Generalized attitudes regarding responsibility for musculoskeletal disorders
The issue of responsibility for an individual's health or illness has no definite answers but many viewpoints. Many patients and most physicians behave as though doctors have the primary responsibility. Others strongly believe that the ultimate responsibility for health lies or should lie firmly with the individual. Still others believe that no one is ultimately responsible for health or illness [16
A majority of the participants in the present study had internal views regarding responsibility for musculoskeletal disorders, i.e. they thought that they themselves should take responsibility and not place responsibility in the hands of employers or consider the matter to be out of their hands. As the dimensions provide information on separate but closely related constructs an overlap could be expected. An individual who shows internal view regarding out of my hands probably also does so in the other externally directed dimensions as well, but as the dimensions were not highly correlated we found it valuable to report results for the dimensions separately.
That the investigated sample showed internal views could be seen as a positive result, encouraging for public musculoskeletal health interventions. The findings are also consistent with those of Jamison (2000) [6
]. That many people expressed the attitude of shared responsibility between themselves and medical professionals can also be considered positive, as individuals who express the belief that their health is controllable are possibly the most adaptive. This belief could be particularly beneficial to those who must cope with a chronic illness [16
The investigated population probably would benefit from the treatments currently available for musculoskeletal disorders, as these usually include medical professionals involvement but also some degree of self-responsibility [17
]. Support has been found for the definition of compliance as an active, responsible process in which the patient works to maintain health in close collaboration with health care personnel [20
]. Internal scores in the "responsibility self-active" dimension and intermediate scores in the "responsibility (medical) professionals" dimension in the present study show that chances are good for such a process.
However, previous studies have shown that patients with chronic musculoskeletal pain with high agency orientation benefited more from a group learning program with regard to pain reduction and improved pain coping than did those patients with low agency orientation [21
]. Studies has also shown that people with weak beliefs in the controllability of their back problem were more likely to have poor clinical outcomes six months after they consulted their doctor [22
]. So, there still could be a need of identifying and better targeting psychosocial interventions at those who are at high risk of persistent pain, and are likely to respond better to interventions with a more cognitive-behavioural focus [23
Also in other fields relationships of attitudes and response to treatment have been found. Galgut and co-workers showed that subjects who perceived their susceptibility to disease as being influenced by powerful external factors or who believed that susceptibility could be controlled by their own actions responded more positively to a plaque control regime than those who considered susceptibility to disease an event of chance [24
Associations between attitudes towards responsibility for musculoskeletal disorders and background variables
The choice of using logistic regression was based on the fact that data were mainly on categorical level and the original scaling included too many levels for ordinal regression. A clinical interest in those with most external attitudes and as studies in other fields show that external attitude have associations to poorer health led to the decision of using the upper quartile as cut-off.
The main associations found were that physical inactivity, musculoskeletal disorder related sick leave and no education beyond compulsory level increased the odds of placing responsibility for musculoskeletal disorders externally.
That those with lower socio-economic status tend to have higher external scores, while people with higher socio-economic status and/or beneficial health behaviour, such as regular exercise, tend to have higher internal scores agrees with closely related research areas, such as health locus of control and coping [25
]. Since physical activity has been shown to be associated to low prevalence of musculoskeletal disorders [29
], one might expect people to be physically active to prevent disorders. However, the association between external attitude and physical inactivity as found in the present study suggests that ARM is a mediating variable. In other words, people who do not think they can influence their musculoskeletal disorders (external attitudes) might not bother to exercise.
An interesting finding in the present study was that people who had musculoskeletal disorder related sick leave had two to three times higher odds of scores in the most external group. This may to some degree be consistent with the work of Haldorsen et al. [30
] who found low scores on Internal Health Locus of Control Scale to be a dominant variable for those who did not return to work in a 12-month follow-up study. Millet and Sandberg [31
] also found that unemployed individuals with an internal orientation (locus of control) had much shorter periods of sick leave than individuals with an external orientation. What could be the rationale for this? Does sick leave lead to a more external approach to musculoskeletal disorders, or is there a higher probability to be on sick leave because of an external attitude? Do the disorder and its consequences force the individual towards externality? The present study can not answer these questions because no cause and effect relationships were studied. They are however of interest for future studies.
Association with gender was found only in the "responsibility employer" dimension. As the ARM instrument is quite new, it remains to be seen whether this result can be replicated. The results agree with those in the multidimensional health locus of control among New Zealand adolescents [32
], a Japanese cohort [27
] and in people at risk for coronary heart disease in Scotland [33
], but are contrary to patients with chronic fatigue syndrome, where gender related differences were not found [34
In the present study, elderly people most frequently attributed responsibility for musculoskeletal disorders to medical professionals. On the other hand, there was a negative association to scoring externally in the "responsibility self-active" dimension. This could be interpreted such that people place responsibility both on the medical professionals and on themselves. Healthy elderly people have been characterized by an internal health locus of control and high general self-efficacy, which somewhat supports our results [35
]. The combination of an external view of medical professionals' responsibility and internal view of self-active responsibility for musculoskeletal disorders might be the most responsive to health advice and education, similar to "believers in control" [16
The present study has provided some insight in where a general population place responsibility for musculoskeletal disorders. Previous studies have shown that attitudes and beliefs about how to manage musculoskeletal disorders, as for example low back pain, differ from stated official guidelines [7
] but there has been limited information about people's attitudes regarding the responsibility
of management of musculoskeletal disorders. Attitudes and behaviour in the matter of management [37
] are not easily changed but maybe associated background variables found in the present study can be helpful for more directed interventions in the population.
Although the number of respondents (61%) was not completely satisfying, the sample could be seen as fairly socio-demographically representative according to official municipal and national statistics. However, the category "middle-aged" was slightly over-represented. In this group musculoskeletal disorders are quite common, which may have led to a stronger interest in responding.
Even though the questionnaire had a simple yes/no format in questions about presence of musculoskeletal disorders and visits to care-providers, many of the respondents failed to answer these questions resulting in a large number of internal missing cases. However, comparisons between partial and full respondents showed significant differences in some of the background variables but since female sex, low education, inactivity and sick leave have been found to be associated with higher externality in the full analysis, we conclude that the partial respondents show similar associations (even though they can be shown on group level only).
How then, with knowledge of people's attitudes, can we best avoid or decrease the suffering and burden of musculoskeletal disorders? Payton and associates [39
] found that the general public needed much more information about what to expect of physical therapy. Patients need an individualised analysis of how they view their role in health care and instruction on how to assume greater responsibility for their care [39
]. Von Korff et al. (1997) presented a model where patients and care providers share goals, a sustained working relationship, mutual understanding of roles and responsibilities and requisite skills for carrying out these roles [40
]. A randomised trial of a cognitive-behavioural program for enhancing back pain self-care in a primary care setting showed that the self-care intervention led to significantly greater reductions in back-related worry and fear-avoidance beliefs than controls [5
]. Further research is needed to study timing and inclusion criteria for interventions that enhance self-care and affect patient outcomes.
Furthermore, we believe that information on perceptions of responsibility for musculoskeletal disorders could help in the development of personalized action plans to manage pain and to make them more specific in preventive care. Where attitudes differ between care providers and the general population, the options are to either go along with common attitudes or challenge them.
Horneij (2001) and co-workers explained their non significantly different results between two interventions such that, as the aetiology of musculoskeletal disorders is multifactorial, a combination of the two programs might be preferable [41
]. Perhaps a sub-categorisation, for example on the grounds of attitude, also could have improved the outcome. Haldorsen (2002) and co-workers questioned whether there is a right treatment for a particular patient group when they evaluated comparisons of ordinary treatment, light multidisciplinary treatment and extensive multidisciplinary treatment for long-term sick listed employees with musculoskeletal pain. Their conclusion was that multidisciplinary treatment was effective when given to those most likely to benefit from that treatment and that a simple screening instrument could be a useful clinical tool for allocating patients to the appropriate level of treatment [42
]. Another study showed that patients allocated to the intervention that they had expressed a preference for, had clinically important reductions in pain and disability [43
]. Smeets and co-workers found significant differences when they compared patients on waiting list with patients who received treatment (either cognitive-behavioural or physical rehabilitation or both) for chronic low back pain. However, no clinically relevant differences between the treatment groups were found [44
]. Would they have found a difference if they had screened for sub-groups? Would a screening instrument as the one described in Haldorsen's study [42
] or could perhaps the use of ARM and the information this study provides give guidance to who might benefit better from what?
It might be useful to further investigate who would take responsibility and benefit from, for example, community based musculoskeletal health interventions or self-care programs provided by a physiotherapist. Might it be that those with an external attitude towards responsibility for musculoskeletal disorders would be more likely to benefit from a structured and controlled intervention?
Research on beliefs about responsibility is needed, as there is little information on the benefits of different approaches in preventive care and treatment for musculoskeletal disorders. Beliefs about responsibility could possibly influence clinical practice, policy and funding in both treatment and research, which has been discussed previously in the area of substance use disorders [45
Future research should explore attitudes towards the responsibility for musculoskeletal disorders of health care providers, where Toombs (1987) described physicians and patients encountering the experience of illness from different "worlds" [46
]. Parental high concerns about illness and inadequate beliefs in antibiotics led to more physician consultations and prescriptions for children who had respiratory tract infections [47
]. Negative illness attitudes were also independently associated to more consultations in primary care over a 5-year period [48
]. A mismatch between professional and patient beliefs may be a partial explanation for the generally poor management of chronic musculoskeletal pain [4
]. Can intervention studies with an active approach towards agreement between the provider and patient as to the responsibility for musculoskeletal disorders affect rehabilitation outcome or reduce recurrences? Could an active cognitive approach towards a more internal attitude have such an effect? Future research should also address the need for a deeper understanding of how attitudes towards responsibility for musculoskeletal disorders are formed. How do people reason their allocation of responsibility for management of musculoskeletal disorders?