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.
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.
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 (Figure 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.
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.