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Self-management can be regarded as a daily action to maintain patients’ condition. (Lorig and Holman, 2003), It is also one of the important aspects of physiotherapy in order to deliver a holistic rehabilitation approach. One of the most common problems that will be associated with self-management is the chronic lower back pain. (Clark and Horton, 2018). Patients will be prescribed with exercise such as a lower back extension to do at home for self-management. While low back pain is also one of the most prevalent disabling conditions around the world. Among them, chronic lower back pain is also a common and costly to society healthcare system. (Geurts et al., 2018) Moreover, the major challenge of self-management is often the adherence rate. The average self-managed exercise adherence rate is on at 67%. (Peek et al., 2016) Studies have shown that when the adherence rate was low, it will, therefore, lead to unsatisfactory treatment outcome and ultimately patients’ quality of life. (Sabaté, 2003)
In order to improve the adherence rate of self-management in physiotherapy, various interventions have been adopted such as advise booklet, videotape and so on but none of them shows a solid promising improvement. (Jordan et al., 2010 ) However, with the advanced technology development of mobile phone and its software applications. There is a potential of incorporating digital technology in self-management physiotherapy. (Argent, Daly and Caulfield, 2018) Adherence rate has been shown to increase in the medication area with the help of mobile phone text messaging. (Thakkar et al., 2016). Therefore, the aim of this study is determining the effect on adherence rate quantitatively, a qualitative analysis to explore the barriers and reasons for adherence failure is also be adopted for future practical improvement.
Research question: The effect and barriers of mobile digital intervention on adherence of self-management exercise in patients with chronic lower back pain.
I have adopted a pragmatic view for this research question. With such view, methodological approach is used in a way that best answering the research question but not on any pre‐existing philosophical commitment. The basis of pragmatism is change and action. (Goldkuhl, 2012) which will be useful in health research study. (Cornish and Gillespie, 2009) Since purist argue that accommodation between paradigms is impossible. (Guba, 1990). But in pragmatic stance, both quantitative and qualitative methods could be used at the same time due to the non-existence of the incompatibility which accepts both single and multiple truth. (Morgan, 2007). A mixed method approach can be used in order to address inductively the complexity on the reasons and barriers on the self-management adherence while deductively on the patients’ adherence rate sequentially (Ivankova, Creswell, and Stick, 2006). So the perceived disadvantage of the quantitative method can be compensated by the qualitative method. (O’Cathain, Murphy and Nicholl, 2007) Therefore, a better result can be obtained. (Johnson and Onwuegbuzie, 2004) . Through exploring qualitatively for the adherence rate from the quantitative data, a 2-phase explanatory design (Creswell and Plano Clark, 2003) has been used which quantitative results will be built or explained by the qualitative results. (Creswell and Plano Clark, 2003). The effectiveness of the mobile digital intervention will be analysed quantitatively. After that, barriers and reasons for patients not adhering the self-management exercise will be explained by conducting a qualitative method such as an interview. Despite the fact that a mixed method methodology adopts the strength of both qualitative and quantitative method, some weaknesses can be identified such as more time will be needed and it will be more costly. (Johnson and Onwuegbuzie, 2004)
On the other hand, this research can be viewed from positivism point of view which consider reliability, validity and generalisation (Tobin and Begley, 2004). Positivist will search for a single truth via a quantitative deductive approach that can be generalised to represent the whole population which individual experience is not considered. Although there is a lack of a well-established system of measurement for capturing the adherence. (Bollen et al., 2014) Possible outcome measure will be numeric scale rating ranging from 0 to 10 for the adherence to exercise. (Lambert et al., 2017) Numerical rating scales like this have also been widely used in medication adherence, because of good validity and reliability. (Williams et al., 2014). However, with this approach, although the effectiveness of the intervention on adherence can be determined, the potential barriers will be ignored. So the breadth of study will be significantly reduced. Apart from that, predictors of adherence can be analysed quantitatively by finding the relationships between adherence and certain preset conditions such as demographical conditions (age, gender, family income), kinds of health symptoms and so on. (Tiedemann et al., 2012) Nonetheless, the potential barriers will be limited by researchers thinking because of its deductive approach in positivism. Therefore, despite the fact that the effectiveness of the intervention and predictors of adherence can be determined, these
Apart from positivism, an opposite stance – Interpretivism can be adopted as well. Its approach is to have an understanding of the world from the views from each participant that are unique to each other due to their own experiences and there is no single general rule to explain the phenomenon. (Mackenzie and Knipe, 2006). Unlike positivist, interpretivists do not begin with a theory. They develop knowledge inductively. (Creswell, 2003). Therefore a multiple truth will be generated. So the qualitative method will be used among interprevists. Interpretivist will answer this research question in a way that finding the unique response of each participant to the intervention. They will explore the responses as much as possible. For example, an in-depth interview using opening end questions can be conducted for patients to give opinions and reflections on why they adhere to the self-managed exercise or not. (Campbell, 2001). A qualitative study will be useful in capturing the important reasons and barriers of the interventions that can be used for further improvement of it. (Morton et al., 2018). However, in terms of measuring the effectiveness of the intervention, interpretivism approach will not be able to do so due to the lack of generalisation.
In conclusion, due to the recent advance development of mobile technology and the incorporation of the mobile applications into health intervention. In addition, with the promising beneficial effect in using mobile technology in other health care area such as medication, there is a potential in harnessing this technology to improve the long existed problem of low adherence rate in self-management exercise for patients with chronic back pain. A study to evaluate its effectiveness on patient adherence of self-managed exercise and obstacles should be performed. With the pragmatic view, there is no incompatibility between different research method. Hence it allows me to mix different methods that suit the best for answering the researching question. On top of that through adopting a mixed method approach which includes both qualitative and quantitive study methods, it allows me to maximise the strength of both methods but at the same time keeping the weakness as low as possible. So not only the effectiveness of the mobile intervention can be determined but also the potential barriers and reasons for non-adherence which will be useful for future practical refinement.
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