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Open Access Research

Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework

André E Bussières12*, Andrea M Patey3, Jill J Francis4, Anne E Sales56, Jeremy M Grimshaw37 and the Canada PRIme Plus Team8

Author Affiliations

1 Population Health Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada

2 Departement Chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Canada

3 Clinical Epidemiology Program, Ottawa Hospital Research Institute – General Campus, Ottawa, Canada

4 Health Psychology Group and Health Services Research Unit, University of Aberdeen, Foresthill campus, Aberdeen, UK

5 School of Nursing, University of Michigan, Ann Arbor, USA

6 Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, USA

7 Faculty of Medicine, University of Ottawa, Ottawa, Canada

8 Canada PRIme Plus is a collaboration of international researchers, Canada, UK

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Implementation Science 2012, 7:82  doi:10.1186/1748-5908-7-82

Published: 31 August 2012

Abstract

Background

The Theoretical Domains Framework (TDF) was developed to investigate determinants of specific clinical behaviors and inform the design of interventions to change professional behavior. This framework was used to explore the beliefs of chiropractors in an American Provider Network and two Canadian provinces about their adherence to evidence-based recommendations for spine radiography for uncomplicated back pain. The primary objective of the study was to identify chiropractors’ beliefs about managing uncomplicated back pain without x-rays and to explore barriers and facilitators to implementing evidence-based recommendations on lumbar spine x-rays. A secondary objective was to compare chiropractors in the United States and Canada on their beliefs regarding the use of spine x-rays.

Methods

Six focus groups exploring beliefs about managing back pain without x-rays were conducted with a purposive sample. The interview guide was based upon the TDF. Focus groups were digitally recorded, transcribed verbatim, and analyzed by two independent assessors using thematic content analysis based on the TDF.

Results

Five domains were identified as likely relevant. Key beliefs within these domains included the following: conflicting comments about the potential consequences of not ordering x-rays (risk of missing a pathology, avoiding adverse treatment effects, risks of litigation, determining the treatment plan, and using x-ray-driven techniques contrasted with perceived benefits of minimizing patient radiation exposure and reducing costs; beliefs about consequences); beliefs regarding professional autonomy, professional credibility, lack of standardization, and agreement with guidelines widely varied ( social/professional role & identity); the influence of formal training, colleagues, and patients also appeared to be important factors ( social influences); conflicting comments regarding levels of confidence and comfort in managing patients without x-rays ( belief about capabilities); and guideline awareness and agreements ( knowledge).

Conclusions

Chiropractors’ use of diagnostic imaging appears to be influenced by a number of factors. Five key domains may be important considering the presence of conflicting beliefs, evidence of strong beliefs likely to impact the behavior of interest, and high frequency of beliefs. The results will inform the development of a theory-based survey to help identify potential targets for behavioral-change strategies.

Keywords:
Theoretical domains framework; Focus groups; Content analysis; Social/professional role and identity; Social influence; Chiropractors; Radiography; X-ray guidelines; Back pain