Experiences of Health Care Access Challenges for Back Pain Care Across the Rural-Urban Continuum in Canada: Protocol for Cross-sectional Research

Background Back pain is common and costly, with negative impacts on both individuals and the health care system. Rural, remote, and Indigenous populations are at greater risk of experiencing back pain compared to urban and non-Indigenous populations. Potential barriers to health care access among Canadians with chronic back pain (CBP) have been identified; however, no study has used lived experiences of people with CBP to drive the selection, analysis, and interpretation of variables most meaningful to patients. Objective The aims of this study are to (1) engage with rural, remote, and urban Indigenous and non-Indigenous patients, health care providers, and health system decision makers to explore lived experiences among people with CBP in Saskatchewan, Canada; (2) cocreate meaningful indicators of CBP care access and effectiveness; and (3) identify program and policy recommendations to overcome access barriers to CBP care. Methods In phase 1, one-on-one interviews with 30 people with current or past CBP and 10 health care providers residing or practicing in rural, remote, or urban Saskatchewan communities will be conducted. We will recruit Indigenous (n=10) and non-Indigenous (n=20) rural, remote, and urban people. In phase 2, findings from the interviews will inform development of a population-based telephone survey focused on access to health care barriers and facilitators among rural, remote, and urban people; this survey will be administered to 383 residents with CBP across Saskatchewan. In phase 3, phase 1 and 2 findings will be presented to provincial and national policy makers; health system decision makers; health care providers; rural, remote, and urban people with CBP and their communities; and other knowledge users at an interactive end-of-project knowledge translation event. A World Café method will facilitate interactive dialogue designed to catalyze future patient-oriented research and pathways to improve access to CBP care. Patient engagement will be conducted, wherein people with lived experience of CBP, including Indigenous and non-Indigenous people from rural, remote, and urban communities (ie, patient partners), are equal members of the research team. Patient partners are engaged throughout the research process, providing unique knowledge to ensure more comprehensive collection of data while shaping culturally appropriate messages and methods of sharing findings to knowledge users. Results Participant recruitment began in January 2021. Phase 1 interviews occurred between January 2021 and September 2022. Phase 2 phone survey was administered in May 2022. Final results are anticipated in late 2022. Conclusions This study will privilege patient experiences to better understand current health care use and potential access challenges and facilitators among rural, remote, and urban people with CBP in Saskatchewan. We aim to inform the development of comprehensive measures that will be sensitive to geographical location and relevant to culturally diverse people with CBP, ultimately leading to enhanced access to more patient-centered care for CBP. International Registered Report Identifier (IRRID) DERR1-10.2196/42484

This application meets the criteria of the competition. The research team has multiple and diverse patient perspectives fully integrated multiple and diverse patient perspectives, including under represented populations. They have collaborations and research partners in two jurisdictions, SK and AB. The area of chronic lower back pain is a huge health concern with significant impact on the health care system.

Research Approach
This proposal responds exceptionally well to the objective of the funding opportunity which is to engage patients, family members and others in a really meaningful way to build a new research approach. The proposed work is to meaningfully engage community-dwelling older adults and health and social service providers in conceptualizing the research program. The commitment of co-design of the research questions, methods and outputs in this proposal are very strong and this proposal demonstrates a deep understanding of the objectives of this research funding opportunity. This proposal demonstrates the team's sophisticated understanding of patient and citizen engagement and co-design. There is real and meaningful engagement in the proposed work. The proposed work is very clear and it is very important. In fact it is quite relevant to SPOR in the sense of potentially improving health systems and health outcomes. There is meaningful engagement of people with lived experience in the proposed methods. There has been extensive work undertaken to date to engage those with lived experience into the development of the research issue. The team has previous experience in both the subject matter and co-design with people with lived experience. People with lived experience have been and will be meaningfully engaged in identifying the topic of the work, the methods and the products of the research. The team has put together a thoughtful and broad recruitment strategy largely based on previous engagement with the study population. From identifying the research priorities and outcomes to the methodology. People with lived experience will play a central role in co-designing the research intervention. More specifics as to how the research team will undertake specific recruitment strategies to mitigate and address inequities would be hlpful. There is stated intent here but not a lot of detail as to how that will actually occur. But one assumes that the strong understanding of co-design and the meaningful engagement of those with lived experience may enable this outcome to be realized. The team could have explained this particular strategy to address inequities in more detail in the proposal. The team is strong academically speaking. It is also strong from a multi-disciplinary perspective and in working with those with lived experience.
There is the opportunity for this work to very meaningfully impact health systems practice and policy. The work could also help address health inequities and ensure more inclusive community design that enables more active, healthy living for older adults. Sex and gender has been integrated into the proposal.

Feasibility
This work is very feasible and builds on previous work. It seeks to improve knowledge of an under-served, under researched and under valued population, both geographically and demographically. The commitment to co-design in the proposal should quite likely lead to a larger and possibly successful larger research grant. The methods are very appropriate for the proposed work. It is very likely this work can be completed in the time allocated and the commitments of the project are reasonable The budget is appropriate for the proposed work. Potential Impact of the Research I believe the proposed work could meaningfully improve health experience, health outcomes and improved community design for older adults. The partnership is diverse and strong The proposed work could very meaningfully contribute to the improvement of health care systems and practices that support patient-oriented research for older adults. Then the measures will be used in future studies to evaluate current and future community-based CBP interventions and cross provincial/ national comparisons, ultimately leading to enhanced access to more patient-centred care for CBP. There are several phases to the study and a developed Knowledge dissemination plan.
Phase 1 = Qualitative interviews to develop survey Phase 2 = Deployment of telephone survey to 383 individuals in Saskatchewan. Phase 3 = An interactive end-of-project knowledge translation event.

Feasibility:
Team seems feasible -the random cold calling seems tough in today's environment Solid team -likely doable in the year timeframe

Impact of the Research:
Clearly the strength lies in the mixed populations and the attempt to span several cross cultural themes. Clearly patient oriented and a good knowledge dissemination plan with appropriate timelines outlined. Fundable. This study aims to identify barriers to health care access for chronic back pain of remote, rural and Indigenous dwellers. This will lead according to the applicants to improved access to patient-centered care for back pain across geographical situations and cultural backgrounds. To do this, the applicants propose to explore lived experiences of back pain patients, co-create indicators of back pain care access and effectiveness, and identify programs or policy changes that could be implemented. These objectives will be achieved using a mixed methods design. The project focuses on gathering the opinion (qualitatively and quantitatively) of patients from different profiles as well as health care providers in order to gather necessary information for future patient-oriented research projects.
There is a vast body of knowledge on systemic barriers to health care access in Canada, not only for back pain but for all types of chronic pain. It was difficult to fully appreciate the novelty and need for this project given what is already known. The Canadian Task Force on Chronic Pain was launched last year and has a 3-year mandate on increasing access to chronic pain treatment. They have produced their first report this June of access to chronic pain treatment across the country and across different subpopulations. As such, it is difficult to see what more this study will bring to the table in the context of an important national endeavor already going on. At the minimum how are the applicants planning on informing and being informed by the work of this national task force?
The research idea stems from prior work from the research team and identified by patients. Patients are included in the research team and patient perspective will be prioritized during open dialogue during team meetings. They will be involved in conducting some of the interviews, interpret outcomes and disseminate knowledge. How this will be realized concretely however is unclear.
In particular 4 meetings throughout the project does not guarantee complete involvement of patient partners.
Sex-and Gender-Based Analysis Plus (SGBA+) is discussed but not fully integrated within the proposal. It is unknown whether selection of participants will ensure adequate representation of sex and gender or how it will be taken into account in the analysis or dissemination. There are no concrete examples given as to how dissemination messages or modalities for example will be targeted to the different needs of men and women.

Feasibility
The team is composed of researchers with significant experience in the proposed subject. There are also 3 patient partners involved in the study who suffer from chronic back pain. Different policy makers and stakeholders have signed letters of collaboration.
The timeline is realistic and reasonable. The project is well circumscribed and delineated.
Budget seems reasonable and includes in-kind contributions.
Potential Impact of the Research