Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study.

PURPOSE: Low back pain management has evolved with researchers advocating for a biopsychosocial management model. The biopsychosocial management model has been predominantly applied in high-income countries and underexplored in low- and middle-income countries including Ghana. This study aimed to explore the potential barriers and facilitators to patients with chronic low back pain (CLBP) and physiotherapists engagement with a biopsychosocial intervention (exercise and patient education) as part of a feasibility study. MATERIAL AND METHODS: This was a qualitative study embedded within a mixed-methods, sequential, feasibility study, in Ghana, applying semi-structured interviews. Two categories of participants involved in this study were, two trained physiotherapists, and six patients with CLBP, sampled within the feasibility study. RESULTS: Regarding the barriers and facilitators to the delivery of the BPS intervention, five interlinked themes emerged from the thematic analysis. These were: structure and process of delivery; patients' expectations; patients' health beliefs, autonomy, and engagement; external influences and personal and professional characteristics of physiotherapists. CONCLUSION: The themes that emerged from this study demonstrated many positive facilitators based on participants' improved understanding of LBP and the clarity and purpose of the biopsychosocial intervention. The results therefore demonstrate a potential to deliver the biopsychosocial intervention in a Ghanaian context.

A biopsychosocial approach to managing chronic low back pain offers a promising alternative to patients and physiotherapists in Ghana.A biopsychosocial approach to managing chronic low back pain has the potential to improve physiotherapists' thoughts and attitudes, and have a positive influence on their professional development in Ghana.A biopsychosocial approach to managing chronic low back pain has the potential to reverse patients' maladaptive beliefs, improve their understanding of their condition, improve outcomes in Ghana.

'Specialist before physiotherapist': physicians' and physiotherapists' beliefs and management of chronic low back pain in Ghana - A qualitative study.

PURPOSE: This study provides an understanding of the chronic low back pain (CLBP) beliefs and management practices of physicians/doctors and physiotherapists in Ghana, and the mechanisms underlying their beliefs and practices. MATERIALS/METHODS: Thirty-three individual semi-structured interviews, involving eighteen physio-therapists and fifteen physicians involved with CLBP management, were carried out. Interviews were audio recorded, transcribed, and analysed using Straussian grounded theory principles and critical realist philosophy. RESULTS: Five categories were derived: The predominance of bio-medical/mechanical beliefs, maladaptive beliefs, maladaptive practices, limited involvement of physiotherapists and other healthcare professionals (HCPs) and evidence-based beliefs and practices. The predominant mechanisms underlying the HCPs beliefs and practices were: the healthcare environment (professional roles/identity hinged around paternalistic and biomedical care, fragmented CLBP management, limited physiotherapy/HCPs' knowledge) and sociocultural environment (sociocultural/patients' expectations of passive therapy and paternalism). CONCLUSION: The CLBP beliefs and practices of HCPs involved with CLBP in Ghana is modelled around a professional identity that is largely hinged on paternalism and bio-medical/mechanical understandings. Lack of collaboration and sociocultural expectations also play a significant role. There is the need for a reconstitution of Ghanaian HCPs' CLBP beliefs and management approaches to align with evidenced-based approaches (e.g., imaging should not be universally prescribed, biopsychosocial and patient-centred care).

The burden of low back pain is substantial globally, with an increasing burden identified in low-to-middle income countries.This study highlights a predominance of non-evidence-based understandings around chronic low back pain and its management among Ghanaian healthcare professionals, although some evidence-based approaches were also identified.Ghanaian healthcare professionals need to engage with current evidence for chronic low back pain management, incorporate psychological factors and consider non-specific chronic low back pain as a possible diagnostic label.Professional, structural, and sociocultural inclinations towards paternalism, passive therapies, biomedical and fragmented approaches to chronic low back pain management need to be addressed.

A Qualitative Investigation of the Psychosocial Impact of Chronic Low Back Pain in Ghana.

INTRODUCTION: Chronic low back pain (CLBP) is a global health concern associated with multidimensional/biopsychosocial levels of affectation in developed countries, with holistic management requiring consideration of these factors. There has been minimal research exploring the psychosocial impact of CLBP, and the factors influencing it, in African contexts, with none in Ghana. OBJECTIVES: To explore the psychosocial impact of CLBP among patients with CLBP in Ghana. DESIGN: Qualitative study using individual semistructured face-to-face interviews, underpinned by Straussian grounded theory principles and critical realist philosophy. PARTICIPANTS: Thirty patients with CLBP attending physiotherapy at two hospitals in Ghana. RESULTS: Five categories: loss of self and roles, emotional distress, fear, stigmatisation and marginalisation, financial burden, and social support and three mechanisms: acquired biomedical/mechanical beliefs from healthcare professionals (HCPs), sociocultural beliefs and the socioeconomic impact of CLBP were derived. CONCLUSION: CLBP adversely affects multidimensional/biopsychosocial aspects of individuals experiencing CLBP in Ghana. This delineates the need for a biopsychosocial approach to care. There is the need for HCPs in Ghana to reassess current CLBP management strategies to address the influence of adverse HCPs biomedical inclinations on patients' psychosocial consequences. Population-based education strategies and consideration of formal support systems for persons with disabling CLBP may also be beneficial.

Understanding how patients' pain beliefs influence chronic low back pain management in Ghana: a grounded theory approach.

INTRODUCTION: Chronic low back pain (CLBP) is associated with negative consequences in high and low/middle-income countries. Pain beliefs are important psychosocial factors that affect the occurrence and progression of CLBP and may be influenced by the sociocultural context and interactions with healthcare professionals (HCPs). The pain beliefs of Ghanaian patients with CLBP are unknown and the factors influencing pain beliefs in African contexts are unclear. OBJECTIVES: To explore the pain beliefs of Ghanaian patients with CLBP, how they influence CLBP management/coping and to identify the mechanisms influencing them. DESIGN: Qualitative study using individual semistructured face-to-face interviews, situated within Straussian grounded theory principles and critical realist philosophy. PARTICIPANTS: Thirty patients with CLBP accessing physiotherapy at two teaching hospitals in Ghana. RESULTS: Participants suggested dominant biomedical/mechanical beliefs (related to CLBP causes, posture and activity, and the belief of an endpoint/cure for CLBP). Maladaptive beliefs and practices, in particular fear-avoidance beliefs, and dependence on passive management and coping, were common among participants. These beliefs and practices were mostly influenced by HCPs and sociocultural expectations/norms. Although spirituality, pacing activity and prescribed exercises were commonly mentioned by participants, other active strategies and positive beliefs were expressed by a few participants and influenced by patients' themselves. Limited physiotherapy involvement, knowledge and awareness were also reported by participants, and this appeared to be influenced by the limited physiotherapy visibility in Ghana. CONCLUSION: Participants' narratives suggested the dominant influence of HCPs and the sociocultural environment on their biomedical/mechanical beliefs. These facilitated maladaptive beliefs and adoption of passive coping and management practices. Therefore, incorporation of more positive beliefs and holistic/active strategies by Ghanaian patients and HCPs may be beneficial. Furthermore, patient empowerment and health literacy opportunities to address unhelpful CLBP/sociocultural beliefs and equip patients with management options for CLBP could be beneficial.

Operationalisation of a biopsychosocial approach for the non-pharmacological management of patients with chronic musculoskeletal pain in low- and middle-income countries: A systematic review.

BACKGROUND: Chronic musculoskeletal pain is a major health concern. The biopsychosocial approach is an evidence-based approach recommended for managing chronic musculoskeletal pain. However, the evidence for this approach is largely reported from high-income countries; therefore, it is important to ascertain how biopsychosocial approaches are operationalised in low- and middle-income countries to inform practice. AIM: To examine the evidence for the operationalization of biopsychosocial interventions in managing patients with chronic musculoskeletal pain in low-and middle-income countries. METHODS: The search included studies published in English from 2008 to September 2019 in: Cochrane library, OVID, CINAHL, Scopus, PUBMED, Web of Science, and SportDiscus. Randomised and non-randomised trials using a biopsychosocial intervention were considered. The review team developed a search strategy; two independent reviewers screened and assessed results for quality. RESULTS: Sixteen studies were included (n = 996) with mainly low back pain populations (n = 11 studies). Others were osteoarthritis (n = 1) and other musculoskeletal pain (n = 4). The majority (n = 12) of studies attained fair to poor quality, three had good quality, one scored excellent quality. Interventions applied biopsychosocial principles such as cognitive functional therapy, and graded activity, delivered by healthcare professionals such as physiotherapists and doctors. However, most results provided insufficient information regarding healthcare professionals' capacity to deliver interventions, lack of information regarding intervention delivery and training of healthcare professionals. CONCLUSIONS: The results highlight the potential for delivering biopsychosocial interventions in low- and middle-income countries; however, future research should consider robust methodological approaches with clear details to achieve high-quality trials.

Patients' Satisfaction With Inpatient Orthopedic Physiotherapy Services at a Tertiary Hospital in Ghana.

BACKGROUND: Although assessing patient satisfaction ensures quality assurance, compliance, and better effects of therapy, patient satisfaction studies are lacking within the Ghanaian physiotherapy domain. OBJECTIVE: To ascertain patients' satisfaction with physiotherapy services and evaluate factors that influence satisfaction levels at the trauma and orthopedic directorate of Komfo Anokye Teaching Hospital. METHOD: A cross-sectional survey was done, and systematic random sampling was used to recruit participants. One-hundred twenty (120) patients participated in the study. Data were collected using an adapted structured patient satisfaction questionnaire. Data obtained were analyzed using SPSS version 24. Descriptive statistics and nonparametric tests were performed. RESULTS: The mean age of participants was 39.9 ± 15.8 years. They comprised 48 (40%) females and 72 (60%) males. The most common cause of patient admission was road traffic accident (71.7%). All dimensions of satisfaction assessed were highly rated (>90%). Majority of the participants reported that they were satisfied (95.7%) and compliant (91.6%) with the physiotherapy treatment. Respect shown by therapist (98%) and courtesy and friendliness (97%) were the most rated indices; however, some respondents had uncertainties pertaining to patient involvement in decision-making. The majority of participants also reported that due to their satisfaction, compliance came naturally (75.9%) and reported compliance had a significant association with satisfaction (P = .02). Age was also found to influence satisfaction (P = .04). CONCLUSION: Patient satisfaction with physiotherapy services rendered at the inpatient facility was high, and satisfaction reportedly translated into ease with compliance.

Chronic low back pain beliefs and management practices in Africa: Time for a rethink?

BACKGROUND: Chronic low back pain (CLBP) beliefs are important psychosocial risk factors affecting the occurrence and progression of CLBP. To address pain beliefs and implement recommended biopsychosocial approaches for CLBP management, an understanding of the beliefs of patients and healthcare professionals (HCPs), and also CLBP management practices, is necessary. A narrative review was conducted to explore CLBP beliefs and practices in African countries. METHODS: Two systematic searches were conducted using seven databases (MEDLINE, Embase, PsychInfo, CINAHL Plus, AMED, PubMed and Web of Science) with combined variations of the terms "Management", "Guidelines", "Chronic Low Back Pain", "Beliefs", "Patients", "Healthcare Professionals" and "Africa". RESULTS: Five studies and one standard treatment guideline document were included. No systematically developed African CLBP treatment guideline was found, although CLBP practices were identified in two African countries. CLBP management in African countries appears to be biomedically orientated. Only three research articles investigated the CLBP beliefs of patients in Africa, with none assessing HCP beliefs. Unhelpful CLBP beliefs (catastrophizing and fear avoidance) and biomedical thoughts about the causes of CLBP were identified. Unhelpful CLBP beliefs were associated with increased disability. CONCLUSIONS: Management practices for CLBP in African countries appear to contradict recommended biopsychosocial management guidelines by developed countries and are not sufficiently documented. Research on CLBP beliefs and CLBP management practices in Africa is lacking. To enhance the uptake of biopsychosocial approach in Africa, research around CLBP beliefs in African CLBP patients and HCPs is required.