Exploring the lived experience and chronic low back pain beliefs of English-speaking Punjabi and white British people: a qualitative study within the NHS

Introduction Disabling chronic low back pain (CLBP) is associated with negative beliefs and behaviours, which are influenced by culture, religion and interactions with healthcare practitioners (HCPs). In the UK, HCPs encounter people from different cultures and ethnic backgrounds, with South Asian Indians (including Punjabis) forming the largest ethnic minority group. Better understanding of the beliefs and experiences of ethnic minorities with CLBP might inform effective management. Objectives To explore the CLBP beliefs and experiences of English-speaking Punjabi and white British people living with CLBP, explore how beliefs may influence the lived experience of CLBP and conduct cross-cultural comparisons between the two groups. Design Qualitative study using semistructured interviews set within an interpretive description framework and thematic analysis. Setting A National Health Service hospital physiotherapy department, Leicester, UK. Participants 10 CLBP participants (5 English-speaking Punjabi and 5 white British) purposively recruited from physiotherapy waiting lists. Results Participants from both groups held negative biomedical CLBP beliefs such as the ‘spine is weak’, experienced unfulfilling interactions with HCPs commonly due to a perceived lack of support and negative psychosocial dimensions of CLBP with most participants catastrophising about their CLBP. Specific findings to Punjabi participants included (1) disruption to cultural-religious well-being, as well as (2) a perceived lack of understanding and empathy regarding their CLBP from the Punjabi community. In contrast to their white British counterparts, Punjabi participants reported initially using passive coping strategies; however, all participants reported a transition towards active coping strategies. Conclusion CLBP beliefs and experiences, irrespective of ethnicity, were primarily biomedically orientated. However, cross-cultural differences included cultural-religious well-being, the community response to CLBP experienced by Punjabi participants and coping styles. These findings might help inform management of people with CLBP.


Strengths and limitations of this study
• The first study to provide a cross-cultural exploration of CLBP beliefs and experiences of English-speaking Punjabi and White British people living with CLBP.
• Using purposive sampling, 1:1 semi-structured interviews were conducted through a cultural lens to explore beliefs and experiences of Punjabi and White British people with CLBP.
• The study findings were data-driven and embedded in the participants' voice.
• Participants were all English-speaking and were only selected from one geographical location, which may limit the transferability of the findings.
• Member checking was not conducted to validate interview transcripts. Chronic low back pain (CLBP) is the primary cause of disability and financial burden to healthcare and society in the United Kingdom (UK). 1 Despite increasing resources spent to improve CLBP management, the associated disability continues to rise. 2 Historically, the impact of CLBP on developing populations was perceived to be minimal, but is now understood to be similar to western populations. [3][4][5][6][7][8] In the UK a higher incidence of spinal pain has been reported in South Asians, 9 and a higher prevalence of widespread musculoskeletal pain reported in South Asian Indian Punjabis (22%) compared with Europeans (9%). 10 Biomedical beliefs about CLBP are common within western populations and are emergent within developing populations. 3 11 12 Factors thought to influence these beliefs include ethnicity, religion, family and friends, as well as unhelpful interactions with healthcare practitioners (HCPs). 13 14 Current CLBP research has largely focused on western societies with little emphasis on minority ethnic populations; a concern given ethnic migration and cultural diversity is increasing within western societies. According to the last UK Census (2011) 15 Leicester hosts the largest Indian (referring to themselves as Asian or British Asian) population (30%) of any local authority in England and Wales.
Understanding cultural variations in pain perception, beliefs, expectations, and behaviours is important to accurately identify patients' needs and behaviours relative to one's own potentially divergent culture. 16 This may help avoid health inequalities and suboptimal outcomes. 17 18 To tailor management, HCPs might benefit from understanding an individual's beliefs and experiences of CLBP within the cultural context in which they occur. 7 19 Therefore, research is required to understand the management of CLBP within different populations within the UK. Cross-cultural comparative studies utilising qualitative Therefore, this study aimed to investigate the beliefs and experiences of people living with CLBP in English speaking Punjabi and White British populations. The objectives were to explore how these beliefs influence, and impact on, the experience of living with CLBP and identify similarities and differences between the two ethnic groups.

Methodology
Using semi structured interviews this study followed the COnsolidated criteria for REporting Qualitative studies (COREQ) (Supplementary File 1). 20 Interpretative description (ID) was chosen as this qualitative approach has been specifically developed for healthcare enquiries of a clinical phenomenon, using subjective accounts, for the purpose of informing clinical understanding. 21 Prior theoretical and clinical knowledge is valued as a starting point for research in ID, although this can be challenged and developed as the research progresses. 22

Sample
Purposive sampling 23 was employed to recruit White British and Punjabi participants sufficient to enable relevant data to be obtained and analysed. 24 The study setting was Leicester (UK), which hosts a large White British and Punjabi population.
Eligible participants were White British and English speaking Punjabi people aged  years with CLBP of ≥ 6-month duration. 25 Individuals with a previous history of surgery for CLBP, diagnosed with a specific or a serious underlying cause of their CLBP (i.e. fracture, infection, inflammatory spondyloarthropathy, cancer, or nerve root compression) 26 27 or who had previous physiotherapy treatment from the authors (GS, CN) were excluded.

Recruitment
Potential participants were identified by GS following a GP or Consultant referral to an NHS Physiotherapy department for CLBP between April 2014 and April 2015. Study information was posted to eligible individuals with their physiotherapy appointment letter. Following this, an interview was arranged via telephone, prior to physiotherapy commencing. GS obtained written informed consent pre-interview. Recruitment continued until saturation was achieved. 28 All participants were eligible and included. The sample comprised of five White British (2 males: 3 females) and five English speaking Punjabi (3 males: 2 females) people, with a mean age of 40 years (Table 1).

Data collection
In-depth semi-structured interviews were conducted by GS (British Punjabi male) or CN (White British male), with 11 and 13 years musculoskeletal physiotherapy experience respectively, with a special interest and a-priori knowledge of CLBP. Both authors undertook three hours of National Institute of Health Research training on semi-structured interviewing. 29 No prior relationship was established with participants. Interviews took place in a quiet room in the physiotherapy department and lasted between 60-70 minutes.
A topic guide was informed by contemporary CLBP literature, 7 13 and research team expertise. Further refinements were made following two pilot interviews with CLBP patients. 30 The Participants provided demographic data and completed validated questionnaires for pain severity (Numerical Pain Rating Scale was a sub-item score from the Short Form Orebro Musculoskeletal Questionnaire (SFOQ)), 31 functional disability (Oswestry Disability Index) 32 and psychosocial risk profile (including sleep, anxiety, depression, catastrophising, fearactivity and fear-work were sub-item scores from the SFOQ) 31 (Tables 1 and 2).

Data analysis
Interviews were audio-recorded and transcribed verbatim by GS who analysed the data using thematic analysis. 33 Each transcript was analysed line-by-line using an iterative model immediately after the first interview. This involved: data sampling, collection and analysis occurring in tandem as an on-going constant comparative process 34 to facilitate the capture of emergent themes during data collection. 33 This process allowed active engagement and familiarisation with the data and some of the terms for beliefs and coping were identified from previous literature. 7 13 From this, initial themes were generated and data-driven coding facilitated the development of a thematic table, which was modified as data analysis and interpretation evolved (Table 3). Crucially this involved critique by the co-authors (CN, KOS, AS and NH) 35 to enhance rigour and trustworthiness of study findings. 23

Future outlook
Participants tried to maintain a positive future outlook; this was mainly based on prior pain experiences, and individual personalities.
"I even think now that I will wake up and it will all go away and it maybe will." [S2] Despite this, there was an overriding feeling of uncertainty:

"I don't want to think about that because I don't know how I'm going to be" [S5]
For some Punjabi participants' religion was expressed as a key part of their lives and interlinked with their positive outlook on pain. One participant described a hand injury whereby his fingers were amputated as 'God's will' and expressed his positive outlook in the context of his religious beliefs: "Someone up there wanted them so they were gone...my sin plate was wiped clean on that day and we start again." [S1]

Active coping strategies
White British participants' predominantly demonstrated active coping 'self-help' strategies based on prior CLBP experiences and searching online for knowledge and understanding: "I went onto NHS choices and typed in sciatica -just that word and a whole load of stuff comes up and there is one big sentence and it says 'keep active…." [S2] Amongst the White British group, exercise strategies such as stretching, yoga and football were utilised. They commonly shared the narrative 'confronting pain and battling on'. Influenced by a need to avoid interference in one's life, fulfill family and parental duties and to avoid burdening others, this often meant enduring pain.
"I even think now that I will wake up and it will all go away and it maybe will." [S2]

Reliance on HCPs and biomedical interventions
A lack of understanding and control over pain led some participants to rely on HCPs in an unrelenting search for a diagnostic label, whilst others sought reassurance via scans: "I wanted to have a scan just to see if there was anything major ermmm major Both groups expressed varying levels of reliance on medication, ranging from daily use, to situations of desperation where they felt 'physically stuck' or to prevent pain intensifying.
In contrast to White British participants, Punjabi participants' demonstrated a passive reliance on HCPs to provide 'quick fix" interventions including acupuncture, massage and most frequently manual therapies:

"you go there (manual therapist) for a quick fix" [S6]
Protective and avoidance coping strategies In terms of bending, lifting and heavy physical tasks, many participants used protective and avoidance strategies. Meanwhile, experiencing exercise-related pain, increased fear avoidance around exercise, which promoted resting behaviours. Uncertainty about the cause of pain increased hypervigilance to the threat of pain and adherence to manual handling advice to protect the back reflecting a belief of spinal vulnerability: "I think a bit more…. if I have a task that it would probably involve lifting a box or whatever, I will now consciously think, make sure you bend your knees and you keep your back straight if you're lifting something or whatever. Whereas previously you think you are fine, it doesn't matter, nothing is going to happen so…" [S1] Coping transition An interesting difference emerged in the coping trajectories of White British and Punjabi participants. Although, it was not clear how this transition took place, all Punjabi participants' reported a transition from a passive reliance on HCPs for a "quick fix" to more active coping

Psychological and emotional consequences
Across both groups, a number of negative psychological and emotional dimensions of CLBP were expressed. Those with more disabling CLBP most frequently reported depressed mood, hopelessness, frustration, catastrophising thoughts, and uncertainty about pain and lack of control over it.
Depressed mood was most often expressed in relation to the persistence of CLBP, and as a consequence of failed interventions, disruption to sleep and engagement in meaningful activities. Some attributed disabling CLBP to weight gain resulting in depressed mood:

"because I put on a lot of weight when I was bed bound that got me really down" [S5]
Hopelessness was attributed to a lack of control over pain and a lack of support from HCPs, who in some cases painted a pessimistic outlook: "No I mean they just said it's just down to wear and tear basically and you've got to live with it" [S9] Frustration was repeatedly expressed in relation to a lack of understanding of the cause of pain, and the interference with daily life, and in some cases the desire to exercise and lose weight. Participants with more disabling pain held catastrophic CLBP thoughts. Similar to depressed mood and frustration, this was associated with diagnostic uncertainty and a lack of control over pain, resulting in catastrophising about the future:

"I might not walk again" [S5]
Catastrophic nature of pain flare-ups Often participants' used catastrophic language to portray the unpredictable, fluctuating and uncontrollable disabling impact of flare-ups, for example: Threat to self-identity Cross-cultural comparisons highlighted that CLBP posed a major threat to participants' 'self' and their identity. Some described negative consequences of CLBP such as low selfesteem, reduced independence and disempowerment. One participant expressed disabling CLBP as a major loss: "Everything is just gone now like dignity, confidence. I had a stick but I would only use that sometimes if I was going out" [S5] During flare-ups, a small number expressed difficulties carrying out daily functional activities.
The greatest impact seemed to be on bending-related tasks such as putting on socks and hoovering. This led to dependency on family members and changing roles in their relationships, which negatively impacted participants' psychological and emotional wellbeing. However, uncertainty about the actual cause of their pain was most common, partly due to mixed messages conveyed by HCPs and inconclusive radiological investigations.

Biomedical beliefs
Biomedical CLBP beliefs were common amongst all participants, their family, friends and particularly the wider Punjabi community. This supports the view that biomedical beliefs may not be exclusive to certain populations, instead reflecting the views of western society overall. 8 36 Biomedical beliefs conveyed by HCPs were adopted by, or were similar to those already held by, participants', consistent with other studies. 13 37 These beliefs were often associated with negative CLBP information, 38 around bending and lifting, perpetuating beliefs of spinal vulnerability culminating in fear avoidance beliefs and behaviours. 39 Further, the role of cultural-religious pain beliefs in promoting a positive future outlook has been documented in other cultural groups. 40 However only one Punjabi participant expressed pain beliefs within a positive cultural-religious context, perhaps reflecting participants' predominantly biomedical beliefs.

Coping strategies and transition
Illustrated as an on-going challenge by many participants, coping strategies have been shown to influence the development and persistence of CLBP. 41 Most White British medications. 44 In contrast, in our study Punjabi participants' pursued more conventional western medications and interventions. This may reflect greater awareness of, or access to, these treatment options. A novel finding of our study is that all Punjabi participants reported a transition from passive to active coping strategies. 3 5 This may reflect the limited effects of passive interventions, as well as greater knowledge and understanding of CLBP and the potential benefits of active coping strategies. Alternatively, this group may have complied with the HCPs approach to management even if it was not their preference.

Psychological and emotional dimensions
The impact of CLBP has been found to extend beyond physical domains, 3 with many negative and often life-changing psychological and emotional effects. 19 36 45 Contrary to earlier research, 46 participants did not appear to consider these factors as contributors to CLBP, instead viewing these as secondary effects of CLBP. Supporting this, one study found South Asians were unwilling to recognise the influence of psychological, emotional and social factors on their pain. 43 However, negative beliefs about the control of CLBP and the resulting passive coping often reported by participants may have a mediating influence  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59

Social and cultural-religious dimensions
Similar to other studies, CLBP was highly disabling, described as a 'major loss' by some. It impacted on many aspects of individual's lives including their identity, self-esteem and independence, leaving some disempowered. 45 51 52 For many, this meant their lives were 'on hold', a finding consistent with a recent systematic review. 36 Our data supports the notion that CLBP impacts meaningful relationships, threatening parental and family duties and for some resulting in social isolation. 3 5 45 With regards to work, although participants' demonstrated some avoidance behaviours in the workplace, at the time of interviewing only one participant was absent from work due to CLBP. This may reflect active coping in relation to work, possibly influenced by financial concerns associated with sickness absence, good work support and job satisfaction 53 or positive HCP advice relating to work.

Cultural differences
To date, qualitative research in the UK has paid little attention to the CLBP experience through a cultural and ethnic lens. This requires consideration, given the degree to which individuals identify with their ethnic group, share beliefs and engage in culture roles, which can influence pain experiences. 40 Consistent with other ethnic minority CLBP studies, 7 11 Punjabi participants' experienced a disruption to cultural-religious wellbeing, and endured a negative response from the wider community. In this context, some novel and potentially important themes were identified. As Punjabi participants expressed, religion maybe important to people in ethnic minority populations, 40 disruption to sitting-based meditation in some cases resulted in immense frustration and isolation. In some populations the perceived view of the female role involves housework and preparing for marriage, or serving the husband. 3 11 This perception appears similar to those held within the Punjabi community.
CLBP undermined the ability to carry out these duties. For one participant this created uncertainty about finding a marriage partner, and feelings of guilt and burden on other female family members, due to increased workloads placed upon them. Our findings support those in other ethnic populations where gender differences exist in the experience of CLBP. 3 5 One novel finding of our study was that Punjabi participants' perceived a lack of empathy and understanding from the Punjabi community, and for some CLBP was a source of CLBP was associated with negative psychological and social consequences. Cross-cultural differences related to the negative impact on cultural-religious aspects of Punjabi participants' lives particularly the perceived female role. Punjabi participants also reported a transition from passive to active CLBP coping strategies and experiencing a lack of empathy from Punjabi community members. HCPs should therefore adopt a culturally-sensitive approach to the management of CLBP, which considers individuals' beliefs and experiences.

Acknowledgements
Thanks to all participants who took the time to share their stories and experiences.

Introduction to the interview:
The interviewer will reassure the person being interviewed that: • The research study is interested in finding out about their beliefs and experiences in living with CLBP • There is no intention of 'testing' the interviewees about how well they are managing their CLBP.
• That they are free to say as much or as little as they wish in response to any line of questioning.
• That the content of the interview will not be divulged to their Doctor or Physiotherapist.

Background information:
In order to be able to describe the sample of patients who contribute to the study, the interviewer will invite the person being interviewed to provide information about: • Ethnicity -participant to define their ethnicity • Age • Occupation • When their LBP first started • Previous treatment Interview guide with prompts: Opening A. History of illness and health seeking behaviour 1) When did it start to impact on your daily life?
2) Who have seen regarding your CLBP problem? Probe: • Have you had any Investigations? • What did they show?
• What treatment (s) have you had in the past for your LBP?
• How helpful were these treatments?

B. Coping strategies
3) How do you cope with your CLBP at present? Probe: • What strategies do you have to manage your CLBP?
• What do you do when you have a flare up of pain?
• How do those around you cope/help (i.e. family or friends)?
• Does anyone in your family suffer with CLBP? How do they cope?
How well do you think you manage your CLBP? • Is bending/ lifting safe to do?

C. Cause of condition
• Is there anything you avoid doing because of your CLBP?

11) What do you think is the effect of CLBP on your mood?
12) How much of your focus and attention does your CLBP take?
13) What do you feel will be the best way to treat your CLBP from now? Probe: • What type of treatment? 14) How do you see the future with regards to your CLBP?

Probe:
• How hopeful are you about the future?
• Do you feel your LBP will get better?

Ending questions
15) Is there anything else that you would like to say that we may not have covered already or discussed?
Thank you for co-operation and for taking the time to answer all the questions.

After 3 rd interview Revised Topic guide Background information:
In order to be able to describe the sample of patients who contribute to the study, the interviewer will invite the person being interviewed to provide information about: • Ethnicity -participant to define their ethnicity • Age • When did it start to impact on your life?
• How did this affect you?

B. CLBP experiences and beliefs
Childhood/Family history of LBP/pain

Can you recall any early life experiences of LBP /pain?
• What was your experience?
• Were you told anything about it at the time? By whom?
• How did you cope with it?
• How did your family/friends react /respond towards your LBP/pain?
• What was the attitude of your parents towards your LBP/pain?
While you were growing up, did your parents/family member(s) suffer with LBP/pain?
• What was their experience?
• How did it impact on them?
• What was the cause of their pain?
• How did they try to cope with it?
• Did it have any impact on you and your family?
• Do you feel these experiences of pain have affected the way you think about your LBP?
Who have you been to see regarding your LBP?
• What was your experience?
• Did you have any examinations or tests? i.e. MRI/ x-ray • What did they show?
• How was this explained to you?
• Was the language used simple, or did it include medical terms?
• What was your understanding of this? • How did this make you feel?

What have you been told about the cause of your LBP?
• By whom?
• How was this explained to you?
• Was the language used simple, or did it include medical terms?
• What was your understanding of this?
• How did this make you feel?
What are your thoughts about the cause of your LBP?
• What makes you think this?
• What things have influenced your thoughts? o Family, culture, pain experiences, interactions with HCPs?
What do you feel people around you think causes LBP?
• Where do you think these ideas come from?

What treatment(s) have you had in the past for your LBP?
• What was your experience of these treatments?
• Did they match what you thought would be best for your LBP? If not, why not?
• Did these treatments influence your: o Control over your LBP?
o Ability to do things you wanted to do?
o Confidence regarding your back?
How do you cope with your LBP now?
• If you had a flare up, how would you manage it? Why?
• How would you manage an acute ankle or knee sprain?
• Would this be the same or different to a LBP flare up? If not, why?
• How do those around you respond or react to you regarding your LBP (i.e. family or friends)?

How do you feel HCP's have interacted with you regarding your LBP?
• What was your experience of the time they spent?
• How well did they listening to you?
• Did they build your confidence? • What are your experiences?
• Have you experienced any differences or inequalities due to your cultural background?

D. Views on exercise and physical activity
What are your thoughts about people with LBP doing physical exercise?
• Is there anything you should avoid doing because of your LBP? Why?
• What are views on people with LBP bending/ lifting? Why?

E. Alternative treatments
Many people use alternative treatments e.g. acupuncture/reiki/reflexology for LBP How do you picture yourself in 5 years with regards to your CLBP?
• How hopeful are you about the future?
• Do you feel your LBP will get better? Why?
Ending questions Is there anything else that you would like to say that we may not have covered already or discussed? Thank you for co-operation and for taking the time to answer all the questions.

Interview transcript exerts and comments
The GS's comments on interviews are illustrated below, Transcript S1, lines 1019-1042 I: Right, that's interesting. So with regards to bending and lifting, what are your thoughts on that? P: I make sure that . when I am lifting something or I have to bend down, I make absolutely sure that I am bending my knees and not just tipping over or whatever I: Ok P: You know, your manual handling and all that comes in .so you start thinking, the last thing I want to do is injure myself further or cause any more discomfort I: Ok P: So you are bending your knees and making sure you are lifting it .GS's thoughts Impact of manual handling training/Impact of pain on function -bending/lifting -Adopted cautious/protective behvoiur to bending /lifting -Psychological impact vigilance/catstrophising I: And how long have you been doing that for? P: Well, years now I: So before your back started hurting? P: O yeah I: Then has that changed at all since your back? P: No .I think a bit more .conscious. Consciously, it's almost like if you have .when I say you , if I have a task that it would probably involve lifting a box or whatever, I will now consciously think, make sure you bend your knees and you keep your back straight if you're lifting something or whatever. Whereas previously you think you are fine, it doesn't matter, nothing is going to happen so . GS's thoughts Psychological impact of painhypervigilance/ catastrophising with lifting having -Adopted manual handling behavoiur to protect back from future pain -Increased threat to back I: So your thought process around your lifting has changed? P: It has changed, yes. It will change I: Ok. So what thoughts are going through your mind then when you see something heavy on the floor? P: Making sure that you don't end up causing more damage GS's thoughts Coping startgeies-Atuuidtde to pain -Biomedical belief -Protective behavoiur/Caution  "I went pick a pair of socks up from the floor so and as I went to pick it up as I was getting back up there was just like this crack sounding noise and erm I think that was my first experience of it." [S10] "It was definitely related, there was a timber and I went to pick it up and I felt my back hurt" [S2] "I was involved in a car accident where my car, at a roundabout junction, was hit from the back and I think because of the angle I was standing with my neck turned, the impact was quite severe" [S1 PM MD MPR]. "I had a complicated pregnancy in 1995. Ahh, with my son, it was a very difficult birth; really prolonged labour and ammm significant problems during the actual birth. That was quite a shock, needless to say. I didn't have any epidural or anything like that when I had him so my body went in to shock I think with the experience .I started to get it ." [S4 WBF MD MPR] "It could be a trapped nerve, a slipped disc" [S1 PM MD MPR] " I suppose I'd always think it gets to the point where they cant actually find anything wrong so its wear and tear because of your age, because there's 50 odd years of and its almost something which I accept. You almost expect it because you see old people who are struggling with joints and this sort of thing and you think well yeah but for 80 odd years those knees have worked so I can understand a bit of it" [S8 WM LD LPR] "My mother in law just says its lifting and stuff"  Pessimism "I even think now that I will wake up and it will all go away and it maybe will." [S2 WBM MD HPR] "Well hopefully in a little less pain than I am in right now" [S3 WBF MD MPR] "I think it's always going to hurt me and it's always going to cause me pain" [S5 PF HD HPR] "When I look into the future I just think how am I gonna cope with a child when I can't yknow "I try and do other things now to like maybe go to the cinema and like sit in the big seats and like try and make myself a bit comfortable and like..because I've had it for so long I've gotten used to like erm making plans with my back pain so erm I'm not as depressed as I would've been maybe 5-10 years ago" [S10 PF HD HPR]  "The pain constraints on work"[S1 PM MD MPR]. "I've also had to raise it with work because of the amount of time I sit by the computer and they've had to get me a special chair" [S10 PF HD HPR] "While my job is actually fully sitting down, any activities where they have asked me to go and do outreach sessions, I have had to restrict them or send other people, which again isn't ideal but other people can deputise as necessary" [S2 WBM MD HPR] "I didn't drive.,,.,,I went into the office a few times but then got a lift into the office from colleagues" [S7 PM MD MPR] "I think I only might have had a few days off in the whole time I was there for the pain" [S3 WBF MD MPR] "I'm off work I've had so much time off work"[S9 WBF MD HPR] "I'm in the building trade without a back I can't earn no money. So that goes through your mind as well as that you're not going to get no sick pay or anything" [S6 PM LD LPR] "Still go to work ermmm because I've got still got bills to pay and I've still for me daughter to support through university and so on and so forth so there's that pressure" [S8 WM , he was just getting more and more annoyed every time because there was no answers"[S5 PF HD HPR] "People were badgering me, yknow its not getting any better you ought to go ..and see"[S8 WM LD LPR] "Yeah and whenever I did anything they'd say oh watch your back, you'd be carefully about, you don't want that happening again" [S9 WBF MD HPR] "Everyone thinks like "oh her back her back, she just uses that as an excuse now " [S10 PF HD HPR] "Unfortunately there is always this advice from the community that oh I had a similar thing no you didn't because you have no idea what the cause of my problem is "[S1 PM MD MPR] "I believe they're like the doctors that I've experienced. They always assume the worst first yknow" [S10 PF HD HPR] "Oh there comes a fat cow, she's got back, yknow she just can't get up, or oh let's make room for her she's like she can't stand up or just that kind of response. It's not about pain it's about oh she's too big, she can't do Information, and a consent letter for telephone contact were posted to eligible individuals with their physiotherapy appointment letter.

Sample size
How many participants were in the study?
Ten Methods and Results - Table 1 13. Non-participation How many people refused to participate or dropped out? Reasons?
Ten potential participants that were invited for a semi-structured interview, all gave informed consent and completed the interview. There were no participants who subsequently refused to participate, withdrew consent or dropped out.

Setting of data collection
Where was the data collected? e.g. home, clinic, workplace All interviews were conducted in a quiet room in the physiotherapy department.

Presence of nonparticipants
Was anyone else present besides the participants and researchers? Provided in Table 3: The thematic development illustrating key stages when themes were changed.

Strengths and limitations of this study
• The first study to provide a cross-cultural exploration of CLBP beliefs and experiences of English-speaking Punjabi and White British people living with CLBP.
• Using purposive sampling, 1:1 semi-structured interviews were conducted through a cultural lens to explore beliefs and experiences of Punjabi and White British people with CLBP.
• The study findings were data-driven and embedded in the participants' voice.
• Participants were all English-speaking and were only selected from one geographical location, which may limit the transferability of the findings.
• Member checking was not conducted to validate interview transcripts. Historically, the impact of CLBP on developing populations was perceived to be minimal, but is now understood to be similar to western populations. [3][4][5][6][7][8] In the UK a higher incidence of spinal pain has been reported in South Asians, 9 and a higher prevalence of widespread musculoskeletal pain reported in South Asian Indian Punjabis (22%) compared with Europeans (9%). 10 Biomedical beliefs about CLBP are common within western populations and are emergent within developing populations. 3 11 12 Factors thought to influence these beliefs include ethnicity, religion, family and friends, as well as unhelpful interactions with healthcare practitioners (HCPs). 13 14 Current CLBP research has largely focused on western societies with little emphasis on minority ethnic populations; a concern given ethnic migration and cultural diversity is increasing within western societies. According to the last UK Census (2011) 15 Leicester hosts the largest Indian (referring to themselves as Asian or British Asian) population (30%) of any local authority in England and Wales.
Understanding cultural variations in pain perception, beliefs, expectations, and behaviours is important to accurately identify patients' needs and behaviours relative to one's own potentially divergent culture. 16 This may help avoid health inequalities and suboptimal outcomes, 17 18 an important consideration for healthcare policy makers and those

Methodology
Using semi structured interviews this study followed the COnsolidated criteria for REporting Qualitative studies (COREQ) (Supplementary File 1). 20 Interpretative description (ID) was chosen as this qualitative approach has been specifically developed for healthcare enquiries of a clinical phenomenon, using subjective accounts, for the purpose of informing clinical understanding. 21 Prior theoretical and clinical knowledge is valued as a starting point for research in ID, although this can be challenged and developed as the research progresses. 22

Sample
Purposive sampling 23 was employed to recruit White British and Punjabi participants sufficient to enable relevant data to be obtained and analysed. 24 The study setting was Leicester (UK), which hosts a large White British and Punjabi population.
Eligible participants were White British and English speaking Punjabi people aged 18-65 years with CLBP of ≥ 6-month duration. 25 Individuals with a previous history of surgery for CLBP, diagnosed with a specific or a serious underlying cause of their CLBP (i.e. fracture, infection, inflammatory spondyloarthropathy, cancer, or nerve root compression) 26 27 or who had previous physiotherapy treatment from the authors (GS, CN) were excluded.

Recruitment
Potential participants were identified by GS following a GP or Consultant referral to an NHS Physiotherapy department for CLBP between April 2014 and April 2015. Study information was posted to eligible individuals with their physiotherapy appointment letter. Following this, an interview was arranged via telephone, prior to physiotherapy commencing. GS obtained written informed consent pre-interview. Recruitment continued until saturation was achieved 28 , where robust common themes were established which included knowledge that could

Data collection
In-depth semi-structured interviews were conducted by GS (British Punjabi male) or CN (White British male), with 11 and 13 years musculoskeletal physiotherapy experience respectively, with a special interest and a-priori knowledge of CLBP. Both authors undertook three hours of National Institute of Health Research training on semi-structured interviewing. 29 No prior relationship was established with participants, following the interview all participants commenced physiotherapy treatment with physiotherapists that were not involved with this study. Interviews took place in a quiet room in the physiotherapy department and lasted between 60-70 minutes.
A topic guide was informed by contemporary CLBP literature, 7 13 and research team expertise. This informed the basis and boundary of focus moving forward to analysis in accordance with interpretive description 21 . Further refinements were made following two pilot interviews with CLBP patients. 30 The Participants provided demographic data and completed validated questionnaires for pain severity (Numerical Pain Rating Scale was a sub-item score from the Short Form Orebro Musculoskeletal Questionnaire (SFOQ)), 31 functional disability (Oswestry Disability Index) 32  31 (Tables 1 and 2).

Data analysis
Interviews were audio-recorded and transcribed verbatim by GS who analysed the data using thematic analysis. 33 GS considered each script repeatedly as a way to immerse himself in the data before coding began 21 . Each transcript was analysed line-by-line using an iterative model immediately after the first interview. This involved: data sampling, collection and analysis occurring in tandem as an on-going constant comparative process 34 to facilitate the capture of emergent themes during data collection. 33 This process allowed active engagement and familiarisation with the data. However some of the terms for beliefs and coping were identified from previous literature. 7 13 These terms represented critical analysis and recontexulisation of knowledge from which the analysis could be shaped 21 . From this, initial themes were generated and data-driven coding facilitated the development of a thematic table, which was modified as data analysis and interpretation evolved      Consistent with these beliefs, in cases where a physical causal mechanism could not be recalled, participants self-diagnosed a structural/anatomical cause for their CLBP. The most frequently expressed labels included: 'slipped disc' (n=5), 'wear and tear' (n=3) and 'trapped nerve' (n=3).

Vulnerability of the spine
Many viewed their spine as vulnerable, central to function and critical to one's well-being.
Given participants' had 'one back', that was hard to see, combined with a feeling of weakness, the back was commonly described as 'precious', and when compared to an ankle sprain required more protection:

Future outlook
Participants tried to maintain a positive future outlook; this was mainly based on prior pain experiences, and individual personalities.
"I even think now that I will wake up and it will all go away and it maybe will." [S2] Despite this, there was an overriding feeling of uncertainty:

"I don't want to think about that because I don't know how I'm going to be" [S5]
For some Punjabi participants' religion was expressed as a key part of their lives and interlinked with their positive outlook on pain. One participant described a hand injury whereby his fingers were amputated as 'God's will' and expressed his positive outlook in the context of his religious beliefs: "Someone up there wanted them so they were gone...my sin plate was wiped clean on that day and we start again." [S1]

Active coping strategies
White British participants' predominantly demonstrated active coping 'self-help' strategies based on prior CLBP experiences and searching online for knowledge and understanding:

"I went onto NHS choices and typed in sciatica -just that word and a whole load of stuff comes up and there is one big sentence and it says 'keep active ." [S2]
Amongst the White British group, exercise strategies such as stretching, yoga and football were utilised. They commonly shared the narrative 'confronting pain and battling on'. Influenced by a need to avoid interference in one's life, fulfill family and parental duties and to avoid burdening others, this often meant enduring pain.
"I even think now that I will wake up and it will all go away and it maybe will." [S2]

Reliance on HCPs and biomedical interventions
A lack of understanding and control over pain led some participants to rely on HCPs in an unrelenting search for a diagnostic label, whilst others sought reassurance via scans:

Psychological and emotional consequences
Across both groups, a number of negative psychological and emotional dimensions of CLBP were expressed. Those with more disabling CLBP most frequently reported depressed mood, hopelessness, frustration, catastrophising thoughts, and uncertainty about pain and lack of control over it.
Depressed mood was most often expressed in relation to the persistence of CLBP, and as a consequence of failed interventions, disruption to sleep and engagement in meaningful activities. Some attributed disabling CLBP to weight gain resulting in depressed mood:

"because I put on a lot of weight when I was bed bound that got me really down" [S5]
Hopelessness was attributed to a lack of control over pain and a lack of support from HCPs, who in some cases painted a pessimistic outlook:

"No I mean they just said it's just down to wear and tear basically and you've got to live with it" [S9]
Frustration was repeatedly expressed in relation to a lack of understanding of the cause of pain, and the interference with daily life, and in some cases the desire to exercise and lose weight. Participants with more disabling pain held catastrophic CLBP thoughts. Similar to depressed mood and frustration, this was associated with diagnostic uncertainty and a lack of control over pain, resulting in catastrophising about the future:

"I might not walk again" [S5]
Catastrophic nature of pain flare-ups Often participants' used catastrophic language to portray the unpredictable, fluctuating and uncontrollable disabling impact of flare-ups, for example: During flare-ups, a small number expressed difficulties carrying out daily functional activities.
The greatest impact seemed to be on bending-related tasks such as putting on socks and hoovering. This led to dependency on family members and changing roles in their relationships, which negatively impacted participants' psychological and emotional wellbeing.

Threat to family/friend relationships and social life
Mostly expressed by White British participants', the interference of CLBP on family relationships and fulfilling parental roles was described as 'restrictive' on their spouse/partner, often eliciting negative emotions in family members. One participant identified her coping strategies as a potential cause of frustration: However, uncertainty about the actual cause of their pain was most common, partly due to mixed messages conveyed by HCPs and inconclusive radiological investigations.

Appraising interventions and ability to control CLBP
Reflecting on prior CLBP management, this was embedded within the biomedical model for the majority. Treatment interventions were appraised in relation to their therapeutic effect and the participant's ability to control their pain. Medications, despite being taken for long periods were deemed largely ineffective by many, as was acupuncture. In addition, a reliance on manual therapies offered minimal long-term effect:

"If I'm honest -at the time it's a psychological plaster" [S4]
Expectations of future management strategies, but all reported a transition to active coping strategies.

Biomedical beliefs
Biomedical CLBP beliefs were common amongst all participants, their family, friends and particularly the wider Punjabi community. This supports the view that biomedical beliefs may not be exclusive to certain populations, instead reflecting the views of western society overall. 8 36 Biomedical beliefs conveyed by HCPs were adopted by, or were similar to those already held by, participants', consistent with other studies. 13 37 These beliefs were often associated with negative CLBP information, 38 44 In contrast, in our study Punjabi participants' pursued more conventional western medications and interventions. This may reflect greater awareness of, or access to, these treatment options, given Punjabi participants were third generation UK born and likely well acculturated. A novel finding of our study is that all Punjabi participants reported a transition from passive to active coping strategies. 3 5 This may reflect the limited effects of passive interventions, as well as greater knowledge and understanding of CLBP and the potential benefits of active coping strategies. Alternatively, this group may have perceived the HCP as an authoritarian figure and complied with the HCPs approach to management even if it was not their preference.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 22

Psychological and emotional dimensions
The impact of CLBP has been found to extend beyond physical domains, 3 with many negative and often life-changing psychological and emotional effects. 19 36 45 Contrary to earlier research, 46 participants did not appear to consider these factors as contributors to CLBP, instead viewing these as secondary effects of CLBP. Supporting this, one study found South Asians were unwilling to recognise the influence of psychological, emotional and social factors on their pain. 43 However, negative beliefs about the control of CLBP and the resulting passive coping often reported by participants may have a mediating influence on depressed mood, pain and disability. 47 Feelings of frustration were common amongst participants' due to a lack of explanation and understanding about CLBP, including inconclusive diagnostic radiological investigations. This may reflect their desire for answers linked with pain legitimisation and validation. 48 Contrary to previous research, 49 perceptions of 'not feeling believed' were not consistent with participants' views, nor were feelings of anger and perceived injustice associated with the negative impact of CLBP. Perhaps, these feelings did exist, but were not expressed due to fear of being judged or it negatively impacting on physiotherapy. Furthermore, our findings lend support to a study showing catastrophic thoughts were associated with a magnified threat to the 'unpredictable' and 'fluctuating' nature of pain flare-ups, excessive worry about pain and a pessimistic view of controlling pain. 50

Social dimensions
Similar to other studies, CLBP was highly disabling, described as a 'major loss' by some. It impacted on many aspects of individual's lives including their identity, self-esteem and independence, leaving some disempowered. 45 51 52 For many, this meant their lives were 'on hold', a finding consistent with a recent systematic review. 36 Our data supports the notion that CLBP impacts meaningful relationships, threatening parental and family duties and for some resulting in social isolation. 3 5 45 With regards to work, although participants'  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 23 demonstrated some avoidance behaviours in the workplace, at the time of interviewing only one participant was absent from work due to CLBP. This may reflect active coping in relation to work, possibly influenced by financial concerns associated with sickness absence, good work support and job satisfaction 53 or positive HCP advice relating to work.

Therapeutic alliance and a person-centred approach
Strong therapeutic alliance in the management of CLBP has been associated with greater treatment compliance, improved clinical outcomes 54 and greater levels of patient satisfaction. 55 However, most participants' experienced weak therapeutic alliance.
Associated with weak therapeutic alliance, 56 the management of CLBP for most was viewed as lacking an individualised and holistic approach. Furthermore, participants' predominantly experienced a lack of guidance and support, and poor HCP communication. 19  It is also worth noting that participants' in our study did not experience inequalities in accessing care or treatment, contrary to findings in other South Asian ethnic populations, 61 62 who utilised participants' with low acculturation levels. Participants' experience of HCP interactions highlighted a biomedical approach to CLBP. This may be due to the influence of  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   24 HCPs biomedical CLBP beliefs on their clinical management. 13 Interestingly, most participants' sought an individualised self-management approach 59 60 63 delivered by empathetic HCPs with effective communication, 64 perhaps more aligned with the biopsychosocial model. This quest, along with Punjabi participants' transition to seek active coping strategies, demonstrates a desire for self-efficacy, which has been linked with reduced disability. 65 HCPs biomedical preference for managing CLBP may highlight discordance with the bio-psychosocial model advocated by recent NICE guidelines, 66 and has been associated with poor adherence to treatment. 13 Thus more individualised multidimensional approaches to management, 67 built on effective communication facilitating strong therapeutic alliance 68 and self-management might be needed.

Cultural differences
To date, qualitative research in the UK has paid little attention to the CLBP experience through a cultural and ethnic lens. This requires consideration, given the degree to which individuals identify with their ethnic group, share beliefs and engage in culture roles, which can influence pain experiences. 40 Consistent with other ethnic minority CLBP studies, 7 11 Punjabi participants' experienced a disruption to cultural-religious wellbeing, and endured a negative response from the wider community. In this context, some novel and potentially important themes were identified. As Punjabi participants expressed, religion maybe important to people in ethnic minority populations, 40 disruption to sitting-based meditation in some cases resulted in immense frustration and isolation. In some populations the perceived view of the female role involves housework and preparing for marriage, or serving the husband. 3 11 This perception may be similar to those held within the Punjabi community.

Strengths limitations and implications for future research
One of the study strengths is its relevance to clinical practice. This is the first cross-cultural study to explore CLBP beliefs and experiences in English speaking Punjabi and White British people living with CLBP. The study findings were data-driven and embedded in the participants' voice. Reflexivity was demonstrated throughout with the authors declaring how their ethnicity; novice researcher role, special clinical interest in CLBP and a-priori knowledge may have influenced data collection, analysis and interpretation.

Implications for practice and policy
This study contributes to existing knowledge by providing HCPs managing CLBP in White British and English-speaking Punjabi people new insights, Which could improve CLBP management within these groups. There may be specific training needs for HCPs to better understand the multifactorial nature of CLBP, specifically the individual's beliefs and experiences within their psychosocial and cultural-religious context. 58 70 This, in addition to developing a flexible communication style that facilitates strong therapeutic alliance may help tailor management within a person-centred approach.
Other HCP priorities could include disseminating evidence-based beliefs amongst patients and the public including ethnic minority populations. 7 47 Conclusion CLBP beliefs and experiences similar across both groups were biomedically-orientated.

Acknowledgements
Thanks to all participants who took the time to share their stories and experiences.

Footnotes
Twitter: Follow @gsingh1902, @ChrisNewtonPT, @A_Soundy, @kieranosull @HeneghanNicola Contributor ship statement: GS together with CN, KOS, AS and NH were responsible for the conception and design of the study. GS and CN were responsible for data collection. GS was responsible for transcription, leading data analysis and initial drafting of the article. GS, CN, KOS, AS and NH contributed to analysis, interpretation and manuscript development.

Sample size
How many participants were in the study?
Ten Methods and Results - Table 1 13. Non-participation How many people refused to participate or dropped out? Reasons?
Ten potential participants that were invited for a semi-structured interview, all gave informed consent and completed the interview. There were no participants who subsequently refused to participate, withdrew consent or dropped out.

Setting of data collection
Where was the data collected? e.g. home, clinic, workplace All interviews were conducted in a quiet room in the physiotherapy department.

Presence of nonparticipants
Was anyone else present besides the participants and researchers? Provided in Table 3: The thematic development illustrating key stages when themes were changed.

Introduction to the interview:
The interviewer will reassure the person being interviewed that:  The research study is interested in finding out about their beliefs and experiences in living with CLBP  There is no intention of 'testing' the interviewees about how well they are managing their CLBP.
 That they are free to say as much or as little as they wish in response to any line of questioning.
 That the content of the interview will not be divulged to their Doctor or Physiotherapist.

Background information:
In order to be able to describe the sample of patients who contribute to the study, the interviewer will invite the person being interviewed to provide information about:  Ethnicity -participant to define their ethnicity  Age  Occupation  When their LBP first started  Previous treatment Interview guide with prompts: Opening A. History of illness and health seeking behaviour 1) When did it start to impact on your daily life?
2) Who have seen regarding your CLBP problem?

Probe:
 Have you had any Investigations?  Do you feel your LBP will get better?

Ending questions
15) Is there anything else that you would like to say that we may not have covered already or discussed?
Thank you for co-operation and for taking the time to answer all the questions.

After 3 rd interview Revised Topic guide Background information:
In order to be able to describe the sample of patients who contribute to the study, the interviewer will invite the person being interviewed to provide information about:  Ethnicity -participant to define their ethnicity  Age  How was this explained to you?
 Was the language used simple, or did it include medical terms?
 What was your understanding of this?  What was your experience of the time they spent?
 How well did they listening to you?
 Did they build your confidence?  Do you feel your LBP will get better? Why?