Table 2 Description of the steps used to choose the behaviour change techniques for the IMPLEMENT intervention

Low awareness of the meanings and actions associated with the guideline’s key messages; low awareness of LBP red flags and skills in how to identify them

Knowledge (GP)

Technique: Information provision

Mode: Facilitated workshop; GP opinion leader led; DVD

Content:

· GP opinion leader/content expert [29] presents information about the guideline key messages. Algorithm provided for diagnosis of red flags.

Small group activity: participants reword key messages from the guideline to create behaviourally worded specific key messages (who, what, where, when) [30, 31].

GPs’ perceptions of patients’ expectations and of patients’ beliefs about consequences

Knowledge (patient)

Technique: Information provision (directed at patient)

Mode: Patient handout [32]

Content: Handout contains lay language about key messages from the guideline [33]; GPs encouraged to give patients with acute LBP the handouts to reinforce verbal advice

Attitudes towards managing patients without x-ray, based on perceived consequences of the behaviour, e.g. fear of missing underlying pathology and belief that patient will feel reassured with an x-ray

1. Beliefs about consequences

2. Knowledge (GP)

Techniques: Information provision; Persuasive communication

Mode: Facilitated workshop; DVD

Content:

· Highly respected senior clinician presents persuasive message about harms (harmful amounts of unnecessary radiation) and limited benefits (poor diagnostic utility) of x-ray for LBP

· GPs provide examples of when important underlying pathology was missed due to absence of x-ray of LBP episode, giving opportunity for expert to discuss this case and demonstrate that x-ray wasn’t required.

Beliefs about negative consequences and beliefs about positive consequences of practising in a manner consistent with the guideline’s key messages

Beliefs about consequences

Techniques: Monitoring of consequences of own behaviour; Barrier identification; Persuasive communication

Mode: Pre-workshop activity; facilitated workshop; DVD

Content:

· GPs record number of times they ordered plain x-ray and it didn’t change patient management, i.e. x-ray unnecessary.

Highly respected senior clinician presents persuasive message about consequences of behaving in a manner consistent with the key messages.

Skills and beliefs about capabilities related to guideline key messages

1. Skills

2. Knowledge (GP)

3. Beliefs about capabilities

Techniques: Barrier identification; Model/demonstrate the behaviour; Rehearsal

Mode: Facilitated workshop; DVD

Content:

· Participants write down wording of their last or usual message to stay active and then discuss in small groups.

In pairs, with one GP role playing a patient with pre-prepared patient vignette, GP to create a script and role play with feedback from facilitator.

Perceived need to give the patient something to replace x-ray

Skills

Techniques: Provide instruction and modelling to increase a competing behaviour

Mode: Facilitated workshop; DVD

Content: Instruct, model/role-play and create a script to facilitate the competing behaviour of prescribing an activity log for patients (rather than giving x-ray referral).

Limited time to explain why patient does not need an x-ray and explain advice to stay active

Environmental context

Techniques: Information provision; Model/demonstrate the behaviour by a peer expert

Mode: Facilitated workshop; DVD

Content: use of handouts (patient handout [32] and activity log) to save time in consultation, and demonstration by a peer expert of how to incorporate into standard consultation.

Beliefs about the role of the GP when managing acute low back pain

Professional role and identity

Techniques: Persuasive communication; Provide opportunities for social comparison

Mode: Facilitated workshop; DVD

Content:

· Highly respected senior clinician presents persuasive message about the role of the GP to minimise harm (from unnecessary irradiation from plain x-ray) and in encouraging patients to stay active.

· Small group work discussion to allow opportunity for discussion of behaviours among peers.

Skills and beliefs about capabilities related to negotiating with/reassuring patients that plain x-ray is unnecessary

1. Skills

2. Beliefs about capabilities (in reassuring the patient that an x-ray isn’t helpful)

Technique: Rehearsal (prompt practice)

Mode: Facilitated workshop

Content: Small group activity: participants to take clinical history with a trained simulated patient to identify red flags. Simulated patients trained to expect and apply pressure for GP to order an x-ray. Discuss after task with feedback from facilitators [34–36].

GPs forget to give advice to stay active in standard consultation

Memory

Technique: Model/demonstrate the behaviour by a peer expert

Mode: Facilitated workshop; DVD

Content: Peer expert goes through 10 step management plan as a prompt for remembering CPG target behaviours

GPs’ perception that other people/organisations expectx-rays e.g., third party payors, radiologists

Social influences

Techniques: Information provision; Persuasive communication

Mode: Facilitated workshop; DVD

Content: Peer expert to discuss content of guideline and highlight organisations that endorse it.