Table 4.

Overview of the data synthesis supported by illustrative quotes.

CFIRa domain, construct, and subconstruct					Barriers (–) and facilitators (+) with illustrative quotes
Digital health service characteristics
	Innovation source			Commercially neutral (+) “Some could not see themselves ‘offering patients something done by a lab’ since it was unlikely the labs were ‘doing this for philanthropic reasons.’” [General practitioner] [42] Link with an institution with a good image (+) “I think it’s really good because I have heard that other hospitals... doesn’t have a programme that is as good as yours and physios that look after you.” [Patient] [53]
	Relative advantage			Adherence (+) “In my busy life, the reminders motivated me to take some time to get it done.” [Patient] [43] Self-management (+) “I think it did take away from that expectation of manual therapy. I know when people come into the clinic and they’re coming in for a similar issue...because you’re in the room with them quite often there is an expectation of manual therapy and being on the phone it just completely takes it out of the equation. You don’t have to quite justify why you’re not doing the manual therapy quite as much because it’s just not an option.” [Physiotherapist] [47] Empowerment (+) “I was at home, I could relax, I could feel okay about what I was doing and I didn’t feel intimidated at all.” [Patient] [48] Motivation through support (+) “So it really helped to pick me up and actually having someone talk. Physio phoned up and spoke to me a few times, and that was really, really helpful, because it’s really encouraging that, ‘No, it’s all right keep moving, keep going.’” [Patient] [59] Access to health care (+) “I think the positive would be that I could do it at home, so I didn’t have to incorporate travel time and money for petrol, and trying to get there after work and all that type of stuff.” [Patient] [40] Societal awareness (+) “It is normal to experience back pain and it is often benign, which means that patients don’t have to restrict their activities. I sometimes wish that there was a more general understanding of back pain in society. This type of information could easily be shared through an application, I think.” [General practitioner] [56] Continuous care chain (+) “So that when they go away, and they think about it, that they have the opportunity to you know, reengage with the information if they haven’t taken it all on board at the time of the consultation.” [Physiotherapist] [33] Blended care (+) “A hybrid model would be awesome for people... maybe the first three weeks in person to really nail technique...then almost last three weeks via Telehealth so that they can learn to exercise in their own home environment.” [Physiotherapist] [44] Quality of care (+ and –) “You don’t necessarily need to be putting your hands on [to assess]...that might be 30 s worth...most of the other information we get about that kind of diagnosis and planning is with our eyes, and our ears, and our brains, which we still have over a computer.” [Physiotherapist] [44] “Yeah, some joint mobilities are a little tricky via the computer. Because, again, it is all about knowing and feeling the sensation and the amount of pressure. What amount of distraction and how much is too much.”” [Physiotherapist] [41] Patient–health care professional relationship (+ and –) “You had the time to really investigate what was motivating them or what their main issues were. Whereas I guess if you were more face-to-face and doing more of a traditional role you would be more focused on their range of movement and their strength...it is more about finding out more about them as a person and helping them to remain motivated to continue with the program. I think over the phone facilitated that to a certain degree.” [Physiotherapist] [47] “Humans are social creatures and you sort of lose that when everyone’s in their individual rooms online. Yes, you can still see them. Yes, you still engage with them, but it’s a different engagement.” [Physiotherapist] [44] Privacy and safety (–) “After reinstalling the app on my phone, I had to look through my old e-mails to find the login code, and it’s, of course, strange that if anyone else gets his hands on that email, they can see all my exercises and my private information.” [Patient] [43]
	Adaptability			Flexibility (+) “Somehow, you want to prevent it from turning into some kind of assembly line work, and that the therapist no longer thinks about the kind of care that they provide.” [Physiotherapist] [30] Specificity (+) “Basically, I think it is a good app. However, the questions appear too frequent, too standard.” [Patient] [39] Suitability (+) “There is going to be a group both of patients and GPs who just don’t want to engage with that type of model. But I think that will be the case no matter what model is designed or developed.” [General practitioner] [54] Evolving intervention (+) “Renewing the exercises, for me it’s a good thing, because if you put a little bit of change, that makes it more enjoyable. From the moment you start a new exercise, it will stimulate you.” [Patient] [61]
	Complexity			Usability factors (+) “What you often see in information provision in digital applications is that information is too complicated or too difficult to practically apply.” [Physiotherapist] [30] Health care professional management (+) “I think it’s a shame that the physiotherapist did not know how the program worked.” [Patient] [28]
	Design quality and packaging			Variety and range of content and functionalities (+) “Well I suppose the variety. It wasn’t just you should be active. There were reasons behind and the self-awareness. I think it’s complete.” [Patient] [59] Persuasive design (+) “Options such as ticking off assignments and knowledge that the physiotherapist had insight in the progress were experienced by patients as ‘something that serves as a carrot.’” [Patient] [45] Modality (+) “I would very much like to stress that it should be an app. It’s just that it would really help because it is really tricky on the phone. It’s hard in the gym I want to look at the examples really quick and remind myself... an app would be better. You can use it offline.” [Patient] [53]
	Cost			Reduced number of treatment sessions (+ and –) “I think it [e-Health] can be very cost-effective for health care, especially for jaw complaints. You can see your orofacial physiotherapist less often because you already have your tools with you. I think it’s a very good idea.” [Patient] [29] “I believe this intervention is good for everyone, but especially for the healthcare insurers.” [Patient] [46] Patient expenses (+ and –) “I think the positive would be that I could do it at home, so I didn’t have to incorporate travel time and money for petrol, and trying to get there after work and all that type of stuff.” [Patient] [40] “General practitioners generally felt that it should be funded by sources other than patients: ‘Ideally it should be...provided for free.’” [Patient] [54]
Outer setting
	Patient needs and resources			Personal traits of patients (–) “Sufficient Internet skills and self-discipline were described as prerequisite to use the web-based component.” [Patient] [28] Entertaining strategies (+) “It needs to be fun...like an adventure or detective game. For people like me, it would work.” [Patient] [61]
	External policy and incentives			Acceptance by stakeholders (+) “You sometimes get this kind of pessimism from general practitioners. It’s not that they don’t want better interventions, it’s just that they’re sceptical that they will truly become a routine easily accessible part of practice.”” [General practitioner] [54] Health care guidelines (–) “It would be easier when there would be a national e-Health policy.” [Physiotherapist] [46] Privacy regulations (–) “We do have big confidentially chunk of potential[lity] issues. We cannot send information over an email without the patient’s permission; we cannot send any personalized data over an email.” [Physiotherapist] [41] External financial incentive (–) “According to physical therapists, this lack of financial incentive was seen as a potential barrier to use the proposed intervention in practice.” [Patient] [62]
Inner setting
	Networks and communications			Communication channels (+) “I think it comes down to the practicalities to be honest for a lot of these systems whether they succeed or fail, and that’s about taking time with the communication that was set up and getting the foundation in place to be effective.” [General practitioner] [54] Personal relationship (+) “The idea of handing a patient over to an anonymous group of people...I don’t see a great attraction.” [General practitioner] [54]
	Implementation climate
		Tension for change	Accessibility of health care (+) “My father is from a small mountain town where there is almost no mobile coverage... and we don’t even talk about the internet (laughs).” [Physiotherapist] [49] Need for trustworthy information (+) “GPs found that patients would have difficulty in discerning accurate content from inaccurate content.” [Patient] [56]
	Readiness for implementation
		Compatibility	Change of treatment routines (+ and –) “Required them to give me a lot more input, you know, describing what’s going on a little bit more, it will eliminate, I suppose, some of my normal go-to tactics.” [Physiotherapist] [48] “Once you’d done a couple, it was like—yeah, this is okay, it’s going to work. And we learned as we went.” [Physiotherapist] [44] Incompatibility with other initiatives and guidelines (–) and incompatibility with existing payment structures (–) “There’s all these other things that are happening in the background that will influence how general practitioners engage with a programme like this. Thinking about how this will fit into the regular work of a general practitioner will make a big difference, to whether it succeeds or fails.” [General practitioner] [54] Information incongruence (–) “There’s a possibility that...the way that they approach the problem is going to be a little bit different to mine...every now and then it’s some seemingly innocent or innocuous comment the patient turns over and then brings it back to you and you have to sort of spend time addressing that.” [General practitioner] [54]
		Learning climate	Support from colleagues (+) “Support from colleagues and the absence of a national e-Health guideline or standard influenced the use of e-Exercise.” [Patient] [46] Professional autonomy (+) “I had the idea that I was in charge of the treatment.” [Physiotherapist] [45]
	Knowledge and beliefs about the intervention
		Available resources	Technology-related issues (–) “I didn’t have earphones so I didn’t quite understand this whole process. I think it was the second time that I’d used it. His receptionist was fabulous in coaching me through it and she set it up.” [Patient] [40] Time (+ and –) “We have more time to focus on therapy, as it is web-based so many small chats with patients are cut and therapy session is focused.” [Physiotherapist] [41] “The physiotherapist thought it was too much [time spent on the app during treatment]. However, I thought, well, you know, if it is necessary, it is necessary.” [Patient] [30] Physical space (+) “People just sort of popping in or out, or doors opening, and external noise going on, or tradies in the house next-door...that was probably a barrier.” [Patient] [44] Electronic health records “We need to start looking at developing and rolling out, you know, electronic records...more equipment and more investment...as a nation, we are probably just a little bit behind...particularly in the public system.” [Physiotherapist] [33]
		Access to knowledge and information	Health care professionals’ training (+) “I think we [as physiotherapists] got a lot of information prior the trial so for me all the documents that we received actually allowed the process to be very routine and very kind of straight forward and I think obviously once you have done one or two sessions it really starts to become just quite mechanically because you know what you are doing and you know what your expectations are.” [Physiotherapist] [60] Access for patients (+) “Physiotherapists reported that to improve implementation in the future they would need to improve their own proficiency in using TRAK and allow patients time to explore TRAK before a consultation.” [Patient] [51] Instructions (+) “To have a bit more resources that you could offer patients... like a video that patients could see and understand what a telehealth session is, whereas I think telehealth has been mentioned in the news a lot and certainly general practitioners use it a lot but they tend to just use it as a phone call, which I think is very, very different to the way physios utilize it.” [Physiotherapist] [44]
Characteristics of individuals
	Knowledge and beliefs about the intervention			Health care professional acceptance (+ and –) “The way you will work and the way you will give information to the patients and counsel people. Changes are coming, I am sure of that.” [Physiotherapist] [29] “It would not suit me at all. I would have preferred to see someone in real life.” [General practitioner] [42] Health care professionals’ job satisfaction (+ and –) “It was easier on my body.” [Physiotherapist] [48]
Process
	Engaging
		Opinion leaders	Peer opinion leaders (+) “General practitioners who were not familiar with relevant web-based information for low back pain patients expressed that it was not common to actively search for new material to present to their patients. Only if relevant material was presented to them, and preferably by a coworker who could vouch for the material, would they consider recommending it to their patients. Only if relevant material was presented to them, and preferably by a coworker who could vouch for the material, would they consider recommending it to their patients.” [Patient] [56]
	Executing
		Key stakeholders (health care professional)	Involvement (+) “I have used the research concepts to improve the telerehab that I do in the clinic...it was much more vigorous and a bit more standardised [than] what we did so I found it very satisfying and I think I have got more confidence.” [Physiotherapist] [60] Willingness to try (+) “When asked directly about their level of willingness to try telerehabilitation if introduced into their N/OPSC&MDS facility, almost all participants stated that ‘would certainly be willing to give it a go.’” [Patient] [52] Organizational uncertainties (–) “The argument will be, with the way that the HHS’s [hospital and health service districts] are, who does it and who pays for it?” [Physiotherapist] [52] Support team (+) “Participants considered the telerehabilitation technical support team as part of team providing therapy and they all expressed that they felt well supported by the entire team at all times.” [Patient] [50]
			Justification and delegation (–) “I thought that they might feel a bit self-conscious being at the gym and chatting away, but most of them wholeheartedly just come and had no issue whatsoever with doing it, so that was good...but I had a couple of the gyms that did not enjoy the patients having their shoes off during the sessions so we had a number of those where either negotiate with the gym or they [patients] had to wear different shoes.” [Physiotherapist] [60]

^aCFIR: Consolidated Framework for Implementation Research.