The present study has provided information about how patients with musculoskeletal disorders view responsibility for the management of musculoskeletal disorders.
In the standards of care for acute and chronic musculoskeletal pain document [3
], one of the objectives is to promote partnerships among the community, patients and clinicians in decision-making in relation to pain – its prevention and management. Partnership is also stressed as important by the informants in this study. The partnership can however be viewed from different aspects and levels. Partnership can occur on different structural levels such as community, society, health care and employer but the informants also described different views in this partnership. Some informants are without question taking on responsibility for management of the disorder. They believe that it is their responsibility to see to their own body in the best way and to get the right help at the right time. They can't rely on anyone else.
Others see this relationship as a collaborative process in which society, health care and employer and even the family are partners. Yet some express partnership by following what's recommended. The least active partnership for the individual in this matter is to be receiving. No doubt the individuals are experts of their own disorder but there is a need to balance professional knowledge with the individual's expertise. The different standpoints or attitudes taken by the patients require different strategies for health providers for successful management of the disorder.
The self-efficacy concept [11
] could be addressed related to the results of the present study. Cognitive, social, emotional and behavioural sub-skills capabilities must be coordinated and organised effectively to serve many purposes. Self-efficacy is not concerned with the number of skills a person has, but with what he believes he can do with what he has [12
]. In the category Taking on responsibility
, a high level of self-efficacy could be seen whereas in Disclaiming responsibility
, a low level of self-efficacy is shown as the patients want others to manage the disorder. Self-efficacy has been shown to be important in for example rehabilitation after anterior cruciate ligament injury [13
Taking an active approach towards health management is seen as beneficial. Those who take an active part are more likely to follow treatment regimes. Passive patients may be less likely to have help from others and may be predisposed to sickness to start with. Ironically patients who, on the surface seem to be adjusted or compliant, but are adjusted in a passive way are more likely to be ill at follow up [14
One might relate the taken attitude of responsibility to coping style. Lazarus's stress and coping model defined coping as "constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person" [15
]. Two major types of coping were proposed; the problem-focused coping which includes efforts directed at controlling or changing the sources of the stress (here as ways of handling the problem that causes disorders) and emotion-focused coping strategies which are attempts at managing emotional responses to the stressor (strategies for handling for example fears due to the disorder). As coping attempts to diminish the physical, emotional, and psychological burden of the disorder both problem and emotion-focused coping may play a part in the response [15
Brown and Nicassio [16
] further conceptualize coping as active or passive in nature. Active coping was referred to as adaptive strategies used by the individual to control a disorder. On the contrary, passive coping used strategies that gave control of disorder management to others or as acceptance of restrictions in life [16
]. Frequent use of passive coping strategies in high pain could contribute to higher levels of depression over time [17
]. Taking active responsibility might reduce the risk of disability due to the disorders. A systematic review by Pincus and coworkers [18
] in low back pain which investigated cognitive risk factors for disability, passive coping strategies were risk factors for an unfavourable outcome.
The present study's categories Taking on responsibility, Ambiguity about responsibility and Collaborating responsibility could be related to the description of active coping and patients with musculoskeletal disorder might benefit from these taken attitudes for a favourable management. Whilst still taking responsibility but perhaps in a more passive coping way the category Complying with recommendations could be seen. The categories Disclaiming responsibility and Responsibility irrelevant might be seen as related to the possible adoption of passive coping styles.
Another closely related construct and to which the present study's results could be related is internal and external health locus of control, the concept of people having different ways of ascribing responsibility and causality in their lives. This concept was originally developed by Julian Rotter in the 1960s [19
] and originally regarded internal and external locus of control of reinforcement, but has been used widely in health-specific instruments such as the Multidimensional Health Locus of Control Scales (MHLC) [20
]. Those with an internal locus of control see themselves responsible for the outcomes of their own actions. Someone with an external locus of control sees environmental causes and situational factors as being more important than internal ones.
Larsson and Nordholm [21
] further developed these ideas of responsibility to a musculoskeletal specific instrument and in a study of a general population, it was investigated where
people placed responsibility for musculoskeletal disorder [5
]. The present study has explored and described how
these attitudes might be taken, how it can be explained, what rationales lay behind a taken attitude. In contribution to what is already known about attitudes and how they might affect management of musculoskeletal disorders, the information provided in the present study could help with how to approach and meet different taken attitudes.
The researchers of this study were not the patients' clinicians nor did they work at the departments from which the informants were recruited (the interviewer (MEHL) worked at one of the departments more than five years ago), so the interviewer was not known to the patients. The interviewer presented herself as a PhD student and did not state medical profession. This approach was used to avoid the interviewer's profession influencing responses. However, some of the informants asked about the interviewer's profession (physiotherapist). Usually this question was posed after the interview but some did ask before the interview started or somewhere in the middle of it. The possibility that this might have affected the responses due to social desirability may not be able to be disregarded. Neither were the patients in the study asked whether they were self-referred or physician-referred to treatment, which might represent differences in their views.
Also, one must reflect on the researchers' possible influence in formulation of the research question, in data collection and of course in the interpretation. The research question was mainly grounded in clinical empirical work but also based on previous studies in the area [5
]. The data collection was made through strategic sample [6
], but it was to a certain degree also a convenient sample by the chosen geographical area. The area is located in the vicinity of Gothenburg (which is the second largest city of Sweden) and includes a mix of both rural and urban districts, with a proportion of people commuting to the metropolitan area but not living there. The issue of generalizability is in qualitative research usually addressed as transferability, which represents the possibility of transferring the results in a study to other settings or groups [23
]. It is an empirical matter depending on the similarity between the sending and receiving context. As the present study was performed in Sweden, which still mainly has a socialized health care system although an increasing number of private health providers, one may wonder if informants in for example the U.S. would hold a different view on responsibility? To provide empirical evidence of possibly contextual similarity, descriptions of both the clinical setting and the chosen geographical area were given [7
]. One can always also discuss whether 20 individuals can be representative for a population, which leads us to the question of confirmability i.e. the degree to which results can be confirmed by others. The results of the present study, have somewhat verified what was found in a study of a general population on how attitudes were placed [5
]. But the present sample of 20 individuals did not allow us to make comparisons due to socio-demographic variables which was shown by Larsson and Nordholm in a previous study [5
]. Whether the results can be confirmed and are of direct use for the clinic and in other settings or countries still needs to be explored.
One can also speculate about the problem of selection bias of informants as these were recruited by their clinician. Maybe the clinicians recruited the most satisfied patients? This problem was addressed by explicitly explaining to the clinicians that it was not the treatment that was to be evaluated, but patient experiences, with no regard to outcome of treatment.
Working as a physiotherapist for more then ten years will naturally influence beliefs about musculoskeletal disorders and about patients suffering from these disorders even when taking on the role as a researcher. Therefore, it was a strength and advantage for the present study to have two co-researchers from different occupations (nurse, psychologist) and research areas (diabetes, social psychology) when interpreting the results.
Studies have shown that there are disparate attitudes regarding self-responsibility and coping with pain between health care staff and patients where health care staff rated self-responsibility of higher importance for recovery from a work place injury than the patients did [25
]. It has also been shown that clinicians might underestimate patients' willingness to take on own responsibility and may overlook an opportunity to promote health [26
]. For prevention of recurrent musculoskeletal pain allowing the individual to take responsibility for care with continued support from the family and the physician as well as the employer and other people involved in the process is desired [3