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Publicly Available Published by De Gruyter July 1, 2017

The effects of a brief educational intervention on medical students’ knowledge, attitudes and beliefs towards low back pain

  • Christina Abdel Shaheed EMAIL logo , Jane Graves and Chris Maher

Abstract

Background and aims

Knowledge, attitudes and beliefs towards low back pain (LBP) can significantly impact a health care provider’s clinical decision making. Several studies have investigated interventions designed to change practitioner attitudes and beliefs towards LBP, however no such studies involving medical students have been identified.

Methods

This study explored medical students ‚ knowledge, attitudes and beliefs towards LBP before and after a brief educational intervention on LBP. Responses from medical students (n = 93) were evaluated before and after a 15-min educational video on back pain. The intervention was developed using Camtasia™ video editor and screen recorder. Knowledge, attitudes and beliefs were measured using the “Modified Back Beliefs Questionnaire”, with items from two previously reported questionnaires on back beliefs. The questionnaire asks participants to indicate their agreement with statements about LBP on a 5-point Likert scale. Preferred responses were based on guidelines for the evidence-based management of LBP. The primary analysis evaluated total score on the nine-inevitability items of the Back Beliefs Questionnaire (“inevitability score”).

Results

Following the brief intervention there was a significant improvement in the inevitability score (post-workshop mean [SD] 20.8 [4.9] vs pre-workshop mean [SD] 26.9 [4.2]; mean difference (MD) 6.1, p < 0.001; lower score more favourable 1) and large improvements in the proportion of students providing correct responses to items on activity (pre: 49% vs post: 79%), bed rest (41% vs 75%), imaging (44% vs 74%) and recovery (25% vs 66%).

Conclusions

After watching the educational video students’ knowledge, beliefs and attitudes towards LBP improved and thus aligned more closely with evidence-based guidelines.

Implications

Medical doctors are at the forefront of managing low back pain in the community, however there is a need to strengthen musculoskeletal education in medical training programmes. The results from this research suggest educational interventions on back pain do not need to be extensive in order to have favourable outcomes on medical students’ knowledge, attitudes and beliefs towards back pain. The translational effects of these changes into clinical practice are not known.

1 Introduction

Low back pain (LBP) is the leading cause of disease burden in Australasia [1] in terms of both disability adjusted life year and years lived with disability. The condition is the leading chronic disease forcing older Australians to retire early from the workforce. It is commonly managed by general practitioners – being the 7th most common reason for a general practitioner (GP) visit in Australia [2, 3].

Several studies highlight a discord between guideline-endorsed recommendations for back pain management and actual practice among Australian physicians, including those with a special interest in LBP [4, 5, 6]. Reports from overseas suggest that inadequate training during medical school on how to examine, diagnose, and manage musculoskeletal conditions [7] could be an important attributing factor. A 2010 Australian study exploring back pain management among primary care physicians showed evidence practice gaps for key aspects of care including referral for imaging, provision of advice and analgesic medicines [3]. A more recent study found that many GPs skip key parts of the clinical assessment e.g. there was 22% compliance with performing a neurological examination, 21% compliance in screening for infection and only 12% compliance in screening for cauda equina syndrome [8].

One explanation for these findings is that there is a gap in back pain education in entry level medical training in Australia. To date, there has been no exploration of medical students’ knowledge, attitudes and beliefs towards LBP or the effectiveness of back pain education in this group. Given the time constraints and demands of medical programmes, there is a need to consider methods of education that would be both time-efficient and effective in relaying evidence-based messages regarding back pain management to medical students. The aim of this study was therefore to investigate first year medical students’ knowledge, attitudes and beliefs towards LBP before and after a brief 15-min educational video presentation on LBP. Prior to the intervention, the students had not received any formal LBP education through the programme.

2 Ethical approval

Ethics approval for this project was obtained from Western Sydney University Human Research Ethics Committee (HREC) Approval No. H9989.

3 Materials and methods

Intervention

We used Camtasia™ to create a 15-min video covering key aspects of back pain education including: prevalence and economic burden of the disease, triage and evidence-based pharmacological and non-pharmacological management of LBP, signs/symptoms of red flags associated with acute onset LBP. The video was administered to medical students during a statistics workshop in July 2015.

Instrument

Knowledge, attitudes and beliefs were measured using the 25-item.

‘Modified’ Back Beliefs Questionnaire’ (MBBQ), developed with items taken from two previously tested and reliable back beliefs questionnaires [4, 9]. The MBBQ was administered to a group of first year medical students before and after watching the video on back pain. The first 14 items were taken from the validated 14-item “Back Beliefs Questionnaire” whilst items 15–25 were sourced from the 11-item “Buchbinder scale” [4, 9] (Table 1). The wording of the final two items from the Buchbinder scale (items 24 and 25 of the MBBQ) was changed from ‘doctors’ to ‘doctors and pharmacists’. Furthermore, the subject of item 6 of the Buchbinder scale (item 20 of the MBBQ) was changed from first person ‘I’ to ‘doctor’ to make it clear that the item referred to medical referral for imaging. Participants indicated their agreement with each statement on a 5-point Likert scale of ‘Strongly Disagree’ (1) to ‘Strongly Agree’ (5) before and immediately after the video. The MBBQ took the medical students approximately 5-min to complete.

Table 1

Modified back beliefs questionnaire.

Survey item Correct response
(1) There is no real treatment for back trouble Disagree
(2) Back trouble will eventually stop you from working Disagree
(3) Back trouble means periods of pain forthe rest of one’s life Disagree
(4) Doctors cannot do anything for back trouble Disagree
(5) A bad back should be exercised Agree
(6) Back trouble makes everything in life worse Disagree
(7) Surgery is the most effective way to treat back trouble Disagree
(8) Back trouble may mean you end up in a wheelchair Disagree
(9) Alternative treatments are the answer to back trouble Disagree
(10) Back trouble means long periods of time off work Disagree
(11) Medication is the only way to relieve back trouble Disagree
(12) Once you have had back trouble there is always a weakness Disagree
(13) Back trouble MUST be rested Disagree
(14) Later in life back trouble gets progressively worse Disagree
(15) Patients with acute LBP should be recommended complete bed rest until the pain goes away Disagree
(16) Patients should not return to work until they are almost pain free Disagree
(17) X rays of the lumbar spine are useful in the work up of patients with acute LBP Disagree
(18) Encouragement of physical activity is important in the recovery of LBP Agree
(19) Interventions by doctors and other health care providers have very little positive impact on the natural history of acute LBP Disagree
(20) Doctors are likely to order x rays for LBP because patients often expect them to do so Disagree
(21) There is nothing physically wrong with many patients with chronic back pain Agree
(22) Well motivated patients are unlikely to have long term problems with LBP Agree
(23) I have no difficulty in assessing the motivation of people with LBP Agree
(24) Practice guidelines are useful to help doctors and pharmacists in the management of medical conditions Agree
(25) Doctors and pharmacists would find practice guidelines helpful in the management of LBP Agree
  1. Based on current evidence-based management guidelines. Responses on Likert scale of 1: strongly disagree; 2: disagree; 3: neither disagree or agree;4: agree; 5: strongly agree. Items 1–14 taken from Symonds et al. (1996); items 15–25 taken from Buchbinder et al. (2009).

    Note: Disagreement: disagree/strongly disagree; agreement: agree/strongly agree. Bold items: 9-inevitabililty items: disagreement correct response.

We calculated the inevitability score (sum of the 9-inevitability items: 1, 2, 3, 6, 8,10,12,13,14 taken from the original BBQ; scale range 9–45) as this score has been previously used to measure the effect of an educational intervention on LBP knowledge, attitudes and beliefs [10, 11]. This analysis also allows a comparison to previous interventions which assessed doctors’ and pharmacists’ knowledge, attitudes and beliefs towards LBP using the same outcome measure (total mean inevitability score) [4, 12]. An analysis of a composite score (range –50 to +50) (sum of transformed mean score [SD] for all 25-items) is also presented. With this method, responses on the Likert scale were transformed to a score ranging from –2 to +2 for each item, where for agreement items, 2 points were allocated for ‘strongly agree’, 1 point for ‘agree’, 0 for ‘neither disagree or agree’, -1 for ‘disagree’ and -2 for ‘strongly disagree’, whereas for disagreement items 2 points were allocated for ‘strongly disagree’, 1 point for ‘agree’, 0 for ‘neither disagree or agree’, -1 for ‘agree’ and –2 for ‘strongly agree’. Here a higher composite score (range –50 to 50) was indicative of more positive responses.

The inevitability items are knowledge-based items encompassing issues around physical activity, bed rest, return to work and recovery within the context of acute LBP. Disagreement with these items is considered the correct response based on recommendations in the LBP literature [13, 14]. Given the direction of the Likert scale used in this study, a lower inevitability score was considered more favourable. A mean change in inevitability score of 3 units was considered to be a meaningful effect, in line with previous LBP intervention studies investigating changes to these same items [11].

Demographic data including age and gender were collected from medical students.

Data analysis

Data analysis was carried out using Statistical Package for the Social Sciences (SPSS®) version 22. After testing for normality, a non-parametric Wilcoxon Sign Ranks test was used to compare pre- and post- inevitability scores. A Mann–Whitney U test was used to determine differences in responses based on gender. Additionally we tallied the percentage of favourable responses to each questionnaire item before and after the video.

4 Results

A total of 93 medical students completed this study (response rate 97%). The mean age of participants was 20.2 years SD (3.6) and 43% of the cohort were male (n = 43). The distributions of age and gender in this group are broadly representative of medical students in NSW (mean age 24 years, 48.5% male) [15].

5 Key findings

Following the 15–min video on LBP management there was a favourable change in medical students’ knowledge, attitudes and beliefs towards LBP so that it more closely aligned with evidence-based guidelines. This was demonstrated by the significant shift towards correct responses on the post- workshop inevitability score compared with the pre-workshop inevitability score; mean [SD] 20.8 [4.9] and 26.9 [4.2] respectively (lower scores more favourable); mean difference (MD) 6.1, p < 0.001.There was also a marked improvement in post intervention composite score compared with pre-intervention composite score (20.2 [9.2] vs 5.8 [6.9] respectively; (higher composite score favourable) – see Table 2).

Table 2

Number (percentage) of correct responses pre- and post- educational intervention (n = 93).

Item Pre Post
(1) There is no real treatment for back trouble 61 (65.6) 74 (82.6)
(2) Back trouble will eventually stop you from working 35 (37.7) 58 (62.4)
(3) Back trouble means periods of pain for the rest of one’s life 40 (43.0) 64 (68.8)
(4) Doctors cannot do anything for back trouble 85 (91.4) 83 (89.2)
(5) A bad back should be exercised 37 (39.8) 61 (65.6)
(6) Back trouble makes everything in life worse 34 (36.5) 46 (49.5)
(7) Surgery is the most effective way to treat back trouble 60 (64.5) 88 (94.7)
(8) Back trouble may mean you end up in a wheelchair 27 (29.1) 53 (57.0)
(9) Alternative treatments are the answer to back trouble 37 (39.8) 44 (47.3)
(10) Back trouble means long periods of time off work 38 (40.9) 68 (73.1)
(11) Medication is the only way to relieve back trouble 76 (81.1) 82 (88.2)
(12) Once you have had back trouble there is always a weakness 25 (26.9) 66 (71.0)
(13) Back trouble MUST be rested 41 (44.1) 75 (91.4)
(14) Later in life back trouble gets progressively worse 11 (11.9) 31 (33.3)
(15) Patients with acute LBP should be recommended complete bed rest until the pain goes away 52 (55.9) 89 (95.7)
(16) Patients should not return to work until they are almost pain free 37 (39.8) 77 (82.8)
(17) X rays of the lumbar spine are useful in the work up of patients with acute LBP 44 (47.3) 74 (76.6)
(18) Encouragement of physical activity is important in the recovery of LBP 49 (52.7) 79 (85.0)
(19) Interventions by doctors and other health care providers have very little positive impact on the natural history of acute LBP 66 (71.0) 67 (72.1)
(20) Doctors are likely to order x rays for LBP because patients often expect them to do so 30 (32.3) 36 (38.7)
(21) There is nothing physically wrong with many patients with chronic back pain 9 (9.7) 22 (23.6)
(22) Well motivated patients are unlikely to have long term problems with LBP 16 (17.3) 45 (48.4)
(23) I have no difficulty in assessing the motivation of people with LBP 11 (11.8) 21 (22.6)
(24) Practice guidelines are useful to help doctors and pharmacists in the management of medical conditions 77 (82.8) 83 (89.2)
(25) Doctors and pharmacists would find practice guidelines helpful in the management of LBP 81 (87.1) 79 (85.0)
Inevitability score mean (SD) (lower score favourable) 26.9 (4.2) 20.8 (4.9)
Composite score mean (SD) (higher score favourable) 5.8 (6.9) 20.2 (9.2)
  1. Inevitability score (IS): sum of mean (SD) for the 9-inevitability items. Lower inevitability score favourable.

    Composite score (CS): sum of transformed mean (SD) for items 1–25. Higher composite score favourable.

Compared with pre-intervention responses, by the end of the intervention there was a large and significant increase in the number of medical students responding correctly to items regarding return to work ‘2. Back trouble will eventually stop you from working’ (35% vs 58%), and the need to exercise the back ‘5. A bad back should be exercised’ (37% vs 61%), ‘18. Encouragement of physical activity is important in the recovery of LBP’ (49% vs 79%). The most notable changes centred around the need for imaging ‘17. X-rays of the lumbar spine are useful in the workup of patients with acute LBP’ (44% vs 74%), recovery ‘12. Once you have had back trouble there is always a weakness’ (25% vs 66%) and the need for bed rest in acute LBP ‘13. Back trouble must be rested’ (41% vs 75%). There was minimal change to attitudes regarding chronicity of LBP ‘14. Later in life back trouble gets progressively worse’ (11% vs 33%). The two items on the value of practice guidelines were answered similarly pre and post the video with most students endorsing their value (see Table 2). There was no significant effect of gender on questionnaire responses (p >0.05).

6 Discussion

This study has shown that medical students’ knowledge, attitudes and beliefs towards LBP improved following a 15–min educational video on the evidence-based management of LBP so that it more closely aligned with messages in LBP guidelines. Importantly following the video presentation the students were much less likely to endorse common misconceptions regarding the need for bed rest and imaging in acute non-specific LBP.

The intervention was relatively short (lasting approximately 15–min), and the findings would suggest that LBP educational interventions do not need to be extensive in order to be effective. A previous study targeting practising pharmacists employed an intervention which lasted 2-hours and yielded results similar to those observed here [12].

Following the video intervention less students held incorrect beliefs regarding bed rest and the need for imaging in acute LBP among medical students. The knowledge that imaging and bed rest can delay recovery in non-specific back pain [16, 17] may serve to inform their clinical decision making once they become practising clinicians. The impact of practitioner beliefs on treatment choices for their patients is well documented in the LBP literature [18, 19], therefore education and training designed to challenge existing beliefs and behaviours may serve to improve back pain care and alleviate the economic burden of this common condition.

A limitation of this study was that it was conducted at only one undergraduate medical school in Australia, therefore the findings may not be representative. The extent to which this favourable shift in knowledge, attitudes and beliefs towards LBP will be retained is also unknown. It is likely this information will need to be revisited, particularly in the latter years of the programme as the students prepare for entry into the workforce. Another limitation is the use of a pre post design which does not provide as robust evidence as a randomised controlled trial. It would also be interesting to replicate this study with practising GPs to see if the 15–min video has the same influence as we saw in this study of medical students.

7 Conclusion

Following a brief educational intervention medical students’ knowledge, attitudes and beliefs towards low back pain improved so that they more closely aligned with guideline endorsed recommendations.

Highlights

  • Medical doctors are at the forefront of managing low back pain.

  • There is a need to strengthen musculoskeletal education in medical training programmes.

  • A brief back pain intervention improved medical students’ attitudes and beliefs towards back pain.

  • Following the intervention beliefs regarding bed rest and the need for imaging in acute LBP improved.


School of Medicine, Building 30 Goldsmith Avenue, Campbelltown, NSW 2560, Australia.

  1. Conflict of interest: CGM has been an investigator on 2 trials evaluating medicines for back pain that received industry co-funding.

  2. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Received: 2017-02-16
Revised: 2017-03-30
Accepted: 2017-04-01
Published Online: 2017-07-01
Published in Print: 2017-07-01

© 2017 Scandinavian Association for the Study of Pain

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