Barriers and facilitators to implementing exercise therapy for nonspecific low back pain in China: A qualitative study using the consolidated framework for implementation research (CFIR)

Chronic nonspecific low back pain (NSLBP) imposes a substantial burden on individuals and healthcare systems globally. Although exercise therapy is a recommended first-line intervention, its implementation faces significant challenges. This study employed the Consolidated Framework for Implementation Research (CFIR) to systematically identify multi-level factors influencing the implementation of exercise interventions for NSLBP patients within the Chinese healthcare context. A qualitative study design was utilized. Participants (n=25) included spine surgeons, rehabilitation physicians, and patients with chronic NSLBP recruited from multiple hospitals in Jining, Shandong Province. A semi-structured interview guide, developed based on the CFIR framework, was used for data collection via face-to-face or telephone interviews. The CFIR comprises five overarching domains; however, the 'Process' domain was excluded from this study as it focused on pre-implementation factors . Data were analyzed using directed content analysis. The study identified 37 factors influencing implementation, mapped onto four CFIR domains. From the physician perspective (n=18), 14 facilitators and 15 barriers were identified. Patient perspectives (n=7) revealed 4 facilitators and 4 barriers across the same domains. Physicians acknowledged the cost-effectiveness and benefits of exercise therapy but highlighted challenges including the need for professional patient evaluation, lack of standardized protocols, insufficient insurance coverage, and limited surgeon engagement. Primary healthcare institutions expressed willingness to promote exercise therapy. Rehabilitation departments possessed advantages in facilities and expertise, while spine surgery departments faced shortages in resources, personnel, and training. At the individual level, perceptions, habits, and knowledge gaps among both physicians and patients significantly impacted implementation. This CFIR-guided qualitative study elucidated salient barriers and facilitators influencing exercise therapy implementation for NSLBP in China. Consequently, healthcare policymakers and managers should prioritize revising relevant policies to mitigate identified barriers and amplify facilitators. Enhanced implementation is expected to improve quality of life for chronic back pain patients and lessen the societal burden. • Identifies 37 multi-level factors influencing exercise therapy implementation for chronic low back pain in China using the CFIR framework. • Reveals contrasting physician (14 facilitators, 15 barriers) and patient (4 facilitators, 4 barriers) perspectives on implementation challenges. • Highlights key physician barriers: need for evaluation, lack of protocols, poor insurance, low surgeon engagement. • Emphasizes resource disparities: rehab departments' advantages vs. spine surgery's shortages in facilities, staff, training. • Proposes tailored interventions targeting system (policy, resources, insurance), provider (training, collaboration), and patient (education, support) levels.