ELSEVIER
loumalof Back and Musculoskeletal Rehabilitation Journal of Back and Musculoskeletal Rehabilitation 9 (1997) 61-63
The 'back home' leaflet: developing a self-management leaflet for people with acute low back pain J.A. Chapman*, L. Smith, P. Little, E. Cantrell, J. Langridge, R. Pickering School of Occupational Therapy and Physiotherapy, University of Southampton, Highfield, Southampton son lBJ, UK
The purpose of this pilot study was to determine what information patients with low back pain (LBP) felt would be appropriate in a printed leaflet to help them manage their condition at home. The Quebec Task Force on Spinal Disorders identified that 74% of episodes of LBP resolve within 4 weeks [1]. People suffering from an occurrence of LBP are, however, often unaware of this and place heavy demands on healthcare services, as they attempt to get help to alleviate their symptoms and to reduce any apprehension that is caused by not knowing how permanent or severe the symptoms will be. Studies have shown that educating patients can improve the self-management of their condition and decrease the use of health services [2,3]' There is also evidence to suggest that if the information is given verbally, patients will quickly forget the advice [4,5]. Instructions given by a healthcare professional can be reinforced by giving the patient a supplementary leaflet that reinforces and expands on the verbal advice [6].
*Corresponding author. Tel.: +44 1703 595293; fax: +44 170595301.
In a funded Randomised Controlled Trial we are developing and evaluating the effectiveness of a 12-page leaflet given out by General Practitioners. The leaflet, which aims to educate people about how to manage their LBP at home, is given to the patient when he/she first presents at the surgery with a new episode of acute LBP. The goal of the leaflet is to empower patients, reduce their anxiety and their need for healthcare interventions. Health education leaflets have been criticised for not containing information relevant to the patient and for being written at levels beyond the comprehension of most readers [7]. We, therefore, developed our leaflet using the Precede model of health [8,9]. This model emphasises the need to obtain the opinion of clients about what information should be included in an educational package. Before designing the leaflet, we sent postal questionnaires to 24 patients with acute LBP with an open ended question asking them what they would like to ask their doctor about their condition. On the reverse of the questionnaire we listed topics on back pain management. A likert scale was placed against each statement and the
1053-8127/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved.
PH 51053-8127(97)00053-5
62
l.A. Chapman et al. / lournal of Back and Musculoskeletal Rehabilitation 9 (1997) 6]-63
patients indicated how important they felt each item to be, by using the scale. Seven responded, and based on that response, we drew up a second questionnaire that was given to a group of 13 patients with acute LBP in semi-structured interviews. We hoped that this type of interview would elicit more information from the patients about what they needed in a leaflet. As in the first questionnaire, patients were first asked to give an indication of what they would most like advice about in an unsolicited response. They then filled in the Likert scale, which had been rewritten, based on the feedback from the original group of respondents. The patients were then asked to rank the five most important issues. The research team expected that people with LBP would want to know what they themselves could do to manage their pain. Our results from the Likert scale showed, however, that people wanted information on what treatment was available. The issue identified as most important was pain control. The five most important issues, rank ordered by the 13 patients were: 1. How the back works. 2. How soon is my back pain likely to settle. 3. What exercise can I do. 4. How can I sleep comfortably. 5. How can I control my pain using self-help measures.
They also wanted to know where to go to get further advice and how to lift things. Using Maslow's hierarchy of needs [10], this feedback from patients suggests that in an acute phase of an episode of LBP, patients are interested in their physiological and survival needs being satisfied, i.e. having their basic needs met. Unable to do this themselves, they tum to the health professionals for help. The research team would have included topics much higher up the hierarchy in the leaflet, based on the assumption that the basic needs have already been met. For instance: achievement of independence, ability to meet one's own need, etc. These perhaps become more of a priority when the acute episode is over. We subsequently designed a 12-page draft leaflet, based on the clients' identified needs, and
piloted the draft leaflet. Physiotherapists, and clients attending a back school in the area (n = 35) completed a 'Tell us what you think' questionnaire to gauge their impression of the leaflet. Most people found the page size convenient (1/3 A3); the wording easy to read and the pictures helpful in illustrating the information. However, the print size (10 point font) was described as too small by over half of the respondents. The leaflet was revised based on their answers. We also considered those factors found by reseach in the literature to help with reading and understanding. Only two other leaflets have been described in the literature relating to the management of LBP [11,12], but this is the first leaflet that has had extensive testing to find out what patients felt necessary to include. The results highlight the importance of establishing the patients' priorities in designing educational material for them. The study into the effectiveness of the leaflet in the management of patients with acute LBP is currently continuing as a Randomised Controlled Trial in Southampton and the New Forest area, and will be complete in 1997. References [1] Quebec Task Force on Spinal Disorders. Scientific approach to the assessment and management of activityrelated spinal disorders. Spine 1987;12:S9-S59. [2] Bartlet EE. Putting patient education back into control. Patient Educ Couns 1990;16:185-'186. [3] Hirano PC, Laurent DD, Lorig KR. Arthritis patient education studies 1987-1992. A review of the literature. Patient Educ Couns 1994;24:9-54. [4] Brody DS. An analysis of patient recall of their therapeutic regimens. J Chron Dis 1980;33:57-63. [5] Skelton AM, Murphy EA. Murphy RJL, O'Dowd TC. Patient education for low back pain in general practice. Patient Educ Couns 1995;25:329-334. [6] Meuwissen JHJM. Patient education by physicians: a new Dutch approach. Patient Educ Couns 1994;23:69-71. [7] Petterson T. How readable are the hospital information leaflets available to elderly patients? Age and Ageing 1994;23:14--16. [8] Green LW, Kreuter MW, Deeds SG, Partridge KB. Health education planning: a diagnostic approach. Palo Alto, California: Mayfield Publ., 1980. [9] Jenny J. A future perspective on patient/health education in Canada. J Adv Nurs 1993;18:1408-1414.
J.A. Chapman et al. / Journal of Back and Musculoskeletal Rehabilitation 9 (1997) 61-63
[10] Maslow A. Motivation and personality. New York: Harper and Row, 1970. [11] Roland M, Dixon M. Randomized controlled tial of an educational booklet for patients presenting with back pain in general practice. J R Coli Gen Pract 1989;39:244-246.
63
[12] Waddell G, Burton K, Roland M et al. Preliminary evaluation of a new 'Back Book'. Presented at the Society for Back Pain Research. Spring Meeting, March 1996.
loumalof Back and Musculoskeletal Rehabilitation Journal of Back and Musculoskeletal Rehabilitation 9 (1997) 61-63
The 'back home' leaflet: developing a self-management leaflet for people with acute low back pain J.A. Chapman*, L. Smith, P. Little, E. Cantrell, J. Langridge, R. Pickering School of Occupational Therapy and Physiotherapy, University of Southampton, Highfield, Southampton son lBJ, UK
The purpose of this pilot study was to determine what information patients with low back pain (LBP) felt would be appropriate in a printed leaflet to help them manage their condition at home. The Quebec Task Force on Spinal Disorders identified that 74% of episodes of LBP resolve within 4 weeks [1]. People suffering from an occurrence of LBP are, however, often unaware of this and place heavy demands on healthcare services, as they attempt to get help to alleviate their symptoms and to reduce any apprehension that is caused by not knowing how permanent or severe the symptoms will be. Studies have shown that educating patients can improve the self-management of their condition and decrease the use of health services [2,3]' There is also evidence to suggest that if the information is given verbally, patients will quickly forget the advice [4,5]. Instructions given by a healthcare professional can be reinforced by giving the patient a supplementary leaflet that reinforces and expands on the verbal advice [6].
*Corresponding author. Tel.: +44 1703 595293; fax: +44 170595301.
In a funded Randomised Controlled Trial we are developing and evaluating the effectiveness of a 12-page leaflet given out by General Practitioners. The leaflet, which aims to educate people about how to manage their LBP at home, is given to the patient when he/she first presents at the surgery with a new episode of acute LBP. The goal of the leaflet is to empower patients, reduce their anxiety and their need for healthcare interventions. Health education leaflets have been criticised for not containing information relevant to the patient and for being written at levels beyond the comprehension of most readers [7]. We, therefore, developed our leaflet using the Precede model of health [8,9]. This model emphasises the need to obtain the opinion of clients about what information should be included in an educational package. Before designing the leaflet, we sent postal questionnaires to 24 patients with acute LBP with an open ended question asking them what they would like to ask their doctor about their condition. On the reverse of the questionnaire we listed topics on back pain management. A likert scale was placed against each statement and the
1053-8127/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved.
PH 51053-8127(97)00053-5
62
l.A. Chapman et al. / lournal of Back and Musculoskeletal Rehabilitation 9 (1997) 6]-63
patients indicated how important they felt each item to be, by using the scale. Seven responded, and based on that response, we drew up a second questionnaire that was given to a group of 13 patients with acute LBP in semi-structured interviews. We hoped that this type of interview would elicit more information from the patients about what they needed in a leaflet. As in the first questionnaire, patients were first asked to give an indication of what they would most like advice about in an unsolicited response. They then filled in the Likert scale, which had been rewritten, based on the feedback from the original group of respondents. The patients were then asked to rank the five most important issues. The research team expected that people with LBP would want to know what they themselves could do to manage their pain. Our results from the Likert scale showed, however, that people wanted information on what treatment was available. The issue identified as most important was pain control. The five most important issues, rank ordered by the 13 patients were: 1. How the back works. 2. How soon is my back pain likely to settle. 3. What exercise can I do. 4. How can I sleep comfortably. 5. How can I control my pain using self-help measures.
They also wanted to know where to go to get further advice and how to lift things. Using Maslow's hierarchy of needs [10], this feedback from patients suggests that in an acute phase of an episode of LBP, patients are interested in their physiological and survival needs being satisfied, i.e. having their basic needs met. Unable to do this themselves, they tum to the health professionals for help. The research team would have included topics much higher up the hierarchy in the leaflet, based on the assumption that the basic needs have already been met. For instance: achievement of independence, ability to meet one's own need, etc. These perhaps become more of a priority when the acute episode is over. We subsequently designed a 12-page draft leaflet, based on the clients' identified needs, and
piloted the draft leaflet. Physiotherapists, and clients attending a back school in the area (n = 35) completed a 'Tell us what you think' questionnaire to gauge their impression of the leaflet. Most people found the page size convenient (1/3 A3); the wording easy to read and the pictures helpful in illustrating the information. However, the print size (10 point font) was described as too small by over half of the respondents. The leaflet was revised based on their answers. We also considered those factors found by reseach in the literature to help with reading and understanding. Only two other leaflets have been described in the literature relating to the management of LBP [11,12], but this is the first leaflet that has had extensive testing to find out what patients felt necessary to include. The results highlight the importance of establishing the patients' priorities in designing educational material for them. The study into the effectiveness of the leaflet in the management of patients with acute LBP is currently continuing as a Randomised Controlled Trial in Southampton and the New Forest area, and will be complete in 1997. References [1] Quebec Task Force on Spinal Disorders. Scientific approach to the assessment and management of activityrelated spinal disorders. Spine 1987;12:S9-S59. [2] Bartlet EE. Putting patient education back into control. Patient Educ Couns 1990;16:185-'186. [3] Hirano PC, Laurent DD, Lorig KR. Arthritis patient education studies 1987-1992. A review of the literature. Patient Educ Couns 1994;24:9-54. [4] Brody DS. An analysis of patient recall of their therapeutic regimens. J Chron Dis 1980;33:57-63. [5] Skelton AM, Murphy EA. Murphy RJL, O'Dowd TC. Patient education for low back pain in general practice. Patient Educ Couns 1995;25:329-334. [6] Meuwissen JHJM. Patient education by physicians: a new Dutch approach. Patient Educ Couns 1994;23:69-71. [7] Petterson T. How readable are the hospital information leaflets available to elderly patients? Age and Ageing 1994;23:14--16. [8] Green LW, Kreuter MW, Deeds SG, Partridge KB. Health education planning: a diagnostic approach. Palo Alto, California: Mayfield Publ., 1980. [9] Jenny J. A future perspective on patient/health education in Canada. J Adv Nurs 1993;18:1408-1414.
J.A. Chapman et al. / Journal of Back and Musculoskeletal Rehabilitation 9 (1997) 61-63
[10] Maslow A. Motivation and personality. New York: Harper and Row, 1970. [11] Roland M, Dixon M. Randomized controlled tial of an educational booklet for patients presenting with back pain in general practice. J R Coli Gen Pract 1989;39:244-246.
63
[12] Waddell G, Burton K, Roland M et al. Preliminary evaluation of a new 'Back Book'. Presented at the Society for Back Pain Research. Spring Meeting, March 1996.
