Project objectives

Our first aim was to explore primary HCPs’ attitudes towards treatments for PNS-LBP, focussing on those recommended in the guidelines. This would enable identification of facilitators and barriers to guideline adherence. Our second aim was to develop a new concise questionnaire that can measure patients’ beliefs about a range of PNS-LBP treatments. We could then use this questionnaire to test the hypothesised relationship between patients’ illness perceptions and treatment beliefs in this population.

Objectives

The objective associated with our first aim was to identify facilitators and barriers to adherence to the NICE guidelines, from HCPs’ perspectives. The objectives associated with our second aim were to:

1. Explore and describe patients’ beliefs about LBP treatments;
2. Develop questionnaire items to measure these beliefs;
3. Establish the questionnaire’s acceptability and psychometric characteristics (face validity, construct validity, internal consistency, convergent and divergent validity, test-retest reliability);
4. Develop a preliminary brief version of the questionnaire for use in clinical practice and/or clinical trials to identify patient preferences; and
5. Test whether there is common-sense coherence between patients’ illness perceptions and treatment beliefs.

Changes to project objectives

Aims and Objectives

In Study 3 we did not develop a separate brief version of the questionnaire for use in clinical practice (original objective 4) as instead we ensured that the main version of the questionnaire was kept sufficiently brief so that it could be used clinically.

Research Plan and Methodology

In Study 3 we used more sophisticated statistical analysis methods (including non-parametric item response theory, Mokken analysis and confirmatory factor analysis) than originally planned.  This change improved the quality of our work and enhanced the skills of the researcher.

Brief summary

Background

Back pain has severe consequences and affects 36% of the UK population. The NICE guidelines (May 2009) present a number of options for the management of persistent non-specific low back pain (PNS-LBP) including conventional, complementary/alternative, and combined physical and psychological treatments.

There has been no research to date documenting GPs’ and other primary HCPs’ (e.g. physiotherapists) responses to the recent NICE recommendations for PNS-LBP. This is needed to enable identification of facilitators and barriers to guideline adherence and suggest improvements to future iterations of LBP guidelines.

There has been no research to date documenting patients’ beliefs about all of the treatments including in the guidelines. Health psychology theory suggests patients’ beliefs about treatment are important determinants of uptake of and adherence to treatment. In order to test this, a reliable and valid questionnaire that measures patients’ beliefs about treatment is needed, but there is no existing comprehensive questionnaire that assesses beliefs about diverse treatments and has good psychometric properties.

Aims

Our first aim was to explore primary HCPs’ attitudes towards treatments for PNS-LBP, focussing on those recommended in the guidelines.

Our second aim was to develop a new concise questionnaire that can measure patients’ beliefs about a range of PNS-LBP treatments.  Associated objectives were to:

1. Explore and describe patients’ beliefs about LBP treatments;
2. Develop questionnaire items to measure these beliefs;
3. Establish the questionnaire’s acceptability and psychometric characteristics (face validity, construct validity, internal consistency, convergent and divergent validity, test-retest reliability);
4. Develop a preliminary brief version of the questionnaire for use in clinical practice and/or clinical trials to identify patient preferences; and
5. Test whether there is common-sense coherence between patients’ illness perceptions and treatment beliefs.

Methods

A mixed methods, exploratory sequential, design was used. Two qualitative studies explored and described HCPs’ (study 1) and patients’ (study 2) attitudes towards, experiences of, and beliefs about recommended treatments for PNS-LBP. Study 2 also developed questionnaire items to measure patients’ beliefs. A quantitative validation study (study 3) established the questionnaire’s psychometric characteristics.

Key Findings

Study 1 (interviews with 53 purposively sampled primary care clinicians) showed that National clinical guidelines comprised one of many possible inputs to the complex process of matching individual patients (perceived in terms of their medical history, clinical presentation, personal preferences, concerns, and psychosocial context) to familiar treatments (viewed primarily in terms of likely effectiveness). Some clinicians found the term used in the NICE guideline - “non-specific LBP” - unfamiliar and of limited relevance to practice. Decisions about which treatment to prescribe, refer, or deliver to an individual patient were made while clinicians were working within a broader context informed by personal experience and inter-professional networks and constrained by organisational factors. Clinicians were frustrated by disparities between the idealised care pathway described in the NICE guideline and the real-world situation of short consultation times, difficult-to-access specialist services and failure to commission guideline-recommended treatments. Specific actions that address each key element of clinical decision-making which could increase the pragmatic relevance of the LBP guidelines for clinical practice involve: ensuring terminology used in guidelines reflects that used in clinical practice; dispelling the image of guidelines as rigid and prohibiting patient-centred care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended complementary therapies; and commissioning guideline-recommended treatments for NHS patients.

Study 2 (in which 75 adults with LBP participated in 13 focus groups) showed that diverse treatments were perceived by patients in terms of the same underlying dimensions: credibility, effectiveness, concerns, individual fit. Participants’ primary concern was to get a clear explanation of their back pain – not just a label; importantly, an understanding of the cause(s) of their back pain. In the absence of this, any treatment decisions were seen as unsystematic “trial and error”.

In study 3 439 LBP patients completed our new questionnaire assessing treatment beliefs via equivalent items measuring four dimensions identified as relevant in study 2: credibility, effectiveness, risks and suitability. Using non-parametric item response theory (Mokken R) we removed poorly functioning items and achieved four 4-item subscales with good homogeneity and monotonicity levels and Cronbach’s α values. This resulted in the development of a 16-item questionnaire with four 4-item uni-dimensional subscales that reliably measure patients’ beliefs about treatment credibility, effectiveness, risks, and personal suitability across diverse LBP therapies - acupuncture, manual therapy, medication, and exercise.  Our questionnaire appears to be suitable for use in conventional and complementary medicine settings.

Expected Impact

In our paper reporting Study 1 we outline specific ways in which future guidelines could be designed to as to be better implemented in practice. In our paper reporting Study 2 we describe patients’ values and preferences regarding low back pain treatment which could enhance GPs’ understandings of patients’ priorities. In our paper reporting Study 3 we present our new questionnaire and make it available for others to use. We hope that researchers and practitioners will use our new questionnaire to better understand patients’ beliefs about low back pain treatments and thus aid in treatment-related shared decision-making.

Conclusions

Specific actions that address each key element of clinical decision-making are needed to increase the relevance of the national LBP guidelines for clinical practice. These actions involve: ensuring terminology used in guidelines reflects that used in clinical practice; dispelling the image of guidelines as rigid and prohibiting patient-centred care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended complementary therapies; and commissioning guideline-recommended treatments for NHS patients.

Patients want an individualized understanding of their LBP to form the basis for a rationale for treatment decisions. Patients focus on finding a treatment that suits them personally and their own particular problem, and in doing so they consider concerns, effectiveness, and credibility. These findings are broadly consistent with theorised importance of treatment beliefs and illness perceptions in treatment decisions. However, existing theories/measures of treatment beliefs do not encompass all the dimensions needed to capture patients’ beliefs about LBP treatments. Our new questionnaire thus fills this gap and will facilitate future research to test whether treatment beliefs (beyond expectations of effectiveness) influence behaviour and outcomes.

There is scope help clinicians explore patients’ illness perceptions and treatment beliefs in primary care. For example, clinicians could elicit and address patients’ concerns about diagnosis and help them to develop a clearer more confident understanding of their pain. Investigating treatment-specific dimensionality may also inform tailoring of decision-making in clinical practice. More research is needed to pursue these ideas.  This project achieved its main objectives.

Plain English summary

Low back pain is a very common problem in the UK and it can be debilitating. NICE guidelines offer a number of options for doctors to consider when advising patients with low back pain. These options include conventional (e.g. exercise), complementary/alternative (e.g. acupuncture), and combined physical and psychological treatments. There has been no research to date documenting either primary health care practitioners’ responses to the NICE guidelines or patients’ beliefs about all of the treatments including in the guidelines. Psychological theory suggests that patients’ beliefs influence their choice of treatment and the extent to which they continue using a treatment once they have started it. In order to test this, a reliable and valid questionnaire that measures patients’ beliefs about treatment is needed.

We conducted three studies to explore health care practitioners’ and patients’ beliefs about low back pain treatments. In study 1 we interviewed 53 clinicians and asked them all about how they treat patients with low back pain (16 GPs, 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses). We found that the NICE guidelines were one, relatively peripheral, influence on their clinical decision-making and we identified key barriers that prevented better implementation of the guidelines. In study 2, 75 adults with low back pain participated in 13 focus groups and discussed treatments for low back pain. We found that participants’ primary concern was to get a clear explanation of their back pain, and that they evaluated all back pain treatments according to similar criteria, whether a treatment was perceived as: credible, effective, having few concerning features, and being a good “fit” for the individual person concerned. In study 3, 439 adults with low back pain filled in a new questionnaire that we designed based on study 2. Our questionnaire appears to be a reliable and valid measure of treatment beliefs and is suitable for use in conventional and complementary medicine settings.

Our findings have implications for clinical practice and we have published specific recommendations for changes based on our research. Our questionnaire can be used in future research to help patients and doctors get the most out of available treatments for low back pain.

Dissemination

Published articles

1. Dima A, Lewith GT, Little P, Moss-Morris R, Foster NE, Hankins M, Surtees G, Bishop FL. (2015). Patients' Treatment Beliefs in Low Back Pain: Development and Validation of a Questionnaire in Primary Care.  Pain, 156, 1489–1500.
   http://dx.doi.org/10.1097/j.pain.0000000000000193
2. Dima A, Lewith GT, Little P, Moss-Morris R; Foster NE, Bishop FL.  (2013). Identifying patients’ beliefs about treatments for chronic low back pain: A focus group study.  British Journal of General Practice, 63(612), e490-e498.
   http://dx.doi.org/10.3399/bjgp13X669211

Planned articles

1. F.L.Bishop, A. Dima, J. Ngui, P. Little, R. Moss-Morris, N.E. Foster, G.T. Lewith. (in press). "Lovely pie in the sky plans": A qualitative study of clinicians' perspectives on guidelines for managing low back pain in primary care in England. Spine.
2. F.L. Bishop, A. Dima, J. Ngui, P. Little, R. Moss-Morris, N. E. Foster, G.T. Lewith. “I don’t know what you’re talking about so I’m sure the patients wouldn’t”: the NICE guidelines for low back pain in primary care. (in preparation for BMJ)
3. A. Dima, G.T. Lewith, P. Little, R. Moss-Morris, N.E. Foster, M. Hankins, G. Surtees, F.L. Bishop. Treatment Beliefs in Low Back Pain: development and validation of a condition-specific patient-report measure (in preparation for Pain)

Poster presentations

1. A. Dima, J. Ngui, G.T. Lewith, P. Little, R. Moss-Morris, N.E. Foster, F. Bishop. Treating low back pain:  a qualitative exploration of clinicians’ treatment beliefs. Poster presented at BPS Division of Health Psychology Annual Conference, Southampton, September 2011.  
2. A.L. Dima, J. Ngui, G.T. Lewith, P. Little, R. Moss-Morris, N.E. Foster, F.L. Bishop. “What suits one person doesn't suit another”: clinicians’ treatment beliefs in low back pain. Oral Presentation at the 26th EHPS Conference, Prague, Czech Republic, August 21st -25th, 2012.
3. A. Dima, G.T. Lewith, P. Little, R. Moss-Morris, N.E. Foster, F.L. Bishop. Anything that would actually work, I’ll try it”: patients’ beliefs on low back pain treatments. Poster Presentation at the 26th EHPS Conference, Prague, Czech Republic, August 21st -25th, 2012.
4. A.L. Dima, J. Ngui, G.T. Lewith, P. Little, R. Moss-Morris, N.E. Foster, F.L. Bishop. “What suits one person doesn't suit another”: clinicians’ treatment beliefs in low back pain. Oral Presentation at the BPS Division of Health Psychology Annual Conference, Liverpool, September 2012.
5. A. Dima, G.T. Lewith, P. Little, R. Moss-Morris, N.E. Foster, F.L. Bishop. "Anything that would actually work, I'll try it": patients' beliefs about low back pain treatments. Oral Presentation at the 41st Annual Scientific Meeting of the SAPC, Wednesday 3rd and Thursday 4th October 2012 at the SECC, Glasgow.
6. A.L. Dima, J. Ngui, G.T. Lewith, P. Little, R. Moss-Morris, N.E. Foster, F.L. Bishop."What suits one person doesn't suit another": clinicians' treatment beliefs in low back pain. Poster Presentation at the 41st Annual Scientific Meeting of the SAPC, Wednesday 3rd and Thursday 4th October 2012 at the SECC, Glasgow. 
7. F.L. Bishop. Patients’ perspectives on MSK care:  “I’ll try anything, as long as it works”. Keynote at the 10th Annual Chiropractic, Osteopathy and Physiotherapy undergraduate research conference, Anglo-European College of Chiropractic (AECC), Bournemouth. November 2013.  
8. A.L. Dima , J Ngui , G.T. Lewith , P. Little , N.E. Foster , R. Moss-Morris , F.L.Bishop. “What suits one person doesn’t suit another”: clinicians’ treatment beliefs in low back pain treatments. Oral presentation at the 8th Annual Congress of the International Society for Complementary Medicine Research, London. April 2013.
9. A.L. Dima , G.T. Lewith, P.  Little, N.E. Foster, R. Moss-Morris, F.L. Bishop. “Anything that would actually work, I’ll try it”: patients’ beliefs about low back pain treatments. Oral presentation at the 8th Annual Congress of the International Society for Complementary Medicine Research, London. April 2013.
10. A.L. Dima, G.T. Lewith, P. Little, R. Moss-Morris, N.E. Foster, M. Hankins, F.L. Bishop. Beyond medication beliefs: a comparative NIRT analysis of patients’ beliefs on four back pain treatments. Oral Presentation at the 27th EHPS Conference, Bordeaux, France, August 2013.
11. A.L Dima, G.T. Lewith, P. Little,  R. Moss-Morris, N.E. Foster, F.L. Bishop. Identifying patients’ beliefs about treatments for chronic low back pain: A focus group study. (2013). British Journal of General Practice, 63(612), e490-e498.  DOI: http://dx.doi.org/10.3399/bjgp13X669211
12. F.L. Bishop, A. Dima,  G. Surtees, P. Little, R. Moss-Morris, N.E. Foster, M. Hankins, G.T. Lewith. Beyond Expectations:  Developing a New Questionnaire to Measure Patients’ Beliefs about Conventional and Complementary Therapies for Low Back Pain. Poster presented at the  2014 International Research Congress on Integrative Medicine and Health in Miami, Florida, USA, May 13 – 16, 2014

Public involvement

We sought input from two PPI volunteers with back pain which helped us to improve our core study documents for participants (e.g. information leaflets).

Impact

In our paper reporting Study 1 we outline specific ways in which future clinical guidelines could be designed to as to be better implemented in practice. In our paper reporting Study 2 (published in a GP journal) we describe patients’ values and preferences regarding low back pain treatment which could enhance GPs’ understandings of patients’ priorities. As we continue to disseminate our findings, we hope that researchers and practitioners will use our new questionnaire to better understand patients’ beliefs about low back pain treatments and thus aid in treatment-related shared decision-making.

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 75)

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.