What behaviour change techniques have been used to improve adherence to evidence-based low back pain imaging?

Amanda Hall*, Helen Richmond, Andrea Pike, Rebecca Lawrence, Holly Etchegary, Michelle Swab, Jacqueline Y. Thompson, Charlotte Albury, Jill Hayden, Andrea M. Patey, James Matthews

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

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Background: Despite international guideline recommendations, low back pain (LBP) imaging rates have been increasing over the last 20 years. Previous systematic reviews report limited effectiveness of implementation interventions aimed at reducing unnecessary LBP imaging. No previous reviews have analysed these implementation interventions to ascertain what behaviour change techniques (BCTs) have been used in this field. Understanding what techniques have been implemented in this field is an essential first step before exploring intervention effectiveness.

Methods: We searched EMBASE, Ovid (Medline), CINAHL and Cochrane CENTRAL from inception to February 1, 2021, as well as and hand-searched 6 relevant systematic reviews and conducted citation tracking of included studies. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study and intervention characteristics. Study interventions were qualitatively analysed by three coders to identify BCTs, which were mapped to mechanisms of action from the theoretical domains framework (TDF) using the Theory and Techniques Tool.

Results: We identified 36 eligible studies from 1984 citations in our electronic search and a further 2 studies from hand-searching resulting in 38 studies that targeted physician behaviour to reduce unnecessary LBP imaging. The studies were conducted in 6 countries in primary (n = 31) or emergency care (n = 7) settings. Thirty-four studies were included in our BCT synthesis which found the most frequently used BCTs were ‘4.1 instruction on how to perform the behaviour’ (e.g. Active/passive guideline dissemination and/or educational seminars/workshops), followed by ‘9.1 credible source’, ‘2.2 feedback on behaviour’ (e.g. electronic feedback reports on physicians’ image ordering) and 7.1 prompts and cues (electronic decision support or hard-copy posters/booklets for the office). This review highlighted that the majority of studies used education and/or feedback on behaviour to target the domains of knowledge and in some cases also skills and beliefs about capabilities to bring about a change in LBP imaging behaviour. Additionally, we found there to be a growing use of electronic or hard copy reminders to target the domains of memory and environmental context and resources.

Conclusions: This is the first study to identify what BCTs have been used to target a reduction in physician image ordering behaviour. The majority of included studies lacked the use of theory to inform their intervention design and failed to target known physician-reported barriers to following LBP imaging guidelines.

Protocol Registation: PROSPERO CRD42017072518.

Original languageEnglish
Article number68
Number of pages22
JournalImplementation Science
Issue number1
Early online date2 Jul 2021
Publication statusPublished - Dec 2021

Bibliographical note

Funding Information:
We would like to acknowledge Daphne To for providing assistance with the title/abstract screening process.

Publisher Copyright:
© 2021, The Author(s).


  • Behaviour change techniques
  • Evidence-based
  • Imaging
  • Low back pain
  • Theoretical domains framework

ASJC Scopus subject areas

  • Health Policy
  • Health Informatics
  • Public Health, Environmental and Occupational Health


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