The behavioural mechanisms of a primary care intervention to proactively identify oropharyngeal dysphagia in older adults and provide advice: A focus group study

Problem

30-70% of older adults have swallowing difficulties known as oropharyngeal dysphagia (OD), but it is not identified and managed until it has caused harm, e.g., aspiration pneumonia. A behavioural science realist review, undertaken alongside stakeholders and patient and public involvement advisors, developed five programme theories (PTs) to describe how interventions support primary care healthcare professionals (HCPs) to proactively identify OD and provide advice: 1) OD education and training, 2) OD identification tools, 3) incorporating OD into existing workflow, 4) making HCPs aware of older adults and carers expectations to address OD in primary care and 5) raising awareness of OD’s adverse outcomes. Evidence from the realist review originated from different countries, healthcare settings and clinical populations. To inform the development of a future intervention, the aim of this focus group study was to contextualise the existing PTs derived from the realist review to the NHS primary care context and develop any new PTs.

Approach

Three 90-minute focus groups were convened with 19 primary care HCPs (general practitioners, pharmacists, nurses and pharmacy technicians). Analysis was underpinned by the Theoretical Domains Framework and followed three stages; inductive thematic analysis to identify barriers and enablers to OD identification and management, deductive mapping of barriers and enablers to existing PTs and generation of new PTs from remaining barriers and enablers.

Findings

Inductive thematic analysis generated five themes: i) Status quo (OD is not currently proactively identified), ii) Sinister pathology (HCPs are conditioned to view OD exclusively as a red flag for cancer), iii) Roles (HCPs and patients need to know their role in proactive OD identification), iv) Education and training (to increase awareness of OD and its impact to patients) and v) Conducive work environment (to embed OD into routine practice for minimum impact to HCP workload). Participant feedback on these findings supported all five themes. Healthcare professionals across all three focus groups emphasised the importance of addressing Theme 2, Sinister pathology, in order to change HCP perceptions and ensure patients are not referred down the wrong care pathway and consequently lost to follow-up.

Deductive analysis supported all five PTs from the realist review. Three new PTs were also generated, mapped to three TDF domains; Changing HCP perceptions that OD is a red flag for cancer (Beliefs about consequences), practical support to provide advice (Social/professional role and identity) and providing incentive to identify OD and provide advice (Reinforcement).

Consequences

Interventions to support identification and management of OD in primary care should be underpinned by these eight PTs. Co-design workshops with healthcare professionals, people with OD and commissioners will develop these programme theories into a behaviour change intervention, tailored to the NHS primary care context.