Journal of Chiropractic Humanities (2012) 19, 1–11

Editorial

Multiple views to address diversity issues: an initialdialog to advance the chiropractic professionClaire Johnson DC, MSEd a, b,⁎, Lisa Zaynab Killinger DC c,Mark G. Christensen PhDd, John K. Hyland DC, MPHe, John P. Mrozek DC, MEd f,R. Fred Zuker PhD g, Anupama Kizhakkeveettil BAMS(Ayu), MAOMh,Stephen M. Perle DC, MS i, Tolu Oyelowo DC, MS j

a Editor, Journal of Chiropractic Humanitiesb Professor, National University of Health Sciences, Lombard, ILc Professor, Palmer College of Chiropractic, Davenport, IAd Assistant Executive Vice President, National Board of Chiropractic Examiners, Greeley, COe Senior Chiropractic Specialist, National Board of Chiropractic Examiners, Greeley, COf Dean of Academic Affairs, Texas Chiropractic College, Pasadena, TXg Vice President of Enrollment Management, Texas Chiropractic College, Pasadena, TXh Associate Professor, Southern California University of Health Sciences, Whittier, CAi Professor, University of Bridgeport College of Chiropractic, Bridgeport, CTj Chair, Department of Health Promotion and Wellness, Northwestern Health Sciences University,Bloomington, MN

Key indexing terms: Abstract The purpose of this article is to provide expert viewpoints on the topic of diversity in

1h

Chiropractic;Cultural competency;Cultural diversity;Education;Minority health;Health occupations

the chiropractic profession, including cultural competency, diversity in the profession,educational and clinical practice strategies for addressing diversity, and workforce issues.Over the next decades, changing demographics in North America will alter how thechiropractic profession functions on many levels. As the population increases in diversity, wewill need to prepare our workforce to meet the needs of future patients and society.

⁎ Corresponding author. 200 E. RoE-mail address: cjohnson@nuhs

556-3499/$ – see front matter © 2ttp://dx.doi.org/10.1016/j.echu.201

© 2012 National University of Health Sciences.

Introduction

The qualities that make us human and unique asindividuals provide context and value for how wecommunicate and interact in interpersonal and social

osevelt Rd Lombard, IL 60148.edu.

012 National University of H2.10.003

.

ealth S

settings. These communications develop relationshipsthat may produce meaningful contributions and growthfor individuals and society. It is generally understoodthat each person sees the world through his own lens(eg, values, judgment, culture). However, to becontributors to society, it is not necessarily enough toacknowledge that we each have a different way ofinteracting in the world. To be truly effective, we must

ciences.

Diversity and Chiropractic: Why We Should Care Lisa Zaynab Killinger, DC

Diversity in the Chiropractic Profession Mark G. Christensen, PhD John K. Hyland, DC, MPH

Overcoming Barriers of Diversity: Chiropractic Education John P. Mrozek, DC, MEd

Improving Diversity in Future Chiropractic Graduates R. Fred Zuker, PhD

Cultural Diversity in Patient Perceptions of Health Care Anupama Kizhakkeveettil, BAMS(Ayu), MAOM

Diversity from a Minority Point of View Stephen M. Perle, DC, MS

Overcoming Barriers as a Healthcare Provider. Tolu Oyelowo, DC, MS.

Fig 1. Expert authors and their topics relating to diversityin the chiropractic profession.

2 C. Johnson et al.

understand and grow from the richness that others offerto the social fabric.

The concept of diversity is composed of much morethan skin color, holidays we celebrate, or the languagethat we speak. Diversity also goes beyond toleranceand is the appreciation of differences in ethnicity,race, socioeconomic status, sex, gender identity,religion, age, and abilities of the members of society,including the health care workforce and the patientswe serve. 1 Diversity is complex and requires properattention and study to be valued as a contributioninstead of seen as a barrier.

As one of the healing arts, chiropractic has facedmany challenges over the years and has grown despitediscrimination and bias against its unique methods ofhealth care. 2 Because of these challenges, efforts andresources had been directed to fundamentals inpreserving the survival of the profession instead of itsgrowth. Thus, development of higher-order abilitiesmay have been underdeveloped until recently. Asevidenced by few publications that address issues ofdiversity in the chiropractic profession, 1 research andfocus on diversity in our professional activities havemuch room to grow.

The purpose of this editorial is to capture variousviewpoints on the topic of diversity and bring themtogether in a combined discussion. The multipleviewpoints offered here may assist those in chiro-practic as we look for ways to address issuessurrounding diversity and prepare for a rich andmultidimensional future.

Methods

For the purpose of expanding the dialog on the topicof diversity, the Association of Chiropractic Collegesselected “diversity” as the theme for the 2012conference, held in Las Vegas, NV, March 16-17. Inthe opening plenary session titled “Diversity: theFuture of Healthcare and the Chiropractic Profession,”panelists were asked to address the changing diversityof the population and its impact on the future of healthcare and the chiropractic profession from the view-points of education, research, and clinical practice. Inthe closing plenary session titled “Overcoming Bar-riers: Training, Treating, and Researching in anIncreasingly Diverse World,” the speakers focused onthe obstacles to diversity in chiropractic education,practice, and research and how we might overcomebarriers in these domains. Each of the opening and

closing panelists was invited to contribute a section tothis collaborative editorial. Of those invited, 8 agreed toparticipate. The resulting contributions are eachauthor's reflection on the topic of diversity from hisor her unique viewpoint and expertise (Fig 1).

Diversity and Chiropractic: WhyWe Should CareLisa Zaynab Killinger, DCDiversity is growing in importance because our

world is becoming increasingly diverse. By the year2050, it is projected that racial minorities will make upmore than half the US population.3,4 In some US citiesand a few US states, whites are already in theminority. 4 The chiropractic profession must prepareto care for an increasingly diverse patient base.Achieving cultural competence or becoming aware ofcultural differences that may impact patient health andthe doctor/patient interaction is important for all healthprofessionals including doctors of chiropractic.

It still may not be clear to some doctors ofchiropractic why cultural issues or training in culturalcompetency might be important. Some may feel thattheir care will be the same, regardless of thebackground or ethnicity of the patient; therefore, theymay feel that such training is irrelevant. However, thereis a growing body of literature that states that healthprofessionals that provide culturally competent care

Fig 3. Percentage of male DCs and patients from 1990 to2010.

3Chiropractic diversity

achieve better patient outcomes. 5–10 Providing the bestcare possible should be all health professionals’ toppriority, so cultural competency training may help usmeet that goal. Furthermore, increasing culturalcompetency in the US health care workforce is anational health priority. 11 The oldest and largest healthorganization in the United States, the American PublicHealth Association, remains consistently committed toachieving equity in health status of all Americansthrough improvements in the cultural awareness of thepublic health workforce. 12

Culturally competent care is important for providingthe best care since various ethnicities, religions, races,and other groups all have a unique set of health risks.For example, white men have nearly twice the risk oftesticular cancer than black men13; yet black men havea significantly higher risk of prostate cancer than otherracial groups.11 Women of Asian or European descenthave a higher risk of osteoporosis, 14 and NativeAmericans have nearly twice the disability rate due tolow back pain than any other group.15,16 As conscien-tious clinicians, it is important that we know ourpatients’ relative risk for various diseases and recom-mend appropriate evidence-based screenings withthose risks in mind.

Diversity in the Chiropractic ProfessionMark G. Christensen, PhDJohn K. Hyland, DC, MPHSome of the most accurate data available concerning

the chiropractic profession have been gathered over thepast 18 years by the National Board of ChiropracticExaminers. Based on extensive, well-designed, andcarefully implemented surveys, the National Board ofChiropractic Examiners has published 4 reports thatdescribe the chiropractic profession: Job Analysis ofChiropractic,17 Job Analysis of Chiropractic 2000,18

Job Analysis of Chiropractic 2005,19 and PracticeAnalysis of Chiropractic 2010.20 These reports catalogthe frequency and importance of the many tasksperformed by doctors of chiropractic during their daily

Fig 2. Percentage of non-Hispanic white DCs and patientsfrom 1990 to 2010.

Fig 4. Percentage of non-Hispanic white DCs and the USpopulation from 1990 to 2010.

health care activities and are the basis for thedevelopment of the tests of competence required forlicensure in the United States. The data presented hereare from respondents who reported spending at least 20hours each week in clinical chiropractic practice.

Questions regarding race/ethnicity and sex ofchiropractic practitioners and their patients wereincluded in the first survey in 1991. Data from thatsurvey (reported in 1993) documented that 96% of theprofession classified themselves as non-Hispanicwhite, and 87% were male. This contrasts with theirreported patient population, which was described as65% non-Hispanic white and 40% male. In the 2000report, responding chiropractors classified themselvesas 94% non-Hispanic white and 81% male, whiledescribing their patients as 60% non-Hispanic whiteand 40% male. The survey responses reported in 2005were very similar, with 92% of chiropractors self-described as non-Hispanic white and 82% male,whereas their patients were classified as 57% non-Hispanic white and 40% male. Most likely because of achange in wording of the race/ethnicity question(specifically allowing more than one answer), therespondents to the most recent survey reported that theywere 85% non-Hispanic white and 78% male. Thequestion regarding patient race/ethnicity did not appearon that survey, but extrapolation from previous datawould suggest that approximately 52% of chiropractic

4 C. Johnson et al.

patients were non-Hispanic white. The reported patientsex distribution remained at 40% male. Figs 2 and 3present the data comparing doctors of chiropractic (DC)and their patients (Pt.), as well as their trends over time.

During the period that doctors of chiropractic andtheir patients have become somewhat more diverse intheir race/ethnicity, the demographics of the USpopulation have also been changing. The 1990 Censusreported that 75.6% of respondents chose the classifi-cation of non-Hispanic white as their only race/ethnicity. 21 By the 2000 Census, that proportion haddecreased to 69.1%22; and a further decrease to 63.7%was reported in a 2010 Census Brief. 23 Fig 4 illustratesthe comparison of the US population with thechiropractic profession over this 20-year period.

In an attempt to predict future diversity trendsamong doctors of chiropractic, the 2009 Surveyresponses were further evaluated based on the numberof years in practice. Those who reported being inchiropractic practice for more than 15 years describedthemselves as 85.5% non-Hispanic white and 82.3%male. The race/ethnicity of those in practice for lessthan 5 years was essentially identical (85.9%), althoughthere was a smaller proportion of men (64.2%). Thesefindings appear to indicate that, although the morerecent additions to the chiropractic profession are morebalanced by sex, they are still predominantly white andnon-Hispanic.

Practice differences between men and women wereinvestigated further. The proportion of respondents whoreported practicing in a rural small town or rural area wassimilar for women (17.0%) and men (15.6%). A smallerpercentage of female respondents identified themselvesas non-Hispanic white: 80.0% vs 86.5% of men. Femalerespondents were much more likely to have a practicewhere more than 75% of the patients were female (8.7%compared with 4.4%) and somewhat more likely to treatpatients less than 5 years of age (83.1% vs 80.2%). Asimilar 6.0% of male and 5.7% of female respondentsreported a primarily geriatric patient population (ie, morethan 50% of their patients were older than 65 years).

Overcoming Barriers of Diversity: ChiropracticEducation

John P. Mrozek, DC, MEdChiropractic has the potential to improve health care

if the chiropractic workforce is more representative ofthe population. 1 A corollary to this is that theprofession needs to extend care provision to raciallydiverse populations. Hence, a more racially diversechiropractic profession providing health care to raciallydiverse populations should be a strategic goal of the

profession. Indeed, ignoring the issue of diversity inchiropractic college recruitment, education, and careprovision would be a big mistake.

To pretend that the issue of diversity simply needsthe attention of the recruitment and education arm of acollege would be underestimating a much larger anddaunting challenge. The literature on cultural diversityprovides a confused terminology to clinical teaching onculture and learning objectives that are inconsistent. Agood example of the challenge lies in the terminology.The terms multi-culturalism, cultural awareness, andcultural diversity are often used interchangeably. 24

Race, for example, can refer to a biological character-istic or a social construct. 25 What is meant by culturalawareness and sensitivity? How best can we prepareour students to apply their learning to specific culturesand health beliefs, relate to culture bound illness, andformulate a critical response to health inequalities?

Approaches to diversity education often focus on the4 “Ds” of multiculturalism of dress, diet, dialect, anddance. Although well intended, the 4 “D” approach maynot provide the opportunity to address issues such ashealth disparities and discrimination. 26 Classroomdiscussion of topics such as cultural sensitivity andhealth inequalities must be conducted in a “culturallysafe” environment to encourage dialog and the exchangeof ideas on diversity.27 The teaching of diversity andcultural sensitivity early in a curriculum shows littleimpact in later clinical years.28 Stand-alone courses havelittle chance to contribute a long-lasting influencewithout reinforcement throughout the curriculum. Ob-stacles to effective diversity education include studentresistance to formal learning about cultural diversity,discomfort with the subject matter, and personally heldviews. Students may not wish to discuss issues that areculturally sensitive at the risk of offending others.24

Student resistance to cultural diversity educationalso includes the influence of informal peer networksand the hidden curriculum. A hidden curriculum,functioning at the level of organizational structure, isresponsible for much of what is learned in school andtakes place outside of formal course offerings. 29

Aspects contributing to the hidden curriculum includethe local customs, rituals, and the student's daily livedexperience. The challenge is to explore, debate, andaddress the tension between the formal, informal, andhidden curriculum with regard to diversity education.The greater challenge is to prepare faculty to encouragethis discourse in a safe learning environment and tofoster student engagement in the discourse.

The dominant values in chiropractic educationplaced on the basic clinical sciences and clinical

5Chiropractic diversity

learning may marginalize the intended outcomes ofdiversity education. Students understand early theemphasis placed on passing Board examinations andthat the payoff resides in studying the biological andclinical sciences. Culturally sensitive subjects dealt within a bioscience context are perceived as having greaterimportance and are more readily discussed. 27 Althoughproviding a pretext for avoiding the discussion ofpersonally held views on diversity, the biosciencecontext does present an opportunity and platform toextend the discourse on diversity and culturallysensitive matters throughout the preclinical and clinicalcurriculum. Clinical faculty need to be aware of thecontextual catalyst to diversity discourse and of theimportance of promoting this discourse. The use of real-world clinical encounters as a substrate for engaging in adiversity discourse should be encouraged.

Going forward, desired outcomes of diversityeducation include encouraging discussion and open-ness of cultural issues within a safe environment.Curriculum planners aware of the effect that institu-tional culture and student attitudes have on diversityeducation can take steps to mitigate that effect. Studentengagement on the topic of diversity in curriculum

The following questions present the challenges faceretention of underrepresented students.

Potential questions that address diversity on our

• Which stakeholders should be included in th• What are the opportunities in our catchment • What resources do we have that can reach oustudents, faculty, staff and alumni?• Do our recruitment programs facilitate the id• Do our academic support programs provide non-traditional backgrounds survive and thrive in thchiropractic program?

Possible solutions to increase diversity through apractices:

• Audit recruitment materials and practices to increasing diversity. Consider the look of publishedin social media. • Evaluate if your campus is user friendly to u• Consider where you recruit students and incdiverse students. These may include community cothe primary market area of each chiropractic college• Volunteer to speak at the meetings of organiunderrepresented students such as chamber of command parent groups. • Invite student groups to visit your campus fochiropractic education. • Make underrepresented and non-traditional scampus by introducing them to students and faculty

Fig 5. Challenges faced by a campus addressing enro

design can ensure that this important stakeholder voiceis heard. Faculty development should be focused onpromoting diversity and cultural sensitivity discourse.The effectiveness of these efforts should be studied andreported in the literature. As noted earlier, this is asubject that calls for thoughtful literature contributions.

An effective approach to diversity education is morethan the sum of its parts. It is made up of recruitmentand enrollment efforts targeted on a more raciallydiverse student population, courses focused on diver-sity, the provision of a safe environment to promotediversity discourse, an institutional climate that pro-motes diversity, and a constant effort to ensure that allvoices are heard.

Improving Diversity in Future ChiropracticGraduates

R. Fred Zuker, PhDHow can we reach underrepresented students and

encourage them to seek higher education and profes-sional training? Often, the term underrepresentedrelates to students of Latino and African heritage; andstudents of Asian or Native American heritage may alsobe included depending on the campus.

d by a campus addressing enrollment and

campuses:

e discussion about underrepresented students?area to reach underrepresented students? t to these students - currently enrolled

entification of underrepresented students? the resources necessary to help students from e demanding environment of the doctor of

dmission/enrollment management

ensure that they are not counterproductive to materials, web sites, and representations

nderrepresented, non-traditional students. lude places where there are populations of lleges, four year colleges and universities in . zations that have influence with erce education committees, church groups,

r tours and information on chiropractic and

tudents feel welcomed when they visit your with similar backgrounds.

llment and retention of underrepresented students.

6 C. Johnson et al.

The reasons for efforts to reach traditionallyunderrepresented students are many. One of the mostimportant is the loss of potential talent by the absenceof a large and growing number of disenfranchisedstudents who are not able to enter the workforce at alevel that is commensurate with their abilities andinterests. In addition, the inclusion of students fromnontraditional backgrounds adds richness to theeducational experience of everyone on the campusesthat are successful in recruiting and retaining them.

One of the greatest challenges facing higher educationin the United States, including chiropractic education, isfinding a way to reach students and especially underrep-resented students who are likely candidates for chiro-practic education. We are charged to find students whowill add to the profession and assist their communities byproviding high-quality effective health care. Therefore,wemust becomemore creative and active in overcomingthis knowledge gap about chiropractic that existsbetween potential students and the profession (Fig 5).

Increasing diversity on chiropractic college cam-puses is a community-wide responsibility. All elementsof the campus must be included in our outreach efforts.We must also engage our alumni and other friends ofchiropractic who share our interest in diversifying theprofession. The imperative to reach out to theseunderserved groups is not something waiting tohappen. It is happening now, and we must positionourselves and our institutions to take every opportunityto reach this pool of talented students that will addincredible richness to our campuses and communities.

Cultural Diversity in Patient Perceptions ofHealth Care

Anupama Kizhakkeveettil, BAMS(Ayu), MAOMHealth care structures are thoroughly entwined with

the economic, political, philosophical, and social systemof culture. Thus, culture plays a major role in thepractices of physicians. Culture affects health in anassortment of ways, including influencing risk behaviorsthat can lead to disease exposure. Culture has social,political, and economic impacts on health and healthcare. Culture can conceptualize health woes such asillness, disease, sickness, and suffering. Culture alsoinfluences health care providers and their organizationalreactions to health care requirements. The favorableoutcome of patient encounters is dependent on thepresence of culturally competent health care providers.30

Diversity in ethnicity, race, language, age, sex/gender, religion, education, socioeconomic status, andabilities is observed in the patient population of theUnited States. Patients bring a wide variety of

perspectives and perceptions to clinician offices;therefore, diversity in the health care setting is animportant issue because it has an influence on theexpectations and treatment outcomes of patients.

Cultural competence is an approach that health careproviders can use to improve quality while addressingminority health care disparities. Culturally competenthealth care can be defined as providing servicesreverential to the cultural and linguistic needs ofpatients. It is important to note that, although languageand culture have common characteristics, there exists adistinction between the two. As much as languageproficiency contributes to cultural competence, it aloneis not equivalent to cultural competence. Thus, beingbilingual does not make one culturally competent.

Racial and ethnic minorities tend to receive lower-quality health care when compared with nonminoritieseven when income and insurance conditions arecontrolled. 31 Lack of cultural competence can possiblylead to inconsistencies in patient treatment. Educationand training in cultural competence can generatebenefits for patients by humanizing the patient-provider interaction when cultural discrepancies exist.Improved confidence in the practitioner and morecontentment are reported as benefits of generalpractitioner culturally competent communication be-haviors. 31 As well, sex is a factor for quality of healthcare. Satisfaction with care is not equal between thesexes. Women's satisfaction is more strongly tied tothe connection to their health care provider and qualityof health education than men's satisfaction. Womenare more likely to accept delivery of additionalinformation, ask questions, and practice mutualdecision-making. 32 Differences in communicationstyles and languages also affect health care.

Language proficiency is the capacity to speak as wellas write in a specific language. Language proficiencyfacilitates the learning of new culture, but it cannotautomatically guarantee cultural competence. 33 Profes-sional interpreters are needed to translate and advocatefor patients to provide culturally competent care.

Developed at personal and organizational levels,cultural competency is considered indispensable foreffectual public service delivery. Health care organiza-tions can provide better service delivery by consideringthe language, lifestyle, values, and norms of the targetpopulation. Cultural competency provides a levelplaying field for addressing racial and ethnic disparitiesin service delivery. The rationale for cultural compe-tence ranges from quality of care to risk management.As such, cultural competence comprises a fundamentalsocial responsibility. 34

7Chiropractic diversity

Cultural competency can be a challenge to practi-tioners who are not well versed in the social structuresnecessary for a successful patient-practitioner encoun-ter. A list of what to do or not do for patients of aparticular culture may not be enough to define how tocompetently provide care to diverse groups of patientspresenting in a practice. Practitioners may feel that theyare too busy to learn cultural competency or that is notworth learning if they will not be paid more.

The solution for these issues is specialized trainingfor health care practitioners on the importance ofunderstanding cultural diversity and the process ofchanging a practice to obtain better outcomes from adiversified patient base. Practice procedures should beexamined and modified as appropriate to better servethe diversity of patient cultures seen. Health carepractitioners should be hired to reflect the diversity ofthe patient population served. Administrative timeshould be granted to practitioners to develop theresources and skills necessary for the task.

Care for patients of diverse backgrounds can becomemore effective when there is culture sensitivity toasking questions and listening to the patient's percep-tion of the problem. In addition, practitioners shouldthen explain their perception of the problem andtreatment, acknowledge and discuss differences andsimilarities, and respect the patient's culture.

Cultural competence necessitates compassion to theuniqueness of religions, customs, and spiritual needs. Italso requires an understanding of patient wishes,preferences, and developmental needs. Cultural com-petence enables health care practitioners to elicitdistinct information that is unique to the client tomake accurate diagnoses and develop and implementclient-centered interventions. Cultural competence in-creases client and family satisfaction, facilitatespositive clinical outcomes, and expands client involve-ment. Thus, cultural competence should be included asa skill set for health care practitioners.

Diversity from a Minority Point of ViewStephen M. Perle, DC, MSI propose that understanding the plight of minor-

ities should, in theory, be easy for chiropracticphysicians even if they are not a member of a racialminority. I say this because, with approximately 16million people in the US health care workforce,doctors of chiropractic (DCs), with a population ofapproximately 60000 to 70000, make up approxi-mately 4% of that workforce. Therefore, being achiropractor makes one a part of a minority group. Inpopular culture, we can see this when watching TV or

movies, as it is rare for there to be a character in thescreenplay that is a chiropractic physician. In the rarecase a DC character is included, the fact spreadsthrough the chiropractic profession like wildfire. Thismay be equivalent to how African Americans feltwhen Bill Cosby (an early African American star) wasseen in a TV drama series in 1965.

Unlike some racial minority groups, the chiropracticphysician's status is not inherently visible like skin coloror cultural attire. Thus, as long as the DC does not wearan article of clothing or jewelry that identifies him as aDC, no one will know simply by looking at him. Thus, Ipropose that the historical discrimination that membersof the profession have experienced should evokeempathy and thus a compassion for patients, researchparticipants, or chiropractic students who are membersof a minority group whether overtly a minority or not.

The American Chiropractic Association Code ofEthics states that “With the exception of emergencies,doctors of chiropractic are free to choose the patientsthey will serve, just as patients are free to choose whowill provide health care services for them. However,decisions as to who will be served should not be basedon race, religion, ethnicity, nationality, creed, gender,handicap or sexual preference.”35 A professional'smoral duty to put patients first and treat all patientsequally is a lofty goal. Some may pretend to respect thisgoal, but many who honestly believe that they have nopreference for any particular type of human and treat alltheir patients with equal compassion may still harborinner prejudice. Recognition of one's prejudice is onestep toward eradicating such prejudice.

What looks like diversity depends upon who isdoing the looking. Consider the different viewpointswhen a single person, who is a member of a minority,joins a group of individuals who are part of thedominant culture. To the majority, this looks likediversity. They can see it because there is one minorityperson there, which may be different from what theyare used to. To the minority person, this does not at alllook like diversity—there is only one minority person.They are the “token” minority. As an example of howthis feels, go to a large scientific conference andobserve if it feels like an “integrated” conference if youare the only chiropractor there.

Overcoming Barriers as a Health Care ProviderTolu Oyelowo, DC, MSCultural competency and diversity in the clinical

setting contribute to providing patient-centered com-munication and patient-centered care. The goal ofpatient-centered communication according to Epstein

8 C. Johnson et al.

et al36 is to facilitate the provision of care that isconsistent with the patient's values and empowerspatients to be active participants in their health care.Patient-centered communication has been linked toimproved recovery rates, fewer symptoms, and im-proved emotional health. 37 When patients perceive thatthey have found common ground with their providers,their overall health status improves. 37

Patients and providers are simultaneously culturallysimilar and dissimilar. Potential areas of dissonance in thepatient/provider interaction may include the following:

• Stereotyping: Individuals from a specified back-ground do not always reflect the cultural or ethniccharacteristics of that population or group.

• Explanatory models: The patient's and theprovider's explanatory models for disease etiol-ogy may differ. Salimbene38 describes culturalgroups that perceive disease as caused by the evileye; this may conflict with the provider'sconcepts of disease from a biomedical model.

• Distrust: The Tuskegee syphilis study is oneexample of a violation of patient trust byproviders. These and other more current acts ofdiscrimination continue to shape the sense ofdistrust of the system that persists in somepopulations today.39 Rebuilding trust may neces-sitate longer-term relationships and a sustainedpresence in the community.

• Family structure and family identity: Health caredecisions in some communities are not made bythe person with the presenting complaint; they aremade by the community or by the head ofhousehold. It is important to ascertain who shouldbe consulted before treatment is initiated. 38

• Communication styles: In some African Americancommunities, raising one's voicemay imply honestyand heartfelt feelings; by contrast, some Anglo-Saxon communities perceive the raised voice ascontentious. Many Native American communitiesuse the gently limp handshake as a sign of respect;by contrast, this may be perceived as a sign ofweakness by those in the Anglo-Saxon communitywho perceive the strong firm handshake as implyingconfidence and authenticity. Direct eye contact isperceived by some Asian and Middle Easterncommunities as disrespectful and by many Anglo-Saxon communities as evidence of candor.

• Views of professional roles—hierarchical oregalitarian: Persons from places such as Russiaand the United States, for example, have histori-cally ascribed to the physician a certain degree of

authority and respect. By contrast, persons fromsome parts of East Africa, for example, Somalia,have a more egalitarian approach to the patient-provider relationship.

• Diseases without illness: In a culture where thehealth care provider is consulted only when thepatient is very ill, preventive care may be lessvalued. Thus, blood pressure medications, spinalscreens, and other preventive measures may berefused or challenged if not carefully explained.

• Terminology: Often highlighted when nonprofes-sionals are solicited as interpreters; examplesinclude the cervical spine described as the cervix.

• Interpretations of disability: Epilepsy in somecultures is a disability that should be managed. Inother cultures such as the Hmong, epilepsy is aunique spiritual gift that should be nourished. 40

• Intake forms: The standard intake form can be achallenge to a new immigrant who is not Englishliterate. In addition, reference points such as datesof birth may create challenges for patients fromcultures who associate birth contextually. Forexample, the date of birth may be associated witha significant event.

• Task/relationship: In some cultures, the relation-ship has greater value than the task. It is moreimportant for the patient to develop a relation-ship with the provider and, conversely, to havethe provider get to know him/her beforedivulging personal information. This suggeststhat the initial visit that was conversational anddid not yield “pertinent clinical information”may appear unprofitable to the provider butbeneficial to the patient who may have toldstories about family in lieu of descriptions aboutthe cause of the presenting complaint.

• Time: Individuals from historically Nordicclimates may appear more literal with time,whereas those from tropical climates mayperceive time conceptually. This has implica-tions for scheduling patient appointments.

The following are suggestions that may assistpractitioners with improving cultural competencyskills. The LEARN model41 addresses communicationskills. The acronym stands for the following: Listenwith sympathy and understanding to the patient'sperception of the problem; Explain your perceptions ofthe problem; Acknowledge and discuss the differencesand similarities between these perceptions; Recom-mend treatment while remembering the patient's

9Chiropractic diversity

cultural parameters; and Negotiate agreement. It isimportant to understand the patient's explanatorymodel so that treatment (and ultimately compliance)fits into their cultural framework. It is important forpractitioners to be aware of personal bias42; acknowl-edge the influence of culture on the individual and thehealth system43; and approach patients with humility;understanding that mistakes will be made, but humilityand respect engender forgiveness.

Discussion

By the year 2050, it is estimated that more thanhalf of the US population will be racial minority,whereas some states have already reached thismilestone. 3,4 When compared with other leadinghealth professions, chiropractic has not made similarprogress in terms of addressing diversity in thechiropractic workforce. 1 At present, the chiropracticprofession is made up of a majority of white men(Figs 6 and 7). If the profession is to embrace

Fig 6. Racial percentages of men and women, chiropracticprofession and medical graduates in the United States.Reprinted with permission from Johnson CD, Green BN.Diversity in the chiropractic profession: preparing for 2050. JChiropr Educ 2012;26:1-13.1

Fig 7. Sex percentages of men and women, chiropracticprofession and medical graduates in the United Statescompared with patient percentages. Reprinted with permis-sion from Johnson CD, Green BN. Diversity in thechiropractic profession: preparing for 2050. J Chiropr Educ2012;26:1-13.1

diversity and the upcoming changes in the population,a greater diversity in the workforce is needed.

As described in the commentaries above, there arevarious approaches and considerations that we can useas a profession to address issues of diversity. These areby no means the only views or methods. However, thisis an initial attempt to start a dialog about the issues ofdiversity so that we may better address the upcomingdemographic changes in our population.

Limitations

It is recognized that the topics here do not include alltopics relevant to addressing diversity. Other topic

10 C. Johnson et al.

areas and approaches are important if we are toproperly address diversity in the profession. Thepurpose of this article was to address important issuesand to help establish an initial dialog for additionalfuture discussions.

Conclusion

Over the next decades, changing demographics inNorth America will alter how the chiropractic profes-sion functions on many levels. As the patientpopulation increases in diversity, we will need toprepare our workforce to better meet the needs of futurepatients and society.

Funding sources and potential conflicts ofinterest

No funding sources or conflicts of interest werereported for this study.

References

1. Johnson CD, Green BN. Diversity in the chiropracticprofession: preparing for 2050. J Chiro Ed 2012;26(1):1–13.

2. Johnson C. Reflecting on 115 years: the chiropractic profes-sion's philosophical path. J ChiroprHumanit 2010;17(1):1–5.

3. Day JC. Population profile of the United States: nationalpopulation projections. Suitland, MD: United States CensusBureau; 2011. Available from: http://www.census.gov/population/www/pop-profile/natproj.html.

4. United States Census Bureau. Population projections:U.S.interim projections by age, sex, race, and Hispanic origin:2000-2050. Suitland, MD: United States Census Bureau; 2011.Available from: http://www.census.gov/.

5. Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE,Normand J. Culturally competent health care systems. Asystematic review. Am J Prev Med 2003;24(3 suppl):68–79.

6. Tucker CM, Marsiske M, Rice KG, Nielson JJ, Herman K.Patient-centered culturally sensitive health care: model testingand refinement. Health Psychol 2011;30(3):342–50.

7. Zeh P, Sandhu HK, Cannaby AM, Sturt JA. The impact ofculturally competent diabetes care interventions for improvingdiabetes-related outcomes in ethnic minority groups: asystematic review. Diabet Med 2012;4:1464–9.

8. Like RC. Educating clinicians about cultural competence anddisparities in health and health care. J Contin Educ Health Prof2011;31(3):196–206 Summer.

9. Beavers FP, Satiani B. Diversity does not equal disparity: howcultural competence can overcome. J VascSurg 2010;51(4suppl):1S–3S.

10. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong IIO. Defining cultural competence: a practical framework foraddressing racial/ethnic disparities in health and health care.Public Health Rep 2003;118(4):293–302.

11. United States Department of Health of Human Services. HHSaction plan to reduce racial and ethnic health disparities: anation free of disparities in health and health care. Washington,DC: United States Department of Health and Human Services;2011. Available from: http://www.minorityhealth.hhs.gov/npa/files/Plans/HHS/HHSPlancomplete.pdf.

12. American Public Health Association. Mission statement.http://ttp://www.apha.org/about/gov/execboard/executiveboardvisionmission.htm.

13. U.S. Cancer Statistics Working Group. United States cancerstatistics: 1999-2007 incidence and mortality Web-basedreport. Atlanta (GA): Department of Health and HumanServices, Centers for Disease Control and Prevention, andNational Cancer Institute; 2010. Available at: http://www.cdc.gov/uscs.

14. Johnell O, Kanis JA. An estimate of the worldwide prevalenceof disability associated with osteoporotic fractures. Osteoporo-sis Int 2006;17:1726–33.

15. Waterman BR, Belmont PJ, Schoenfeld AJ. Low back pain inthe United States: incidence and risk factors for presentation inthe emergency setting. Spine J 2012;12(1):63–70.

16. Docking R, Fleming J, Brayne C, et al. Epidemiology of backpain in older adults: prevalence and risk factors for back painonset. Rheumatology 2011;50(9):1645–53.

17. Christensen MG, Delle Morgan DR. Job analysis of chiroprac-tic. Greeley, CO: National Board of Chiropractic Examiners.

18. Christensen MG, Kerkhoff D, Kollasch MW. Job analysis ofchiropractic 2000. Greeley, CO: National Board of ChiropracticExaminers; 2000.

19. Christensen MG, Kollasch MW. Job analysis of chiropractic2005. Greeley, CO: National Board of Chiropractic Examiners;2005.

20. Christensen MG, Kollasch MW, Hyland JK. Practice analysisof chiropractic 2010. Greeley, CO: National Board ofChiropractic Examiners; 2010. Available from: http://www.nbce.org/publication/practice.

21. US Census Bureau. United States summary: general populationcharacteristics. Table 3. Race and Hispanic origin: 1990. Availablefrom: http://www.census.gov/prod/cen1990/cp1/cp-1-1.pdf.

22. US Census Bureau. Census 2000. Table DP-1. Profile ofgeneral demographic characteristics: 2000. Available from:http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=DEC_00_SF1-DP1&prodType=table.

23. Humes KR, Jones NA, Ramirez RR. Overview of race andHispanic origin: 2010. US Census Bureau. Available from:http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf.

24. Roberts JH, Sanders T, Wass V. Students’ perceptions of race,ethnicity and culture at two UK medical schools: a qualitativestudy. Med Educ 2008;42:45–52.

25. Kaufman JS, Cooper RS. Commentary: considerations for useof racial/ethnic classification in etiologic research. Am JEpidemiol 2001;154(4):291–8.

26. Frank B, MacLeod A. Beyond the ‘four Ds of multicultural-ism’: taking difference into account in medical education. MedEduc 2005;39:1178–9.

27. Roberts JH, Sanders T, Mann K, Wass V. Institutionalmarginalisation and student resistance: barriers to learning

11Chiropractic diversity

about culture, race and ethnicity. Adv in Health Sci Educ2010;15:559–71.

28. Beagan BL. Teaching social and cultural awareness to medicalstudents: “It's all nice to talk about it in theory, but ultimately itmakes no difference”. Acad Med 2003;78(6):605–14.

29. Hafferty FW. Beyond curriculum reform: confronting med-icine's hidden curriculum. Acad Med 1998;73(4):403–7.

30. Winkelman M. Culture and health: applying medical anthro-pology. San Francisco, CA: Jossey-Bass; 2009. p. 5.

31. Hunter WJ. Cultural competency in health care providers'ethical decision-making and moral reasoning: implications forreducing racial and ethnic health disparities for diversepopulations. Cambridge, UK: ProQuest; 2008. p. 12–3.

32. Antai-Otong D. Nurse-client communication: a life spanapproach. Sudbury, Mass: Jones and Bartlett Publishers;2007. p. 176–7.

33. Carter J, Marion S. Pharmacy in public health: basics andbeyond. Bethesda, MD: American Society of Health-SystemPharmacists; 2010. p. 138–9.

34. Major KA, Susan TG. Cultural competency for publicadministrators. Armonk, N.Y.: M.E. Sharpe; 2012. p. 64–5.

35. American Chiropractic Association. Code of ethics. http://www.acatoday.org/content_css.cfm?CID=719 retrieved on Oc-tober 8, 2012.

36. Epstein RM, Franks P, Fiscella K, Shields CG, MeldrumSC, Kravitz RL, et al. Measuring patient-centered commu-nication in patient-physician consultations: theoretical andpractical issues. Soc Sci Med 2005;61(7):1516–28.

37. Stewart M, Brown JB, Donner A, McWhinney IR, Oates J,Weston WW, et al. The impact of patient-centered care onoutcomes. J Fam Pract 2000;49(9):796–804.

38. Salimbene S. What language does your patient hurt in?.Diversity Resources: Amherst MA; 2005.

39. Scharff DP, Mathews KJ, Jackson P, Hoffsuemmer J, Martin E,Edwards D. More than Tuskegee: understanding mistrust aboutresearch participation. J Health Care Poor Underserved 2010;21(3):879–97.

40. Fadiman A. The spirit catches you and you fall down: a Hmongchild, her American doctors, and the collision of two cultures.New York, NY: Farrar, Straus, and Giroux; 1997.

41. Elois A, Fowkes W. A teaching framework for cross-culturalhealth care—application in family practice. West J Med1983;139(6):934–8.

42. Stone J, Moskowitz GB. Non-conscious bias in medicaldecision making: what can be done to reduce it? Med Educ2011;45(8):768–76.

43. Kirmayer L. Multicultural medicine and the politics ofrecognition. J Med Philos 2011;36(4):410–23.