Knowledge, attitudes and beliefs on contributing factors among low back pain patients attending outpatient physiotherapy treatment in Malawi

Background Low back pain (LBP) affects many people globally. Its aetiology is not clear. Patients lack knowledge of its contributing factors and have negative perception about their LBP. This study aimed to identify knowledge, attitudes and beliefs regarding the perceived contributing factors to LBP among patients attending physiotherapy outpatient departments in Malawi. This information can possibly facilitate planning of a LBP education programme in Malawi. Methods A quantitative cross-sectional survey was conducted, using a six-part self-administered questionnaire with questions on demographic information, participants’ attitudes and beliefs regarding their LBP, knowledge about the course and causes of LBP, beliefs regarding nine contributing factors to LBP (identified in a Delphi study) and the sources of the participants’ knowledge. Data were analysed descriptively using the Statistical Package for Social Sciences (version 19.0). A Chi-square test was used to determine any association between variables (alpha 0.05). All ethical procedures were strictly followed. Results Most participants (186, 91.2 %) did not manage to answer all six questions regarding knowledge correctly and were regarded as ‘partially knowledgeable’ about the course and causes of LBP. More than half (67%) portrayed negative attitudes and beliefs about LBP in general. The findings also showed a statistically significant relationship between knowledge, attitudes and beliefs (p = 0.04). Conclusion This study highlighted that many patients with LBP in Malawi are not adequately knowledgeable about LBP and hold negative attitudes and beliefs regarding their LBP. Therefore, LBP management programmes in Malawi should include education programmes aimed at empowering patients with knowledge regarding LBP, as well as changing their negative attitudes and beliefs about their pain. Patients’ understanding of the cause and nature of their pain may enhance the achievement of treatment goals.


Introduction
Low back pain (LBP) has been reported as a worldwide health problem, affecting individuals physically, socio-economically and psychologically (Hoy et al. 2012;Manchikanti et al. 2014). Although most epidemiological studies on the prevalence of LBP have been conducted in developed countries (Bruce et al. 2004;Ghaffari et al. 2006), there is not much difference between the prevalence of LBP in developed and developing countries (Louw, Morris & Grimmer 2007). In developed countries, the lifetime prevalence is between 60% and 70% (WHO 2004). In Africa alone, it ranges between 28% and 74% and is most likely to increase globally in the next few years (Hoy et al. 2012;Louw et al. 2007).
The general public, including patients living with LBP, lack knowledge about the causes and contributing factors of LBP (Allock, Elkan & Williams 2007;Ng'uurah & Frantz 2006;Tavafian et al. 2004). This implies that during management of LBP, patients' knowledge, attitudes and beliefs about their pain should be identified and followed by education regarding their pain. In Malawi, LBP is one of the leading musculoskeletal conditions treated at hospital physiotherapy outpatients' departments. However, no information is available regarding patients' knowledge, attitudes and beliefs regarding their LBP. This study thus aimed to establish the knowledge (understanding), attitudes and beliefs regarding perceived contributing factors to LBP among patients seeking physiotherapy management for their LBP at health centres in Malawi.

Methods and materials
This study was conducted in the physiotherapy outpatient departments of Queen Elizabeth and Kamuzu Central hospitals in Malawi. A quantitative research design using a cross-sectional survey was used. Convenience sampling was used as the recruitment method with a self-administered questionnaire for data collection. The questionnaire consisted of six sections. In the first two sections, demographic and social data as well as information on the current state of participants' LBP was gathered. The third section, on the attitudes and beliefs regarding LBP, was based on the Back Beliefs Questionnaire (Symonds et al. 1996) and the Survey of Pain Attitude Questionnaire (Jensen et al. 1994). The fourth section, based on pertinent literature and the LBP Knowledge Questionnaire (Maciel et al. 2009), sought participants' knowledge and understanding of the course and causes of LBP in general. The fifth section of the questionnaire explored participants' beliefs regarding nine contributing factors to LBP. Firstly, a literature review was conducted to identify the contributing factors to LBP. Fifteen contributing factors were identified (Table 1). A Delphi method was then used to establish the most important contributing factors to LBP by seeking the opinion from a panel of experts (physiotherapists with more than 2 years of experience in the field of LBP). Twenty experts were identified and 15 agreed to participate. The Delphi method included three rounds (Custer, Scarcella & Stewart 1999). In the first round, the 15 contributing factors were sent to the experts and they were requested to add any other contributing factors. After the first round, a new list of 38 factors was compiled, which included the factors added by the experts (Table 2). In the second and third rounds, the experts were asked to rate the 38 factors on a four-point Likert scale ranging from 1 = 'not important' to 4 = 'very important'. Seventy per cent or higher agreement on an element was interpreted as an acceptable level of consensus (Hsu & Standford 2007). Factors rating 30% or less were eliminated from the list. All factors (nine in total) that were ranked 70% and above were identified and included  in the questionnaire (Table 3). The last section of the questionnaire identified the sources of the participants' knowledge and their views on their own LBP. The developed questionnaire was tested in a pilot study to determine the user-friendliness, the clarity of the instrument as well as time to complete the questionnaire (De Vos 2002). Ten patients with LBP participated in the pilot study and they were excluded from the main study. The pilot study revealed that a few questions were slightly unclear to the participants, because of the use of medical terminologies. The questions were revised and the modifications to those medical terms were made by replacing them with simple terms (Table 4).

Ethical consideration
Ethical clearance was obtained from the University of the Western Cape and the College of Medicine in Malawi with certificate numbers 10/9/22 and P.10/10/1005, respectively. Participants were informed regarding the study before participation and all participants signed informed consent.

Socio demographic characteristics
Two hundred and five participants were recruited, of whom 109 (53%) were women, with a mean age of 47.74 (± 13.29) years. Table 5 illustrates the socio demographic characteristics of the study sample.

Low back pain frequency and duration
The majority of the participants 99 (48.3%) reported that the pain was continuous, while 81 participants (39.5%) indicated that the LBP was episodic, and only 25 participants (12.2 %) reported a first-time (or once-off) episode of LBP.
Seventy-eight per cent of all participants reported LBP for more than 6 months, followed by 21 (10.2%) who reported LBP for 2-3 months and 24 (11.8%) reported pain for 1 month or less.

Attitudes and beliefs about their own low back pain
Twelve statements were provided in the questionnaire (Table 6), requiring participants to indicate from strongly disagree to strongly agree, their opinion regarding their own LBP. The majority of the participants, 190 (93%), reported fear of movement and activity avoidance because of their LBP, while 147 (72%) believed that their LBP eventually would prevent them from working and would remain with them for the rest of their lives. Thirty-three per cent of all participants demonstrated positive attitudes and beliefs on all statements but the majority of participants, 137 (66.8%), demonstrated negative attitudes and beliefs regarding their LBP.

Knowledge of the participants about the course and causes of low back pain
Participants were given a series of six questions to indicate their choices on the factors that possibly cause LBP ( Table 7). The majority of the participants, 186 (91.2%), were partially knowledgeable on the course and causes of LBP in general. Only 18 (8.8%) of them answered all questions correctly and were considered to be fully knowledgeable on the course and causes of LBP. Table 8 summarises the participants' knowledge on causes and contributing risk factors to LBP.

Attitudes and beliefs of contributing factors to their low back pain
The minimum level of consensus during the Delphi study was set at 70%. Nine contributing factors were ranked high by the experts and therefore included in the questionnaire of this study. Patients living with LBP were then requested to indicate their opinions regarding these nine factors, with the responses ranging from strongly disagree to strongly agree. The majority (86.3%) of the participants living with LBP agreed that all nine factors could contribute to the development and/or worsening of their LBP.

Sources of participants' knowledge of low back pain
The results demonstrated that more than half, 114 (55.6%), of the participants received information regarding their LBP from various sources, including medical officers, physiotherapists, books, Internet, media and schools. The predominant sources of information were medical officers, 38 (33.3%), and physiotherapists, 35 (30.7%). The information obtained was on self-care and the importance of exercises. Less than 1% received information only on contributing factors. Overall, 66 (57.9%) of the participants indicated that the information they received was completely understood by them, while 84 (73.7%) acknowledged that the information was useful to manage their LBP. A chi-squire test revealed a significant relationship between knowledge, attitudes and beliefs of the participants (p = 0.04).

Socio demographic characteristics and low back pain status of participants
The majority of the patients with LBP attending hospital physiotherapy outpatient departments in Malawi were middle-aged women, married, living in an urban area and had a primary level of education. Several population-based studies conducted in both Western and African countries reveal that women are more affected by LBP than men (Sikiru & Hanifa 2010). The female dominance in reported LBP could be because of the fact that women are more likely to seek healthcare for their pain than men and that women may have lower pain thresholds than men (Seotanto, Chung & Wong 2006). Almost half of the participants in our study reported living with chronic recurrent LBP.

Knowledge of low back pain
Patients with LBP tend to seek information regarding their pain from diverse sources. More than 50% of the participants reported having received information regarding their LBP from medical officers and physiotherapists. The information received included self-care and the importance of exercises for their LBP. Less than 1% received information on the contributing factors for LBP. This was also the case in the study by Tavafian et al. (2004). However, Ng'uurah andFrantz (2006) found that the main reasons for patients seeking healthcare are because of their pain experience as well as because of understanding the causes and available remedies for their pain (Ng'uurah & Frantz 2006). It is well known that patients rely on healthcare providers to understand the causes as well as to educate and advise them on possible management of their health problems (Foster et al. 2003). Therefore, Ng'uurah and Frantz (2006) advised that in order to avoid patients' misconceptions regarding their LBP, the information should be given in a form that patients can easily understand.
It is therefore essential for healthcare providers and other individuals who are involved in managing patients with LBP to identify the needs and the reasons for patients seeking health services (Nasser 2005). In the management of recurrent LBP, patients' knowledge regarding the source and mechanism of the pain is important in achieving better treatment outcomes (Ng'uurah & Frantz 2006;Tavafian et al. 2004).Our study results demonstrate that the majority of participants were partially knowledgeable on the course and causes of LBP. Ng'uurah and Frantz (2006) in their study conducted in Kenya also concluded that the majority of patients lacked knowledge regarding the causes and contributing factors for LBP. Similarly, Allock et al. (2007) and Mwilila (2008) found that the majority of patients did not understand the cause of their pain, and the main reason for them visiting healthcare providers was to be educated on the cause of their pain and to seek reassurance regarding the diagnosis and the role of the medication prescribed for their problem. Health education regarding patient's LBP should be included in the management programme of LBP. Tugwell et al. (2007) proposed that although patients are the experts of their experience of their own illness, they still need to be educated about their illness and its possible causes to enable them to make their own decisions regarding their health. Education has long been used in order to alleviate pain and reduce disability associated with LBP (Udermann et al. 2004). Many studies have examined the effect of education on pain and disability and reported excellent outcomes. The results show that the introduction of an individualised educational booklet on back biomechanics may result in decreased pain and frequency of LBP episodes in patients living with chronic LBP (Coudeyre et al. 2007;Dupeyron et al. 2011;Udermann et al. 2004).
Recent studies evaluated the use of neuroscience education in decreasing pain and disability among patients with LBP (Louw, Nijs & Puentedura 2017). Neuroscience education focuses on neurophysiology and the processing of pain (Louw et al. 2017). Studies that utilise neuroscience education have been shown to decrease fear and change patients' perception of their pain (Meeus et al. 2010;Ryan et al. 2010).
Providing patients with education on pain physiology assists in reconceptualising the concept of pain, enhances the patient's understanding of their chronic pain and limits the development of inappropriate pain cognitions and negative beliefs (Meeus et al. 2010). Furthermore, it decreases the fear of re-injury among patients, thus enhancing their physical performances (Ryan et al. 2010). A systematic review provided strong evidence for education on pain neuroscience, addressing pain, disability and physical performance in musculoskeletal pain, particularly spinal disorders (Louw et al. 2011). It is therefore clear that the available literature indicates that pain neurophysiology education should be included as part of the management of LBP.

Attitudes and beliefs regarding low back pain
Ascertaining the attitudes and beliefs patients may hold regarding their pain could facilitate the management of their pain (May 2007). The continuous fostering of negative attitudes and beliefs among patients living with LBP may hinder the achievement of the desired treatment outcomes (Symonds et al. 1996). This implies that changing attitudes and beliefs through education regarding the source and contributing factors to patients' pain could speed up recovery and enhance earlier return to functional activities (May 2007). The majority of participants in our study indicated negative attitudes and beliefs regarding their own LBP. Participants reported fear of movements and activity avoidance. Threequarters of the participants believed that their LBP would eventually prevent them from working and that it would remain for the rest of their lives. Darlow et al. (2014) found that the majority of patients believed that movements and physical activity could cause more harm to their LBP, resulting in avoiding certain activities. Hanney, Kolber and Beekhuizein (2008) and Linton, Vlaeyen and Ostelo (2002) indicated that negative beliefs among patients living with LBP may aggravate their pain, leading to functional limitations and chronic pain patterns. It is therefore important, during management of LBP, that patients' misconceptions regarding their pain be identified and addressed (Darlow et al. 2014).
LBP could occur as a result of many contributing factors and the debate in the literature regarding the exact causes or contributing factors to the occurrence of LBP is still inconclusive. However, both physical and psychosocial factors have been indicated as contributing factors to LBP (George et al. 2006;Heymans et al. 2010;Soucy et al. 2006). The majority of our participants strongly believed that all nine factors (identified in the Delphi study) could contribute to the development or maintenance of their LBP. Our participants strongly believed that factors including repetitive heavy lifting, physically demanding jobs, frequent twisting and bending of the spine and flexion combined with compressive forces to the lumbar spine, fear avoidance beliefs, injury to the back and previous history of LBP could contribute to the occurrence of LBP. Samad et al. (2010) found that factors such as repetitive heavy lifting, prolonged sitting and prolonged flexing of the spine were also indicated as potentially contributing to the occurrence of LBP. Fear avoidance beliefs and somatisation (feeling sick without an actual disease) may also increase the risk of pain chronicity, disability and abstinence from physical activities (George et al. 2006). Because the causes or contributing factors of LBP are several and seldom caused by a single factor (Adam 2009), patients may hold different perceptions regarding the causes of their LBP (Sarah 2000). Therefore, it is important for healthcare providers to identify patients' perceptions regarding the causes of their LBP because this could help to clear the misconceptions they may hold regarding their pain and could also positively influence their choice of taking up a particular type of treatment (Darlow et al. 2014;Linton, Helsing & Halden 1998).

Relationship between knowledge, attitudes and beliefs
A statistically significant relationship between knowledge, attitudes and beliefs was confirmed in our study. The knowledge, attitude and beliefs of patients regarding illness and pain are interrelated and inextricable (Bradley 1995). The author further alluded that it is difficult to make a distinction between knowledge and beliefs of the patient (Bradley 1995). Furthermore, Furinghetti and Pehkonen (2002) indicated that a belief is a prerequisite for knowledge and that there is a fine line between belief and knowledge. This implies that the knowledge of patients regarding their condition is linked with the beliefs they hold and their knowledge could influence these beliefs of their pain experience (Gbiri, Olawale & Obi 2015).

Conclusion
This study highlighted that many patients with LBP in Malawi are not adequately knowledgeable about LBP and hold negative attitudes and beliefs regarding their LBP. Even though no differentiation was made between the knowledge, attitude and beliefs of patients living with chronic versus recurrent LBP, it can be concluded that providing education to the patients regarding their LBP and especially pain neuroscience education may enhance their knowledge regarding LBP. Therefore, LBP management approaches in Malawi should include education programmes aimed at empowering patients with knowledge regarding LBP, its contributing factors as well as changing their negative attitudes and beliefs about their pain. Patients' understanding of the cause and nature of their pain may enhance the achievement of treatment goals.