Identification of behaviour change components in swallowing interventions for head and neck cancer patients: protocol for a systematic review

Govender et al. Systematic Reviews (2015) 4:89 DOI 10.1186/s13643-015-0077-4 PROTOCOL Open Access Identification of behaviour change components in swallowing interventions for head and neck cancer patients: protocol for a systematic review Roganie Govender1*, Christina H Smith2, Stuart A Taylor3, Daphne Grey4, Jane Wardle5 and Benjamin Gardner6,7 Abstract Background: Dysphagia (difficulty in swallowing) is a predictable consequence of head and neck cancer and its treatment. Loss of the ability to eat and drink normally has a devastating impact on quality of life for survivors of this type of cancer. Most rehabilitation programmes involve behavioural interventions that include swallowing exercises to help improve swallowing function. Such interventions are complex; consisting of multiple components that may influence outcomes. These interventions usually require patient adherence to recommended behaviour change advice. To date, reviews of this literature have explored whether variation in effectiveness can be attributed to the type of swallowing exercise, the use of devices to facilitate use of swallowing muscles, and the timing (before, during or after cancer treatment). This systematic review will use a behavioural science lens to examine the content of previous interventions in this field. It aims to identify (a) which behaviour change components are present, and (b) the frequency with which they occur in interventions deemed to be effective and non-effective. Methods/design: Clinical trials of behavioural interventions to improve swallowing outcomes in patients with head and neck cancers will be identified via a systematic and comprehensive search of relevant electronic health databases, trial registers, systematic review databases and Web of Science. To ascertain behaviour change intervention components, we will code the content for its theory basis, intervention functions and specific behaviour change techniques, using validated tools: the Theory Coding Scheme, Behaviour Change Wheel and Behaviour Change Technique Taxonomy v1. Study quality will be assessed for descriptive purposes only. Given the specialisation and focus of this review, a small yield of studies with heterogeneous outcome measures is anticipated. Therefore, narrative synthesis is considered more appropriate than meta-analysis. We will also compare the frequency of behavioural components in effective versus non-effective interventions, where effectiveness is indicated by statistically significant changes in swallowing outcomes. Discussion: This review will provide a synthesis of the behaviour change components in studies that currently represent best evidence for behavioural swallowing interventions for head and neck cancer patients. Results will provide some guidance on the choice of optimal behavioural strategies for the development of future interventions. Systematic review registration: PROSPERO CRD42015017048 Keywords: Head and neck cancer, Dysphagia, Swallowing rehabilitation, Behaviour change, Behavioural interventions, Systematic review * Correspondence: 1 Head and Neck Cancer Centre, University College London Hospital and Health Behaviour Research Centre, University College London, 250 Euston Road, London NW1 2PQ, UK Full list of author information is available at the end of the article © 2015 Govender et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Govender et al. Systematic Reviews (2015) 4:89 Background Head and neck cancer is a cluster term that refers to cancers that arise in the oral cavity, pharynx, larynx, paranasal sinuses, nasal cavity or salivary glands. Since the 1990s, trends have suggested a 30 % increase for oral cancer and a 50 % increase for oropharyngeal cancer [1]. Risk factors for the increase include oral human papillomavirus (HPV) infection and betel nut chewing, as much as the more commonly reported smoking- and alcoholrelated causality. The age at which individuals develop head and neck cancer has dropped, meaning that many are still actively employed. Cancer Research UK [2] have estimated the current lifetime risk for a newborn infant of developing head and neck cancer is 1 in 84 for males and 1 in 160 for females. Advances in treatment have improved 5-year survival rates, but this has resulted in a corresponding increase in functional burden such as swallowing difficulties. There are therefore a greater number of individuals, often still of employment age, living longer following their cancer treatment, but with significant functional morbidity. The need to optimise interventions to reduce this morbidity has become increasingly important. Dysphagia (difficulty in swallowing) is a highly prevalent morbidity following oncological treatment for head and neck cancers, affecting most patients at some stage over the course of treatment [3, 4]. The presence of a tumour in the mouth or throat may result in problems with eating and drinking, but the treatments for cancer (surgery, radiotherapy, chemotherapy) also cause alterations to swallowing function which may persist for many months or even years [5, 6]. Some individuals never regain the ability to eat and drink normally following treatment. Surgery may involve the removal of important oropharyngeal or laryngeal structures with resultant changes to the anatomy and physiology for normal swallowing. The side effects of radiotherapy include a dry mouth, taste changes, fibrosis and stiffening of tissues, which all affect the movement of this finely tuned dynamic process. Dysphagia is also a known late-effect of radiotherapy, meaning that new swallowing symptoms may arise years after the treatment is completed [7]. Difficulty swallowing is often rated as the most significant factor affecting quality of life amongst survivors of head and neck cancers [8, 9]. It has also been identified by head and neck cancer patients, as one of the highest priorities for rehabilitation [10]. Description of the condition as related to the target population Individuals who are diagnosed with head and neck cancer may experience some changes to their swallowing function as one of the early symptoms that prompt their visit to a doctor. Usually, most patients continue to Page 2 of 8 maintain an oral diet at this stage. However, the treatments for this type of cancer are known to have a significant impact on the physiology of normal swallow function [3, 4]. Most notably, problems may be associated with swallow safety (aspiration of food and drink into the lungs) or swallow efficiency (prompt and timely transit of food and dr (...truncated)