Table 2 Summary of theoretical domains identified from two focus groups (n = 12) as key to adherence to LBP radiography guidelines and LBP imaging ordering behaviours (including overarching themes and belief statements)

Knowledge

Knowledge and awareness of LBP radiography guidelines and indications for imaging. (Enabler)

I know the limitations of X-rays and when it would be appropriate to choose X-ray as an imaging modality

I am aware of guidelines and/or indications for LBP and imaging

I agree with the content of the guidelines for imaging and LBP

I think the guidelines are evidence-based

My knowledge of indications for imaging comes from school

Lack of awareness and/or knowledge of LBP radiography guidelines. (Barrier)

I do not follow a guideline

I have limited knowledge/awareness of guidelines for imaging

Skills

Adequate training is required to manage LBP without imaging. (Enabler)

A lot of expertise and training is needed in order to manage someone with LBP (and determine if they need an X-ray)

Having good communication skills is important for managing LBP without imaging. (Enabler)

Good communication skills are required for managing LBP without X-rays

Social/professional role and identity

Chiropractors’ responsibility to manage LBP without imaging. (Enabler)

It is my responsibility as a clinician to manage someone’s LBP without taking an X-ray

Chiropractors should not be routinely taking X-rays

Other healthcare providers’ responsibility to manage LBP without imaging. (Barrier)

It is the medical doctor’s role to order imaging

Beliefs about consequences

Negative consequences to imaging for LBP. (Enabler)

Radiation is a negative consequence of taking X-rays

Cost to the healthcare system is a negative consequence of taking X-rays

Delayed treatment (waiting for results) is a negative consequence of taking X-rays

Exposure to infectious diseases is a negative consequence of sending a patient for an X-ray

Patient worry is a negative consequence of taking an X-ray

Negative consequences to not using imaging for LBP. (Barrier)

Missing a diagnosis is a potential negative consequence of NOT taking an X-ray

Neutral consequences to not using imaging for LBP. (Enabler)

The plan of management does not change with taking an X-ray

Memory, attention, and decision processes

Decision for LBP imaging is based on a patient’s clinical presentation. (Enabler)

I decide whether a patient needs an X-ray based on their clinical presentation

Decision for LBP imaging is based on gut feeling. (Barrier)

I would decide to order an X-ray (instead of following the guidelines) if I have a gut feeling that there is something else going on

Able to remember indications for LBP imaging. (Enabler)

I can remember indications for when a patient needs imaging/needs a referral

Behavioural regulation

Communication is a strategy that can be used to reduce imaging for LBP. (Enabler)

I manage LBP without X-rays by explaining to my patients why they do not need X-rays

Continuing education requirements is a strategy that can be used to reduce imaging for LBP. (Enabler)

Continuing education in radiology helps me manage LBP [with or without X-rays]

Having access to a patient’s previous imaging is a strategy that can be used to reduce imaging for LBP. (Enabler)

Being able to access previous X-rays/reports helps me manage LBP without taking an X-ray

A better health system organisation that facilitates better communication amongst health care professionals would help with reducing imaging for LBP. (Enabler)

Having a system to easily communicate with physicians and access previous imaging would help me better manage LBP [without X-rays]