international journal of quantitative and qualitative research methods

Combining qualitative and quantitative research within mixed method research designs: a methodological review

Affiliation.

• 1 Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden. [email protected]
• PMID: 21084086
• PMCID: PMC7094322
• DOI: 10.1016/j.ijnurstu.2010.10.005

Objectives: It has been argued that mixed methods research can be useful in nursing and health science because of the complexity of the phenomena studied. However, the integration of qualitative and quantitative approaches continues to be one of much debate and there is a need for a rigorous framework for designing and interpreting mixed methods research. This paper explores the analytical approaches (i.e. parallel, concurrent or sequential) used in mixed methods studies within healthcare and exemplifies the use of triangulation as a methodological metaphor for drawing inferences from qualitative and quantitative findings originating from such analyses.

Design: This review of the literature used systematic principles in searching CINAHL, Medline and PsycINFO for healthcare research studies which employed a mixed methods approach and were published in the English language between January 1999 and September 2009.

Results: In total, 168 studies were included in the results. Most studies originated in the United States of America (USA), the United Kingdom (UK) and Canada. The analytic approach most widely used was parallel data analysis. A number of studies used sequential data analysis; far fewer studies employed concurrent data analysis. Very few of these studies clearly articulated the purpose for using a mixed methods design. The use of the methodological metaphor of triangulation on convergent, complementary, and divergent results from mixed methods studies is exemplified and an example of developing theory from such data is provided.

Conclusion: A trend for conducting parallel data analysis on quantitative and qualitative data in mixed methods healthcare research has been identified in the studies included in this review. Using triangulation as a methodological metaphor can facilitate the integration of qualitative and quantitative findings, help researchers to clarify their theoretical propositions and the basis of their results. This can offer a better understanding of the links between theory and empirical findings, challenge theoretical assumptions and develop new theory.

Copyright © 2010 Elsevier Ltd. All rights reserved.

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• Research Design*

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Access, acceptance and adherence to cancer prehabilitation: a mixed-methods systematic review

• Open access
• Published: 06 May 2024

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• Tessa Watts 1 ,
• Nicholas Courtier 1 ,
• Sarah Fry 1 ,
• Nichola Gale 1 ,
• Elizabeth Gillen 1 ,
• Grace McCutchan 1 ,
• Manasi Patil 1 ,
• Tracy Rees 1 ,
• Dominic Roche 1 ,
• Sally Wheelwright 2 &
• Jane Hopkinson 1  

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The purpose of this systematic review is to better understand access to, acceptance of and adherence to cancer prehabilitation.

MEDLINE, CINAHL, PsychINFO, Embase, Physiotherapy Evidence Database, ProQuest Medical Library, Cochrane Library, Web of Science and grey literature were systematically searched for quantitative, qualitative and mixed-methods studies published in English between January 2017 and June 2023. Screening, data extraction and critical appraisal were conducted by two reviewers independently using Covidence™ systematic review software. Data were analysed and synthesised thematically to address the question ‘What do we know about access, acceptance and adherence to cancer prehabilitation, particularly among socially deprived and minority ethnic groups?’

The protocol is published on PROSPERO CRD42023403776

Searches identified 11,715 records, and 56 studies of variable methodological quality were included: 32 quantitative, 15 qualitative and nine mixed-methods. Analysis identified facilitators and barriers at individual and structural levels, and with interpersonal connections important for prehabilitation access, acceptance and adherence. No study reported analysis of facilitators and barriers to prehabilitation specific to people from ethnic minority communities. One study described health literacy as a barrier to access for people from socioeconomically deprived communities.

Conclusions

There is limited empirical research of barriers and facilitators to inform improvement in equity of access to cancer prehabilitation.

Implications for Cancer Survivors

To enhance the inclusivity of cancer prehabilitation, adjustments may be needed to accommodate individual characteristics and attention given to structural factors, such as staff training. Interpersonal connections are proposed as a fundamental ingredient for successful prehabilitation.

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Introduction

Prehabilitation is a core component of supportive care for health and well-being during cancer survivorship. It aims to improve cancer treatment outcomes and long-term health by preparing people awaiting cancer treatments, not only surgery, through support for physical activity, nutrition and emotional well-being either alone or in combination, and from the point of diagnosis [ 1 ]. Growing international evidence indicates that, in specific cancers, engagement with either uni or multimodal prehabilitation interventions can improve individuals’ pre-treatment functional capacity [ 2 , 3 ], reduce treatment-related complications [ 4 , 5 , 6 ], ease anxiety [ 7 ] and enhance post-treatment recovery [ 8 , 9 ]. As the evidence base develops and momentum for prehabilitation grows, the need to embed prehabilitation as the standard of care across different cancers has been recognised [ 10 , 11 , 12 ]. In some regions, multimodal prehabilitation is now offered as the standard of care in certain cancers, particularly lung [ 13 ] and colorectal [ 14 ].

Internationally, there are persistent health disparities following cancer treatment. Treatment and survival outcomes are poor among people from socioeconomically deprived communities and some minority ethnic groups compared to socioeconomically advantaged and majority groups [ 15 , 16 , 17 ]. To ease the overall social and economic impact of cancer on individuals and society, and to reduce the societal and healthcare costs of suboptimal treatment outcomes, it is important to identify the facilitators of and barriers to individuals’ engagement with interventions. People from socioeconomically deprived communities and some minority ethnic groups are known to be underserved in prehabilitation interventions [ 1 , 18 ]. Accordingly, to better understand reasons for informed action, this mixed-methods systematic review aims to identify, critically appraise and synthesise international empirical evidence of the facilitators of and barriers to access, acceptance  and adherence of cancer prehabilitation. For this review, prehabilitation is defined as proactive and preventative for all cancer treatments (not only surgery and including neoadjuvant) and includes interventions to support physical activity, nutritional intake or psychological well-being, alone or together, carried out at any time before a course of treatment begins.

Review question

What is known about access, acceptance and adherence to cancer prehabilitation, particularly among socially deprived and minority ethnic groups?

The systematic review was informed by the Joanna Briggs Institute (JBI) mixed-methods systematic reviews (MMSR) methodology [ 19 ]. A convergent, integrated approach to data synthesis and integration was adopted [ 19 , 20 ]. The review was registered in PROSPERO CRD42023403776) on 3 March 2023 and is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines [ 21 ]. Ethical approval was not required.

Database searches

In collaboration with a specialist health service systematic review librarian, the search strategy was developed using medical subject headings (MeSH) and keywords including and relating to cancer, prehabilitation, inequity, inequality, socioeconomic deprivation, ethnic groups and health services accessibility, and then tested and refined. The electronic databases Ovid SP MEDLINE, CINAHL via EBSCO host, PsycINFO, Ovid SP EMBASE, Ovid Emcare, Allied and Complementary Medicine (AMED), Physiotherapy Evidence Database (PEDRo) and Cochrane Central were systematically searched by EG for studies published in English between January 2017 and May 2023. The search strategy was tailored for each database and detailed in online resource (Supplementary information 1 ). Supplementary searches of grey literature using the Overton, Dimensions and Proquest dissertation and theses databases (PQDT), and relevant organisational websites were conducted. Reference lists of papers retrieved for full review were scrutinised for potentially useful papers not identified through the database searches.

Selection criteria

The PICO framework was used to guide inclusion criteria on population (P), Intervention (I), comparators (C) and outcomes (O) and context (Co). It enabled identification of primary qualitative, quantitative and mixed-methods research studies about prehabilitation, published in peer-reviewed journals. Eligibility criteria were used during study selection to screen this body of literature for empirical data about barriers and facilitators of prehabilitation. Non-empirical, opinion pieces, theoretical and methodological articles, reviews and editorials were excluded, as were studies involving children, adolescents and focusing on end-of-life care.

Study selection

All search results were stored in Endnote™. Following deduplication, results were imported into Covidence™ systematic review management software. For study selection, standardised systematic review methods [ 22 ] were used. All project team members were involved in study screening and selection. Firstly, two reviewers independently screened all returned titles and abstracts. Based on eligibility and relevance, these were sifted into ‘yes’, ‘no’ or ‘maybe’ categories. Disagreements were resolved by a third reviewer. Where a definite decision could not be made, full text was retrieved and assessed. Secondly, full text of all potentially relevant abstracts was retrieved and independently assessed for inclusion by two reviewers against the eligibility criteria. Arbitration by an independent reviewer in the event of disagreement was not required at this stage. Reasons for exclusion at full text review were recorded.

Quality assessment

Two reviewers independently assessed the quality of included studies via Covidence ™ using the Mixed Methods Appraisal Tool (MMAT) version 18 [ 23 ]. The MMAT was constructed specifically for quality appraisal in mixed studies reviews and is widely used [ 23 , 24 ]. Within a single tool, Version 18 of the MMAT can be used to appraise the methodological quality of five broad categories of study design, namely qualitative, randomised controlled trials, non-randomised, quantitative descriptive and mixed methods studies. The MMAT comprises two screening questions to establish whether or not the quality appraisal should proceed and 25 core questions: five criteria which mostly relate to the appropriateness of study design and approaches to sampling, data collection and analysis relevant to each of the five study designs [ 23 ]. Each criterion is assessed as being met (Yes) or not (No). There is also scope to indicate uncertainty. A third reviewer independently moderated all quality assessments for accuracy.

Data extraction

Two reviewers independently extracted data systematically via Covidence™ using an adapted, piloted JBI mixed-methods data extraction form. Information extracted included study author, aim, year and country of publication, setting, intervention type, design, sample, data collection, analysis, data relating to prehabilitation facilitators and barriers and, as relevant, data on intervention for support of access, acceptance or adherence to prehabilitation. A third reviewer cross-checked the data extraction tables independently for accuracy and completeness.

Data synthesis and integration

All extracted findings were imported into Microsoft Excel. Quantitative data were ‘qualitised’ into textual descriptions of quantitative results to enable assimilation with qualitative data [ 25 ]. To analyse and synthesise all findings, thematic synthesis [ 26 , 27 ] was used. Thematic analysis is an established process involving the identification and development of patterns and analytic themes in primary research data. Two reviewers coded the findings and then grouped related codes into preliminary descriptive themes which captured patterns across the data describing barriers to and facilitators of cancer prehabilitation [ 26 ]. Preliminary themes were discussed with a third reviewer. Themes were then further combined and synthesised to generate three overarching analytical themes relative to the review question [ 26 ].

Figure 1 shows the PRISMA flow chart of search results. Following the first and second round screening, 56 papers published between 2017 and 2023 were included: 33 quantitative; 14 qualitative and nine mixed methods.

PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources. *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/

A synopsis of study characteristics and the quality appraisal outcomes is found in Table 1 . Brief narrative summaries of the included papers’ findings of relevance to the review question, namely access, acceptance and adherence of prehabilitation interventions, are provided in the online supplementary information (supplementary information 2 ).

Study characteristics

Of the 32 quantitative studies reviewed, there were eight randomised controlled trials, two single-arm multi-centre trials, seven cohort studies and one cross-sectional survey. Others were pilot ( n = 3), feasibility ( n = 7), observational ( n = 1) and prevalence ( n = 1) studies, with one non-randomised trial and one audit. Qualitative studies ( n = 15) mainly used a broad qualitative approach ( n = 12), one used phenomenology, one participatory action research and one used a cross-sectional survey. Nine studies used mixed methods.

Study populations

The majority of included studies were conducted in Europe ( n = 33) (UK ( n = 19), Netherlands ( n = 4), Denmark ( n = 3), Spain ( n = 1), France ( n =1), Portugal ( n = 1), Belgium ( n = 1), Slovenia ( n = 1), Norway ( n = 1) and Sweden ( n = 1)). Eleven were conducted in North America (Canada ( n = 8), United States ( n =3)), and eight were from Australia. The remaining studies were from Japan ( n = 1) and China ( n =1), and two studies were conducted across two countries, Australia and New Zealand and the UK and Norway. Studies focused on prehabilitation in different settings including hospitals ( n = 12), local communities (including universities and local gymnasiums), individuals’ homes ( n = 14) and outdoors ( n = 1). Ten studies reported a hybrid, home and hospital approach to prehabilitation, whilst digital prehabilitation was reported in nine studies. Fifty-three studies were conducted in a range of cancers. Of these, 41 reported data for a single cancer site: colorectal ( n = 11); gastrointestinal ( n = 9); lung ( n = 7); haematology ( n= 4); breast ( n = 3); head and neck ( n =2); bladder ( n = 2) prostate ( n =1) and a range of abdominal surgeries ( n = 3). In 12 studies, cancer sites were pooled. Three studies focused on healthcare professionals ( n = 2) and key stakeholders ( n = 1).

Methodological quality

There was considerable variation in the methodological quality of the 56 studies included. Twelve studies, 10 qualitative and two quantitative, satisfied all the MMAT criteria [ 23 ]. Fourteen studies, nine mixed methods, two qualitative and three quantitative, satisfied just one or two criteria. Thus, data were extracted from a body of literature where one-fifth (21%) of publications were about research of the highest quality, defined as having met 100% of the MMAT criteria [ 23 ]. Detailed results of the MMAT quality assessments are found in supplementary information (supplementary information 3 ).

Thematic synthesis

The thematic synthesis identified three cross-cutting analytic themes. As illustrated in Figure 2 , these themes reflected individual, structural and interpersonal facilitators of and barriers to access, acceptability and adherence of cancer prehabilitation:

Overarching themes

Theme 1 The influence of individual drivers of cancer prehabilitation engagement

Theme 2 Providing acceptable cancer prehabilitation service and interventions

Theme 3 Interpersonal support – the unifying golden thread

Interpersonal support was the unifying golden thread as it facilitated the fit between the individual and the structural for access to, acceptance of and adherence to prehabilitation.

Theme 1. The influence of individual drivers of cancer prehabilitation engagement

Factors at the level of the individual were found to shape prehabilitation access, acceptance and adherence. These included perceived need and benefits, motivations, health status and everyday practicalities.

The perceived need for and potential benefits of prehabilitation

A key stimulus for accessing and adhering to cancer prehabilitation was a belief that engagement might confer benefit. Influences included clinicians’ prehabilitation endorsement and encouragement [ 12 , 13 , 42 , 52 , 55 , 59 , 60 , 65 , 66 , 71 ], positive prior personal experiences of routine physical activities [ 60 , 69 , 70 , 77 ] and weight loss programmes [ 77 ], other patients’ support [ 12 , 71 ] and the perceived need to improve personal fitness [ 60 , 63 ]. Some participants in UK-based studies believed they had a social responsibility to engage in prehabilitation [ 63 , 64 ] as enhanced fitness would benefit healthcare services financially [ 12 , 64 ].

The money, the cost per night in the hospital, goodness knows how much that costs and the follow-up with all the doctors, the dieticians and everyone else behind (….). It’s (prehabilitation) saving the NHS thousands and thousands of pounds of money ([ 64 ] p.4).

Several studies indicated some individuals perceived prehabilitation to be beneficial in that interventions provided a welcome distraction from their illness and situation [ 64 , 72 , 74 ]. Benefit was understood in terms of being psychologically and physically prepared for cancer treatments, potentially enhancing post-treatment recovery and survival [ 12 , 55 , 60 , 63 , 64 , 66 , 67 , 68 , 70 , 71 , 74 ].

I benefited a lot from it because it caught me in that time just after diagnosis when things were pretty scary and pretty awful and I felt like it was one of the key pieces of my plan for positivity during this whole thing, because it was setting a tone for recovery ([ 74 ] p. 8)

Yet, it was also clear that some individuals were disinterested in engaging with prehabilitation [ 56 , 58 , 66 , 74 , 80 ]. Some studies suggested a connection between imminent surgery and patients’ perceptions of little benefit of prehabilitation in the short timescales [ 47 , 54 , 63 , 69 , 77 , 79 ]. Some individuals felt that making additional hospital visits for prehabilitation was onerous [ 54 ]. Others were unaccustomed to or did not want to exercise [ 36 , 70 ] or perceived exercise as demanding [ 41 ], particularly when combined with cancer treatment [ 51 ]. Some considered their existing fitness levels [ 61 , 63 ] and diet [ 61 ] sufficient. A sense of low perceived benefit of or need for prehabilitation meant it was considered a low priority [ 36 ].

Personal motivators

A cancer diagnosis [ 71 , 77 ] conjoined with the desire to improve fitness [ 63 , 64 , 72 ], survive surgery [ 63 , 64 ] and to be present for and enjoy their families [ 64 ] were influential motivators for individuals’ proactively effecting lifestyle change and thus engagement with prehabilitation. Having accessed prehabilitation, exercise logs and diaries [ 64 , 68 , 74 ], personal goal setting [ 61 , 64 , 71 ], progress self-monitoring [ 61 , 64 , 68 , 71 , 77 ], activity tracking and objective feedback [ 56 , 60 ] motivated individuals to maintain participation. They inspired them to remain on track, enabled them to realise their progress, build self-efficacy for prehabilitation adherence [ 60 , 70 , 73 , 76 , 77 ] and, through a process of cognitive reframing, regain a sense of control [ 71 ].

Now I have a feeling of control over my body . . . I don’t want cancer to define me. [ 71 ]

Nonetheless, one study reported that motivation to access prehabilitation may be negatively affected by low levels of health literacy, which is associated with socioeconomic deprivation [ 46 ]. Furthermore, sustaining motivation to continue prehabilitation could be challenging [ 43 , 45 , 58 , 64 , 70 , 74 ], especially when faced with unanticipated setbacks such as delayed surgery [ 57 ] or insufficient peer support [ 64 ].

The enduring problems of health limitations

Individuals’ physical and psychological health status influenced prehabilitation access and adherence, particularly when there was a perception of insufficient on-going professional [ 61 , 72 , 73 ] and family support [ 31 ], and interventions were located away from home. Pancreatic cancer [ 33 ] adversely affected individuals’ access to prehabilitation. Furthermore, physical health problems limited some individuals’ ability to travel and thus access hospital-based prehabilitation [ 54 , 59 , 71 ]. Symptoms experienced and perceived health status influenced individuals’ prehabilitation adherence. Reported adherence barriers included physical symptoms [ 61 , 67 , 70 , 72 , 73 , 81 ] such as fatigue [ 45 , 50 , 57 , 70 , 73 ], pain [ 40 , 45 , 57 , 59 , 70 , 71 , 73 ], digestive problems [ 30 , 35 , 39 , 47 , 55 , 67 ] and feeling unwell [ 40 , 43 , 64 , 79 ]. In addition, functional limitations [ 63 , 70 ] associated with comorbidities [ 31 , 37 , 40 , 49 , 51 , 57 , 64 , 70 , 77 ], disease status [ 37 , 41 ], pre-surgery neoadjuvant treatments [ 37 , 53 , 64 , 70 , 81 ] and mental health problems [ 35 , 39 ] were all reported to negatively affect individuals’ ability to engage with and adhere to prehabilitation, particularly in terms of physical activities.

Several studies reported that psychological distress had a negative effect on prehabilitation access and adherence [ 59 , 61 , 70 , 73 ]. Described by a participant in one study [ 63 ] as ‘dark moments’, as anxiety and stress were often connected with attending hospitals [ 71 ]. In addition, several studies reported that individuals felt overwhelmed, both generally [ 42 , 57 , 74 ] and emotionally [ 12 , 70 ], in advance of their treatments. Information overload [ 62 ] and competing personal matters which required their attention pre-treatment [ 70 , 80 ] contributed to the sense of feeling overwhelmed.

The challenges of everyday life

Across studies, insufficient time for prehabilitation was frequently reported [ 40 , 50 , 51 , 55 , 58 , 66 , 71 , 72 , 74 , 77 , 78 ]. Some individuals described competing priorities in the short space of time between diagnosis and treatment [ 49 , 57 , 59 , 70 , 79 ]. This was partly due to putting affairs in order, prioritising family time [ 61 ] or treatments being scheduled earlier than originally planned [ 35 , 54 , 55 ]. Others were constrained by their employment [ 51 , 70 , 73 , 80 ] and family responsibilities, including caring for other family members [ 55 , 58 , 70 ]. Additional barriers to prehabilitation engagement included geographical distance to hospitals delivering prehabilitation [ 28 , 32 , 41 , 51 , 54 , 57 , 63 , 74 ]; transport difficulties [ 29 , 49 , 51 , 54 , 58 , 60 , 66 , 79 ] and associated financial costs [ 51 , 66 , 71 ]; inclement weather, particularly in relation to prehabilitation with outdoor exercise components [ 45 , 57 , 64 , 70 , 73 , 74 ]; low digital literacy [ 34 , 42 , 76 ]; restricted or limited access to and problems with technology [ 42 , 56 , 76 , 80 ], notably broadband [ 45 , 79 ] and experiencing physical discomfort with exercise equipment [ 60 , 64 ].

Theme 2. Providing acceptable cancer prehabilitation service and interventions

The prehabilitation environment, mode of delivery (which might be technological) and the perceived utility of interventions were important facilitators of access [ 34 , 48 , 57 , 66 , 71 , 75 , 80 ] and adherence [ 36 , 45 , 48 , 61 ] and influenced acceptance [ 36 , 52 , 61 , 64 , 69 , 71 , 77 , 80 , 81 ].

The value of home-based prehabilitation

Home-based prehabilitation interventions with remote professional supervision and support were accepted for their convenience [ 38 , 74 ], capacity to motivate [ 38 , 61 , 64 , 73 ] and build self-efficacy [ 40 , 61 , 64 , 73 ] and perceived benefit [ 40 , 69 , 74 ]. Specifically, individuals reported that home-based prehabilitation enabled them to integrate interventions into their everyday lives [ 61 , 64 ]. Exercising in the safe, private, space of home was enjoyable [ 36 , 66 ], could help with overcoming self-consciousness and engendered a sense of control [ 61 , 64 ].

I couldn’t go to the gym any longer. I can’t very well be running out to the toilet the whole time. So, I had to find something else, so it was that [static bike at home]. ([ 61 ] p. 206) …I don’t want to do it [prehabilitation] in a hospital because I think it then becomes really competitive. And people are, like, if they can’t do it, they feel…. They would feel like, ‘Oh, I’m not strong enough…’ you know what I mean. It might depress them. Whereas if you do it in the house, you can do it at your own pace, there’s nobody watching over you and everything. [ 64 ]

Home-based prehabilitation interventions were important facilitators of access [ 48 , 66 ] and adherence [ 36 , 48 , 61 ]. The provision of portable exercise equipment such as resistance bands enabled sustained adherence, particularly when individuals were temporarily away from home [ 74 ]. Some individuals welcomed the freedom and flexibility of home-based prehabilitation [ 72 ]. Yet despite being provided with resources to monitor [ 34 , 42 , 52 , 64 , 66 , 76 ], supplement and continue physical activity at home [ 48 , 63 , 66 , 74 , 77 ], insufficient in-person healthcare professional engagement and encouragement could mean adherence was often difficult to monitor [ 69 , 81 ] and sustained intervention adherence could be challenging [ 28 , 63 , 64 ] and afforded a low priority by individuals [ 61 , 72 , 73 ].

There had to be real pressure, there really had! And then if suddenly they were not around (the health professionals), then I’m not sure I’d finish it. That’s how I am. You have to keep an eye on me. [ 72 ]

Navigating the technological space of tele-prehabilitation

Sometimes referred to as ‘tele’ or ‘digital’-prehabilitation, technology-based uni and multimodal home-based prehabilitation capitalised on internet and/or telephone communication services and was delivered using smartphones, videos, wearable technology, tablets, mobile applications, video platforms and secure video conferencing [ 34 , 36 , 42 , 45 , 56 , 70 , 71 , 76 , 80 ]. In terms of acceptability, individuals perceived home-based, tele-prehabilitation programmes as accessible, particularly during the SARS-CoV-2 pandemic [ 34 , 71 , 80 ]:

Having prehabilitation outside of the hospital setting made things easier. I wasn’t feeling good with the pain and couldn’t travel too far. Could also do it in my own time ([ 71 ] p. 646)

Home-based tele-rehabilitation was also perceived as motivating [ 36 , 45 , 56 , 76 ], conferred benefit [ 34 , 36 , 45 , 56 , 80 ], particularly when personalised [ 34 , 45 , 56 , 71 ] and reduced transport-associated costs [ 80 ].

Sustained tele-prehabilitation engagement was aided by the provision of smartphones [ 56 , 76 ], tablets with relevant applications and content downloaded [ 34 ], training watches [ 34 , 56 , 76 ], supplementary information and alternate web browser pathways for those without access to or with low digital literacy [ 42 ] and integrated digital training and support during the intervention’s implementation [ 34 , 36 , 42 ].

I would not have been able to endure the treatments and the surgery thereafter had it not been for the continuous support I was receiving through the digital platform. [ 34 ]

Reported barriers were primarily intervention specific. They included technical [ 45 , 80 ] and device connectivity issues [ 34 , 76 ], broadband and website interface problems, particularly for individuals unaccustomed to using technology [ 45 ]. Negative views of mobile mindfulness apps [ 56 ] and equipment aesthetics [ 76 ] were also described.

The perceived utility of prehabilitation interventions

Interventions that were perceived as being accessible in terms of their user-friendliness [ 34 , 56 , 74 , 76 ] and appropriately designed to meet individuals’ needs, preferences and capabilities in terms of their structure [ 40 , 52 , 60 , 68 , 74 , 77 , 78 ], notably coherence [ 36 , 38 , 45 , 75 , 76 ] and components [ 38 , 54 , 55 , 64 , 69 , 74 ], including nutritional supplements [ 44 , 54 , 55 , 67 ], enhanced acceptability. The acceptability of prehabilitation interventions was reflected in the expressions of gratitude [ 12 ] and the positive ways in which interventions were variously described by individuals in some studies [ 12 , 38 , 58 , 64 , 74 ] as ‘excellent’, ‘very good’, ‘great’, ‘brilliant’, ‘hugely beneficial’ and ‘fun’. Some would even recommend home-based prehabilitation to people preparing for cancer treatments [ 52 , 63 , 68 , 74 ]. However, one study [ 42 ] reported that unfamiliarity with the English language had a negative impact on access, whilst in another study [ 56 ], individuals reported adhering to protein targets challenging.

At an individual level, the availability [ 61 ] and extent of integrated healthcare professional supervision and support was perceived to enable intervention access [ 75 ] and adherence [ 42 , 60 , 61 , 64 , 66 , 68 , 69 , 74 , 78 ], particularly when this was personalised [ 34 , 45 , 56 , 65 , 68 , 71 , 78 ]. Unpalatable nutritional interventions had a negative effect on intervention adherence [ 30 , 50 ], and it was reported that inspiratory muscle training devices could be difficult for individuals to use [ 38 ].

Healthcare professionals reported organisational barriers to implementation, and thus individuals’ access to, acceptance of and adherence with prehabilitation. These barriers included workforce capacity limitations [ 12 , 65 , 75 , 79 , 81 ], including insufficient embedded specialist prehabilitation professionals [ 69 , 81 ], delayed or insufficient referral to prehabilitation [ 33 , 44 , 63 ], disconnect in cross-boundary systematic service delivery and communication [ 12 , 28 , 75 , 81 ], inadequate funding [ 12 , 65 , 79 , 81 ] and awareness of local prehabilitation provision, uncertainty regarding what constitutes prehabilitation among some healthcare professionals [ 28 , 79 , 81 ] and space and time constraints [ 69 , 81 ] together with insufficient equipment [ 28 ] in hospital settings to deliver interventions [ 81 ].

Theme 3. Interpersonal support: the unifying golden thread

Across the studies reviewed, the unifying golden thread was interpersonal support, for this was an important, valued enabler of prehabilitation access [ 64 ] acceptance and adherence. It was reported that interpersonal support was derived from family and friends [ 12 , 45 , 60 , 61 , 64 , 70 , 73 ], prehabilitation healthcare professionals [ 42 , 51 , 55 , 60 , 61 , 63 , 64 , 66 , 69 , 71 , 75 , 78 ], prehabilitation peers [ 51 , 59 ], volunteers [ 79 ] and in-person and online peer support groups [ 71 , 79 ]. When embedded within interventions, a network of interpersonal support helped to sustain prehabilitation adherence, particularly in relation to physical activity [ 59 , 60 , 68 , 72 , 79 ]. During what could be challenging times, the interpersonal support experienced during prehabilitation enhanced interventions’ acceptability [ 52 , 60 , 63 , 68 ].

The active involvement of family during physical activities such as walking and exercise routines was reported to generate a sense of companionship, encouragement and motivational and psychological support [ 34 , 60 , 61 , 64 , 70 , 71 , 77 ]. In these ways, prehabilitation interventions with embedded family support enhanced their acceptability [ 52 ].

My wife did the same ones with me so there were two of us doing the same stuff. We did the walks together. Then we would both do the exercises. So that was good company. [ 64 ]

Findings reported in one study [ 31 ] indicated that living alone could have a negative effect on prehabilitation adherence.

The acceptability of prehabilitation interventions was enhanced by relevant healthcare professionals’ supportive dialogue in the shape of information, personalised encouragement, validation and timely, constructive feedback on individuals’ engagement, progress and performance [ 69 , 77 ], signposting to other support services [ 63 ] and broader emotional support [ 77 ]. In addition to sustaining prehabilitation behaviours through collaboration, activation and motivational support [ 60 , 61 , 71 , 72 , 77 , 78 ], healthcare professionals’ presence instilled a sense of trust [ 71 ], comfort [ 51 ] and safety [ 38 , 62 , 63 ] and reduced feelings of social isolation [ 71 ]. The need for and importance of supportive dialogue with healthcare professionals during prehabilitation was identified by participants in one study investigating individuals’ experiences of multimodal prehabilitation delivered via a leaflet and with no embedded healthcare professional support [ 73 ].

I have only been a number. Like I was a garden shovel with a barcode that you scanned at the cash register. There is no one who thinks about what this means for one’s self-understanding–- just to be regarded as a disease [...] There is no one asking about the human being behind it. It is insane [ 73 ]

For some participants, peer support in the shape of information sharing was beneficial and enabled prehabilitation access [ 63 , 71 ]. Integrated group or one to one peer support was reported to enhance an intervention’s acceptability [ 12 , 63 ]. In part, this was because individuals did not always want to engage their families, and peer support reduced their sense of isolation [ 71 ]. Peer support was reported to be beneficial in terms of interaction with others in a similar situation, thereby lending individuals’ social, emotional and motivational support, enabling them to remain on track with their prehabilitation programme [ 51 , 59 , 64 , 66 , 71 ].

Exercising in a group motivates. Let new patients exercise with other patients who are further along and have more experience exercising. They (experienced patients) can then tell them, Yes, you will get muscle aches, but they will subside too. [ 59 ]

It was clear from some studies that the absence of peer support in prehabilitation interventions was lamented [ 64 , 71 ], with some participants exercising agency and accessing online patient forums to derive required support [ 71 ].

This review reports findings from across the globe regarding facilitators of and barriers to access, acceptance and adherence of cancer prehabilitation. The findings draw attention to cross-cutting themes at individual and structural levels and interpersonal factors that connect the levels. As illuminated in Fig. 2 , the multifaceted facilitators and barriers underscore the complexity of cancer prehabilitation access, acceptance and adherence.

This review found interpersonal connections, support either directly obtained from peers, family, healthcare professionals or via digital connectivity, can facilitate a fit between the individual factors and structural factors that affect engagement with prehabilitation. Examples include encouragement from a spouse willing to engage in a recommended physical activity with the patient, practical help with digital technology, peer support during group prehabilitation and health professional supervision. Support through these interpersonal connections may be a core ingredient for successful access, acceptance and adherence. This proposition should now be explored and tested. There may be sub-groups with need or preference for certain sources of interpersonal support. Our review was designed to find out ‘what is known about access, acceptance and adherence to cancer prehabilitation, particularly among socially deprived and minority ethnic groups’ because of the known benefits from prehab for post treatment recovery [ 8 , 9 ]. It found no empirically based analysis of prehabilitation access, acceptance or adherence by people from these groups.

The individual and structural context

This review revealed individual factors enabling or impeding prehabilitation access, acceptance and adherence include personal beliefs and understandings about potential harms or benefits; motivations, for example finding enjoyment in participation; health status and everyday practicalities such as time and transport availability. Structural factors identified included the availability of knowledgeable and supportive health professionals and/or people affected by cancer’ service organisation, such as the availability of a prehabilitation multidisciplinary team and the place and space of service delivery, for example, if it was available in the community.

Individual and structural level factors affecting access to cancer treatment and care are widely reported [ 82 , 83 , 84 , 85 ]. Some are proposed to be modifiable for improved health outcomes in groups at risk of poor health because of poverty and/or discrimination based on age, race, ethnicity or gender [ 84 ]. The findings of the review are consistent with this wider literature on service access, acceptance and adherence. It is notable that although our search was designed to identify all literature about access, acceptance and adherence to cancer prehabilitation from 2017 to 2023, we found no analysis of structural differences. The differential experience of people from structurally vulnerable groups, for example, those who are socioeconomically deprived or from minority communities, had not been considered. Yet, evidence indicates that cancer rehabilitation services are underutilised by people from socioeconomically deprived communities [ 86 , 87 ] and ethnic minorities [ 88 ]. We also know patient engagement with prehabilitation is variable [ 89 ], and third sector organisations claim people from socioeconomically deprived communities, which include people from some ethnic minorities, are underserved by prehabilitation services [ 1 ]. Exploration and understanding of difference in prehabilitation experiences across social groups is needed if support for access, acceptance and adherence is to achieve equity in health outcomes.

Interpersonal connections linking individual experience and structural context

This review identified that it was people, namely peers, family members and friends, who, through their support, influenced the extent to which individual and structural level factors were obstacles or enablers of prehabilitation. In the relational space between individual experience and the infrastructure in place to enable prehabilitation, these people were supportive actors, influencing individuals’ access to, acceptance of and adherence to prehabilitation.

International studies have revealed that interpersonal support is related to mental and physical health. Low perceived social support has been shown to be associated with mental and physical health problems [ 90 ]. In the USA, a high level of perceived social support was found more likely in women and young people and low level of perceived social support more likely for those living in poverty [ 90 ]. Loneliness has been proposed the mediating factor between socioeconomic status and health in a Norwegian population-based study of people aged over 40 years [ 91 ]. Two explanations were suggested. Firstly, people with few social contacts have low levels of physical activity. Secondly, people with poor physical or emotional health are more likely to have low self-esteem and self-efficacy in self-care, which is associated with less successful occupational career and low socioeconomic status and thus fewer social contact resources to manage health [ 91 ].

This review supports an argument that interpersonal connections can be important for prehabilitation access, acceptance and adherence. It found evidence of relationships with family, peers and cancer care staff influencing access to, acceptance of, and adherence to prehabilitation. Perceived social support may have a key role in successful prehabilitation. This proposition should be further explored, paying attention to the known relationship between social support and socioeconomic status in other contexts and the potential for this to be an explanation of any observed difference in access across socioeconomic groups.

Technology as interpersonal connection?

An interesting finding is of data showing some people find web-based resources and/or online help to satisfy their prehabilitation information and support needs. These people experienced interpersonal connection through technology. An online survey among 1037 adults (18+) in the UK found that 80% of those with a long-term condition used technology for managing their health, a majority for seeking information whilst a third used wearable technology or apps. Those most likely to use technologies were younger and/or of high socioeconomic status, leading the authors to caution completely digital approaches because of the potential to exclude some groups from the care they need [ 92 ]. Arguably, technology may provide a partial solution to enabling successful prehabilitation.

What this review adds

Our finding of structural and individual level factors affecting access to, acceptance of and adherence to prehabilitation is consistent with Levesque et al.’s [ 93 ] socioecological model of access to health services. Levesque et al.’s [ 93 ] model sets out access as a process with five dimensions of accessibility (approachability; acceptability; availability and accommodation; affordability; appropriateness) and five corresponding abilities of populations (ability to perceive; ability to seek; ability to reach; ability to pay; ability to engage). The model enables attention to social, service organisation and person-centred factors that influence access. However, the model does not address the relational dimensions derived from our data analysis, i.e. how person-centred and structural factors interrelate for better or poorer service access. Based on our findings, an important ingredient for improving access to prehabilitation may be attention to what happens in the relational space connecting these factors. Voorhees et al. [ 94 ] interpreted findings of participatory research about access to general practice and claimed it is the human abilities of workforce and clients that are an important yet absent consideration in Levesque’s model. They argued that staff training and support for human interaction were needed. We agree. In addition, and based on our analysis, we also consider important the network of interactions between patient and others. Understanding the nature and mechanisms of these interactions may be important for health equity in prehabilitation.

Strengths and limitations

A strength of this review is that established, rigorous systematic review processes were followed to identify and select relevant peer-reviewed literature. Methods and thematic synthesis procedures were reported explicitly, providing an audit trail for dependability. To maximise study identification, the detailed and comprehensive search strategy was developed with the assistance of an expert information specialist, and the review was conducted by a multidisciplinary team with a minimum of two reviewers engaged in the screening and extracting process. Searches were limited from 2017 to 2023 and published in the English language. By limiting the search dates in this way, we have ensured that the evidence assessed has context and relevance to current policy and practices. This systematic review, as a result, provides an overarching picture and holistic understanding of access, acceptance and adherence to cancer prehabilitation. However, this review is not without its limitations. It is possible that some potentially useful studies, notably those not published in the English language have been omitted. Furthermore, we did not take account of study quality in our analysis. To reduce the risk of selection bias, studies were included irrespective of their methodological quality assessment. However, this means that some low quality evidence has been included, and this is a limitation to the credibility of the analysis. Nevertheless, there is some consistency between studies and across international healthcare settings. This does indicate a level of trustworthiness in the review findings. The review was of mixed cancer sites. Cancer site along with its symptoms and treatment-related problems may affect access, acceptance and adherence to prehabilitation. As the body of literature about engagement with prehabilitation grows, further work will be warranted to investigate cancer site–specific factors affecting inclusion in prehabilitation.

ThQueryere is limited empirical study of barriers and facilitators to inform improvement in equity of access to cancer prehabilitation. To enhance the inclusivity of cancer prehabilitation, adjustments may be needed to accommodate individual preferences and characteristics, such as comorbidity, and attention given to structural factors, such as staff training. Based on our findings, we propose interpersonal connections as a fundamental core ingredient for facilitation of prehabilitation access, acceptance and adherence.

Systematic review registration

This systematic review was registered in PROSPERO (CRD42023403776)

Data Availability

All data generated for this review are included in the manuscript and/or the supplementary files.

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Tessa Watts, Nicholas Courtier, Sarah Fry, Nichola Gale, Elizabeth Gillen, Grace McCutchan, Manasi Patil, Tracy Rees, Dominic Roche & Jane Hopkinson

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T.W. and JH wrote the main manuscript. E.G. Designed and tested the search strategy, ran all the searches and prepared supplementary file 1 E.G. and TW prepared figure 1 JH prepared figure 2 All authors contributed to study selection, quality assessment and data extraction TW and MP prepared supplementary file 2 TW prepared supplementary file 3 TW, MP and JH analysed data. All authors reviewed the manuscript.

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Watts, T., Courtier, N., Fry, S. et al. Access, acceptance and adherence to cancer prehabilitation: a mixed-methods systematic review. J Cancer Surviv (2024). https://doi.org/10.1007/s11764-024-01605-3

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DOI : https://doi.org/10.1007/s11764-024-01605-3

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Bridging Knowledge in Long Term Care 2009

Qualitative and quantitative methods in health research, m. luisa vázquez navarrete.

Health Policy Research Unit, Consorci Hospitalari de Catalunya, Barcelona, Spain

Introduction

Research in the area of health has been traditionally dominated by quantitative research. However, the complexity of ill-health, which is socially constructed by individuals, health personnel and health authorities have motivated the search for other forms to approach knowledge.

To discuss the complementarities of qualitative and quantitative research methods in the generation of knowledge.

The purpose of quantitative research is to measure the magnitude of an event, to make predictions, develop causal explanations. To achieve this it uses a pre-established design based on hypothesis and theories, conducts extensive data collection to a statistical sample and develops statistical data analysis. Quantitative research objectives can be to establish the incidence or prevalence of a health problem; the health personnel degree of adherence to a new intervention; or, the users’ level of satisfaction with a service. Qualitative research aims at understanding what exists from social actors’ perspectives. Its design is open, flexible and circular, data collection is intensive and based on a purposive sample and results will be achieved through inductive analysis. Qualitative research allows to explore aspects thought as known, understands differences in personnel opinions and practice in front of new interventions or users’ opinion on services utilization.

Quantitative and qualitative methods are different research approaches, that not only provide complementary knowledge that contributes to gaining better understanding of a problem or situation, but that can be used in a combined way, to approach a new research area, to develop instruments and to interpret results.

Presentation slides available from: http://www.bridgingknowledge.net/Presentations/Symp11_Vazquez.pdf

Title: How the green supply chain can transform the economic prosperity

Authors : Muhammad Saeed Shahbaz; Zahoor Ur Rehman; Hassan Raza; Raja Zuraidah Raja Mohd Rasi

Addresses : Shaheed Zulfikar Ali Bhutto Institute of Science and Technology (SZABIST), Pakistan ' Faculty of Technology Management and Business, Universiti Tun Hussein Onn, Malaysia ' Shaheed Zulfikar Ali Bhutto Institute of Science and Technology (SZABIST), Pakistan ' Faculty of Technology Management and Business, Universiti Tun Hussein Onn, Malaysia

Abstract : The green supply chain (GSC) plays a major role in cost reduction and increased supply chain efficiency. The study aim is to determine the impact of GSC on the supply chain of the country, the purpose of which is to assess the impact of value creation on the economic prosperity of the production supply chain. Methodologically, the study used both qualitative and quantitative methods. The data was collected through interviews, and empirical verification was done through a questionnaire. The researcher interviewed the country's employees that belong to either the economic division or supply chain. The collected data was analysed using content analysis and multiple regression through SPSS. The results reveal that creation of value creates increased market share and competitiveness and that there is mutual understanding, close relationships, and contracts between consumers and suppliers to motivate suppliers to improve product quality and reduce inventory costs over the course of time.

Keywords : green supply chain management; economic prosperity; empirical study.

DOI : 10.1504/IJSOM.2024.138594

International Journal of Services and Operations Management, 2024 Vol.48 No.1, pp.99 - 112

Received: 09 Mar 2021 Accepted: 07 Jan 2022 Published online: 14 May 2024 *

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• Published: 13 May 2024

Sexual and reproductive health implementation research in humanitarian contexts: a scoping review

• Alexandra Norton 1 &
• Hannah Tappis 2  

Reproductive Health volume  21 , Article number:  64 ( 2024 ) Cite this article

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Meeting the health needs of crisis-affected populations is a growing challenge, with 339 million people globally in need of humanitarian assistance in 2023. Given one in four people living in humanitarian contexts are women and girls of reproductive age, sexual and reproductive health care is considered as essential health service and minimum standard for humanitarian response. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on appropriate methods and analytical frameworks is limited.

A scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Peer-reviewed papers published from 2013 to 2022 were identified through relevant systematic reviews and a literature search of Pubmed, Embase, PsycInfo, CINAHL and Global Health databases. Papers that presented primary quantitative or qualitative data pertaining to a sexual and reproductive health intervention in a humanitarian setting were included.

Seven thousand thirty-six unique records were screened for inclusion, and 69 papers met inclusion criteria. Of these, six papers explicitly described the use of an implementation research framework, three citing use of the Consolidated Framework for Implementation Research. Three additional papers referenced other types of frameworks used in their evaluation. Factors cited across all included studies as helping the intervention in their presence or hindering in their absence were synthesized into the following Consolidated Framework for Implementation Research domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process.

This review found a wide range of methodologies and only six of 69 studies using an implementation research framework, highlighting an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

Plain English summary

Three hundred thirty-nine million people globally were in need of humanitarian assistance in 2023, and meeting the health needs of crisis-affected populations is a growing challenge. One in four people living in humanitarian contexts are women and girls of reproductive age, and provision of sexual and reproductive health care is considered to be essential within a humanitarian response. Implementation research can help to better understand how real-world contexts affect health improvement efforts. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on how best to do so is limited. This scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Of 69 papers that met inclusion criteria for the review, six of them explicitly described the use of an implementation research framework. Three used the Consolidated Framework for Implementation Research, a theory-based framework that can guide implementation research. Three additional papers referenced other types of frameworks used in their evaluation. This review summarizes how factors relevant to different aspects of implementation within the included papers could have been organized using the Consolidated Framework for Implementation Research. The findings from this review highlight an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

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Over the past few decades, the field of public health implementation research (IR) has grown as a means by which the real-world conditions affecting health improvement efforts can be better understood. Peters et al. put forward the following broad definition of IR for health: “IR is the scientific inquiry into questions concerning implementation – the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions)” [ 1 ].

As IR emphasizes real-world circumstances, the context within which a health intervention is delivered is a core consideration. However, much IR implemented to date has focused on higher-resource settings, with many proposed frameworks developed with particular utility for a higher-income setting [ 2 ]. In recognition of IR’s potential to increase evidence across a range of settings, there have been numerous reviews of the use of IR in lower-resource settings as well as calls for broader use [ 3 , 4 ]. There have also been more focused efforts to modify various approaches and frameworks to strengthen the relevance of IR to low- and middle-income country settings (LMICs), such as the work by Means et al. to adapt a specific IR framework for increased utility in LMICs [ 2 ].

Within LMIC settings, the centrality of context to a health intervention’s impact is of particular relevance in humanitarian settings, which present a set of distinct implementation challenges [ 5 ]. Humanitarian responses to crisis situations operate with limited resources, under potential security concerns, and often under pressure to relieve acute suffering and need [ 6 ]. Given these factors, successful implementation of a particular health intervention may require different qualities than those that optimize intervention impact under more stable circumstances [ 7 ]. Despite increasing recognition of the need for expanded evidence of health interventions in humanitarian settings, the evidence base remains limited [ 8 ]. Furthermore, despite its potential utility, there is not standardized guidance on IR in humanitarian settings, nor are there widely endorsed recommendations for the frameworks best suited to analyze implementation in these settings.

Sexual and reproductive health (SRH) is a core aspect of the health sector response in humanitarian settings [ 9 ]. Yet, progress in addressing SRH needs has lagged far behind other services because of challenges related to culture and ideology, financing constraints, lack of data and competing priorities [ 10 ]. The Minimum Initial Service Package (MISP) for SRH in Crisis Situations is the international standard for the minimum set of SRH services that should be implemented in all crisis situations [ 11 ]. However, as in other areas of health, there is need for expanded evidence for planning and implementation of SRH interventions in humanitarian settings. Recent systematic reviews of SRH in humanitarian settings have focused on the effectiveness of interventions and service delivery strategies, as well as factors affecting utilization, but have not detailed whether IR frameworks were used [ 12 , 13 , 14 , 15 ]. There have also been recent reviews examining IR frameworks used in various settings and research areas, but none have explicitly focused on humanitarian settings [ 2 , 16 ].

Given the need for an expanded evidence base for SRH interventions in humanitarian settings and the potential for IR to be used to expand the available evidence, a scoping review was undertaken. This scoping review sought to identify IR approaches that have been used in the last ten years to evaluate SRH interventions in humanitarian settings.

This review also sought to shed light on whether there is a need for a common framework to guide research design, analysis, and reporting for SRH interventions in humanitarian settings and if so, if there are any established frameworks already in use that would be fit-for-purpose or could be tailored to meet this need.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews was utilized to guide the elements of this review [ 17 ]. The review protocol was retrospectively registered with the Open Science Framework ( https://osf.io/b5qtz ).

Search strategy

A two-fold search strategy was undertaken for this review, which covered the last 10 years (2013–2022). First, recent systematic reviews pertaining to research or evaluation of SRH interventions in humanitarian settings were identified through keyword searches on PubMed and Google Scholar. Four relevant systematic reviews were identified [ 12 , 13 , 14 , 15 ] Table 1 .

Second, a literature search mirroring these reviews was conducted to identify relevant papers published since the completion of searches for the most recent review (April 2017). Additional file 1 includes the search terms that were used in the literature search [see Additional file 1 ].

The literature search was conducted for papers published from April 2017 to December 2022 in the databases that were searched in one or more of the systematic reviews: PubMed, Embase, PsycInfo, CINAHL and Global Health. Searches were completed in January 2023 Table 2 .

Two reviewers screened each identified study for alignment with inclusion criteria. Studies in the four systematic reviews identified were considered potentially eligible if published during the last 10 years. These papers then underwent full-text review to confirm satisfaction of all inclusion criteria, as inclusion criteria were similar but not fully aligned across the four reviews.

Literature search results were exported into a citation manager (Covidence), duplicates were removed, and a step-wise screening process for inclusion was applied. First, all papers underwent title and abstract screening. The remaining papers after abstract screening then underwent full-text review to confirm satisfaction of all inclusion criteria. Title and abstract screening as well as full-text review was conducted independently by both authors; disagreements after full-text review were resolved by consensus.

Data extraction and synthesis

The following content areas were summarized in Microsoft Excel for each paper that met inclusion criteria: publication details including author, year, country, setting [rural, urban, camp, settlement], population [refugees, internally displaced persons, general crisis-affected], crisis type [armed conflict, natural disaster], crisis stage [acute, chronic], study design, research methods, SRH intervention, and intervention target population [specific beneficiaries of the intervention within the broader population]; the use of an IR framework; details regarding the IR framework, how it was used, and any rationale given for the framework used; factors cited as impacting SRH interventions, either positively or negatively; and other key findings deemed relevant to this review.

As the focus of this review was on the approach taken for SRH intervention research and evaluation, the quality of the studies themselves was not assessed.

Twenty papers underwent full-text review due to their inclusion in one or more of the four systematic reviews and meeting publication date inclusion criteria. The literature search identified 7,016 unique papers. After full-text screening, 69 met all inclusion criteria and were included in the review. Figure  1 illustrates the search strategy and screening process.

Flow chart of paper identification

Papers published in each of the 10 years of the review timeframe (2013–2022) were included. 29% of the papers originated from the first five years of the time frame considered for this review, with the remaining 71% papers coming from the second half. Characteristics of included publications, including geographic location, type of humanitarian crisis, and type of SRH intervention, are presented in Table  3 .

A wide range of study designs and methods were used across the papers, with both qualitative and quantitative studies well represented. Twenty-six papers were quantitative evaluations [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ], 17 were qualitative [ 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ], and 26 used mixed methods [ 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 ]. Within the quantitative evaluations, 15 were observational, while five were quasi-experimental, five were randomized controlled trials, and one was an economic evaluation. Study designs as classified by the authors of this review are summarized in Table  4 .

Six papers (9%) explicitly cited use of an IR framework. Three of these papers utilized the Consolidated Framework for Implementation Research (CFIR) [ 51 , 65 , 70 ]. The CFIR is a commonly used determinant framework that—in its originally proposed form in 2009—is comprised of five domains, each of which has constructs to further categorize factors that impact implementation. The CFIR domains were identified as core content areas influencing the effectiveness of implementation, and the constructs within each domain are intended to provide a range of options for researchers to select from to “guide diagnostic assessments of implementation context, evaluate implementation progress, and help explain findings.” [ 87 ] To allow for consistent terminology throughout this review, the original 2009 CFIR domains and constructs are used.

Guan et al. conducted a mixed methods study to assess the feasibility and effectiveness of a neonatal hepatitis B immunization program in a conflict-affected rural region of Myanmar. Guan et al. report mapping data onto the CFIR as a secondary analysis step. They describe that “CFIR was used as a comprehensive meta-theoretical framework to examine the implementation of the Hepatitis B Virus vaccination program,” and implementation themes from multiple study data sources (interviews, observations, examination of monitoring materials) were mapped onto CFIR constructs. They report their results in two phases – Pre-implementation training and community education, and Implementation – with both anchored in themes that they had mapped onto CFIR domains and constructs. All but six constructs were included in their analysis, with a majority summarized in a table and key themes explored further in the narrative text. They specify that most concerns were identified within the Outer Setting and Process domains, while elements identified within the Inner Setting domain provided strength to the intervention and helped mitigate against barriers [ 70 ].

Sarker et al. conducted a qualitative study to assess provision of maternal, newborn and child health services to Rohingya refugees residing in camps in Cox’s Bazar, Bangladesh. They cite using CFIR as a guide for thematic analysis, applying it after a process of inductive and deductive coding to index these codes into the CFIR domains. They utilized three of the five CFIR domains (Outer Setting, Inner Setting, and Process), stating that the remaining two domains (Intervention Characteristics and Characteristics of Individuals) were not relevant to their analysis. They then proposed two additional CFIR domains, Context and Security, for use in humanitarian contexts. In contrast to Guan et al., CFIR constructs are not used nor mentioned by Sarker et al., with content under each domain instead synthesized as challenges and potential solutions. Regarding the CFIR, Sarker et al. write, “The CFIR guided us for interpretative coding and creating the challenges and possible solutions into groups for further clarification of the issues related to program delivery in a humanitarian crisis setting.” [ 51 ]

Sami et al. conducted a mixed methods case study to assess the implementation of a package of neonatal interventions at health facilities within refugee and internally displaced persons camps in South Sudan. They reference use of the CFIR earlier in the study than Sarker et al., basing their guides for semi-structured focus group discussions on the CFIR framework. They similarly reference a general use of the CFIR framework as they conducted thematic analysis. Constructs are referenced once, but they do not specify whether their application of the CFIR framework included use of domains, constructs, or both. This may be in part because they then applied an additional framework, the World Health Organization (WHO) Health System Framework, to present their findings. They describe a nested approach to their use of these frameworks: “Exploring these [CFIR] constructs within the WHO Health Systems Framework can identify specific entry points to improve the implementation of newborn interventions at critical health system building blocks.” [ 65 ]

Three papers cite use of different IR frameworks. Bolan et al. utilized the Theoretical Domains Framework in their mixed methods feasibility study and pilot cluster randomized trial evaluating pilot use of the Safe Delivery App by maternal and newborn health workers providing basic emergency obstetric and newborn care in facilities in the conflict-affected Maniema province of the Democratic Republic of the Congo (DRC). They used the Theroetical Domains Framework in designing interview questions, and further used it as the coding framework for their analysis. Similar to the CFIR, the Theoretical Domains Framework is a determinant framework that consists of domains, each of which then includes constructs. Bolan et al. utilized the Theoretical Domains Framework at the construct level in interview question development and at the domain level in their analysis, mapping interview responses to eight of the 14 domains [ 83 ]. Berg et al. report using an “exploratory design guided by the principles of an evaluation framework” developed by the Medical Research Council to analyze the implementation process, mechanisms of impact, and outcomes of a three-pillar training intervention to improve maternal and neonatal healthcare in the conflict-affected South Kivu province of the DRC [ 67 , 88 ]. Select components of this evaluation framework were used to guide deductive analysis of focus group discussions and in-depth interviews [ 67 ]. In their study of health workers’ knowledge and attitudes toward newborn health interventions in South Sudan, before and after training and supply provision, Sami et al. report use of the Conceptual Framework of the Role of Attitudes in Evidence-Based Practice Implementation in their analysis process. The framework was used to group codes following initial inductive coding analysis of in-depth interviews [ 72 ].

Three other papers cite use of specific frameworks in their intervention evaluation [ 19 , 44 , 76 ]. As a characteristic of IR is the use of an explicit framework to guide the research, the use of the frameworks in these three papers meets the intention of IR and serves the purpose that an IR framework would have in strengthening the analytical rigor. Castle et al. cite use of their program’s theory of change as a framework for a mixed methods evaluation of the provision of family planning services and more specifically uptake of long-acting reversible contraception use in the DRC. They describe use of the theory of change to “enhance effectiveness of [long-acting reversible contraception] access and uptake.” [ 76 ] Thommesen et al. cite use of the AAAQ (Availability, Accessibility, Acceptability and Quality) framework in their qualitative study assessing midwifery services provided to pregnant women in Afghanistan. This framework is focused on the “underlying elements needed for attainment of optimum standard of health care,” but the authors used it in this paper to evaluate facilitators and barriers to women accessing midwifery services [ 44 ]. Jarrett et al. cite use of the Centers for Disease Control and Prevention’s (CDC) Guidelines for Evaluating Public Health Surveillance Systems to explore the characteristics of a population mobility, mortality and birth surveillance system in South Kivu, DRC. Use of these CDC guidelines is cited as one of four study objectives, and commentary is included in the Results section pertaining to each criteria within these guidelines, although more detail regarding use of these guidelines or the authors’ experience with their use in the study is not provided [ 19 ].

Overall, 22 of the 69 papers either explicitly or implicitly identified IR as relevant to their work. Nineteen papers include a focus on feasibility (seven of which did not otherwise identify the importance of exploring questions concerning implementation), touching on a common outcome of interest in implementation research [ 89 ].

While a majority of papers did not explicitly or implicitly use an IR framework to evaluate their SRH intervention of focus, most identified factors that facilitated implementation when they were present or served as a barrier when absent. Sixty cite factors that served as facilitators and 49 cite factors that served as barriers, with just three not citing either. Fifty-nine distinct factors were identified across the papers.

Three of the six studies that explicitly used an IR framework used the CFIR, and the CFIR is the only IR framework that was used by multiple studies. As previously mentioned, Means et al. put forth an adaptation of the CFIR to increase its relevance in LMIC settings, proposing a sixth domain (Characteristics of Systems) and 11 additional constructs [ 2 ]. Using the expanded domains and constructs as proposed by Means et al., the 59 factors cited by papers in this review were thematically grouped into the six domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process. Within each domain, alignment with CFIR constructs was assessed for, and alignment was found with 29 constructs: eight of Means et al.’s 11 constructs, and 21 of the 39 standard CFIR constructs. Three factors did not align with any construct (all fitting within the Outer Setting domain), and 14 aligned with a construct label but not the associated definition. Table 5 synthesizes the mapping of factors affecting SRH intervention implementation to CFIR domains and constructs, with the construct appearing in italics if it is considered to align with that factor by label but not by definition.

Table 6 lists the CFIR constructs that were not found to have alignment with any factor cited by the papers in this review.

This scoping review sought to assess how IR frameworks have been used to bolster the evidence base for SRH interventions in humanitarian settings, and it revealed that IR frameworks, or an explicit IR approach, are rarely used. All four of the systematic reviews identified with a focus on SRH in humanitarian settings articulate the need for more research examining the effectiveness of SRH interventions in humanitarian settings, with two specifically citing a need for implementation research/science [ 12 , 13 ]. The distribution of papers across the timeframe included in this review does suggest that more research on SRH interventions for crisis-affected populations is taking place, as a majority of relevant papers were published in the second half of the review period. The papers included a wide range of methodologies, which reflect the differing research questions and contexts being evaluated. However, it also invites the question of whether there should be more standardization of outcomes measured or frameworks used to guide analysis and to facilitate increased comparison, synthesis and application across settings.

Three of the six papers that used an IR framework utilized the CFIR. Guan et al. used the CFIR at both a domain and construct level, Sarker et al. used the CFIR at the domain level, and Sami et al. did not specify which CFIR elements were used in informing the focus group discussion guide [ 51 , 65 , 70 ]. It is challenging to draw strong conclusions about the applicability of CFIR in humanitarian settings based on the minimal use of CFIR and IR frameworks within the papers reviewed, although Guan et al. provides a helpful model for how analysis can be structured around CFIR domains and constructs. It is worth considering that the minimal use of IR frameworks, and more specifically CFIR constructs, could be in part because that level of prescriptive categorization does not allow for enough fluidity in humanitarian settings. It also raises questions about the appropriate degree of standardization to pursue for research done in these settings.

The mapping of factors affecting SRH intervention implementation provides an example of how a modified CFIR framework could be used for IR in humanitarian contexts. This mapping exercise found factors that mapped to all five of the original CFIR domains as well as the sixth domain proposed by Means et al. All factors fit well within the definition for the selected domain, indicating an appropriate degree of fit between these existing domains and the factors identified as impacting SRH interventions in humanitarian settings. On a construct level, however, the findings were more variable, with one-quarter of factors not fully aligning with any construct. Furthermore, over 40% of the CFIR constructs (including the additional constructs from Means et al.) were not found to align with any factors cited by the papers in this review, also demonstrating some disconnect between the parameters posed by the CFIR constructs and the factors cited as relevant in a humanitarian context.

It is worth noting that while the CFIR as proposed in 2009 was used in this assessment, as well as in the included papers which used the CFIR, an update was published in 2022. Following a review of CFIR use since its publication, the authors provide updates to construct names and definitions to “make the framework more applicable across a range of innovations and settings.” New constructs and subconstructs were also added, for a total of 48 constructs and 19 subconstructs across the five domains [ 90 ]. A CFIR Outcomes Addendum was also published in 2022, based on recommendations for the CFIR to add outcomes and intended to be used as a complement to the CFIR determinants framework [ 91 ]. These expansions to the CFIR framework may improve applicability of the CFIR in humanitarian settings. Several constructs added to the Outer Setting domain could be of particular utility – critical incidents, local attitudes, and local conditions, each of which could help account for unique challenges faced in contexts of crisis. Sub-constructs added within the Inner Setting domain that seek to clarify structural characteristics and available resources would also be of high utility based on mapping of the factors identified in this review to the original CFIR constructs. As outcomes were not formally included in the CFIR until the 2022 addendum, a separate assessment of implementation outcomes was not undertaken in this review. However, analysis of the factors cited by papers in this review as affecting implementation was derived from the full text of the papers and thus captures content relevant to implementation determinants that is contained within the outcomes.

Given the demonstrated need for additional flexibility within an IR framework for humanitarian contexts, while not a focus of this review, it is worth considering whether a different framework could provide a better fit than the CFIR. Other frameworks have differing points of emphasis that would create different opportunities for flexibility but that do not seem to resolve the challenges experienced in applying the CFIR to a humanitarian context. As one example, the EPIS (Exploration, Preparation, Implementation, Sustainment) Framework considers the impact of inner and outer context on each of four implementation phases; while the constructs within this framework are broader than the CFIR, an emphasis on the intervention characteristics is missing, a domain where stronger alignment within the CFIR is also needed [ 92 ]. Alternatively, the PRISM (Practical, Robust Implementation and Sustainability Model) framework is a determinant and evaluation framework that adds consideration of context factors to the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) outcomes framework. It has a stronger emphasis on intervention aspects, with sub-domains to account for both organization and patient perspectives within the intervention. While PRISM does include aspects of context, external environment considerations are less robust and intentionally less comprehensive in scope, which would not provide the degree of alignment possible between the Characteristics of Systems and Outer Setting CFIR domains for the considerations unique to humanitarian environments [ 93 ].

Reflecting on their experience with the CFIR, Sarker et al. indicate that it can be a “great asset” in both evaluating current work and developing future interventions. They also encourage future research of humanitarian health interventions to utilize the CFIR [ 51 ]. The other papers that used the CFIR do not specifically reflect on their experience utilizing it, referring more generally to having felt that it was a useful tool [ 65 , 70 ]. On their use of an evaluation framework, Berg et al. reflected that it lent useful structure and helped to identify aspects affecting implementation that otherwise would have gone un-noticed [ 67 ]. The remaining studies that utilized an IR framework did not specifically comment on their experience with its use [ 72 , 83 ]. While a formal IR framework was not engaged by other studies, a number cite a desire for IR to contribute further detail to their findings [ 21 , 37 ].

In their recommendations for strengthening the evidence base for humanitarian health interventions, Ager et al. speak to the need for “methodologic innovation” to develop methodologies with particular applicability in humanitarian settings [ 7 ]. As IR is not yet routinized for SRH interventions, this could be opportune timing for the use of a standardized IR framework to gauge its utility. Using an IR framework to assess factors influencing implementation of the MISP in initial stages of a humanitarian response, and interventions to support more comprehensive SRH service delivery in protracted crises, could lend further rigor and standardization to SRH evaluations, as well as inform strategies to improve MISP implementation over time. Based on categorizing factors identified by these papers as relevant for intervention evaluation, there does seem to be utility to a modified CFIR approach. Given the paucity of formal IR framework use within SRH literature, it would be worth conducting similar scoping exercises to assess for explicit use of IR frameworks within the evidence base for other health service delivery areas in humanitarian settings. In the interim, the recommended approach from this review for future IR on humanitarian health interventions would be a modified CFIR approach with domain-level standardization and flexibility for constructs that may standardize over time with more use. This would enable use of a common analytical framework and vocabulary at the domain level for stakeholders to describe interventions and the factors influencing the effectiveness of implementation, with constructs available to use and customize as most appropriate for specific contexts and interventions.

This review had a number of limitations. As this was a scoping review and a two-part search strategy was used, the papers summarized here may not be comprehensive of those written pertaining to SRH interventions over the past 10 years. Papers from 2013 to 2017 that would have met this scoping review’s inclusion criteria may have been omitted due to being excluded from the systematic reviews. The review was limited to papers available in English. Furthermore, this review did not assess the quality of the papers included or seek to assess the methodology used beyond examination of the use of an IR framework. It does, however, serve as a first step in assessing the extent to which calls for implementation research have been addressed, and identify entry points for strengthening the science and practice of SRH research in humanitarian settings.

With one in 23 people worldwide in need of humanitarian assistance, and financing required for response plans at an all-time high, the need for evidence to guide resource allocation and programming for SRH in humanitarian settings is as important as ever [ 94 ]. Recent research agenda setting initiatives and strategies to advance health in humanitarian settings call for increased investment in implementation research—with priorities ranging from research on effective strategies for expanding access to a full range of contraceptive options to integrating mental health and psychosocial support into SRH programming to capturing accurate and actionable data on maternal and perinatal mortality in a wide range of acute and protracted emergency contexts [ 95 , 96 ]. To truly advance guidance in these areas, implementation research will need to be conducted across diverse humanitarian settings, with clear and consistent documentation of both intervention characteristics and outcomes, as well as contextual and programmatic factors affecting implementation.

Conclusions

Implementation research has potential to increase impact of health interventions particularly in crisis-affected settings where flexibility, adaptability and context-responsive approaches are highlighted as cornerstones of effective programming. There remains significant opportunity for standardization of research in the humanitarian space, with one such opportunity occurring through increased utilization of IR frameworks such as a modified CFIR approach. Investing in more robust sexual and reproductive health research in humanitarian contexts can enrich insights available to guide programming and increase transferability of learning across settings.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Availability, Accessibility, Acceptability and Quality

Centers for Disease Control and Prevention

Consolidated Framework for Implementation Research

Democratic Republic of the Congo

Exploration, Preparation, Implementation, Sustainment

• Implementation research

Low and middle income country

Minimum Initial Service Package

Practical, Robust Implementation and Sustainability Model

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Reach, Effectiveness, Adoption, Implementation, Maintenance

• Sexual and reproductive health

World Health Organization

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AN and HT designed the scoping review. AN conducted the literature search. AN and HT screened records for inclusion. AN extracted data from included studies. Both authors contributed to synthesis of results. AN drafted the manuscript and both authors contributed to editorial changes.

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Correspondence to Alexandra Norton .

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Additional file 1.

. Literature search terms: Exact search terms used in literature search, with additional detail on the methodology to determine search terms and definitions used for each component of the search

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Norton, A., Tappis, H. Sexual and reproductive health implementation research in humanitarian contexts: a scoping review. Reprod Health 21 , 64 (2024). https://doi.org/10.1186/s12978-024-01793-2

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Received : 06 November 2023

Accepted : 12 April 2024

Published : 13 May 2024

DOI : https://doi.org/10.1186/s12978-024-01793-2

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