International Journal of Clinical Pharmacy

, Volume 37, Issue 4, pp 616–625 | Cite as

The effects of educational interventions on pharmacists’ knowledge, attitudes and beliefs towards low back pain

  • Christina Abdel Shaheed
  • Christopher G. Maher
  • Wendy Mak
  • Kylie A. Williams
  • Andrew J. McLachlanEmail author
Research Article


Background Practitioner beliefs and attitudes towards low back pain (LBP) influence treatment decisions. Little is known about pharmacists’ knowledge, attitudes and beliefs towards LBP. Objectives To investigate the effect of educational interventions on pharmacists’ knowledge, attitudes and beliefs towards LBP. Setting Sydney Metropolitan Area. Methods Knowledge, attitudes and beliefs was measured using the “Pharmacists’ Back Beliefs Questionnaire”, with items from two previously reported questionnaires on back beliefs. Responses from pharmacists attending a 2-h educational workshop on LBP (n = 204) and pharmacists recruiting participants for a LBP clinical trial (n = 66) were compared to responses from a control group of pharmacists (n = 65) to allow an evaluation of the two interventions. Responses from workshop participants were also evaluated before and after the session. Participants indicated their agreement with statements about LBP on a 5-point Likert scale. Preferred responses were based on guidelines for the evidence-based management of LBP. The primary analysis evaluated total score on the nine-inevitability items of the Back Beliefs Questionnaire (“inevitability score”). Main outcome measure Inevitability score. Results There was no significant difference in inevitability score between LBP clinical trial pharmacists and the control group [mean difference (MD) 0.47 (95 % CI −1.35 to 2.29; p = 0.61)]. The educational workshop led to a significant and favourable change in inevitability score (MD 7.23 p < 0.001) and notable changes in responses to misconceptions regarding bed rest and the need for imaging (p < 0.001) among participating pharmacists. Conclusions Pharmacists attending the educational workshop provided the most compelling evidence that education specifically aimed at delivering evidence-based information can be successful in changing practitioner knowledge, beliefs and attitudes towards LBP.


Australia Evidence-based management Community pharmacy Education Low back pain 



The authors gratefully acknowledge the support of Dr Christine Lin, Mr Daniel Steffens, Ms Paula Beckencamp, Ms Pauline Zahara, Ms Dominique Bartlett, Mr Tarscisio Folly, Ms Amanda Hese, Ms Anurina Das, Dr Sasha Bennett, Mr Vidya Perera and all the pharmacists who participated in this study. The authors also acknowledge the financial support of The George Institute for Global Health.


This research received no specific funding from any funding agency in the public, commercial or not-for-profit sectors. CAS is supported by an Australian Postgraduate Award. CGM is supported by a research fellowship funded by the National Health and Medical Research Council.

Conflicts of interest

CGM and AJM are investigators on the PACE trial ( which is jointly funded by a project grant from the National Health and Medical Research Council and GlaxoSmithKline.

Supplementary material

11096_2015_112_MOESM1_ESM.docx (14 kb)
Supplementary material 1 (DOCX 14 kb)


  1. 1.
    Chou R, Qaseem A, Snow V, Casey D, Cross TJ Jr, Shekelle P, et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478–91.PubMedCrossRefGoogle Scholar
  2. 2.
    Britt H, Miller GC, Charles J. General practice activity in Australia 2007–2008. Canberra, Australia Australian Institute of Health and Welfare. General Practice Series No. 22. Catalog No. GEP 22, 2008. ISBN: 9781740248280.Google Scholar
  3. 3.
    Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain: Frequency, clinical evaluation, and treatment patterns from a U.S. National survey. Spine. 1995;20(1):11–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Lim S, Vos T, Flaxman AD, Danaei G, Shibuya K, The Global Burden of Disease Study Group. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study. Lancet. 2012;380(9859):2224–60.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Schofield DJ, Shrestha RN, Passey M, Earnest A, Fletcher S. Chronic disease and labour force participation among older Australians. Med J Aust. 2008;189(8):447–50.PubMedGoogle Scholar
  6. 6.
    Walker BF, Muller R, Grant WD. Low back pain in Australian adults: health provider utilization and care seeking. J Manipulative Physiol Ther. 2004;27(5):327–35.PubMedCrossRefGoogle Scholar
  7. 7.
    Silcock J, Moffett JK, Edmondson H, Waddell G, Burton AK. Do community pharmacists have the attitudes and knowledge to support evidence based self-management of low back pain? BMC Musculoskelet Disord. 2007;8:10.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Abdel Shaheed C, Maher CG, Williams KA, McLachlan AJ. Interventions available over the counter and advice for acute low back pain: systematic review and meta-analysis. J Pain. 2014;15(1):2–15.PubMedCrossRefGoogle Scholar
  9. 9.
    Slater H, Briggs A, Watkins K, Chua J, Smith A. Translating evidence for low back pain management into a consumer-focussed resource for use in community pharmacies: a cluster-randomised controlled trial. PLoS One. 2013;8:e71918. doi: 10.1371/journal.pone.0071918 (eCollection 2013).PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine. 2009;34(20):1218–26 (discussion 1227).PubMedCrossRefGoogle Scholar
  11. 11.
    Houben RMA, Gijsen A, Peterson J, de Jong PJ, Vlaeyen JWS. Do health care providers’ attitudes towards back pain predict their treatment recommendations? Differential predictive validity of implicit and explicit attitude measures. Pain. 2005;114(3):491–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Linton SJ, Vlaeyen J, Ostelo R. The back pain beliefs of health care providers: are we fear-avoidant? J Occup Rehabil. 2002;12(4):223–32.PubMedCrossRefGoogle Scholar
  13. 13.
    Williams CM, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, et al. Low back pain and best practice care: a survey of general practice physicians. Arch Intern Med. 2010;170(3):271–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463–72.PubMedCrossRefGoogle Scholar
  15. 15.
    Kent P, Keating J. Do primary-care clinicians think that nonspecific low back pain is one condition? Spine. 2004;29(9):1022–31.PubMedCrossRefGoogle Scholar
  16. 16.
    van Tulder M, Becker A, Bekkering T, Breen A, Del Real MTG, Hutchinson A, et al. Chapter 3: European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15(Suppl. 2):S169–91.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Frankel BS, Moffett JK, Keen S, Jackson D. Guidelines for low back pain: changes in GP management. Fam Pract. 1999;16(3):216–22.PubMedCrossRefGoogle Scholar
  18. 18.
    Gonzalez-Urzelai V, Palacio-Elua L, Lopez-de-Munain J. Routine primary care management of acute low back pain: adherence to clinical guidelines. Eur Spine. 2003;12(6):589–94.CrossRefGoogle Scholar
  19. 19.
    Wilk V, Palmer HD, Stosic RG, McLachlan AJ. Evidence and practice in the self-management of low back pain: findings from an Australian internet-based survey. Clin J Pain. 2010;26(6):533–40.PubMedCrossRefGoogle Scholar
  20. 20.
    Houben RMA, Ostelo RWJG, Vlaeyen JWS, Wolters PMJC, Peters M, Stomp-van den Berg SGM. Health care providers’ orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity. Eur J Pain. 2005;9(2):173–83.PubMedCrossRefGoogle Scholar
  21. 21.
    Buchbinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and disability: three part evaluation. BMJ. 2001;322(7301):1516–20.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Bishop PB, Wing PC. Knowledge transfer in family physicians managing patients with acute low back pain: a prospective randomized control trial. Spine J. 2006;6(3):282–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Dey P, Simpson CWR, Collins SI, Hodgson G, Dowrick CF, Simison AJM, et al. Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial. Br J Gen Pract. 2004;54(498):33–7.PubMedCentralPubMedGoogle Scholar
  24. 24.
    Eccles M, Steen N, Grimshaw J, Thomas L, McNamee P, Soutter J, et al. Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial. Lancet. 2001;357(9266):1406–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Kerry S, Oakeshott P, Dundas D, Williams J. Influence of postal distribution of the Royal College of Radiologists’ guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial. Fam Pract. 2000;17(1):46–52.PubMedCrossRefGoogle Scholar
  26. 26.
    Symonds TL, Burton AK, Tillotson KM, Main CJ. Do attitudes and beliefs influence work loss due to low back trouble? Occup Med (Oxf). 1996;46(1):25–32.CrossRefGoogle Scholar
  27. 27.
    George SZ, Teyhen DS, Wu SS, Wright AC, Dugan JL, Yang G, et al. Psychosocial education improves low back pain beliefs: results from a cluster randomized clinical trial (NCT00373009) in a primary prevention setting. Eur Spine J. 2009;18(7):1050–8.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Gross D, Russell A, Ferrari R, Crites Battie M, Schoplocher D, Hu R, et al. The Alberta Back Pain Initiative Study: Evaluation of a population-based social marketing intervention study for the prevention of disability associated with low back pain. Final report Available at: Accessed June 5, 2013.
  29. 29.
    Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain—a guide for clinicians. Bowen Heads: Australian Academic Press; 2004. ISBN 9781875378524.Google Scholar
  30. 30.
    Williams CM, Maher CG, Latimer J, McLachlan AJ, Hancock MJ, Ray RO, et al. Efficacy of paracetamol for acute low-back pain: a double-blind randomised controlled trial. Lancet. 2014;384(9954):1586–96.PubMedCrossRefGoogle Scholar
  31. 31.
    Doctors4U®—Sydney Doctors Medical Directory (2011) A-to-Z: Sydney Chemists and Pharmacies by location. Accessed August 3, 2011.
  32. 32.
    Charlton JE (2005) Core curriculum for professional education in pain. Accessed from: Accessed June 18, 2011.
  33. 33.
    Mezei L, Murinson BB, Johns Hopkins Pain Curriculum Development T. Pain education in North American medical schools. J Pain. 2011;12(12):1199–208.PubMedCrossRefGoogle Scholar
  34. 34.
    Australian Institute of Health and Welfare: General Characteristics of persons involved in health and community services occupations. Accessed July 28, 2013.
  35. 35.
    Pharmacy Board of Australia. Pharmacy Registrant Data. Accessed April 22, 2014.
  36. 36.
    National Prescribing Service. National Medicines Symposium Poster. A brief education session and participation in a clinical trial both improve pharmacists’ knowledge of evidence-based low back pain management. Accessed July 29, 2014.
  37. 37.
    Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010;6:CD007612.PubMedGoogle Scholar
  38. 38.
    Buer N, Linton SJ. Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population. Pain. 2002;99(3):485–91.PubMedCrossRefGoogle Scholar
  39. 39.
    Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27(5):E109–20.PubMedCrossRefGoogle Scholar
  40. 40.
    Gohner W, Schlicht W. Preventing chronic back pain: evaluation of a theory-based cognitive-behavioural training programme for patients with subacute back pain. Patient Educ Couns. 2006;64(1–3):87–95.PubMedCrossRefGoogle Scholar
  41. 41.
    Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO, et al. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. Lancet. 2007;370(9599):1638–43.PubMedCrossRefGoogle Scholar
  42. 42.
    Epstein RM, Hadee T, Carroll J, Meldrum SC, Lardner J, Shields CG. “Could this be something serious?” Reassurance, uncertainty, and empathy in response to patients’ expressions of worry. J Gen Intern Med. 2007;22(12):1731–9.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Murinson BB, Agarwal AK, Haythornthwaite JA. Cognitive expertise, emotional development, and reflective capacity: clinical skills for improved pain care. J Pain. 2008;9(11):975–83.PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Strassels S, Pepin J, Petty H, Torges K, Driver L. (404) Texas pharmacists’ knowledge, attitudes, and practices may contribute to inadequate pain care. J Pain. 2008;9:77.Google Scholar
  45. 45.
    Artner J, Kurz S, Cakir B, Reichel H, Luttiq F. Intensive interdisciplinary outpatient pain management program for chronic back pain: a pilot study. J Pain Res. 2012;5:209–16.PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Coudeyre E, Rannou F, Tubach F, Baron G, Coriat F, Brin S, et al. General practitioners’ fear-avoidance beliefs influence their management of patients with low back pain. Pain. 2006;124(3):330–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Engers AJ, Wensing M, van Tulder MW, Timmermans A, Oostendorp RAB, Koes BW, et al. Implementation of the Dutch low back pain guideline for general practitioners: a cluster randomized controlled trial. Spine. 2005;30(6):559–600.PubMedCrossRefGoogle Scholar
  48. 48.
    Jackson JL, Browning R. Impact of national low back pain guidelines on clinical practice. South Med J. 2005;98(2):139–43.PubMedCrossRefGoogle Scholar
  49. 49.
    Somerville S, Hay E, Lewis M, Barber J, van der Windt D, Hill J, et al. Content and outcome of usual primary care for back pain: a systematic review. Br J Gen Pract. 2008;58(556):790–7 (i–vi).PubMedCentralPubMedCrossRefGoogle Scholar
  50. 50.
    Mc Namara KPM. Duncan GJ, McDowell J, Marriott JL. Community pharmacists’ preferences for continuing education delivery in Australia. J Contin Educ Health Prof. 2009;29(1):52–7.CrossRefGoogle Scholar
  51. 51.
    Kennedy N, Healy J, O’Sullivan K. The beliefs of third-level healthcare students towards low-back pain. Pain Res Treat. 2014;. doi: 10.1155/2014/675915 (Epub 2014 Apr 10).PubMedCentralPubMedGoogle Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015

Authors and Affiliations

  • Christina Abdel Shaheed
    • 1
  • Christopher G. Maher
    • 2
    • 3
    • 4
  • Wendy Mak
    • 2
  • Kylie A. Williams
    • 5
  • Andrew J. McLachlan
    • 1
    • 6
    Email author
  1. 1.Faculty of PharmacyUniversity of SydneySydneyAustralia
  2. 2.The George Institute for Global Health, SydneySydneyAustralia
  3. 3.SydneyAustralia
  4. 4.Sydney Medical SchoolUniversity of SydneySydneyAustralia
  5. 5.School of Pharmacy, Graduate School of HealthUniversity of Technology, SydneyBroadwayAustralia
  6. 6.Centre for Education and Research on AgeingConcord Repatriation General HospitalSydneyAustralia

Personalised recommendations