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Association Between Beliefs and Care-Seeking Behavior for Low Back Pain

Mannion, Anne F., PhD*; Wieser, Simon, PhD; Elfering, Achim, PhD

doi: 10.1097/BRS.0b013e31828473b5

Study Design. Cross sectional population-based survey.

Objective. To investigate the relationship between low back pain (LBP) beliefs and care seeking in LBP.

Summary of Background Data. Not all people experiencing LBP seek care for their problem. Consistent predictors of care-seeking behavior seem to be female sex and high perceived disability; the role of beliefs about LBP has not been investigated sufficiently.

Methods. A questionnaire booklet was mailed to a random sample of 2860 individuals otherwise participating in an epidemiological study of musculoskeletal health. It contained the Back Beliefs Questionnaire (BBQ), the Fear-Avoidance Beliefs Questionnaire (FABQ; physical activity and work scales), and questions about sociodemographics, LBP characteristics, and LBP-related care seeking in the last month (“yes” = visit to specialist, general practitioner, physiotherapist, or other health care practitioner; “no” = none of these). Logistic regression was used to identify whether beliefs made a significant contribution to care-seeking behavior, beyond known predictors conceptualized in the behavioral model of health services use.

Results. A total of 2507 of 2860 (88%) individuals completed the questionnaire; 1071 (43%) reported current LBP, 301 (28%) of which had sought care. In univariate analyses the following were all significantly related to care seeking (all P < 0.01): female sex; increasing age; not working full time; lower income; greater LBP frequency, LBP intensity, and limitations in activities of daily living; worse general health; higher FABQ-Physical Activity, FABQ-Work, and Back Beliefs Questionnaire scores. In multiple regression, female sex (odds ratio [OR], 1.731; 95% confidence interval [CI], 1.174–2.551; P = 0.006), LBP frequency (OR, 1.492; 95% CI, 1.249–1.783; P < 0.0001), limitations in activities of daily living (OR, 1.010; 95% CI, 1.001–1.020; P = 0.037), and high FABQ-Work Scores (OR, 1.025; 95% CI, 1.005–1.044, P = 0.012) contributed significantly to the final model.

Conclusion. That the odds of seeking care are higher in fear-avoidant individuals, even when controlling for other established predictors, emphasizes the importance of addressing such beliefs during the consultation; public health education programs may serve to underpin the delivery of positive messages, ultimately reducing health care demands.

In a population-based survey of individuals suffering from LBP, female gender, LBP-frequency, limitations in activities of daily living and more negative fear-avoidance beliefs about work were each significantly associated with increased odds of care-seeking for LBP. Beliefs should be addressed in the medical consultation and through public health education.

*Department of Research and Development, Spine Center Division, Schulthess Klinik, Zürich, Switzerland

Winterthur Institute of Health Economics WIG, Zurich University of Applied Sciences, Winterthur, Switzerland; and

Department of Work and Organizational Psychology, University of Berne, Berne, Switzerland.

Address correspondence and reprint requests to Anne F. Mannion, PhD, Schulthess Klinik, Lengghalde 2 8008 Zürich, Switzerland; E-mail:

Acknowledgement date: June 28, 2012. First revision date: November 22, 2012. Second revision date: December 18, 2012. Acceptance date: December 19, 2012.

The manuscript submitted does not contain information about medical device(s)/drug(s).

The research project was supported by the National Research Programme NRP53 “Musculoskeletal Health—Chronic Pain” of the Swiss National Science Foundation (Project 405340-104826).

No relevant financial activities outside the submitted work.

© 2013 Lippincott Williams & Wilkins, Inc.