From Beliefs to Practice: A Mixed Methods Study of Clinical Reasoning and Barriers to Evidence‐Based Management of Back Pain Among Physiotherapists

BACKGROUND: Evidence-based management of low back pain remains inconsistent, particularly in developing settings, where clinicians' beliefs and contextual factors may influence practice. Research specifically examining how physiotherapists in the Maldives manage LBP is scarce, highlighting the need for context-specific evidence to guide both clinical practice and policy development. OBJECTIVE: To explore physiotherapists' beliefs, clinical reasoning, and barriers to evidence-based management of low back pain in the Maldives. METHODS: A convergent mixed method design was employed. Quantitative data were collected using the Back Pain Attitudes Questionnaire (Back-PAQ), while semi-structured interviews explored clinical reasoning and perceived barriers. Data were analysed using descriptive statistics and thematic analysis, and findings were integrated. RESULTS: Physiotherapists demonstrated moderate levels of unhelpful beliefs, reflected in a spectrum of clinical reasoning patterns ranging from structurally oriented and procedural approaches to more patient-centred strategies. However, the implementation of evidence-based care was inconsistent and influenced by limited access to continuing professional development, resource constraints, and patient expectations. CONCLUSION: This study demonstrates that physiotherapists in the Maldives exhibit moderate level of unhelpful beliefs towards low back pain, reflected in a spectrum of clinical reasoning patterns ranging from structurally oriented to more patient-centred approaches. The presence of more evidence-aligned practices may, in part, reflect the diverse educational backgrounds of a workforce that includes a substantial proportion of foreign-trained clinicians. However, the consistent implementation of evidence-based care remains constrained by contextual factors, including limited access to continuing professional development and system-level barriers.