Introduction

Low back pain (LBP) has prevailed worldwide as one of the three leading causes of non-fatal health loss for almost three decades [1]. It has been identified as a leading cause of years lived with disability and its burden has steadily increased, despite the extended research and health care resources that have been developed in this area [2–4]. In Portugal, LBP is the most prevalent musculoskeletal condition, with a significant proportion of patients reporting disability as well as a high level consumption of health services [5–7].

It has been suggested that the current clinical practice has not followed clinical guideline recommendations and may not be delivering the best treatment to Portuguese patients with LBP [8]. In particular, the advice to rest, analgesic, anti-inflammatories and medical imaging prescriptions as well as sickness certifications were amongst the most common approaches to Portuguese patients with LBP in primary care [8]. These findings were consistent with those from worldwide studies, which have called attention to the poor outcomes of this approach on pain, disability and sense of well-being in patients with LBP [9–13].

Research has recommended a greater use of biopsychosocial model in the management of patients with LBP [3,14,15]. Stratified care for LBP has tried to reassure the aforementioned model in clinical practice, by targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment and underlying mechanisms [16]. The STarT Back—Subgroups for Targeted Treatment is a stratified model of care that has been developed and tested by researchers from Keele University over the last 15 years [17]. According to this model, patients with LBP are assessed with the Keele STarT Back Tool (KSBT) that categorizes them into three subgroups based on their risk (low, medium or high) of developing persistent disabling pain. Based on this categorization, patients are provided with matched treatments [18]. Research focused on the STarT Back has demonstrated better clinical outcomes at 4 and 12 months, as well as lower health costs when compared with current best practice [19]. Further research on the STarT Back has strengthened its clinical and cost effectiveness and demonstrated its feasibility in primary care in the UK [20,21]. Additionally, one study has reported positive results in Ireland [22]. However, further research is needed to determine if these benefits are still evident when compared to current practice in other countries, and six studies are in progress [17].

Considering previous findings from research on the STarT Back, the SPLIT project aimed to introduce a similar approach, involving General Practitioners (GPs) and Physiotherapists (PTs) in the triage and targeted treatment for patients with LBP, in a Group of Portuguese Health Centres (ACES Arrábida), in primary care. The KSBT was translated into Portuguese and validated in Portuguese population [23], and then funding was obtained for the SPLIT Project in 2018.

Since previous qualitative research has called attention for potential barriers that may prevent the successful implementation of the STarT Back in the UK as well as in other countries [24–27], the SPLIT research team has introduced several adjustments to the original model since its early conception. For example, rheumatologists and PTs from the research team delivered a training program, which was tailored to each professional group. GPs attended two 2-hours workshops focused on the triage process as well as on the model of care proposed for patients with LBP, inspired on the STarT Back. PTs also attended the latter workshop, as well as to a 4-days course focused on the assessment and treatment of patients classified, by the KSBT, with low, medium and high risk of developing persistent disabling pain. A book in Portuguese including detailed information about the contents of the course was also developed in order to support the PTs while attending the course and afterwards in their clinical settings.

In order to promote the successful implementation of the SPLIT project, the exploration of the perceptions of the GPs and PTs, who had attended the aforementioned training, regarding its upcoming implementation was considered fundamental. In particular, the knowledge about acceptability as well as potential facilitators and barriers prior to its implementation was considered essential to better prepare researchers and health professionals.

Materials and methods

Data collection

Two focus groups (one with GPs and one with PTs) were carried out in order to collect data. The focus group is defined as a discussion-based interview that produces data and insights via group interaction, which would be less accessible without the interaction founded in a group [41,42]. The focus groups were selected as a method for data collection since the aim of this study was focused on understanding the combined local perspectives of each professional group participating in the implementation of the SPLIT project. The research team aimed to explore potential agreements or disagreements as the discussion progressed and to grasp each professional group perceptions regarding the future implementation of the SPLIT project. The focus group sessions had a 60-minute duration and were held by the first author (CC), while SP took notes in order to summarize the main topics discussed during the session. CC had previous experience in facilitating focus group discussions and SP had experience as a research assistant in focus groups.

Both focus groups were carried out immediately after the end of the previously mentioned training program. The five stages for moderating focus groups suggested by Finch et al (2014) were followed: scene setting and ground rules; individual introduction; the opening topic; discussion; and, ending the discussion [42]. The discussion was based on a semi-structured interview schedule based on exploratory open-ended questions. Particularly, open, transitional, key questions and probes were used, following Krueger and Casey`s recommendations [43]. The questions were grouped into two sections, as outlined in Table 1. The first section included generic questions, designed to explore the participants`perceptions regarding the acceptability of the SPLIT project; the second section contained specific questions designed to explore the potential facilitators and barriers to the upcoming implementation of this project. Since questions on the first section were generic, they were asked to both professional groups. The second section was tailored to each professional group, according to the expected role on the SPLIT project.

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Table 1. Interview schedule.

https://doi.org/10.1371/journal.pone.0225336.t001

The focus group sessions were audio-recorded and transcribed verbatim by SP. The participants`names were replaced by the pseudonymous they had selected prior the focus group session.

Results

Twelve participants (9 female, 3 male) were included. Five of the participants were 30–39, four were 40–49, and three were 20–29, 50–59 and 60–69, respectively. The GPs`group had an average of 13.17 years of professional experience, from which 10.17 years were based in primary care. The PTs`had an average of 21 years of professional experience, from which 13.87 years were based in primary care.

Four themes and twelve sub-themes emerged from data analysis, as outlined in Table 2. These themes explored the aspects that this study`s participants considered relevant to promote the effective and successful implementation of the SPLIT project in the context of primary care. Excerpts from the focus groups are presented to support the analysis.

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Table 2. Main themes and sub-themes emerged from data analysis.

https://doi.org/10.1371/journal.pone.0225336.t002

Discussion

The SPLIT project aims to improve clinical outcomes and cost-efficiency of services delivered to patients with LBP as well as improve their experiences in the NHS. Given the GPs and PTs involvement in all changes proposed to care delivery, it became important to explore their perceptions regarding the acceptability, potential facilitators and barriers before the implementation of the aforementioned project. Qualitative research methods have been considered useful for the development, evaluation and implementation of complex interventions in health care [44]. Previous qualitative studies have already been published on the perceptions of GPs as well as PTs about this topic [24–27], however, data from both groups have been explored separately. To the authors`knowledge, this is the first study encompassing and combining the perceptions of both professional groups, which were expected to implement an interdisciplinary approach. The exploration of the potential barriers and facilitators to the implementation of an intervention, rather than simply focusing on observations before and after its implementation may provide an opportunity for future triangulation of data. This could increase the understanding of both the outcomes of the project as well as the implementation process and how the latter influences the health care delivery and its outcomes [45].

This study`s participants highlighted the feasibility of the SPLIT project. On the one hand, the GPs valued the possibility of referring patients with LBP for physiotherapy in the health unit without adding extra work and consuming time from their appointments. On the other hand, the PTs emphasised the easy usage of KSBT as well as the usefulness of the information obtained from it for their clinical reasoning. The use of KSBT by PTs, rather than by GPs was introduced in the SPLIT project, since previous research carried out in the UK has suggested GPs`reluctance in using the tool due to time constraints and pressures inherent to a busy practice [24]. On the other hand, the study by Karstens and colleagues (2015) has called attention to the lack of agreement among German GPs regarding the most appropriate KSBT administering health professional. Findings from the current study as well as the latter two studies called attention to differences in the organization of health care services and health professionals’ perceptions regarding the use of KSBT across different countries. Despite the demonstration of STarT Back clinical and cost effectiveness in the UK [19], further evidence for the adaptations required to test and implement it in other countries is still needed [17]. In the current study, both professional groups anticipated a potential increase of the quality of health care provided, following the introduction of the SPLIT project in their health units. This was related to a potential reduction of waiting time to start physiotherapy as well as to the provision of evidence-based and patient-centred care. The future implementation of the SPLIT project was viewed as an important step to improve the experiences of patients with LBP, by providing a new service designed to enable a better management of time and human resources and, simultaneously, respond to patients' needs. This study`s participants`perceptions regarding the potential impact of the SPLIT project were aligned with the advantages associated with the implementation of models of care that have been reported in previous research [46,47]. Moreover, both professionals`groups demonstrated awareness of some inconsistencies between their current clinical practice and the international guidelines for treating patients with LBP. This awareness seemed to promote the acceptability of the SPLIT project. Acceptability is a multi-faceted construct that reveals the extent to which people delivering or receiving a health care intervention consider it to be appropriate, taking into account anticipated or experiential cognitive and emotional responses to the intervention [48]. It has been considered a key element in the design, evaluation and implementation of health care interventions [48]. Although the interview schedule used in this study was not designed to explore all dimensions comprised in acceptability, the participants discussed several of them such as their affective attitude about the project, the perceived amount of work required, the extent to which the intervention was perceived as likely achieve its purpose, as well as the extent to which they understood the project and how it would work [48]. The acceptability demonstrated by this study`s participants could be viewed as an important indicator that the implementation of the SPLIT project will be possibly delivered as intended by the research team [49].

GPs and PTs, who participated in this study, perceived their motivation to take part in the implementation of the SPLIT project as a facilitator. The importance of health professionals`engagement in the operating of workforce changes had already been stressed in previous research [45]. Furthermore, this study`s participants also considered the promotion of interdisciplinary work as an important facilitator. This finding is coherent with previous studies that had already called attention to the need to improve inter-professional collaboration to successfully implement the STarT Back [27]. While in previous research GPs`limited levels of trust in PTs`work and education was identified as a significant challenge [27], in the current study GPs were the professional group who stressed this cooperation the most and emphasised the importance of knowing in more depth the work of PTs. Additionally, the centralization of care in each unit without the need for referral to outsourced physiotherapy services was considered one of the most important facilitators, since this is expected to increase patients' accessibility to health services and reduce the costs for the NHS.

This study`s participants also identified potential barriers to the implementation of the SPLIT project. The change of routine care was stressed by both professionals groups and had already been identified in previous research [24,25,45]. The GPs`anticipated struggle to remember identifying patients who might benefit from the project had already been reported by GPs, who had participated in the STarT Back Trial, in the UK. Similarly, the PTs, who participated in this study, highlighted the challenges inherent to the change of their treatment from a biomechanical perspective to a biopsychosocial model, as PTs in the UK had identified before [25]. Furthermore, patients`resistance to a different treatment approach was also identified as a potential barrier, although GPs and PTs were not in agreement regarding the group of patients that might be the most reluctant. Patients' resistance was not particularly emphasised in former studies [24,26,27], with the exception of the study by Sanders and colleagues (2013) that mentioned the PTs`anticipation of patients' resistance regarding the discussion of psychosocial dimension of LBP. Previous research has focused the resistance to new health care interventions on health professionals, due to the perceived threat to their autonomy [24]. The difference found in the current study may be related to the aforementioned GPs and PTs`awareness of some inconsistencies between their current clinical practice and the international guidelines for treating patients with LBP. Nevertheless, it is important to take into consideration the potential impact of social desirability on the participants`interventions in the focus groups, which were conducted by two members of the research team implementing the SPLIT project. Moreover, the lack of available appropriate rooms was also identified as a potential barrier. This seemed to be a contextual issue, which might be related to the recent financial crisis that has affected the quality of health care provided in Portugal [50]. In spite of this potential problem, both professionals groups seemed to be committed to find solutions.

Finally, both GPs and PTs that participated in this study stressed the need for a tailored planning and specific adaptation of the project to the context where it was going to be implemented. Both professionals groups valued the training delivered and considered it adequate to prompt the implementation of the SPLIT project. Indeed, this training program integrated specific adaptations to the Portuguese context. For example, workshops were used for answering questions from GPs and PTs about their role on this process and two dates were offered for each workshop in order to facilitate adherence. A specific program was designed for PTs, including seminars, practical sessions, role-plays and mentoring sessions in the PTs`clinical settings were also planned to be operating on a monthly basis in the first six months of implementation. Additionally, two members from the research team were also available to provide assistance by telephone during this initial stage of implementation. Feedback about referrals and clinical outcomes was also planned to be delivered to GPs and PTs on a regular basis, in the first six months of implementation. Although the practicalities of conducting the SPLIT trial had already been considered by the research team, the GPs and PTs emphasised new aspects in the focus groups that deserved further attention. For instance, the need for reorganizing the health services was stressed by this study`s participants. This seemed to demonstrate their willingness regarding the implementation of a model of care for patients with LBP in primary care. Additionally, both professional groups, in particular GPs, emphasised the need for new strategies to facilitate inter-professional communication and work team. These findings indicated that there might be a good adherence from GPs and PTs to this project, although it is known that the adoption rates for complex interventions tend to be low, which is partially explained by poor or ineffective implementation [51]. Further research on GPs and PTs perceptions after an initial period of implementation is recommended and may provide important knowledge, especially if combined with the analysis of clinical outcomes and cost-efficacy. Furthermore, it is important to assess acceptability and clinical outcomes from the perspective of patients with LBP, since it may offer a deep understanding of the adhesion to the interventions proposed [48,52].

Some limitations should be considered. Respondent validation, that is participants`revision of data collection and/or analysis [53], could have been used to increase the credibility of findings. However, this procedure was not carried out as it might burden the participants, who were expected to be focused on the initial stage of implementation of the SPLIT project. Additionally, the number of participants included may be seen as a potential limitation, particularly if this study`s findings are considered in terms of empirical generalizability. It is important to take into account that the 7 seven health units, where the SPLIT project was going to be piloted, had at least one practitioner participating in the focus groups. Thus, the participants could be considered representative of the practitioners that would be involved in the future implementation of the project. However, they cannot be considered representative of all GPs and PTs`perceptions regarding interdisciplinary stratified care for patients with LBP. These findings should be considered in terms of transferability, which is described as the ability to transfer the study`s findings to individuals in contexts that may have some similarities to the context where the study was carried out [54]. Thus, some procedures were undertaken in order to enable the aforementioned transferability. For example, attention was given to describing the Portuguese context as well as the participants`characteristics and verbatim transcriptions from focus groups were presented to support the researchers`interpretations.

Conclusions

This study provided the first insights into the perceptions of both GPs and PTs regarding the upcoming implementation of an interdisciplinary stratified model of care for patients with LBP. The use of qualitative research methods provided useful knowledge for the development and upcoming implementation of the SPLIT Project. The exploration of the acceptability, potential barriers and facilitators to the implementation of this project may provide an opportunity for future triangulation of data and, thus, for developing a deep understanding about the clinical outcomes and cost-efficacy as well as about the process of implementation and how they impact on each other. Further research focused on patients' perceptions regarding the interdisciplinary stratified model of care integrated into the SPLIT project is recommended.

Acknowledgments

The authors would like to thank the General Practitioners and Physiotherapists for taking part in this study.