Intervention
Illness beliefs, treatment beliefs and information needs as starting points for patient information—Evaluation of an intervention for patients with chronic back pain

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Abstract

Objective

The objective of the study was to evaluate an intervention which applied the extended Common Sense Model to the provision of information about illness and treatment during inpatient rehabilitation for patients with chronic back pain.

Methods

The intervention was evaluated in a sequential control group design (control group N = 105; intervention group N = 96). Changes with respect to illness and treatment beliefs, satisfaction with information, and health status at the end of rehabilitation were selected as outcome measures. Analyses of covariance were used to assess differences between control and intervention group.

Results

Significant time-by-group interactions were shown for causal beliefs, personal control, satisfaction with information about illness and rehabilitation, and for general health. All time-by-group interactions indicated superiority of the intervention group.

Conclusion

The intervention group assessed their back pain as personally controllable and their information needs at the end of rehabilitation as being met to a greater extent than did patients who received care as usual.

Practice implications

The extended Common Sense Model seems promising as a frame for discussing illness and treatment perceptions as well as information needs in patients with chronic back pain.

Introduction

Low back pain is a considerable health problem with reported lifetime prevalence between 49% and 70% [1], [2]. Primarily due to indirect costs that are associated with long-term disability or early retirement [1], back pain is one of the most expensive illnesses in industrialized countries [3]. With respect to the transition from acute to chronic low back pain (CLBP), increasing evidence demonstrates the importance of psychosocial factors such as pain catastrophizing, work-related factors, patients’ expectations, self-efficacy, and coping [2], [4]. Thus, these factors are considered “yellow flags” for the identification of patients at risk of further chronicity.

In recent years, many clinical guidelines have been published on the management of CLBP. In all of these, multidisciplinary biopsychosocial treatment programmes are recommended. Furthermore, a paradigm shift took place from passive measures to active measures, as well as psychological therapy and yellow flags to be taken more into consideration [2], [3], [5].

However, patients are often dissatisfied with treatment for back pain, and obviously there is a gap between what is offered by healthcare providers and what – based on a more biomedical model – is expected by patients: a clear diagnosis of the cause of the pain, pain relief, physical examination, physical oriented pain management, and sickness certification [6], [7]. With a generally pessimistic view of back pain, back pain beliefs of the general public are also “lagging behind current evidence” ([5], p. 2144). Therefore, several researchers suggest that it could be worthwhile to pay more attention to patients’ beliefs about CLBP [5], [6], [7] that limit pain management and to strengthen the development of therapies that change “maladaptive” or unhelpful illness beliefs. For example, the recommendation to stay active may not make sense from the patient's perspective if the patient has low perceptions of personal control (cf. [8]). However, in the context of CLBP there is thus far a lack of research examining illness perceptions [9], [10].

A framework that highlights the importance of illness perceptions by linking illness perceptions to behaviour and health outcomes is the Common Sense Model of self-regulation (CSM) [11], [12]. According to the CSM, individuals who are faced with a health threat develop cognitive and emotional illness representations that determine the selection of coping procedures – such as adherence – and health outcomes. The cognitive illness representations are composed of five interrelated components – identity (the symptoms and the “diagnostic label” associated with the illness), causal beliefs, timeline beliefs, beliefs about control/cure, and consequences [13]. Focussing on treatment beliefs in addition to illness beliefs, Horne et al. [14], [15] postulated an extended self-regulatory model. Leventhal's working group has given many explanations of the development of the components of self-regulation [16]. One basic assumption is that self-regulation is embedded in a social context and therefore depends on the input of others. Medical care can be seen as one of the most obvious examples of social input, and expert input is crucial as other sources of shaping the representations – such as perceptual input – often are vague. However, social influences do not define the representations completely. Rather, the individual is assumed to be the “nexus” (p. 56) for the use of information from the social context. That is, illness representations serve as a framework for making sense of information from health care providers, and social input is rejected if it is inconsistent with personal experience [16].

In the past 15 years, research has yielded evidence about the relationships between illness perceptions, coping procedures, and different outcomes in many acute and chronic illnesses [13], [17], [18], [19], [20], [21]. In patients with low back pain, Foster et al. [9] found that patients who expected their back pain to have a chronic timeline, who perceived serious consequences, and who did not believe in the controllability of the pain were more likely to have a poor clinical outcome. Concerning treatment beliefs, there is particular evidence that beliefs about medicines predict adherence [22], [23], [24], [25], and also in the context of chronic pain, an extended self-regulatory model is supported [10]. Treatment beliefs with respect to non-medication treatment have thus far been studied far less frequently. However, preliminary results indicate that treatment control is also a precondition for compliance with physiotherapy in patients with osteoarthritis [26].

To date, most illness perception studies have been carried out to demonstrate relationships between illness perceptions and outcomes. In contrast, relatively little work has been reported regarding interventions that were developed on the basis of the CSM [27]. This is all the more surprising, as the CSM can provide concrete starting points for designing therapeutic interventions – e.g. modification of illness-related dysfunctional schemata in the context of cognitive behaviour approaches. However, existing results from intervention studies – conducted mainly on patients with coronary heart disease – are promising [28], [29], [30], and a recent review referring to this issue therefore concludes that the CSM can be usefully applied to designing interventions to change beliefs [31].

To the best of the authors’ knowledge, no intervention study aimed at illness perceptions has thus far been conducted in the context of CLBP. The aim of this study was therefore to evaluate an intervention which applied the extended CSM to the provision of information about illness and treatment during inpatient rehabilitation in patients with CLBP. In view of the assumption that illness and treatment representations serve as a framework for making sense of information from health care providers [28], the objective of the intervention was to better meet the information needs of patients by linking information to patient beliefs and thus improve health status after rehabilitation. The following issues were investigated:

  • -

    Is the intervention effective with respect to outcomes proximal to the intervention? Illness and treatment perceptions as well as the satisfaction with information about medicines, illness and rehabilitation were selected as measures of proximal outcome.

  • -

    Is the intervention effective with respect to health status as an outcome distal to the intervention?

In Germany, inpatient rehabilitation care is provided for nearly every chronic disease. This is also the case with CLBP. Rehabilitation programmes usually are multimodal and multidisciplinary. However, altering illness or treatment beliefs is not an explicit or standardized component of these programmes.

Section snippets

Intervention

The aim of the intervention was to improve information on illness and treatment by using patients’ beliefs about illness and treatment as well as information needs with respect to illness, medicines, and rehabilitation as starting points for providing information. On the one hand, by analogy with Petrie et al. [28], the intervention comprised an equivalent structure for all patients: it consisted of three 20-min patient sessions with a physician and a psychologist of the rehab centres and had

Results

Table 3 displays the changes in the outcome variables between the start and completion of rehabilitation. With respect to the causal beliefs, the control group named “chance or bad luck” as a cause for back pain less often than at the start of rehabilitation (Mt0 = 2.58; SDt0 = 1.09 vs. Mt1 = 2.27; SDt1 = 1.11; t = 2.195; p = .030; SES = −.28). Patients in the intervention group named “my own behaviour” (Mt0 = 2.74; SDt0 = 1.19 vs. Mt1 = 3.10; SDt1 = 1.06; t = −3.085; p = .003; SES = .30) and “my mental attitude” (Mt0 = 

Discussion

The results of our study show that the intervention group seemed to benefit to a greater extent than the control group, especially with respect to proximal outcomes. After rehabilitation, patients in the intervention group identified factors lying in their own sphere of influence – own behaviour and mental attitude – as causes of their pain to a greater extent than at the start of rehabilitation. Furthermore, the perception of personal control increased substantially, while it remained nearly

Acknowledgements

The project “Bedarfsgerechte Patienteninformation auf der Basis subjektiver Konzepte” (Needs-based Patient Information Based on Subjective Concepts) is funded by the German Pension Association in the funding priority “Versorgungsnahe Forschung” (Patient-oriented Research). We would like to thank the funders, the cooperating centres Fachklinikum Sachsenhof in Bad Elster, Rehabilitationsklinik Moorbad Bad Doberan in Bad Doberan, Sankt-Rochus-Kliniken in Bad Schönborn, Schön Klinik Harthausen in

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