Abstract
Objective
To investigate chiropractic students’ comfort and confidence levels in modifying care for vulnerable patient groups. A second aim is to present data on students’ self-identification as belonging to one or more of these groups.
Methods
A cross-sectional survey of 117 second-year students enrolled in a Special Populations course was conducted. Respondents selected special population groups (SPG) to which they identified as belonging. They rated their comfort interacting with and confidence levels modifying care for each SPG on a 5-point scale. A general patient group (GPG), representing patients not belonging to any SPG, served as a benchmark. Responses were grouped into 3 categories: those lacking comfort or confidence, those unsure or neutral, and those with comfort or confidence.
Results
Comfort and confidence levels were found to be higher for the GPG than the SPG average. Perceptions of a sociocultural vulnerable subgrouping were much closer to GPG than a physically vulnerable subgrouping. Students perceived themselves most comfortable and confident with ethnically, racially, and religiously diverse patient groups and least comfortable and confident with physically and mentally disabled groups. Thirty-seven percent of respondents identified as belonging to one or more SPG.
Conclusion
Respondents perceived their comfort levels to be higher than their confidence levels. Ratings for sociocultural vulnerable groups were higher than physically vulnerable groups. Gaps between comfort and confidence were higher in the sociocultural subgroup than the physically vulnerable subgroup. A significant minority of students identified as belonging to one or more of the studied groups.
Keywords: Chiropractic, Cultural Competency, Vulnerable Populations, Health Education, Students, Health Occupations
INTRODUCTION
The critical need for training health professions students on cultural competency (CC) has been an emerging topic of study in the 21st century.1,2 The aim of CC training is to improve students’ ability to better understand and interact with diverse patient groups with the goal of overcoming disparities of health care quality.3 Various terms have evolved to address the nuances of this training, including cultural awareness, sensitivity, and/or humility, collectively referred to as cultural competence for this article. Cultural variables that result in worse health are many and varied and exist on both individual and structural levels.4 As such, the knowledge, attitudes, and skills imparted through CC training are applicable not only to culturally different groups but also to other groups impacted by health care inequities, that is, vulnerable populations. It is incumbent upon the chiropractic profession to understand and appreciate the challenges faced by these groups and take meaningful steps to train students how to provide effective and equitable care for them.
Vulnerable populations have been characterized as groups of individuals who encounter persistent disadvantages gaining access to health care or having higher risk exposure to different health risk factors.5 Vulnerable populations experience challenges to access services due to discrimination based on socioeconomic status, gender, disability, age, and sexual orientation.6 Common factors that determine health equity include race, geographic location, age, poverty, disabilities, gender, and mental health.7,8 For example, racial and ethnic minorities, those with limited education or income, and those with disabilities are in worse health, receive worse health care, and have poorer health care outcomes.9 A pertinent example for the chiropractic profession is the finding that underserved populations are disproportionately impacted by spine-related disorders.10
Health professions educational research supports the effectiveness of CC training.11,12 Students’ CC knowledge,13–18 awareness and sensitivity,16,17,19 and confidence levels14,20 have been shown to improve through training. Cultural competency training increases students’ awareness of and reflection on their own identity and biases and the impact these may have on patient care.19 From a patient perspective, CC training has been shown to increase satisfaction,3,11 attitudes toward their provider,12 perceptions of physician empathy, and compliance to care plans.12,21 Despite the positive impact on patients and students, CC training has been shown to have limited to no impact on provider behavior,13,16,17 quality of care,12 and patient outcomes.3,12,22
Research on CC training in the chiropractic profession consists primarily of calls for action and curricular recommendations. The significant diversity gap that exists between chiropractic students, providers, patients, and the US populace has been identified as a professional issue driving the need for CC training.3,20–22 It has been suggested that chiropractic educational institutions lack an organized or systematic approach to training students in CC.23 Only 2 studies were found that evaluated CC training’s impact on chiropractic students. An Australian study found that students perceived increased value of being exposed to diverse socioeconomic and cultural backgrounds through participation in clinical care outside of chiropractic college clinics.24 A study at a US chiropractic institution evaluated the impact of targeted CC training, finding it increased second year chiropractic students’ knowledge but did not impact their confidence.14
The purpose of this study was to determine second year chiropractic students’ self-rated perceptions of their comfort and confidence levels in providing care for an array of vulnerable patient groups. Secondarily, the study sought to determine these students’ self-identification as belonging to any of these groups.
METHODS
A cross-sectional, quantitative, online, single-group survey study was conducted (SurveyMonkey Inc). The study received exempt–limited institutional review board approval through California State University East Bay (CSUEB-IRB-2024-48). The survey was administered by the Institutional Research and Effectiveness (IRE) department at Palmer College of Chiropractic (Davenport, IA).
The study utilized nonprobability convenience sampling as the target population for the survey was 117 sixth trimester students enrolled in a new Special Populations course at Palmer College of Chiropractic during the Summer 2024 term.25 A survey invitation (Supplemental Appendix 1, available online accompanying this article) and 4 reminders were sent via students’ college email addresses, and the course faculty encouraged students to participate. The invitation explained the research study, risks, and benefits of participation and that survey participation constituted consent. Participants were informed of the voluntary nature of the survey and their ability to withdraw at any time, to not answer questions, or to not submit the survey. The survey closed prior to the second session of the course.
The survey was developed by reviewing course syllabi and course content and through discussions by the principal investigator, program faculty, and a survey statistician. All reached consensus on face validity of the survey. The first question set of the survey (Supplemental Appendix 2) asked respondents to select any of the special populations groups (SPG) from the survey to which they identified as belonging. The next 2 question sets asked respondents to rate their comfort and confidence levels interacting with and modifying care for each SPG. The SPG for each question set consisted of pregnant, pediatric, physically disabled, mentally disabled, racially diverse, ethnically diverse, sexual orientation diverse, socioeconomically disadvantaged, and trauma-influenced (physical, emotional, sexual). The pediatric SPG was not included as a response option for the belonging question set. A general patient group (GPG), defined as patients not belonging to any SPG, was included in both the comfort and confidence question sets to provide baseline comfort and confidence levels for nonvulnerable patients. Responses were indicated on a 5-point scale from very uncomfortable/unconfident to very comfortable/confident. Each question set contained an optional comment response that allowed for open-ended qualitative feedback.
The data for the comfort and confidence question sets were analyzed by grouping responses into 1 of 3 categories: those expressing some level of discomfort or lack of confidence (1 or 2 rating selected), those who were neutral or uncertain (3 selected), and those expressing some level of comfort or confidence (4 or 5 selected). A descriptive analysis of the results was performed and reported as a percentage of respondents in each category.
Data Analysis
Data analysis occurred using basic descriptive information to summarize demographic, comfort, and confidence data with SPSS version 29 (IBM Corp). Cronbach’s alpha was calculated to account for the internal consistency of data resulting from the comfort and confidence scales by examining alpha (α), the scaled mean (M) and scaled SD. Given the limitations of SPSS with calculated confidence intervals for alpha, a web-based confidence interval calculator was utilized.26 Because the instrument was developed for the purpose of this study, the psychometric properties of the data, that is, reliability, validity, and factor structure, have not been previously assessed. Conventional wisdom for internal consistency denotes α = .7 as acceptable internal consistency for nonclinical data and necessitates α = .9 for data being used for clinical or diagnostic purposes.27
RESULTS
Response Rates
Overall, there were 41 unique survey respondents from the target audience of 117 students, a response rate (RR) of 35%. Not all respondents answered every question, creating variances in RR from 30% to 35% across the 3 question sets (Table 1). Respondents tended to answer all questions within a question set before ending the survey.
Table 1.
Response Rate
| Question Set | No. | RR |
|---|---|---|
| Belonging | 41 | 36% |
| Comfort | 36–37 | 32%–33% |
| Confidence | 35–36 | 31%–32% |
Internal Consistency
Data for the comfort (α = .93; M = 36.5; SD = 6.138; 95% CI, .89-.96) and confidence (α = .98; M =38.0; SD = 6.78; 95% CI, .98-.99) scales exhibited high reliability, indicating an excellent degree of internal consistency with reasonable levels of variability to discriminate between respondents.
Belonging
The percentage of respondents who identified as belonging to one or more SPG is shown in Table 2. Thirty-seven percent of students identified as belonging to an SPG, whereas 61% did not. Students most frequently identified as belonging to the trauma-influenced group (17%), which included physical, emotional, and sexual trauma. The next most frequent responses were for the ethnically diverse (12%) and sexual orientation diverse (10%) groups. Twelve percent of respondents identified as belonging to more than 1 group.
Table 2.
Percentage of Students That Identified as Belonging to Each SPG
| Group | No. | Percentage |
|---|---|---|
| None | 25 | 61.0% |
| Trauma-influenced | 7 | 17.1% |
| Ethnically diverse | 5 | 12.2% |
| Sexual orientation diverse | 4 | 9.8% |
| Racially diverse | 3 | 7.3% |
| Religiously diverse | 3 | 7.3% |
| Mentally disabled | 2 | 4.9% |
| Socioeconomically disadvantaged | 2 | 4.9% |
| Pregnant | 1 | 2.4% |
| Physically disabled | 1 | 2.4% |
| Preferred to not answer | 1 | 2.4% |
| ID as >1 group | 5 | 12.2% |
Comfort
When aggregated across all SPG, 63% of respondents perceived themselves to have a level of comfort interacting with and providing clinical care for SPG individuals (Table 3). By comparison, 89% of respondents perceived themselves to be comfortable treating GPG. Twenty-one percent of respondents were unsure or uncertain of their comfort level for SPG compared with GPG at 8%. Sixteen percent were uncomfortable with SPG compared with 3% for GPG. When analyzing the individual groups of the SPG, students were most comfortable with racially and ethnically diverse groups (92% each). The lowest perceived comfort levels were for physically disabled and mentally disabled groups (35% and 38%, respectively). Physically disabled and mentally disabled groups had the highest levels of uncertainty (38% each), whereas the pediatric group had the highest level of discomfort (35%).
Table 3.
Percentage of Students at Each Comfort Level
| Group | Comfortable | Unsure | Uncomfortable |
|---|---|---|---|
| General patient | 89% | 8% | 3% |
| SPG average | 63% | 21% | 16% |
| Sociocultural subgroup average | 81% | 11% | 8% |
| Racially diverse | 92% | 5% | 3% |
| Ethnically diverse | 92% | 3% | 5% |
| Religiously diverse | 83% | 8% | 8% |
| Socioeconomically disadvantaged | 73% | 22% | 5% |
| Sexual orientation diverse | 64% | 17% | 19% |
| Vulnerable subgroup average | 45% | 30% | 24% |
| Trauma-influenced | 57% | 30% | 14% |
| Pediatric | 54% | 11% | 35% |
| Pregnant | 43% | 35% | 22% |
| Mentally disabled | 38% | 38% | 24% |
| Physically disabled | 35% | 38% | 27% |
Confidence
Students’ aggregate perception of confidence in modifying their clinical approach to effectively and respectfully care for patients in the SPG was 53% compared with 75% for the GPG (Table 4). Thirty-one percent of respondents were unsure or uncertain of their confidence level with SPG compared with 22% for GPG, whereas 17% lacked confidence with SPG compared with 3% for GPG. The highest perceived SPG confidence levels were for ethnically diverse (72%), religiously diverse (71%), and racially diverse (67%) groups. The smallest percentage of students perceived themselves as being confident for treatment of mentally disabled (33%), physically disabled (33%), and trauma-influenced (42%) groups. The greatest perceived level of being neutral or uncertain was with the physically disabled group (42%). The mentally disabled (31%), physically disabled (25%), and trauma-influenced (25%) had the largest percentage of students perceiving themselves to lack confidence.
Table 4.
Percentage of Students at Each Confidence Level
| Group | Confident | Unsure | Lack Confidence |
|---|---|---|---|
| General patient | 75% | 22% | 3% |
| SPG average | 53% | 31% | 17% |
| Sociocultural subgroup average | 64% | 26% | 10% |
| Ethnically diverse | 72% | 25% | 3% |
| Religiously diverse | 71% | 17% | 11% |
| Racially diverse | 67% | 28% | 6% |
| Socioeconomically disadvantaged | 60% | 34% | 6% |
| Sexual orientation diverse | 51% | 26% | 23% |
| Vulnerable subgroup average | 41% | 36% | 23% |
| Pediatric | 49% | 34% | 17% |
| Pregnant | 47% | 33% | 19% |
| Trauma-influenced | 42% | 33% | 25% |
| Physically disabled | 33% | 42% | 25% |
| Mentally disabled | 33% | 36% | 31% |
Comfortable vs Confident
The aggregate percentage across all SPG demonstrated students perceived a greater level of comfort (4 or 5 rating) than confidence at 63% vs 53%, respectively (Table 5). The gap between students’ perceived comfort and confidence levels was consistent with the GPG ratings (89% vs 75%, respectively). This gap was also found to varying degrees within individual SPG. The racially diverse group had the greatest gap between comfort (92%) and confidence (67%) ratings, followed by the ethnically diverse group (92%/72%). There was little perceived difference in comfort and confidence levels for the physically disabled (35%/33%), mentally disabled (38%/33%), and pediatric (54%/49%) groups. The pregnant group was an exception, with a small percentage of students expressing greater confidence (47%) than comfort (43%).
Table 5.
Comfortable vs Confident Gaps
| Group | Comfortable | Confident | Change |
|---|---|---|---|
| General patient | 89% | 75% | 14% |
| SPG average | 63% | 53% | 11% |
| Sociocultural groups average | 81% | 64% | 17% |
| Racially diverse | 92% | 67% | 25% |
| Ethnically diverse | 92% | 72% | 20% |
| Socioeconomically disadvantaged | 73% | 60% | 13% |
| Sexual orientation diverse | 64% | 51% | 12% |
| Religiously diverse | 83% | 71% | 12% |
| Vulnerable groups average | 45% | 41% | 4% |
| Trauma-influenced | 57% | 42% | 15% |
| Pediatric | 54% | 49% | 5% |
| Mentally disabled | 38% | 33% | 5% |
| Physically disabled | 35% | 33% | 2% |
| Pregnant | 43% | 47% | −4% |
When the data was further analyzed through a sociocultural vulnerable subgrouping (ie, racially, ethnically, religiously, socioeconomically, and sexual orientation groups) and a physically vulnerable subgrouping (ie, trauma-influenced, pediatric, pregnant, physically and mentally disabled groups), differences were more pronounced. For instance, the percentage of respondents perceiving themselves to have a level of comfort and confidence for the sociocultural subgroup (81% and 64%, respectively) was higher than the vulnerable subgroup (45% and 40%) (Tables 3 and 4). When comparing GPG to the sociocultural subgrouping, the gap of students perceiving themselves to be comfortable was 8%, and confidence was 11%. This same comparison for the physically vulnerable subgrouping found a much larger gap: 44% for comfort and 34% for confidence (Table 5). The aggregate average ratings within these subgroups also exhibited a higher perceptual gap between comfort and confidence of the sociocultural subgroup (17%) when compared with the physically vulnerable subgroup (4%).
DISCUSSION
The aim of this study was to evaluate students’ perceptions of their level of comfort and confidence for treating a variety of sociocultural and other vulnerable patient groups, collectively referred to as SPG. The study sought to establish chiropractic students’ attitudes engaging with SPG through a set of questions on comfort level and their perceived ability to apply their combined knowledge, attitudes, and skills through a set of questions on confidence levels. This appears to be the first study of chiropractic students to examine comfort and confidence levels across a variety of different diverse patient groups.
The SPG studied all fall within the vulnerable population definition.5 The data revealed an unexpected but clear separation between 2 subgroups within the SPG. One subgroup was based on sociocultural status (sociocultural group) and included the racially, ethnically, religiously, socioeconomically, and sexual orientation diverse patient groups. The other subgroup consisted of those with physically and cognitively impaired status (physically vulnerable group) and included the trauma-influenced, pediatric, pregnant, physically disabled, and mentally disabled groups. Overall, the sociocultural group aggregate average ratings were much closer to the benchmark GPG average than the physically vulnerable group for both comfort and confidence. The physically vulnerable group aggregate average ratings were well below both the GPG and sociocultural group with generally smaller comfort versus confidence gaps. This suggests the respondents perceived themselves to be more at ease engaging with the sociocultural group yet needing more experience to develop their skills. With the physically vulnerable group, the respondents perceived themselves with a greater lack of both comfort and confidence in providing care for these patients.
Chiropractic students demonstrated a high degree of perceived comfort engaging with patients of sociocultural diversity. Notably, the percentage of students who perceived themselves to be comfortable with the racially and ethnically diverse groups was slightly larger than the GPG. The religiously diverse, socioeconomically disadvantaged, and sexual orientation diverse groups had more than 60% of students rate themselves as comfortable. These attitudinal findings were at the preintervention stage and could decrease after taking the Special Populations course. Cultural competency training has been shown to help students discover their own level of “cultural blindness” and the need to become more aware of their own values and cultural identities and the impact they have on others.19
Students perceived themselves as significantly less comfortable with the physically vulnerable subgroup, especially the physically disabled, mentally disabled, and pregnant groups. Discomfort treating people with disabilities is not limited to chiropractic students. Kinesiology students, who also often engage in hands-on physical medicine careers, were found to experience negative attitudes toward treatment of people with disabilities due to a lack of knowledge and/or fear of causing harm.28 The finding of discomfort with pediatric patients aligns with those of practicing Canadian chiropractors who felt that chiropractic education on pediatric care was inadequate, and their comfort was achieved through postgraduate training and clinical experience.29 A perception of lacking preparedness was also found in medical students due to lack of case exposure.30 The variance of comfort levels across the different SPG supports the necessity of approaching each group on an individual basis. It also reinforces the value of students improving their cultural humility, that is, their self-awareness of bias and learning-oriented approach toward other cultures rather than striving for a mastery of knowledge about other cultures, as suggested with cultural competency.31
Confidence ratings were lower than comfort ratings when aggregated across all groups and for each specific group. As found with comfort levels, there were higher confidence ratings for sociocultural groups and lower ratings for physically vulnerable groups. The higher comfort and confidence ratings for the sociocultural groups may reflect an improved cultural awareness of current students, perhaps due to greater societal acceptance and exposure, minimizing the attitudinal challenges of providers when caring for diverse sociocultural groups. The lower comfort and confidence ratings for patients with physical and cognitive challenges may be related to preclinical anxiety of being able to successfully treat the patients they will soon be encountering, creating doubt about their ability to apply the hands-on skills they have learned. A previous study on second year chiropractic students found CC training had little impact on confidence levels; however, this was attributed to confidence levels being high at the preintervention survey.14 The inclusion of physically vulnerable groups beyond the typical sociocultural focus of CC training may have lowered confidence levels for those in the current study. Overall, the gap between comfort and confidence suggests that, whereas the need for CC training remains very important, students may be more concerned with their ability to effectively and safely adapt their hands-on application of patient care interventions than their mindset toward respectfully engaging with these patients.
This study also appears to be the first to report on chiropractic student self-identification as belonging to vulnerable groups. Seventeen percent of students self-identified as belonging to the trauma-influenced group. The inclusion of 3 potentially distinct traumas—physical, emotional, and sexual—likely confounded the data. Students who experienced a physical trauma that was effectively treated with chiropractic care may have been influenced to pursue a career in the profession and may represent a significant portion of the group total. Of the remaining groups, at least 1 student identified as belonging to every group with no more than 12% of students identified as belonging to any 1 group. This lack of diversity is in line with prior findings in chiropractic2 and health professions in general.32 Intersectionality examines how belonging to multiple SPG adds to one another to produce unique adversities.33 This study found 12% of students identified as belonging to more than 1 group, evidencing the importance of recognizing and valuing intersectionality of these students and the patients they serve when discussing identity.34
Future Studies
A study assessing this same target population on changes in their perceived comfort and confidence levels after completion of the Special Populations course is planned. Future studies involving a more representative sample of chiropractic students with qualitative elements such as open-ended questions and focus groups is also warranted.
Strengths
A strength of this study is the discrimination between students’ ratings for GPG and SPG. The ratings for the GPG to establish baseline comfort and confidence levels for patients not belonging to a diverse group demonstrated a level of face validity for the resulting data. The lack of principal investigator involvement with the course development, site of research, enrolled students, and course faculty, minimized bias toward the outcomes or data interpretation.
Limitations
There are several limitations to this study. Whereas internal consistency reliability was high for both comfort and confidence items, these results should be interpreted with caution as estimates may be conservative (underestimated) given that the study did not have at least 10 respondents for each item assessed.35 Also, we treated the confidence and comfort scales as unidimensional (tau equivalent) although it may be possible that each scale could contain a multidimensional factor structure.
The study target group represents a single course cohort at a single chiropractic program. Given the specific and targeted nature of the study, which limited sampling techniques to nonprobability, that is, convenience sampling, generalization beyond the targeted sampling population to all students in this program or other chiropractic or health care programs should be avoided. Although the survey development process resulted in good face validity and adequate data reliability (internal consistency), the limited use of the survey requires further testing before more comprehensive and exhaustive statements about data reliability and validity can be made. Although survey respondents’ confidence and comfort were assessed relative to a variety of potential patient population groups, the groups were broadly conceived. For example, the racially diverse group didn’t include subpatient populations such as African American, Latino, etc. Additionally, the broad patient groupings did not account for individuality or intersectionality among groups, for example, African American men, physically disabled Hispanic women, etc. As such, respondents’ perceptions cannot account for the heterogeneity and intersectionality inherently contained within these broad patient groupings. The aggregation of data into 3 categories from the 5-point Likert-like responses may have neutralized the impact of responses on either end of the scale. The combination of 2 responses neutral/uncertain for the 3 response in 2 of the question sets may have been confounding; students who were uncertain may be anywhere on the scale, whereas those who were neutral were appropriately midscale.
CONCLUSIONS
Second year chiropractic students demonstrated a high degree of perceived comfort and, to a lesser degree, confidence when engaging with and modifying care for patients of sociocultural diversity. Students were much less comfortable and confident engaging with and modifying care for physically vulnerable patients. At least 1 student identified as belonging to every group and some to more than 1 group, evidencing the importance of valuing intersectionality when discussing identity.
SUPPLEMENTARY FILE
Supplementary material associated with this article can be found in the online version at doi:10.7899/JCE-25-9.
DECLARATIONS
Acknowledgments
Gregory Snow acknowledges the contributions of Mary Jo Verbitsky for her mentorship and guidance with the development of the research protocol and design of this study through the California State University Masters of Science, Educational Leadership program.
Funding
No funding was received for this study.
Competing Interests
The authors declare no competing interests.
Data Availability
Data may be requested from the author upon reasonable request.
Artificial Intelligence
Artificial intelligence was not used to prepare this paper.
Contributorship
Concept development: GJS. Design: GJS. Supervision: GJS. Data collection/processing: GJS, DCD. Analysis/interpretation: GJS, DCD. Literature search: GJS. Writing: GJS, DCD. Critical review: GJS, DCD.
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Data may be requested from the author upon reasonable request.