Patient and Public Involvement (PPI) in evidence synthesis: how the PatMed study approached embedding audience responses into the expression of a meta-ethnography

Barriers and enablers to maintaining self-management behaviours after attending a self-management support intervention for type 2 diabetes: a systematic review and qualitative evidence synthesis

Attendance at type 2 diabetes self-management interventions is associated with improved outcomes. However, difficulties maintaining self-management behaviours attenuate long-term impact. This review aimed to identify and synthesise qualitative research on barriers and enablers to maintaining type 2 diabetes self-management behaviours after attending a self-management intervention. Eight electronic databases were searched to identify relevant peer-reviewed and grey literature studies. Data were synthesised using the best-fit framework synthesis approach guided by the themes and constructs identified by Kwasnicka et al. (2016) on their review of theoretical explanations for behaviour change maintenance. Study methodological limitations and confidence in findings were assessed using an adapted version of the Critical Appraisal Skills Programme (CASP) tool and the GRADE-CERQual approach respectively. Eleven articles reporting on 10 studies were included. Twenty-eight barriers and enablers were coded to the a priori themes. Barriers were commonly coded to the themes self-regulation, resources, and environmental and social influences. Enablers were commonly coded to the themes habits and maintenance motives. Methodological limitations of included studies varied, leading to moderate or low confidence in most findings. Interventions may improve behavioural maintenance by providing post-intervention support, promoting positive behaviour change motives, self-regulation, habit formation, and facilitating access to resources and support.

A meta-ethnography of how children and young people with chronic non-cancer pain and their families experience and understand their condition, pain services, and treatments

BACKGROUND

Chronic non-cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non-cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children's chronic non-cancer pain, with many services being inadequate. Fourteen Cochrane Reviews assessing the effects of pharmacological, psychological, psychosocial, dietary or physical activity interventions for managing children's chronic non-cancer pain identified a lack of high-quality evidence to inform pain management. To design and deliver services and interventions that meet the needs of patients and their families, we need to understand how children with chronic non-cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them.

OBJECTIVES

1. To synthesise qualitative studies that examine the experiences and perceptions of children with chronic non-cancer pain and their families regarding chronic non-cancer pain, treatments and services to inform the design and delivery of health and social care services, interventions and future research. 2. To explore whether our review findings help to explain the results of Cochrane Reviews of intervention effects of treatments for children's chronic non-cancer pain. 3. To determine if programme theories and outcomes of interventions match children and their families' views of desired treatments and outcomes. 4. To use our findings to inform the selection and design of patient-reported outcome measures for use in chronic non-cancer pain studies and interventions and care provision to children and their families. The review questions are: 1. How do children with chronic non-cancer pain and their families conceptualise chronic pain? 2. How do children with chronic non-cancer pain and their families live with chronic pain? 3. What do children with chronic non-cancer pain and their families think of how health and social care services respond to and manage their child's chronic pain? 4. What do children with chronic non-cancer pain and their families conceptualise as 'good' chronic pain management and what do they want to achieve from chronic pain management interventions and services?

SEARCH METHODS

Review strategy: we comprehensively searched 12 bibliographic databases including MEDLINE, CINAHL, PsycInfo and grey literature sources, and conducted supplementary searches in 2020. We updated the database searches in September 2022.

SELECTION CRITERIA

To identify published and unpublished qualitative research with children aged 3 months to 18 years with chronic non-cancer pain and their families focusing on their perceptions, experiences and views of chronic pain, services and treatments. The final inclusion criteria were agreed with a patient and public involvement group of children and young people with chronic non-cancer pain and their families.

DATA COLLECTION AND ANALYSIS

We conducted a qualitative evidence synthesis using meta-ethnography, a seven-phase, systematic, interpretive, inductive methodology that takes into account the contexts and meanings of the original studies. We assessed the richness of eligible studies and purposively sampled rich studies ensuring they addressed the review questions. Cochrane Qualitative Methods Implementation Group guidance guided sampling. We assessed the methodological limitations of studies using the Critical Appraisal Skills Programme tool. We extracted data on study aims, focus, characteristics and conceptual findings from study reports using NVivo software. We compared these study data to determine how the studies related to one another and grouped studies by pain conditions for synthesis. We used meta-ethnography to synthesise each group of studies separately before synthesising them all together. Analysis and interpretation of studies involved children with chronic non-cancer pain and their families and has resulted in theory to inform service design and delivery. Sampling, organising studies for synthesis, and analysis and interpretation involved our patient and public involvement group who contributed throughout the conduct of the review. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We used a matrix approach to integrate our findings with existing Cochrane Reviews on treatment effectiveness for children's chronic non-cancer pain.

MAIN RESULTS

We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Included studies involved 633 participants. GRADE-CERQual assessments of findings were mostly high (n = 21, 58%) or moderate (n = 12, 33%) confidence with three (8%) low or very low confidence. Poorly managed, moderate or severe chronic non-cancer pain had profound adverse impacts on family dynamics and relationships; family members' emotions, well-being, autonomy and sense of self-identity; parenting strategies; friendships and socialising; children's education and future employment prospects; and parental employment. Most children and parents understood chronic non-cancer pain as having an underlying biological cause and wanted curative treatment. However, families had difficulties seeking and obtaining support from health services to manage their child's pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Over time, some children and families gave up hope of effective treatment. Outcomes measured within trials and Cochrane Reviews of intervention effects did not include some outcomes of importance to children and families, including impacts of pain on the whole family and absence of pain. Cochrane Reviews have mainly neglected a holistic biopsychosocial approach, which specifies the interrelatedness of biological, psychological and social aspects of illness, when selecting outcome measures and considering how chronic pain management interventions work.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.

A qualitative systematic review of family caregivers' experiences of artificial nutrition and hydration at home: A meta-ethnography

BACKGROUND

Artificial nutrition and hydration (AN&H) may be provided to individuals in the home environment, and family caregivers are often involved in the management of this intervention. This experience can have multiple consequences for families.

AIMS

The aim of this meta-ethnography is to explore and synthesize the personal experiences of family caregivers providing care to a person receiving home AN&H.

METHODS & PROCEDURES

A comprehensive search of the literature was conducted without any time limitations applied. Seven stages of meta-ethnography were followed. Public and patient involvement was incorporated into the development of the line of argument synthesis in this review. This review is reported following the eMERGe guidelines and it was registered in PROSPERO.

MAIN CONTRIBUTION

A total of 22 studies were included representing the experiences of 336 family caregivers. Two main themes emerged: (1) sink or swim, being thrown in at the deep end; and (2) professional support as a bedrock. The first theme represents the experiences from the very start of home AN&H when the family caregivers may be overwhelmed with the level of skills they have to acquire. With time, family caregivers perceived the benefits, but also the challenges, associated with managing home AN&H. If a person receiving home AN&H was able to continue with some oral intake, it had a positive impact on family caregivers' experiences. The second theme represents the influence of professional support on the lived experience of family caregivers managing home AN&H. This support should be individualized, comprehensive, and co-created with the family caregiver and the person receiving home AN&H.

CONCLUSIONS & IMPLICATIONS

This review concluded that caring for a person receiving home AN&H can be very challenging for family caregivers. Family caregivers require personalized support from a multidisciplinary team of healthcare professionals to acquire skills, competence and confidence in this new role. Speech and language therapists are important members of this multidisciplinary team because they can facilitate a continuation of oral intake as appropriate.

WHAT THIS PAPER ADDS

What is already known on the subject AN&H has an impact not only on the person receiving it but also on the wider family and family caregivers. Healthcare professionals have a role in supporting people living with AN&H. What this paper adds to existing knowledge This review presents a rigorous qualitative evidence synthesis that adheres fully to the eMERGe guidance for reporting of meta-ethnography. Within this meta-ethnography a current caregiver was consulted during the creation of the line of argument synthesis to provide a unique perspective to the review process. This review synthesized the current body of evidence that explores the lived experience of home AN&H (any type) for family caregivers, identifies where professional support is required and highlights current gaps. What are the potential or actual clinical implications of this work? Family caregivers require personalized support from a multidisciplinary team of healthcare professionals to adjust to living with home AN&H. This support assists people living with home AN&H in perceiving benefits and developing more positive experiences. Speech and language therapists are important members of the multidisciplinary team supporting individuals with home AN&H and their family caregivers as they can facilitate a continuation of oral intake as appropriate.

Barriers and enablers to sustaining self-management behaviours after attending a self-management support intervention for type 2 diabetes: a protocol for a systematic review and qualitative evidence synthesis

Background: Attendance at self-management support interventions is associated with improved outcomes for people with type 2 diabetes. However, initial improvements are often not sustained beyond one year, which may be a result of difficulties in sustaining positive changes made to self-management behaviours. The aim of this systematic review is to synthesise qualitative research on the barriers and enablers to sustaining self-management behaviours following attendance at a self-management support intervention for type 2 diabetes.

Methods: The review will use the “best fit” framework synthesis method to develop a new conceptual model of sustained behaviour change in type 2 diabetes. MEDLINE (Ovid), EMBASE (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), SCOPUS, ProQuest Dissertations and Theses, WorldCat and Open Grey will be searched to identify primary qualitative studies. A parallel search will be conducted in Google Scholar to identify relevant theories for the development of an a priori framework to synthesise findings across studies. Methodological limitations of included studies will be assessed using an adapted version of the Critical Appraisal Skills Programme tool for Qualitative Studies. A sensitivity analysis will be conducted to examine the impact of studies with methodological limitations on synthesis findings. Confidence in the synthesis findings will be assessed using the GRADE-CERQual tool. Screening, data extraction, methodological limitation assessment, synthesis and GRADE-CERQual assessment will be conducted by one author with a second author independently verifying a randomly selected 20% sample.

Discussion: This review will develop a new model of sustained behaviour change in type 2 diabetes self-management. The findings can be used to inform the development of new interventions or revision of existing interventions to better support sustained engagement in type 2 diabetes self-management behaviours.

Barriers and enablers to sustaining self-management behaviours after completing a self-management support intervention for type 2 diabetes: a protocol for a systematic review and qualitative evidence synthesis

Background: Attendance at self-management support interventions is associated with improved outcomes for people with type 2 diabetes. However, initial improvements are often not sustained beyond one year, which may be a result of difficulties in sustaining positive changes made to self-management behaviours. The aim of this systematic review is to synthesise qualitative research on the barriers and enablers to sustaining self-management behaviours following completion of a self-management support intervention for type 2 diabetes. Methods: The review will use the “best fit” framework synthesis method to develop a new conceptual model of sustained behaviour change in type 2 diabetes. MEDLINE (Ovid), EMBASE (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), SCOPUS, ProQuest Dissertations and Theses, WorldCat and Open Grey will be searched to identify primary qualitative studies. A parallel search will be conducted in Google Scholar to identify relevant theories for the development of an a priori framework to synthesise findings across studies. Methodological limitations of included studies will be assessed using an adapted version of the Critical Appraisal Skills Programme tool for Qualitative Studies. A sensitivity analysis will be conducted to examine the impact of studies with methodological limitations on synthesis findings. Confidence in the synthesis findings will be assessed using the GRADE-CERQual tool. Screening, data extraction, methodological limitation assessment, synthesis and GRADE-CERQual assessment will be conducted by one author with a second author independently verifying a randomly selected 20% sample. Discussion: This review will develop a new model of sustained behaviour change in type 2 diabetes self-management. The findings can be used to inform the development of new interventions or revision of existing interventions to better support sustained engagement in type 2 diabetes self-management behaviours.

A qualitative meta-synthesis of evidence (meta-ethnography) exploring the personal experiences of gastrostomy tube in neurodegenerative diseases: a case of motor neurone disease

PURPOSE

The lived experiences of a gastrostomy tube (GT) in adults with neurodegenerative diseases (NDDs) are not well understood. The aim of this qualitative meta-synthesis was to review and synthesise the available evidence to inform clinical practice and identify research gaps.

METHODS

Meta-ethnographic synthesis of qualitative studies was conducted with systematic searching of eight databases from inception to March 2021. Qualitative studies reporting personal experiences of GTs in adults with NDDs were identified. New theories were developed during translation of concepts from each study and combined as a "line-of-argument" synthesis. Patient and public involvement was incorporated as two of the authors are living with an NDD and a GT.

RESULTS AND CONCLUSIONS

Of 2863 unique records identified, only nine fulfilled the review criteria. All studies recruited participants with motor neurone disease (MND); no other NDDs were represented. Two main themes emerged: decision making and living with GT. Decision making was the predominant theme and data regarding living with GT were sparse. There is limited research on the lived experience of a GT in adults with NDDs. The lived experience of GT in MND is complex and individualised. Future research is indicated to inform clinical practice.Implications for rehabilitationEvidence related to the lived experiences of gastrostomy tube (GT) in neurodegenerative diseases (NDDs) is lacking especially in relation to the time after GT insertion.Decision making in relation to GT is a complex and individualised psychological process for some people, while others perceive no decisional conflict.Support from healthcare professionals is crucial during the decision-making time and should not cease after GT insertion.Support from healthcare professionals can help resolve any clinical complications and also incorporate GT into everyday routines.Healthcare professionals should be aware that their views on the benefits and problems related to GT may differ to those of individuals with a NDD.