnes, D., Taylor, S., Homer, K., Eldridge, S., . . . Underwood, M.

(2018). The over-prescription of opioids for chronic musculoskeletal pain in UK

primary care: results from a cohort analysis of the COPERS trial.

Austevoll, I. M., Gjestad, R., Grotle, M., Solberg, T., Brox, J. I., Hermansen, E., . . . Hellum, C.

(2019). Follow-up score, change score or percentage change score for determining

clinical important outcome following surgery? An observational study from the

Norwegian registry for Spine surgery evaluating patient reported outcome measures

in lumbar spinal stenosis and lumbar degenerative spondylolisthesis. BMC

musculoskeletal disorders, 20(1), 31.

Barnett, K., Mercer, S. W., Norbury, M., Watt, G., Wyke, S., & Guthrie, B. (2012).

Epidemiology of multimorbidity and implications for health care, research, and

medical education: a cross-sectional study. The Lancet, 380(9836), 37-43.

doi:10.1016/S0140-6736(12)60240-2

Bauman, A. E., Fardy, H. J., & Harris, P. G. (2003). Getting it right: why bother with patient‐

centred care? Medical Journal of Australia, 179(5), 253-256.

Bausewein, C., Daveson, B., Benalia, H., Simon, S., & Higginson, I. (2011). Outcome

measurement in palliative care: the essentials. PRISMA, 1-48.

133

Bilbao, A., García-Pérez, L., Arenaza, J. C., García, I., Ariza-Cardiel, G., Trujillo-Martín, E., . . .

Martín-Fernández, J. (2018). Psychometric properties of the EQ-5D-5L in patients

with hip or knee osteoarthritis: reliability, validity and responsiveness. Quality of Life

Research, 1-12.

Blyth, F. M., & Noguchi, N. (2017). Chronic musculoskeletal pain and its impact on older

people. Best practice & research clinical rheumatology, 31(2), 160-168.

Bradley, C. (2000). The 12-Item Well-Being Questionnaire: origins, current stage of

development, and availability. Diabetes care, 23(6), 875-875.

Braun, V., & Clarke, V. (2012). Thematic analysis.

Brett, T., Arnold-Reed, D. E., Troeung, L., Bulsara, M. K., Williams, A., & Moorhead, R. G.

(2014). Multimorbidity in a marginalised, street-health Australian population: a

retrospective cohort study. BMJ open, 4(8), e005461.

Bronfenbrenner, U. (1979). The ecology of human development: Harvard university press.

Bronfenbrenner, U. (1994). Ecological models of human development. International

encyclopedia of education, 3(2), 37-43.

Brooks, R. (1996). EuroQol: the current state of play. Health Policy, 37(1), 53-72.

doi:https://doi.org/10.1016/0168-8510(96)00822-6

Calvert, M. J., & Freemantle, N. (2003). Use of health‐related quality of life in prescribing

research. Part 1: why evaluate health‐related quality of life? Journal of clinical

pharmacy and therapeutics, 28(6), 513-521.

Cassidy, C. (1994). Unraveling the ball of string: Reality, paradigms, and the study of

alternative medicine. Advances, 10(1), 5-31.

134

Cassidy, C. (1998a). Chinese medicine users in the United States part I: Utilization,

satisfaction, medical plurality. The Journal of Alternative and Complementary

Medicine, 4(1), 17-27.

Cassidy, C. (1998b). Chinese medicine users in the United States part II: preferred aspects of

care. The Journal of Alternative and Complementary Medicine, 4(2), 189-202.

Chamberlain, A. M., Rutten, L. J. F., Wilson, P. M., Fan, C., Boyd, C. M., Jacobson, D. J., . . .

Sauver, J. L. S. (2020). Neighborhood socioeconomic disadvantage is associated with

multimorbidity in a geographically-defined community. BMC public health, 20(1), 1-

10.

Chen, J., Ou, L., & Hollis, S. J. (2013). A systematic review of the impact of routine collection

of patient reported outcome measures on patients, providers and health

organisations in an oncologic setting. BMC health services research, 13(1), 211.

Cheung, P. W. H., Wong, C. K. H., Samartzis, D., Luk, K. D. K., Lam, C. L. K., Cheung, K. M. C.,

& Cheung, J. P. Y. (2016). Psychometric validation of the EuroQoL 5-Dimension 5-

Level (EQ-5D-5L) in Chinese patients with adolescent idiopathic scoliosis. Scoliosis

and spinal disorders, 11(1), 19.

Clarke, S., Ells, C., Thombs, B. D., & Clarke, D. (2017). Defining elements of patient-centered

care for therapeutic relationships: A literature review of common themes. European

journal for person centered healthcare, 5(3), 362-372.

Clohesy, N., & Schneiders, A. (2018). A preliminary investigation examining patient reported

outcome measures for low back pain and utilisation amongst chiropractors in

Australia: facilitators and barriers to clinical implementation. Chiropractic & manual

therapies, 26(1), 38.

135

Cooper, K., Smith, B. H., & Hancock, E. (2008). Patient-centredness in physiotherapy from

the perspective of the chronic low back pain patient. Physiotherapy, 94(3), 244-252.

Crawford, B. F., Snyder, K. E., & Adelson, J. L. (2019). Exploring obstacles faced by gifted

minority students through Bronfenbrenner’s bioecological systems theory. High

Ability Studies, 1-32.

Crawford, P., Penzien, D. B., & Coeytaux, R. (2017). Reduction in pain medication

prescriptions and self-reported outcomes associated with acupuncture in a military

patient population. Medical acupuncture, 29(4), 229-231.

Cruz, E. B., Moore, A., & Cross, V. (2012). Clinical reasoning and patient-centred care in

musculoskeletal physiotherapy in Portugal – A qualitative study. Manual therapy,

17(3), 246-250. doi:https://doi.org/10.1016/j.math.2012.02.007

D’Anna, L. H., Hansen, M., Mull, B., Canjura, C., Lee, E., & Sumstine, S. (2018). Social

Discrimination and Health Care: A Multidimensional Framework of Experiences

among a Low-Income Multiethnic Sample. Social work in public health, 33(3), 187-

201.

Daley, B. (1997). Therapeutic touch, nursing practice and contemporary cutaneous wound

healing research. Journal of advanced nursing, 25(6), 1123-1132. doi:10.1046/j.1365-

2648.1997.19970251123.x

Delaney, L. J. (2018). Patient-centred care as an approach to improving health care in

Australia. Collegian, 25(1), 119-123.

Derksen, F., Hartman, T. C. O., van Dijk, A., Plouvier, A., Bensing, J., & Lagro-Janssen, A.

(2017). Consequences of the presence and absence of empathy during consultations

in primary care: A focus group study with patients. Patient education and counseling,

100(5), 987-993.

136

Deshpande, P. R., Rajan, S., Sudeepthi, B. L., & Nazir, C. A. (2011). Patient-reported

outcomes: a new era in clinical research. Perspectives in clinical research, 2(4), 137.

Devlin, N. J., & Appleby, J. (2010). Getting the most out of PROMS. Putting health outcomes

at the heart of NHS decision-making. London: The King's Fund.

Diez-Roux, A. V., Northridge, M. E., Morabia, A., Bassett, M. T., & Shea, S. (1999). Prevalence

and social correlates of cardiovascular disease risk factors in Harlem. American

journal of public health, 89(3), 302-307.

Doyle, K., Hungerford, C., & Cleary, M. (2017). Study of intra‐racial exclusion within

Australian Indigenous communities using eco‐maps. International journal of mental

health nursing, 26(2), 129-141.

Dueñas, M., Salazar, A., de Sola, H., & Failde, I. (2019). Limitations in Activities of Daily Living

in People With Chronic Pain: Identification of Groups Using Clusters Analysis. Pain

Practice.

Dyer, M. T., Goldsmith, K. A., Sharples, L. S., & Buxton, M. J. (2010). A review of health

utilities using the EQ-5D in studies of cardiovascular disease. Health and Quality of

Life Outcomes, 8(1), 13.

Enthoven, P., Peolsson, A., Ludvigsson, M. L., Wibault, J., Peterson, G., & Öberg, B. (2019).

Validity, Internal Consistency and Self-Rated Change of the Patient Enablement

Instrument in Patients with Chronic Musculoskeletal Pain. Journal of rehabilitation

medicine, 51(8), 587-597.

EuroQol Research Foundation. (2020, 2020). Choosing a value set. Retrieved from

https://euroqol.org/eq-5d-instruments/eq-5d-3l-about/valuation/choosing-a-value-

set/

137

Fennelly, O., Blake, C., Desmeules, F., Stokes, D., & Cunningham, C. (2018). Patient‐reported

outcome measures in advanced musculoskeletal physiotherapy practice: a

systematic review. Musculoskeletal Care, 16(1), 188-208.

Frances, S., Yip, B. H., Kung, K., Fung, C. S., Wong, C. K., Lam, A. T., . . . Wong, S. Y. (2015).

The association of types of training and practice settings with doctors’ empathy and

patient enablement among patients with chronic illness in Hong Kong. PloS one,

10(12), e0144492.

Fries, J. F. (1983a). The assessment of disability: from first to future principles. British journal

of rheumatology, 22(3 Suppl), 48-58.

Fries, J. F. (1983b). Toward an Understanding of Patient Outcome Measurement. Arthritis &

Rheumatism, 26(6), 697-704. doi:10.1002/art.1780260601

Frost, J., Currie, M. J., Cruickshank, M., & Northam, H. (2018). Using the lens of enablement

to explore patients’ experiences of Nurse Practitioner care in the Primary Health

Care setting. Collegian, 25(2), 193-199.

Fuller-Rowell, T. E., Curtis, D. S., Chae, D. H., & Ryff, C. D. (2018). Longitudinal health

consequences of socioeconomic disadvantage: Examining perceived discrimination

as a mediator. Health psychology, 37(5), 491.

Garcia-Garcia, G., & Jha, V. (2015). CKD in disadvantaged populations. In: BioMed Central.

Gemmell, H. A., & Jacobson, B. H. (1995). The immediate effect of activator vs. meric

adjustment on acute low back pain: a randomized controlled trial. Journal of

manipulative and physiological therapeutics, 18(7), 453-456.

Gilbody, S. M., House, A., & Sheldon, T. (2003). Outcomes measurement in psychiatry: a

critical review of outcomes measurement in psychiatric research and practice: NHS

Centre for Reviews and Dissemination.

138

Glaser, B. G. (1965). The constant comparative method of qualitative analysis. Social

problems, 12(4), 436-445.

González-Chica, D. A., Vanlint, S., Hoon, E., & Stocks, N. (2018). Epidemiology of arthritis,

chronic back pain, gout, osteoporosis, spondyloarthropathies and rheumatoid

arthritis among 1.5 million patients in Australian general practice: NPS MedicineWise

MedicineInsight dataset. BMC musculoskeletal disorders, 19(1), 20.

Goss, C. H., Rubenfeld, G. D., Park, D. R., Sherbin, V. L., Goodman, M. S., & Root, R. K. (2003).

Cost and incidence of social comorbidities in low-risk patients with community-

acquired pneumonia admitted to a public hospital. Chest, 124(6), 2148-2155.

Goz, V., Baker, J. F., & Brodke, D. S. (2017). Patient-Reported Outcome Measures Available

for Adult Lumbar Scoliosis. In Adult Lumbar Scoliosis (pp. 31-47): Springer.

Guyatt, G. H., Joan Eagle, D., Sackett, B., Willan, A., Griffith, L., McIlroy, W., . . . Turpie, I.

(1993). Measuring quality of life in the frail elderly. Journal of clinical epidemiology,

46(12), 1433-1444. doi:https://doi.org/10.1016/0895-4356(93)90143-O

Hahn, D. L., Hoffmann, A. E., Felzien, M., LeMaster, J. W., Xu, J., & Fagnan, L. J. (2017).

Tokenism in patient engagement. Family Practice, 34(3), 290-295.

Hammerich, K., Stuber, K., Hogg-Johnson, S., Abbas, A., Harris, M., Lauridsen, H. H., . . .

Morales, V. (2019). Assessing attitudes of patient-centred care among students in

international chiropractic educational programs: a cross-sectional survey.

Chiropractic & manual therapies, 27(1), 46.

Hammersley, M., & Atkinson, P. (1995). Ethnography: Principles and Practice (London and

New York, Routledge).

139

Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., . . . Sieper,

J. (2018). What low back pain is and why we need to pay attention. The Lancet,

391(10137), 2356-2367.

Hays, R. D., Spritzer, K. L., Sherbourne, C. D., Ryan, G. W., & Coulter, I. D. (2019). Group and

individual-level change on health-related quality of life in chiropractic patients with

chronic low back or neck pain. Spine, 44(9), 647-651.

Haywood, K. L., Garratt, A. M., Dziedzic, K., & Dawes, P. T. (2003). Patient centered

assessment of ankylosing spondylitis-specific health related quality of life: evaluation

of the Patient Generated Index. The Journal of Rheumatology, 30(4), 764-773.

Herdman, M., Gudex, C., Lloyd, A., Janssen, M., Kind, P., Parkin, D., . . . Badia, X. (2011).

Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-

5L). Quality of Life Research, 20(10), 1727-1736.

Hermann, K., Kraus, K., Herrmann, K., & Joos, S. (2014). A brief patient-reported outcome

instrument for primary care: German translation and validation of the Measure

Yourself Medical Outcome Profile (MYMOP). Health and Quality of Life Outcomes,

12(1), 112-112. doi:10.1186/s12955-014-0112-5

Holmes, M. M., Lewith, G., Newell, D., Field, J., & Bishop, F. L. (2017). The impact of patient-

reported outcome measures in clinical practice for pain: a systematic review. Quality

of Life Research, 26(2), 245-257.

Howie, J., Heaney, D. J., & Maxwell, M. (1997). Measuring quality in general practice. Pilot

study of a needs, process and outcome measure. Occasional paper (Royal College of

General Practitioners)(75), i-32.

140

Howie, J., Heaney, D. J., Maxwell, M., & Walker, J. J. (1998). A comparison of a Patient

Enablement Instrument (PEI) against two established satisfaction scales as an

outcome measure of primary care consultations. Family Practice, 15(2), 165-171.

Huang, W., Yang, J., Liu, Y., Liu, C., Zhang, X., Fu, W., . . . Liu, G. (2018). Assessing health-

related quality of life of patients with colorectal cancer using EQ-5D-5L: a cross-

sectional study in Heilongjiang of China. BMJ open, 8(12).

Hudon, C., St‐Cyr Tribble, D., Bravo, G., & Poitras, M. E. (2011). Enablement in health care

context: a concept analysis. Journal of evaluation in clinical practice, 17(1), 143-149.

Hurwitz, E. L., Randhawa, K., Yu, H., Côté, P., & Haldeman, S. (2018). The Global Spine Care

Initiative: a summary of the global burden of low back and neck pain studies.

European spine journal, 27(6), 796-801.

Ijaz, N., Rioux, J., Elder, C., & Weeks, J. (2019). Whole systems research methods in health

care: A scoping review. The Journal of Alternative and Complementary Medicine,

25(S1), S21-S51.

Janssen, M., Birnie, E., & Bonsel, G. (2008). Quantification of the level descriptors for the

standard EQ-5D three-level system and a five-level version according to two

methods. Quality of Life Research, 17(3), 463-473.

Jarosz, B. S. (2010). Chiropractic treatment of chronic patellar tendinopathy in a professional

basketball player: a case report. Chiropractic Journal of Australia, 40(1), 3.

Kaarlola, A., Pettilä, V., & Kekki, P. (2004). Performance of two measures of general health-

related quality of life, the EQ-5D and the RAND-36 among critically ill patients.

Intensive Care Medicine, 30(12), 2245-2252.

Kassam, A.-A., Batten, T., Keenan, J., Williams, M., & Yarlagadda, R. (2018). MEASURE YOUR

MEDICAL OUTCOME PROFILE (MYMOP): CAN PATIENT-SPECIFIC OUTCOME

141

MEASURES BE USEFUL IN TOTAL HIP ARTHROPLASTY?: A VALIDATION STUDY. Paper

presented at the Orthopaedic Proceedings.

Katikireddi, S. V., Skivington, K., Leyland, A. H., Hunt, K., & Mercer, S. W. (2017). The

contribution of risk factors to socioeconomic inequalities in multimorbidity across

the lifecourse: a longitudinal analysis of the Twenty-07 cohort. BMC medicine, 15(1),

152.

Kendrick, T., El‐Gohary, M., Stuart, B., Gilbody, S., Churchill, R., Aiken, L., . . . de Jong, K.

(2016). Routine use of patient reported outcome measures (PROMs) for improving

treatment of common mental health disorders in adults. Cochrane Database of

Systematic Reviews(7).

Kinmonth, A. L., Woodcock, A., Griffin, S., Spiegal, N., & Campbell, M. J. (1998). Randomised

controlled trial of patient centred care of diabetes in general practice: impact on

current wellbeing and future disease risk. Bmj, 317(7167), 1202-1208.

Kitson, A., Marshall, A., Bassett, K., & Zeitz, K. (2013). What are the core elements of

patient‐centred care? A narrative review and synthesis of the literature from health

policy, medicine and nursing. Journal of advanced nursing, 69(1), 4-15.

Koc, M. (2018). Patient Reported Outcome Measures in Chronic Low Back Pain for

Assessment of Physical Disability. J Yoga Phys Ther, 8, 286.

Kuluski, K., Ho, J. W., Hans, P. K., & Nelson, M. L. (2017). Community care for people with

complex care needs: bridging the gap between health and social care. International

journal of integrated care, 17(4).

Kvåle, K., & Bondevik, M. (2008). What is important for patient centred care? A qualitative

study about the perceptions of patients with cancer. Scandinavian Journal of Caring

Sciences, 22(4), 582-589.

142

Kyte, D., Calvert, M., Van der Wees, P., Ten Hove, R., Tolan, S., & Hill, J. (2015). An

introduction to patient-reported outcome measures (PROMs) in physiotherapy.

Physiotherapy, 101(2), 119-125.

Little, P., Everitt, H., Williamson, I., Warner, G., Moore, M., Gould, C., . . . Payne, S. (2001).

Preferences of patients for patient centred approach to consultation in primary care:

observational study. Bmj, 322(7284), 468.

Loudon, K., Treweek, S., Sullivan, F., Donnan, P., Thorpe, K. E., & Zwarenstein, M. (2015). The

PRECIS-2 tool: designing trials that are fit for purpose. Bmj, 350, h2147.

MacPherson, H., Mercer, S. W., Scullion, T., & Thomas, K. J. (2003). Empathy, enablement,

and outcome: an exploratory study on acupuncture patients' perceptions. The

Journal of Alternative & Complementary Medicine, 9(6), 869-876.

Maigne, J.-Y., & Vautravers, P. (2003). Mechanism of action of spinal manipulative therapy.

Joint Bone Spine, 70(5), 336-341. doi:https://doi.org/10.1016/S1297-319X(03)00074-

Manning, R. F. (2017). Place-consciousness and Bronfenbrenner's ecological systems model:

A discussion of recurring issues that undermine the teaching of Indigenous histories

in New Zealand and Australian schools. The Australian Journal of Indigenous

Education, 46(2), 148-159.

Mayo, N. E., Brouillette, M.-J., Kuspinar, A., Moriello, C., Rodriguez, A. M., & Scott, S. (2017).

In support of an individualized approach to assessing quality of life: comparison

between Patient Generated Index and standardized measures across four health

conditions. Quality of Life Research, 26(3), 601-609.

143

McCaffrey, N., Kaambwa, B., Currow, D. C., & Ratcliffe, J. (2016). Health-related quality of

life measured using the EQ-5D–5L: South Australian population norms. Health and

Quality of Life Outcomes, 14(1), 133.

McClure, N. S., Al Sayah, F., Ohinmaa, A., & Johnson, J. A. (2018). Minimally important

difference of the EQ-5D-5L index score in adults with type 2 diabetes. Value in

Health, 21(9), 1090-1097.

Meadows, K. A. (2011). Patient-reported outcome measures: an overview. British journal of

community nursing, 16(3), 146-151.

Meehan, T. C. (1998). Therapeutic touch as a nursing intervention. Journal of advanced

nursing, 28(1), 117-125. doi:10.1046/j.1365-2648.1998.00771.x

Mercer, S. W., Jani, B. D., Maxwell, M., Wong, S. Y., & Watt, G. C. (2012). Patient

enablement requires physician empathy: a cross-sectional study of general practice

consultations in areas of high and low socioeconomic deprivation in Scotland. BMC

Family Practice, 13(1), 6.

Mercer, S. W., Neumann, M., Wirtz, M., Fitzpatrick, B., & Vojt, G. (2008). General

practitioner empathy, patient enablement, and patient-reported outcomes in

primary care in an area of high socio-economic deprivation in Scotland—a pilot

prospective study using structural equation modeling. Patient education and

counseling, 73(2), 240-245.

Mercer, S. W., & Reilly, D. (2004). A qualitative study of patient’s views on the consultation

at the Glasgow Homoeopathic Hospital, an NHS integrative complementary and

orthodox medical care unit. Patient education and counseling, 53(1), 13-18.

144

Mercer, S. W., Reilly, D., & Watt, G. C. (2002). The importance of empathy in the

enablement of patients attending the Glasgow Homoeopathic Hospital. Br J Gen

Pract, 52(484), 901-905.

Micha, R., Peñalvo, J. L., Cudhea, F., Imamura, F., Rehm, C. D., & Mozaffarian, D. (2017).

Association between dietary factors and mortality from heart disease, stroke, and

type 2 diabetes in the United States. Jama, 317(9), 912-924.

Mielck, A., Vogelmann, M., & Leidl, R. (2014). Health-related quality of life and

socioeconomic status: inequalities among adults with a chronic disease. Health and

Quality of Life Outcomes, 12(1), 58.

Miranda-Filho, A., Piñeros, M., & Bray, F. (2019). The descriptive epidemiology of lung

cancer and tobacco control: a global overview 2018. salud pública de méxico, 61(3),

219-229.

Mistiaen, P., Van Osch, M., Van Vliet, L., Howick, J., Bishop, F., Di Blasi, Z., . . . Van Dulmen, S.

(2016). The effect of patient–practitioner communication on pain: a systematic

review. European Journal of Pain, 20(5), 675-688.

Mitchell, J., & Bradley, C. (2001). Psychometric evaluation of the 12-item Well-being

Questionnaire for use with people with macular disease. Quality of Life Research,

10(5), 465-473.

Mlinac, M. E., & Feng, M. C. (2016). Assessment of activities of daily living, self-care, and

independence. Archives of Clinical Neuropsychology, 31(6), 506-516.

Moscoso-Porras, M. G., & Alvarado, G. F. (2018). Association between perceived

discrimination and healthcare–seeking behavior in people with a disability. Disability

and health journal, 11(1), 93-98.

145

Mueller, G., Palli, C., & Schumacher, P. (2019). The effect of therapeutic touch on back pain

in adults on a neurological unit: An experimental pilot study. Pain Management

Nursing, 20(1), 75-81.

Mulkins, A. L., & Verhoef, M. J. (2004). Supporting the transformative process: experiences

of cancer patients receiving integrative care. Integrative cancer therapies, 3(3), 230-

237.

Nelson, E. C., Eftimovska, E., Lind, C., Hager, A., Wasson, J. H., & Lindblad, S. (2015). Patient

reported outcome measures in practice. Bmj, 350, g7818.

Nicholas, M., Vlaeyen, J. W., Rief, W., Barke, A., Aziz, Q., Benoliel, R., . . . Goebel, A. (2019).

The IASP classification of chronic pain for ICD-11: chronic primary pain. Pain, 160(1),

28-37.

Nolan, C. M., Longworth, L., Lord, J., Canavan, J. L., Jones, S. E., Kon, S. S., & Man, W. D.

(2016). The EQ-5D-5L health status questionnaire in COPD: validity, responsiveness

and minimum important difference. Thorax, 71(6), 493-500.

Ocloo, J., Goodrich, J., Tanaka, H., Birchall-Searle, J., Dawson, D., & Farr, M. (2020). The

importance of power, context and agency in improving patient experience through a

patient and family centred care approach. Health Research Policy and Systems, 18(1),

10.

Ogden, K., Barr, J., & Greenfield, D. (2017). Determining requirements for patient-centred

care: a participatory concept mapping study. BMC health services research, 17(1),

780.

Orrock, P. J. (2016). The patient experience of osteopathic healthcare. Manual therapy, 22,

131-137. doi:https://doi.org/10.1016/j.math.2015.11.003

146

Paterson, C. (1996). Measuring outcomes in primary care: a patient generated measure,

MYMOP, compared with the SF-36 health survey. Bmj, 312(7037), 1016-1020.

Paterson, C. (2004). Seeking the patient's perspective: a qualitative assessment of EuroQol,

COOP-WONCA charts and MYMOP. Quality of Life Research, 13(5), 871-881.

Paterson, C., Baarts, C., Launsø, L., & Verhoef, M. J. (2009). Evaluating complex health

interventions: a critical analysis of the'outcomes' concept. BMC Complementary and

Alternative Medicine, 9(1), 18.

Paterson, C., & Britten, N. (2000). In Pursuit of Patient-Centred Outcomes: A Qualitative

Evaluation of the ‘Measure Yourself Medical Outcome Profile’. Journal of Health

Services Research & Policy, 5(1), 27-36. doi:10.1177/135581960000500108

Paterson, C., & Britten, N. (2003). Acupuncture for people with chronic illness: combining

qualitative and quantitative outcome assessment. The Journal of Alternative &

Complementary Medicine, 9(5), 671-681.

Paterson, C., & Dieppe, P. (2005). Characteristic and incidental (placebo) effects in complex

interventions such as acupuncture. BMJ: British Medical Journal, 330(7501), 1202.

Paterson, C., Langan, C., McKaig, G., Anderson, P., Maclaine, G., Rose, L., . . . Campbell, M.

(2000). Assessing patient outcomes in acute exacerbations of chronic bronchitis: the

measure your medical outcome profile (MYMOP), medical outcomes study 6-item

general health survey (MOS-6A) and EuroQol (EQ-5D). Quality of Life Research, 9(5),

521-527.

Paterson, C., Unwin, J., & Joire, D. (2010). Outcomes of traditional Chinese medicine

(traditional acupuncture) treatment for people with long-term conditions.

Complementary therapies in clinical practice, 16(1), 3-9.

147

Paterson, C., Vindigni, D., Polus, B., Browell, T., & Edgecombe, G. (2008). Evaluating a

massage therapy training and treatment programme in a remote Aboriginal

community. Complementary therapies in clinical practice, 14(3), 158-167.

doi:https://doi.org/10.1016/j.ctcp.2008.03.004

Patrick, R., Capetola, T., Townsend, M., & Hanna, L. (2011). Incorporating sustainability into

community-based healthcare practice. EcoHealth, 8(3), 277-289.

Payakachat, N., Ali, M. M., & Tilford, J. M. (2015). Can the EQ-5D detect meaningful change?

A systematic review. PharmacoEconomics, 33(11), 1137-1154.

Payne, R. A., Abel, G. A., Guthrie, B., & Mercer, S. W. (2013). The effect of physical

multimorbidity, mental health conditions and socioeconomic deprivation on

unplanned admissions to hospital: a retrospective cohort study. CMAJ : Canadian

Medical Association Journal, 185(5), E221-E228. doi:10.1503/cmaj.121349

Poleshuck, E., Perez‐Diaz, W., Wittink, M., ReQua, M., Harrington, A., Katz, J., . . . Cerulli, C.

(2019). Resilience in the midst of chaos: Socioecological model applied to women

with depressive symptoms and socioeconomic disadvantage. Journal of community

psychology, 47(5), 1000-1013.

Polus, B. I., Kimpton, A. J., & Walsh, M. J. (2011). Use of the measure your medical outcome

profile (MYMOP2) and W-BQ12 (Well-Being) outcomes measures to evaluate

chiropractic treatment: an observational study. Chiropractic & manual therapies,

19(1), 7.

Poochikian-Sarkissian, S., Sidani, S., Ferguson-Pare, M., & Doran, D. (2010). Examining the

relationship between patient-centred care and outcomes. Canadian Journal of

Neuroscience Nursing, 32(4), 14-21.

148

Prince, M. J., Wu, F., Guo, Y., Robledo, L. M. G., O'Donnell, M., Sullivan, R., & Yusuf, S.

(2015). The burden of disease in older people and implications for health policy and

practice. The Lancet, 385(9967), 549-562.

Rayner, L., Hotopf, M., Petkova, H., Matcham, F., Simpson, A., & McCracken, L. M. (2016).

Depression in patients with chronic pain attending a specialised pain treatment

centre: prevalence and impact on health care costs. Pain, 157(7), 1472.

Reid, R., Tulloch, H., Sigal, R., Kenny, G., Fortier, M., McDonnell, L., . . . Coyle, D. (2010).

Effects of aerobic exercise, resistance exercise or both, on patient-reported health

status and well-being in type 2 diabetes mellitus: a randomised trial. Diabetologia,

53(4), 632-640.

Rejas, J., & Albertos, F. (2017). EQ-5D-5L Utility Values For Spanish Patients With Painful

Chronic Osteoarthritis, Low-Back-Pain Or Cancer Pain. Value in Health, 20(9), A559.

Ritenbaugh, C., Verhoef, M. J., Fleishman, S., Boon, H., & Leis, A. (2003). Whole systems

research: A Discipline for studying complementary and alternative medicine.

Alternative Therapies in Health and Medicine, 9(4), 32-36.

Ritte, R. E., Lawton, P., Hughes, J. T., Barzi, F., Brown, A., Mills, P., . . . Maple-Brown, L.

(2020). Chronic kidney disease and socio-economic status: a cross sectional study.

Ethnicity & health, 25(1), 93-109.

Roberts, K., Rao, D., Bennett, T., Loukine, L., & Jayaraman, G. (2015). Prevalence and

patterns of chronic disease multimorbidity and associated determinants in Canada.

Health promotion and chronic disease prevention in Canada: research, policy and

practice, 35(6), 87.

149

Rööst, M., Zielinski, A., Petersson, C., & Strandberg, E. L. (2015). Reliability and applicability

of the Patient Enablement Instrument (PEI) in a Swedish general practice setting.

BMC Family Practice, 16, 31. doi:10.1186/s12875-015-0242-9

Ruberton, P. M., Huynh, H. P., Miller, T. A., Kruse, E., Chancellor, J., & Lyubomirsky, S.

(2016). The relationship between physician humility, physician–patient

communication, and patient health. Patient education and counseling, 99(7), 1138-

1145.

Ruta, D., & Garratt, A. (1996). MYMOP, a patient generated measure of outcomes.

Reliability of such instruments needs to be proved. BMJ: British Medical Journal,

313(7057), 626.

Ruta, D., Garratt, A., Leng, M., Russell, I., & MacDonald, L. (1994). A new approach to the

measurement of quality of life: the Patient-Generated Index. Medical care, 1109-

1126.

Sakthong, P., Sonsa-ardjit, N., Sukarnjanaset, P., & Munpan, W. (2015). Psychometric

properties of the EQ-5D-5L in Thai patients with chronic diseases. Quality of Life

Research, 24(12), 3015-3022.

Scalone, L., Ciampichini, R., Fagiuoli, S., Gardini, I., Fusco, F., Gaeta, L., . . . Mantovani, L. G.

(2013). Comparing the performance of the standard EQ-5D 3L with the new version

EQ-5D 5L in patients with chronic hepatic diseases. Quality of Life Research, 22(7),

1707-1716.

Schanzer, B., Dominguez, B., Shrout, P. E., & Caton, C. L. (2007). Homelessness, health

status, and health care use. American journal of public health, 97(3), 464-469.

Seitz, H. K., Bataller, R., Cortez-Pinto, H., Gao, B., Gual, A., Lackner, C., . . . Tsukamoto, H.

(2018). Alcoholic liver disease. Nature Reviews Disease Primers, 4(1), 1-22.

150

Selivanova, A., Buskens, E., & Krabbe, P. F. (2018). Head-to-Head Comparison of EQ‐5D‐3L

and EQ‐5D‐5L Health Values. PharmacoEconomics, 36(6), 715-725.

Shankar, A., McMunn, A., Demakakos, P., Hamer, M., & Steptoe, A. (2017). Social isolation

and loneliness: Prospective associations with functional status in older adults. Health

psychology, 36(2), 179.

Shelton, L. (2018). The Bronfenbrenner Primer : A Guide to Develecology. Milton, UNITED

KINGDOM: Routledge.

Shmagel, A., Ngo, L., Ensrud, K., & Foley, R. (2018). Prescription medication use among

community-based US adults with chronic low back pain: a cross-sectional population

based study. The Journal of Pain, 19(10), 1104-1112.

Silverman, D. (2016). Qualitative research: Sage.

Smith, K. T., Monti, D., Mir, N., Peters, E., Tipirneni, R., & Politi, M. C. (2018). Access is

necessary but not sufficient: factors influencing delay and avoidance of health care

services. MDM policy & practice, 3(1), 2381468318760298.

Solberg, T. K., Olsen, J.-A., Ingebrigtsen, T., Hofoss, D., & Nygaard, Ø. P. (2005). Health-

related quality of life assessment by the EuroQol-5D can provide cost-utility data in

the field of low-back surgery. European spine journal, 14(10), 1000-1007.

Stepanikova, I., & Oates, G. R. (2017). Perceived discrimination and privilege in health care:

the role of socioeconomic status and race. American journal of preventive medicine,

52(1), S86-S94.

Stomski, N., Morrison, P., Maben, J., Amorin-Woods, L., Ardakani, E., & Théroux, J. (2019).

The adoption of person-centred care in chiropractic practice and its effect on non-

specific spinal pain: An observational study. Complementary Therapies in Medicine,

44, 56-60.

151

Stringhini, S., Carmeli, C., Jokela, M., Avendaño, M., Muennig, P., Guida, F., . . . Bochud, M.

(2017). Socioeconomic status and the 25× 25 risk factors as determinants of

premature mortality: a multicohort study and meta-analysis of 1· 7 million men and

women. The Lancet, 389(10075), 1229-1237.

Sullivan, P. W., Lawrence, W. F., & Ghushchyan, V. (2005). A national catalog of preference-

based scores for chronic conditions in the United States. Medical care, 736-749.

Tabatabaee, A., Tafreshi, M. Z., Rassouli, M., Aledavood, S. A., AlaviMajd, H., & Farahmand,

S. K. (2016). Effect of therapeutic touch in patients with cancer: a literature review.

Medical Archives, 70(2), 142.

Tarlov, A. R., Ware, J. E., Greenfield, S., Nelson, E. C., Perrin, E., & Zubkoff, M. (1989). The

medical outcomes study. Jama, 262(7), 925-930.

Temple, J. B., Kelaher, M., & Williams, R. (2018). Discrimination and avoidance due to

disability in Australia: evidence from a National Cross Sectional Survey. BMC public

health, 18(1), 1347.

The Wellington. (2020). Caring in Collingwood. Retrieved from https://thewellington.org.au/

Trenaman, L., Stacey, D., Bryan, S., Taljaard, M., Hawker, G., Dervin, G., . . . Bansback, N.

(2017). Decision aids for patients considering total joint replacement: a cost-

effectiveness analysis alongside a randomised controlled trial. Osteoarthritis and

Cartilage, 25(10), 1615-1622.

van Amstel, R. N., Vaes, P., & Malone, S. (2018). The measurable impact of a protocoled

multimodal physiotherapeutic intervention on the quality of life in patients with

non-specific chronic low back pain. A RCT study. Physical Therapy and Rehabilitation,

5(1), 2.

152

Van Exel, N., op Reimer, W. S., & Koopmanschap, M. (2004). Assessment of post-stroke

quality of life in cost-effectiveness studies: The usefulness of the Barthel Index and

the EuroQoL-5D. Quality of Life Research, 13(2), 427-433.

Van Wilder, L., Rammant, E., Clays, E., Devleesschauwer, B., Pauwels, N., & De Smedt, D.

(2019). A comprehensive catalogue of EQ-5D scores in chronic disease: results of a

systematic review. Quality of Life Research, 1-9.

Verhoef, M., Casebeer, A. L., & Hilsden, R. J. (2002). Assessing efficacy of complementary

medicine: adding qualitative research methods to the" Gold Standard". The Journal

of Alternative & Complementary Medicine, 8(3), 275-281.

Verhoef, M., Lewith, G., Ritenbaugh, C., Boon, H., Fleishman, S., & Leis, A. (2005).

Complementary and alternative medicine whole systems research: Beyond

identification of inadequacies of the RCT. Complementary Therapies in Medicine,

13(3), 206-212. doi:https://doi.org/10.1016/j.ctim.2005.05.001

Verhoef, M., Mulkins, A., & Boon, H. (2005). Integrative health care: how can we determine

whether patients benefit? Journal of Alternative & Complementary Medicine,

11(supplement 1), s-57-s-65.

Verhoef, M., Vanderheyden, L., Dryden, T., Mallory, D., & Ware, M. (2006). Evaluating

complementary and alternative medicine interventions: in search of appropriate

patient-centered outcome measures. BMC Complementary and Alternative

Medicine, 6(1), 38.

Verhoef, M. J., Vanderheyden, L. C., Dryden, T., Mallory, D., & Ware, M. A. (2006).

Evaluating complementary and alternative medicine interventions: in search of

appropriate patient-centered outcome measures. BMC Complementary and

Alternative Medicine, 6(1), 38.

153

Volkow, N. D., & McLellan, A. T. (2016). Opioid abuse in chronic pain—misconceptions and

mitigation strategies. New England Journal of Medicine, 374(13), 1253-1263.

Wang, H., Kindig, D. A., & Mullahy, J. (2005). Variation in Chinese population health related

quality of life: results from a EuroQol study in Beijing, China. Quality of Life Research,

14(1), 119-132.

Ware Jr, J. E., & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-

36): I. Conceptual framework and item selection. Medical care, 473-483.

Weerapong, P., Hume, P. A., & Kolt, G. S. (2005). The mechanisms of massage and effects on

performance, muscle recovery and injury prevention. Sports medicine, 35(3), 235-

256.

Widerström-Noga, E., Anderson, K. D., Perez, S., Hunter, J. P., Martinez-Arizala, A., Adcock, J.

P., & Escalona, M. (2017). Living with chronic pain after spinal cord injury: a mixed-

methods study. Archives of Physical Medicine and Rehabilitation, 98(5), 856-865.

Winkleby, M. A., Jatulis, D. E., Frank, E., & Fortmann, S. P. (1992). Socioeconomic status and

health: how education, income, and occupation contribute to risk factors for

cardiovascular disease. American journal of public health, 82(6), 816-820.

Zangrando, F., Piccinini, G., Tagliolini, C., Marsilli, G., Iosa, M., Vulpiani, M. C., & Paolucci, T.

(2017). The efficacy of a preparatory phase of a touch-based approach in treating

chronic low back pain: a randomized controlled trial. Journal of pain research, 10,

941.

154

Appendices

Appendix A: Ethics Approval (Page 1 of 2)

155

Appendix A: Ethics Approval (Page 2 of 2)

156

Appendix B: Recruitment Flyer

157

Appendix C: Measure Yourself Medical Outcome Profile (MYMOP)

158

Appendix D: European Quality of Live Five Domain Five Level Health Questionnaire (EQ-5D-5L) (Page 1 of 3)

159

Appendix D: European Quality of Live Five Domain Five Level Health Questionnaire (EQ-5D-5L) (Page 2 of 3)

160

Appendix D: European Quality of Live Five Domain Five Level Health Questionnaire (EQ-5D-5L) (Page 3 of 3)

161

Appendix E: Interview Schedule (Clients) (Page 1 of 2)

162

Appendix E: Interview Schedule (Clients) (Page 2 of 2)

163

Appendix E: Interview Schedule (All Other Interview Groups) (Page 1 of 2)

164

Appendix E: Interview Schedule (All Other Interview Groups) (Page 2 of 2)

165