To our knowledge this is the first study to utilise a quantitative tool to measure the broader elements of health literacy among community-dwelling individuals with CLBP and those with no history of LBP, and capture information which has predominantly been reported in qualitative investigations previously [21
]. No differences were observed between the groups on seven of the eight domains of the instrument. Nonetheless, individuals with CLBP clearly experienced more difficulty in managing their health; that is seeking and using
health information, within their current lifestyle (domain 1). These findings suggest that either overall personal management of health is the main health literacy area in which individuals with CLBP experience difficulty - a clinically important factor - or that the instrument was unable to detect other clinically important differences in health literacy between the groups.
Individuals are increasingly expected to take responsibility for their healthcare, particularly in the self-management of chronic conditions [10
], including pain syndromes [40
] and CLBP. Government policies and programmes are being developed and implemented to facilitate this process, particularly through models of care and models of health service delivery [41
], including frameworks for LBP [42
]. Although the reorientation of health services to support self-management is welcome, and based on evidence for the efficacy of self-management programmes for chronic conditions [44
], our data highlight a situation where those health consumers who have a chronic condition, in this case CLBP, report greater difficulty in engaging in positive health behaviours compared to those individuals without LBP. This observation underlines the importance of self-management support and enablers for health behaviour change directed towards individuals with CLBP. It is also consistent with direct reports from patients with CLBP [36
] and other musculoskeletal conditions [46
], and mirrors the importance of self-management support for other chronic conditions [10
Based on our data, individuals with CLBP had no greater difficulty in understanding health information (domain 2), engaging social support (domain 3), accessing healthcare (domain 4), accessing GP services (domain 5), communicating with health professionals (domain 6), being proactive (domain 7) or using health information (domain 8) than those individuals without LBP. Although our previous qualitative study highlighted that individuals with CLBP had difficulty in understanding anatomic and biomedical terms [21
], in the current study they reported no greater difficulty than controls in understanding general health information. The absence of a group difference in this domain is likely due to the HeLMS items relating to general health information, whereas responses collected in the qualitative study related to specific biomedical terms used by health practitioners. Consistent with findings in the current study, participants in our earlier qualitative study also revealed no particular difficulty in engaging social support, communicating with health professionals or being proactive [21
]. However, we did identify in the qualitative study that treatment costs were a barrier to utilising health information fully for individuals with CLBP [21
]. Data from the current study demonstrate no difference in the ability to access health services between people with and without LBP, suggesting the capacity to access healthcare is comparable between the groups studied. Consistent with a lower score for domain 1, the score for each item within this domain was significantly lower among individuals with CLBP. The increased difficulties in making time for personal healthcare, paying attention to health needs, finding energy to manage health and optimising lifestyle habits are analogous to qualitative findings we reported previously among individuals with CLBP in the context of utilising
health information [21
], and other reports [36
]. These also reflect barriers encountered by patients with other pain-related conditions such as rheumatoid arthritis [47
], osteoarthritis [48
] and spinal cord injury [49
]. In our earlier qualitative study we found that a combination of personal and societal factors hindered utilisation of health information. Specifically, lifestyle commitments such as family responsibilities were cited as reasons for not engaging in positive health behaviours, such as exercise programmes. Participants also reported in the qualitative study that they could not incorporate behaviour changes into their current lifestyle due to lack of time and being unable to prioritise their health over other commitments [21
The lower ability to engage in positive health behaviours by using health information among individuals with CLBP may represent an important factor in the aetiology or persistence of CLBP. For example, studies suggest that poor adherence to home exercise programmes, a key component of self-management for CLBP, mediates treatment efficacy for LBP [50
] and contributes to sub-optimal recovery [36
]. Suboptimal health behaviours may also relate to ineffective coping strategies for CLBP. A recent study identified that individuals with chronic pain who frequently used self-perceived ineffective coping strategies experienced more depression and pain-related anxiety compared to those who used effective coping strategies [52
]. The authors suggested that a perceived lack of effective coping precludes individuals from engaging in more positive health behaviours, thereby perpetuating a cycle of chronic pain, ineffective coping and emotional distress. We cannot comment with certainty whether the difficulties experienced by participants with CLBP are causative for their pain experience or reflect sequelae of the increased personal burden associated with the experience of CLBP.
It is well established that patient beliefs and attitudes drive behaviour [21
]. Therefore, efforts should be directed towards optimising LBP-related beliefs among individuals with CLBP in order to increase the likelihood of effective self-management behaviours. A range of factors influence self-management and health behaviour change including individual patient attributes, health professionals' beliefs and practice behaviours and health system functionality. Pain behaviours persist over time among individuals with CLBP, independent of pain severity and psychological factors, highlighting the difficulty in behaviour change and the need for a multifactorial approach [55
]. Health behaviour change may only be observed once an individual decides on a readiness for change, identifies the importance of change and has the confidence to make change, although these phases may be facilitated with particular consultation skills [56
]. Motivation and support from clinicians has been cited by patients with CLBP as critical to perseverance with self-management for CLBP [36
] and other conditions [46
]. Beliefs and attitudes held by clinicians are also critically important in a health behaviour change process [58
]. The reluctance of the clinical community to adopt a patient-centred approach to CLBP management within a biopsychosocial model of care [59
], consistent with best practice clinical guidelines, represents a key barrier to effective self-management and positive health behaviour change. At a system level, integration between health services, particularly in primary care, is also a critical element of health system reform needed to better support self-management in a flexible and patient-centred manner [39
The health literacy characteristics highlighted in this study represent important barriers to adoption of positive health behaviours among individuals with CLBP. Clinicians should be cognizant of these health literacy components when expecting patients to engage in an extensive self-management programme for CLBP, particularly when programmes demand a large time or financial investment. For example, specific questions could be posed within a consultation to elucidate any barriers to seeking, understanding and utilising health information. In the context of pain syndromes, the Pain Stages of Change Questionnaire may be an appropriate tool to assess the extent to which individuals accept responsibility to engage in self management of their pain [67
]. There is also evidence to suggest that self-management education for individuals with CLBP must be specific and individualised, rather than generic [68
], since self-management and coping behaviours differ between subgroups of patients with chronic pain [52
]. Successful implementation of health information into an individual's activities of daily living is likely to be contingent on personal attitudes towards their health in addition to family support, financial security and social support [10
]. Care providers should therefore consider exploring these issues when expecting patients to undertake lifestyle changes as part of an overall management approach. The HeLMS may be an appropriate instrument to use in this context.
Despite the poorer back pain beliefs of the responding controls compared to the non-responding controls, significant differences in HeLMS scores were identified between the control and CLBP groups, which further supports the findings in this study. In the absence of a responder bias more differences between the groups may have been identified. We did not observe a difference in BBQ scores between back pain groups in this study. Whilst this is consistent with a recent study examining back pain beliefs in community-dwelling women [70
], it is contrary to population-based surveys [71
]. Recent data highlight that BBQ scores are influenced by level of pain, level of disability and impact of pain [21
], and these factors may account for the absence of a group difference in this study.
Although we have reported statistically significant differences in HeLMS scores between the groups, the clinical significance remains uncertain. Future studies should establish the minimum clinically important difference (MCID) for the HeLMS domains and items. This would need to be explored across a range of normative and clinical populations. Further, this is the first time the questionnaire has been used in this setting and therefore a web of evidence is required before its utility can be judged fully. That is, further cohorts should be assessed with the HeLMS in order to assess consistency in any findings and aid in their interpretation. Although the response rate of this study was good (64-72%), the results should be interpreted within the context of some limitations. First, the study is limited by its cross-sectional design and relatively small sample resulting in power to only identify large effects. Second, our study population may not have been a truly representative sample of the Australian adult general population. The JSHS purposely recruited participants from the same middle-class geographical area, thereby minimising variability in socioeconomic status, an important correlate of health literacy [33
]. Therefore, future studies should examine the potentially mediating influence of socioeconomic status on HeLMS scores. Third, all participants were middle-aged and utilised the internet at home, both factors associated with better functional health literacy scores compared with advanced age and lack of home internet access [33
]. These factors were inclusion criteria for the JSHS. Fourth, all participants in the study were Australian residents and therefore health literacy characteristics should be interpreted within the context of the Australian primary health care setting.
Future studies should prospectively examine the effect of health literacy on the experience of back pain and determine whether the nature and history of the back pain experience, for example the duration, severity and particular functional impairments are related to particular health literacy skills and impairments. Difficulties experienced by individuals in the areas health attitudes and using health information should also be examined from a health provider perspective.