Messages

Disability from low back pain is a growing public health problem in Australia and developed countries worldwide, and one of the major issues targeted in the Bone and Joint Decade (2000-2010).¹ Most population-based surveys of back pain report a point prevalence of 15%-30%, a one-year prevalence of 50%, and a lifetime prevalence of 60%-80%.² Although episodes of acute low back pain are mostly short-lived, back complaints still constitute the second most common symptom (after upper respiratory complaints) prompting general practice encounters.³ Furthermore, disability from back pain places a significant socioeconomic burden on the individual and the community. In Australia, back problems are the leading specific musculoskeletal cause of health system expenditure, with an estimated total cost of $700 million in 1993-1994.⁴ Moreover, these costs are rising: in Victoria alone, claims lodged for back injury with the workers' compensation scheme cost the community $510 million in the 1999-2000 financial year.⁵

Attempts to reduce the burden of disability associated with back pain have often been directed towards prevention of pain per se, particularly in an occupational setting. Although direct involvement of workplace management in primary prevention strategies has had positive effects, interventions such as education, training and exercise programs for the back, ergonomic interventions and screening potential employees for risk factors for the development of back pain or injury have had limited success.⁶ Paradoxically, interventions aimed at preventing chronicity, such as early exercise, physiotherapy, rehabilitation and education programs, when implemented early (ie, within the first few weeks of back pain), are largely ineffective for improving longer-term outcomes.⁷

Attitudes and beliefs, particularly fear-avoidance beliefs, pain-coping strategies and illness behaviours, are important issues to consider when treating patients with back pain.⁸ While psychosocial approaches that seek to remedy unfounded fears and poor coping methods have met with limited success in treating patients with established chronic back disability, these approaches may be effective when implemented early in the course of back pain and could even be of value when directed towards those who have yet to develop back complaints. Provision of positive messages, such as those designed to improve attitudes to back pain and diminish fear, reduce self-reported disability in patients presenting with low back pain in general practice.⁹ These interventions also reduce extended work absence in industrial settings.^10,11

The Victorian WorkCover Authority's statewide media campaign "Back pain — don't take it lying down", which commenced in 1997 (Box 1), aimed to provide a new approach through prime-time television advertisements featuring health professionals, and sports and local television celebrities. The messages, all endorsed by the relevant professional healthcare organisations, were simple:

• back pain is not a serious medical problem;

• disability can be reduced and even prevented by positive attitudes; and

• treatment should consist of continuing to perform usual activities, not resting for prolonged periods, exercising and remaining at work.

The campaign counselled individuals with low back pain, their doctors and employers to avoid excessive medicalisation of the problem, and unnecessary diagnostic testing and treatment.

A three-part evaluation of this campaign (evaluating general population attitudes, general practitioners, and the WorkCover Authority claims database) suggests that there has been widespread adoption of these messages (Box 2).^13,14 The campaign successfully managed to:

• "de-medicalise" a public health problem;

• ease the burden on general practitioners and specialists;

• empower workers to solve their own health challenges; and

• save workers' compensation payments.

The success of the campaign has been attributed to many factors, including the simple, direct language used to convey the messages, and the evidence-based content, both pioneered by the authors of The back book.¹² In addition, virtually every professional body with a stake in back pain in Australia supported the campaign.

Before this campaign, there was limited empirical evidence that primary preventive interventions reduce the overall burden of illness associated with low back pain. Now, evaluation of the campaign has shown that a public policy initiative directed towards managing the disability of back pain can be highly successful. There are compelling arguments for this approach. These include, firstly, the impression that informative interventions may be of more value when initiated early, even before the onset of symptoms; and, secondly, predictive models of low back pain are not presently able to identify those at risk of disability. By targeting the entire population, this public health approach reaches those hard-to-identify high-risk groups. There is evidence that a population strategy of universal change has greater overall effect than targeted high-risk strategies. Finally, the population approach may be an effective way of modifying doctors' behaviour, both through direct influences as well as through a change in the attitudes of their patients.

Media campaigns are an established strategy for delivering preventive health messages. They have been particularly successful in Australia in altering health-related behaviours, such as sunlight exposure through the Slip! Slop! Slap program and smoking through the Quit program. With good evidence that negative attitudes and beliefs are important predictors of disability related to back pain, altering societal views of back pain would seem a highly appropriate policy to adopt.

The long-term impact of this campaign is not clear. Recent publicity by the Victorian WorkCover Authority has focused on ergonomic interventions in the workplace — strategies that the United States has controversially rejected. Clinical effectiveness is not the only influence on policy:¹⁵ policymakers' own interests and ideologies are often significant. We may have to look to other interested industrialised societies, such as Sweden, the Netherlands or Canada, for evidence of this novel campaign's long-term effectiveness.

Competing interests

We received funding from the Victorian WorkCover Authority to conduct an independent evaluation of the media campaign.

Rachelle Buchbinder
Director, Department of Clinical Epidemiology, Cabrini Hospital; and
Associate Professor, Monash University Department of Epidemiology and
Preventive Medicine, Melbourne, VIC

Damien Jolley
Associate Professor, School of Health Sciences
Deakin University, Melbourne, VIC

Mary Wyatt
Occupational Physician, Melbourne, VIC

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