Co-creating a Choosing Wisely Leaflet Supporting the Reduction of Imaging Usage in Low Back Pain Management - A Multi-Method Study.

Introduction: Low back pain is a global health challenge with negative consequences for both individuals and healthcare systems. The 'Choosing Wisely' initiative aims to improve communication between patients and clinicians to promote informed healthcare decisions while avoiding unnecessary tests and treatments. The objective of this project is to co-create an information resource in the form of a leaflet, to be distributed in clinical settings, websites or social media targeting people with low back pain. Methods: This multi-method study was conducted in four stages: literature search, input from practice consultants, program theory development, and think-aloud interviews with people experiencing low back pain. Each stage was followed by a consensus meeting in which the steering group refined the leaflet based on the emerging knowledge. Results: The literature search highlighting patients' need for understandable information about diagnosis, treatment options, and self-management strategies. Practice consultants emphasized concise, relatable content. The program theory identified potential mechanisms and design targets for content creation, development, and implementation of the leaflet, such as addressing patient concerns, reducing diagnostic uncertainty, offering insights into management options, and validation. Think-aloud interviews with 18 people living with low back pain informed the iteration of the leaflet, enhancing language clarification and content comprehension. Conclusion: We co-created a new Choosing Wisely leaflet, created with end-users in mind, specifically focused on reducing unnecessary imaging for low back pain. Valuable feedback from end-users prompted significant revisions, underscoring the importance of involving multiple end-user viewpoints into the creation process.