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Table 5 Determinants of change – enablers and barriers with major TDF domains, themes and illustrative quotes

From: Using theory to improve low back pain care in Australian Aboriginal primary care: a mixed method single cohort pilot study

TDF domain Theme Illustrative quote
Enablers
 Knowledge Changes to knowledge “…then we are not going for radiology until the red flag signs are there which are really serious indicators for radiology or something. So we’re giving more importance to conservative management and not jumping on radiology or medical treatment.” (Participant 1)
“…(managing patients) discussing mental health issues, and what is the barrier for them, like not going for physio, like what are their thoughts or beliefs, like about the pain and the progress of the disability.” (Participant 3)
 Knowledge Changes for new staff “..I think either you do it or we do it (educational workshops), every year with our new doctors make sure they have access to the information and the training so that they know why this is the way we do it (manage low back pain).” (Participant 2)
 Beliefs about consequences Imaging “..now I understand that until the red flags signs or something really needs to be - management is going to change, then I’m not referring patients that much (for imaging), and I’m doing management by ourselves here…. (Previously) if an unnecessary patient was going to see a specialist and there was not going to be any change in the management, then a few patients were getting unnecessary radiology.” (Participant 3)
“Trying to wean them off imaging, because imaging really puts a negative scenario, “oh, I’ve got something wrong with my back and it can’t be cured”. (Participant 4)
 Environment context resources Teamwork on site “if you want the guidelines you need a supported team, otherwise it doesn’t really help the patient and they don’t feel like we are doing good enough and they rely on medical model” (Participant 1)
 Environment context resources Patient resources/Communication “So we have to come up with a way of being able to explain that in, probably, a written way, a speaking way, maybe a video way; maybe a group way of trying to explain what chronic pain is and what that perception is and why we use this multi-modality. Until we can do that and we can communicate that well, we are stuck with a group of people who are absolutely sure that every time they move their back in a certain way they are injuring their back.” (Participant 2)
 Environment context resources Funding model “Given that we can offer them (patient) the facilities - not every doctor can offer them facilities. They have to - I mean, we have the - now, we have that they get these things relatively - not an out of pocket expense. I think that’s a very important factor as well. (Participant 4)
 Environment context resources Processes for locum staff “… for the sleepers or [other] medication we ask locums also to follow strictly....protocol, so maybe for back pain also, or radiology….we put it on everyone’s clinic, maybe good not to do unnecessary radiological investigations. Because you can’t specifically advise them to do that, but in general if we are putting something like that (protocol), that may be good.” (Participant 2)
 Goals Holistic practice “…I think we’ve given ourselves enough time to do it (biopsychosocial LBP assessment), and we consider it a priority for dealing with, I guess, the multi-morbidity of our patients.” (Participant 2)
 Social professional role GP role “…we are the first point of encounter. So if we can do a bit of (best practice) more on the first encounter that will be easier for everyone to support (The patient)” (Participant 1)
 Social influences Trust in investigator “Before we had guidelines…. and those things, but we were not following that much. But when you showed us videos and case discussions and those things, then we realised that, yeah, the things are really important, how we deal with patients.” (Participant 3)
 Behavioural regulation Audit and feedback “I think another area where you get behavioural change is if you regularly audit and you provide feedback….So looking at whether people are using it and whether it’s changing their practice and what sort of feedback they’re getting from it allows, I guess, you to look at where it falls apart.” (Participant 2)
Barriers
 TDF domain Theme Illustrative quote
 Environment context resources – barrier Locum staff “If locums came in and they looked at - and they did what we did, it would not be a problem, but we - the trouble with locums is that they quite frequently have their own way of doing things. They come in and they don’t tend to really work with what’s going on, because it’s all just too hard for them to learn, I guess. I don’t know. It may be something about the personality of people who do locums.” (Participant 2)
 Environment context resources – barrier Clinical tools/recording practices “(The STart Back) needs to be on the computer somewhere where you can get it. This is the problem with online tools. There’s no way of recording whether you’ve used them so it needs to be made into an interactive whatever that can be used on Communicare and becomes a document on their file. You create a document. We’ve got them for mini-mentals, we’ve got them for other tools” (Participant 2)
 Environment context resources – barrier Teamwork availability “..from my side, I think it’s a bit of a hassle, because we have the psychologist here only two and a half days, two days a week. There is some waiting list for them to see a psychologist. He’s also busy with really the mental health issues, rather than chronic pain issues.” (Participant 4)
 Social influences – barrier Other doctors “…it’s very hard when they’ve (the patient has) already seen somebody else and they’ve already been told a bunch of information and got a whole bunch of expectations or whatever. I think I’ve really, really, really struggled to get people to move beyond when that’s been their attitude.” (Participant 2)
 Social influences – barrier Workers compensation Because they - some employer organisations they are - they’re told that without the x-ray evidence or whatever they really don’t want to help [the patient] back to their job.” (Participant 1)