General practitioner participants
Twenty-one general medical practitioners were approached to participate. Of these, four (19%) declined as they either did not consistently see patients with low back pain, or did not want to participate. Of the 17 general medical practitioners that participated in the study, 14 (82%) completed the interview at the end of the study; three general medical practitioners could not be contacted. Of the 14 general medical practitioners completing the study, 57% (8/14) were female, with a mean (SD) of 16.6 (10.0) years in clinical practice. Sixty-four percent (9/14) reported performing continuing education in low back pain in the last two years. Only two general medical practitioners (14%) reported a special interest in low back pain. All general medical practitioners either completely disagreed or disagreed with the statements ‘Imaging of the lumbar spine is useful in the workup of patients with acute low back pain’ (8/14 completely disagreed, 6/14 disagreed) and ‘I am likely to order imaging for acute low back pain’ (13/14 completely disagreed, 1/14 disagreed). Practice locations were in a spread of low (2/14; 14%), medium (5/14; 36%), and high (7/14; 50%) socioeconomic areas, as determined by postcode and socioeconomic index (19).
How general medical practitioners used the booklet (adoption)
General medical practitioners participated in the study for between five to 11 months (mean, SD: 8.4, 2.2), depending on their date of recruitment into the study. They used the booklet between zero to 15 times (mean, SD: 5.2, 4.1) each, for a total use across all clinicians with 73 low back pain patients. The patient record form was fully completed for 71% of patients (52/73), with partial data available for the rest.
Most patients with whom the booklet was used had low back pain presentations of less than 2 weeks duration (30/52, 57.7%, 95%CI: 44.2, 70.1). Previous episodes of low back pain had been experienced by 39 of 57 patients (68.4%, 95%CI: 55.5, 79.0). Prior imaging for low back pain was performed in 16 of 57 patients (28.1%, 95%CI: 18.1, 40.8). General medical practitioners reported concern of underlying serious pathology in four of 57 patients (7.0%, 95%CI: 2.8, 16.7).
General medical practitioners commonly customised the booklet to the patient and either discussed the booklet throughout the consult (27/60, 45.0%, 95%CI: 33.1, 57.5), or gave the customised booklet to the patient to read at the end of the consult (25/60, 41.7%, 95%CI: 30.1, 54.3). For the remaining patients, general medical practitioners did not customise the booklet and either handed it to the patient to take home (4/60, 6.7%, 95%CI: 2.6, 15.9), or discussed the booklet with patients who subsequently declined to take it home (4/60, 6.7%, 95%CI: 2.6, 15.9). This quantitative data was consistent with themes arising from the interviews (Table 1). General medical practitioners who did not use the booklet during the consult but provided it to the patient to read at home thought there was value in providing the patient with further information; but thought they had either already discussed what they needed with the patient using their own strategies, or were running short of time for further discussion.
Table 1
Themes related to ‘How general medical practitioners used the booklet’
Theme | | Quotes |
Used as designed throughout the consult to: 1) show patients why they don’t require imaging, 2) demonstrate key educational messages, and 3) provide a customised patient management plan | | “I go through it [the booklet] together with them [patients], so I actually use it as an educational tool” (GP2) “I like the diagrams that are in there [decision tree at beginning] that I can sort of go through and say, well you don’t have all these symptoms, so you don’t need any imaging” (GP2) “Yes, that’s not bad [to have somewhere to write patient management] because you’re not giving them necessarily a prescription for prescription drugs, so it doesn’t hurt to write something down, some instructions, and when to come back in for review” (GP8) |
Used at the end of the consult only, by customising the management plan and providing it to the patient | | “Mostly at the end of the consultation, I’d talk to them about it all and then at the end I’d remember to use it [the booklet], and go through it then and fill in some information” (GP9) |
No customisation, given to the patient as a hand-out to read at home at the end of the consult only | | “If I thought that someone didn’t need imaging, I simply, towards the end of the consult, gave it [the booklet] to them. I gave it to them to take and read, and in our practice, there was a follow-up appointment made at the time, and at that time we discussed the content of the book“ (GP5) |
Used throughout consult to discuss the key messages, but not customised or given to the patient | | “Whilst I did go through it [the booklet] with a few patients who were half-interested in looking at it, they didn’t want to take it away, they just thought that they didn’t want the material but were happy just to talk about it” (GP6) |
Most general medical practitioners reported that they found the booklet useful, and would be likely to continue using it in the future, particularly with specific patients: those that requested imaging or required more reassurance or information about their low back pain.
“I genuinely think it’s [the booklet] really useful and I’ll continue to use it” (GP10)
“I’d certainly consider using it [the booklet], but not necessarily with every single patient that I see with back pain” (GP8)
One general medical practitioner did not use the booklet during the study and two general medical practitioners reported that they would be unlikely to continue to use the booklet. These general medical practitioners reported that they already felt confident that patients would follow their advice without additional resources and they either don’t keep paper booklets in their office, or they would forget to use it.
“I suspect that there’d be more of me forgetting to use it [the booklet] again [moving forward]” (GP11)
Barriers and facilitators impacting use of the booklet (feasibility)
Themes relating to barriers and facilitators impacting on general medical practitioners’ use of the low back pain management booklet are presented in Table 2. Key barriers included the ability to conveniently store and remember to use the booklet, and a lack of time during the consult. Facilitators included the ease of use of the booklet, and the perceived usefulness of the booklet to help educate and reassure the patient in a time efficient manner, particularly for clinicians who felt less confident in their ability to manage patients with low back pain. In particular, the request for imaging by the patient acted as a reminder to use the booklet.
Table 2
Themes related to ‘Barriers and facilitators impacting use of the booklet’
Theme | | Facilitator or Barrier | | Quotes |
Storage location and remembering to use the booklet | | Facilitator: Storing the booklet in a visible location with convenient access | | “Yes I did find the booklet OK to use, and because it was somewhere where I can reach it, it was good” (GP2) |
| | Barrier: Nowhere to store the booklet with good visibility or convenient access | | “In offices you just lose pieces of paper and little booklets and all of the rest. You don’t have room to store everything” (GP4) |
| | Barrier: Forgetting to use the booklet | | “I only used the one and I think that’s probably not the booklet, but because it’s difficult to remember” (GP1) |
Clinician having the necessary knowledge/ skills to use the booklet | | Facilitator: Training or clinician prior knowledge was sufficient to use the booklet | | “I think it [the training] was absolutely fine, the booklet’s quite self-explanatory, it’s quite clearly laid out so that was fine” (GP1) |
| | Barrier: Some points were missed in the training session, and the booklet wasn’t used completely | | “Yes, I think I missed a few points [in training] so that’s what I failed to explain fully to my patients” (GP14) |
Perceived usefulness of the booklet within a consult | | Facilitator: The information in the booklet is appropriate and useful for patient education | | “My general experience [with the booklet] was that it was very helpful, that it helps explain this to the patients really well. It was very didactical, it followed a logical order and I found it very useful” (GP7) |
| | Facilitator: The booklet was used because the clinician felt the patient required more education or reassurance | | “I think for instance I felt [in the patients that did use the booklet with] there was an expectation that was either voiced or implied of imaging, and so to sort of counter that view the booklet was handy” (GP5) |
| | Barrier: Booklet was not needed as current clinician method of managing clinical consults sufficient | | “So I think that the main reason that I didn’t use the booklet more is that I do feel quite confident in being able to sort out when to use imaging” (GP1) |
| | Barrier: Clinician felt the patient didn’t require more education or reassurance | | “Not everybody comes and asks for an X-ray, some of them understand it’s muscular not underlying bone pathology there you know” (GP13) |
| | Barrier: Low back pain an uncommon presentation for the clinician | | “I might see a back pain patient you know, maybe only once a fortnight because I don’t have that big throughput” (GP3) |
Time efficiency of using the booklet in a consult | | Facilitator: Use of the booklet improved time efficiency in the consult | | “I think also at least in a couple of cases [when used the booklet] that I recall, I was very much pushed for time. It’s handy to say, here it is, have a read” (GP5) |
| | Barrier: Not enough time in a consult to use additional resources | | “The time factor [why didn't use the booklet with other patients], because if lots of patients are waiting, if you don’t have a lot of time, then I didn’t go into this much detail” (GP13) |
| | Barrier: Using the booklet took additional time in the consult | | “I mean it [using the booklet] did add time for me. I could imagine that there could be ways to do it that it wouldn’t, but that’s just not how I, I suppose, talk to people” (GP9) |
Perceived receptiveness of the patient to receiving the booklet | | Facilitator: Clinician felt the patient would be receptive to receiving the booklet | | “Yes they [the patients] liked it [the booklet], I think patients always like to go away with something, so yes I think they liked it” (GP9) |
| | Barrier: Clinician felt the patient would not be receptive to receiving the booklet | | “Whilst I did go through it [the booklet] with a few patients who were half-interested in looking at it, they didn’t want to take it away” (GP6) |
How helpful general medical practitioners found the booklet (appropriateness)
Imaging referral was provided to six of 57 patients (10.5%, 95%CI: 4.9, 21.1) with whom the booklet was used; however, suspicion of underlying serious pathology was reported in three of these patients. Of the 53 patients with no suspicion of underlying serious pathology, three received imaging referrals that were likely to be non-indicated (5.7%, 95%CI: 1.9, 15.4).
The perceived effects on low back pain management of using the booklet, as identified by general medical practitioners (Table 3), were largely consistent with how the booklet had been designed to work (Fig. 1) (8). Most general medical practitioners reported that they felt using the booklet improved their ability to manage patients with low back pain without using non-indicated imaging, particularly with patients who were requesting imaging or needed more reassurance. Some general medical practitioners already felt confident managing low back pain without non-indicated imaging, and didn’t feel using the booklet greatly impacted them. Three general medical practitioners reported some uncertainty as to whether using the booklet would reduce patient pressure for imaging, particularly if the patient had a strong desire for imaging.
Table 3
Themes related to ‘How helpful general medical practitioners found the booklet’
Theme | | Quotes |
Improved clinician knowledge of how to manage patients with LBP | | “I feel like having read the information [in the booklet], it’s something that I’ve incorporated into the talk I give to patients with back pain” (GP6) “It [the booklet] also helped me, remind me of a few things which I forget sometimes because I can’t necessarily always remember all these things or sometimes I just focus more on one thing or the other” (GP7) |
Improved clinician-patient communication and management | | “It was useful to have that approach [in the booklet] to show them [the patients] when we might need it [imaging] and when we don’t need it” (GP5) “I actually found the booklet really comprehensive. I found it really helpful [to reduce unnecessary imaging], so I don’t think you need, I mean I wouldn’t use other things” (GP2) “Yes, yes, it allows you to initiate it [conversation with patient that imaging isn't necessary]” (GP12) |
Perceived to improve patient understanding and acceptance | | “I think the booklet was, for me, a quick way of explaining the rationale behind not imaging, and the patient seemed to appreciate this to a greater depth when given the booklet” (GP5) “I think if you did have someone who was quite adamant to want imaging it [the booklet] would be then more useful for those certain patients” (GP6) “I find that when I did that [use the booklet], it had a fairly good response with the patients because they realise the importance of it. First of all it was reassuring for them that they don’t have something that serious so that they need an X-ray. On the other hand it also gives them a framework of what we can be doing, or can be done for them, to alleviate their back discomfort or pain and that this is something quite manageable without the need for a lot of investigations” (GP7) |
Reinforced clinician management advice, both during and after the consult | | “I think giving people written data, you know like a written pamphlet, gives a bit more credibility to what you say, so you can educate people about not needing imaging” (GP11) “It [the booklet] probably backs me up, makes me feel more confident, and I think I’ve got some research backing me up and then I can counter it [patient request for imaging], and I can say well look there’s this and they’ve done this, and they’ve looked at this, and if you’re worried then this can be our plan” (GP3) “I think they [the patients on receiving the booklet] appreciated that it wasn’t just my opinion that they didn’t need medication, or an X-ray, and it was acknowledged by, if you like, another valid source, that such investigations were unnecessary” (GP5) |
Confident in current ability to manage patient with low back pain without non-indicated imaging, additional resources not required | | “I think it [the booklet] would be reassuring for lots of clinicians but for me personally I think I can communicate my confidence to the patient and I might be wrong but I feel they’re OK with me just explaining why they don’t need anything” (GP1) “I’m pretty confident that I don’t need to do the imaging in the first place, so I don’t know whether it [using the booklet] makes a tremendous difference for me really” (GP7) |
Uncertain whether using the booklet will impact patient pressure for imaging | | “I guess it [the booklet] helps reinforce the message for people who are accepting the message, but I think the people that really have come in with an agenda and you can’t sway them, the booklet’s not going to sway” (GP4) |
Suggestions for improvement to the booklet or associated clinician training
Suggested improvements to the booklet
Very few suggestions were made about improving the content or layout of the booklet. One general medical practitioner suggested a checklist of specific symptoms indicating the need for imaging instead of the decision-tree. Other suggestions for improvement (e.g. links to other low back pain information sources) were already present in the booklet but were overlooked by general medical practitioners. Further emphasis of these features in the booklet during clinician training is indicated to increase awareness of them.
Suggested improvements to the implementation of the low back pain management booklet
The most commonly reported barrier to using the booklet was the ability to store and remember to use a hardcopy version. General medical practitioners suggested a digital version of the booklet would facilitate use.
“I generally find that paper resources are harder to use than computer-based resources because you’ve got to stop and find them in drawers of other paper resources. So perhaps just a PDF version of the same thing would be more useful” (GP11)
“I think looking forward, a booklet like that must have something online because you’re going to lose a lot of doctors that just don’t use things that are paper based, they don’t look for it, it’s not what they do, not how they’ve been taught” (GP12)
Suggestions for format of a digital version varied including: 1) an A4 information handout to be printed off the computer and handed to patients; 2) a digital version of the booklet that could be worked through with the patient in a similar fashion to the hardcopy booklet, and printed out as needed; or 3) a digital copy of the booklet which could be emailed to patients. Digital versions were suggested to be integrated within practice management software with built-in electronic reminders, to further trigger memory to use the booklet. General medical practitioners reported that they were quite accustomed to using digital documents and printing information sheets for patients, and would be likely to use the booklet in the same way.
“The practice software does have information sheets that are built into the software as well, so I mean if the booklet could be incorporated in that way it would be helpful. Because we do print off information sheets” (GP6)
“You know something that’s easy to access and easy to print off would be doable. So I’ve got some things saved, some PDF’s saved in a share drive that I can access pretty easily, so yes potentially having it [the booklet] that way would be good” (GP9)
Additional benefits to a digital version of the booklet were suggested, such as decreased cost, increased accessibility, and keeping content up-to-date.
Some general medical practitioners saw benefit in a hardcopy version of the booklet being available to patients in the waiting room in addition to the digital version.
“I think so, absolutely [patient pick up the booklet in the waiting room and bring to the consult]. I mean I don’t want to waste your money printing lots of them but I think it could be worthwhile, and the other thing is that someone could actually pick them up if they’re coming to see you about that particular problem. They could see that [the booklet] there, and pick it up and bring it in with them, and then they’re ready to discuss it with you” (GP3)
Suggested improvements to the training session
Most general medical practitioners felt the face-to-face training provided was adequate, and they were able to use the low back pain management booklet effectively. The need for face-to-face training was seen as a potential barrier, and an online option, such as a pre-recorded video or webinar, was suggested. Two general medical practitioners reported concerns that online training may not be suitable, as it may get lost in the volume of online information they receive, or clinicians may not be motivated to engage in it. Two general medical practitioners suggested that increased information on appropriate examination routines within the training session would be useful. One general medical practitioner requested more information on possible management strategies such as exercises.
Mapping of barriers to implementation strategies
The mapping of the identified barriers to implementation strategies is presented in Table 4 with definitions of the implementation strategies outlined in Additional file 7. Additional implementation strategies selected in this process included: development of a digital version of the booklet to allow for easy storage; hardcopy booklets available for patients in the reception area; reminders to use the booklet through the practice management software; audit and feedback of imaging referral behaviour to clinicians; and selection of a local opinion leader to champion use of the booklet. The proposed implementation strategies were selected to increase the adoption, feasibility, and fidelity of use of the booklet.
Table 4
Mapping barriers to using the booklet to implementation strategies
Barrier | COM-B/TDF Domain | Behavioural change techniques | Implementation strategy (EPOC taxonomy) | Implementation strategy (detail) |
Nowhere to store the booklet with good visibility or convenient access | Physical opportunity/Environmental | Adding objects to the environment | Educational materials | Patient education booklet provided in both digital and hardcopy formats |
| | Environment | Areas identified or created to place booklets (waiting room, office space) |
Forgetting to use the booklet | Psychological capability/Memory | Adding objects to the environment | Educational materials | Patient education booklet provided in both digital and hardcopy formats |
| | Prompts/cues | Reminders | Automatic reminders to use booklet through practice management software |
| | Information about social and environmental consequences | Educational outreach visit | Strategies to remember to use the booklet discussed in the individualised training session for the clinician |
Some points were missed in the training session, and the booklet wasn’t used completely | Psychological capability/Knowledge | Information about social and environmental consequences | Educational outreach visit | Individualised training session for clinician with discussion of key points and modelling use of the booklet |
| | | Educational materials | Training resources provided for future clinician reference (low back pain guidelines, training video and sheets to use the booklet) |
Booklet was not needed as current clinician method of managing clinical consults sufficient | Reflective motivation/Beliefs about capabilities | Feedback on outcomes of behaviour | Audit and feedback | Low back imaging referral audit, provided to the clinician (individual and population data) to show current imaging referral behaviour |
| | Feedback on outcomes of behaviour | Educational outreach visit | Individualised training session for clinician with discussion of how the booklet may help in different scenarios |
| | Credible source | Local opinion leader | Champion within each clinic to encourage active engagement with decreasing non-indicated imaging for low back pain |
Clinician felt the patient didn’t require more education or reassurance | Reflective motivation/Beliefs about consequences | Information about social and environmental consequences | Educational outreach visit | Individualised training session for clinician with discussion of patient beliefs and need for reassurance |
Not enough time in a consult to use additional resources | Physical capability/Physical skills Reflective motivation/Beliefs about consequences | Instruction on how to perform a behaviour Demonstration of the behaviour | Educational outreach visit | Individualised training session for clinician with modelling of how to use the booklet and educate the patient within a standard consult |
Clinician felt the patient would not be receptive to receiving the booklet | Reflective motivation/Beliefs about consequences | Information about social and environmental consequences | Educational outreach visit | Individualised training session for clinician with discussion of patient receptiveness for educational resources |
| | Credible source | Local opinion leader | Champion within each clinic to encourage active engagement with decreasing non-indicated imaging for low back pain |