We are a profession that takes evidence seriously and rightly so. The body of research underpinning physiotherapy practice is robust, growing and genuinely impressive. 

From pain neuroscience to exercise prescription, manual therapy protocols to chronic disease self-management, we have developed a sophisticated clinical toolkit, one grounded in decades of rigorous investigation, peer review and outcome measurement. 

As a profession, we should be proud of that. But pride in our evidence base should not prevent us from asking a harder question: who designed these programs and did anyone consult the patient first? 

The gap between evidence and engagement 

Chronic disease self-management programs (CDSMPs) are perhaps the clearest example of this tension. The evidence for these programs is compelling. 

Structured, evidence-based interventions that build self-efficacy, promote behaviour change and teach symptom management skills have been shown to improve health-related quality of life and psychological wellbeing (Brady et al 2013, Damush et al 2016), reduce GP consultations (Hevey et al 2020, Leong et al 2020) and decrease hospital readmissions (Hevey et al 2020). 

For a healthcare system straining under the weight of an aging population‚ where 81.4 per cent of Australians reported at least one long-term health condition in 2022 (Australian Bureau of Statistics 2023), the promise of programs that empower individuals to actively manage their own health is not just clinically sound – it is economically necessary. 

And yet participation rates tell a very different story. Despite the strength of the evidence, uptake remains a persistent and troubling gap. Acceptance rates across CDSMP studies are strikingly variable – ranging from as low as 10 per cent to as high as 98 per cent depending on how, where and to whom programs are offered (Kessler et al 2023). 

A Canadian study of patients with chronic conditions found that just 36 per cent of those invited chose to participate (Hudon et al 2016). We have built evidence-based, clinically sound and demonstrably beneficial programs but a significant proportion of the intended participants are not walking through the door. 

That variability is the clue. If poor attendance were purely a patient problem, a matter of motivation or health literacy, we would expect consistently low numbers. Instead, the wide range tells us something else entirely: that uptake is sensitive to context, logistics and format. 

To whether the program feels like it was designed for this community or merely delivered to it. This is not a failure of evidence. It is a failure of fit. 

The comfort of the repeatable 

There is a quiet risk embedded in the success of evidence-based practice: it can make us very good at repeating what we already know works, in the way we already know how to do it. 

Protocols become comfortable. 

Delivery formats become defaults. 

The randomised controlled trial that validated a particular group program in a metropolitan setting gets translated into a template and that template gets rolled out across communities that are geographically, culturally and socially quite different from where it was tested. 

This is not negligence. 

It is an entirely understandable response to the pressure of clinical workload, resource constraints and the reasonable assumption that evidence-based should mean universally applicable. 

But chronic disease does not exist in a vacuum. It exists in a person and that person exists in a community – a community with its own rhythms, transport challenges, digital literacy levels, cultural values and deeply held views about helpseeking and healthcare.

The evidence reflects this: Kessler et al (2023) found that barriers to CDSMP attendance are fundamentally individualised and context-dependent – a program that works well in one community setting may fail entirely in another. 

When we design programs from the top down and then wonder why uptake is low, we are perhaps unintentionally prioritising the evidence over the person the evidence was meant to serve. 

Health literacy and self-efficacy 

As physiotherapists, we talk a great deal about the goal of transitioning patients toward health literacy and self-efficacy. 

We want people to understand their condition, trust their body and make informed decisions about their own care. 

These are not just clinically desirable outcomes; they are philosophically important ones. 

A patient who is genuinely health literate is no longer dependent on us. They are empowered. And the relationship between the two is well established: health literacy is a key antecedent of self-efficacy in people with chronic conditions. 

Greater health knowledge is directly linked to greater confidence in managing one’s own care (Mackey et al 2016, Peters et al 2019). But here is the paradox: we cannot build self-efficacy in someone using methods that do not resonate with them. 

We cannot cultivate agency through programs the person does not attend, cannot access or did not feel consulted about. Self-efficacy is not something we deliver to a patient; it is something that emerges through engagement, trust and relevance (Cameron et al 2018, Damush et al 2016, Peters et al 2019). 

Which raises the question: if our ultimate clinical goal is patient empowerment, shouldn’t the very first step be asking what empowerment looks like to them? 

Community as co-designer 

Before we decide how to help, we should find out how people want to be helped. 

The only way to get this architecture right is to ask – systematically, respectfully and with a genuine commitment to being shaped by the answer. Not just at the point of program evaluation but at the point of design. 

Community consultation is not a nicety. 

It is a clinical imperative. Kessler et al (2023) put it plainly in their scoping review: including community members and service users in the design and implementation of CDSMP may be one of the most effective strategies for improving access and attendance. 

A call to the profession 

Physiotherapy is exceptionally well placed to lead this shift. We are already embedded in communities. We know how to translate research into practice. 

We believe formally and philosophically in person-centred care. Now we need to match that belief with a methodology. 

That means investing in community needs assessments before program rollout, not after. It means valuing qualitative data about lived experience alongside quantitative data about clinical outcomes. 

It means sitting with the discomfort of designing something locally, knowing it may look different from the evidence-based template and trusting that local fit is part of what makes something evidence-based in the fullest sense. 

The evidence tells us what works. The community tells us what will be used. 

We need both. We are a profession of clinical excellence. 

Let us also become a profession that is genuinely, structurally and habitually curious about the people and places it serves. Not just what they need but how they need it. 

Not just what the literature recommends but what the community will walk through the door for. Think about the patient who was referred to a program and never came. 

The one who was too fatigued to drive across town at 10 am on a Tuesday. The one who didn’t want to sit in a circle and talk about their body with strangers. 

The one who would have thrived in a different format, a different location, a different conversation. 

Every one of those patients is a person we had the knowledge to help and the systems to reach but lost at the door. Not because the evidence failed them but because the design did. 

Ask first, build second. 

References. 

>>Belinda Stephens APAM is a physiotherapist who has worked across the scope of healthcare, primarily in community private practice. 

She has a postgraduate degree in business and is currently completing a master’s of rehabilitation and wellness.