Methods: Using a participatory research method (Israel, Eng, Schulz, Parker, 2013), specifically, a grounded theory (Cho, 2014) qualitative study using a focus group (Carver, 2014) with chiropractors (n = 4). The chiropractors were purposively selected to participate due to their leadership positions in the chiropractic community. One focus group session, lasting 45 minutes, was held on a university campus. Participants were provided informed consent prior to the start of the focus group. The focus group participants were asked four questions about the barriers and facilitators related to adopting evidenced-based systems change to address patient tobacco use and cessation, clinical quality measures related to tobacco use, and to identify key factors for researchers to consider when developing the intervention for the pilot study. The focus group was audio-recorded and transcribed verbatim. During the initial analysis three researchers read and analyzed the transcript separately. The researchers independently identified key content using a matrix method (Averill, 2002). The researchers then collaboratively reviewed the matrices to develop codes and themes through constant comparison and discussion. Using an inductive consensus-based analytic approach (Cho, 2014; Graneheim & Lundman, 2004), the authors agreed upon the results.
Results: The focus group participants identified facilitators, barriers, clinical quality measures, and identification of the most important factors to consider for development of this pilot study. The factors that facilitate evidence-based tobacco control strategies within chiropractic clinics included trusting relationships developed between chiropractors and their patients, accessibility of chiropractors due to their presence in multiple geographical locations, potential expansion of typical scope of practice and related potential reimbursement, wellness focus of chiropractic care is consistent with addressing tobacco use, knowledge of the connection between tobacco use and pain and healing, a responsibility or desire to help their patients, and the frequency of patient visits. Barriers included concerns of “confronting” patients regarding tobacco use may result in loss of positive relationships with patients, and subsequent loss of business, the chiropractor’s lack of knowledge, confidence, and skills to address tobacco cessation with patients in a positive manner, and lack of reimbursement. Clinical quality measures and benchmarks that were discussed by the chiropractors included Medicare, meaningful use of electronic health records, lack of the medical necessity of addressing tobacco use for musculoskeletal conditions, as well as being future-focused for how reimbursement is evolving, and the cost-benefit analysis of all quality measures. The economic business model is an important framework for chiropractor assessment of selecting quality improvement changes. Factors considered most important to the development of the intervention included ease of process, methods for engaging with patients free of confrontation, recognition of conflicting philosophies of chiropractors in relationship to pharmaceutical interventions.
Conclusion: These findings clarified the concerns that chiropractors practicing in a rural state in the USA have about incorporating evidenced-based health systems change to address their patients’ tobacco use within their clinics. The importance of making this economically neutral, that is, not cost a small business income, were also stressed by the participants. The findings from this study are being used to implement a collaborative, interdisciplinary tobacco systems change education program for chiropractors in a rural state in the USA. Results from this study emphasize the importance of addressing the unique needs of health care practitioners when implementing health systems changes to address tobacco use (CDC, 2014; CDC, 2016). As public health nurses often provide outreach and education of healthcare professionals on tobacco cessation, it is important to consider inclusion of chiropractors while being sensitive to their distinctive concerns. In addition, this study demonstrates the importance of interdisciplinary research, practice, and education to improve population health.