ORIGINAL RESEARCH
Influence of self-management and self-management support on chronic low back pain patients in primary care Jennifer Kawi, PhD, MSN, APRN, FNP-BC (Assistant Professor) Department of Physiological Nursing, School of Nursing, University of Nevada, Las Vegas, Nevada
Keywords Low back pain; self-management; self-management support; functional ability. Correspondence Jennifer Kawi, PhD, MSN, APRN, FNP-BC, Department of Physiological Nursing, School of Nursing, University of Nevada, Las Vegas, 4505 Maryland Parkway, Las Vegas, NV 89154-3018. Tel: 702-895-5930; Fax: 702-895-4807; E-mail: [email protected] Received: 19 October 2012; accepted: 30 January 2013 doi: 10.1002/2327-6924.12117
Abstract Purpose: This study utilized a nonexperimental, cross-sectional, descriptive design to examine self-management (SM), self-management support (SMS), and other pain-related variables in chronic low back pain (CLBP), and described participants’ perceptions of their SM, SMS, and functional ablement. Data sources: Data were collected from 120 participants in four primary care clinics using survey measures. Conclusions: SMS was found to significantly influence SM and mental health. Overall health significantly influenced functional ablement and pain intensity. Participants described using medications, exercising, and making lifestyle changes as most common SM strategies. Prescribing medications, giving encouragement, and providing information were main participantperceived SMS activities. Depression and anxiety were key responses to perceptions on functional ablement. Implications for practice: Study findings increase our understanding of the SM, SMS, and functional ablement of CLBP patients with relevance to application in practice. There is a great need to develop evidence-based SM and SMS programs specific to CLBP patients’ needs. Nurses and nurse practitioners play major roles in leading this initiative. Study findings also reinforce the importance of psychologists and physical therapists’ collaboration in the complex care of CLBP. Longitudinal and experimental studies are recommended to evaluate SM and SMS programs that include physical therapy and psychological care components.
Approximately 116 million American adults are afflicted with chronic pain costing about $635 billion annually from healthcare treatments and lost productivity (Institute of Medicine [IOM], 2011). This translates to over $5,000 yearly for each chronic pain patient. The most common pain complaint is low back pain; 28.5% of those 18 years or over reported pain in the last 3 months (National Center for Health Statistics [NCHS], 2012) and back pain itself accounts for $100– 200 billion in healthcare costs annually (Freburger et al., 2009). Although healthcare costs have risen in attempts to manage CLBP, current modalities have demonstrated limited benefits (IOM, 2011). The persistence of chronic low back pain (CLBP) is related to several modifiable factors (i.e., low fitness level, inactive lifestyle, high di-
664
etary fats and carbohydrates, occupational risks, and cigarette smoking; National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMS], 2009). In effect, great interest has come about in the concepts of self-management (SM) and self-management support (SMS) to help address modifiable factors and enhance patients’ management of their chronic pain and functional ability. Studies on SM and SMS in other chronic illnesses have shown success in improving outcomes, including positive health-directed behaviors, more symptom-free days, and better quality of life (Agency for Healthcare Research and Quality, 2007). However, consensus on the current state of the science is lacking on SM and SMS of CLBP. Therefore, this study aimed to elucidate the influences of SM and SMS on patients with CLBP.
Journal of the American Association of Nurse Practitioners 26 (2014) 664–673 C 2014 American Association of Nurse Practitioners
Self-management on chronic low back pain
J. Kawi
Background About 80% of the U.S. population experiences low back pain during their lifetime (Hellman & Imboden, 2009). Some individuals will recover; unfortunately, about 20% of those with acute low back pain develop chronic pain (Weiner & Nordin, 2010). CLBP is pain that persists intermittently or continuously for at least 3 months (NIAMS, 2009). Consequently, estimates are that 49.5% of adults with low back pain suffer from limitations in functional ability and/or disability (NCHS, 2012). Pain-related conditions in arthritis and back problems are the top two causes of disability (Centers for Disease Control and Prevention, 2009). Nurses and healthcare professionals have a responsibility to assist patients in meeting their needs toward optimum health (Orem, 1991). A philosophical perspective of optimism in the term functional ablement is rendered in this research study recognizing that despite CLBP, there is potential to minimize disability and maximize functional ability. Functional ablement is defined as one’s capacity to function in response to stressors in the environment; it is the extent to which functional level is affected by disability as derived from Verbrugge and Jette’s (1994) disablement concept. The concept of SM is important in CLBP toward achieving functional ablement. SM refers to the performance of tasks and skills, including self-efficacy, to allow patients the capability to make decisions and engage in behaviors toward adequately managing their chronic illness (Lorig & Holman, 2003). While patients make choices in activating SM (Hibbard, Stockard, Mahoney, & Tusler, 2004), healthcare professionals have a responsibility to influence patient activation by supporting patients in their SM (Wagner et al., 2001). Therefore, it is essential to examine SM and SMS in patients with CLBP, especially in evaluating influences to key outcomes (functional ablement and pain intensity). Equally, mental health state is also a significant outcome that should be examined because of its impact on chronic pain and disability (Covington, 2007). SM programs have been found to positively influence common outcomes measured in CLBP, namely disability or function and pain intensity (Coudeyre et al., 2006; May, 2010; Schulz, Rubinell, & Hartung, 2007; Sokunbi, Cross, Watt, & Moore, 2010). However, some research studies noted contrasting effects on CLBP outcomes from SM strategies (Escolar-Reina et al., 2009; Haas et al., 2005; Oliviera et al., 2012). Hence, there is a strong need to investigate this further. Currently, there is a growing body of research on SM in CLBP patients. In evaluating patient SM experiences, findings showed that patients verbalized undergoing several unsuccessful pain management modal-
ities, but they also recognized their lack of adherence to advice and health-directed SM behaviors (Cooper, Smith, & Hancock, 2009; Liddle, Baxter, & Gracey, 2007; Townley et al., 2010). Poor adherence was related to lack of knowledge, symptom recurrence, and lack of precise diagnosis (Cooper et al., 2009; Liddle, Baxter et al., 2007). Patients also sought improved understanding from their healthcare professionals concerning the impact of CLBP (Liddle, Baxter et al., 2007; Townley et al., 2010). The necessity for SMS has been reinforced to enhance SM (May, 2010; Zufferey & Schulz, 2009). Further, a qualitative study conducted by Crowe, Whitehead, Gagan, Baxter, and Panckhurst (2010) found that common patient SM strategies were taking medications, exercising, and using heat application, while typical provider SMS roles were prescribing exercise and medications. In the area of SMS and CLBP, there is a dearth of empirical research. In a randomized controlled trial, the combination of advice and exercise were found to be effective SMS strategies to improve pain, function, and disability (Liddle, Gracey et al., 2007). Another randomized controlled trial showed that adherence to exercise was facilitated by supervised individualized exercise programs (Jordan, Holden, Mason, & Foster, 2010). Research on the concepts of SM and SMS on CLBP is insufficient and there remains an essential gap to be addressed to enhance the management of CLBP patients and potentially improve care outcomes. The Chronic Care Model serves as the theoretical guide for this research. This model specifies that when patients are activated (engaged in SM), and healthcare teams are prepared, proactive, and sustain a working partnership with patients (demonstrating SMS), then patient outcomes improve (Wagner et al., 2001). The following specific aims were designed for this research study: ■
■
■
To identify the level of SM, amount of perceived SMS, level of functional ablement, mean pain intensity, and mental health state in CLBP patients. To examine the influences of (a) perceived SMS on SM and (b) perceived SMS and SM on functional ablement, pain intensity, and mental health state, after controlling for potential demographical covariates (i.e., age, sex, ethnicity, race, educational level, income, duration of CLBP, overall health, social support, and number of medical conditions). To describe patients’ perceptions of their SM, SMS, and functional ablement.
Methods A nonexperimental, cross-sectional, descriptive design addressed the aims of this research study. A qualitative 665
Self-management on chronic low back pain
descriptive approach using qualitative content analysis was incorporated to increase insight into the study findings. Qualitative content analysis is a process of summarizing participant responses through coding and development of themes regarding phenomena using everyday language without representation of information (Sandelowski, 2000). Data were summarized staying close to the words of the participants without reinterpretation.
Settings and subjects This study was conducted in four primary care clinics in the state of Nevada. Inclusion criteria were patients in primary care clinics who were 18 years old and above having a provider-diagnosed nonmalignant CLBP. No exclusions were made based on gender, ethnicity, or other demographic variables. With power set at . 80 and alpha level at .01, the target sample size was 110 that included a 20% allowance in sampling in case of attrition or missing data. Through nonprobability convenience method, 120 participants were recruited successfully.
Ethical considerations and data collection This study commenced after obtaining approval from the University of Nevada, Las Vegas Institutional Review Board with permission from the designated representatives of the primary care clinics. During clinic visits, patients were asked if they were willing to take part in this research study. Informed written consent was given by all patients who decided to participate. There were no risks or adverse effects encountered during the study.
Measures A demographic survey and five self-report instruments were used in this study. One of the self-report instruments evaluated SM and SMS beliefs in relation to health behaviors based on other outcomes commonly seen in the literature specific to patients with CLBP (i.e., use of pain medications, number of healthcare professional visits, and level of physical activity). The other surveys were as follows: (a) short form of the Patient Activation Measure (PAM) to measure SM, (b) Patient Assessment of Chronic Illness Care (PACIC) to measure SMS, (c) Oswestry Disability Index (ODI) version 2.1a to measure functional ablement, and (d) Mental Health Inventory (MHI-5) to measure mental health state. PAM. The PAM evaluated SM knowledge, skills, and behaviors in managing chronic illnesses (Hibbard et al., 2004). This is a unidimensional, cumulative survey with 666
J. Kawi
a 4-point Likert scale structured in a hierarchical order of four developmental levels: (a) level 1 focuses on starting to take a role in SM, (b) level 2 includes building confidence and knowledge in SM, (c) level 3 involves taking action, and (d) level 4 (highest activation to SM) includes the ability to maintain health-directed behaviors and stay within course (Hibbard et al., 2004). The conceptual validation of PAM originated from a 22-item measure utilizing a psychometric method allowing the authors to identify the four levels from SM items. This resulted to fit values that indicated conformity of the items. Infit values ranged from 0.71 to 1.44 and outfit statistics from 0.80 to 1.34, supporting conformity of all the items in the measure. Stability was demonstrated in various self-rated health responses (0.87–0.91) and chronic conditions (0.90–0.91). To enhance feasibility, Hibbard et al. (2004) created the short form 13-item PAM that also demonstrated item conformity with infit values of 0.92–1.05 and outfit values of 0.85–1.11. PACIC. The PACIC measured patients’ viewpoints on the chronic illness care they received (Glasgow et al., 2005). It is composed of 20 items with a 5-point Likert scale asking SMS questions on patient activation, decision support, goal setting, problem solving, and followup, consistent with the Chronic Care Model. Content validity was supported using a national pool of experts in chronic illness care (Glasgow et al., 2005). Overall internal consistency was 0.93 with a median subscale alpha of 0.84 (range = 0.77–0.90). Overall test–retest reliability was 0.58 (range = 0.47–0.68). ODI. The ODI evaluated functional ablement or painrelated disability specific to low back pain patients (Fairbank & Pynsent, 2000). The ODI version 2.1a is composed of 10 sections with six statement options under each section. The sections include pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life (if applicable), social life, and traveling. Information is converted to quantitative data by summation (Fairbank & Pynsent, 2000). A test–retest reliability of r = 0.83 was reported by the authors with various published studies documenting internal consistency ranging from 0.71 to 0.87. MHI. MHI originated from the RAND Medical Outcomes Study: 36-Item Short Form Survey created as part of the national health insurance study (Veit & Ware, 1983). MHI-5 is a five-item questionnaire structured in a 6-point Likert scale evaluating positive and negative aspects of mental health state from psychological wellbeing to distress with questions inquiring about positive effect, anxiety, and depression. Overall reliability for the five items was 0.82, ranging from 0.66 to 0.90 (Berwick et al., 1991).
Self-management on chronic low back pain
J. Kawi
Lastly, three open-ended questions were included in the surveys to gather patient perceptions relevant to the aims of this study. The questions were as follows: ■ ■
■
What are ways you manage your CLBP? What are ways your healthcare professionals give you support in the management of your CLBP? What are your concerns about your functional ablement (ability)?
Data analysis Data were entered into a secured computer for analysis using the Statistical Package for the Social Sciences software. Data were analyzed using descriptive statistics and general linear modeling. Reliability coefficients for the four main measures in this study were (a) PAM (0.81), (b) PACIC (0.95), (c) ODI (0.87), and (d) MHI (0.75). Qualitative content analysis was used for the openended questions. This is the strategy of choice in qualitative description (Sandelowski, 2000).
Results Boxplots were examined across each of the four primary care sites for the PAM, PACIC, ODI, and MHI. The scores were within the interquartile range among sites and the medians were not demonstrably different. Given this, there was justification for combining the sites in the data analyses because the settings did not influence the outcomes. The demographic surveys are summarized and presented in Tables 1 and 2. Surveyed participants had a mean duration of 10.55 years of CLBP. They used a mean of 3.77 pain management modalities. For example, 60.8% used pain medications other than opioids (Carisoprodol, Gabapentin, NSAIDs, Acetaminophen), 52.5% used ice/heat packs, 46.7% noted that they exercised, 31.7% had interventional injections (i.e., steroid injections), 30.8% used opioids (i.e., Oxycodone, Hydrocodone, Tapentadol), 28.3% underwent physical therapy, 20% had chiropractic treatments, and 16.7% had surgery (i.e., laminectomy, fusion, kyphoplasty). Participants had a mean of four chronic illnesses other than CLBP. Most prevalent were arthritis (60%), chronic pain other than CLBP (57.5%), high blood pressure (51.7%), anxiety disorder (47.5%), and depression (43.3%). Lastly, 54.2% believed that if they managed their CLBP appropriately (SM), they would use less pain medications, 50.8% agreed that they would have less provider visits, and 60% felt their physical activity level would increase. Participants also noted that if their healthcare
Table 1 Demographic profile (N = 120) Total Demographic Variables
n
Percent
Gender Male Female
38 82
31.7 68.3
Marital Status Single Currently married Living with partner
73 32 15
60.8 26.7 12.5
Hispanic, Spanish, Latin origin Yes No
15 105
12.5 87.5
Race White/Caucasian Black/African American Hispanic Asian Native Hawaiian/Pacific Islander Other
39 59 9 5 1 7
32.5 49.2 7.5 4.2 0.8 5.8
Highest Grade Level Completed Less than high school graduate High school graduate to some college/trade College graduate or higher
18 83 19
15.0 69.2 15.8
Employment status Employed Unemployed Disabled, unable to work
37 30 53
30.8 25.0 44.2
Annual net household income
Influence of self-management and self-management support on chronic low back pain patients in primary care Jennifer Kawi, PhD, MSN, APRN, FNP-BC (Assistant Professor) Department of Physiological Nursing, School of Nursing, University of Nevada, Las Vegas, Nevada
Keywords Low back pain; self-management; self-management support; functional ability. Correspondence Jennifer Kawi, PhD, MSN, APRN, FNP-BC, Department of Physiological Nursing, School of Nursing, University of Nevada, Las Vegas, 4505 Maryland Parkway, Las Vegas, NV 89154-3018. Tel: 702-895-5930; Fax: 702-895-4807; E-mail: [email protected] Received: 19 October 2012; accepted: 30 January 2013 doi: 10.1002/2327-6924.12117
Abstract Purpose: This study utilized a nonexperimental, cross-sectional, descriptive design to examine self-management (SM), self-management support (SMS), and other pain-related variables in chronic low back pain (CLBP), and described participants’ perceptions of their SM, SMS, and functional ablement. Data sources: Data were collected from 120 participants in four primary care clinics using survey measures. Conclusions: SMS was found to significantly influence SM and mental health. Overall health significantly influenced functional ablement and pain intensity. Participants described using medications, exercising, and making lifestyle changes as most common SM strategies. Prescribing medications, giving encouragement, and providing information were main participantperceived SMS activities. Depression and anxiety were key responses to perceptions on functional ablement. Implications for practice: Study findings increase our understanding of the SM, SMS, and functional ablement of CLBP patients with relevance to application in practice. There is a great need to develop evidence-based SM and SMS programs specific to CLBP patients’ needs. Nurses and nurse practitioners play major roles in leading this initiative. Study findings also reinforce the importance of psychologists and physical therapists’ collaboration in the complex care of CLBP. Longitudinal and experimental studies are recommended to evaluate SM and SMS programs that include physical therapy and psychological care components.
Approximately 116 million American adults are afflicted with chronic pain costing about $635 billion annually from healthcare treatments and lost productivity (Institute of Medicine [IOM], 2011). This translates to over $5,000 yearly for each chronic pain patient. The most common pain complaint is low back pain; 28.5% of those 18 years or over reported pain in the last 3 months (National Center for Health Statistics [NCHS], 2012) and back pain itself accounts for $100– 200 billion in healthcare costs annually (Freburger et al., 2009). Although healthcare costs have risen in attempts to manage CLBP, current modalities have demonstrated limited benefits (IOM, 2011). The persistence of chronic low back pain (CLBP) is related to several modifiable factors (i.e., low fitness level, inactive lifestyle, high di-
664
etary fats and carbohydrates, occupational risks, and cigarette smoking; National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMS], 2009). In effect, great interest has come about in the concepts of self-management (SM) and self-management support (SMS) to help address modifiable factors and enhance patients’ management of their chronic pain and functional ability. Studies on SM and SMS in other chronic illnesses have shown success in improving outcomes, including positive health-directed behaviors, more symptom-free days, and better quality of life (Agency for Healthcare Research and Quality, 2007). However, consensus on the current state of the science is lacking on SM and SMS of CLBP. Therefore, this study aimed to elucidate the influences of SM and SMS on patients with CLBP.
Journal of the American Association of Nurse Practitioners 26 (2014) 664–673 C 2014 American Association of Nurse Practitioners
Self-management on chronic low back pain
J. Kawi
Background About 80% of the U.S. population experiences low back pain during their lifetime (Hellman & Imboden, 2009). Some individuals will recover; unfortunately, about 20% of those with acute low back pain develop chronic pain (Weiner & Nordin, 2010). CLBP is pain that persists intermittently or continuously for at least 3 months (NIAMS, 2009). Consequently, estimates are that 49.5% of adults with low back pain suffer from limitations in functional ability and/or disability (NCHS, 2012). Pain-related conditions in arthritis and back problems are the top two causes of disability (Centers for Disease Control and Prevention, 2009). Nurses and healthcare professionals have a responsibility to assist patients in meeting their needs toward optimum health (Orem, 1991). A philosophical perspective of optimism in the term functional ablement is rendered in this research study recognizing that despite CLBP, there is potential to minimize disability and maximize functional ability. Functional ablement is defined as one’s capacity to function in response to stressors in the environment; it is the extent to which functional level is affected by disability as derived from Verbrugge and Jette’s (1994) disablement concept. The concept of SM is important in CLBP toward achieving functional ablement. SM refers to the performance of tasks and skills, including self-efficacy, to allow patients the capability to make decisions and engage in behaviors toward adequately managing their chronic illness (Lorig & Holman, 2003). While patients make choices in activating SM (Hibbard, Stockard, Mahoney, & Tusler, 2004), healthcare professionals have a responsibility to influence patient activation by supporting patients in their SM (Wagner et al., 2001). Therefore, it is essential to examine SM and SMS in patients with CLBP, especially in evaluating influences to key outcomes (functional ablement and pain intensity). Equally, mental health state is also a significant outcome that should be examined because of its impact on chronic pain and disability (Covington, 2007). SM programs have been found to positively influence common outcomes measured in CLBP, namely disability or function and pain intensity (Coudeyre et al., 2006; May, 2010; Schulz, Rubinell, & Hartung, 2007; Sokunbi, Cross, Watt, & Moore, 2010). However, some research studies noted contrasting effects on CLBP outcomes from SM strategies (Escolar-Reina et al., 2009; Haas et al., 2005; Oliviera et al., 2012). Hence, there is a strong need to investigate this further. Currently, there is a growing body of research on SM in CLBP patients. In evaluating patient SM experiences, findings showed that patients verbalized undergoing several unsuccessful pain management modal-
ities, but they also recognized their lack of adherence to advice and health-directed SM behaviors (Cooper, Smith, & Hancock, 2009; Liddle, Baxter, & Gracey, 2007; Townley et al., 2010). Poor adherence was related to lack of knowledge, symptom recurrence, and lack of precise diagnosis (Cooper et al., 2009; Liddle, Baxter et al., 2007). Patients also sought improved understanding from their healthcare professionals concerning the impact of CLBP (Liddle, Baxter et al., 2007; Townley et al., 2010). The necessity for SMS has been reinforced to enhance SM (May, 2010; Zufferey & Schulz, 2009). Further, a qualitative study conducted by Crowe, Whitehead, Gagan, Baxter, and Panckhurst (2010) found that common patient SM strategies were taking medications, exercising, and using heat application, while typical provider SMS roles were prescribing exercise and medications. In the area of SMS and CLBP, there is a dearth of empirical research. In a randomized controlled trial, the combination of advice and exercise were found to be effective SMS strategies to improve pain, function, and disability (Liddle, Gracey et al., 2007). Another randomized controlled trial showed that adherence to exercise was facilitated by supervised individualized exercise programs (Jordan, Holden, Mason, & Foster, 2010). Research on the concepts of SM and SMS on CLBP is insufficient and there remains an essential gap to be addressed to enhance the management of CLBP patients and potentially improve care outcomes. The Chronic Care Model serves as the theoretical guide for this research. This model specifies that when patients are activated (engaged in SM), and healthcare teams are prepared, proactive, and sustain a working partnership with patients (demonstrating SMS), then patient outcomes improve (Wagner et al., 2001). The following specific aims were designed for this research study: ■
■
■
To identify the level of SM, amount of perceived SMS, level of functional ablement, mean pain intensity, and mental health state in CLBP patients. To examine the influences of (a) perceived SMS on SM and (b) perceived SMS and SM on functional ablement, pain intensity, and mental health state, after controlling for potential demographical covariates (i.e., age, sex, ethnicity, race, educational level, income, duration of CLBP, overall health, social support, and number of medical conditions). To describe patients’ perceptions of their SM, SMS, and functional ablement.
Methods A nonexperimental, cross-sectional, descriptive design addressed the aims of this research study. A qualitative 665
Self-management on chronic low back pain
descriptive approach using qualitative content analysis was incorporated to increase insight into the study findings. Qualitative content analysis is a process of summarizing participant responses through coding and development of themes regarding phenomena using everyday language without representation of information (Sandelowski, 2000). Data were summarized staying close to the words of the participants without reinterpretation.
Settings and subjects This study was conducted in four primary care clinics in the state of Nevada. Inclusion criteria were patients in primary care clinics who were 18 years old and above having a provider-diagnosed nonmalignant CLBP. No exclusions were made based on gender, ethnicity, or other demographic variables. With power set at . 80 and alpha level at .01, the target sample size was 110 that included a 20% allowance in sampling in case of attrition or missing data. Through nonprobability convenience method, 120 participants were recruited successfully.
Ethical considerations and data collection This study commenced after obtaining approval from the University of Nevada, Las Vegas Institutional Review Board with permission from the designated representatives of the primary care clinics. During clinic visits, patients were asked if they were willing to take part in this research study. Informed written consent was given by all patients who decided to participate. There were no risks or adverse effects encountered during the study.
Measures A demographic survey and five self-report instruments were used in this study. One of the self-report instruments evaluated SM and SMS beliefs in relation to health behaviors based on other outcomes commonly seen in the literature specific to patients with CLBP (i.e., use of pain medications, number of healthcare professional visits, and level of physical activity). The other surveys were as follows: (a) short form of the Patient Activation Measure (PAM) to measure SM, (b) Patient Assessment of Chronic Illness Care (PACIC) to measure SMS, (c) Oswestry Disability Index (ODI) version 2.1a to measure functional ablement, and (d) Mental Health Inventory (MHI-5) to measure mental health state. PAM. The PAM evaluated SM knowledge, skills, and behaviors in managing chronic illnesses (Hibbard et al., 2004). This is a unidimensional, cumulative survey with 666
J. Kawi
a 4-point Likert scale structured in a hierarchical order of four developmental levels: (a) level 1 focuses on starting to take a role in SM, (b) level 2 includes building confidence and knowledge in SM, (c) level 3 involves taking action, and (d) level 4 (highest activation to SM) includes the ability to maintain health-directed behaviors and stay within course (Hibbard et al., 2004). The conceptual validation of PAM originated from a 22-item measure utilizing a psychometric method allowing the authors to identify the four levels from SM items. This resulted to fit values that indicated conformity of the items. Infit values ranged from 0.71 to 1.44 and outfit statistics from 0.80 to 1.34, supporting conformity of all the items in the measure. Stability was demonstrated in various self-rated health responses (0.87–0.91) and chronic conditions (0.90–0.91). To enhance feasibility, Hibbard et al. (2004) created the short form 13-item PAM that also demonstrated item conformity with infit values of 0.92–1.05 and outfit values of 0.85–1.11. PACIC. The PACIC measured patients’ viewpoints on the chronic illness care they received (Glasgow et al., 2005). It is composed of 20 items with a 5-point Likert scale asking SMS questions on patient activation, decision support, goal setting, problem solving, and followup, consistent with the Chronic Care Model. Content validity was supported using a national pool of experts in chronic illness care (Glasgow et al., 2005). Overall internal consistency was 0.93 with a median subscale alpha of 0.84 (range = 0.77–0.90). Overall test–retest reliability was 0.58 (range = 0.47–0.68). ODI. The ODI evaluated functional ablement or painrelated disability specific to low back pain patients (Fairbank & Pynsent, 2000). The ODI version 2.1a is composed of 10 sections with six statement options under each section. The sections include pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life (if applicable), social life, and traveling. Information is converted to quantitative data by summation (Fairbank & Pynsent, 2000). A test–retest reliability of r = 0.83 was reported by the authors with various published studies documenting internal consistency ranging from 0.71 to 0.87. MHI. MHI originated from the RAND Medical Outcomes Study: 36-Item Short Form Survey created as part of the national health insurance study (Veit & Ware, 1983). MHI-5 is a five-item questionnaire structured in a 6-point Likert scale evaluating positive and negative aspects of mental health state from psychological wellbeing to distress with questions inquiring about positive effect, anxiety, and depression. Overall reliability for the five items was 0.82, ranging from 0.66 to 0.90 (Berwick et al., 1991).
Self-management on chronic low back pain
J. Kawi
Lastly, three open-ended questions were included in the surveys to gather patient perceptions relevant to the aims of this study. The questions were as follows: ■ ■
■
What are ways you manage your CLBP? What are ways your healthcare professionals give you support in the management of your CLBP? What are your concerns about your functional ablement (ability)?
Data analysis Data were entered into a secured computer for analysis using the Statistical Package for the Social Sciences software. Data were analyzed using descriptive statistics and general linear modeling. Reliability coefficients for the four main measures in this study were (a) PAM (0.81), (b) PACIC (0.95), (c) ODI (0.87), and (d) MHI (0.75). Qualitative content analysis was used for the openended questions. This is the strategy of choice in qualitative description (Sandelowski, 2000).
Results Boxplots were examined across each of the four primary care sites for the PAM, PACIC, ODI, and MHI. The scores were within the interquartile range among sites and the medians were not demonstrably different. Given this, there was justification for combining the sites in the data analyses because the settings did not influence the outcomes. The demographic surveys are summarized and presented in Tables 1 and 2. Surveyed participants had a mean duration of 10.55 years of CLBP. They used a mean of 3.77 pain management modalities. For example, 60.8% used pain medications other than opioids (Carisoprodol, Gabapentin, NSAIDs, Acetaminophen), 52.5% used ice/heat packs, 46.7% noted that they exercised, 31.7% had interventional injections (i.e., steroid injections), 30.8% used opioids (i.e., Oxycodone, Hydrocodone, Tapentadol), 28.3% underwent physical therapy, 20% had chiropractic treatments, and 16.7% had surgery (i.e., laminectomy, fusion, kyphoplasty). Participants had a mean of four chronic illnesses other than CLBP. Most prevalent were arthritis (60%), chronic pain other than CLBP (57.5%), high blood pressure (51.7%), anxiety disorder (47.5%), and depression (43.3%). Lastly, 54.2% believed that if they managed their CLBP appropriately (SM), they would use less pain medications, 50.8% agreed that they would have less provider visits, and 60% felt their physical activity level would increase. Participants also noted that if their healthcare
Table 1 Demographic profile (N = 120) Total Demographic Variables
n
Percent
Gender Male Female
38 82
31.7 68.3
Marital Status Single Currently married Living with partner
73 32 15
60.8 26.7 12.5
Hispanic, Spanish, Latin origin Yes No
15 105
12.5 87.5
Race White/Caucasian Black/African American Hispanic Asian Native Hawaiian/Pacific Islander Other
39 59 9 5 1 7
32.5 49.2 7.5 4.2 0.8 5.8
Highest Grade Level Completed Less than high school graduate High school graduate to some college/trade College graduate or higher
18 83 19
15.0 69.2 15.8
Employment status Employed Unemployed Disabled, unable to work
37 30 53
30.8 25.0 44.2
Annual net household income
