Ampiah, Josephine Ahenkorah
(2022)
Chronic low back pain: a representation of liminality in illness identity and professional identity.
PhD thesis, University of Nottingham.
Abstract
Background: Chronic low back pain (CLBP) accounts for most of the negative consequences associated with low back pain (disability, costs, productivity). Certain risk factors, particularly pain beliefs, facilitate the occurrence and progression of CLBP. Patients’ beliefs may be influenced by healthcare professionals’ (HCPs’) beliefs and the sociocultural context. HCPs’ beliefs are critical to the uptake of recommended biopsychosocial approaches for CLBP. However, the beliefs of Ghanaian patients and HCPs are unknown. Therefore, this research explored patients’ and HCPs’ CLBP beliefs and how these affected CLBP management in Ghana.
Methodology/Methods: A Straussian grounded theory situated within a critical realist philosophy underpinned this research. This facilitated understanding the beliefs, agencies and structures embedded within the management pathways for CLBP in Ghana. Data was collected from physiotherapists, doctors, and patients (n=63) using semi-structured interviews. The study settings were two teaching hospitals in Ghana.
Results: The interpretative frameworks for this study were drawn from Charmaz’s (1995) work on illness identity and Tajfel and Turner’s (1979) and Turner et al.’s (1987) work on social identity approach (SIA). Identity was the derived core category, with illness identity and professional identity as sub core-categories. This study proposed the illness identity state, liminality (Turner, 1967), to explain the protracted states of rejection and engulfment, and the limited acceptance and enrichment recorded. Rejection, engulfment and liminality were fostered by patients’ and HCPs’ bio-medical/mechanical beliefs, maladaptive beliefs/behaviours and the psychosocial impact of CLBP. Acceptance was facilitated by patients themselves. Foucault’s (1979) theory on panoptic surveillance provided an explanatory framework for the ‘power’ of HCPs, evidenced in their significant influence on rejection, engulfment and liminality in this study. HCPs’ beliefs were mostly influenced by their professional identities (described in terms of paternalistic and bio-medical/mechanical care). Socialization at work was identified as the major intragroup dynamic within doctors and physiotherapists, influencing their practices. Intergroup dynamics identified between doctors and physiotherapists were medical dominance (explored using Freidson 1970), the referral pattern of ‘specialist before physiotherapist’ and limited appreciation of the roles of other HCPs.
Conclusion: The dominant maladaptive illness identity states, bio-medical/mechanical framework and limited collaboration identified in this study highlights the need for evidence-based practice, interprofessional working, biopsychosocial model, patient empowerment and increased professional autonomy for physiotherapists.
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