Ampiah, Paapa Kwesi
(2023)
A physiotherapist-led biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana: a mixed-methods feasibility study.
PhD thesis, University of Nottingham.
Abstract
Background
Low back pain (LBP) is a common musculoskeletal disorder which causes substantial years lived with disability globally and in Sub-Saharan Africa. The biopsychosocial (BPS) model of management has been recommended in national and international practice guidelines for the management of chronic low back pain (CLBP) and has also demonstrated to be effective in clinical research. However, this clinical research has been predominantly delivered in high income countries (HICs), although evidence suggests that the prevalence of LBP is substantially higher in low- and middle-income countries (LMICs) especially in Africa (39%; 95% CI 30 – 47). Understanding the effectiveness of BPS interventions in LMICs especially in Africa is a very underexplored area, with substantial inequity between research from HICs and LMICs. Ghana is a LMIC where the effectiveness of BPS interventions for the management of CLBP has been underexplored. The aim of this PhD was therefore to establish the feasibility of delivering a physiotherapist-led BPS programme for the management of patients with CLBP in a Ghanaian context.
Philosophical paradigm: This study applied a critical realism paradigm for the purpose of understanding research phenomenon by their causal mechanisms. Methodology: A mixed-methods methodology was applied with the rationale of achieving the depth and breadth of corroboration and understanding from quantitative and qualitative data. Theoretical framework: Normalisation process theory (NPT) was applied as a theoretical framework to identify, characterize, and explain the important mechanisms that are barriers or facilitators to the successful delivery of the BPS intervention. Methods: The aim of this study was achieved through two interlinked research components. • A systematic review to explore the operationalisation of BPS interventions for the management of chronic musculoskeletal pain in LMICs and inform the development of the BPS intervention applied in this study. • A mixed-methods, sequential, feasibility, pretest-posttest quasi-experimental study to investigate the feasibility of delivering the BPS intervention.
This study was conducted in a teaching hospital in Ghana involving 30 recruited patients with CLBP and 2 physiotherapists. Feasibility outcomes regarding management (for example, intervention fidelity) and processes (for example, recruitment rate, retention rate, data completion rate) were captured pre-intervention, post-intervention, and 3- iii months post intervention. Semi-structured interviews were conducted post-intervention to explore participants’ experiences with the BPS intervention. Patients’ demographics were collected at baseline. Patient reported outcome measures such as intensity of pain, disability, pain catastrophising, kinesiophobia, self-efficacy, and general quality of life, were collected pre-intervention, post-intervention and at 3-months follow-up. Thematic analysis was conducted to explore participants’ experiences and identify any barriers and facilitators to the delivery of the BPS intervention in a Ghanaian context.
Results: The results of the systematic review highlighted the potential to deliver BPS interventions in LMICs; however, the majority of studies (14 out of 20) were of low methodological quality. The results of the feasibility study demonstrated that the training programme was acceptable to physiotherapists. Recruitment rate (5 patient participants per week - 100% recruitment met), retention rate post-intervention (90%), data completion rate post-intervention (99.8%) and intervention fidelity (83.1%), all met feasibility thresholds. There were no adverse events. Thematic analysis of qualitative data identified 5 interlinked themes namely, structure and process of delivery; patients’ expectations; patients’ health beliefs, autonomy, and engagement; external influences; and personal and professional characteristics of physiotherapists. Qualitative data demonstrated that the BPS intervention was acceptable to physiotherapist and patient participants. The application of the constructs of NPT offered an understanding of the barriers and facilitators to the delivery of the BPS intervention and identified the mechanisms by which the delivery of the BPS intervention was possible in the study.
Conclusion: This PhD has established the potential to deliver a BPS intervention programme in a Ghanaian hospital setting. This BPS intervention therefore shows promise, and the result of the study provides a platform upon which further knowledge can be developed.
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