Stroke survivors’ health priorities and targeted interventions in home-based post-discharge rehabilitation

doi:10.21203/rs.3.rs-5281095/v1

Background

This study aimed to describe health problems of the stroke survivors and the corresponding nursing interventions implemented during 12-week home-based post-discharge rehabilitation.

Methods

This was a descriptive secondary analysis within the context of a randomized controlled trial. Randomly selected raw audio recordings of follow-up calls between nurses and stroke survivors in a home-based post-discharge rehabilitation program were used to assess the intervention characteristics. The research protocol and the Omaha System was adopted to guide the analysis of health needs and nursing practice.

Results

A total of 459 minutes of audio-recordings from eighty-nine telephone contacts with fifteen participants were analyzed, revealing 22 of the 42 Omaha System health problems across all four domains. The most prevalent issues were “Neuro-musculo-skeletal function” (21.2%), “Circulation” (14.6%), and “Nutrition” (10.6%). The four interventions categories were fully implemented with “Surveillance” being the primary approach (54.6%), followed by “Teaching, Guidance, and Counseling” (35.6%). “Case Management” was crucial for "Health care supervision," and “Treatments and Procedures” were frequently applied to "Neuro-musculo-skeletal function" and "Speech and language" problems. Intervention targets varied significantly across different problem-category matches.

Conclusions

The Omaha System facilitates the precise identification of critical health issues among stroke survivors during post-discharge home rehabilitation, and enables targeted nursing interventions in addressing the problems. Surveillance and educational strategies are particular vital for rehabilitation support. There is a potential to build a structured care model using information technology that can facilitate the delivery of comprehensive and standardized quality nursing care to ensure the optimal rehabilitation of stroke patients.

Trial registration

The study was registered as a randomized controlled trial in ClinicalTrials.gov. Registration Date: 2019-3-21, Registration Number: NCT03884621.

Transitional care

Stroke

Omaha System

Rehabilitation

Stroke is the second leading causes of death and third leading causes of death and disability combined globally, accounting for approximately 11.6% of total death and 5.7% of total disability-adjusted-life-years in 2019 [1]. Among stroke subtypes, ischemic stroke still constitutes the largest proportion (62.4%) of all new stroke worldwide, with a prevalence of 77.19 million in 2019. In China, there were 3.94 million incidence cases of stroke, and 2.87 million were ischemic stroke in 2019 [2]. Among 3,418,432 stroke case from 1599 hospitals, 81.9% were ischemic stroke [3]. Importantly, the age-standardized prevalence of ischemic stroke increased by 33.5% from 1990 to 2019, and the subgroup aged 80–84 years had the highest ischemic stroke incidence [2]. Owing to the aging population and increased exposure to risk factors (eg, hypertension), the incidence of stroke will increase substantially in China, with an estimated crude prevalence being 4.1% of the population by 2050 [4].

Recurrence and disability are major challenges to overcome for ischemic stroke survivors. Stroke survivors with functional disability are particularly vulnerable to recurrent stroke and death [5], and adherence to secondary prevention care is associated with better functional status and decreased risks of recurrence [6]. However, according to the 2016 Global Burden of Disease Study, stroke was ranked as the second lowest in the Healthcare Access and Quality index among 32 disease or conditions in China [7]. Provision of acute stroke care services have been relatively short hospital length of stays. The mean length of hospital stay was 10 (8–13) days for ischemic stroke in China [8]. The trend toward shorter length of hospital stays and increasing number of stroke survivors underscore the importance of post-acute supportive service.

Care transition from the inpatient setting to the home is one of the most vulnerable and significant events for both stoke survivors and their families. Supportive interventions for stroke survivors provided at the transition home after hospitalization can address self-management challenges and promote rehabilitation [9]. O’Callaghan et al.’s meta-analysis shown that multi-component transition care supportive interventions improved functional status, as assessed by the Barthel Index, up to three months, and depression and anxiety in the medium to long-term after stroke [10]. Recommendations to improve stroke transitions of care include incorporating patient/family centered strategies, improving communication, and identifying the impact of issues related to social determinants of health [11]. However, there exists a gap in our knowledge about the major health problems that stroke survivors face and corresponding supportive interventions implemented during the transition from hospital to home. A better understanding of core elements of the complex interventions that are supportive during this transition is urgently needed to elucidate the healthcare resources needed for stroke survivors.

During care transitions, nurses, who are usually the primary care coordinators, are actively engaged in verbal communication with their patients [12]. It is therefore useful to examine the supportive intervention delivery and receipt in terms of actual patient problems addressed through analyzing nurse-patient interactions. In the context of a randomized controlled trial of a 12-week nurse-led home-based post-discharge rehabilitation program [13], we set out to address the gap on the health priorities and supportive interventions that stroke survivors needed during transition from hospital to home.

The 12-week post-discharge rehabilitation program achieved sound patient outcomes and was cost-effective with significantly higher quality-adjusted life-years for stroke survivors when compared with usual care [13]. In this study, the Omaha system was adopted to guide the implementation of nursing interventions; which offers an opportunity to retrieve the details of intervention approaches and describe what happened; enabling the exploration of the link among client needs, specific nursing interventions through standardized telephone follow-up data [14]. The Omaha System contains 3 standardized and interrelated components: the Problem Classification Scheme, the Intervention Scheme, and the Problem Rating Scale for Outcomes, utilizing standardized nursing terminology [15].

The current study aiming at identifying health needs of stroke survivor’s during transition from hospital to home, and examining problem-specific nursing interventions adopted to address patients’ needs. The specific objectives were: (1) to assess fidelity of implementing the post-discharge telephone follow-ups during the nurse-led transitional home-based care program for stroke survivors; (2) to identify the health needs of stroke patients during the transition; and (3) to explore the intervention approaches adopted to handle with the main health problems for stroke survivors.

Study design

This was a descriptive secondary analysis of a previously published randomized controlled trial aiming at evaluating a home-based transitional care model for stroke survivors conducted from February 2019 to May 2020. The program involved 116 ischemic stroke survivors. Participants in the intervention group received a 12-week structured 4C, home-based post-discharge program, including a pre-discharge session, six post-discharge home visits (in odd-numbered weeks) and six telephone follow-up calls (in even-numbered weeks). Nurses’ audio-recorded telephone follow-up calls for each contact throughout the program. For this secondary analysis, randomly selected audio recordings of follow-up calls between nurses and stroke survivors in the post-discharge rehabilitation program were analyzed to describe major health problems stroke survivors encountered after discharge, and specific nursing interventions implemented. This study was approved by the ethics committees of the host university (HSEARS20180619003) and the study hospital (2018 Ethical Review #005). The trial was registered in ClinicalTrials.gov (NCT03884621). A detailed description of the study design and methods was previously reported [13, 16].

Participants

Participants were recruited from neurological unites in an acute general hospital in Harbin, China. The inclusion criteria were adults aged 18 years and older, with a diagnosis of ischemic stroke based on magnetic resonance imaging and clinical judgement of stroke neurologists, severity of disease rated as mild to moderate (National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 and < 16), with slightly to moderately severe disability (Modified Rankin Scale, mRS score 2–4), discharged home, and pre-morbidly independent. Exclusion criteria were cognitively impaired with a Montreal Cognitive Assessment (MoCA)-Beijing score ≤ 22, with neurological or other diseases affecting the limbs, discharged to a rehabilitation setting or dying [13].

Procedures

All audio recordings captured the nurse-patient communication during each telephone contact were screened. Audios of the follow-up communication were eligible if they: 1) had at least 5 complete follow-ups calls (> 80%), 2) capture discharge interactions between one nurse and one participant, and 3) captured utterances with adequate audio quality. Cases that met audio recordings criteria were randomly selected for this study. All audio recordings of nurse telephone follow-up calls from 15 participants were retrieved. The data were completely anonymized before the analysis process.

Data analysis

All audio recordings were transcribed. One researcher (S.L.) read all verbatim transcripts and analyzed data using direct content analysis. Transcripts were firstly divided into speech turns for alternating speakers, with each turn containing one or more utterances (complete thought). The researcher assigned each utterance spoken by the patient or nurse to one of coding categories according to the research protocol. For this study, the problem classification scheme, and the intervention scheme from the Omaha System were used to identify the stroke survivor’s status and care provided during the transition through telephone follow-ups. The Problem Classification Scheme consists of signs and symptoms in 4 domains (Environmental, Psychosocial, Physiological and Health-related behaviors) that are further divided into 42 problems. The Intervention Scheme classifies nursing services or actions specific to a problem into one of four mutually exclusive categories: “Surveillance”, “Teaching, Guidance, and Counselling”, “Treatments and Procedures”, and “Case Management”. The target of the Intervention Scheme consists of a list of defined actions and activities that further describe the intervention content. One intervention can be defined as three linked terms: problem–category–target. Linking the problem, category, and target terms enables to describe the unique patient-centered actions of the nursing care in a standardized way.

After conducting the qualitative coding of verbal communication, all transcripts and the problem scheme, interventions were mapped to patient problems, categories and target terms by the researcher (S.L.). Another two researchers who are familiar with the Omaha System independently reviewed and compared the categories of verbal transcripts extractions describing similar health problems and interventions that were mapped to the same Omaha System domains. Three researchers collaborated and discussed differences until a final agreement was obtained. All transcripts and coded data were documented in Excel worksheets, formulating a data extraction matrix.

Descriptive statistics were used to describe the number, the frequency, the time required, and the content of all nurse-patient contact episodes during the post-discharge telephone follow-ups, indicating the extent to which the intervention implemented as planned, as well as the health needs and correspondingly intervention approaches.

Rigour

In order to avoid the selection bias, the cases were selected based on a computer-generated randomized number. Nurses and stroke patients involved in this study were aware that the audio recordings could be utilized in program evaluation, but were blind to case selection criteria and analysis methodologies. Three researchers involved the data analysis process were expertise in the use of the Omaha System, and thus having an understanding of the problem domains, and the intervention classification. Categorization of the problems and interventions were discussed and confirmed among the three researchers, who were well acquainted with the data.

Characteristics of the participants

As shown in Table 1,15 participants were included in this study. The average age of the participants was 62.0 years (range 41–76 years) and 53.3% were male. Over half (53.3%) of the participants were married. Majority of the participants were retired (80.0%), covered by medical insurance (93.3%), and with tertiary education (80.0%). Our sample was dominant in patients with first ever stroke (66.7%). Nearly half (46.7%) had a moderate and moderately severe disability.

Table 1

Characteristics of the participants (n = 15)
Characteristic	Mean (SD) / n (%)
Age, years	62.0 (9.1)
Gender
Male	8 (53.3)
Education level
Primary and below	1 (6.7)
Secondary	2 (13.3)
Tertiary	12 (80.0)
Marital status
Married	8 (53.3)
Employment status
Employed	2 (13.3)
Unemployed	1 (6.7)
Retired	12 (80.0)
Type of insurance
Urban employee basic medical insurance	12 (80.0)
New rural cooperative medical scheme	2 (13.3)
Self-pay	1 (6.7)
Financial status
More than sufficient	2 (13.3)
Barely sufficient	12 (80.0)
Insufficient	1 (6.7)
Smoking
Yes	6 (40.0)
Drinking
Yes	6 (40.0)
Obesity (BMI ≥ 25 kg/m²)	8 (53.3)
First ever stroke	10 (66.7)
Comorbidity
Hypertension	9 (40.0)
Diabetes	5 (33.3)
Coronary heart disease/	3 (20.0)
Hyperlipidemia	9 (60.0)
Homocysteinemia	4 (26.7)
Arthritis	1 (6.7)
NIHSS score	4.9 (1.1)
mRS
Mild disability	8 (53.3)
Moderate disability	6 (40.0)
Moderately severe disability	1 (6.7)
BMI: body mass index; NIHSS, National Institute of Health Stroke Scale; mRS: modified Rankin score

Implementation fidelity

According to the research protocol, each case should be provided with six biweekly telephone follow-ups (T1 to T6), and at least 5 major problems should be evaluated during each contact episode. Overall, 89 (98.9%) follow-up calls were delivered as scheduled, and 93.3% (14/15) of the participants received all calls. One follow-up telephone call was not reached as scheduled, and one call did not have an ending due to telephone problems. The mean follow-up communications for each participants was 30.6 ± 10.1 minutes (range 14.5–50.8 minutes), with an average of 5.1 ± 1.7 minutes (range 2.4–8.5 minutes) for each contact. All cases covered at least 5 problems according to the protocol during the follow-up communications, ranging from 11 to 16 problems (Mean = 13.4).

Health problems

In 459 minutes of patient-nurse communications analyzed, 27 coding categories were abstracted, including greeting, asking for availability, introduction, overall health assessment, health problems and ending statement. In total, 22 health problems were discussed, and the overall frequencies of those health problem mentioned were 3944.

As shown in Fig. 1, the identified health problems were distributed across four domains of the Problem Classification Scheme, with 1 problem in Environmental domain, 4 problems in Psychosocial domain, 10 problems in Physiological domain, and 7 problems in Health-related Behaviours domain. The Physiological domain (frequency = 1822) was the most frequently mentioned health concerns during the transition, followed by the Health-related Behaviour domain (frequency = 1671).

The most frequent addressed health problems during the transition were predominantly from the Physiological domain, specifically “Neuro-musculo-skeletal function” (P25, 838/3944, 21.2%), and “Circulation” (P27, 575/3944, 14.6%). From the Health-related Behaviours domain, “Nutrition” (P35, 418/3944, 10.6%), “Medication regimen” (P42, 392/3944, 9.9%), and “Health care supervision” (P41, 325/3944, 8.2%) were also prominent concerns. See Fig. 2.

Interventions and targets

The two most widely employed intervention approaches were “Surveillance” (54.6%) and “Teaching, Guidance, and Counseling” (35.6%), followed by “Treatments and Procedures” (5.3%) and “Case Management” (4.6%). As shown in Table 2, “Neuro-musculo-skeletal function”, “Circulation”, “Nutrition” and “Medication regimen” problems required a combined use of all intervention approaches. “Mental health” problem was mainly handled by “Surveillance”; while “Substance use” problem was mainly addressed by “Teaching, Guidance, and Counselling” intervention. Even though “Case Management” was the least employed intervention approach, it was an important approach used in handling “Health care supervision” problem. The “Treatments and Procedures” intervention was frequently employed in “Neuro-musculo-skeletal function” and “Speech and language” problems.

Table 2

Frequencies of interventions adopted in handling with the top 10 health problems
Problems	Surveillance	Teaching, Guidance, and Counseling	Treatments and Procedures	Case Management	Total
Neuro-musculo-skeletal function	341 (54.2)	210 (33.4)	75 (11.9)	3 (0.5)	629
Circulation	269 (61.1)	126 (28.6)	42 (9.5)	3 (0.7)	440
Nutrition	157 (55.7)	109 (38.7)	12 (4.3)	4 (1.4)	282
Medication regimen	146 (57.5)	82 (32.3)	5 (2.0)	21 (8.3)	254
Health care supervision	10 (4.5)	114 (51.1)	0 (0)	99 (44.4)	223
Substance use	88 (43.1)	112 (54.9)	0 (0)	4 (2.0)	204
Sleep and rest-patterns	117 (66.5)	59 (33.5)	0 (0)	0 (0)	176
Speech and language	84 (54.2)	54 (34.8)	17 (11.0)	0 (0)	155
Mental health	111 (73.0)	41 (27.0)	0 (0)	0 (0)	152
Social contact	93 (68.4)	43 (31.6)	0 (0)	0 (0)	136

“Signs/symptoms-physical” was the most common target for “Surveillance” and “Teaching, Guidance, and Counseling” action. “Behavior modification” was an important intervention content for the “Teaching, Guidance, and Counseling”. For “Treatments and Procedures” intervention, “Exercise”, “Cardiac care” and “Gait training” were the main targets. The primary actions for the “Case Management” intervention were “Nursing care”, “Medical/dental care” (Table 3).

Table 3

Proportion of the top 5 targets for each category of the interventions
Interventions	Targets	n (%)
Surveillance		1605 (54.6)
	T62 Signs/symptoms - physical	587 (36.6)
	T23 Exercise	132 (8.2)
	T33 Interaction	130 (8.1)
	T39 Medication administration	123 (7.7)
	T15 Dietary management	122 (7.6)
Teaching, Guidance, and Counseling		1044 (35.5)
	T62 Signs/symptoms - physical	158 (15.1)
	T3 Behavior modification	109 (10.4)
	T23 Exercise	99 (9.5)
	T44 Nursing care	98 (9.4)
	T15 Dietary management	72 (6.9)
Treatments and Procedures		158 (5.4)
	T23 Exercise	71 (44.9)
	T7 Cardiac care	42 (26.6)
	T27 Gait training	18 (11.4)
	T65 Specimen collection	11 (7.0)
	T42 Medication set-up	5 (3.2)
Case Management		134 (4.6)
	T44 Nursing care	91 (67.9)
	T37 Medical/dental care	15 (11.2)
	T40 Medication coordination/ordering	9 (6.7)
	T73 Support system	6 (4.5)
	T18 Durable medical equipment	6 (4.5)

Appendix presents the details of the problem-category-target matches. Neuro-musculo-skeletal function–Surveillance–Signs/symptoms-physical, Circulation–Surveillance–Signs/symptoms-physical, Nutrition–Surveillance–dietary management, Health care supervision–Teaching, Guiding, and Counselling–Nursing care, Medication regimen–Surveillance–Medication Administration, and Substance use–Teaching, Guiding, and Counselling–Behavior modifications were the main problem-category-target matches.

With the increasing prevalence of stroke and survival rate, there is greater emphasis on home-based support following discharge. Organising this form of care may however be challenging considering the often-significant emphasis placed on hospital-based care for stroke survivors. Meanwhile, the transitional follow-up activities are often referred as a “black box”, as they involve a complex set of interventions with many unknown elements [17]. The current study follows on from implementing a home-based comprehensive care program for stroke survivors as they transition from the hospital to the home/ community. With the use of the Omaha System, the problems that commonly emerge during the transitioning period have been identified, including concerns regarding neuro-musculo-skeletal, circulation, and nutrition. The Omaha System's structured approach not only provides a comprehensive framework to help identify issues that maybe of concerns, but also enables the proposal of targeted intervention domains. Among the four problem domains, Physiological domain had the highest prevalence and correspondingly among the four Intervention Schemes, “Surveillance” and “Teaching, Guidance and Counseling” occupied the highest counts of the nursing interventions. Put together, the evolving nature of the post-stroke recovery suggests a great need for ongoing aftercare support as the survivor transitions to the home. Also, the findings highlight the usefulness of the Omaha System in underpinning a potential comprehensive program of care for stroke survivors and their families supported by nurse follow-up.

Although several health problems were identified, the top three recurring needs during the transitioning period were identified in the physiological domain in the areas of neuro-musculo-skeletal, circulation, and nutrition. The key health issues identified are consistent with the physiological challenges typically associated with post-stroke recovery. Undoubtedly, stroke affects the neurological system and as such, deficits emerging from this part are likely to be pronounced as the individual recovers. Similarly, previous studies have highlighted higher rates of disabilities in the areas of cognition, muscle weakness, and spasticity among stroke survivors [18,19]. Although a physiological concern, neuro-musculo-skeletal deficits are likely to impact an individual sense of self and self-image. As noted in a recent qualitative study examining the experiences of first time Chinese stroke survivors, the notion of “shaken sense of self and perceived helplessness” resonated across the data which was associated with the neurological deficits [20]. Further to this, existing evidence also suggests that persons recovering from a stroke may experience reduced blood flow and decreased arterial diameter in the hemiparetic limb, thus, highlighting a concern regarding circulation [21]. In the absence of adequate support, the arterial changes can exercise performance and functional ambulation. Concerns regarding nutrition may also be evident due to issues such as oropharyngeal dysphagia which if unresolved, can lead to nutritional issue following stroke survival [22]. Though these triad of physiological needs may be apparent in the acute phase of care, their presence during the transitioning period may suggest their protracted nature affirming a great need for continuing aftercare or comprehensive rehabilitative support as the stroke survivor transitions to the home/ community. Apart from the triad of concerns noted above, other needs were identified across physiological, psychosocial, and health-related behaviour domains of the Omaha System. Although the intensity of these needs was not captured in the current study, the plethora of complex needs warrants a comprehensive aftercare programme such as the one previously implemented by the research team to support stroke survivors [16].

In response to these complex needs, although “Surveillance” and “Teaching, Guidance, and Counseling” emerged as the most utilised schemes, there were instances of “Case Management” and “Treatments and Procedures”. “Case Management” was mostly employed to address issues regarding medication regimen and healthcare supervision. Valuable nursing interventions are crucial for stroke survivors during the transition from hospital to home, primarily preventing serious adverse patient outcomes by monitoring for subtle changes. In the currently study, “Surveillance” accounted for 54.6% of the interventions, aligning closely with previous nurse-led transitional care programs that ranged from 50% to 68% [23,24]. For mental health specifically, surveillance was identified as a key intervention during this transition phase. In China, the willingness of patients to seek mental health support is often hindered by the associated stigma [25], thereby limiting the application of other types of nursing interventions. High-quality transitional care is characterized by effective patient education and counselling, where nurses significantly contribute to teaching, guidance, and counselling. These efforts are directed towards optimising functional recovery and fostering behavior changes that enhance patient outcomes, particularly in relation to exercise and diet. Given that a diet high in sodium is a more significant risk factor for ischemic stroke in China compare to countries with high socio-demographic index [26], alongside smoking being an undeniable risk factor for stroke [2], dietary management and smoke cessation are pivotal interventions for stroke survivors in transition. Due to the lack of prescribing authority, nurses in the current study primarily utilised behavioral modifications to address substance use. Put together, these findings may suggest a multidisciplinary approach to organising and implementing aftercare support for stroke survivors [27].

Additionally, the current study emphasises the potential usefulness of the Omaha System in underpinning a potential program of aftercare support for stroke survivors. The system’s ability to support home-based or community care among patients with varying medical conditions and to facilitate multidisciplinary interaction has been reported to be useful [28]. The study provided revealing insights into the key issues faced by stroke patients during transition, coupled with the utility of the Omaha System in capturing and addressing these issues, laying the foundation for development of a comprehensive aftercare program that can be supported by information systems to ensure a structured treatment plan. This approach is essential for providing the ongoing aftercare support necessary for stroke survivors as they navigate the complex journey from hospital to home. This integration not only aids in the efficient allocation of nursing resources but also contributes to the overall improvement of patient care and satisfaction.

Despite the interesting findings observed in this study, some limitations are noteworthy. Firstly, the transitioning period focused on the first 12 weeks following discharge. Thus, how the complex needs evolve and vary in the long term remains yet to be articulated. That said, it is possible the needs identified in this study can offer a view into what may be expected in the long term. Secondly, the current study focused only on the stroke survivors. Although the Omaha System has the capacity to identify family concerns, this was not captured in the current study. Future studies may therefore need to consider exploring the family concerns as well to attain a more comprehensive understanding of both family and survivor needs.

The stroke survivors face multi-faceted issues when returning home after hospital discharge, as revealed in this study. The application of the Omaha System supports the identification of the areas that need support and plans targeted intervention in addressing the concerns. The mapping of problems and corresponding intervention strategies, in a standardized way, can ensure that the stroke survivors to achieve optimal rehabilitation in their return to normal lives.

NIHSS: National Institutes of Health Stroke Scale

MoCA: Montreal Cognitive Assessment

Acknowledgements

This study is dedicated to the late Madam Sheila Iu, Chair of the Hong Kong Nurses Training and Education Foundation. The authors express their sincere gratitude to all of the patients and nursing and medical professionals involved in this study.

Funding information

This work was supported by the T. S. Lo Foundation [5.53.56.ZH2Q, 2018].

Data availability

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

Ethics approval and consent to participate

The Ethics Committee of the Hong Kong Polytechnic University and the study hospital approved the study protocol (HSEARS20180619003, 2018 Ethical Review #005). The study followed accepted ethical standards, as outlined in the Declaration of Helsinki. The purpose of the study was explained to the participants, and written informed consent was obtained.

Competing interests

The authors declare no competing interests.

Author contributions

Study conception and design: X. Tao, S. Wong, F. Wong; Data collection: H. Li, S. Wong, L. Wu, Y. Zhang; Data analysis and interpretation: X. Tao, J. Bayuo, H. Li, S. Wong, C. Chun, X. Zhu, L. Wu, Y. Zhang, F. Wong; Drafting of the article: X. Tao, J. Bayuo; Critical revision of the article: X. Tao, J. Bayuo, H. Li, S. Wong, C. Chun, X. Zhu, L. Wu, Y. Zhang, F. Wong.

Consent for Publication

Not applicable.

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No competing interests reported.

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Appendix

Stroke survivors’ health priorities and targeted interventions in home-based post-discharge rehabilitation

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Trial registration

Figures

Introduction

Methods

Study design

Participants

Procedures

Data analysis

Rigour

Results

Characteristics of the participants

Implementation fidelity

Health problems

Interventions and targets

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1