Physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care: protocol for a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework.

INTRODUCTION: Overprescription of antibiotics poses a significant threat to healthcare globally as it contributes to the issue of antibiotic resistance. While antibiotics should be predominately prescribed for bacterial infections, they are often inappropriately given for uncomplicated upper respiratory tract infections (URTIs) and related conditions, such as the common cold. This study will involve a qualitative systematic review of physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care settings and synthesise the findings using a theoretical basis. METHODS AND ANALYSIS: We will conduct a systematic review of qualitative studies that assess physicians' reported barriers to following evidence-based antibiotic prescription guidelines in primary care settings for URTIs. We plan to search the following databases with no date or language restrictions: MEDLINE, Web of Science, CINAHL, Embase, the Cochrane Library and PsycInfo. Qualitative studies that explore the barriers and enablers to following antibiotic prescription guidelines for URTIs for primary care physicians will be included. We will analyse our findings using the Theoretical Domains Framework (TDF), which is a theoretically designed resource based on numerous behaviour change theories grouped into 14 domains. Using the TDF approach, we will be able to identify the determinants of our behaviour of interest (ie, following antibiotic prescription guidelines for URTIs) and categorise them into the 14 TDF domains. This will provide the necessary information to develop future evidence-based interventions that will target the identified issues and apply the most effective behaviour change techniques to affect change. This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. ETHICS AND DISSEMINATION: Ethical approval is not required. Findings will be published in a peer-reviewed journal and presented at conferences.

What do the general public believe about the causes, prognosis and best management strategies for low back pain? A cross-sectional study.

BACKGROUND: Low back pain (LBP) is one of the most common reasons for seeking health care and is costly to the health care system. Recent evidence has shown that LBP care provided by many providers is divergent from guidelines and one reason may be patient's beliefs and expectations about treatment. Thus, examining the nature of patient beliefs and expectations regarding low back pain treatment will help coordinate efforts to improve consistency and quality of care. METHODS: This study was a cross-sectional population-based survey of adults living in Newfoundland, Canada. The survey included demographic information (e.g. age, gender, back pain status and care seeking behaviors) and assessed outcomes related to beliefs about the inevitable consequences of back pain with the validated back beliefs questionnaire as well as six additional questions relating beliefs about imaging, physical activity and medication. Surveys were mailed to 3000 households in July-August 2018 and responses collected until September 30th, 2018. RESULTS: Fout hundred twenty-eight surveys were returned (mean age 55 years (SD 14.6), 66% female, 90% had experienced an episode of LBP). The mean Back Beliefs Questionnaire score was 27.3 (SD 7.2), suggesting that people perceive back pain to have inevitable negative consequences. Large proportions of respondents held the following beliefs that are contrary to best available evidence: (i) having back pain means you will always have weakness in your back (49.3%), (ii) it will get progressively worse (48.0%), (iii) resting is good (41.4%) and (iv) x-rays or scans are necessary to get the best medical care for LBP (54.2%). CONCLUSIONS: A high proportion of the public believe LBP to have inevitable negative consequences and hold incorrect beliefs about diagnosis and management options, which is similar to findings from other countries. This presents challenges for clinicians and suggests that considering how to influence beliefs about LBP in the broader community could have value. Given the high prevalence of LBP and that many will consult a range of healthcare professionals, future efforts could consider using broad reaching public health campaigns that target patients, policy makers and all relevant health providers with specific content to change commonly held unhelpful beliefs.

Evaluating the impact of a champion on implementation of the Back Skills Training (BeST) programme in Canada: a mixed methods feasibility study protocol.

INTRODUCTION: There is global recognition that low back pain (LBP) should be managed with a biopsychosocial approach. Previous implementation of this approach resulted in low uptake and highlighted the need for ongoing support. This study aims to explore the feasibility of (i) training and using a champion to support implementation, (ii) using a cluster randomised controlled trial (RCT), (iii) collecting patient reported outcome measures in a Canadian public healthcare setting and to identify contextual barriers to implementation. METHODS: A pragmatic cluster RCT with embedded qualitative study with physiotherapists treating LBP in publicly funded physiotherapy departments in Newfoundland and Labrador, Canada. Participants will complete a previously developed online training course to equip them to deliver a biopsychosocial intervention for LBP. Clusters randomised to the intervention arm will receive additional support from a champion. A minimum champion training package has been developed based on known barriers in the literature. This includes strategies to target barriers relating to group-based scheduling issues, lack of managerial support, perceived patient factors such as addressing patient expectations for other types of treatments or selecting which patients might be best suited for this intervention, and anxiety about delivering something new. This package will be further codeveloped with study champions based on identified implementation barriers using the Behaviour Change Wheel. Clusters will be monitored for 6 months to assess champion and physiotherapist recruitment and retention, acceptability and implementation of the champion training, and the viability of conducting a cluster RCT in this setting. A purposive sample of physiotherapists will be interviewed from both arms. ETHICS AND DISSEMINATION: This study was approved by Newfoundland and Labrador Health Research Ethics Authority in December 2018. Results will be disseminated to academic audiences through conferences and peer reviewed publications; to all study participants, their clinical leads, and patients with LBP. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT04377529; Memorial University of Newfoundland Protocol Record 20190025; Pre-results.