Exploring peer-mentoring for community dwelling older adults with chronic low back pain: a qualitative study

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Exploring

peer-mentoring

for

community

dwelling

older

adults

with

chronic

low

back

pain:

a

qualitative

study

Kay

Cooper

a,∗

,

Patricia

Schofield

b

,

Susan

Klein

c

,

Blair

H. Smith

d

,

Llinos

M. Jehu

a

a_Robert_Gordon_University,_School_of_Health_Sciences,_Garthdee_Road,_Aberdeen_AB10_7QG,_UK b_Anglia_Ruskin_University,_Bishop_Hall_Lane,_Chelmsford_CM1_1SQ,_UK

c_Robert_Gordon_University,_Faculty_of_Health_&_Social_Care,_Garthdee_Road,_Aberdeen_AB10_7QG,_UK

d_University_of_Dundee_Ninewells_Hospital_&_Medical_School,_The_Mackenzie_Building,_Kirsty_Semple_Way,_Dundee_DD2_4DB,_UK

Abstract

Objectives Toexploretheperceptionsofpatients,physiotherapists,and potentialpeermentorson thetopicofpeer-mentoringfor self-managementofchroniclowbackpainfollowingdischargefromphysiotherapy.

Design Exploratory,qualitativestudy.

Participants Twelvepatients,11potentialpeermentorsand13physiotherapistsrecruitedfromphysiotherapydepartmentsandcommunity locationsinonehealthboardareaoftheUK.

Interventions Semi-structuredinterviewsandfocusgroups.

Mainoutcomemeasures Participants’perceptionsof the usefulnessand appropriateness ofpeer-mentoringfollowingdischarge from physiotherapy.Datawereprocessedandanalysedusingtheframeworkmethod.

Results Fourkeythemeswereidentified:(i)self-managementstrategies,(ii)barrierstoself-managementandpeer-mentoring,(iii)vision ofpeer-mentoring,and(iv)thevoiceofexperience.Peer-mentoringmaybebeneficialforsomeolderadultswithchroniclowbackpain. Barrierstopeer-mentoringwereidentified,andmanysolutionsforovercomingthem.Nosingleformatwasidentifiedassuperior;participants emphasisedtheneedforanyinterventiontobeflexibleandindividualised.Importantaspectstoconsiderindevelopingapeer-mentoring interventionarerecruitmentandtrainingofpeermentorsandmonitoringthementor–menteerelationship.

Conclusions Thisstudyhasgeneratedimportantknowledgethatisbeingusedtodesignandtestapeer-mentoringinterventiononagroup ofolderpeoplewithchroniclowbackpainandvolunteerpeermentors.Ifsuccessful,peer-mentoringcouldprovideacosteffectivemethod offacilitatinglonger-termself-managementofasignificanthealthconditioninolderpeople.

Keywords:Chroniclowbackpain;Peer-support;Peer-mentoring;Self-management;Olderadults

Introduction

Chronicpainaffects25to76% ofcommunitydwelling olderadults[1].Prevalenceoflowbackpainincreaseswith age [2], with many older adults experiencing chronic or recurrentsymptoms[3].Chroniclowbackpain(CLBP) is

∗_{Correspondence:}_Tel.:₊₄₄₀₁₂₂₄_262677.

E-mailaddresses:k.cooper@rgu.ac.uk(K.Cooper), patricia.schofield@anglia.ac.uk(P.Schofield),s.klein@rgu.ac.uk (S.Klein),b.h.smith@dundee.ac.uk(B.H.Smith),l.m.jehu@rgu.ac.uk (L.M.Jehu).

complexandchallengingtomanage,andthehealthcarecosts forpeoplewithCLBParedoublethosewithout[4].The grow-ing population of older adults will inevitably increase the prevalenceandimpactofCLBPfurther;therefore,effective methodsofmanagingCLBPinolderadultsarerequired.

A range of methods is recommended for CLBP man-agement [1,5], commonly including physiotherapy and self-managementstrategies[1,6,7].Self-managementcanbe challenginggiventheindividualnatureofCLBP,and differ-entself-managementapproachesmaysuitdifferentpeople, thereforearangeofself-managementinterventionsmaybe required.

http://dx.doi.org/10.1016/j.physio.2016.05.005

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Self-management can be clinically effective and cost-effectiveinolderadults[8],andadultswithCLBParekeen to participate in self-management activities [9,10]. How-ever, several barriers to self-management exist including: timeconstraints;fear ofpain/re-injury, andtheabsence of aself-managementstrategy[10–12].

Peer-support might provide a strategy for overcoming someofthesebarriers,enablingolderadultstoengagewith CLBPself-management.Definedas“...thegivingof assis-tanceandencouragementbyanindividualconsideredequal”

[13],thetypeof assistanceofferedbypeer-supportis typ-ically “emotional, appraisal and informational” [13]. Peer volunteersarelaypeoplewhoreceiveamoderateamountof trainingtoenablethemtodeliveranintervention[14],but nottotheextentthattheywouldbeconsidereda “parapro-fessional”[13].

Peer-supportcantakemanyforms,andiscommonly deliv-ered in a group format, with chronic pain groups being widespread[15].However,supportgroupsarenot appropri-ateforor acceptabletoall[16],suggestingthatalternative forms such as one-to-one peer-mentoring [17,18], should also be explored. Throughout this paper the term peer-supportrefers to any form of peer-to-peersupport, whilst peer-mentoringreferstoitbeingconductedonaone-to-one basis.

Peer-supportcanenhancethemanagementandoutcome of severalconditions [13,19–21], including low back pain

[22].Toourknowledge,nostudieshaveexploredthe effec-tivenessofpeer-supportspecificallyasawayoffacilitating self-managementof CLBPfollowingdischargefrom phys-iotherapy,andnonehasfocusedonpeer-mentoringforolder adultswithCLBP.Theaimofthisresearchwasthereforeto exploretheperceptionsofcommunitydwellingolderadults withCLBP, physiotherapists,andpotential peervolunteers in relation to peer-mentoring for CLBP self-management followingdischargefromphysiotherapy.Theknowledge gen-eratedwillinformthedesignofapeer-mentoringintervention forolderadultswithCLBPfollowingdischargefrom phys-iotherapy.

Methods

Studydesign

Thiswasan exploratory,qualitative study onthe views ofolderadultsandphysiotherapistsontheconceptof peer-mentoring to facilitate self-management. As the research wasappliedinnature,themethodologyandmethodswere adopted from appliedsocial policy researchto informthe developmentofanintervention.Ratherthanadheringtoa par-ticularqualitativemethodology,thisapproachisgroundedin aspectsofbothinterpretivismandpragmatism,andakey fea-tureistheresearcher’sobjectivity[23].Thestudytookplace intheGrampianregionofScotland,andethicalapprovalwas

grantedbythelocalcommitteeoftheUKNationalResearch EthicsService(StudyNo:13/NS/0094).

Participants

Werecruitedthreeconveniencesamples:(i)Community dwellingolderadultswithCLBPwhoweredischargedfrom physiotherapy3to6monthsbeforethestudy;(ii) Physiother-apistswhoroutinelytreatcommunitydwellingolderadults withCLBP;(iii)Communitydwellingolderadultswith self-reportedexperience of successful CLBPself-management, definedaseithermanagingtheirowncondition,or suppor-tingsomeonewithCLBPtoself-manage.Forclaritywehave termedthisthirdgroupofparticipants“potentialpeers”.The potentialpeershadmuchincommonwiththefirstgroupof participants.However,thedurationofsuccessfulCLBP self-managementdistinguishedthemfromthosewhohadreceived physiotherapyintheprevious3to6months.Inkeepingwith previousresearch,olderadultsweredefinedasaged65years andaboveandCLBPas12weeksdurationorlonger.

OlderadultswithCLBPwererecruitedbytheir physio-therapist,whoidentifiedpotentialparticipantsfromdischarge filesandmailedthestudyinformationpackstothem. Inter-estedparticipantssentareply-sliptotheresearchteam,who contactedthembytelephonetodiscussthestudyandconfirm eligibility.Eightphysiotherapydepartmentsparticipated.We also recruited participants with CLBP and experience of physiotherapyfromachronicpainsupportgroup.

Physiotherapistsinonehealthboardareawererecruited viaane-mailinvitationsentbytheirleadphysiotherapiston behalfofthestudyteam.Interestedparticipantscontactedthe researchteam,andwerethenrecruitedasfortheolderadults. Potentialpeerswererecruited bydistributingpostersin communityvenues,circulatingstudy informationto volun-taryandstatutoryorganisationsinvolvedwitholderpeople, and speaking directly with older people participating in variousgroups.Allparticipantsprovidedwritten,informed consent.

Datacollection

OlderadultswithCLBPandpotentialpeerstookpartin semi-structuredinterviewsconductedbytheresearch assis-tant at alocation of each participant’s choosing; a public venueortheirhome.Allinterviewswereaudiorecorded,and fieldnotestakenduringorimmediatelyaftertheinterviews wereincludedintheanalysis.

Physiotherapiststookpartinafocusgrouporindividual interviews,bothof whichwere audio-recorded.Interviews were deemed appropriate for the olderpeoplewith CLBP andpotentialpeers,astheuniquenessoftheCLBPexperience mayhavebeenlostinafocusgroupsetting[24].Focusgroups weredeemedappropriateforthephysiotherapistsbyvirtueof theirfamiliaritywithdiscussinganddebatingclinicalissues. Becauseitwasnotpossibleforallphysiotherapiststoattend

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Table1

Areasexploredinsemi-structuredinterviews. OlderpeoplewithCLBP

1.CLBPself-management:Strategiesusedandhowtheywere developed

2.SupportforCLBPSelf-management:Supporttheyareawareofand supporttheymayhavefoundusefulondischargefromphysiotherapy 3.Peer-mentoring:Viewsonpeer-mentoringforolderpeoplewith CLBP

Physiotherapists

1.CLBPself-management:Whatadvicedotheygivetoolderpeople withCLBP

2.SupportforCLBPself-management:Supportthatexistsandsupport theythinkmaybeusefulforpatientsfollowingdischargefrom physiotherapy

3.Peer-mentoring:Viewsonpeer-mentoringforolderpeoplewith CLBP

Potentialpeers

1.CLBPself-management:Strategiesusedandhowtheywere developed

2.SupportforCLBPself-management:Whatsupportcouldthey providetoanolderpersonwithCLBP

3.Peer-mentoring:Viewsonpeer-mentoringforolderpeoplewith CLBP

Key:CLBP,chroniclowbackpain.

thefocusgroups,individualinterviewswerealsoconducted, inkeepingwiththeflexiblenatureofqualitativeresearch.

Theinterviewsandfocusgroupswereinformedbythe lit-erature anddiscussion withorganisations involved inpeer support for people with other long-term conditions and guidedbyaninterviewschedule.Table1identifiestheareas exploredwitheachsample(Thefullinterviewschedulefor eachsampleisavailableonrequest).

Dataprocessingandanalysis

Theinterviewsweretranscribedverbatimandcheckedfor accuracy.Readingandre-readingthetranscriptsallowedthe researcherstofamiliarisethemselves withthe data. There-after theywereimportedtoNVivo 10(QSRInternational, Victoria, Australia). A thematic (coding) index was con-structed,andappliedindependentlytothefirstfewtranscripts bytworesearchers.Becausehighlevelsofagreementwere achieved,oneresearchersubsequentlyindexedtheremaining transcripts. Thethematic indexwas informedby the liter-ature,theinterview schedule,andthemes arisingfromthe data.

Framework analysis [25] was conducted by two researchers. As a systematic and comprehensive analysis process,itallowswithinandbetween-caseanalysisand pro-videsaclearaudittrail[26].Thefirstthreestageshavebeen described(familiarisation,identifyingathematicframework, indexing).Thefinaltwostages(charting,mapping& inter-pretation)wereconductedusingmatrix-basedchartswithin NVivo10,therawdatabeingfrequentlyreferredbacktoat thisstage.Thedataforeachsamplewerefirstindexedand

Table2

Participantcharacteristics. Olderadults withCLBP

PotentialPeers Physiotherapists

N 12 11 13 FemaleN(%) 9(75) 7(64) 11(85) DurationofCLBP(years) <5 1 0 5to10 0 2 11to20 1 2 21to30 6 2 31to40 2 1 41to50 1 2 50+ 1 2 NHSgrade Band5 4 Band6 6 Band7 3

Key:CLBP,chroniclowbackpain;NHS,NationalHealthService.

chartedseparately,thenthedatasetasawholewascharted, mappedandinterpretedtoidentifycommonthemes.

Results

Participants

Thirty-six(27female)participantstookpartinthe inter-views and focus groups(Table2).Eight olderadultswith CLBP wererecruitedfrom physiotherapydepartmentsand fourfromthechronicpainsupportgroup.Nine physiother-apistsparticipatedintwofocusgroups;fourparticipatedin individualinterviews.Elevenpotentialpeersparticipatedin individualinterviews.

Themes

Numerous dimensions were identified from the data, whichcontributedto144categories.Becauseseveral cate-gorieswerecommontoeachofthethreesamples,analysis resulted in 21 classes of data, which contributed to four keythemes:(i)“Self-managementstrategies”,(ii)“visionof peer-mentoring”,(iii)“barrierstoself-managementand peer-mentoring”,and(iv)“thevoiceofexperience”.Thefirstthree themeswerecommontoallthreesamplesofparticipants;the last-namedwasdiscussedbythepotentialpeersonly.Table3

detailstheclassesofdatathatcontributedtoeachofthesefour themes,whicharediscussedindetailbelowwiththe excep-tionof“self-managementstrategies”whichissummarised, duetothestudybeingfocussedonpeer-mentoringandnot thegeneralconceptofself-management.

Self-managementstrategies

Older people withCLBP andpotential peers discussed usingawiderangeofself-managementstrategies(Table4). All three groups discussed the need to take responsibility

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Table3

Classesand themesarisingfromthedata indicatingwhich participants contributed.

Themes Classes

Self-management strategies

Takingresponsibility(PT;OP;PP) Education(PT;OP;PP)

Exercise(PT;OP;PP) Othersupport(PT;OP;PP) Visionof

peer-mentoring

Whatpeersupportcouldprovide(PT;OP;PP) Whatpeersupportcouldachieve(PT;OP;PP) Delivery/modeofPM(PP)

Addedvalue/credibilityofpeer(PT) Barriersto

self- management/peer-mentoring

Peoplebarriers(PP)

Person-specificbarriers(PT;OP) Motivation(PT)

Age-relatedbarriers(PT) Practicalbarriers(PP) Location(PT)

Pain-relatedbarriers(OP) Needfortraining(PT) Matchingprocessvital(PT;OP)

PotentialnegativeconsequencesofPM(PP;PT) Thevoiceof

experience

Knowledge/experienceofdifferentpeersupport relationships(PP)

Knowledge/experienceofdifferenttypes/modes ofpeersupport(PP)

WhatImightsayasapeer-mentor(PP)

Key:PT,physiotherapist;OP,olderpersonwithCLBP;PP,potentialpeer.

fortheircondition.Table4showsthattheself-management strategiesemployedrelatedtoeducation, exercise(general orspecific), andotherstrategies(e.g.medicationuse, con-sultingotherhealthprofessionals,andcomplementary and alternativemedicine).

Barrierstoself-managementandpeer-mentoring

Self-management. Person-specific barriers were discussed by physiotherapists and included: lack of time; low fit-ness levels; patients’ expectations, and the presence of co-morbidities.Thesebarrierswererelatedtoolderpeople’s abilitytoadheretoexerciseasaself-management interven-tion.Somephysiotherapistsrelatedthesebarriersdirectlyto age,suggestingthatolderpeopleoftenhadlowerexpectations oftheircapacityforexercise,orforsymptomatic improve-ment.Thesewerenotsuggestedbyolderpeopleorpotential peersasbarrierstoself-management.

Physiotherapistsfromrurallocations discussedthelack ofresources,(e.g.exerciseclassesandwalkinggroups),and theshort-termnatureof someresources,commonlydueto lackofcontinuedfunding:

...Wedosignposttowhat’savailable,butIdotendtoﬁnd inasmallruralarea,there’snotthesamefacilitiesasthere mightbein[Cityname]...”[Physiotherapist13]

Peer-mentoring. Ruralitywasalsoseenasapotentialbarrier topeer-mentoring,duetoarangeoffactorssuchaspublic transportandpoorwinterweather:

Table4

Self-managementstrategiesusedbyolderadultswithCLBPandpotential peers.

Education NHSBackBook Painmanagement Posture Pacing

Exercise Physiotherapyexercises Strength&balanceclasses Swimming

Walking Wii Yoga/Pilates Otherinterventions Heat/Cold

Relaxation TENS

Complementary&AlternativeMedicine Medication Weightcontrol Acupuncture Chiropractic Massage Osteopathy

Adaptingbeds/seating/otheraids Takingresponsibility Self-motivation

Supportfrompeers Supportfromfamily

Key:NHS,NationalHealthService,TENS,transcutaneouselectricalnerve stimulation.

“Peer-mentoringwouldhavetobeverylocal,becausepeople, whenitcomestowintertime,don’twanttobegoingoutand thingslikethat”[Potentialpeer09Female]

Internet-based peer-mentoring was viewed by some as apotential methodofovercoming thisbarrier.However, it wasacknowledgedthatitcouldalsoimposerestrictionsdue tosecurityconcerns,andageneralpreferenceforpersonal contact.

Perceivedbarrierstoface-to-facepeer-mentoringincluded thepersonalnatureofCLBP:

“Ithinkit’squiteapersonalsortofthing,actually.Imean, whatcanworkforsomebodywouldn’tnecessarilyworkfor me.AndIthinkit’s,it’salmostlike ajourney.Youhaveto ﬁndoutwhatworksforyou.[Potentialpeer08Female]

Physiotherapistsexpressedconcernthatmentorsmayuse mentoring as an opportunityto expresspersonal anxieties or demands for attention, and that mentors may dwell on the problem of CLBP rather than facilitating active self-management. Some expressed concern about the lack of controloverapeer-mentoringrelationship:

“[It’simportant]that peoplearegetting theright informa-tion, and correct information, that they need. It’s not just googledandIfoundx,y,andz...”[Physiotherapist12]

This concern was mainly that peer-mentors may rec-ommend interventions that were not evidence-based or recommended. However,physiotherapistsagreedthat none

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ofthesepotentialbarrierswereinsurmountableandsuggested thatclearguidelines,adequatetrainingandcarefulmatching ofolderpeopletopeer-mentorswereessential.

Someolder peoplewithCLBP expressedthe viewthat supportfrom apeermay notbe valued or ratedas highly as support from “someonewho had an official capacity”. One participant suggested that there may be a sense of obligation to a peer and it may be difficult to elect to discontinue the relationship, whereas with a paid profes-sional:

“...if youfeel, if you don’t wantto do it,you canignore them.”[Olderperson8Female]

Conversely,severalphysiotherapistsfelttheempathyand shared experiences that peers could offer would provide “added value” and impart greater confidence in self-managementthancouldbeachievedbyprofessionalsalone, therebybreakingdependencyonhealthcareservices: “...mentorstakingtheonusawayfromthehospitalsideof things, into the realworld.It’s really trying tobreak that chain of them being dependent on hospital...it wouldbe reallygood”[Physiotherapist12]

Oneparticipantfeltthatifapeer-mentoringintervention wasseenas“justfortheelderly”thenitmightputpeopleoff, recallingherexperiencewithbeingrecommendedtoattend anexerciseclass:

“IfeltthatwasforelderlypeopleandI’mnotthatelderly”

[Olderperson5,Female]

Visionofpeer-mentoring. Someparticipants discussedthe relative merits of peer-support withina groupand one-to-onepeer-mentoring.Potentialpeershadnoclearpreference, identifyingadvantagesandlimitationsinboth.One partici-pantprofferedthefollowingsuggestionforone-to-onepeer mentoring:

“....Meetingsomeoneover a cupofcoffee andgetting to knowthemjustalittlebit,Ithink,wouldbethewayforward.”

[Potentialpeer11Male].

Therewasgoodagreementacrossallthreesamplesthat peer-mentoringshouldbetailoredtotheindividual’sneeds. Despitetheinternet-basedbarrierspreviouslydiscussed, it wasfelt that theinternet maybea usefulformof peer-mentoringforthosewhowereconfidentinitsuse.Indeed,one participantdiscussedtheimportanceofnotmaking assump-tionsaboutolderpeopleandtechnology:

“Yep, because a lot ofolder people, I knowfromwalking group,theydohavetheinternet,andforthemit’showthey keepintouch withyouknow,their familieswho’ve moved away.”[Potentialpeer04Female]

Most participants agreed that sharing information and giving support and advice could be components of a

peer-mentoringintervention,aswellasempathisingand help-ingpeopleputthingsintoperspective:

“Knowing somebody else is havingthe same problems as you”[Potentialpeer02Female]

“They’remorelikelytolistentoanotherpatient,ratherthan listentoadoctor.Becauseadoctordoesn’tknow...doctors don’tknowthepainyou’regoingthrough”[Potentialpeer10 Male]

Empathywasseenbymanyasthemostimportant dimen-sion – more important than practical advice or support. Participantsusedphrasessuchas“beingbelieved”and “peo-ple notunderstandinghow itcanreallytakeyoudown”to illustratethepoint.

Similarly, physiotherapists agreed that encouragement andreassurancecouldbeanimportantroleforapeer-mentor, particularlyasitwouldoccurinaninformalway.Theyalso feltthatpeer-mentorscouldprovidepositiverole-modelling, thereby reducing anxiety,andsuggested that peer-mentors mightaccompanyolderpeopletoexerciseclasses,whichis somethingaprofessionalisrarelyabletodo.

Whilst most older people were positive regarding the potentialbenefitsofpeer-mentoringthiswasnotthecasefor all.Twofeltthatitwouldnothavebenefittedthempersonally. Thisisinkeepingwithindividualisingpeer-mentoring,and itnotbeing“onesizefitsall”orindeednotappropriatefor allolderpeoplewithCLBP.

Finally,allparticipantsagreedthatoneofthemost impor-tant practicalaspects ofapeer-mentoringinterventionwas thematchingprocess.Ageandgenderwerenotseenbymany asparticularlyimportantattributestoconsider,butcommon interestswere.

The voiceofexperience. Somepotentialpeersalreadyhad experienceofpeer-mentoringormoregeneralpeer-support, including:volunteeringatsupportgroups;supportingfriends orfamilymembers;peer-mentoringduringacademicstudy, andsupportingfellowsportscoaches. Oneparticipantwas asked byhis surgeontospeaktopatients about his CLBP experience.Severalhadexperienceofinformalpeer-support throughtheirrolesaswalkleaders,membersofgroups,and withintheirsocialcircles.

Potential peers were asked what they felt they might contributeinaCLBPpeer-mentoringrelationship.They com-monly discussed the needto supportpeopletobe/become positiveanddetermined:

“Keepgoing,keepgoing.Don’tletitgetyoudown”[Potential peer06Male]

Theyalsodiscussedsupportingpeopletolearnpacingand taking responsibility and the importance of understanding thatnotallpaincouldbemanagedwellallofthetime.The abilitytomanagetheirownpaindidn’tappeartoinfluence their opinionof otherswhose pain management strategies maynotbeaseffective:

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“Fortunatelymineclearedup...butIknowthatotherpeople’s doesn’t...Icanappreciatetheproblemssomepeoplehave”

[Potentialpeer02,Female]

Overwhelmingly,regardless of the nature of their back pain andpersonal circumstances, potential peers felt they could provide empathy and understanding to others with CLBPandthatdespitetheindividualnatureofthepain expe-riencetherewouldbeanelementofcommonalityinpeople’s approachestoself-management.Forthisreason,allthe poten-tialpeersfelttheypersonallywouldhavesomethingtooffer anotherpersonwithCLBPintermsofpeersupport.

Discussion

To our knowledge this is the first study toexplore the perceptions of older adults with CLBP, physiotherapists and potential peers in relation to peer-mentoring to sup-port self-management following physiotherapy discharge. Despitesomedifferencesamongthethreesamplestherewas generalagreementthat;peer-mentoringmightbebeneficial for older adults with CLBP, and whilst barriers to peer-mentoringandself-managementmust beacknowledged,it isconceivablethat theycouldbe overcomeindesigning a peer-mentoringintervention.

The older people and potential peers in this study describedself-management strategies inkeepingwith pre-vious literature [9,27], in which medical management, role management, and emotional management are essen-tial elements. The barriers discussed are also in keeping with previous research [11,12]. The sample may there-fore be viewed as broadly typical of older people with CLBP.

ThefindingsdemonstratedthatolderpeoplewithCLBP, potentialpeers,andphysiotherapistscouldidentifypositive and negative aspects of peer-mentoring. Physiotherapists’ concernsthatpeer-mentorsmayusetheprocesstoexpress their own anxieties or to recommend non evidence-based treatmentsforCLBPcouldbeovercomewithcareful atten-tiontorecruitmentofpeer-mentorsandtheirtraining,with predetermined criteriathat potential mentors mustachieve beforeparticipatinginanyintervention.Previousresearchon peer-mentoringindiabeteshasemployedthisapproach effec-tively [28]. However, the physiotherapists’ concerns may be indicative of their own elevated fear-avoidance beliefs inrelationtoCLBP[29]andperhaps physiotherapistsand peer-mentorsworkingcollaborativelytosupportolder peo-plewithCLBPmightresultinacomprehensiveapproachto person-centredcare.

Arecentqualitativesynthesishighlightingthepotentialfor unevenpowerrelationshipsbetweenmentorandmentee[30], alsosuggestedthatcarefuldesignmightavoidsuchnegative aspects,andthattherelationshipmaybecomemorebalanced withtime.Consequently, theduration ofa peer-mentoring interventionisimportanttoconsider.

Thatphysiotherapists,butnotolderpeople,identified age-relatedbarrierstoself-managementandpeer-mentoringmay relate tophysiotherapists’ perceptionsof olderpeopleand theircapacityforself-management,and/ormaybereflective oftheage-differencebetweenthegroupsofparticipants.In contrast severalolderpeople werekeen toavoid interven-tions that would label themas “elderly” andto challenge commonmisconceptions(e.g.internetusebyolderpeople). Thesefindingshavewiderimplicationsforphysiotherapyin general,andmaybenefitfromfurtherresearchtoidentifythe extentofsuchperceptionsandhowtheymaybealtered.

That peer-mentoring was broadly viewedpositively by participants, andthatsuggestionsfor overcomingpotential barrierswereforthcomingsuggeststhatpeer-mentoringfor CLBPmaybeworthexploringfurther.Importantcomponents ofapeer-mentoringintervention,fromtheperspectiveofour participants,areinkeepingwiththosedeliveredinprevious studiesonotherchronicconditions,whichhaveemphasised information-sharing,practicalsupportandadvice[17,28].

Thatempathywasseenasimportantbybotholder peo-pleandphysiotherapistssuggeststhatallthreedimensionsof peer-support (emotional, appraisal andinformational) [13]

shouldbe incorporatedinanintervention.The importance placedonindividualisingapeer-mentoringintervention rein-forcesthatanyintervention,whetherhealth-professionalor peerdelivered,shouldbepatient-centred.Thus,anelement of flexibilityneeds tobe incorporatedintoan intervention aimedatfacilitatingself-managementofCLBP.

Peer-mentoringwasnotperceivedas beingone particu-larformat;participantsdiscussedone-to-one,internet-based, andone-to-onewithingroupformats,oftenwithno promp-ting.Whilstpeer-mentoringhasbeensuccessfullydelivered inalltheseformats[20–22],someofthe practicalbarriers discussedinourstudymightbeovercomebythedesignofa flexibleinterventionthatcanbedeliveredinvariousformats. The potentialpeersdiscussedexperiences thatcould be termed peer-support, suggesting that some older people may possess relevant knowledge, skills and interpersonal behavioursthataresuitedtoparticipatinginpeer-support.It willbeimportanttoacknowledgethisinanytrainingprovided tovolunteerpeer-mentors,andtotailortraining,aswellas thedesignofanindividualisedpeer-mentoringintervention, toindividuals’needs.

Limitations

Ourparticipantsweremostlyfemaleandourresearchwas conductedinoneregionoftheUK;Consequently,different perceptionsofpeer-mentoringmayexistinthewider popu-lation.Weusedconveniencesampling,andrecruitmentfrom physiotherapydepartmentswaslow.Itispossiblethat purpo-sivesamplingwouldresultinabroaderrangeofviews.Wedid notperformmember-checkingofthetranscriptsordata anal-ysis.However, focusgroupsandinterviewswere recorded and transcribed verbatim, reducing the potential for error, andthedatawereanalysedbymorethanoneresearcher,one

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ofwhomwasexperiencedinframeworkanalysis,inkeeping withrecommendedpractice[31].

Conclusion

Peer-mentoringappearstobeanacceptable conceptfor olderpeoplewithCLBP,andapeer-mentoringintervention could be used to provide support, particularly emotional, to older people following discharge from physiotherapy. In designing such an intervention careful attention should be paid to the: recruitment of peer-mentors; provision of appropriatetraining,andmonitoringthementee-mentor rela-tionship to prevent any negative consequences. Both the trainingandpeer-mentoringinterventionshouldbe person-centredandflexibleinnature,inordertomeetindividuals needs and prior experience. These results are being used toinformthedesignofsuchanintervention,whichwillbe testedonagroupofolderpeoplewithCLBPandvolunteer peer-mentors.Ifsuccessful,itmightprovideacost-effective methodoffacilitatinglonger-termself-managementofa sig-nificanthealthconditioninolderpeople.

Acknowledgements

Wewouldliketothankalltheolderpeopleand physiother-apistswhoparticipatedinthestudy,andthephysiotherapists whoassistedwithparticipantrecruitment.

Ethicalapproval:EthicalapprovalwasgrantedbytheNorth ofScotlandResearchEthicsCommittee.

Funding:ThisworkwassupportedbyTheDunhillMedical Trust[grantnumber:R300/0513].

Conﬂictofinterest:Therearenoconflictsofinterest.

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