Back pain is saddled by misconceptions that contribute to low-value care and poor outcomes. Many patients and clinicians mistakenly view the spine as fragile, believe that pain equates to damage, and over-emphasise the role and value of rest, imaging, medication, and surgery.1 Guideline-based care will not be embraced if such misconceptions are not countered. Here we provide four arguments for accessible, engaging and convincing education to the public and health professionals

Deshpande, S

Gross, DP

Maher, CG

O'Connell, NE

O'Keefe, M

O'Sullivan, K

Stanton, TR

British Journal of Sports Medicine

Brunel University Research Archive

A mass media campaign is needed to counter misconceptions about back pain and promote higher value careMary O’Keeffe1,2Chris G. Maher1,2Tasha R. Stanton3,4Neil E. O’Connell5Sameer Deshpande6Douglas P. Gross7Kieran O’Sullivan8,91 School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.2 Institute for Musculoskeletal Health, Sydney, Australia.3School of Health Sciences & PainAdelaide Consortium, The University of South Australia, Adelaide, SA, Australia.4 Neuroscience Research Australia, Randwick, NSW, Australia.5 Health Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical Sciences, Brunel University London, Uxbridge, United Kingdom.6 Department of Marketing, Griffith Business School, Griffith University, Brisbane, QLD, Australia. 7 Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada. 8 Sports Spine Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.9 School of Allied Health, University of Limerick, Limerick, Ireland.Corresponding author: Dr. Mary O'KeeffeSchool of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, AustraliaE: Mary.OKeeffe@sydney.edu.au T: +612 8627 6856Word count: 799Keywords: back pain, public health, campaignBack pain is saddled by misconceptions that contribute to low-value care and poor outcomes. Many patients and clinicians mistakenly view the spine as fragile, believe that pain equates to damage, and over-emphasise the role and value of rest, imaging, medication, and surgery.1 Guideline-based care will not be embraced if such misconceptions are not countered. Here we provide four arguments for accessible, engaging and convincing education to the public and health professionals. Mass media campaigns can workThe “Back Pain: Don’t Take it Lying Down” media campaign in Victoria, Australia, aired in the late 1990s and aimed to shift public attitudes about what to do when you experience back pain.2 Television advertisements aired for the first 12 months and again for the final three months of the 3-year period. There were substantial improvements in workers’ compensation costs (15% reduction in the number of claims), as well as back pain beliefs, disability, and medical management by the end of the campaign. Variants of this campaign have been repeated elsewhere, with observed improvements in pain beliefs.3 However, the Australian campaign was the only one to have a significant impact on health care utilisation and disability behaviours, such as work loss. Key contributors to its success are thought to have been significant funding, use of multiple media sources (TV, radio advertising, billboards), and clear advice on staying at work.We need to address ongoing challenges and seize new opportunities   Two decades on from the Victorian media campaign,  additional insights have emerged:Low-value tests and treatments for back pain have proliferated, with increases in the use of medicines, imaging, and surgery. Campaigns that aim to reduce low-value investigations and treatments for back pain, such as Choosing Wisely, have so far failed. Perhaps we could update the successful Victorian campaign to explicitly target low-value care, and steer people towards ‘higher-value’ alternatives. We have an expanded understanding of the myriad of factors that can be involved in the back pain experience. Accurate patient education can provide long-term reassurance to individuals with back pain, and reduce primary care visits.4 Updating the Victorian campaign to include pre-emptive education at the societal level, on the multiple influences (e.g., beliefs, fear, stress, mood) that can influence back pain, may help promote recovery from back pain episodes. We need to integrate new media The media has a central role in our lives. However, the changing media environment in recent decades may stimulate more ‘fake news’ and ‘clickbait’ than reliable scientific reporting.  Any contemporary media strategy should include a social media presence and strategy - “get visible or vanish”.5  To enhance impact, we propose this strategy; (1) prioritise evidence-based communication on social media platforms; (2) develop apps based on theory and rigorous pre-testing, unlike several existing apps which merely distort evidence and spread myths about back pain; (3) target online messaging (e.g. Google Ads) such that when someone searches ‘back pain’ they would receive appropriate information instead of advertisements about non-evidence-based treatments -  as tested with cancer risk and tanning bed use; and (4) promote citizen science endeavours which establish online communities in specific areas to engage the public in research.                                                                                       Such approaches will require knowledge translation funding,  novel thinking to create multimedia assets that will capture attention (e.g., infographics, videos, podcast, etc.) and cater to different learning preferences.5We need to learn from other fieldsPublic health campaigns have contributed to improved behaviours in other fields, for example reducing smoking, use of sunscreen, and road safety.6 Close examination of campaigns outside our field will help our back pain advice "stick," and not backfire. Targeting specific population segments, and using slogans are examples of ‘sticky’ messages. For example, the successful VERB campaign7 was a multiethnic media campaign to increase physical activity among US children which applied marketing techniques at multiple levels (e.g., teens, parents, teachers, etc.). The motto was VERB: “It’s what you do” to encourage lifestyle changes, such as playing more and "trying new verbs."The concepts of ‘demarketing’ and ‘countermarketing’ – encouraging the avoidance of unhelpful behaviours and the promotion of desired behaviours are gaining popularity in other fields.8 For example, discouraging the consumption of sugary drinks and junk food and promoting healthy food.8 For back pain, this could involve discouraging inappropriate imaging and non-evidence based products and encouraging desired alternatives (e.g., watchful waiting, active living).Call to actionNew opportunities and challenges mean we need to update the successful Victorian “Back Pain: Don’t Take it Lying Down” mass media campaign. Long duration, high intensity, campaigns which use multiple media platforms are critical ingredients for a successful campaign.6 Adequate funding, clarity of messaging, and the use of clever visual advertising may also contribute to campaign success. An updated, and contemporary campaign, could form one essential part of a multi-pronged approach to tackling the burden of back pain. Declarations: KOS serves in a voluntary capacity as Senior Associate Editor of BJSM. References: Darlow B, Dowell A, Baxter GD, et al. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med 2013; 11(6): 527-34. 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. Gross DP, Russell AS, Ferrari R, et al. Evaluation of a Canadian back pain mass media campaign. Spine (Phila Pa 1976) 2010; 35(8): 906-13.  Traeger AC, Hübscher M, Henschke N, et al. Effect of Primary Care-Based Education on Reassurance in Patients With Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA Intern Med. 2015;175(5):733–743. Barton CJ, Merolli MA. It is time to replace publish or perish with get visible or vanish: opportunities where digital and social media can reshape knowledge translation. Br J Sports Med 2017 [Epub ahead of print]Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. The Lancet 2010 Oct 9;376(9748):1261-71. Wong F. Huhman M, Asbury L, et al. VERB — A Social Marketing Campaign to Increase Physical Activity Among Youth. Prev Chronic Dis 2004; 1(3): A10.Bellew, W., Bauman, A., Freeman, B, et al. Social countermarketing: brave new world, brave new map. Journal of Social Marketing 2017;7(2): 205-222.

A mass media campaign are needed to counter misconceptions about back pain and promote higher value care.

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A mass media campaign are needed to counter misconceptions about back pain and promote higher value care.

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