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Promoting the use of self-management in novice chiropractors treating individuals with spine pain: the… Eilayyan, Owis; Thomas, Aliki; Hallé, Marie-Christine; Ahmed, Sara; Tibbles, Anthony C; Jacobs, Craig; Mior, Silvano; Davis, Connie; Evans, Roni; Schneider, Michael J; Alzoubi, Fadi; Barnsley, Jan; Long, Cynthia R; Bussières, Andre Sep 11, 2018

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RESEARCH ARTICLE Open AccessPromoting the use of self-management innovice chiropractors treating individualswith spine pain: the design of a theory-based knowledge translation interventionOwis Eilayyan1,2*, Aliki Thomas1,2, Marie-Christine Hallé1,2, Sara Ahmed1,2, Anthony C. Tibbles3, Craig Jacobs3,Silvano Mior3, Connie Davis4,5, Roni Evans6, Michael J. Schneider7, Fadi Alzoubi1,2, Jan Barnsley8, Cynthia R. Long9and Andre Bussières1,2AbstractBackground: Clinical practice guidelines generally recommend clinicians use self-management support (SMS) whenmanaging patients with spine pain. However, even within the educational setting, the implementation of SMSremains suboptimal. The objectives of this study were to 1) estimate the organizational readiness for changetoward using SMS at the Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario from the perspective ofdirectors and deans, 2) estimate the attitudes and self-reported behaviours towards using evidence-based practice(EBP), and beliefs about pain management among supervisory clinicians and chiropractic interns, 3) identifypotential barriers and enablers to using SMS, and 4) design a theory-based tailored Knowledge Translation (KT)intervention to increase the use of SMS.Methods: Mixed method design. We administered three self-administered questionnaires to assess clinicians’ andinterns’ attitudes and behaviours toward EBP, beliefs about pain management, and practice style. In addition, weconducted 3 focus groups with clinicians and interns based on the Theoretical Domain Framework (TDF) to exploretheir beliefs about using SMS for patients with spine pain. Data were analysed using deductive thematic analysis by2 independent assessors. A panel of 7 experts mapped behaviour change techniques to key barriers identifiedinforming the design of a KT intervention.Results: Participants showed high level of EBP knowledge, positive attitude of EBP, and moderate frequency of EBPuse. A number of barrier factors were identified from clinicians (N = 6) and interns (N = 16) corresponding to 7 TDFdomains: Knowledge; Skills; Environmental context and resources; Emotion; Beliefs about Capabilities; Memory, attention& decision making; and Social Influence. To address these barriers, the expert panel proposed a multifaceted KTintervention composed of a webinar and online educational module on a SMS guided by the Brief Action Planning,clinical vignettes, training workshop, and opinion leader support.(Continued on next page)* Correspondence: owis.eilayyan@mail.mcgill.ca1School of Physical and Occupational Therapy, McGill University, 3654 PromSir-William-Osler, Montréal, QC H3G 1Y5, Canada2Center for Interdisciplinary Research in Rehabilitation of Greater Montreal(CRIR), Montréal, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Eilayyan et al. BMC Musculoskeletal Disorders  (2018) 19:328 https://doi.org/10.1186/s12891-018-2241-1(Continued from previous page)Conclusion: SMS strategies can help maximizing the health care services for patients with spine pain. This may inturn optimize patients’ health. The proposed theory-based KT intervention may facilitate the implementation of SMSamong clinicians and interns.Keywords: Spine pain, Self-management, Theory-based intervention, Knowledge translation, Theoretical domainframework, Chiropractic, Brief action planningBackgroundSpine pain is very common and is a leading cause of dis-ability worldwide [1–5]. Between 50 and 80% of adultssuffer from spine pain during their lives [6, 7], which isassociated with a high individual (physical, psychological,emotional) and societal burden [6, 8–16]. In Canada, theestimated direct cost of spine pain ranges from $6 to$12 billion annually [17].Many people with spine pain consult chiropractors forpain relief [18–20]. Clinical practice guidelines (CPGs) gen-erally recommend offering self-management support (SMS)strategies to individuals with spine pain [21–28] as thesehelp reduce the associated individual and societal burden[29]. SMS strategies are designed to facilitate adoption ofhealthy lifestyle in people with a range of health issues in-cluding spine pain and related co-morbidities (e.g. heart dis-ease, type 2 diabetes, depression) [30–39]. In patients withspine pain, SMS can help decrease levels of pain, disability,and psychological distress [40, 41]. However, the routineadoption of evidence-based practices (EBPs) including theuse of CPGs remains suboptimal among care providers in-cluding chiropractors [42–45]. Barriers to implementingEBPs among chiropractors include: lack of time, lack ofgeneralizability of guidelines, lack of compensation, timesince graduation greater than 10 years, insufficient skills orconfidence in using findings from the literature, predefinedbeliefs and a more narrowed scope of practice [43].SMS interventions empower the patient to be effi-ciently involved in their own care by involving them inthe decision-making process [46, 47]. SMS strategies alsonecessitate a close collaboration between clinicians andpatients [47–49]. However, a number of barriers toimplementing SMS among clinicians have been docu-mented, including: the lack of sufficient knowledge andskills to empower patients or to provide them with use-ful information, lack of time, and unfavourable patientviews about this approach. Inadequate communicationbetween clinicians and patients may also limit the use ofSMS [50–53]. In addition, organizational barriers couldrestrict the use of SMS in clinical settings, such as pa-tient overload, short treatment session, and long waitinglists [53]. Together, these barriers can contribute to re-ducing the effectiveness of SMS. Given the documentedbarriers to adoption of EBPs - and SMS in particular -changing clinicians’ behaviour is challenging [43, 54].Knowledge Translation (KT) is an approach used to fa-cilitate’ behavioural change in practitioners [55]. It canbe used to promote the early use of EBP and CPGs dur-ing professional training, which may be more effectivethan changing existing professional practice to supportthe long-term use of best evidence [56, 57]. EBP requiresthe integration of research evidence, clinical expertiseand patients’ preferences into clinical decision-making[58]. Systematic reviews suggest that, whileclassroom-based teaching primarily improves EBP know-ledge, clinically integrated teaching of EBP may be themost effective approach for improving the knowledge,attitudes, skills and behaviours associated with the useof EBP. Thus, academic programs must first lay downthe foundations of EBP over the course of professionaltraining, and then move students along a trajectory ofprogressive development of EBP competencies [56, 59].Clinically integrated teaching of EBP delivered in theclinical setting can support deeper reflection on practicethrough actual patient management [60, 61].Thus, providing chiropractic interns with the oppor-tunity to routinely use CPGs to inform their clinical de-cisions should increase the likelihood of uptake andsustained use of EBP in their future practices. These in-terns will be more likely to become lifelong learners andreflective practitioners who will be equipped to over-come barriers to the use of CPGs - including SMS – andcontribute to reducing research-practice gaps [43].In Canada, the majority of practising chiropractors(58%) are trained at the Canadian Memorial Chiroprac-tic College (CMCC) [62]. While CMCC revised its cur-riculum to promote the sustainable use of EBP amonggraduates, structured SMS that allows forpatient-centred goals such as the Brief Action Planning(BAP) [63] has not yet been integrated into the curricu-lum [64]. Consequently, supervisory clinicians and in-terns do not systematically use SMS with patients acrossthe CMCC outpatient teaching clinics [64].The objectives of this study were to 1) estimate theorganizational readiness for change toward using SMS atthe Canadian Memorial Chiropractic College (CMCC),Toronto, Ontario from the perspective of Directors andDeans, 2) estimate the attitudes towards andself-reported use of evidence-based practice (EBP) be-haviours, as well as beliefs about pain managementEilayyan et al. BMC Musculoskeletal Disorders  (2018) 19:328 Page 2 of 13among supervisory clinicians and chiropractic interns, 3)identify potential barriers and enablers to using SMS,and 4) design a theory-based tailored Knowledge Trans-lation (KT) intervention to increase the use of SMS.Conceptual frameworkThe Theoretical Domain Framework (TDF) has beenused across several health disciplines, settings, and con-ditions to assess barriers to change and guide the devel-opment of theory-based interventions [65–69]. The TDFcovers the main factors that influence behaviour changein clinical practice: Knowledge, Skills, Social/ProfessionalRole and Identity, Beliefs about Capabilities, Optimism,Beliefs about Consequences, Reinforcement, Intentions,Goals, Memory/Attention and Decision Processes, Envir-onmental Context and Resources, Social Influences, Emo-tion, and Behavioural Regulation [70].MaterialsStudy designMixed-methods sequential transformative design com-prising both quantitative and qualitative analyses. Ethicalapproval was obtained from the Research Ethics Boardof McGill University (McGill IRB: A08-E54-16B), andwritten informed consent was obtained from allparticipants.SettingFive outpatient-teaching clinics of the Canadian Memor-ial Chiropractic College (CMCC), a major teaching insti-tution in Ontario were approached to participate in thestudy.The development of a KT intervention aiming to pro-mote the use of SMS was guided by a systematic ap-proach proposed by French et al. (2012) [69]. Theapproach includes 4 questions:1) Who needs to do what, differently? (i.e. identify theevidence-practice gap). For this question, the litera-ture suggests that the use of SMS among cliniciansis suboptimal [50–53].2) Using a theoretical framework (i.e. TDF [70]), whichbarriers and enablers need to be addressed? and3) Which intervention components (behaviour changetechniques and mode(s) of delivery) could overcomethe modifiable barriers and enhance the enablers?The latter 2 questions were addressed in two separatephases: Phase 1A aimed to 1) explore CMCCorganizational readiness to use of EBP and SMS (Quan-titative), 2) explore clinicians’ and interns’ behavioursand attitudes towards the use of EBP and their beliefsabout pain management (Quantitative). Phase 1B aimedto identify barriers and enablers to the use of SMSamong a subgroup of clinicians and interns who wererepresentative of CMCC clinicians and interns in termsof age, gender, and years of experience (Qualitative). Re-sults from phase 1 were integrated and used to informphase 2, where we mapped key barriers to using SMS.Ultimately, the findings served to design KT interventioncomponents to address these barriers.4) How can behaviour change be measured andunderstood? This question is beyond the scope ofthis paper.Phase 1A targeting objectives 1 and 2: Clinicians’ andinterns’ behaviours and attitudes toward EBP use, and theorganizational readiness for change in healthcare settings(Quantitative Data)Participants Chiropractic interns working within 20 Pa-tient Management Teams (PMTs) and their 20 supervis-ory clinicians were invited to participate in this phase.Chiropractic interns had to be in their final year atCMCC and working in one of these 20 PMTs. Directorsand deans at CMCC (decision makers) were also invitedto participate in the study.Data collection Study instrumentsThe decision makers at CMCC completed theOrganizational Readiness for Implementing Change(ORIC) questionnaire which assesses organizationalreadiness for change in healthcare settings [71]. Clini-cians and interns completed 3 self-administered ques-tionnaires: 1) The Knowledge, Attitude, and BehaviourQuestionnaire (KABQ) that assesses knowledge, atti-tudes, and behaviour toward EBP [72], 2) the Pain Atti-tudes and Beliefs Scale (PABS) which assesses thestrength of 2 treatment orientations of health care prac-titioners: biomedical and behavioural orientations [73],and 3) the practice style questionnaire to classify clini-cians and interns based on their practice [74].Organizational readiness for implementing change(ORIC) The ORIC is comprised of 12 questions forming2 domains: change commitment and change efficacy[71]. Each question is rated on 5-point Likert scale(Strongly Disagree – Strongly Agree), scores range 12–60, with higher scores indicating high readiness forchange among organization members [71]. The ORIChas good psychometric properties [71].Knowledge, attitude, and behaviour questionnaire(KABQ) The KABQ is a 33–item validated questionnairecomprised of 4 EBP domains: knowledge, attitudes, behav-iours and outcomes/decisions [72]. The ‘knowledge’ do-main includes 8 items each rated on a 7-point Likert scale,Eilayyan et al. BMC Musculoskeletal Disorders  (2018) 19:328 Page 3 of 13with higher scores indicating a higher level of EBP know-ledge. The ‘attitudes towards EBP’ domain contains 14items rated on a 7-point Likert scale, with higher scoresindicating more positive attitudes toward EBP. The “Be-haviour towards EBP” domain includes 8 items rated on a5-point Likert scale, with higher scores indicating a higherfrequency of using EBP. Lastly, the “outcomes/decisions”domain includes 3 items rated on a 6-point Likert scale,with lower scores indicating less favourable patient out-comes and poorer clinical evidence-based decision making[72]. This questionnaire has demonstrated good psycho-metric properties [72].Pain attitudes and beliefs scale (PABS) The PABSquestionnaire assesses the strength of 2 treatment orien-tations of health care practitioners: biomedical and be-havioural orientations [73]. The amended version of thePABS is comprised of 19 items (10 biomedical items and9 behavioural items) [75]. Each question is rated on a6-point scale “(‘Totally disagree’ = 1 to ‘Totally agree’ =6)”, where higher scores on a subscale indicate a stron-ger treatment orientation [75]. The PABS has acceptablepsychometric properties [73, 76].Practice style questionnaire The practice style question-naire is used to classify clinicians into 4 categories basedon their style of practice: Seekers, Receptives, Traditional-ists, and Pragmatists [74]. The questionnaire includes 17statements about clinicians’ practice rated on 5-pointLikert scale (Strongly Agree – Strongly Disagree).Procedure A member of the research team and Directorof Clinical Education and Patient Care at CMCC (C.J.)personally introduced the study to the CMCC decisionmakers (N = 20) and at a faculty meeting. Decisionmakers who agreed to participate in the study completedthe ORIC tool online.We first pilot tested the KABQ, PABS, and practicestyle questionnaires with one volunteering PMT com-posed of a supervisory clinician and seven interns. Teammember (C.J.) sent these PMT participants an email witha link to the online survey along with a feedback form.Respondents were invited to indicate the length of timeneeded to complete the questionnaire and any questionsor comments they had regarding the clarity of the ques-tionnaires. Feedback received allowed the research teamto correct typographical errors and develop an appendixproviding additional clarifications for a few questions forwhich the wording or the meaning appeared to be con-fusing. C.J. then sent an email to all supervisory clini-cians (N = 20) and interns (N = 173) of the remainingPMTs informing them about the study (e.g., goal, time-line and procedures) and inviting them to dedicate halfan hour of their administrative time to complete thequestionnaires in the upcoming week. To avoid coer-cion, clinicians were invited to complete the same ques-tionnaires at the same time as their interns, but in adifferent room. All supervisory clinicians and interns re-ceived the link to the online surveys and the appendixproviding additional clarifications about the surveys viaan email sent by C.J. An online consent form precededthe surveys.Sample size and data analysis Descriptive analysis wasconducted for the 4 administered questionnaires usingSAS 9.4 [77]. The scores were calculated for each sub-scale of the KABQ, PABS, and ORIC. For the practicestyle questionnaire, the frequency of each category wascalculated. The associations between demographic vari-ables and the sub-scores/total score of each question-naire were assessed using simple and multiple linearregression models. The socio-demographic variables in-cluded age, gender, education, grade point average(GPA), and clinical experience. Β-coefficients were usedto assess the association between KABQ and PABS withother factors. All studied factors were considered as cat-egorical variables with the exception of age, which was acontinuous variable.Sample size in multiple regression depends upon thenumber of studied variables following the rule ofthumb of (N ≥ 50 + 8 m), where m refers to numberof studied (predictors) variables [78]. As this study in-cluded 5 predictors, a sample size of 106 subjects wasneeded to run a multiple linear regression with analpha of 0.05 and 80% power (as a function ofmedium effect size) [78, 79].Phase 1B: Barriers and enablers to the use SMS (qualitative)We conducted three 90-min focus groups with a subsetof supervisory chiropractors and interns to identify thekey barriers and enablers to the use SMS.Focus group guide The interview topic guide was devel-oped based on the TDF framework [70] and further in-formed by our previous work [80–84]. The topic guideincluded 27 open-ended questions which covered all 14TDF domains, with on average 2–3 questions per do-main. Probing questions were used for further clarifica-tion if needed (See Additional file 1). Each focus grouptook approximately 90 min.Procedure A member of the research team (C.J.) sentan invitation email to all clinicians and interns at CMCCto participate in a focus group. The email included a linkto an online form requesting potential participants’authorization to be contacted by the research team andasking them to provide their name, contact informationand a few socio-demographic information. Three focusEilayyan et al. BMC Musculoskeletal Disorders  (2018) 19:328 Page 4 of 13groups were conducted: one with 6 clinicians, and twowith 8 interns each. All focus groups took place in per-son at CMCC. A research assistant, experienced in con-ducting qualitative interviews based on the TDF,facilitated the focus groups. All participants completedand signed a consent form prior to the focus groups.Each focus group took approximately 90 min, was audiorecorded, anonymized and transcribed verbatim.Data analysis The analysis in this study followed thesame analysis used by the research team previously [68,82]. The focus group data were coded deductively by 2independent reviewers (HO & OE). Disagreements wereresolved by 2 other team members who have previousexperience with using the TDF (AB and FZ). Eachtranscript was divided into different statements thatwere coded into relevant TDF domains. Statementswere then linked with specific beliefs. A specific beliefis defined as “a core statement that captures a com-mon theme from multiple response statements andprovides detail about the role of a given domain ininfluencing practice behaviour” [68, 80]. The specificbeliefs were classified into one of 3 categories basedon the likelihood that they would 1) increase (facilita-tor), 2) decrease (barrier), or 3) have no influence onthe use of SMS. Similar specific beliefs within eachTDF domain were identified and grouped into over-arching themes. Three criteria were used concurrentlyto identify the key barriers: frequency of belief, im-portance of the belief, and contrasting beliefs.Sample size The sample size needed for deriving the-matic saturation from focus groups cannot be deter-mined in advance. The literature suggests having 2–3focus groups, a size of 8 participants each to discovermost of the themes about the studied area [85]. Therewas no a priori plan to assess the saturation of focusgroup data. However, both clinicians and interns indi-cated almost identical barriers to using SMS.Phase 2: Intervention design The aim of phase 2 wasto review the key barriers identified in phase 1 in orderto inform the design of a KT intervention to addressthese barriers.Participants Seven research team members with experi-ence using Behaviour Change Techniques (BCTs) andthe TDF attended a half-day meeting to consider andpropose possible KT intervention components. Theteam included 3 KT researchers, a researcher in medicaleducation, 2 CMCC faculty members, and 1 patientrepresentative.Procedure All possible KT intervention componentswere first selected by a subgroup of 3 team members(AB, AT, OE) after mapping key TDF barriers onto cor-responding BCTs (as per Michie et al. [86, 87]). Otherteam members received the results of this mapping exer-cise for consideration prior to the group meeting. Find-ings were reviewed by the team members, and they wereasked to brainstorm other possible KT interventioncomponents. Consensus on the selection of KT interven-tion components and modes of delivery was reachedbased on the evidence of their effectiveness and thefeasibility of implementation.The selected KT interventions in this study that aimedto promote the use of SMS were guided by Brief ActionPlanning (BAP) framework [63]. The literature supportedthe use of the BAP framework to enable the implementa-tion of SMS [63, 88]. The framework was developed basedon motivational interviewing, and it was considered an ex-cellent SMS program for busy clinics [63].ResultsPhase 1A— ORIC, KABQ, BAPS and practice styleThe data set included 12 decision makers, 14 clinicians,115 chiropractic interns, with a mean age of 57 ±6.3 years, 46 ± 12 years and 27 ± 2.4 years, respectively.Twenty-five percent of decision makers, 14% of clini-cians, and 46% of interns and were females. The rawdata are presented in Additional files 2 & 3.Results from the ORIC showed that decisionmakers perceived that members of the CMCC werehighly committed (mean = 20.6 ± 3.5) to, and confidentabout (mean = 29.3 ± 4) implementing SMS for pa-tients with spine pain in CMCC outpatient teachingclinics, Fig. 1 A&B.Results from the KABQ revealed that both cliniciansand interns had high levels of knowledge about EBP(Clinician mean = 29.1 ± 3.7, Intern mean = 28.5 ± 4),positive attitudes towards the use of EBP (Clinicianmean = 50.1 ± 6.2, Intern mean = 54.4 ± 5.4) and moder-ate frequency of using EBP (Clinician mean = 12.9 ± 3.3,Intern mean = 12.8 ± 2.8). The participants reported hav-ing favourable patient outcomes and good clinicalevidence-based decision-making (Clinician mean = 13.3± 2.9, Intern mean = 12.1 ± 2.2). While interns had a sig-nificantly stronger behavioural than biomedical treat-ment orientation, clinicians did not show a significantdifference in treatment orientation (Table 1). Lastly, 54%(7/13) of clinicians have a traditional practice style (theirintervention decisions are guided by their clinical experi-ence [89]), while 81% (87/108) of interns have a prag-matic practice style (their practice primarily depends onthe workload [89]). Neither clinicians nor interns wereclassified as seekers (their intervention decisions areguided by evidence [89]), Fig. 2.Eilayyan et al. BMC Musculoskeletal Disorders  (2018) 19:328 Page 5 of 13The multiple regression models showed that none ofthe demographic factors appeared to influence theinterns’ self-reported use of EBP. However, the modelrevealed that men had significantly higher knowledge ofEBP than women (β = 1.74, p = 0.043) and interns whohad a previous university degree had more negative atti-tudes toward EBP (β = 4.3, p = 0.035). Regression ana-lyses were not conducted on the clinician anddecision-maker data due to the small sample sizes.Phase 1B—Focus groupsWe conducted one focus group with 6 supervisory clini-cians and 2 focus groups with 8 interns each. Clinicians’and interns’ average age was 40.8 ± 6 years and 27 ±2.8 years, respectively. Almost 33% (2/6) and 44% (7/16)of the clinicians and interns were females, respectively.Clinicians who participated in the focus group had anaverage of 12.7 ± 4.4 years of clinical experience.Key themes identified within relevant domainsWe identified 720 statements from clinicians representing38 specific beliefs and 18 themes. For interns, 509 state-ments were found and represented 56 specific beliefs and22 themes (Additional files 4, 5, 6 and 7). Four key TDF do-mains were considered to have a greater likelihood to influ-ence the targeted behaviour among both clinicians andabFig. 1 Response frequency (%) on ORIC. a Response frequency (%) on the “Change commitment subscale” of the ORIC, b Response frequency(%) on the “Change efficacy (confidence) subscale” of the ORIC. Agree or somewhat agree, Neither agree nor disagree, Somewhat disagreeor disagreeTable 1 Behavioural and biomedical treatment orientation among supervisory clinicians and internsGroup Behavioural Treatment Orientation Biomedical Treatment Orientation p-value*Clinicians (N = 13) 34.69 (5.7) 29.31 (7.4) 0.12Interns (N = 108) 34.96 (4.3) 32.6 (5.9) 0.001*Dependent t testEilayyan et al. BMC Musculoskeletal Disorders  (2018) 19:328 Page 6 of 13interns: 1) Knowledge; 2) Skills; 3) Environmental contextand resources; and 4) Emotion. In addition, another 3 keyTDF domains were considered to have a greater influenceon the targeted behaviour among only interns: 1) Beliefsabout Capabilities; 2) Memory, attention and decision mak-ing; and 3) Social Influence.Key TDF domains (phase 1)Shared domains by supervisory clinicians and internsFour key TDF domains were shared by both cliniciansand interns: 1) Knowledge; 2) Skills; 3) Environmentalcontext and resources; and 4) Emotions.KnowledgeCliniciansSixteen statements were mapped to the knowledge do-main. Three specific beliefs corresponded to the state-ments forming 2 themes: awareness of SMS andknowledge of SMS. Almost all clinicians stated that theydid not attend a specific course on SMS, and that theyhad acquired a little knowledge of SMS from differentcourses. In addition, they said that there was a lack of acomprehensive SMS course. Most participants indicatedthat they were aware of SMS guidelines and evidence.There were conflicting opinions between clinicians re-garding interns’ knowledge of SMS: 3 clinicians consideredthat interns to lack knowledge of SMS, while 2 cliniciansconsidered interns to have adequate knowledge of SMS.InternsFifty-four statements were associated with the know-ledge domain. Three specific beliefs corresponded to thestatements forming 2 themes: awareness of SMS andknowledge of SMS. Most interns indicated that theywere aware of SMS guidelines and evidence, and hadenough knowledge of SMS. Few interns stated that for-mal SMS courses were needed.SkillsCliniciansTwelve statements referred to the skills domain. Twospecific beliefs corresponded to the statements repre-senting one theme: skills needed to use SMS. Most clini-cians stated that they needed to gain the skills requiredto use SMS, especially communication skills. Also, theclinicians indicated that interns had the skills needed touse SMS, as they had already attended SMS lectures.InternsForty-one statements pertained to the skills domain.These statements formed 3 specific beliefs and onetheme: skills needed to use SMS. Almost half of internsstated that they lacked the skills to use SMS efficiently,and indicated that they were not trained on SMS. Fur-thermore, the interns referred to the need for trainingcourses to gain skills required to use SMS. Few internsmentioned that they lacked the skills to support behav-ioral change.Environmental context and resourcesCliniciansThirty-one clinician statements were mapped on to theenvironmental context and resources domain. Thesestatements represented 4 specific beliefs and formed 3themes: 1) lack of time; 2) clinic’s characteristics; and 3)patients’ characteristics. Most of the clinicians statedthat lack of time was a barrier to the use of SMS. Partici-pants reported that the clinic’s characteristics (e.g. hav-ing rehabilitation equipment and sufficient space,collaborative clinicians, and having interns on place-ment) could facilitate the use of SMS among clinicians.Furthermore, clinicians indicated that patient’s charac-teristics could restrict the use of SMS, including patient’slack of compliance, resources, or time; patient’s prior-ities; psychological overlay; not accepting the condition;a bFig. 2 Interns’ and clinicians’ practice style trait. a Interns’ practice style trait, b Clinicians’ practice style traitEilayyan et al. BMC Musculoskeletal Disorders  (2018) 19:328 Page 7 of 13not trusting the clinicians; and/or language and culturalbarriers.InternsSeventy statements linked to the environmental contextand resources. The statements represented 8 specific be-liefs and formed 6 themes: 1) lack of time; 2) clinic’scharacteristics; 3) patients’ characteristics; 4) financial is-sues; 5) lack of guidelines; and 6) course training. Al-most half of interns stated that lack of time was abarrier to the use of SMS. Interns who participated inthe focus groups listed the clinic’s characteristics thatcould facilitate the use of SMS: collaborative clinicians,having kinesiology students to refer patients to, andsmaller caseload. On the other hand, interns indicatedthat certain clinic characteristics could restrict the use ofSMS: lack of space and equipment, staff shortage, clin-ician characteristics (unaware of guidelines), lack ofcommunication with peers, and not having enough ex-posure to different patient conditions. Furthermore, theinterns stated that certain patient characteristics couldrestrict the use of SMS, including: fear avoidance behav-iour, lack of patient adherence to SMS, lack of patientmotivation to use SMS, and/or patient preference forpassive care.In addition, interns reported 2 additional major bar-riers: financial considerations and internship require-ments. The interns believed that focusing on SMS andactive care may result in losing patients who preferred apassive care approach. Interns were also concerned thatusing SMS would increase the duration of their treat-ment sessions, thereby causing them to see fewer pa-tients. Regarding internship program requirements, theinterns stated that the use of SMS was not a programrequirement.EmotionCliniciansEleven statements were associated with the emotion do-main. These statements corresponded to 3 specific be-liefs and formed one theme: anxiety about the use ofSMS. Although almost all clinicians felt anxious whenusing SMS with patients who had psychological overlay,almost half of participants felt excited about using SMS.One clinician felt terrified of having self-managementguidelines; he thought that this might discourage stu-dents from using their clinical judgement.InternsThirty-three statements mapped to the emotion domain.The statements corresponded to 5 specific beliefs andformed one theme: feelings toward the use of SMS.Some interns felt concerned and frustrated when pa-tients did not adhere to SMS or if they had psychologicaloverlay. On the other hand, some interns felt exited andoptimistic about the use of SMS. Furthermore, some in-terns stated that they felt disappointed because of certainclinicians’ behaviours, including: prioritizing one treat-ment over another, non-awareness of the guidelines, andnot using SMS.Key domains identified only for internsThree additional TDF domains were identified amonginterns: 1) Beliefs about Capabilities; 2) Memory, atten-tion and decision making; and 3) Social Influence.Beliefs about capabilitiesThe interns provided 52 statements that were associatedwith the beliefs about capabilities domain, representing6 specific beliefs and 2 themes: acceptance and capabil-ities. Almost all interns stated that they were confidentin managing spine pain using SMS, and they had theability to use SMS. However, most interns indicated thatthe delivery of SMS was not easy, and the factors thatcould increase their level of confidence included observ-ing patients benefits from SMS, having experience withSMS, and asking clinicians and colleagues.Memory, attention & decision makingTwenty-three statements were mapped to the domain ofmemory, attention & decision-making. The statementsrepresented 5 specific beliefs and formed one theme: de-cision making on use of SMS. Most of the interns statedthat their decisions on SMS varied according to patients’needs. However, some interns mentioned that they didnot follow a guideline to guide decisions on the use ofSMS; one intern used intuition to decide whether or notto use SMS. Interestingly, one intern decided to not useSMS in order to keep patients coming to the clinic, asthe patients preferred passive treatments. Lastly, few in-terns decided to refer patients with psychological overlayto other healthcare providers.Social influenceThirty-four statements were related to the social influ-ence domain. These statements corresponded to 4 spe-cific beliefs and formed one theme: influence of others.Almost half of the interns stated that the clinicians’ per-ception of SMS restricted their use of SMS, while theother half mentioned that clinicians’ views facilitatedtheir use of SMS. About half of participants mentionedthat they consulted either supervisory clinicians or col-leagues on the use of SMS. In addition, interns indicatedthat patients who preferred passive care could influencetheir decision to use SMS.Eilayyan et al. BMC Musculoskeletal Disorders  (2018) 19:328 Page 8 of 13Phase 2 — Final selection of knowledge translationintervention componentsAdditional file 8 presents the BCTs mapped onto keybarriers identified. The research team members consid-ered intervention components to facilitate the use ofSMS among clinicians and interns for patients withspine pain, based on current evidence and feasibility ofimplementation at CMCC clinics. The proposed inter-vention includes 6 components: 1) supportive handoutssummarizing how to use the SMS guided by the BAP; 2)webinar describing the benefits of using SMS and theBAP in particular; 3) an online educational module withprofessional actors demonstrating the delivery of theBAP by a clinician with a patient; 4) clinical vignettes toapply the BAP using case scenarios; 5) a training work-shop to practice and receive feedback when deliveringthe BAP; and 6) use of an opinion leader. The main rolesof the opinion leader are to advise colleagues about SMSpractice and ease the delivery of SMS.Taking into account the teaching institution calendaryear and curriculum, the KT intervention will be deliv-ered as follows: clinicians and interns will first be askedto complete the self-study webinar and online educa-tional module. They will then receive practice BAP andfeedback from the opinion leaders. Clinicians and in-terns will also receive supportive materials on motiv-ational interviewing and on how to deliver SMS guidingby BAP. They will also attend one- day training sessiondelivered by a BAP trainer and have more opportunityto practice SMS and get personalised feedback. Further,2 clinicians agreeing to act as champions (i.e. opinionleaders) will attend a BAP training to become certifiedin this approach prior to implementation the KT inter-vention. The main roles of the opinion leaders will be tosupport other clinicians and interns in using SMS and toprovide them with coaching on applying the BAP withpatients. Additional file 9 presents the final selection ofKT intervention.DiscussionOrganisational support increases the likelihood of clini-cians’ successful uptake of EBP and CPG recommenda-tions [90, 91]. Decision makers working at CMCCperceived that faculty and supervisory clinicians werehighly committed to and confident about implementingSMS for patients with spine pain. Participating cliniciansand interns showed positive attitudes toward EBP, andbehaviours associated with EBP, which is consistent withthe literature [92, 93]. These findings suggest that SMSstrategies can be implemented in this environment.Nonetheless, some barriers corresponding to four TDFdomains that restricted both clinicians’ and interns’ use ofSMS: Knowledge, Skills, Environmental context and re-sources, and Emotion. Aadditional barriers correspondingto three TDF domains that restricted the intern’ use ofSMS were: Beliefs about Capabilities; Memory, attention& decision making; and Social Influence. To address thesebarriers, a panel of experts mapped BCTs to each barrierand selected the appropriate intervention components.Both clinicians and interns felt that they needed moretraining to improve their knowledge and skills on theuse of SMS, and they reported that lack of time was akey barrier to using SMS. Interns also indicated that theyhad a lack of confidence to use SMS. These findings areconsistent with the literature showing that clinicians donot have sufficient knowledge and confidence in how touse SMS, and that they lack the appropriate training andcompetence to use SMS with patients [94, 95]. Further-more, as the clinicians and interns did not receive inten-sive training on SMS, they admited sometimes feelinganxious about the use of SMS with complex patients.These findings are supported by the planned change the-ories, where the knowledge and skills are required toachieve confidece, [96], which may reduce the likelhoodof anxiety [97]. In addition, according to these theoriesthe presence of an opinion leader may improve one’sconfidence regarding behavior change [96].Not surprisingly, novices starting to develop their clin-ical judgment skills and working under the supervisory cli-nicians faced additional challenges in using SMS thanclinicians. Interns indicated that they lacked the confi-dence and knowledge needed to routinely incorporateSMS, did not follow a systematic process to deliver SMSto patients, and had to rely on supervisory clinicians’ ad-vice, even though some may not be comfortable or willingto use SMS in their own clinical practice. Together, thesefindings support the need to target both chiropractic in-terns and supervisory clinicians with strategies to helpthem improve their uptake and use of SMS in the clinicalteaching environment.Both clinicians and interns were generally motivated touse SMS in the clinical setting. This might be related totheir beliefs about the effectiveness of SMS as well as tothe collaborative nature of the relatiosnhips between clini-cians and collegues, and the support from managers. Inaddition, the interns in this study stated that they wouldkeep delivering SMS if it improved patients’ health out-comes. This is consistent with the operant learning theorywhere the achievements of a behaviour determines thecontinued use of that behaviour in the future [68].The expert panel proposed different KT interventionstrategies based on BCTs aimed at addressing the keybarriers to using SMS among clinicians and interns. Theselected KT intervention components formed a multifa-ceted theory-based intervention, which aims to simul-taneously overcome several barriers [98]. The main KTintervention components were selected based on thecurrent evidence [99] and feasibility to be implementedEilayyan et al. BMC Musculoskeletal Disorders  (2018) 19:328 Page 9 of 13in the chiropractic clinical settings. These include sup-portive educational material, a webinar, an online educa-tional module, a training workshop, and support byopinion leaders. A high-quality review demonstrated thatimplementing educational meetings, either alone orcombined with other interventions, significantly im-proved the clinicians’ practice in the clinical setting[100]. Furthermore, two high-quality reviews showedthat using educational material was effective for improv-ing healthcare providers’ practice [101, 102]. Educationalmaterial could change clinicians’ beliefs, which may re-sult in behaviour change among clinicians toward adher-ence to EBP [103]. In contrast, three other high-qualityreviews showed that educational meetings had mixed ef-fects for improving clinicians’ practice [104–107].Of interest, the literature supported the effectiveness ofinternet-based learning (e.g. webinar, online module) onclinicians’ knowledge [108, 109]; internet-based learninghad a larger positive effects than no intervention [109].However, it had small effect comparing to non-internetlearning [109]. Lastly, the literature supports the effective-ness of having an opinion leader, alone or combined withother interventions, to facilitate clinicians’ practice behav-iour change [110, 111] and promote the adherence to EBP[112]. Interestingly, the availability of an opinion leaderwas proposed as a factor that made the new interventionimplementation quicker [113]. Opinion leader has a smallbut worthy effect on clinicians behaviour change [114].Strengths/ limitationsTo our knowledge this is the first study aimed at devel-oping a theory-based intervention to support the use ofSMS among chiropractors and interns within an educa-tional setting. The KT intervention components in thisstudy were developed based on behavioural change theor-ies using a systematic approach with a panel of experts.This may increase the likelihood of successful use of SMSin the clinical setting. A limitation of this study is that theresults cannot be generalized to all chiropractic clinics.While the inclusion of additional clinicians may have re-sulted in different views, barriers identified are similar tothose found on the use of multimodal care by practicingchiropractors when managing neck pain [68].ConclusionThe key TDF factors that influence the uptake of SMSamong clinicians and interns included: knowledge, skill,environmental context and resources, and emotion.Three additional TDF factors were identified only by in-terns: Beliefs about Capabilities; Memory, attention &decision making; and Social Influence. This may optimizethe delivery of self-management support in spine painclinics. The effectiveness of the selected KT interventioncomponent remains to be tested.Additional filesAdditional file 1: “Topic guide for focus groups with chiropractic internsand clinicians”. It provides the interview guide for focus group. (DOCX 14 kb)Additional file 2: An Excel sheet that provides the raw data forclinicians and interns (XLSX 99 kb)Additional file 3: An Excel sheet that provides the raw data for decisionmakers (XLSX 10 kb)Additional file 4: “Thematic analysis based on the TDF – Clinicians”. Itprovides number of clinicians’ statements for each TDF domain, TDFspecific beliefs and themes. (DOCX 17 kb)Additional file 5: “Thematic analysis based on the TDF – Interns”. Itprovides number of clinicians’ statements for each TDF domain, TDFspecific beliefs and themes. (DOCX 18 kb)Additional file 6: “Specific Beliefs for each TDF with illustrative quotes –Clinicians”. It provides clinicians quotes representing specific TDFdomains and beliefs. (DOCX 17 kb)Additional file 7: “Specific Beliefs for each TDF with illustrative quotes –Interns”. It provides interns quotes representing specific TDF domains andbeliefs. (DOCX 20 kb)Additional file 8: “Mapping behaviour change techniques on keydomains, proposed KT interventions and actions”. It provides a list of self-management-TDF barriers and the proposed KT interventions. (DOCX 19 kb)Additional file 9: “Final Selection of KT Intervention Components andRelated Learning”. It provides the final selection of KT intervention forclinicians and interns to promote the use of self-management support inthe clinic. (DOCX 14 kb)AbbreviationsBAP: Brief action planning; BCT: Behavioural change technique;CMCC: Canadian Memorial Chiropractic College; CPGs: Clinical practiceguidelines; EBP: Evidence-based practice; IQR: Interquartile range;KABQ: Knowledge, Attitude, and Behaviour Questionnaire; KT: Knowledgetranslation; ORIC: Organizational Readiness for Implementing Change;PABS: Pain Attitudes and Beliefs Scale; PAM: Patient activation measure;PMT: Patient Management Teams; SMS: Self-management strategy;TDF: Theoretical domain frameworkAcknowledgementsWe acknowledge CMCC for the support to conduct this research project.FundingCanadian Chiropractic Guidelines Initiative. The funding body did notinfluence the study design, analysis, and results.Availability of data and materialsThe raw data that support the conclusions of this manuscript is available inthe Additional files 2 & 3. The focus group data are available in Additionalfiles 4, 5, 6 and 7.Authors’ contributionsMCH helped in conducting the focus groups. OE analysed the quantitativeand qualitative data under the supervision of AB and AT (principleinvestigators). OE, AB, AT, CJ, ACT, CD, FA, and JB contributed to the designof Knowledge Translation intervention. All authors: OE, AB, AT, MCH, CJ, ACT,CD, FA, JB, SA, SM, RE, MJS and CL contributed to the preparation of themanuscript. All authors have read and approved the manuscript.Ethics approval and consent to participateEthical approval was obtained from the Research Ethics Board of both McGillUniversity (McGill IRB: A08-E54-16B) and the Canadian Memorial ChiropracticCollege (CMCC REB Approval 1512B02), and written informed consent wasobtained from all participants.Consent for publicationNot applicable.Eilayyan et al. BMC Musculoskeletal Disorders  (2018) 19:328 Page 10 of 13Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1School of Physical and Occupational Therapy, McGill University, 3654 PromSir-William-Osler, Montréal, QC H3G 1Y5, Canada. 2Center for InterdisciplinaryResearch in Rehabilitation of Greater Montreal (CRIR), Montréal, Canada.3Canadian Memorial Chiropractic College, North York, Canada. 4University ofBritish Columbia, Vancouver, Canada. 5Centre for Collaboration, Motivationand Innovation, Vancouver, Canada. 6University of Minnesota, Minneapolis,USA. 7University of Pittsburgh, Pittsburgh, USA. 8University of Toronto,Toronto, Canada. 9Palmer College Davenport, Davenport, USA.Received: 11 April 2018 Accepted: 24 August 2018References1. Global Burden of Disease Study 2013 Collaborators. 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