title: Swallowing interventions for the treatment of dysphagia after head and neck cancer: a systematic review of behavioural strategies used to promote patient adherence to swallowing exercises.
abstract: Dysphagia is a significant side-effect following treatment for head and neck cancers, yet poor adherence to swallowing exercises is frequently reported in intervention studies. Behaviour change techniques (BCTs) can be used to improve adherence, but no review to date has described the techniques or indicated which may be more associated with improved swallowing outcomes.
  
  
  
  A systematic review was conducted to identify behavioural strategies in swallowing interventions, and to explore any relationships between these strategies and intervention effects. Randomised and quasi-randomised studies of head and neck cancer patients were included. Behavioural interventions to improve swallowing were eligible provided a valid measure of swallowing function was reported. A validated and comprehensive list of 93 discrete BCTs was used to code interventions. Analysis was conducted via a structured synthesis approach.
  
  
  
  Fifteen studies (8 randomised) were included, and 20 different BCTs were each identified in at least one intervention. The BCTs identified in almost all interventions were: instruction on how to perform the behavior, setting behavioural goals and action planning. The BCTs that occurred more frequently in effective interventions, were: practical social support, behavioural practice, self-monitoring of behaviour and credible source for example a skilled clinician delivering the intervention. The presence of identical BCTs in comparator groups may diminish effects.
  
  
  
  Swallowing interventions feature multiple components that may potentially impact outcomes. This review maps the behavioural components of reported interventions and provides a method to consistently describe these components going forward. Future work may seek to test the most effective BCTs, to inform optimisation of swallowing interventions.
authors.affiliation: University College London, Health Behaviour Research Centre & University College London Hospital, Head & Neck Cancer Centre, Ground Floor Central, 250 Euston Road, London, NW1 2PQ, UK. Roganie.Govender@uclh.nhs.uk.
authors.forename: Roganie
authors.identifier: 0000-0003-2249-434X
authors.initials: R
authors.lastname: Govender
authors.affiliation: Division of Psychology & Language Sciences University College London, London, UK.
authors.forename: Christina H
authors.initials: CH
authors.lastname: Smith
authors.affiliation: Centre for Medical Imaging, University College London, London, UK.
authors.forename: Stuart A
authors.initials: SA
authors.lastname: Taylor
authors.affiliation: Department of Applied Health Research, University College London, London, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Barratt
authors.affiliation: Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), Kings College London, London, UK & UCL Department of Epidemiology & Public Health, University College London, London, UK.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Gardner
mesh_terms: D001521:Behavior Therapy; D003680:Deglutition Disorders / Q000209:etiology / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D005081:Exercise Therapy; D006258:Head and Neck Neoplasms / Q000150:complications*; D015438:Health Behavior; D006801:Humans; D010349:Patient Compliance; D011379:Prognosis
keywords: Adherence; Behavior change techniques; Complex interventions; Dysphagia; Head neck cancer; Swallowing exercises