Although there are few studies that have examined factors that positively impact on non-chiropractic health professionals’ association membership, the most important predictor of membership seems to be an individual’s perception of the value of association membership . In particular, an individual’s decision to join or remain in a PA depends on whether they perceive that the benefits outweigh the costs . We will consider each of the five themes that emerged from our research individually and propose solutions.
Theme 1: tarnished image of the profession
The experiences of interviewees provided insights into a chiropractic profession that they thought to be internally conflicted and viewed negatively by the wider community and other health professionals. This view appeared to cast a shadow over all the respondents’ deliberations. The respondents’ views on the respectability of chiropractic are not without reason. The occupation of chiropractic is not rated as prestigious by the public  nor by other healthcare professions . This is not helped by an inadequately informed public about the nature of chiropractic care in Australia [22, 23], and not unique to the profession of chiropractic. Studies with other health care professions have shown that scandals in PAs  and disagreement with PA positions and policies  resulted in lower levels of membership. Finally, it should be borne in mind, that a person’s self-esteem is influenced by the degree to which other people value their role, and this may also be a contributing factor .
There is a body of research exploring image repair that is relevant for Australian chiropractic PAs . The main strategies are thought to be denial, evading responsibility, reducing offensiveness, mortification and corrective action . When applied to chiropractic PAs, denial may involve convincing non-members that PAs did not create the current image for chiropractic, whereas evading responsibility could be to claim that the blame lay elsewhere e.g., a recalcitrant minority. Reducing offensiveness may be seeking to minimize the importance of the respectability issue and turn the tables by attacking those who raise accusations while at the same time promoting the PAs positive aspects. PAs could also communicate regret (mortification) and engage in corrective actions aimed at rectifying the damages. Finally, they could consider inoculating their members against likely future attacks against the profession by forewarning them of pending likely reputational attacks as well as providing members with counter arguments that weaken this threat. All of this presupposes that PAs have the resources (financial, expertise, person-power) to undertake these tasks and this may not be the case. It also assumes that image is the only barrier for non-PA members and this study suggests this is not the case.
Interestingly Australian chiropractic students, whose membership is free to PAs, did not see the image of the profession or PA as a barrier or facilitator to membership . Perhaps this may be explained by the student population not having been exposed to the financial reality of day-to-day practice and persistent negative community opinions of chiropractic.
Theme 2: not worth the money
The views of the respondents in this study were reflected in the findings of previous studies of the importance of benefit outweighing cost as an influencing factor for PA membership . Perhaps this can be explained by Rational Choice Theory which posits that individuals are purposive and intentional, seeking to achieve their given preferences . To this end people tend to make choices to maximize their chances for achieving their preferences, generally driven by some tangible benefits . Factors that were viewed as costs in this study and common to other health professionals were excessive membership fees , PA scandals  and disagreement with their positions and policies . This study did not resonate with other health professions that PA involvement impacts negatively on their work life balance . Shared factors that were viewed as benefits by the interviewed chiropractors in this study, Australian chiropractic students, and Welsh chiropractors were well priced membership while promoting the public and professional image of chiropractic, promoting research, providing workplace support and access to continuing professional development activities [9, 10]. Continuing education and networking has also been found to be important to other health professionals [19, 31].
Several respondents suggested that PAs could help chiropractors improve their practices by making clinical guidelines available. This function already occurs, as PAs provide seminars and continuing professional development to help members interpret and effectively use existing guidelines. Two possibilities exist. First the message of their availability is not reaching all members of the profession. Second, we have noticed that chiropractors seem to prefer ‘feel good’ seminars rather than research and evidence-oriented ones. This observation may warrant further investigation.
Theme 3: going it alone / What’s in it for me?
The narratives of many participants seem to echo aspects of the choice to belong to large groups, however their focus was on their own individual needs rather than on those of the wider group . It is possible that this may reflect an increasing trend among younger health professionals where PAs are perceived as lacking in personal relevance .
Chiropractic practice in Australia can be insular, arising from a variety of historical, educational, geographic, and professional factors [33,34,35]. Therefore, the finding of an individualistic mentality should not be surprising. Historically, chiropractic developed outside mainstream medicine, and medicine viewed chiropractic as a competitor, driving chiropractors to practice on their own . Some chiropractors also had and have an alternative paradigm of health and disease, leading them to have little or no association with medicine . Chiropractic education in Australia, although predominantly within the public university system, tends to stand alone within those universities, rather than be integrated with other health care disciplines. Nearly all chiropractors in Australia work in private practice . Just over 75% work with another practitioner and this is overwhelmingly either another chiropractor or a masseur . Just over one-half of all chiropractors report receiving or making referrals to a medical practitioner and only 25% practice in more than one location . Chiropractic is also largely excluded from the single-payer reimbursement system in Australia, and few chiropractors work in medical offices or hospitals .
Another factor thought to be influential, but not reflected in non-chiropractic PA members responses in this study, is the presence of broader social forces . Here people organize themselves in order to assert their personal interests, enhance their personal reputation, and gain access to desired goods. The non-influence could be explained, at least in part, by the preference of ‘going it alone’. Other social motives are thought to influential were the seeking to belong for principles of solidarity or ideological (political, ethical, or religious) convictions, as well as to be emotionally associated with the community. These were echoed in the recorded interviews as unfulfilled desires and deemed to be an unlikely occurrence in PAs.
Recent research has looked at the degree to which people in a society are integrated into groups and this theoretical framework is known as ‘Individualism and Collectivism’ . These two traits exist on a continuum, where those at the collectivistic end are more likely to show attentiveness to others and see themselves as exemplars of the larger group. At the individualistic end are people who show self-directedness, autonomy, and independence and see themselves as makers of their own destiny. On the surface it appears that chiropractic PA non-members are more likely to possess individualistic traits which warrants further investigation.
Theme 4: two warring factions
The chiropractic profession is not homogeneous. Some practitioners see the practice of chiropractic as being an evidenced-based approach to musculoskeletal care (MSK) of the spine . Others have adopted an alternative paradigm and believe that spinal manipulation has a role to play in disease and wellness more generally (Non-MSK) by the removal of biomechanical lesions called subluxations that impact on the nervous system [40,41,42]. For example one Australian PA (A.C.A.) sees chiropractic as a health profession concerned with mechanical disorders of the musculoskeletal system and the effects of these on the function of the nervous system and general health but provides no website information or policy on subluxations . The other PA (C.A.) sees it role as promoting evidence-based chiropractic care and inter-professional cooperation in order to improve community health through high quality, patient-focused care and has policy statements on subluxation as a historical concept, not supported by any clinical research evidence . It is generally thought that the MSK and non-MSK factions exist as polar extremes with the majority falling somewhere in the middle . The two factions strongly defend their own position and question the other’s paradigm [46,47,48], to the extent that a recent discussion paper proposed that these differences were irreconcilable and the profession should consider divorcing along these lines .
Several of the respondents in this study thought that PAs had a role to play by regulating substandard behaviour of its members. PAs are not empowered by statute to enforce laws or regulatory standards by suspending members from practice, or imposing fines. Their remedy is exclusion from the group and may not hold weight if the practitioner does not highly value membership in the first place. Perhaps they have the option of playing a role more broadly in addressing substandard behaviour by offering the public information about reporting such behaviours, publishing position statements on known issues, work alongside licensing / registration boards and advocate for the government to adopt positions that improve the standards of practice. The PAs potential to generate change is diluted when many in the profession have no interest in their particular definition of professionalism and will not join. This is further complicated when different chiropractors have fundamental differences in the definition of substandard behaviour. Ultimately this places PAs in a conundrum between needing as many members as possible to fund various activities and taking an ethical stand to represent the highest standards of professionalism. How PAs respond to this issue will most likely be influenced by their understanding of the reasons for their existence.
Finally, suggestions have been made that the way forward for the profession is through bringing these factions together and presenting a unified front by embracing all views to co-exist under the term chiropractor . However, this ‘big tent’ approach, according to the respondents, may be another reason people do not to join, because they believe the association, in representing all permutations of chiropractic, does not adequately represent their particular views.
Theme 5: lack of visibility
The PAs were perceived to be of inconsequential value to the workplace and as struggling to be visible. It is easy to speculate, based on the findings of this study, that the lack of visibility is related to a lack of desirability. The participants’ views paint a picture of a squabbling profession with a poor image, whose PAs are thought to be costly and largely irrelevant and this fails to ‘catch the eye’ of the siloed Australian chiropractic practitioner.
Social media marketing may be one avenue for PAs to consider as this has demonstrated an ability to enable word of mouth as well as change attitudes towards a brand . Most commonly this involves Facebook and Twitter, however other forms of social media such as virtual worlds, content community sites and sites dedicated to feedback have also been shown to enhance brand images . The impact of marketing efforts in these domains are difficult to measure as the exact mechanism of how online sharing of information takes place and in turn shapes the co-creation of value by consumers remains largely unknown [50, 51]. Also, there are non-traditional marketing alternative strategies such as entrepreneurial marketing that better serve smaller organizations, such as PAs, and warrant consideration to overcome this proffered lack of visibility .
Strengths and limitations
This is the first study to explore chiropractors’ views on why they chose not to belong to a representative PA. This study sampled the views of nine experienced Australian chiropractors with an average of nearly 10 years of non-membership in a PA. We are confident they have provided a rich insight into the issues surrounding non-membership in a chiropractic PA. However, as this was a qualitative study, our sample cannot be assumed to be representative of the views of all non-members of PAs nationally and internationally. However, the embedded messages inherent in the participants responses demand and direct attention to issues of concern for the profession. The authors are confident they have addressed the issues surrounding qualitative research of reflexivity , credibility, transferability, dependability and confirmability .
Additional qualitative research could further explore some of the themes uncovered here. A quantitative survey of a representative sample of non-PA members will ultimately confirm the degree to which the factors identified by the small number of respondents in this study contribute to non-membership. Ideally this would involve chiropractic and non-chiropractic PAs from around the world to enhance its generalisability. On the surface it appears that chiropractic PA non-members are more likely to possess individualistic traits and any further studies should consider incorporating measures to this end.
This study when combined with the previous study of Australian chiropractic students’ attitudes to PAs suggests that, for some, there is a change for the negative in their view of the profession. An exploration of the factors surrounding this change would necessarily be longitudinal in nature.