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01.12.2018 | Research article | Ausgabe 1/2018 Open Access

BMC Health Services Research 1/2018

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

BMC Health Services Research > Ausgabe 1/2018
Hazel J. Jenkins, Niamh A. Moloney, Simon D. French, Chris G. Maher, Blake F. Dear, John S. Magnussen, Mark J. Hancock
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Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1186/​s12913-018-3526-7) contains supplementary material, which is available to authorized users.



Imaging is overused in the management of low back pain (LBP). Interventions designed to decrease non-indicated imaging have predominantly targeted practitioner education alone; however, these are typically ineffective. Barriers to reducing imaging have been identified for both patients and practitioners. Interventions aimed at addressing barriers in both these groups concurrently may be more effective. The Behaviour Change Wheel provides a structured framework for developing implementation interventions to facilitate behavioural change. The aim of this study was to develop an implementation intervention aiming to reduce non-indicated imaging for LBP, by targeting both general medical practitioner (GP) and patient barriers concurrently.


The Behaviour Change Wheel was used to identify the behaviours requiring change, and guide initial development of an implementation intervention. Preliminary testing of the intervention was performed with: 1) content review by experts in the field; and 2) qualitative analysis of semi-structured interviews with 10 GPs and 10 healthcare consumers, to determine barriers and facilitators to successful implementation of the intervention in clinical practice. Results informed further development of the implementation intervention.


Patient pressure on the GP to order imaging, and the inability of the GP to manage a clinical consult for LBP without imaging, were determined to be the primary behaviours leading to referral for non-indicated imaging. The developed implementation intervention consisted of a purpose-developed clinical resource for GPs to use with patients during a LBP consult, and a GP training session. The implementation intervention was designed to provide GP and patient education, remind GPs of preferred behaviour, provide clinical decision support, and facilitate GP-patient communication. Preliminary testing found experts, GPs, and healthcare consumers were supportive of most aspects of the developed resource, and thought use would likely decrease non-indicated imaging for LBP. Suggestions for improvement of the implementation intervention were incorporated into a final version.


The developed implementation intervention, aiming to reduce non-indicated imaging for LBP, was informed by behaviour change theory and preliminary testing. Further testing is required to assess feasibility of use in clinical practice, and the effectiveness of the implementation intervention in reducing imaging for LBP, before large-scale implementation can be considered.
Additional file 1: Selection of appropriate intervention options. Mapping of the Com-B components and the Theoretical Domains Framework to intervention functions and policy categories that meet the APEASE criteria. (DOCX 15 kb)
Additional file 2: Barriers and facilitators to using the booklet. Barriers and facilitators to the use of the second iteration of the developed clinical resource in clinical practice. (DOCX 17 kb)
Additional file 3: Patient education booklet. PDF copy of the final clinical resource: LBP education and management booklet. (PDF 797 kb)
Additional file 4: Outline of GP training. Outline of GP training session. (DOCX 17 kb)
Additional file 5: GP information sheet. (PDF 260 kb)
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