Chronic Obstructive Pulmonary Disease (COPD) is a chronic, life-threatening lung disease and the third leading cause of death worldwide. Active smoking is the main risk factor, while other factors such as occupational factors, infections and the role of air pollution are becoming more influential . In the Netherlands approximately 325,000 people are formally diagnosed with COPD and more than 6,000 people die of COPD annually . Clinical practice guidelines have been developed to assist healthcare practitioners in clinical decision making, by providing recommendations about appropriate healthcare for specific circumstances . In the Netherlands an evidence-based guideline for physical therapy diagnosis and treatment in patients with COPD was issued by the Royal Dutch Society for Physical Therapy (KNGF) and developed according to a rigorous procedure . An important component of the guideline is the recommended use of measurement instruments to establish parameters for treatment and evaluation .
Publication of guidelines does not automatically lead to their uptake and change of physical therapists’ behavior based on guideline recommendations shows room for improvement . Several studies reported multiple barriers for adherence of physical therapists to clinical guidelines and measurement instruments [7–9]. Multifaceted implementation strategies are more likely to result in change of professional behavior compared to educational activities [10–12], and a comprehensive implementation strategy is essential in promoting the uptake of clinical guidelines. Such an implementation strategy should be tailored to specific barriers and facilitators . Therefore, assessment of specific barriers is important for implementation planning.
The focus of many interventions to enhance uptake is aimed at health care practitioners (knowledge, skills, attitude), although social factors (influence of patients, colleagues, stakeholders) and external factors (financial, organizational, regulatory influences, guideline characteristics) are also important to address when designing implementation strategies .
Several theories and models exist to understand behavioral change of healthcare practitioners [15–18]. These models suggest that behavior is determined by three important factors: attitude, defined as positive and negative beliefs associated with a particular behavior; social norms, defined as beliefs of reference persons about a particular behavior; and self-efficacy expectations, defined as abilities to perform a particular behavior. Such models have been used to develop frameworks for implementation in order to identify barriers to change at different healthcare levels . Each type of barrier may require a specific intervention, and the analysis of facilitators and barriers is a crucial step in a systematic approach for designing implementation interventions. Methods such as intervention mapping  or the behavior change wheel approach  can be used to design and select interventions.
A recently updated systematic review showed that interventions tailored to prospectively identified barriers are more likely to improve professional practice compared to no intervention or dissemination of guidelines only. Barriers are typically identified using interviews and questionnaires, while the most effective ways to identify barriers are unknown . There is a need for valid methods to identify specific barriers for the topic of interest, integrated in comprehensive approaches for designing implementation strategies.
In the Netherlands a questionnaire was developed and tested among general practitioners to identify barriers for the implementation of clinical practice guidelines . The questionnaire allows for tailoring to specific context and target groups, and has been used in follow-up studies to conduct surveys among Dutch general practitioners and physical therapists [22, 23]. To identify barriers towards the use of measurement instruments, a general questionnaire was developed in assessing the attitude of physical therapists by asking their beliefs about the use of measurement instruments and reasons for (not) using measurement instruments . We were interested whether the combined use of these two available questionnaires may be useful to identify barriers to implementing the Dutch physical therapy COPD guideline.
The specific objective of our study was to construct a questionnaire for reliable and valid assessment of barriers and facilitators among Dutch physical therapists for implementing the COPD guideline and its recommended measurement instruments.