Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework

Table 5 Summary of findings regarding physician-reported barriers to prescribing simple analgesics instead of stronger medication

TDF domain	TDF sub-domain	Specific theme from the study	Studies (participants)	Confidence in the evidence	Explanation
Knowledge	Knowledge of condition/scientific rationale	Disagreement with guideline advice regarding simple analgesics, muscle relaxants and opioids. “Also, most GPs disagreed with the guidelines on opioid use, stating that these were often necessary to effectively manage pain despite the associated adverse effects.”	2 (39)	Moderate³	No or very minor concerns regarding methodological limitations, coherence and relevance Moderate or serious concerns regarding adequacy
Skills	Skills	Perception that patients want something stronger and that it is difficult to “sell” simple analgesics instead. “Most GPs agreed with the guidelines advice to prescribe simple analgesics, and not a muscle relaxer. However, most said that they did not always adhere to this advice. Motives were diverse. Some could not sell “simple” analgesics to their patients…”	1 (31)	Very low⁵	Moderate or serious concerns regarding methodological limitations, coherence, and adequacy

CERQual Assessment: Confidence was downgraded 1 level for each of the four CERQual domains that had moderate or serious concerns defined as ¹methodological limitation (the majority of the supporting data comes from studies with low methodological rigour threating the validity or reliability of the theme), ²coherence (the supporting data for the theme is drawn from studies that provided ambiguous or incomplete data that threatened the coherence of this theme), ³adequacy (the majority of the supporting data for the theme is drawn from few and/or small studies and the quality is superficial lacking sufficient richness to fully explore the theme), and ⁴relevance (the majority of the supporting data is of indirect, partial or unclear relevance to the theme. ⁵When the data come from a single study with few participants and of moderate rigour we downgraded to very low confidence. Please see Additional file 2 for a full description of the criteria used for assessing confidence in the evidence supporting the review findings using the CERQual approach

ISSN: 1748-5908