Occupational Medicine Advance Access originally published online on September 4, 2008
Occupational Medicine 2008 58(8):580-583; doi:10.1093/occmed/kqn116
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Short Reports |
Working Backs Project—implementing low back pain guidelines
1 School of Physiotherapy and Performance Science, Health Science Centre, University College Dublin, Dublin, Ireland
2 Occupational Health and Physiotherapy Departments, St Vincent’s University Hospital, Dublin, Ireland
Correspondence to: Caitriona G. Cunningham, UCD School of Physiotherapy and Performance Science, Health Sciences Centre, University College Dublin, Belfield, Dublin 4, Ireland. Tel: +353 1 7166512; fax: +353 17166501. e-mail: caitriona.g.cunningham{at}ucd.ie
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Abstract |
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Background The St Vincent's Working Backs Project (WBP) represents a strategy for the implementation of the UK Faculty of Occupational Medicine guidelines for the management of low back pain (LBP) in the workplace (Carter J, Birrell L. Occupational Health Guidelines for the Management of Low Back Pain at Work—Principal Recommendations. London: Faculty of Occupational Medicine, 2000).
Aim To evaluate the efficacy of the St Vincent's WBP.
Methods Questionnaire survey of staff and managers before and after the WBP intervention together with review of Occupational Health Department (OHD) data. The intervention included changes to LBP management pathways and protocols, combined with a guideline-based health promotion campaign. Outcomes included WBP awareness, LBP-related sickness absenteeism, staff back beliefs, intended management of LBP and manager attitudes towards LBP and it management.
Results Following the WBP intervention, 85% (n = 46) of managers and 57% (n = 124) of staff reported having heard of the WBP. LBP-related sickness absenteeism in the previous year had not decreased significantly (95% confidence interval: –0.03 to 0.06). Among staff, a mean improvement of 1.8 had occurred on the Back Beliefs Questionnaire score. More staff (36%) reported that they would try to stay active (P < 0.05) with LBP and would choose to attend the OHD if they required treatment. More managers demonstrated guideline-consistent attitudes.
Conclusions Following the WBP, staff and manager attitudes and beliefs towards LBP and its management were more consistent with the LBP guidelines although LBP-related sickness absenteeism did not decrease significantly. Future occupational guideline implementation strategy studies are required which should include a control worksite and rely on pre- and post-intervention organizational data.
Keywords Guideline implementation; low back pain; occupational health guidelines; workplace
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Introduction |
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Low back pain (LBP) is associated with major costs, in terms of health resource usage, worker disability and absenteeism [1] with LBP established as one of the most common causes of sick leave in the Western world [2,3].
The UK Faculty of Occupational Medicine (FOM) Occupational Guidelines for the Management of LBP in the Workplace were published in 2000 [4], with the purpose of facilitating the implementation of evidence-based LBP management in the workplace. Strategies for the implementation of such guidelines need to be evaluated [5]. In 2003, St Vincent's University Hospital, Dublin (SVUH) embarked on the Working Backs Project (WBP) to address the issue of LBP and related disability among all its workers (n = 2237). This project represents the first comprehensive organizational strategy for the implementation of the UK FOM Occupational LBP Guidelines.
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Methods |
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A pre- and post-intervention study design was utilized. A multidisciplinary WBP management team conducted an organizational needs assessment, which included a series of baseline surveys [6,7] and a review of LBP management structures and resources. This facilitated the development of a tailored study intervention package [8], which utilized a ‘health promotion in the workplace’ framework. This package included guideline-based line manager (n = 92), staff (n = 2237) and back clinician (n = 26) health promotion campaigns, distribution of the WBP booklet [8] to key stakeholders, establishment of an organizational LBP database and a clear LBP management pathway with early reporting and guideline-based clinical management. The WBP intervention was launched in June 2004 with post-intervention studies 2 years later.
At the time of this study, SVUH had a staff of 2237 from which disproportionate random samples were drawn for both pre- and post-intervention staff surveys. Based on standard power calculations, the statistical package for the social sciences (SPSS V 11.) was used to generate equal size, random samples of 80 from each of five occupational groups (administration, medical, general support, nursing and health professionals) giving two independent samples of 400 staff [6]. Ninety-two of the 208 line managers were randomly selected for the initial and repeat manager surveys [7].
Study outcomes included staff and managers' awareness of the new WBP services, number of staff on LBP-related sick leave and associated number of sick leave days in the previous year, staff and manager attitudes and beliefs regarding LBP including level of agreement with guideline-based statements and intended management and choice of health care practitioner for LBP. The Back Beliefs Questionnaire (BBQ), which has been found to have good internal consistency and test–retest reliability [9], was incorporated into the staff questionnaires. All survey data were entered onto SPSS (V.11). Data were analysed using descriptive statistics with chi-square and Fisher's exact tests utilized for subgroup comparisons of categorical variables. Mean BBQ scores were compared using an independent t-test and a Mann–Whitney test was used to examine for change in the median number of sick leave days.
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Results |
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Response rates for pre- and post-intervention staff surveys were 62% (n = 246) and 57% (n = 228), respectively. Thirty-one per cent of post-intervention respondents were male and 61% were manual handlers. Response rates for pre- and post-intervention manager surveys were 64% (n = 59) and 63% (n = 58), respectively, with 29% male respondents post-intervention. The gender and occupational group profile of respondents was similar for both the pre- and post-intervention staff and manager surveys.
Eighty-five per cent of managers and 57% of staff who responded to the repeat surveys reported having heard of the WBP. Awareness of the department to contact for LBP management was higher with 91% of managers and 88% of staff reporting that they would contact the Occupational Health Department (OHD) or the Physiotherapy Department.
The proportion of staff on LBP-related sick leave in the previous year showed a non-significant decrease from 9% (n = 21) to 7% (n = 16) (95% confidence interval (CI): 0.03 to 0.06). The median number of LBP-related sick leave days taken by staff showed a non-significant decrease from 5 to 3 days.
A significant improvement in BBQ scores occurred between successive staff surveys with a positive shift in mean score of 1.8 (P < 0.05, 95% CI: –3.0 to –0.66).
Following the WBP, fewer staff reported that they would resort to bed rest (P > 0.05) or seek treatment (P < 0.05) and an increased proportion of staff (36%) reported that they would try to stay active (P < 0.05), demonstrating a shift towards an evidence-based active, self-management approach (Table 1). The practitioners cited most frequently by staff for intended LBP treatment were their general practitioner (GP) and physiotherapist, but there was a significant increase in the proportion of staff who would attend OHD (Table 1). Overall, managers (n = 58) demonstrated a more positive evidence-based attitude towards LBP following the WBP (Table 2).
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Discussion |
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Following the WBP, attitudes and beliefs of staff and managers were more consistent with current evidence but further improvements are required. Despite the more positive beliefs post-WBP, LBP-related sickness absenteeism did not decrease significantly. The mean improvement in BBQ score was 1.8 close to Buchbinder's [10] change of 1.9 which in the case of that study coincided with a decrease in workers’ compensation claims.
This WBP ‘real world research’ presented a number of challenges many of which are likely to be encountered by others seeking to implement workplace guidelines. Pre- and post-intervention organizational data would have been preferable to survey data but were not available at the research worksite. The survey response rates were all <70% and therefore the issue of selection bias needs to be considered. The lack of a control worksite limits the interpretation of any changes which did occur. Given the multiple stakeholders who needed to be targeted and the level of staff turnover, greater resources than those available would have strengthened the health promotion campaigns.
As most workers reported an intention to attend their GP for LBP treatment, the WBP needs to target GPs more strongly. Future occupational guideline implementation strategy studies are required which should include a control worksite, involve GPs and rely on pre- and post-intervention organizational outcome data.
Key points
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None declared.
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References |
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- Carter J, Birrell L. Occupational Health Guidelines for the Management of Low Back Pain at Work—Principal Recommendations (2000) London: Faculty of Occupational Medicine.
- Staal JB, Hlobil H, van Tulder MW, et al. Occupational health guidelines for the management of low back pain: an international comparison. Occup Environ Med (2003) 60:618–626.
[Abstract/Free Full Text] - Cunningham C, Flynn T, Blake C. Low back pain and occupation among Irish health service workers. Occup Med (Lond) (2006) 56:447–454.[CrossRef][Medline]
- Cunningham C, Doody C, Blake C. Managing low back pain in the workplace: knowledge and attitudes of hospital managers. Occup Med (Lond) (2008) 58:282–288.[CrossRef][Medline]
- Cunningham C, Flynn T, Toole C, et al. St Vincent's University Hospital Working Backs Project (2006) Dublin, Ireland: Dublin University College.
- Symonds T, Burton A, Tillotson K, Main C. Do attitudes and beliefs influence work loss due to low back trouble? Occup Med (Lond) (1996) 46:25–32.[Medline]
- Buchbinder R, Jolley D, Wyatt M. Population based intervention to change back beliefs and disability: three part evaluation. Br Med J (2001) 322:1516–1520.
[Abstract/Free Full Text]
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