title: Systematic review of qualitative and quantitative studies on the attitudes and barriers to percutaneous endoscopic gastrostomy feeding.
abstract: Percutaneous endoscopic gastrostomy (PEG) is now commonly used in long-term care and community settings. However, regional variations exist in the acceptability of PEG tube feeding with long-term nasogastric feeding still commonplace in many Asian nations.
  
  
  
  To evaluate the evidence relating to attitudes towards PEG feeding and to determine potential barriers to the acceptance of PEG tube feeding.
  
  
  
  We searched Ovid MEDLINE, EMBASE, the Cochrane Library, Web of Science and CINAHL databases. The search for the studies was performed without restrictions by using the terms "PEG", "percutaneous endoscopic gastrostomy", "enteral feeding", "attitude", "perception" and "opinion". Qualitative and quantitative studies were included. Quality of studies was assessed with the Alberta checklists.
  
  
  
  From 981 articles, 17 articles were included in the final analysis. Twelve qualitative and four quantitative studies were considered of good quality. Seven of the 14 studies reported positive attitudes towards PEG. Three major themes were identified in terms of barriers to PEG feeding: lack of choice (poor knowledge, inadequate competency and skills, insufficient time given, not enough information given, lack of guidelines or protocol, resource constraints), confronting mortality (choosing life or death, risk of procedure) and weighing alternatives (adapting lifestyle, family influences, attitudes of healthcare professionals (HCPs), fear and anxiety).
  
  
  
  Only half of the reviewed studies reported positive perceptions towards PEG feeding. The themes identified in our systematic review will guide the development of interventions to alter the current attitudes and barriers towards PEG tube feeding.
authors.affiliation: Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. Electronic address: hasifjaafar@siswa.um.edu.my.
authors.forename: Mohamad Hasif
authors.initials: MH
authors.lastname: Jaafar
authors.affiliation: Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. Electronic address: sanjiv@ummc.edu.my.
authors.forename: Sanjiv
authors.initials: S
authors.lastname: Mahadeva
authors.affiliation: Perdana University, MAEPS Building, MARDI Complex, Jalan MAEPS Perdana, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia. Electronic address: karenmorgan@perdanauniversity.edu.my.
authors.forename: Karen
authors.initials: K
authors.lastname: Morgan
authors.affiliation: Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. Electronic address: mptan@ummc.edu.my.
authors.forename: Maw Pin
authors.initials: MP
authors.lastname: Tan
mesh_terms: D001208:Asia; D001290:Attitude; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D003680:Deglutition Disorders / Q000628:therapy; D004750:Enteral Nutrition / Q000379:methods*; D005774:Gastrostomy / Q000193:education / Q000379:methods*; D006801:Humans; D007441:Intubation, Gastrointestinal; D008134:Long-Term Care; D010342:Patient Acceptance of Health Care; D017410:Practice Guidelines as Topic
keywords: Attitude; Barrier; Enteral feeding; Gastrostomy