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

Caroline Smith € ,1 Debi Bhattacharya,1 Dharinee Hansjee,2 Charlotte Jeffries,1 Keisha Richards,1 Sion Scott ©1

To cite: Smith C,
Bhattacharya D, Hansjee D, et al. Tackling unmanaged oropharyngeal dysphagia in primary care: a behavioural science realist review of interventions. BMJ Open 2024;14:e086184. doi:10.1136/ bmjopen-2024-086184
► Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/ bmjopen-2024-086184).
Received 07 March 2024 Accepted 29 July 2024

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© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
1School of Healthcare, University of Leicester College of Life Sciences, Leicester, UK 2School of Health Science, University of Greenwich, London, UK

Correspondence to
Dr Sion Scott;
s.scott@leicester.ac.uk

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ABSTRACT
Introduction Oropharyngeal dysphagia (OD) is difficulty manipulating a food bolus from the mouth to the throat. Up to 70% of older adults develop 0D; however, it is unmanaged in primary care, leading to avoidable hospitalisation.
Objective This behavioural science realist review aimed to develop programme theories to describe how interventions facilitate primary care healthcare professionals (HCPs) to proactively manage OD. Methods We developed initial programme theories (IPTs) inductively using the expertise of stakeholders and deductively using the theoretical domains framework (TDF). Databases were searched to identify evidence regarding contexts, behavioural mechanisms and outcomes related to proactive management of OD and comparative behaviours which offer transferrable learning. IPTs were tested with the evidence to confirm, refine or refute, to produce final programme theories.
Results 36 sources of evidence were included. Five final programme theories were generated explaining how primary care HCPs can be facilitated to proactively manage OD: (1) OD education and training, (2) checklists with OD signs and symptoms, (3) incorporating 0D identification into existing workflow, (4) making HCPs aware that older adults and carers expect them to manage OD and (5) raising awareness of the adverse outcomes of OD. Conclusion The five programme theories provide the behavioural mechanisms by which an intervention may facilitate primary care HCPs to proactively manage OD. Through the programme theories’ linkage to the TDF, behaviour change techniques (BCTs) mapped to the relevant TDF domain can be selected for an intervention. Operationalisation of selected BCTs into a coherent intervention package should be undertaken using codesign methodology.
PROSPERO registration number CRD42022320327.
INTRODUCTION
Oropharyngeal dysphagia (OD) is a swallowing difficulty characterised by impairments to manipulating and transporting a bolus (eg, food, drink or medicine) from the mouth to the oesophagus.1 2 Research into OD has previously focused on ‘typical’
STRENGTHS AND LIMITATIONS OF THIS STUDY
=> Incorporation of behavioural science into this realist review provides recognised definitions of mechanisms that yield uniformity in data interpretation and reporting.
=> Combining realist methodology and behavioural science enables identified mechanisms to be conceptualised as theoretical behavioural constructs which are required in order to develop behaviour change interventions.
=> There was limited evidence underpinning ContextMechanism-Outcome configurations for the behaviour “Provide initial OD advice and support prior to formal assessment by a specialist’, thus further exploration of the determinants of this behaviour is required high-risk clinical groups, such as stroke survivors and people with Parkinson’s, particularly in hospitals and nursing/care homes.3-5 As a result, there are clear guidelines stipulating a proactive approach to OD identification and management for these groups and healthcare settings. Within these populations early identification and management of OD has been shown to reduce the risk of adverse outcomes, such as aspiration pneumonia,89 and unnecessary health resource use such as avoidable hospital admissions.
However, the vast majority of people with OD are not stroke survivors and people with Parkinson’s, they are the general older adult population (265 years).10 This population’s main interaction with the health system is with primary care healthcare professionals (HCP).1410-14 A 2022 meta-analysis estimated that up to 72.4% of older adults have some degree of OD.10 As the occurrence of OD positively correlates with increase in age, the prevalence of OD is expected to increase as the population ages.15 Unlike for stroke survivors and people with Parkinson’s, there are

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no guidelines or formal processes to facilitate early identification and management of OD for older adults living in their own homes.341617 Furthermore, most older adults incorrectly perceive swallowing difficulties as a normal part of ageing and thus do not actively seek support from their primary care HCP.18-24 Left unmanaged, OD in older adults leads to adverse outcomes including aspiration pneumonia, malnutrition and hospitalisation.“ Low healthcare-seeking behaviour from older adults increases the need for primary care HCPs to proactively identify potential OD in older adults to ensure prompt
'	28 29
management.
Currently, primary care HCPs, who are not OD experts, report overlooking and undermanaging OD.1630-32 Only around 1 in 20 general practitioners (GP) and pharmacists working in primary care report routinely asking older adults about their swallowing.2'’ Reported barriers include a lack of knowledge, skills and confidence to proactively manage OD.17
There is a global drive towards proactive and preventative care for older adults supported by policy changes which advocate an increased role for primary care to reduce avoidable hospital admissions.14 Introducing proactive OD management in primary care requires a change in HCPs’ behaviour. The first step in changing behaviour is to define the target behaviour.33 Once defined, behavioural science provides a lens for conceptualising barriers and enablers to undertaking the new behaviour(s). This provides the theoretical understanding tor developing an intervention.'
Realist reviews aim to understand the mechanisms by which interventions work, or do not work, in different contexts.37 33 They draw on evidence to describe contextual (C) factors that instigate a mechanism(s) (M) to produce an outcome(s) (O).39
This realist review combined behaviour change theory with realist methodology to understand what works, for whom, under what circumstances and how, to facilitate primary care HCPs to proactively manage OD in older adults.
MATERIALS AND METHODS
Detailed methods are provided in the associated published realist review protocol.40 The review was registered with PROSPERO (CRD42022320327), adhered to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication standards (see online supplemental file 1)4142 and followed an approach for embedding behaviour change theory into realist review methodology.43 44 This combination of realist methodology and behavioural science is an emerging approach and is being increasingly used in both realist reviews4344 and realist evaluations.45-47 There is often uncertainty within the field of ‘traditional’ realist review methodology regarding what defines a context(s) versus a mechanism(s).48 A context may be cultural norms and social identity; however, mechanisms by whicli behaviour change may be brought about are also cultural norms and social identity. Incorporating behavioural science into a realist review provides recognised definitions of mechanisms to drive uniformity in realist review data interpretation and reporting. This realist review will report on behavioural mechanisms defined as ‘the process by which the active ingredients of an intervention affect behaviour’.49 Context, therefore, is defined as how the mechanism is operationalised or experienced by the target audience of an intervention. For example, for the behavioural mechanism of ‘Skills’, the context may be a training session to the target audience to address a skills gap.4350 Use of formal theory from disciplines such as behavioural science also provides a framework from which to generate and structure programme theories.51 This review used the theoretical domains framework (TDF), a synthesis of behaviour change theories, which can broaden the scope from which initial programme theories (IPT) are generated.4452 It enables consideration of contextual influences at different environmental levels (eg, individual, interpersonal, institutional, etc).51
Patient and public involvement
For this realist review, we convened a stakeholder group whicli comprised an older adult with OD, a carer, three speech and language therapists, a GP, two geriatricians and two pharmacists.40 The group contributed from study inception to inform review design and scope. Meetings with the stakeholder group occurred: prior to the review to inform review questions and refine the scope (see section 2.1), during IPT development and prioritisation (see section 2.2) and after testing of IPTs to evaluate final CMOcs (see section 2.6).
Defining the review questions and scope
The review questions and scope were first defined in the associated protocol,40 in which the target behaviours were:
1.		Recognising OD.
2.		Initially diagnosing OD.
Following a workshop witli the stakeholder group, the older adult witli OD and carer stakeholder members expressed that they also expect HCPs to provide some level of support prior to the patient seeing a specialist. The group also expressed that ‘recognising’ and ‘initially diagnosing’ could be subsumed under one behaviour. However, they felt that primary care HCPs should not be required to formally diagnose OD as this is the domain of specialists, such as speech and language therapists. Accordingly, the two target behaviours were redefined as: 1. Proactively identifying potential OD in older adults.
2.		Providing initial OD advice and support prior to formal assessment by a specialist.
The researcli questions were:
1.		What are the barriers and enablers (determinants) to primary care HCPs undertaking the target behaviours?
2.		What are the behavioural mechanisms by which interventions to facilitate the target behaviours result in their outcomes?
3.		What contextual factors influence the behavioural mechanisms?
While the review focuses on OD in the primary care setting, the stakeholder workshop confirmed that evidence from OD in the hospital setting and cancer screening evidence offers transferrable learning.3'40
IPT development and prioritisation
Development of IPTs drew on die following:
1. Initial scope of the evidence.
2.		The experience within the research team and stakeholder group.
3.		An a priori framework of behaviour change theories, the Theoretical Domains Framework.3 53 54
Witli the stakeholder group, IPTs were generated inductively, describing the beliavioural mechanisms by whicli interventions may facilitate the target behaviours. These were then mapped to relevant domains of the TDF (see table 1). Stakeholders also worked alongside the researcli team to generate additional IPTs deductively for any unmapped TDF domains. Deductive development of IPTs for any TDF domains not represented in the inductive
Table 1 The 14 domains of the theoretical domains framework reproduced from Atkins et al5256	
Domain	Definition	Examples of domain constructs	
Knowledge	An awareness of the existence of something.	► Knowledge (including knowledge of condition/scientific rationale)
► Procedural knowledge	
Skills	An ability or proficiency acquired through practice.	► Competence
► Interpersonal skills
► Practice	
Social/professional role and identity	A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting.	► Professional identity
► Professional role
► Professional confidence	
Beliefs about capabilities	Acceptance of the truth, reality or validity about an ability, talent or facility that a person can put to constructive use.	► Self-confidence
► Self-efficacy
► Self-esteem	
Optimism	The confidence that things will happen for the best or that desired goals will be attained.	► Optimism
► Pessimism
► Unrealistic optimism	
Beliefs about consequences	Acceptance of the truth, reality or validity about outcomes of a behaviour in a given situation.	► Outcome expectancies
► Anticipated regret	
Reinforcement	Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus.	► Rewards
► Incentives
► Punishment	
Intentions	A conscious decision to perform a behaviour or a resolve to act in a certain way.	► Stability of intentions	
Goals	Mental representations of outcomes or end states that an individual wants to achieve.	► Goal priority
► Goal/target setting
► Action planning	
Memory, attention and decision	The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives.	► Memory
► Attention	
processes		► Decision-making	
Environmental	Any circumstance of a person’s situation or environment that	► Environmental stressors	
context and	discourages or encourages the development of skills and	► Resources/material resources	
resources	abilities, independence, social competence and adaptive behaviour.	► Organisation culture/climate	
Social influences	Those interpersonal processes that can cause individuals to change their thoughts, feelings or behaviours.	► Social pressure
► Social norms
► Social support	
Emotion	A complex reaction pattern, involving experiential, behavioural and physiological elements, by which the individual attempts to deal with a personally significant matter or event.	► Fear
► Anxiety
► Stress	
Behavioural regulation	Anything aimed at managing or changing objectively observed or measured actions.	► Self-monitoring
► Breaking habit	
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generation of IPTs was still guided by (1) evidence and (2) experience and is not, therefore, intended to be exhaustive.43 50
The stakeholder group then prioritised IPTs for testing with the evidence according to their importance in facilitating the target behaviour(s). This was conducted through two phases; an online activity, using the JISC Discovery tool, followed by a 2-hour workshop.43 44 The online activity asked stakeholders to rate IPTs as ‘important’, ‘not sure’, ‘not important’ or ‘the meaning of this statement is unclear’. IPTs witli 100% rated as ‘important’ by all stakeholders in the online activity were automatically selected for testing in the review. IPTs with partial consensus, between 75% and 99% rated as ‘important’, were discussed in the stakeholder workshop.55 Any IPTs with less than 75% agreement for ‘important’ were excluded from any further discussion or testing. If IPTs were rated by more than 25% of stakeholders as ‘the meaning of this statement is unclear’, then these were also discussed in the workshop. Stakeholders were also invited at the end of the online activity to provide comments on the IPTs and propose additional IPTs for discussion in the workshop.56
Searching for evidence
We searched Medline, Google Scholar, PubMed, EMBASE, CINAHL, AMED, Scopus and PsycINFO from inception up to the time the primary search was conducted (June 2022). For full search strategies, see online supplemental file 2. This primary search was supplemented witli snowballing by reviewing the reference lists of included evidence and performing targeted searches based on emerging evidence. Online supplemental file 3 provides the eligibility criteria for identified evidence.
Selecting and appraising evidence
Two reviewers (CS and KR) independently screened titles, abstracts and full texts for eligibility. Full text appraisal was based on:
(1)		Methodological rigour.
Assessed using the Mixed Methods Appraisal Tool, the Critical Appraisal Skills Programme checklist for systematic reviews57 and the Authority, Accuracy, Coverage, Objectivity, Date, Significance checklist.58
(2)		Relevance to the IPTs being tested.
See online supplemental file 4 for criteria used to rate evidence from high to no relevance.39
(3)		Richness of causal insights.311160
See online supplemental file 4 for criteria used to rate evidence from high richness to thin.61
Discrepancies were discussed and any disagreements resolved with a third reviewer (SS).
Data extraction
Included evidence was imported into NVivo for data extraction and analysis.40 62-64 The data extraction process was tested on a 10% sample of included evidence to ensure consistency. Evidence was then divided between
two reviewers (CS and CJ) for initial study and any text deemed relevant to the review was highlighted witli a brief note attached on its pertinence to existing or emerging programme theories (eg, ΊΡΤ 1, Context’). Once the reviewer read through and highlighted the paper, coding to the appropriate TDF domain and IPT was completed.
Title nodes were created in a hierarchical structure to organise codes under the relevant IPT and corresponding TDF domain and also to categorise the code as supporting or contradicting an IPT, for example, ‘Skills’ -> IPT 2 -> Supporting. Code names originated from the data itself (inductively) relating to the (1) context, (2) mechanism and/or (3) outcome and then mapped to an existing or new IPT and corresponding TDF domain (deductively). If numerous manuscripts provided the same supporting/ contradicting evidence, it was then mapped to the same code. New IPTs were generated where there was sufficient evidence. Discrepancies in coding were resolved among the two reviewers, with any disagreements resolved with a third reviewer (SS).
Data analysis and synthesis
Coded data were used to create notes in a Microsoft Excel spreadsheet to record the key supporting and contradicting evidence for existing and emerging IPTs. The two reviewers (CS and CJ) met on a weekly basis to discuss the new evidence generated from analysed manuscripts and to discuss any queries or uncertainties in evidence coding and/or mapping. These data were then synthesised and used to refine or reject IPTs to accurately reflect the emerging evidence after discussions and agreement with the rest of the researcli team. Evidence synthesis comprised the following steps:
►		Generating themes across the codes amid patterns among context, mechanism and outcomes, to confirm, refute or refine IPTs.
►		Linking the patterns to refine programme theories.
IPTs supported by the evidence were then presented as CMOcs to explicitly express the relationship between context, mechanism and outcome. Refined IPTs and CMOcs were presented to the project’s stakeholder group for feedback and refined where necessary.
RESULTS
IPT development and prioritisation
10 inductive IPTs were developed and mapped to eight TDF domains. A further 12 IPTs were deductively generated for the remaining six TDF domains (see online supplemental file 5). Online supplemental file 6 provides the results from the stakeholder prioritisation online activity. Nine stakeholders completed the online activity. The number of participants rating an IPT ‘important’ in order to achieve partial consensus (75-99%) was set between 6 and 8. One IPT, mapped to the TDF domain ‘Skills’, was rated as important by 100% of the stakeholder group. 11 IPTs received partial consensus and one IPT,
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Prioritised IPT No	TDF domain	Prioritised IPT statement	Target behaviour	
1	Knowledge	If HCPs are given education about the signs, symptoms and risk factors of OD (C), then they are more likely to proactively identify OD (Ο), because they have the appropriate knowledge (M).	Proactively identify potential OD in older adults.	
2	Skills	If HCPs are trained to provide initial advice and support to older adults with suspected OD (C), then they are more likely to provide this (0), because they have the necessary skills to do so (M).	Provide initial OD advice and support prior to formal assessment by a specialist.	
3	Memory, attention and decision processes	If HCPs have a screening tool to follow (C), then they will be more likely to proactively identify OD (0), because it facilitates decision-making (M).	Proactively identify potential OD in older adults.	
4	Environmental context and resources	If there are websites, forums, information leaflets, etc to give to patients (C), then HCPs are more likely to provide initial advice and support for older adults with suspected OD (0), because they have the required resources (M).	Provide initial OD advice and support prior to formal assessment by a specialist.	
5	Social, professional role and identity	If HCPs perceive that their role includes proactively identifying OD and providing initial advice and support for older adults with suspected OD (C), then they will be more likely to carry this out, because they feel obligated to (M).	►		Proactively identify potential OD in older adults.
►		Provide initial OD advice and support prior to formal assessment by a specialist.	
6	Beliefs about consequences	If the adverse outcomes that occur from unaddressed OD are highlighted to HCPs (C), then they will be more likely to proactively identify OD and provide initial advice and support to older adults with suspected OD (Ο), because they are aware of the adverse consequences of not doing so (M).	►		Proactively identify potential OD in older adults.
►		Provide initial OD advice and support prior to formal assessment by a specialist.	
7	Optimism	If HCPs hear about case studies of positive outcomes associated with proactively identifying OD and providing initial advice and support to older adults with suspected OD (C), then they will be more likely to carry this out (O), because they will be confident that them undertaking the behaviour will also lead to positive outcomes (M).	►		Proactively identify potential OD in older adults.
►		Provide initial OD advice and support prior to formal assessment by a specialist.	
HCP, healthcare professional; IPT, initial programme theory; OD, oropharyngeal dysphagia; TDF, theoretical domains framework.	
Table 2 Prioritised initial programme theories
mapped to the TDF domain Intentions, was rated as ‘the meaning of this statement is unclear’.
Online supplemental file 7 provides a summary of workshop discussions, witli stakeholders' rationale to prioritise or discard the remaining IPTs. Table 2 provides the seven IPTs which were prioritised for testing by the stakeholder group.
Search results
Figure 1 provides the PRISMA flow diagram.
Online supplemental file 8 provides the characteristics of included evidence from the primary search and online supplemental file 9 from snowballing. Most of the studies from the primary searcli were conducted across several
settings, for example, community, nursing homes and residential care,41820B'68 or in general practice/primary care.1'19 2369 Cross-sectional questionnaire studies were the most common design for evidence included from the primary search. The majority of studies from the snowballing sample were conducted in a hospital setting.
Predominantly qualitative and mixed methods studies were included through snowballing. Nurses were the most common HCP to be involved in proactively identifying OD and/or providing advice.
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Manuscripts identified in X			
database search: N=2311
AMED- 61
CINAHL- 78		•	Duplicates removed:
N= 919	
EMBASE- 1072			
Medline- 610			
Scopus- 490	/			
Number of manuscripts
after duplicates removed:
N= 1392
+
Title and abstract screening:
N= 1392
	Excluded: N= 1179	
	7	
Full text screening and
appraisal:
N= 213
Total evidence included in
review: N=36
Primary care OD: Ν= 25
Secondary care OD: Ν= 7
Cancer screening: N=4
N= 188
OD specialist management and/or assessment- 40 Self-assessment- 6 Secondary care- 6
Not enough focus on OD*- 13 Oesophageal dysphagia- 3 Low relevance & ‘thin’- 69 Not available in English- 25 NH evidence below appraisal criteria- 22
Beyond scope of review**- 4
Snowballing:
N= 11
Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of evidence search. *Evidence focused on interventions for conditions in which oropharyngeal dysphagia (OD) is a symptom. **Evidence which uses/reports on screening tools/identification processes which use observation and/or oral trials to detect potential OD. NH, nursing home.
Main findings
Table 3 shows the development of the seven prioritised IPTs and two new IPTs into five final programme theories and associated CMOcs.
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 (0)
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.7 6 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).55 68 78-81 One intervention provided a half-hour education session supplemented by an
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Smith C, et al. BMJ Open 2024;14:e086184. doi:10.1136/bmjopen-2024-086184
Prioritised IPT No and TDF domain/ mechanism	IPT	Refined/new IPT	Rationale for refinement	Final Context-Mechanism-Outcome configuration (CMOc)	Target behaviour	
1 Knowledge	If healthcare professionals are given education about the signs, symptoms and risk factors of dysphagia, then they are more likely to proactively identify OD, because they have the appropriate knowledge.	If healthcare professionals are not provided with basic education about the signs, symptoms and risk factors of dysphagia, then they will be less likely to proactively identify and provide initial advice and support for older adults with suspected OD, because they do not have the appropriate knowledge.	Refined from IPTs 1 and 2.
Evidence suggested HCPs require both knowledge and skills to proactively identify OD as well as provide initial advice and support. Negatively worded to reflect majority of evidence demonstrating healthcare professionals without	CMOc 1
Healthcare professionals 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).
17 19-23 65 67-69 71 72 76-81 91	►		Proactively identify potential OD in older adults.
►		Provide initial OD advice and support prior to formal assessment by a specialist.	
2 Skills	If healthcare professionals are trained to provide initial advice and support to older adults with suspected OD, then they are more likely to provide this, because they have the necessary skills to do so.	If healthcare professionals are not provided with basic training about how to identify signs, symptoms and risk factors of dysphagia, then they will be less likely to proactively identify and provide initial advice and support for older adults with suspected OD, because they do not have the appropriate skills.	required knowledge and skills did not undertake the target behaviour(s). Interventions which targeted knowledge and skills were pragmatic—brief and basic.	Merged with CMOc 1	N/A	
3 Memory, attention and decision processes	If healthcare professionals have a screening tool to follow, then they will be more likely to proactively identify OD, because it facilitates decision-making.	If healthcare professionals do not have the required knowledge and skills, then they will be less likely to proactively identify and provide initial advice and support for older adults with suspected OD, because they will not be able to make correct decisions around what and how to screen for OD.	Refined from IPT 3. Evidence suggested that screening tools address a lack of knowledge and skills required to make correct decisions regarding OD identification. Screening tools are a standardised approach to facilitating HCPs’ (correct) decision-making.	CMOc 2
Healthcare professionals 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 (0).
17 68 70 71 74 77 80-82 84 87 100 101	►		Proactively identify potential OD in older adults.
►		Provide initial OD advice and support prior to formal assessment by a specialist.	
4
Environmental context and resources	If there are websites, forums, information leaflets, etc to give to patients, then healthcare professionals are more likely to provide initial guidance and support for older adults with suspected OD, because they have the required resources.	N/A	Discarded—insufficient evidence to support mechanism.	Merged with CMOc 1	N/A	
NEW Environmental context and resources	N/A	If OD identification is incorporated into existing health reviews/assessments/ systems used by healthcare professionals for older adults, such as medication reviews, then they will be more likely to proactively identify suspected OD in older adults, because of a more conducive work environment.	Evidence supported IPT without refinement.	CMOc 3
Incorporating OD identification into existing workflow (C) will create a conducive environment (M) for healthcare professionals to carry out this behaviour (0).
19 67 71 86-88	Proactively identify potential OD in older adults.	
5 Social, professional role and identity	If healthcare professionals perceive that their role includes proactively identifying OD and providing initial advice and support for older adults with suspected OD, then they will be more likely to carry this out, because they feel obligated to.	Discarded—insufficient evidence to support mechanism.	N/A	N/A	N/A	
Table 3 Development of seven IPTs to five final programme theories and CMOcs
Continued
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Open access
Smith C, et al. BMJ Open 2024;14:e086184. doi:1O.1136/bmjopen-2O24-O86184
Prioritised IPT No and TDF domain/ mechanism	Final Context-Mechanism-Outcome
IPT	Refined/new IPT	Rationale for refinement	configuration (CMOc)	Target behaviour	
NEW
Social influence	N/A	If healthcare professionals are aware	Evidence supported IPT without	CMOc 4	► Proactively identify
that patients and carers expect them	refinement.	Healthcare professionals who are aware	potential OD in older
to address OD, then they will be more	that older adults and carers expect them	adults.
likely to proactively identify and provide	to address OD (C) will be encouraged (M) ► Provide initial OD advice
initial advice and support for older	to proactively identify OD and provide	and support prior to
adults with suspected OD, because they	initial advice and support to older adults	formal assessment by a
will be encouraged to address patient	with suspected OD (O).	specialist,
concerns/wishes.	188990	
6
Beliefs about consequences	If the negative outcomes that occur	N/A	Evidence supported IPT without	CMOc 5	► Proactively identify
from unaddressed OD are highlighted to	refinement.	Healthcare professionals who are aware	potential OD in older
healthcare professionals, then they will be	of the adverse outcomes associated with	adults.
more likely to proactively identify OD and	OD (C) will recognise the importance (M)	► Provide initial OD advice
provide initial advice and support to older	of proactively identifying OD and providing	and support prior to
adults with suspected OD, because they are	initial advice and support for older adults	formal assessment by a
aware of the adverse consequences of not	with suspected OD (O).	specialist.
doing so.	17 19 65 69 78 88 102	
7 Optimism	If healthcare professionals hear about	Discarded—insufficient evidence to	N/A	N/A	N/A
examples of positive outcomes associated support mechanism.
with proactively identifying OD and
providing initial advice and support to older
adults with suspected OD, then they will be
more likely to carry this out, because they
will be confident that them undertaking
the behaviour will also lead to positive outcomes.	
Table 3 Continued
HCP, healthcare professional; IPT, initial programme theory; OD, oropharyngeal dysphagia; TDF, theoretical domains framework.
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information pamphlet witli key messages for participants to take away. 78 HCPs who received the intervention scored an 80% average on their dysphagia knowledge, compared witli 50% in the control group.78 The intervention group also reported being more likely to proactively identify OD in their practice compared witli the control group.‘
Training to develop ‘Skills’ was delivered through case-based sessions69 70 and simulations for HCPs to practise.68 777881 Sessions focused on developing HCPs' ability to identify OD using appropriate tools/protocols and communicating a potential OD diagnosis witli patients (Skills).68-70 7/ 7881 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 00 (0)
Without the required knowledge and skills and validated OD checklists, HCPs were less likely to correctly identify OD and provide appropriate advice.4 1774778283 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 syniptoms they looked out for.'3 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.'4 In the absence of validated tools/protocols, HCPs also become more reliant on patients self-reporting their swallowing difficulties.'182
Checklists provide a standardised approach to HCPs’ ‘Memory, attention and decision processes’ to facilitate them to identify OD.4 11 /3 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 ' ' 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.818284 858' 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 (0)
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 witli 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 witli 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 witli adverse consequences in older adults.196'88
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 0D (0)
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 witli 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.8990 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 0D (0)
HCPs may ‘trivialise’ OD as an inevitable and minor consequence of ageing.65 7891 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. Stakeholders also highlighted the importance of emphasising the positive consequences of HCPs proactively identifying and providing initial advice and support.
DISCUSSION
This behavioural science realist review, undertaken collaboratively with stakeholders, has determined that an intervention is required to facilitate primary care HCPs to (a) proactively identify potential OD in the general older population and (b) provide initial advice and support to those with suspected OD while they wait for formal assessment by a specialist. Interventions should provide education and training (Knowledge and Skills), facilitate HCPs’ decision-making (Memory, attention and decision processes), incorporate OD identification into existing workflow (Environmental context and resources), increase HCP awareness of older adults and carers’ expectations (Social influences) and raise awareness of the adverse outcomes of OD (Beliefs about consequences). All CMOcs, apart from CMOc 3 (Environmental context and resources), are relevant to both target behaviours.
The initial barrier for HCPs appears to be a lack of awareness of patient/carer expectations, as well as the size and nature of the problem in older adults. Therefore, interventions need to address ‘Social influence’ to make HCPs aware of the patient/carer expectations and ‘Beliefs about consequences’ that OD is inconsequential. A systematic review of interventions to increase HCPs’ awareness of patient expectations indicates several characteristics which influence HCP behaviour.9' Characteristics of successful HCP behaviour change include perceived credibility of the information source conveying patient expectations, congruency of information witli selfperceptions and performance expectations and encouraging HCPs to reflect on the extent their practice aligns witli patient expectations. *
Once awareness of a required change in practice has been established, equipping them witli the ‘Knowledge’ and ‘Skills’ to identify OD and provide initial advice

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and support is necessary. While the evidence consistently demonstrated improved knowledge and skills, the extent to which these findings are replicable beyond the research setting is unclear. However, it was notable that burden to HCPs was minimised in all provided education and training by focusing on the core concepts of OD.
Implementing validated checklists is a recognised strategy to improve the quality of care and patient outcomes.93 Evidence supporting the use of checklists in OD indicates that they address knowledge and skill gaps and are thus useful for HCPs with limited OD knowledge and skills. Additionally, checklists facilitate 'Memory, attention and decisions processes’ by acting as a prompt and guiding decision-making. They, therefore, have a place in interventions delivered even to HCPs with the required knowledge and skills.71
Successful interventions adapted to recognise resource limitations. Increasingly, the healthcare literature reports on the additional time pressures experienced by primary care health services.94 Incorporating OD identification into existing workflows used existing ‘Environmental context and resources’ and aligns witli initiatives sucli as the ‘Make Every Contact Count’ campaign in the UK, whicli supports using any day-to-day patient interactions to make positive health changes.95 Embedding OD identification into existing work patterns may also minimise the negative perceptions of an increase in practitioner workload, often associated witli mass population screening.96 For older adults who perceive OD to be a natural part of ageing, a separate process to identify OD may be viewed as an annoyance. Avoiding an additional stand-alone service for identifying OD may thus lead to better engage
. 71 96 ment.
The application of behavioural science to conceptualise mechanisms is a strength of this realist review. A relatively new and novel approach to evidence syntheses, underpinning this review witli a behavioural science framework, the TDF, ensured all potential mechanisms of action of behaviour change were considered when generating IPTs. Through the TDF’s linkage to a taxonomy of behaviour change techniques, future research can identify and select the ‘active ingredients’ of an intervention to be delivered via these behavioural mechanisms.97 Due to the nature of realist reviews,37 learning from different contexts (eg, care homes and hospitals) and clinical groups (eg, stroke, cancer, etc) was drawn on. The review process was supported throughout by the stakeholder group, ensuring the review remained pertinent to primary care HCPs, patients and the primary care context.
The review was, however, limited by the richness of the evidence underpinning some CMOcs. Wliile evidence related to the target behaviour of proactively identifying OD was rich, evidence to support CMOcs describing how to support HCPs to provide initial advice and support lacked richness. For example, CMOc 3 only relates to the first target behaviour, proactively identify OD. This may be because the behavioural mechanism is not applicable to both target behaviours. However, further exploration

is required to enhance the richness of evidence related to the determinants of the second target behaviour of providing initial advice and support. Oilier limitations are shared with those of many evidence syntheses, for example, the included evidence predominantly originated from higher income countries, potentially limiting the applicability of findings to low- and middle-income settings. Realist evaluations may be used to confirm, refine or refute programme theories which have been developed from realist reviews.98 This approach allows for enrichment of the evidence supporting the causal assumptions described by CMOcs and thus more accurate prediction of the likely outcomes from an intervention, developed from CMOcs, prior to its implementation.9899
CONCLUSION
The review identified five programme theories across six domains of the TDF explaining how primary care HCPs can be supported to proactively identify OD in older adults and provide initial advice for those with suspected OD.
This understanding of why intervention components work enables different operationalisations according to the resource and infrastructure of an organisation. However, no one intervention included in this review addresses all six behavioural mechanisms, further work is required by service delivery teams to operationalise the behavioural mechanisms into a comprehensive complex intervention. By developing these programme theories using ‘recognised’ behavioural mechanisms, this facilitates intervention development through the linkage between the TDF and the corresponding behaviour change techniques for each domain.46 Selection and operationalisation of behaviour change techniques as intervention components may be achieved via codesign with patients, HCPs and other professions in the healthcare system.
X Caroline Smith @CarolineS_SLT
Acknowledgements Thank you to the University of Leicester Library services team for their support in developing the review's search strategy. Thank you also to the stakeholder group that comprised an older adult with OD, a carer, three speech and language therapists, a general practitioner, two geriatricians and two pharmacists.
Contributors DB, SS and CS conceptualised the review and wrote the manuscript. DB conceptualised the approach used in this review for embedding behaviour change theory into realist review methodology. SS and DB supervised the project. CS conducted the evidence search, selection, appraisal, extraction and synthesis. KR was involved with initial and full text screening and appraisal. CJ was involved with evidence extraction and synthesis. DH provided clinical expertise throughout the review. SS is the guarantor for the project.
Funding This work was funded by the College of Life Sciences at the University of Leicester under a PhD scholarship programme.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Patient consent for publication Not applicable.
Ethics approval Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.0rg/licenses/by-nc/4.0/.
ORCID IDs
Caroline Smith http://orcid.org/0000-0002-5993-4591
Sion Scott http://orcid.org/0000-0001-7669-0632
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84 Bowen A, Gómez-Trillos S, Curran G, et al. Advancing health equity: a qualitative study assessing barriers and facilitators of implementing hereditary breast and ovarian cancer risk screening tools in community-based organizations. J Genet Couns 2023;32:965-81.
85 Takeuchi Κ, Aida J, Ito Κ, et al. Nutritional status and dysphagia risk among community-dwelling frail older adults. J Nutr Health Aging 2014;18:352-7.
86 Bottino-Bravo Ρ, Thomson J. When It??s a hard act to swallow. Home Health Nurs J Home Care Hosp Prof 2008;26:244-50.
87 Ireland CJ, Laws ΤΑ, Thompson SK. General practitioners’ use of risk prediction tools and their application to barrett’s oesophagus: a qualitative study. J Primary Health Care Gen Pract 2018;2.
88 Clave Ρ, Rofes L, Carrion S, et al. Pathophysiology, relevance and natural history of oropharyngeal dysphagia among older people. Nestle Nutr Inst Workshop Ser 2012;72:57-66.
89 Tudiver F, Brown JB, Medved W, et al. Making decisions about cancer screening when the guidelines are unclear or conflicting. J Fam Pract 2001;50:682-7.
90 Haggerty J, Tudiver F, Brown JB, et al. Patients’ anxiety and expectations: how they influence family physicians’ decisions to order cancer screening tests. Can Fam Physician 2005;51:1658-9.
91 Lindroos E, Saarela RKT, Soini Η, et al. Caregiver-reported swallowing difficulties, malnutrition, and mortality among older people in assisted living facilities. J Nutr Health Aging 2014;18:718-22.
92 Baines R, Regan de Bere S, Stevens S, et al. The impact of patient feedback on the medical performance of qualified doctors: a systematic review. BMC Med Educ 2018;18:173.
93 Park KD, Kim TH, Lee SH. The gugging swallowing screen in dysphagia screening for patients with stroke: a systematic review. Int J Nurs Stud 2020;107:103588.
94 Salisbury SHH. The 10 minute appointment. BMJ 2019;365:l2389.
95 Public Health. Making Every Contact Count (MECC): Consensus Statement, 2016. Available: https://www.england.nhs.uk/wp- content/uploads/2016/04/making-every-contact-count.pdf
96 Kelly MP. Screening and health promotion. Medicine (Abingdon) 2018;46:375-8.
97 Michie S, Johnston M. Theories and techniques of behaviour change: developing a cumulative science of behaviour change. Health Psychol Rev 2012;6:1-6.
98 Greenhalgh Τ, Pawson R, Wong G, et al. Realist evaluation, realist synthesis, realist research - what’s in a name, 2017. Available:
https://www.ramesesproject.org/media/RAMESES_ll_RE_RS_RR_ whatsJn_a_name.pdf
99 Renmans D, Castellano Pleguezuelo V. Methods in realist evaluation: a mapping review. Eval Program Plann 2023;97:102209.
100		Oliveira I de J, Da Mota LAN, Freitas SV, et al. Dysphagia screening tools for acute stroke patients available for nurses: a systematic review. NPT 2019;Available from.
101		Murray A, Mulkerrin S, O’Keeffe ST. The perils of “risk feeding.” Age Ageing 2019;48:478-81.
102		Lindroos E, Jyvàkorpi S, Soini Η, et al. Swallowing difficulty and nutrient intakes among residents in assisted living facilities in Helsinki. Eur Geriatr Med 2017;8:228-33.
Supplementary file 1. RAMESES Publication standards: Realist syntheses*(1)
Section	Page No°	
Title		
1		In the title, identify the document as a realist synthesis or review.	1	
Abstract		
2		While acknowledging publication requirements and house style, abstracts should ideally contain brief details of: the study's background, review question or objectives; search strategy; methods of selection, appraisal, analysis and synthesis of sources; and implications for practice.	2	
Introduction		
3	Rationale for review.	Explain why the review is needed and what it is likely to contribute to existing understanding of the topic area.	3-5	
4	Objectives and focus.	State the objective(s) of the review and/or the review question(s). Define and provide a rationale for the focus of the review.	3-6	
Methods		
5	Changes in the review process	Any changes made to the review process that was initially planned should be briefly described and justified.	5-6	
6	Rationale for using realist synthesis.	Explain why realist synthesis was considered the most appropriate method to use.	3-5	
7	Scoping the literature.	Describe and justify the initial process of exploratory scoping of the literature.	See protocol (2)	
8	Searching processes.	While considering specific requirements of the journal or other publication outlet, state and provide a rationale for how iterative searching will be done. Where searching in electronic databases will take place, the details should include, for example, name of database, search terms, dates of coverage and date last searched. If individuals familiar with the relevant literature and/or topic area will be contacted, indicate how they will be identified and selected.	9 (see supplementary file 6 and protocol for further	

			details(2))	
9	Selection and appraisal of documents.	Explain how judgements will be made about including and excluding data from documents.	9	
10	Data extraction.	Describe and explain how data or information will be extracted from the included documents and justify this selection.	9-10	
11	Analysis and synthesis processes.	Describe the proposed analysis and synthesis processes in detail.	10	
Results		
12	Document flow diagram	Provide details on the number of documents assessed for eligibility and included in the review with reasons for exclusion at each stage as well as an indication of their source of origin (for example, from searching databases, reference lists and so on). You may consider using the example template: (which are likely to need modification to suit the data) that are provided.	12, Figure 1	
13	Document characteristic	Provide information on the characteristics of the documents included in the review.	12 (see also supplementary file 8 & 9)	
14	Main findings	Present the key findings with a specific focus on theory building and testing.	12-17	
Discussion		
15	Summary of findings	Summarize the main findings, taking into account the review's objective(s), research question(s), focus and intended audience(s).	18	
16	Strengths, limitations and future research directions	Discuss both the strengths of the review and its limitations. These should include (but need not be restricted to) (a) consideration of all the steps in the review process and (b) comment on the overal strength of evidence supporting the explanatory insights which emerged.
The limitations identified may point to areas where further work is needed.	19	
17	Comparison with existin literature	Where applicable, compare and contrast the review's findings with the existing literature (for example, other reviews) on the same topic.	18-19	
18	Conclusion and recommendations	List the main implications of the findings and place these in the context of other relevant literature, appropriate, offer recommendations for policy and practice.	20	
19	Funding	Provide details of funding source (if any) for the review, the role played by the funder (if any) and any conflicts of interests of the reviewers.	28	

1.		Wong G. Greenhalgh Τ, Westhorp G, Buckingham J, Pawson R. RAMESES publication standards: realist syntheses. BMC Med. 2013 Jan 29;11(1):21.
2.		Smith C, Bhattacharya D. Scott S. Understanding how primary care practitioners can be supported to recognise, screen and initially diagnose oropharyngeal dysphagia: protocol for a behavioural science realist review. BMJ Open. 2023 Feb;13(2):e065121.
Realist review final search strategies
Medline search strategy
Ovid MEDLINE(R) ALL <1946 to June 07, 2022>
1		Deglutition Disorders/ 22692
2		oropharyngeal dysphagia.mp.	1094
3		dysphagia.mp. 32319
4		((swallow* or deglutit* or dysphag*) adj (disturbance* or disorder* or difficult* or dysfunction* or impair* or condition* or abnormal* or damage* or injur*)).ab,hw,kf,kw,ot,sh,ti,ui. 25430
5		(scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or diagnos* or detect* or hazard or risk or test or advi* or support*).ab,hw,kf,kw,ot,sh,ti,ui. 20638634
6		Primary Health Care/	88219
7		Primary care.mp.	135699
8		primary health care.mp.104620
9		General Practice/	14857
10		general practice.mp.	51373
11		Home Care Services/ 35640
12		Nursing Homes/	38080
13		nursing home*.mp.	50940
14	care home*.mp. 5068
15	1 or 2 or 3 or 4 43518
16	6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14	308021
17	5 and 15 and 16
610
Embase search strategy
Embase <1974 to 2022 June 08>
1		dysphagia/ 81193
2		oropharyngeal dysphagia.ab,kw,ti.	2003
3		((swallow* or deglutit* or dysphag*) adj (disturbance* or disorder* or difficult* or dysfunction* or impair* or condition* or abnormal* or damage* or injur*)).ab,kw,ti. 7906
4		screening/ 186037
5		(scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or diagnos* or detect* or hazard or risk or test or advi* or support*).ab,kw,ti.	20721189
6		primary health care/	74450
7		primary care.ab,kw,ti.	183060
8		general practice/	81739
9		"care home*".ab,kw,ti.	6402
10		"nursing home*".ab,kw,ti. 44223
11		dysphagia.ab,kw,ti.	56058
12		lor 2 or 3 or 1194067
13		4 or 5 20731684
14		6 or 7 or 8 or 9 or 10	340877
15		12 and 13 and l4
1072
Scopus search strategy
( TITLE-ABS-KEY ( "Deglutition Disorders" OR "oropharyngeal
dysphagia" OR dysphagia OR (swallow* OR deglutit* OR dysphag*) W/ ( disturbance
*		OR disorder* OR difficult* OR dysfunction* OR impair* OR condition* OR abnormal
*		OR damage* OR injur*))
AND TITLE-ABS
KEY (scale* OR screen* OR checklist* OR assess* OR exam* OR identif* OR recog ni* OR evaluat* OR diagnos* OR detect* OR hazard OR risk OR test OR advi* OR support* )
AND TITLE-ABS-KEY ("Primary Health Care" OR "Primary care" OR "primary health care" OR "General Practice” OR "Home Care Services" OR "Nursing Home*" OR "care home"))
490
AMED search strategy
"Deglutition Disorders" OR "oropharyngeal dysphagia" OR dysphagia OR "swallow disorder*" OR "swallow impairment*" OR "swallow difficult*"
AND
scale* OR screen* OR checklist* OR assess* OR exam* OR identif* OR recogni* OR evaluat* OR diagnos* OR detect* OR hazard OR risk OR test OR advi* OR support*
AND
"Primary Health Care" OR "Primary care" OR "primary health care" OR "General Practice" OR
"Home Care Services" OR "Nursing Home*" OR "care home"
67
CINAHL & Psychinfo search strategy
Tl ( "Deglutition Disorders" OR "oropharyngeal dysphagia" OR dysphagia OR (swallow* OR deglutit* OR dysphag*) W (disturbance* OR disorder* OR difficult* OR dysfunction* OR impair* OR condition* OR abnormal* OR damage* OR injur*))
AND Tl (scale* OR screen* OR checklist* OR assess* OR exam* OR identif* OR recogni* OR evaluat* OR diagnos* OR detect* OR hazard OR risk OR test OR advi* OR support*)
AND TX ( "Primary Health Care" OR "Primary care" OR "primary health care" OR "General Practice" OR "Home Care Services" OR "Nursing Home*" OR "care home" )
Results 78

Supplementary file 3. Evidence eligibility criteria
Inclusion criteria	
P- Population	HCPs, for example, doctors, nurses, pharmacists, allied health professionals. Patients or caregivers with experience of HCPs proactively identifying and/or providing initial advice and support for OD or cancer populations.	
I- Intervention	Interventions to proactively identify and/or provide initial advice and support to people with suspected OD or cancer populations.	
C- Comparator	None.	
0- Outcome	Outcomes depended on the nature of the intervention. Examples include: HCPs' knowledge/skills/behaviours related to proactively identify and/or provide initial advice and support for OD or cancer populations.
Patients'/carers' response to OD or cancer identification, acceptance of advice/adjustments, relationship with HCPs.
Process or implementation outcomes, for example, health service use, change in care delivery.	
S- Setting.	Any primary care or community-based health or social care service, e.g. general practice, care homes, charities.
Hospital (Snowball sample only)	
Study design	
No restriction on study design.	
Include non-empirical sources, e.g., commentaries, guidelines, theses etc. through citation searches or identification through the core research team and stakeholder group.	
Exclusion criteria	
Non-English evidence.	
Evidence that focussed solely on interventions targeting patient behaviour.	
Evidence that used/reported on screening tools/identification processes which use observation and/or oral trials to detect potential OD or cancer populations.	

Supplementary file 4. Relevance and richness criteria
High relevance	Primary care interventions targeting practitioner behaviour to proactively identify and/or provide initial advice and support for patients with suspected OD.
Evidence reports on HCPs knowledge /skills /behaviours needed to proactively identify and/or provide initial advice and support for patients with suspected OD.
Evidence reports on process or implementation outcomes, for example, health service use, change in care delivery.
OPTIONAL:
Evidence reports on patients, for example, response to diagnosis of the condition, acceptance of advice/adjustments, relationship with HCPs.	Conceptually rich	Causal insight and in depth detail of the intervention which can contribute to/create a CMO configuration.	
Moderate relevance	Primary care interventions targeting practitioner behaviour to proactively identify and/or provide initial advice and support for patients with suspected OD.
Evidence reports on patients, for example, response to diagnosis of the condition, acceptance of advice/adjustments, relationship with HCPs.
OPTIONAL:
Evidence reports on process or implementation outcomes, for example, health service use, change in care delivery.	Moderately rich	Some degree of causal insight with sufficient detail of the intervention which can contribute to/create parts of a CMO configuration (e.g. context & outcome)	
Low relevance	Methods which use proactive identification processes and/or initial advice and support by the research team in a primary care setting which could be used by practitioners.
Evidence reports on quantitative patient outcomes and/or process or implementation outcomes, for example, health service use, change in care delivery.	"Thin"	Lim ited or no causal insight with into the context, mechanisms or outcomes of the intervention	
No relevance	Does not meet any of the above criteria.		

Supplementary file 5. Inductively and deductively generated initial programme theories
Inductively generated IPTs	
TDF domain	IPT statement	
Knowledge	If HCPs are given education about the signs, symptoms and risk factors of dysphagia, then they are more likely to proactively identify OD, because they have the appropriate knowledge.	
Skills	If HCPs are shown how to proactively identify OD by dysphagia specialists, they are more likely to carry this out, because they will have developed the necessary skills.	
Social/professional role and identity	If HCPs perceive that their role includes proactively and providing initial advice and support for patients with suspected OD, then they will be more likely to carry this out, because they feel obligated to.	
Reinforcement	If the organisation incentivises proactively identifying and providing initial advice and support for patients with suspected OD, then HCPs will be more likely to carry this out, because they will be rewarded for doing so.	
Goals	If there is a dysphagia champion, then HCPs will be more likely to proactively identify OD and provide initial advice and support for patients with suspected OD, because they will perceive it as important.	
Memory, attention and decision processes	If HCPs have a screening tool to follow, then they will be more likely to proactively identify OD, because it facilitates decision making.	
Memory, attention and decision processes	If prompts are incorporated into HCP work flow, then this will trigger HCPs to proactively identify OD, because they will be reminded to carry it out.	
Environmental context and resources	If there are websites, forums, information leaflets etc. to give to patients, then HCPs are more likely to provide initial guidance and support for patients with suspected OD because they have the required resources to give to patients.	
Environmental context and resources	If HCPs have a guideline to follow, then they are more likely to provide initial advice to patients with suspected OD, because they have the required resources.	
Social influence	If HCPs perceive that patients, carers and relatives expect initial advice and support, then they will be more likely to provide this, because they will feel obligated to do so.	

Deductively generated IPTs	
TDF domain	IPT statement	
Skills	If HCPs are trained to give initial advice and support to patients with suspected OD, then they are more likely to provide this, because they have the necessary skills to do so.	
Beliefs about capabilities	If HCPs receive encouragement (e.g. certificates/congratulations/verbal persuasion) that they have the knowledge and skills around OD, then they will feel able to proactively identify OD and provide initial advice and support to patients with suspected OD, because they will believe themselves to have the capability.	
Optimism	If HCPs hear about case studies of positive outcomes associated with proactively identifying OD and providing initial advice and support to patients with suspected OD, then they will be more likely to carry this out, because they will be confident that them undertaking the behaviour will also lead to positive outcomes.	
Beliefs about consequences	If the adverse outcomes that occur from unaddressed OD are highlighted to HCPs, then they will be more likely to proactively identify OD and provide initial advice and support to patients with suspected OD, because they are aware of the adverse consequences of not doing so.	
Intentions	If HCPs make a conscious decision to proactively identify OD and provide initial advice and support for patients with suspected OD, then they will be more likely to carry this out, because they will have the intention to do so.	
Goals	If NHS settings identify proactively identifying OD and providing initial care for OD as one of their targets for improvement, then HCPs will want to include this in their practice because it achieves the organisation's goals.	
Memory, attention and decision processes	If HCPs have a decision support resource to guide them to provide initial advice and support to patients with suspected OD, then they are more likely to undertake the activity, because it facilitates appropriate decision making.	
Environmental context and resources	If HCPs have access to a screening tool, then they are more likely to proactively identify OD, because they have the necessary resources to facilitate this.	
Environmental context and resources	If HCPs' workplaces provide opportunities for relevant training, then they will be more likely to proactively identify OD and provide initial advice and support to patients with suspected OD, because they will have access to the required resources.	
Social influence	If HCPs observe that their peers are proactively identifying OD, then they will be more likely to carry this out, because they will be encouraged by their peers' behaviour.	
Emotion	If HCPs hear of patient experiences about the effects of OD/the benefits to getting a diagnosis, then they will be more likely to proactively identify OD and provide initial advice and support for patients with suspected OD, because they will feel more empathetic towards the patient experience.	
Behavioural regulation	If HCPs monitor the extent to which they proactively identify OD and provide initial advice and support for their patients with suspected OD, then they will be more likely to carry this out, because they will be able to evaluate their performance and make adjustments as necessary.	

Supplementary file 6. Stakeholder IPT prioritisation online activity
1.		If HCPs are given education about the signs, symptoms and risk factors of dysphagia, then they are more likely to proactively identify OD, because they have the appropriate knowledge.

2.		If HCPs are shown how to proactively identify OD by dysphagia specialists, they are more likely to carry this out, because they will have developed the necessary skills.

3.		
9 (100%)

If HCPs are trained to give initial advice and support to patients with suspected OD, then they are more likely to provide this, because they have the necessary skills to do so.
Important •
Not sure | 0
Not important | 0
The meaning of this statement | 0 is unclear

4.		If HCPs perceive that their role includes proactively and providing initial advice and support for patients with suspected OD, then they will be more likely to carry this out, because they feel obligated to.

5.		If HCPs receive encouragement (e.g. certificates/congratulations/verbal persuasion) that they have the knowledge and skills around OD, then they will feel able to proactively identify OD and provide initial advice and support to patients with suspected OD, because they will believe themselves to have the capability.

6.		If HCPs hear about case studies of positive outcomes associated with proactively identifying OD and providing initial advice and support to patients with suspected OD, then they will be more likely to carry this out, because they will be confident that them undertaking the behaviour will also lead to positive outcomes.

7.		If the adverse outcomes that occur from unaddressed OD are highlighted to HCPs, then they will be more likely to proactively identify OD and provide initial advice and support to patients with suspected OD, because they are aware of the adverse consequences of not doing so.

8.		If the organisation incentivises proactively identifying and providing initial advice and support for patients with suspected OD, then HCPs will be more likely to carry this out, because they will be rewarded for doing so.

9.		If HCPs make a conscious decision to proactively identify OD and provide initial advice and support for patients with suspected OD, then they will be more likely to carry this out, because they will have the intention to do so.

10.		If HCPs have a decision support resource to guide them to provide initial advice and support to patients with suspected OD, then they are more likely to undertake the activity, because it facilitates appropriate decision making.

11.		If there is a dysphagia champion, then HCPs will be more likely to proactively identify OD and provide initial advice and support for patients with suspected OD, because they will perceive it as important.

12. If HCPs have a screening tool to follow, then they will be more likely to proactively identify OD, because it facilitates decision making.

13.		If prompts are incorporated into HCP work flow, then this will trigger HCPs to proactively identify OD, because they will be reminded to carry it out.

14.		If HCPs have a decision support resource to guide them to provide initial advice and support to patients with suspected OD, then they are more likely to undertake the activity, because it facilitates appropriate decision making.

15.		If HCPs have access to a screening tool, then they are more likely to proactively identify OD, because they have the necessary resources to facilitate this.

16.		If there are websites, forums, information leaflets etc. to give to patients, then HCPs are more likely to provide initial guidance and support for patients with suspected OD because they have the required resources to give to patients.

17.		If HCPs have a guideline to follow, then they are more likely to provide initial advice to patients with suspected OD, because they have the required resources.

18.		If HCPs' workplaces provide opportunities for relevant training, then they will be more likely to proactively identify OD and provide initial advice and support to patients with suspected OD, because they will have access to the required resources.

19.		If HCPs observe that their peers are proactively identifying OD, then they will be more likely to carry this out, because they will be encouraged by their peers' behaviour.

20.		If HCPs perceive that patients, carers and relatives expect initial advice and support, then they will be more likely to provide this, because they will feel obligated to do so.

21.		If HCPs hear of patient experiences about the effects of OD/the benefits to getting a diagnosis, then they will be more likely to proactively identify OD and provide initial advice and support for patients with suspected OD, because they will feel more empathetic towards the patient experience.

22.		If HCPs monitor the extent to which they proactively identify OD and provide initial advice and support for their patients with suspected OD, then they will be more likely to carry this out, because they will be able to evaluate their performance and make adjustments as

Supplementary file 7. Stakeholder IPT prioritisation workshop outcome
Prioritised	
IPT statement	TDF domain	
If healthcare professionals are trained to give initial advice and support to older adults with suspected OD, then they are more likely to provide this, because they have the necessary skills to do so.	Skills	
Reason for prioritising	
Rated 'Important' by 100% of stakeholders in pre-workshop survey.	
Whilst training to proactively identify OD may not be necessary, healthcare professionals felt that being shown how to provide initial advice and support, or watching someone else deliver this, would be of benefit to their clinical and communication skills.	
May aid healthcare professionals to adapt to the different needs and expectations of older adults.	
IPT statement	TDF domain	
If healthcare professionals perceive that their role includes proactively identifying OD and providing initial advice and support for older adults with suspected OD, then they will be more likely to carry this out, because they feel obligated to.	Social, professional role & identity	
Reason for prioritising	
Ensuring people have an idea of their roles and responsibilities is quite powerful. You can provide healthcare professionals with numerous tools to help them carry out the desired behaviour, but if they do not perceive it to be their role, they are unlikely to do it.	
May particularly help early career primary care healthcare professionals, who may be even more unsure on the boundaries of their practice.	
The time pressures on NHS healthcare professionals means that it is important for them to know what is within their role and responsibilities, otherwise they will not do it.	

In other settings, e.g. hospitals, this has been seen to work with nurses who now conduct OD screening of stroke survivors as part of their role.	
IPT statement	TDF domain	
If healthcare professionals hear about examples of positive outcomes associated with proactively identifying OD and providing initial advice and support to older adults with suspected OD, then they will be more likely to carry this out, because they will be confident that them undertaking the behaviour will also lead to positive outcomes.	Optimism	
Reason for prioritising	
For every practitioner role, their purpose is to produce positive outcomes. This is the motivation for most healthcare professionals.	
As our target behaviours may be new to most healthcare professionals, their awareness of the positive outcomes as a result of these behaviours may not be as high for other behaviours considered more common or traditional in their practice.	
Healthcare professionals receiving this as an intervention component may come away with a more enjoyable experience and positive outlook.	
IPT Statement	TDF domain	
If healthcare professionals have a screening tool to follow, then they will be more likely to proactively identify OD, because it facilitates decision making.	Memory, attention & decision processes	
Reason for prioritising	
We are asking healthcare professionals to carry out a new behaviour, receiving a tool can provide reassurance in your decision making.	
Care algorithms and pathways enable healthcare professionals to personalise care for each patient based on their clinical presentation, personal needs etc.	
IPT statement	TDF Domain	
If healthcare professionals are given education about the signs, symptoms and risk factors of dysphagia, then they are more likely to proactively identify OD, because they have the appropriate knowledge.	Knowledge	
Reason for prioritising	

If healthcare professionals do not know why they are being asked to do something, they will not carry this out.	
The right knowledge can help healthcare professionals decide who they need to identify, support and refer on to specialists and not lead to all older people being referred to SLT or other dysphagia specialists.	
All stakeholders were quick to agree that education was imperative to awareness and ability to proactively identify OD and initially support those with suspected OD.	
IPT statement	TDF domain	
If the negative outcomes that occur from unaddressed OD are highlighted to healthcare professionals, then they will be more likely to proactively identify OD and provide initial advice and support to older adults with suspected OD, because they are aware of the adverse consequences of not doing so.	Beliefs about consequences	
Reason for prioritising	
People and healthcare professionals have different motivators and different values. Some may prefer being motivated towards action by being made aware of the negative outcomes of them not carrying out the desired behaviour, more than feeling optimistic about producing positive outcomes for older adults. By having both statements potentially included in the intervention, it recognises these variations across healthcare professionals.	
This may also influence patient behaviour as well, if healthcare professionals are aware of the negative outcomes and highlighting these to older adults to make them more aware of potential symptoms and encourage caution until formal assessment and diagnosis.	
IPT statement	TDF domain	
If there are websites, forums, information leaflets etc. to give to patients, then healthcare professionals are more likely to provide initial guidance and support for older adults with suspected OD because they have the required resources.	Environmental context & resources	
Reason for prioritising	
Of particular important to PPI advisors in the stakeholder group to ensure patients are left with some physical form of reassurance and guidance whilst waiting for formal assessment and potential diagnosis.	
Also provides reassurance to healthcare professionals who may not be as familiar with OD, but to still be able to sign post patients to the necessary and relevant information.	

Supplementary file 8. Evidence characteristics from primary search
Author (Year)	Title	Country	Study setting	Practitioner group	Study design	Study description	Relevant findings	Relevance Richness Rigour*	
Altman et al.
(2013)
(1)	Dysphagia in Stroke, Neurodegenerative
Disease, and
Advanced Dementia	America	Not specified	Nurse	Expert
review/commentary	Discussion of protocols to care for OD to facilitate non-specialist HCPs to recognise the early indicators of OD to facilitate identification of OD.	Protocols standardise the approach to identify OD by non- specialist nurses. Non-specialist nurses who are able to recognise early indicators to swallowing decline then refer patients to specialists	Moderate relevance Moderate richness Rigour: 5/6	
Barczi et al. (2000) (2)	How should dysphagia care of older adults differ? Establishing optimal practice patterns	America	Hospital Community
Nursing home	Physician
SLT
Nutritionist
Social worker
Nurse Radiologist	Expert review/commentary	Discussion of nonspecialist HCPs knowledge about OD and required knowledge for identifying OD in older adults, e.g. effect of aging on swallowing, effective communication with older adults.	Many HCPs incorrectly perceive OD as a normal and inconsequential part of the ageing process.	High relevance Moderate richness Rigour: 5/6	
Barrado- Martin et al. (2021) (3)	Family caregivers' and professionals' experiences of supporting people living with dementia's nutrition and hydration needs towards the end of life	UK	Community Care home Hospital	Family caregivers (N=21)
Dieticians (N= 1) Nurse (N= 6) Doctor (N= 6) SLT (N=3) Occupational therapist (N= 2) Dementia link worker (N= 1) Day care manager (N= 1)	Qualitative- Semistructured interviews	Exploration of caregiver and HCP perspectives on care provision for people living with dementia and OD.	Caregivers expect HCP to proactively identify and provide advice for people with OD as part of their role.	Moderate relevance Moderate richness
Rigour: 7/7	

BottinoBravo et al. (2008) (4)	When it's a hard act to swallow. Dysphagia in home care.	America	Home care	Nurse
SLT
Dietician
Physiotherapist Occupational therapist Doctor	Expert review/commentary	Discussion of OD identification processes in the home care setting to facilitate SLT referral for non-specialist HCPs.	Embedding OD identification into existing processes facilitates nonspecialist HCPs to know when to refer on to SLT.	Moderate relevance Thin Rigour: 6/6	
Clave et al. (2012) (5)	Pathophysiology, relevance and natural history of oropharyngeal dysphagia among older people	Spain	Not specified	Not specified	Expert
review/commentary	Discussion of the importance of OD identification and strategies to ensure HCPs carry out OD identification.	HCPs incorrectly perceive OD as inconsequential in older adults. Creating a systematic identification process will facilitate OD identification.	Moderate relevance Thin Rigour: 4/6	
Cochran et al. (2021) (6)	Introduction of Complementary Foods for Children with Down Syndrome: Parent and Physician Experiences	America	Academic medical centre	Carers (N=22) Paediatrician (N=5)
Family medicine
clinician (N=2)
Nurse practitioner (N=1)	Qualitative- Semistructured interviews	Exploration of carers' and HCPs' perspectives on care provision for children with Down's syndrome who have swallowing difficulties.	HCPs would like additional training, resources and simple guidelines to be able to offer more consistent advice.	High relevance Moderate richness Rigour: 6/7	
Doan et al. (2022) (7)	Prevalence and Methods for Assessment of Oropharyngeal Dysphagia in Older Adults: A Systematic Review and MetaAnalysis	Taiwan	Community Nursing homes Hospitals	Not specified	Systematic review and Meta-Analysis	Investigation of OD identification methods used by HCPs.	Without formal checklists, HCPs are unable to identify OD and have significant variation in their OD identification practices.	Moderate relevance Moderate richness Rigour: 8/10	
Ekberg et al.
(2002)
(8)	Social and Psychological Burden of Dysphagia: Its Impact on Diagnosis and Treatment	Germany
France
Spain
United Kingdom	Nursing homes Clinics	Patients (N=360)	Cross sectional mixed methods study	Investigation of the psychological impacts of OD and identifying the relationship between this and OD diagnosis and care.	Patients will not disclose swallowing difficulties unless prompted by HCPs or caregivers.
HCPs are unaware of the prevalence and impact of OD.	High relevance Moderate Richness Rigour: 5/7	

Estupinan Artiles et al. (2021) (9)	Dysphagia screening in residential care settings: A scoping review	Ireland	Residential care	Dentist
SLT
Nurse Physicians Dietitians Social workers	Scoping review	Investigation of the types, use and accuracy of checklists used in primary care settings to identify OD.	Absence of formal checklists for primary care settings leaves HCPs reliant on patients selfreporting OD.	High relevance Moderate richness Rigour: 9/10	
Hibbert et al. (2022) (10)	Designing clinical indicators for common residential aged care conditions and processes of care: the CareTrack Aged development and validation study	Australia	Residential care Nursing homes	Nurse
SLT Dietician Pharmacist	Reliability and validity study	Development of clinical indicators for appropriate care of commonly managed conditions in aged care.	Including OD in key clinical indicators motivates investigation of symptoms.	High relevance Low richness Rigour: 6/7	
Johansson et al. (2016) (11)	Oral Health Status of Older Adults in Sweden Receiving Elder Care: Findings From Nursing Assessments	Sweden	Home care Retirement homes Specialist housing	Nurse
Patients (N=667)	Descriptive longitudinal study	Introduction and evaluation of an oral health checklist using trained nurses.	Training nurses to use simple checklists facilitated identification and grading of swallowing difficulties for referral on to specialists, e.g. dentists and SLTs.	Moderate relevance Moderate richness
Rigour: 7/7	
Lindroos et al. (2017) (12)	Swallowing difficulty and nutrient intakes among residents in assisted living facilities in Helsinki	Finland	Assisted living facility	Nurse
Patients (N=345)	Cross sectional questionnaire study	Investigation of OD identification and care practices of nurses.	Nurses incorrectly perceive OD to be less of a risk in older adults relative to other groups e.g. stroke survivors	Moderate relevance Thin Rigour: 6/7	
Lindroos et al. (2014) (13)	Caregiver-reported swallowing difficulties, malnutrition, and mortality among older people in assisted living facilities	Finland	Assisted living facility	Patients	Cross sectional questionnaire study	Investigation of OD identification and care practices of nurses.	Nurses incorrectly perceive OD to be less of a risk in older adults relative to other groups e.g. stroke survivors	Moderate relevance Moderate richness
Rigour 5/7	
Llorca (2011) (14)	Discussion of prevalence and management of discomfort when swallowing pills: Oro- dispersible tablets expand treatment	France	Not specified	Physician GP	Expert review/commentary	Discussion of the characteristics, identification processes and care provision for patients with difficulties	GPs/physicians are unaware that older adults will not come forward about their swallowing difficulties and thus underestimate the	Moderate relevance Moderate richness
Rigour: 6/6	

	options in patients with depression					swallowing medication.	prevalence and impact of swallowing difficulties.		
Marquis et al., 2013 (15)	Swallowing difficulties with oral drugs among polypharmacy patients attending community pharmacies	Switzerland	Community pharmacies	Pharmacist
(N=59)
Patients (N=410)	Prospective cohort study	Determined the prevalence and characteristics of swallowing difficulties among primary care patients and pharmacists' awareness of these problems.	Pharmacists are unaware that older adults will not come forward about their swallowing difficulties and thus underestimate the prevalence and impact of swallowing difficulties.	Moderate relevance Moderate richness
Rigour: 5/7	
Morris (2005) (16)	Audit highlights prevalence of dysphagia	UK	General practice	Doctor Pharmacist
Nurse
Patients (N=171)	Audit	Determined the extent of OD and issues arising from OD care in general practice.	HCPs do not proactively enquire about swallowing difficulties. Embedding OD identification into existing practices facilitates HCPs to identify OD.	High relevance Moderate richness Rigour: 3/7	
Mullaney (1992) (17)	The effect of a dysphagia teaching module on knowledge, application, and attitudes of registered nurses working in a nursing home	America	Nursing homes	Nurses (N=54)	Thesis (Intervention development)	Development and evaluation of an education session and information pamphlet providing knowledge to nurses about how to identify, refer and care for patients with OD.	Increased knowledge on OD, application of new knowledge to check for signs of OD and carry out OD identification
processes.	High relevance High richness
Rigour: 6/6	
Mushero et al. (2022) (18)	An Interactive Workshop on Managing Dysphagia in Older Adults With Dementia	America	Primary care	Medical residents (N=17)	Intervention development	Development and evaluation of casebased workshops covering how to evaluate dysphagia in older adults with dementia.	Medical residents demonstrated; increased knowledge on OD, change in attitudes around OD care and increased confidence to identify OD in practice.	High relevance High richness Rigour: 4/7	

O'Loughlin et al. (1998) (19)	Swallowing problems in the nursing home: a novel training response	Australia	Nursing homes	Nurse (N=30)	Intervention development	Development and evaluation of a training programme for OD identification and care.	Increased knowledge, embedding of in-service training provision and application of new knowledge in practice to identify OD.	High relevance High richness Rigour: 6/6	
Park et al. (2015) (20)	Effects of the Evidence-Based Nursing Care Algorithm of Dysphagia for Nursing Home Residents	South Korea	Nursing home	Nurses Geriatric care helpers Patients	Control-intervention, time-series study	Evaluation of a 6- month Evidence-Based Nursing Care Algorithm of Dysphagia on oral health status, risk of aspiration, and dysphagia-related quality of life.	Following a simple OD algorithm facilitated nurses and helpers to identify OD. Training and visual resources helped nurses to integrate the algorithm into routine care.	High relevance High richness Rigour: 5/7	
Pownall et al. (2019) (21)	The Development of a Digital Dysphagia Guide with Care Homes: CoProduction and Evaluation of a Nutrition Support Tool	UK	Nursing homes	Nursing home staff (inc. nurse and carer) (N=57)	Intervention development	Development and evaluation of a coproduced digital OD guide for nursing home staff.	The guide provided bitesized, accessible learning for nursing staff to refer to as and when needed to support OD identification and care. 73% of staff reported the guide helped them provide support for residents with OD.	High relevance High richness Rigour: 6/7	
Schiele et al.
(2013)
(22)	Difficulties swallowing solid oral dosage forms in a general practice population: prevalence, causes, and relationship to dosage forms	Germany	General practice	GP (N=16)
Patients (N=1051)	Cross sectional questionnaire study	Assessment of the prevalence of OD and GPs' practice in relation to OD identification and care.	GPs are unaware that patients do not report their swallowing difficulties and underestimate the prevalence and impact of OD. GPs should proactively enquire about OD, particularly in higher risk groups.	High relevance
High richness
Rigour: 7/7	
Takeuchi et al. (2014) (23)	Nutritional status and dysphagia risk among community-dwelling frail older adults	Japan	Clinics	Patients aged >65 years (N=874)	Cross sectional questionnaire study	Estimation of OD risk among communitydwelling older adults using an OD checklist.	Of 1057
respondents,65.6% were at risk of OD. Embedding OD into routine identification processes supported by use of a simple checklist	Low relevance Moderate richness Rigour: 6/7	

							facilitated early detection.		
Ueshima et al. (2019) (24)	Comprehensive Geriatric Assessment and Nutrition-Related Assessment: A CrossSectional Survey for Health Professionals	Japan	Hospital Rehabilitation settings Nursing homes Long term care facilities Community	Dietician (N=184) Physiotherapist
(N=172)
SLT (N=101)
Nurse (N=60)
Doctor (N=43) Occupational therapist (N=36)
Dental hygienist (N=24)
Dentist (N=24) Pharmacist (N=7)
Care worker (N=1)	Cross sectional questionnaire study	Investigation into the correlation between use of geriatric assessment tool and OD identification.	Only 11% of HCPs used the geriatric assessment. HCPs who use the assessment, where questions on OD are incorporated, are more likely to assess OD and define nutritional goals. HCPs who are trained to use the tool may be more likely to use it.	High relevance Moderate richness Rigour: 6/7	
Wesrtuck et al. (2021) (25)	Dysphagia Identification and Assessment in Adults in Primary Care Settings—A Canadian Study of Dietitians	Canada	Primary care	Dietician (N=70)	Cross sectional questionnaire study	Investigation of OD identification and assessment practices of dietitians working in primary care.	Dieticians felt they did not have the required knowledge or skills to identify OD. Provision of training, checklists, educational and awareness of OD identification as part of the dietician role would facilitate OD identification.	High relevance High richness Rigour: 6/7	

References
1.		Altman KW, Richards A, Goldberg L, Frucht S, McCabe DJ. Dysphagia in Stroke, Neurodegenerative Disease, and Advanced Dementia. Otolaryngologic Clinics of North America. 2013;46(6):1137-49.
2.		Barczi SR, Sullivan ΡΑ, Robbins J. How should dysphagia care of older adults differ? Establishing optimal practice patterns. Semin Speech Lang. 2000;21(4):347-61.
3.		Barrado-Martin Y, Nair Ρ, Anantapong Κ, Aker Ν, Moore KJ, Smith CH, et al. Family caregivers' and professionals' experiences of supporting people living with dementia's nutrition and hydration needs towards the end of life. Health & Social Care in the Community [Internet]. 2021 May 6; Available from: https://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2021-44701-001&site=ehost-live
4.		Bottino-Bravo Ρ, Thomson J. When it's a hard act to swallow. Dysphagia in home care. Home Healthc Nurse. 2008;26(4):244-2.
5.		Clave Ρ, Rofes L, Carrion S, Ortega O, Cabre M, Serra-Prat M, et al. Pathophysiology, relevance and natural history of oropharyngeal dysphagia among older people. Nestle Nutr Inst Workshop Ser. 2012;72(101577268):57-66.
6.		Cochran Ε, Breithaupt Κ, Williams L, Atkins K. Introduction of Complementary Foods for Children with Down Syndrome: Parent and Physician Experiences. Phys Occup Ther Pediatr. 2022;42(3):333-49.
7.		Doan TN, Ho WC, Wang LH, Chang FC, Nhu NT, Chou LW. Prevalence and Methods for Assessment of Oropharyngeal Dysphagia in Older Adults: A Systematic Review and Meta-Analysis. JCM. 2022 May 6;ll(9):2605.
8.		Ekberg 0, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega Ρ. Social and Psychological Burden of Dysphagia: Its Impact on Diagnosis and Treatment. Dysphagia. 2002 Apr l;17(2):139-46.
9.		Estupinan Artiles C., Regan J., Donnellan C. Dysphagia screening in residential care settings: A scoping review. Int J Nurs Stud. 2021;114((Estupinan Artiles) School of Nursing and Midwifery, Faculty of Health Sciences, Trinity College Dublin, lreland):103813.
10.		Hibbert PD, Molloy CJ, Wiles LK, Cameron ID, Gray LC, Reed RE, et al. Designing clinical indicators for common residential aged care conditions and processes of care: the CareTrack Aged development and validation study. Int J Qual Health Care. 2022;34(2).
11.		Johansson I, Jansson Η, Lindmark U. Oral Health Status of Older Adults in Sweden Receiving Elder Care: Findings From Nursing Assessments. Nurs Res. 2016;65(3):215- 23.
12.		Lindroos Ε, Jyvàkorpi S, Soini Η, Muurinen S, Saarela RKT, Pitkala ΚΗ, et al. Swallowing difficulty and nutrient intakes among residents in assisted living facilities in Helsinki. European Geriatric Medicine. 2017;8(3):228-33.
13.		Lindroos Ε, Saarela RKT, Soini Η, Muurinen S, Suominen MH, Pitkala ΚΗ. Caregiver-reported swallowing difficulties, malnutrition, and mortality among older people in assisted living facilities. J Nutr Health Aging. 2014;18(7):718-22.
14.		Llorca PM. Discussion of prevalence and management of discomfort when swallowing pills: Orodispersible tablets expand treatment options in patients with depression. Therapeutic Delivery. 2011;2(5):611-22.
15.		Marquis J, Schneider ΜΡ, Payot V, Cordonier AC, Bugnon 0, Hersberger ΚΕ, et al. Swallowing difficulties with oral drugs among polypharmacy patients attending community pharmacies. Int J Clin Pharm. 2013 Dec;35(6):1130-6.
16.		Morris Η. Audit highlights prevalence of dysphagia. Practice Nursing. 2005;16(12):590—3.
17.		Mullaney NS. The effect of a dysphagia teaching module on knowledge, application, and attitudes of registered nurses working in a nursing home. COLUMBIA UNIVERSITY TEACHERS COLLEGE; 1992.
18.		Mushero Ν, Demers LB, Chippendale R. An Interactive Workshop on Managing Dysphagia in Older Adults With Dementia. MedEdPORTAL publ. 2022;18(101714390):11223.
19.		O'Loughlin G, Shanley C. Swallowing problems in the nursing home: a novel training response. Dysphagia. 1998;13(3):172-83.
20.		Park Υ, Oh S, Chang Η, Bang HL. Effects of the Evidence-Based Nursing Care Algorithm of Dysphagia for Nursing Home Residents. J Gerontol Nurs. 2015;41(ll):30-9.
21.		Pownall S, Barnett Ε, Skilbeck J, Jimenez-Aranda A, Fowler-Davis S. The Development of a Digital Dysphagia Guide with Care Homes: Co-Production and Evaluation of a Nutrition Support Tool. Geriatr. 2019;4(3).
22.		Schiele JT, Quinzler R, Klimm HD, Pruszydlo MG, Haefeli WE. Difficulties swallowing solid oral dosage forms in a general practice population: prevalence, causes, and relationship to dosage forms. Eur J Clin Pharmacol. 2013;69(4):937-48.
23.		Takeuchi Κ, Izumi M, Furuta M, Takeshita Τ, Shibata Y, Kageyama S, et al. Denture Wearing Moderates the Association between Aspiration Risk and Incident Pneumonia in Older Nursing Home Residents: A Prospective Cohort Study. Int J Environ Res Public Health. 2019;16(4).
24.		Ueshima J, Maeda Κ, Wakabayashi Η, Nishioka S, Nakahara S, Kokura Y. Comprehensive Geriatric Assessment and Nutrition-Related Assessment: A Cross-Sectional Survey for Health Professionals. Geriatr. 2019;4(l).
25.		Werstuck MM, Steel C. Dysphagia Identification and Assessment in Adults in Primary Care Settings—A Canadian Study of Dietitians. Cahill Ν, editor. Canadian Journal of Dietetic Practice and Research. 2021 Jun l;82(2):84-9.

Supplementary file 9. Evidence characteristics from snowballing
Author	Title	Country	Study setting	Practitione r group	Study design	Study description	Relevant findings	Relevance Richness Rigour*	
Barker et al. (2022)
(1)	The development and implementation of an evidence-based risk reduction algorithm for post extubation dysphagia in intensive care	Canada	Hospital	Respiratory therapists (N= 20)
Physicians
(N=14)
Dietician (N=1)
Physiotherapists
(N=4)	Intervention development	Evaluation of the Swallowing Algorithm Post- Extubation (SAPE) algorithm and associated training to guide registered nurses to identify dysphagia and make decisions regarding referral to speech & language therapy.	After training, 74% of HCPs felt confident to identify OD risk factors. After following SAPE, 84% said they would consider SLT referral.	High relevance Moderate richness Rigour: 6/7	
Bowen et al. (2023) (2)	Advancing health equity: A qualitative study assessing barriers and facilitators of implementing hereditary breast and ovarian cancer risk screening tools in community-based organizations	America	Community	Administrator (N=2) Patient Navigator (N=7) Nurse (N=7) Director (N=3) Community Health Educator (N=7)
Volunteer (N= 5) Healthcare provider (N=3) Other (N=1)	Qualitative- Focus groups	Exploration of preferences for cancer risk screening tools and identified barriers and facilitators for screening tool implementation.	Screening tools which are quick, simple and with clear referral guidelines facilitate HCPs to decide whether to refer to SLT.	High relevance High richness Rigour: 7/7	

Farpour et al. (2019)
(3)	Dysphagia
Management in Iran: Knowledge, Attitude and Practice of
Healthcare Providers	Iran	Hospitals	Nurses (N=112)
Physicians
(N=54)	Cross sectional questionnaire	Investigating the knowledge, attitude and practice of healthcare providers in relation to OD management.	40% did not know the definition of OD and were unsure. Whilst most believed their role included identifying and caring for patients with OD, only 10% knew how to identify.	High relevance Moderate richness Rigour: 5/7	
Guo et al. (2023)
(4)	Nursing adherence, barriers and facilitators to conduct post-stroke dysphagia screening and assessment: A study based on theoretical domain framework	China	Secondary & tertiary hospitals	Nurses (N=956)	Mixed methods- Cross sectional online survey and semistructured interviews	Exploration of nurses' adherence, barriers, facilitators and views on OD identification and assessment of poststroke dysphagia.	Nurses with the required knowledge and skills felt more confident to identify OD. Integration of OD identification into electronic systems would prompt nurses to carry this out.	High relevance High richness Rigour: 4/7	
Haggerty et al. (2005) (5)	Patients' anxiety and expectations; How they influence family physicians' decisions to order cancer screening tests	Canada	General practice	Physicians (N=351)	Cross sectional questionnaire	Investigation of the influence of patients' anxiety or expectations on physicians' decision to order cancer screening tests.	88% of physicians would be influenced to order a screening if they knew patients' expectations.	High relevance Moderate richness Rigour: 6/7	
Ireland et al. (2018) (6)	General Practitioners' Use of Risk Prediction Tools and their Application to Barrett's Oesophagus: A Qualitative Study	Australia	General practice	GPs (N=5) Gastroenterolog ist (N=1)	Qualitative- Semistructured interviews	Exploration of GPs' perspectives of the barriers and enablers to cancer risk prediction models and identification tools.	Due to workload, doctors prefer identification tools/protocols which are simple to use and easy to access. These prompt doctors to ask questions, provide clear guidance, aid in keeping focus.	High relevance High richness Rigour: 6/7	
Murray et al. (2021)
(7)	Four-hour swallow screening target for stroke - from	Australia	Hospital	Patients (N=365)
Nurses (N=7)
Nurse unit	Mixed methods- Cross-sectional	Investigation of nurses' compliance with identifying swallow	Checklists which are simple to use, have clear guidelines and	High relevance	

	guidelines to practice: A mixed methods knowledge translation study			manager (N=2) Specialist stroke nurse consultant
(η=1)
Medical staff
(N=2)
SLT (N= 2)	observational and semistructured interviews study	difficulties within the 4- hour target for stroke patients and exploration of clinicians' perceptions of enablers and barriers to meeting this target.	indicators, can be completed in a timely manner, and facilitate HCPs to identify at-risk patients.	Moderate richness Rigour: 5/7	
Oliveira et al. (2020) (8)	Nurses' preferred items for dysphagia screening in acute stroke patients: A qualitative study	Portugal	Hospital	Nurses (N=20)	Qualitative- Focus groups	Exploration of signs and symptoms stroke nurses prioritize to identify OD in acute stroke patients.	Nurses investigate different signs of OD during informal identification. Informal processes lead to inconsistencies in identifying OD.	High relevance High richness Rigour: 3/7	
Pierpoint et al. (2020) (9)	Post-stroke dysphagia: An exploration of initial identification and management performed by nurses and doctors	South Africa	Hospital	Nurses (N=21)
Doctors (N=4)	Cross sectional questionnaire study	Investigation of how doctors and registered nurses identify and manage patients with post-stroke OD.	Without the required knowledge on OD or formal checklist, nurses and doctors have no standardised approach to OD identification and miss key symptoms of OD.	High relevance High richness Rigour: 5/7	
Sanchez- Sanchez et al. (2021) (10)	Knowledge and Practice of Health Professionals in the Management of Dysphagia	Spain	Hospital Primary care	Nurses (N=400)	Descriptive cross sectional questionnaire study	Investigating the knowledge, attitude and practice of healthcare providers in relation to OD management.	Nurses and physicians were unsure of how to identify OD or the processes/tools used in their settings for OD identification.	High relevance Moderate richness Rigour: 5/7	
Tudiver et al. (2001)
(11)	Making Decisions About Cancer Screening When the Guidelines Are Unclear or Conflicting	Canada	Community	Family physicians (N= 73)	Qualitative- Focus groups	Exploration of factors involved in cancer screening decisions when clinical practice guidelines are unclear/conflicting.	Patient expectations and demands for screening were major determinants of physicians' decision to screen when guidelines were unclear.	High relevance Moderate richness Rigour: 5/7	
References
1.		Barker J, Davidson M, Fan Ε, Hellen S, Williams T. The development and implementation of an evidence-based risk reduction algorithm for post extubation dysphagia in intensive care. Canadian Journal of Critical Care Nursing. 2022;33(1):22-30.
2.		Bowen A, Gómez-Trillos S, Curran G, Graves KD, Sheppard VB, Schwartz MD, et al. Advancing health equity: A qualitative study assessing barriers and facilitators of implementing hereditary breast and ovarian cancer risk screening tools in community-based organizations. Journal of Genetic Counseling. 2023 Apr 16;jgc4.1705.
3.		Farpour S, Farpour HR, Smithard D, Kardeh Β, Ghazaei F, Zafarghasempour M. Dysphagia Management in Iran: Knowledge, Attitude and Practice of Healthcare Providers. Dysphagia. 2019;34(1):105-11.
4.		Guo Y, Guo L, Dong X, Yang C, Wang M, Gao Η, et al. Nursing adherence, barriers and facilitators to conduct post-stroke dysphagia screening and assessment: A study based on theoretical domain framework. Journal of Clinical Nursing. 2023 Jan 30;jocn.16623.
5.		Haggerty J, Tudiver F, Brown JB, Herbert C, Ciampi A, Guibert R. Patients' anxiety and expectations; How they influence family physicians' decisions to order cancer screening tests. Canadian Family Physician. 2005;51:1659-67.
6.		Ireland CJ, Laws ΤΑ, Thompson SK. General Practitioners' Use of Risk Prediction Tools and their Application to Barrett's Oesophagus: A Qualitative Study. 2018;2(l).
7.		Murray J, Havlis J, Varvounis Ν. Four-hour swallow screening target for stroke - from guidelines to practice: A mixed methods knowledge translation study. International Journal of Speech-Language Pathology. 2021 Sep 3;23(5):519-28.
8.		Oliveira IDJ, Couto GR, Neves Da Mota LA. Nurses' preferred items for dysphagia screening in acute stroke patients: A qualitative study. ΝΡΤ [Internet]. 2020 Jun 21 [cited 2023 May 4]; Available from: https://publish.kne-publishing.com/index.php/NPT/article/view/3351
9.		Pierpoint M, Pillay M. Post-stroke dysphagia: An exploration of initial identification and management performed by nurses and doctors. South African Journal of Communication Disorders [Internet]. 2020 May 28 [cited 2023 May 9];67(1). Available from: http://www.sajcd.org.za/index.php/SAJCD/article/view/625
10.		Sanchez-Sanchez Ε, Avellaneda-Lopez Y, Garcia-Marin Ε, Ramirez-Vargas G, Diaz-Jimenez J, Ordonez FJ. Knowledge and Practice of Health Professionals in the Management of Dysphagia. IJERPH. 2021 Feb 22;18(4):2139.
11.		Tudiver F, Brown JB, Medved W, Herbert C, Ritvo Ρ, Guibert R. Making Decisions About Cancer Screening When the Guidelines Are Unclear or Conflicting. J Fam Pract. 2001 Aug;50(8):682-7.