The findings from this exploratory study reveal novel and interesting insights about the beliefs and behaviours of significant others in relation to disabling back pain, and how these may act as obstacles to work participation. Significant others shared, and perhaps further reinforced, claimants' unhelpful beliefs including fear of pain/re-injury associated with certain types of work and activity, and pessimism about the likelihood of return to work. In some cases, significant others appeared more resigned to the permanence and negative inevitable consequences of the claimant's back pain condition on work participation, and were more sceptical about the availability of suitable work and sympathy from employers. In their pursuit of authenticity, claimants were keen to stress their desire to work whilst emphasising how the severity and physical limitations of their condition prevented them from doing so. In this vein, and seemingly based on their perceptions of what makes a 'good' significant other, significant others acted as a 'witness to pain', supporting claimants' self-limiting behaviour and statements of incapacity, often responding with empathy and assistance. The beliefs and responses of significant others may also have been influenced by their own experience of chronic illness, thus participants lives were often intertwined and defined by illness.
Unfortunately, the small sample size in this exploratory study meant that it was not possible to establish whether the illness perceptions of significant others had a direct association with claimant illness perceptions and subsequent behavioural responses and/or outcomes. Relatively little research investigating the influence of significant others' illness perceptions on the illness beliefs of partners has been conducted , and more research of this nature with larger samples is required. The small sample size also means that other possible influences on claimant beliefs, such as socio-demographic/economic characteristics cannot be further explored, but which we believe may be important. Nevertheless, many findings in this study are supported by those documented in other studies of chronic back pain, those investigating the influence of significant others on illness, and qualitative research on work participation, all with wider sample heterogeneity.
For example, the desire to be seen as genuine is a common finding in populations experiencing persistent and disabling back pain, probably because it is likely that the cause remains medically unexplained, as is the case for 90% of sufferers . It has been shown that the avoidance of cultural stereotypes associated with unexplained back pain (such as 'malingerer') becomes very important and individuals feel the need to establish their credibility, proving their pain is real [29, 30]. In addition, the associations that participants made between type of work (i.e. manual/heavy/repetitive) and inflexible or unsympathetic employers have been reported in other research carried out with disability benefit claimants , and it should be acknowledged that the ability to re-train or obtain further educational qualifications in order to move into a more suitable occupation is often out of reach for disability benefit claimants due to financial constraints, existing educational level, and limitations posed by ill-health. This highlights the difficulties faced by certain groups in the population in maintaining work participation, and illustrates how sickness absence is mediated by wider social factors . This is supported by the findings from a systematic review of the qualitative literature on return to work after injury which suggest that return-to-work extends beyond concerns about managing physical function to the complexities related to beliefs, roles and perceptions of those involved .
It is acknowledged that qualitative research has its limitations, with criticisms usually focused on issues related to validity and reliability. However, the theoretical model on which this study was based (the SRM) has been successfully applied in many studies investigating various health conditions across a number of settings, and there are several examples in the published literature where qualitative research methods have been used to investigate and elaborate upon its components [[34–36]]. More specifically, a semi-structured interview based on the IPQ-R was recently used in a study of patients with sciatica . It should also be stressed that this study was conceived in response to a call for more qualitative research in this area, and therefore the chosen methodology and the inclusion of significant others helped initiate a wider investigation of psychosocial obstacles to work participation. Further research of this nature is currently underway, and it is hoped that findings will add weight to those of the current study.
Future research may also need to incorporate an examination of the perceived role expectations within relationships (i.e. between parent and child and between spouses) and between genders (for example, all significant others in this study were female), and also the influence that others' own health problems may exert. Findings from the current study appear to support other research which suggests that pain-related empathy is seen by many partners as an essential ingredient of relationship quality, being viewed by many as an important requisite for meeting the patient's support needs . However, the difference between support and solicitous behaviour (responding to pain with expressions of empathy and assistance) may not be clearly understood and unfortunately, such behaviour is linked to poorer functional outcomes, greater pain behaviours and reports of greater pain intensity in patients with chronic pain [[39–42]]. Further investigation of the influence of significant others (who could also be defined as healthcare professionals, employers and those in the welfare system) appears to be a promising area of research and may provide a better understanding of mechanisms that facilitate work retention and effective vocational rehabilitation.