Systematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists. We systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed. Formative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation. Intervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process.

Background: Various guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive.Objective: The main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients.Design: This was an observational prospective cohort study (2005–2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients.Methods: Therapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses.Results: Higher percentages of adherence were associated with fewer functional limitations (β=−0.21, P=.023) and fewer treatment sessions (β=−0.27, P=.005).Limitations: The relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses.Conclusions: The results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence.

In health promotion research, enthusiasm for patient and public involvement (PPI) is growing. However, a lack of conceptual clarity leads to ambiguities in participatory processes and purposes, and hampers efforts to achieve and evaluate PPI in research. This study provides an overview of its underlying reasons—or rationales—so as to better understand, guide and interpret PPI in research practice. We conducted a critical review to identify typologies of rationales for PPI. We re-categorized the different types of rationales from these typologies based on their content. We illustrated the resulting categories of rationales with examples from a case study on PPI in research on Lyme disease. Five categories of rationales for PPI were identified. The democratic rationale reflects the normative right of citizens to have a voice in research. The consumerist rationale refers to the economic right of stakeholders with interests to have a say. Rooted in social justice, the transformative rationale seeks to empower marginalized groups. The substantive rationale starts from epistemic considerations and aims to improve the quality of knowledge that research generates. The instrumental rationale is of pragmatic origin and refers to improved efficiency and effectiveness of the research. Our overview of categories of rationales can be used as a frame of reference for PPI in health promotion research. Exploring, stating explicitly and reflecting on the underlying reasons for PPI may help to define realistic purposes, select matching approaches and design appropriate evaluation studies. This might also contribute to the conceptualization of PPI. Enthusiasm for patient and public involvement in health promotion research is growing. However, it often remains unclear why this involvement is being organized. This lack of clarity makes it difficult to implement such participatory research and to evaluate its added value. We searched for reasons that were given for starting patient and public involvement in research. We found five different reasons. The first is the right of all citizens to have a say in research that affects them. The second is the right of individuals to demand the best research. The third is the desire to involve and empower marginalized groups. The fourth aims to improve the quality of the knowledge generated by the research. The fifth is to achieve more effective and efficient research. Together, these reasons may help researchers get more clarity about why patients or the public should be involved in their studies. This may in turn help to define realistic purposes, design a good participatory process, and conduct appropriate evaluations. All in all, using these five reasons as a frame of reference might lead to a better understanding of what good participatory research in health promotion should look like.

Background: Evidence-based practice has become a major issue in physical therapy. Many evidence-based guidelines, however, are not used extensively after dissemination, and interventions aimed at increasing guideline adherence often have limited effects.Objective: As a prerequisite for changing this situation, the aims of this study were to gain an in-depth understanding of the determinants of guideline adherence among physical therapists in the Netherlands and to evaluate the opportunities of a theoretical framework in this respect.Design and Methods: This observational study consisted of 3 focus group interviews (n=12, 10, and 8) between November 2002 and January 2003. Physical therapists were asked to discuss their opinions about and experiences with the Dutch guidelines for low back pain. Data were analyzed qualitatively using a directed approach to content analysis. Both the interview route and the analysis of the interviews were informed by Rogers’ Diffusion of Innovations Theory.Results: Our study yielded in-depth insights into the various determinants of guideline adherence. Overall, the participants had rather unfavorable opinions about issues related to the dissemination of the guidelines (first phase of the diffusion process) and provided relatively little information on the subsequent adoption process (second phase of the diffusion process). The theoretical framework appeared to be a useful tool to properly structure the focus group interviews, to systematically analyze the data collected, and to determine that supplementary interviews would be necessary to cover the entire diffusion process.Conclusions: Our findings indicated that the diffusion process of guidelines among physical therapists was not yet completed. The use of theory can provide added value to guideline implementation studies.