Using evidence-based guidelines to inform service provision: a structured mapping exercise within the National Health Service Diabetes Prevention Programme in England
Haste et al. BMC Res Notes
Using evidence-based guidelines to inform service provision: a structured mapping exercise within the National Health Service Diabetes Prevention Programme in England
Anna Haste 0 1 2
Linda Penn 0 1 2
Angela M. Rodrigues 0 2
Marta M. Marques 0 3
Kirsten Budig 0
Ruth Bell 0
Carolyn Summerbell 2 4
Martin White 0 5
Ashley J. Adamson 0 1 2
Falko F. Sniehotta 0 2
0 Institute of Health & Society, Newcastle University , Baddiley Clark Building, Newcastle upon Tyne NE2 4AX , UK
1 Human Nutrition Research Centre, Newcastle University , Newcastle upon Tyne , UK
2 Fuse: UKCRC Centre for Translational Research in Public Health , Newcastle upon Tyne , UK
3 Department of Clinical , Educational and Health Psychology , University College London , 1-19 Torrington Place, London WC1E 7HB , UK
4 School of Applied Social Sciences, Durham University , 32 Old Elvet, Durham DH1 3HN , UK
5 MRC Epidemiology Unit, University of Cambridge , Cambridge Biomedical Campus, Cambridge CB2 0QQ , UK
Objective: The National Health Service (NHS) in England planned a national diabetes prevention programme (NHS DPP) with phased implementation. Evidence-based guidelines and service specifications support efficient and effective translation of research into practice. We aimed to evaluate the use of a structured mapping exercise to appraise how evidence, service specification and early phase practice could inform recommendations to guide subsequent implementation of the NHS DPP. Results: The mapping exercise facilitated comparison and appraisal of key components from different documentary sources (evidence-based NICE guidelines, service specification, and provider documents). Key components were categorised into (A) pathways into programmes, (B) intervention content (C) inequalities and (D) quality assurance and staff training. We identified where key components were the same (accordance), where they varied (discrepancies) and where they were lacking (discontinuities), across the documentary sources. For example there was discrepancy in intervention duration and discontinuity in intervention enrolment procedures. This mapping exercise was useful to compare the fidelity in translation of evidence-based guidance into service specification and programme documents, thus identifying where future service implementation might be improved. This method may be applicable for use with other health conditions where research evidence requires translation into real world population programmes.
Evidence-based guidelines; Structured mapping; Practical implementation; Diabetes prevention
Introduction
The NHS 5 year forward view in England emphasised
the need for ‘a radical upgrade in prevention and public
health’ and included a plan for a national diabetes
prevention programme (NHS DPP) [
1
].
The NHS DPP in England, for individuals at high risk
of developing type 2 diabetes (T2D), was planned to be
rolled out in phases (i) demonstrator site phase (seven
sites in England), (ii) wave 1 (four procured providers
in 27 sites across England, permitting 20,000 referrals in
2016/17) and (iii) wave 2 (nationally to the whole country
by 2020 with an expected 100,000 referrals available each
year). The stated objectives were reduction in incidence
of T2D, blood glucose parameters and weight [
2
].
The NHS DPP service specification [
2
] was developed
by NHS England using research evidence reviews and
reports [
3, 4
], input from an Expert Reference group, a
User Involvement group and analysis of the Health
Survey for England data. The demonstrator site phase relied
mostly on applications from local health economies,
where relevant services were already being delivered, and
was intended to inform subsequent implementation of
the NHS DPP.
National Institute for Health and Care Excellence
(NICE) guidelines are created to improve outcomes for
those using health services [
5
]. However, evidence-based
guidelines do not necessarily result in the anticipated
change in practice. Where guidance is available there are
often gaps between evidence-based principles,
contractual agreements around intervention commissioning and
actual provision of services and interventions [
6
].
Translation of research into practice involves making
sure research findings about effective treatments reach
populations that can benefit and are implemented as
intended [
7
]. Reflection on the guidelines available and
how these are implemented in practice is necessary to
make best use of the recommendations in an applied
setting [
8
].
Summary of the process evaluation of the
demonstrator and wave 1 phases of the NHS DPP are reported
elsewhere [
9
].
We aimed to appraise how evidence informed practice
to guide subsequent implementation of the NHS DPP
through a structured mapping exercise [
10
].
Main text
Methods
To conduct the mapping exercise we reviewed and
extracted data from all the relevant
evidence/documentary sources. The documentary sources used within the
mapping method were:
1. NICE guidelines—PH38 preventing T2D guidance
for individuals at high risk [
11
].
2. The draft NHS DPP service specification
(demonstrator site phase).
3. The final NHS DPP service specification [
2
] (wave 1
phase).
4. All of the seven demonstrator site applications and
Memoranda of Understanding (MoU) submitted
to become part of the NHS DPP demonstrator site
phase. Any provided baseline documentation from
the seven sites.
5. All of the four procurements and Memoranda of
Understanding (MoU) submitted to become a
provider for the NHS DPP wave 1 phase. Any provided
baseline documentation from the four providers was
reviewed.
Data was extracted from the above documentary
sources in relation to Key components. Components
related to the whole of the programme were extracted
to enable the complete T2D prevention pathway to be
reviewed and synthesised. These included:
A. Pathways into the programmes (identification,
recruitment, referral, enrolment)
B. Intervention content (intervention components
using existing reporting frameworks and taxonomies
[
12–14
])
C. Inequalities using PROGRESS equality indicators
(place of residence, race/ethnicity/language,
occupation, gender/sex, religion, education, socioeconomic
status, social capital) [
15
]
D. Quality assurance and staff training (fidelity
measures, resources, staffing, training requirements)
Information was extracted on staff or health care
professional involvement at each stage of the programme
and also areas of responsibility, i.e. training of delivery
staff.
Structured mapping was used to collate the evidence
and enable comparison of the findings across the
different documentary sources. Initially we used a spreadsheet
to facilitate the mapping process and we used
recommendations in NICE guidance (PH38) to identify key
components [
16
]. The extracted data were then organised
into tables (Table 1).
The mapping exercise drew on Structured Mapping
Theory, which describes the use of mapping and how
evaluation of the analogy gives a measure of the
quality of match between the base and a target [
10
]. Critical
appraisal identified whether key components across and
between the documentary sources were in:
1. Accordance—components that were common and
reported across all documentary sources, e.g. the
format of the intervention (face-to-face group sessions).
2. Discrepancies—components that varied across
documentary sources, e.g. duration or intensity of the
intervention.
3. Discontinuities—components that did not appear
across all documentary sources, e.g. intervention
enrolment procedures.
We used the Accordance, Discrepancies,
Discontinuities (ADD) ‘ADD-Fuse’ method outlined above, which
was developed during the NHS DPP demonstrator and
wave 1 phase evaluation projects, to facilitate critical
appraisal. Critical appraisal identified where programmes
or specifications consistently met the desired criteria or
where differences or gaps were present and therefore
where improvements could be recommended.
Recommendations were formulated from the appraisal process
and provided to the NHS DPP management team to
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inform subsequent phases (Additional file 1). Using this
mapping exercise on two different phases of the NHS
DPP showed how the programmes and service
specifications progressed between these phases.
The mapping exercise was completed independently by
two reviewers with expertise in behaviour change
interventions and checked by a third reviewer in both phases,
any disparities were resolved through discussion.
However, we found that the clear specification of key
components and the agreed classification as Accordance,
Discrepancy and Discontinuity for each key component
across each documentary source led to a high degree of
consistency between reviewers. The data collection and
methodology are summarised in a flow chart (Fig. 1).
Results
Table 1 provides an example of how the mapping exercise
was conducted.
Table 1 illustrates how the mapping exercise facilitated
the identification of key components, actors and
responsibilities within the NICE guidelines, NHS DPP service
specification and NHS DPP provider documentation
(the applied setting/context). Tables were then used to
compare and contrast across the different documentary
sources.
We described this method as identifying
Accordance, Discrepancies and Discontinuities (the ADD-Fuse
method), which was used to highlight the key
commonalities, differences and gaps between the documentary
sources (Table 2).
Table 2 illustrates how the identification of accordance,
discrepancies and discontinuities (ADD-Fuse method)
led to the formulation of recommendations for
improvements in relation to the NHS DPP service specification,
the planned implementation of the DPPs (provider
documents) or both. Recommendations were provided to the
NHS DPP Management team and responses to the
recommendations were received from the Management
team back to the research team (Additional file 1). This
method identified key components in the service
specification that impact on implementation.
Accordance
In both the demonstrator and wave 1 phases, the format
of the intervention was in accordance with the NHS DPP
service specification (in person group sessions).
Discrepancy
The reporting of the content of the face-to-face sessions,
the level of detail on outcomes, mechanisms of action
and techniques used varied greatly between providers. As
outlined in Tables 1 and 2 discrepancies were identified
in the duration and intensity of the intervention provided
in both phases (demonstrator and wave 1). One wave 1
provider did not meet the required standard for
duration and intensity, which varied across the four
providers. This variation poses an issue for outcome evaluation
across the provider interventions. Therefore monitoring
of patient contacts is vital to ensure clarity in
intervention provision and the impact of this on intervention
outcomes.
Discontinuity
A gap (discontinuity) in the draft NHS DPP service
specification was identified at the demonstrator phase for
the description of behaviour change techniques (BCTs)
when compared with recommendation s in NICE
guidelines (Table 1). However, by wave 1 more detailed BCT
description was requested in the NHS DPP service
specification, all providers incorporated the recommended
BCTs, and most used additional evidence-based
techniques for sustained behaviour change. Detail on
additional contact with patients (i.e. telephone support, text
messages or social media contact) outside of the standard
in group sessions was an identified discontinuity in wave
1 provider documents. The remote contact and materials
used, including digital components, should be described
with the same level of detail as the other components,
including reference to the specific behavioural outcomes,
theoretical basis and techniques used. While this level of
detail was recommended in the NHS DPP national
service specification, the providers did not provide it in such
detail.
Discussion
Key findings
Evidence-based documentary sources were used to
examine incorporation of evidence in the planned
context of the NHS DPP programme. Comparison identified
accordance, discrepancies and discontinuities (ADD-Fuse
method). Different components, actors and
responsibilities that may impact the implementation and evaluability
of the NHS DPP were revealed. This process identified
recommendations (Additional file 1), informing
subsequent phases of the NHS DPP, as to where further
clarification and consideration was required to either improve
the service specification and/or support the transition of
evidence into practice.
Comparison with other studies
Evidence-based lifestyle interventions to prevent or
treat diabetes have been shown to be effective and have
the potential to reduce morbidity and mortality rates
[
17–20
]. A difficulty in translating DPP’s into practice
is the need to adapt to all patients, clinicians or
setting needs. As all local services need to adapt for the
NICE PH 38
Recommendations
NICE web site
Demonstrator site phase
Data collection
NHS DPP Draft
service specification
NHS DPP
management
group
Provider
documents
NHS DPP
management
group
Documents
NICE PH 38
Recommendations
Source
NICE web site
First Wave of implementation
Data collection
NHS DPP National
specification
NHS DPP
management
group
Provider
documents
NHS DPP
management
group
Identify categories of components: NICE PH38
recommendations
(A: pathways into the programmes, B: intervention content, C:
inequalities, D: quality assurance and staff training)
Identify categories of components: NICE PH38
recommendations
(A: pathways into the programmes, B: intervention content, C:
inequalities, D: quality assurance and staff training)
Identify Key components across all documentary sources
Identify Key components across all documentary sources
Allocate reviewers to each Key component category
Extract information from all documents to spreadsheets:
key components (vertical) document extracts (horizontal)
Identify Accordance, Discrepancies and Discontinuities
across Key components
Meet (three reviewers) to discuss and agree data extraction
and classification into key components and identification of
text in terms of Accordance, Discrepancies and
Discontinuities
Allocate reviewers to each Key component category
Extract information from all documents to spreadsheets:
key components (vertical) document extracts (horizontal)
Identify Accordance, Discrepancies and Discontinuities
across Key components
Meet (three reviewers) to discuss and agree data
extraction and classification into key components and
identification of text in terms of Accordance, Discrepancies
and Discontinuities
Summarise, collate Demonstrator site programme data, and
prepare summary tables for categories (A, B, C and D as
above)
Summarise, collate Demonstrator site programme data,
and prepare summary tables for categories (A, B, C and D
as above)
Agree summary tables (three reviewers)
Agree summary tables (three reviewers)
Critically appraise the data using the detailed mapping and
summary tables (three reviewers)
Critically appraise the data using the detailed mapping and
summary tables (three reviewers)
Formulate Recommendations, using the critical appraisal and
tables as above
Formulate Recommendations, using the critical appraisal
and tables as above
Submit recommendations to the
NHS DPP management group
Submit recommendations to the
NHS DPP management group
diverse UK population it is vital to monitor intended
variations as well as unintended variations that occur
during implementation, highlighting the importance of
process evaluations [
21
]. A previous review identified
translational strategies and cultural adaptations were
frequency used to in order for DPP’s to reach diverse
populations and those from disadvantaged
socioeconomic backgrounds, e.g. adapting materials
(including information on local foods or traditional physical
activities), reducing the frequency of classes or using
community health workers to deliver classes. This
review stated how adaptations often go unreported
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and supports the use of a structured approach to
documenting translation, as offered in this current
manuscript, to facilitate identification of implementation and
effectiveness [
22
].
Strengths
Mapping two stages of the NHS DPP (demonstrator
phase and wave 1) made it possible to trace the
progression of a new service as the phases were rolled out in
England and observe changes in the NHS DPP service
specification over time. The mapping exercise evaluated
the programme as a whole, informing on wider aspects
of a health improvement programme that could be
improved, which would not be assessed if focused solely
on the intervention.
Implications
Variance in delivered programmes is likely to have an
impact on the assessed outcomes. This structured
mapping exercise has utility for implementation science and
real-world programmes in explaining differences in
outcomes based on specific components of the interventions
and how each programme is implemented in relation to
the service specification. This method could also enable
the identification of key areas that require improvement.
The mapping exercise examined the progression of a
national programme rollout, identifying how the service
specification developed from a draft to a final document
(e.g. incorporating greater detail on the inclusion of BCTs
and addressing inequalities). This mapping exercise could
be utilised in further rollout of the NHS DPP. This
process could be used for the development of future service
specifications and in the reporting of behaviour change
programmes. Fidelity measures need to be established in
order to judge whether implementation of a programme
meets the required standards.
Conclusion
A mapping exercise was applied in the context of the
NHS DPP in England. Using NICE guidelines allowed
the service specification and provider documents to
be examined in relation to the evidence base. This
enabled identification of whether the implementation of a
new health care programme may experience problems
owing to shortcomings in the service specification or
whether problems lie within the transition from evidence
into practice. We suggest the method may be applicable
for use within other disease or health conditions where
research evidence requires translation into real world
population programmes.
Limitations
The strength of the evidence base varies across different
health conditions and therefore using a mapping exercise
like this may not be applicable to programmes that do
not have existing evidence-based guidelines and where
the evidence is minimal or of poor quality.
The NHS DPP explicitly entered other sources of
evidence into the specification development (users, experts,
new evidence syntheses) and this has implications for
how closely the programme tracks the research evidence.
There are of course reasons for doing this, for
example practicality and funding can impact greatly, but this
brings risks that the key components that make an
intervention effective become diluted.
Since the mapping exercise additional evidence has
become available, in particular the 2017 update to the
NICE PH38 guidelines [
23
]. Data extraction relied on
information provided from demonstrator site and wave 1
providers.
Additional file
Additional file 1. Recommendations provided to the NHS DPP
Management team and responses received from the NHS DPPManagement team.
Abbreviations
BCTs: behaviour change techniques; DPP: diabetes prevention programme;
NHS: National Health Service; NHS DPP: National Health Service Diabetes
Prevention Programme; NICE: National Institute for Health and Care Excellence;
T2D: type 2 diabetes.
Authors’ contributions
AH, LP, AMR, MMM, and KB conducted the data collection, extraction and
analysis. AJA, FFS, MW, CS, RB and LP designed the study and accessed
funding. All authors read and provided feedback on previous versions. All authors
read and approved the final manuscript.
Acknowledgements
We thank the NHS Diabetes Prevention Programme (NHS DPP)
demonstrator sites, wave 1 providers and the NHS Diabetes Prevention Programme
Management Group for access to documentation supplied by the various
organisations through the NHS DPP demonstrator site and wave 1 application
procedures. In particular, we thank the NHS DPP demonstrator and wave 1 site
key contact personnel, providers and members of the NHS DPP Management
Group for their help and co-operation with our research.
This is a paper of independent research funded by the NIHR SPHR. The
views expressed are those of the author(s) and not necessarily those of the
NHS, the NIHR or the Department of Health.
Competing interests
The authors declare that they have no competing interests.
Availability of data and materials
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Funding
This formative evaluation of the NHS Diabetes Prevention Programme
demonstrator site phase is funded via the National Institute for Health Research
School for Public Health Research.
The National Institute for Health Research School for Public Health
Research (NIHR SPHR) is a partnership between the Universities of Sheffield,
Bristol, Cambridge, UCL; The London School for Hygiene and Tropical
Medicine; The Peninsula College of Medicine and Dentistry; the LiLaC collaboration
between the Universities of Liverpool and Lancaster and Fuse; The Centre for
Translational Research in Public Health, a collaboration between Newcastle,
Durham, Northumbria, Sunderland and Teesside Universities.
AH, LP, AR, CS, AJA and FFS are members of Fuse, the Centre for
Translational Research in Public Health (http://www.fuse.ac.uk). Fuse is a UK Clinical
Research Collaboration (UKCRC) Public Health Research Centre of Excellence.
Funding for Fuse from the British Heart Foundation, Cancer Research UK,
Economic and Social Research Council, Medical Research Council, the National
Institute for Health Research, under the auspices of the UKCRC, is gratefully
acknowledged. (Fuse Grant Reference Number is: MR/K02325X/1).
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
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