Table 4 The six themes of the six programme sessions

Theme 1 (Session 1)

Challenging the biomechanical understanding of non-specific chronic low back pain (CLBP). Exercises and postural training are noted as important tools in managing CLBP. The educational aspect of the session covers spinal anatomy and physiology, epidemiology of nonspecific low back pain, exercises, and postural education. The theme is related to participants’ understanding of CLBP as a disease of hard labour, deprivation and rural habitation, specific environmental factors and rural health care facilities. Discussion involves explanation of CLBP as ubiquitous regardless of the level of exposure to biomechanical factors; exploration of good attributes of rural habitation and identifying participants’ ability to influence their own environment, example working from a table rather than the ground.

Theme 2 (Session 2)

Challenging the infective-degenerative explanation of CLBP. The educational aspect of the session covers the epidemiology of specific back pain. This is related to participants’ infective-degenerative understanding of CLBP with explanation that most cases of CLBP are not due to infection. The differences between the symptoms and treatment of specific back pain and non-specific back pain are explored with the application of analogies.

Theme 3 (Session 3)

Challenging negative beliefs and thoughts about back pain including sexuality, fertility, occupational activities and spiritual explanations of CLBP. The educational aspect of the session covers challenging thoughts about back pain. Participants are educated and empowered to challenge and control their thoughts/beliefs and the impact they have on their back pain. Occupational activities and the spiritual understanding of CLBP are explored in group sessions. The utility of spiritual causal explanations of CLBP is compared with spirituality leading to pain acceptance, relinquishment of the sick role and social support. The effect of CLBP on occupational activities and the impact on gender roles are explored with participants. For participants who have questions about the role of CLBP on sexuality and fertility, individual sessions may be used to explore gender roles in terms of sexuality and fertility due to the sensitive nature of this topic. The importance of communication for sexuality should be discussed, and the lack of association between CLBP and fertility in women can be explained. People with fertility problems should be encouraged to visit the hospital and seek medical advice.

Theme 4 (Session 4)

Managing exercise, pacing, goal setting and relaxation, the use of exercise both as a preventive and therapeutic tool in CLBP, and the role of drugs in CLBP. The educational aspect of the session covers managing exercise, pacing, goal setting and relaxation. Participants’ understanding of exercise either as a preventive or therapeutic strategy is explored. The explanation emphasizes how exercise fulfils both roles and the different types of exercises are discussed. This is related to the use of drugs in CLBP with an explanation that drugs are only meant to be used temporarily for short-term relief of symptoms and that no drug cures CLBP. Explanation about the dangers of drug dependence such as toxicity and inhibition of adaptive behaviour change are provided.

Theme five (Session 5)

Biopsychosocial model of CLBP and the chronic disease model. The educational aspect of the session covers chronic pain and chronic disease such as hypertension and diabetes. The differences between acute and chronic conditions and their management are explored with participants. Participants are facilitated in developing an understanding of the contribution of psychosocial factors to the impact of not only CLBP but also the common chronic conditions in rural Nigeria including hypertension and diabetes. Participants are supported in identifying relevant psychosocial factors influencing the impact of CLBP in their lives and how they can control them.

Theme six (Session 6)

Self-management of CLBP, help seeking, managing and coping with flare ups. The educational aspect of the session covers managing and coping with flare ups, relaxation, help seeking and self-management. CLBP is compared with other chronic conditions such as diabetes and hypertension. The difference between the conditions in relation to drug use is explored. Participants are helped to explore how people managed acute conditions such as malaria, and how this is different from how people managed chronic conditions such as diabetes. Participants are then encouraged to explore the similarity and differences between the management of CLBP and other chronic conditions such as hypertension and diabetes.