Our findings suggest that chiropractic students’ attitudes tend toward a patient-centred approach to care delivery across international chiropractic programs. However, scores differed significantly between institutions and although these differences were small on the metric of the scales, they translated to having moderate to large effect sizes . In our study, scores increased with increasing student age and were higher on average for females than for males. The overall average PPOS score for chiropractic students in our study was 4.18, with average Sharing and Caring scores of 3.89 and 4.48 respectively. The overall average PPOS score in our study appears to be at the lower end of those reported for medical students, where average scores ranged from 4.1  to 4.66 . Similarly, average Caring subscale scores ranged from 4.4  to 5.20 , and average Sharing subscales from 3.8  to 4.10  among medical students. It is of note that the spread of the outcomes measured (as indicated by the standard deviations) appear very similar in these studies, ranging about 0.4 to 0.5. The observed lower score among chiropractic students may be related to curricular content or timing/nature of actual patient exposure in chiropractic programs that primarily occurs in the final term. Such limited exposure may not provide sufficient time for students to develop their self-confidence as doctors nor nurture their desire to help patients, similarly reported among medical students [19, 20].
This is the first study assessing worldwide student attitudes towards patient-centred care in chiropractic education. The Council on Chiropractic Education International aims to harmonize chiropractic education worldwide; however, its advice to national councils are implemented at the discretion of the educational institutions who create curricular content . In our mobile society, common frameworks could ensure consistency across major curricular content worldwide. We observed significant differences across institutions, but it is not clear what might be driving those differences. Woloschuk et al.  suggested that examining the hidden curriculum and the null curriculum would identify content that may influence scores of student attitudes. However, our study did not address specific curricula or, arguably more importantly, recruitment policies. As a consequence, it is unknown if and how curricula or recruitment strategy influence student patient-centred attitudes. For example, communication skills are considered a means to seek common ground in the interaction , but it is unknown if and how these skills are integrated into the curricula of chiropractic programs, or if/how this capability affects success at the recruitment stage.
Unlike results from other healthcare programs, student PPOS scores in chiropractic programs did not significantly differ by program year or semester. The similar PPOS scores between chiropractic program year or semester may be explained by the curricular content or varying response rates. The varying response rates may also explain the difference between scores reported in medical programs and in our study. Future work could assess how patient centred care is taught across the curriculum and may change over time. In medical school and residency programs, evidence suggests [14, 20, 36] scores degrade over time suggesting a shift towards a more doctor-centred attitude, particularly in Overall and Sharing scores.
The overall tendency for female students to have more patient-centred attitudes is reflective of previous studies [14, 5, 20, 36]. Such higher scores may be due to differences in early socialization, as well as a greater importance placed on empathy specifically for female students and physicians . The tendency for female healthcare students and professionals to communicate in a more patient-centred manner has been reported [14, 5] to affect patient outcomes such as satisfaction. Greater understanding of the development of gender-based differences in patient-centredness may thus have a significant future effect on doctor-patient relations by reducing the gender disparity in patient-centred communication.
Our study identified a positive relationship between student age and PPOS scores, but no relationship between PPOS scores and whether a family member was a healthcare practitioner or not. This is not wholly consistent with previous studies, however, with Haidet et al. , reporting similarly with respect to family background, but contrary to us in terms of age and PPOS scores in fourth-year students. Additionally. Lee et al.  suggested that a student’s experience of health care systems, either as a patient or having to care for family was associated with higher PPOS scores, but exposure to an acute event was not, attributing the higher scores to maturity gained through life experiences. We, on the other hand, found no relationship between PPOS scores and whether the respondent had received chiropractic care in the past or not.
Strengths and limitations
A strength of our study was using an instrument which has been used extensively across disciplines and in a context-specific manner that is, testing students’ attitudes. A further strength was that we explored student attitudes across different chiropractic programs worldwide.
Even though the multi-site study was international and used the English version of the PPOS instrument in all schools except one (i.e. IFEC in France), it is unknown if the culture and language of the country affected the understanding and interpretation of the questions. No exploration into cross-cultural adaptation and validation was performed. Additionally, while seven schools participated in this study, although a reasonable guide, the results may not be representative of all chiropractic education worldwide. We did not assess the representativeness of our sample to that of the student body in each program. Thus, the results may not be generalizable to worldwide views of patient-centredness.
Another limitation was our response rate and the risk of non-response bias, which may provide results different than for the entire target student population. Unfortunately, it was not possible to compare responders to non-responders to inform representativeness of the sample. Further, response rates differed across institutions, where three had rates below 33%, which may influence our results; however, institutional response rates did not seem to correlate with PPOS scores. Furthermore, the overall participation rate was recorded as 48.9%, similar to the 43% average online survey response rates reported by Nulty .
Finally, despite standardizing our data collection method, there were variations related to administration of the survey, including providing class time and incentives, which may have contributed to differential non-response bias. Indeed, we note that the response rates in the schools providing class time and incentives tended to be higher than those not. To what degree these differences influenced PPOS score is unknown.
The study was conducted across all years and semesters of each chiropractic program. However, no detailed curricular analysis was conducted, hence it is unclear if course content and curricular design/delivery may have impacted the results. Nor did we consider student recruitment policies which may impact results.