Skip to main content

Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework



Low back pain (LBP) is a leading cause of disability and is among the top five reasons that patients visit their family doctors. Over-imaging for non-specific low back pain remains a problem in primary care. To inform a larger study to develop and evaluate a theory-based intervention to reduce inappropriate imaging, we completed an assessment of the barriers and facilitators to reducing unnecessary imaging for NSLBP among family doctors in Newfoundland and Labrador (NL).


This was an exploratory, qualitative study describing family doctors’ experiences and practices related to diagnostic imaging for non-specific LBP in NL, guided by the Theoretical Domains Framework (TDF). Data were collected using in-depth, semi-structured interviews. Transcripts were analyzed deductively (assigning text to one or more domains) and inductively (generating themes at each of the domains) before the results were examined to determine which domains should be targeted to reduce imaging.


Nine family doctors (four males; five females) working in community (n = 4) and academic (n = 5) clinics in both rural (n = 6) and urban (n = 3) settings participated in this study. We found five barriers to reducing imaging for patients with NSLBP: 1) negative consequences, 2) patient demand 3) health system organization, 4) time, and 5) access to resources. These were related to the following domains: 1) beliefs about consequences, 2) beliefs about capabilities, 3) emotion, 4) reinforcement, 5) environmental context and resources, 6) social influences, and 7) behavioural regulation.


Family physicians a) fear that if they do not image they may miss something serious, b) face significant patient demand for imaging, c) are working in a system that encourages unnecessary imaging, d) don’t have enough time to counsel patients about why they don’t need imaging, and e) lack access to appropriate practitioners, community programs, and treatment modalities to prescribe to their patients. These barriers were related to seven TDF domains. Successfully reducing inappropriate imaging requires a comprehensive intervention that addresses these barriers using established behaviour change techniques. These techniques should be matched directly to relevant TDF domains. The results of our study represent the important first step of this process – identifying the contextual barriers and the domains to which they are related.

Peer Review reports


Low back pain (LBP) is extremely common; it is widely understood to be a leading cause of disability [1] and is among the top five reasons that patients visit their family doctors [2]. As a result, LBP is responsible for substantial economic and social burden [3,4,5,6]. While the prognosis for episodes of LBP is generally favorable (most recover within six weeks), some experience pain for up to one year.

International, evidence-based guidelines for the treatment and management of LBP have been established for some time [7]. They recommend that physicians should first assess the patient for evidence of rare cases of specific spinal pathology or radicular syndrome. Only if they suspect the patient might have one of these conditions should they consider imaging as indicated for the specific condition. The remaining cases are considered non-specific low back pain (NSLBP) or low back pain that is not attributable to a recognizable, specific pathology [3]. For these patients, investigations are not required; management should include reassurance, advice to remain active, simple analgesics, and self-care strategies. If patients fail to improve after six weeks, they should be referred to additional conservative care options such as exercise therapy, cognitive behavioural therapy, or chronic pain management programs [7].

Unfortunately, in most cases, patients do not receive care that aligns with these guidelines [8, 9]. This results in poor health outcomes for patients and unnecessary costs and resource use for health systems [10, 11]. One of the main drivers of unnecessary health system costs and resource use in the management of LBP is an overreliance on diagnostic imaging (DI) (e.g., lumbar spine x-ray, CT, or MRI) [12,13,14]. Roughly 90% of LBP presentations in primary care are NSLBP [3, 15] that should not be imaged as it isn’t useful and introduces potential harm to patients via unnecessary radiation exposure and inappropriate procedures due to incidental findings [12]. Nevertheless, up to half of all requests for lumbar spine imaging are estimated to be inappropriate [16,17,18,19,20,21]. As a result, one of Choosing Wisely Canada’s key de-implementation campaigns targeting healthcare providers focuses on reducing unnecessary lumbar spine imaging.

Improving uptake of clinical practice guidelines for LBP, thereby reducing unwanted behaviours such as inappropriate imaging requests for NSLBP patients, requires that we understand the full scope of why the behaviour is occurring [22, 23]. This will involve a detailed assessment of the barriers and facilitators to performing the guideline-recommended behaviour so that we can select behaviour change strategies for our intervention that will appropriately address those factors. Ideally, this process should be theoretically-driven using a framework of established psychological theories of behaviour change, [22,23,24,25] such as the Theoretical Domains Framework (TDF) which has been used to identify barriers and enablers of behavior change in a variety of contexts [26,27,28,29]. Originally developed by Michie et al., [28] the TDF is comprised of a comprehensive assortment of behavior change theories and constructs synthesized into 14 key domains [26,27,28,29]. The importance of each domain depends upon the behaviour under study and related contextual factors.

A number of potential barriers to reducing imaging for LBP have been reported in the literature including both practitioner and patient-related factors [30, 31]. A recent systematic review found that for LBP imaging guidelines, reported barriers included pressure from patients requesting an image or wanting a diagnosis, physicians’ beliefs that providing a scan will reassure patients, and a lack of time during a typical patient encounter to converse with patients about diagnosis and why imaging isn’t needed) [31]. While this information is helpful for intervention design, only one of the studies included in the review used a theoretical framework to guide their work. Using a theory-based interview guide may provide a more comprehensive assessment of barriers by ensuring that we do not miss asking important questions related to known barriers to behaviour change. It is possible that without these specific questions, interview data may be limited only to the most common barriers such as time and resources that readily come to mind and may miss capturing important, but perhaps more subtle, barriers. In addition, none of the studies completed to date are tied to the local context, widely considered responsible for study-to-study variation in the outcomes of implementation interventions [32].

As part of a larger study to develop and evaluate a theory-based intervention to reduce inappropriate LBP imaging, we undertook a TDF-guided assessment to identify the barriers and facilitators to following imaging guidelines for NSLBP among family doctors in Newfoundland and Labrador (NL).



This was an exploratory, qualitative study describing family doctors’ experiences and practices related to diagnostic imaging for LBP. We used the Atkins et al.[26] guide for applying the TDF to assess barriers and enablers to behaviour change. A description of how we applied the TDF in our data collection and analysis is described below.


Eligible participants included family doctors practicing in NL who were treating patients with LBP. Purposive sampling was used to identify study participants. We identified family doctors through an established practice-based network (Atlantic Practice Based Research Network) – a group of clinicians who have agreed to be contacted to participate in primary care research. To help ensure a diverse range of perspectives, we sought participants practicing in both urban and rural environments, as well as both academic and community settings. We planned to recruit and interview 10–15 family doctors or until we reached data saturation – the point at which no novel information was being contributed by additional participants [33].

Data collection

Following previously established methods outlined in the TDF Guide [26] and other studies using the TDF for barriers assessments, [34] data were collected using in-depth, semi-structured interviews. Potential participants were emailed an invitation to participant in a study investigating family physicians views on imaging for LBP by a local researcher (AH). If interested, they were provided with additional information about the study (including the reasons for the study and our interest in the topic) and an interview time was scheduled.

The interview guide (please see Additional file 1) included 1–4 questions per domain for a total of 31 questions. Prompts were provided in the interview guide to assist the interviewer in clarifying participants’ responses if needed.

Interviews were conducted by two female healthcare researchers (PhD and Master’s – prepared) with experience and training in qualitative interviewing (AH, AP). An undergraduate student (RL) also attended some interviews to take field notes. Otherwise, notes were taken by the interviewers. Interviews were conducted in-person (at the participant’s or interviewer’s place of work) or via telephone, whichever was private and most convenient for the participant. They took approximately 1h to complete, and participants were provided a CAD $100 gift card honorarium (paid using funds from the CIHR grant supporting this research). All interviews were audio-recorded and transcribed verbatim; participants were not provided opportunity to review their transcripts.

Data analysis

To begin, coders read and reread the transcripts to become familiar with the data; they began coding after we had completed and transcribed three interviews. Using the TDF to generate a framework for content analysis, researchers analyzed the data deductively (assigning text to one or more domains) and inductively (generating themes at each of the domains) [26].

Deductive analysis

Under the direction of a TDF expert (AMP), two researchers (AP, RL) were trained to code data from the transcripts into TDF domains. They used transcripts from a previous study (on a different topic but using the same TDF coding scheme) to practice coding. From this work, they created a codebook specific to the current study that served as a guideline and reference to ensure accuracy and consistency.

The codebook contained (1) the coding strategy and (2) a table of coded text which defined, for coders, a clear method for making decisions on whether and how much text to code, which domain was appropriate, and how to deal with any disagreements. Please see Additional file 2 for the codebook developed during the training exercise.

Using the codebook, AP and RL coded all transcripts in NVivo V.12. They coded one pilot interview simultaneously to consensus, with access to an expert coder (AMP) as needed. Using the second pilot interview, they coded independently and calculated Fleiss’ kappa (κ) for each domain to assess reliability of coding. After this, they began coding independently. All interviews were reviewed together and coded to consensus.

Inductive analysis

After the data (quotes from interviews) were coded into TDF domains, we generated themes at each domain, phrased as belief statements, that represented important beliefs about a barrier or enabler to the target behaviour common across participants responses (e.g., “I sometimes image NSLBP patients because I don't have the time to explain to them why imaging is unnecessary”). All belief statements and broad themes with supporting quotes were reviewed by the second coder and a TDF expert (AMP). These data were then further analyzed to identify specific barriers/enablers to change.

Finally, the results were examined to determine which of the domains and associated beliefs should be targeted to reduce imaging for LBP. These decisions were made through consensus discussion between the researcher responsible for theme generation (AP) and a TDF expert (AMP); it was subsequently reviewed with the second coder (RL), a key knowledge user (KAB), and the larger research team. Domains were considered relevant if they met any of the following conditions:

  1. a)

    A majority of participants (in our case 5 or more) expressed a belief that contradicted guideline recommendations thereby indicating a lack of understanding or practice of evidence-based guidelines.

  2. b)

    A majority of participants described the same or similar barrier to following imaging guidelines.

  3. c)

    There were a mix of views expressed on a particular issue (for a particular domain) indicating the presence of conflicting beliefs.

  4. d)

    A participant(s) reported a belief that could potentially have a large impact on the target behaviour.

  5. e)

    A participant(s) expressed a belief that they perceived to be a major clinical concern or that they were particularly vocal about (determined by considering the amount of text taken up discussing the issue as well as emphatic or emotional speech).

  6. f)

    Clinical experts on the research team felt strongly that the beliefs expressed at a particular domain represent an important clinical issue.



Nine family doctors (four males; five females) participated in this study. At the time of the interviews these participants were working in community (n = 4) and academic (n = 5) clinics in both rural (n = 6) and urban (n = 3) settings. Seven of nine participants had no previous interactions with the interviewers; two had a previous working relationship with them. None of the participants we contacted refused participation or dropped out. We initially planned to recruit and interview up to 15 family doctors. However, after completing and coding eight interviews we felt that we had reached saturation. To test our assumption, we interviewed one additional participant (adding some additional prompts in an attempt to elicit new information). Since no novel information was added after this interview, we did not pursue additional participants. The team did not feel it necessary to complete any repeat interviews.

Interrater reliability – Domain coding

Interrater reliability at each domain ranged from a low of κ = 0.67 (SD = 0.32) to a high of κ = 0.92 (SD = 0.21) (with 9 of 14 domains reaching κ = 0. 75 or above) thereby demonstrating substantial to almost perfect agreement [35, 36]. However, while interrater reliability was calculated to help ensure consistency between the coders, all interviews were coded to consensus (100% agreement).

Relevant domains

Our analysis revealed a number of barriers related to the following domains: 1) beliefs about consequences, 2) beliefs about capabilities, 3) emotion, 4) reinforcement, 5) environmental context and resources, 6) social influences, and 7) behavioural regulation. We generated 49 themes, phrased as belief statements, from the data coded at these domains. Table 1 presents the specific beliefs together with illustrative quotes for each of the relevant domains. Overall, five main barriers to reducing imaging for patients with NSLBP were evident in the data: 1) negative consequences, 2) patient demand 3) health system organization, 4) time, and 5) access to resources.

Table 1 Summary of relevant domains (including belief statements and supporting participant quotes)

Negative consequences

Physicians reported imaging cases of NSLBP because they feared missing a serious illness (beliefs about consequences, emotion). Related to this was a fear of litigation that could result if a serious condition was missed (emotion). Over a third of our sample reported that previous negative experiences (e.g., missing the presence of an underlying serious pathology in a previous case) play a role in their decision-making (reinforcement). Some believed they can use imaging as a sort of “fail-safe” to pick up serious conditions they might have otherwise missed (beliefs about consequences).

Patient demand

Seven of nine participants reported that their patients and/or family members pressure them for imaging and that patient pressures of this nature influence their image-ordering decisions (social influences). They also felt that, in some cases, ordering the image will be beneficial for patients by reducing anxiety and frustration and increasing patient satisfaction (beliefs about consequences). Related to this, some physicians reported difficulty convincing patients that they don’t need an image (beliefs about capabilities). Patient demand can also become a factor when physicians within a clinic do not adhere to the same imaging practices. Physicians reported that patients sometimes pressure them for images because other doctors at their place of work image more liberally and patients believe that to be a higher standard of care (social influences).

Health system organization

Many participants reported a lack of system-level rewards for not imaging patients with NSLBP (reinforcement). Further, some felt the health system punishes physicians for using conservative ordering practices (reinforcement). They explained that because of the way physicians are remunerated in this province (fee-for-service model), they lose income when they take the time required to explain to patients why imaging isn’t necessary and counsel them on alterative therapies for treatment. Because of this, it makes it difficult for them to take the time necessary to avoid imaging (environmental context and resources). Related to this issue, some physicians reported they sometimes image patients with NSLBP when referring a patient to other healthcare providers (because they think it will be required), at the request of other providers, or when their patient requires that documentation for an insurance company or workers compensation.


Participants reported that it takes much longer to explain why an image is not needed than to simply order an image (beliefs about consequences). They don’t feel they have adequate time to convince patients that they don’t require imaging in the run of a busy clinic day (environmental context and resources).

Access to resources

Physicians reported they sometimes image because their patients do not have the means and/or opportunity to assess appropriate treatment modalities and/or health professionals and, as a result, their condition fails to improve (environmental context and resources). They explained that access to publicly-funded physiotherapists is very limited and that wait times to see these practitioners are often prohibitively long. Compounding this issue, is the fact that their patients often don’t have insurance plans that would cover some or all of the costs associated with private practitioners (e.g., physiotherapists, massage therapists, and chiropractors) and therefore can’t afford these treatment venues. Finally, in some rural environments, there is not always a private practitioner available. Family physicians believe that alternative/allied health professionals and community-based programs for the treatment of NSLBP including the addition of other health professionals to the clinic environment or a physiotherapist-based low back pain management program would encourage them to avoid imaging their patients with NSLBP (behavioural regulation). A large majority of our participants also felt that improved access to quality patient education materials would encourage family physicians to image more conservatively. They suggested a one-page handout to give patients during an encounter or a trusted, online repository for evidence-based patient education materials (behavioural regulation). A smaller number also wished for improved clinical tools (behavioural regulation) such as an evidence-based algorithm that could be inserted into existing electronic medical records.

Irrelevant domains

The remaining seven TDF domains were not considered relevant and included: 8) knowledge, 9) skills, 10) social professional role and identity, 11) optimism, 12) intentions, 13) goals, and 14) memory, attention and decision-making. The data coded at each of these domains revealed 34 specific beliefs, presented in Table 2 with illustrative quotes. Below we provide a brief summary of these beliefs which did not indicate the presence of any barriers to reducing imaging for patients with LBP.

Table 2 Summary of irrelevant domains (including belief statements and supporting participant quotes)

All participants were aware of the behaviours specified by the guidelines for the appropriate management of NSLBP and most understood them to be evidence-based (knowledge). However, a few were not sure of the quality of the evidence supporting the guidelines. Likewise, most of our participants believed that family physicians require good clinical skills (e.g., history-taking, symptom recognition) – acquired over the course of their educational experiences – to manage low back pain without the use of imaging (skills). There was no evidence of disagreement among our participants and no conflicting or incorrect beliefs noted.

For the most part, the family doctors in our sample don’t feel that their ordering decisions are automatic but they also don’t struggle with those decisions. Most reported considering the patient’s history and physical exam findings when deciding whether or not an image is warranted. Other considerations include assessments for red flag conditions and surgical candidacy as well as response to previous treatments and resource stewardship (memory, attention, and decision-making).

All participants felt that managing patients with NSLBP without the use of imaging was a part of doing their job and meant they were practicing “good medicine” (social professional role and identity). Further, most reported that stewardship of health care resources was a part of their role as responsible practitioners and that avoiding low value care (such as imaging the low back) means they are practicing evidence-based medicine (social professional role and identity, goals). There was no evidence of discord or other salient information that leads us to suspect the existence of barriers related to this domain.

The majority of participants felt that, generally speaking, managing patients with NSLBP without imaging is a good idea (optimism). Further, most also reported wanting to manage their patients with NSLBP without imaging (goals) and their intention to manage their patients with NSLBP without imaging (intentions). There were no conflicts in these messages, however, two participants stressed that their priority is to ensure their patients’ well-being and not resource stewardship (goals).


This study used the TDF to conduct a theory-informed, comprehensive investigation of the barriers and enablers to reducing unnecessary imaging for LBP in the Canadian province of NL. Our investigation revealed a number of barriers related to the following domains: beliefs about consequences, beliefs about capabilities, emotion, reinforcement, environmental context and resources, social influences, and behavioural regulation. Overall, five main barriers were evident in the data. Briefly, they are 1) negative consequences – family physicians fear that if they do not image they may miss something serious, 2) patient demand – physicians face significant patient demand for imaging, 3) health system organization – family physicians are working in a system they feel encourages unnecessary imaging, 4) time – family physicians don’t have enough time during a typical busy clinic data to counsel patients about why they don’t need imaging, and 5) access to resources – family physicians reported a lack access to appropriate practitioners, community programs, quality education materials, and treatment modalities to prescribe to their patients. We found that the remaining seven domains in the TDF (knowledge; skills; memory, attention, and decision-making; social professional role and identity; optimism; intentions; and goals) were not relevant to reducing unnecessary imaging.

Previous research on the determinants of unnecessary imaging

Our findings are largely supported by previous studies that have investigated barriers and enablers to following guideline-recommended treatment and management of LBP in primary care. Two systematic reviews have assessed the literature focused specifically on physician-reported barriers to guideline-recommended imaging. In 2016, Slade et al., [30] performed a systematic review and meta-synthesis of qualitative studies investigating primary care physicians’ perspectives on clinical practice guidelines for LBP including barriers and enablers to their adherence. Building on this work, Hall et al., [31] completed a systematic review that included much of the same literature (plus two additional studies) and used a theoretical framework (the TDF) to guide the analysis. Several of our findings are in line with the results of these previous reviews. Briefly, social influence in the form of patient demand was an important factor in the decision to image for NSLBP, [30, 31] physicians felt imaging would ease patient anxiety and increase their satisfaction with care, [31] time is a barrier to reducing unnecessary imaging, [30, 31] and physicians imaged patients with NSLBP in part because they felt that it could act as a sort of “fail-safe” to protect them against missing a serious underlying condition [30].

There were, however, some important differences between the current investigation and existing literature. For example, unlike the Slade review [30], the participants in our investigation did not lack knowledge of guideline content and did not take issue with the credibility of clinical practice guidelines for LBP. Overall, they were also confident in their clinical skills to manage patients with NSLBP without the use of imaging. That being said, similar to findings noted in Hall’s review [31], the physicians we interviewed all reported some degree of struggle related to avoiding imaging for LBP. In many cases, they believe it is easier to order an image than negotiate with patients in order to avoid imaging. All physicians reported that they either a) don’t have the time to explain to patients that an image isn’t needed and/or b) struggle to convince patients who insist on imaging and/or c) believe that because some patients are reassured by imaging, it would damage the therapeutic relationship to deny it. Interestingly, a review including patient perspectives on imaging for low back pain found that some patients are, in fact, frustrated by imaging – particularly when the results are are inconclusive, don’t provide a clear reason for their back pain, or indicate degenerative or other issues perceived to be permanent or irreversible [37].

Our investigation also found an important barrier related to physician remuneration that has not been noted elsewhere in the literature on barriers to reducing imaging for LBP among family physicians. While physicians in NL are not remunerated for generating a referral, those we interviewed reported that the way they are remunerated (under a fee-for-service model) encourages imaging patients with NSLBP. They explained that under the current fee-for-service model in this province, they lose income by taking the time to explain why imaging is not necessary and counsel patients on alternative therapies for treatment. This finding underscores the importance of completing a context-specific barriers assessment before intervening to change behaviour.

Implications for research and practice

A number of studies have now assessed barriers to following guidelines in the treatment and management of low back pain in a variety of settings in 10 countries and have identified similar barriers in these different contexts [31]. Our study revealed five important barriers to reducing unnecessary imaging, many of which align with the key barriers noted in previous reviews [30, 31]. Given the convergence of research in this area, it is unlikely that repeating barriers assessments in similar contexts will change these overall findings. Thus, any future research to examine barriers related to imaging guidelines for low back pain should consider focusing on areas that may add new and valuable information to the established knowledge base. For example, researchers may want to consider targeting particular contexts that have been under-studied in current literature such as resource-poor settings, or physicians with higher-than-average rates of imaging. Similarly, when an intervention to reduce imaging is being planned within a local context for which a full barriers assessment has not been conducted, we recommend using the existing literature as a reliable foundation to start selecting potential strategies and consider conducting 3–5 interviews with key contacts to confirm if there are any other issues that might be specific to the local context. These assessments would be undertaken not to generate new scientific knowledge but to optimize an intervention for a particular context.

Several interventions have been implemented to address over-imaging for low back pain [38,39,40,41,42]. However, most have focused on providing information to clinicians to increase their knowledge of the guidelines and have been largely unsuccessful in changing clinician ordering practices [42]. While lack of knowledge has been identified as a barrier to evidence-based ordering in some contexts, [30] the bulk of the evidence in this area shows us that addressing only knowledge via strategies like practitioner education or passive dissemination of guidelines is not enough [38,39,40,41,42]. Rather, moving evidence into practice for this behaviour will require more comprehensive interventions that address the most relevant barriers using behaviour change techniques matched to as many of the implicated domains as possible. Following guidance from the Medical Research Council (MRC), theory-based interventions should be tested in randomized controlled trials (RCTs) that include a robust process evaluation [43]. A randomized design is important to consider wherever possible since we don’t have a good understanding of other confounders related to behaviour change, making it difficult to adjust for them in non-randomized designs. Process evaluations allow us to explain how complex interventions work by examining the processes through which an intervention generates outcomes. When testing behaviour change interventions (BCIs), a process evaluation should be carried out to assess (i) fidelity and quality of implementation of the intervention, (ii) clarify causal mechanisms and (iii) identify contextual factors associated with variation in outcomes [43, 44]. These evaluations are vital for understanding how interventions function in different settings.

Next steps will involve using what is known about the barriers to reducing imaging to develop a comprehensive intervention to improve uptake of imaging guidelines for the treatment and management of NSLBP using the resources developed by Michie et al. to complement the TDF [27, 45, 46]. These include the Behaviour Change Wheel—a systematic guide for designing BCIs and the Behaviour Change Technique Taxonomy – an extensive list of 93 techniques, divided into 16 categories that will form the active components of an intervention [27, 45, 46]. Using this method, an intervention to reduce imaging for low back pain should include behavior change techniques that target domains directly related to specific barriers. Each barrier may be related to a number of different TDF domains and each domain is, in turn, associated with several BCTs. The theory and techniques tool ( has been developed to help researchers map behavior change techniques to identified TDF domains [47,48,49]. The tool is essentially a heat map in which each cell represents a link between a BCT and a TDF domain with colour-coding used to provide indication of the strength of the evidence link between them. The strength of the links was determined through a literature synthesis study that extracted data from 277 behavior change intervention articles, [47] an expert consensus study including 105 international behavior change experts, [48] and a triangulation study (statistically assessing concordance between the first two studies supplemented by a consensus exercise to reconcile discrepancies) [49]. Tool developers have also established a repository where new behavior change intervention study data can be uploaded and synthesized in order to help keep this tool up-to-date. As such, it is susceptible to change as the evidence base grows. Using the theory and techniques tool, we have included an example of how BCTs could be used to build an intervention targeting barriers to reducing imaging for LBP in Table 3. For the purposes of this example, we have focused on only one barrier.

Table 3 Example of how behavior change techniques can be used to build an intervention targeting TDF domains related to barriers to reducing imaging for LBP

We will complement this process by also involving family physicians and other relevant stakeholders who can advise the research team on the acceptability and plausibility of successfully implementing the intervention. This intervention will be tested in a RCT that includes both a rigorous process evaluation (to identify causal mechanisms) and fidelity assessment (to determine the extent to which the intervention was implemented as intended).


As recommended by a host of national health and research organizations (e.g., the National Institute for Healthcare Excellence, the MRC, Health Canada, Canadian Institutes of Health Research, and the Quality Enhancement Research Initiative), [43, 50,51,52,53] this study used a theory-informed approach to investigate the barriers and enablers of unnecessary imaging for NSLBP. While both physician and patient-related barriers to reducing imaging for NSLBP have been noted elsewhere in the literature, [30, 31] only one study that we are aware of used a theoretical framework to guide their assessment [54]. Our study was designed using the Atkins et [26] on how to apply the TDF to the development of data collection and analysis methods for assessing barriers and enablers to behaviour change. Using this approach allowed us to produce results that can be used to guide the development of an intervention that will appropriately tackle barriers related to each of the TDF domains.

Additionally, we used a rigorous approach to data analysis as recommended by Atkins et al. [26] in their guide to applying the TDF to barriers assessments which included double coding the transcripts, training coders extensively, oversight of analysis by a professional expert in the TDF, review of the results by a family physician team member in detail and again by the larger investigative team. The team also used the Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist to guide our methods and reporting [55].


Despite these strengths, the results are limited in important ways. For example, our sample size was small and included only nine family physicians. While we did assess data saturation and found no new information after the eighth interview, it is possible that we reached data saturation prematurely by not interviewing participants with sufficient diversity to allow for more variety in responses. For example, although we sampled purposively to ensure that we interviewed rural and urban, community and academic, male and female physicians at varying stages of their professional practice, we were limited to a convenience sample of those who agreed to participate. We also didn’t assess the ordering rates of our sample to engage similar numbers of participants that order images at different rates or actively seek participants in equal numbers who had differing views on imaging conservatively.


LBP is a common but serious problem that is burdensome and costly for patients and the health system. One of the main drivers of this burden is an overreliance on imaging. Researchers estimate that up to half of all requests for lumbar spine imaging are inappropriate [16,17,18,19,20,21]. Our study interviewed family physicians in NL to determine context-specific barriers and enablers for reducing unnecessary imaging. We found five key barriers related to seven TDF domains. Successfully changing physician behaviour (which is determined by multiple factors) to reduce inappropriate imaging will require a comprehensive intervention that addresses the most relevant contextual barriers using established behaviour change techniques matched to as many of the implicated domains as possible. The results of our study represent the important first step of this process – identifying the contextual barriers and the domains to which they are related. These results will be used to develop an intervention that will be tested in a later study.

Availability of data and materials

De-identified data collected and analyzed for the current study are available from the corresponding author on reasonable request.



Low back pain


Non-specific low back pain


Diagnostic imaging


Computed tomography


Magnetic Resonance Imaging


Theoretic Domains Framework


Newfoundland and Labrador


Canadian Dollars


Standard deviation


Medical Research Council


Randomized controlled trial


Behaviour change intervention


Consolidated criteria for reporting qualitative research


  1. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos T, Barendregt J. The global burden of low back pain: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73:968–74.

    Article  Google Scholar 

  2. St Sauver JL, Warner DO, Yawn BP, Jacobson DJ, McGree ME, Pankratz JJ, et al. Why patients visit theirdoctors: assessing the most prevalent conditions in a defined American population. Mayo Clin Proc. 2013;88(1):56–67.

    Article  Google Scholar 

  3. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389:736–47.

    Article  Google Scholar 

  4. Kent PM, Keating JL. The epidemiology of low back pain in primary care. Chiropr Osteopat. 2005;13:13.

    Article  Google Scholar 

  5. Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. JBJS. 2006;88:21–4.

    Google Scholar 

  6. Lidgren L. The bone and joint decade 2000–2010. SciELO Public Health. 2003.

    Google Scholar 

  7. Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19:2075–94.

    Article  Google Scholar 

  8. Williams CM, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, et al. Low back pain and best practice care: a survey of general practice physicians. Arch Intern Med. 2010;170:271–7.

    Article  Google Scholar 

  9. Piccoliori G, Engl A, Gatterer D, Sessa E, J in der Schmitten, Abholz HH. Management of low back pain in general practice - is it of acceptable quality: an observational study among 25 general practices in South Tyrol (Italy). BMC Fam Pract. 2013;14:148.

    Article  Google Scholar 

  10. Andersen J. Is immediate imaging important in managing low back pain? J Athl Train. 2011;46:99–102.

    Article  CAS  Google Scholar 

  11. Cutler R, Fernandez-Llimos F, Frommer M. Economic impact of medication non-adherence by disease groups: a systematic review. BMJ Open. 2018;8:e016982.

    Article  Google Scholar 

  12. Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for evaluation of low back pain. Radiol Clin N Am. 2012;50:569–85.

    Article  Google Scholar 

  13. Clinician lists. Recommendations for low back pain. Accessed 12 Jan 2018.

  14. Darlow B, Forster BB, O’sullivan K, O’sullivan P. It is time to stop causing harm with inappropriate imaging for low back pain. Br J Sports Med. 2017;51(5):414–5.

    Article  Google Scholar 

  15. Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. CMAJ. 2017;189:E1386–95.

    Article  Google Scholar 

  16. Rao JK, Kroenke K, Mihaliak KA, Eckert GJ, Weinberger M, Rao JK, Kroenke K, Mihaliak KA, Eckert GJ, Weinberger M. Can guidelines impact the ordering of magnetic resonance imaging studies by primary care providers for low back pain? Am J Manag Care. 2002;8:27–35.

    PubMed  Google Scholar 

  17. Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of magnetic resonance imaging. JAMA Intern Med. 2013;173:823–5.

    Article  Google Scholar 

  18. Muntion-Alfaro MT, Benitez-Camps M, Bordas-Julve JM, De Gispert-Uriach B, Zamora-Sanchez V, Galindo-Parres C. Back pain: do we follow the recommendations of the guidelines? [Spanish]. Aten Primaria. 2006;37:215–20.

    Article  CAS  Google Scholar 

  19. Gonzalez-Urzelai V, Lopez-de-Munain J. Routine primary care management of acute low back pain: adherence to clinical guidelines. Eur Spine J. 2003;12:589–94.

    Article  Google Scholar 

  20. Kennedy SA, Fung W, Malik A, Farrokhyar F, Midia M. Effect of governmental intervention on appropriateness of lumbar MRI referrals: a Canadian experience. J Am Coll Radiol. 2014;11:802–7.

    Article  Google Scholar 

  21. Logan GS, Pike A, Copsey B, Parfrey P, Etchegary H, Hall A. What do we really know about the appropriateness of radiation emitting imaging for low back pain in primary and emergency care? A systematic review and meta-analysis of medical record reviews. PLoS ONE. 2019;14(12):e0225414.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Grol R, Wensing M. Effective implementation: a model. Improv Patient Care Implement Change Clin Pract. 2005;41:57.

    Google Scholar 

  23. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362:1225–30.

    Article  Google Scholar 

  24. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8:1–72.

    Article  Google Scholar 

  25. Improved clinical effectiveness through behavioural research group (ICEBERG). Designing theoretically-informed implementation interventions. Implement Sci. 2006;1:4.

    Article  Google Scholar 

  26. Atkins L, Francis J, Islam R, et al. A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12:77.

    Article  Google Scholar 

  27. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.

    Article  Google Scholar 

  28. Michie S, Johnston M, Abraham C, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14:26–33.

    Article  CAS  Google Scholar 

  29. Michie S, Johnston M, Francis J, et al. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol. 2008;57:660–80.

    Article  Google Scholar 

  30. Slade SC, Kent P, Patel S, Bucknall T, Buchbinder R. Barriers to Primary Care Clinician Adherence to Clinical Guidelines for the Management of Low Back Pain: A Systematic Review and Metasynthesis of Qualitative Studies. Clin J Pain. 2016;32(9):800–16. (PMID: 26710217).

    Article  PubMed  Google Scholar 

  31. Hall AM, Scurrey SR, Pike AE, Albury C, Richmond HL, Matthews J, Toomey E, Hayden JA, Etchegary H. Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework. Implement Sci. 2019;14(1):49. PMID:31064375;PMCID:PMC6505266.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Nilsen P, Bernhardsson S. Context matters in implementation science: a scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. BMC Health Serv Res. 2019;19:189.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine; 1967.

    Google Scholar 

  34. Patey AM, Islam R, Francis JJ, et al. Anesthesiologists’ and surgeons’ perceptions about routine pre-operative testing in low-risk patients: application of the theoretical domains framework (TDF) to identify factors that influence physicians’ decisions to order pre-operative tests. Implement Sci. 2012;7:52 (1748-5908-7-52).

    Article  Google Scholar 

  35. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159.

    Article  CAS  Google Scholar 

  36. Fleiss JL. The measurement of interrater agreement. Stat Methods Rates Proportions. 1981;2:212–36.

    Google Scholar 

  37. Sharma S, Traeger AC, Reed B, Hamilton M, O’Connor DA, Hoffmann TC, Bonner C, Buchbinder R, Maher CG. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open. 2020;10(8):e037820.

    Article  Google Scholar 

  38. Jenkins HJ, Moloney NA, French SD, et al. Using behaviour change theory and preliminary testing to develop an implementation intervention to reduce imaging for low back pain. BMC Health Serv Res. 2018;18:734.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Min A, Chan VWY, Aristizabal R, et al. Clinical Decision Support Decreases Volume of Imaging for Low Back Pain in an Urban Emergency Department. J Am Coll Radiol. 2017;14:889–99.

    Article  PubMed  Google Scholar 

  40. French SD, McKenzie JE, O’Connor DA, et al. Evaluation of a Theory-Informed Implementation Intervention for the Management of Acute Low Back Pain in General Medical Practice: The IMPLEMENT Cluster Randomised Trial. PLoS ONE. 2013;8:e65471.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Al Zoubi FM, Menon A, Mayo NE, et al. The effectiveness of interventions designed to increase the uptake of clinical practice guidelines and best practices among musculoskeletal professionals: a systematic review. BMC Health Serv Res. 2018;18:435.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Hall A, Richmond H, Pike A, Lawrence R, Etchegary H, Swab M, et al. What behaviour change techniques have been used to improve adherence to evidence-based low back pain imaging? Implement Sci. 2021;16(1):68.

    Article  Google Scholar 

  43. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, Moore L, O’Cathain A, Tinati T, Wight D, Baird J. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Grimshaw JM, Zwarenstein M, Tetroe JM, et al. Looking inside the black box: a theory-based process evaluation alongside a randomised controlled trial of printed educational materials (the Ontario printed educational message, OPEM) to improve referral and prescribing practices in primary care in Ontario Canada. Implementation Sci. 2007;2:38.

    Article  Google Scholar 

  45. Michie S, Wood CE, Johnston M, Abraham C, Francis JJ, Hardeman W. Behaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data). Health technology assessment (Winchester, England). 2015;19(99):1–188.

    Article  Google Scholar 

  46. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science: IS. 2011;6:42.

    Article  PubMed Central  Google Scholar 

  47. Carey RN, Connell LE, Johnston M, Rothman AJ, de Bruin M, Kelly MP, Michie S. Behavior Change Techniques and Their Mechanisms of Action: A Synthesis of Links Described in Published Intervention Literature. Ann Behav Med. 2019;53(8):693–707.

    PubMed  Google Scholar 

  48. Connell LE, Carey RN, de Bruin M, Rothman AJ, Johnston M, Kelly MP, Michie S. Links Between Behavior Change Techniques and Mechanisms of Action: An Expert Consensus Study. Ann Behav Med. 2019;53(8):708–20.

    Article  Google Scholar 

  49. Johnston M, Carey RN, Connell Bohlen LE, Johnston DW, Rothman AJ, de Bruin M, Kelly MP, Groarke H, Michie S. Development of an online tool for linking behavior change techniques and mechanisms of action based on triangulation of findings from literature synthesis and expert consensus. Transl Behav Med. 2021;11(5):1049–65.

    Article  PubMed  Google Scholar 

  50. NICE. Behaviour change: general approaches. 2007.

  51. Craig P, Petticrew M. Developing and evaluating complex interventions: reflections on the 2008 MRC guidance. Int J Nurs Stud. 2013;50(5):585–7.

    Article  PubMed  Google Scholar 

  52. Health-Canada. Knowledge Translation Planner Toolkit Health Canada. 2017.

  53. Curran GM, Mukherjee S, Allee E, Owen RR. A process for developing an implementation intervention: QUERI Series. Implementation science: IS. 2008;3:17.

    Article  PubMed  PubMed Central  Google Scholar 

  54. French SD, Green SE, O’Connor DA, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implementation Sci. 2012;7:38.

    Article  Google Scholar 

  55. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.

    Article  PubMed  Google Scholar 

Download references


The authors formally acknowledge the contributions of the De-implementing Wisely Research Group to the conceptualisation and design of this work. Members of the group not formally listed as authors on this manuscript include: Sacha Bhatia, D’Arcy Duquettes, Erin Gionet, Kyle Kirkham, Wendy Levinson, Brian Johnston, Kelly Mrklas, Patrick Parfrey, Justin Presseau, Todd Sikorski, Monica Taljaard, Kednapa Thavorn, Krista Mahoney, Shannon Ruzycki. To reach the group, please email


This work was funded by the Canadian Institute of Health Research, grant number 398 527. The funding body played no role in the design of the study; collection, analysis, and interpretation of data; or in writing the manuscript.

Author information

Authors and Affiliations




AH, AMP, JG, SD, KAB, and the remaining members of the De-implementing Wisely Research Group conceptualised and designed this barriers assessment. AP and AH drafted the paper. AH, AMP, RL, SM, and YJ developed and reviewed the question guide. AMP, AH, RL, AP developed the codebook. All named authors provided feedback on both content and clarity of the analysis and results. All authors reviewed the manuscript and provided feedback and their approval to publish the manuscript.

Corresponding author

Correspondence to Andrea Pike.

Ethics declarations

Ethics approval and consent to participate

This study was reviewed and approved by Newfoundland and Labrador’s Health Research Ethics Board (file no: 20180484). Waiver of written consent was provided by this Health Research Ethics Board as consent was implied by participation in the interview. All relevant data protection guidelines specified by our Health Research Ethics Board were followed throughout the study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Pike, A., Patey, A., Lawrence, R. et al. Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework. BMC Prim. Care 23, 143 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: