Exploring Chiropractic Healthcare in Hong Kong: Sick Leave Certification Dilemma

Objective This study aims to investigate the characteristics of chiropractic patients in Hong Kong, their experiences with chiropractic care, and their perspectives on chiropractors' authority over sick leave certificates. Method A cross-sectional survey was conducted among individuals receiving chiropractic treatment in Hong Kong. Data were collected through an online survey from May 11 to August 8, 2023, and descriptive analysis was employed to examine patient demographics, treatment effectiveness, and views on chiropractic sick leave authorization. A total of 522 valid responses were received. Result Among respondents, back pain was the primary reason for seeking chiropractic care, with many experiencing rapid relief and high satisfaction. However, many patients initially consulted other healthcare professionals, indicating potential integration challenges. Lengthy orthopedic wait times in Hong Kong highlight the need for chiropractic care. Concerns arose over chiropractors' inability to issue sick leave certificates, impacting patient convenience, treatment effectiveness, finances, and emotional well-being. Allowing chiropractors to authorize sick leave, with proper regulation, could address these issues. Conclusion In conclusion, this study underscores chiropractic care's potential in Hong Kong's healthcare system and suggests that recognizing chiropractors' role in sick leave authorization can enhance comprehensive patient care.


Introduction
Chiropractors in Hong Kong have gained widespread popularity as primary healthcare providers by offering non-invasive and drug-free treatments for managing neuromusculoskeletal complaints [1,2].Since 1993, chiropractors in Hong Kong have gained legal recognition as primary healthcare providers specializing in the diagnosis and management of neuromusculoskeletal complaints [3].As the profession continues to grow, they have become essential members of the city's primary healthcare system, delivering effective chiropractic interventions and providing holistic education and counseling to the general public [4].
Despite their efficacy and proficiency in managing neuromusculoskeletal disorders, chiropractors are currently excluded from the authorization to issue sick leave certificates, limiting their ability to grant patients leave from work or school for recovery.According to Hong Kong's labor law, only medical practitioners, Chinese medicine practitioners, and dentists are authorized to issue sick leave for employees [5].The authorization of sick leave certificates for chiropractors has not been extensively discussed within the Hong Kong government.The only known initiative from the government was an interdepartmental working group established in 2005; however, no conclusive outcomes were reached [6].
Given this limitation, individuals undergoing chiropractic care will find it necessary to consult other healthcare professionals in order to obtain sick certificates.This additional process is anticipated to potentially impose burdens on the patients, either in terms of their financial commitments or physical wellbeing [7].
Prior reviews have been conducted to analyze the demographic attributes of individuals who undergo chiropractic care [8,9].Nevertheless, there is limited information available concerning treatment effectiveness, opinions, and comments regarding the authority of chiropractors in relation to sick leave.This study aims to delve into the present state of chiropractic patient characteristics while gathering their perspectives on chiropractors holding the authority to make decisions about sick leave.

Design
The study utilizes a cross-sectional survey design to investigate the current characteristics of chiropractic patients and their perspectives regarding chiropractors' authority over sick leave certificates.The study received approval from the ethics committee of the Chiropractic Doctors' Association of Hong Kong (Causeway Bay, Hong Kong; IRB ID: CDA20230102), and written consent was waived since consent was implied by the return of the completed survey.To ensure respondent anonymity, names and other identifying information were not collected.

Setting
The target population of this study comprises individuals currently receiving chiropractic treatment in Hong Kong.

Instrument
A comprehensive survey questionnaire was formulated bilingually in Chinese and English to investigate various aspects, including the characteristics of chiropractic patients, the effectiveness of treatments, and viewpoints on chiropractic sick leave authorization.This questionnaire was informed by references from earlier reviews [8,9].It comprised 20 questions spread across three sections: demographic information, experiences related to chiropractic care, and perspectives concerning chiropractic sick leave authorization (see Appendices 1).

Data sources
The data for this study were collected by distributing a survey using the Google Forms platform.The survey was distributed to all registered chiropractors in Hong Kong through their respective chiropractic associations then the survey was circulated to all individuals who visited chiropractic clinics by either chiropractors or clinic staff in Hong Kong between May 11, 2023 and August 8, 2023.The completed survey forms served as the sole source of data for this study.Data were extracted from the survey responses and input into a spreadsheet format for further analysis.

Bias
To ensure the clarity of survey items and estimate the time required to complete the questionnaire, a pilot test was conducted with 10 chiropractic patients.All participants completed the survey within 10 minutes, and the pilot test indicated that the questions were clear and easily understandable.No adjustments were deemed necessary.

Sample size
The sample size was determined using a rule-of-thumb estimation, suggesting that each survey item should have a minimum of five respondents.As a result, a total of 100 respondents were required for this study.

Analysis
The data extracted from the questionnaires were analyzed using Microsoft Excel.Frequency tables and descriptive statistics were employed to investigate the present characteristics of chiropractic patients, the effectiveness of treatment, and perspectives on chiropractic sick leave authority.

Results
The survey was administered online through a Google Forms link from May 11 to August 8, 2023.Out of the 524 responses received, two were incomplete, resulting in 522 valid responses (99.6% completion rate).
Among the respondents, a majority (78.7%, n=411) were engaged in economic activities.Retired individuals constituted 7.7% (n=40) of the participants, while students and homemakers represented 7.1% (n=37) and 4.4% (n=23), respectively.In terms of educational background, the survey results indicate that a majority of respondents (63.3%, n=329) have attained post-secondary education.This is followed by secondary education (33.3%, n=173) and primary education and below (3.5%, n=18).

Treatment effectiveness
Respondents' assessments of their conditions' impact on daily activities and work-related tasks varied.A significant portion (32.3%, n=168) reported a slight impact, while 28.8% (n=150) experienced a moderate influence.Moreover, 16.2% (n=84) indicated a significant impact, signifying substantial hindrance and 11.3% (n=59) reported being unable to perform daily activities or work-related tasks due to their conditions.
The majority of the respondents (72.1%, n=373) sought treatment from other healthcare professionals before turning to chiropractic care.Specifically, 55.1% (n=255) of the respondents consulted a physiotherapist, 53.3% (n=247) visited a general medical practitioner, 52.7% (n=244) sought help from a traditional Chinese medicine practitioner, 47.7% (n=221) opted for acupuncture, 41.5% (n=192) consulted with a specialist, and 27% (n=125) sought assistance from a bone setter.Regarding treatment effectiveness, a significant majority of respondents, 89.8% (n=464), affirmed that the treatment effectively addressed their condition.Additionally, 48.4% (n=249) reported experiencing immediate improvement, while 25.3% (n=130) noted improvements within a few days.About 10.5% (n=54) reported improvement within approximately a week, 6% (n=31) within two weeks, 4.5% (n=23) within one month, and 5.3% (n=27) reported seeing improvements after more than a month of treatment.Table 7 shows the time taken for noticeable improvement in respondents' condition after beginning chiropractic care.Nearly all respondents (91.9%, n=480) expressed high levels of satisfaction with their chiropractic treatment experience, and a noteworthy 89.6% (n=468) of the respondents expressed their willingness to recommend chiropractic care to their significant others.

Sick leave authority
Among the respondents, a significant majority (53.6%, n=270) had taken sick leave due to the condition for which they sought chiropractic care.Of those, the majority (64.6%, n=188) had taken one to three days of leave, while 24.7% (n=72) had taken four to seven days, 5.8% (n=17) had taken eight to 14 days, and 4.8% (n=14) had taken 15 days or more.Notably, 65.2% (n=320) of these respondents obtained sick leave certificates from chiropractors.
The survey also addressed a crucial question concerning the potential ramifications if chiropractors were unable to issue sick leave, necessitating patients to seek alternative healthcare professionals for this purpose.The responses unveiled a spectrum of concerns regarding such a scenario, underscoring its multifaceted impact.An overwhelming majority, 85.1% (n=430), expressed deep concern about the financial implications of obtaining sick leave from an alternate source, emphasizing the potential for increased costs.Furthermore, a substantial 82.6% (n=417) of respondents foresaw significant inconveniences in this process, while 72.9% (n=368) voiced apprehensions about extended waiting times.Notably, 59.8% (n=302) were concerned about the possibility of delayed recovery, underscoring the pivotal role of timely sick leave authorization.Moreover, respondents highlighted several potential challenges, including fragmented care (44.8%, n=226), reduced trust in chiropractors (43.8%, n=221), miscommunication (45.5%, n=230), an overburdened healthcare system (56.6%,n=286), and diminished patient autonomy (51.1%, n=258).Table 8 illustrates whether respondents agree that they would be affected by any circumstances if their chiropractor is unable to issue sick leave and they are required to seek another healthcare professional for sick leave.

Discussion
This survey was conducted to assess the demographics, reasons for seeking chiropractic care, treatment effectiveness, and sick leave authority of chiropractic patients in Hong Kong.The results provide valuable insights into the role of chiropractic care in the Hong Kong healthcare system.
The findings of this study echo previous research, highlighting the predominance of back pain as the primary driver for seeking chiropractic care, aligning with multiple studies [8][9][10][11].Moreover, a substantial portion of respondents in this investigation reported favorable outcomes, corroborating the effectiveness of chiropractic treatment, with many experiencing rapid relief and improvements within days.Furthermore, various studies have delved into the extensive examination of the impact of chiropractic treatment, with some emphasizing its cost-effectiveness in managing musculoskeletal disorders, notably in cases involving low back conditions [11][12][13][14][15].
In this study, a majority of respondents expressed satisfaction with the chiropractic treatment they received.Chiropractors firmly believe that their interventions can act as a preventive measure against the persistence or recurrence of low back pain [16].Additionally, they emphasize that the treatment's effectiveness hinges on patients' understanding of both low back pain and the corresponding therapeutic approaches [17,18].Guided by these chiropractic principles, patients often receive preventive advice and detailed explanations of their treatment, leading to high levels of patient satisfaction [11,19].
Despite the evident effectiveness and the high satisfaction reported by patients, a significant portion of respondents in this study sought treatment from other healthcare professionals before considering chiropractic care.The most prevalent reasons for choosing chiropractic care were referrals from others and a desire to explore whether chiropractic interventions could provide relief for their specific conditions.These trends suggest a potential lack of awareness within the community regarding the potential benefits of chiropractic care.This, in turn, could imply that chiropractors are not fully integrated or utilized within the healthcare system in Hong Kong.
Presently, the Hong Kong Hospital Authority reports an extensive waiting period for new case bookings in orthopedics and traumatology, with wait times ranging from 80 to 99 weeks [20].This delay in assessment undoubtedly has the potential to exacerbate patient conditions and significantly impact their overall quality of life.
Chiropractors, as primary healthcare providers with expertise in diagnosing and managing neuromusculoskeletal complaints [10], offer a viable solution.Given the demonstrated effectiveness and cost-efficiency of chiropractic treatments, it is imperative for authorities to promote the role of chiropractic care to the public.Furthermore, exploring potential public-private partnerships in managing the long wait times for orthopedic patients could alleviate the burden on the healthcare system and improve patient outcomes.
The Hong Kong government's current stance does not extend recognition to chiropractic sick leave certificates.Consequently, patients who acquire such certificates from chiropractors may still find themselves compelled to consult with a general medical practitioner or specialist for other healthcare requirements.Notably, this study revealed that nearly half of the respondents had indeed taken sick leave due to health issues for which they sought chiropractic care.Moreover, the majority of respondents disclosed that their daily lives were significantly affected by their conditions.They expressed their perspectives on the inability of chiropractors to issue sick leave certificates, highlighting various consequences, including inconvenience, concerns about treatment effectiveness, financial strains, and even mental burdens.
The potential benefits of allowing chiropractors to issue sick leave certificates in Hong Kong are multifaceted.Firstly, it can alleviate the burden on other healthcare professionals, particularly general medical practitioners and specialists, by providing an alternative avenue for sick leave authorization.Secondly, it can enhance the accessibility and convenience of obtaining sick leave, especially beneficial for patients balancing work or other commitments.Thirdly, it can contribute to ensuring patients receive timely and suitable care for their conditions.However, the potential challenges of this authority include the risk of misuse or abuse.Nevertheless, this risk can be effectively managed by establishing clear guidelines and regulations governing chiropractic sick leave certification.
The Chiropractic Doctors Association of Hong Kong (CDAHK), being the largest chiropractic organization [21], has recognized the potential issue of misuse and taken proactive steps by issuing a Sick Leave Guideline for Chiropractors in 2014.This guideline provides chiropractors with clear instructions on when sick leave is medically necessary for common conditions falling within their scope of practice [22].To ensure responsible use of sick leave authority, chiropractors could be subjected to the same oversight and auditing requirements as other healthcare professions that possess this privilege.This approach would enable chiropractors to certify sick leave for the conditions they are qualified to treat while simultaneously minimizing the risks associated with overprescribing or misapplying with this authority.
This study has several limitations worth noting.First, the use of an online survey method and reliance on self-reported data might introduce bias in the findings.Additionally, the study's reliance on descriptive analysis alone could affect the representativeness and generalizability of the results.Furthermore, this research did not investigate the underlying reasons behind the observed treatment effectiveness and patient satisfaction among chiropractic patients.Therefore, further studies are needed to address these limitations and explore the factors contributing to treatment effectiveness and patient satisfaction within the context of chiropractic care in Hong Kong.

Conclusions
This study provides insights into the characteristics of chiropractic patients in Hong Kong, their experiences with chiropractic care, and their perspectives on chiropractors' authority over sick leave certificates.
This study reveals that back pain remains the primary reason for seeking chiropractic care, with rapid relief being a common outcome.High patient satisfaction stems from education and preventive approaches.Despite these benefits, many patients first consult other healthcare professionals, highlighting awareness gaps and integration issues within the healthcare system.Hong Kong's lengthy orthopedic wait times suggest a more significant role for chiropractors, potentially through public-private partnerships and increased public awareness.However, the government's stance on chiropractic sick leave certificates is problematic.Many respondents needed sick leave, and the inability of chiropractors to issue certificates raised concerns about convenience, treatment efficacy, finances, and emotional well-being.Allowing chiropractors to authorize sick leave could address these issues, offering timely care and reducing the burden on other healthcare providers.Proper regulation can prevent misuse.
In summary, this study emphasizes the potential of chiropractic care in Hong Kong's healthcare system.Further research and recognizing chiropractors' role in sick leave authorization can enhance the comprehensive care provided by this profession.

Table 1
presents the demographic information of the respondents.

TABLE 1 : Demographical information by the respondents
n= number of respondents

Table 2
illustrates the number of chiropractic treatments received during the past 12 months by the respondents.

TABLE 2 : Number of chiropractic treatments received during the past 12 months
n= number of respondents

TABLE 3 : Reason for choosing chiropractic treatments by respondent
n= number of respondents

Table 4
describes the reason for seeking chiropractic treatments and the part of the body that has received treatment by the respondents.

TABLE 4 : Reason for seeking chiropractic treatments and part of the body having received treatment by the respondent
n= number of respondents

Table 6
presents whether respondents had received other kinds of treatment before receiving chiropractic treatment.

TABLE 6 : Whether respondents had received other kinds of treatment before receiving chiropractic treatment
n= number of respondents

TABLE 7 : The time taken for noticeable improvement in respondents' condition after beginning chiropractic care
n= number of respondents

TABLE 8 : Whether respondents agree that they would be affected by any circumstances if their chiropractor is unable to issue sick leave and they are required to seek another healthcare professional for sick leave
n= number of respondents