Table 3 Summary of findings regarding physician-reported barriers for performing recommended assessments and diagnosis
| TDF domain | TDF sub-domain | Specific theme from the study | Studies (participants) | Confidence in the evidence | Explanation |
|---|---|---|---|---|---|
| Performing all assessments | |||||
| Environment context and resources | Resources |
GP’s do not have enough time to complete all assessments, full history, full exam and full neurological assessment “you are lucky to have a 10-minute interview, consultation, to actually obtain a full history, and full examination, full back neurological assessment is hard” | 3 (42) | Moderate3 | No or very minor concerns regarding methodology, coherence, and relevance. Moderate or serious concerns about adequacy |
| Assessing for red flags | |||||
| Knowledge | Scientific knowledge |
Lack of awareness of red flags for serious pathology “low awareness of LBP red flags and skills in how to identify them” | 1 (42) | Low2–3 | No or very minor concerns regarding methodology and relevance. Moderate or serious concerns regarding coherence and adequacy |
| Assessing for yellow flags | |||||
| Knowledge | Scientific knowledge |
A general lack of knowledge regarding what yellow flags were or their importance in relation to the management of low back pain There were a range of views regarding when patient attitudes and beliefs become important, reflecting general uncertainty about how and why they influence pain and outcomes | 4 (50) | Moderate3 | No or very minor concerns regarding methodological limitations coherence, or relevance. Moderate or serious concerns regarding adequacy |
| Social/professional role and identity | Professional role |
GP’s do not believe it is their role to assess psychosocial factors “All but 1 GP…thought that the assessment of psychosocial factors was not their role” | 2 (19) | Moderate3 |
No or very minor concerns regarding methodology coherence, or relevance. Moderate or serious concerns regarding adequacy |
| Beliefs about consequences | Beliefs |
GP’s were reluctant to assess yellow flags because they were unsure that that managing yellow flags was a good idea as it may lead to conflict with the patient’s expectations of GP management and adversely affect the doctor-patient relationship. “…identifying and managing yellow flags could present conflicts with the patient’s expectations. They thought most patients expected to be managed using a biomedical and not a biopsychosocial approach, and the one found in the guidelines.” | 3 (30) | Low2–3 | No or very minor concerns regarding methodology and relevance. Moderate or serious concerns regarding coherence and adequacy |
| Environmental context and resources | Resources |
Lack of time to assess this after all the other assessments “Most GPs mentioned that short treatment sessions, limited frequency and long intervals…restricted the capacity to assess and manage yellow flags.” | 2 (19) | Moderate3 | No or very minor concerns regarding methodology, coherence, and relevance. Moderate or serious concerns regarding adequacy |
| Skills | Skills |
A lack of skills in how to assess yellow flags and facilitating discussion around their link to pain and recovery “The assessment of disability prognosis and psychosocial factors, essentially with questionnaires, was new for all GPs” | 2 (19) | Moderate3 | No or very minor concerns regarding methodology, coherence, and relevance. Moderate or serious concerns regarding adequacy |
| Providing a diagnosis of non-specific low back pain | |||||
| Knowledge | Scientific knowledge |
Physicians thought they did not have sufficient understanding of anatomy to explain the natural healing process with non-specific low back pain. “GPs admitted difficulties in conveying the epidemiologic concept of unspecified LBP” | 2(19) | Moderate3 | No or very minor concerns regarding methodology, coherence, and relevance. Moderate or serious concerns regarding adequacy |
| Social influence | Social pressure |
Patients want a “specific” diagnosis and lack of a “precise” diagnosis is not reassuring to them. “The problem with back pain is making a precise diagnosis. They always complain, ‘So what is the diagnosis?’…why do they want a CT? Simply in order to get a diagnosis.” | 3 (80) | Moderate3 | No or very minor concerns regarding methodology, coherence, and relevance. Moderate or serious concerns regarding adequacy |
| Beliefs about consequence | Outcome expectancy |
Physicians did not believe providing a diagnosis of non-specific low back pain would help their patients recover because it is hard to understand. “I do not know what you are talking about so I am sure the patients would not. Non- specific, I mean it’s not really very helpful. they have either got muscle and joint and ligament pain or they have got nerve entrapment and that’s what they want to hear, they do not want to hear terms like non-specific back pain, they want to know what it is and what it is not.” | 1 (16) | Very low5 | Moderate or serious methodological concerns, coherence, and adequacy |