Abstract
Introduction
Understanding healthcare utilization by Canadians with back problems informs healthcare planning nationally.
Research question
What is the prevalence of utilization of healthcare providers (medical doctors, chiropractors, physiotherapists, nurses), and associated characteristics among Canadians with chronic back problems (2001–2016)?
Material and methods
This population-based study used Canadian Community Health Survey data (2001–2016) restricted to respondents with chronic back problems (aged ≥12 years). We used self-reported consultation with healthcare providers (medical doctors, chiropractors, physiotherapists, nurses) from 2001–2010, and self-reported regular healthcare provider from 2015–2016. We calculated the 12-month prevalence of utilization with providers, and used modified Poisson regression to assess sociodemographic, health-related and behavioural factors associated with utilization of different providers.
Results
From 2001 to 2010 and 2015/2016, respectively, prevalence of utilization of medical doctors was 87.9% (95% CI 87.6–88.2) and 86.7% (95% CI 85.9–87.5); chiropractors 24.0% (95% CI 23.6–24.4) and 14.5% (95% CI 13.8–15.3); physiotherapists 17.2% (95% CI 16.9–17.6) and 10.7% (95% CI 10.0–11.4); nurses 14.0% (95% CI 13.7–14.2) and 6.6% (95% CI 6.1–7.0). Females were more likely to see any provider than males. Persons of lower socioeconomic status were less likely to consult chiropractors or physiotherapists (2001–2016), or nurses (2001–2010). Immigrants were less likely to consult chiropractors or nurses. Persons aged >65 years were less likely to consult chiropractors or physiotherapists, and those with fair/poor general health were less likely to consult chiropractors, but more likely to consult other providers.
Discussion and conclusion
Medical doctors were most commonly consulted by Canadians with back problems, then chiropractors and physiotherapists. Characteristics of healthcare utilization varied by provider. Findings inform the need to strengthen healthcare delivery for Canadians with back problems.
Keywords: Back pain, Prevalence, Health care providers, Population-based, Canadian Community Health Survey
Highlights
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Canadians with back problems most commonly consulted medical doctors for healthcare.
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After medical doctors, adults with back problems mostly consulted chiropractors then physiotherapists.
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Characteristics of healthcare utilization related to back problems varied by provider.
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These characteristics include age, socioeconomic status, and general health.
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Findings inform healthcare delivery related to back problems to mitigate the burden on health systems.
1. Introduction
Back pain is the leading cause of disability worldwide, and this burden is projected to further increase over time (Hoy et al., 2014; Wu et al., 2020). Back pain also drives healthcare use and costs across many high-income countries (Hart et al., 1995; Dieleman et al., 2016; Cypress, 1983; Côté et al., 2001; Wong et al., 2021). Given the burden of back pain and changing nature of healthcare systems in Canada, it is important to understand which providers Canadians with back problems consult for their healthcare. Canadians with back pain can directly seek primary care from family physicians, chiropractors, and physiotherapists without referral, while physician referral is needed to see specialists. Physician services are publicly funded in Canada, but chiropractic and physiotherapy for back conditions are generally not publicly funded (with few exceptions that are provincially dependent). In 2000–2001, Canadians with back problems primarily consulted family doctors (87%), chiropractors (26%), and physiotherapists (17%) (Lim et al., 2006). In 2009/2010, most Canadians with chronic back pain consulted family physicians (85.9%), followed by chiropractors (23.7%), and physiotherapists (17.5%) (Bath et al., 2018). Moreover, studies suggest that differences in healthcare utilization may be associated with age, gender, socioeconomic status and health-related factors (Lim et al., 2006; Bath et al., 2018). These population-based studies used Canadian data from 2000 to 2010, so results are outdated and require updating (Lim et al., 2006; Bath et al., 2018).
Healthcare utilization data is important given the Canadian healthcare system is currently overburdened and considered in crisis (The Fraser Institute, 2022; Canadian Medical Association, 2022; Moir and Barua, 2021). Recently, the Fraser Institute compared the global performance of universal healthcare countries (Moir and Barua, 2021). Although Canada was ranked second highest in healthcare spending (% Gross Domestic Product), it ranked modest-to-poor on performance, including availability of doctors, hospital beds, and specialist wait (Moir and Barua, 2021). An up-to-date population-based analysis is needed to investigate the utilization of various healthcare providers among Canadians with back pain to inform healthcare planning. This focus on back pain is important due to its high prevalence and main reason for unmet needs for rehabilitation globally, highlighting that many people requiring rehabilitation are not receiving these services (Cieza et al., 2021).
Rehabilitation is a set of interventions to optimize physical, mental and social functioning when a person is experiencing limitations when interacting with their environment (World Health Organization, 2021). Rehabilitation may help decrease healthcare burden associated with more intensive care such as hospitalizations, and help people be independent in performing daily activities and participating in education, work, recreation, and meaningful life roles (World Health Organization, 2021; World Health Organization (WHO), 2017; Stucki et al., 2005; Katajisto and Laitinen, 2017; Thomas et al., 2019). Rehabilitation services are delivered by different healthcare providers, and understanding their utilization across the health system and differences in patient characteristics by provider group could help identify gaps in access-to-care and rehabilitation. Underserved populations, including older adults and those of lower socioeconomic status, have unmet care needs related to functioning and challenges accessing different types of healthcare (Lim et al., 2006; Bath et al., 2018; Abdi et al., 2019). Elucidating healthcare access across sociodemographic, health-related, and behavioural factors can inform the development of strategies to improve access. Overall, a nationwide, comprehensive view on healthcare access among Canadians with back pain provides the evidentiary basis for knowledge users (government, health professional associations) to inform healthcare delivery and resource planning. This information guides areas to strengthen and integrate healthcare and rehabilitation in the health system, particularly in primary care settings across a range of providers in efforts to mitigate the burden of back pain. Our research is aligned with SPINE20 recommendations to inform strategies ensuring accessible and affordable quality care to persons with spine disorders, and spine care delivery systems tailored to individual and population health needs (Chhabra et al., 2023).
Overall, an updated national perspective on utilization of different healthcare providers and associated characteristics among Canadians with back problems is needed. Therefore, our objectives were to determine the: 1) prevalence of healthcare utilization with different providers (medical doctors, chiropractors, physiotherapists, and nurses); and 2) prevalence of healthcare utilization with different providers stratified by sociodemographic, health-related, and behavioural characteristics among Canadians (aged ≥12 years) with chronic back problems from 2001 to 2016. We also aimed to examine sociodemographic, health-related, and behavioural factors associated with utilization of different healthcare providers in this population.
2. Materials and methods
2.1. Study design
A population-based analysis of cross-sectional data collected in six cycles of the Canadian Community Health Survey (CCHS) was conducted from 2001 to 2010 and 2015/2016. The study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology Statement (STROBE Statement, 2009). This project was approved by the Research Ethics Board at Ontario Tech University (#15791–130103).
2.2. Study sample and setting
Study population included all Canadian participants aged ≥12 years in at least one CCHS cycle between 2001 and 2010 and 2015/2016. Study sample included participants who self-reported chronic back problems by answering “yes” to the question: “Do you have back problems, excluding fibromyalgia and arthritis?” (2015/2016 cycle also excluded scoliosis). This question refers to “conditions diagnosed by a health professional and expected to last or have already lasted ≥6 months.”
In Canada, many medical healthcare services are publicly funded through the government-run provincial health insurance plan. This includes physician visits (including specialists) and most basic and emergency medical healthcare services. Chiropractic and physiotherapy services for back conditions are not generally publicly funded, with few exceptions that depend on the province. Instead, these rehabilitation services for back pain may be paid out-of-pocket or through other sources (extended health insurance, workers’ compensation, automobile insurance). In general for primary care settings, people do not need a referral to see a family physician, chiropractor, or physiotherapist. Physician referral is needed to see a specialist.
2.3. Data sources
The CCHS is a cross-sectional survey administered by Statistics Canada that collects data on the distribution of health determinants, outcomes, and healthcare use across Canada. (Statistics Canada) The survey uses a multistage sampling survey design to target Canadians aged ≥12 years living in private dwellings. The survey excludes persons living in institutions (e.g., long-term care, complex continuing care facilities), full-time members of the Canadian Forces, and persons living on reserves and other First Nations settlements. CCHS collected data from a sample of respondents every two years from 2001 to 2007, after which data were collected annually. (Statistics Canada) CCHS data are representative of 98% of the Canadian population aged ≥12 years in private dwellings at the provincial and national level, with response rates >60%. (Statistics Canada) Detailed survey methodology is described by Statistics Canada (Statistics Canada, 2005).
2.4. Outcomes
2.4.1. Consultation with healthcare provider (2001–2010)
Outcomes for 2001–2010 CCHS cycles were consultation with medical doctors, nurses, chiropractors, or physiotherapists in the past 12 months.
Outcome of consultation with medical doctors was based on a derived variable from two CCHS questions:
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Not counting when you were an overnight patient, in the past 12 months, have you seen, or talked to a family doctor or general practitioner (about your physical, emotional or mental health)?” (responding “yes”); or
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Not counting when you were an overnight patient, in the past 12 months, have you seen, or talked to any other medical doctor or specialist (such as surgeon, allergist, orthopedist, gynaecologist, or psychiatrist?” (responding “yes”)
Outcomes of consulting with chiropractors, physiotherapists or nurses were based on the CCHS question:
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2001–2005 cycles: “Not counting when you were an overnight patient, in the past 12 months, how many times have you seen, or talked to a chiropractor, physiotherapist, or nurse (about your physical, emotional or mental health)?” (≥1 consultation considered as yes to having consulted each provider)
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2007–2009 cycles: “Not counting when you were an overnight patient, in the past 12 months, have you seen, or talked to a chiropractor, physiotherapist, or nurse (about your physical, emotional or mental health)?” (responding “yes”).
2.4.2. Regular healthcare provider (2015/2016)
Outcome for the 2015–2016 CCHS cycle was self-report of receiving regular healthcare from medical doctors, chiropractors, physiotherapists, or nurses, based on three CCHS questions:
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“Do you have a regular healthcare provider? (one health professional that you regularly see or talk to when you need care or advice for your health)” (responding “yes”);
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“Is that regular healthcare provider a …” with response options of ‘family doctor/general practitioner’, ‘medical specialist’, ‘nurse’, or ‘other’;
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“Other than from the above regular healthcare provider, who else do you receive regular healthcare from (regular healthcare can also be considered as routine healthcare)?” with 10 response options that listed different healthcare providers.
Outcome of receiving regular care from medical doctors (including specialists) included “family doctor/general practitioner” or “medical specialist” response options from question #2; or “another family doctor/general practitioner” or “specialist doctor” from question #3. Outcome of regular care from chiropractors or physiotherapists was based on the response “chiropractor” or “physiotherapist”, respectively from question #3. Outcome of regular care from nurses was based on the response “nurse” from question #2 or “another nurse or nurse practitioner” from question #3. Previous studies used these questions to describe healthcare utilization in Canada (Lim et al., 2006; Bath et al., 2018; Nehumba et al., 2022; Ravichandiran et al., 2022).
2.5. Covariates
Informed by literature, (Côté et al., 2001, 2005; Lim et al., 2006; Bath et al., 2018) the following were hypothesized to be associated with healthcare utilization (Appendix A.1):
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Sociodemographic: age, sex, province/territory of residence, cultural/racial background, immigrant status, education, income, working status, marital status.
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Health-related: body mass index (BMI), self-perceived general health.
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Behavioural: smoking status, alcohol drinking status, physical activity level.
CCHS cycle was included in the models to assess differences in the prevalence of healthcare utilization over time.
2.6. Analysis
The 12-month prevalence of utilization of healthcare providers was calculated as the number of respondents with back problems who consulted (or received regular care from) a specific healthcare provider, divided by all respondents with back problems. Similarly, the sociodemographic, health-related and behavioural-specific prevalence estimates were calculated. In calculating prevalence of healthcare utilization with different providers, participants with missing data for each outcome of interest were excluded (<1%).
Univariable and multivariable modified Poisson regression models were conducted to assess factors (sociodemographic, health-related, and behavioural factors as independent variables) associated with consultation with each healthcare provider (dependent variable) to calculate crude and adjusted prevalence ratios (PR) and 95% confidence intervals (CI). All stated variables were kept in the multivariable model. In regression analyses, participants with missing data across all covariates were excluded (<10%), except household income, working status, and BMI (‘not applicable’/‘not stated’ category for these variables).
All analyses incorporated the CCHS survey weights provided by Statistics Canada to generate population estimates, and bootstrap weights were applied using balanced repeated replication (for 2015/2016). A pooled approach was used to combine data across CCHS cycles to increase sample size and statistical power (Thomas and Wannell, 2009). Analyses were performed using SAS software, version 9.4 (SAS Institute, Cary, NC).
3. Results
3.1. Sample characteristics
A total of 875,371 Canadians participated in the CCHS between 2001–2010 and 2015/2016 (Appendix A.2-A.3). After applying exclusions (no self-reported back problem or invalid response to back problem question), the study sample included 135,202 CCHS participants with chronic back problems between 2001 and 2010 (weighted to population of 5.2 million) and 22,836 participants in 2015/2016 (weighted to population of 5.7 million).
Among Canadians with chronic back problems in 2001–2010, 53% were female, 31% were aged 35–49 years, 28% aged 50–64 years, and 15% aged 65–79 years (Table 1). Most were white (84%), non-immigrant (78%), had post-secondary education (59%), worked in the past week (53%), non-smoker (72%), regular alcohol drinker (≥1 drink per month; 60%), physically inactive (53%), and overweight/obese (51%). For self-perceived general health, 23% reported fair/poor, 34% good, 31% very good, and 12% excellent.
Table 1.
Characteristics of participants with chronic back problems and those who consulted health professionals: Pooled analysis of CCHS 2001–2010a.
| Consultations with health care professionals among Canadians with chronic back problems |
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|---|---|---|---|---|---|
| Characteristics | Canadians with chronic back problems |
Medical doctor (incl. specialists) |
Chiropractor |
Physiotherapist |
Nurse |
| N (%) | n (%) | n (%) | n (%) | n (%) | |
| Weighted sample | 5,177,667 (100.0%) | 4526363 (100.0%) | 1241766 (100.0%) | 890651 (100.0%) | 721282 (100.0%) |
| Age group (years) | |||||
| 12–19 | 153438 (3.0%) | 125209 (2.8%) | 47066 (3.8%) | 28947 (3.3%) | 24962 (3.5%) |
| 20–34 | 968514 (18.7%) | 812281 (17.9%) | 269312 (21.7%) | 173950 (19.5%) | 167283 (23.2%) |
| 35–49 | 1626494 (31.4%) | 1379564 (30.5%) | 447672 (36.1%) | 306642 (34.4%) | 211681 (29.3%) |
| 50–64 | 1460551 (28.2%) | 1308727 (28.9%) | 331597 (26.7%) | 248698 (27.9%) | 175153 (24.3%) |
| 65–79 | 753250 (14.5%) | 699565 (15.5%) | 123002 (9.9%) | 106262 (11.9%) | 98022 (13.6%) |
| ≥80 | 215419 (4.2%) | 201017 (4.4%) | 23117 (1.9%) | 26151 (2.9%) | 44181 (6.1%) |
| Sex | |||||
| Male | 2438085 (47.1%) | 2013342 (44.5%) | 588977 (47.4%) | 389595 (43.7%) | 275162 (38.1%) |
| Female | 2739582 (52.9%) | 2513021 (55.5%) | 652789 (52.6%) | 501056 (56.3%) | 446120 (61.9%) |
| Province of residence | |||||
| Newfoundland | 84353 (1.6%) | 77341 (1.7%) | 10040 (0.8%) | 12048 (1.4%) | 11555 (1.6%) |
| Prince Edward Island | 21198 (0.4%) | 18993 (0.4%) | 2249 (0.2%) | 3695 (0.4%) | 2883 (0.4%) |
| Nova Scotia | 168551 (3.3%) | 153705 (3.4%) | 19314 (1.6%) | 31587 (3.5%) | 20355 (2.8%) |
| New Brunswick | 129342 (2.5%) | 115795 (2.6%) | 16388 (1.3%) | 21628 (2.4%) | 18547 (2.6%) |
| Quebec | 1056063 (20.4%) | 885565 (19.6%) | 189526 (15.3%) | 165162 (18.5%) | 197753 (27.4%) |
| Ontario | 2066139 (39.9%) | 1828734 (40.4%) | 495368 (39.9%) | 334286 (37.5%) | 272115 (37.7%) |
| Manitoba | 180427 (3.5%) | 155209 (3.4%) | 62197 (5.0%) | 34326 (3.9%) | 22581 (3.1%) |
| Saskatchewan | 161018 (3.1%) | 142343 (3.1%) | 50890 (4.1%) | 25927 (2.9%) | 20767 (2.9%) |
| Alberta | 531226 (10.3%) | 460435 (10.2%) | 181675 (14.6%) | 101540 (11.4%) | 67923 (9.4%) |
| British Columbia | 766805 (14.8%) | 678097 (15.0%) | 212221 (17.1%) | 158228 (17.8%) | 82749 (11.5%) |
| Yukon, Northwest Territories and Nunavut | 12545 (0.2%) | 10146 (0.2%) | 1901 (0.2%) | 2225 (0.2%) | 4053 (0.6%) |
| Cultural/racial background | |||||
| White | 4360237 (84.2%) | 3822806 (84.5%) | 1092830 (88.0%) | 737787 (82.8%) | 624629 (86.6%) |
| Non-white | 675691 (13.1%) | 586093 (12.9%) | 124226 (10.0%) | 128547 (14.4%) | 77099 (10.7%) |
| Unknown | 141738 (2.7%) | 117464 (2.6%) | 24710 (2.0%) | 24317 (2.7%) | 19554 (2.7%) |
| Immigrant status | |||||
| Non-immigrant | 4038148 (78.0%) | 3518140 (77.7%) | 1034807 (83.3%) | 687048 (77.1%) | 605343 (83.9%) |
| Immigrant (0–9 years) | 171453 (3.3%) | 147083 (3.2%) | 29401 (2.4%) | 33412 (3.8%) | 15476 (2.1%) |
| Immigrant (≥10 years) | 845610 (16.3%) | 760598 (16.8%) | 157006 (12.6%) | 149763 (16.8%) | 83938 (11.6%) |
| Unknown | 122456 (2.4%) | 100541 (2.2%) | 20551 (1.7%) | 20427 (2.3%) | 16526 (2.3%) |
| Highest level of education | |||||
| Less than secondary | 1165673 (22.5%) | 1011138 (22.3%) | 201898 (16.3%) | 147950 (16.6%) | 156275 (21.7%) |
| Secondary graduate | 850607 (16.4%) | 735072 (16.2%) | 210912 (17.0%) | 133909 (15.0%) | 106732 (14.8%) |
| Some post-seconday education | 404047 (7.8%) | 354856 (7.8%) | 108037 (8.7%) | 69984 (7.9%) | 62387 (8.6%) |
| Post-secondary grad/university degree | 2629333 (50.8%) | 2320633 (51.3%) | 700893 (56.4%) | 516862 (58.0%) | 379318 (52.6%) |
| Unknown | 128008 (2.5%) | 104664 (2.3%) | 20027 (1.6%) | 21944 (2.5%) | 16571 (2.3%) |
| Total household income | |||||
| 1st quintile | 695108 (13.4%) | 610630 (13.5%) | 94321 (7.6%) | 90187 (10.1%) | 116315 (16.1%) |
| 2nd quintile | 689621 (13.3%) | 603827 (13.3%) | 140445 (11.3%) | 106885 (12.0%) | 100142 (13.9%) |
| 3rd quintile | 906331 (17.5%) | 799761 (17.7%) | 221402 (17.8%) | 148084 (16.6%) | 125532 (17.4%) |
| 4th quintile | 1104385 (21.3%) | 962282 (21.3%) | 309700 (24.9%) | 206286 (23.2%) | 142809 (19.8%) |
| 5th quintile | 1033120 (20.0%) | 906477 (20.0%) | 317388 (25.6%) | 217155 (24.4%) | 134365 (18.6%) |
| NA/NSb | 749101 (14.5%) | 643385 (14.2%) | 158510 (12.8%) | 122054 (13.7%) | 102120 (14.2%) |
| Working status last week | |||||
| Working | 2753985 (53.2%) | 2333258 (51.5%) | 797090 (64.2%) | 479954 (53.9%) | 324307 (45.0%) |
| Absent | 258068 (5.0%) | 230943 (5.1%) | 71966 (5.8%) | 71471 (8.0%) | 50939 (7.1%) |
| No job | 1348962 (26.1%) | 1213741 (26.8%) | 257697 (20.8%) | 212287 (23.8%) | 197742 (27.4%) |
| Unable/permanent | 256875 (5.0%) | 244287 (5.4%) | 31433 (2.5%) | 46789 (5.3%) | 55182 (7.7%) |
| NA (age <15 or >75)b | 457744 (8.8%) | 420063 (9.3%) | 64966 (5.2%) | 61749 (6.9%) | 80798 (11.2%) |
| Unknown | 102033 (2.0%) | 84071 (1.9%) | 18614 (1.5%) | 18401 (2.1%) | 12313 (1.7%) |
| Marital status | |||||
| Married | 2809757 (54.3%) | 2496604 (55.2%) | 704692 (56.7%) | 491456 (55.2%) | 339439 (47.1%) |
| Common-law | 515814 (10.0%) | 426850 (9.4%) | 126402 (10.2%) | 87120 (9.8%) | 80845 (11.2%) |
| Widowed/Divorced/Separated | 827494 (16.0%) | 749504 (16.6%) | 153500 (12.4%) | 130003 (14.6%) | 131856 (18.3%) |
| Single | 1016061 (19.6%) | 846423 (18.7%) | 255407 (20.6%) | 180639 (20.3%) | 168040 (23.3%) |
| Unknown | 8540 (0.2%) | 6982 (0.2%) | 1765 (0.1%) | 1432 (0.2%) | 1102 (0.2%) |
| Type of smoker | |||||
| Daily | 1180476 (22.8%) | 988027 (21.8%) | 226332 (18.2%) | 166314 (18.7%) | 167293 (23.2%) |
| Occasional | 242317 (4.7%) | 207575 (4.6%) | 61874 (5.0%) | 40366 (4.5%) | 37291 (5.2%) |
| Not at all | 3736084 (72.2%) | 3315522 (73.2%) | 949823 (76.5%) | 680707 (76.4%) | 514355 (71.3%) |
| Unknown | 18789 (0.4%) | 15238 (0.3%) | 3736 (0.3%) | 3264 (0.4%) | 2344 (0.3%) |
| Type of alcohol drinker | |||||
| Regular | 3086270 (59.6%) | 2664000 (58.9%) | 815941 (65.7%) | 553295 (62.1%) | 398377 (55.2%) |
| Occasional | 942035 (18.2%) | 840294 (18.6%) | 216226 (17.4%) | 154575 (17.4%) | 143954 (20.0%) |
| Did not drink | 1070831 (20.7%) | 957915 (21.2%) | 195220 (15.7%) | 169853 (19.1%) | 169068 (23.4%) |
| Unknown | 78531 (1.5%) | 64153 (1.4%) | 14379 (1.2%) | 12927 (1.5%) | 9883 (1.4%) |
| Physical activity | |||||
| Active | 1084632 (20.9%) | 929654 (20.5%) | 301144 (24.3%) | 217750 (24.4%) | 151049 (20.9%) |
| Moderate active | 1182652 (22.8%) | 1043926 (23.1%) | 314808 (25.4%) | 216813 (24.3%) | 162665 (22.6%) |
| Inactive | 2740793 (52.9%) | 2403453 (53.1%) | 595892 (48.0%) | 428613 (48.1%) | 381677 (52.9%) |
| Unknown | 169590 (3.3%) | 149331 (3.3%) | 29923 (2.4%) | 27475 (3.1%) | 25892 (3.6%) |
| BMIc | |||||
| Underweight | 133840 (2.6%) | 118892 (2.6%) | 26602 (2.1%) | 23716 (2.7%) | 22094 (3.1%) |
| Normal weight | 1900439 (36.7%) | 1638081 (36.2%) | 462199 (37.2%) | 341051 (38.3%) | 258428 (35.8%) |
| Overweight (incl. obese) | 2626192 (50.7%) | 2317354 (51.2%) | 636533 (51.3%) | 442140 (49.6%) | 352911 (48.9%) |
| NA (age<18 or pregnant)b | 331682 (6.4%) | 288364 (6.4%) | 80259 (6.5%) | 56296 (6.3%) | 52726 (7.3%) |
| Unknown | 185515 (3.6%) | 163672 (3.6%) | 36173 (2.9%) | 27448 (3.1%) | 35123 (4.9%) |
| Perceived general health | |||||
| Poor | 355517 (6.9%) | 337329 (7.5%) | 48015 (3.9%) | 72971 (8.2%) | 87556 (12.1%) |
| Fair | 834648 (16.1%) | 773144 (17.1%) | 144947 (11.7%) | 145416 (16.3%) | 144038 (20.0%) |
| Good | 1745341 (33.7%) | 1533808 (33.9%) | 415934 (33.5%) | 298906 (33.6%) | 232624 (32.3%) |
| Very good | 1610222 (31.1%) | 1375292 (30.4%) | 447410 (36.0%) | 269426 (30.3%) | 192390 (26.7%) |
| Excellent | 625295 (12.1%) | 501447 (11.1%) | 184323 (14.8%) | 102667 (11.5%) | 63545 (8.8%) |
| Unknown | 6645 (0.1%) | 5343 (0.1%) | 1136 (0.1%) | 1265 (0.1%) | 1129 (0.2%) |
| CCHS survey cycle | |||||
| 2001 | 905678 (17.5%) | 802508 (17.7%) | 234444 (18.9%) | 161442 (18.1%) | 109379 (15.2%) |
| 2003 | 1043833 (20.2%) | 906309 (20.0%) | 250440 (20.2%) | 166935 (18.7%) | 136984 (19.0%) |
| 2005 | 1017931 (19.7%) | 882461 (19.5%) | 244313 (19.7%) | 170283 (19.1%) | 144558 (20.0%) |
| 2007 | 1129597 (21.8%) | 981872 (21.7%) | 257370 (20.7%) | 191145 (21.5%) | 164222 (22.8%) |
| 2009 | 1080627 (20.9%) | 953213 (21.1%) | 255199 (20.6%) | 200844 (22.6%) | 166139 (23.0%) |
BMI – body mass index; CCHS – Canadian Community Health Survey; NA – not applicable; NS – not stated.
Weighted using Canadian Community Health Survey sampling weights provided by Statistics Canada to provide population estimates.
NA = not applicable according to population exclusions; NS = not stated or responses without enough information for classification.
BMI = BMI categories based on classification system recommended by Health Canada and the World Health Organization.
In 2015/2016, 53% of Canadians with chronic back problems were female, with 24% aged 35–49 years, 33% aged 50–64 years, and 20% aged 65–79 years (Table 2). Most were white (77%), non-immigrant (76%), some post-secondary education (59%), non-smoker (76%), and overweight/obese (56%). For self-perceived general health, 25% rated fair/poor, 34% good, 30% very good, and 12% excellent.
Table 2.
Characteristics of participants with chronic back problems and those who received regular health care from different health professionals: CCHS 2015–2016*.
| Have received regular health care from a health professional |
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|---|---|---|---|---|---|
| Characteristics | Canadians with chronic back problems |
Medical doctor (incl. specialists) |
Chiropractor |
Physiotherapist |
Nurse |
| N (%) | n (%) | n (%) | n (%) | n (%) | |
| Weighted sample | 5679185 (100.0%) | 4850240 (100.0%) | 809276 (100.0%) | 595914 (100.0%) | 365952 (100.0%) |
| Age group (years) | |||||
| 12–19 | 152259 (2.7%) | 119563 (2.5%) | 24629 (3.0%) | 29640 (5.0%) | 6837 (1.9%) |
| 20–34 | 892353 (15.7%) | 647658 (13.4%) | 115302 (14.2%) | 82263 (13.8%) | 46453 (12.7%) |
| 35–49 | 1373547 (24.2%) | 1135529 (23.4%) | 247393 (30.6%) | 155272 (26.1%) | 72436 (19.8%) |
| 50–64 | 1855816 (32.7%) | 1626724 (33.5%) | 261024 (32.3%) | 196390 (33.0%) | 115374 (31.5%) |
| 65–79 | 1114184 (19.6%) | 1052057 (21.7%) | 142121 (17.6%) | 109735 (18.4%) | 89645 (24.5%) |
| ≥80 | 291026 (5.1%) | 268709 (5.5%) | 18806 (2.3%) | 22615 (3.8%) | 35207 (9.6%) |
| Sex | |||||
| Male | 2715722 (47.8%) | 2250817 (46.4%) | 386721 (47.8%) | 250191 (42.0%) | 150664 (41.2%) |
| Female | 2963464 (52.2%) | 2599422 (53.6%) | 422555 (52.2%) | 345723 (58.0%) | 215288 (58.8%) |
| Province of residence | |||||
| Newfoundland | 100582 (1.8%) | 93413 (1.9%) | 13010 (1.6%) | 10284 (1.7%) | 10478 (2.9%) |
| Prince Edward Island | 22574 (0.4%) | 20789 (0.4%) | 1905 (0.2%) | 2589 (0.4%) | 2009 (0.5%) |
| Nova Scotia | 191084 (3.4%) | 171468 (3.5%) | 22807 (2.8%) | 19605 (3.3%) | 16234 (4.4%) |
| New Brunswick | 138278 (2.4%) | 125175 (2.6%) | 11697 (1.4%) | 12726 (2.1%) | 10562 (2.9%) |
| Quebec | 1238378 (21.8%) | 946074 (19.5%) | 105319 (13.0%) | 107831 (18.1%) | 89354 (24.4%) |
| Ontario | 2167335 (38.2%) | 1944385 (40.1%) | 337056 (41.6%) | 226820 (38.1%) | 158167 (43.2%) |
| Manitoba | 198888 (3.5%) | 172128 (3.5%) | 37729 (4.7%) | 29604 (5.0%) | 14207 (3.9%) |
| Saskatchewan | 170695 (3.0%) | 145062 (3.0%) | 42790 (5.3%) | 25143 (4.2%) | 16161 (4.4%) |
| Alberta | 624265 (11.0%) | 522998 (10.8%) | 119163 (14.7%) | 69037 (11.6%) | 26803 (7.3%) |
| British Columbia | 808536 (14.2%) | 700736 (14.4%) | 116403 (14.4%) | 90799 (15.2%) | 19766 (5.4%) |
| Yukon, Northwest Territories and Nunavut | 18571 (0.3%) | 8011 (0.2%) | 1397 (0.2%) | 1477 (0.2%) | 2211 (0.6%) |
| Cultural/racial background | |||||
| White | 4395169 (77.4%) | 3829257 (78.9%) | 694224 (85.8%) | 471702 (79.2%) | 305286 (83.4%) |
| Non-white | 1075890 (18.9%) | 899948 (18.6%) | 102901 (12.7%) | 114344 (19.2%) | 53449 (14.6%) |
| Unknown | 208126 (3.7%) | 121035 (2.5%) | 12151 (1.5%) | 9868 (1.7%) | 7217 (2.0%) |
| Immigrant status | |||||
| Non-immigrant | 4304899 (75.8%) | 3701523 (76.3%) | 680146 (84.0%) | 450169 (75.5%) | 306714 (83.8%) |
| Immigrant (0–9 years) | 193228 (3.4%) | 142566 (2.9%) | 13404 (1.7%) | 11999 (2.0%) | 4387 (1.2%) |
| Immigrant (≥10 years) | 947396 (16.7%) | 861467 (17.8%) | 103065 (12.7%) | 123686 (20.8%) | 46365 (12.7%) |
| Unknown | 233661 (4.1%) | 144684 (3.0%) | 12662 (1.6%) | 10059 (1.7%) | 8486 (2.3%) |
| Highest level of education | |||||
| Less than secondary | 975414 (17.2%) | 826317 (17.0%) | 95632 (11.8%) | 66531 (11.2%) | 76841 (21.0%) |
| Secondary graduate | 1267576 (22.3%) | 1091126 (22.5%) | 171487 (21.2%) | 111558 (18.7%) | 80634 (22.0%) |
| Some post-secondary education | 3353680 (59.1%) | 2864303 (59.1%) | 536410 (66.3%) | 411405 (69.0%) | 203446 (55.6%) |
| Unknown | 82515 (1.5%) | 68494 (1.4%) | 5748 (0.7%) | 6420 (1.1%) | 5032 (1.4%) |
| Distribution of total household income | |||||
| 1st quintile | 1240789 (21.8%) | 1012543 (20.9%) | 88244 (10.9%) | 75306 (12.6%) | 88773 (24.3%) |
| 2nd quintile | 1181106 (20.8%) | 991814 (20.4%) | 123704 (15.3%) | 94629 (15.9%) | 74974 (20.5%) |
| 3rd quintile | 1193127 (21.0%) | 1032125 (21.3%) | 171377 (21.2%) | 127630 (21.4%) | 75242 (20.6%) |
| 4th quintile | 1020416 (18.0%) | 891798 (18.4%) | 197883 (24.5%) | 135374 (22.7%) | 67597 (18.5%) |
| 5th quintile | 1022285 (18.0%) | 911537 (18.8%) | 226421 (28.0%) | 160646 (27.0%) | 56624 (15.5%) |
| NA (residents of territories)b | 18211 (0.3%) | 8011 (0.2%) | 1397 (0.2%) | 1477 (0.2%) | 2135 (0.6%) |
| Unknown | 3251 (0.1%) | 2411 (0.0%) | 251 (0.0%) | 853 (0.1%) | 607 (0.2%) |
| Working status last week | |||||
| Working | 2796283 (49.2%) | 2321209 (47.9%) | 493565 (61.0%) | 313329 (52.6%) | 134063 (36.6%) |
| Absent | 298633 (5.3%) | 256158 (5.3%) | 59560 (7.4%) | 47310 (7.9%) | 21981 (6.0%) |
| No job | 1866849 (32.9%) | 1667869 (34.4%) | 200489 (24.8%) | 179585 (30.1%) | 149232 (40.8%) |
| NA (age <15 or >75)b | 579002 (10.2%) | 537273 (11.1%) | 50800 (6.3%) | 51199 (8.6%) | 57003 (15.6%) |
| Unknown | 138418 (2.4%) | 67732 (1.4%) | 4863 (0.6%) | 4491 (0.8%) | 3673 (1.0%) |
| Marital status | |||||
| Married | 2859623 (50.4%) | 2566505 (52.9%) | 476423 (58.9%) | 319133 (53.6%) | 183297 (50.1%) |
| Common-law | 712836 (12.6%) | 582761 (12.0%) | 101484 (12.5%) | 68106 (11.4%) | 43835 (12.0%) |
| Widowed/Divorced/Separated | 948310 (16.7%) | 839801 (17.3%) | 100308 (12.4%) | 96165 (16.1%) | 74259 (20.3%) |
| Single | 1144408 (20.2%) | 850426 (17.5%) | 129203 (16.0%) | 110526 (18.5%) | 64341 (17.6%) |
| Unknown | 14008 (0.2%) | 10746 (0.2%) | 1858 (0.2%) | 1983 (0.3%) | 221 (0.1%) |
| Type of smoker | |||||
| Daily | 1056320 (18.6%) | 836916 (17.3%) | 88733 (11.0%) | 57430 (9.6%) | 67593 (18.5%) |
| Occasional | 280471 (4.9%) | 219923 (4.5%) | 41963 (5.2%) | 37611 (6.3%) | 21830 (6.0%) |
| Not at all | 4338906 (76.4%) | 3791715 (78.2%) | 678436 (83.8%) | 500760 (84.0%) | 276157 (75.5%) |
| Unknown | 3489 (0.1%) | 1685 (0.0%) | 144 (0.0%) | 112 (0.0%) | 372 (0.1%) |
| Type of alcohol drinker | |||||
| Regular | 3457259 (60.9%) | 2927937 (60.4%) | 582371 (72.0%) | 385246 (64.6%) | 198011 (54.1%) |
| Occasional | 987033 (17.4%) | 844644 (17.4%) | 106322 (13.1%) | 93314 (15.7%) | 80157 (21.9%) |
| Did not drink | 1207389 (21.3%) | 1057028 (21.8%) | 118231 (14.6%) | 113835 (19.1%) | 85591 (23.4%) |
| Unknown | 27505 (0.5%) | 20631 (0.4%) | 2353 (0.3%) | 3520 (0.6%) | 2193 (0.6%) |
| Physical activity | |||||
| Active | 2946824 (51.9%) | 2485971 (51.3%) | 480747 (59.4%) | 328,301 (55.1%) | 182,393 (49.8%) |
| Moderate active | 1207048 (21.3%) | 1038834 (21.4%) | 170,454 (21.1%) | 124,390 (20.9%) | 75,734 (20.7%) |
| Inactive | 1306891 (23.0%) | 1144331 (23.6%) | 128,721 (15.9%) | 112,182 (18.8%) | 95,348 (26.1%) |
| NA (age <18)b | 94,521 (1.7%) | 75,639 (1.6%) | 16,195 (2.0%) | 19,068 (3.2%) | 5135 (1.4%) |
| Unknown | 123,901 (2.2%) | 105,464 (2.2%) | 13,160 (1.6%) | 11,973 (2.0%) | 7342 (2.0%) |
| BMIc | |||||
| Underweight | 92,489 (1.6%) | 72,874 (1.5%) | 9753 (1.2%) | 3179 (0.5%) | 8926 (2.4%) |
| Normal weight | 1922755 (33.9%) | 1578804 (32.6%) | 261,141 (32.3%) | 210,287 (35.3%) | 95,985 (26.2%) |
| Overweight (incl. obese) | 3168292 (55.8%) | 2758962 (56.9%) | 487,465 (60.2%) | 329,036 (55.2%) | 221,391 (60.5%) |
| NA (age<18 or pregnant)b | 95,524 (1.7%) | 76,579 (1.6%) | 16,548 (2.0%) | 19,443 (3.3%) | 5135 (1.4%) |
| Unknown | 400,125 (7.0%) | 363,021 (7.5%) | 34,369 (4.2%) | 33,969 (5.7%) | 34,515 (9.4%) |
| Perceived general health | |||||
| Poor | 462,785 (8.1%) | 416,092 (8.6%) | 33,668 (4.2%) | 48,088 (8.1%) | 54,794 (15.0%) |
| Fair | 943,777 (16.6%) | 817,537 (16.9%) | 92,614 (11.4%) | 95,642 (16.0%) | 72,685 (19.9%) |
| Good | 1925078 (33.9%) | 1657109 (34.2%) | 282,295 (34.9%) | 213,201 (35.8%) | 132,345 (36.2%) |
| Very good | 1683598 (29.6%) | 1411123 (29.1%) | 292,084 (36.1%) | 171,514 (28.8%) | 81,615 (22.3%) |
| Excellent | 654,091 (11.5%) | 541,941 (11.2%) | 108,088 (13.4%) | 67,286 (11.3%) | 23,780 (6.5%) |
| Unknown | 9855 (0.2%) | 6437 (0.1%) | 527 (0.1%) | 184 (0.0%) | 734 (0.2%) |
BMI – body mass index; CCHS – Canadian Community Health Survey; NA – not applicable; NS – not stated.
a Weighted using Canadian Community Health Survey sampling weights provided by Statistics Canada to provide population estimates.
NA = not applicable according to population exclusions; NS = not stated or responses without enough information for classification.
BMI=BMI categories based on classification system recommended by Health Canada and the World Health Organization.
3.2. Prevalence of healthcare provider consultation
From 2001 to 2010, 12-month prevalence of consultation with medical doctors was 87.9% (95% CI 87.6–88.2), chiropractors 24.0% (95% CI 23.6–24.4), physiotherapists 17.2% (95% CI 16.9–17.6), and nurses 14.0% (95% CI 13.7–14.2) (Appendix A.4). Prevalence of consultation with different providers varied by certain sociodemographic, health-related, and behavioural characteristics (Appendix A.4). When stratified by region (provinces/territories), prevalence of consultation with medical doctors ranged 81.1–92.0%; chiropractors ranged 10.6–34.5%; physiotherapists ranged 14.3–20.7%; and nurses ranged 10.8–32.4%. Prevalence of consultation with healthcare providers was greater with higher education levels (higher than secondary graduate) across all providers. Across most providers, prevalence of healthcare consultation was higher in females (except chiropractors), white populations (except physiotherapists), and poor self-perceived general health (except chiropractors).
3.3. Prevalence of receiving care from regular healthcare provider
In 2015/2016, prevalence of receiving regular healthcare from medical doctors was 86.7% (95% CI 85.8–87.6), chiropractors 14.5% (95% CI 13.7–15.3), physiotherapists 10.7% (95% CI 10.0–11.4), and nurses 6.6% (95% CI 6.1–7.0) (Appendix A.5). Prevalence of receiving regular care varied by certain sociodemographic, health-related, and behavioural characteristics (Appendix A.5). When stratified by region, prevalence of regular care from medicals doctor ranged 43.5–92.9%; chiropractors ranged 7.6–25.4%; physiotherapists ranged 8.0–15.0%; and nurses ranged 2.5–12.0%. Across most providers, prevalence of receiving regular care was higher in females (except chiropractors), white populations (except physiotherapists), higher income (except nurses), poor general health (except chiropractors and physiotherapists).
3.4. Factors associated with consultation with specific healthcare provider
Across all healthcare providers in regression analyses, females were more likely to consult a provider than males (ranged PRchiropractor = 1.06, 95% CI 1.02–1.09 to PRnurse = 1.37, 95% CI 1.31–1.44) (Table 3).
Table 3.
Regression analysis of the association between personal characteristics and self-reported consultations with health professionals among Canadians with chronic back problems: Pooled analysis of CCHS 2001–2010a.
| Medical doctor (including specialists) |
Chiropractor |
Physiotherapist |
Nurse |
|||||
|---|---|---|---|---|---|---|---|---|
| Characteristics | Crude PR (95% CI) | PR (95% CI)c | Crude PR (95% CI) | PR (95% CI)c | Crude PR (95% CI) | PR (95% CI)c | Crude PR (95% CI) | PR (95% CI)c |
| Age group (years) | ||||||||
| 12–19 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| 20–34 | 1.03(1.00–1.05) | 1.00(0.97–1.03) | 0.91(0.84–0.98) | 0.86(0.77–0.96) | 0.95(0.86–1.05) | 0.91(0.79–1.05) | 1.06(0.95–1.17) | 1.15(1.00–1.33) |
| 35–49 | 1.04(1.01–1.06) | 1.00(0.97–1.03) | 0.90(0.83–0.96) | 0.84(0.75–0.94) | 1.00(0.91–1.10) | 0.93(0.81–1.07) | 0.80(0.72–0.88) | 0.88(0.76–1.02) |
| 50–64 | 1.10(1.07–1.12) | 1.03(1.00–1.06) | 0.74(0.69–0.80) | 0.73(0.65–0.82) | 0.90(0.82–0.99) | 0.82(0.71–0.95) | 0.74(0.66–0.82) | 0.73(0.62–0.84) |
| 65–79 | 1.14(1.12–1.17) | 1.06(1.03–1.09) | 0.53(0.49–0.58) | 0.61(0.54–0.68) | 0.75(0.68–0.83) | 0.72(0.63–0.83) | 0.80(0.72–0.89) | 0.72(0.62–0.83) |
| ≥80 | 1.16(1.13–1.18) | 1.08(1.05–1.11) | 0.35(0.31–0.39) | 0.42(0.36–0.49) | 0.64(0.57–0.73) | 0.70(0.59–0.84) | 1.26(1.13–1.41) | 0.97(0.82–1.15) |
| Sex | ||||||||
| Male | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Female | 1.11(1.11–1.12) | 1.11(1.10–1.12) | 0.99(0.96–1.02) | 1.06(1.02–1.09) | 1.14(1.10–1.19) | 1.19(1.14–1.25) | 1.44(1.38–1.51) | 1.37(1.31–1.44) |
| Province of residence | ||||||||
| Newfoundland | 1.03(1.02–1.05) | 1.03(1.02–1.05) | 0.50(0.44–0.56) | 0.49(0.43–0.55) | 0.88(0.79–0.99) | 0.97(0.86–1.10) | 1.04(0.93–1.16) | 0.93(0.82–1.05) |
| Prince Edward Island | 1.01(0.99–1.03) | 1.02(1.00–1.04) | 0.44(0.37–0.53) | 0.43(0.35–0.52) | 1.08(0.94–1.23) | 1.21(1.06–1.38) | 1.03(0.89–1.19) | 0.96(0.82–1.12) |
| Nova Scotia | 1.03(1.01–1.04) | 1.02(1.01–1.03) | 0.48(0.43–0.53) | 0.48(0.43–0.54) | 1.16(1.06–1.27) | 1.23(1.12–1.35) | 0.92(0.83–1.01) | 0.82(0.74–0.91) |
| New Brunswick | 1.01(0.99–1.02) | 1.01(0.99–1.02) | 0.53(0.48–0.58) | 0.53(0.47–0.58) | 1.03(0.94–1.13) | 1.11(1.01–1.22) | 1.09(0.99–1.19) | 0.96(0.87–1.06) |
| Quebec | 0.94(0.93–0.95) | 0.96(0.95–0.97) | 0.75(0.71–0.79) | 0.72(0.68–0.76) | 0.97(0.91–1.03) | 1.00(0.94–1.07) | 1.42(1.35–1.50) | 1.37(1.29–1.45) |
| Ontario | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Manitoba | 0.97(0.96–0.99) | 0.98(0.97–1.00) | 1.44(1.36–1.53) | 1.39(1.31–1.48) | 1.18(1.08–1.28) | 1.27(1.16–1.39) | 0.95(0.86–1.05) | 0.92(0.83–1.02) |
| Saskatchewan | 1.00(0.99–1.01) | 1.01(0.99–1.02) | 1.32(1.25–1.39) | 1.25(1.18–1.32) | 1.00(0.91–1.08) | 1.05(0.96–1.15) | 0.98(0.90–1.07) | 0.91(0.83–1.00) |
| Alberta | 0.98(0.97–0.99) | 0.99(0.98–1.00) | 1.43(1.36–1.50) | 1.32(1.26–1.39) | 1.18(1.10–1.27) | 1.18(1.10–1.27) | 0.97(0.90–1.05) | 0.95(0.87–1.02) |
| British Columbia | 1.00(0.99–1.01) | 1.00(0.99–1.01) | 1.16(1.11–1.21) | 1.12(1.07–1.17) | 1.28(1.21–1.35) | 1.26(1.19–1.33) | 0.82(0.77–0.88) | 0.81(0.75–0.87) |
| Yukon, Northwest Territories and Nunavut | 0.91(0.88–0.94) | 0.95(0.92–0.98) | 0.63(0.55–0.72) | 0.64(0.55–0.73) | 1.09(0.97–1.24) | 1.14(1.00–1.31) | 2.46(2.25–2.67) | 2.47(2.23–2.74) |
| Cultural/racial background | ||||||||
| White | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Non-white | 0.99(0.98–1.01) | 1.00(0.98–1.01) | 0.73(0.69–0.79) | 0.80(0.74–0.86) | 1.12(1.05–1.20) | 1.10(1.02–1.19) | 0.80(0.74–0.86) | 0.90(0.83–0.99) |
| Immigrant status | ||||||||
| Non-immigrant | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Immigrant (0–9 years) | 0.99(0.97–1.01) | 1.00(0.97–1.02) | 0.67(0.58–0.78) | 0.73(0.62–0.85) | 1.15(1.00–1.31) | 1.11(0.96–1.29) | 0.60(0.50–0.72) | 0.54(0.44–0.66) |
| Immigrant (≥10 years) | 1.04(1.03–1.05) | 1.00(0.99–1.01) | 0.72(0.68–0.77) | 0.81(0.77–0.86) | 1.04(0.98–1.11) | 1.05(0.98–1.12) | 0.66(0.61–0.72) | 0.70(0.64–0.77) |
| Highest level of education | ||||||||
| Less than secondary | 0.99(0.98–1.00) | 0.96(0.95–0.97) | 0.65(0.62–0.68) | 0.85(0.81–0.89) | 0.65(0.61–0.68) | 0.72(0.67–0.76) | 0.93(0.89–0.98) | 0.74(0.70–0.79) |
| Secondary graduate | 0.98(0.97–0.99) | 0.97(0.96–0.98) | 0.93(0.89–0.97) | 0.96(0.92–1.00) | 0.80(0.76–0.85) | 0.84(0.79–0.90) | 0.87(0.82–0.93) | 0.85(0.79–0.90) |
| Some post-secondary education | 1.00(0.98–1.01) | 1.00(0.99–1.01) | 1.00(0.95–1.06) | 1.03(0.97–1.09) | 0.88(0.82–0.95) | 0.90(0.84–0.97) | 1.07(0.99–1.16) | 0.96(0.89–1.04) |
| Post-secondary grad/university degree | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Total household income | ||||||||
| 1st quintile | 1.01(1.00–1.02) | 0.96(0.95–0.98) | 0.44(0.41–0.47) | 0.68(0.63–0.74) | 0.62(0.57–0.67) | 0.60(0.54–0.65) | 1.29(1.20–1.38) | 0.91(0.83–0.99) |
| 2nd quintile | 1.00(0.99–1.01) | 0.97(0.95–0.98) | 0.66(0.62–0.70) | 0.90(0.85–0.96) | 0.74(0.68–0.79) | 0.74(0.68–0.80) | 1.12(1.04–1.20) | 0.89(0.82–0.97) |
| 3rd quintile | 1.01(1.00–1.02) | 0.99(0.97–1.00) | 0.79(0.76–0.83) | 0.98(0.93–1.04) | 0.78(0.73–0.83) | 0.79(0.74–0.85) | 1.07(0.99–1.14) | 0.92(0.85–0.99) |
| 4th quintile | 0.99(0.98–1.00) | 0.99(0.98–1.00) | 0.91(0.87–0.95) | 1.01(0.97–1.05) | 0.89(0.84–0.94) | 0.91(0.86–0.97) | 0.99(0.93–1.07) | 0.92(0.85–0.98) |
| 5th quintile | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| NA/NSb | 0.99(0.98–1.01) | 0.97(0.95–0.98) | 0.69(0.66–0.73) | 0.92(0.87–0.98) | 0.78(0.73–0.83) | 0.76(0.71–0.83) | 1.05(0.98–1.13) | 0.86(0.79–0.94) |
| Working status last week | ||||||||
| Working | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Absent | 1.06(1.04–1.07) | 1.04(1.02–1.05) | 0.96(0.90–1.03) | 1.02(0.95–1.09) | 1.59(1.48–1.71) | 1.54(1.43–1.66) | 1.68(1.54–1.82) | 1.51(1.38–1.64) |
| No job | 1.07(1.06–1.07) | 1.02(1.01–1.03) | 0.66(0.64–0.69) | 0.85(0.81–0.89) | 0.90(0.86–0.95) | 1.03(0.97–1.09) | 1.25(1.18–1.31) | 1.22(1.15–1.30) |
| Unable/permanent | 1.13(1.12–1.14) | 1.07(1.06–1.08) | 0.42(0.38–0.47) | 0.69(0.62–0.78) | 1.05(0.96–1.14) | 1.18(1.06–1.32) | 1.83(1.70–1.97) | 1.46(1.33–1.59) |
| NA (age <15 or >75)b | 1.10(1.09–1.11) | 1.01(0.99–1.02) | 0.49(0.46–0.52) | 0.84(0.76–0.92) | 0.78(0.73–0.83) | 0.96(0.86–1.07) | 1.51(1.42–1.60) | 1.29(1.15–1.44) |
| Marital status | ||||||||
| Married | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Common-law | 0.93(0.92–0.94) | 0.97(0.95–0.98) | 0.98(0.93–1.03) | 0.98(0.92–1.03) | 0.97(0.90–1.04) | 1.00(0.93–1.08) | 1.30(1.21–1.39) | 1.04(0.96–1.12) |
| Widowed/Divorced/Separated | 1.02(1.02–1.03) | 0.99(0.98–1.00) | 0.74(0.71–0.77) | 0.98(0.93–1.03) | 0.90(0.85–0.95) | 1.04(0.98–1.10) | 1.32(1.25–1.39) | 1.10(1.04–1.17) |
| Single | 0.94(0.93–0.95) | 0.98(0.96–0.99) | 1.00(0.96–1.04) | 0.94(0.90–0.99) | 1.02(0.97–1.07) | 1.04(0.98–1.10) | 1.37(1.30–1.44) | 1.11(1.04–1.19) |
| Type of smoker | ||||||||
| Daily | 0.94(0.93–0.95) | 0.96(0.95–0.97) | 0.75(0.72–0.79) | 0.75(0.72–0.79) | 0.77(0.73–0.82) | 0.79(0.74–0.84) | 1.03(0.98–1.08) | 0.95(0.90–1.01) |
| Occasional | 0.97(0.95–0.98) | 0.99(0.98–1.01) | 1.00(0.93–1.08) | 0.92(0.85–0.99) | 0.91(0.83–1.01) | 0.87(0.78–0.97) | 1.12(1.02–1.23) | 1.05(0.95–1.16) |
| Not at all | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Type of alcohol drinker | ||||||||
| Regular | 0.96(0.95–0.96) | 1.00(1.00–1.01) | 1.45(1.38–1.52) | 1.07(1.02–1.13) | 1.13(1.07–1.19) | 1.10(1.04–1.17) | 0.82(0.78–0.86) | 0.93(0.88–0.98) |
| Occasional | 0.99(0.98–1.00) | 1.00(0.99–1.01) | 1.26(1.19–1.33) | 1.06(1.00–1.12) | 1.03(0.97–1.10) | 1.03(0.96–1.10) | 0.97(0.91–1.02) | 0.99(0.93–1.06) |
| Did not drink | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Physical activity | ||||||||
| Active | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Moderate active | 1.03(1.02–1.04) | 1.01(1.00–1.02) | 0.96(0.92–1.00) | 1.00(0.96–1.05) | 0.91(0.86–0.97) | 0.91(0.86–0.96) | 0.99(0.93–1.05) | 0.95(0.89–1.02) |
| Inactive | 1.03(1.02–1.04) | 0.99(0.98–1.00) | 0.78(0.75–0.81) | 0.95(0.91–0.99) | 0.78(0.74–0.82) | 0.82(0.78–0.86) | 1.00(0.95–1.06) | 0.89(0.83–0.94) |
| BMI | ||||||||
| Underweight | 1.04(1.02–1.05) | 1.02(1.00–1.04) | 0.82(0.73–0.91) | 0.88(0.79–0.99) | 0.99(0.88–1.12) | 0.98(0.87–1.11) | 1.21(1.08–1.37) | 1.01(0.90–1.14) |
| Normal weight | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Overweight (incl. obese) | 1.02(1.02–1.03) | 1.02(1.01–1.02) | 1.00(0.96–1.03) | 1.01(0.98–1.05) | 0.94(0.90–0.98) | 0.95(0.91–1.00) | 0.99(0.94–1.04) | 1.02(0.97–1.07) |
| NA (age<18 or pregnant)b | 1.01(1.00–1.02) | 0.99(0.97–1.01) | 1.00(0.94–1.06) | 1.11(1.02–1.21) | 0.95(0.88–1.02) | 1.09(0.98–1.21) | 1.17(1.09–1.26) | 1.10(0.99–1.22) |
| Perceived general health | ||||||||
| Poor | 1.20(1.19–1.22) | 1.18(1.16–1.20) | 0.46(0.42–0.50) | 0.78(0.71–0.86) | 1.25(1.15–1.37) | 1.77(1.60–1.96) | 2.43(2.23–2.66) | 2.62(2.36–2.90) |
| Fair | 1.16(1.15–1.18) | 1.15(1.13–1.17) | 0.59(0.55–0.63) | 0.85(0.79–0.91) | 1.06(0.98–1.15) | 1.43(1.31–1.57) | 1.70(1.56–1.85) | 1.88(1.72–2.07) |
| Good | 1.10(1.08–1.11) | 1.10(1.08–1.11) | 0.81(0.77–0.85) | 0.95(0.90–1.00) | 1.04(0.97–1.12) | 1.22(1.13–1.31) | 1.31(1.21–1.43) | 1.40(1.28–1.52) |
| Very good | 1.07(1.05–1.08) | 1.06(1.05–1.08) | 0.94(0.90–0.99) | 0.97(0.92–1.02) | 1.02(0.95–1.10) | 1.06(0.98–1.14) | 1.18(1.08–1.28) | 1.19(1.09–1.30) |
| Excellent | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| CCHS survey cycle | ||||||||
| Every two-year increase | 1.00(1.00–1.00) | 1.00(1.00–1.00) | 0.98(0.97–0.99) | 1.02(1.00–1.03) | 1.02(1.00–1.03) | 1.04(1.02–1.06) | 1.06(1.04–1.07) | 1.06(1.04–1.08) |
BMI – body mass index; CCHS – Canadian Community Health Survey; CI – confidence interval; NA – not applicable; NS – not stated; PR – prevalence ratio.
Weighted using Canadian Community Health Survey sampling weights provided by Statistics Canada to provide population estimates; public use microdata file used (without bootstrap weights; only scaled sampling weight applied).
NA = not applicable according to population exclusions; NS = not stated or responses without enough information for classification.
Multivariable modified Poisson regression model adjusted for age, sex, province, cultural/racial background, immigrant status, education, income, working status, marital status, smoking status, alcohol consumption, physical activity, BMI, perceived general health, CCHS cycle.
Medical doctor. We observed a positive association with age, with older ages more likely to consult medical doctors than 12–19 years (PR65–79years = 1.06, 95% CI 1.03–1.09; PR ≥ 80years = 1.08, 95% CI 1.05–1.11) (Table 3). No differences were observed across sociodemographic or behavioural factors. Those with fair/poor (PRfair = 1.15, 95% CI 1.13–1.17; PRpoor = 1.18, 95% CI 1.16–1.20) general health were more likely to consult medical doctors. Prevalence of consultation with medical doctors was stable over time (PR = 1.00, 95% CI 1.00–1.00).
Chiropractor. Older age groups were less likely to consult chiropractors than 12–19 years (PR65–79years = 0.61, 95% CI 0.54–0.68; PR ≥ 80years = 0.42, 95% CI 0.36–0.49) (Table 3). The following were less likely to consult chiropractors: non-White (PR = 0.80, 95% CI 0.74–0.86), immigrants (PR 0.73–0.81), less than secondary education (PR = 0.85, 95% CI 0.81–0.89), lower income (PR 0.68–0.90), no job or unable/permanently off work (PR 0.69–0.85), or smoker (PR 0.75–0.92). Those reporting fair/poor (PRfair = 0.85, 95% CI 0.79–0.91; PRpoor = 0.78, 95% CI 0.71–0.86) general health were less likely to consult chiropractors. Prevalence of consultation with chiropractors was stable over time (PR = 1.02, 95% CI 1.00–1.03).
Physiotherapist. Older ages were less likely to consult physiotherapists than 12–19 years (PR65–79years = 0.72, 95% CI 0.63–0.83; PR ≥ 80years = 0.70, 95% CI 0.59–0.84) (Table 3). Persons who were non-white (PR = 1.10, 95% CI 1.10–1.19), absent or unable/permanently off work (PR 1.18–1.54) were more likely to consult physiotherapists. Persons with less than secondary education (PR = 0.72, 95% CI 0.67–0.76), lower income (PR 0.60–0.74), smokers (PR 0.79–0.87), or physical inactive (PR = 0.82, 95% CI 0.78–0.86) were less likely to consult physiotherapists. Individuals reporting fair/poor (PRfair = 1.43, 95% CI 1.31–1.57; PRpoor = 1.77, 95% CI 1.60–1.96) general health were more likely to consult physiotherapists. Prevalence of consultation with physiotherapists increased by 4% every two years (PR = 1.02, 95% CI 1.02–1.06).
Nurse. Individuals aged 50–79 years were less likely to consult nurses than 12–19 years (PR50–64years = 0.73, 95% CI 0.62–0.84; PR65–79 years = 0.72, 95% CI 0.62–0.83) (Table 3). The following were less likely to consult nurses: non-white (PR = 0.90, 95% CI 0.83–0.99), immigrants (PR 0.54–0.70), less than secondary education (PR = 0.74, 95% CI 0.70–0.79), lower income (PR 0.89–0.91), not working (PR 1.22–1.51), or physically inactive (PR = 0.89, 95% CI 0.83–0.94). Individuals reporting fair/poor (PRfair = 1.88, 95% CI 1.72–2.07; PRpoor = 2.62, 95% CI 2.36–2.90) health were more likely to consult nurses. Prevalence of consultation with nurses increased by 6% every two years (PR = 1.06, 95% CI 1.04–1.08).
3.5. Factors associated with receiving care from regular healthcare provider
Across all providers in regression analyses, females were more likely to consult a provider than males (ranged PRmedical doctor = 1.06, 95% CI 1.04–1.09 to PRnurse = 1.31, 95% CI 1.11–1.55) (Table 4).
Table 4.
Regression analysis of the association between personal characteristics and regular health care utilization among Canadians with chronic back problems: CCHS 2015–2016.
| Medical doctor (including specialists) |
Chiropractor |
Physiotherapist |
Nurse |
|||||
|---|---|---|---|---|---|---|---|---|
| Characteristics | Crude PR (95% CI) | PR (95% CI)c | Crude PR (95% CI) | PR (95% CI)c | Crude PR (95% CI) | PR (95% CI)c | Crude PR (95% CI) | PR (95% CI)c |
| Age group (years) | ||||||||
| 12–19 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| 20–34 | 0.92(0.86–0.98) | 0.89(0.78–1.01) | 0.80(0.59–1.08) | 0.60(0.40–0.91) | 0.47(0.34–0.66) | 0.42(0.23–0.78) | 1.15(0.71–1.89) | 1.57(0.58–4.23) |
| 35–49 | 1.05(0.99–1.12) | 0.97(0.85–1.10) | 1.12(0.83–1.50) | 0.77(0.55–1.08) | 0.58(0.42–0.81) | 0.45(0.25–0.82) | 1.18(0.73–1.91) | 1.63(0.60–4.48) |
| 50–64 | 1.12(1.05–1.19) | 1.01(0.89–1.15) | 0.88(0.66–1.17) | 0.64(0.43–0.94) | 0.55(0.40–0.75) | 0.40(0.22–0.73) | 1.39(0.88–2.22) | 1.74(0.64–4.75) |
| 65–79 | 1.20(1.13–1.27) | 1.06(0.94–1.20) | 0.79(0.59–1.06) | 0.74(0.49–1.13) | 0.51(0.37–0.70) | 0.43(0.23–0.79) | 1.79(1.13–2.84) | 2.08(0.75–5.78) |
| ≥80 | 1.19(1.12–1.27) | 1.05(0.93–1.19) | 0.41(0.29–0.57) | 0.49(0.28–0.86) | 0.41(0.28–0.59) | 0.39(0.18–0.86) | 2.75(1.67–4.53) | 3.36(1.11–10.2) |
| Sex | ||||||||
| Male | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Female | 1.06(1.04–1.08) | 1.06(1.04–1.09) | 1.01(0.91–1.11) | 1.13(0.98–1.31) | 1.27(1.12–1.44) | 1.30(1.13–1.50) | 1.31(1.14–1.52) | 1.31(1.11–1.55) |
| Province of residence | ||||||||
| Newfoundland | 1.01(0.98–1.04) | 1.01(0.98–1.04) | 0.81(0.58–1.12) | 0.77(0.46–1.27) | 0.95(0.64–1.40) | 1.00(0.66–1.51) | 1.38(0.91–2.11) | 1.12(0.68–1.86) |
| Prince Edward Island | 1.01(0.97–1.04) | 1.01(0.97–1.04) | 0.53(0.35–0.81) | 0.49(0.36–0.68) | 1.07(0.70–1.64) | 1.08(0.65–1.81) | 1.19(0.80–1.78) | 0.78(0.49–1.25) |
| Nova Scotia | 0.98(0.95–1.01) | 0.99(0.96–1.03) | 0.75(0.56–1.00) | 0.71(0.53–0.95) | 0.96(0.69–1.32) | 1.01(0.71–1.45) | 1.13(0.84–1.53) | 1.02(0.73–1.44) |
| New Brunswick | 0.99(0.96–1.03) | 0.99(0.95–1.02) | 0.53(0.37–0.77) | 0.46(0.33–0.65) | 0.86(0.64–1.16) | 0.90(0.66–1.23) | 1.02(0.75–1.40) | 0.86(0.61–1.22) |
| Quebec | 0.84(0.81–0.86) | 0.86(0.84–0.89) | 0.53(0.45–0.63) | 0.49(0.42–0.58) | 0.81(0.68–0.97) | 0.94(0.77–1.14) | 0.97(0.80–1.16) | 0.95(0.76–1.17) |
| Ontario | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Manitoba | 0.94(0.91–0.98) | 0.96(0.92–1.00) | 1.19(0.98–1.44) | 1.05(0.91–1.21) | 1.39(1.05–1.83) | 1.47(1.12–1.94) | 0.95(0.72–1.26) | 0.96(0.71–1.30) |
| Saskatchewan | 0.94(0.90–0.97) | 0.94(0.90–0.98) | 1.58(1.34–1.86) | 1.38(1.21–1.56) | 1.38(1.01–1.88) | 1.37(1.01–1.87) | 1.27(0.97–1.68) | 1.11(0.81–1.53) |
| Alberta | 0.93(0.90–0.96) | 0.94(0.91–0.97) | 1.21(1.05–1.39) | 1.06(0.87–1.29) | 1.04(0.85–1.27) | 1.01(0.81–1.25) | 0.58(0.43–0.78) | 0.56(0.39–0.79) |
| British Columbia | 0.95(0.92–0.97) | 0.95(0.92–0.97) | 0.91(0.78–1.05) | 0.84(0.73–0.97) | 1.05(0.87–1.27) | 1.00(0.81–1.22) | 0.33(0.24–0.44) | 0.32(0.23–0.45) |
| Cultural/racial background | ||||||||
| White | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Non-white | 0.96(0.94–0.99) | 0.99(0.96–1.03) | 0.61(0.51–0.73) | 0.79(0.62–1.00) | 1.00(0.81–1.23) | 1.09(0.86–1.37) | 0.72(0.57–0.91) | 1.09(0.83–1.42) |
| Immigrant status | ||||||||
| Non-immigrant | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Immigrant (0–9 years) | 0.86(0.78–0.94) | 0.89(0.81–0.97) | 0.44(0.25–0.77) | 0.53(0.32–0.89) | 0.59(0.35–1.02) | 0.58(0.31–1.06) | 0.32(0.07–1.47) | 0.46(0.10–2.13) |
| Immigrant (≥10 years) | 1.06(1.04–1.09) | 1.00(0.97–1.03) | 0.69(0.58–0.83) | 0.76(0.64–0.90) | 1.26(1.03–1.53) | 1.34(1.09–1.65) | 0.69(0.54–0.89) | 0.63(0.45–0.88) |
| Highest level of education | ||||||||
| Less than secondary | 0.99(0.97–1.02) | 0.97(0.94–0.99) | 0.61(0.52–0.72) | 0.89(0.80–0.99) | 0.56(0.42–0.73) | 0.56(0.38–0.82) | 1.30(1.09–1.54) | 0.91(0.72–1.15) |
| Secondary graduate | 1.01(0.99–1.03) | 1.01(0.98–1.03) | 0.85(0.75–0.96) | 0.97(0.87–1.09) | 0.72(0.62–0.84) | 0.83(0.70–0.98) | 1.05(0.88–1.26) | 0.99(0.81–1.23) |
| Some post-secondary education | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Distribution of total household income | ||||||||
| 1st quintile | 0.93(0.90–0.96) | 0.95(0.91–0.98) | 0.33(0.27–0.39) | 0.64(0.50–0.82) | 0.39(0.32–0.48) | 0.42(0.32–0.54) | 1.32(1.05–1.65) | 1.03(0.79–1.34) |
| 2nd quintile | 0.96(0.94–0.99) | 0.96(0.93–0.99) | 0.48(0.41–0.57) | 0.74(0.56–0.98) | 0.52(0.43–0.64) | 0.54(0.43–0.68) | 1.17(0.95–1.44) | 0.89(0.70–1.13) |
| 3rd quintile | 0.98(0.95–1.01) | 0.98(0.96–1.01) | 0.65(0.56–0.76) | 0.82(0.67–1.00) | 0.69(0.57–0.84) | 0.72(0.59–0.87) | 1.15(0.90–1.47) | 1.02(0.79–1.33) |
| 4th quintile | 0.98(0.96–1.01) | 0.98(0.95–1.01) | 0.88(0.77–1.00) | 0.98(0.83–1.15) | 0.84(0.72–0.99) | 0.79(0.66–0.94) | 1.20(0.94–1.53) | 1.14(0.88–1.47) |
| 5th quintile | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Working status last week | ||||||||
| Working | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Absent | 1.03(0.98–1.08) | 1.02(0.97–1.06) | 1.12(0.91–1.39) | 1.22(0.92–1.62) | 1.41(1.13–1.75) | 1.35(1.07–1.70) | 1.53(1.10–2.12) | 1.32(0.93–1.88) |
| No job | 1.07(1.05–1.10) | 1.03(1.01–1.06) | 0.61(0.54–0.68) | 0.73(0.62–0.87) | 0.86(0.74–0.99) | 0.98(0.82–1.17) | 1.67(1.42–1.95) | 1.28(1.04–1.57) |
| NA (age <15 or >75) | 1.14(1.11–1.16) | 1.03(1.00–1.06) | 0.51(0.43–0.60) | 0.78(0.62–0.98) | 0.81(0.65–1.00) | 0.82(0.51–1.32) | 2.10(1.73–2.54) | 1.20(0.84–1.73) |
| Marital status | ||||||||
| Married | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Common-law | 0.90(0.87–0.93) | 0.97(0.94–1.00) | 0.84(0.72–0.99) | 0.88(0.73–1.06) | 0.85(0.68–1.05) | 0.88(0.70–1.12) | 0.95(0.74–1.21) | 1.00(0.76–1.33) |
| Widowed/Divorced/Separated | 0.99(0.97–1.00) | 0.97(0.94–0.99) | 0.63(0.55–0.73) | 0.89(0.72–1.09) | 0.91(0.74–1.12) | 1.14(0.88–1.47) | 1.22(1.03–1.45) | 0.89(0.72–1.11) |
| Single | 0.82(0.79–0.85) | 0.88(0.85–0.92) | 0.67(0.59–0.77) | 0.77(0.66–0.91) | 0.86(0.73–1.02) | 0.86(0.71–1.05) | 0.87(0.72–1.06) | 0.88(0.69–1.11) |
| Type of smoker | ||||||||
| Daily | 0.91(0.88–0.93) | 0.95(0.92–0.98) | 0.54(0.46–0.63) | 0.59(0.51–0.69) | 0.47(0.39–0.57) | 0.50(0.40–0.63) | 1.00(0.82–1.22) | 0.95(0.76–1.19) |
| Occasional | 0.90(0.85–0.95) | 0.95(0.90–1.01) | 0.95(0.76–1.20) | 0.90(0.75–1.08) | 1.16(0.88–1.53) | 1.13(0.85–1.49) | 1.22(0.91–1.65) | 1.36(0.97–1.90) |
| Not at all | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Type of alcohol drinker | ||||||||
| Regular | 0.96(0.94–0.98) | 1.00(0.98–1.03) | 1.69(1.47–1.95) | 1.26(1.07–1.48) | 1.16(0.97–1.39) | 1.05(0.85–1.30) | 0.79(0.67–0.94) | 1.01(0.82–1.24) |
| Occasional | 0.97(0.95–1.00) | 0.99(0.96–1.02) | 1.09(0.91–1.30) | 0.93(0.76–1.13) | 0.99(0.77–1.29) | 0.93(0.69–1.24) | 1.13(0.92–1.40) | 1.21(0.94–1.56) |
| Did not drink | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Physical activity | ||||||||
| Active | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Moderate active | 1.02(1.00–1.05) | 0.99(0.97–1.02) | 0.87(0.76–0.99) | 0.98(0.89–1.08) | 0.93(0.79–1.09) | 0.98(0.83–1.17) | 1.01(0.86–1.20) | 0.89(0.74–1.07) |
| Inactive | 1.06(1.03–1.08) | 0.99(0.97–1.02) | 0.62(0.54–0.71) | 0.83(0.69–0.99) | 0.79(0.66–0.94) | 0.84(0.68–1.03) | 1.21(1.02–1.43) | 0.78(0.63–0.96) |
| BMI | ||||||||
| Underweight | 0.94(0.85–1.04) | 0.99(0.89–1.09) | 0.76(0.47–1.24) | 0.94(0.56–1.58) | 0.31(0.15–0.65) | 0.34(0.14–0.81) | 1.90(0.81–4.45) | 1.69(0.73–3.92) |
| Normal weight | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Overweight (incl. obese) | 1.05(1.03–1.07) | 1.03(1.01–1.05) | 1.13(1.01–1.26) | 1.10(0.95–1.27) | 0.94(0.82–1.09) | 0.95(0.81–1.10) | 1.39(1.18–1.63) | 1.30(1.10–1.53) |
| Perceived general health | ||||||||
| Poor | 1.10(1.06–1.14) | 1.06(1.02–1.11) | 0.45(0.32–0.62) | 0.63(0.38–1.05) | 1.03(0.76–1.39) | 1.80(1.21–2.70) | 3.33(2.40–4.61) | 2.94(1.93–4.49) |
| Fair | 1.04(1.00–1.08) | 1.02(0.97–1.06) | 0.59(0.48–0.73) | 0.84(0.69–1.02) | 0.98(0.77–1.26) | 1.77(1.33–2.35) | 2.12(1.56–2.87) | 1.97(1.37–2.85) |
| Good | 1.04(1.00–1.07) | 1.01(0.98–1.05) | 0.89(0.75–1.05) | 1.04(0.96–1.12) | 1.08(0.87–1.34) | 1.50(1.17–1.94) | 1.89(1.39–2.57) | 1.92(1.34–2.73) |
| Very good | 1.01(0.97–1.04) | 0.99(0.95–1.02) | 1.04(0.89–1.22) | 1.05(0.96–1.15) | 0.99(0.79–1.24) | 1.18(0.91–1.52) | 1.33(0.98–1.80) | 1.34(0.94–1.90) |
| Excellent | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
BMI – body mass index; CCHS – Canadian Community Health Survey; CI – confidence interval; NA – not applicable; NS – not stated; PR – prevalence ratio.
a Weighted using Canadian Community Health Survey sampling weights provided by Statistics Canada to provide population estimates.
b NA = not applicable according to population exclusions; NS = not stated or responses without enough information for classification.
Multivariable modified Poisson regression model adjusted for age, sex, province, cultural/racial background, immigrant status, education, income, working status, marital status, smoking status, alcohol consumption, physical activity, BMI, perceived general health, CCHS cycle.
Medical doctor. Recent immigrants (PR0–9 years = 0.89, 95% CI 0.81–0.97) were less likely to report medical doctor as a regular healthcare provider (Table 4). No differences were observed for other sociodemographic or behavioural factors. Persons reporting poor general health were slightly more likely to report medical doctor as regular provider (PR = 1.06, 95% CI 1.02–1.11).
Chiropractor. Persons aged ≥80 years were less likely to consult chiropractors than 12–19 years (PR = 0.49, 95% CI 0.28–0.86) (Table 4). Persons who were immigrants (PR 0.53–0.76), lower income (PR 0.64–0.74), no job (PR = 0.73, 95%CI 0.62–0.87), daily smokers (PR = 0.59, 95% CI 0.51–0.69), or physically inactive (PR = 0.83, 95% CI 0.69–0.99) were less likely to consult chiropractors. Persons absent from work in the past week were more likely to have regular care from chiropractors. Individuals with fair (PR = 0.84, 95% CI 0.69–1.02) general health tended to be less likely to consult chiropractors.
Physiotherapist. Older ages were less likely to consult physiotherapists than 12–19 years (PR65–79years = 0.43, 95% CI 0.23–0.79; PR ≥ 80years = 0.39, 95% CI 0.18–0.86) (Table 4). Persons with less than secondary education (PR = 0.56, 95% CI 0.38–0.82), lower income (PR 0.42–0.54), or daily smokers (PR = 0.50, 95% CI 0.40–0.63) were less likely to consult physiotherapists. Persons absent from work in the past week were more likely for regular care from physiotherapists (PR = 1.35, 95% CI 1.07–1.70). Those with fair/poor (PRfair = 1.77, 95% CI 1.33–2.35; PRpoor = 1.80, 95% CI 1.21–2.70) health were more likely to consult physiotherapists.
Nurse. Older ages were more likely to have nurse as regular provider (PR65–79years = 2.08, 95% CI 0.75–5.78; PR ≥ 80years = 3.36, 95% CI 1.11–10.2) (Table 4). Persons who were physically inactive were less likely (PR = 0.78, 95% CI 0.63–0.96), while those overweight/obese (PR = 1.30, 95% CI 1.10–1.53) or absent from work/no job (PR 1.28–1.32) were more likely to consult nurses. Those with fair/poor (PRfair = 1.97, 95% CI 1.37–2.85; PRpoor = 2.94, 95% CI 1.93–4.49) general health were more likely to consult nurses. No differences by other sociodemographic or behavioural factors were observed.
4. Discussion
Among selected providers, medical doctors were most commonly consulted by Canadians with chronic back problems, followed by chiropractors then physiotherapists. From 2001 to 2010, prevalence of consultation with medical doctors was 87.9%, chiropractors 24.0%, physiotherapists 17.2%, and nurses 14.0%. In 2015/2016, prevalence of receiving regular healthcare from medical doctors was 86.7%, chiropractors 14.5%, physiotherapists 10.7%, and nurses 6.6%. Females were more likely to see a provider than males across all groups. Persons of lower socioeconomic status (education and income) were less likely to consult chiropractors or physiotherapists (2001–2016), or nurses (2001–2010). Older ages were less likely to consult chiropractors or physiotherapists, but more likely to consult medical doctors or nurses. Persons with fair/poor general health were less likely to consult chiropractors, but more likely to consult medical doctors, physiotherapists, or nurses.
Findings extend our knowledge of healthcare utilization of a range of providers in Canadians with back problems. Findings support those in previous studies that medical physicians were most consulted (>85%) by Canadians with back pain, followed by chiropractors, then physiotherapists,(Lim et al., 2006; Bath et al., 2018) but extend knowledge by comparing estimates with those consulting nurses. Studies also reported that persons with lower socioeconomic status were less likely to consult healthcare providers (Lim et al., 2006; Bath et al., 2018). A notable addition from our study is that those of lower socioeconomic status (income and education levels) were less likely to consult chiropractors or physiotherapists across all time points. While physician services are publicly funded in Canada, chiropractic and physiotherapy are not generally publicly funded (with few exceptions that are provincially dependent), and patients need to pay using other means (e.g., extended health insurance) or out-of-pocket. Therefore, care-seeking for back pain is likely driven by structural barriers to accessing rehabilitation services including costs. Study results also showed important differences by age and self-perceived general health across provider groups. Older ages were less likely to consult chiropractors or physiotherapists, but more likely to consult medical doctors or nurses, suggesting potential inequitable access to allied healthcare by age. Moreover, persons with fair/poor general health were less likely to consult chiropractors, but more likely to consult physiotherapists, medical doctors, or nurses. This may highlight barriers to accessing care provided by chiropractors among persons with fair/poor health; future research in this area is warranted. The results also showed regional differences in utilization of different providers among adults with back problems. Prevalence of consultation with chiropractors ranged by over 20% across provinces. This may reflect differences in provincial publicly-funded and extended health insurance coverage for chiropractic services, affecting access to care. Prevalence of consultation with nurses was higher in the territories than provinces, whereas consultation with medical doctors was lower in the territories than provinces. This may reflect less access to medical doctors in the territories, (Canadian Institute for Health Information (CIHI), 2015) which may be supplemented by consultation with nurses. Further research is needed to explore factors associated with regional differences in utilization of providers in this population.
Findings have important implications for healthcare planning in Canada, particularly to help address the high burden and costs of back pain. First, it provides an up-to-date national perspective of healthcare utilization in Canadians with back problems, examining associated characteristics across sociodemographic, health-related and behavioural factors. Second, findings highlight potential inequities to accessing care and rehabilitation services delivered especially by allied healthcare providers, particularly related to age, socioeconomic status, and overall general health. Healthcare planning that enhances access to allied healthcare providers, including chiropractors, physiotherapists, and nurses, may assist in addressing unmet rehabilitation needs for back pain in Canada and abroad (Cieza et al., 2021). Further research focused on studying population-based programs of care for back pain in primary care settings is warranted (Ahmadzadeh et al., 2023). Third, findings provide the evidentiary basis to inform knowledge users, including government and health professional associations, to guide the delivery of tailored healthcare and rehabilitation services to help meet the needs of persons with back problems in Canada. Demographics of Canadians are changing with aging of the population and increasing immigration (The Organisation for Economic Co-operation and Development (OECD), 2021; Statistics Canada, 2022). These changing demographics would likely place greater needs for healthcare services among older adults and communities of newcomers with back pain, and increase inequities to care in the future. Further studies are needed to explore potential facilitators and barriers to accessing healthcare providers, including allied healthcare, in diverse groups to promote equitable and inclusive care.
4.1. Strengths and limitations
This study has strengths. First, CCHS data are representative of 98% of the community-dwelling Canadian population aged ≥12 years. (Statistics Canada) This study was thus able to determine prevalence and associations generalizable to the entire Canadian population. Second, a range of sociodemographic, health-related, and behavioural factors were accounted for when assessing association with prevalence of healthcare utilization. Third, analyses were conducted using CCHS data nationwide over 15 years to provide a comprehensive perspective on access to care in persons with back problems.
There are limitations. There may be measurement error with self-reported data on healthcare utilization and these CCHS questions have unknown validity and reliability. However, previous studies have used these questions to describe healthcare utilization in persons with back problems and other populations (Lim et al., 2006; Bath et al., 2018; Nehumba et al., 2022; Ravichandiran et al., 2022). In addition, CCHS sampling frame includes individuals living in private dwellings only, and results may not be generalizable to other populations (e.g., persons living in institutions, on reserve and other First Nations settlements). Finally, our study focused on prevalence of healthcare utilization; information such as treatment duration, effectiveness, patient satisfaction, and cost-effectiveness of healthcare services were not captured in CCHS and remains outside the scope of our study. We were also unable to examine surgeries for back problems. Although CCHS has some questions on surgical treatment, they are not specific to back problems and could be surgeries for various other health conditions. Future research in this area is warranted.
5. Conclusion
Findings showed that medical doctors were most commonly consulted by Canadians with chronic back problems, followed by chiropractors then physiotherapists. Factors associated with healthcare utilization varied by provider, particularly with age, socioeconomic status, and self-perceived general health. Findings inform knowledge users, including government and health professional associations, to guide healthcare delivery to meet the needs of persons with back problems in Canada. Further research is required to understand the impact and address identified health inequities and unmet needs of diverse Canadians with back problems.
Source of funding
This work was supported by a research grant from the Canadian Chiropractic Research Foundation. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Author contributions
Jessica Wong: conceptualization, methodology, writing – original draft, review, and editing; Dan Wang: conceptualization, methodology, formal analysis, writing – review and editing; Sheilah Hogg-Johnson: conceptualization, methodology, writing – review and editing; Silvano Mior: conceptualization, methodology, writing – review and editing; Pierre Côté: conceptualization, methodology, writing – review and editing. All authors have approved the final article.
Declaration of competing interest
Jessica Wong is supported by a Canadian Institutes of Health Research (CIHR) Research Excellence, Diversity and Independence Early Career Transition Award, was previously supported by a Banting Postdoctoral Fellowship from CIHR and reports research grant from the Canadian Chiropractic Research Foundation (paid to university); research grants from CIHR, Social Sciences and Humanities Research Council (SSHRC), Canadian Memorial Chiropractic College and Canadian Chiropractic Research Foundation (paid to university) and travel reimbursement for teaching and research meetings from Eurospine and Chiropractic Academy of Research Leadership outside the submitted work. Dan Wang reports research grant from the Canadian Chiropractic Research Foundation (paid to Ontario Tech University) and postdoctoral fellowship at Ontario Tech University (funded by Ontario Tech University and Canadian Memorial Chiropractic College). Sheilah Hogg-Johnson reports research grant from the Canadian Chiropractic Research Foundation (paid to Ontario Tech University); and research grants from the Canadian Chiropractic Research Foundation outside the submitted work. Silvano Mior reports research grant from the Canadian Chiropractic Research Foundation (paid to Ontario Tech University); research grants from the Canadian Chiropractic Research Foundation (paid to Ontario Tech University and Canadian Memorial Chiropractic College) and Canadian Chiropractic Association (paid to Canadian Memorial Chiropractic College), and honoraria for lecturing from the Chiropractic Association of Saskatchewan outside the submitted work. Pierre Côté was supported by the Canada Research Chair award from CIHR (paid to Ontario Tech University), and reports research grant from the Canadian Chiropractic Research Foundation (paid to Ontario Tech University); research grants from CIHR, Canadian Chiropractic Research Foundation, and College of Chiropractors of British Columbia (paid to Ontario Tech University), payment to provide medical-legal expertise in court cases from the Canadian Chiropractic Protective Association and NCMIC, and travel reimbursement to the university for teaching and conference presentations from Eurospine, European Chiropractic Union and Chiropractic Association of Alberta outside the submitted work.
Acknowledgements
The results or views expressed are those of the authors and are not those of Statistics Canada.
Handling Editor: Prof F Kandziora
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.bas.2024.102812.
Contributor Information
Jessica J. Wong, Email: jessica.wong@ontariotechu.ca.
Dan Wang, Email: dawang@cmcc.ca.
Sheilah Hogg-Johnson, Email: shoggjohnson@cmcc.ca.
Silvano A. Mior, Email: smior@cmcc.ca.
Pierre Côté, Email: pierre.cote@ontariotechu.ca.
Appendix A. Supplementary data
The following is the supplementary data to this article:
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