Tackling unmanaged oropharyngeal dysphagia in primary care: a behavioural science realist review of interventions

CMOc 1: HCPs without OD education and training (C) will not have the required knowledge and skills (M) to proactively identify and provide initial advice and support to older adults with suspected OD (O)

HCPs who are not OD specialists lack the required ‘Knowledge’ and ‘Skills’ regarding how to identify OD and provide advice. A cross-sectional survey of primary care nurses and doctors in Spain reported almost 40% of respondents did not know the definition of dysphagia and only 10% of respondents to a similar survey in Iran knew how to identify OD.72 76 A cross-sectional survey of primary care dieticians in Canada also found that 41% of respondents did not feel they had the competency or skill to provide advice to people with OD and 70% requested more training before feeling confident to identify OD.17

Education to address ‘Knowledge’ was provided through workshops,69 lectures,77 information pamphlets78 and digital guides.79 Content focused on the ‘major concepts’78 of OD, for example, symptoms and risk factors, and changes in swallowing physiology in older adults (Knowledge).65 68 78–81 One intervention provided a half-hour education session supplemented by an information pamphlet with key messages for participants to take away.78 HCPs who received the intervention scored an 80% average on their dysphagia knowledge, compared with 50% in the control group.78 The intervention group also reported being more likely to proactively identify OD in their practice compared with the control group.78

Training to develop ‘Skills’ was delivered through case-based sessions69 70 and simulations for HCPs to practise.68 77 78 81 Sessions focused on developing HCPs’ ability to identify OD using appropriate tools/protocols and communicating a potential OD diagnosis with patients (Skills).68–70 77 78 81 Case-based sessions delivered to nurses and allied health professionals allowed HCPs to review and rehearse the use of an OD checklist which in turn increased OD screening from 43% to 74%.70

All education training programmes were designed as one-off concise commitments to recognise HCPs’ limited time and competing priorities.

CMOc 2: HCPs without the required knowledge and skills (C) will fail to make correct decisions (M) about proactively identifying and providing initial advice and support to older adults with suspected OD (O)

Without the required knowledge and skills and validated OD checklists, HCPs were less likely to correctly identify OD and provide appropriate advice.4 17 74 77 82 83 A survey characterising OD identification and management practice in primary care dieticians found 75% of participants did not use a protocol to identify OD and 17% produced their own checklist/tool.17 Interviews with nurses identified a lack of consistency in what they considered to be OD and what signs and symptoms they looked out for.73 A cross-sectional study of hospital doctors and nurses reported, respectively, 75% and 89% used informal processes to identify OD. When compared with a validated OD checklist, the use of informal processes/tools misses key indicators, such as a wet voice and ability to cough voluntarily.74 In the absence of validated tools/protocols, HCPs also become more reliant on patients self-reporting their swallowing difficulties.71 82

Checklists provide a standardised approach to HCPs’ ‘Memory, attention and decision processes’ to facilitate them to identify OD.4 17 73 74 80 82 They guide HCPs to gather the information required to identify OD and determine the likelihood of OD based on this information.4 77 80–82 84 85 Checklists can also highlight ‘red flags’86 for potentially serious OD and indicate when to refer on to OD specialists. Simple checklists were defined as quick to use, easy to access, clear, comprised non-invasive patient assessment and appropriate for use by any HCP regardless of existing knowledge.81 82 84 85 87 After implementing an OD checklist in an intensive care setting referrals to speech and language therapy for suspected OD increased from 20% to 60%.70 Evidence from cancer evidence further indicates that these tools act as a prompt for HCPs and guide decision-making.87

CMOc 3: incorporating OD identification into existing workflow (C) will create a conducive environment (M) for HCPs to carry out this behaviour (O)

Addressing ‘Environmental context and resources’ by incorporating OD identification into relevant activities that HCPs already undertake may facilitate HCPs to undertake this target behaviour. One example is requiring HCPs to ask about OD during routine consultations with older people, facilitated by programming electronic health records to prompt HCPs during the consultation.67 71 87 Interviews with GPs identified that a prerequisite for incorporating cancer screening tools into routine workflow was embedding tools into existing information technology systems. This provided quick and easy access to the tool and meant assessments were automatically recorded in patients’ health records.87

Existing contact with older adults who are likely to be at high risk of OD is a targeted opportunity to integrate OD identification.22 75 The comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic and treatment process with a requirement to investigate OD. Health reviews for older adults underpinned by CGA are over 40% more likely to include an OD investigation than those without.67 Incorporating OD into existing processes that HCPs regard as important may also motivate HCPs who do not associate OD with adverse consequences in older adults.19 67 88

CMOc 4: HCPs who are aware that older adults and carers expect them to address OD (C) will be encouraged (M) to proactively identify OD and provide initial advice and support to older adults with suspected OD (O)

CMOc 4 is mapped to ‘Social influence’ as older adults and informal carers expect HCPs to ask about OD and provide advice where necessary.18 Semistructured interviews exploring the experiences of 21 caregivers and 20 HCPs highlighted a disconnect between their expectations and that of HCPs.18 While caregivers to family members with dementia expected early identification of and education on OD, ‘I want [HCPs] to advise me. What do I do?’,18 the majority reported feeling alone in dealing with their care recipients’ swallowing difficulties, ‘I’m learning myself… and asking questions on the blog… I’ve learnt myself, you know.’18

HCPs are more likely to undertake a behaviour if they are made aware that it is an expectation from patients and caregivers.89 90 A cross-sectional survey of physicians in Canada found 88% said they would incorporate proactive identification of health conditions into their routine practice if they knew a patient expected them to do so.90 This was reinforced by the review’s patient and public involvement advisors who felt strongly that HCPs, rather than patients and carers, are responsible for proactively identifying OD.

CMOc 5: HCPs who are aware of the adverse outcomes associated with OD (C) will recognise the importance (M) of proactively identifying and providing initial advice and support to older adults with suspected OD (O)

HCPs may ‘trivialise’ OD as an inevitable and minor consequence of ageing.65 78 91 Emphasising the seriousness of OD beyond a ‘secondary or minor disorder’ may shift HCPs’ ‘Beliefs about consequences’ to recognise the importance of proactively identifying OD.91 This was observed in evidence which raised awareness of adverse outcomes from unaddressed OD in older adults.69 78 Following attendance at workshops involving patient cases, used to convey the prevalence and impact of OD, HCPs reported an increase in their perception of the importance of proactive OD care.69 Similarly, on receipt of education on the aetiology of OD, an increase in the extent to which nurses proactively identified OD signs and symptoms was observed.78 Stakeholders also highlighted the importance of emphasising the positive consequences of HCPs proactively identifying and providing initial advice and support.