An objective review of consumer books about back pain.(Statistical Data Included)

Abstract: Back pain is epidemic, and dozens of books inform the public about this disorder. The increase in "self-help" medical books has not been accompanied by objective critiques of this important literature. We conducted an objective, quantified evaluation of the comprehensiveness and quality of these books. A Books in Print search resulted in 38 books on back pain, of which 27 were round and purchased. Topics covered, organization, and emphasis were coded according to scales with excellent interrater reliability. Alternative and conventional treatments were emphasized in most books, but epidemiology, natural history, and risk factors were substantially de-emphasized, covering less than 3% of the text. This objective and validated evaluation of the consumer literature provides a format for researching patient education in other health areas.

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As a result of many factors, such as the Internet, healthcare reform, and the rise in popularity of alternative and complementary health care, patients are seeking unbiased, independent information on healthcare issues. "Self-help" books abound on a number of topics ranging from mental health to cancer. Back pain is one of the most prominent areas of self-directed inquiry.

Statistically, the prevalence of back pain is remarkable in its implications. Eighty percent of the adult U.S. population will surfer an acute episode of back pain, and 10% of these patients will develop chronic back pain (Frymoyer, 1996). It is no wonder that researchers refer to low back pain as an epidemic and a costly one at that. Back pain costs the U.S. economy $16 billion-$60 billion annually. Low back pain is the most common cause of disability in the U.S. working population younger than 45 years (Frymoyer). From 1957 to 1976, low-back-pain disability increased at a rate 14 times the U.S. population growth. Of patients with acute back pain, 80%-90% will recover regardless of treatment (Frymoyer).

This epidemic continues amidst a backdrop of growing healthcare consumerism; patient education is a vital component of an age in which a greater emphasis is placed on patient autonomy, health promotion, and self-care. Patients no longer take a passive role in their care, and studies show an informed, involved patient is a healthier one. Patients who agree with their practitioner's assessment and plan are less likely to stay disabled by back pain (Sandstrom & Esbjomsson, 1986).

Patient education is also important in treatment. Studies show a patient's understanding of his or her pain significantly predicts treatment success (Deyo, 1988). Lack of knowledge can cause concerns about serious physical problems and greater disability (Deyo & Diehl, 1988). In a study by Symonds, Burton, Tillotson, and Main (1995), patients who received a pamphlet on pain significantly reduced work absenteeism compared with patients who did not receive the information. Because of their low cost and relatively known level of effectiveness, patient education pamphlets have been viewed as a reasonable placebo treatment against which to compare more expensive or aggressive treatments (Cherkin, Deyo, Battie, Street, & Barlow, 1998).

The prevalence of back pain makes this population an extremely attractive target audience for an abundance of various medical and alternative treatments, guides, and assorted products. Books on back pain available in the mainstream press are potentially of great use to patients. However, when healthcare providers are asked by patients, "What should I read?", recommending an inappropriate text can mean not only a disservice to the patient, but also a liability to the provider. How is one to choose? No effective screening tools for evaluating this literature exist, and, in fact, very few tools for evaluating patient education exist in medicine.

The objectives of this study were twofold: to develop an evaluation tool for assessing consumer-press medical literature and to evaluate consumer-press back pain literature in terms of (a) technical content, (b) design and quality, and (c) reading level and comprehension.

Methods

Books were selected by searching Books in Print during the summer of 1997 for books on backache. Technical books were defined by title, the researchers' exposure to the book, or a price greater than $50. Booklets with fewer than 50 pages were eliminated. Books not available for order through www.amazon.com or Borders Books were eliminated. All books were reviewed by the first three authors, medical students who had completed their first year of training but had no clinical experience in back pain. During the rating period they were not allowed to discuss specific books with the senior author, who is a physiatrist specializing in spinal disorders, but were allowed to ask for clarification of medical information.

The following 13 general categories were selected after preliminary discussion and review of about 10 books: anatomy, background, biomechanical diagnoses, complementary / alternative treatments, diagnostic techniques, epidemiology, natural history, pain, psychosocial factors, providers, risk factors, prevention, and conventional treatments, and other resources. A total of 165 subtopics were added to the list throughout the reviews. Determining the percentage of the books that addressed each general category was calculated at the paragraph level. The total number of pages in each category was calculated, and from those data, the percentage of the book that addressed each category was determined.

Each book's quality was then evaluated. Fig 1 indicates the scales used to judge organization, objectivity, technical detail, illustrations, comprehensiveness, primary emphasis of the book, readability, biases, and overall quality. Readability was determined by two commonly used methods, the Flesh Kincaid (Klare, 1984; Ott & Hardie, 1997)and the SMOG (Mumford, 1997). Unfortunately, there was confusion in the final coding of the data, and these scales were not able to be reported. A five-point analog scale was used to record the reviewers' overall judgment of each book.

Tests were performed to examine interrater reliability. Each reviewer read and rated four books. The other two reviewers each rated two of these. For each book, raters completed an evaluation, and the results in terms of technical content and overall usefulness ratings were then compared. Specifically, the proportion of the book recorded for technical content in each of the 13 categories was compared for each rater. There was an average error of 2 [+ or -] 1% in trials of technical content. The poor/average/excellent gradations of overall usefulness were similarly compared; there was no discrepancy among the reviewers in terms of overall usefulness ratings.

Results

Thirty-eight books met the evaluation criteria; of these, 27 were reviewed. The other 11 either could not be ordered or were not delivered during the project timeline. Investigators also checked local bookstores for stock copies.

Table 1 shows the overall comprehensiveness ratings for each book (varying from 5% to 59%) and the percentage of text in each of the 13 categories of interest. Specific areas of emphasis, as expected, varied widely, but the aspects of alternative treatment (averaging 19.1% of text volume) and conventional treatment (19.3% of text volume) were covered most frequently; prevention was the next most prominent. Epidemiology, risk factors, natural history, and other resources were not covered in any detail in most books.

Table 2 provides information on the quality of the books. The organization of the books varied substantially; some books were quite logical, whereas others varied in depth and order of discussion. Some books appeared to rely on their objectivity as a strength; others espoused specific theories, philosophies, or treatment modalities. The level of detail ranged from superficial to quite detailed, but the more detailed books were not always the best organized ones. Some books were encyclopedic and provided great detail about a comprehensive list of topics. Others went into detail only in areas of interest to the authors. Three books had excellent illustrations. Prices varied; all appeared within reason for individual consumers. A clinic might find it useful to bulk order some of the less expensive books.

Discussion

The purpose of this study was to evaluate books about back pain in the consumer press. The experience has led to insight into two…