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Table 4 Examples of how barriers to changing professionals' behaviour or guideline adherence can be classified

From: Factors affecting general practitioners' decisions about plain radiography for back pain: implications for classification of guideline barriers – a qualitative study

Revising Cabana et al.'s [12] system, Espeland and Baerheim [current study] related barriers to*

Oxman and Flottorp [22] related barriers to

Thompson et al. [24] related barriers to

Grol [21] related barriers to

Mäkelä and Thorsen [23] related barriers to

Knowledge

Knowledge and attitudes

Information management

Individual clinician

Professionals

Lack of knowledge of the guideline

Clinical uncertainty

Clinical uncertainty

Knowledge

Knowledge

Attitudes/feelings

Sense of competence

Sense of competence

Skills

Skills

Lack of agreement with its decision criteria

Compulsion to act

Standards of practice

Attitudes

Attitudes

Lack of outcome expectancy

Information overload

Financial disincentives

Habits

Patients

Lack of process expectancy

Prevailing opinion

Administrative issues

Social context

Knowledge

Lack of feelings expectancy

Standards of practice

Perception of liability

Patients

Skills

Lack of self-efficacy

Opinion leaders

Patient expectations

Colleagues

Attitudes

Lack of motivation/inertia of previous practice

Medical training

 

Authorities

Other resources

External barriers related to

Advocacy

 

Organisational context

Environment

Guideline (e.g., guideline unclear)

Practice environment

 

Available resources

Social factors

Patient (e.g., patient pressure)

Financial disincentives

 

Organisational climate

Organisational factors

Setting

Organisational constraints

 

Structures, etc.

Economic factors

- lack of time

Perception of liability

   

- lack of other practice resources

Patient expectations

   

- increased costs

    

- increased malpractice liability

    

- pressures in the health care system

    

- improper access to health care services

    
  1. * Possible strengths and weaknesses of this revised system: • Specifically concerns physicians' adherence to clinical practice guidelines [12] • Includes barriers actually reported by physicians in published studies [12] • Specifies several different types of attitude/feeling-related barriers • Separates these 'internal' barriers related to the physician from external barriers • Can be used to examine the relationship between internal and external barriers [40] • Includes lack of process expectancy in addition to lack of outcome expectancy • Explicitly lists guideline-related barriers, which guideline developers can prevent • Incorporates specific aspects of physicians' uncertainty, not a broad category (see text) • Lists attitudes that may underlie a 'compulsion to act', e.g., lack of process expectancy • Does not seem to have been used to classify barriers perceived by non-physicians, as opposed to for example Oxman and Flottorp's system [22, 41] • Does not explicitly list specific reasons for internal barriers that can be directly addressed • Only implicitly incorporates medical training, advocacy and opinion leaders as sources of barriers • Concerns only barriers and not facilitators, as opposed to Mäkelä and Thorsen's [23] system, although lack of a barrier can also be a facilitator