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Table 1 Data charting tool for included studies

From: Knowledge of psychosocial factors associated with low back pain amongst health science students: a scoping review

Author [Year of publication]Study populationMethodsAims of the studyOutcome measuresResults and conclusions
Ferreira PH et al. [2004] [19]3rd and 4th year Brazilian physiotherapy students (n = 153)• Survey study design utilizing the HC-PAIRS which was translated from English to Portugese.
• Student in their 3rd and 4th years had already a taken a musculoskeletal course, but had not treated nor observed the management of patients with LBP. The results of the survey were compared to data published by Latimer et al. (2004) which included 3rd and 4th year physiotherapy from Australia (n = 618). The scores of the Brazilian and Australian students were compared with scores of healthcare providers reported by Rainville et al. (1995).
• Compare HC-PAIRS of Brazilian students with Australian students.
• Compare students’ scores to those of North American Healthcare Providers.
HC-PAIRSa• All HC-PAIRS scores were higher than the recommended 38.
• Brazilian students had significantly higher total HC-PAIRS scores than Australian students.
• Brazilian students had higher scores on every factor of the HC-PAIRS with the greatest differences being seen in factors 1 and 3.
• Factor 4 scored the lowest.
• They conclude Brazilian students agree more strongly that pain justifies limitation in function, and that ethnicity can influence beliefs about low back pain.
Latimer J et al. [2004] [20]3rd (98′, 99′, 00′) & 4th (98′) year physiotherapy students
(n = 618)
• Survey administered pre- and post- 16 h course on chronic low back pain.
• The 98′ and 00′ 3rd year students were surveyed immediately before and after the module.
• The 99′ class was surveyed before and one year after taking the module.
To describe the attitudes and beliefs of physiotherapy students to chronic LBP and investigate whether these attitudes changed following exposure to a teaching module.HC-PAIRS• All HC-PAIRS scores were higher than the recommended 38, indicating stronger beliefs that pain justifies disability and functional limitation.
• In the 98′ cohort there was improvement in factors 1 and 2.
• In the 00′ cohort the improvement was seen in factors 1 and 2.
• Factor 4 did not improve significantly in either group.
The 99′ cohort that was tested 1 year after taking the module had significant improvement in total scores and factors 1–3.
• They conclude that attitudes and beliefs of 3rd year physiotherapy students can be changed following a teaching module, and that these changes are still presents one year later. However, these scores are still above the maximum recommended score of 38.
Burnett A et al. [2009] [21]2nd-4th year undergraduate physiotherapy and nursing students from Australia, Taiwan, and Singapore (n = 382).Cross-sectional survey studyTo determine if country (Australia, Taiwan, and Singapore), undergraduate healthcare major (physiotherapy and nursing), LBP history, and year of course influenced back pain beliefs in undergraduate females.• HC-PAIRS
• BBQb
• All HC-PAIRS scores were higher than the recommended 38.
• HC-PAIRS scores were lower in physiotherapy students compared to nursing students.
• No significant difference between HC-PAIRS scores of physiotherapy students from Australia, Singapore, and Taiwan.
• 3rd year Australian physiotherapy students had significantly lower HC-PAIRS scores than 2nd year.
• Amongst nursing students HC-PAIRS scores were lowest in Taiwanese students, followed by Australian and Singaporean.
• BBQ scores were significantly lower in nursing students versus PT students.
• BBQ scores were significantly lower in Taiwanese and Singaporean students as compared to Australian students.
• There was a significant correlation between BBQ and HC-PAIRS scores.
• They conclude that Chinese students have more negative beliefs about functional limitations associated with low back pain as compared to white Australian students.
Ryan C et al. [2010] [22]1st & 4th year physiotherapy (n = 62) & non-healthcare students (n = 61)Cross-sectional survey studyTo investigate the difference in attitudes between 1st and 4th year physiotherapy students and between physiotherapy students and non-healthcare students toward functioning in individuals with LBP.HC-PAIRS• All HC-PAIRS scores were higher than the recommended 38.
• First year physiotherapy students had lower total and factor 1 scores than non-healthcare students.
• Fourth year physiotherapy students had lower total scores and all factors except 4 when compared with non-healthcare students.
• There was a greater gap between 4th year physiotherapy students and non-healthcare students than 1st year physiotherapy students and non-healthcare.
• Fourth year physiotherapy students scored lower than 1st year students in total and on all 4 factors except factor 4.
• There was more improvement in HC-PAIRS scores in physiotherapy students than non-healthcare students, however there scores were still greater than 38.
• They conclude physiotherapy education creates more positive attitudes toward the functioning of individuals with low back pain than non-healthcare education.
Morris H et al. [2012] [23]1st (n = 62) & final year (n = 61) medical students & business students as controlsCross-sectional survey studyTo investigate whether medical student training fosters positive attitudes towards patients with LBP and their ability to function.HC-PAIRS• All HC-PAIRS scores were higher than the recommended 38.
• Undergraduate medical students had lower HC-PAIRS scores than business students, and the scores decreased between 1st and final year students.
• There was no improvement in factor 3, but factors 1 and 2 improved in final year students.
• They conclude that final year medical students develop appropriate attitude toward people with chronic low back pain, but that more education is needed because the scores did not reach the recommended 38.
Briggs AM et al. [2013] [24]Final year students (n = 602):
medicine (n = 176), chiropractic (n = 46), occupational therapy (n = 71), pharmacy (n = 138), & physiotherapy (n = 171)
Cross-sectional survey studyTo investigate beliefs and clinical recommendations for LBP, and their alignment to the current evidence-based guidelines, in Australian university allied health and medical students.• HC-PAIRS
• BBQ
• Questionnaire to assess likely practice behaviorc
• All HC-PAIRS scores were higher than the recommended 38.
• Physiotherapy and chiropractic students had lowest HC-PAIRS scores (better), and pharmacy students had the highest.
• The HC-PAIRS scores were strongly associated with clinical recommendations.
• Physiotherapy and chiropractic students scored higher on the BBQ, while pharmacy students reported the lowest scores.
• BBQ scores were associated with clinical recommendations as well. A 1-pt increase in BBQ was associated with an increase in the odds of recommendations consistent with guidelines with the exception of work recommendations.
• Physiotherapy and chiropractic students demonstrated more “guideline consistent” recommendations as far as physical activity, work, and bedrest were concerned.
• Pharmacy and occupational therapy students were least likely to recommend consistent with the guidelines.
• They conclude that across disciplines, physiotherapy and chiropractic students have more helpful beliefs about functioning with low back pain than occupational therapy, pharmacy, or medical students. They believe this is a reflection of the curricula for physiotherapy and chiropractic students having more low back pain related modules.
Chinball JT et al. [2014] [25]Final year medical students (n = 132)• Randomized experiment using 4 vignettes were patients with LBP were seeking long-term disability.
• Levels of patient accountability were manipulated by having the patient only be seen 1 time (weak) or for long-term care (strong).
• Levels of societal accountability were manipulation by having the student be the secondary source for disability award (weak) or the primary (strong).
• Clinical judgements (symptom validity, pain/distress/disability (PDD), and psychosocial factors) and empathy were measured.
• Investigate the effects of empathy and accountability (patient and societal) on clinical judgements of medical students relative to patients and legal/societal obligations.• Questionnaire with 21 clinical judgment questionsd
• 7 Empathetic concern items from the IRIe
• The mean empathy score was 19.5 indicating slightly greater than moderate levels of self-reported empathy.
• Higher empathy scores were associated with higher symptom validity and P/D/D, but not with psychosocial factors.
• There was no clear relationship between high patient or societal accountability alone and clinical judgements.
• When patient and societal accountability were consistent (ie. both weak or strong) symptoms were viewed as less valid, and P/D/D and psychosocial factors played a greater role.
• When patient and societal accountability were inconsistent (ie. 1 weak, 1 strong) symptoms were viewed as more valid and P/D/D and psychosocial factors played less of a role.
• When societal accountability was weak symptoms were viewed as more valid in those who had high patient accountability. Psychosocial factors and PDD were considered low.
• When Societal accountability was high and students’ patient accountability was low (ie. 1-time consultation) symptom validity was low and P/D/D and psychosocial factors were high.
• They suggest that students take the path of least resistance when seeing a patient only 1 time, and validate their symptoms, thus awarding their disability. OR students who anticipate ongoing care believe psychosocial factors are a malleable component of the pain experience and they will direct their treatment toward those.
Kennedy N et al. [2014] [26]Physiotherapy (n = 107), medicine (n = 63), nursing (including midwifery) (n = 101) studentsCross-sectional survey administered to physiotherapy, medical, and nursing students of all years.To compare the belief of Irish university physiotherapy, medical, and nursing students toward LBP and to investigate whether demographics (current or previous LBP, gender, and year of study) influence these beliefs.• BBQ
• FABQ-PAf
• Physiotherapy students had significantly higher BBQ and lower FABQ-PA scores than medical and nursing students.
• Medical students had significantly higher BBQ scores than nursing students.
• Beliefs among physiotherapy and medical student improved as their education advanced (1st vs. 4th year students).
• BBQ and FABQ-PA scores improved to indicate more positive beliefs as year of study progressed in both physiotherapy and medical students.
• Physiotherapy students have more positive beliefs toward LBP than medical and nursing students. Physiotherapy and medical students beliefs significantly improved over the course of their studies.
Weiner DK et al. [2014] [27]3rd year medical students not exposed to pain module (n = 28), and those exposed to the module (n = 27)Cross-sectional survey studyTo describe development of an educational module on evaluation and treatment of chronic LBP in older adults and the effect of the module on medical students clinical skills.OSCEg• Following implementation pain module students were assessed via an OSCE.
• The components of the OSCE included history and physical examination.
• 96% of students enrolled in the low back pain module passed the OSCE, compared with 61% of students not enrolled who passed. This was a statistically significant improvement (P < .001)
• They conclude that the findings are encouraging about the potential for educational interventions to positively affect evaluation and management of chronic low back pain in adults.
Alshami AM et al. [2015] [28]3rd or 4th year physiotherapy students from Saudi Arabia (n = 135) compared with data published by Latimer et al. (2004) and Ferreira et al. (2004)Cross-sectional survey study administered to Saudi Arabian students. Those scores were compared to previously reported scores on Brazilian and Australian students. The HC-PAIRS was translated to Arabic.To investigate the attitudes and belief of Saudi Arabian physical therapy students toward chronic LBP. Scores were compared to previously published data on Brazilian and Australian students.HC-PAIRS• All HC-PAIRS scores were higher than the recommended 38.
• Saudi Arabian students had significantly higher total HC-PAIRS scores, and higher scores in factors 1 and 2.
• There was no difference between scores in 3rd and 4th year physiotherapy Saudi Arabian students.
• All groups had poor factor 4 scores.
• They conclude there are differences in beliefs about functioning with low back pain between different nationalities, and that physiotherapy students at junior levels had more negative beliefs about low back pain.
Abdel Shaheed C et al. [2017] [29]First year medical students (n = 93)Cross-sectional survey using the MBBQ that was administered to medical students pre- and post-15-min educational video.To explored medical students’ knowledge, attitudes, and beliefs toward LBP before and after a 25-min educational video on LBP.• MBBQh• Following the educational intervention students demonstrated improvement in the inevitability score, and the proportion of students who answered correctly on items dealing with activity, bed rest, imaging, and recovery.
• Post-intervention students’ knowledge, attitudes, and beliefs toward LBP improved and aligned more closely with current evidence-based guidelines.
• Authors conclude that educational interventions do not need to be extensive in order to improve students’ knowledge, attitudes, and beliefs regarding LBP.
Hilbink H [2017] [30]New Zealand osteopathy students (n = 83) in all years of their education.
Year 1 (n = 12)
Year 2 (n = 17)
Year 3 (n = 21)
Year 4 (n = 14)
Year 5 (n = 19)
Online cross-sectional survey administration.To identify common LBP attitudes and beliefs of New Zealand osteopathy students.• Modified HC-PAIRS
• Back-PAQi
• The median Back-PAQ score was 6.5. The score increased with more education (year 1 vs. year 4).
• Students had the most negative scores in ‘the need to protect’ theme, and highest scores in ‘the correlation between pain and injury’.
• The median HC-PAIRS score was 46. Scores decreased as education advanced.
• Osteopathy have less than optimal attitudes and beliefs about the back and back pain that are not consistent with current guidelines. However, improvements were seen as education advanced.
Leysen M et al. [2017] [31]2nd (n = 766) and 4th (n = 584) year physiotherapy students in 6 different Universities in Belgium.Cross-sectional survey.• To explore attitudes and beliefs of bachelor and master physiotherapy students in Belgium toward LBP.• PABSj
• HC-PAIRS
• Vignette with associated questionnaire to assess treatment recommendations k
• 2nd year students scored significantly higher on the PABS- BM scale and on the HC-PAIRS.
• 4th year students scored significantly higher on the PABS-PS sub-scale.
• After reading the vignette, 4th year students had more correct (guideline-consistent) answers regarding activity and work. However, only 45% of 4th year students answered correctly (compared with 15% of the 2nd year students).
• The PABS-BM was negatively correlated with PABS-PS and positively correlated with the HC-PAIRS.
• The HC-PAIRS correlated negatively with the PABS-PS.
• 4th year students have more biopsychosocial beliefs and attitudes about LBP compared with 2nd year students. However, guideline-consistent recommendations is low in all students.
Leahy A et al. [2019] [32]Physiotherapy (n = 115), Occupational therapy (OT) (n = 48), and general nursing (n = 79) students at any point in their education at the University of Limerick in Ireland.Cross-sectional survey of physiotherapy, occupational therapy, and general nursing pre-registration students in Ireland.To investigate the beliefs of healthcare students about how harmful common daily activities are perceived to be for their lower back.• MPHODA surveyjl• Physiotherapy students had significantly more positive beliefs where they considered activities of daily living to be less harmful for the lower back followed by occupational therapy, and lastly nursing students.
• Physiotherapy students later in their education had more positive beliefs than year 1 students, but the same was not true for OT and nursing students.
  1. aThe Healthcare Providers’ Pain and Impairment Relationship Scale (HC-PAIRS) consists of 15 items with each item rated on a Likert scale from 1 (completely disagree) to 7 (completely agree). Scores range from 15 to 105, and higher scores indicate stronger beliefs that low back pain justifies disability and limited activity. The modified version consists of 13 items and replaces “chronic low back pain” with “low back pain”. The scoring remains the same. The tool has 4 sub scales (with corresponding numbers of the HC-PAIRS):
  2. 1. functional expectations
  3. 2. social expectations
  4. 3. need for a cure
  5. 4. projected cognition
  6. bThe Back Pain Beliefs Questionnaire (BBQ) consists of 14 statements on a 5-point Likert scale ranging from 1 (completely disagree) to 5 (completely agree), and scores range from 9 to 45. Lower scores represent negative beliefs about future consequences of a life with low back pain. These consequences include illness progression, disability, and effectiveness of treatments
  7. cThe questionnaire to assess likely practice behavior consists of 3 items rated on a 5-point Likert scale investigating health professional’s recommendations for patient behavior in relation to work, activity, and bed rest. Lower scores represent more restrictive recommendations. The questionnaire is used following a vignette describing a 28 year-old woman with acute non-specific low back pain without red flags. Responses to the vignette are considered either ‘guideline consistent’ or ‘guideline inconsistent’
  8. d21-questions assessing clinical judgement rated on a Likert scale of 0–10. Higher scores indicate greater amounts of the variable being measured (e.g. Patient honesty in presentation. 0 = not at all, 10 = definitely)
  9. eInterpersonal Reactivity Index (IRI): Empathy components (n = 7) are rated on a 0–4 Likert scale with total scores ranging from 0 to 28. Higher scores indicate higher levels of empathy. The full IRI includes other sub-scales (Fantasy, involvement, personal distress, and perspective talking) that were not used in the study
  10. fFear Avoidance Beliefs Questionnaire (FABQ) consists of 2 sub-scales for physical activity (PA) and work (W). The FABQ-PA was used to determine the level of fear-avoidant behaviors that healthcare students display in their everyday lives. Four individual items are scored on a Likert scale of 0–6. The total score ranges from 0 to 24 with lower scores indicating more positive beliefs about physical activity and higher scores indicating more fear-avoidant beliefs about physical activity
  11. gObjective structure clinical examination (OSCE) is a versatile multipurpose clinical evaluation tool used to assess a number of clinical competencies through objective observation. The OSCE utilized in Weiner et al.’s study included standardized patients with chronic low back and leg pain. The students were asked to take a history, perform the physical examination, or do the documentation. The faculty directly observing the student marker a “yes” or “no” if the students performed a particular task. Students were given real-time feedback
  12. hModified Back Pain Beliefs Questionnaire (MBBQ) that asks students to rate their agreement with statements on a 1–5 Likert scale (1 = strongly disagree, 5 = strongly agree). There are 25 items, wherein the first 14 were taken from the BBQ, and items 15–25 were sourced from the 11-item Buchbinder scale. Preferred responses are based on evidence-based management of low back pain. The “inevitability score” was calculated based on 9 inevitability items of the questionnaire comprised of questions regarding physical activity, bed rest, return to work, and recovery within the context of acute LBP. A lower inevitability score is considered more favorable, and a mean score change of 3 is considered to be a meaningful effect
  13. iBack Pain Attitudes Questionnaire (BACK-PAQ) uses 34 items to evaluate students attitudes and beliefs about their own back and back pain, rather than their beliefs about their patients’ back pain. Each item is rated on a 5-point Likert scale (− 2 to + 2; “false” to “true”). Scoring ranges from − 68 to 68, and although there is no cut off for “good” or “bad” attitudes and beliefs, more negative scores indicate negative beliefs, and positive scores indicate positive beliefs that are in line with current guidelines. The internal consistency is rated using Cronbach’s alpha of 0.70–0.91. There are 6 themes within the questionnaire:
  14. 1. The vulnerability of the back
  15. 2. The need to protect the back
  16. 3. The correlation between pain and injury
  17. 4. The special nature of back pain
  18. 5. Activity participation while experiencing back pain
  19. 6. The prognosis of the back
  20. jPain Attitudes and Beliefs Scale (PABS) contains 2 sub-scales: the biomedical (BM) and psychosocial (PS). The questionnaire is used to assess students affinity toward either a biomedical model or a biopsychosocial model when it comes to the management of LBP. It is comprised of 19 items: 10 biomedical and 9 behavioral. Each item is scored on a 1–6 Likert scale (1 = Totally disagree and 6 = Totally agree). Higher scores in the different sub-scales indicate a stronger affinity for that model
  21. kVignette with associated questionnaire to assess treatment recommendations. No additional information can be ascertained about this questionnaire because this resource was an abstract presented at a conference
  22. lModified Photograph Series of Daily Activities (MPHODA) survey which was derived from the Photograph Series of Daily Activities survey comprised of 100 pictures. The MPHODA consists of 12 pictures indicative of various postures that load the spine in day-to-day activities. Students rate each picture on a Likert scale of 0–100 where 0 = not harmful and 100 = extremely harmful. Lower scores indicate more positive beliefs