Fostering equitable change in health services: Using critical reflexivity to challenge dominant discourses in low back pain care in Australia

Abstract

Objectives

Justice and equity-focused practices in health services play a critical but overlooked role in low back pain (LBP) care. Critical reflexivity – the ability to examine and challenge power relations, and broader social issues embedded in everyday life – can be a useful tool to foster practices that are more socially just. No research has yet explored this approach in back pain health services. This study sought to understand how clinicians construct LBP in relation to broader socio-cultural-political aspects of care and explore if those constructions changed when clinicians engaged with critically reflexive dialogues with researchers.

Methods

Using critical discourse analysis methods, this qualitative study explored institutionalised patterns of knowledge in the construction of LBP care. We conducted 22 critically reflexive dialogues with 29 clinicians from two health services in Australia – a private physiotherapy clinic and a public multidisciplinary pain clinic.

Results

Our analyses suggested that clinicians and services often constructed LBP care at an individual level. This dominant individualistic discourse constrained consideration of justice-oriented practices in the care of people with LBP. Through dialogues, discursive constructions of LBP care expanded to incorporate systems and health service workplace practices. This expansion fostered more equitable clinical and service practices – such as assisting patients to navigate health care systems, considering patients’ socioeconomic circumstances when developing treatment plans, encouraging staff discussion of possible systemic changes to enhance justice, and fostering a more inclusive workplace culture. Although such expansions faced challenges, incorporating broader discourses enabled recommendations to address LBP care inequities.

Conclusions

Critical reflexivity can be a tool to foster greater social justice within health services. By expanding constructions of LBP care beyond individuals, critical reflexive dialogues can foster discussion and actions towards more equitable workplace cultures, services and systems.

Introduction

In the last four decades, there has been a sustained research focus on how health services might implement multidimensional care for people with low back pain (LBP). As LBP is multifactorial, ¹ approaches often aim to encompass physiological, psychological, and social aspects of care. The biopsychosocial model is one of the most well-known and advocated models that intends to account for such multidimensionality. ² However, the model falls short in incorporating important broader dimensions of care, including ethics, culture, and spirituality, ³ along with institutional power dynamics and socio-cultural considerations.^4–6 The neglect of such aspects of care might prevent health care professionals and health services from offering equitable practices that offer just outcomes for all patients.

The World Health Organization conceptualises equity as ‘the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality (e.g. sex, gender, ethnicity, disability, or sexual orientation’.^7(p1) In contrast, health inequities are the unfair and avoidable systematic differences in health status between groups – addressing health inequities is a matter of social justice. ⁸ Like other health conditions, there are gross disparities in equity for people with LBP. Those who have been historically and socially marginalised have greater pain and disability, ⁹ and health services and systems are implicated in such disparities. ¹⁰ Health equity and social justice are becoming a high priority in LBP care, ¹¹ including explorations of the impact of social determinants on health outcomes. ¹² This body of work highlights the complex interrelationship between social disadvantage, financial resource strain, social isolation, and poorer health status and outcomes for people with LBP. Although such macro and contextual factors require systemic changes, individual clinicians have an important role in foregrounding social determinants of health in LBP care by attending to the needs and contextual circumstances of those seeking pain care. ¹²

Equity-focused implementation strategies are not straightforward tasks. According to Browne et al, ‘implementing health equity interventions in health care organisations requires fundamentally shifting taken-for-granted practices, policies and systems that contribute to inequities’.^13(p2) Research has called for more critical and equity-focused approaches to implementation science^14,15 – the study of methods to improve quality and effectiveness of health services and care. ¹⁶ Arguably, every project should have an equity focus. ¹⁵

Critical reflexivity is a possible and underexplored strategy for clinicians and those working in health services to explore taken-for-granted aspects of their practices (here considered as broader human aspects of LBP care). Coburn and Gormally ¹⁷ discuss critical reflexivity as the ability to examine and challenge power relations, and other social and moral issues embedded in everyday life. Reflexive health professionals question how their own backgrounds, dominant forms of knowledge, colleagues’ and workplace values, societal norms and discourses are intertwined, influencing their practice and relation to others.^17–21 The ultimate aim is being to enact social change, implementation as regular practice may promote equitable care in health services.

The use of critical methodologies in implementation studies is scarce, ¹⁴ with little translation into equitable improvements in health services. ¹⁵ Only a few studies used critical reflexivity in rehabilitation contexts, and to our knowledge, no research has explored critical reflexivity as a means to foster justice in LBP care. There is a paucity of scholarship exploring how forces implicated in inequities in LBP care – ethics, culture, institutional and interpersonal power dynamics ― might be reflexively attended to, to implement equity in LBP care services. Thus, our study had two aims: (1) understand how clinicians construct LBP care in relation to social, cultural and ethical aspects of care, and (2) explore if those constructions changed when clinicians engaged with critically reflexive dialogues.

Methods

We used a Foucauldian discourse analysis (FDA) methodology adapted from Willig ²² and Fairclough’s ²³ extension of critical discourse analysis. Willig, ²² following Parker’s work, defines discourses as ‘sets of statements that construct objects and an array of subject positions,’^22(p.130) where these constructions make visible particular ways of being and seeing the world. FDA can help investigate hidden power dimensions in the construction of care of people with LBP. For example, what is discussed or prioritised in consultations and team meetings, what questions are asked and followed up upon with patients, and what treatment pathways are preferred. FDA can be used to explore not only the language used by clinicians, patients, and institutions but also to understand how power operates throughout LBP health care interactions, institutions, and organisations that influence people’s way of thinking and practising health care.

We analysed the following data:

(1) Transcripts from critically reflexive dialogues between clinicians and researchers at two health services where people with LBP commonly seek care, and

(2) Recommendations to enhance LBP care, co-developed by clinicians, researchers and people with lived experience of LBP. These recommendations were aimed to improve attention and action towards human aspects of LBP care, to foster more equitable practices. They were addressed to patients, clinicians, and staff from the two study sites.

The study sites were two metropolitan Australian health care settings. The first was a private fee-for-service physiotherapy clinic staffed by physiotherapists and Pilates instructors, specialising in musculoskeletal care. This we called Site 1. The second, a multidisciplinary pain clinic, was a large tertiary publicly funded clinic which specialised in providing care for patients with persistent pain and associated disability. This was Site 2. Both data sets were produced as part of a wider project conducted between April 2019 and June 2021.^5,6,24,25

All 45 clinicians from the two study sites were invited to participate in the dialogues. A total of 29 clinicians provided written consent and participated in the dialogues (seven from Site 1 and 22 from Site 2), a response rate of 64.4%. Twenty-one of the clinicians identified as female and eight as male. Participants’ ages were between 25 and 64 years. The clinicians had an average of 18 years’ experience in their occupation.

Clinicians at the Site 2 were from diverse professional backgrounds, including physiotherapy, occupational therapy, pain and addiction medical specialisations, general practice, psychiatry, psychology, nursing, and pharmacy. We did not collect other characteristics such as race, ethnicity, employment status, and level of education.

A total of 22 dialogues were conducted between researchers and site clinicians. Thirteen were conducted at Site 1, and nine at Site 2. Each dialogue lasted between one and 2 hours and occurred approximately at 2-month intervals over the course of the study. Most were facilitated during in-service hours (i.e., time dedicated by the clinics to staff development activities) in a large group. Four were held with individual clinicians to accommodate their work commitments. Dialogues were audio-recorded and professionally transcribed.

Authors KM and JS facilitated the dialogues, with occasional assistance from RO. KM and JS are both physiotherapists with training in sociology, critical reflexivity and qualitative research methodologies, and RO is a health sociologist with extensive qualitative research experience. With other researchers, JS developed and successfully used this methodology in another project. ²⁶

To explore assumptions and prompt critical reflexivity, the researchers worked with the participants in a collaborative exchange of making clinical practices ‘strange’. ²⁷ ‘Making strange’ is a process of disrupting automaticity, fixed beliefs and practices, to reimagine and foster a more humanistic patient-therapist relationship. ²⁷ This process was achieved by sharing data excerpts from ethnographic observations (another data collection approach from the wider project) of each site with clinicians. Observations contained researchers’ fieldnotes about clinical interactions, staff meetings, and the clinics’ physical space. Clinicians and researchers then collaboratively analysed the notes to critically reflect on the human aspects of health care practices. More details on our research method are available in the online supplement Table S1.

The recommendations were co-developed by the clinicians (n = 29), the research team (n = 10) and an advisory group of people with lived experience with LBP (n = 7). They were generated during the final dialogues and were specific to each site. The Site 1 recommendations included reduce power differences between patients and clinicians, acknowledge and validate emotions, change systems, manage time pressure, and attend to non-verbal cues. The Site 2 recommendations included: set up connections to community at service discharge, attend to patients’ physical and emotional comfort, discuss team values and workplace culture, be aware of Anglo-centric perspectives, and prioritise a sense of community among clinical staff. We apply FDA to the recommendations as part of our analysis below. Further details on recommendations are given in the online supplement, Figure S2.

Results

In the following two sub-sections, we present how both sites constructed LBP, the changes that occurred in these constructions, and their connection to broader discourses. We then discuss the challenges of operationalising these new expanded constructions. We use pseudonyms for all participants.

Expanding beyond individualistic to include systemic discourses

In early dialogues, participants at both sites constructed and positioned LBP care as mainly an individual concern and therefore within individualistic discourses – positioning the patient as the site of care, and a problem for clinicians and patients to manage. However, as the study progressed, participants’ discourses broadened to include and construct LBP care within systems – implicating institutions and systems in LBP and LBP care. This expansion allowed participants to also consider broader aspects such as equitable access to health care, social and economic dimensions of health, community engagement, and treatment equity and social justice as part of LBP care. Although dominant individualistic discourses were entangled with systemic discourses, dialogues and recommendations seemed to facilitate the consideration of broader social, economic, and political dimensions of LBP care.

Although there was some overlap at the beginning of dialogues, the two sites drew from slightly different discourses regarding LBP. When asked about the aspects of LBP care, participants at Site 1 promptly constructed LBP care as centred on individuals and had difficulty identifying social (and broader) aspects of care. In the following exchange, for example, AnaPhysio expressed uncertainty and doubt when asking the facilitator if ‘family commitments’ could be part of social aspects:

JS: What about social? What does that involve?

JadePhysio: Work, hobbies.

AnaPhysio: Family commitments?

JS: Families?

JadePhysio: Support networks again.

[There is then a pause in the discussion.]

JanRecept: I’ve never seen them so quiet, JS. [general laughter]

AnaPhysio: We’re reflecting.

PruePhysio: I’m going to be right out of left field. Many other things you fill in, level of education. Does that come into it?

JS: That’s good, thinking a little bit broader.

JadePhysio: Financial.

PruePhysio: Financial, yeah.

JadePhysio: History of trauma.

Here, participants’ initial perception of ‘social aspects’ of LBP care were limited to individuals and their immediate social circle: work, hobbies, family, and support network. Furthermore, participants’ hesitancy, silence, and doubt indicate that they did not draw from discourses that considered systemic ‘social aspects’ of LBP care. Implicitly, this suggests that these aspects may not be part of their clinical practice. Later, when prompted by the facilitator (JS) to reflexively examine the focus of their work, participants mentioned compensation schemes and cultural and linguistic backgrounds as being part of LBP care. Here, they showed early signs of being able to engage less dominant systemic discourses.

After most dialogues were conducted, participants from Site 1 seemed to construct broader socioeconomic aspects of LBP care as part of their clinical practice. They expanded, broadening towards a systemic discourse, as depicted in JadePhysio’s (Site 1) talk below:

But it comes back to, there was so many [recommendations] to choose from, but there was one in there about checking with them, money, time, distance, and stuff. I think that’s something probably, maybe we don’t address, perhaps because there might be somebody who comes along and really is keen to do it but just can’t afford it and realise at the end and go … I’ve had a few young people who just go, ‘I just can’t come back.’ Sometimes they'll open and tell you and otherwise they’ll just disappear off your list and I’ll think, ‘I wonder whether that was why.’ But maybe if we could link them into the fact, that you can actually get some sessions through the public hospital … Not that we want to smash them into the hospital system, but there is a public system that is designed for that. As well as that, I think it just might be making sure that that's in our mindset in case we think it might be appropriate.

Dialogues and recommendations prompted JadePhysio to attend to patients’ financial constraints and health care access issues. Such issues were something participants at Site 1 did not readily address in the initial dialogues. Expanding to a systemic discourse allowed clinicians to relate LBP care with socioeconomic aspects (by checking about money) and with navigation of health care system (by linking with public hospital).

By contrast, Site 2 participants seemed to draw from both individualistic and systemic discourses when constructing LBP care from the onset. In the first dialogue, when asked about the aspects of LBP care, clinicians promptly identified broader social, political, and cultural aspects, as illustrated in the conversation below:

JohnPainMgmt: Transport. Housing.

NoahDr: General SES [Socioeconomic Status].

EmilyPsychologist: Just that whole environment, the context where they live, and their social connections goes really beyond, even living in Australia and all of that …

JohnPainMgmt: Something that a lot of people have put in an extra box of spirituality and religion …

EmilyPsychologist: And education and health literacy, I think that would go in social probably. But all of those things, education and ...

Female speaker: Capitalism, the pharmaceutical industry.

Clinicians working in this public service considered transport, housing, spirituality, health literacy and even capitalism and its connection to medication as being part of LBP care. Here, LBP is constructed as a complex interaction between individual and societal systems – the different professional contexts and backgrounds between the clinicians at each study site might explain these different constructions of LBP care. Yet, this was not always the case. Complex constructions of LBP co-existed with individualistic discussions.

Throughout the project, when developing and implementing recommendations, initial awareness of systemic discourses came into tension with dominant individualistic discourses. An example was a conversation about the service’s change regarding access and waiting lists at Site 2 during COVID-19. A few participants suggested the service had decided to prioritise patients more likely to respond to treatment to be more targeted with the service’s resources. As one participant said:

Sometimes it’s actually better to take the easy patients, the quick patients and troll through all of those, knowing that the really severe patients, actually, our chances of getting an improvement are very low.

In another dialogue, the facilitator questioned whether this approach would be aligned with an equity model (e.g. ensuring equity of access by adapting levels of support and resources), which prompted the group to critically reflect on their actions:

JS: One question about that change… Does, as a critical question, does that mean you’re excluding the people that are more marginalized because they tend to be more difficult?

KaibaDr: No, it’s not more easier or difficult, I think it’s more whether they respond to treatment, isn’t it?

JS: But would that be the same? Would that be aligned? I’m just not saying it is.

BreePsych: So, I don’t think it’s a hard and fast rule. It’s more just a discussion that we-

JS: No, it totally makes sense.

BreePsych: More comfortable having but there is that risk, but then, of marginalized patients or-

JS: Being the ones who might not get the services?

BreePsych: Yeah, but then at the same time, is that actually okay? If we only have so many resources, where should those be directed? And I think, as a group, we’re willing to have those discussions and maybe disagree with each other on that or at least be willing to acknowledge that as an issue.

Thus, at the start of the discussion, access to care seemed linked to patients being ‘easier’ or more likely to ‘respond to treatment’. Although not necessarily reflective of all clinicians and Site 2’s position, LBP care is constructed here at an individual level, where being easier and responsive are likely related to patients’ level of disability/pain or compliance. In such individualistic approaches, there is little room for considering how social inequalities or multiple social, cultural, and political aspects intertwine with LBP care. The facilitator’s work to prompt critical reflexivity and challenge these individualistic discourses seemed paramount here. The reflexivity resulted in the group keeping conversations open regarding service access equity.

The tendency to focus primarily on individualistic discourses with little consideration of systemic discourses was present throughout the development of the recommendations. The practice of critical reflexivity and consultation with people with lived experience of LBP (or advisors), however, enhanced the expansion of discourses. One example was a recommendation about discharge plans at Site 2 – a priority identified by our lived experience of LBP advisory group. One advisor had gone through an intensive and informative 8-week pain program (in a different service) but was left without resources once the program ended. The intent with this recommendation was to support patients to smoothly transition from Site 2 to the community, without feeling abandoned. This recommendation prompted clinicians to critically reflect on how they could be more proactive in engaging patients with the community as LiaPainSpcl’s words suggest: ‘I guess, things that I’ve mentioned that are social prescribing particularly … I think I’ll ask a few more questions about their social history, rather than just the basics’. This excerpt, together with the previous examples, suggests that dialogues assisted participants to draw on systemic discourses about LBP care to support community connections, and think about broader social aspects of care.

The final list of recommendations at both sites show how participants drew on a range of constructions connected to broader discourses. For example, recommendations included implementing transition plans and connecting patients to the community, reducing power differences between patients and clinicians, supporting Indigenous patients and patients from diverse cultural backgrounds, and increasing consumer involvement in service planning. Thus, recommendations included both individualistic and systemic discourses of LBP care, some of which attended to social justice and equity.

Expanding beyond individualistic to include workplace discourses

Dialogues appeared to assist the expansion from individualistic discourses to discourses that attended to the service as a workplace. These workplace discourses encompassed how workplace culture, values, and identity could enhance or limit actions to the construction of LBP care. This is depicted in NoahDr’s evaluation of the current study:

[T]here’s] isn’t really a formal mechanism in the department beyond your study - that I can think of, at least – where we can actually sit back and have a conversation around system's issues. Lots and lots of times to talk about individual patient care. But nothing really to reflect on ... [The] team meetings we have are so rigid with the agenda that there isn’t really any opportunity for us to just go off the deep end on something.

Dialogues provided an opportunity for the team to critically reflect on their workplace’s identity, and how their service interacted with the health care system and broader society. Unlike the dominant individualistic discourse identified in NoahDr’s discussion (‘Lots and lots of times to talk about individual patient care’), the workplace discourse allowed the service itself to be a site of care and change around system’s issues – including inequities. The dialogues provided a ‘formal mechanism’ for clinicians to ‘have a conversation’ on these matters.

Site 1 clinicians, by contrast, did not have ‘lots of time’ for team meetings and were limited to one in-service hour per week. The in-service time was usually dedicated to professional development or, as one participant mentioned, ‘often gets swallowed up by us finishing our notes’. In this setting, the dominant individualistic discourse seemed to be constrained to interactions with patients, not each other. For example, when asked what it had been like to participate in the dialogues, clinicians replied:

JadePhysio: I think that it makes you reflect on what you do and how you do it, why you do it and what you might be missing out on.

ClairePhysio: You get a few good ideas from other people.

JS: You look surprised!

PruePhysio: We don’t ever sit and think like this.

Dialogues fostered two things that did not seem to be part of participants’ routine: critical reflexivity and teamwork/collaboration. These new elements embedded in the workplace discourse allowed participants to work on assumptions, explore broader aspects of care, and collaborate.

The workplace discourse also highlights how a services’ culture matters to LBP care. These new discourses shed light on changes to encompass a collaborative teamwork culture. An example was a recommendation developed at Site 2 to foster different opinions and spaces for respectful disagreement among clinicians. A clinician with a leadership role in the team added a recommendation to ‘make an environment where everybody can disagree, and not get shut down’. This recommendation about workplace culture was likely possible because of reflexive dialogues, which seemed to promote a sense of collaboration among clinicians. This service had daily multidisciplinary meetings to discuss patients’ cases and invite various opinions and input, where clinicians needed a high level of collaboration to achieve alignment towards treatment decisions. Fostering a sense of collaboration, including allowing for respectful dissent, among clinicians was paramount for better understanding patients’ contexts and how the service could support them. As JohnPainMgmt said:

I think realising that a case conference is a place where we can work out what's going on with people, instead of just being like: ‘We just need to get through this, what pigeonhole does this person go in?’

Together with the sense of collaboration, the workplace discourse at Site 2 made possible an acknowledgement and normalisation of uncertainty and vulnerability among the team. An openness to uncertainty seemed to be incorporated in team meetings, as described by NoahDr:

One of the things that we’ve been building on is this idea of complex case discussions. And with that, I think, comes the acknowledgement, even for the senior staff, that often we don’t really know what to do. And to normalise that so that, particularly the junior staff, when they see that, they presumably feel less distressed by not knowing what to do either. So, I think having more complex case discussions in case conference, another one is where clinicians quite openly acknowledge that they really don’t know what to do from here and that’s okay.

Here, uncertainty and vulnerability are fostered even within more senior staff, implicitly shaping a workplace culture that acts on shifting power, makes conversations more open and collaborative, and prioritises a sense of community amongst clinical staff.

The new workplace discourses clinicians were producing as they created recommendations shows what these discourses made conceivable/possible - a changed workplace via formal to informal actions to foster more open engagement amongst clinicians. For example, having an open-door policy for colleagues to ask questions, creating a safe space for clinician disagreement at case conferences, and having lunch together. Having lunch together was also discussed as an opportunity to level power dynamics among the multidisciplinary team at Site 2, bringing all disciplines together across seniority levels.

Overall, dialogues prompted clinicians to expand their constructions of LBP care from individualistic client-clinician interactions (focussed on individual patients and/or clinicians as the object of intervention to enhance LBP care) to also consider intervening on aspects of services, clinician-clinician dynamics, and systems to enhance LBP care. Dialogues provided a space and time for teams to consider such aspects and facilitated a sense of collaboration amongst clinicians and teams, as well as an openness to different views, uncertainty, and vulnerability. Such changes seemed to expand the construction of LBP beyond an individualistic (patient-clinician) view to a systemic and workplace view that considers teams and services as part of equity and social justice practices.

Challenges to implementing the expanded discourses

Clinicians faced some challenges in operationalising and implementing actions aligned with the expanded systemic and workplace discourses. This is illustrated in this discussion of a neglected set of proposed reforms:

JS: You’ve forgotten about them. But did you do that inadvertently [crosstalk]?

BreePsych: Yeah, I don’t know. I’m not sure.

JS: Is it something you’re still interested in doing?

BreePsych: Yeah, I don’t think it was lack of interest. At the time, I thought it was a good idea. So, it’s interesting why I didn’t prioritise it.

Here, although initially committed to implementing the recommendation, BreePsych reflected on her lack of prioritisation to do so. This suggests that adopting broader discourses needs material support: participants may have benefited from a system to remind themselves of their chosen changes/recommendations. To support success, the operationalisation of expanded discourses also needs to be accompanied by strategies. Even if the broader discourses seemed to resonate with participant-clinicians, their adoption (and therefore implementation of new habits and practices) required resistance to common behaviours.

A lack of prioritisation seemed to be linked with a second challenge of the dialogues: the hegemony of dominant discourses. Dialogues demanded a high engagement with critical reflexivity. The recommendations were drawn from multiple constructions and priorities from researchers, clinicians, and people with lived experience of LBP. Therefore, dialogues could be challenging since they confronted clinicians’ assumptions, practices, and ways of seeing care for people with LBP. One example was the challenge of balancing competing discourses and, therefore, strategies raised by different groups. Such balancing required clinician-participants to consider patients’ suggested recommendations as valid and important to services’ practices. This was not always the case, as illustrated below:

JS: If you had all the resources in the world, write down two or three ways in which you might change the service or whatever, change things so the discharge planning will enhance the human aspects of the patient’s care. So, they’ll feel cared for as they are discharged.

BreePsych: … Why do we care?

NoahDr: Thank you, that’s what I was about to say.

JS: Well, maybe you don’t care, but the patient cares.

BreePsych: Why? So, I guess, why?

JS: It's a really good question.

BreePsych: Yeah. Is it? Okay. Why is that important?

JS: Why does it matter then?

BreePsych: Why does it matter? Why is that our job?

Although clinicians supported this recommendation later, here clinicians did not seem to think that having patients ‘feel cared for’ was important to the service. BreePsych and NoahDr’s resistance implied that service and institutional changes were limited to clinical staff, not service users. Interestingly, such resistance was more common at Site 2 than at Site 1. This may indicate that the different models of service (public vs fee-for-service) take service users’ voices differently: in the former, patients seemed to have less power and status than in the latter. Further, this difference can also be due to professional background: Site 2 mainly had doctors, whose voices were stronger in this clinic.

Finally, not all clinicians were able to take part in the dialogues, particularly at Site 2. This was raised as an issue by NoahDr when providing feedback on the study’s dialogues: ‘I think you need to catch everyone in the department. I have no idea what the solution to that is, but I think it’s important’. His concern suggests that some clinicians at Site 2 could have benefited from the discussions and that discursive expansion requires support and reinforcement across a service.

Discussion

Our analysis suggests that LBP care is mainly constructed at an individual level, having as its object either patients or clinicians, rather than factors oriented towards social justice (such as systemic change). This dominant individualising discourse may limit the acknowledgement of how broader societal systems, practices, and ideologies play a role not only in the prevalence and incidence of LBP^9,28 but in pain management.^29–31 For example, although LBP is considered a multidimensional condition that must be considered within a biopsychosocial approach, aspects such as institutional power relations, social determinants of pain, and cultural considerations are commonly sidelined. ⁴ Further, the biopsychosocial model itself has been critiqued for low-lighting socio-cultural-political accounts on health. ³

The under-appreciation of broader aspects of care was illustrated in our findings. Participants found it difficult to identify what could be considered ‘social aspects’ in LBP and did not consider equity in discussions about access to services. This focus on individuals is also seen in clinical guidelines, that mainly include recommendations of appropriate care regarding diagnostic triage, assessment of prognostic factors and finding effective interventions.^32,33 Broader socio-cultural considerations are rare in such documents. In an analysis of clinical guidelines (not specific to LBP), Shi et al ³⁴ found focusing on individual characteristics can limit discussions of equity and social justice, with others arguing that guidelines can widen health inequalities, by targeting the general population and marginalising disadvantaged groups. ³⁵ Therefore, centring care only at an individual level might limit actions towards socially just equitable practices in LBP care.

Constructing LBP care at an individual level, as is shown in our findings, seems to be aligned with broader neoliberal discourses of health/care, further limiting equitable practices for people with LBP. Neoliberalism is an ideology and policy model that posits health as the responsibility of individuals and has arguably informed the way health is thought, taught, and managed/administered. ³⁶ As a discourse, neoliberalism unfolds with existing circumstances and ways of thought, being entrenched in people’s and institutions’ constructed realities and relationships, with material consequences – for example, on people’s health. ³⁷

In our study, a neoliberal discourse was embedded in several elements of the dialogues. One example was the discussion on prioritising health care access for patients who had more opportunities to comply or respond to treatment, and therefore needed less support from the service. Such an approach is perhaps understandable when seen through a short-term economic rationalist lens, but from a human-rights perspective, it limits health care access for vulnerable groups, exacerbating inequities. ³⁸ Thus, a neoliberal discourse positions equity issues at the margins of health care practices, as it ‘negate [s] the ‘social’ issues of ‘justice’ or ‘injustice’^39(p97) and places social risks – such as unemployment, poverty, and ill health – solely on individuals. Our results demonstrate how LBP care can be constructed on values and assumptions aligned with neoliberal discourses, and can centre care on individuals without consideration of broader socio-political contexts. Analysis of discourses embedded in Australian policy directives targeting LBP has identified similar discourses. ⁴⁰

The dominant individualistic discourse, however, was challenged throughout our dialogues. Our critically reflexive dialogues seemed to facilitate more equitable and collaborative discourses in the construction of LBP care within the study sites. By exploring assumptions embedded within clinical practices in our observations, participants and researchers brought to light taken-for-granted power structures embedded in everyday practice concerning both patients’ contexts and services’ workplaces. For example, participants challenged narrow discussions about patients’ presentations, incorporated more complexity in case conferences, encouraged conversations around system issues that impact clinics and patient interactions, and considered influences of broader socioeconomic contexts in clinical practices. Similar to our findings, Browne et al ¹³ found that critical analyses of systems and policies can disrupt biomedically based discourses fostering consideration of more justice-oriented practices that take into account patients’ socio-historical contexts. Critical reflexivity, among other critical considerations of health, allows an appreciation of context, deepening understandings of how social structures impact people’s health.^17,19,20 Although critical reflexivity has been mainly explored in the medical education field, ²⁷ it has been argued that it can also support health care providers in enhancing interactions with patients, ¹⁹ fostering insights on who gets included/excluded from clinicians’ routine practices, and noting unintended consequences of clinical practice. ²⁰ Our findings add that critical reflexivity can also help clinicians critically attend to workplace cultures by examining the way power operates within them. Strategies suggested by the clinicians in our study included adopting an open-door policy and promoting respectful dissent/collaborative practices.

Collaborative workplace culture in health services is highlighted by Todic´et al ⁴¹ as paramount for building a culture of equity. The researchers argued that the collaboration and connection characteristics of ‘growth-fostering relationships … [can] challenge socially constructed notions of separation and independence, which hinder employee’s agency to confront interpersonal and organizational dynamics that foster inequity’.^41(p982) The sense of collaboration and connection is attended to even in times of conflict and dissent, through the shift from a ‘power over’ (e.g. hierarchical relationships) to a ‘power with’ (e.g. collaborative relationships) model. Considering recent calls for more equitable and socially just LBP care practices,^9,11 our study suggests that in research and clinical practice critical reflexivity can be a useful tool in expanding dominant individualistic discourses to include more collective and equitable approaches.

Critical reflexivity and the expansion to more socially just – or less dominant – discourses, however, might also benefit from institutional support. According to Fairclough ²³ successful incorporation of different discourses could be enhanced by careful reflection in how they are operationalised. For example, in our study, a reminder in participants’ daily schedule to implement the suggested changes could have assisted such operationalisation.

Implementing organisational change is an inherently political process, and new discourses must be aligned with the organisations’ values and directives so change is more likely to occur. ⁴² In our study, the hegemony of dominant individualistic discourses and the challenge of balancing competing discourses might indicate that equity was not yet incorporated into organisations’ values. Therefore, how clinics and institutions are organised matter to LBP care – especially when accounting for more socially just practices. According to Brownson et al, ¹⁵ organisations have a central role in fostering health equity. Because dominant discourses are so embedded in institutions and are ‘institutionalised’, implementing new ways of being and acting seems to require greater effort and resources. Overall, the practice of critical reflexivity seems insufficient – it might benefit from material support and careful consideration of the organisation’s values.

Limitations

There are two main limitations to consider when applying our findings elsewhere. First, although the recommendations and the apparent expansion in discourse through dialogues seemed to foster more equitable practices within the participating services, it is possible such changes were not only due to our study. We did not consider the nuances of, for example, clinic management or organisational changes due to COVID-19.

Second, our methodology and methods were not designed to evaluate the extent to which participants enacted the developed recommendations in their practice. That is because our dialogues relied on what participants said they did rather than what they actually did. Indeed, the extent to which participants enacted the recommendations after the dialogues ended is unclear.

Conclusions

Our study suggests how critically reflexive dialogues could contribute to a broader understanding of the multidimensionality of LBP care. The dialogues made it possible for LBP care to be considered in light of socio-cultural and political contexts, better attending to equity and social justice. This broader understanding involved shifting from a focus on only clinicians and patients, to encompass institutions and systems, expanding how LBP care is usually conceptualised and enacted.

Our findings indicate that critical reflexivity can be a useful tool to foster equitable and socially just practices in both institutions/clinics and research. Although our study focused on LBP care, it is likely that our findings could be expanded to other health conditions and services.

Supplemental Material

Supplemental Material - Fostering equitable change in health services: Using critical reflexivity to challenge dominant discourses in low back pain care in Australia

Supplemental Material for Fostering equitable change in health services: Using critical reflexivity to challenge dominant discourses in low back pain care in Australia by Karime Mescouto, Rebecca E Olson, Nathalia Costa, Kerrie Evans, Miriam Dillon, Kelly Walsh, Niamh Jensen, Paul W Hodges, Kathryn Lonergan, Megan Weier and Jenny Setchell in Journal of Health Services Research & Policy