To our knowledge this is the first study that has investigated the LBP-related beliefs of Chinese HCPs working in metropolitan and regional China, specifically, their beliefs about the inevitable consequences of LBP and fear avoidance beliefs related to their own LBP experience. Our results suggest that younger HCPs and those working in regional community health centres had more negative beliefs about the inevitable consequences of future life with LBP. The estimated statistically significant difference of 2.4-point in BBQ scores between younger (20–29 age group) and older HCPs (>40 years old) and in different work settings is considered clinically meaningful . Buchbinder and colleagues , in a two-year population-based longitudinal study, documented that a 2-point change in BBQ score was associated with a reduction in medical claims related to the management of LBP.
Fear avoidance beliefs were also associated with age, where younger HCPs with LBP were more fearful that engaging in work-related activities would exacerbate their LBP. HCPs who experienced greater LBP-related disability also reported greater fear avoidance attitudes with this study estimating a 3- to 6-point difference in the FABQ physical and work subscale, respectively. The minimal clinically significant changes for the FABQ subscales have not been well validated but it has been theorized that a 6-point change in the FABQ-physical will see a clinically meaningful reduction in self-perceived disability based on the Oswestry Disability Index .
This study estimates that age is an important correlate for both BBQ and FABQ-work scores suggesting that older HCPs, regardless of their disciplines or occupation, had more positive beliefs (better outlook) about inevitable consequence of LBP and less fear avoidance beliefs about work. Possible reasons for this may be because they have more experience in treating people with pain; they may be indifferent to their LBP and continue with their normal level of work and socialization ; and because of their positive beliefs, they play a more active role in their own management . Further, we have captured the older HCPs who continued to stay in the workforce, due to their more positive beliefs, as those who were more fearful that work may make their LBP condition worse may have left the profession. Whilst other studies did not find age to be an important correlate of BBQ [61, 63] and FABQ [30, 64], direct comparisons cannot be made due to the difference in age-group classification used [30, 64] and difference in the characteristics of the samples [61, 63].
Healthcare professionals working in regional community health centres were estimated to have poorer beliefs about the consequences of LBP compared to those working in tertiary teaching hospitals in metropolitan Shanghai. As beliefs can be shaped by education [34, 35, 39], it is reasonable to suggest that the following reasons may account for this; first, there may be lack of resources and opportunities to access contemporary evidence-based clinical guidelines in the more geographically-remote regions. It has been documented that accessibility to LBP information, services and training was more limited in rural country towns compared to metropolitan areas in Western nations, and it is likely this situation is mirrored in China . Second, those HCPs working in teaching hospitals may have more opportunity for continuing professional education programs, attendance at talks/seminars by international speakers and international exchanges; hence greater exposure to current evidence-based practices. Third, by virtue of co-location of clinical teams in tertiary centres, HCPs may more readily engage in interdisciplinary practice for management of LBP and therefore be exposed to more positive patient outcomes associated with this model of care compared to single-discipline practice. Fourth, the level of English amongst HCPs in Shanghai city is generally better than in the outskirts of Shanghai, which may be a barrier to accessing research literature published in English. However, the location of work was not associated with fear avoidance beliefs in HCPs with LBP. This may highlight the general work ethic of the Chinese, where they are generally not afraid of hard work nor pain and just “get on with it” .
In this study, back pain beliefs did not differ amongst different HCP groups unlike previous studies which used the same scales among students of different healthcare disciplines [29, 35, 67]. While there is evidence that back pain beliefs are different in different professional groups who treat LBP patients , direct comparisons cannot be made due to the use of different scales to assess these beliefs and the cross cultural differences between HCPs working in different countries.
Our study suggested that the level of academic qualification is also associated with fear avoidance beliefs. In this study, those with postgraduate degrees (master or doctoral degrees) had significantly lower FABQ-physical scores compared to those with secondary technical academic qualifications. No differences were observed in FABQ-physical scores among other educational categories, suggesting that a substantial variation in academic training is needed (secondary technical vs. postgraduate) before beliefs are mediated by education. The more positive FABQ-physical beliefs observed in postgraduate qualified HCPs may be attributed to their exposure to more contemporary evidence-based literature and/or resources as a result of their formal engagement in postgraduate studies/research which may have been attained locally or overseas.
In this study, Chinese HCPs with a history of LBP who reported higher LBP-related disability levels were estimated to be significantly more fear avoidant, a finding consistent with previous cross sectional and prospective studies which showed that fear avoidance beliefs are predictive of disability [68, 69]. A prospective study involving a large cohort of female healthcare workers showed that high fear avoidance beliefs were predictive of work absenteeism . The fear avoidance model proposes that when the experience of LBP is associated with negative LBP and/or fear avoidance beliefs, this can lead to avoidance of work, social or physical activities, setting up a vicious cycle of chronicity and disability [61, 71, 72]. Evidence points toward a biopsychosocial understanding of LBP, with a focus on fear reduction, self-management and adopting healthy lifestyle behaviours as being a more efficacious model of care of LBP . An important component of this model is the beliefs system .
There are several studies investigating back pain beliefs and fear avoidance beliefs in general populations and in patients with chronic pain [21, 24, 68, 69, 74]. Information regarding these back pain beliefs in practicing HCPs is presently limited. Direct comparisons with previous studies are also difficult due to the lack of consistency in outcome measures [26, 32, 70, 75].
The medical practitioners in this study had similar mean FABQ-work scores (16.8; SD 7.5) compared to French general practitioners (17.5; SD 6.7)  and rheumatologists (16.7; SD 6.9) , but Chinese medical practitioners had higher levels of fear avoidance beliefs related to physical activities than French GPs  (16.9; SD 4.9 vs 9.6; SD 4.8) and rheumatologists (16.9; SD 4.9 vs 9.2; SD 4.4) . In contrast, a large cohort of Australian GPs (n = 2556) from various states across Australia had mean FABQ-physical scores ranging from 13.3 - 14.0, lower than the medical practitioners in this study . That Australian-based study used a modified FABQ-work (summation of 6 items instead of 7 items) thus cannot be directly compared with this study .
Overall, the results of this study revealed that only a small proportion of variance in the dependent variables were explained in the multivariate models. This suggests that potentially more important correlates of the beliefs were not measured in this study. These factors may include the chronicity of pain , health literacy , experience in clinical practice specifically related to their frequency and exposure to the management of patients with LBP [29, 40], their practice behavior (advice about work, activity and bedrest) , management approach to LBP and the aetiologic framework adopted to explain LBP , time off work due to their LBP  and the nature and types of formal and informal postgraduate education or professional training [34, 40, 73, 79, 80]. Future studies will need to consider these factors to gain a more comprehensive understanding of factors influencing Chinese HCPs back pain beliefs, especially those factors that are modifiable.
Additionally, due to the non-probability sampling used in this study, the results of this study may not be generalizable to all HCPs working in China. China is an expansive country with many provinces that have differing cultures, ethnic groups, socioeconomic status and health outcomes . This study attempted to assess if different professional settings influenced back pain beliefs within two arbitrarily-defined geographic locations – urban and urban–rural mix. These hospitals and district community health centers were conveniently sampled due to an existing working relationship with the researchers involved with these sites. The convenience sampling used in this study may have also resulted in recruiting those who were more research aware or have inherent interests in LBP (being sufferers themselves). This may have accounted for the high percentage of questionnaires returned and also to potential responder bias. The total numbers of possible practicing HCPs for the various disciplines in each of the healthcare settings were not determined thus limiting the interpretation of the representativeness of this sample and any potential threats for responder bias. While the authors acknowledge that a convenience sample represents a non-random sample, and thus threatens the generalizability of the findings and increases the likelihood of responder biases, this pragmatic sampling approach was used for two reasons. First, undertaking epidemiologic research in China in a relatively unexplored area presented challenges with a multinational research team and without pre-established relationships between the researchers and the health facilities. Second, we believe this is the first study undertaken to understand the attitudes and beliefs in Chinese HCPs working in China, and thus we sought to provide pragmatically-collected pilot data in this area to develop a framework for future epidemiologic investigations.
Evidence suggests that beliefs and attitude of HCPs influence their clinical management, the patients’ beliefs and consequently treatment outcomes [27, 40]. The present study was aimed at understanding the beliefs of HCPs related to their own LBP experience and their drivers, which is important for the development of professional education and supporting consumers in effective co-management. Future studies should include HCPs groups from different provinces in China and the practice behaviors of these HCPs for the management of LBP. The back beliefs and treatment outcomes of LBP patient groups in China will also need to be investigated.