WHAT’S THE LOW BACK PAIN PROBLEM REPRESENTED TO BE? AN ANALYSIS OF DISCOURSE OF THE AUSTRALIAN POLICY DIRECTIVES

N. Costa¹, F. Blyth¹, S. Parambath¹, C. Huckel Schneider¹

¹The University of Sydney, Menzies Centre for Health Policy and Economics, Sydney, Australia

Background: Low back pain (LBP) is a major public health issue for the Australian healthcare system and elsewhere. To reduce the impact of LBP on both individuals and society and steer health systems towards increasing evidence-based care for LBP, policy makers, experts, clinical leaders and administrators have produced a range of directives about LBP. Such directives provide information about how LBP should be managed, communicated and navigated in a complex health system, making them an important form of policy.

Purpose: The aim of this study was to examine how LBP is problematised in Australian directives. We employed an analysis of discourse drawing on Bacchi’s‘What’s the problem represented to be?’'policy problematisation approach.

Methods: The analysis involved an iterative data examination process guided by Bacchi’s questions (e.g., What presuppositions or assumptions underlie this representation of the problem? What is left unproblematic about this problem representation? Can the problem be thought about differently?). NC, a physiotherapist with experience in discourse analysis, read and re-read all directives, writing notes on general impressions of the data set. On a second reading, NC manually and inductively coded each directive using NVivo, while drawing from Bacchi's questions to identify and scrutinise implicit problematisations surrounding LBP. Throughout the analysis, NC also wrote memo notes. The provisional discourses were then formulated based on all codes of the dataset, a mind-map and memo notes, and recorded in an Excel spreadsheet, along with excerpts representing each of the discourses identified. The directives, provisional discourses, excerpts, mind-map and memo notes were shared with the co-authors and discussed with them on two occasions. The final step of (re)writing the results was essential to the analytical process.

Results: Our analysis suggests that LBP is problematised as a paradox (paradoxical binary discourse), a symptom that tends to improve when individuals take responsibility for themselves, but may require care at times (tension between individual responsibility and provision of care discourse). We also identified silences in this problematisation, including the uncertainties related to scientific knowledge, paradigms other than (post)positivist, multimorbidity, social and structural determinants of health.

Conclusions: We argue that LBP directives may benefit from problematisations of LBP that consider the ongoing nature of LBP and broader contextual factors that are likely to impact on both LBP outcomes and care, beyond individual responsibility. LBP directives may also benefit from consideration of a wider range of paradigms and expanded evidence base, as these may enable individuals, clinicians and the healthcare systems to address LBP while dealing with its complexities, enabling changes in the real-world to lessen the LBP burden.

Implications: Physiotherapists who work with people who experience LBP may benefit from critically reflecting about discourses embedded in policy directives. We also argue that policy change processes may benefit from physiotherapists' engagement to expand the discourses on which LBP policy directives rely. Physiotherapists ability to enact policy recommendations may be enhanced by consideration of the fluctuating nature of LBP, uncertainties, multimorbidity and determinants of health.

Funding acknowledgements: This research is funded by the National Health and Medical Research Council of Australia grant APP1171459.

Keywords:
Low back pain
Policy analysis
Healthcare systems

Topics:
Globalisation: health systems, policies & strategies
Musculoskeletal: spine
Pain & pain management

Did this work require ethics approval? No

Reason: As stated above, this work addresses policy broadly and policy analysis and in the low back pain field specifically, hence why it did not require ethics approval.