Table 1 Possible barriers to adhering to guideline recommendations in practice based on Cabana [10] and results from our focus groups study [11]

Lack of awareness/familiarity:

GPs may be unaware of the (exact) content of the guideline recommendation

Attitude related barriers

Lack of agreement:

GPs may disagree with the guideline recommendation due to perceived lack or inadequate interpretation of evidence or due to a lack of applicability of recommendations in general and more specifically to individual patients

Lack of self-efficacy:

GPs may believe that they cannot perform the guideline recommendation because they lack appropriate training or experience

Lack of outcome expectancy:

GPs may believe that even if they can perform the recommendation it will not affect patient outcomes

Inertia of previous practice/lack of motivation:

GPs may not follow recommendations because of difficulties of changing habits or old routines or lack of motivation

External barriers

Patient factors:

GPs may be unable to reconcile patient preferences and demands with guideline recommendations or believe that patients are unable to perform the necessary action

Guideline factors:

GPs may believe that the guideline recommendations itself are unclear or ambiguous, incomplete, or too complex

Environmental factors:

GPs may be unable to overcome barriers in their practice environments, such as lack of time/time pressure, lack of resources/materials, organisational constraints within the own practice (e.g. arrangements with practice assistants), in other organisations (e.g. out of hours services, pharmacies) or between organisations (e.g. cooperation and arrangements with medical specialists) and lack of reimbursement