A qualitative inquiry into the environmental barriers and facilitators to non-specific low back pain clinical practice guideline adherence among Canadian physiotherapists

BACKGROUND: Nonspecific low back pain (NSLBP) has profound adverse impacts at both the individual level, such as pain and dysfunction, as well as the health system level, including high care costs. Prior research suggests that physiotherapists adhere to some aspects of NSLBP clinical practice guidelines (CPGs) but deviate from others. Little is known about the environmental factors that influence clinician decision-making for this condition. OBJECTIVE: To develop a deeper understanding of the environmental barriers and facilitators to NSLBP clinical practice guideline (CPG) use from the perspectives of physiotherapists across Canada, in the context of public and private sectors of settings. METHODS: The Theoretical Domains Framework and the Ecological Systems Theory were used to inform data collection and analysis. Data collection included 12 in-depth, 1-on-1 semi-structured interviews with Canadian physiotherapists with experience treating patients with NSLBP. Transcripts were first deductively coded to the pre-determined domains of the Theoretical Domains Framework by two independent researchers. Then, the Ecological Systems Theory framed inductive analysis within a subset of data relating to the context of the environment. Dialogic engagement occurred throughout data collection and analysis. RESULTS: Five overarching themes describe the environmental influences for NSLBP adherence and non-adherence: "physical environment and resources," "social influences," "product marketing," "legacy impact of education," and "cultural views of physiotherapy." CONCLUSIONS: Physiotherapists' decision-making for those with NSLBP is complex and multifactorial, influenced by multiple intersecting environmental interfaces. Because broad systemic obstacles are difficult to modify, focusing on microsystem-level factors may help strengthen adherence to guideline recommendations for NSLBP. Clinical leaders can help drive change by promoting mentorship, creating learning opportunities, and ensuring access to evidence-based resources that support the use of CPGs.