National Social Science Association

Consumers’ Attitudes toward Advertising by Chiropractors
and Their Use of Various Media Practices

Gordon L. Freeman, Jr, H. Ronald Moser
Middle Tennessee State University

Introduction
     For the health professions, marketing has traditionally been a controversial issue, and the notion of using advertising to promote a professional’s practice is relatively new. Prior to the 1970s, professional codes of ethics prohibited patient/client solicitation through advertising, but in 1977 the U.S. Supreme Court began striking down many such bans when it overturned a ruling by the Arizona Bar Association regarding disciplinary action against two attorneys for violating the association’s ban on commercial advertising. A study by Rizzo and Zeckhauser found that advertising by health care professionals has increased dramatically during the past decade, and this trend seems likely to continue (Rizzo and Zeckhauser 1992), although many professionals find themselves ill equipped to handle the dynamics of an evolving environment, especially without some form of ongoing marketing plan. Most professional societies and associations have prohibited the marketing of their services. These health care professionals believe that advertising would have an adverse effect on the image of the profession in general and no impact on competitive price reduction (Allen, Wright and Raho 1985; Duffus 1990). Also, a 1989 study conducted by Wright, Raho, and Berkowitz concluded that advertising and marketing are controversial topics among health care professionals. The study further states that the opinion that advertising is evil no longer exists. The study also states that the fear advertising would lead to fraud and hucksterism has not materialized. The chance of false advertising is becoming remote in a modern society where such practice would not be tolerated by consumers or other health care professionals (Wright, Raho, and Berkowitz 1989).
     Medicine is increasingly recognizing itself as a business. The chiropractic industry has grown to more than 50,000 doctors serving 21 million patients each year over the past century (Davis 2002). It is projected that various alternative medical services, which include chiropractic services, will grow by 88 % between 1994 and 2010 (Cooper and Stoflet 1996).
Purpose of the Study
     Until 1980 the American Medical Association prohibited its members from associating professionally with chiropractors, but now that chiropractors are licensed in all 50 states and their services are reimbursed through Medicare, Medicaid, and many private health insurance plans, they are receiving more acceptance throughout the medical profession (Endresen and Wintz 2002; Handlin, Mosca, Forgione, and Pitta 2003). During the past several years, chiropractors have become highly competitive in marketing their services to the public, and it has become common for them to advertise their services using a variety of media. The purposes of this study were to determine (a) consumers’ attitudes toward advertising by chiropractors; (b) which media consumers feel are appropriate for chiropractic advertising; and (c) whether consumers are aware of chiropractic advertising and, if so, through which media. It was the intent of this study to discover information that would be useful to chiropractors in planning and improving the quality of their advertising.
Background and General Research Questions
     There is widespread belief in this country that the hyperinflation that has characterized the field of health care in recent years can be attributed largely to a lack of competition among medical practitioners (Butcher, Sparks, and O’Callaghan 2002; Sheppard 2002). Chiropractors, at one time considered one of various alternative medicine practices, comprise a multibillion-dollar industry with more than 20 million patients in the U.S. (Stevens, Mansfield, and Loudon 2005). However, during the past 30 years, the practices of health care professionals have undergone many changes. Consumers are becoming more involved in their own health care, seeking the type of drugs or pharmaceutical products that best meet their needs, and are willing to take more responsibility for obtaining adequate information for treatments than in the past (Endresen and Wintz 2002; Handlin, Mosca, Forgione, and Pitta 2003). Another change is the frequent use of advertising, which can be attributed in part to sweeping changes in judicial interpretation of (1) commercial free speech (Virginia State Board of Pharmacy v. Virginia Citizens’ Consumer Council 1976; Bates v. State Bar of Arizona 1977) and (2) restraint of trade by professional organizations (Goldfarb v. Virginia State Bar Association 1975). Today it is fairly common in most parts of the United States for people to see one of the many thousands of chiropractic advertisements shown on television every day, receive a spam e-mail advertisement from a chiropractor, view one of the many hundreds of yellow- pages chiropractic ads while using the telephone book, or even see some of the hundreds of highway billboards promoting a chiropractor’s, hospital’s, or physician’s services that are permitted in some areas of the nation (Carabello 2003). Also, Parker reported that many marketing departments at health care organizations view the Web as an effective vehicle for being more proactive in marketing programs and services to present or potential patients (Parker 2000). A marketing budget has become critical for most medical practices, and many health care and legal professionals now use marketing consulting firms or have their own internal marketing/advertising committees (Sahl 2003). According to a study by Butler and Abernethy (1996), yellow-page ads have been the most popular form of health care professional advertising. This study revealed that every month approximately 21.6 million adults in the United States refer to the yellow pages before obtaining medical care (Butler and Abernethy 1996), although a study conducted by Reade and Ratzan in 1987 found that yellow pages are potentially misleading to consumers and suggested that member boards of the American Board of Medical Specialties should consider ways to diminish this possible misrepresentation (Reade and Ratzan 1987). Fernandez (1997) also reported that yellow-page advertising doesn’t attract many new patients and saddles doctors with a monthly expense in the thousands of dollars. The study also states that yellow-page advertising today is almost a total waste of money (Fernandez 1997). Such ads are now the top revenue category for the yellow-page telephone directory with professionals such as lawyers, physicians, and chiropractors spending more than $700 million annually to be listed. In the year 2000, these professionals spent $230 million on television advertising just in the nation’s top 75 TV markets (Freedman 2001).
     While the attitude of health care professionals toward advertising is mixed and the attitude of most state regulators has generally been negative, the attitude of consumers has historically been fairly positive (Hekmat and Heischmidt 1996). Research has shown that the attitudes of other health care professionals toward advertising have become significantly more positive in recent years. Such advertising therefore is expected to increase as health care professionals attempt to prevent erosion of market share and seek new markets for growth within their practices (Sanchez 1988). A study conducted by Fernandez (2004) concluded that a vital key to building a highly successful chiropractic practice is to develop a new practitioner image. This study also states that chiropractors should create an image that attracts new patients to them (Fernandez 2004). A study conducted by Leventhal (1995) concluded that opposition to health care professional advertising appears to center on ethical issues, whereas arguments favoring advertising focus on information needs, economic and competitive issues, and the right to advertise (Leventhal 1995).
     Several academic studies have focused on the main concern of practicing health care professionals: whether advertising attracts patients (Wayne and Weller 1994; Bernstein and Gauthier 1999; Lubalin and Harris-Kojetin 1999). The answer has been a definite “yes.” These studies show that most chiropractors who advertise will likely see an increase in the number of middle- to lower-income patients. Chiropractors who advertise discover quickly that, although advertising is usually very expensive, it works if done properly and ethically. One study found that the return on dollars invested by professionals in advertising was four to six times the cost (Freedman 2001).
     The above discussion shows that professional advertising usually works (producing an increase in patient flow and yielding a good return on chiropractic advertising dollars) and is protected by the First Amendment. It shows that historically consumers have not always had a positive image of chiropractors who advertise but believe chiropractic advertisements provide useful information (Hekmat and Heischmidt 1996; Shekelle and Brook 1991).
     This study explores opinions on the informational function of, importance of price in, presence of deception in, future of, and appropriate media for chiropractic advertising. Specifically, the study examines attitudes concerning whether chiropractic advertising would (1) provide useful information to the public, (2) increase the costs of chiropractic care services, (3) increase the quality of chiropractic services in the future, (4) help consumers make more intelligent choices between chiropractors, (5) tend to lower the credibility and dignity of their services, and (6) make the public more aware of the qualifications of chiropractors.
Methodology
Data Collection
     Much of the initial planning of this study was based on Hite’s study at the University of Arkansas (Hite 1982). The Hite study indicated that advertising and marketing can be advantageous to health care professionals and their practices. Most health care professionals will generally find that consumers are aware of their advertising and appreciate the information communicated to them through advertisements. Hite suggested that the health care professional who researches the significant attitudes of his/her target market is likely to enjoy a competitive advantage over the competition. Acknowledgement is given to the research instruments of Hite (1982) and Miller and Waller (1979), which served as bases for the questionnaire in the current study. Also, acknowledgment is given to Hite’s organization and writing style, which served as a model for this paper.
     A four-part questionnaire was used to collect the data. The first section concerned demographic characteristics of the respondents: city of residence, occupation, age, sex, race, marital status, number of children in household, total family household income, and education. The second section of the questionnaire included 16 statements designed to measure how favorably consumers perceived advertising by chiropractors. The respondents were asked to assess the strength of their agreement with the statements on a scale ranging from “strongly agree” to “strongly disagree.” Tables 1 through 5 contain these 16 statements.
     The third section of the questionnaire listed eight different media that chiropractors could use to advertise their services. The respondents were asked how appropriate each medium was for chiropractic advertising. The responses ranged from “very appropriate” to “very inappropriate.” Table 6 contains the data captured by this section of the questionnaire.
     The fourth section asked the respondents whether they had ever seen chiropractors advertise and, if so, through which media. Tables 7 and 8 contain the data captured by this section. The researchers asked the Marketing System Group (a research company in Fort Washington, Pennsylvania) to draw a random sample of 4,000 consumers from the seven metropolitan statistical areas in Tennessee: Memphis, Nashville, Clarksville, Chattanooga, Knoxville, Jackson, and the Tri-Cities (Bristol, Kingsport, and Johnson City). Appropriate numbers from each city were drawn according to the ratio of each city’s population to the total population of all seven urban areas. The research instrument was mailed to these consumers, and 387 usable questionnaires were received and used in this study, representing a 9.675 percent response rate.
Demographic Variables
     The 387 participants included 215 males and 172 females. Regarding age, 72 (18.7 percent) were 18-25, 37 (9.6 percent) were 26-35, 41 (10.6 percent were 36-45, 86 (22.3 percent) were 46-55, and 150 (38.9 percent) were 56 or older. The majority was white (87.0 percent). In terms of marital status, 112 (28.9 percent) were single, 213 (55.0 percent) were married, 34 (8.8 percent were divorced, 27 (7.0 percent were widowed, and 1 (.3 percent) were separated. Further, 7 (1.8 percent) had less than a high school education, 48 (12.5 percent) were high school graduates, 128 (33.3 percent) had some college education, 127 (33.1 percent) were college graduates, and 74 (19.3 percent) had advanced degrees. Moreover, 152 were professional, and 227 were nonprofessional. Regarding total family household income, 21 (5.7 percent) had $15,000 or less, 46 (12.4 percent) had $15,001-30,000, 52 (14.1 percent had $30,001-45,000, 72 (19.5 percent) had $45,001-60,000, and 179 (48.4 percent) had more than $60,000. Participants in the present study were mostly white, male, age 56 or older, and married. They also had a college education and high income. Therefore, participants in this sample do not match the population perfectly. However, there was no reason to believe this sample was atypical.
Results
     The data obtained from the 387 respondents via the research instrument were analyzed by tabulating the frequency percentages for each item on the questionnaire.
Consumer Attitudes toward Advertising of Chiropractors’ Services
     The percentages given in Table 1 illustrate the distribution of consumer responses to the 16 statements in the questionnaire concerning consumers’ attitudes toward advertising of chiropractors’ services.
     With regard to statement 7, 43.1 percent agreed they presently have a high image of chiropractors, 32.4 percent had no opinion, and 24.5 percent did not have a high image. In general, consumers indicated a somewhat favorable image of chiropractors.
     In response to statement 8, opinions were rather mixed. More than 59.9 percent of consumers disagreed (12.8 percent strongly) that their opinion of chiropractors would be lowered as a result of advertising, while only 14.4 percent agreed. Finally, when asked if they would use the services of chiropractors who advertise (statement 16), 58.4 percent said they would use these services, while 15.1 percent expressed disagreement. These results indicate that consumers’ opinions of chiropractors generally do not suffer as a result of advertising. The marketing implication of these results is that it is important to use a well-conceived, professionally designed advertising program in order to maintain the approval of a majority of clients.
Information Function of Advertising Chiropractors’ Services
     The percentages given in Table 2 illustrate the importance of information in chiropractic advertising and show that opinions are somewhat mixed in this area. The results show that 60.3 percent of respondents agreed while 19.1 percent disagreed with statement 1 that the public would be provided useful information through advertising by chiropractors. Also, 82.7 percent felt that chiropractic advertising would be a useful means of informing potential patients about services and specialties (statement 3). More than 57 percent agreed and 28.7 percent disagreed with statement 13 that advertising makes the public more aware of the qualifications of chiropractors. Finally, 54.9 percent agreed with statement 9 that advertising would help consumers make more intelligent choices between chiropractors, while 23.1 percent disagreed. It would appear from these results that consumers want and seek information concerning chiropractors’ services. The concern for chiropractors would be determining which advertising medium is most appropriate in reaching clients.
Importance of Price in Advertising Chiropractors’ Services
     The percentages given in Table 3 illustrate the importance of price in chiropractic advertising. In response to statement 5 that it is good to deal with chiropractors who offer the lowest price for routine services, 49.9 percent disagreed, 19.9 percent agreed, and 30.2 percent were undecided. Not surprisingly 79.5 percent agreed it is better to deal with a reputable chiropractor than one who offers the lowest price (statement 15), only 8.0 percent disagreed. With regard to the effect on prices of chiropractic advertising, 37.7 percent of respondents disagreed with statement 11 that chiropractic advertising lowers prices due to more competition. It would appear that the primary benefit of chiropractic advertising is to communicate information regarding health care services rather than the price of services. The respondents also indicated that specific price information is not as important as the reputation, image, and qualifications of the chiropractors.
Deception in Advertising Chiropractors’ Services
     The percentages given in Table 4 illustrate the distribution of consumer responses to statements in the questionnaire concerning deception in advertising chiropractic services. In response to statement 4 that advertising by chiropractors would be more deceptive than other forms of advertising, 58.6 percent disagreed, while only 14.1 percent agreed. Also, 70.2 percent of the respondents disagreed with statement 10 that they would be suspicious of chiropractors who advertise. Finally, 72.1 percent disagreed with statement 14 that advertising by chiropractors would primarily benefit quacks and incompetents. Consumers agreed (79.8 percent), however, with statement 6 that people can rely more on what friends tell them about chiropractors than on advertising. These results indicate that, in general, consumers did not view chiropractic advertising as being more deceptive than other forms of advertising.
The Future of Chiropractic Advertising
     The percentages given in Table 5 illustrate responses to statements in the questionnaire concerning consumers’ attitudes toward the future of chiropractic advertising. When asked whether they would like to see more advertising by chiropractors (statement 12), 32.1 percent of respondents disagreed, 40.1 percent were undecided, and 27.8 percent agreed. In addition, a majority of respondents (45.3 percent) disagreed and 30.3 percent agreed that advertising would increase the quality of chiropractic services in the future (statement 2). It would appear that chiropractors need to conduct a comprehensive profile analysis of their target market to determine the attitudes and preferences of their clients and the precise service information their clients want.
Appropriateness of Advertising Media for Chiropractors
     The results in Table 6 indicate that 93.7 percent of the respondents considered the yellow pages an appropriate medium for chiropractors who advertise (38.4 percent said “very appropriate”). Newspapers ranked second; 88.4 percent called them appropriate (25.4 percent said very appropriate). Professional magazines were third; considered appropriate by 87.0 percent.
     On the other hand, 83 percent of the respondents felt that telephones are an inappropriate advertising medium for chiropractors (47.1 percent said “very inappropriate”). Also, 31.9 percent consider direct mail to be inappropriate (12.8 percent said “very inappropriate”). Billboards were third (21.1 percent called them inappropriate for chiropractors and 5.9 percent said “very inappropriate”). Internet was fourth; 20.4 percent felt that it is inappropriate. Popular magazines were fifth (15.7 percent of respondents consider them inappropriate). The results of studies conducted by Moncrief and Bush (1988) found mixed results as to whether chiropractors should advertise and whether they should use television.
Exposure to Advertising by Chiropractors
     One factor that should be considered is the degree to which the respondents have been exposed to chiropractic advertising. In Section IV of the questionnaire, respondents were asked whether they had ever seen advertising by chiropractors and, if so, through which media. Respondents could indicate more than one advertising vehicle. As Table 7 indicates, 295 respondents or 77 percent had seen at least one chiropractic advertisement, while only 88 or 23.0 percent could not recall seeing any advertisements.
     Table 8 indicates that the highest percentage (48.3 percent) of those respondents who had seen chiropractors advertise had viewed an advertisement in the yellow pages. The second-highest percentage (44.1 percent had seen chiropractic advertisements and recalled at least one ad in a newspaper. In third place was television with 40.7 percent and in fourth place billboards with 30.4 percent. A quarter (25 percent) of respondents have seen a chiropractic advertisement through direct mail, and 18.4 percent have heard a radio chiropractic ad.
Conclusion
     The results of this study have a number of implications. First, consumers’ opinions about advertising by chiropractors are somewhat mixed. The results in Table 2 indicate that consumers look for and generally favor advertising as a means of obtaining some kinds of information about chiropractors and health care services. Over 82 percent of the respondents felt that more advertising by chiropractors would be useful as a means of informing potential patients about services and specialties. Chiropractors and other health care providers should be informed of these and similar survey results so they can begin to satisfy the health care needs and desires of the public. However, it is interesting to note that, as indicated in Table 5, 32.1 percent of consumers said they would not like to see more advertising by chiropractors, 27.8 percent indicated they would like to see more advertising, and 40.1 percent were undecided. With such a large percentage of respondents undecided about wanting to see more advertising by chiropractors, a well-conceived, professionally designed advertising program could gain the approval of a majority of consumers. On the other hand, a poorly designed program could cause a chiropractor’s image to suffer.
     Second, opinion leaders among the chiropractors should be encouraged to use informational advertising. Much has been written about the ethical implications of advertising by professionals and the attitudes of those professionals who must make the decision whether to advertise. Although many chiropractors have indicated they would not advertise even if others did, it is likely that some of these chiropractors could be encouraged to try advertising if they were convinced it could be done tastefully and for the purpose of informing and serving prospective patients.
     Third, for those chiropractors with little or no advertising training, it would be increasingly important to involve themselves in educational programs, college or university courses, seminars, and workshops that focus on advertising by health care providers in order to help them identify the most appropriate media for advertising. As indicated in Table 6, the researchers tried to determine which media consumers believed were appropriate for chiropractic advertising. For example, more than 88 percent of the respondents felt that yellow pages and newspapers were appropriate media for chiropractors to use in advertising. However, 83.0 percent felt the telephone was inappropriate, and a surprising, 31.9 percent felt that direct mail was inappropriate.
     The results shown in Tables 7 and 8 indicate the vast majority of consumers have seen chiropractors advertise and have seen most of such advertising in the yellow pages (48.3 percent) and in newspapers (44.1 percent). These results indicate that chiropractors are currently advertising through those media that consumers feel are most appropriate. For their advertising strategies to be effective and accepted by consumers, chiropractors need to continue their efforts through the appropriate media.
     The study seems to confirm the belief of many marketing professionals that advertising is clearly an important function in the management and operation of medical and other professional practices. Chiropractors could find that a well-conceived, professionally designed advertising program as a means of communicating useful information could help gain the approval of the majority of consumers. Health care providers who carefully research the market and investigate attitudes and preferences of specific socioeconomic groups are likely to enjoy a competitive advantage over other health care professionals.

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Table 1
Frequency Percentages of Consumer Responses toward Attitude
Statements (in Percent) for Chiropractors