Table 5 GRADE-CERQual assessment
Summary of review finding | Studies contributing to this review finding | Methodological limitations | Coherence | Adequacy | Relevance | CERQual assessment of confidence |
|---|---|---|---|---|---|---|
1. Coherence is the most commonly utilised construct to understand intervention implementation and is seen as a fundamental first step | Foster et al. [43]; Gilbert et al. [47]; Ong et al. [49]; Peng et al. [51]; Sanders et al. [52]; Saunders et al. [44]; Saunders et al. [53]; Volkmer et al. [55] | No/Very minor concerns (CASP scoring used to support assessment of this criterion) | Moderate concerns (The construct of coherence is the most frequently used construct of NPT across the dataset. However, only 3 studies [4 papers] used coherence in isolation. The remaining 4 studies therefore do not utilise coherence (construct) as a first step and so there are moderate concerns regarding coherence (assessment criterion) for this review finding) | Moderate concerns (The 3 studies utilising coherence as a first step offered limited rationale for this so there are concerns regarding the richness of data supporting this review finding) | No/Very minor concerns (8 studies of relevance to the review question, objectives and eligibility criteria. Range of interventions and MSK/orthopaedic conditions across the studies) | Moderate confidence |
2. To date, only evidence of NPT (including ENPT) use to support the implementation of MSK/orthopaedic interventions is available and so it is unclear how NPT can be used to support intervention development and refinement | Drew et al. [42]; Foster et al. [43]; Gilbert et al. [45]; Gilbert et al. [46]; Gilbert et al. [47]; Hay et al. [48]; Judge et al. [50]; Ong et al. [49]; Peng et al. [51]; Sanders et al. [52]; Saunders et al. [44]; Saunders et al. [53]; Volkmer et al. [55]; Wylde et al. [54] | No/Very minor concerns (CASP scoring used to support assessment of this criterion) | No/Very minor concerns (The review finding is coherent with the underlying data) | Minor concerns (Minor concerns as although NPT is used to support implementation across all 12 studies [14 papers] there is limited discussion offering further detail and insight into its use. Data richness therefore limited) | No/Very minor concerns (12 studies of relevance to the review question, objectives and eligibility criteria. Range of interventions, MSK/orthopaedic conditions and healthcare settings across the studies) | High confidence |
3. There is no evidence that the intervention or MSK/orthopaedic condition being targeted affects the utility of NPT/ENPT | Drew et al. [42]; Foster et al. [43]; Gilbert et al. [45]; Gilbert et al. [46]; Gilbert et al. [47]; Hay et al. [48]; Judge et al. [50]; Ong et al. [49]; Peng et al. [51]; Sanders et al. [52]; Saunders et al. [44]; Saunders et al. [53]; Volkmer et al. [55]; Wylde et al. [54] | No/Very minor concerns (CASP scoring used to support assessment of this criterion) | No/Very minor concerns (The review finding is coherent with the underlying data. No issues were reported in any paper regarding the suitability of NPT for MSK/orthopaedic conditions) | Minor concerns (No discussion in any study regarding the suitability of NPT for any MSK/orthopaedic condition. Data richness to support NPT’s use for any MSK/orthopaedic condition is limited, however data to refute its use is non-evident) | No/Very minor concerns (12 studies of relevance to the review question, objectives and eligibility criteria. Range of interventions, MSK/orthopaedic conditions and healthcare settings across the studies) | High confidence |
4. It is unclear when utilisation of the original constructs of NPT may be more appropriate to those than ENPT and vice versa | Drew et al. [42]; Foster et al. [43]; Gilbert et al. [45]; Gilbert et al. [46]; Gilbert et al. [47]; Hay et al. [48]; Judge et al. [50]; Ong et al. [49]; Peng et al. [51]; Sanders et al. [52]; Saunders et al. [44]; Saunders et al. [53]; Volkmer et al. [55]; Wylde et al. [54] | No/Very minor concerns (CASP scoring used to support assessment of this criterion) | No/Very minor concerns (This review finding is coherent with the underlying data as there is limited to no discussion to support the use of NPT over ENPT and vice versa) | No/Very minor concerns (No discussion in any study regarding the appropriateness of either version of the theory and so there are no/very minor concerns regarding this review findings) | No/Very minor concerns (12 studies of relevance to the review question, objectives and eligibility criteria. Range of interventions, MSK/orthopaedic conditions and healthcare settings across the studies) | High confidence |
5. There is limited evidence to support the NoMAD instruments’ utility | Wylde et al. [54] | No/Very minor concerns | No/Very minor concerns (only one study utilising NoMAD. The instrument is not referred to in any other study and so this review finding is coherence with the underlying data) | Minor concerns (Data richness to support NoMADs use is limited; however, data to refute its use is non-evident) | Minor concerns (1 study and therefore only 1 condition [total knee replacement], intervention type [clinic pathway] and setting [secondary care]) | High confidence |
6. NPT/ENPT is a useful analytical lens to focus researcher’s attention to understanding implementation factors more robustly and accounting for a range of identified issues | Foster et al. [43]; Gilbert et al. [47]; Hay et al. [48]; Judge et al. [50]; Peng et al. [51]; Saunders et al. [44]; Saunders et al. [53] | No/Very minor concerns | No/Very minor concerns (The review finding is coherent with the underlying data) | Minor concerns (7 papers discussing the usefulness of NPT in implementation however further detail to offer greater insight into its use would have been beneficial. This would have added a greater degree of richness to support this review finding) | No/Very minor concerns (6 studies [7 papers] of relevance to the review question, objectives and eligibility criteria. Range of interventions, MSK/orthopaedic conditions and healthcare settings across the studies) | High confidence |
7. The application of ENPT may pose a challenge for researcher’s due to the overlapping nature of constructs | Drew et al. [42] | No/Very minor concerns | No/Very minor concerns (Although only one study supports this review finding, there were no data to challenge it. The finding is therefore coherent with the underlying data) | Moderate concerns (Only 1 study supporting this review finding. Further detail would have added greater insight to support the understanding of the challenged in ENPT’s application) | Minor concerns (1 study and therefore only 1 condition [hip fracture], intervention type [service] and setting [secondary care]) | Moderate confidence |
8. There is limited evidence that the population targeted by the intervention limits the use of particular NPT constructs | Sanders et al. [52] | No/Very minor concerns | Moderate concerns (Moderate concerns with this finding as only one study reported limited evidence to support the use of 3 NPT constructs for their population. However, no issues were reported in all other studies. An alternative explanation may be that although there was no empirical evidence supporting the constructs used in the studies’ population, it does not necessarily mean that NPT is not suitable for use) | Moderate concerns (Only 1 study questioned the utility of NPT (3 constructs) in a specific population. There was limited discussion as to why the authors felt the constructs didn’t reflect the population in question and evidence of this would have provided a greater depth of understanding) | Minor concerns (1 study and therefore only 1 condition [back pain], intervention type [assessment tool] and setting [primary care]) | Moderate confidence |