Individual Enquiry. Research Paper 2014

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1 Individual Enquiry Research Paper 2014 Title: A Qualitative Exploration of Current Osteopathic Practice in Turkey: An Interview Study Author: Huseyin Alat BA Supervisor: Charles Hunt DO, PGCert. The British School of Osteopathy 275, Borough High Street, London SE1 1JE

2 ABSTRACT Background: Research has been conducted into the potential of osteopathy in various countries but no literature about the state and scope of osteopathy in Turkey currently exists. This study aimed to shed light upon the relatively unknown field of emerging osteopathic practice in this nation. Objectives: To explore the experiences of osteopaths practising in Turkey, evaluate perceived benefits and challenges and the extent to which osteopathy is integrated into the main healthcare system. Method: A qualitative semi-structured interview study with six osteopaths practicing in Turkey. Data was analysed using Content Analysis, consistent with elements of Grounded Theory. Results: Five main themes were identified: Osteopathic views in Turkey (practice environment & cultural issues); communication between osteopaths; relations with the medical profession; people s attitudes towards osteopathy; regulations and legal aspects.

3 Conclusions: The findings from this small exploratory study suggest the perceived benefits of practicing osteopathy in Turkey are patient satisfaction, treatment effectiveness, increasing demand for alternative therapies such as osteopathy, and lack of competition due to low number of osteopaths. However, its integration into the main health-care system seems to be a distant hope in the face of current problems, such as lack of regulation. This influences the perception of profession amongst the general public and medical professionals, causing poor working relationships. Further research is needed to explore the scope of osteopathy in Turkey and establish if it may be possible for the profession to be recognised by the government. Keywords: Osteopathy, Turkey, Integration, Communication, Relationships, Recognition and Professional Regulation.

4 1. INTRODUCTION Osteopathy in Turkey: During the past decade, Complementary and Alternative Medicine (CAM) has become a topic of global importance. In many developing countries, despite the prominence of modern, orthodox medicine, CAM has often maintained popularity for historical and cultural reasons (Saraf and Saraf, 2012). For example, osteopathy is growing internationally and the profession has recognised regulatory mechanisms in some countries, such as the General Osteopathic Council in the United Kingdom (UK) (GOsC, 2013). More recently, osteopathy has gained government recognition in nations such as in France (Public Health Law, 2002) and Belgium although the act is yet to be implemented in the latter (OIA, 2011). On the other hand, it is unrecognised and unregulated in others; including Greece, Bulgaria, Cyprus and Turkey (Teyletche, 2012). However, Resmi Gazette (2011) reported that the Turkish Government agreed a law on November 2nd 2011 to regulate CAM, although they have not yet declared whether osteopathy will be one of the modalities considered as a CAM practice.

5 Currently, the only osteopathic body in Turkey is the Turkish Institute for Adapted Osteopathy (TIFAO) founded in Istanbul in 2004, which has so far produced 86 graduates and is run by osteopaths from a German Osteopathic Institution, Instıtut Für Angewandie Osteopathie (IFAO) (OD, 2012). Similarly to Germany, the Diploma of Osteopathy is limited to doctors and physiotherapists who have completed 1500 hours of training (IAO, 2012). Musculoskeletal presentations in Turkey: Turkey is one of the most dynamic developing countries in Europe with a high number of workers (TUIK, 2010). Numerous studies show that musculoskeletal conditions represent a significant issue for the current medical care system in Turkey, with many reporting work-related musculoskeletal low back pain (Akinci et al 2011; Arslan and Celiker 2001; Durmus and Ilhanli 2012; Koc et al 2012; Kuru et al 2011; Nazik et al 2012; Ozyazicioglu et al 2011; Unsal and Gozum 2010; Unlu et al 2008). The numbers of musculoskeletal presentations are increasing dramatically, with up to 92.8% of 250 individuals sampled working adults reporting low back, neck and shoulder pain (Kuru et al 2011). Likewise, in Turkey Osteopathy/CAM is unregulated (LBP) was the commonest body region reported in general practices in Greece (Antonopoulou et al, 2009).

6 LBP presentations appear to be one of the most common presentations, suggesting that osteopathic care may be useful as LBP is one of the most treated bodily regions among UK osteopaths (BOA, 2013). CAM in Turkey: People s attitudes towards CAM are highly important as it influences the success and progression of that modality for both practitioners and patients. The modalities of CAM are widely used for treatment of musculoskeletal presentations in Turkey and the most commonly-used method is herbal medicine (Ozyazicioglu et al 2011; Unsal and Gozum 2010; Akinci et al 2011; Koc et al 2012; Nazik et al 2012; Arslan and Celiker 2001; Unlu et al 2008). This might be because attitudes towards modern medicine and complementary medicine in countries like Turkey are influenced by cultural beliefs (Ozyazicioglu et al, 2011). Massage therapy was the other most frequently used method; this outcome may suggest that there is a potential consumer-base, as osteopathy commonly incorporates soft tissue massage into treatment plans (Ozyazicioglu et al, 2011). Findings about CAM use may also suggest

7 the Turkish population is open-minded about using different healthcare alternatives. Research has also explored the use of manual therapy in the management of chronic pain syndromes (Akyüz and Ozkok, 2002; Senbursa et al, 2011), underlining the potential scope for osteopathic management as osteopathy is a form of manual therapy (GOsC, 2012). Sarsina (2007) demonstrated that in Germany, 70% of GPs support CAM whilst 10% of all working medical doctors hold an additional CAM qualification (an increase of 125% in 8 years) and 5000 hospital doctors hold CAM qualifications, mainly chiropractic and naturopathy. These figures demonstrate the high consumption of CAM throughout regulated and unregulated countries in Europe, as well as the increasing number of professional doctors with additional CAM qualifications. The study of Akan et al (2012) included 943 medical students, showed parallel findings with above study as medical students in Turkey were familiar with CAM modalities and also held positive approaches such as willingness to receive training on the subject and recommend CAM methods to their patients in their future professional lives.

8 A study by Koc et al (2012) reached similar findings with a survey of 129 midwives. This emphasises the need to conduct further research into whether there is a recognised place for osteopathy within health-care system in Turkey. 2. METHODS Study Design: The study used an exploratory qualitative methodology in which the respondents experience, attitudes and beliefs were explored, the use of a rather small but purposive sample allowed for the discovery of much deeper and meaningful data rather than a quantitative approach, which in contrast would produce a generalized result (Patton, 2002). This method accepts that there are ranges of different ways to interpret events and is concerned with understanding the meanings seen by those being researched, rather than the researchers (Jones, 1995).

9 Semi-structured interviews were used for this study. This style of interviewing provides a structural framework to guide the interview towards the required areas, however, it also provides the freedom for the participants to divulge into particular experiences or themes that they feel are important. It is important to extract the participants own thoughts and ideas without imposing the researcher s assumptions or expectations. Interview questions must, therefore, be non-leading and open ended (Mays & Pope, 1996). Participants: An (Appendix 1) was sent to the TIFAO to obtain contact information for potential participants. Despite contacting them 3 times there was no reply so the data was obtained from their website. An internet (Google) search was also conducted to identify other osteopaths fulfilling the recruitment criteria. Upon first contact, 96 potential participants were sent an invitation ( ) (Appendix 2) stating the inclusion criteria and given opportunity to ask any questions regarding the study. On initial attempt 4 and on second contact further 5 osteopaths replied to participate.

10 Having then expressed a wish to take a part, each participant was sent a Patient Information Sheet (PIS) (Appendix 3) and a Consent Form (Appendix 4). 6 participants gave written informed consent and 3 were dropped out without a reason. At this point, remaining participants were sent Interview Questions (Appendix 5) to enable them to reflect on their thoughts and experiences and improve interview flow. It also gave them opportunity to decline to answer any question or ask for a break at any point in the interview at no detriment. However, 2 participants preferred to answer questions in writing due to their environmental inconvenience and time limitations for an interview. Therefore the researcher carried out 1 repeated interview to increase richness of the data. There was no further attempt for recruitments as no new data was obtained. If data saturation did not occur more participants, that volunteer to be re-interviewed, would be invited. Data collection:

11 Some interview questions and prompts were derived from key themes that emerged during previous researches and some of them were structured by the researcher with guidance provided by British School of Osteopathy s (BSO) Critical Analysis and Enquiry (CAE) team. A pilot study was conducted with a qualified osteopath to test the methodology and the interview questions, which were amended after feedback. Due to geographical constraints all interviews were undertaken via the internet using Skype, in home environment with no presence of anyone other than the researcher and participant. This aided in ensuring that all information revealed by participants remains confidential and anonymous. Prior to interviews, in order to minimise coercion, participants were reminded that they were free to withdraw from the study at any point and decline to answer any questions without giving a reason. A Dictaphone was used to record all interviews, which were lasted between minutes, then transcribed verbatim onto a Microsoft word document.

12 Each participant was assigned a case number which was used from this point on to ensure anonymity. Audio recordings and data were stored in a password protected computer throughout the study. To diminish possibilities of bias, participants were then sent the transcripts of their interview to review prior to data analysis to ensure that their views had been recorded accurately and that they were satisfied with the level of anonymity. This process of respondent validation improved the credibility of the research (Barbour, 2011). Appendix 6 details a letter informing participants about this matter. All data will be stored securely at the BSO Research Department and destroyed after six years from the completion of the study. Data analysis: All communication with participants was in Turkish. Therefore, to minimise potential translation error/bias the data was checked by another native speaker, who was also fluent in English, with no vested interest (not an osteopath or receiving osteopathic treatment) in the outcome of the study.

13 Following each interview, the researcher reviewed transcripts twice, in order to increase familiarity with the data and improve efficiency in the analysis process and transcribed the audio-recording and performed preliminary analysis. Problematic areas and those of particular interest was noted and used to edit and formulate the subsequent interviews. This enabled the modification of questions for future interviews in order to pursue emerging avenues of enquiry into further depth (Broom, 2005). This method of analysis prevented the study from being directed entirely by the researcher s preconceived ideas and allowed participants experiences and opinions to help develop new lines of investigation. Then original data was coded for underlying meaning to generate themes relevant to the research questions using content analysis with elements of grounded theory (Benjamin & William, 1999). Identified themes were then analysed to establish the meaning of these themes in relation to the research questions (Ziebland 2006). Kolbe and Burnett (1991) stated that inter-coder reliability is often perceived as the standard measure of research quality and that high levels of disagreement among judges suggest weaknesses in research

14 method. An independent assessor was therefore used to recode 20% of the data to ensure inter-rater reliability and reinforce the accuracy and reproducibility of the coding system. Initially there was 80% agreement, after discussion to agree on errors and omissions and agreement of 90% was achieved. Original data was coded for underlying meaning to generate themes relevant to the research questions using content analysis with elements of grounded theory (Benjamin & William, 1999). Coding: During early stage of analysis initial line-by-line coding (Charmaz, 2006) was adopted to define actions or events of a given situation. Focus coding was then employed to assess which codes appeared to be the most significant (Charmaz, 2006). This led to the development of new focused codes which were used to analyse larger segments of data or a theme. Below illustrates examples of line-by-line coding; focus coding; new focused coding and generating themes:

15 Example 1: Quote: Unfortunately, doctors have a monopoly on health in Turkey and people are so convinced that a medical intervention is the most effective treatment available to them. Osteopath 2 Line by line code: Patients in Turkey are under the influence of doctors and their interventions. Focus coding: Drawbacks/negative experiences New focused Coding: Cultural Issues Theme: Osteopathic view in Turkey Example 2: Quote: The biggest disadvantage of working in Turkey is the lack of a legal arrangement so some patients are cautious when using us. Osteopath 5 Line by line code: Osteopathy is not officially recognised by the government. Focus coding: Drawbacks/negative experiences New focused coding: Regulations/Legal aspects Theme: Osteopathic view in Turkey

16 Trustworthiness The researcher consulted with BSO s CAE team for developing and structuring of the nature, depth and line of enquiry of the questions pertaining to the semi structured interview. The researcher has not encountered any of the participants prior to this study. To further minimise the researcher s bias, feedback from participants on the findings were obtained to ensure that participants own meanings are represented. Ethical Approval Ethical approval was granted by the Research Ethics Committees at the British School of Osteopathy.

17 3. RESULTS Of the six osteopaths who participated in interview, 2 were male and 4 were female. The average number of years of experience ranged between 3 and 13 years and all had previously been trained as physiotherapists and live and work in Istanbul, a city of Turkey. Analysis of the qualitative data identified five main themes: osteopathic views in Turkey (practice environment & cultural issues); communication between osteopaths; relations with the medical profession; people s attitudes towards osteopathy; regulations and legal aspects. Osteopathic views in Turkey: Practice Environment-There was a general agreement that practicing osteopathy in Turkey had both positive and negative aspects. The majority of the participants commented on the benefits of their relationships with osteopaths and the low level of competition and patients satisfaction. However, one of the major drawbacks reported by all participants was that medical doctors dominate the healthcare system and that other healthcare providers are treated inferiorly. Osteopaths

18 constantly have to explain to patients what the role of osteopathy is and patients awareness and beliefs in holistic care were also very low. Holistic approach to the treatment of patients does not make sense to the majority of our patients living in Turkey whilst it is also difficult for medical doctors to grasp. The good thing is that patients who try osteopathy are generally very pleased and suggest it to others. Osteopath 2 It s easier to pick up patients here because patients do not even see the physiotherapist himself during their sessions. We are easily accessible and spend much more time with our patients than other health care providers. However, many patients still do not seek alternative, holistic approaches such as osteopathy. Osteopath 6 Osteopathy is not well known, so often we get labelled as inferior to physiotherapists. I find it unbelievable having to explain what osteopathy is what we do and how it works; even to medical doctors as well as laymen. Osteopath 3 Cultural issues- Even though city of Istanbul is a multi-cultural society, two participants felt that cultural differences affected the trust that exists between patients and practitioners. Also, some pointed out that some patients, because of their religious beliefs were not prepared to undress down to their underwear in front of strangers and because of

19 this they needed to be flexible and alter their treatment plans for these patients. From the point of view of working in Germany previously and now practising in Turkey, there are huge cultural challenges in term of trust and comfort of patients. Osteopath 2 Very rarely patients come in and dress down to their underwear and the vast majority of my patients want to keep all their clothes on. Sadly this influences the way I examine and treat people. Osteopath 7 As a female practitioner I found it very hard to explain my patients why we need to examine them with dress down. I got referrals of female patients from my colleagues just because they are not comfortable with male practitioners. Osteopath 9 Communication between Osteopaths: Four participants reported that there is not a close working relationship between osteopaths practicing in Turkey. However, two of them felt that, as a result of graduating from the same institution they have a good working relationship between them.

20 Istanbul is a very big city and traffic consumes most of the patient s time so cross referrals of patients between them was a common practice. Some of the participanst reported that they felt isolated because there is no real osteopathic community in Turkey. However, some participants reported that there was a good working relationship between osteopaths practicing in Turkey, particularly between TIFAO graduates. I think there are around 100 osteopaths in Turkey and the vast majority of them, until this year 86 osteopaths, are graduated from TIFAO. This is a good thing to have in common and makes it easy to communicate and keep in contact. Osteopath 2 I have a very good working relationship with those osteopaths practicing in Istanbul. We meet often due to my on-going contact with the institution (TIFAO). We do cross refer patients if there is a need. Osteopath 3 I do know very few osteopaths. But generally communication in any subject does not exist due to various reasons. Osteopath 6 Relation with the Medical Profession: According to some of participants, osteopaths relationships with medical doctors are almost non-existent in contrast to their relationship with

21 each other. They feel that the medical profession under-values the osteopathic profession, therefore referrals of patients between them and specialist doctors such as neurologists and orthopaedic surgeons do not happen. As a result, most participants agreed that this prevents an effective health management for the patients and also influence patients perception of osteopathic approach. Providing the best care for our patients almost impossible because if I want to refer my patient for imaging or to see a medical doctor, I have to do it informally or through a doctor I personally know. Sometimes they do not seem to take your letter into account which is very disappointing in terms of patient management. Osteopath 5 The good point of working here is that there is a lack of competition compared to western countries. The patients who have tried the osteopathic approach are amazed by the results and they advise others to try our holistic approach. Osteopath 7 People s Attitudes towards Osteopathy: The majority of the participants commented that people in Turkey are keen to try new health care modalities. However, they reported that people like the idea of osteopathy but doubt that a holistic approach

22 works because their perception of health is heavily influenced by the main, orthodox healthcare system. The majority of the paticipants also pointed out that patient satisfaction rates are very high. Because word of mouth travels very fast in Turkey, they believe that they will increase gradually their patient list. People in here generally are quite open-minded in terms of looking at different healthcare options. Osteopath 3 It can be difficult to convince them about our holistic approach. They do not seem to believe that the cause of their symptoms could be referral from another region of their body. Osteopath 2 The patients I treated so far are amazed by the result but not many of them can afford follow up sessions due to financial difficulties. Osteopath 7 Regulations and Legal Aspects: Due to the lack of statutory regulation of osteopathy in Turkey, all participants agreed that there is a great need to protect the title osteopath to preserve the quality of osteopathic care at present and in the future.

23 All participants also expressed a concern about being considered as inferior to orthodox medical professionals this is primarily due to the fact that osteopathy is not officially recognised by the government. However, one participant noticed that lack of regulations made it easier for osteopaths to practice compared to western countries. Two participants admitted that they did not use certain osteopathic techniques to avoid legal problems. Due to lack of regulation, most of the medical professionals express their negativity towards the osteopathic profession, so this will potentially harm the reputation of osteopathy. People in Turkey are open-minded to try new approaches but they also remain under the influence of present medical practice. Osteopath 6 I do not perform cervical manipulation as one of my colleagues had serious legal problems after performing this treatment. Osteopath 5 Many doctors suggest that we should work under their consultation. This is ridiculous. We did in the past for many years as a physiotherapist and nothing changed. After acknowledging that the holistic approach of osteopathy is more effective, what is the point of sticking to the old-fashion ideas which did not solve the root cause of patients problems? Osteopath 2 It took physiotherapists about 50 years to be fully recognised and regulated in this country so I cannot imagine how long it will take the osteopathy to be there Osteopath 9

24 4. DISCUSSION The study provides an insight into the characteristics of osteopathy in Turkey, as no such research has previously explored this area. There were five main themes developed from data analysis: Osteopathic view in Turkey (practice environment & cultural issues); communication between osteopaths; relation with the medical profession; people s attitudes towards osteopathy; regulations and legal aspects. Due to the extensive nature of this study the discussion will focus on three major themes; Osteopathic view in Turkey, Relationship with Medical Profession, Regulation and Legal aspects. Osteopathic view in Turkey: The preliminary research and contacts made in the process of undertaking this interview study suggested that there were about 100 osteopaths practising in Turkey and the vast majority of them were based in Istanbul. All osteopaths in Turkey had a previous medical background as either mainly- a physiotherapist or a doctor.

25 Participants generally felt that increasing popularity of the profession and patients satisfaction were the main benefit for practising osteopathy in Turkey. Some of the participants commented that people were open minded to try new health care modalities and often willing to pay for their own healthcare as currently there is no funding for osteopathic treatments in Turkey, the case shared in countries such as Sweden, Switzerland and Belgium (Blanchard et al, 2006) The participants did not share the same views about relationships within the profession. Most of them reported good working relationships with other osteopaths. However some of the participants reported they felt isolated because the osteopathic community was fragmented in Turkey. All participants agreed that accessing osteopathy related literature resources was not too distressful as it was always possible to order books over the internet. However, this may not be very practical for non-english speakers. Some participants noted that CAM modalities were widely used for treatment of musculoskeletal presentations in Turkey. This is compatible with findings by Akinci et al (2011), Koc et al (2012), Nazik et al (2012),

26 Unlu et al (2008), which found the most commonly-used method was herbal medicine. Two participants felt that cultural differences affected the trust that exists between patients and practitioners. Also, some pointed out that some patients, because of their religious beliefs were not prepared to undress down to their underwear in front of strangers and because of this they needed to be flexible and alter their treatment plans for these patients. These findings may suggest that cultural beliefs limits the use of osteopathy in contrast to the increasing popularity of herbal medicine as this does not involve hands on intervention. However, all participants agreed that it is due to the patient satisfaction of the effectiveness of treatment that the profession has become more popular. Majority of participants reported that the main reason for clinical encounter at their practices were musculoskeletal presentations. Therefore, there is a potential consumer-base for osteopathy. Likewise, according to Ozyazicioglu et al (2011) massage therapy was the other most frequently used method of CAM. This supports findings from other studies which have found high prevalence of musculoskeletal presentations among people in Turkey - Akinci et al 2011; Arslan and

27 Celiker 2001; Durmus and Ilhanli 2012; Koc et al 2012; Kuru et al 2011; Nazik et al 2012; Ozyazicioglu et al 2011; Unsal and Gozum 2010; Unlu et al Relationship with Medical Profession: According to some of participants, osteopaths relationships with medical doctors are almost non-existent in contrast to their relationship with each other. All pointed out that considerable effort was required to explain to the doctors initially what osteopathy was. They felt that the medical profession under-valued the osteopathic profession, therefore referrals of patients between them and specialist doctors such as neurologists and orthopaedic surgeons did not happen. As a result, most participants agreed that this prevented an effective health management for the patients and also influenced patients perception of the osteopathic approach. However, the following figures demonstrate conflicting results. For example, the study of Akan et al (2012) included 943 medical students, showed parallel findings with above study as medical students in Turkey were familiar with CAM modalities and also held positive approaches such as willingness to receive training on the

28 subject and recommend CAM methods to their patients in their future professional lives. A study by Koc et al (2012) reached similar findings with a survey of 129 midwives. Sarsina (2007) demonstrated that in Germany, 70% of GPs support CAM whilst 10% of all working medical doctors held an additional CAM qualification (an increase of 125% in 8 years) and 5000 hospital doctors held CAM qualifications, mainly chiropractic and naturopathy. These figures demonstrated the high consumption of CAM throughout regulated and unregulated countries in Europe, as well as the increasing number of professional doctors with additional CAM qualifications. These findings suggest that there is a positive correlation between recognition of the profession and its perceptions by general public and medical professional. Regulation and Legal Aspects: Due to the lack of statutory regulation of osteopathy in Turkey, all participants agreed that there was a great need for recognition and regulation of the profession to preserve the quality of osteopathic care at present and in the future. They also expressed a big concern about being considered as inferior to orthodox medical professionals this is primarily due to the fact that osteopathy is not officially recognised by

29 the government. However, one participant reported that lack of regulations made it easier for osteopaths to practice compared to western countries. Two participants admitted that they did not use certain osteopathic techniques to avoid legal problems. Recently a few studies have shown that increasing interest and recognition is being given by governments towards osteopathy and holistic approaches such as in France (Public Health Law, 2002) and Belgium although the act is yet to be implemented in the latter (OIA, 2010). Resmi Gazette (2011) also reported that the Turkish Government agreed a law in November 2nd 2011 to regulate CAM, although they have not yet declared whether osteopathy will be one of the modalities considered as a CAM practice. Although osteopathy does not come under CAM legislation acts, it can still be practiced in Turkey with no obstruction from government. This might be because all osteopaths currently practising in Turkey, are either qualified as a physiotherapists or a doctor.

30 Study limitations One of the possible weaknesses of this study was the small size sample. This was due to there being a very small quantity of literature available to enable researchers to interpret findings. Additionally, data was collected and analysed in Turkish then translated into English. In translation, it is likely nuances existing in the Turkish language were lost. Data gathered within this project might have been insufficient as the researcher was an inexperienced interviewer. However, the researcher attended advanced communications skills classes at the BSO and used the skills and experiences gained from these sessions in a clinical environment to adopt a non-judgemental style of questioning. Further bias may have existed with analysis of data due to the subjective nature of qualitative interpretation (Searle & Barnard, 1998). Furthermore, the responses of the participants may have been biased because they may have wanted to emphasise the negative aspects of practicing in Turkey to pursue recognition and regulation of the

31 profession. This was especially true as data was only collected from a physiotherapist s/osteopath s perspective in Istanbul and not from the general public or medical professionals regarding the perception of osteopathy in this country, its effectiveness and patient satisfaction. Suggestion for further research A further qualitative study possibly to cross reference and verify this study s findings by gathering data from osteopaths patients and medical professionals. A quantitative study may be suggested to further increase awareness of osteopathy within public and/or medical profession. Further research may be recommended to assess the legal challenges and scope for recognition of the osteopathic profession in Turkey.

32 5. CONCLUSION The aim of this small exploratory qualitative study was to explore osteopaths perceptions of the benefits and drawback of practising osteopathy in Turkey, and the potential scope for integration within the main healthcare system. The main benefits were considered to be that patient satisfaction with treatment was gradually increasing the popularity of the profession amongst patients and healthcare professionals. The high practitioner to patient ratio in Turkey meant that competition was low and people were willing to pay for their healthcare and are happy to go to private healthcare practitioners, such as osteopaths. Despite the fact that osteopathy is not officially recognised, participants felt that the government did not obstruct the work of osteopaths. In contrast, participants also stated that, as osteopathy is not recognised by the government. This impacts on the perception of the profession amongst the general public and medical professionals, and limits working relationships. Participants felt that lack of recognition meant that osteopaths are treated inferiorly by the medical profession in Turkey and

33 also left the profession open to fraud and malpractice by those who may not be qualified as osteopaths. Because osteopathy is such a new healthcare modality in Turkey, osteopaths spend a lot of time explaining to patients exactly what they do and there is a significant need for flexibility when treating patients because of the range of different cultural factors, such as the refusal by patients to undress. Osteopathy is not officially recognised in Turkey but has a professional organisation (TIFAO) which provides osteopathy courses for physiotherapists and doctors. Despite all osteopaths in Turkey being previously trained either as medical doctors or physiotherapists, it does not seem to be successfully integrated into the healthcare system. Statutory regulation could be beneficial for osteopaths as it would promote integration, protect the public from malpractice, and encourage inter-professional healthcare relationship. Acknowledgements Researcher would firstly like to thank all the participants that took part in the study and to his supervisors Charles Hunt, Hilary Abbey and to BSO s CAE team for their advice, guidance and support over the course of the entire project. Word Counts:5203

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39 APPENDICES Appendix 1 - Data Collection Authorisation Dear I am a third year student at the British School of Osteopathy, currently studying for a Masters qualification in Osteopathy. As part of my studies, I have to complete an individual research project. I have chosen to perform an interview study of osteopaths practising in Turkey. I am currently submitting my research proposal to the British school of Osteopathy s Ethics Committee and would like to enquire if you would allow me to recruit your institute osteopaths to participate in my study. I intend to interview between 8 and 10 osteopaths at a time and location that is mutually convenient for the participant and the researcher. However, if this is not viable the interviews may be undertaken via the internet using Skype or by phone.the interviews should last approximately minutes If you are happy for your institute osteopaths to participate in this study, I will contact them with further explanation of the study. If they consent to participate I will arrange the interviews at no cost to you or to them. If you are agreeable with this study, please contact me to confirm this using the details listed below. Subject to ethical approval I will be looking to start interviews with participants from September 2013 and will contact participants directly to arrange these nearer the time. If you have any questions or would like more details, please do not hesitate to contact me or my supervisor using the information below. Kind Regards, Researcher: Supervisor: Huseyin Alat Charles Hunt British School of Osteopathy British School of Osteopathy 275 Borough High Street 275 Borough High Street London SE1 1JE London SE1 1JE Tel: Tel:

40 Appendix 2 Invitation to participate. Dear My name is Huseyin Alat and I am a third year student at the British School of Osteopathy, currently studying for a Masters qualification in Osteopathy. As part of my studies, I have to complete an individual research project. I have chosen to perform an interview study of osteopaths practising in Turkey. My study will be supervised by Charles Hunt qualified as an osteopath is current Principal of the BSO. His current role involves an understanding of issues affecting osteopathic practice internationally and he has supervised previous BSO projects. The aim of this study is to gain a deeper insight into the specificity of osteopathic practice in Turkey as there has been no recent study concerning the profession of osteopathy in this country. The following objectives will be addressed during semi-structured interviews: - Exploration of osteopaths positive and negative experiences of practising osteopathy. - Exploration of osteopaths understanding of the public awareness of osteopathy. - Exploration osteopaths opinions of the perceived barriers to the development of the profession in Turkey? - Exploration of Osteopaths opinions on the drawbacks of practising osteopathy in a country where the profession is unrecognised and unregulated? I would like to invite you to take part in my study and have therefore enclosed a Participant Information sheet (PIS) which contains more information about what would be involved should you chose to take part. If you would like to participate in this study, please register your interest to the researcher via return . You will then be contacted with the appropriate paperwork, as discussed in the PIS form. If you have any further questions please do not hesitate to contact me using the details provided below. Yours sincerely, Researcher: Huseyin Alat Supervisor: Charles Hunt

41 British School of Osteopathy British School of Osteopathy 275 Borough High Street 275 Borough High Street London SE1 1JE London SE1 1JE Tel: Tel:

42 Appendix 3-Participant Information Sheet Invitation Study Title: A Qualitative Exploration of Current Osteopathic Practice in Turkey You are invited to take part in a research study. Before you decide if you would like to participate, it is necessary for you to understand why the research is being done and what it will involve for you. Please read through this information sheet carefully, if you wish you may discuss it with others. If anything appears unclear or you require further explanations please don t hesitate to ask using the contact details provided. Take as much time as required to process this information and decide if you would like to participate in this study. What is the purpose of this study? This study makes up part of the researcher s M.Ost degree course at the British School of Osteopathy. Its purpose is to gain a better understanding of osteopaths opinion and their experiences of practising osteopathy in Turkey. The aim of this study is to explore the experiences, attitudes and beliefs of osteopaths practising in Turkey evaluate the benefits and challenges encountered while practising osteopathy in this country and the extent to which osteopathy is integrated into the health care system of Turkey. Furthermore, the study will identify osteopaths opinions about the beneficial aspects of practising in Turkey as well as the potential drawbacks such as isolation (communication between osteopaths/ within the medical profession), access to osteopathic literature (language barrier). Consequently, this study will help to address the gap in literature and understanding of issues affecting osteopathic practice internationally. Who is conducting this study? This research is being carried out by Huseyin Alat, a third year student at the British School of Osteopathy in London (England), under the supervision of Charles Hunt who is a qualified osteopath and is current Principal of the BSO, and Hillary Abbey who is also a qualified osteopath and a member of CAE team. In order to be able to complete the M.Ost qualification the students are required to carry out a research project in the osteopathic field. This research project has been approved by the BSO Research Ethics Committee.

43 Why have I been invited? You have been invited because you are an osteopath who is currently practising in Turkey. Participants must be willing to discuss their experiences and their challenges they have encountered whilst practising in Turkey. There will be 8 to10 osteopaths taking part in this study. Do I have to take part? No. Participation in this study is completely voluntary. If you do decide to take part in this study then you should retain this participant information sheet and you will be asked to sign a consent form. You are free to withdraw from the study at any point. Declining to take part or withdrawing requires no reason and will have no detriment /effect on your standing as an osteopath. What will happen to me if I take part? Within 2 weeks of receiving this invitation you will be required to register your interest in participating in the study via return . You will then be required to sign a consent form confirming you are voluntarily taking part in the study. A Draft of the interview schedule and probe questions will be sent to you so that you can review and reflect on the proposed topics prior to the interview. An interview will be scheduled incorporating at least a week long coolingoff period to ensure you are sure you want to be involved. Ideally, you will be required to attend a minute interview with the researcher at a pre-agreed, mutually convenient time and location. However, if this is not possible it may be undertaken via the internet (using Skype) or by telephone. What do I have to do? The interview will last no longer than minutes and the conversation will be recorded using a Dictaphone. Each participant will be assigned a case number which will be used in written papers throughout the study to provide a degree of anonymity; your name will not be used in written papers. You should retain your assigned number in case you later wish to withdraw from the study or to review/alter the transcribed material from your interview. Before the interview starts you will be taken through this information sheet once more to check there are no points that need clarifying. You

44 will be reminded not to disclose any personal information about your patients. The semi-structured interview will then take place, using both the questions detailed on the interview schedule and your responses to questions to generate further lines of inquiry. Following the interview, the audio data will be transcribed. You will then have the opportunity to review the transcripts to confirm you agree with the transcription and levels of confidentiality. What are the possible disadvantages and risks of taking part? There are no risks involved in participating with this study. The only disadvantage present is the loss of your time whilst the interview is taking place. The interview will be arranged at a time that is mutually convenient to both the researcher and the participant in order to reduce the impact of the time commitment involved and to avoid loss of earnings. However, if this is not viable the interviews may be undertaken via the internet using Skype or by phone. All participants will be reminded at the start of their interviews to refrain from mentioning personal, identifying details any of their patients in order to maintain their patient-practitioner confidentiality agreement. If participants unintentionally include confidential information the researcher will omit it from the recorded information. What are the possible benefits of taking part? There will be no clinical or financial benefits from participating in this study. Participation may however, help improve the understanding of osteopathic practice in Turkey. What if there is a problem? You are free to withdraw from this study at any point without giving a reason. If at any point participants feel uncomfortable, harmed or wish to make a complaint, the project supervisor should be contacted using the details provided at the end of this form. Will my taking part in the study remain confidential? All information collected about participants will be kept strictly confidential. Only the researcher (Huseyin Alat), study supervisor (Charles Hunt) and BSO CAE Team will have access to the data collected. Your identity and anonymity will be protected through the use of unique numerical codes that will be assigned to each participant and will be used in all written papers in place of the participants names. All names and other identifiable information will be omitted from the written papers.

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