Table 3 -.

Themes and sub-themes mapped to study objective

Themes	Sub-themes	Description of link: How does the theme contribute to non-adherence to guideline recommendations?	Exemplar quotes
Guideline Related Factors	Culturally inappropriate recommendations.	Participants believe that a significant number of the recommendations should be culturally appropriate for Indian society and accepted by the community in which they live in order to be accepted.	“These exercises prescribed are not for me, who drapes a saree” (traditional attire). (R1, 55F, no formal education, housewife, rural location) “I am the head of my family and need to show a strong character. Performing recommended exercises, such as the Superman and Fire Hydrant exercises, reduces my value.” (R28,58M, school education, self-employment, rural location) “The recommended exercises should be appropriate for the community in which I live. I accept walking; I reject anything else.” (R2,52M, college education, employed, rural location) “At their best, these exercises are acceptable inside a hospital or department, not in the community.” (R21, 47M, school educated, unskilled labor, rural location) “I’ve seen patients with other illnesses perform walking as an exercise. I am okay with it; I will not perform other strange exercises.” (R23, 57F, no formal education, housewife, rural location)
	Onus is on the care seeker	Participants perceive that exercise and self-management have shifted the entire burden of recovery onto them, while the physiotherapist assumes a mentoring role. According to participants, this does not align with the typical duties of a healthcare professional.	“I went to seek a cure. The physiotherapist laid all responsibilities on me for recovery from lifestyle changes to self-exercise.” (R8, 45M, employed, college educated, urban location) “It’s easy for the healthcare provider. If I recover, his recommendations win, and if I don’t, I haven’t adhered to them.” (R12, 29M, Employed, college-educated, urban location)
	Focus on biopsychosocial perspective	Participants question the appropriateness of treatment recommendations aimed at psychological and social factors for addressing physical pain.	“I have endured pain for many years and know from my experience that my work aggravates pain. Assigning psychological variables or changes to the brain for this behavior questions my mental strength” (R24,44M, college educated, employed, urban location)
	Involvement of patients with back pain in guidelines development?	Participants assert that a representative from one of their members should be involved in the guideline formulation process to ensure their expectations are considered, hence facilitating the appropriateness and acceptance of the recommendations.	“If at all there is a patient representative during this recommendation development process, I am confident that they must be someone who represents the privileged class rather than someone from the middle class, such as us.” (R14, 44F, college educated, housewife, urban location)
Institution related factor	Focus on modern equipment purchase and development of physical infrastructure	Participants believe that acquiring the most advanced equipment improves any department’s infrastructure. Clinics bill patients based on the number of electrotherapy devices they prescribe but charge less for exercise sessions. Consequently, participants consider electrotherapy to be a more appropriate recommendation than exercises.	“If exercise is all-powerful, why are there advanced machines and expensive electrotherapy sessions?’ (R18, 54M, college educated, self-employment, urban location) “I see physiotherapists giving different people the same exercises to do. I see that more effort is being put into improving equipment and facilities than into giving people more advanced training. Because of this, I think that electrical therapies are better than exercises.” (R11, 56M, Employed, college-educated, urban location)
	Overcrowded department that lacks privacy	Participants perceive that numerous physiotherapy departments, particularly those at government facilities, are overcrowded and lack sufficient privacy. The participants believe such locations are unsuitable for exercising, so they avoid the recommendations.	“The government-run physiotherapy centers are too overcrowded. It is very difficult to perform exercises when someone watches you.” (R13, 54F, school-educated, housewife, rural location) “There will be 3-5 people in the same room where one is receiving therapy. It’s sometimes embarrassing to receive physiotherapy services.” (R20, 42F, college educated, housewife, rural location)
Patient-related factors	Disregard for patient expectations	Participants felt that most clinics do not provide enough information about their diagnosis or assessment results, nor do they engage in discussions about their treatment expectations and course of care. Consequently, they tend not to accept imposed recommendations that do not align with their expectations.	“After listening to my complaint, the physiotherapist does some tests on me, the results of which are not explained.” (R6, 39M, College educated, employed, urban location) “The physiotherapist dictates my plan of care with junior staff. I hardly get time to discuss my progress or problems with the senior staff. My treating physio says that the senior physio is told every day about my progress” (R4, 31M, college educated, employed, urban location) “They (physiotherapists) say exercises are most important, but there has been no review of my exercise schedule since the first day.’ (R22,53F, college educated, employed, urban location)
	Insufficient patient engagement in goal-setting
			“The physiotherapist says that self-management is the best way to go. After that, he provides a treatment plan. If sticking to it is what makes it work, should I not participate in the care planning process?”- (R2,52M, college education, employed, rural location).
	Financial factors	The participants suspect that healthcare organizations may raise the costs associated with LBP treatment under the guise of a bundled package, as specified in the recommendations. Consequently, the participants desire the advice to align with their preferences and expectations rather than favoring a multidisciplinary approach to care.	“I am confident that this presents an opportunity to increase the already high costs of physiotherapy” (R6, 39M, college educated, self-employment, urban location) “Why does my physiotherapist charge so much when he insists on self-management?” (R9,46M, no formal education, self-employment, urban location)
	No variability in treatment despite shifts in symptoms and disregard for lived experience	Despite differing complaints and symptoms, participants believe the suggested exercises are uniform and do not cater to individual needs. Consequently, they deem exercises irrelevant to their needs.	“Both me and my friend were prescribed walking as a home exercise despite having different complaints.” (R24,44M, college educated, employed, urban location) “I have been continuing the same set of exercises for 8 weeks now, irrespective of my improvement or deterioration of symptoms.” (R4, 31M, college educated, employed, urban location)
Physiotherapist related factors	Divergence in treatment recommendations among settings and physiotherapists	Participants think that there are significant differences in LBP treatment recommendations between healthcare settings and physiotherapists, raising the possibility that these recommendations are invalid and, therefore, unacceptable.	“If recommendations are universal, why is there so much variability in treatment prescriptions across different set-ups and among physiotherapists working in the same unit?” (R24,44M, college educated, employed, urban location)
	Absence of close supervision	Participants contend that physiotherapists have diminished their ‘hands-on’ care for patients under the pretext of self-management. The participants desire a human element in the treatment and dispute the self-management approach.	“The physiotherapist says I am in charge of my back and instructs me to self-exercise, which is not to my liking….. Where is the human touch in terms of treatment?” (R23, 57F, no formal education, housewife, rural location)
	Lack of experience in managing LBP	Participants hold the belief that not all physiotherapists demonstrate equal interest and competence in treating LBP and that even if recommendations are appropriate, their implementation is not effective.	“I want physiotherapists to demonstrate the exercises so that I can learn. I have seen therapists who periodically treat children assigned to me, and they are unable to demonstrate or answer queries to satisfaction.” (R18, 54M, college educated, self-employment, urban location) “The physiotherapist says my technique is wrong. But, he never demonstrates all the exercise progressions.” (R17, 57F, housewife, no formal education, rural location) “I think a physiotherapist is unable to target the diseased structures with his management. That’s why he pass the ball on to me, saying no structures are identified as sources of pain or refer to complex factors as sources of pain.” (R12, 29M, employed, college educated, urban location)
	Ineffective communication in conveying the rationale behind recommendations	Participants suggest that physiotherapists lack the communication skills necessary to persuade them regarding the foundations for the recommendations given. .	“There is hardly an explanation by my physiotherapist why I should stretch or strengthen my muscles.” (R24,44M, college educated, employed, urban location) “I don’t think physiotherapists are able to explain the concepts behind the exercises well. For example, he says that if I am not interested in participating in trunk muscle training, he recommends walking or cycling as an alternative. How will exercises that target the lower limb be a substitute for trunk muscles?” (R6, 39M, college educated, employed, urban location) “My physiotherapist puts things so unclearly. He says everything is in my head, and I need to get rid of my pain from the head. My family thinks I have some psychological disorder.” (R17, 57F, housewife, no formal education, rural location)
	Non-compliance with CPGs	Participants claim that physiotherapists do not comply with the stipulations set forth in the guidelines, hence making patient acceptance unlikely.	“When he is called away for other work, my physiotherapist instructs the assistant to apply electrotherapy modalities for me. Given the importance of exercises, shouldn’t I be required to participate in exercises?” (R22,53F, college educated, employed, urban location)
	Recommendations are inconsistent with expectations.	Participants state that the recommended interventions are incongruent with the personal and cultural expectations of their comprehension of pain. This hinders their acceptance of active treatment strategies.	“My physiotherapist says pain while exercising is acceptable. How can pain be an answer to my pre-existing pain?” (R1, 55F, no formal education, housewife, rural location) “I want pain relief. My physiotherapist says, ‘if you improve your function, the pain will come down.’ Isn’t my function reduced because of pain?” (R5, 56F, housewife, school educated, rural location) My daily activities involve a significant amount of physical activity. Why should I engage in other exercises?” (R17, 57F, housewife, no formal education, rural location) “There are days when low back pain severely limits my function, and I do not wish to work. If exercise is management, this is not for me.” (R15,33F, college education, rural location) “Statements like “low back pain has no source” and “exercises are the best pain management” would have led my entire family to believe I had been lying for all these years.” (R13, 54F, school educated, housewife, rural location) “Going to physiotherapy clinics for electrotherapy is a relaxing experience. I get to know and interact with other people. Exercises do not provide this experience.” (R15,33F, college education, rural location)
Healthcare related factors	Not on par with the medical practitioners	Participants perceive that physiotherapists do not occupy a central role within the healthcare system or the hierarchy of back pain management. Given their limited capacity to order investigations and establish diagnoses, the participants regard the physiotherapist’s position as supportive, leading them to believe that their recommendations may not be strictly adhered to.	“The physiotherapists take orders from medical practitioners, and I will listen to their (medical doctors’) recommendations, which are easy to comply.” (R8, 45M, employed, college educated, urban location)
	Lack of consistency in recommendations among healthcare providers	The recommendations provided by physiotherapists contradict those of other healthcare providers, and this casts doubt on the validity of physiotherapists’ recommendations.	“My physiotherapist says it’s okay for me to bend forward; my doctor says no to bending forward. How can two different recommendations be appropriate?” (R18, 54M, college educated, self-employment, urban location) “Other health care providers do not appear to endorse exercises as strongly as a physiotherapist” (R14, 44F, college educated, housewife, urban location)
	No flexibility in treatment recommendations despite investigation outcomes.	Participants are of the opinion physiotherapists hesitate to alter treatment recommendations, leading to skepticism regarding the validity of the recommendations based on the investigation’s results.	“ My physiotherapists shows not much enthusiasm in interpreting these outcomes.” (R14, 44F, college educated, housewife, urban location) “My treatment remains the same irrespective of the MRI findings.” (R22, 53F, college educated, employed, urban location)
	Availability of alternative healthcare options	Participants believe that there are many alternative treatment methods available and that following physiotherapists’ recommendations is not necessary.	“When we do not get better with the treatments and therapies provided in hospitals and clinics, we can rely on local healers and traditional therapies. There is no pressure on us to engage in exercises, which we do not prefer”. (R32,58M, school education, employed, rural location)
	Negative expectations concerning recovery	Participants anticipate minimal positive effects from physiotherapists’ recommendations due to the prolonged duration of their symptoms and their past experiences with various treatments.	“When they can’t even confirm the possible reasons for pain, how do they propose a management plan? ” (R32, 58M, school education, employed, rural location) “After such a long treatment, I am convinced there is no cure for my pain. All I expect is a non-aggravation of pain and some treatment that can ease my pain” (R22, 53F, college educated, employed, urban location)
Health information	Impact of media on healthcare options	Participants indicate that several media sources and healthcare providers disseminate supplementary information on exercise and other physiotherapeutic methods, making it challenging to determine appropriateness.	“None of the techniques my physiotherapist demonstrates resemble what I see on social media” (R10, 25M, PhD student, urban location) “I wonder if my physiotherapist possesses the same knowledge as the person who provides information on social media.” (R10, 25M, PhD student, urban location) “There is so much conflicting information provided by healthcare practitioners that I do not know whom to trust” (R8, 45M, employed, college educated, urban location)