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Table 1 Changes required at the general practitioner (GP) and patient level to reduce GP use of non-indicated imaging for low back pain, mapped to the associated barriers and facilitators, the domains of the Theoretical Domains Framework, and the Behaviour Change Wheel

From: Using behaviour change theory and preliminary testing to develop an implementation intervention to reduce imaging for low back pain

Changes required to reduce referral for non-indicated imaging for low back pain Barriers and facilitators (identified through literature review) that will be influenced by the identified change Theoretical Domains Framework component COM-B component (Behaviour Change Wheel)
General practitioner (GP) changes required:
 - GPs need to have the skills to:
  1. Screen for clinical suspicion of underlying pathology to determine if imaging is necessary
  2. Communicate with patients to explain their diagnosis and advise them that they don’t need imaging
Barriers:
- Diagnostic uncertainty [30, 46, 54, 55]
GPs uncertain in their skills in adequately diagnosing low back pain without imaging; Fear of missing a diagnosis of underlying pathology
- Unsure how to advise patients that imaging is not needed [52]
GPs uncertain how to convincingly explain to patients that imaging is not needed
Facilitators:
- Communication with patients [46]
GPs confident in communicating with patients, to educate and reassure them
Skills Physical capability
 - GPs need to have knowledge of:
  1. Guidelines and appropriate indications for imaging
  2. Limitations of imaging in the diagnosis and management of low back pain
  3. Risks of imaging
  4. Key concepts required in patient explanations explain why imaging isn’t necessary
Barriers:
- Lack of guideline awareness [30, 46, 52, 55]
GPs lack knowledge and awareness of current guidelines recommending appropriate use of imaging for low back pain
- Unsure how to advise patients that imaging is not needed [52]
GPs uncertain how to convincingly explain to patients that imaging is not needed
Facilitators:
- Guideline awareness [51, 52]
GPs display knowledge of current guidelines recommending appropriate use of imaging for low back pain
- Awareness of limitations of imaging [51]
GPs aware of limitations of imaging in providing diagnoses, directing management, or reassuring patients.
- Awareness of danger of radiation exposure [51]
GP aware that x-rays and CT scans add to radiation exposure and may be harmful
Knowledge Psychological capability
 - GPs need to use a decision-making process which incorporates the appropriate use of imaging Barriers:
- Diagnostic uncertainty [30, 46, 54, 55]
GPs uncertain in their skills in adequately diagnosing low back pain without imaging; Fear of missing a diagnosis of underlying pathology
Facilitators:
- Availability of guidelines [51]
Guidelines act as a memory-aid and are more likely to be followed if they are accessible, concise and user-friendly.
Memory, attention, and decision process Psychological capability
 - GPs need to have:
  1. Increased time for patient education
  2. Cues to remind them of imaging appropriateness
  3. Resources to give to patient to improve ability to educate and reassure the patient in a limited time
Barriers:
- Time constraints [30, 48,49,50, 54, 55]
GPs don’t have enough time with patients to provide explanations and reassurance; Imaging seen as a quick way to reassure the patient and increase patient compliance
- Diagnostic uncertainty [30, 46, 54, 55]
GPs uncertain in their skills in adequately diagnosing low back pain without imaging; Fear of missing a diagnosis of underlying pathology
- Perceived need to give the patient something to take home [30]
GPs feel that patients expect to receive something from the consult and an imaging referral is often used to achieve this
Environmental context and resources Physical opportunity
 - GPs need to use their role as a trusted source of information provision to educate patients Facilitators:
- Communication with patients [46]
GPs confident in communicating with patients, to educate and reassure them
- Senior GP who adheres to guidelines [52]
Having a senior GP to model correct behaviour and act as a potential opinion leader to the other GPs
Social influences Social opportunity
 - GPs need to be confident in their ability to:
  1. Screen for clinical suspicion of underlying pathology to determine feel that imaging Ps feel that imaging if imaging is necessary
  2. Reassure patients without imaging
Barriers:
- Perceived patient expectations [30, 46, 48, 50,51,52, 54, 55]
GPs feel that patients often want or expect imaging, and that they don’t understand the limited usefulness of imaging to manage low back pain; Fear that patients will be upset if they don’t receive imaging or may devalue the GP
Beliefs about capabilities Reflective motivation
 - GPs need to be aware of the risks and benefits of referring for imaging, and the likely consequences of referring for imaging when it isn’t indicated Barriers:
- Perceived usefulness of imaging and negative consequences to following guidelines [30, 46, 47, 49,50,51,52, 55]
GPs feel that imaging will be useful – provide diagnosis, help to reassure the patient, help to facilitate patient management, build patient relationships; They feel there are more negative consequences associated with following guideline advice not to refer for imaging
- Pressure from patients [20, 49,50,51, 54, 55]
GPs report that they receive direct pressure from patients to refer for imaging; They feel that if they don’t comply with the request patients will devalue them and go elsewhere to obtain imaging
- Perceived patient anxiety [30, 46, 47, 49, 51, 55]
GPs perceive that imaging will help to reassure anxious patients that their condition is not serious and will increase compliance with advice
- Possible litigation [48, 51, 55]
GPs feel that they may open themselves to possible litigation if they don’t refer for imaging
- Specific patient characteristics [46, 50]
Specific patient characteristics more likely to lead to increased imaging (i.e. elderly, workers compensation claims, etc.)
Facilitators:
- Perceived positive consequences to following guidelines [30, 55]
GPs are in agreement with the guidelines and feel that more positive consequences are associated with following guideline advice not to refer for imaging
Beliefs about consequences Reflective motivation
Patient changes required:
 - Patients need to have knowledge of:
  1. Limitations of imaging in the management of low back pain
  2. Risks of imaging
  3. Signs to be aware of that may indicate the need for imaging
Barriers:
- Perceived reassurance and explanation of symptoms from imaging [19, 21, 45, 56]
Patients feel that imaging will provide reassurance to them by excluding pathological causes of low back pain and providing a diagnosis, particularly when pain levels are high or not resolving
- Lack of awareness of risks of imaging [19]
Patients report being unaware of potential risks of imaging, and even where some risks are recognised report that potential benefits outweigh these risks.
Knowledge Psychological capability
 - Patients need to be aware of the decision process that was used to determine that they don’t need imaging Barriers:
- Perceived reassurance and explanation of symptoms from imaging [19, 21, 45, 56]
Patients feel that imaging will provide reassurance to them by excluding pathological causes of low back pain and providing a diagnosis, particularly when pain levels are high or not resolving
Facilitators
- Communication with patients [46]
Patients whose GPs communicate with them adequately are more likely to be reassured without the use of imaging
Memory, attention, and decision process Psychological capability
 - Patients need to receive educational resources focusing on patient reassurance, appropriate management and why imaging isn’t required Barriers:
- Perceived reassurance and explanation of symptoms from imaging [19, 21, 45, 56]
Patients feel that imaging will provide reassurance to them by excluding pathological causes of low back pain and providing a diagnosis, particularly when pain levels are high or not resolving
- Lack of awareness of risks of imaging [19]
Patients report being unaware of potential risks of imaging, and even where some risks are recognised report that potential benefits outweigh these risks
Environmental context and resources Physical opportunity
 - Patients need to have less access to contradictory information sources, or more access to evidence-based information sources Barriers:
- Influences from friends, family, or other healthcare practitioners, and previous experience that imaging is important [19]
Advice from friends, family, or other healthcare practitioners, and previous experience of referral for imaging for low back pain likely to increase perceived need for imaging
Social influences Social opportunity
 - Patients need to be aware of possible outcomes of the suggested management plan, and possible consequences of being referred for imaging when not indicated Barriers:
- Perceived reassurance and explanation of symptoms from imaging [19, 21, 45, 56]
Patients feel that imaging will provide reassurance to them by excluding pathological causes of low back pain and providing a diagnosis, particularly when pain levels are high or not resolving
Beliefs about consequences Reflective motivation
 - Patients need to feel that they are receiving emotional support from the GP without imaging Barriers:
- Emotional support and validation of pain from GP referring for imaging [21]
Patients feel that GPs who comply with their wishes to refer for imaging are providing necessary emotional support and validating their pain
Emotion Automatic motivation