Table 4.

The key stakeholder groups to target behavioural interventions for the respective barriers and enablers to the adoption of the biopsychosocial approach.

Themes	Healthcare professionalsa including researchers	Educatorsb including researchers	Guideline developersc including researchers	Workplace managersd including researchers	Policymakerse including researchers
Micro-level	√	√
1.1 Healthcare professional knowledge and skills Healthcare professional’s knowledge of psychosocial factors, evidence-based practice and other healthcare disciplines, and their interpersonal and people skills.
1.2 Healthcare professional personal factors Individual factors and arbitrary choices of healthcare professionals: their emotions associated with chronic pain management; beliefs; level of self-awareness with pre-existing clinical habits; desire to learn; the role and professional identity they assumed; qualifications and work experience associated with the use of a biopsychosocial approach in pain care.	√	√
1.3 Healthcare professional misconceptions of clinical practice guidelines (CPGs) Healthcare professionals may misunderstand guidelines as being too generic, simplistic, prescriptive or lacking in flexibility to account for the necessary individualised management of musculoskeletal pain. The presentation of information on guidelines may be unappealing to learning quickly.	√	√	√
1.4 Healthcare professional perceptions about patient factors Healthcare professional perceptions and judgments about patient factors may overemphasize the psychological framing of the condition and the negative stereotype of the difficult patient.	√	√
1.5 Healthcare professional perception of time Healthcare professionals perceived there is insufficient time to explore psychosocial factors within a clinical consultation, and the lack of time for learning.	√			√
Meso-level			√
2.1 CPG formulation Guideline development may be unable to account for different categories of patients, patients’ expectations, healthcare professionals’ former knowledge and training, contextual factors and real-world situations.
2.2 Clinical community factors Ready access and availability of an egalitarian interdisciplinary or multidisciplinary team to consult for challenging clinical cases, and whether or not the treatment orientation and communication among professionals within a team is aligned.	√			√
2.3 Funding models Financial barriers such as patients’ lack of health insurance, the lack of funding to incentivise healthcare professionals for their time, effort and qualifications, as well as the funding required to construct models of care appropriate to deliver high value musculoskeletal pain care may impact the feasibility of using the biopsychosocial approach.				√	√
2.4 Health service provision Work processes such as needing to complete a large amount of administrative work, or performance indicators such as requiring to see many patients or the structure of group therapy sessions may not facilitate the use of a biopsychosocial approach to pain care.	√			√	√
2.5 Resourcing issues Lack of resources such as time, specialist services, appointment slots and clinic infrastructure to support the use of a biopsychosocial approach to pain care.				√	√
2.6 Workforce training issues Workforce training issues such as a lack of explicit communication training, counselling and psychosocial competencies in undergraduate and postgraduate training programs.		√		√	√
Macro-level					√
3.1 Health policy Health policy may not prioritise or align to best practice, evidence-based care of musculoskeletal conditions.
3.2 Organizational factors Organizational factors such as healthcare financing models and regulations within healthcare delivery may not align with high value, person-centred musculoskeletal pain care.				√	√
3.3 Social factors Social factors such as the persistence and dominance of the biomedical paradigm in healthcare professions and systems, and stigma towards psychological services.	√	√		√	√

CPG, clinical practice guidelines; √, represents consensus has been achieved among research team members when asked the question “Is the theme critical for the stakeholder group to intervene on to improve biopsychosocial adoption?”.

^a Medical or allied health professionals licensed to provide musculoskeletal pain care and deliver health care services to patients. Examples include (but not restricted to) anaesthetists, chiropractors, clinical psychologists, general practitioners, nurses, occupational therapists, osteopaths, pain physicians, physiotherapists and rheumatologists.

^b Teachers who provide education, instruction or clinical guidance in musculoskeletal sciences and/or pain curriculums, in the capacity as college/university educators, tutors, clinical educators and/or facilitators of continuing professional education.

^c Researchers, professional organizations/associations, or department/ministry of health who develop clinical practice guidelines to grade evidence and develop recommendations based on best available evidence for musculoskeletal pain conditions.

^d Clinic managers who oversee the day-to-day operation or management of healthcare facilities/musculoskeletal outpatient clinics, maintain responsibility for the administrative aspects of the clinical services, and liaise between healthcare professionals and patients.

^e Members of professional organizations/associations, department/ministry of health or other government departments who are involved in legislation and healthcare funding rules, and are responsible for formulating healthcare policies and making policy decisions.