Patients’ and physiotherapists’ perspectives on implementing a tailored stratified treatment approach for low back pain in Nigeria: a qualitative study

Background Stratified care has the potential to be efficient in addressing the physical and psychosocial components of low back pain (LBP) and optimise treatment outcomes essential in low-income countries. This study aimed to investigate the perceptions of physiotherapists and patients in Nigeria towards stratified care for the treatment of LBP, exploring barriers and enablers to implementation. Methods A qualitative design with semistructured individual telephone interviews for physiotherapists and patients with LBP comprising research evidence and information on stratified care was adopted. Preceding the interviews, patients completed the Subgroups for Targeted Treatment tool. The interviews were recorded, transcribed and analysed following grounded theory methodology. Results Twelve physiotherapists and 13 patients with LBP participated in the study (11 female, mean age 42.8 (SD 11.47) years). Seven key categories emerged: recognising the need for change, acceptance of innovation, resistance to change, adapting practice, patient’s learning journey, trusting the therapist and needing conviction. Physiotherapists perceived stratified care to be a familiar approach based on their background training. The prevalent treatment tradition and the patient expectations were seen as major barriers to implementation of stratified care by the physiotherapists. Patients see themselves as more informed than therapists realise, yet they need conviction through communication and education to cooperate with their therapist using this approach. Viable facilitators were also identified as patients’ trust in the physiotherapist and adaptations in terms of training and modification of the approach to enhance its use. Conclusion Key barriers identified are the patients’ treatment expectations and physiotherapists’ adherence to the tradition of practice. Physiotherapists might facilitate implementation of the stratified care by communication, hierarchical implementation and utilisation of patients’ trust. Possibilities to develop a consensus on key strategies to overcome barriers and on utilisation of facilitators should be tested in future research.


Methods:
The study design is appropriate. Procedures are clearly described.
Please, specify inclusion and exclusion criteria for participants to be allocated to the study. Page 6, lines 23-24: Participants were contacted following set inclusion criteria specifically comprising physiotherapists and patients living in Nigeria.

Results:
Findings are clearly presented.

Discussion / Conclusion:
The discussion reflects what authors found and how it relates to the literature. The authors incorporated previous research into their interpretation of the results. However, relevant limitations of this research should be discussed. Page 21: A strength of this study is its design, ...

VERSION 1 -AUTHOR RESPONSE
Reviewer: 1 Comments to the Author: 1) This is a qualitative interview study describing Patients' and physiotherapists' perspectives of implementing a tailored stratified treatment approach for low back pain in Nigeria. The interview questions were drafted in the backdrop of categories in the Consolidated Framework for Advancing Implementation Research (CFIR). For analysis of the interview material grounded theory (GT) is used. GT is a method appropriate to develop a theory. In the current study the theory is already based on the Consolidated Framework for Advancing Implementation Research (CFIR). Therefore, it is not appropriate to apply GT.

RESPONSE:
The authors thank Reviewer 1 for these comments.
In our perspective, our use of the ambiguous sentence here might have led Reviewer 1 to a wrong assumption.
'The interview questions drafted in the backdrop of categories in the CFIR' does NOT mean 'the theory was already based on the CFIR' as Reviewer 1 assumed. It rather means the CFIR framework was used to reflect the INITIAL interview questions for comprehensiveness in all aspects relating to implementation. The interview questions in Grounded theory should also reflect the depth and span of enquiry as inferred from research by, Willig et al. 2008 andCorbin et al. 1990 '…The initial questions should focus the attention of participants on the phenomenon they want to investigate' taking all aspects into consideration. This was further reiterated by Charmaz et al. 2006: '…plan to gather sufficient data to fit your task and to give you as full a picture of the topic as possible within the parameters of this task'. Additionally, this initial interview guide was also modified severally in the direction of the data collected (see Appendix 2) consistent with Grounded theory. It was also flexible, semi-structured and 'theoretical sampling' was employed in subsequent rounds fully compliant with Grounded theory methodology. Hence, an authentic outcome resulted.
Our interview questions development was also in fulfilment of the COREQ criteria number 17 (Tong et al. 2007).
Therefore, by 'Backdrop' the authors meant they had considered the implementation aspect from a holistic viewpoint. We understand that this might have caused a misunderstanding. We have thus replaced this in the manuscript with the following statement in PG6, LINE 26: 'In developing the initial interview questions, the aspect of implementation was duly considered (42)'

2)
Although the categories and subcategories look interesting, I would suggest producing these using e.g. qualitative content analysis (ref: Corbin and Strauss, 1996, Basics of qualitative research. Techniques and procedures for developing grounded theory.; Glaser and Strauss 1967: The purpose of grounded theory is to construct theory grounded in data).

RESPONSE:
The authors thank Reviewer 1 for these comments.

The researchers believe that content analysis might not be a suitable method in this study and does not fit the criteria by Mayring 2000 '…The procedures of qualitative content analysis seem less appropriate, if the research question is highly open-ended, explorative, variable…, or if a more holistic analysis is planned.' (Mayring 2000. Qualitative Content Analysis).
Since our research enquiry was highly explorative, open-ended and variable; aiming to consider all aspects in a holistic viewpoint. Also, the direction of research enquiry was modified via theoretical sampling along with the data collected. We thus consider Grounded Theory more suitable.
The authors, however, also considered that other qualitative methods might give the chance for a more concise presentation of findings in this study. Hence, we added two statements on this in our limitations.
Limitations, PG20, Line25: 'One limitation of this study might be in the presentation of findings. A common challenge with presenting results in Grounded theory is the degree of detail in outcomes (Backman and Kyngas 1999). However, through constant comparisons, the authors created sufficient connections between the highest levels of abstraction and the data through variations. These were thoroughly explained ensuring all aspects of the data were represented'. 'This study was carried out in Nigeria, hence care should be taken when generalising results to other countries. However, having context factors in mind we believe that due to the rigour of the study, interesting comparisons based on these results can be made (Sowden et al, 2018)'.
Reviewer: 2 Comments to the Author: The study investigates the perceptions of physiotherapists and patients in Nigeria towards stratified care for the treatment of low back pain, exploring barriers and enablers to implementation. Findings of this study are in my opinion of relevance to medical research and would fit the scope of the journal. There are, however minor concerns which should be addressed.

RESPONSE:
The authors thank Reviewer 2 for the comments on the relevance and suitability of our study.
Abstract: It does reflect the content of the article.

RESPONSE:
Thanks for this comment.

Methods:
The study design is appropriate. Procedures are clearly described.

RESPONSE:
Thanks for this comment Please, specify inclusion and exclusion criteria for participants to be allocated to the study. Page 6, lines 23-24: Participants were contacted following set inclusion criteria specifically comprising physiotherapists and patients living in Nigeria.