Introduction
The home environment is the setting for 50% of all falls in older adults.1-3 Current evidence supports occupational therapists completing home assessments with patients to identify potential environmental hazards and prescribe home modifications to improve safety, reduce falls risk, and optimize occupational performance.3 Home assessment recommendations may include provision of assistive devices (eg, grab bars, shower chair), material adaptations (eg, clearing pathways, installing non-slip strips), behavioral adaptations (eg, avoiding ladders, adapting night time toileting routine), or structural modifications (eg, removing shower hobs to improve accessibility).4,5
The most commonly reported reasons for obtaining a home assessment include: accessibility to bath/shower (83.7%), feeling safe (79.3%), general household functioning (73.9%), toilet use (69.6%), requiring less help (68.4%), mobility outside the house (66.3%), and continuing interests (55.4%).6 Home assessments and modifications are more common in adults over 65 years,7-9 in females, and those who live alone.7,10 Specific health conditions (eg, diabetes, stroke, fracture, joint replacement) increase the likelihood of home assessments and modifications.7,10
A key determinant of success following an occupational therapy home assessment is the patient's adherence to the recommendations provided.11 A scoping search of the literature has revealed that adherence with occupational therapy home assessment recommendations is an issue identified in previous randomized controlled trials.3,12,13 Low adherence rates have been reported (approximately 50% 12 months after intervention11,14,15) and have been associated with poorer outcomes, such as increased falls and reduced function.11,14-16 Fragmented and a lack of detailed information about facilitators and barriers to adherence make it difficult to implement research findings into practice, highlighting the need for this review.
Previous research has identified barriers, such as disagreement between the occupational therapist and adult or caregiver regarding the need for the recommendation,17 a low perception of need, and denial of disability.18 However, home assessments that are not delivered sensitively can disempower older adults by removing their choice and control over the process.10 Some adults may fear the prospect of their own decline and put off getting recommended home modifications.18 Other research has reported that some adults lack the social support to undertake home modifications themselves and are unaware of available supports.1,7,18,19 Another possible barrier impacting on adherence to home assessment recommendations could be the perceived stigma from utilizing assistive aids or having external modifications completed.7
Facilitators, such as a strong personal belief that making changes to one's home could prevent falls, have been identified in other research.14 Gosselin et al.20 found that perceived need for a home modification was the strongest predictor of having completed at least one recommendation within six months.20 Additionally, an increasing number of comorbidities have been reported as a significant predictor of increased adherence. However, the coexistence of depression or psychological distress had a negative impact on uptake.21 Recommendations requiring follow-up from external providers (eg, installing rails) were more likely to be completed than those relying on the older adult or family member.21
Overall, the existing literature identifies some initial barriers and facilitators associated with adherence to recommendations provided during occupational therapy home assessments. The barriers and facilitators identified in this review will be further explored through the Capability Opportunity Motivation Behavior (COM-B) model of health behavior change.22 Michie et al.22 propose that adults need capability, opportunity, and motivation to perform a health behavior. Capability is defined as the patient's psychological and physical capacity to engage in the activity concerned, such as having the necessary knowledge.22 Motivation is defined as brain processes that energize and direct behavior, and opportunity is all the factors that lie outside the patient that make the behavior possible or prompt it.22 The barriers and facilitators identified in this review will be classified into the three model themes to understand how they impact on adherence.
Overall this review aims to first identify and describe the barriers and facilitators that influence adherence to recommendations. Secondly, the review can contribute evidence-based knowledge about facilitators and barriers to develop strategies to improve adherence in future clinical practice. Initial strategies to increase adherence may include a comprehensive assessment, utilization of a joint problem-solving approach, motivational interviewing, and supportive follow-up as required.23 However, adherence levels of approximately 50% indicate that further work is required.
A preliminary search of PROSPERO, PubMed, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports was conducted. No systematic reviews on adherence to occupational therapy home assessment recommendations were identified as completed or registered within the databases. For this mixed methods review, a quantitative and qualitative approach will be utilized for data collection. Quantitative data will capture patient adherence levels and intervention methodology; qualitative studies will be included to explore patient perceptions of adherence and the barriers and enablers that impact on implementing home assessment recommendations. The findings of this review will help to improve clinician awareness of the complexities of patient adherence, leading to improved intervention models. This review will also help guide future research on occupational therapy home assessments.
Review question
What are the barriers and facilitators that influence adherence to occupational therapy home assessment recommendations in adults (>18 years) or their caregivers who reside in private homes in the community?
Inclusion criteria
Participants
This review will focus on studies that include adults (>18 years) and their caregivers living in the community in private dwellings who received an occupational therapy home assessment. All adult ages will be included to understand if barriers and facilitators change with age. Adults or caregivers can be recruited from any setting, including acute hospital, outpatient, or community settings, etc. Caregivers are defined as individuals, such as family, who are actively engaged in providing care. This may range from providing occasional support to assisting regularly with personal or domestic activities of daily living, such as shopping, cleaning, or showering. Formal paid services are not included in this definition.
Phenomena of interest
This review will include studies that explore adherence to home assessment recommendations, which may include:
- i. assistive or adaptative equipment as a single or stand-alone intervention (eg, shower chair, grab bar installation, personal alarm, non-slip footwear)
- ii. material adaptations (eg, clearing pathways, non-slip strips on step edge, removal of mats)
- iii. behavioral adaptations, including providing information or education on environmental risks
- iv. structural modifications that aim to remove barriers to function and improve task performance (eg, ramps, shower hob removal).4,5
Interventions may include one or many home assessment recommendations delivered by an occupational therapist. Home assessments can be conducted in the home setting or via tele-rehabilitation.4,24 This review will consider all types of home assessment recommendations and all delivery modalities. Consideration will be given to the terms used in studies originating from different countries (compliance, adherence, uptake, etc.).
This review will consider the barriers and facilitators in relation to adherence to home assessment recommendations. Barriers or facilitators are individual, organizational, or contextual factors that impede or facilitate the implementation of home assessment recommendations. The barriers and facilitators identified in this review will be further explored through the Capability Opportunity Motivation Behaviour (COM-B) model of health behavior change.22
Context
This review will only consider studies that focus on home assessment recommendations for adults living in the community in private dwellings. The home environment can include indoor and outdoor settings. Adults residing in residential aged care facilities will be excluded.
Types of studies
This review will consider quantitative, qualitative, and mixed methods studies. Quantitative studies will include both experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, and pre-test post-test design. In addition, prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. Qualitative studies will include designs that focus on qualitative data including, but not limited to, phenomenology, qualitative descriptive, and narrative research. Mixed methods studies will only be considered if data from the quantitative or qualitative components can be clearly extracted. Only studies published in English will be included, with a lower date limit of January 2000. Initial searches of the literature have identified that this time period will capture recent and relevant studies.25
Methods
The proposed systematic review will be conducted in accordance with JBI methodology for mixed methods systematic reviews. 26 This review has been registered with PROSPERO (CRD42020159233).
Search strategy
The search strategy will aim to locate both published and unpublished studies. A three-step search strategy will be employed. A preliminary search of PubMed and Emcare will be undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles will be used to develop a full search strategy for PubMed (see Appendix I). Secondly, the search strategy, including all identified keywords and index terms will be adapted for each included information source. Thirdly, the reference list of all studies selected for critical appraisal will be screened for additional studies.
Information sources
A database search for quantitative and qualitative studies will include PubMed (including MEDLINE), CINAHL (EBSCO), EMCARE (Ovid), PsycINFO (Ovid), OT Seeker, and Embase (Ovid). The Cochrane Central Register of Controlled Trials (CENTRAL) will be searched for additional quantitative studies. A search for unpublished studies will include Google Scholar, Open Grey, ProQuest Dissertations and Theses, and MedNar.
Study selection
Following the search, all identified citations will be loaded into EndNote X9 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).27 The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.28
Assessment of methodological quality
Quantitative and qualitative papers (and the relevant components of mixed methods papers) selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from JBI SUMARI, dependent on study design.26,27 The methodological quality of the relevant components of the mixed methods studies will be assessed in relation to both the qualitative and quantitative assessment tools. Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of critical appraisal will be reported in narrative form and in tables. All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible) and the impact of methodological quality will be considered when developing conclusions and recommendations for practice.
Data extraction
Quantitative and qualitative data will be extracted from studies included in the review by two independent reviewers using the standardized JBI data extraction tool in JBI SUMARI.26 The extraction form will be initially piloted by the reviewers. The data extracted will include specific details about the populations, study methods, phenomena of interest, context, and outcomes of relevance to the review questions. Data extracted will include:
- study design, method of data collection, and inclusion/exclusion criteria
- study setting, geographical location, study follow-up period, and sample size
- intervention scope, duration, intensity (eg, nature of assessment, tools utilized, follow up), professionals involved
- method of assessment of adherence (eg, self-reported via telephone, follow up home assessment with an occupational therapist)
- patient adherence levels
- barriers and facilitators associated with patient adherence.
Specifically, quantitative data will be composed of data-based outcomes of descriptive and/or inferential statistical tests. In addition, qualitative data will be composed of factors with corresponding illustrations and will be assigned a level of credibility.26 Study authors will be again contacted for clarification or to seek missing data. Should any disagreements in the data extraction process arise, the third reviewer will be consulted.
Data transformation
Extracted quantitative data will be converted into qualitized data. This will involve transformation into textual descriptions or narrative interpretation of the quantitative results in a way that answers the review questions.
Data synthesis and integration
This review will follow a convergent integrated approach according to the JBI methodology for mixed methods systematic reviews using JBI SUMARI.26,27 This will involve assembling the qualitized data with the qualitative data. Assembled data are categorized and pooled together based on similarity in meaning to produce a set of integrated findings in the form of line of action statements.
Appendix I: Search strategy
PubMed
Search conducted July 2020
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