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BackgroundChronic pain is a global health problem, affecting around 1 in 5 individuals in the general population. The understanding of the key role of functional brain alterations in the generation of chronic pain has led researchers to focus on pain treatments that target brain activity. Electroencephalographic neurofeedback attempts to modulate the power of maladaptive electroencephalography frequency powers to decrease chronic pain. Although several studies have provided promising evidence, the effect of electroencephalographic neurofeedback on chronic pain is uncertain. ObjectiveThis systematic review aims to synthesize the evidence from randomized controlled trials to evaluate the analgesic effect of electroencephalographic neurofeedback. In addition, we will synthesize the findings of nonrandomized studies in a narrative review. MethodsWe will apply the search strategy in 5 electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycInfo, and CINAHL) for published studies and in clinical trial registries for completed unpublished studies. We will include studies that used electroencephalographic neurofeedback as an intervention for people with chronic pain. Risk-of-bias tools will be used to assess methodological quality of the included studies. We will include randomized controlled trials if they have compared electroencephalographic neurofeedback with any other intervention or placebo control. The data from randomized controlled trials will be aggregated to perform a meta-analysis for quantitative synthesis. The primary outcome measure is pain intensity assessed by self-report scales. Secondary outcome measures include depressive symptoms, anxiety symptoms, and sleep quality measured by self-reported questionnaires. We will investigate the studies for additional outcomes addressing adverse effects and resting-state electroencephalography analysis. Additionally, all types of nonrandomized studies will be included for a narrative synthesis. The intended and unintended effects of nonrandomized studies will be extracted and summarized in a descriptive table. ResultsEthics approval is not required for a systematic review, as there will be no patient involvement. The search for this systematic review commenced in July 2020, and we expect to publish the findings in early 2021. ConclusionsThis systematic review will provide recommendations for researchers and health professionals, as well as people with chronic pain, about the evidence for the analgesic effect of electroencephalographic neurofeedback. Trial RegistrationInternational Prospective Register of Systematic Reviews (PROSPERO) CRD42020177608; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=177608 International Registered Report Identifier (IRRID)PRR1-10.2196/22821

A considerable proportion of quantitative research remains unpublished once completed. Little research has documented non-dissemination and dissemination bias in qualitative research. This study aimed to generate evidence on the extent of non-dissemination in qualitative research. We followed a cohort of qualitative studies presented as conference abstracts to ascertain their subsequent publication status. We searched for subsequent full publication in MEDLINE, in the Cumulative Index to Nursing & Allied Health Literature and in Google Scholar. We matched abstracts to subsequent publications according to authors, method of data collection and phenomenon of interest. Fisher's exact test was calculated to examine associations between study characteristics and publication. Factors potentially associated with time to publication were evaluated with Cox regression analysis. For 91 of 270 included abstracts (33.70%; 95% CI 28.09%-39.68%), no full publication was identified. Factors that were found to be associated with subsequent full publication were oral presentation (OR 4.62; 95% CI 2.43-8.94) and university affiliation (OR 1.96; 95% CI 1.05-3.66). Compared to oral presentations, studies presented as posters took longer time to reach full publication (hazard ratio 0.35, 95% CI 0.21-0.58). This study shows that it was not possible to retrieve a full publication for over one-third of abstracts. Our findings suggest that where this non-dissemination is systematic, it may lead to distortions of the qualitative evidence-base for decision-making through dissemination bias. Our findings are congruent with those of other studies. Further research might investigate non-dissemination of qualitative studies in other disciplines to consolidate our findings.

Background Mental health crises cause significant disruption to individuals and families and can be life-threatening. The large number of community crisis services operating in an inter-agency landscape complicates access to help. It is unclear which underpinning mechanisms of crisis care work, for whom and in which circumstances. Aim The aim was to identify mechanisms to explain how, for whom and in what circumstances adult community crisis services work. Objectives The objectives were to develop, test and synthesise programme theories via (1) stakeholder expertise and current evidence; (2) a context, intervention, mechanism and outcome framework; (3) consultation with experts; (4) development of pen portraits; (5) synthesis and refinement of programme theories, including mid-range theory; and (6) identification and dissemination of mechanisms needed to trigger desired context-specific crisis outcomes. Design This study is a realist evidence synthesis, comprising (1) identification of initial programme theories; (2) prioritisation, testing and refinement of programme theories; (3) focused realist reviews of prioritised initial programme theories; and (4) synthesis to mid-range theory. Main outcome The main outcome was to explain context, mechanisms and outcomes in adult community mental health crisis care. Data sources Data were sourced via academic and grey literature searches, expert stakeholder group consultations and 20 individual realist interviews with experts. Review methods A realist evidence synthesis with primary data was conducted to test and refine three initial programme theories: (1) urgent and accessible crisis care, (2) compassionate and therapeutic crisis care and (3) inter-agency working. Results Community crisis services operate best within an inter-agency system. This requires compassionate leadership and shared values that enable staff to be supported; retain their compassion; and, in turn, facilitate compassionate interventions for people in crisis. The complex interface between agencies is best managed through greater clarity at the boundaries of services, making referral and transition seamless and timely. This would facilitate ease of access and guaranteed responses that are trusted by the communities they serve. Strengths and limitations Strengths include the identification of mechanisms for effective inter-agency community crisis care and meaningful stakeholder consultation that grounded the theories in real-life experience. Limitations include the evidence being heavily weighted towards England and the review scope excluding full analysis of ethnic and cultural diversity. Conclusions Multiple interpretations of crises and diverse population needs present challenges for improving the complex pathways to help in a crisis. Inter-agency working requires clear policy guidance with local commissioning. Seamless transitions between services generate trust through guaranteed responses and ease of navigation. This is best achieved where there is inter-agency affiliation that supports co-production. Compassionate leaders engender staff trust, and outcomes for people in crisis improve when staff are supported to retain their compassion. Future work Further work might explore inter-agency models of crisis delivery, particularly in rural communities. Future work could focus on evaluating outcomes across crisis care provider agencies and include evaluation of individual, as well as service-level, outcomes. The implementation and effect of mental health triage could be explored further, including via telehealth. Barriers to access for marginalised populations warrant a specific focus in future research. Study registration The study is registered as PROSPERO CRD42019141680. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 15. See the NIHR Journals Library website for further project information. Plain language summary The issue A mental health crisis can be traumatic for individuals and families. There are a lot of different agencies delivering crisis care. This can make getting the right help from services difficult, confusing and slow. It is not clear which services work best or who they work best for. What we did This research explored community mental health crisis services for adults. We focused on what is working, who it is working for and in what situations it is working. Service users, carers, mental health professionals and service managers formed an ‘expert stakeholder group’ to guide the project by helping the researchers make sense of what we learned. We gathered information from research reports, other documents and interviews with experts (i.e. service users, carers, professionals, managers). We focused on three questions: How can services make sure that people in crisis can get the right help, quickly? What makes crisis care compassionate? Does it help if different crisis services work together? What we learned Community crisis services are most compassionate and effective when staff from different organisations share information. When leaders of crisis care help staff to work together across services, they find better ways to help people. Close working across teams gives professionals a better understanding of what other services do and makes it easier for them to give people the right help at the right time. When leaders are kind and supportive to staff, they feel better at work and provide better crisis care. What future work can be done It would be useful to explore if the most effective crisis services are the same ones that service users like best. We need to know more about mental health triage, inter-agency working and telehealth. Our project did not explore diversity, but this is an important topic to investigate. Scientific summary Background Mental health crises cause significant disruption to the lives of individuals and families and can be life-threatening. The drive for community care alongside large reductions in hospital beds has led to a proliferation of community crisis services delivered by a diverse range of provider agencies, contributing to difficulties for people in navigating to timely crisis support. There is no single definition of a mental health crisis; people have diverse needs, resulting in a large variation in routes into and through mental health crisis care. Service users report unmet need. Services have diversified quickly in response to reported gaps and delayed responses, and continue to do so. Diversification has led to geographic differences in available crisis care and created a complex web of agencies with different values, referral processes, interventions and access thresholds. It is unclear, in this complex system, which underpinning mechanisms of crisis care are most effective, for whom and in which circumstances. Aim The aim was to identify mechanisms to explain how, for whom and in what circumstances mental health community crisis services for adults work to resolve crises, with a view to informing current and future intervention design and development. Objectives Use stakeholder expertise, current practice and research evidence to develop programme theories to explain how different crisis services work to produce the outcome of resolution of mental health crises. Use a context, intervention, mechanism and outcome (CIMO) framework to construct a sampling frame to identify subsets of literature within which to test programme theories. Iteratively consult, via an expert stakeholder group (ESG) and individual interviews, with diverse stakeholders to test and refine programme theories. Identify and describe pen portraits of UK crisis services that provide exemplars of the programme theories to explain how mental health crisis interventions work in order to explore and explain contextual variation. Synthesise, test and refine the programme theories, and, where possible, identify mid-range theory, to explain how crisis services work to produce the outcome of resolution of the crisis. Provide a framework for future empirical testing of theories in and for further intervention design and development. Produce dissemination materials that communicate the most important mechanisms needed to trigger desired context-specific crisis care outcomes, to inform current and future crisis care interventions and service designs. Design A four-phase realist evidence synthesis, reported in accordance with Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) reporting guidelines and comprising (1) identification of candidate programme theories from academic and grey literature; (2) iterative consultation with an ESG and individual interviews to prioritise, test and refine programme theories; (3) focused realist reviews of prioritised theory components; and (4) synthesis to mid-range theory. Main outcome measures The principal aim of the review was to generate and test programme theories, and then synthesise these with mid-range theory, to explain what works, for whom and in what circumstances in adult mental health community crisis care. Data sources The following were conducted: Google Scholar (Google Inc., Mountain View, CA, USA) searches to identify initial programme theories and logic models, focused searches of academic databases with backward citation searching, grey literature searches and hand-searches by the research team and expert stakeholders to test and refine three theory components. An ESG, with membership from lived experience, health professional, social care, policy expertise, health management and commissioning, was consulted on four occasions across the life of the research to test and refine theories and to connect them with real-world experience. Twenty individual realist interviews were conducted with 19 participants to further test, refine and sense-check theory components where there were gaps in topic expertise or theory; the 19 participants included service users; health, social care, ambulance and police professionals; and research and policy experts. Analysis A realist evidence synthesis with stakeholder primary data was used to test and refine three initial programme theories in adult mental health community crisis care: (1) urgent and accessible crisis care, (2) compassionate and therapeutic crisis care and (3) inter-agency working. Data analysis involved using realist logic to identify initial programme theories (objectives 1–3), and testing and refining the programme theories through a focused review of the literature, to extract and configure explanatory causal relationships between CIMO (objectives 3–5). Expert stakeholder consultations supported analysis through linking theories to real-world experience, enabling exploration and explanation of contextual variation as it related to putative mechanisms (objectives 3–5). Individual interviews with experts, who were purposively selected for their topic expertise related to the programme theory components, were deductively analysed according to the CIMO framework. An inductive process identified any new mechanisms not identified from other data sources (objective 3). Pen portraits were developed as illustrative exemplars of the link between CIMO and were refined in collaboration with expert stakeholders (objective 4). Findings from the focused review of the three theory components were synthesised with mid-range theories to produce a framework for any future empirical testing that may be developed (objective 5). Results The scope of the realist review was refined through an initial consultation and discussion between the ESG and the research team. A Diamond-9 prioritisation process was used to facilitate discussion between the ESG and the research team and to refine the scope of the review. This process resulted in three initial programme theories for testing, focused on (1) urgent and accessible crisis care, (2) compassionate and therapeutic crisis care and (3) inter-agency working. The findings from the three focused reviews were synthesised with mid-range theory. Mental health crisis care is provided by a complex array of agencies, each with different definitions of crises, different values about the nature of interventions and different approaches to prioritisation. This is further complicated by multiple overlapping service boundaries. What is apparent is that these differences can only be accommodated within an inter-agency system in which information and decisions are shared from commissioning through to front-line delivery. Inter-agency working provides mechanisms that trigger seamless service delivery through improved communication and collaboration. For this system to work, representation from all agencies and stakeholders is needed. National co-ordination at policy level ensures that investment is appropriately targeted and that important strategic aspirations are met. National co-ordination should steer, but not dictate, local configurations of the agencies needed. Local crisis services should be configured to meet the crisis care needs of local populations within their geography, taking account of any marginalised individuals or communities they serve. Commissioning for inter-agency working needs a focus on managing complex boundaries and transitions across agencies to avoid gaps and disputes. Attention is also needed on how the inter-agency crisis system engages with wider systems important to resolution of crises, including, for example housing, police, local authority, safeguarding and the justice system. The ultimate aim of inter-agency system should be that there is no wrong door through which to access mental health crisis care, and, once in a service, navigation should be facilitated via a single trusted point of liaison. Evaluation is not restricted by organisational boundaries and aims to provide data that take account of how the whole inter-agency system is operating. Conceptualisations of crises as single events or as the sole responsibility of statutory secondary mental health systems are unhelpful and generate fragmentation, leading to gaps and delays for those seeking crisis care and frustration for leaders and front-line staff. The perception of whether or not a service and service providers are accessible carries more of an inhibitive effect than the way that the service is actually organised. People experiencing a crisis choose to access services they perceive as providing a guaranteed response, that are easy to navigate to and that fit with their definition of the crisis. Although the timing of responses in relation to outcomes remains unclear, what is clear is that people feel safer and have a reduced sense of urgency when they trust services. Trust is established through compassionate interactions and proactive management of transitions and waiting. Involvement of the person and their family or support network in decisions supports a sense of trust and relational safety, which may help meet a need for continuity for some. To sustain compassion, front-line staff need access to support for themselves, as well as resources to deliver crisis care that meets their personal and professional ideals. Training in the knowledge, skills and values required for compassion can build confidence among front-line staff in all agencies. System leaders must provide resources and communicate an expectation for compassionate engagement so that it becomes the norm for staff to seek support. This is achieved in an inter-agency context when there is interpersonal contact between all levels of worker, from commissioning through to front-line delivery, that facilitates learning, communication and appreciation of different roles. Furthermore, co-production of crisis care can be facilitated within the inter-agency system, enabling crisis care to be recognised and valued by the community it serves. Service users perceive a crisis when they feel overwhelmed and anxious and when they perceive that they lack a sense of control. Familiar contacts and a safe environment, coupled with reassurance, can help to shape their perception of the service, but, more importantly, can help to reduce distress, thereby mitigating risk and making it more likely that a service user is able to respond to suggested strategies. With an emphasis on rapport and compassion, professionals are encouraged to exhibit positive behaviours that mitigate against the dehumanisation and stigma that service users may perceive when they encounter a service, and which may precipitate or exacerbate a crisis. Compassion shown to front-line staff by leaders leads to compassionate care. A tension between exerting control and providing support was evident at all levels. As integrated care systems are introduced, there is an aspiration that strategic partnerships will reduce competing priorities, which appear debilitating to organisations. Alongside these strategic partnerships, there is a need for coherent local strategies for compassionate and psychologically safe crisis care cognisant of the fact that high-quality care can coexist alongside the worst examples of care in the same organisation. Strategies should include how compassionate and psychologically safe crisis care is provided. Different values and definitions of crisis are accommodated, allowing challenge and debate to become accepted as an opportunity to drive quality improvement. Strengths and limitations Much of the literature was descriptive; therefore, the evidence base was limited. The programme theories identified outline the mechanisms needed to facilitate the best inter-agency community crisis care. Meaningful consultation with expert stakeholders grounded the theories in the reality of community crisis care, although UK evidence is heavily weighted towards England. Project delivery was affected by the COVID-19 pandemic, reducing the number of individual interviews and delaying stakeholder consultations. Stakeholder consultation did not reach as wide a group as originally intended. Conclusion Community crisis care is likely to continue to be delivered by a complex array of agencies responding to a heterogeneous population that presents with different mental health concerns and perceptions of crisis. Inter-agency working provides a platform for seamless transitions between services and timely responses. To deliver desired outcomes, inter-agency working requires continual systems of engagement locally and nationally involving all providers of crisis care through compassionate leadership, sharing of values and shared understanding of systems. Compassion is central and begins with leaders who can influence the culture of crisis organisations. Compassionate leadership is focused on people over systems, enabling front-line staff to retain their compassion and hope, and to work collaboratively across agencies, and it provides a platform for shared decision-making and co-production. All of this helps people in crisis to recognise the service as designed for them and to have trust in community crisis services. The study achieved its objectives, despite unexpected difficulties resulting from the effects of the COVID-19 pandemic, owing to an agile and committed research team, flexible and accommodating stakeholders and support from the funders. Project milestones were adjusted to accommodate the changing context of the study. Future work A framework of programme theories synthesised with mid-range theory developed from this study can inform future research that seeks to develop better mental health crisis care systems. Further work might explore how inter-agency service configurations work, including how telehealth interventions are perceived by service users and how these interventions produce optimal outcomes. Evaluation of crisis care for marginalised groups is needed. The implementation and effect of mental health triage could be explored further. Meaningful engagement with expert stakeholders could be incorporated routinely into research design and delivery. Mental health triage appears to be a promising approach, but has a limited evidence base. Future research could explore and test the implementation and effect of mental health triage systems. This work could focus on different values about prioritisation and how these can be accommodated within an inter-agency system. Further exploration of models of crisis care to mitigate barriers to access for those with substance use or alcohol use problems, personality disorders, physical health conditions and autistic spectrum disorders is needed. Inter-agency models of crisis care are causally linked to optimal crisis outcomes. A focused realist evaluation is needed to explore in more depth the factors influencing access to, and transition through, crisis care for these populations. These outcomes are at times theoretical and have been subjected to limited testing in primary research. UK inter-agency crisis service models provide an opportunity for mixed-method case study approaches to evaluation. A neglected area of focus for this research is the efficacy of models for rural populations. Crisis interventions involving police and mental health services have a growing body of evidence; however, there is a lack of evidence for co-response models involving ambulance paramedic staff or emergency control rooms. There is a lack of focus on individual recovery outcomes. This review highlights the importance of mechanisms such as psychological and relational safety, compassion and trust in producing optimal crisis outcomes. Research is needed to develop evaluation approaches to measure the presence and impact of these mechanisms in crisis care. Data from the literature and from engagement with stakeholders (via the ESG and individual interviews) were combined to refine the realist programme theory/ies to identify key mechanisms that might operate across multiple interventions to ‘trigger’ an appropriate treatment response, and contexts related to these key mechanisms that might enhance or detract from intervention success. Meaningful co-production with service users and other expert stakeholders enhances the relevance of research and should be incorporated routinely into research design and delivery. Study registration The study is registered as PROSPERO CRD42019141680. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR127709) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 15. See the NIHR Journals Library website for further project information.

ObjectiveHigh blood pressure is one of the main modifiable risk factors for dementia. However, there is conflicting evidence regarding the best antihypertensive class for optimizing cognition. Our objective was to determine whether any particular antihypertensive class was associated with a reduced risk of cognitive decline or dementia using comprehensive meta-analysis including reanalysis of original participant data.MethodsTo identify suitable studies, MEDLINE, Embase, and PsycINFO and preexisting study consortia were searched from inception to December 2017. Authors of prospective longitudinal human studies or trials of antihypertensives were contacted for data sharing and collaboration. Outcome measures were incident dementia or incident cognitive decline (classified using the reliable change index method). Data were separated into mid and late-life (>65 years) and each antihypertensive class was compared to no treatment and to treatment with other antihypertensives. Meta-analysis was used to synthesize data.ResultsOver 50,000 participants from 27 studies were included. Among those aged >65 years, with the exception of diuretics, we found no relationship by class with incident cognitive decline or dementia. Diuretic use was suggestive of benefit in some analyses but results were not consistent across follow-up time, comparator group, and outcome. Limited data precluded meaningful analyses in those ≤65 years of age.ConclusionOur findings, drawn from the current evidence base, support clinical freedom in the selection of antihypertensive regimens to achieve blood pressure goals.Clinical trials registrationThe review was registered with the international prospective register of systematic reviews (PROSPERO), registration number CRD42016045454.

Background There is a considerable body of systematic review evidence considering the effectiveness of rehabilitation programmes on clinical outcomes. However, much less is known about effectively engaging and sustaining patients in rehabilitation. There is a need to understand the full range of potential intervention strategies. Methods We conducted a mapping review of UK review-level evidence published 2017–21. We searched MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health (CINAHL) and conducted a narrative synthesis. Included reviews reported factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation, or an intervention to facilitate these factors. Study selection was undertaken independently by two reviewers. Results In total, we identified 20 review papers that met our inclusion criteria. There was a bias towards reviews considering cardiac rehabilitation, with these numbering 16. An additional 11 unpublished interventions were also identified through internet searching of key websites. The reviews included 60 identifiable UK primary studies that considered factors which affected attendance at rehabilitation; 42 considered cardiac rehabilitation and 18 considering pulmonary rehabilitation. They reported on factors from the patients’ point of view, as well as the views of professionals involved in referral or treatment. It was more common for factors to be reported as impeding attendance at rehabilitation rather than facilitating it. We grouped the factors into patient perspective (support, culture, demographics, practical, health, emotions, knowledge/beliefs and service factors) and professional perspective (knowledge: staff and patient, staffing, adequacy of service provision and referral from other services, including support and wait times). We found considerably fewer reviews (n = 3) looking at interventions to facilitate participation in rehabilitation. Although most of the factors affecting participation were reported from a patient perspective, most of the identified interventions were implemented to address barriers to access in terms of the provider perspective. The majority of access challenges identified by patients would not therefore be addressed by the identified interventions. The more recent unevaluated interventions implemented during the COVID-19 pandemic may have the potential to act on some of the patient barriers in access to services, including travel and inconvenient timing of services. Conclusions The factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation consist of a web of complex and interlinked factors taking into consideration the perspectives of the patients and the service providers. The small number of published interventions we identified that aim to improve access are unlikely to address the majority of these factors, especially those identified by patients as limiting their access. Better understanding of these factors will allow future interventions to be more evidence based with clear objectives as to how to address the known barriers to improve access. Limitations Time limitations constrained the consideration of study quality and precluded the inclusion of additional searching methods such as citation searching and contacting key authors. This may have implications for the completeness of the evidence base identified. Future work High-quality effectiveness studies of promising interventions to improve attendance at rehabilitation, both overall and for key patient groups, should be the focus moving forward. Funding This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HSDR programme or the Department of Health. Study registration The study protocol is registered with PROSPERO [CRD42022309214]. Plain language summary While we know quite a lot about what makes rehabilitation for heart (cardiac) or lung (pulmonary) conditions effective, less is known about how to engage people with these services and how to encourage them to continue to attend. We have looked at what studies have already been done to summarise the factors that affect whether someone chooses to attend rehabilitation and what is being tried to improve rates of attendance. We were particularly interested in people who are less likely to attend for rehabilitation. We searched in research databases for studies published since 2017 that included UK patients and services. We found 17 relevant summary papers which included a total of 52 UK studies. Most of these papers looked at the factors that affect attendance at rehabilitation, with far fewer studies considering ways to improve attendance. There were more studies looking at rehabilitation for cardiac than pulmonary conditions. Whether someone attended rehabilitation was affected by factors such as whether they felt supported, cultural and personal factors, practical factors such as travel and access, plus patient health, emotions, knowledge and beliefs about rehabilitation services. From a staff perspective, knowledge (staff and patient), staffing levels, level of service provision, and referral from other services were believed to affect attendance. We found a few studies where changes had been made to try to improve access including a number of studies of online delivery of rehabilitation services during COVID-19. Our summary of the factors that affect attendance at rehabilitation may be helpful to inform services about what changes they should make in the future to improve levels of attendance. Scientific summary Introduction There is a considerable body of systematic review evidence considering the effectiveness of rehabilitation programmes on clinical outcomes, comparing one mode of delivery with another (e.g. community vs. centre-based rehabilitation) or considering the relative effectiveness of rehabilitation using new technologies. However, much less is known about what is effective in terms of engaging patients in rehabilitation and sustaining that engagement over time. Despite increasing awareness of the factors that influence engaging with and sustaining rehabilitation, a lack of understanding of these factors (particularly in relation to differential effects for different populations) continues to impact on implementation of rehabilitation programmes. Existing reviews do not focus on understanding what might work for populations with lower uptake. There is therefore a need to map the evidence across both pulmonary and cardiac rehabilitation to understand the full range of potential intervention strategies. We conducted a time-constrained mapping review of factors which facilitate or impede engagement (commencement, continuation and completion) with pulmonary and cardiac rehabilitation. The review searched for evidence at the systematic review level. This review addresses three related sub-questions: •What are the factors that impede or facilitate engagement (commencement, continuation or completion) in rehabilitation by patients with heart disease or chronic lung disease? •Which intervention components, evaluated or innovative, have been proposed to increase engagement in rehabilitation and which factors do they propose to address? •What evidence is there for the effectiveness of such interventions as documented at a review level? An important subtext of these questions relates to health inequalities and differential uptake. Evidence suggests that inequalities that are already present are further exacerbated due to intrinsic features of rehabilitation programmes (Campkin LM, Boyd JM, Campbell DJT. Coronary artery disease patient perspectives on exercise participation. J Mol Signal 2017;37:305–14; Mamataz T, Ghisi GLM, Pakosh M, Grace SL. Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review. BMC Cardiovasc Disord 2021;21:459; Resurreccion DM, Motrico E, Rigabert A, Rubio-Valera M, Conejo-Ceron S, Pastor L, Moreno-Peral P. Barriers for nonparticipation and dropout of women in cardiac rehabilitation programs: a systematic review. J Womens Health (Larchmt) 2017;26:849–59; Vanzella LM, Oh P, Pakosh M, Ghisi GLM. Barriers to cardiac rehabilitation in ethnic minority groups: a scoping review. J Immigr Minor Health 2021b;23:824–39). Methods For inclusion, a review must have reported factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation, or an intervention that aims to increase the commencement, continuation or completion of rehabilitation. We included systematic reviews that reported factors identified from a UK context published between 2017 and 2021. Reviews that focused on the clinical effectiveness of rehabilitation or compare modes of rehabilitation (e.g. physical activity vs. other), or location of rehabilitation (e.g. community vs. hospital) were considered to be outside the scope of this review. We conducted a single search process to retrieve both systematic reviews of intervention effectiveness (i.e. quantitative) and of factors impacting upon engagement (i.e. qualitative). The search privileged the main subject headings for the two focal topics of interest: Cardiac Rehabilitation [MESH] and Lung Diseases/rehabilitation* OR Pulmonary Disease, Chronic Obstructive/rehabilitation. The main subject headings were combined with free-text terms and synonyms for engagement, uptake, completion, barriers and facilitators. The searches on MEDLINE, EMBASE and Cumulative Index to Nursing and Allied Health (CINAHL) used filters to retrieve references to review publications. Further web-based searches were also conducted to facilitate the inclusion of recent initiatives that are not yet reported in the systematic review literature. Sources of recent initiatives included the databases of the King’s Fund and Health Services Management Centre, alongside brief internet-based searches. Study selection was undertaken independently by two reviewers. Following piloting of a test set each record was screened by two of the three reviewers. In cases of uncertainty each was cross referred to the third reviewer. Data synthesised from quantitative studies were determined by the reporting characteristics of the included reviews. Interventions have been tabulated alongside the summary results of included reviews. Data relating to PROGRESS-Plus variables were also extracted where reported. The review includes published and formally evaluated projects and programmes together with recent initiatives awaiting evaluation. Results Included reviews The total number of hits from our searches was 566, of which 518 were excluded at the title and abstract stage, leaving 48 that were considered as full papers for inclusion in the review. In total, we identified 20 papers that met the inclusion criteria for the review and could contribute to answering one of the research questions. Although individual quality appraisal was not undertaken, the reviews all met minimum standards for conducting and reporting systematic reviews. Two had no identifiable disaggregated data for the UK studies they included (Mamataz et al., 2021, Supervia M, Medina-Inojosa JR, Yeung C, Lopez-Jimenez F, Squires RW, Perez-Terzic CM, et al. Cardiac rehabilitation for women: a systematic review of barriers and solutions. Mayo Clin Proc 2017;13:13). These two reviews (both of cardiac rehabilitation) have been included in the review-level analysis as they are relevant but they do not contribute any data at the primary study level). For the remaining 18 reviews, disaggregated data on at least one UK primary study were identified. There was a bias towards reviews considering cardiac rehabilitation, with these numbering 15; only 5 reviews considered pulmonary rehabilitation. Seventeen reviews included qualitative data from studies that reported on factors which facilitate or impede attendance at rehabilitation from patient (n = 9) or provider/system (n = 6) perspectives or considered both perspectives (n = 2). Three reviews reported on interventions to improve referral, uptake, adherence and/or completion of rehabilitation. Population In terms of defining the population under interest, most reviews that considered cardiac rehabilitation did not limit their included studies to any particular stage of, or setting for, the rehabilitation. Only three reviews included studies only from one specific stage of rehabilitation that included phase one cardiac rehabilitation patients (acute), phase 2 cardiac rehabilitation (subacute), and rehabilitation either at the intake appointment or at six weeks post hospital discharge. Location Eight reviews mentioned the location of rehabilitation, which specifically included outpatient clinics, patients post hospital discharge, in patients programmes, home- and centre-based programmes in hospital or outpatients, or after an acute care hospitalization (which included home or hospital-based rehabilitation). One review considered virtual education delivery of cardiac rehabilitation programmes via online platforms. Primary studies From the included reviews, a total of 60 UK primary studies were identifiable that were relevant to the review questions. Of the 60 identifiable primary studies that considered factors affecting attendance at rehabilitation, 42 considered cardiac rehabilitation, with the remaining 12 considering pulmonary rehabilitation. Over half of the papers reported on factors from the patient point of view (n = 23), with 17 considering the views of professionals involved in referral or treatment. It was more common for factors to be reported as impeding attendance at rehabilitation rather than facilitating it (despite the fact that most factors could be reported as their inverse). We grouped the reported factors as those from a patient perspective (including support, culture, demographics, practical, health, emotions, knowledge/beliefs, and service factors) and from a professional perspective (knowledge: staff and patient, staffing, adequacy of service provision, and referral from other services (including support and wait times). Intervention reviews In total, three reviews identified interventions; two that considered cardiac rehabilitation and one pulmonary rehabilitation. The two reviews of cardiac rehabilitation (Matata BM, Williamson SA. A review of interventions to improve enrolment and adherence to cardiac rehabilitation among patients aged 65 years or above. Curr Cardiol Rev 2017;13:252–62; Santiago de Arauja Pio C, Chaves G, Davies P, Taylor R, Grace S. Interventions to promote patient utilization of cardiac rehabilitation: Cochrane systematic review and meta-analysis. J Clin Med 2019;8:189) included the same UK study (McPaul J. Home Visit Versus Telephone Follow‐up in Phase II Cardiac Rehabilitation Following Myocardial Infarction. MSc dissertation. Chester: University of Chester; 2007). However there were no statistics details for the UK study by Matata and Williamson (2017). Whereas in Santiago de Araujo Pio et al. (2019), the intervention was reported to study the effects of home visits versus telephone follow-up by an occupational therapist on attendance for cardiac rehabilitation. The review by Early et al. (Early F, Wellwood I, Kuhn I, Deaton C, Fuld J. Interventions to increase referral and uptake to pulmonary rehabilitation in people with COPD: a systematic review. Int J Chron Obstruct Pulmon Dis 2018;13:3571–86) was the only review to address pulmonary rehabilitation. This review included six UK-based studies as a part of a narratively synthesised systematic review. The review aimed to establish the effectiveness of interventions to improve referral to and uptake of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD) when compared with standard care, alternative interventions or no intervention. Four studies reported statistically significant improvements in referral (range 3.5–36%) and two studies reported statistically significant increases in uptake (range 18–21.5%). Balance of factors In considering our typology of factors that improve or impede attendance at cardiac and/or pulmonary rehabilitation, it is interesting to note that most of the identified interventions were implemented to address barriers to access in terms of provider perspective. This was particularly true of the studies identified by Early et al. (2018), which considered access to pulmonary rehabilitation. A better understanding of the access challenges from the patient perspective may facilitate interventions to address the service provision challenges they experience more effectively. Only two interventions to improve attendance at cardiac rehabilitation were identified. However, these did better address some of the patient barriers to access, including improving support and motivation to exercise, and overcoming issues with travel to cardiac rehabilitation. Overall, however, the majority of access challenges identified by patients would not be addressed by the identified interventions. This reflects the very small number of patient access interventions identified. Effectiveness One small study on an intervention to improve attendance at cardiac rehabilitation suggested a positive effect (McPaul, 2007), although the change was not statistically significant. For pulmonary rehabilitation, two intervention studies reported an increase in referral rates (Roberts CM, Gungor G, Parker M, Craig J, Mountford J. Impact of a patient-specific co-designed COPD care scorecard on COPD care quality: a quasi-experimental study. NPJ Prim Care Respir Med 2015;25:15017; Hopkinson NS, Englebretsen C, Cooley N, Kennie K, Lim M, Woodcock T, et al. Designing and implementing a COPD discharge care bundle. Thorax 2012;67:90–2) but one-third were not effective (Graves J, Sandrey V, Graves T, Smith DL. Effectiveness of a group opt-in session on uptake and graduation rates for pulmonary rehabilitation. Chron Respir Dis 2010;7:159–64). Unpublished interventions Through additional website searching we identified 11 unpublished interventions not reported in the systematic review literature. Nine consisted of online delivery of cardiac rehabilitation (n = 7) or pulmonary rehabilitation (n = 2) during the COVID-19 pandemic. These interventions may have the potential to act on some of the patient barriers around access to services, including travel and inconvenient timing of services. One further intervention for cardiac rehabilitation trained staff in communication skills to encourage more patients to exercise, which may impact on patients’ knowledge and beliefs about rehabilitation. The final pulmonary rehabilitation intervention (developing a toolkit to increase inclusivity) may have the potential to impact on some of the demographic and cultural patient barriers identified in the factors literature. Discussion Implications for service delivery Services should in particular, consider the barriers imposed for some patients by cultural and demographic factors which may require additional effort to: •make service alterations to improve engagement with specific patient groups (e.g. females, ethnic minorities) •consider the implications of group exercise on creating reluctance to attend for some individuals •provide patient educational interventions to alter perceptions of rehabilitation and ensure that patients have a good understanding of what it involves and how it is appropriate for their needs •provide staff training around engagement with specific patient groups, communication to encourage exercise and to better explain both the content and benefits of rehabilitation •consider the impact of location and timing of service provision on attendance, including whether the continued provision of online services may be appropriate in some instances. As variations between the factors reported as impacting on cardiac or pulmonary rehabilitation are not due to fundamental differences in the patient reported factors (except those related to the specific condition (e.g. smokers reluctance for COPD rehabilitation), specialities can learn from each other in terms of potential interventions to improve attendance. Implications for research The existing review level literature on the factors which impact on attendance for rehabilitation of both pulmonary and cardiac conditions would benefit from a greater focus on what could be done to facilitate attendance as the evidence currently has a negative focus. Research into interventions to improve attendance at rehabilitation, both overall and for key patient groups, should be the focus moving forward. In developing interventions to improve access to an engagement with rehabilitation services the perspectives of both the patients and the services providers should be considered. Conclusions The factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation consist of a web of complex and interlinked factors taking into consideration the perspectives of the patients and the service providers. Although most of the factors affecting participation were reported from a patient perspective, most of the identified interventions were implemented to address barriers to access in terms of the provider perspective. Thus, the majority of access challenges identified by patients would not be addressed by the identified interventions. Better understanding of these factors will allow future interventions to be more evidence based with clear objectives as to how to address the known barriers to improve access. Funding This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HSDR programme or the Department of Health. Study registration The study protocol is registered with PROSPERO [CRD42022309214].

Background: Societal changes have led to greater isolation and higher levels of loneliness particularly for older generations. Loneliness is a significant public health challenge leading to increased levels of poor mental health. Depression and anxiety are also increasing in prevalence amongst children and young people. Intergenerational activities are interventions designed to bring together older and younger generations with the purpose of allowing participants to utilise their experiences and skills, and to give participants a chance to experience the pleasure and excitement that occurs with the transmission of knowledge and skills from one generation to another. Intergenerational activities are therefore potential interventions that can address the growing problems associated with loneliness and lack of wellbeing. Objectives: This systematic review aims to examine the impact of intergenerational interventions on the wellbeing and mental health in children and adolescents, and potential harmful effects. It also aims to identify areas for future research as well as key messages for service commissioners. Search Methods: We searched an evidence and gap map published in 2022 (comprehensive searches conducted July 2021 and updated June 2023) to identify randomised controlled trials of intergenerational interventions that report mental health and wellbeing outcomes for children and young people. Selection Criteria: Randomised controlled trials of intergenerational interventions that involved unrelated younger and older people with at least one skipped generation between them and reported mental health or wellbeing outcomes for children and young people were included in this review. Data Collection and Analysis: We used standard methodological procedures expected by The Campbell Collaboration. We conducted data extraction and Cochrane risk of bias assessments in EPPI reviewer. Main Results: While we identified 500 evaluations of intergenerational interventions, where the impact on participating children and/or young people was evaluated this was most often limited to assessing their impact on attitudes to aging. We identified five studies evaluating five different types of intergenerational interventions which included one‐off sessions to ones that spanned a year measuring their impact on the mental health and wellbeing of children and/or young people. The purposes of the interventions differed, which included promoting social skills, preventing harmful behaviour and promoting learning. The ages of children also varied across the five studies, with one targeting younger children, two targeting younger teenagers and two targeting older teenagers. One study included socioeconomically disadvantaged children, and in the other studies the socioeconomic backgrounds of the children and young people were not described. The outcome measures used to evaluate the interventions varied with none of the studies measuring the same outcomes. One study showed improvements in wellbeing measures, and this was an intervention delivered to children in deprived neighbourhoods, where the intervention duration was for a year allowing the development of a greater depth of relationship between the younger and older participants. Four studies found no....... The included studies were at high risk of bias therefore raising uncertainty in the reliability of the findings. Underpinning theories that supported the development of the interventions and explained the mechanisms of effect were poorly described. Authors' Conclusions: The evidence for the effectiveness of intergenerational interventions on the mental health and wellbeing of children and young people is limited and inconclusive. Few evaluations have sought to measure how intergenerational interventions impact children and young people and where this impact is measured the focus is usually limited to attitudes to aging. The evidence that has been collected is too heterogenous to allow synthesis of the findings. The underpinning theories to support their development are poorly described with no follow‐up data to ascertain if benefits are maintained. Intergenerational interventions show promise but researchers have failed to measure how they impact on the mental health and wellbeing of children and young people. This is a serious limitation of the evidence base that needs to be addressed in robust and rigorous evaluations. [ABSTRACT FROM AUTHOR]

Our previous work identified that nine leading guidance documents for seven different types of systematic review advocated the same process of literature searching. We defined and illustrated this process and we named it 'the Conventional Approach'. The Conventional Approach appears to meet the needs of researchers undertaking literature searches for systematic reviews of clinical interventions. In this article, we report a new and alternate process model of literature searching called 'A Tailored Approach'. A Tailored Approach is indicated as a search process for complex reviews which do not focus on the evaluation of clinical interventions. The aims of this article are to (1) explain the rationale for, and the theories behind, the design of A Tailored Approach; (2) report the current conceptual illustration of A Tailored Approach and to describe a user's interaction with the process model; and (3) situate the elements novel to A Tailored Approach (when compared with the Conventional Approach) in the relevant literature. A Tailored Approach suggests investing time at the start of a review, to develop the information needs from the research objectives, and to tailor the search approach to studies or data. Tailored Approaches should be led by the information specialist (librarian) but developed by the research team. The aim is not necessarily to focus on comprehensive retrieval. Further research is indicated to evaluate the use of supplementary search methods, methods of team-working to define search approaches, and to evaluate the use of conceptual models of information retrieval for testing and evaluation. [ABSTRACT FROM AUTHOR]

This study aimed to address the question: what does "effectiveness" mean to researchers in the context of literature searching for systematic reviews? We conducted a thematic analysis of responses to an e-mail survey. Eighty-nine study authors, whose studies met inclusion in a recent review (2018), were contacted via e-mail and asked three questions; one directly asking the question: in literature searching, what does effective (or effectiveness in) literature searching mean to you? Thirty-eight (46%) responses were received from diverse professional groups, including: literature searchers, systematic reviewers, clinicians and researchers. A shared understanding of what effectiveness means was not identified. Instead, five themes were developed from data: (1) effectiveness is described as a metric; (2) effectiveness is a balance between metrics; (3) effectiveness can be categorized by search purpose; (4) effectiveness is an outcome; and, (5) effectiveness is an experimental concept. We propose that these themes constitute a preliminary typology of understandings. No single definition of effectiveness was identified. The proposed typology suggests that different researchers have differing understandings of effectiveness. This could lead to uncertainty as to the aim and the purpose of literature searches and confusion about the outcomes. The typology offers a potential route for further exploration.

The requirement for literature searches that identify studies for inclusion in systematic reviews should be systematic, explicit, and reproducible extends, at least by implication, to other types of literature review. However, realist reviews commonly require literature searches that challenge systematic reporting; searches are iterative and involve multiple search strategies and approaches. Notwithstanding these challenges, reporting of the "realist search" can be structured to be transparent and to facilitate identification of innovative retrieval practices. Our six-component search framework consolidates and extends the structure advanced by Pawson, one of the originators of realist review: formulating the question, conducting the background search, searching for program theory, searching for empirical studies, searching to refine program theory and identifying relevant mid-range theory, and documenting and reporting the search process. This study reviews reports of search methods in 34 realist reviews published within the calendar year of 2016. Data from all eligible reviews were extracted from the search framework. Realist search reports poorly differentiate between the different search components. Review teams often conduct a single "big bang" multipurpose search to fulfill multiple functions within the review. However, it is acknowledged that realist searches are likely to be iterative and responsive to emergent data. Overall, the search for empirical studies appears most comprehensive in conduct and reporting detail. In contrast, searches to identify and refine program theory are poorly conducted, if at all, and poorly reported. Use of this framework offers greater transparency in conduct and reporting while preserving flexibility and methodological innovation.

The aim of this study was to provide guidance to improve the completeness and clarity of meta-ethnography reporting. Evidence-based policy and practice require robust evidence syntheses which can further understanding of people's experiences and associated social processes. Meta-ethnography is a rigorous seven-phase qualitative evidence synthesis methodology, developed by Noblit and Hare. Meta-ethnography is used widely in health research, but reporting is often poor quality and this discourages trust in and use of its findings. Meta-ethnography reporting guidance is needed to improve reporting quality. The eMERGe study used a rigorous mixed-methods design and evidence-based methods to develop the novel reporting guidance and explanatory notes. The study, conducted from 2015 to 2017, comprised of: (1) a methodological systematic review of guidance for meta-ethnography conduct and reporting; (2) a review and audit of published meta-ethnographies to identify good practice principles; (3) international, multidisciplinary consensus-building processes to agree guidance content; (4) innovative development of the guidance and explanatory notes. Recommendations and good practice for all seven phases of meta-ethnography conduct and reporting were newly identified leading to 19 reporting criteria and accompanying detailed guidance. The bespoke eMERGe Reporting Guidance, which incorporates new methodological developments and advances the methodology, can help researchers to report the important aspects of meta-ethnography. Use of the guidance should raise reporting quality. Better reporting could make assessments of confidence in the findings more robust and increase use of meta-ethnography outputs to improve practice, policy and service user outcomes in health and other fields. This is the first tailored reporting guideline for meta-ethnography.

Introduction: Registration and publication of trial protocols has become increasingly important and a requirement in some sources of funding and publication. Increased access to protocols yields many potential benefits, but there are issues regarding identification of published protocols. The aim of this investigation is to compare methods of retrieval for identifying trial protocols in a systematic review. Methods: Six stages of searching (checking published trial reports, searching journal Web sites, Internet searching, trial registers, bibliographic databases, and contact with authors) were completed to identify 74 trial protocols. Results: Fifty-seven percent of the trial protocols were identified upon completion of all 6 stages of searching. The most comprehensive method was searching trial registers that identified 51% of the protocols. Contact with authors was most effective at uniquely identifying protocols; 12% were retrieved via this single method. Contact with authors was the only effective method of identifying protocols for trials pre-2005. Discussion: When attempting to identify trial protocols to include in systematic reviews, some methods are relatively quick to undertake but deliver a low yield. The most effective search strategy for most sources was retrieval by trial registration number where available. Conclusions: For protocols of trial results published pre-2005, review authors should contact authors as a priority. For protocols post-2005, they should check the trial publication for protocol details, search trial registers, and contact authors, ceasing searching once a predetermined point of diminishing returns has been reached.

Background: Comprehensive resuscitation plans document treatment recommendations, such as 'Not for cardiopulmonary resuscitation'. When created early in admission as a shared decision-making process, these plans support patient autonomy and guide future treatment. The characteristics of patients who have resuscitation plans documented, their timing, and associations with clinical outcomes remain unclear. Objectives: To characterise factors associated with resuscitation plan completion, early completion, and differences in mortality rates and Intensive Care Unit (ICU) admissions based on resuscitation plan status. Methods: This retrospective study analysed non-elective admissions to an Australian tertiary centre from January to June 2021, examining plan completion timing (early < 48 h, late > 48 h) and associations with mortality and ICU admission. Results: Of 13,718 admissions, 5745 (42%) had a resuscitation plan recorded. Most plans (89%) were completed early. Furthermore, 9% of patients died during admission, and 8.2% were admitted to the ICU. For those without resuscitation plans, 0.5% died (p < 0.001), and 9.7% were admitted to the ICU (p = 0.002). Factors associated with plan completion included a medical unit, in-hours admission, older age, female gender, limited English proficiency, and non-Indigenous status. Plans completed late (>48 h) correlated with a higher mortality (14% vs. 9%; p < 0.001) and more ICU admissions (25% vs. 6%; p < 0.001). Aboriginal and/or Torres Strait Islander patients were often overlooked for resuscitation documentation before death. No resuscitation plans were documented for 62% of ICU admissions. Conclusions: Important disparities exist in resuscitation plan completion rates across highly relevant inpatient and demographic groups. [ABSTRACT FROM AUTHOR]

Background: Supplementary search methods, including citation searching, are essential if systematic reviews are to avoid producing biased conclusions. Little evidence exists on how to prioritise databases for citation searching or to establish whether using multiple sources is beneficial. Objectives: A systematic review examining urgent and emergency care reconfiguration was used to investigate the utility of citation searching on Web of Science (WOS) and/or Google Scholar (GS). Methods: This case study investigated numbers of studies, additional studies and unique studies retrieved from both sources. In addition, the time to search, the ease of adding references to reference management software and obtaining abstracts of studies for screening are briefly considered. Results: WOS retrieved 62 references after deduplication of the results, 52 being additional references not retrieved during the database searching. GS retrieved 134 unique references with 63 additional references. WOS and GS retrieved the same three additional included studies. WOS was less time intensive to search given the facility to restrict to English language papers and availability of abstracts. Conclusions: In a single systematic review case study, citation searching was required to identify all included studies. Citation searching on WOS is more efficient, where a subscription is available. Both databases identified the same studies but GS required additional time to remove non‐English language studies and locate abstracts. [ABSTRACT FROM AUTHOR]