Knowledge of osteopathic manipulative medicine and osteopathic physicians in a New York South Asian community

Methods

The study was deemed exempt by the NYIT Institutional Review Board for the Protection of Human Participants (Protocol BHS-1514).

Participants and data collection

Study participants were located within Hicksville, NY, USA a town in the Long Island region with a prolific South Asian community [11]. The most predominant Asian race reported in the 2019 United States Census for the city of Hicksville were Asian Indians (7,944 out of 12,722, 62.4%) [11].

The research team used convenience sampling at high traffic sites in the Hicksville area, concentrated around grocery stores and restaurants (Figure 1). All subjects were approached verbally for potential inclusion into the study, and no other recruitment methods were used. All participants took the survey of their own volition; no compensation or any other form of incentive was offered. Collection took place from 1 to 6 pm on Friday, January 17, 2020.

Figure 1:

Data collection was conducted within Hicksville, NY at the marked locations.

Per the protocol approved by the NYIT Institutional Review Board, participants self-identified as South Asian and no further distinctions were made (i.e., mixed descent). No participants were excluded due to a language barrier between the research team and the medical student researchers. No other specific exclusion criteria was set, apart from any participant’s lack of ability to give consent for participation in the study.

Participants were initially provided with a paper consent form (Supplementary Material), approved by the New York Institute of Technology (NYIT) Institutional Review Board, to review; they subsequently provided verbal consent of their willingness to participate anonymously in the study. Participants were also informed that if they agreed to take the survey, they could withdraw at any time and would not be penalized for doing so. A paper survey was given to all subjects, but research team members provided options for participants to complete it verbally or fill it out on their own; this was done based on the subject’s preference. Criteria for inclusion are people who self-identify as South Asian.

Results

Of 100 participants, 53 (53%) were male and 47 (47%) were female; participant ages ranged from 18 to 81 years (mean, 41.2 years; median range, 18–29 years: 29 participants [29%]; Table 1). The majority of the participants were born in India (52 of 100 [52%]), Pakistan (21 of 100 [21%]), and the United States (14 of 100 [14%]).

Thirty-four participants (34.0%) had heard of OMM and 26 (26.0%) had knowledge of what a DO physician does. Of the 34 who had knowledge of OMM, 24 (70.6%) also indicated knowledge of what a DO physician does; likewise, 24 of the 26 participants who had knowledge of DOs (92.3%) reported also having knowledge of OMM.

Survey participants were more likely to have knowledge of DOs if they were born or had lived longer in the United States. Of the 14 respondents born in the US, 8 indicated knowledge of what a DO physician does, while only 18 of the 86 respondents born in other countries indicated knowledge (57.1 vs. 20.9%; p=0.006; Table 1). Of those 18 participants, nine were born in India (34.6%), seven from Pakistan (26.9%), and two from others (7.7%). In comparison, the respondents born in other countries made up the majority of the participants who did not have knowledge of DOs (55 of 58, 94.8%, Table 1). Those who had lived longer in the US (more than 26 years) were more likely to have knowledge of DOs as they made up 11 of the 26 respondents who have knowledge of DOs (42.3%; p=0.039; Table 1). The participants who indicated knowledge of DOs had a median 24 years of stay in the US vs. 15 years of stay for those who had no knowledge.

In contrast, participants who spoke a primary language other than English or who had lived in the United States for a shorter time were less likely to have knowledge of DOs. Of the 58 participants who indicated no knowledge of DOs, 46 (79.3%) spoke a primary language other than English (p=0.042; Table 1). Those languages included Hindi (13, 22.4%), Punjabi (8, 13.8%), Urdu (8, 13.8%), Bengali (3, 5.2%), Gujarati (3, 5.2%), and others (11, 19.0%). Male participants were also less likely to have knowledge of OMM (men, 33 of 53 [62.3%] vs. women, 20 of 53 [37.7%]; p=0.036; Table 1). Age, education level, and English proficiency were not found to have any statistically significant association with knowledge of OMM or DOs (Table 1).

There was no statistically significant difference found in knowledge of DOs or OMM between participants who visited their doctor regularly vs. those who did not (Table 2). Of 100 participants who reported regularly seeing their doctor, 95 (95%) reported seeing their family physician (Table 2). Seven of 100 participants (7%) indicated that they would see a DO physician for low back pain, while 54 (54%) would see a family doctor, 16 (16%) would see a chiropractor, and 10 (10%) would see a physical therapist (Table 2).

Discussion

A limited awareness of DOs and OMM exists within the South Asian community in Hicksville, New York. Among the factors assessed in this survey study, knowledge of DOs was negatively associated with male sex, location of birth outside of the United States, having spent less time in the United States, and a non-English primary language.

Previous studies of other Asian populations in New York city showed that different factors influenced participant knowledge about DOs and OMM [6, 7]. In the Chinese community, factors like age, English proficiency, and education were associated with having knowledge of DOs [6]. In the Korean community, primary language was the main determinant for knowledge of DOs and OMM [7]. None of the participants in that study [7] spoke English as their primary language; most indicated that Korean was their primary language, and the majority (86.4%) had no knowledge of OMM). Our results suggest that knowledge of OMM and DOs among this particular South Asian study population are influenced by a different set of factors compared with Chinese and Korean communities of prior studies [6,7], which exemplifies why the disaggregation of data on Asians is necessary and important.

In the US, chronic low back pain is the second most common cause of disability in adults and has a prevalence of 13.1% [13, 14]. A study conducted in Bangladesh, India, Nepal, Pakistan, and Sri Lanka found that the prevalence of back pain in older adults who engaged in some level of physical activity was 64.8, 19.8, 69.5, 40.6, and 36.2% respectively [15]. In our study, the majority of participants were of Indian or Pakistani descent (Table 1), so it may be appropriate to assume that low back pain is represented in our study population.

Most survey participants responded that they would manage their low back pain by seeking treatment from a family doctor (54%), but only 7.0% of participants indicated that they would specifically see an osteopathic physician. This could be due to the fact that a majority of DO physicians do not use OMM; one survey showed that 77.7% of the 1,683 DO physicians who responded only used OMM on less than 5.0% of their patients; 45.6% of the surveyed population were family doctors [16]. It is possible that for this reason, participants in our study may not be able to distinguish between DO and MD family practitioners. Future studies might evaluate whether participants are able to make a distinction between an osteopathic (DO) physician or allopathic (MD) physician, and whether it has an impact on the care they seek. Interestingly, in a study of 63,966 participants in the United Kingdom, South Asian participants were more likely than White participants to visit a general practitioner to manage their musculoskeletal pain [17]. This may be a possible reason why participants in our study would choose to see a family practice doctor for their low back pain because they are accustomed to doing so.

Lack of awareness of OMM may also cause participants to seek other treatment modalities. For example, 16% of our participants indicated they would choose to see a chiropractor for low back pain. Many of the techniques in chiropractic therapy share similar mechanisms to OMM, which can make these participants more receptive to OMM [18]. Specifically for the South Asian population, management of chronic low back pain can also include Ayurvedic massage (Sahacharadi Taila), which is popular in India and shown to be effective for short term pain relief [19]. Ayurvedic tenets are similar to some tenets of osteopathic medicine, such as the concept of bodily interconnectedness or bodily unity, and the idea that imbalance or disruption of harmony causes muscular pathologies called Vata diseases [20]. A group of Ayurvedic practitioners (Vaidya) also practice traditional bone setting and treat muscular pains and blood clots, which are viewed as related pathologies [21]. One technique is called puttur kattu, which is the setting of fractures and dislocations [22]. Perhaps osteopathic physicians could promote more interest in osteopathic medicine within the South Asian population by drawing parallels to traditional Ayurvedic principles and practices.

There are no known osteopathic organizations recognized by the Osteopathic International Alliance in India [23]. The shortage of osteopathic training programs proposes a challenge to osteopathic awareness in South Asia. One possible reason for the shortage is the inability to distinguish osteopathy performed by osteopaths in India and osteopathic medicine performed by DOs in the US. Osteopaths in India solely practice osteopathic manipulation, whereas DOs can perform OMM in addition to their general practice of medicine [24]. Osteopathy in India may unintentionally predispose the general public to misconstrue the osteopathic medicine practiced by DOs, thereby not necessitating the demand for osteopathic training programs in India. A second reason for the shortage is the challenge for foreign trained medical professionals to practice in India. According to the Indian Medical Council Act of 1956, foreign medically trained Indian citizens are not allowed to practice in India unless they obtain an eligibility certificate that permits them to sit for the screening test, an entrance exam required for students who wish to pursue medical education [25]. The most recent Amendment of 2018 to the screening test regulations written in 2002 mandatorily qualifies foreign trained medical Indian citizens for the National Eligibility cum Entrance Test (NEET) and the result of the NEET is treated as an eligibility certificate [25]. The NEET allows foreign trained physicians to take a step closer to practice in India that was not initially present in the Act of 1956. However, the process remains tedious and difficult, which still affects the ability to create osteopathic training programs in India.

Conclusions

There was a general lack of knowledge of osteopathic physicians and OMM among participants in the South Asian community in Hicksville, New York. Sex, birthplace, length of time in the US, and primary language used were all factors that influenced knowledge of osteopathic medicine. Those who use English as their primary language and those who were born or who had lived longer in the US were found to be more likely to have knowledge of DOs, as were female participants. The differences between our results and those found in previous studies of the Chinese and Korean communities highlight the importance of disaggregation of Asian populations. This study adds to the research on osteopathic awareness in ethnic communities and may further promote more targeted efforts to develop educational resources and programs to increase public knowledge of OMM and osteopathic physicians.