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Genusperspektiv på rehabilitering för patienter med rygg- och nackbesvär i primärvård
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
2012 (Swedish)Doctoral thesis, comprehensive summary (Other academic)Alternative title
A gender perspective on rehabilitation for patients with neck and back pain in primary health care (English)
Abstract [en]

Introduction

Gender as a social and cultural construction has an impact on physiotherapist and patient beliefs, understanding, and behaviour and could affect physiotherapy encounters. Gender studies in early rehabilitation are scarce. The aim of this thesis was to study gender during different parts of the rehabilitation process for primary health care patients with neck and back pain.

Method

The analyses are based on data from three different samples. One sample is composed of physiotherapists and two samples consist of patients consulting primary health care providers because of neck and back pain. All data were gathered from primary health care provided in Västerbotten County.

Baseline data on 73 physiotherapists and 586 of their patients with neck and back pain were collected by questionnaire during three consecutive days in 2006. Patient data included affected pain site and treatment procedures used by the physiotherapist (Study I). Differences in treatment procedures used by female and male physiotherapists and differences in use for female or male patients were analysed using Chi square-test, Fisher’s exact tests, Mann-Whitney U tests and logistic regressions with cluster analysis.

Thematised interviews with 12 patients were made before the patient’s first appointment with a physiotherapist or doctor and repeated after three months. Data were analysed according to grounded theory (Study II) and qualitative content analysis (Study III).

A comprehensive questionnaire was answered at the first appointment when patients sought a physiotherapist in primary health care. The questionnaires included questions about pain intensity, self-rated health, function, psychological stress reactions, domestic work, work environment, self-efficacy and kinesiophobia. Response patterns were linked to the International Classification of Functioning Disability and Health (ICF) and analysed using principal component analysis (PCA) and partial least squares projections to latent structures (PLS).

Result

Patients were given the same treatment procedures irrespective of gender. The treatment procedures most often used were training of joint motion (48%), training of muscle functions and strength training (31%), massage (31%), physical treatment (28%), information about health/ill health (24%), and acupuncture (18%). Female and male physiotherapists used the same treatment procedures with a few exceptions. Female physiotherapists used treatment for mental functions and acupuncture more often than male physiotherapists. The women gave their patients a unique mixture of treatment procedures more frequently (43%) compared to their male colleagues (25%). Male physiotherapists used more training of joint motion.

"To be confirmed" emerged as the core category when analysing interviews that considered expectations or experiences. Five categories were extracted: "To be taken seriously", "To get an explanation", "To be individually assessed and treated", "To be invited to participate", and "To be taken care of in a trustworthy environment". These were factors leading to confirmation. Two ideal types were identified: "confident" and "ambiguous". The "confident" did not doubt their right to health care and blamed their work for causing the pain. They related to a positive identity of strong or hard working. The "ambiguous" were afraid of being regarded as old, whining women and not being taken seriously. They were ashamed of having neck or back pain and blamed themselves; they thought they were not fit enough. The ideal types were not completely defined by gender, but more men were among the "confident" ideal type and more women were among the "ambiguous" type. Patients reacted differently to feelings of being confirmed or not, and this depended on whether they were the "confident" or "ambiguous" ideal type.

The "confident" were satisfied and reacted with reorientation when they felt confirmed, even if they were not totally cured. When not confirmed, the "confident" reacted with anger, frustration, and feelings of shame or remained proud and blamed the health care personnel for being incompetent.

The "ambiguous" also were satisfied and felt reoriented when they were confirmed. They then moved from being an "ambiguous" type to a more "confident" type. When the "ambiguous" were not confirmed in healthcare, they became dissatisfied and unhappy. They doubted the assessment, felt forlorn, and felt increased shame. Not being confirmed was experienced more negatively by women than by men irrespective of ideal type.

Interesting information was found about how patients view their body in relation to pain during analysis of expectations and experiences in study II interviews. This led to Study III.

In study III, "Fear of hurting the fragile body" emerged as an interview theme. Five categories supported or undermined beliefs about pain and physical activity: "The mechanical body", "Messages about activity", "Earlier experiences of pain and activity", "To be a good citizen", and "Support to be active". Patients thought their pain was due to tissue damage and viewed their bodies in a mechanical way. Clear messages from health care personnel about activity led to less fear of physical activity. Vague and contradictory messages led to more fear. Gender-stereotyped messages were given to patients. "The take it carefully" was such a message, and was more often to women when women were thought to be weak and in need of training. Another message was "Pain goes with heavy work". This message was more often given to men when men were thought to be strong and not in need of training. Earlier experiences of pain and activity could have been positive or negative. If positive, the experiences led to less fear of engaging in physical activity. A wish to be a good citizen, such as being a good parent, led to patients being more engaged in child care and playing more than they thought was good for their pain. Women, more than men, expressed avoidance of sick leave because they did not want to be a burden to society or to their work colleagues. Patients were anxious about how to do the "correct" exercises to avoid further injury. Practical support and a follow up to adjust the training program were important to reduce the fear of engaging in physical activity and to maintain motivation.

One hundred and eighteen patients (84 women and 34 men) completed the questionnaire. PCA of all questions identified five significant components. The model explained 37% of the variance. The predictive power was 17%. PC1 explained 17% of the variance and the predictive power was 0.13%.

PC1 was mainly explained by questions classified in ICF as Activity and Participation. These included questions about physical function and self-efficacy (classified as Content of Thought). Questions about support (classified as Environmental Factors) and stress reactions (classified as Body Function (Emotional Functions)) mainly explained PC2. PC3 was mainly explained by reported pain and symptoms from muscles (classified as Body Functions) and domestic work and leisure time activities (classified as Activity and Participation).

There were differences in t-scores between women and men in PC2 (p=0.045) and PC3 (p=0.003). Variables that discriminated between women and men were questions about stress reactions and support at work in PC2, and questions about pain intensity and domestic work in PC3.

Conclusion

As a physiotherapist working with neck and back pain rehabilitation patients, it is important to be aware of both one’s own and the patient’s preconceptions about women and men. It is also important to be aware of the impact of gender on the professional role when choosing treatment procedures in order to ensure that choices will be based on evidence of effectiveness and not from stereotypes. Awareness of the patient’s individual needs and subsequent adaptation of treatments is also important.

Some patients display a negative self-assessment and shame. They need more support to be able to reorient. Unless these patients are confirmed, they are at risk of prolonged disability.

Gender stereotypes can hinder rehabilitation of neck and back pain if women are seen as weak and in need of protection and men are seen as strong and not in need of preventive muscle training.

When assessing neck and back pain patients with questionnaires, gender has less significance than when asking questions about physical function and self-efficacy. Questions about emotions of stress reactions, support at work, and pain intensity contribute to gender differences for women. Questions on the level of domestic work contribute to gender differences for men.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2012. , 85 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1482
Keyword [en]
Gender, neck pain, back pain, physiotherapy, rehabilitation, treatment, primary health care, confirmation, grounded theory, qualitative content analysis, questionnaire, principal component analysis, physical activity
National Category
Physiotherapy
Research subject
Physiotherapy
Identifiers
URN: urn:nbn:se:umu:diva-52274ISBN: 978-91-7459-374-7 (print)OAI: oai:DiVA.org:umu-52274DiVA: diva2:503440
Public defence
2012-03-09, Aulan, Vårdvetarhuset, Umeå Universitet, 901 87, Umeå, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2012-02-17 Created: 2012-02-15 Last updated: 2012-02-17Bibliographically approved
List of papers
1. A gender perspective on physiotherapy treatment in patients with neck and back pain
Open this publication in new window or tab >>A gender perspective on physiotherapy treatment in patients with neck and back pain
2010 (English)In: Advances in Physiotherapy, ISSN 1403-8196, E-ISSN 1651-1948, Vol. 12, no 1, 35-41 p.Article in journal (Refereed) Published
Abstract [en]

Women report more pain from the musculoskeletal system, and more disability, than do men. As a consequence, women more often seek healthcare than men do, and are more often on sick leave. Research shows that female patients and male patients are treated differently by physicians and that the physician's gender also influenced the choice of treatment. The aim was to study whether the patients’ and/or the physiotherapists’ gender influences physiotherapy treatments for patients with neck and/or low back pain. During 3 days in April 2006, 73 physiotherapists in primary care and private practices collected information on 586 patients with neck and/or low back pain. The information included data on the affected pain sites and the treatment procedures used by the physiotherapist. Baseline data on the physiotherapists were collected with a questionnaire. The results showed that female and male physiotherapists mainly used the same treatment procedures, but with some differences. The female physiotherapists used significantly more acupuncture and procedures directed toward treatment of mental function. They also gave their patients a unique combination of treatment procedures to a greater extent than their male colleagues. The malte physiotherapists used significantly more training of joint mobility. Male and female patients were given the same treatment.

Place, publisher, year, edition, pages
Informa Healthcare, 2010
Keyword
Cross-sectional study, gender, physiotherapy, questionnaire
National Category
Gender Studies Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-33598 (URN)10.3109/14038190903174270 (DOI)
Available from: 2010-04-28 Created: 2010-04-28 Last updated: 2012-02-17Bibliographically approved
2. "Getting confirmation": gender in expectations and experiences of healthcare for neck or back patients
Open this publication in new window or tab >>"Getting confirmation": gender in expectations and experiences of healthcare for neck or back patients
2012 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 44, no 2, 163-171 p.Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of this study was to explore, from a gender perspective, patients' expectations prior to seeking healthcare for neck or back pain, and their subsequent experiences of the care and rehabilitation they received.

Methods: Thematized interviews with 12 patients, 7 women and 5 men, using open-ended questions, were analysed according to grounded theory. Each patient was interviewed before their first appointment with a physiotherapist or general practitioner and 3 months later.

Results: Analysis resulted in 5 categories: "To be taken seriously", "Getting an explanation", "To be invited to participate", "To be assessed and treated individually", and "To be taken care of in a trustworthy environment", which were linked by a core category "Getting confirmation". Two ideal types were identified: the "Confident" type, characterized by self-confidence and pride, and the "Ambiguous" type, characterized by disparagement and shame. The categories were partly perceived in different ways from the two ideal types. The ideal types were not defined by sex; however, more men were found to be of the "Confident" type and more women of the "Ambiguous" type.

Conclusion: Gender appears to affect expectations and experiences, in addition to how patients view and express their problems. Healthcare professionals should take this into account in consultations.

Keyword
gender, back pain, neck pain, primary healthcare, qualitative research
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-51418 (URN)10.2340/16501977-0912 (DOI)22234575 (PubMedID)
Available from: 2012-02-15 Created: 2012-01-20 Last updated: 2017-12-08Bibliographically approved
3. 'I am afraid to make the damage worse': fear of engaging in physical activity among patients with neck or back pain : a gender perspective
Open this publication in new window or tab >>'I am afraid to make the damage worse': fear of engaging in physical activity among patients with neck or back pain : a gender perspective
2014 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 28, no 1, 146-154 p.Article in journal (Refereed) Published
Abstract [en]

Rationale: Neck and back pain are major public health problems in Western societies and cause considerable disability and health service use. Swedish women report more severe neck and back pain compared with Swedish men. Most studies on the aetiology of gender differences in pain deal with biological mechanisms, and less with the role of psychological and sociocultural factors. 'Pain beliefsis a sociocultural factor and can be expressed in different ways among women and men. It is important to know what pain beliefs are held by neck and back pain patients, especially when medical guidelines recommend that back pain patients stay physically active.

Aim: Exploring pain beliefs in relation to physical activity among neck and back pain patients consulting primary health care.

Method: Twelve patients (seven women, five men) consulting primary health care for an initial episode of neck or back pain were interviewed before their first appointment with a physiotherapist or general practitioner and 3 months later. The interviews covered patient experiences of neck or back pain, consequences, strategies and treatment experiences. The interviews were analysed with qualitative content analysis from a gender perspective.

Result: One theme 'Fear of hurting the fragile body' was expressed by all neck or back pain patients. Five categories were identified 'The mechanical body', 'Messages about activity', 'Earlier experiences of pain and activity', 'To be a good citizen' and 'Support to be active' supported or undermined beliefs about pain and physical activity. Gender expressions occurred in the categories 'Messages about activity', 'To be a good citizen' and 'Support to be active'.

Conclusions: Neck or back pain patients in the study saw the body as fragile and were afraid of hurting it. Notions of gender had an impact on the given advice about activity and on how patients perceived the message about staying active.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2014
Keyword
gender, primary care, neck pain, back pain, physical activity, pain beliefs, qualitative research
National Category
Physiotherapy Nursing
Research subject
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-52236 (URN)10.1111/scs.12043 (DOI)000329925600017 ()23578006 (PubMedID)
Note

Article first published online: 12 APR 2013

Available from: 2012-02-14 Created: 2012-02-14 Last updated: 2017-12-07Bibliographically approved
4. Similarities and differences: patterns of reported problems and ICF classification in women and men with back or neck pain seeking physiotherapy treatment
Open this publication in new window or tab >>Similarities and differences: patterns of reported problems and ICF classification in women and men with back or neck pain seeking physiotherapy treatment
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Objective: The primary aim of this study was to examine similarities and differences in problem areas reported by women and men who seek physiotherapy treatment for back or neck pain. A second aim was to evaluate the appropriateness of ICF classification in relation to gender.

Methods: Principal component analysis (PCA) and partial least squares of latent structures (PLS) were used to analyse questionnaire data including background data, questions about pain, domestic work, stress, EQ-5D, Neck Disability Index (NDI), Oswestry Disability Questionnaire (ODQ), psychosocial and physical workload, Tampa Scale and Functional Self-Efficacy Scale.

Results: One hundred and eighteen patients (84 women and 34 men) completed the questionnaire. Men and women scored similarly on the NDI, ODQ, Functional Self Efficacy, and Tampa Scale, but women rated higher on stress reactions. PCA showed that questions from the NDI, ODQ and Functional Self-Efficacy Scale explained most of the variance in this patient group. Questions about stress and social support at work constituted the second component. Questions about domestic workload and pain comprised the third component. Gender differences were found in the two last components.

Conclusion: Further investigation of the impact of gender on neck and back pain in different cultures is important.

Keyword
physiotherapy, back pain, neck pain, ICF, gender, questionnaire, principal component analysis
National Category
Medical and Health Sciences Physiotherapy
Research subject
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-52237 (URN)
Available from: 2012-02-14 Created: 2012-02-14 Last updated: 2016-03-07

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