A qualitative study of influences on older women’s practitioner choices for back pain care

Back pain represents a significant public health issue, affecting approximately 70% of the population over the life course [1‐4], and incurring direct and indirect costs of greater than AU$8 billion per year in Australia [5‐7]. Chronic back pain can be particularly debilitating, limiting capacity for work and participation in leisure and family life [8‐12]. Given the rapidly ageing populations in Australia and OECD countries more broadly, the cost, provision and organisation of back pain care is a prominent healthcare problem [3, 10, 13, 14]. The underlying causes of back pain are often difficult to identify, and treatment options are multifaceted and distributed across practitioner groups [1, 15, 16]. People with acute back pain who have sought treatment may experience slow or limited recovery [12], and progress relatively quickly from acute to chronic back pain status. In Australia, back pain care in its various forms includes general practitioners (GPs), medical specialists (e.g. rheumatologists), allied health providers (e.g. physiotherapists) and complementary and alternative medicine (CAM) practitioners (e.g. chiropractors, acupuncturists and massage therapists). The national publicly funded Medicare system reimburses patients (at least partially) for the majority of consultations and treatments provided by biomedical practitioners and some provided by allied health practitioners, but relatively few provided by CAM providers. In the case of CAM practitioners, the consultation and treatment is either funded out-of-pocket or is subsidised by private health insurance [17]. Despite these funding variations, the majority of chronic pain sufferers continue to seek care from multiple practitioners [1, 18‐20].

This project was conducted as part of the Australian Longitudinal Study on Women’s Health (ALSWH), designed to examine multiple factors affecting the health and well-being of Australian women over a 20-year period. The baseline cohort was recruited in 1996, and consisted of women in three age groups (18–23, 45–50, and 70–75 years) randomly selected from the national Medicare database [57]. The cohort has been shown to be broadly representative of the national population of women in the targeted age groups [58]. The focus of the current study is on the ‘mid-age’ cohort, aged 60–65 at the time of data collection, and was designed to explore women’s experiences of back pain, consultation practices, health service utilisation, attitudes towards treatment options and health status more broadly. For this study, women who had indicated that they had sought help from a healthcare practitioner for their back pain were recruited to initially complete a questionnaire [19]. During 2011/2012, and following University of Queensland ethics approval, a nationally representative sample of 1,310 women aged 60–65 completed a questionnaire (response rate: 80.9%) [19]. In the questionnaire, the women indicated a willingness to participate in a face to face interview (n = 513; response rate: 39.1%). Seventy-five women in South East Queensland indicated a willingness to participate, sixty-one were contacted and invited to participate (via telephone call), and fifty were interviewed. The interviews lasted for between forty-five minutes and two hours, and were conducted in the participants’ homes at a time of their convenience. The sample for the qualitative study included representation of a range of cases according to duration of pain, intensity of pain, urban/regional location, and employment status (as self-reported in the survey). The qualitative, semi-structured interviews continued until the point of data saturation. Of the sample of 50 women, 29 were in paid employment, 32 were married, and 43 had one or more children. The length of time with back pain broadly reflected patterns for the full questionnaire cohort (less than one year, n = 2; 1–10 years, n = 12; 11–20 years, n = 13; 21–20 years, n = 9; 31–40 years, n = 11; more than 40 years, n = 3). The mean length of time with back pain for the qualitative sample (n = 50) and questionnaire sample (n = 1,310) were 20.3 years and 20.4 years respectively. Interviews were audio recorded and transcribed verbatim, and were guided by an interview schedule (See Additional file 1) which was adapted to the individual circumstances of the interviewee. The interviews were designed to explore the following domains: decision-making practices and experiences of care; understandings of lay-professional and inter-professional communication; and, the meanings associated with various models of care.

Here we report the influences on women’s decision-making around practitioner and provider choice of treatment for their most recent episode of back pain. We refer to ‘providers’ and ‘practitioners’ respectively to distinguish between participants’ accounts of a group of professionals/practitioners (e.g. general practitioners, chiropractors or physiotherapists in general), and individual practitioners (e.g. an individual or named GP, chiropractor, etc.). Each of the women offered a detailed account of the practitioners they had visited or were planning to visit, and the circumstances which led to these decisions. All of the participants had sought care from at least one practitioner during their time with back pain. Four significant themes emerged from the interviews related to the influences on decision-making regarding health care service provider consultation: a) familiarity with treatment, and experiences with providers/practitioners; b) recommendations or anecdotes from networks of family/friends; c) proximity of practitioners; and, d) qualifications and credentials of practitioners. A summary of key findings and examples is included in Table 1.

Back pain care is a highly diversified area of health service delivery and the majority of sufferers actively juggle multiple treatment and provider options concurrently or over time. In order to do so, and as illustrated in the results of the current study, sufferers draw on, and are influenced by, various stakeholders, social networks and resource practicalities. Although formalised (largely biomedical and allied health) models exist which aim to provide and deliver appropriate and evidence-based care to chronic back pain sufferers, the results presented here suggest that women seek help beyond biomedical and allied health practices, and furthermore, that subjective, interpersonal and social factors fundamentally shape their choices and actions. While the production and existence of a biomedical evidence-base may drive funding and delivery of many back pain care practices (at least those provided via the State), from the perspective of individual sufferers, familiarity, convenience and resonance with social networks may in fact be more significant in their decision-making about practitioners.

A key process identified here was the lay consultation process which was focused on establishing appropriate provider types and recommendation for a specific practitioner. Once a decision to seek some form of treatment had been made, recommendations from social networks, familiarity with provider-specific treatments and proximity to practitioners were the main drivers of action. Our findings reflect the diversified and often fragmented landscape of back pain care. Moreover, our analysis reveals that back pain sufferers lack guidance (in the form of clinical evidence) for choices around care seeking. The lack of coherent and systematic support or clinical evidence across biomedicine, allied health and CAM in the context of back pain [21‐27] may create a decision-making context which is heavily mediated by lay knowledge and expertise. In our study it was clear that participants wanted to know more about available treatment options, but found such information difficult to access and/or assess or measure. Participants thus sought social and community-based avenues for advice to manage their own care pathways [56, 62]. In such circumstances, trust may become more focused on lay sites of expertise rather than on practitioner and formalised expertise. In line with existing research, our findings show an explorative approach to care, and a willingness to try various treatment options (biomedical, allied, and CAM) [15, 19, 39]. Moreover, our findings add to the emerging body of work which has drawn attention to the significance of treatment for back pain as an interpersonal and interactional experience [31, 32, 34, 63].

Ultimately, the interviews illustrate that within the context of a pluralistic and often fragmented system, involving significant self-management, there may be key distinctions between professional and lay foci on care. Whilst providers may be focusing on evidence-creation in their own area of practice, in the community issues around access, familiarity, relationships, social networks and confidence are key drivers of choice and care pathways. Research into back pain care and choice has largely focused on beliefs, perceptions and preferences around care [20, 32, 33, 49, 63], and rarely have there been rigorous qualitative examinations of the factors which underpin illness experience and practitioner engagement. While clinical research has focused on what practitioners do and outcomes (whether subjective or objective), here we have focused on what leads women to engage practitioners. Put simply, our findings raise questions about the importance of what practitioners actually ‘do’ for people looking for available back pain treatment, compared to practitioner personality, ‘track record’, reputation and standing within the community. While these facets clearly work in tandem, previously we have seen insufficient emphasis on, and exploration of, the pathways to care and the assumptive basis of patient action.

This study has various limitations. Although our sample of women is relatively large for a qualitative study, it only captures the experiences of women from one geographic region, and from a specific age group. As such, our findings cannot be generalised to other people in other settings, nor to those of the broader nationally representative sample from which participants in this study were drawn. Furthermore, the sample of women included in the study all experienced chronic back pain, and for a significant number of years. Our findings therefore may not represent the views or experiences of people with acute back pain, or those who have not lived with (often unsuccessfully treated) back pain for a considerable period of time.

This study provides a means for better understanding the lay underpinnings of choice and action in the context of chronic back pain. Given our findings, further research is needed on the social and community influences on (and determinants of) practitioner engagement and the development of models which capture clinical efficacy and lay experiences concurrently. An absence of such understandings will further marginalise decision-making practices from practitioners (who are providing or potentially providing care), leading to sub-optimal communication, teamwork and coordination of care across sectors, as well as having negative impacts upon recovery.